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15 Trauma Flashcards

1
Q

1st peak for trauma deaths

A

0-30 minutes
Due to lacerations of heart, aorta, brain, brainstem or spinal cord
Cannot really save these patients - they die too quickly

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2
Q

2nd peak for trauma deaths

A

30 min - 4 hours
Death due to head injury (#1) and hemorrhage (#2)
These patients can be saved with rapid assessment
‘golden hour’

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3
Q

3rd peak for trauma deaths

A

Days to weeks

Death due to MODS and sepsis

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4
Q

Most common solid organ damaged in blunt trauma?

A

Liver

Spleen

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5
Q

What is the biggest predictors of survival in a fall?

A

Age and body orientation

LD50 is 4 stories

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6
Q

Most common organ damaged in penetrating trauma?

A

Small bowel

Liver

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7
Q

What is the most common cause of death in the first hour?

A

Hemorrhage

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8
Q

How much blood can you lose without effecting BP?

A

30%

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9
Q

Treatment of hemorrhage?

A

2L LR then switch to blood

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10
Q

What is the most common cause of death after reaching the ER alive?

A

Head injury

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11
Q

Most common cause of death in trauma patients over the long term?

A

Infection

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12
Q

Most common cause of upper airway obstruction?

A

Tongue

Perform jaw-thrust

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13
Q

What injuries are associated with seat belts?

A

Small bowel perforations
Lumbar spine fractures
Sternal fractures

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14
Q

What is the best site for cutdown for venous access?

A

Saphenous vein

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15
Q

Diagnostic peritoneal lavage

A

Hypotensive patients with blunt injuries

Need laparotomy if positive

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16
Q

What indicates a DPL is positive?

A 
>10cc blood
>100,000 RBCs/cc
Food particles
Bile
Bacteria
>500 WBC/cc
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17
Q

What does DPL miss?

A

Retroperitoneal bleeds

Contained hematomas

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18
Q

Focused abdominal sonography for trauma

A

Perihepatic fossa, perisplenic fossa, pelvis and pericardium

If positive - take to OR

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19
Q

FAST misses?

A

Free fluid <50-80cc
Retroperitoneal bleeding
Hollow viscus injury

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20
Q

In hypotensive patient with negative FAST scan?

A

Find source of bleeding

Pelvic fracture, chest or extremity

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21
Q

Indications for CT scan following blunt trauma?

A

ABdominal pain, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria
Negative DPL

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22
Q

CT scan misses in trauma?

A

Hollow viscous injury

Diaphragm injury

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23
Q

Indications for laparotomy in trauma?

A 
Peritonitis
Eviseration
Positive DPL
Uncontrolled visceral hemorrhage
Free air
Diaphragm injury
Intraperitoneal bladder injury
Contrast extravasation from hollow viscus
Specific renal, pancreas and biliary tract injury
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24
Q

Treatment for penetrating abdominal injury?

A

Laparotomy

Exception - knife or low velocity injuries: local exploration and obs if fascia no violated

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25
Q

Abdominal compartment syndrome

A

Bladder pressure > 25-30
IVC compression is the final common pathway for decreased CO
Low CO causes visceral and renal malperfusion (decreased urine output)
Upward displacement of diaphragm affect ventilation

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26
Q

Causes of abdominal compartment syndrome?

A

Massive fluid resuscitation
Trauma
Abdominal surgery

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27
Q

Treatment for abdominal compartment syndrome?

A

Decompressive laparotomy

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28
Q

Pneumatic antishock garment

A

Controversial use for pt with SBP<50 and no thoracic injury

Remove one compartment at a time upon arriving at ED

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29
Q

Indications for ED thoracotomy

A

Blunt trauma - only if pressure/pulses lost in ED

Penetrating trauma - If pressure/pulses lost enroute or within the ED

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30
Q

Performing an ED thoracotomy?

A

Through fourth and fifth intercostal spaces
Open pericardium anterior to the phrenic nerve
Cross-clamp the aorta (watch anteriorly to the esophagus)

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31
Q

If the thoracotomy is performed for abdominal injury?

A

Clamp the descending thoracic aorta.
IF BP improves to >70 - transport to OR for laparotomy
If BP does NOT improve - further treatment is futile

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32
Q

If the thoracotomy is performed for a cardiac injury?

A

Open the pericadrium longitudinally and anterior to the phrenic nerve. The heart can be rotated out of the pericardium for repair.

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33
Q

When do catecholamines peak after injury?

What other hormones increase?

A

24-48hrs

ADH, ACTH, glucagon

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34
Q

Glasgow Coma Scale

A

Motor (6)
Verbal (5)
Eye opening (4)

<14 - head CT
<10 - intubation
< 8 - ICP monitor

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35
Q

Scores for motor rating of GCS?

A 
6 - follows commands
5 - localizes pain
4 - withdraws from pain
3 - flexion with pain (decorticate)
2 - extension with pain (decerebrate)
1 - no response
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36
Q

Scores for verbal ratings of GCS?

A 
5 - Oriented
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds
1 - no response
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37
Q

Scores for eye opening ratings of GCS?

A

4 - Spontaneous opening
3 - Opens to command
2 - Opens to pain
1 - No response

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38
Q

Indications for head CT in trauma?

A

Suspected skull penetration by a foreign body
Discharge of CSF, blood or both from nose
Hemotympanum or discharge of blood/CSF from ear
Head injury with intoxication
Altered state of consciousness at time of exam
Focal neurologic signs or symptoms
Any situation precluding proper surveillance
Head injury plus additional trauma
Protracted unconsciousness

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39
Q

Indications for surgical intervention in epidural hematoma?

A

Significant neurologic degeneration

Significant mass effect (shift > 5mm)

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40
Q

Indications for surgical intervention in subdural hematoma?

A

Significant neurologic degeneration

Significant mass effect (>1cm)

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41
Q

Indications for ventriculostomy in traumatic IVH?

A

Hydrocephalus

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42
Q

Indications for craniectomy with diffuse axonal injury?

A

Elevated ICP

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43
Q

Cerebral perfusion pressure

A

CPP = MAP - ICP

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44
Q

Signs of elevated ICP?

A

Decreased ventricular size
Loss of sulci
Loss of cisterns

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45
Q

Indications for ICP monitors

A

GCS < 8
Suspected increased ICP
Patients with moderate to severe head injury and inability to follow clinical exam

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46
Q

Normal ICP? Needs treatment? Goal CPP?

A

Normal ICP 10, >20 needs treatment

Goal CPP is >60

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47
Q

Treatment for ICP?

A 
Sedation and paralysis
Raid head of bed
Relative hyperventilation
Hypertonic saline (keep Na 140-150, sOsm 295-310)
Mannitol
Barbiturate coma
Ventriculostomy w/ CSF drainage
Craniotomy decompression
Fosphenytoin or Keppra (prophylaxtic)
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48
Q

How does relative hyperventilation effect ICP?

A

CO2 causes modest cerebral vasoconstriction
Goal CO2 30-35
Avoid over-hyperventilation and cause cerebral ischemia from too much vasoconstriction

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49
Q

Raccoon eyes

A

Peri-orbital ecchymosis

Anterior fossa fracture

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50
Q

Battle’s sign

A 
Mastoid ecchymosis
Middle fossa fracture
Can injury facial nerve (CN VII)
If deficit presents:
- Acute: exploration and repair
- Delayed: secondary to edema, no exploration
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51
Q

Temporal skull fracture

A

Can injure CN VII/VIII

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52
Q

Most common site of facial nerve injury?

A

Geniculate ganglion

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53
Q

Most common cause of temporal skull fractures?

A

Lateral skull or orbital blow

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54
Q

Indications for operation in skull fracture?

A

Significantly depressed (>1cm)
Contaminated
Persistent CSF leak

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55
Q

Cause of coagulopathy with traumatic brain injury?

A

Release of tissue factor

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56
Q

Jefferson fracture

A

C-1 burst
Caused by axial loading
Tx: Rigid collar

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57
Q

Hangman’s fracture

A

C-2
Distraction and extension
Tx: traction and halo

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58
Q

Odontoid fracture

A

C-2
Type I - above base, stable
Type II - at base, unstable (Requires fusion or halo)
Type III - extends into vertebral body (fusion or halo)

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59
Q

Facet fractures or dislocations

A

Can cause cord injury

Associated with hyperextension and oration with ligamentous disruption

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60
Q

Three columns of the thoracolumbar spine?

A

Anterior - anterior longitudinal ligament and anterior 1/2 of the vertebral body
Middle - posterior 1/2 of the vertebral body and posterior longitudinal ligament
Posterior - facet joints, lamina, spinous processes, interspinous ligament

More than one column = unstable

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61
Q

Compression fractures

A

Anterior column only

Stable

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62
Q

Burst fractures

A

Unstable (involve more than one column)

Require fusion

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63
Q

At risk for fracture in upright fall?

A

Calcaneus
Lumbar
Wrist/forearm

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64
Q

Indications for emergent surgical spine decompression?

A

Fracture or dislocation not reducible with distraction
Open fractures
Soft tissue or bony compression of the cord
Progressive neurologic dysfunction

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65
Q

Most common cause of facial nerve injury?

A

Temporal bone fracture

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66
Q

Le Fort Classification - Type I

A

Maxillary fracture straight across ( — )

Tx: Reduction, stabilization, intramaxillary fixation +/- circuzygomatic and orbital rim suspension wires

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67
Q

Le Fort Classification - Type II

A

Lateral to nasal bone, underneath eyes, diagonal toward maxilla ( / \ )
Tx: Reduction, stabilization, intramaxillary fixation +/- circuzygomatic and orbital rim suspension wires

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68
Q

Le Fort Classification - Type III

A

Lateral orbital walls ( – – )

Tx: Suspension wiring to stable frontal bone; may need external fixation

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69
Q

Nasoethmoidal orbital fractures

A

70% have a CSF leak
Conservative therapy for up to 2 weeks
Can use epidural catheter to decrease CSF pressure and help close leak
May need surgical closure of dura to stop leak

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70
Q

Anterior nose bleed - treatment?

A

Packing

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71
Q

Posterior nose bleed?

A

Balloon tamponade
Angioembolization
Arteries - internal maxillary artery or ethmoidal artery

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72
Q

Orbital blowout fracture

A

Indications for repair:
Impaired upward gaze or diplopia with upward vision

Perform restoration fo orbital floor with bone fragments or bone graft

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73
Q

Mandibular injury

A

Malocclusion
Diagnosis - fine-cut facial CT with reconstruction
Most repaired with IMP for 6-8 weeks or open reduction and internal fixation (ORIF)

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74
Q

Tripod fracture

A

Zygomatic bone

ORIF for cosmesis

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75
Q

What must you have a high suspicion for with maxillofacial fractures?

A

Cervical spine issues

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76
Q

Work up for asymptomatic blunt trauma to the neck?

A

Neck CT scan

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77
Q

Work up for asymptomatic penetrating trauma?

A

Based on neck zone

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78
Q

Penetrating trauma - Zone I

A

Clavicle to cricoid cartilage
Workup: angiography, bronchoscopy, esophagoscopy and barium swallow
Tx: pericardial window, median sternotomy

(Potential for damage to great vessels)

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79
Q

Penetrating trauma - Zone II

A

Cricoid to angle of mandible

Workup: Neck exploration in OR

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80
Q

Penetrating trauma - Zone III

A

Angle of mandible to the base of skull
Workup: angiography, laryngoscopy
Tx: Jaw subluxation, digastric and SCM muscle release, mastoid sinus resection to reach vascular injuries to this location

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81
Q

Symptomatic neck trauma? Indications? Treatment?

A

Shock, bleeding, expanding hematoma, losing/lost airway, subQ air, stridor, dysphagia, hemoptysis, neurological deficit

Neck exploration

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82
Q

Work up of esophageal injuries?

A

Esophagoscopy and esophagogram

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83
Q

Treatment of contained esophageal injuries?

A

Observation

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84
Q

Treatment of non-contained esophageal injuries?

A

Small, with minimal contamination - primary closure
Extensive or contaminated:
- Neck - place drains
- Chest - chest tube and place split fistula in neck (eventually will need esophagectomy)

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85
Q

Approach to esophageal injuries?

A

Neck - left side
Upper 2/3 of thoracic esophagus - right thoracotomy
Lower 1/3 of thoracic esophagus - left thoracotomy

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86
Q

Laryngeal fracture and tracheal injuries?

A

Airway emergency
Sx: Crepitus, stridor, respiratory compromise
Emergent Tx: secure airway (cricothyroidotomy)
Tx: Primary repair (strap muscles); convert to trachyeostomy (allows for edema to subside)

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87
Q

Thyroid gland injuries

A

Control bleeding and drain

NOT thyroidecomy

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88
Q

Recurrent laryngeal nerve injury

A

Can repair or reimplant in cricoarythenoid muscle

Sx: hoarseness

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89
Q

Shotgun injury to neck

A

Requires angiogram and next CT

Evaluate the esophagus and trachea

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90
Q

Vertebral artery bleeds

A

Embolize or ligate

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91
Q

Common carotid bleed

A

Ligation causes stroke in 20%

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92
Q

Indications for OR after chest tube placement?

A

> 1500cc after initial insertion
250cc/h for 3 hrs
2500cc/24hrs
Bleeding with instability

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93
Q

Treatment for unresolved hemothorax after 2 well-placed chest tubes?

A

Thoracoscopic drainage

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94
Q

Sucking chest wound (open pneumothorax)

A

Needs to be at least 2/3 diameter of the trachea to be significant
Cover wound with valve dressing

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95
Q

Tracheobronchial injury

A

Worse oxygenation after CT placement - clamp the chest tube
Bronchus injuries are more common on the right
ED tx: mainstem intubate on unaffected side
DX: bronchoscopy
Tx:
- Immediately if large air leak and respiratory compromise
- After 2 weeks of persistent air leak

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96
Q

Indication for right thoracotomy in tracheobronchial injury?

A

Right mainstem, trachea, and proximal mainstem injuries (avoids the aorta)

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97
Q

Indication for left thoracotomy in tracheobronchial injury?

A

Distal left mainstem injury

98
Q

Diaphragmatic injuries

A

Most commonly on the left and secondary to blunt injuries
Dx: CXR (air-fluid level in chest)
TX:
- If less than 1 week - transabdominal approach
- If greater than 1 week (chest approach)
May need mesh

99
Q

Signs of aortic transection on CXR?

A 
Widened mediastinum
1st or 2nd rib fractures
Apical capping
Loss of aortopulmonary window
Loss of aortic contour
Left hemothorax
Trachea deviation to right
100
Q

Locations for aortic transection?

A

Ligamentum arteriosum (distal to subclavian tackeoff)
Near aortic valve
Diaphragmatic hiatus

101
Q

Diagnosis of aortic transection?

A

CT angiogram of chest

102
Q

Operative approach to repair of aortic transection?

A

Left thoracotomy with repair with partial left heart bypass
OR
Covered stent endograft (distal transection only)

103
Q

Indication for median sternotomy?

A

Injuries to ascending aorta, innominate artery, proximal right subclavian artery, innominate vein, proximal left common carotid

104
Q

Indication for left thoracotomy?

A

Injuries to left subclavian artery, descending aorta

105
Q

Access for distal right subclavian artery?

A

Midclavicular inscision resection of medial clavicle

106
Q

Most common cause of death after myocardial contusion?

A

V-tach and V-fib

Highest risk in first 24hrs

107
Q

Flail chest

A

2 consecutive ribs broken at > 2 sites
Paradoxical motion
Risk for pulmonary contusion

108
Q

Penetrating chest injury - first step

A

If stable - CXR

109
Q

Penetrating ‘box’ injuries?

A 
borders are clavicle, xiphoid process and nipples
Requires:
- Pericardial window (FAST scan)
- Bronchoscopy
- Esophagoscopy
- Barium swallow
110
Q

Penetrating ‘non-box’ injuries without pneumothorax or hemothorax?

A

Needs chest tube if patient requires intubation

Otherwise, serial CXR

111
Q

Pericardial window

A

If you find blood - median sternotomy (to fix possible injury to heart or great vessels)
Place pericardial drain

112
Q

Penetrating injuries anterior-medial to midaxillary line and below nipples

A

Laparotomy

Plus work up for penetrating ‘box’ injuries

113
Q

Traumatic causes of cardiogenic shock?

A

Cardiac tamponade
Cardiac contusion
Tension pneumothorax

114
Q

Tension pneumothorax

A

Sx: hypotension, increased airway pressure, decrease breath sounds, bulging neck veins, tracheal shift
Can see bulging diaphragm during laparotomy
Cardiac compromise seconary to decreased venous return (IVC, SVC compression)
Tx: Chest tube

115
Q

Hemodynamically unstable with pelvic fracture and negative DPL, negative CXR, and no other signs of blood loss or reasons for shock

A 
Stabilize pelvis (C-clamp, external fixator, sheet)
Go to angio for embolization
116
Q

Type I pelvic fracture

A

Ubstable (crush)

Fracture in multiple facets

117
Q

Type II pelvic fracture

A

Unstable

Book fracture - one rami and sacroiliac join

118
Q

Type III pelvic fracture

A

Stable

Through a rami

119
Q

Bleeding in anterior pelvic fractures

A

Venous

120
Q

Bleeding in posterior pelvic fractures

A

Arterial

121
Q

Intra-op penetrating injury pelvic hematomas

A

Open (possibly angiography)

122
Q

Intra-op blunt injury pelvic hematomas

A

Leave
If expanding or patient unstable - stablize pelvic fracture, pack paelvis if inOR
Go to angiography for embolization

123
Q

Most common cause of duodenal trauma

A

Blunt trauma

Crush or deceleration injury

124
Q

Most common area of duodenal injury?

A

2nd portion of the duodenum

125
Q

Which segment of the duodenum cannot be repaired with primary end-to-end closure

A

Second portion of the duodenum

126
Q

Intra-op paraduodenal hematomas

A

> 2cm are considered significant
Most common in 3rd portion of the duodenum overlying the spine
Need to open both blunt and penetrating injuries

127
Q

Paraduodenal hematoma on CT scan

A

Can present as SBO 12-72hrs after injury
UGI: ‘stacked coins’ or ‘coiled sping’
Tx: NGT and TPN (90% resolve over 2-3 weeks)

128
Q

If at laparotomy and duodenal injury is suspected?

A

Perform kocher maneuver and open lesser sac through the omentum
Check for hematoma, bile, succus and fat necrosis
If found - need to inspect entire duodenum and check for pancreatic injury

129
Q

Diagnosing suspected duodenal injury

A

Abdominal CT with contrast
- Bowel wall thickening, hematoma, free air, contrast leak or retroperitoneal fluid/air
UGI contrast study*

130
Q

Treatment of duodenal injury

A

Try to get primary repair or anastomosis
May need to divert with pyloric exclusion and gastrojejunostomy
Place a distal feeding jejunostomy and possble draining jejunostomy tube that threads to the duodenum
Place drains

131
Q

Treatment of 2nd portion of duodenum and cannot get a primary repair

A 
Place jejunal serosal patch
Pyloric exclusion and gastrojejunostomy
Consider feeding and draining jenuostomy
Leave drains
Will eventually need a whipple
132
Q

When do you remove drains after duodenal injury?

A

When patient can tolerate PO feeding without increased in drain output

133
Q

Treatment of fistulas

A

Bowel rest
TPN
Octreotide
Conservative management for 4-6 weeks

134
Q

Most common organ injured in penetrating injury?

A

Small bowel (liver)

135
Q

Occult small bowel injuries

A

Abdominal CT - intra-abdominal fluid not associated with solid organ injury, bowel wall thickening, mesenteric hematoma suggestive of inury
Repeat CT in 24hrs
Need to be tolerating a diet before they can be discharged home

136
Q

Criteria for resection and reanastomosis after small bowel injury?

A

Defect >50% bowel circumference

Results in lumen diameter <1/3 normal

137
Q

When do you open a mesenteric hematoma?

A

Expanding

Large (>2cm)

138
Q

Most common cause for colon trauma?

A

Penetrating

139
Q

Repair of right and transverse colon injuries?

A

Primary repair

Anastamosis

140
Q

Repair of left colon injuries?

A

Primary repair/anastamosis
AND
Diverting ileostomy is patient is in shock or there is gross contamination

141
Q

Paracolonic hematomas

A

Both blunt and penetrating hematomas need to be opened

142
Q

Repair of an extraperitoneal rectal hematoma

A

Serial debridement

Consider diverting ileostomy

143
Q

Repair of intraperitoneal rectal hematoma

A

Repair defect, prescral drainage

Consider diverting ileostomy

144
Q

Indications for diverting ileostomy?

A

Shock
Gross contamination
Extensive injury

145
Q

Most common organ injured in blunt trauma?

A

Liver (spleen)

146
Q

When common hepatic artery is ligated, where do collaterals run through?

A

Gastroduodenal artery

147
Q

Pringle maneuver

A

Clamp the portal triad - using non-crushing vascular clamps
Does NOT stop bleeding from hepatic veins
Limited to 15-20 minute intervals

148
Q

Atriocaval shunt

A

For retrohepatic IVC injury

Allows for control while performing repair

149
Q

Portal triad hematomas

A

Need to be explored

150
Q

Repair of common bile duct injuries?

A

<50% circumference - repair over stent
>50% circumference or complex injury - choledochoejunostomy
May need intra-op cholangiogram to define injury
10% will leak - place a drain

151
Q

Portal vein injury

A

Need to repair
Can transect pancreas to get to the injury in the portal vein
Perform distal pancreatectomy
Ligation of portal vein has 50% mortality

152
Q

Omental graft

A

Can be placed in liver lacerations to help with bleeding and prevent bile leaks

153
Q

Patient has failed conservative management of blunt liver injury if:

A 
Unstable despite aggressive resuscitation
4uPRBCs (HR >120, SBP <90)
OR
>4uPRBCs to keep Hct >25
Go to OR
154
Q

Indications to go to OR with blunt liver injury

A

Failure of conservative management
Active blush on abdominal CT
Pseudoaneurysm

Posterior injuries may respond to angiogram

155
Q

How long does it take for spleen trauma to heal?

A

6 weeks

156
Q

Greatest risk of post-splenectomy sepsis?

A

Within 2 years of splenectomy

157
Q

Failure of conservative management for blunt splenic injuries?

A

Unstable despite aggressive management

  • 2 uPRBCs with HR >120 or SBP <90
  • Requiring 2uPRBC to keep Hct >25
158
Q

Indications for OR in blunt splenic injuries?

A

Failure of conservative management
Active blush
Pseudoaneurysm

159
Q

Indications of pancreatic trauma

A

Edema

Necrosis of peripancreatic fat

160
Q

Treatment of pancreatic contusion

A

Leave if stable

If in OR - drain

161
Q

Treatment of distal pancreatic duct injury?

A

Distal pancreatectomy

Can take up to 80%

162
Q

Pancreatic head duct injury that is not repairable?

A

Place drains

Delayed whipple or ERCP with stent eventually

163
Q

How do you decide between whipple and distal pancreatectomy?

A

Duct injury in relation to the SMV

164
Q

Pancreatic hematoma

A

Both penetrating and blunt injuries need to be explored

165
Q

Signs of a missed pancreatic injury?

A

Persistent or rising amylase

166
Q

Major signs of vascular injury

A 
Active hemorrhage
Pulse deficit
Expanding or pulsatile hematoma
Distal ischemia
Bruit
Thrill

All require OR for exploration (possible intra-op angio)

167
Q

Moderate/soft signs of vascular injury

A

History of hemorrhage
Deficits of anatomically related nerve
Large stale/nonpulsatile hematoma
ABI < 0.9

Go for angio

168
Q

When do you need a saphenous vein graft?

A

When deficit is greater than 2cm

Take from opposite leg

169
Q

Venous injuries that require repair?

A 
Vena cava
Femoral
Popliteal
Brachiocephalic
Subclavian
Axillary
170
Q

Treatment for transection of single artery in the calf of an otherwise health patient

A

Ligate

171
Q

When do you perform a fasciotomy?

A

> 4-6 hours ischemia

172
Q

Compartment syndrome

A

Pressures >20mmHg or clinical exam

Pain > paresthesia > anesthesia > paralysis > poikilothermia > pulselessness

173
Q

Most common causes of compartment syndrome?

A

Supracondylar humeral fractures
Tibial fractures
Crush injuries

174
Q

How much blood can you lose from a femur fracture?

A

> 2L

175
Q

Orthopedic emergencies?

A 
Pelvic fractures in unstable patient
Spine injury with deficit
Open fractures
Dislocations or fractures with vascular compromise
Compartment syndrome
176
Q

Complication of femoral neck fracture

A

Avascular necrosis of femoral head

177
Q

Long bone fracture or dislocation with loss of pulse (or weak pulse)

A

Immediate reduction of fracture for dislocation and reassessment of pulse
- Pulse does not return - OR (vascular bypass/repair, intra-op angio)
- Pulse returns, but weak - angiogram
(Exception - knee dislocations go to angio even if full pulse returns)

178
Q

Fractures associated with upright falls?

A

Calcaneus
Lumbar
Distal forearm

179
Q

Anterior shoulder dislocation

A

Axillary nerve

180
Q

Posterior shoulder dislcoation

A

Axillary nerve

181
Q

Proximal humerus fracture

A

Axillary nerve

182
Q

Midshaft humerus fracture (or spiral humerus fracture)

A

Radial nerve

183
Q

Distal (supracondylar) humerus fracture

A

Brachial artery

184
Q

Elbow dislocation

A

Brachial artery

185
Q

Distal radius fracture

A

Median nerve

186
Q

Anterior hip dislocation

A

Femoral artery

187
Q

Posterior hip dislocation

A

Sciatic nerve

188
Q

Distal (supracondylar) femur fracture

A

Popliteal artery

189
Q

Posterior knee dislocation

A

Popliteal artery

190
Q

Fibular neck fracture

A

Common peroneal nerve

191
Q

Temporal or parietal bone fracture

A

Epidural hematoma

192
Q

Maxillofacial fracture

A

Cervical spinal fracture

193
Q

Sternal fracture

A

Cardiac contusion

194
Q

First or second rib fracture

A

Aortic transection

195
Q

Scapula fracture

A

Pulmonary contusion

Aortic transection

196
Q

Rib fractures - left, 8-12

A

Spleen laceration

197
Q

Rib fractures - right, 8-12

A

Liver laceration

198
Q

Pelvic freacture

A

Bladder rupture

Urethral transection

199
Q

Best indicator of renal trauma?

A

Hematuria

Requires abdominal CT

200
Q

Benefit of Intravenous pyelogram before going to OR with kidney trauma?

A

Can identify presence of functional contralateral kidney

201
Q

Left renal vein

A

Can be ligated near the IVC
Has adrenal and gonadal vein collaterals
(NOT seen in the right renal vein)

202
Q

Renal hilum structures (anterior to posterior)

A

Vein, artery, pelvis (VAP)

203
Q

Indications for operative intervention in kidney trauma?

A 
Acutely - ongoing hemorrhage with instability
After acute phase:
- Major collecting system disruption
- Non-resolving urine extravasation
- Severe hematuria
204
Q

How do you assess for leak after repair for kidney trauma?

A

Methylene blue dye to check for leak

205
Q

When found at exploration for another injury - blunt renal injury with hematoma

A

Leave unless pre-op CT/IVP shows no function or significant urine extravasation

206
Q

When found at exploration for another injury - penetrating renal injury with hematoma

A

Open unless pre-op CT/IVP shows good function without significant urine extravasation

207
Q

Trauma to flank and IVP shows no uptake in stable patient

A

Angiogram

Stent if flap present

208
Q

Best indicator for bladder trauma?

A

Hematuria

209
Q

Signs and symptoms of bladder trauma

A

Meatal blood

Sacral or scrotal hematoma

210
Q

Diagnosis for bladder trauma

A

Cystogram

211
Q

Extraperitoneal bladder rupture

A

Cystogram shows starburts

Tx: Foley 7-14 days

212
Q

Intraperitoneal bladder rupture

A

Cystogram shows leak

Tx: Operation and repair of defect, followed by foley drainage

213
Q

Best test for identifying ureteral injury?

A 
NOT hematuria (unreliable)
IVP and retrograde urethrogram
214
Q

Large ureteral segment is missing and cannot perform reanastomosis

A

> 2 cm
Upper 1/3 and middle 1/3 (above pelvic brim) - don’t reach bladder
- Temporaize with percutaneous nephrostomy (tie off both ends of the ureter)
- Ileal interposition or trans-ureteroureterostomy
Lower 1/3 - reimplant in Bladder

215
Q

Small ureteral segment is missing

A

<2cm
Upper and middle 1/3 - mobolize ends of ureter and perform primary repair over stent
Lower 1/3 - re-implant in the bladder

216
Q

Blood supply to the ureters

A

Medial in upper 2/3rds

Lateral in lower 1/3rd

217
Q

Signs of uretheral injury

A

Hematuria*
Blood at meatus*
Free-floating prostate gland
(Associated with pelvic fracture)

218
Q

Best test for uretheral injury

A

REtrograde uretherogram

219
Q

Area of the urethra that is at greatest risk for transection?

A

Membranous portion

220
Q

Treatment of significant urethral injury

A

Suprapubic cystostomy
Repair in 2-3 months
(High stricture and impotence rate if repaired early)

221
Q

Treatment of small, partial urethral tears

A

Bridging urethral catheter across tear

Repair in 2-3 months

222
Q

Genital trauma

A

Can get fracture in erectile bodies from vigorous sex

Need to repair the tunica and Buck’s fascia

223
Q

Testicular trauma

A

Get US to see if tunica alburginea is violated

Repair if needed

224
Q

Best indicators of shock in children

A

Heart rate, respiratory rate, mental status and clinical exam
BP is NOT reliable - last to go

225
Q

Indications for C-section during exploratory laparotomy for trauma

A

Persistent maternal shock or severe injuries and pregnancy near term (>34 weeks)
Pregnancy a threat to mother’s life (hemorrhage, DIC)
Mechanical limitation to life-threatening vessel injury
Risk of fetal distress exceeds risk of immaturity
Direct intra-uterine trauma

226
Q

Uterine rupture

A

If after fetal delivery - aggressive resuscitation

Uterus will eventually clamp down

227
Q

Placental abruption

A

Most likely to occur in the posterior fundus
>50% of placental - 100% fetal demise
Signs - uterine tenderness, contractions, fetal HR <120
Can be caused by shock or mechanical forces

228
Q

Kleihauer-Betke test

A

Test for fetal blood in the maternal circulation

Signs of placental abruption

229
Q

Pelvic hematoma

A

Open penetrating

Leave blunt

230
Q

Paraduodenal hematoma

A

Open penetrating

Open blunt

231
Q

Portal triad

A

Open penetrating

Open blunt

232
Q

Retrohepatic

A

Leave penetrating

Leave blunt

233
Q

Midline supramesocolic

A

Open penetrating

Open blunt

234
Q

Midline inframesocolic

A

Open penetrating

Open blunt

235
Q

Pericolonic

A

Open penetrating

Open blunt

236
Q

Perirenal

A

Open penetrating

Leave blunt

237
Q

Zone I of the peritoneum

A

Central retroperitoneum

Pancreaticouodenal injury or major abdominal vascular injury

OPEN hematomas in these areas

238
Q

Zone II of the peritoneum

A

Flank or perinephric area

Injuries to the gentiurinary tract or to the colon

OPEN hematomas in these areas

239
Q

Zone III of the peritoneum

A

Pelvis

Pelvic fractures

LEAVE hematomas in these areas

240
Q

When should you always leave a drain?

A

Pancreatic, liver, biliary system, urinary and duodenal injuries

241
Q

Snake bites

A

Sx: Shock, bradycardia, arrythmias
Tx: Stabilize patients, anti-venim, tetanus shot

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