ATLS Flashcards
1
Q
Effects of electrical burns
A
local thrombosis
local nerve injury
Severe - contracture of affected extremity
Rhabdomyolysis
Cardiac Arrhythmias
Spinal cord transsection + fractures (Because of muscle tetany)
2
Q
Sign that deep soft-tissue injury is extensive for electrical burn
A
clenched hand with small electrical entrance wound
3
Q
What type of electrical current is more dangerous and why?
A
AC more dangerous than DC because causes tetany at low voltage – locked in and can’t release
4
Q
What is the risk with labial/mouth electrical burns?
A
Delayed arterial bleeding from the facial artery
5
Q
Labs needed for workup of significant electrical injury
A
ECG
CBC, renal function
CK, Troponin
6
Q
Worse prognosis factors in drowning - after injury
A
Lack of pupillary light reflex
Male
Hyperglycemia
Asystole on arrival to ED
7
Q
Risk factors for drowning
A
Infants/toddlers
Impulsive behaviour
Trauma
Alcohol/drug use
Lack of adult supervision
No fence around pools
Don’t know how to swim
8
Q
When is aspiration during drowning more common?
A
Drug abuse
head trauma
seizure
cardiac arrhythmia
9
Q
How many minutes of hypoxia causes irreversible CNS damage?
A
4-6 mins
10
Q
How does fresh water aspiration affect the lungs?
A
disrupts surfactant - higher surface tension and alveolar instability
capillary/alveolar membrane damage - fluid leak into alveoli - pulmonary edema
decrease pulmonary compliance
increase airway resistance
increase pulmonary artery pressure
diminished pulmonary flow
fall in PaO2 - tissue hypoxia - metabolic acidosis
11
Q
How does salt water aspiration affect the lungs?
A
creates osmotic gradient for fluid into lungs - dilutes surfactant
decrease pulmonary compliance
increase airway resistance
increase pulmonary artery pressure
diminished pulmonary flow
fall in PaO2 - tissue hypoxia - metabolic acidosis
12
Q
What are the major determinants of outcome for drowning
A
duration of submersion
degree of pulmonary damage by aspiration
effectiveness of initial rescusitative measures
degree of hypothermia
13
Q
Target O2 Sat in drowning?
A
92% (minimum)
14
Q
What are the components of the “initial assessment” in a patient coming in for trauma?
A
Preparation
* Triage
*Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries
*Adjuncts to the primary survey and resuscitation
* Consideration of the need for patient transfer
* Secondary survey (head-to-toe evaluation and patient history)
* Adjuncts to the secondary survey
* Continued postresuscitation monitoring and reevaluation
* Definitive care
15
Q
What are the critical components of hospital preparation to receive a trauma?
A
- have trauma resuscitation area available
- check all airway equipment is working
- have warmed IV crystalloid solutions available
- Have monitoring devices ready
- Have a protocol to summon additional medical assistance and ensure prompt response by lab/radiology
- ensure your centre is able to receive the type of patient
16
Q
What is the definition of a mass casualty event?
A
the number of patients and severity of their injuries DOES exceed the capability of the facility and staff
17
Q
How can unsuccessful intubation be avoided?
A
identify patients with difficult anatomy
identify the most skilled person on the team
ensure appropriate equipment available to rescue the failed attempt
be prepared to perform a surgical airway
18
Q
What are the elements of clinical observation that tell you about circulatory status?
A
- Level of consciousness
- Skin perfusion
- Pulse
19
Q
What temperature should IV fluids given in trauma be?
A
37-40 degrees C
20
Q
What are examples of adjuncts used in the primary survey?
A
- Pulse oximetry
- cardiac monitor
- EtCO2
- RR
- ABG
- urinary catheter (monitor output)
21
Q
Give 3 bedside tests that can be done in conjunction with the primary survey to detect intra-abdominal blood, pneumothorax and hemothorax
A
FAST
eFAST
DPL
22
Q
What are the components of an “AMPLE” history?
A
Allergies
Medication
Past illnesses/pregnancy
Last meal
Events/Environment related to the injury
23
Q
What injuries could be expected in a frontal impact car collision?
A
- Cervical spine fracture
- Anterior flail chest
- *Myocardial contusion
- Pneumothorax
- Aortic disruption
- Fractured spleen or liver
- *Posterior fracture/dislocation of hip or knee
- Head injury
- Facial fracture
24
Q
What injuries could be expected in a rear impact car collision?
A
Cervical spine injury
Head injury
Soft tissue injury to neck
25
What injuries could be expected in an MVC vs pedestrian?
- Head injury
- Traumatic aortic disruption
- Abdominal visceral injuries
- Fractured lower extremities/pelvis
26
What injuries could be expected in a fall from height?
- head injury
- *axial spine inury
- abdo visceral injuries
- *fractured pelvis or acetabulum
- bilateral LE fractures (including *calcaneal fractures)
27
What injuries could be expected in a side impact car collision?
- *contralateral neck sprain
- head injury
- cervical spine fracture
- lateral flail chest
- pneumothorax
- traumatic aortic disruption
- *diaphragmatic rupture
- fractured spleen/liver and/or kidney
- *fractured pelvis or acetabulum
28
what information do you need to know about an automobile collision?
- seat-belt use
- steering wheel deformation
- presence and activation of air-bag
direction of impact
- damage to the car
- patient position in the vehicle
- ejection
29
What is important to know in penetrating trauma?
- body region that was injured
- organs in the path of the penetrating object
- velocity of the missile
30
What should eyes be examined for right away on secondary survey?
- visual acuity
- pupillary size
- hemorrhage
- penetrating injury
- contact lenses
- dislocation of the lens
- ocular entrapment
31
Neck injuries resulting from blunt force trauma
-subcutaneous emphysema
- tracheal deviation
- laryngeal fracture
- carotid bruit - dissection or thrombosis
32
Neck injuries that require urgent surgical exploration
- active arterial bleeding
- expanding hematoma
- arterial bruit
- airway compromise
33
Physical exam findings of cardiac tamponade
- distant heart sounds
- decreased pulse pressure
- distended neck veins
34
Physical exam findings of pelvic fracture
- ecchymosis over iliac wings/pubis/labia/scrotum
- pain on palpation of pelvic ring
35
What types of injuries are at high risk of compartment syndrome?
long-bone fractures
crush injuries
prolonged ischemia
circumferential thermal injuries
36
What is the triad of clinical signs indicating laryngeal trauma?
Hoarseness
Subcutaneous emphysema
Palpable fracture
37
What imaging modality diagnoses laryngeal fracture?
CT
38
At what level of spinal injury is diaphragmatic function impaired?
C3 and above
39
What is the definition of a "definitive airway"?
Tube placed in the trachea with cuff inflated below the vocal cords, tube connected to oxygen-enriched assisted ventilation and airway secured in place with appropriate stabilizing method
40
What are the 3 types of definitive airways?
Orotracheal tube
Nasotracheal tube
Surgical airway
41
What are contraindications to nasotracheal intubation?
Facial, frontal sinus, basilar skull and cribriform plate fractures
42
How low does HGb have to be for pulse oximetry not to work?
< 5g/dL
43
How is cardiac output calculated?
Heart rate x stroke volume = cardiac output
44
How do you calculate blood volume for a child?
70-80mL/kg
45
What are the classes of hemorrhage and the associated approximate blood loss?
Class 1 - < 15%
Class 2 - 15-30%
Class 3 - 31-40%
Class 4 - > 40%
46
At what class of hemorrhage do we start seeing tachycardia?
Class 2
47
At what class of hemorrhage do we start seeing hypotension?
Class 3
48
At what class of hemorrhage do we start seeing decreased pulse pressure?
Class 2
49
At what class of hemorrhage do we start seeing decreased urine output?
Class 3
50
At what class of hemorrhage do we start seeing increased respiratory rate?
class 3
51
At what class of hemorrhage do we start seeing decreased GCS?
Class 3
52
What base deficit is associated with each class of hemorrhage?
1 - 0 to -2
2 - -2 to -6
3 - -6 to -10
4 - -10 or less
53
What are potential consequences of gastric dilation/distension in a trauma patient?
Hypotension
Cardiac dysrhythmia - brady from vagal stim
Aspiration of gastric contents
54
What is the definition of "massive transfusion"?
> 10 units of pRBCs in first 24hrs of admission or > 4 units in 1 hr
55
What are the major physiologic consequences of thoracic trauma?
Hypoxia, hypercarbia, acidosis
56
What is the most common cause of tension pneumothorax in trauma patients?
Mechanical positive-pressure ventilation in patients with visceral pleural injury
57
What are the signs and symptoms of tension pneumothorax?
- Chest pain
* Air hunger
* Tachypnea
* Respiratory distress
* Tachycardia
* Hypotension
* Tracheal deviation away from the side of the injury
* Unilateral absence of breath sounds
* Elevated hemithorax without respiratory movement
* Neck vein distention
* Cyanosis (late manifestation)
58
What are possible causes of PEA?
Cardiac tamponade
Tension pneumothorax
Profound hypovolemia
Blunt rupture of atria or ventricles
5 Hs + Ts
59
What is the classic clinical triad of cardiac tamponade?
Muffled heart sounds
Hypotension
Distended neck veins
60
What is Kussmaul's sign?
Rise in venous pressure with inspiration when breathing spontaneously
61
What are possible causes of traumatic circulatory arrest?
Severe hypoxia
Tension pneumothorax
Profound hypovolemia
Cardiac tamponade
Cardiac herniation
Severe myocardial contusion
62
What is involved in te secondary survey of patients with thoracic trauma?
Physical Exam
Ongoing ECG + Pulse-ox monitoring
ABG
CXR - lung expansion, fluid, widening of mediastinum, shift of midline, loss of anatomic detail, rib fractures
CT - if suspected aortic or spinal injury
63
What potentially life-threatening injuries should be looked for on secondary survey of thoracic trauma?
Simple pneumothorax
Hemothorax
Flail chest
Pulmonary contusion
Blunt cardiac injury
Traumatic aortic disruption
Traumatic diaphragmatic injury
Blunt esophageal rupture
64
What is a flail chest?
Segment of chest wall does not have bony continuity with rest of thoracic cage
2 or more adjacent ribs fractured in 2+ places
65
What is the initial treatment of flail chest and pulmonary contusion?
Humidified O2
ventilation
Cautious fluid resuscitation - avoid volume overload
66
What injuries are associated with blunt cardiac injury?
myocardial muscle contusion
cardiac chamber rupture
coronary artery dissection and/or thrombosis
valvular disruption
67
What are the most common ECG findings of cardiac contusion?
Multiple PVCs, unexplained sinus-tach, afib, RBBB, ST changes
68
What are the signs of CXR of blunt aortic injury?
* Widened mediastinum
* Obliteration of the aortic knob
* Deviation of the trachea to the right
* Depression of the left mainstem bronchus
* Elevation of the right mainstem bronchus
* Obliteration of the space between the pulmonary artery and the aorta (obscuration of the aortopulmonary window)
* Deviation of the esophagus (nasogastric tube) to the right
* Widened paratracheal stripe
* Widened paraspinal interfaces
* Presence of a pleural or apical cap
* Left hemothorax
* Fractures of the first or second rib or scapula
69
Possible complications of esophageal trauma
Tear in lower esophagus
Leakage into mediastinum
Mediastinitis - immediate or delayed rupture into pleural space - empyema
70
What is the typical clinical setting of esophageal injury?
L pneumothorax or hemothorax without rib fracture - pain or shock out of proportion to apparent injury
71
How do you diagnose esophageal rupture?
CXR - mediastinal air
Confirm with contrast study or esophagoscopy
72
Which ribs sustain most effects of blunt trauma?
4-9
73
What landmarks delineate the "flank"
area between the anterior and posterior axillary lines from 5th intercostal space to the iliac crest
74
What structures are contained in the retroperitoneal space?
Abdominal aorta
IVC
Duodenum
Pancreas
Kidneys
Ureters
Posterior aspect of ascending colon and descending colon
75
What abdominal structures are most commonly involved in stab wounds?
Liver, small bowel, diaphragm, colon
76
What abdominal structures are most frequently injured in blunt abdominal trauma?
Spleen, liver, small bowel
77
What abdominal structures are most frequently injured in GSWs?
small bowel, colon, liver, abdominal vascular structures
78
What abdominal structures are most frequently injured in association with lap seat belt?
Compression + Hyperflexion
- tear/avulsion of bowel mesentery (bucket handle)
- Rupture of small bowel or colon
- thrombosis of iliac artery or abdominal aorta
- Chance fracture of lumbar vertebrae
- Pancreatic or duodenal injury
79
What abdominal structures are most frequently injured in association with shoulder harness?
Sliding under the belt, compression
- Rupture of upper abdo viscera
- Intimal tear or thrombosis in innominate, carotid, subclavian or vertebral arteries
- Fracture or dislocation of cervical spine
- Rib fractures
- Pulmonary contusion
80
What abdominal structures are most frequently injured in association with air-bag deployment?
- Face and eye abrasions
- Cardiac Injuries
- Spine fractures
81
What are physical exam findings suggestive of pelvic fracture?
Evidence of ruptured urethra
Discrepancy in limb length
Rotational deformity of a leg without obvious fracture
82
When is a retrograde urethrogram mandatory?
When patient is unable to void, requires a pelvic binder or has evidence of urethral laceration
83
What are the advantages of DPL?
Early operative determination
Performed rapidly
Can detect bowel injury
Can be performed in resusc area
84
What are the disadvantages of DPL?
* Invasive
* Risk of procedure-related
injury
* Requires gastric and urinary
decompression for prevention
of complications
* Not repeatable
* Interferes with interpretation
of subsequent CT or FAST
* Low specificity
* Can miss diaphragm injuries
85
What are advantages of FAST?
* Early operative determination
* Noninvasive
* Performed rapidly
* Repeatable
* No need for transport from
resuscitation area
86
What are disadvantages of FAST?
* Operator-dependent
* Bowel gas and subcu-
taneous air distort images
* Can miss diaphragm, bowel,
and pancreatic injuries
* Does not completely assess
retroperitoneal structures
* Does not visualize
extraluminal air
* Body habitus can limit image
clarity
87
What are indications for laparotomy in patients with penetrating abdominal wounds?
Hemodynamic abnormality
Gunshot wound with transperitoneal trajectory
Signs of peritoneal irritation
Signs of peritoneal penetration
88
What area of the diaphragm is most commonly injured?
postero-lateral L hemidiaphragm
89
What are signs of diaphragmatic injury on CXR?
elevation or blurring of hemidiaphragm
Hemothorax
Abnormal gas shadow that obscures hemidiaphragm
Gastric tube positioned in the chest
90
Where do meningeal arteries lie?
Between the dura and internal surface of the skull in the epidural space
91
What is the most commonly injured meningeal vessel and where is it located?
Middle meningeal artery
Over the temporal fossa
92
Why does a "blown pupil" occur?
Oculomotor nerve (CN 3) runs along edge of tentorium and can become compressed against it during temporal lobe herniation
Parasympathetic fivbers that constrict pupils lie on CN3 - compression = restriction of their effect = blown pupil
93
What is the uncus?
Medial part of the temporal lobe
94
What does uncal herniation cause in the brain that produces the symptoms we see?
compression of the corticospinal (pyramidal) tract in the midbrain
- results in weakness of opposite side of body
95
What are the symptoms of uncal herniation?
Ipsilateral pupillary dilatation associated with contralateral hemiparesis
96
What is normal ICP in resting state?
10mmHg
97
What is the formula for cerebral perfusion pressure?
MAP = ICP
98
What are clinical signs of a basilar skull fracture?
periorbital ecchymosis (raccoon eyes)
retroauricular ecchymosis (Battle’s sign)
CSF leakage from the nose (rhinorrhea) or ear (otorrhea)
dysfunction of cranial nerves VII and VIII (facial paralysis and hearing loss)
99
What GCS is associated with the following severities of TBI?
Mild
Moderate
Severe
Mild: 13-15
Moderate: 9-12
Severe: 3-8
100
How is mortality rate for patients with severe brain injury affected by hypotension on admission?
mortality rate > double those who do not have hypotension
101
What O2 Sat is desirable for brain injury?
> 95%
102
What PCO2 is desirable for brain injury?
35mmHg
103
What is the target BP in TBI?
100mmHg +
104
What is the target temp in TBI?
36-38
105
What is the target Glucose in TBI?
8-18
106
What is the target HGB in TBI?
70+
107
What is the target INR in TBI?
<1.4
108
What is the target PaO2 in TBI?
100+
109
What is the target PaCO2 in TBI?
35-45
110
What is the target PH in TBI?
7.35-7.45
111
What is the target CPP in TBI?
60+
112
What is the target ICP in TBI?
5-15mmHg
113
What is the therapeutic dose of mannitol?
1g/kg given over 5 mins
114
What are the reversal agents for the following?
Antiplatelets (Eg. aspirin, plavix)
Coumadin/Warfarin
Heparin
Direct thrombin inhibitors
Platelets
FFP, Vitk, Factor 7a
Protamine
Idarucizumab (praxbind)
115
Which is preferred to decrease ICP in hypotensive patients - mannitol or 3% NaCl?
3% NaCl
- mannitol is a diuretic and may worsen hypotension
116
What are the 3 main factors linked to high incidence of late epilepsy in TBI?
Seizures within first week
Intracranial Hematoma
Depressed skull fracture
117
What are the criteria for brain death?
GCS 3
nonreactive pupils
absent brainstem reflexes (oculocephalic, corneal, dolls eyes, gag)
no spontaneous ventilatory effort
absence of confounding factors - alcohol, drugs, hypothermia
118
According to the PECARN rule, who should have head CT?
GCS 14, altered mental status, palpable skull fracture, signs of basliar skull fracture
Occipital or parietal or temporal scalp hematoma, LOC > 5sec, severe mechanism of injury, severe headache, vomiting
119
What is a "Severe mechanism of injury" According to the PECARN score?
MVC with patient ejection, death of another passenger or rollover
Pedestrian or cyclist without helmet struck by car
Fall > 0.9m (3ft) or head struck by high-impact object
120
According to the CATCH2 rule, who needs a head CT?
Minor head injury +
GCS < 15 2hrs post injury
Suspected open or depressed skull fracture
Worsening headache
Irritability on exam
Sign of basal skull fracture
Large, boggy hematoma of scalp
Dangerous mechanism of injury
4+ episodes of vomiting
121
Per the CATCH2 rule, what is a dangerous mechanism?
MVC, fall > 3f or 5 stairs, fall from bike with no helmet
122
To whom does the CATCH 2 rule apply?
Minor head injury:
within past 24h
witnessed LOC
amnesia
disorientation
persistent vomiting (>1)
persistent irritability (<2y)
GCS 13-15
123
What are anatomical considerations in trauma in children?
Small body mass with large surface area - increased heat loss + greater external force per body unit area
Proportionally larger and less protected solid organs
Pliable ribcage - more mobile mediastinum - more thoracic injury without obvious external trauma
Larger head-to-body ratio - higher proportion of head injuries + diff cervical spine injury patterns
124
What are physiological considerations in trauma in children?
Higher metabolic - increased O2 + glucose demands + insensible fluid losses
Compensated shock for longer then quick crash
125
What are the standard pediatric trauma films required after blunt trauma?
chest, pelvic and cervical spine radiography (prior to transport)
126
What views are required for screening radiography in children?
< 8y - AP + lateral neck
>8y - add odontoid view
127
What are factors to consider before transport of a trauma patient?
» Life-threatening injuries identified and addressed
» Early communication with receiving center established
» Ongoing analgesia, sedation +/- paralysis plan
» Analgesia addressed, fractures splinted, abx given for open fractures
» If pneumothorax is identified, a chest tube may need to be placed prior to land transport; should definitely be placed for air
transport.
» Communication of key clinical information including patient status, weight (can be estimated with Broselow tape), age,
identified injuries, interventions performed, and estimated time of arrival.
» IV or IO access in place and stabilized
» Airway controlled & equipment well-secured
» Gastric tubes & urinary catheters secured as needed
» Imaging, lab results & paperwork available to crew
128
How should cerebral herniation be managed?
1. Hyperventilation to pupillary response, reversal of Cushing’s Triad, and/or ETCO2 of 30-35.
2. Raise head of bed to 30o and loosen cervical collar or provide manual in-line stabilization.
3. Hyperosmolar agents
4. Airway protection with Drug Assisted Intubation while spinal motion restriction is maintained.
5. Neurosurgical intervention for hematoma evacuation or decompressive craniectomy.
129
What doses of the following medications should be used in pediatric severe head trauma?
Fentanyl (pain)
Fentanyl (induction for intubation)
Midazolam
Atropine
Ketamine
Etomidate
Propofol
Rocuronium
Succinylcholine
3% NaCl
Mannitol
Fentanyl (pain) 1mcg/kg/dose (max 50) IV, 1mcg/kg/hr
Fentanyl (induction) 3mcg/kg/dose (max 200mcg)
Midazolam 0.1mg/kg/dose (max 5mg), 50mcg/kg/hr
Atropine 0.02 mg/kg/dose (max 0.6mg)
Ketamine 2mg/kg/dose (max 100mg)
Etomidate 0.3mg/kg/dose (max 20mg)
Propofol 1-3mg/kg/dose (max 200mg) - repeat PRN
Rocuronium 1mg/kg/dose (max 100mg)
Succinylcholine - infants 2mg/kg/dose, children 1-2 mg/kg/dose, ado 1-1.5mg/kg/dose
3% NaCl 5mL/kg/dose (max 250mL)
Mannitol 1g/kg/dose (max 100g)
Midazolam
130
What part of the spine sustains the the majority of injuries in multiple trauma?
cervical spine
131
How many vertebra are there each in the cervical, thoracic and lumbar spine?
7 cervical
12 thoracic
5 lumbar
132
What are the difference in a child's cervical spine (<8y/o)
more flexible joint capsules + interspinous ligaments
flat facet joints
vertebral bodies that tend to slide forward with flexion
133
What type of thoracic spine fracture is most common?
compression fractures
134
Where is the corticospinal tract, what is its function and how can you test it?
- anterior + lateral segments of the cord
- controls motor power on same side of body
- voluntary muscle contractions or involuntary response to painful stimuli
135
Where is the spinothalamic tract, what is its function and how can you test it?
- anterolateral aspect of the cord
- transmits pan and temperature sensation from OPPOSITE side of the body
- pinprick
136
Where is the dorsal columns, what is its function and how can you test it?
- posteromedial aspect of the cord
- proprioception, vibration, light-touch from same side of body
- position sense in toes/fingers, vibration sense
137
What areas do the following spinal nerve segments innervate?
C5
C6
C7
C8
T4
T8
T10
T12
L4
L5
S1
S3
S4+5
C5 - over the deltoid
C6 - thumb
C7 - middle finger
C8 - Little finger
T4 - nipple
T8 - xiphisternum
T10 - umbilicus
T12 - symphysis pubis
L4 - medial aspect of calf
L5 - space between 1st + 2nd toes
S1 - lateral border of foot
S3 - ischial tuberosity
S4+5 - perianal region
138
What muscle movements are controlled by each of the following:
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
C5 - ELBOW FLEXORS
C6-wrist extensors
C7 - elbow extensors
C8 - finger flexors
T1- finger abductors
L2- hip flexors
L3- knee extensors
L4- ankle dorsiflexors
L5- long toe extensor
S1- ankle plantar flexor
139
What is spinal shock?
flaccidity and loss of reflexes that occur immediately after spinal cord injury. After a period of time there is spasticity
140
What nerve roots control the diaphragm?
C3-C5
141
What is the neurological level of injury?
the most caudal segment of the spinal cord that has normal sensory and motor function (min 3/5) on both sides of the body
142
What are "incomplete" spinal cord injuries?
Any areas with some motor or sensory function below the injury level. does not include reflexes
143
What is "Central cord syndrome"?
Disproportionately greater loss of motor strength in upper vs lower extremities, with varying degrees of sensory loss
- usually occurs after hyperextension injury in a patient with previously existing cervical canal stenosis (eg. forward fall with facial impact)
144
What is "anterior cord syndrome"
Paraplegia and bilateral loss of pain and temperature sensation but proprioception, vibration + deep pressure is preserved (intact dorsal column)
- poorest prognosis, usually following cord ischemia
145
What is "Brown-Séquard Syndrome"?
- results from hemisection of cord (penetrating trauma)
- ipsilateral motor loss (Corticospinal tract) and loss of proprioception (dorsal column) with contralateral loss of pain + temperature sensation 1-2 levels below area of injury
146
What is the most common type of C1 fracture?
Jefferson fracture - burst fracture
- axial loading
- disruption of anterior and posterior rings of C1 with lateral displacement of the lateral masses
- best seen on open-mouth view of C1-C2 region
147
What is a cervical spine injury much more commonly found in peds?
C1 Rotary sublixation
- can occur spontaneously, after major or minor trauma. URTI or RA
- presents with torticollis
- on xray odontoid not equidistant from 2 lateral masses of C1
148
What type of cervical spine fracture is usually caused by an extension injury?
hangman's fracture/posterior element fracture (C2)
149
What is a chance fracture?
transverse fracture through the vertebral body (thoracic spine) caused by flexion about an axis anterior to the vertebral column
- most common in MVC with patient improperly restrained with lap belt
- associated with retroperitoneal and abdominal visceral injuries
150
What mechanism of injury makes you at higher risk of fracture at the thoracolumbar junction?
fall from height
restrained ddriver with severe flexion with highe-kinetic energy transfer
151
Injury at what level can injure the conus medullaris and result in bladder and bowel dysfunction
L1
152
To whom do the canadian c-spine rules apply?
Alert (GCS 15) stable trauma patients
153
What is considered a "dangerous mechanism" in the canadian c-spine rules?
Fall from > 1m or 5 stairs
axial load to head
MVC > 100km/hr, rollover or ejection
Motorized recreational vehicle collision
Bike collision
154
Where is the fulcrum of the cervical spine of an infant?
C2-C3
155
Where is the fulcrum of the cervical spine at 5-6 yrs?
C3-C4
156
Where is the fulcrum of the cervical spine at age 8+
C5-C6
157
Why are there more injuries involving the cervical spine in children than in adults?
relatively larger head
weaker neck muscles
poor protective reflexes
158
What are low-risk factors that allow safe ROM assessment of the cervical spine?
- simple rear-end MVC
- sitting in ED
- Ambulatory at any time
- delayed onset of neck pain
- no midline cervical tenderness
159
What are high-risk factors mandating imaging in canadian c-spine rules?
> 65y/o
dangerous mechanism
paresthesias in extremities?
160
What are the low-risk criteria for NEXUS criteria?
- no posterior midline cervical-spine tenderness
- no evidence of intoxication
- normal LOC
- no focal neuro deficit
- no painful distracting injuries
NEXUS Mnemonic
N– Neuro deficit
E– EtOH (alcohol)/intoxication
X– eXtreme distracting injury(ies)
U– Unable to provide history (altered level of consciousness)
S– Spinal tenderness (midline)
161
Temps of mild moderate and severe hypothermia
Mild - 32-35
Moderate 30-32
Severe - below 30
162
Indications for immediate laparoscopy or laparotomy for abdo trauma
Multisystem injuries with indications for craniotomy in the presence of free peritoneal fluid on ultrasonography, or strong historical, physical, or radiographic evidence of abdominal injury
Persistent and significant hemodynamic instability with evidence of abdominal injury in the absence of extra-abdominal injury
Penetrating wounds to the abdomen
Pneumoperitoneum
Significant abdominal distention associated with hypotension
163
What abdominal injuries are most likely to be missed even on CT?
small gastrointestinal perforation
pancreatic injury
164
Indications for administration of RBC in trauma
Class 3 + 4 hemorrhage
hypotension refractory to 40ml/kg crystalloids
ongoing active bleeding
165
When should a tourniquet be used?
Only when direct pressure is not effective and the patient’s life is threatened
166
Signs of carotid injury
Bleeding - internal or external
Expansile or pulsatile hematoma
Bruit
Absent pulsations
Unexplained hypotension
Hemiplegia
Hemiparesis
Aphasia
Monocular blindness
Loss of consciousness
Neck asymmetry/swelling/discoloration
Cranial nerve abnormality
167
Most commonly injured intra-abdominal organs?
1. spleen
2. liver
168
What is the Kehr sign?
Subphrenic blood causing referred L shoulder pain
169
Most common fatal abdominal injury
blunt liver trauma
170
Injuries most likely to be missed in blunt abdominal trauma
Pancreatic injury/pancreatic pseudocyst (late presentation)
Hollow visceral injury
duodenal hematoma (late presentation)
hematobilia (late presentation)
171
What is the classic triad of findings in pancreatic injury (abdo trauma)
epigastric pain
palpable abdominal mass
hyperamylasemia
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Most common mechanisms of injury (blunt abdo trauma) that cause intestinal perforation
Automobile-pedestrian
Automobile lap belt injuries
child abuse
173
How does intestinal perforation occur in blunt abdominal trauma?
rapid acceleration or deceleration of a structure near a point of anatomic fixation trapping a piece of bowel
174
Sign on imaging indicating duodenal hematoma (intramural)
"coiled-spring sign" or soft tissue mass in bowel wall
175
What are the types of blunt cardiac injuries?
Myocardial contusion
atrial rupture
ventricular rupture
valvular disruption
176
What is the Beck Triad?
jugular venous distension
low BP
muffled heart tones
(signs of pericardial tamponade)
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