Ch 3, 4 Resus & Trauma Flashcards
Bleeding reversal (ex ICH) 1. Warfarin 2. LMWH 3. UFH 4. Dabigatran 5. Xa inhibitors (apixaban, rivaroxaban, edoxaban) 6. Thrombolytics
- Warfarin = IV 4 factor PCC 1500 units (Octaplex) and Vit K IV over 10 mins. Repeat INR in 15 mins and 5-6 hours. Target INR 1.5
- LMWH = Protamine.
- UFH = Protamine
4. Dabigatran = Idarucizumab (or 4 factor PCC/Octaplex) - Xa inhibitors (apixaban, rivaroxaban, edoxaban) = 4 factor PCC (or andexanet alfa)
- Thrombolytics = cryoprecipitate
Upper extremity peripheral nerve testing (3)
- Radial nerve – thumb’s up, sensory first dorsal webspace
2. Median nerve – power to the people (make a fist), pincer grip, sensory dorsum 2nd finger - Ulnar nerve – peace sign, sensory fifth fingertip
Toxic dose of lidocaine and bupivacaine? (3)
- 7mg/kg lidocaine with epi
- 5mg/kg lidocaine
- 3mg/kg bupivacaine
* Lidocaine 1% is 10mg/mL, so in a 70kg person, you can use 20mL 1% lido
Back pain red flags (8)
- Cauda equine – bowel bladder, saddle anaesthesia
- Cancer
- Focal neurological sign
4. Elderly - Fever
6. IVDU - Immunocompromised
- Vital sign abnormalities (hypotension)
- Do they have a AAA
Indications for lumbosacral Xrays (3)
- Age >50
- Duration >6 weeks
- Any back pain red flag
Cauda equina symptoms (6)
- Dysfunction of bladder, bowel, sexual
- Sensory changes in saddle or perianal area
1 and 2 are very sensitive.
** PVR <200mL 96% NPV
3. Back pain - Sensory changes
- Lower limb weakness
- Loss of lower limb reflexes
When are compression fractures unstable (4)
- Compression # >50%
- Kyphosis of fracture >30 degrees
- Rotational component
- Compression # at more than 1 level
* Then get a CT
Describe the START technique for multi-casualty triage (5)
- ** R-P-M, airway+bleeding, colors
1. Respirations: Is the patient breathing? If yes, >30/min?
2. Perfusion: Is there a palpable radial pulse? If no radial, is CR >2sec?
3. Mental status:Able to follow simple commands?
4. Only 2 interventions are provided:open an obstructed airway anddirect pressure on a bleed
5. Green – walking wounded
6. Black – deceased (RPM)
7. Red – Resp >30, perfusion >2sec, mental status change
8. Yellow – all others
How do you stratify a patient into a “low-risk” GI bleed? (1)
- Glasgow-Blatchford bleeding scale. A score of 0 is very low risk. Follow-up with family doctor. No need to consult GI. Any high risk features (low HGB, high BUN, melena, syncope, female, tachycardia, cardiac disease is HIGH risk – call GI).
Treatment of anaphylaxis (5)
- Epinephrine 0.3mg IM (0.3mL of 1:1,000)
- +/- Fluids if hypotensiove
- +/- Hydrocortisone 125mg IV or Dexamethasone 10mg PO
- +/- Reactine (Ceterizine) 10mg PO *Non-sedating (Benadryl is sedating)
- +/- Ranitidine 50mg IV or PO
Hard signs of penetrating neck trauma (6)
Soft signs of penetrating neck trauma (6)
Hard signs
- Airway compromise
- Air bubbling wound
- Expanding or pulsatile hematoma
- Active bleeding
- Shock/hypotension
- Hematemesis
- Neurological injury (neuro deficit/paralysis/cerebral ischemia)
* HARD BRUIT = Hypotension, arterial bleeding/hematoma, Rapid expanding hematoma, Deficits (pulse or neuro), Bruit
Soft signs
- Venous oozing
- Minor hematemesis
- SubQ emphysema
- Dysphagia
- Dyspnea
- Non-pulsatile, non-expanding hematoma
- Chest tube air leak
- Parastesia
* Hard signs of penetrating neck get airway control and OR. Soft signs CT and surgical consult
Zones of penetrating neck injury (3)
- Anything penetrating the platysma muscle is a “penetrating neck injury”
- *Think of neck zones like an elevator. 1st 2nd 3rd floor.
1. Zone 1 – below cricoid cartilage
2. Zone 2 – cricoid cartilage to angle of the mandible
3. Zone 3 – Angle of the mandible up
Which pressure is indicative of compartment syndrome? (1)
- Compartment pressure > 30 or a change from dBP (diastolic BP – compartment pressure <30)
Indications for peri-mortum Ceasarian section (2)
- Witnessed arrest
- CSx can be performied within 5minutes
- Fetus >24weeks (4cm above umbilicus)
Beck’s triad for cardiac tamponade (3)
- Muffled heart sounds
- JVD
- Hypotension
Cushing’s reflex (3)
- HTN
- Bradycardia
- Irregular breathing
(BP, Bradycardia, Breathing)
Classes of hemorrhagic shock (4)
- I - normal
- II - narrow pulse pressure, tachy
- III - hypotensive, alert/anxious
- IV - ++ hypotensive, altered mental status
Neurogenic vs spinal shock (2)
- Neurogenic shock – life threatening. Bradycardia, hypotension, peripheral dilatation due to SCI (loss of sympathetic vascular tone)
- Spinal shock – spinal cord concussion. Flaccid areflexia after a spinal cord injury, lasting days to weeks.
Nexus criteria (5)
C-PAIN
- Cervical midline pain
- Pain, distracting
- Altered LOC
- Intoxication
- Neuro deficit
Unstable C-spine fractures (6)
Jefferson Bit Off A Hangman’s Tit
- Jefferson’s fracture – burst of C1 (axial load – diving injury)
- Bilateral facet dislocation
- Odontoid fracture
- Atlanto-occipital dislocation
- Hangman’s fracture
- Teardrop fracture
Hemothorax: indications for thoracic surgery management (4)
- Persistently unstable vital signs
- Initial 1.5L of chest-tube blood
- > 200mL/hour chest-tube blood
- Chest-tube persistent air leak
Indications for ED thoracotomy (3)
- Penetrating chest trauma
- Witnessed loss of vital signs (in field with immediate CPR, or in ED)
- At a centre that has definitive management capabilities
- Other injuries are survivable
* Incision is 5th intercostal space, lateral to midline, spread the ribs, push the lung aside, incise the pericardium vertically and parallel and anterior to the phrenic nerve.
Aortic dissection CXR findings (6)
- Wide mediastinum (most Sens)
- Obscured aortic knob (most Sens)
- Trachea or NG tube deviated right
- Right mainstem pushed down
- Pleural effusion
- Apical cap
- Double calcium sign
Injuries associated with first/second rib fractures (5)
- Bad fractures. Implies a severe mechanism
1. Vascular injury
2. Pulmonary contusion – can be delayed. Repeat CXR 6hours.
3. Cardiac contusion
4. Traumatic aortic dissection
5. Pneumothorax
Difference between epidural, subdural, traumatic SAH (3)
- Epidural is above the dura and beneath bone. From middle meningeal artery
- Epidural classically has LOC, then a lucid period, then decreasing LOC. Associated with temporal bone #, a dilated ipsilateral pupul, and a better prognosis. - Subdural is below dura near the brains inner membrane. From bridging veins
- Subdural is often altered, in the alcoholics and elderly. Higher mortality and worse prognosis. - Sub-arachnoid is within the brain parenchyma. Often from brain arterial vessels
Three brain herniation syndromes (1)
- Subfalcine herniation (most common - gives you abnormal gait)
- Uncal herniation
- Tonsillar herniation – coma and death very quickly
Signs of uncal herniation (3)
Ipsilateral temporal brain pushes down onto the uncus, compresses CN III
- Dilated pupil ipsilateral
- Contralateral hemiparesis
- Altered LOC, Cushing triad, coma, death
Total CNIII palsy gives you (1)
- Cranial nerve is down and out
Le Fort facial fracture classification (3)
- Palate (upper teeth) are mobile - # below nasal bone
- Nose is mobile - # above nasal bone through inferior orbits
- Face is mobile - # through zygomatic arch
Treatment of mandibular fractures (1)
- Almost all of these are open except condyle fractures (most common). Rx penicillin and surgery.
Most common orbital fracture (1)
- Orbital floor blow-out #. Can you give entrapment (can’t look up – diplopia) with infraorbital paresthesia.
Blunt neck trauma + neuro deficits = _________ (1)
- Carotid artery dissection
* Neuro deficits may be delayed
Compartment syndrome symptoms (6)
- PAIN OUT OF PROPORTION
- Parastesia
- Pallor
- Paralysis
- Pulseless
- Pokilothermia (cold)
Trauma in pregnancy: what is the diagnosis we need to exclude and the workup (2)
- Trauma in pregnancy = placental abruption (MVC, uterine contractions, pain, vaginal bleeding)
- Type + screen, LLDecub, US, consult, and FHR monitoring (Normal FHR=120-160)
Formula for anion gap (1)
- Na + K – (Cl + HCO3)
Treatment of aortic dissection (3)
- Treat pain! Fentanyl
- HR to 60, sBP <110
- Labetalol or esmolol
- Nicardipine/nitroglycerin
Abdominal seatbelt sign injuries (5)
- Hollow viscus injury (small bowel injury)
- Chance fracture
- Mesenteric bucket handle injury
- Aortic injury
- Liver, renal, spleen, pancreas injuries as well
Anaphylaxis mechanism, examples, treatment (3)
Anaphylactoid mechanism, examples, treatment (3)
Angioedema mechanism, examples, treatment (3)
Anaphylaxis: IgE mediated hypersensitivity reaction from previous exposure. Ex nuts, shellfish, bees, medications. Rx Epi
Anaphylactoid: Non-IgE mediated hypersensitivity. Does not require prev exposure. Ex ASA, NSAIDs, radiocontrast dye, quinolones, vancomycin. Rx Epi
Angioedema: increased vascular permeability from bradykinin excess. Ex ACEi, Hereditary angioedema (C1 esterase). Rx FFP, C1 esterase, bradykinin antagonist (Icatibant)
What is the dermatome for C4-5-6-7-8? (1)
- C4=deltoid, C5=forearm, C6=Six shooter (thumb+pointer), C7=middle finger, C8=small finger
Where is the posterior column, anterior horn, corticospinal tract, spinothalamic tract, and spinocerebellar tract located? (5) What do lesions to these areas produce? (5)
- Posterior column - vibration, pressure, light touch, proprioception. The GPS is in the back.
- Anterior horn - low motor neurons (flaccid paralysis). The motor is anterior.
- Corticospinal tract - upper motor neurons (spastic paralysis). Anterolateral.
- Spinothalamic tract - pinprick, pain, temperature. Anterolateral.
- Spinocerebellar - unconscious proprioception. Anterolateral.
Define (3)
- Anterior cord syndrome
- Central cord syndrome
- Brown-Seqard syndrome
- Anterior cord syndrome - from disk herniation, bony fragment protrusion, hyper flexion injury, anterior spinal artery. Causes distal motor paralysis, loss of pinprick, pain temp, proprioception. Vibration, pressure, light touch are all preserved.
- Central cord syndrome - from hyper-extension. MUDE. Motor>Sensory. Upper>Lower. Distal>Proximal. Extension mechanism.Think little old lady in a shawl.
- Brown-Seqard syndrome - from spinal cord hemisection (ex stabbed on left side). Causes complete ipsilateral motor paralysis, loss of vibration, pressure, proprioception. Contralateral loss of pain and pinprick.You lose motor on the same side, and you can’t feel the stab wound on the other side.
NEXUS criteria for C-spine fractures (5)
- No midline pain
- No neurological deficit
- Normal alertness
- Not intoxicated
- No distracting injuries
What is massive transfusion? (2)
When to activate massive transfusion protocol? (1)
- Massive transfusion: replacement of >1 blood volume in 24 hours
- > 50% blood volume in 4 hours (adult volume 70mL/kg)
- Activate massive transfusion protocol when a bleeding patient is predicted to need a massive transfusion (often when reaching for the 2nd or 3rd blood unit)
Parameters to measure in a massive transfusion? (3)
- Temp >35
- iCa2+ >1.1 - Rx Ca2+ glucanate
- HGB (no threshold - use hemodynamics/perfusion to trigger transfusion)
- Platelets >50, >100 if intracranial bleed - Rx Plt
- PT/PTT <1.5X normal - Rx FFP
- Fibrinogen >1g/L - Rx cryo
What is massive transfusion protocol?
- 1:1:1 pRBC:Plt:FFP
* Add Cryo if fibrinogen low (<1g/L)
