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ITE '23 > Ch. 3 Trauma > Flashcards

Ch. 3 Trauma Flashcards

1
Q

What is the correct ratio for MTP?

A

1:1:1 pRBCs to platelets to FFP

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2
Q

Giving TXA within __ hours of injury has been proven to reduce mortality

A

3

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3
Q

What are the 5 signs of life for resuscitative purposes?

A
  1. palpable pulse
  2. spontaneous movement
  3. spontaneous resuscitative efforts
  4. cardiac activity on ECG
  5. pupillary light response
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4
Q

What is the survival rate for ED thoracotomy following blunt trauma with cardiac arrest?

A

<2%

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5
Q

What are the 3 indications for ED thoracotomy in blunt trauma?

A
  1. prehospital/hospital signs of life with loss for LESS than 10 minutes
  2. Unresponsive hypotension (BP <70 mmHg) despite resuscitation with echo evidence of cardiac tamponade
  3. Rapid exsanguination from a chest tube (>1500 cc output upon insertion)
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6
Q

What are 3 contraindications to ED thoracotomy for blunt trauma?

A
  1. prehospital CPR >10 minutes without response
  2. asystole as presenting rhythm and no echo evidence for cardiac tamponade
  3. significant head trauma
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7
Q

What are 3 indications for ED thoracotomy in PENETRATING trauma?

A
  1. prehospital/hospital signs of life
  2. echo evidence of cardiac activity with cardiac tamponade
  3. unresponsive hypotension (BP<70mmHg) despite resuscitation with penetrating chest wound
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8
Q

What are 3 contraindications for ED thoracotomy for penetrating trauma?

A
  1. Prehospital CPR >15 minutes without response
  2. Asystole as presenting rhythm and no echo evidence for cardiac tamponade
  3. Significant head trauma
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9
Q

What is ideal Cerebral Perfusion Pressure (CPP)?

A

> 60mmHg

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10
Q

What is ideal MAP in head injuries?

A

> 80mmHg

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11
Q

What is ideal ICP in head injuries?

A

<15 mmHg

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12
Q

What are the 2 brainstem tests?

A
  1. Oculocephalic response
  2. Oculovestibular response
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13
Q

What is oculocephalic response?

A

Conjugate deviation of eyes in direction opposite to passive head rotation (once C-spine cleared) - indicates intact brainstem function in a comatose patient

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14
Q

What is oculovestibular response?

A

Instillation of 30-mL cold saline into the ear;
horizontal nystagmus with FAST component AWAY from tested ear indicates intact brainstem function.

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15
Q

What is uncal herniation syndrome?

A

Compression of ipsilateral CN III →
IPSILATERAL pupillary dilation and decreased reactivity
“Down and out” position of eye with only lateral rectus (CN VI) and superior oblique (CN IV) functioning
Eventual compression of ipsilateral peduncle → contralateral hemiparesis

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16
Q

What is mannitol dosing for decreasing ICP in adults?

A

0.25-1g/kg IV Mannitol bolus

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17
Q

How is ICP decreased in pediatric patients?

A

Hypertonic saline 3% 0.1-1mL/kg/h (infants and children) - produces osmotic diuresis

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18
Q

What is dispo for anticoagulated patient with head injury and negative head CT?

A

Admit for obs given increased risk for delayed bleed

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19
Q

What types of fractures are NG tubes contraidicated?

A

Cribriform plate fractures

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20
Q

What are the 3 main concerns for blunt neck trauma?

A

intimal tear
pseudoaneurysm
carotid or vertebral artery dissection

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21
Q

Zones of the neck: What are the landmarks for Zone I?

A

Clavicles to cricoid cartilage

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22
Q

Zones of the neck: What structures are involved in Zone I?

A

trachea, esophagus, vertebral and carotid arteries
Great vessels, lung apices, thoracic duct, spinal cord

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23
Q

Zones of the neck: What are the landmarks for Zone II?

A

Cricoid cartilage to angle of mandible

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24
Q

Zones of the neck: What structures are involved in Zone II?

A

trachea, esophagus, vertebral and carotid arteries
larynx, jugular veins

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25
Q

Zones of the neck: What are the landmarks for Zone III?

A

Angle of mandible to base of skull

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26
Q

Zones of the neck: What structures are involved in Zone III?

A

pharynx, jugular veins, vertebral, and internal carotid arteries, skull base

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27
Q

Neck wounds with violation of the ____ indicates possibility of significant neck injury and requires surgical consultation.

A

platysma

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28
Q

What is NEXUS Cspine criteria?

A

According to NEXUS, cervical spine imaging is NOT required if patient meets all the following
low risk criteria:
No posterior midline cervical spine tenderness
No focal neurologic deficits
No evidence of intoxication
Normal level of alertness
No painful distracting injuries

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29
Q

What is the Canadian Cspine Rule?

A

A “Yes” Answer to all Three Question/Assessment
Criteria Means Cervical Spine Imaging is Unnecessary:
There are no high-risk factors that
mandate radiography. (>65yo, dangerous mechanism, paresthesias)
There are low-risk factors that allow a
safe assessment of range of motion.
The patient is able to actively rotate
his/her neck.

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30
Q

What are the 6 unstable fractures of the Cspine?

A
  1. Jefferson fracture (C1 burst
    fracture)
  2. Bilateral facet dislocation
  3. Odontoid type II/III
  4. Atlantoaxial or atlantooccipital
  5. Hangman’s fracture (bilateral C2 pedicle
    fracture)
  6. Teardrop fracture (The teardrop is the
    anteroinferior portion of the
    vertebral body)
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31
Q

What are the 5 Major/Unstable Thoracolumbar Spine Fractures?

A
  1. Wedge compression fx
  2. Chance fracture
  3. Burst fx
  4. Flexion Distraction Injury
  5. Translational fx
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32
Q

What is a chance fx?

A

Horizontal fracture through the vertebral body and all
posterior elements

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33
Q

What is Brown-Séquard Syndrome?

A

Hemisection of the cord, usually associated with penetrating trauma (best prognosis)

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34
Q

What are the signs/sx of Brown-Sequard Syndrome?

A

Ipsilateral loss of motor, proprioception, and vibratory sensation with
contralateral loss of pain and temperature sensation.

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35
Q

What is central cord syndrome?

A

It is caused by a hyperextension
injury on a congenitally narrow canal or preexisting cervical spondylosis (older patients), resulting in buckling of the ligamentum flavum and compression
of the central cord.

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36
Q

what are the signs/sx of central cord syndrome?

A

Numbness and/or weakness greater in the arms than the legs (patients may have complete quadriplegia); bowel and bladder control remain in all but the most severe cases

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37
Q

What is anterior cord syndrome?

A

Caused by flexion or extension with vascular or bony fragment injury of the anterior spinal artery.

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38
Q

What are the signs and symptoms of anterior cord syndrome?

A

Paralysis and loss of pain and temperature sensation but preserved position, crude touch, and vibration sensation

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39
Q

What is spinal shock?

A

a transient depression of all spinal cord function below
the level of a partial or complete injury. Reflex function below the level of injury spontaneously returns (typically within 24-48 hours), at which time the degree of cord injury can be fully determined.

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40
Q

What are the signs/symptoms of spinal shock?

A

Flaccid paralysis, including bowel and bladder, priapism.
■ Bulbocavernosus reflex (anal sphincter contraction in response to squeezing penile glans or pulling on the Foley) returns first. Presence of this reflex early after injury is associated with better long-term outcomes.

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41
Q

What is neurogenic shock?

A

A distributive shock state that results from the loss of sympathetic outflow in a cervical or thoracic spinal cord injury, leading to loss of peripheral vascular resistance and unopposed vagal tone.

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42
Q

What are signs and sx of neurogenic shock?

A

Patients are peripherally vasodilated, warm, hypotensive with relative bradycardia.

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43
Q

A small traumatic pneumothorax < ___-___% in a stable patient may be treated with 100% O2 via non-rebreather (NRB) mask and repeat CXR.

A

15-25%

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44
Q

What is the treatment for a sucking chest wound?

A

Place a three-sided dressing to allow air to exit and not enter the pleural space while preparing for placement of a chest tube. A dressing that completely occludes the wound may cause a tension pneumothorax (PTX).

■ Do not insert a chest tube through the wound

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45
Q

What is the next step in working up pneumomediastinum found on CXR?

A

Further testing to exclude esophageal injury (such as an x-ray with oral contrast) may be necessary in patients with a history of penetrating trauma, vomiting, or other mechanism that might implicate the esophagus.

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46
Q

Hemothorax: Upright CXR will show blunting of the costophrenic angle when >____ mL
blood is present.

A

250

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47
Q

What is the definition of massive hemothorax?

A

> 1500cc immediate output or >200mL/h; If this is the case –> OR for thoracotomy

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48
Q

Patients with __ or more rib fractures should be admitted

A

3

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49
Q

What percentage of rib fractures are not evident on CXR?

A

50%

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50
Q

What is the definition of flail chest?

A

the presence of fractures in more than 1 location on
each of 3 or more adjacent ribs causing a free floating segment of ribs and an unstable chest

51
Q

What is Beck’s triad for cardiac tamponade?

A

Hypotension, JVD, muffled heart sounds

52
Q

What is the treatment for pericardial tamponade?

A

not in extremis –> US-guided paracentesis; IV fluids help maximize cardiac output

Hypotensive (BP <70mmHg) –> ED thoracotomy

53
Q

Where do most traumatic aortic injuries take place?

A

at the Aortic Isthmus, distal to the left subclavian artery

54
Q

What can be symptoms of descending aortic injury?

A

paraplegia (vertebral artery deficits), mesenteric and LE ischemia, and anuria

55
Q

What findings are consistent with aortic injury on supine AP films?

A

widened mediastinum >8 cm on supine AP film
and
loss of distinct aortic knob

56
Q

What is the initial treatment for aortic injury?

A

beta blockade to control BP < 120 mmHg and replace fluids carefully
Instruct patient not to Valsalva

57
Q

What do you do if there is an impaled foreign body?

A

Keep in place –> goes to OR! surgical managemnt

58
Q

Which side of the diaphragm is more commonly injured?

A

Left diaphragm is injured 3x as much as right diaphragm

59
Q

What are signs and symptoms of diaphragmatic injury?

A

abdominal pain radiating to the ipsilateral shoulder (kehr sign) - worse when supine
Absent breath sounds or positive bowel sounds in the chest

60
Q

What is the gold standard for diagnosing diaphragm injury

A

Laparoscopy or thoracoscopy

61
Q

What is the first step in management of diaphragmatic injury?

A

Emergent NG decompression

62
Q

What is the definitive treatment for diaphragmatic injury?

A

surgical repair

63
Q

What is the definitive treatment for diaphragmatic injury?

A

surgical repair

64
Q

What is the definitive treatment for diaphragmatic injury?

A

surgical repair

64
Q

What is the definitive treatment for diaphragmatic injury?

A

surgical repair

65
Q

Which three abdominal injuries in blunt trauma are difficult to diagnose with CT imaging?

A

diaphragm
pancreas
bowel

66
Q

What is the most commonly injured organ in blunt abdominal traum?

A

Spleen

67
Q

What is the utility of lipase and amylase levels in blunt abdominal traumas?

A

Neither sensitive nor specific; can be used in conjunction with other imaging and can be trended

68
Q

Surgery is often required for splenic injuries grade ___ or higher.

A

III

69
Q

What percentage of anterior abdominal stab wounds penetrate the peritoneum?
What percentage of those cause organ damage?

A

70%; 50%

70
Q

What are the most commonly injured organs in stabbings? GSWs?

A

Stabbings: 1. liver 2. Small bowel
GSW: 1. Small bowel 2. Colon 3. Liver

71
Q

When is DPL indicated?

A

In blunt abdominal trauma where CT or FAST is not obtainable or is equivocal; OR when there is high suspicion for hollow viscous injury with negative or equivocal CT imaging

72
Q

What represents positive DPL in blunt trauma?

A
  1. aspiration of 10 mL of free flowing blood
  2. RBCs >100,000 (10,000 for GSWs or penetrating)
  3. Presence of GI contents
  4. WBCs >500,000
  5. Amylase >20 IU/L
  6. Alk phosphatase >/= 3 IU/L
73
Q

How does baseline heart rate change in pregnancy?

A

increases by 10-15 BPM

74
Q

How dose baseline BP change in pregnancy?

A

Decreases in first and second trimester

75
Q

What is normal fetal HR?

A

120-160 BPM; abnormal rate suggests fetal distress

76
Q

Continuous fetal monitoring should be initiated in patients beyond ___ weeks of gestation, even in minor trauma.

A

24 wks

77
Q

How do you determine how much RhoGAM to give in women with fetomaternal hemorrhage that are >20 weeks?

A

Kleihauer-Betke test

78
Q

In maternal cardiac arrest with EGA >24 weeks, when should you perform a perimortem C-section?

A

If no ROSC by 4 minutes of resuscitative efforts

79
Q

What is Destot sign and what does it indicate?

A

Hematoma above inguinal ligament or over scrotum; may indicate pelvic ring fracture

80
Q

What is the proper way to evaluate the pelvis in traumas?

A

compress pelvis medially at iliac crests and anteroposteriorly at pubic symphysis

81
Q

What is the next step in a patient with blood at the urethral meatus?

A

Urethrogram prior to Foley placement

82
Q

What type of hip dislocation is most common?

A

Posterior dislocations (80-90%)

83
Q

How do posterior hip dislocations present?

A

extremity is shortened, internally rotated, and adducted

84
Q

What complication can occur if hip dislocation is prolonged?

A

avascular necrosis

85
Q

What might a high-riding prostate on rectal examination indicate?

A

Posterior urethral injury

86
Q

What volume of contrast is recommended to be instilled into bladder for retrograde cystogram?

A

400 mL (or 5mL/kg in children)

87
Q

What is the treatment of intraperitoneal bladder rupture? Tx of extraperitoneal bladder injury?

A

intraperitoneal rupture –> surgery
extraperitoneal –> foley catheter decompression for 10-14 days

88
Q

What is the treatment for bladder contusions?

A

no intervention necessary

89
Q

What is the diagnostic test of choice for ureteral injury?

A

CT with IV contrast or IV pyelogram

90
Q

What is the treatment for ureteral injury?

A

surgical repair or interventional radiology (IR) stenting

91
Q

Which traumatic kidney injuries require intervention?

A

Grade III - lacerations >1 cm depth into renal cortex
Grades IV and V - those with vascular injury

92
Q

Compartment syndrome is most commonly associated with what type of fractures?

A

midshaft fractures of the tibia

93
Q

What is normal compartment pressure?

A

0-10 mmHg

94
Q

What structures are first affected by compartment syndrome?

A

Nerves (>20mmHg) - leads to loss of two point discrimination

95
Q

At what compartment pressure should fasciotomy be considered?

A

> 30 mmHg

96
Q

After what type of injury should you avoid fasciotomy?

A

after snake bites! will lead to worse outcomes

97
Q

What are the 5 HARD signs of arterial injury?

A
  1. Pulsatile bleeding
  2. Audible bruit/palpable thrill
  3. Rapidly expanding hematoma
  4. Obvious arterial occlusion
  5. Decreased temperature
98
Q

What is a duplex scan?

A

real time B mode ultrasound with doppler

99
Q

What should you be concerned for with knee dislocations?

A

popliteal injury; monitor post-reduction ABIs

100
Q

Do not leave tourniquets on for great than ____ minutes

A

120 minutes

101
Q

Major arterial injuries must be repaired within ____ hours.

A

6

102
Q

A penis may be replanted up to ___ hours after amputation

A

12 hours

103
Q

What is the rule of 9s for estimating TBSA?

A

9% for each upper extremity
18% for each lower extremity
18% each for front and back of torso
9% for head
1% for perineum
1% for palm and fingers

104
Q

What defines a superficial burn?

A

involves epidermal layer only

105
Q

What defines a partial thickness burn?

A

Epidermis and superficial dermis

106
Q

What defines a full-thickness burn?

A

epidermis and dermis (all structures)

107
Q

What defines a subdermal burn?

A

Subdermal structures (muscles, nerves, bones)

108
Q

Describe the appearance of a superficial burn

A

Similar to sunburn: red, painful, tender,
no blistering

109
Q

Describe the appearance of a superficial partial thickness burn

A

Red, painful, blistering, blanching

110
Q

Describe the appearance of a deep partial thickness burn

A

Red to pale white-yellow, blistering
with rupture, no blanching
Decreased two-point discrimination
but can feel pressure

111
Q

Describe the appearance of a full thickness burn

A

Charred, white/black, painless, and
leathery

112
Q

What is the Parkland formula for fluid resuscitation in patients with significant burn?

A

4 mL × %burn × weight (kg) = fluid requirement (mL) over first 24 hours

Give half of fluid over first eight hours. The Parkland formula is merely
a guide, and adequate fluid must be given to maintain urine output of
0.5-1 mL/kg/h.

113
Q

How is Parkland formula adjusted for children?

A

Multiply by 3 mL instead of 4 mL in children and add maintenance fluids.

3 mL × %burn × weight (kg) = fluid requirement (mL) over first 24 hours

114
Q

How do you determine % burn for parkland formula?

A

Use only area of partial- and full-thickness burns to determine % burn
for resuscitation. aka blistering or worse

115
Q

How is TBSA calculated in children?

A

Lund Browder chart (rather than rule of 9s)

116
Q

What type of chemical burns cause coagulative necrosis?

A

Acids – creating a tough eschar preventing deep penetration of burn.

117
Q

What type of chemical burns cause liquefactive necrosis?

A

alkalis – burns travel deep & are worse that acid burns

118
Q

How can cement cause chemical burn?

A

Cement contains lime, which is converted with water to the alkali calcium
hydroxide.

119
Q

When irrigating chemical burns, for which substances should you use oil instead of water?

A

Sodium metals

120
Q

How do you treat patients affected by lacrimators (tear gas, pepper spray)?

A

copious water irrigation

121
Q

How can airbag deployment cause injury?

A

Airbag deployment utilizes an exothermic reaction that can cause burns
(sodium azide) and keratitis (sodium hydroxide). These are treated with
copious water irrigation.

122
Q

When must bullets be removed from the body?

A
  • spinal canal
  • synovial fluid (intraarticular, disk space, and bursa) - can lead to lead poisoning

ITE '23 (20 decks)

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