Ch. 3 Trauma Flashcards
What is the correct ratio for MTP?
1:1:1 pRBCs to platelets to FFP
Giving TXA within __ hours of injury has been proven to reduce mortality
3
What are the 5 signs of life for resuscitative purposes?
- palpable pulse
- spontaneous movement
- spontaneous resuscitative efforts
- cardiac activity on ECG
- pupillary light response
What is the survival rate for ED thoracotomy following blunt trauma with cardiac arrest?
<2%
What are the 3 indications for ED thoracotomy in blunt trauma?
- prehospital/hospital signs of life with loss for LESS than 10 minutes
- Unresponsive hypotension (BP <70 mmHg) despite resuscitation with echo evidence of cardiac tamponade
- Rapid exsanguination from a chest tube (>1500 cc output upon insertion)
What are 3 contraindications to ED thoracotomy for blunt trauma?
- prehospital CPR >10 minutes without response
- asystole as presenting rhythm and no echo evidence for cardiac tamponade
- significant head trauma
What are 3 indications for ED thoracotomy in PENETRATING trauma?
- prehospital/hospital signs of life
- echo evidence of cardiac activity with cardiac tamponade
- unresponsive hypotension (BP<70mmHg) despite resuscitation with penetrating chest wound
What are 3 contraindications for ED thoracotomy for penetrating trauma?
- Prehospital CPR >15 minutes without response
- Asystole as presenting rhythm and no echo evidence for cardiac tamponade
- Significant head trauma
What is ideal Cerebral Perfusion Pressure (CPP)?
> 60mmHg
What is ideal MAP in head injuries?
> 80mmHg
What is ideal ICP in head injuries?
<15 mmHg
What are the 2 brainstem tests?
- Oculocephalic response
- Oculovestibular response
What is oculocephalic response?
Conjugate deviation of eyes in direction opposite to passive head rotation (once C-spine cleared) - indicates intact brainstem function in a comatose patient
What is oculovestibular response?
Instillation of 30-mL cold saline into the ear;
horizontal nystagmus with FAST component AWAY from tested ear indicates intact brainstem function.
What is uncal herniation syndrome?
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
What is mannitol dosing for decreasing ICP in adults?
0.25-1g/kg IV Mannitol bolus
How is ICP decreased in pediatric patients?
Hypertonic saline 3% 0.1-1mL/kg/h (infants and children) - produces osmotic diuresis
What is dispo for anticoagulated patient with head injury and negative head CT?
Admit for obs given increased risk for delayed bleed
What types of fractures are NG tubes contraidicated?
Cribriform plate fractures
What are the 3 main concerns for blunt neck trauma?
intimal tear
pseudoaneurysm
carotid or vertebral artery dissection
Zones of the neck: What are the landmarks for Zone I?
Clavicles to cricoid cartilage
Zones of the neck: What structures are involved in Zone I?
trachea, esophagus, vertebral and carotid arteries
Great vessels, lung apices, thoracic duct, spinal cord
Zones of the neck: What are the landmarks for Zone II?
Cricoid cartilage to angle of mandible
Zones of the neck: What structures are involved in Zone II?
trachea, esophagus, vertebral and carotid arteries
larynx, jugular veins
Zones of the neck: What are the landmarks for Zone III?
Angle of mandible to base of skull
Zones of the neck: What structures are involved in Zone III?
pharynx, jugular veins, vertebral, and internal carotid arteries, skull base
Neck wounds with violation of the ____ indicates possibility of significant neck injury and requires surgical consultation.
platysma
What is NEXUS Cspine criteria?
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
What is the Canadian Cspine Rule?
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.
What are the 6 unstable fractures of the Cspine?
- Jefferson fracture (C1 burst
fracture) - Bilateral facet dislocation
- Odontoid type II/III
- Atlantoaxial or atlantooccipital
- Hangman’s fracture (bilateral C2 pedicle
fracture) - Teardrop fracture (The teardrop is the
anteroinferior portion of the
vertebral body)
What are the 5 Major/Unstable Thoracolumbar Spine Fractures?
- Wedge compression fx
- Chance fracture
- Burst fx
- Flexion Distraction Injury
- Translational fx
What is a chance fx?
Horizontal fracture through the vertebral body and all
posterior elements
What is Brown-Séquard Syndrome?
Hemisection of the cord, usually associated with penetrating trauma (best prognosis)
What are the signs/sx of Brown-Sequard Syndrome?
Ipsilateral loss of motor, proprioception, and vibratory sensation with
contralateral loss of pain and temperature sensation.
What is central cord syndrome?
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.
what are the signs/sx of central cord syndrome?
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
What is anterior cord syndrome?
Caused by flexion or extension with vascular or bony fragment injury of the anterior spinal artery.
What are the signs and symptoms of anterior cord syndrome?
Paralysis and loss of pain and temperature sensation but preserved position, crude touch, and vibration sensation
What is spinal shock?
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.
What are the signs/symptoms of spinal shock?
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.
What is neurogenic shock?
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.
What are signs and sx of neurogenic shock?
Patients are peripherally vasodilated, warm, hypotensive with relative bradycardia.
A small traumatic pneumothorax < ___-___% in a stable patient may be treated with 100% O2 via non-rebreather (NRB) mask and repeat CXR.
15-25%
What is the treatment for a sucking chest wound?
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
What is the next step in working up pneumomediastinum found on CXR?
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.
Hemothorax: Upright CXR will show blunting of the costophrenic angle when >____ mL
blood is present.
250
What is the definition of massive hemothorax?
> 1500cc immediate output or >200mL/h; If this is the case –> OR for thoracotomy
Patients with __ or more rib fractures should be admitted
3
What percentage of rib fractures are not evident on CXR?
50%
What is the definition of flail chest?
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
What is Beck’s triad for cardiac tamponade?
Hypotension, JVD, muffled heart sounds
What is the treatment for pericardial tamponade?
not in extremis –> US-guided paracentesis; IV fluids help maximize cardiac output
Hypotensive (BP <70mmHg) –> ED thoracotomy
Where do most traumatic aortic injuries take place?
at the Aortic Isthmus, distal to the left subclavian artery
What can be symptoms of descending aortic injury?
paraplegia (vertebral artery deficits), mesenteric and LE ischemia, and anuria
What findings are consistent with aortic injury on supine AP films?
widened mediastinum >8 cm on supine AP film
and
loss of distinct aortic knob
What is the initial treatment for aortic injury?
beta blockade to control BP < 120 mmHg and replace fluids carefully
Instruct patient not to Valsalva
What do you do if there is an impaled foreign body?
Keep in place –> goes to OR! surgical managemnt
Which side of the diaphragm is more commonly injured?
Left diaphragm is injured 3x as much as right diaphragm
What are signs and symptoms of diaphragmatic injury?
abdominal pain radiating to the ipsilateral shoulder (kehr sign) - worse when supine
Absent breath sounds or positive bowel sounds in the chest
What is the gold standard for diagnosing diaphragm injury
Laparoscopy or thoracoscopy
What is the first step in management of diaphragmatic injury?
Emergent NG decompression
What is the definitive treatment for diaphragmatic injury?
surgical repair
What is the definitive treatment for diaphragmatic injury?
surgical repair
What is the definitive treatment for diaphragmatic injury?
surgical repair
What is the definitive treatment for diaphragmatic injury?
surgical repair
Which three abdominal injuries in blunt trauma are difficult to diagnose with CT imaging?
diaphragm
pancreas
bowel
What is the most commonly injured organ in blunt abdominal traum?
Spleen
What is the utility of lipase and amylase levels in blunt abdominal traumas?
Neither sensitive nor specific; can be used in conjunction with other imaging and can be trended
Surgery is often required for splenic injuries grade ___ or higher.
III
What percentage of anterior abdominal stab wounds penetrate the peritoneum?
What percentage of those cause organ damage?
70%; 50%
What are the most commonly injured organs in stabbings? GSWs?
Stabbings: 1. liver 2. Small bowel
GSW: 1. Small bowel 2. Colon 3. Liver
When is DPL indicated?
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
What represents positive DPL in blunt trauma?
- aspiration of 10 mL of free flowing blood
- RBCs >100,000 (10,000 for GSWs or penetrating)
- Presence of GI contents
- WBCs >500,000
- Amylase >20 IU/L
- Alk phosphatase >/= 3 IU/L
How does baseline heart rate change in pregnancy?
increases by 10-15 BPM
How dose baseline BP change in pregnancy?
Decreases in first and second trimester
What is normal fetal HR?
120-160 BPM; abnormal rate suggests fetal distress
Continuous fetal monitoring should be initiated in patients beyond ___ weeks of gestation, even in minor trauma.
24 wks
How do you determine how much RhoGAM to give in women with fetomaternal hemorrhage that are >20 weeks?
Kleihauer-Betke test
In maternal cardiac arrest with EGA >24 weeks, when should you perform a perimortem C-section?
If no ROSC by 4 minutes of resuscitative efforts
What is Destot sign and what does it indicate?
Hematoma above inguinal ligament or over scrotum; may indicate pelvic ring fracture
What is the proper way to evaluate the pelvis in traumas?
compress pelvis medially at iliac crests and anteroposteriorly at pubic symphysis
What is the next step in a patient with blood at the urethral meatus?
Urethrogram prior to Foley placement
What type of hip dislocation is most common?
Posterior dislocations (80-90%)
How do posterior hip dislocations present?
extremity is shortened, internally rotated, and adducted
What complication can occur if hip dislocation is prolonged?
avascular necrosis
What might a high-riding prostate on rectal examination indicate?
Posterior urethral injury
What volume of contrast is recommended to be instilled into bladder for retrograde cystogram?
400 mL (or 5mL/kg in children)
What is the treatment of intraperitoneal bladder rupture? Tx of extraperitoneal bladder injury?
intraperitoneal rupture –> surgery
extraperitoneal –> foley catheter decompression for 10-14 days
What is the treatment for bladder contusions?
no intervention necessary
What is the diagnostic test of choice for ureteral injury?
CT with IV contrast or IV pyelogram
What is the treatment for ureteral injury?
surgical repair or interventional radiology (IR) stenting
Which traumatic kidney injuries require intervention?
Grade III - lacerations >1 cm depth into renal cortex
Grades IV and V - those with vascular injury
Compartment syndrome is most commonly associated with what type of fractures?
midshaft fractures of the tibia
What is normal compartment pressure?
0-10 mmHg
What structures are first affected by compartment syndrome?
Nerves (>20mmHg) - leads to loss of two point discrimination
At what compartment pressure should fasciotomy be considered?
> 30 mmHg
After what type of injury should you avoid fasciotomy?
after snake bites! will lead to worse outcomes
What are the 5 HARD signs of arterial injury?
- Pulsatile bleeding
- Audible bruit/palpable thrill
- Rapidly expanding hematoma
- Obvious arterial occlusion
- Decreased temperature
What is a duplex scan?
real time B mode ultrasound with doppler
What should you be concerned for with knee dislocations?
popliteal injury; monitor post-reduction ABIs
Do not leave tourniquets on for great than ____ minutes
120 minutes
Major arterial injuries must be repaired within ____ hours.
6
A penis may be replanted up to ___ hours after amputation
12 hours
What is the rule of 9s for estimating TBSA?
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
What defines a superficial burn?
involves epidermal layer only
What defines a partial thickness burn?
Epidermis and superficial dermis
What defines a full-thickness burn?
epidermis and dermis (all structures)
What defines a subdermal burn?
Subdermal structures (muscles, nerves, bones)
Describe the appearance of a superficial burn
Similar to sunburn: red, painful, tender,
no blistering
Describe the appearance of a superficial partial thickness burn
Red, painful, blistering, blanching
Describe the appearance of a deep partial thickness burn
Red to pale white-yellow, blistering
with rupture, no blanching
Decreased two-point discrimination
but can feel pressure
Describe the appearance of a full thickness burn
Charred, white/black, painless, and
leathery
What is the Parkland formula for fluid resuscitation in patients with significant burn?
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.
How is Parkland formula adjusted for children?
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
How do you determine % burn for parkland formula?
Use only area of partial- and full-thickness burns to determine % burn
for resuscitation. aka blistering or worse
How is TBSA calculated in children?
Lund Browder chart (rather than rule of 9s)
What type of chemical burns cause coagulative necrosis?
Acids – creating a tough eschar preventing deep penetration of burn.
What type of chemical burns cause liquefactive necrosis?
alkalis – burns travel deep & are worse that acid burns
How can cement cause chemical burn?
Cement contains lime, which is converted with water to the alkali calcium
hydroxide.
When irrigating chemical burns, for which substances should you use oil instead of water?
Sodium metals
How do you treat patients affected by lacrimators (tear gas, pepper spray)?
copious water irrigation
How can airbag deployment cause injury?
Airbag deployment utilizes an exothermic reaction that can cause burns
(sodium azide) and keratitis (sodium hydroxide). These are treated with
copious water irrigation.
When must bullets be removed from the body?
- spinal canal
- synovial fluid (intraarticular, disk space, and bursa) - can lead to lead poisoning
