Chapter 15 - Trauma Flashcards
1
Q
What is the second peak of trauma death? causes
A
30 minutes- 4 hours. -#1 head injury -#2 hemorrhage -Golden hour, rapid assessment
2
Q
What is the 3rd peak of trauma death?
A
days to weaks -multisystem organ failure -sepsis
3
Q
What is the most commonly injured organ in blunt trauma?
A
Liver (some say spleen)
4
Q
What is the LD50 fall height in stories?
A
4 stories
5
Q
What is the most commonly injured organ in penetrating trauma?
A
Small bowel (some say liver)
6
Q
What site is best for cutdown access?
A
Saphenous vein
7
Q
If a pelvic fx is present, where must DPL be performed?
A
Supraumbilical
8
Q
Where does a FAST look for blood?
A
-perihepatic fossa -perisplenic fossa -Pelvis -Pericardium
9
Q
CT after blunt trauma needed for what?
A
-Abdominal Pain -Need for General Anasthesia -closed head injury -intoxicants -paraplegia -distracting injury -Hematuria
10
Q
These patients need a laparotomy after blunt trauma:
A
-Peritonitis -evisceration -(+) DPL -clinical deterioration -uncrontrolled hemorrhage -free air -diaphragm injury -intraperitoneal bladder injury -specific renal, pancreas, biliary tract injury
11
Q
Bladder pressures of what indicate abdominal compartment syndrome?
A
>25-30
12
Q
What causes decreased urine output in abdominal compartment syndrome?
A
- compressed renal vein
- sympathetics also cause renal artery vasoconstriction
- Consequently the RAAS system is activated. Kidney behaves as if pre-renal, so urine sodium/chloride are decreased.
13
Q
When do you use a pneumatic antishock garment?
A
There is no evidence to suggest that MAST/PASG application reduces mortality, length of hospitalisation or length of ICU stay in trauma patients and it is possible that it may increase these. These data do not support the continued use of MAST/PASG in the situation described. However, it should be recognised that, due to the poor quality of the trials, conclusions should be drawn with caution.
Study: Medical anti-shock trousers (pneumatic anti-shock garments) for circulatory support in patients with trauma.
14
Q
Along with catecholamines, what rises after trauma?
A
-ADH -ACTH -Glucagon Fight or flight response
15
Q
Type specific, non-screened, non-crossmatched blood can be given safely with what side effects?
A
effects from antibodies to minor antigens
16
Q
Glasgow coma score verbal
A
5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no response
17
Q
GCS that gets head CT, Intubation, ICP monitor
A
<= 8 ICP monitor
18
Q
Subdural Hematoma caused by damage to what? Head CT shows? when do you operate?
A
-venous plexus tearing between dura and arachnoid -CT shows crescent deformity -operate for significant mass defect
19
Q
Cerebral contusions can be one of these 2 types
A
coup or contracoup
20
Q
When imaging is best for DAI?
A
MRI better than CT
21
Q
What are imaging signs of elevated ICP?
A
Decreased ventricular size, loss of sulci, loss of cisterns
22
Q
What is a normal ICP?
A
-10, >20 needs tx
23
Q
What is supportive therapy for increased ICP?
A
- sedation and paralysis
- raise head of bed
- relative hyperventilation
- Na 140-150
- Serum Osm 295-310
- Manitol
- Barbituate coma
- ventriculostomy with CSF drainage
- Phenytoin/Keppra
24
Q
What does dilated pupil show?
A
Temporal pressure on SAME side (CNIII compression)
25
Battle's sign shows what?
* middle fossa fx
* acute may need exploration
* delayed secondary to edema
26
What is the most common site of facial nerve injury?
geniculate ganglion
27
What is a Jefferson cervical fx?
* C1 burst
* caused by axial loading
* tx rigid collar
28
What are the 3 types of C2 odontoid fx?
Flexion or extension of the head in an AP orientation (ie, sagittal plane), as occur with a forward fall onto the forehead, may result in a fx of the odontoid process (dens). Fxs can occur above the transverse ligaments (type I) or, most commonly, at the base of the odontoid process where it attaches to C2 (type II).
* Type I fractures are stable. Although spinal cord injury is uncommon
* Type II odontoid fractures are unstable and complicated by nonunion in over 50 percent
* treated with halo vest immobilization
* Type III fractures are unstable since they allow the odontoid and the occiput to move as a unit
* Angulation of the force results in extension of through the upper portion of the body of C2
* Best seen on the AP odontoid radiograph (ie, open-mouth view)
* Cause prevertebral soft tissue swelling on lateral radiographs
29
What is the anterior column of thoracolumbar spine?
anterior longitudinal ligament and 1/2 of vertebral body
## Footnote
where wedge fractures occur
30
What is the posterior column of the thoracolumbar spine?
facet joints, lamina, spinous processes, interspinous ligament
31
What are wedge fractures? stable or unstable?
anterior column only; stable
32
What bones are at risk after upright fall?
* calcaneus
* lumbar spine
* wrist/forearm fractures
33
What skull fracture is most common cause of facial nerve injury?
temporal bone FX
34
What is type II Le Fort fx? tx?
Lateral to nasal bone, underneath eyes, diagonal toward maxilla ( / \ )
Tx with reduction, stabilization, intramaxillary fixation, +/- circumzygomatic and orbital rim suspension wires
35
What is a type III Le Fort Fx? tx?
Lateral orbital walls ( - - ) -suspension wiring to stable frontal bone; may need external fixation
36
What is the #1 indicator of mandibular injury?
malocclusion
37
What are patients with maxillofacial fx at a high risk for?
cervical spine injury
38
Neck Zone I? penetrating injury gets what?
Clavicle to Cricoid
* angiography
* bronchoscopy
* rigid esophagoscopy
* barium swallow
* may need pericardial window/sternotomy
39
Neck Zone III? Penetrating injury gets what?
Angle of mandible to base of skull
* Angio
* Laryngoscopy
* may need jaw subluxation/digastric SCM release/mastoid sinus resection to reach vascular injuries
40
Contained esophageal injuries treated how?
**Observation**
## Footnote
Criteria: early diagnosis or delayed diagnosis with contained leak, perforation not in the abdomen, contained perforation in the mediastinum, content of the perforation draining back to the esophagus, perforation does not involve neoplasm or obstruction of the esophagus, absence of sepsis, presence of experienced thoracic surgeon and contrast imaging in the hospital.
Nonoperative treatment includes large bore intravenous access, supplemental oxygen and cardiopulmonary monitoring in a critical care setting. Patient should be kept nil per oral and should have a nasogastric tube placed to clear gastric contents and limit further contamination. Broad spectrum intravenous antibiotics should be instituted as early as possible and should be given for minimum of 7 – 10 days.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139851/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139851/)
41
What percentage of esophageal and hypoesophageal injuries leak?
20%. always drain
42
What are the sx of laryngeal fx?
crepitus, stridor, respiratory compromise
43
Tx recurrent laryngeal nerve injury?
repair or reimplant in cricoarytenoid muscle
44
Tx for vertebral artery injury?
ligate or embolize without sequelae
45
When chest tube placed, indications for thoracotomy?
* \>1500 initially
* \>250cc/h for 3 h
* \>2500cc for 24h
* instability
46
unresolved hemothorax after 2 tubes?
thorascopic or open drainage
47
**Tracheobronchial injury** can be suspected and diagnosed by?
Intrathoracic injury can be subtle and indolent, presenting with retained secretions, recurrent pneumothoraces, and obstruction. The sine qua non of intrathoracic tracheobronchial injury is a significant air leak and pneumothorax or pneumomediastinum that reaccumulates despite tube thoracostomy. A cervical injury may present without a significant air leak, if the tear or rupture is contained by the adventitia. Signs of cervical tracheal injury include dyspnea, hoarseness, and subcutaneous emphysema.
_Radiographs_ generally reveal marked air in local soft tissue (ie, subcutaneous emphysema). Fractures of the first three ribs are associated with intrathoracic injury. Other radiologic findings on plain film include: persistent pneumothorax with a dependent lung, interstitial air in the wall of the trachea or mainstem bronchus, abnormal location of the endotracheal tube (ETT), and a distended ETT cuff due to protrusion of the trachea.
DX: _operating room_ or by _bronchoscopy_. _Multidetector CT scan_ (MDCT) enables diagnosis of some tracheal tears, but its sensitivity is unknown. If tracheobronchial injury is suspected, obtain a MDCT or consult a thoracic surgeon for evaluation and possible bronchoscopy.
TX: primary repair or possible lung resection. The need for surgical repair is generally based on the risk for airway obstruction, massive air leak, or mediastinitis.
Tracheobronchial injuries occur in less than 1 percent of patients with blunt thoracic trauma, and few studies exist to guide diagnosis and management. Most patients who sustain such injuries die at the scene. The trachea is protected from injury by its position relative to the mandible, sternum and vertebral column, and its relative elasticity. Injury of the cervical trachea is uncommon but can occur from a direct blow, which may be of low energy; injury of the intrathoracic trachea results from high-energy trauma, generally motor vehicle collisions (MVCs) and sometimes crush injuries. Most tracheal or bronchial injuries occur as part of multiple trauma, including additional injuries to the lungs and chest wall. The right main bronchus is involved most often, generally within 1 to 2 cm of the carina, followed by the left main bronchus.
[https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-thoracic-trauma-in-adults?search=tracheobronchial%20injury§ionRank=1&usage\_type=default&anchor=H26&source=machineLearning&selectedTitle=1~134&display\_rank=1#H26](https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-thoracic-trauma-in-adults?search=tracheobronchial%20injury§ionRank=1&usage_type=default&anchor=H26&source=machineLearning&selectedTitle=1~134&display_rank=1#H26)
48
What kind of intubation may be needed for bronchial injuries?
mainstem to unaffected side
49
When would you do left thoracotomy for tracheobronchial injury?
-distal left mainstem injuries
50
When would you do right thoracotomy for tracheobronchial injury?
right mainstem, tracheal, proximal left mainstem -avoid aorta
51
What side are bronchial injuries more common?
right
52
How large does a sucking chest wound need to be to be significant?
\>2/3 diameter of trachea -cover wound with dressing that has tape on 2 sides
53
If all blood from hemothorax not drained in \_\_\_\_\_hours, risk this
48 hours; fibrothorax, pulmonary entrapment, infected hemothorax
54
Common carotid bleed mgmt?
can tx with ligation - 20% will stroke
55
What do shot gun injuries to the neck need other than a pine box?
angiogram, neck CT, esophagus/tracheal evaluation.
56
Tx for thyroid injuries?
control bleeding, drain
57
What is the approach for esophageal injuries?
* neck - left side
* upper 2/3 - right thoracotomy
* lower 1/3 - left thoracotomy
58
Non-contained injuries to esophagus treated how?
small, \<24h old, stable - primary closure
otherwise, spit fistula and drain leak with chest tube
59
What is the best method to evaluate esophageal injury?
rigid esophagoscopy and esophogram (95% of injuries found)
60
Neck Zone II? penetrating injury gets what?
Cricoid to angle of the mandible -Exploration in the OR
61
Asymptomatic blunt neck trauma gets what?
Neck CT
62
What is a tripod fx? what do you do?
zygomatic bone fx. May need ORIF for cosmesis
63
What are the 2 types of Nosebleeds? Tx?
* Anterior - Packing
* Posterior - balloon tamponade first, may need embolization of internal maxillary a or ethmoidal a
64
What percentage of nasoethmoidal bone fx have CSF leak?
70%
65
What is type I Le Fort fx? tx?
* maxillary fx straight across ( - )
* tx with reduction, stabilization, intramaxillary fixation, +/- circumzygomatic and orbital rim suspension wires
66
What are the indications for emergent surgical spine decompression?
* fx not reducible with distraction
* acute anterior spinal syndrome
* open fractures
* soft tissue or bony compression of the cord
* progressive neurological dysfunction
67
What are burst fractures? stable or unstable?
\>1 column and usually require fusion
68
How many columns of thoracolumbar spine must be disrupted for fx to be considered unstable?
\>1
69
What is the middle column of thoracolumbar spine?
Posterior 1/2 of vertebral body and posterior longitudinal ligament
70
What can facet fractures or disocations cause? how do they happen?
cord injury associated with hyperextension and rotation with ligamentous disruption
71
What is a hangman's fx?
- C2 distraction and extension
- traction and halo
72
when do skull fx need treatment?
* 8-10 mm or \> depression
* contaminated
* persistent CSF leak
73
Temporal skull fx can injure what cranial nerves?
VII and VIII
74
Raccoon eyes indicates what?
anterior fossa fx
75
When does ICP peak after injury?
48-72 hours
76
What do you want the CPP to be?
\>60
77
When are ICP monitors needed?
GCS = 8, suspected increased ICP, and inability to follow clinical exam
78
how do you calculate cerebral perfusion pressure?
MAP minus ICP
79
When do traumatic intraventricular hemorrhages need treatment?
ventriculostomy if causing hydrocephalus
80
Intracerebral hematomas usually where? When do they need operation?
-Usually frontal or temporal -operate for significant mass effect
81
Epidural Hematoma caused by damage to what? What does head CT show? What is patient presentation? When do you operate?
-Arterial bleed from middle meningeal A -CT shows lens shape lenticular deformity -initial LOC, lucid interval, sudden deterioration -Operate for significant degeneration or mass effect shift \>5mm
82
Glasgow coma score eye opening
4 spontaneous 3 to command 2 to pain 1 no response
83
Glasgow coma score Motor
6 follows commands 5 localizes pain 4 withdraws from pain 3 flexion with pain 2 extension with pain 1 no response
84
What blood type is a universal donor? Why? Rh can and cannot go to who?
-O, does not contain A or B antigens -Males can get Rh positive -prepubescent and child bearing age females must get Rh negative
85
When do catecholamines peak after trauma?
24-48 hours
86
What is tx for abdominal compartment syndrome?
decompressive laparotomy
87
What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?
ICV compression
88
When does abdominal compartment syndrome happen?
-massive fluid resuscitation -trauma -abdominal surgery
89
What does a CT scan of blunt trauma miss?
-hollow viscous injury -retroperitoneal bleed
90
What are flaws with FAST?
-Operator Dependent (fuckin Belsky) -Obesity -May not detect fluid \<50-80 -Misses retroperitoneal bleed and hollow viscous injury
91
What does a DPL miss?
Retroperitoneal hematoma Contained hematomas
92
When is a DPL positive?
\>10cc blood \>100k RBC's -food particles, bile, bacteria \>500cc WBC
93
What injuries to seat belts cause?
-small bowel perfs -lumbar spine fxs -Sternal fxs
94
What is the most common cause of long term death with trauma?
Sepsis
95
At what point of blood loss is blood pressure effected?
30%
96
What is the formula for kinetic energy?
1/2 MV^2
97
What percentage of trauma is blunt?
80%
98
What is the first peak of trauma death? causes
0-30 minutes. -Heart/aorta -brain/brainstem/spinal cord -cannot save these patients
