Chapter 15 - Trauma Flashcards
What is the first peak of trauma death? causes
0-30 minutes.
- Heart/aorta
- brain/brainstem/spinal cord
- cannot save these patients
What is the second peak of trauma death? causes
30 minutes- 4 hours.
- # 1 head injury
- # 2 hemorrhage
- Golden hour, rapid assessment
What is the 3rd peak of trauma death?
days to weaks
- multisystem organ failure
- sepsis
What percentage of trauma is blunt?
80%
What is the most commonly injured organ in blunt trauma?
Liver (some say spleen)
What is the formula for kinetic energy?
1/2 MV^2
What is the LD50 fall height?
4 stories
At what point of blood loss is blood pressure effected?
30%
What is the most commonly injured organ in penetrating trauma?
Small bowel (some say liver)
What is the most common cause of long term death with trauma?
Sepsis
What is the most common cause of upper airway obstruction and how is it alleviated?
Tongue, jaw thrust (ohhhh yeaaaa)
What injuries to seat belts cause?
- small bowel perfs
- lumbar spine fxs
- Sternal fxs
What site is best for cutdown access?
Saphenous vein
When is a DPL positive?
> 10cc blood
100k RBC’s
-food particles, bile, bacteria
500cc WBC
If a pelvic fx is present, where must DPL be performed?
Supraumbilical
What does a DPL miss?
Retroperitoneal hematoma
Contained hematomas
Where does a FAST look for blood?
- perihepatic fossa
- Pelvis
- Pericardium
What are flaws with FAST?
- Operator Dependent (fuckin Belsky)
- Obesity
- May not detect fluid <50-80
- Misses retroperitoneal bleed and hollow viscous injury
CT after blunt trauma needed for what?
- Abdominal Pain
- Need for General Anasthesia
- closed head injury
- intoxicants
- paraplegia
- distracting injury
- Hematuria
What does a CT scan of blunt trauma miss?
- hollow viscous injury
- retroperitoneal bleed
These patients need a laparotomy after blunt trauma:
- Peritonitis
- evisceration
- (+) DPL
- clinical deterioration
- uncrontrolled hemorrhage
- free air
- diaphragm injury
- intraperitoneal bladder injury
- specific renal, pancreas, biliary tract injury
When does abdominal compartment syndrome happen?
- massive fluid resuscitation
- trauma
- abdominal surgery
Bladder pressures of what indicate abdominal compartment syndrome?
> 25-30
What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?
ICV compression
What causes decreased urine output in abdominal compartment syndrome?
Compressed renal vein
What is tx for abdominal compartment syndrome?
decompressive laparotomy
When do you use a pneumatic antishock garment?
- SBP <50 without thoracic injury
- release one compartment at a time after reaching ED
When do catecholamines peak after trauma?
24-48 hours
Along with catecholamines, what rises after trauma?
-ADH
-ACTH
-Glucagon
Fight or flight response
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
Type specific, non-screened, non-crossmatched blood can be given safely with what side effects?
effects from antibodies to minor antigens
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
Glasgow coma score verbal
5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no response
Glasgow coma score eye opening
4 spontaneous
3 to command
2 to pain
1 no response
GCS that gets head CT, Intubation, ICP monitor
<= 8 ICP monitor
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
Subdural Hematoma caused by damage to what? Head CT shows? when do you operate?
- venous plexus tearing between dura and arachnoid
- CT shows crescent deformity
- operate for significant mass defect
Intracerebral hematomas usually where? When do they need operation?
- Usually frontal or temporal
- operate for significant mass effect
Cerebral contusions can be one of these 2 types
coup or contracoup
When do traumatic intraventricular hemorrhages need treatment?
ventriculostomy if causing hydrocephalus
When imaging is best for DAI?
MRI better than CT
how do you calculate cerebral perfusion pressure?
MAP minus ICP
What are signs of elevated ICP?
- decreased ventricular size
- loss of sulci
- loss of cisterns
When are ICP monitors needed?
- GCS </= 8
- suspected increased ICP and inability to follow clinical exam
What is a normal ICP?
-10, >20 needs tx
What do you want the CPP to be?
> 60
What is supportive therapy for increased ICP?
- sedation and paralysis
- raise head of bed
- relative hyperventilation
- Na 140-150
- Serum Osm 295-310
- Manitol
- Barbituate coma
- ventriculostomy with CSF drainage
- Phenytoin
When does ICP peak after injury?
48-72 hours
What does dilated pupil show?
Temporal pressure on SAME side (CNIII compression)
Raccoon eyes indicates what?
anterior fossa fx
Battle’s sign shows what?
middle fossa fx
- acute need exploration
- delayed secondary to edema
Temporal skull fx can injure what cranial nerves?
VII and VIII
What is the most common site of facial nerve injury?
geniculate ganglion
when do skull fx need treatment?
8-10 mm or > depression
- contaminated
- persistent CSF leak
What is a Jefferson cervical fx?
- C1 burst
- caused by axial loading
- tx rigid collar
What is a hangman’s fx?
-C2
distraction and extension
-traction and halo
What are the 3 types of C2 odontoid fx?
I above base, stable
II at base, unstable- need fusion or halo
III extend to vertebral body-need fusion/halo
What can facet fractures or disocations cause? how do they happen?
cord injury
associated with hyperextension and rotation with ligamentous disruption
What is the anterior column or thoracolumbar spine?
anterior longitudinal ligament and 1/2 of vertebral body
What is the middle column of thoracolumbar spine?
Posterior 1/2 of vertebral body and posterior longitudinal ligament
What is the posterior column of the thoracolumbar spine?
facet joints, lamina, spinous processes, interspinous ligament
How many columns of thoracolumbar spine must be disrupted for fx to be considered unstable?
> 1
What are wedge fractures? stable or unstable?
anterior column only; stable
What are burst fractures? stable or unstable?
> 1 column and usually require fusion
What structures are at risk after upright fall?
calcaneus
lumbar
wrist/forearm fractures
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
What skull fracture is most common cause of facial nerve injury?
temporal bone FX
What is type I Le Fort fx? tx?
- maxillary fx straight across ( - )
- tx with reduction, stabilization, intramaxillary fixation, +/- circumzygomatic and orbital rim suspension wires
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
What percentage of nasoethmoidal bone fx have CSF leak?
70%
What is a type III Le Fort Fx? tx?
Lateral orbital walls ( - - )
-suspension wiring to stable frontal bone; may need external fixation
What are the 2 types of Nosebleeds? Tx?
- Anterior - Packing
- Posterior - balloon tamponade first, may need embolization of internal maxillary a or ethmoidal a
What is the #1 indicator of mandibular injury?
malocclusion
What is a tripod fx? what do you do?
zygomatic bone fx. May need ORIF for cosmesis
what are patients with maxillofacial fx at a high risk for?
cervical spine injury
Asymptomatic blunt neck trauma gets what?
Neck CT
Neck Zone I? penetrating injury gets what?
Clavicle to Cricoid
- angiography
- bronchoscopy
- rigid esophagoscopy
- barium swallow
- may need pericardial window/sternotomy
Neck Zone II? penetrating injury gets what?
Cricoid to angle of the mandible
-Exploration in the OR
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
What is the best method to evaluate esophageal injury?
rigid esophagoscopy and esophogram (95% of injuries found)
Contained esophageal injuries treated how?
observation
Non-contained injuries to esophagus treated how?
small, <24h old, stable- primary closure
-otherwise, spit fistula and drain leak with chest tube
What percentage of esophageal and hypoesophageal injuries leak?
20%. always drain
How do you approach esophageal injuries?
- Neck- left side
- upper 2/3- right thoracotomy
- lower 1/3- left thoracotomy
What are the sx of laryngeal fx?
crepitus, stridor, respiratory compromise
Tx for thyroid injuries?
control bleeding, drain
Tx recurrent laryngeal nerve injury?
repair or reimplant in cricoarytenoid muscle
What do fucking shot gun injuries to the neck need other than a pine box?
angiogram, neck CT, esophagus/tracheal evaluation.
Tx for vertebral artery injury?
ligate or embolize without sequelae
Common carotid bleeds?
can tx with ligation - 20% will stroke
When to placed, indications for thoracotomy?
> 1500 initially
250cc/h for 3 h
2500cc for 24h
instability
If all blood from hemothorax not drained in _____hours, risk this
48 hours; fibrothorax, pulmonary entrapment, infected hemothorax
unresolved hemothorax after 2 tubes?
thorascopic or open drainage
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
Tracheobronchial injury can be diagnosed by what?
worse oxygenation after chest tube placement
What side are bronchial injuries more common?
right
What kind of intubation may be needed for bronchial injuries?
mainstem to unaffected side
When would you do right thoracotomy for tracheobronchial injury?
right mainstem, tracheal, proximal left mainstem
-avoid aorta
When would you do left thoracotomy for tracheobronchial injury?
-distal left mainstem injuries
