CR - traumatic disorders Flashcards
What is the most appropriate diagnostic study in trauma patients with blood at the urethral meatus?
Retrograde urethrogram
In the setting of acute trauma in a hemodynamically stable patient, this test should be performed if renal artery injury is suspected or needs to be excluded
CT scanning with 3-D reconstruction and IV contrast
What are the classic signs of compartment syndrome?
The 6 P’s
Pain out of proportion
Pallor
Poikilothermic
Pulselessness
Paresthesia
Paralysis
What is the role of hyperventilation in the management of elevated intracranial pressure secondary to trauma?
The role is very limited. Hyperventilation should only be considered for herniation or clinical deterioration despite adequate resuscitation and mannitol; if used, the pCO2 should be maintained between 35-40 mm Hg
What is the immediate cause of death from an untreated tension pneumothorax?
Obstructive shock
The tension pneumothorax severely impedes venous return which results in a fatal reduction in cardiac output
In a patient presenting with a periorbital hematoma or a hyphema, what diagnosis should be excluded?
Orbital fracture
At what age can surgical cricothyroidotomy be performed on a child?
When the cricothyroid membrane is palpable, around 10 years
When viewing cervical spine films in a child with possible injury, what are normal variants?
Wedging of the anterior cervical bodies (especially C3 which is seen up to age 12)
Anterior pseudosubluxation of C2 over C3 or C3 on C4
Pseudosubluxation is common in children <7 year old. Swischuk’s line drawn from the anterior aspect of posterior arch of C1 to anterior aspect of posterior arch of C3. Anterior aspect of posterior arch of C2 should be within 1-2mm of this line
A patient with a head injury is unresponsive to both verbal and painful stimuli. There is no eye opening whatsoever.
What is the Glasgow Coma score?
3
The patient scores a one for each eye opening, speech, and best motor
What is the leading cause of death in patients sustaining pelvic fractures?
Hemorrhagic shock
Children (<11 years old) with cervical spine injuries are most commonly injured in what region of the cervical spine?
The upper C-spine
What is the most common cause of sudden death following a MVC or fall from a great height?
A traumatic aortic rupture
Clinical presentation: a patient has a facial laceration that requires suturing. He claims an allergy to procaine. Which of the following is the safest choice for local anesthesia?
Benoxinate HCl
Benzocaine
Cocaine
Tetracaine
Mepivicaine
Mepivicaine
Procaine is the prototype “ester” local anesthetic. All of the anesthetics listed are chemically related to procaine except mepivicaine which is an “amide”
The amide anesthetics are associated with far fewer allergic reactions. The other amides are lidocaine, bupivacaine, etidocaine, and prilocaine
Pelvic fractures are associated with bladder injury. What should you check for?
Hematuria
The greater the degree of hematuria, the greater the risk of significant intra-abdominal injury. Pelvic fractures are associated with posterior urethral injury (above urogenital diaphragm) and bladder injury.
How does on differentiate pulmonary contusion from adult respiratory distress syndrome (ARDS) on chest x-ray
Pulmonary contusion occurs within minutes to hours of the injury and is seen on x-ray as an infiltrate or consolidation that is usually localized to a pulmonary segment or lobe.
ARDS is associated with delayed onset (12-72 hours after injury) with diffuse patchy infiltrates seen on chest x-ray (24-72 hours after injury)
Death from drowning is due to ___
Hypoxia
What is the most common cause of fetal death following blunt trauma?
Second only to maternal death, abruptio placentae is the most common cause of fetal death.
What are the NEXUS criteria?
No posterior midline cervical tenderness
No evidence of intoxication
Normal level of alertness
No focal neurological deficit
No distracting painful injuries
What is the most common ureteral injury in the setting of blunt trauma
Ureteropelvic disruption
Should be suspected with fractures of the lumbar spine: urinalysis may be normal
What are the most common sequela following blunt abdominal trauma during pregnancy?
Preterm contractions
Any pregnant woman at 24 weeks or more gestation who suffers blunt trauma should undergo at least 4 hours of fetal monitoring even if she looks well
What is the most common site of penetrating trauma to the heart?
The right ventricle
A patient with no head injury and multiple long-bone fractures undergoes a dramatic worsening of his neurological status. What diagnosis should be considered in this scenario?
Fat embolism syndrome
The classic triad of symptoms is: acute respiratory failure, global neurologic dysfunction an da petechial rash.
Usual cause of death is ARDS and 20% mortality rate. May occur 1-2 days after injury or intramedullary nailing.
When assessing indications for thoracotomy in trauma arrest patients, signs of life in the field or on arrival in the ED include:
Blood pressure
Pulse
Cardiac rhythm
Respiratory effect
Echo cardiac activity or tamponade
Others include reactive pupils and spontaneous movement
Sensory loss on the chest or abdomen is presumptive evidence of ___
Spinal cord injury / involvement
What percent of patients with a c-spine fracture have a second, noncontiguous vertebral fracture?
10%
If one fracture is present, complete radiographic screening of the entire spine is needed
Which reversible conditions can mimic the appearance of brain death?
Hypothermia
Barbiturate coma
Baclofen and benzodiazepine OD
What should you be looking ofr on AP and lateral films of the thoracic and lumbar spine in trauma patients?
AP: vertical alignment of the pedicles as well as the distance between them (unstable fractures commonly cause widening of the interpedicular distance)
Lateral: subluxations, compression fractures and Chance fractures
Patients in hypovolemic shock are usually ___ while those in neurogenic shock are typically ___
Hypovolemic shock = tachycardic
Neurogenic shock = bradycardic
CT scanning of the thoracic and lumbar spine is particularly useful for detecting which injuries?
Fractures of the posterior elements (pedicles, laminae + spinal processes) and the degree of canal compromise caused by burst fractures
True or false: corticosteroids should not be used to treat head injury (whatever the severity)
True
CRASH Trial - patients given steroids were 18% more likely to die within 14 days than those treated with placebo
In mild traumatic brain injury and no loss of consciousness, a head CT is indicated for:
Focal neurological deficits
Severe headache or vomiting
Age >60 years
Physical signs of basilar skull fracture
CGS < 15
Coagulopathy
Dangerous mechanism of injury
Intoxication
Short term memory deficits
External signs of trauma above the clavicle
Post-traumatic seizure
Important factors for identifying children at low risk for traumatic brain injury after blunt head trauma include:
No loss of consciousness
Normal mental status, GCS = 15
No clinical signs of skull fracture
No history of vomiting and/or severe headache
Fall less than 3 feet (<2 years old), 5 feet (>2 years old)
No non-frontal scalp hematoma in children <2 years old
No seizure
What are the indications for emergent exploratory thoracotomy after initial chest tube is placed?
Blood loss >/= 1,500 mL in the initial chest tube drainage
Blood loss >200 ml/hr for 2-4 hours
Refractory hypotension or cardiopulmonary decompensation
Persistent bleeding requiring serial blood transfusions >/= 50% pneumothorax
Which odontoid fractures are considered unstable?
Type II and III are unstable
Type I is considered stable
What injuries are associated with lap seat belt restraint?
Tear/avulsion of bowel mesentery
Rupture of small bowel or colon
Thrombosis of iliac artery or abdominal aorta
Chance fracture of lumbar vertebrae
Pancreatic or duodenal injury
What is the IOP indication for a lateral canthotomy
An intraocular pressure of 40 mmHg or higher
What are the nexus C-spine rules
99.6% sensitive and 99.9% negative predictive value for presence of fractures if patient meets all the criteria below
No neurological deficits
No spinal midline tenderness
No altered mental status
No intoxication
No distracting injuries
If any criteria are met, consider obtaining CT imaging
What are some physical exam findings that may suggest non-accidental trauma
Multiple injuries in various stages of healing
Injuries in defensive pattern - nightstick fracture, hand injuries
Injuries to protected body locations - inner thighs, genitalia, axilla
Burns of entire hand or foot or buttocks
Lighter or cigarette burns
Bruises to thorax, ears, neck
Bruises on any child less than 4 months
Evidence of neglect, malnutrition, developmental delay
A patient who fell from a ladder and presented with parasthesia and inability to move both upper and lower extremities, now has bradycardia and hypotension
What is the suspected site of injury and treatment?
Patient has neurogenic shock
Most likely cervical or upper thoracic cord injury
Patient requires IV fluids, atropine for severe bradycardia, may need vasopressor support to improve perfusion
In penetrating neck trauma, violation of the ___ muscle is indication for surgical consultation
Platysma
True or false: penetrating abdominal GSW requires immediate operative intervention
False
While transabdominal GSW is usually an indication for OR, stable patients may receive CT scans at surgeon’s discretion for delineation of injuries
What anatomical features place the pediatric population at an increased risk for significant thoracoabdominal organ injury?
The rib cage is more cartilaginous which may result in significant pulmonary contusion in the absence of rib fractures. Abdominal and pelvic organs are less well protected by ribs and pelvic bones. The liver and spleen extend beyond the lower costal margins
Inclusion criteria for canadian c-spine rule
Alert (GCS 15)
Stable
Adult or child >8 years old
hard signs of penetrating neck trauma which indicate need for immediate operative intervention
Airway compromise
Expanding or pulsatile hematoma
Active, brisk bleeding
Hemorrhagic shock
Hematemesis
Neurological deficits
Massive subcutaneous emphysema
Air bubbling through wound
What anatomical landmark separates neck zone I and zone II
Cricoid cartilage
What anatomical landmark separates neck zone II and zone III
Angle of mandible
A patient is complaining of severe chest pain after a high-speed MVC, and portable CXR shows a widened mediastinum. Vitals remain stable. What is the preferred imaging modality to diagnose great vessel injuries?
CT angiography
Define spinal shock
The initial loss of spinal reflexes below the level of cord injury, which is followed by gradual recovery.
Bulbo-cavernosis reflex is among the first to return with resolution of spinal shock (anal sphincter contraction with penis/clitoris stimulation)
