Crawford - Trauma Flashcards
Definition of trauma
Physical damage to living tissue caused by extrinsic forces, often violence, accident, etc.
Describe timing and causes of death in triphasic disease.
1st phase – Seconds to minutes; deaths due to major or severe injuries
2nd phase – Minutes to hours; deaths due to treatable but life-threatening injuries
3rd phase – Days to weeks; deaths due to multiple organ system failure or infection
80% of trauma deaths occur when?
first hour after injury
“Lethal triad” seen in ER
hypothermia -> coagulopathy -> acidosis -> hypothermia…
What is the primary survey?
ABCDE
Quickly assess vital functions and intervene
What is secondary survey?
“Head to toe, treat as you go”
H&P exam
Every square cen/meter
“A finger or tube in every orifice”
Initial XR in ER trauma
Cross table C-spine, pCXR, Pelvis
When is FAST (Focused Abd Sonogram for Trauma) used? What is specifically examined?
Unstable patient in ED
Rapid U/S looking for blood or fluids around heart or in abdomen
4 views: perihepatic space, perisplenic space, pericardium, bladder/pelvis
Downsides of FAST exam?
High false negative
Operator dependent
Only picks up fluid over 500mL
Poor for use in obese
When to intubate according to GCS?
“less than 8, intubate”
Signs of basilar skull fracture
Battle’s sign
Hemotympanum
Raccoon’s eyes
Cerebral perfusion pressure = _______ - ________
mean arterial pressure - ICP
In an epidural hematoma, keep cerebral perfusion pressure above _______. How?
65-70 mmHg
with pressors (vasopressin, norepi, epi, dopamine)
What is Cushing’s Reflex?
HTN and bradycardia = BAD!!!
may occur in response to epidural bleed and elevated ICP
How is elevated ICP treated?
- Seda/on and pain management
- Hypertonic saline 3% - limits 3OM spacing in brain
- Mannitol – diure/c to remove intracellular fluid (osmo/c) 4. Hyperven/la/on- very temporarily
- Chemical paralysis – reduces cerebral oxygen demand
- Surgical procedures – craniotomy vs craniectomy
How to r/o ruptured globe in eye trauma?
good EOM
EOM entrapment is _________ until proven otherwise.
orbital fracture
How to treat retrobulbar hematoma?
emergency lateral canthotomy
LeFort fractures
facial fractures involving the maxillary bone and surrounding structures
Nexus Rules for clearing C-spine precautions and getting XR
No midline tenderness No neurologic deficits
No intoxicants
No distracting injury Normal mental status
If none of the above criteria present, C-Spine cleared and imaging is not required.
Spinal fracture management
Immobilization - NOT traction
Chance fracture
- Complete anterior-posterior spinal fracture
- Unstable fracture
- High association with mesenteric or bowel injury
What is SCIWORA?
Spinal cord injury without obvious radiographic abnormality
young adult with sudden CVA symptoms =
Carotid Artery Dissection
Why give anticoagulation in carotid artery dissection?
prevent embolic stroke
Typical location of aortic disruption? Why?
ligamentum arteriosum due to rapid deceleration
Signs of aortic disruption on PE and XR
Difference of +10mmHg between R/L arms should raise suspicion
CXR demonstrates widened mediastinum, apical capping, or tracheal displacement
Treatment of aortic disruption
Emergent aor/c repair (endovascular) or replacement
Treatment of open pneumothorax
cover hole on 3 sides
Treatment of tension pneumothorax
EMERGENCY needle decompression
Late signs of tension pneumothorax
JVD
Tracheal deviation
Location of needle decompression for tension pneumothorax
2nd intercostal space at midclavicular line; advance needle OVER rib
How to do tube thoracostomy?
36 Fr or bigger tube (bigger the better)
Sentinel hole must be within pleural cavity
Output from CT (>1500ml ini/ally, or >200ml/hr) requires surgical exploration
Iatrogenic cause of hemothorax
intercostal vessel injured during chest tube insertion
Sign of diaphragm injury on exam
bowel sounds in chest
Significance of any 1st rib or scapular fractures
require large energy to produce fracture
must look for other injuries even if patient ok
What must be causing a continued large air leak with 2 well-placed chest tubes?
tracheal or bronchial tree injury
Hallmark sign of Pericardial Tamponade
Becks triad - hypotension, muffled heart tones, JVD
What must you think in association with PEA?
Pericardial tamponade
Prophylactic immunizations for splenectomy or higher than Grade III laceration
Izzies for encapsulated organisms: H. flu, Menigococus, Pneumococcus
Abdominal compartment syndrome exam findings
Exam reveals a hypotensive pa/ent, increasing ven/lator resistance, diminished urine output, with a
firm abdomen, and significantly elevated bladder pressures >30mmHg
Treatment of abdominal compartment syndrome
laparotomy (open abd) even if in ED or ICU - can’t wait!!!
All open fractures require what treatment?
antibiotics
What should always be eval’d on a fall from height injury?
entire spine and bilateral calcanei
Treatment of pelvic fractures
“close the book”, Sam-Sling, sheet, external fixation, surgical repair
What urethral injuries require RUG before advancing a catheter?
Blood at the meatus, high-riding prostate, or perineal ecchymosis
Fat embolism syndrome characterized by what symptoms?
petechial rash, confusion, hypoxia, bilateral pulm infiltrates, microfat in urine
If vascular injury suspected, then what should be checked?
Ankle/Brachial index
ABI less than 0.90 needs further eval
What is occluded in compartment syndrome?
arterial blood flow to contained space
Pain out of proportion to exam with absent pulse and pallor of extremity =
compartment syndrome
How is compartment syndrome treated?
Fasciotomy
Best method of hemorrhage control? other options?
Direct pressure and elevation
others: Tourniquet, Cautery, Suture
Where can you lose enough blood to bleed to death?
“CARTS” = Chest, Abdomen, Retroperitoneum, Thigh, Street (at the scene)
Rule ratio for massive blood transfusion
1:1:1:1 Rule (try to make whole blood) - plasma, platelets, RBCs
______ is narrowest part of pediatric airway, whereas ______ is narrowest part in adults.
cricoid
vocal cords
Rule for trauma in a pregnant patient
Treat the mother = save the fetus
Important positioning of pregnant patient
prop on right side or roll backboard to keep uterus off the vena cava
First degree vs second vs third
1st: only epidermis affected
2nd: epidermis and dermis; BLISTERS
3rd: dermis destroyed including dermal appendages; no pain or blanching
Rule of 9’s when estimating percentage of body burned
Head = 9 Each arm = 9 Front of each leg = 9 Front of torso = 18 Back of torso = 18
Leading complication in burns, causing high morbidity
infection -> systemic sepsis
Fluid resuscitation treatment in burns
Parkland formula:
% BA x kg x 4mL/hr = total fluid needed in next 24 hrs
1/2 in first 8 hrs and 1/2 in next 16 hrs
NS or LR
How to measure adequate circulation and hemodynamic stability in burn patient? What is normal?
urine output with Foley catheter
at least 0.5 mL/kg/hr in adult
at least 1 mL/kg/hr in child
When is escharotomy indicated?
in circumferential burns of extremities or anterior trunk where there is risk for compartment syndrome
Most common topical burn ointment
Sulfadiazine (Silvadene)
How to treat minor burn?
Bacitracin and gauze
