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Surgery Clerkship > Dr. Pestana's Notes--Trauma > Flashcards

Dr. Pestana's Notes--Trauma Flashcards

1
Q

In which cases will the airway most likely close?

A

expanding hematoma; emphysema in the neck

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2
Q

When is an airway needed? (4 cases)

A

(a) if pt unconscious (GCS

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3
Q

What do you need to do first before dealing with a cervical spine injury?

A

make sure the airway is secured

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4
Q

How is an airway usually inserted?

A

orotracheal intubation using laryngoscope

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5
Q

When an airway in inserted the patient is [awake/asleep].

A

awake

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6
Q

In cervical spine injury, an orotracheal intubation can only be done IF _____.

A

the head is secured and not moved

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7
Q

Use of a fiberoptic bronchoscope is mandatory when securing and airway IF there is _____ present.

A

subcutaneous emphysema in the neck [major disruption of tracheobronchial tree]

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8
Q

If intubation cannot be done via orotracheal or nasotracheal intubation, the quickest and safest way to establish an airway before anoxic injury is to do a _________

A

cricothyroidostomy

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9
Q

Why are docs reluctant to do a cricothyroidostomy in pts younger than 12yo?

A

risk of future laryngeal reconstruction

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10
Q

What are the two requirements to make sure breathing is okay?

A

(1) bilat breath sounds

(2) satisfactory pulse oximetry

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11
Q

Clinical signs of shock.

A

BP under 90mmHg systolic; fast feeble pulse; low urinary output in pt who is pale, cold, shivering, sweating, thirsty, apprehensive

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12
Q

Traumatic shock is caused by [list 3].

A

(1) hemorrhage (2) pericardial tamponade (3) tension pneumothorax

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13
Q

MCC traumatic shock?

A

Hemorrhagic (type of hypovolemic)

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14
Q

List treatment of hemorrhagic shock in (a) big trauma center and (b) all other settings.

A

(a) surgical intervention + volume replacement
(b) other–volume replacement w/ 2L Ringer lactate w/o sugar + packed RBCs until urinary output reaches 0.5-2ml/kg/hr while not exceding CVP of 15mmHg

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15
Q

(a) What is the preferred route of fluid resuscitation in trauma setting? (b) What is the next best? (c) In children under 6yo?

A

(a) 2 peripheral IV lines; 16 gauge
(b) percutaneous femoral vein catheter or saphenous vein cut-down
(c) intraosseus cannulation of proximal tibia

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16
Q

Tx pericaridal tamponade (based on clinical dx and/or sonogram)

A

evacuation of pericardial sac (pericardiocentesis, tube, windo or open thoracotomy) + fluid + blood

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17
Q

Tx tension pneumothorax (based on clinical dx)

A

big needle/IV catheter into pleural space + chest tub connected to underwater seal (both high in anterior chest wall)

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18
Q

Types of hypovolemic shock.

A

hemorrhagic, burns, peritonitis, pancreatitis, massive diarrhea (fluid loss)

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19
Q

Which type of shock has low CVP? High CVP?

A

hypovolemic/vasomotor; pericardial tamponade/tension pneumo/cardiogenic

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20
Q

How do you distinguish pericardial tamponade from tension pneumothorax?

A

PT has no respiratory distress; TP does

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21
Q

What causes cardiogenic shock?

A

massive MI or fulminating myocarditis

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22
Q

Tx cardiogenic shock.

A

circulatory support

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23
Q

Why is Ddx so important in shock?

A

If cardiogenic, increasing fluids + packed RBCs could be lethal

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24
Q

Causes of vasomotor shock.

A

anaphylaxis, high spinal cord transection, high spinal anesthetic

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25
Q

Clinical signs vasomotor shock; tx

A

circulatory collapse (low CVP) in flushed, pink/warm pt; tx vasopressors + fluids

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26
Q

How do you tx a CLOSED linear skull fracture? OPEN?

A

Closed = leave it alone; Open = wound closure

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27
Q

What do all pts w/ head trauma + unconscious get?

A

CT to look for intracranial hematomas [if negative + neuro intact, then can go home if family wakes them up during next 24hrs to eval for coma]

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28
Q

Clinical signs fracture at base of skull.

A

raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind ear

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29
Q

How do you workup fracture at base of skull?

A

assess integrity of cervical spine (big trauma!!); CT

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30
Q

When should naso endotracheal intubation be avoided?

A

fracture at base of skull

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31
Q

What is neurologic damages (3) are caused from trauma? What are tx of each?

A

(1) initial blow [no tx] (2) devo of hematoma that displaces midline structures; tx surgery (3) increase ICP; tx mannitol/furosemide

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32
Q

What is progression of acute epidural hematoma?

A

trauma, unconsciousness, lucid interval and gradual relapsing into coma + ipsi fixed/dilated pupil + contra hemiparesis + decerebrate posture

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33
Q

Tx epidural hematoma

A

emergency craniotomy

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34
Q

Clinical sxs acute subdural hematoma.

A

big trauma, very sick pt who may be asxs at some point + severe neuro damage

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35
Q

Tx subdural hematoma w/ midline structure deviation

A

craniotomy

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36
Q

Tx subdural hematoma w/ no midline structure deviation

A

focus on preventing further damage from subsequent ICP

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37
Q

Tx ICP

A

ICP monitoring, elevate head, hyperventilate, avoid fluid overload, mannitol/furosemide; DO NOT diurese to point of lowering systemic BP; sedation or hypothermia [to dec brain activity/O2 demand]

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38
Q

Goal of tx hyperventilation w/ ICP is to get PCO2 to ____.

A

35mmHg

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39
Q

CT scan of diffuse axonal injury shows:

A

diffusing blurring of gray-white matter interface w/ multiple punctate hemorrhage

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40
Q

Tx DAI

A

prevent further damage from inc ICP [surgery if any hematoma]

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41
Q

Chronic subdural hematoma is seen in ____ or in _____

A

severely old; chronic alcoholics

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42
Q

Cause of chronic subdural hematoma

A

shrunken brain + tearing of venous sinuses

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43
Q

Dx and tx chronic subdural hematoma

A

CT; surgery

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44
Q

Hypovolemic shock ____ happen from intracranial bleeding. This is because ____

A

CANNOT; there isn’t enough space inside head for amt blood loss to produce shock

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45
Q

Penetrating neck trauma requires surgical exploration in the following cases (4)

A

(1) expanding hematoma
(2) deteriorating vital signs
(3) signs of esophageal/tracheal injury [coughing/spitting blood]
(4) GSW of middle zone of neck

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46
Q

GSW Dx in (A) upper zone (B) middle zone (C) base of neck

A

(A) arteriography dx and appropriate tx
(B) surg exploration
(C) arteriography, esophagogram (+ barium if negative), bronchoscopy [all prior to surgery]

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47
Q

Stab wounds w/ asxs Tx (A) upper zone (B) middle zone

A

(A/B) safely observed

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48
Q

In ALL patients w/ severe blunt trauma to the neck, must do these 2 things

A

(1) check integrity of cervical spine

(2) check neurological deficits

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49
Q

Must use CT imaging with severe blunt trauma to the neck in 2 scenarios

A

(1) signs of neuro deficits

(2) neuro intact but pain to local palpation over cervical spine

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50
Q

Clinical sxs Brown-Sequard (typically from clean-cut injury, like a knife)

A

ipsi paralysis and proprioception loss; contra pain/temp loss

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51
Q

Clinical sxs Anterior Cord Syndrome (from burst fractures of vertebral bodies)

A

loss motor/pain/temp function distal to injury; vib/proprioception preserved

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52
Q

Clinical sxs Central Cord Syndrome (elderly w/ forced hyperextension of neck; MVA)

A

paralysis + burning pain in upper extremities w/ preserved most functions of LEs

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53
Q

Best imaging for spinal cord injuries; potential medical tx (besides surgery)

A

MRI; high-dose corticosteroids (dec inflammation post-trauma)

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54
Q

Describe progression of rib fracture in elderly, leading to death.

A

fracture–>pain–>hypoventillation–>atelectasis–>pneumonia–>death

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55
Q

Tx rib fracture

A

local nerve block or epidural catheter

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56
Q

Cause of pneumothorax; sxs

A

broken rib or penetrating weapon; SOB, absence breath sounds on affected side w/ hyperresonant to percussion

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57
Q

Workup of pneumothorax

A

CXR + chest tube (placed anterior, high) and connect to underwater seal

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58
Q

Tx hemothorax if (A) lung (most common) source of bleeding (B) intercostal artery/systemic vessel source of bleeding

A

(A) blood evacuated via chest tube (placed low); usually stops by itself (B) thoracotomy

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59
Q

Indication for surgery to tx hemothorax (2)

A

(1) >1500mL immediately post-chest tube placement

(2) >600mL/6hrs post-chest tube placement

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60
Q

What are the three main “hidden injuries” and subsequent dx in severe blunt trauma to the chest?

A

(1) pulmonary contusion; CXR + blood gases
(2) MI; EKG + cardiac enzymes
(3) transection of aorta; CT angio (most common)

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61
Q

Clinical sxs of sucking chest wound (which can eventually develop into tension pneumothorax)

A

a flap that sucks air with inspiration and closes during expiration

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62
Q

Tx sucking chest wound

A

occlusive dressing that allows air out (taped 3 sides) but not in

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63
Q

Cause of flail chest; “paradoxical breathing”

A

w/ multiple rib fractures; segment of chest wall caves in during inspiration and bulges out during expiration

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64
Q

Underlying problems of flail chest

A

pulmonary contusion, possible transection of aorta

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65
Q

Basic tx pulmonary contusion

A

fluid restriction (lung sensitive to fluid overload) + diuretics + monitor blood gases

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66
Q

Tx if broken rib punctured lung, requiring respirator

A

bilateral chest tubes

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67
Q

Clinical sxs pulmonary contusion

A

deteriorating blood gases, “white out” on CXR

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68
Q

Pulmonary contusion can show up on CXR at two different times…

A

(1) right away (2) up to 48hrs later

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69
Q

Sternal fractures should make one suspect of ______, detected by ____

A

myocardial contusion; EKG/troponins

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70
Q

Tx of myocardial contusion

A

prevent complications, like arrhythmias

71
Q

Signs of traumatic rupture of diaphragm; dx test for suspicious cases

A

bowel on LEFT side in chest; laparoscopy [CXR first]

72
Q

MC location of traumatic rupture of aorta; MCC

A

junction of arch and descending aorta; deceleration injury

73
Q

Sxs traumatic rupture of aorta

A

asxs until hematoma contained by adventitia ruptures; wide mediastinum

74
Q

Fractures in chest bones that are “hard to break” (1st rib, scapula, sternum) suggest possible ____

A

traumatic rupture of aorta

75
Q

Dx traumatic rupture aorta

A

CT angio (MC), transesophageal echo, MRI angio

76
Q

Post-trauma subcutaneous emphysema in upper chest and lower neck or a large “air leak” from a chest tube suggests which morbidity?

A

traumatic rupture of trachea or major bronchus

77
Q

Dx traumatic rupture of trachea or major bronchus

A

CXR (air in tissues), fiberoptic bronchoscopy (+ intubation to secure airway)

78
Q

Tx traumatic rupture of trachea or major bronchus

A

fiberoptic bronchoscopy (+ intubation to secure airway) then surgery

79
Q

Ddx of subcutantous emphysema

A

(1) traumatic rupture of trachea or major bronchus
(2) rupture of esopohagus (post-endoscopy)
(3) tension pneumothorax (+shock and respiratory distress)

80
Q

Sudden death in a chest trauma pat who is intubated and on a respirator suggests ____, leading to ______.

A

air embolism; cardiac arrest

81
Q

What happens when subclavian vein opened to air (supraclavicular node biopsies, CVP lines)

A

can cause air embolism

82
Q

Tx/prevention possible air embolism

A

tx=cardiac massage w/ pt positioned w/ left side down; px = Trendelenburg position when entering great veins at base of neck

83
Q

In a pt w/o chest trauma, a fat embolism can produce ______.

A

respiratory distress

84
Q

MCC fat embolism

A

multiple trauma + several long bone fractures

85
Q

Sxs fat embolism

A

petichial rashes in axillae and neck; fever, tachycardia, low plt; respiratory distress + hypoxemia + bilateral patchy infiltrates on CXR

86
Q

Tx respiratory distress due to fat embolism

A

respiratory support

87
Q

Dx fat embolism

A

CXR (bilateral patchy infiltrates), fat droplets in urine

88
Q

GSW below level of nipple requires ____

A

exploratory laparotomy

89
Q

In select cases involving low-caliber GSW to ____ quadrant, conservative therapy w/ close follow-up w/ [imaging] can be used

A

RUQ; serial abdominal CT scans

90
Q

Penetrating stab wounds (with protruding viscera) require exploratory laparotomy; also if ____ or _____ develop

A

hemodynamic instability; peritoneal inflammation

91
Q

When does blunt trauma to the abdomen require exploratory laparotomy?

A

with peritoneal inflammation [acute abdomen]

92
Q

What main signs (3) indicate internal bleeding in blunt abdominal trauma?

A

hypovolemic shock, low CVP, no obvious external blood loss source; [lower BP, low UOP]

93
Q

Clinically, what does a pt w/ internal bleeding look like? How much volume loss would cause this?

A

cold, anxious, shivering, thirsty, diaphoretic [lower BP, low UOP]; >1500mL (25-30%)

94
Q

Which (4) places can accommodate >1500mL blood loss [causing hypovolemic shock] and can be unnoticed grossly?

A

(1) abdomen (2) thighs (from femur fracture) (3) pelvis (4) pleural cavities (seen on CXR); UE/LE and neck can be noticed grossly

95
Q

In the initial survey of a trauma pt, which 2 places are always checked as potential causes that could lead to hypovolemic shock?

A

femurs and pelvis

96
Q

Dx intraabdominal bleeding from blunt abd trauma; most common injury sites (2)

A

CT scan; spleen (MC significant blood loss) or liver (MC bleeding overall)

97
Q

Tx for pt w/ minor injuries that responds to fluid resuscitation.

A

watch

98
Q

Tx pt w/ major injuries that DOES NOT respond to fluid resuscitation

A

surgery

99
Q

Major limitation of a CT scan in injury

A

can only be done in HEMODYNAMICALLY STABLE pt (also takes about 45min)

100
Q

Dx of hemodynamically UNSTABLE pt having blood in peritoneal cavity in ER/OR w/ resuscitation efforts underway (2 techniques)

A

(1) diagnostic peritoneal lavage (DPL)
(2) sonogram (FAST)
[both only give yes/no answer if blood present; if yes, do exploratory laparotomy]

101
Q

Major limitation of Focused Abdominal Sonogram for Trauma (FAST)

A

operator-dependent

102
Q

Hint that blunt abd trauma has ruptured spleen

A

fractures of lower ribs on LEFT side

103
Q

Why make every effort to repair spleen; in which population in particular

A

has immunologic function; children

104
Q

What do you give for prophylaxis in asplenic pts?

A

postoperative immunization against encapsulated bacteria [pneumococcus, HiB, meningococccus]

105
Q

Empirical Tx of coaggulopathy during prolonged abd surgery for multiple trauma w/ multiple transfusions

A

platelet packs + FFP (about 10 units each)

106
Q

Tx coaggulopathy + hypothermia or acidosis

A

laparotomy must be terminated; packing bleeding surfaces and temporary closure; must wait

107
Q

Abdominal Compartment Syndrome (Occult Syndrome)

A

when lots of fluid/blood given during prolonged sx; tissues swollen so cannot close abd wound w/o tension

108
Q

Tx Abdominal Compartment Syndrome

A

temporary cover over abd contents (absorbable mesh or nonabsorbable plastic) to be removed later

109
Q

Pt SECOND day post abd operation w/ abd distention and retention sutures cutting through tissues can cause (2 things).

A

[ACS] (1) hypoxia secondary to inability to breathe and (2) renal failure from pressure on vena cava

110
Q

Tx up to SECOND day post abd operation w/ ACS

A

abd surgically opened and temporary cover provided

111
Q

Any pt who is predisposed to consumption coagulopathy, hypothermia or ACS should be surgically tx w/ the following 4 steps before doing rest of resuscitation:

A

(1) clamp the bleeders
(2) temporarily occlude damaged viscera
(3) clean up contamination
(4) get out of there [can go back at later date]

112
Q

Pelvic hematomas are typically left alone if they are ______

A

NOT EXPANDING

113
Q

Which injuries must be ruled out in pelvic fracture pt (4)?

A

rectal, bladder, vagina/urethra (retrograde urethrogram)

114
Q

Best tx pelvic hematoma w/ hypovolemic shock

A

pelvic fixators + IR for angiographic embolization of BOTH internal iliac arteries; also transfusion if necessary

115
Q

_____ indicates a urologic injury

A

Blood in the urine

116
Q

Tx Penetrating urologic injuries

A

surgically exploration + repair

117
Q

If blunt injury affects the kidney, usually underlying cause is ______. If blunt injury affects the urethra or bladder, the underlying cause is ______.

A

lower rib fracture; pelvic fracture

118
Q

Urethral injury is MC in [M/F]. Dx?

A

Men; retrograde urethrogram

119
Q

What is 100% contraindicated in urethral injury?

A

Foley insertion

120
Q

Clinical sxs of urethral injury

A

blood at meatus, scrotal hematoma (posterior), obstructive micturition, “high-riding” prostate

121
Q

Dx bladder injury; what are you looking for?

A

retrograde cystogram w/ POSTVOID films; looking for extraperitoneal leaks at base of bladder [may be obstructed when bladder is full]

122
Q

Tx bladder injury causing intraperitoneal leaks

A

sx repair + suprapubic cystostomy

123
Q

Dx renal injuries; MC Tx

A

CT scan; medical tx only [no surgery]

124
Q

Damage to the renal _____ can cause the development of a kidney AV-fistula, leading to congestive heart failure

A

pedicle

125
Q

Fracture of the penis can consist of fracture of ____ or _____.

A

corpora cavernosa; tunica albuginea

126
Q

Sxs of fracture of penis

A

large penile shaft hematoma w/ nml glans

127
Q

Tx fracture of penis; why is this emergent?

A

emergency surgery; if not, AV shunts will develop, causing impotence

128
Q

What is the main concern regarding penetrating injuries of extremities?

A

whether vascular injury has occurred or not

129
Q

Tx penetrating injury of leg w/ NO vascular injury

A

tetanus prophylaxis + cleaning wound

130
Q

Tx asxs pt w/ penetrating injury of leg NEAR major vessels

A

tetanus prophylaxis + cleaning wound + CT angio/US

131
Q

In which sequence do you treat an injury w/ damaged arteries, nerves and bone?

A

(1) stabilize BONE
(2) delicate VASCULAR repair (otherwise would be damaged by bone movement)
(3) NERVES

132
Q

Tx vascular injury of LE/UE causing hematoma

A

fasciotomy (prevent compartment syndrome)

133
Q

______ can produce a large cone of tissue destruction requiring debridements/amputations

A

High-velocity GSWs [military, big-game hunting]

134
Q

4 major concerns in crushing injury of LE/UE

A

(1) hyperkalemia
(2) myoglobinemia/myoglobinuria
(3) renal failure
(4) potential compartment syndrome

135
Q

Tx of hyperkalemia and myoglobinemia-myoglobinuria-renal failure from crushing injury

A

fluids, osmotic diuretics (mannitol), alkalinization of urine

136
Q

Tx for all Chemical Burns

A

massive irrigation

137
Q

[acidic/alkaline] burns are worse than [acidic/alkaline] burns

A

ALKALINE (Drano, liquid plumber); ACIDIC (battery acid)

138
Q

______ burns are always deeper and worse than they appear.

A

High-voltage electrical

139
Q

4 main concerns of high-voltage electrical burns

A

(1) myoglobinemia-myoglobinuria-renal failure
(2) orthopedic injuries secondary to massive muscle contraction
(3) late development of cataracts
(4) late development of demyelinization syndromes

140
Q

Most common orthopedic injuries secondary to massive muscle contraction

A

posterior shoulder dislocation; compression fractures of vertebral bodies

141
Q

Dx of respiratory (inhalation) burns

A

clinical signs of soot around mouth/throat; fiberoptic bronchoscopy (see whether respirator needed); arterial blood gases & carboxyhemoglobin levels

142
Q

Tx of respiratory (inhalation) burns

A

intubation if obstructed airway; 100% O2 (for inc carboxyhemoglobin); +/- respirator

143
Q

______ burns can cause cutoff of blood supply as edema accumulates underneath unyielding eschar.

A

Circumferential

144
Q

Tx circumferential burns

A

escharotomies (at bedside w/ no anesthesia)

145
Q

Tx severely burned pt

A

fluid replacement

146
Q

In severe burns, ____ moves from circulation and is trapped in the burn site.

A

plasma

147
Q

Explain the “Rule of 9s” in aldult burn patients

A

9% body surface area each to head, each UE, 2x for each LE, 4x for trunk

148
Q

How do you calculate amt (mL) RL infused in first 8hrs in severely burned patients using the “Rule of 9s”?

A

(“Rule of 9s” burned body surface area) x (wt in kg) x (about 5) = mL RL

149
Q

In severely burned pts, no fluids are needed on the ____ day because plasma trapped in burn edema is reabsorbed, causing a large diuresis.

A

third

150
Q

What are the 2 goals for fluid tx in severely burned pts?

A

approximately hourly UOP 1-2mL/kg/h and CVP ≥ 15mmHg

151
Q

A predetermined rate of 1000mL/h RL (w/o sugar) is given to adults whose burns exceed greater than _____ of body surface, then adjusted to meet UOP demands.

A

20%

152
Q

Sugar is avoided in RL because it could cause ____, invalidating the hourly UOP.

A

osmotic diuresis (from glycouria)

153
Q

Explain the “Rule of 9s” in baby burn pts. Why is this different?

A

9% body surface area– 2x for head, 3x for 2 legs, one per arm, 4x for trunk; babies have big heads!

154
Q

Explain appearance of third-degree burns in (A) babies and (B) adults

A

(A) deep bright red (B) leathery, dry, gray

155
Q

Because babies need more fluid than adults, the appropriate initial rate of fluid admin is _______ if the burn exceeds _____ of body surface area.

A

20mL/kg/hr; 20%

156
Q

Topical agents for burn patients include ___ for more superficial burns and ___ for deeper ones.

A

silver sulfadiazine; mafenide acetate (can hurt and produce acidosis)

157
Q

Tx burns near eyes

A

triple abx ointment

158
Q

High-cal/high-nitrogen diets [NG or TPN] for a couple of days. After _____ wounds that haven’t regenerated are grafted. Rehab starts on ____ day.

A

2-3 weeks; FIRST

159
Q

Normally, early excision and grafting of wound of extreme burn pt has a burn that is [2 characteristics]

A

(1)

160
Q

Tx for ALL BITES

A

tetanus prophylaxis + wound care

161
Q

When might it be good to start rabies immunization for a dog bite?

A

When it bites you near your face (if you are at all unsure it has rabies)

162
Q

When is rabies prophylaxis mandatory? What does it consist of?

A

unprovoked dog bite/wild animal bite where animal cannot be killed and brain examined; immunoglobulin + vaccine

163
Q

How do you know a snakebite was poisonous?

A

local pain, swelling and discoloration w/in 30 min of bite

164
Q

Labs needed if someone got snakebite

A

blood typing, crossmatch, coagulation studies, LFT, RFT

165
Q

Tx if rattlesnake [crolatid] bites you

A

CROFAB

166
Q

Antivenin dosage related to size of ______. If no antivenin, first aid is to _____.

A

envenomation; splint extremity during transport

167
Q

_____ snakes have a neurotoxin that needs specific antivenin stat!

A

Coral [“red on yellow, kill a fellow”]

168
Q

Bee stings can kill via ______. Tx w/ ____.

A

anaphylaxis and hypotension caused by vasomotor shock (pink and warm); epinephrine

169
Q

Sxs from Black Widow Spider bite

A

nausea, emesis, severe generalized muscle cramps

170
Q

Tx Black Widow Spider bite

A

IV calcium gluconate +/- muscle relaxants

171
Q

Sxs Brown Recluse Spider bite

A

next day–skin ulcer w/ necrotic center and surrounding erythema

172
Q

Tx Brown Recluse Spider bite

A

Dapsone +/- surgical excision if >1wk (also skin grafting)

173
Q

______ bites are the dirtiest bites and require extensive irrigation, debridement and specialized orthopedic care.

A

Human [sharp cut over knuckles after punch in mouth]

Surgery Clerkship (7 decks)

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