EM MED TRUAMA Flashcards
What are the two classifications for respiratory failures
Type 1 respiratory failure
- Hypoxia without hypercapnia
- Conditions that affect oxygenation but not necessarily ventilation
PNA, PE
- Treatment focuses on optimizing oxygenation
Type 2 respiratory failure - Hypoxia with hypercapnia - Conditions that affect ventilation COPD - Treatment focuses on optimizing oxygenation & supporting ventilation
High flow NC is best in what pts?
High-flow NC is best in patients with hypoxia & intact respiratory drive
ADE of using etomidate for induction
Myoclonic jerking and SZR in awake pts
No analgesia
ADE of using propofol as an induction agent
Apena and HOTN
No analgesia
ADE of using ketamine as an induction agent
Increase secretions and BP
ADE of succs
Bradycardia, elevated ICP, increased IOP
Hyperkalemia in burns, crush injuries; days after injury
Prolonged apnea with myasthenia gravis
Malignant Hyperthermia -Tx with Dantrolene and ice
Masseter spasm – BVM and dose with non-depolarizing agent Vs cricothyroidotomy
C/I for Sucs
Hyperkalemia (preexisting)
Burns > 5 days old (new literature >3)
Crush injury >5 days old
Infection >5 days old
Denervation injury >5 days old
Preexisting myopathies
C/I for a cric
Massive trauma to the larynx or cricoid cartilage?
Damage to the affected structures will make it impossible to perform the procedure properly
Children <12
2 goals of tx for head trauma
Prevent HOTN and 2nd brain injury
Uncal hernitation
Most common type
Occurs when the uncus of the temporal lobe is displaced inferiorly through the medial edge of the tentorium
Compression of parasympathetic fibers running with CN III
-> Ipsilateral fixed and dilated pupil due to unopposed sympathetic tone
Further herniation compresses the pyramidal tract
-> Results in contralateral motor paralysis (Babinski)
Eventually Bilateral decerebrate (extension) posturing
Central Transtentorial herniation
2/2 mid line lesions in the brain
Bilateral pinpoint pupils
Bilateral Babinski’s signs
Increased muscle tone
Then fixed midpoint pupils, prolonged hyperventilation & decorticate posturing
Cerebellotonislar herniation
occurs when the cerebellar tonsils herniate through the foramen magnum (brainstem compression)
Pinpoint pupils, flaccid paralysis, and sudden death (mortality 70%)
Upward transtentorial herniation
due to a posterior fossa lesion
(upper brainstem compression)
Conjugate downward gaze
Absence of vertical eye movements
Pinpoint pupils
Eye components of the GCS
E(4)
4 Spontaneous
3 to verbal
2 to pain
1 no response
Verbal GCS
V5
5- Oriented 4-confused 3-innapprop words 2-innapprop noises 1-no response
Motor GCS
Motor (6)
6-Obey commands 5-Localizes pain 4-withdrawals from pain 3-decorticate 2-decerebate 1-no response
A pt with a single fixed dilated pupil =
Intracranial hematoma with uncal herniation that requires rapid surgical decompression
Pt with bilateral fixed and dilated pupils
Increased ICP with poor brain perfusion, bilateral uncal herniation, drug effect (such as atropine), or severe hypoxia
Bilateral pinpoint pupils
Opiate exposure or central pontine lesion
In decorticate posturing
Where is the injury
Above the level of the midbrain
All patients >65 y/o with trauma above the clavicles get
head CT and +/- cervical spine imaging
Primary goals of Head truama MGMT
Prevent secondary injury by maintaining cerebral perfusion and oxygenation
Optimize intravascular volume and ventilation
Correct hypoxia, hypotension
Recognize and treat elevated ICP
Consult neurosurgery to evacuate intracranial mass lesions
Treat other life-threatening injuries
Criteria for ICP monitoring in a pt with NML head CT
Consider ICP monitoring for patients with normal head CT scan if two or more of the following criteria are met (consult with neurosurgery):
- Age over 40 years
- Unilateral or bilateral motor posturing
- Systolic blood pressure <90 mm Hg
How to control head bleeds (external)
If direct pressure is not effective, locally infiltrate lidocaine with epinephrine and clamp or ligate bleeding vessels
Before closure, carefully examine wounds to identify foreign bodies, underlying fractures, and galeal lacerations
Skull fractures that are open or depressed, involve a sinus, or are associated with pneumocephalus should be given
antibiotics
vancomycin 1gm IV and ceftriaxone 2gm IV
Define basilar skull fx
Most common basilar skull fracture involves the petrous portion of the temporal bone, the external auditory canal, & the TM
Patients with acute CSF leaks are at risk for
meningitis
Antibiotic prophylaxis is recommended
What is the most common CT finding in pts with moderate to severe TBI
Traumatic subarachnoid hemorrhage is the most common CT abnormality in patients with moderate to severe TBI
Present with headache, photophobia, and meningeal signs
Time frame to detect Sub arch hem
Generally, CT scans performed 6 to 8 hours after injury are sensitive for detecting traumatic SAH
Pts most at risk of sub dural hem
Elderly
Alcoholic
Peds under 2
Time frame for chronic Subdural
2 weeks
Cause of DAI
Sheering forces (decel injuries)
punctuate hemorrhagic injury along the grey-white junction of the cerebral cortex
DAI
Tx for penetrating brain trama
Intubate
Treat with prophylactic antibiotics (vancomycin 1gm & ceftriaxone 2gm)
33 vertebrae
7 12 5 5 4
MC and 2nd MC spinal injuries
Cervical then Thoracolumbar
Pairs of spinal nerves
31 pairs of spinal nerves: 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal
What is the most vulnerable part of the spine
C7-T1 junction
This designation is important because transitional zones sustain the greatest amount of stress during motion and are most vulnerable to injury
What is the assoc S/s of sacral fxs
Sacral fractures that involve the central sacral canal can produce bowel or bladder dysfunction
Define spinal shock
Patients in spinal shock lose all reflex activities below the area of injury, and lesions cannot be deemed truly complete until spinal shock has resolved
Cortiospinal injury
Damage to the corticospinal tract neurons (upper motor neurons) results in ipsilateral clinical findings such as:
Muscle weakness
Spasticity
Increased deep tendon reflexes
Babinski’s sign
Injury to the spinothalamic
When the spinothalamic tract is damaged, the patient experiences:
Loss of pain & temperature sensation in the contralateral half of the body
Dorsal column injury
Injury to one side of the dorsal columns —> ipsilateral loss of vibration and position sense
Light touch is not completely lost unless there is damage to both the spinothalamic tracts and the dorsal columns
What is a sacral sparing spinal injury
“Sacral sparing” with preservation of anogenital reflexes denotes an incomplete spinal cord level, even if the patient has complete sensory and motor loss
Anterior cord syndrome
Loss of motor function and pain & temperature sensation distal to the lesion
Only vibration, position, and tactile sensation are preserved
Central cord syndrome
Usually seen in older patients with preexisting cervical spondylosis who sustain a hyperextension injury
Decreased strength and decreased pain & temperature
(to a lesser degree)
UE»_space; LE
Vibration and position sensation are usually preserved
Spastic paraparesis or quadriparesis can also be seen
Majority will have bowel and bladder control
May be impaired in the more severe cases
Brown Sequard Syndrome
Ipsilateral loss of motor function, proprioception, & vibratory sensation, and contralateral loss of pain and temperature sensation
Most common cause —> penetrating injury
Cauda equina syndrome
Cauda equina syndrome is not a true spinal cord syndrome
Symptoms and signs may include: Urinary retention Bowel and/or bladder dysfunction Decreased rectal tone Saddle anesthesia Variable motor and sensory loss in the lower extremities Decreased lower extremity reflexes Sciatica
warm, peripherally vasodilated, and hypotensive with a relative bradycardia
Neuro shock
What are the 1st reflexes to return after spinal shock
delayed plantar and bulbocavernosus reflexes are first to return
3 views for cervical spine rule out
Lat
Ap/pA
Odontoid
Focal neurologic findings despite normal plain films and/or CT
Ligamentous injury to the c spine
What is the threshold for out pt spinal mgmt
Compression fractures (“wedge” or “anterior” compression fractures)
-If loss of vertebral height is <40%, may be a candidate for outpatient therapy (discuss with the spine surgeon)
If the loss of vertebral height is ≥50% or if the angle between the damaged vertebra and the rest of the spinal column is >25% - 30%, the compression fracture is generally considered unstable
Define chance fx
Occurs via a flexion-distraction mechanism, involves minor anterior vertebral compression and significant distraction of the middle and posterior ligamentous structures
Typical radiographic findings:
- Transverse fracture lucency in the vertebral body
- Increased height of the posterior vertebral body
- Fracture of the posterior wall of the vertebral body
- Posterior opening of the disk space
MGMT for a coccygeal fx
Imaging is not needed to diagnose coccygeal fractures
Treatment is symptomatic: analgesics & rubber doughnut pillow
Any blunt trauma patient with diffuse peritonitis who is hemodynamically unstable should be taken to the
Or for urgent Lap
A palpable mass inferior to the umbillicus think
Rectus hematomas occur from epigastric trauma or injury to the vessels of the abdominal wall
As hematoma develops between the rectus sheath—>pain develops, often a palpable mass inferior to the umbilicus
What is carnetts sign
-Carnett’s sign —> pain increases with tensing the abdominal muscles (pain from abdominal wall or somatic type pain)
NEG: Decreases with tensing; Intra-abdominal source (suggests deeper, visceral pain)
POS: Pain increases or remains unchanged with tensing; suggests myofascial pain source
Abdominal pain /. Injury in preg pt think
Splenic injury
Pancreatic trauma often occurs from
Rapid decel injuries
Unrestrained drivers who hit the steering column or bicyclists (children) who fall against a handlebar are at risk for pancreatic injuries
Abdominal injury with S/s of gastric outlet obstruction
Ab pain+ distention + vomiting
Think
Duedenal injury
Duodenal rupture generally occurs following high-velocity deceleration events where the intraluminal pressure of the pylorus and proximal small bowel rapidly increases
For patients with a delayed presentation, fever & leukocytosis herald the development of an abscess or sepsis
Greatest benefit of the FAST exam
The greatest benefit of FAST is the rapid identification of free intraperitoneal fluid in the hypotensive patient with blunt abdominal trauma
What is the noninvasive gold standard imaging for abd injuries
Abdominopelvic CT with IV contrast is the noninvasive gold standard study for the diagnosis of abdominal injury
Unless the patient has allergy to iodinated contrast
Ideal study to eval duedenal and pancreatic injuries
CT
Limit the practice of repeat CT for ab injuries for…
Limit the practice of repeat CT imaging following transfer to another facility whenever possible
Non op MGMT for Blunt abdominal trauma
Non-operative management is the treatment of choice for hemodynamically stable blunt hepatic and splenic injured patients
Medication induced coagulopathy gets reversed, i.e. vitamin K, PCCs and TXA
3 zones of frost bite injury
Coagulation
Hyperemia
Stasis
Hyperglycemia that persists after rewarming indicates
Hyperglycemia that persists after rewarming may indicate DKA or pancreatitis
If the Potassium is above what number.. death is likely in cold injuries
Above 12
S. Aureus infection with Prickly heat
Tx with
Desquamate skin with 1% salicylic acid TID
Gauge needle for blood products
14 g if available
ABX for HOTN or AMS combat pts
Ertapenem Ig Iv
Rule of 10s
For burns >20% TBSA, first estimate TBSA burned to the nearest 10%
For adults 40-80kg, give IV fluid as follows:
- 10mL x %TBSA burn per hour
- For every 10kg above 80kg, add another 100mL per hr
**Resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock
Monitor urine output and maintain at 30-50ml/hr in adults
Define fissural pseudotumors
Fluid trapped in between layers of a minor fissure - most common
Trapped, won’t shift with position changes
Usually associated with congestive heart failure
“Fluid in the fissures”
define laminar effusion
Density on lateral chest wall NEAR the costophrenic angle
Trapped, won’t shift with position changes
What should be placed before CXR for diaphram hernias ?
NG tube
NML soft tissue size in the C spine
6mm at C2 and 22mm at C6
Jefferson Fx
Atlas (C1, or Jefferson) fractures
5 to 10% of all cervical spine fractures
result from axial loading
usually not accompanied by significant neurologic injury.
Hangman’s fx
Results from axial compression in combination with hyperextension
resulting in bilateral fracture of the pars interarticularis. (c2)
Fractures affecting the ring of the axis
without C2-C3 angulation are stable
and can be treated with immobilization in a Philadelphia collar or a SOMI brace.
Halo-vest immobilization is recommended in unreliable patients or patients with both C1 and C2 fractures.
Clay Shovelers Fx
Spinous process fractures
(Classically at C6-C7)
Isolated spinous and unilateral lamina and pedicle fractures are usually managed nonoperatively with placement in a rigid cervical collar
Tear drop Fxs
Teardrop fractures (Unstable) from severe hyperflexion injury, and the fractured vertebra is usually displaced posteriorly on the vertebra below;
these patients are often quadriplegic.
Bilateral vertebral arch fractures
with complete anterior translation of the vertebral body present with…
radiculopathy (30% of cases),
central cord syndrome (30%),
or an incomplete cord lesion (30%),
with complete cord lesions occurring rarely
Three types of odontoid Fxs
Fractures of the tip (type I) - uncommon
Fractures of the neck (type II) - more common
-often result from a ground-level fall in the elderly.
Fractures at the junction
of the odontoid process and the axis body (type III)
Dddddkhhcd prevertebral soft tissue swelling on the plain cervical radiograph
or subarachnoid hemorrhage at the craniovertebral junction on the CT scan are present.
Think
AtlantoAxial Fx
What is the NML AFI measuremtn of the spine
The ADI normally 3 mm for adults and 5 mm for children
NML value for the BDI of the spine
The basion-dens interval (BDI) normal values for adults are<12 mm on plain radiographs and <8.5 mm on CT
Most vulnerable area for the L spine
64% occur at the T12-L1 junction
70% are unaccompanied by immediate neurologic injury.
4 major types of L spine injury
compression fractures,
burst fractures,
seat belt fractures (Chance fractures),
and fracture-dislocations.
MGMT for L spine fx with (< 50% loss of height or < 30° of angulation) with an intact posterior column
can be treated with analgesics and brief bed rest.
If the loss of anterior height of the vertebral body exceeds 50%,
there is an increased risk of progressive kyphosis;
evaluation with follow-up radiography is indicated.
MGMT for Burst Fx
Early ambulation should be avoided
Indications for the surgical treatment
- Loss of >50% of body height;
- retropulsed bony fragments -narrowing the canal by more than 50%;
- Kyphotic angulation of 25deg. or more
MGMT for Open Book Pelvic injuries
with minimal dislocation of the symphysis
may be treated conservatively
plate fixation
external fixator
Pt presents with a shortened, externally rotated, and abducted lower extremity
Think
intracapsular (femoral neck) fracture
Spleen enlargement on CXR
If the spleen projects well below the 12th posterior rib and/or displaces the stomach bubble toward or across the midline
the spleen is probably enlarged
Solid organ injury with evidence of active bleeding =
should prompt consideration of angiography
Early angiography is a helpful adjunct in managing liver, spleen, and kidney injuries
How should pts be prepped for thoracostomy and laps ?
When trauma patients are brought to the operating room for a laparotomy or thoracotomy, both body regions should be prepped into the operative field.
Indications for surgical MGMT for Chest wall injuries
Most chest injuries (including penetrating) are treated non-operatively
-Fractured ribs, sternum, clavicle
Pulmonary/Cardiac contusion
PTX/hemothorax
The following are treated surgically
- Penetrating with > 1.5L blood loss
- Diaphragmatic rupture
- Aortic transection
- Cardiac tamponade
MGMT for rib fxs
oral analgesics, encouraging good pulmonary toilet, and use of thoracic epidural analgesia
Deterioration of pulmonary function with worsening hypoxia or hypercarbia despite adequate pain control=
endotracheal intubation and mechanical ventilation
Tx for traumatic Chylothorax 2/2 axial injuries of the chest and spine
Tx begins with limiting oral intake of short- and long-chain triglycerides
Vs. TPN with complete abstinence from oral intake
in conjunction with adequate pleural drainage and lung expansion
successful in approximately 50% of cases after 2 to 6 weeks
Operative strategies - only after conservative measures fail
Patients with obvious cardiac tamponade not in imminent arrest
proceed directly to the OR for a sternotomy or pericardial window when not seen on ultrasound.
MGMT for Patients with risk factors for blunt myocardial injury
EKG, if abnormal then Echo. Trend troponins.
Indications for Thoracotomy
Best for patients who deteriorate rapidly
Penetrating trauma- Prehospital CPR of less than 15 minutes
Blunt- Prehospital CPR of less than 10 minutes
Must have organized rhythm to consider (even PEA)
