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Senoir 21-2 > EM MED TRUAMA > Flashcards

EM MED TRUAMA Flashcards

1
Q

What are the two classifications for respiratory failures

A

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
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2
Q

High flow NC is best in what pts?

A

High-flow NC is best in patients with hypoxia & intact respiratory drive

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3
Q

ADE of using etomidate for induction

A

Myoclonic jerking and SZR in awake pts

No analgesia

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4
Q

ADE of using propofol as an induction agent

A

Apena and HOTN

No analgesia

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5
Q

ADE of using ketamine as an induction agent

A

Increase secretions and BP

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6
Q

ADE of succs

A

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

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7
Q

C/I for Sucs

A

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

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8
Q

C/I for a cric

A

Massive trauma to the larynx or cricoid cartilage?

Damage to the affected structures will make it impossible to perform the procedure properly

Children <12

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9
Q

2 goals of tx for head trauma

A

Prevent HOTN and 2nd brain injury

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10
Q

Uncal hernitation

A

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

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11
Q

Central Transtentorial herniation

A

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

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12
Q

Cerebellotonislar herniation

A

occurs when the cerebellar tonsils herniate through the foramen magnum (brainstem compression)

Pinpoint pupils, flaccid paralysis, and sudden death (mortality 70%)

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13
Q

Upward transtentorial herniation

A

due to a posterior fossa lesion
(upper brainstem compression)

Conjugate downward gaze
Absence of vertical eye movements
Pinpoint pupils

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14
Q

Eye components of the GCS

A

E(4)

4 Spontaneous
3 to verbal
2 to pain
1 no response

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15
Q

Verbal GCS

A

V5

5- Oriented 
4-confused 
3-innapprop words 
2-innapprop noises 
1-no response
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16
Q

Motor GCS

A

Motor (6)

6-Obey commands 
5-Localizes pain 
4-withdrawals from pain 
3-decorticate 
2-decerebate 
1-no response
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17
Q

A pt with a single fixed dilated pupil =

A

Intracranial hematoma with uncal herniation that requires rapid surgical decompression

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18
Q

Pt with bilateral fixed and dilated pupils

A

Increased ICP with poor brain perfusion, bilateral uncal herniation, drug effect (such as atropine), or severe hypoxia

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19
Q

Bilateral pinpoint pupils

A

Opiate exposure or central pontine lesion

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20
Q

In decorticate posturing

Where is the injury

A

Above the level of the midbrain

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21
Q

All patients >65 y/o with trauma above the clavicles get

A

head CT and +/- cervical spine imaging

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22
Q

Primary goals of Head truama MGMT

A

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

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23
Q

Criteria for ICP monitoring in a pt with NML head CT

A

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
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24
Q

How to control head bleeds (external)

A

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

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25
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
26
Define basilar skull fx
Most common basilar skull fracture involves the petrous portion of the temporal bone, the external auditory canal, & the TM
27
Patients with acute CSF leaks are at risk for
meningitis | Antibiotic prophylaxis is recommended
28
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
29
Time frame to detect Sub arch hem
Generally, CT scans performed 6 to 8 hours after injury are sensitive for detecting traumatic SAH
30
Pts most at risk of sub dural hem
Elderly Alcoholic Peds under 2
31
Time frame for chronic Subdural
2 weeks
32
Cause of DAI
Sheering forces (decel injuries)
33
punctuate hemorrhagic injury along the grey-white junction of the cerebral cortex
DAI
34
Tx for penetrating brain trama
Intubate | Treat with prophylactic antibiotics (vancomycin 1gm & ceftriaxone 2gm)
35
33 vertebrae
``` 7 12 5 5 4 ```
36
MC and 2nd MC spinal injuries
Cervical then Thoracolumbar
37
Pairs of spinal nerves
``` 31 pairs of spinal nerves: 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal ```
38
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
39
What is the assoc S/s of sacral fxs
Sacral fractures that involve the central sacral canal can produce bowel or bladder dysfunction
40
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
41
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
42
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
43
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
44
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
45
Anterior cord syndrome
Loss of motor function and pain & temperature sensation distal to the lesion Only vibration, position, and tactile sensation are preserved
46
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 >> 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
47
Brown Sequard Syndrome
Ipsilateral loss of motor function, proprioception, & vibratory sensation, and contralateral loss of pain and temperature sensation Most common cause —> penetrating injury
48
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 ```
49
warm, peripherally vasodilated, and hypotensive with a relative bradycardia
Neuro shock
50
What are the 1st reflexes to return after spinal shock
delayed plantar and bulbocavernosus reflexes are first to return
51
3 views for cervical spine rule out
Lat Ap/pA Odontoid
52
Focal neurologic findings despite normal plain films and/or CT
Ligamentous injury to the c spine
53
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
54
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
55
MGMT for a coccygeal fx
Imaging is not needed to diagnose coccygeal fractures | Treatment is symptomatic: analgesics & rubber doughnut pillow
56
Any blunt trauma patient with diffuse peritonitis who is hemodynamically unstable should be taken to the
Or for urgent Lap
57
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
58
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
59
Abdominal pain /. Injury in preg pt think
Splenic injury
60
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
61
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
62
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
63
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
64
Ideal study to eval duedenal and pancreatic injuries
CT
65
Limit the practice of repeat CT for ab injuries for…
Limit the practice of repeat CT imaging following transfer to another facility whenever possible
66
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
67
3 zones of frost bite injury
Coagulation Hyperemia Stasis
68
Hyperglycemia that persists after rewarming indicates
Hyperglycemia that persists after rewarming may indicate DKA or pancreatitis
69
If the Potassium is above what number.. death is likely in cold injuries
Above 12
70
S. Aureus infection with Prickly heat | Tx with
Desquamate skin with 1% salicylic acid TID
71
Gauge needle for blood products
14 g if available
72
ABX for HOTN or AMS combat pts
Ertapenem Ig Iv
73
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
74
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”
75
define laminar effusion
Density on lateral chest wall NEAR the costophrenic angle Trapped, won’t shift with position changes
76
What should be placed before CXR for diaphram hernias ?
NG tube
77
NML soft tissue size in the C spine
6mm at C2 and 22mm at C6
78
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.
79
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.
80
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
81
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.
82
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
83
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)
84
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
85
What is the NML AFI measuremtn of the spine
The ADI normally 3 mm for adults and 5 mm for children
86
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
87
Most vulnerable area for the L spine
64% occur at the T12-L1 junction | 70% are unaccompanied by immediate neurologic injury.
88
4 major types of L spine injury
compression fractures, burst fractures, seat belt fractures (Chance fractures), and fracture-dislocations.
89
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.
90
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
91
MGMT for Open Book Pelvic injuries
with minimal dislocation of the symphysis may be treated conservatively plate fixation external fixator
92
Pt presents with a shortened, externally rotated, and abducted lower extremity Think
intracapsular (femoral neck) fracture
93
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
94
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
95
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.
96
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
97
MGMT for rib fxs
oral analgesics, encouraging good pulmonary toilet, and use of thoracic epidural analgesia
98
Deterioration of pulmonary function with worsening hypoxia or hypercarbia despite adequate pain control=
endotracheal intubation and mechanical ventilation
99
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
100
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.
101
MGMT for Patients with risk factors for blunt myocardial injury
EKG, if abnormal then Echo. Trend troponins.
102
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)

Senoir 21-2 (77 decks)

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