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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
Q

Skull fractures that are open or depressed, involve a sinus, or are associated with pneumocephalus should be given

A

antibiotics

vancomycin 1gm IV and ceftriaxone 2gm IV

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26
Q

Define basilar skull fx

A

Most common basilar skull fracture involves the petrous portion of the temporal bone, the external auditory canal, & the TM

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27
Q

Patients with acute CSF leaks are at risk for

A

meningitis

Antibiotic prophylaxis is recommended

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28
Q

What is the most common CT finding in pts with moderate to severe TBI

A

Traumatic subarachnoid hemorrhage is the most common CT abnormality in patients with moderate to severe TBI

Present with headache, photophobia, and meningeal signs

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29
Q

Time frame to detect Sub arch hem

A

Generally, CT scans performed 6 to 8 hours after injury are sensitive for detecting traumatic SAH

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30
Q

Pts most at risk of sub dural hem

A

Elderly
Alcoholic
Peds under 2

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31
Q

Time frame for chronic Subdural

A

2 weeks

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32
Q

Cause of DAI

A

Sheering forces (decel injuries)

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33
Q

punctuate hemorrhagic injury along the grey-white junction of the cerebral cortex

A

DAI

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34
Q

Tx for penetrating brain trama

A

Intubate

Treat with prophylactic antibiotics (vancomycin 1gm & ceftriaxone 2gm)

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35
Q

33 vertebrae

A 
7
12
5
5
4
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36
Q

MC and 2nd MC spinal injuries

A

Cervical then Thoracolumbar

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37
Q

Pairs of spinal nerves

A 
31 pairs of spinal nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
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38
Q

What is the most vulnerable part of the spine

A

C7-T1 junction

This designation is important because transitional zones sustain the greatest amount of stress during motion and are most vulnerable to injury

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39
Q

What is the assoc S/s of sacral fxs

A

Sacral fractures that involve the central sacral canal can produce bowel or bladder dysfunction

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40
Q

Define spinal shock

A

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

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41
Q

Cortiospinal injury

A

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
Q

Injury to the spinothalamic

A

When the spinothalamic tract is damaged, the patient experiences:

Loss of pain & temperature sensation in the contralateral half of the body

43
Q

Dorsal column injury

A

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
Q

What is a sacral sparing spinal injury

A

“Sacral sparing” with preservation of anogenital reflexes denotes an incomplete spinal cord level, even if the patient has complete sensory and motor loss

45
Q

Anterior cord syndrome

A

Loss of motor function and pain & temperature sensation distal to the lesion
Only vibration, position, and tactile sensation are preserved

46
Q

Central cord syndrome

A

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&raquo_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

47
Q

Brown Sequard Syndrome

A

Ipsilateral loss of motor function, proprioception, & vibratory sensation, and contralateral loss of pain and temperature sensation

Most common cause —> penetrating injury

48
Q

Cauda equina syndrome

A

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
Q

warm, peripherally vasodilated, and hypotensive with a relative bradycardia

A

Neuro shock

50
Q

What are the 1st reflexes to return after spinal shock

A

delayed plantar and bulbocavernosus reflexes are first to return

51
Q

3 views for cervical spine rule out

A

Lat
Ap/pA
Odontoid

52
Q

Focal neurologic findings despite normal plain films and/or CT

A

Ligamentous injury to the c spine

53
Q

What is the threshold for out pt spinal mgmt

A

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
Q

Define chance fx

A

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
Q

MGMT for a coccygeal fx

A

Imaging is not needed to diagnose coccygeal fractures

Treatment is symptomatic: analgesics & rubber doughnut pillow

56
Q

Any blunt trauma patient with diffuse peritonitis who is hemodynamically unstable should be taken to the

A

Or for urgent Lap

57
Q

A palpable mass inferior to the umbillicus think

A

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
Q

What is carnetts sign

A

-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
Q

Abdominal pain /. Injury in preg pt think

A

Splenic injury

60
Q

Pancreatic trauma often occurs from

A

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
Q

Abdominal injury with S/s of gastric outlet obstruction
Ab pain+ distention + vomiting

Think

A

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
Q

Greatest benefit of the FAST exam

A

The greatest benefit of FAST is the rapid identification of free intraperitoneal fluid in the hypotensive patient with blunt abdominal trauma

63
Q

What is the noninvasive gold standard imaging for abd injuries

A

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
Q

Ideal study to eval duedenal and pancreatic injuries

A

CT

65
Q

Limit the practice of repeat CT for ab injuries for…

A

Limit the practice of repeat CT imaging following transfer to another facility whenever possible

66
Q

Non op MGMT for Blunt abdominal trauma

A

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
Q

3 zones of frost bite injury

A

Coagulation

Hyperemia

Stasis

68
Q

Hyperglycemia that persists after rewarming indicates

A

Hyperglycemia that persists after rewarming may indicate DKA or pancreatitis

69
Q

If the Potassium is above what number.. death is likely in cold injuries

A

Above 12

70
Q

S. Aureus infection with Prickly heat

Tx with

A

Desquamate skin with 1% salicylic acid TID

71
Q

Gauge needle for blood products

A

14 g if available

72
Q

ABX for HOTN or AMS combat pts

A

Ertapenem Ig Iv

73
Q

Rule of 10s

A

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
Q

Define fissural pseudotumors

A

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
Q

define laminar effusion

A

Density on lateral chest wall NEAR the costophrenic angle

Trapped, won’t shift with position changes

76
Q

What should be placed before CXR for diaphram hernias ?

A

NG tube

77
Q

NML soft tissue size in the C spine

A

6mm at C2 and 22mm at C6

78
Q

Jefferson Fx

A

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
Q

Hangman’s fx

A

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
Q

Clay Shovelers Fx

A

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
Q

Tear drop Fxs

A 
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
Q

Bilateral vertebral arch fractures

with complete anterior translation of the vertebral body present with…

A

radiculopathy (30% of cases),
central cord syndrome (30%),
or an incomplete cord lesion (30%),
with complete cord lesions occurring rarely

83
Q

Three types of odontoid Fxs

A

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
Q

Dddddkhhcd prevertebral soft tissue swelling on the plain cervical radiograph
or subarachnoid hemorrhage at the craniovertebral junction on the CT scan are present.

Think

A

AtlantoAxial Fx

85
Q

What is the NML AFI measuremtn of the spine

A

The ADI normally 3 mm for adults and 5 mm for children

86
Q

NML value for the BDI of the spine

A

The basion-dens interval (BDI) normal values for adults are<12 mm on plain radiographs and <8.5 mm on CT

87
Q

Most vulnerable area for the L spine

A

64% occur at the T12-L1 junction

70% are unaccompanied by immediate neurologic injury.

88
Q

4 major types of L spine injury

A

compression fractures,
burst fractures,
seat belt fractures (Chance fractures),
and fracture-dislocations.

89
Q

MGMT for L spine fx with (< 50% loss of height or < 30° of angulation) with an intact posterior column

A

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
Q

MGMT for Burst Fx

A

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
Q

MGMT for Open Book Pelvic injuries

A

with minimal dislocation of the symphysis

may be treated conservatively
plate fixation
external fixator

92
Q

Pt presents with a shortened, externally rotated, and abducted lower extremity
Think

A

intracapsular (femoral neck) fracture

93
Q

Spleen enlargement on CXR

A

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
Q

Solid organ injury with evidence of active bleeding =

A

should prompt consideration of angiography

Early angiography is a helpful adjunct in managing liver, spleen, and kidney injuries

95
Q

How should pts be prepped for thoracostomy and laps ?

A

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
Q

Indications for surgical MGMT for Chest wall injuries

A

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
Q

MGMT for rib fxs

A

oral analgesics, encouraging good pulmonary toilet, and use of thoracic epidural analgesia

98
Q

Deterioration of pulmonary function with worsening hypoxia or hypercarbia despite adequate pain control=

A

endotracheal intubation and mechanical ventilation

99
Q

Tx for traumatic Chylothorax 2/2 axial injuries of the chest and spine

A

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
Q

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.

A
101
Q

MGMT for Patients with risk factors for blunt myocardial injury

A

EKG, if abnormal then Echo. Trend troponins.

102
Q

Indications for Thoracotomy

A

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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