EM Trauma 1 (general trauma)

Question 1

remarks on trauma

Answer 1

trauma
- leading cause of death among children and adults under 46 y/o

US’ highest fatality rate due to trauma:
-firearms
-suffocation
-drowning / submersion

Question 2

in accordance with the principles of ATLS, inured patients are assessed and treated based on 3 concepts:

Answer 2

1. Treat the greatest threat to life first
2. A detailed history is not essential to begin the evaluation of a patient with acute injuries
3. The lack of definitive diagnosis should never impede the application of an indicated treatment

Question 3

Specifi injuries that should be immeditewly identified and addressed during the primary survey include

Answer 3

airway obstruction
tension pneumothorax
open pneumothorax
flail chest

massive internal or external hemorrhage
cardiac tamponade

Question 4

trauma: if the patient is obtunded….

Answer 4

assume a cervical spine injury until proven otherwise

obtunded = a person sleeps more than usual, responds slowly to verbal or painful stimuli and with incomprehensible verbal responses

Question 5

levels of consciousness

Answer 5

1. normal
2. confused (V4)
3. lethargic (E4)
4. somonolent (E3)
5. obtunded (E3, V2)
6. stuporous (E2 or M5 and below)
7. comatose

Question 6

NEXUS crtieria

Answer 6

National Emergency X-Radiography Utilization Study
1. No posterior midline cervical spine tenderness
2. No evidence of intoxication
3. Alert mental status
4. No FNDs
5. No painful distracting injuries
-failure to meet any one criterion indicates need for cervical spine imaging

Question 7

CCS rule

Answer 7

Canadian Cervical Spine rule

Any high-risk factor that mandates radiography?
-age >64y
-dangerou mechanism
-paresthesias in extremities

Any low-risk factor that allows safe assessmet of range of motion
-simple rear-end collision or
-sitting position in the ED or
-ambulatory at any time or
-delayed onset of neck pain or
-absence of midline cervical spine tenderness

Able to rotate neck actively?
45 degress left and right

No radiography indicated if all criteria are met

Question 8

Essential characteristics of level 1 trauma centers

Answer 8

meet the admission volume requirements
≥1200 trauma patients yearly or
≥240 admissions with an Injury Severity Score of >15

maintain a surgically directed critical care service

participate in the training of residents and be a leader in education and outreach activities

conduct trauma research

Question 9

trauma’s B’s

Answer 9

Inspect thorax and neck for
1. deviated trachea
2. open chest wounds
3. paradoxical chest wall motion
4. crepitus at neck or chest

Question 10

remarks on pulses

Answer 10

(+) carotid pulse means ≥60 mm HG
(+) femoral pulse means ≥70 mmHg
(+) radial pulse means ≥80 mmHg

Question 11

indication for thoracotomy or VATS

Answer 11

Massive hemothorax
initial chest tube output of >1500 mL, or
>200 mL/hour

Question 12

remarks on hemorrhage

Answer 12

hemorrhage of up to 30% of total blood volume may be associated with only mild tachycardia and a decrease in pulse pressure

Question 13

fluid resus in hemorrhage

Answer 13

establish 2 large-bore IV lines - 18 gauge or larger

infuse 2L of LACTATED RINGER’S - fluid of choice

Question 14

Class I hemorrhage

Answer 14

up to 15% blood volume loss
(up to 750 mL)

<100 bpm
normal or increased PP

normal BP

Question 15

Class II hemorrhage

Answer 15

15-30% blood volume loss
(750-1500 mL)

100-120 PR
decreased PP (< 40 mmHg)

Normal BP

Question 16

Class III hemorrhage

Answer 16

30-40% blood volume loss
(1500-2000mL)

120-140 PR
decreased PP

low BP

Question 17

Class IV hemorrhage

Answer 17

> 40% blood volume loss
2 L

> 140 pr
dec PP

low BP

Question 18

MOA of tranexamic acid

Answer 18

antifibrinolytic agent
-prevents cleavage of plasmin and degradation of fibril

Question 19

remarks on tranexamic acid

Answer 19

decreases relative risk of death by
32% if within 1 hour of injury
21% if within 1-3 hours

Question 20

remarks on head trauma

Answer 20

Assume that a patient with a history of head trauma with GCS ≤14 to have significant intracranial injury until proven otherwise

Question 21

remarks on hyperventilation as therapy

Answer 21

mild hyperventilation may reduce intracranial pressure, although at the expense of cerebral vasoconstriction and hypoperfusion

avoid hyperventilation during the first 24 hours after injury when cerebral blood flow is often critically reduced

Question 22

remarks on “exposure”

Answer 22

No primary survey is complete without completely disrobing the patient and examining carefully for occult bruising, laceration, impaled foreign bodies, and open fracutres

logroll: palpate the spinous processes for tenderness or deformity

Question 23

remarks on hypothermia

Answer 23

adverse effects:
-coagulopathy and increased bleeding
-reduced myocardial function

Question 24

remarks on traumatic cardiac arrest

Answer 24

the best outcomes were in patients with stab wounds to the chest

Question 25

remarks on ED thoracotomy

Answer 25

The strongest recommendation for performing ED thoracotomy can be made for patients with penetrating chest trauma with witnessed signs of life during transport to or in the ED and at least cardiac electrical activity upon arrival

there were no survivors among patients with blunt trauma and no respiration or pulse in the field. ED thoracotomy for this group is not indicated (including in the presence of myocardial electrical activity)

Question 26

remarks on urethral meatus

Answer 26

if meatal blood is present or the prostate is displaced, which suggets a urethral injury, perform RETROGRADE URETHROGRAPHY before inserting a Foley catheter

Question 27

Most frequently missed conditions in the secondary survey

Answer 27

orthopedic