EMED: Block 5 Flashcards

1
Q

___ is the number one cause of death for PTs <46y/o

? are the 3 major causes of death following trauma?

A

Trauma

Head Chest Vascular injury

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2
Q

In what year did Congress pass something important for EMED

What criteria must be met for a facility to be a Level 1 Trauma Center

A

1990
Trauma Care Systems Planning/Development Act

Admit 1200 PTs/year or,
240 w/ severity score >15

Conduct trauma research

Train residents/lead education and outreach activities

Maintain surgically directed critical care service

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3
Q

Prior to PTs arrival to hospital, EMS provides ? info on PT

What 3 things are prepared for in the ER prior to arrival?

A

Sxs Txs Exam Mechanism Injuries VS

Assign team tasks
Prepare equipment
Surgical consults present

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4
Q

Discovery of ? types of injuries during primary survey need immediate attention

A
Flail chest
Tamponade
Massive hemorrhage
Open PTX
Air obstruction
TnPTX
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5
Q

What are the NEXUS rules for C-spine

What mechanisms of injury classify as dangerous for Canadian rules?

A
No neuro deficit
Evidence of ETOH
X distracting injuries
Unconscious
Spine pain midline
High speed MVC
Fall from >3ft
Collision
Axial loading injury
Rollover/ejection
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6
Q

What are the high risk factors of the Canadian Cervical Spine rules that if met need images?

What are the low risk factors that if No, need imaging

If PTs can’t rotate head past ?*, imaging needed

A

Age >65yo
Mechanism was dangerous
Parathesia in extremity

Sitting in ED
Ambulatory at any time
Delayed neck pain
Absent cervical tenderness
Rear end collision

45* L/R

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7
Q

How are Tension PTx, HemPTx and sucking wounds Tx

PTs w/ no breath sounds and suspected massive injury of what criteria need a thoracotomy?

A

T: Needle thoracostomy
H: 36F chest tube
S: occlusive dressing

Initial output >1500mL
>200mL/hr

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8
Q

Class 1 Hemorrhage

Class 2 Hemorrhage

Class 3 Hemorrhage

Class 4 Hemorrhage

A

<750mL/15%
Pulse <100
Normal BP
Norm/Inc pulse pressure

750-1500mL/15-30%
Pulse 100-120
Normal BP
Dec Pulse Pressure

1500-2000ml/30-40%
Pulse 120-140
Dec BP/pulse pressure

> 2000mL/40%
Pulse >140
Dec BP/Pulse pressure

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9
Q

Initial fluid of choice for ER trauma is ?

What is the next step if 2L are pushed and no improvement is seen?

A

LR w/ 18g or larger

Type O blood
Type O- child bearing age

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10
Q

PTs receiving >10 units of PRBCs show decreased mortality when they received ?

What two factors contribute to these PTs coagulopathy

A

FFP : PRBC of 1 : 1

Acidosis
Hypothermia

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11
Q

Define the REBOA

When/why is tranexamic acid used?

A

Resuscitative endovascular balloon occlusion of aorta through common femoral artery for non-compressible torso hemorrhages x 60min

Antifibrinolytic, dec blood loss, prevents plasmin cleavage or fibirin degradation

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12
Q

? PT presentation has a significant head injury until r/o

GCS Motor
GCS Verbal
GCS Eye

A

Appropriate MOI w/ AMS or GCS <15

6- Obey Local W/draw Flex Extend No
5- Orient Confused Word Sound No
4- Spont Verbal Pain No

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13
Q

How do cardiac tamponades lead to death?

How much fluid does it take to cause this?

A

Dec RV/LV filling
Septum shifts to L
Dec CO, shock/death

65-100mL

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14
Q

What is often the only clinical sign of a cardiac tamponade

What finding is an ominous sign

? presenting trifecta is a tamponade until r/o

A

Sinus Tachy

HOTN

Narrow pulse pressure
Inc CVP

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15
Q

When are cardiac tamponade Tx considered futile

PTs presenting w/ abdominal tenderness or distension and HOTN need ?

A
>15m w/out pulse
Blunt trauma arrest
Asystole at presentation
No pulse/BP in field
Non-survivable injury

Immediate transport to OR for Ex-Lap

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16
Q

? image is not needed for PTs w/ gunshots to the abdomen?

What intervention can be used during secondary survey to Tx scalp lacs

A

US/CT, all go to emergent exploratory laparotomy

Raney clips

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17
Q

What two PE findings have to be normal during Secondary Survey prior to placing catheter?

What is done if these requirements are not met?

What 3 areas of the body can be injured and missed during secondary survey

A

Normal prostate
No blood at meatus

Retrograde urethrography

Esophagus Diaphragm Small bowel

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18
Q

What routine labs are ordered?

What orders are added if PT presents w/ AMS?

A
Hgb/Hcg
Drug screen
Urine dipstick
Ethanol
Type, screen

Glucose
>55y/o ECG, troponin

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19
Q

What are the non-invasive methods to airway management?

What are the invasive methods?

A

Passive oxygenation
BVM ventilation
Supraglotic airway
Non-invasive PPV

ET intubation
Cric
Transcutaneous jet
Tracheostomy

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20
Q

Define Hypoventilation

Define Hypoxia

A

Inadequate CO2 excretion

Inadequate alveolar O2 content

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21
Q

What are the two types of respiratory failure

A

Type 1: PE, PNA
Hypoxia w/out hypercapnia; oxygenation affected

Type 2: COPD
Hypoxia w/ hypercapnia; ventilation affected

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22
Q

When are high flow NC best used?

Unconscious PTs create ? airway obstructions while foreign bodies create ?

A

Hypoxia and intact respiratory drive

Upper functional
Mechanical obstructions

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23
Q

What is the key to airway management?

How much O2 is delivered by the 3 types of masks?

A

PT positioning

NC: 2-6L/min
FM: 5-10L/min
Non-rebreath: 10-15mL

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24
Q

Sequence of Tx steps for tension PTx

Sequence of Tx steps for PTs in stable PTs

A

Needle D
Tube thoracostomy

Tube thoracostomy

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25
How do OPAs work and who are they used for How do NPAs work and who are they used for
Prevents tongue from blocking hypopharynx Comatose/deeply obtunded PT w/out gag reflex Displaces soft palate and posterior tongue PTs w/ gag reflex and no midface trauma
26
# Define NIPPV and what this includes This form of airway helps augment for ?
Pos pressure airway through mask w/out ET tubes BiPAP/CPAP Spontaneous respirations
27
Who is the ideal PT for NIPPV methods? These need to be used w/ caution in ? PTs
Protective reflexes Intact ventilation efforts Cooperative HOTN- worsens volume depletion of CO
28
Advantages of NIPPV Disadvantages of NIPPV
``` Reduces work of breathing Atelectic aveoli recruitment Improves pulm compliance Less sedation Shorter hospital stays ``` Barotrauma Alkalosis Inc pressure Trapped air
29
MC use for NIPPV is ? What other instances is it used for?
Cardiogenic pulmonary edema ``` Flail chest Pneumonia Burns COPD Asthma exacerbation Blunt chest trauma ```
30
Supraglottic airways are placed into ? part of the body What PTs can they be used in What are the complications that can arise from using these airways
Oropharynx Apneic Unconscious Laryngospasm Sore throat
31
What do King LTs block to allow for ventilation What complications can arise from using King LTs and LMAs
Prox- posterior oropharynx Dist: esophagus King: tongue engorgement LMA: obstruction, aspiration
32
Tracheal intubation is a cornerstone to emergency medicine and allows ? five benefits What other tests can be done to verify correct placement
``` Conduit Airway Sedation/paralysis Prevents aspiration Aids O2/ventilation ``` Expired CO2 measurement, Gold= good Capnography >30mmHg
33
# Define Mactintosh blade Define Miller blade
Curved blade placed in vallecula, indirectly lifts epiglottis off larynx w/ less trauma/air way stimulation Straight blade, physically lifts epiglottis to see larynx; easier in PTs w/out central incisors
34
What is usually the best PT position for RSI How are these PTs pre-oxygenated
Ear horizontal to sternal notch 100% O2 x 3min w/ NRB at 15L/min
35
Why would adults be pre-treated prior to RSI Why adverse effect is usually seen in Peds
Reflex sympathetic response, harmful in Pts w/ elevated ICP, MI, dissections Vagal responses
36
What are the 3 RSI induction agents
Etomidate- Non-barbituate hypnotic No sympathetic blunting Propofol- Sedative w/ anti convulsant/emetic ability Ketamine- Dissociative/amnesia, only one w/ analgesia
37
Benefits of using Etomidate Caveats of its use
Dec ICP, occular pressure Neutral BP Decreases cortisol Myoclonic jerking Vomit
38
Benefits of using Propofol Caveats to its use
Anti emetic/convulsant Dec ICP HOTN Apnea
39
Benefits of using Ketamine Caveats to its use
Bronchodilator Analgesia Dissociative amnesia Inc BP/secretions Emergence phenomenon
40
What depolarizing neuromuscular blockers are used for RSI paralytics What non-depolarizing neuromuscular blockers are used for RSI paralytics
Succinylcholine- high affinity for receptors and resistant to Ach-esterase Vecu/Rocuronium Compete w/ Ach for receptor and antagonized by anti-cholingerics
41
3 benefits of RSI paralytics What complications arise from using Succinylcholine
Control intracranial HTN Improve mech ventilation Facilitate intubation ``` Bradycardia Apnea Malignant hyperthermia Fasciculations Increased pressures Spasm, masseter ```
42
What are the 3 ventilator methods What are the 3 classifications of TBI by GCS score
Continuous- OR Assisted- resp distress, ED Synchronized Intermittent Mandatory Vent- predetermined rate Mild: 14-15, concussion Mod: 9-13, disability Sev: 3-8, death <48hrs
43
HTN, Hypocarbia and Alkalosis affect cerebral blood flow by causing ? Normal CPP is ? Maintain MAP above ?
Constriction <60mm- lower limit of autoregulation 80mm or higher (85-90 if CV complications)
44
What happens after the primary brain injury during the secondary injury? What is the difference between secondary neurotoxic cascade w/ secondary insults?
Presynapatic glutamate release- activates enzymes, induces mitochondiral damage, death, necrosis Neurotoxic- glutamate Insult: catalysts to neurotoxic damage- HOTN, Hypoxemia, Hyperglycemia, hypercarbia
45
How does brain edema occur
Cellular swelling/cytotoxic edema: large ionic shifts, lost membrane integrity Extracellular damage: BBB breakdown, altered water exchange mechanism
46
# Define Uncal Herniation What type of brain injury can cause this herniation
MC, temporal lobe through medial tentorium to CN3= Ipsilateral Fixed/Dilated pupil Pyramidal tract compression, contralateral motor paralysis Football shape epidural bleed
47
Central Transtentorial Herniation causes ? prominent Sxs What findings can develop later?
Mid-line lesions causing: Bilateral pin point pupil Inc muscle tone* Bilateral Babinski Prolonged hyperventilation Decorticate posture Fixed mid point pupil
48
# Define Cerebellotonsillar herniation Define Upward Transterorial Herniation
Tonsil herniates through foramen magnum: Sudden death Pinpoint pupil Flaccid paralysis* Posterior fossa lesion: Pinpoint pupils Conjugate downward gaze No vertical eye movement
49
PTs presenting to ER w/ ? 4 findings increase concern for brain injuries
Focal neuro deficit Emesis Dec LoC Seizure
50
Single fixed, dilated pupil indicates ? Bilaterally fixed, dilated pupils indicates ? Bilateral pinpoint pupils indicates ?
Intracranial hematoma w/ uncal herniation Tx: STAT decompression Bilateral uncal herniation Inc ICP w/ poor perfusion Atropine use Severe hypoxia Opiates Central pontine lesions
51
# Define Decorticate Posture Define Decerebrate Posture
UE flexion, LE extension Intracranial injury above midbrain Arm extend, wrist/finger flexion w/ internal rotation LE extension Caudal injury
52
Why does hyperventilation need to be avoided in head trauma PTs What range is used to guide airway Txs
Cerebral vasoconstriction PCO2 35-45mmHg
53
PTs presenting w/ head injuries and what two VS findings have 150% inc or mortality What are CT findings of intracranial HTN
SBP <90 Hypoxemia- PaO2 <60 Compressed lat ventricles Attenuation of sulci/gyri Poor grey/white distinction
54
Brain pressure equation When monitoring these PTs keep CPP between ? range to prevent ? end result Maintain SBP and MAP above ?
CPP= MAP - ICP 55-60 >70= organ damage SBP >90 MAP >80
55
Isolated head injuries rarely produce HOTN except ? In order to prevent hyperglycemia, what is the glucose goal range?
Pre-terminal indication 100-180mg/dL 5.55-9.99mmol/L
56
What are the 4 signs of impending transterntorial herniation? What two meds can be used to lower ICP
Neuro deterioration Pupillary dilation Motor posturing Hemiparesis Mannitol Hypertonic saline
57
ICP monitoring is needed w/ normal CTs and PT meets ? criteria An increase of ?mmHg increases a PTs MnM Linear skull Fx w/ overlying lac is categorized as ?
Two of: SBP <90 Age >40y/o Motor posturing >20mm Open Fx
58
Skull Fxs that cross ? have high complication rates? When would IV Vanc and Ceftriaxone need to be given When do these Fxs need surgical repair
Middle meningeal artery Major venous sinus Linear occipital Fxs Sinus involvement Open/depressed Fxs Pneumocephalus Fxs Depression> skull thick
59
MC basilar skull Fxs involve ? 3 structures Presenting indications PT may have Basilar Skull Fx
Petrous temporal bone EAC TM ``` CSF leak Raccoon/Battle Hemotympanium Vertigo Dec hearing/deaf CN7 palsy ```
60
PTs w/ CSF leaks are at risk for ? and need ? ABX What type of cerebral contusions are associated w/ SAH?
Meningitis Ceftriax and Vanc Subfrontal cortex Frontal/temporal bones Occipital lobes
61
When are CT scans more likely to find trauma induced SAH Define Epidural Hematoma What is the classic PT presentation
6-8hrs after injury Blood between skull/dura from blunt trauma to temporal= Fx, meningeal artery disruption Trauma LoC Lucid Rapid decline
62
What causes subdural hematomas Why do these present so much later?
Accel/Decel tearing dural vein Hematoma between dura and arachnoid Venous origin causes slower accumulation
63
What PT populations are more likely to develop subdural hematomas Criteria for these to be categorized as acute and how do they present
Elderly/Alcoholic (atrophy) Peds <2y/o Acute: <14d, unconscious Chronic: >14d, no memory of fall/trauma
64
How doe acute subdural hematomas look on CT scans How do chronic cases look?
Hyerpdense/white crescent, crosses suture lines Hypodense/dark due to metabolized Fe in blood
65
Table Slide 74
Deck Head trauma
66
# Define Diffuse Axon Injury What types of injuries can cause this Severe cases can cause ? to develop rapidly
Axon fiber disruption in white matter/brain stem from sudden deceleration MVC Shaken baby Edema
67
What are the classic CT findings of diffuse axonal injury What holds C1 and C2 together
Punctuate hemorrhage along grey/white junction of cortex/deep structures Odontoid of axis held against C1 w/ Transverse ligament
68
Where do most vertebral column injuries occur at? Spinal cord is continuous w/ ? brain structure and terminates at ? How many pairs of spinal nerves are there
MC: C2 , C5-7 2nd MC: TL transition zone Medulla oblongata L1-2 31- 8C 12T 5L 5S 1C
69
What is the transition zone between the thoracic and lumbar spine This also serves as the transition zone for ? What is the benefit of having a vertebral injury at the TL junction
T11-L2 End of spinal cord to cauda equina roots Partial, no neuro deficits Thoracic injury-complete
70
What are the 4 lines used for plain film reading from ant to post How does the prevertebral thickness change between C-spine vertebrae
Anterior vertebral Posterior vertebral Spinolaminar Posterior spinous C2: 7mm C7: 2cm
71
Anterior Subluxation of C-Spine
MOI: flexion, usually stable Plain films- normal Ligament failure, no Fx Serious injury- fanning at injury level
72
Atlantoaxial dislocation
MOI: flexion, unstable Transverse ligament rupture w/out Fx = direct blow to occiput Dx w/ predental space: >2mm= injury >5mm- rupture
73
Bilateral Interfacetal Dislocation
MOI- flexion, unstable Anterior, superior facet dislocation Xray shows >50% anterior dislocation Locked facet- neuro Sxs Perched facet- no neuro Sxs
74
Simple Wedge/Compression Fx
MOI: flexion, usually stable MC thoracic Fx Fx of superior end plate, spares inferior end plate Isolated- stable Posterior ligament disruption- unstable
75
Spinous Process Avulsion Fx/Clay Shoveler's Fx
MOI: flexion, stable Usually C7 process avulsion from muscle contraction pulling bone via ligamentous complex No neuro compromise
76
Tear drop Fx
MOI: flexion, highly unstable Extreme hyperflexion disrupts ligaments Teardrop= anteroinferior portion of vertebral body displaced by anterior spinal ligament Saggital Fx on CT Causes Anterior Spinal Cord syndrome
77
Lateral Mass Fx
MOI: Flexion-roation, unstable Unilateral facet dislocation pointing to side of dislocation Sever pain, radiculopathy Sxs Brown Sequard syndrome MRA r/o vertebral artery injury
78
Anterior Compression W/ Transverse Vertebral Body Fx
MOI: flexion-distraction, unstable Seat belt injury, lap belt alone causing posterior vertebral wall Fx Chance Fx- T11-L2 zone Fx/ligament distraction Order CT, abdominal injuries common
79
Jefferson Burst Fx of Atlas
MOI: vertical compression, potentially unstable Vertical compression pushes occipital condyles, burst Fx of C1 Order Odontoid xray Sum of lateral masses displacement >7mm= transverse ligament rupture, unstable
80
Burst Fx
MOI: vertical compression, unstable Vertebrae compressed by axial load, fragments displace in all directions
81
Hyperextension dislocation
Extension, unstable Extreme hyperextension tears ALL and intervetebral disc Prevertebral swelling may be only radiographic finding Central Cord Syndrome presentation
82
Hyperextension Tear Drop Fx
Extension, unstable w/ extension ALL avulses from hyper extension Common in older PTs w/ osteoporosis
83
Traumatic Spondylolisthesis
Hangman Fx Extension, unstable C2 pedicles Fx w/ anterior displacement of C2 on C3 Judicial hanging causing hyperextension not seen in suicide hangings No neuro injury
84
Atlanto-Occipital Dissociation
High energy impact, highly unstable UE paralysis, normal LE= Cruciate paralysis
85
Odontoid/Dens Fxs Translational Fx-Dislocation
``` 2 and 3 unstable Combo/high energy Severe cervical pain w/ muscle spasms Radiating pain to occiput En face- can be missed on CT ``` All 3 spinal columns disrupted= severe neuro presentation Absence of unstable rib Fx, above T7 can be stable
86
Transverse sacral Fx cause ? Longitudinal sacral Fx cause ? Central sacral Fxs cause ?
Cauda Equina Syndrome Radiculopathy Incontinence
87
? system splits the spinal column into 3 elements When is a spine Fx considered unstable
Denis column system- ant, mid, post Two regional columns involved
88
Damage to Spinal Cord is a result of what two types of injury What are the two phases of tissue injury that follow?
Mechanical force Vascular/chemical processes Initial: hemorrhage into cord Secondary: tissue degeneration from Na channel, Ca influx and Glutamine release
89
Cell death from spine trauma can happen due to ? trifecta of events? What are the 3 spinal tracts involved in spinal cord lesions
E+ imbalance Cell edema Oxidants Corticospinal Spinothalamic Dorsal column
90
# Define Corticospinal tract Where do these tracts cross over? Damage to these tracts result in ipsilateral findings of ?
Descending motor pathway Lower medulla Weakness Inc DTRs Spasticity Pos Babinksi
91
# Define Spinothalamic Tract What happens when these tracts are damaged
Transmits pain, temp sensations Contralateral loss of pain, temp
92
# Define the Dorsal Column What happens when these are injured?
Vibration, proprioception transmission Ipsilateral loss of senses
93
Since light touch is transmitted through ? and ?, this sensation is not lost unless both are damaged What is the difference in naming of cervical and thoracic nerves
Spinothalamic and dorsal column C: exit foramen above vertebral body (C8 exits below C7) T: exit foramen below vertebral body
94
Spinal immobilization is no longer recommended for ? PTs HOTN in Pts w/ spinal injuries are assumed to be d/t ? until r/o and Tx w/ ?
Fully conscious Isolated penetrating neck injury Neuro intact Blood loss IV crystalloid
95
What types of presenting Sxs from spinal injury indicate a high cervical injury Define Sacral Sparing
Dyspnea Anxiety Palpitations Abdominal breathing Anal wink, anogenital reflex= incomplete spinal cord lesion
96
Define Anterior Cord Syndrome MOIs and findings
Poor prognosis Corticospinal/spinothalamic damage- tear drop fx Direct anterior compression, Flexed cervical spine= Paralysis below lesion Loss of pain/temp Anterior spine thrombosis= proprioception, vibration preserved
97
Define Central Cord Syndrome MOIs and PE findings
Hyperextension Disrupted blood flow Cervical stenosis Quadriparesis, most in UE Loss of pain/temp, most in UE
98
Define Brown-Sequard Syndrome MOIs and PE findings
MC from penetrating trauma Transverse hemisection Unilateral cord compression Ipsilateral spastic paresis Lost proprioception/vibration Contralateral loss of pain/temp
99
? is not a true spinal cord syndrome How can it present? What image is ordered
Cauda equina syndrome ``` Saddle anesthesia Incontinence dysfunction Motor/sensory loss Dec rectal tone Dec LE reflexes Sciatica ``` MRI of lumbosacral spine
100
# Define neurogenic shock How will PT look
Type of distributive shock- lost peripheral sympathetic tone causes vasodilation HOTN, warm, tachy (T1-4 compromise= brady)
101
# Define Spinal Shock How do PTs present What will be the first reflexes to return
Temporary loss of spinal reflex Flaccid, no reflexes, no voluntary movement Delayed plantar/bulbar reflexes
102
Standard C-spine x-rays include what views For a neck x-ray to be "good" what landmarks must be included? What type of view may be needed to visualize the C-T junction
Lat Ant-Post Odontoid C1-7 and Superior T1 Swimmer's- assistant pulls shoulders down during x-ray
103
What do PTs complain of who have cervical ligamentous injuries What imaging is needed for these presentations What is done if this next imaging is not available
Focal neuro w/ normal x-ray/CT Extremity parethesias Persistent/midline pain MRI D/c w/ rigid C-collar and f/u in 3-5 days
104
When is MRI preferred over CT for spinal cord injuries Thoracolumbar Fxs are at high risk for ?
Herniated disc Nerve injury Cord contusion Spinal cord injury Aortic/visceral injuries
105
When can wedge Fxs of the spine be d/c and managed outpatient When are wedge Fxs conisdered unstable Compression Fxs must have ? r/o
<40% loss of height 50% or more loss of height >25% difference between damage/healthy bone Burst Fx- compression of posterior half of vertebrae
106
What is the next step if a pathologic compression Fx is discovered on CXR What criteria must be met to Tx them outpatient
CT Stable wedge compression Fx w/ no neuro compromise
107
? vasopressor is used for CV complications when hemodynamically significant bradycardia What are the MC injured abdominal organs PTs are at risk of dying from ? of from ? if they survive initial trauma
Atropine Liver- MC organ injured Spleen- MC organ injured from sports Hemorrhage Infection, sepsis
108
What is the preferred imaging modality for abdominal trauma work ups? ? is the MC MOI for blunt abdominal trauma ? is the typical intra-abdominal injury
CT w/ contrast MCV Hollow viscous ruptures
109
How do PTs w/ abdmoninal wall contusions present How do these present as they develop?
Pain w/ trunk flexion/rotation Focal tenderness to percussion Carnnets Sign- pain inferior to umbilicus inc w/ sit up
110
Pts w/ splenic injuries complain of ? while liver injuries complain of ? PTs w/ ? two conditions can predispose them to splenic issues
Spleen- L shoulder pain Liver- R shoulder pain Mono Pregnancy
111
Chemical irritation to the peritoneum differs from bacterial contamination in ? way Pancreatic injuries commonly occur from ? MOI
Chemical/Blood- immediate Bacteria- delayed Rapid deceleration- unrestrained drivers, cyclists
112
How do duodenal injuries present What causes duodenal ruptures to occur in trauma PTs w/ delayed presentations usually have ? signs
S/Sxs outlet obstructions- ab pain, distension, vomit High velocity deceleration causing intralumenal pressure increase in pylorus/prox SB Fever, Leukocytosis herald development of abscess/sepsis
113
What causes discomfort when "getting wind knocked out"? Diaphragm ruptures are almost always on ? side
Diaphragm inability to relax L side= herniation/strangulation of abdominal contents
114
What does FAST stand for How long does this take?
Focused Assessment w/ Sonography for Trauma 4min
115
Massive hemoperitoneum is going to first be seen ? on FAST Where is it going to collect first on the opposite side of the body? What is the disadvantage of FAST over CT
Morrison's pouch, RUQ Splenocholic ligament causes accumulation between diaphragm/spleen Can't ID source of bleeds
116
? is the non-invasive gold standard Dx study of choice for abdominal injuries When is this gold standard c/i CT is the ideal study assessment for what two structures?
CT w/ IV contrast PT w/ contrast allergy Pancreas Duodenum
117
What is the gold standard therapy for significant intra-abdominal injuries All PTs w/ persistent HOTN, abdominal wall disruption or peritonitis need ? If abdominal trauma PT is d/c from ER, what are the f/u orders given?
Laparotomy Surgical exploration Fever Inc pain Vomit Sxs of blood loss
118
What are the five roles of medical care in military medicine
1: self/buddy aid to BAS 2: Brigade/Division- first level w/ blood, x-ray/lab, PT hold ability x 72hrs 3: Corps level- full surgical, lab/rad w/ CT, stabilize for evac 4: Definitive care- Longsthool, out of theater, full rehab, tertiary care 5: US hospital, BAMCI
119
What are the 3 phases of care for TCCC These are developed to address preventable causes of death like ?
Care Under Fire Tactical Field Care Casualty Evac Extremity hemorrhage Hemo/Pneumo thorax Hypothermia/coagulopathy
120
What is the only medical care delivered during Care Under Fire What occurs during Tactical Field Care?
Tourniquets Field/Pressure dressings Longest phase, perform primary survey
121
Needle-D during Tactical Field Care is as effective as a chest tube x __hrs What Tx step is allowed here and why
4hrs Permissive HOTN, prevent dislodging formed clots
122
In sequence of preference, what fluids are preferred for use during tactical field care
``` FWB Plasma/PRBC/Platelet Plasma/PRBC Plasma PRBCs Hextend LR/Plasmalyte ```
123
What is in a Combat Pill pack? What other pain and anti-nausea meds may be issued?
Acetaminophen Meloxicam Moxifloxacin Fentanyl Ketamine Ondansetron
124
What ABXs can be substituted for Moxifloxacin if PT is HOTN or AMS? Airway protection is needed for burn PTs w/ burns covering more than __% TBSA
Cefotetan 2gm Ertapenem 1gm 40%
125
How are fluids calculated for burn PTs What is the desired urine output ranges for adults?
40-80kg adults 10mL x %TBSA per hr Every 10kg above 80kg, add 100mL/hr 30-50mL/hr
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Trench foot is AKA ? and progresses through ? Define Hyperemic Phase of Trench foot What sequelae may remain or persist?
Immersion foot- tingle/numb, pale, pulseless, immobile Hours of rewarming, severe burning as sensation returns Anesthesia Gangrene Cold insensitivity Hyperhidrosis
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# Define Chilblains What PT populations are these more common in?
AKA Pernio- mild, uncomfortable inflammatory lesions from long term damp, non-freezing temps Women, kids in UK Raynauds, Lupus
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What is the difference between Chilblains and Trench foot? What meds can be used for Tx
Chilblains rarely has bullae/ulcerations Nifedipine- dilation Pentoxifylline- dec blood viscosity
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# Define Panniculitis How can this present in kids?
Mild necrosis of SQ fat tissue from prolonged temp just above freezing Popsicle cheeks Thigh/butt in equestrian sports
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# Define Cold Urticaria How is it Tx
Hypersensitivity to cold air/water, rarely anaphylaxis Antihistamines Epinephrine
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What is the critical event of frostbite What sequelaes can occur and increase damaged tissue?
Endothelial damage from thawing Thrombosis Ischemia Necrosis Gangrene
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What are the 3 zones of frostbite
Coagulation: most severe, distal damage is irreversible Hyperemia: most superficial, least cellular damage, can recover w/out Tx Stasis: middle area of severe cell damage, possible reversible
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What are the 4 classifications of frost bite severity
1st: "nip"-numb, central pallor, desquamation 2nd: full thickness freeze w/ clear blisters, erythema and edema 3rd: entire thickness into subdermal plexus, hemorrhagic blisters, necrosis, block of wood sensation- begin poor prognosis 4th: deep involvement, mummy skin, loss
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What tests may be ordered for frostbite for prognostic value and therapy guidance What is the most effective and first definitive step for Tx What other steps can be taken for Tx
T-99 bone scan Angiogram after rewarming Rapid rewarming in water 98-102*F (37-39*C) x 20-30min Tetanus Opioid w/ elevation
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Hypothermia begins at ? temp What are the Primary and Secondary causes
<95*F/35*C P: exposure S: impaired regulation
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PTs can lose body heat through what 4 mechanisms What is the sequence of physiological changes that can lead to death
Conduction Convection Evaporation Radiation Constriction Brady HOTN Myocardial irritability
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Body temps below ? put PTs at risk for cardiac arrest What EKG finding is seen at this point
<32*C/89.6*F Osborn J wave
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Why are PTs cooled after ROSC activity If PT is intubated, what is the preferred location to measure body temps?
50% at 28*C 19% at 18*C 11% at 8* C Lower 1/3 of esophagus Bladder/rectal probes
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What are two common DDxs of accidental hypothermia What is the underlying cause if hyperglycemia is present after rewarming?
Intoxication Sepsis DKA Pancreatitis
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Hypothermia PTs in stage ? and serum K levels above ? will not survive When body temp and humidity are over, convection does not remove heat well Temps above ? prevent body from radiating heat to environment
4, 12mmol or higher 32.2*C/90*F and 35% 35*C/95*F
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Hypothalamus loses ability to regulate body temps below ? or above ? Why is there inc sweat production?
<95*F or >104*F Inc cholinergic stimulation
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What medications can interfere w/ body heat removal mechanisms
``` Anticholinergic- Benadryl Diuretics Phenothiazine BBs CCBs Sympathomimetics ```
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PTs are at increased risk for heat injury w/out an acclamation period of ? Define Confinement Hyperpyrexia
7days PTs in cars/boxes
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What are the 4 minor heat injuries What is the major
Head edema Prickly heat Heat cramps Exhaustion Stoke
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Prickly heat is AKA ? How is it Tx What co-infection is common?
Lichen tropics Miliaria rubra Heat rash Antihistamines PO Vitamin C Staph A infection, Tx w/ 1% salicyclic acid
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What catalyst usually presents w/ heat cramps Deficiency of ? E+ can be cause
Fluid replacement w/ hypotonic solutions Na K Mg Cl
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Heat stress is usually due to deficiency in ? ? can be seen here
Water and Na Rhabdo
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How does heat stroke present Since the CNS is vulnerable during this condition, what may be seen?
>104* and AMS Ataxia- early Seizure- common
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What is the temp goal when Tx heat stroke All heat stroke Pts have ? disposition
102.2 Admit
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What is the definitive form of imaging trauma PTs What are the predictors of difficult non-invasive airway management
Head/C-spine: CT w/out contrast Chest/Abdomen/Pelvis- CT w/ contrast ``` BVM= MOANS- Mask seal Obesity/obstruction Age >55y/o No teeth Stiff lungs/chest wall ``` ``` Supraglottic = RODS Restricted mouth opening Obesity/obstruction Disrupted/orted airway Stiff lung/c-spine ```
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What are two types of PTs that would not need RSI prior to intubation? Unconscious PTs create ? obstructions
Deep comatose Cardiac/Respiratory arrest Upper airway
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C/is for using succinylcholine What are the 4 parts of controlling cerebral blood flow
HyperK Burn Denervation Infection Crush >5d old CPP Autoregulation MAP ICP
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Low BP + high ICP= ? What HTN PE finding may not be present if pressure suddenly/rapidly increases?
Low CPP and brain injury Papilledema
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Etomidate Propofol
Neuroprotective Lowers ICP Low risk for adrenal suppression Rapid on/off Anti-seizure HOTN
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Succinylcholine Rocuronium
Avoid in burns/muscle injury Safe for HyperK
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What is the benefit of using Mannitol for ICP control How long does it take for benefits to be seen?
Improves O2 carrying Dec ICP Improves cerebral blood flow, CPP, metabolism Expands plasma volume 30min
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If Mannitol is not available, how much hypertonic saline can be used on adult PTs? Basilar skull Fxs are associated w/ tearing of ? structure leading to ?
250mL over 30min Dura- oto/rhinorrhea
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Basilar skull Fxs can occur anywhere in skull from ? to ? ? is the MC CT abnormality in PTs w/ Mod-Sev TBIs
Cribiform to Occipital condyles Traumatic SAH
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What part of the vertebral column is narrower than other areas increasing change of neuro injury Potentially unstable neck trauma
Thoracic Jefferson burst atlas Fx
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Unstable neck trauma
``` Anterior compression w/ transverse Fx Lateral mass Fx Atlantoaxial dislocation Bilateral interfacet dislocation Burst Fx Hyperextension dislocation Hyperextension tear drop (only w/ extension) Traumatic spondylolisthesis/Hangman Fx Type 2, 3 Odontoid/Dens Fx Translocational Fx ```
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Highly unstable neck trauma Stable
Flexion teardrop Fx Atlanto-occipital dislocaiton Anterior subluxation Simple Wedge/Compression Spinous process avulsion Unilateral facet dislocation
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Reflexes Chance Fx can be mis-Dx as ? ? may be the only clue of blood loss <15% from solid organ injuries
as Wedge Fx Inc pulse pressure
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How much fluid is needed for a FAST exam to be pos Relative reasons blunt trauma PTs need to go to OR?
Abdomen- 250mL Pleural- 20mL Pos FAST/DPL and hemodynamically stable Solid visceral injury, stable PT Hemoperitoneum on CT w/ou clear source
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What are the 3 zones of the aorta How long can REBOA remain in place
1: descending aorta between subclavian/celiac origins 2: between celiac and lowest renal artery 3: lowest renal artery and aortic bifurcation 60min
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Triage of airway Triage of breathing Triage of Circulation
``` Moving Air? Yes- assess No- open airway, reassess Yes- assess No- expectant ``` >30resp/min Yes- immediate No- circulation Weak/absent radial or HR>140 Yes- immediate No- assess mental status Responds to simple commands: Yes- not immediate No- immediate
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Gold is = to 30
tada