EMED: Block 5 Flashcards
___ is the number one cause of death for PTs <46y/o
? are the 3 major causes of death following trauma?
Trauma
Head Chest Vascular injury
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
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
Prior to PTs arrival to hospital, EMS provides ? info on PT
What 3 things are prepared for in the ER prior to arrival?
Sxs Txs Exam Mechanism Injuries VS
Assign team tasks
Prepare equipment
Surgical consults present
Discovery of ? types of injuries during primary survey need immediate attention
Flail chest Tamponade Massive hemorrhage Open PTX Air obstruction TnPTX
What are the NEXUS rules for C-spine
What mechanisms of injury classify as dangerous for Canadian rules?
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
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
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
How are Tension PTx, HemPTx and sucking wounds Tx
PTs w/ no breath sounds and suspected massive injury of what criteria need a thoracotomy?
T: Needle thoracostomy
H: 36F chest tube
S: occlusive dressing
Initial output >1500mL
>200mL/hr
Class 1 Hemorrhage
Class 2 Hemorrhage
Class 3 Hemorrhage
Class 4 Hemorrhage
<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
Initial fluid of choice for ER trauma is ?
What is the next step if 2L are pushed and no improvement is seen?
LR w/ 18g or larger
Type O blood
Type O- child bearing age
PTs receiving >10 units of PRBCs show decreased mortality when they received ?
What two factors contribute to these PTs coagulopathy
FFP : PRBC of 1 : 1
Acidosis
Hypothermia
Define the REBOA
When/why is tranexamic acid used?
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
? PT presentation has a significant head injury until r/o
GCS Motor
GCS Verbal
GCS Eye
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
How do cardiac tamponades lead to death?
How much fluid does it take to cause this?
Dec RV/LV filling
Septum shifts to L
Dec CO, shock/death
65-100mL
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
Sinus Tachy
HOTN
Narrow pulse pressure
Inc CVP
When are cardiac tamponade Tx considered futile
PTs presenting w/ abdominal tenderness or distension and HOTN need ?
>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
? image is not needed for PTs w/ gunshots to the abdomen?
What intervention can be used during secondary survey to Tx scalp lacs
US/CT, all go to emergent exploratory laparotomy
Raney clips
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
Normal prostate
No blood at meatus
Retrograde urethrography
Esophagus Diaphragm Small bowel
What routine labs are ordered?
What orders are added if PT presents w/ AMS?
Hgb/Hcg Drug screen Urine dipstick Ethanol Type, screen
Glucose
>55y/o ECG, troponin
What are the non-invasive methods to airway management?
What are the invasive methods?
Passive oxygenation
BVM ventilation
Supraglotic airway
Non-invasive PPV
ET intubation
Cric
Transcutaneous jet
Tracheostomy
Define Hypoventilation
Define Hypoxia
Inadequate CO2 excretion
Inadequate alveolar O2 content
What are the two types of respiratory failure
Type 1: PE, PNA
Hypoxia w/out hypercapnia; oxygenation affected
Type 2: COPD
Hypoxia w/ hypercapnia; ventilation affected
When are high flow NC best used?
Unconscious PTs create ? airway obstructions while foreign bodies create ?
Hypoxia and intact respiratory drive
Upper functional
Mechanical obstructions
What is the key to airway management?
How much O2 is delivered by the 3 types of masks?
PT positioning
NC: 2-6L/min
FM: 5-10L/min
Non-rebreath: 10-15mL
Sequence of Tx steps for tension PTx
Sequence of Tx steps for PTs in stable PTs
Needle D
Tube thoracostomy
Tube thoracostomy
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
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
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
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
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
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
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
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
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
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
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
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
Benefits of using Etomidate
Caveats of its use
Dec ICP, occular pressure
Neutral BP
Decreases cortisol
Myoclonic jerking
Vomit
Benefits of using Propofol
Caveats to its use
Anti emetic/convulsant
Dec ICP
HOTN
Apnea
Benefits of using Ketamine
Caveats to its use
Bronchodilator
Analgesia
Dissociative amnesia
Inc BP/secretions
Emergence phenomenon
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
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
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
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)
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
How does brain edema occur
Cellular swelling/cytotoxic edema: large ionic shifts, lost membrane integrity
Extracellular damage: BBB breakdown, altered water exchange mechanism
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
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
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
PTs presenting to ER w/ ? 4 findings increase concern for brain injuries
Focal neuro deficit
Emesis
Dec LoC
Seizure
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
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
Why does hyperventilation need to be avoided in head trauma PTs
What range is used to guide airway Txs
Cerebral vasoconstriction
PCO2 35-45mmHg
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
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
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
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
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
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
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
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
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
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
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
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
Table Slide 74
Deck Head trauma
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
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
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
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
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
Anterior Subluxation of C-Spine
MOI: flexion, usually stable
Plain films- normal
Ligament failure, no Fx
Serious injury- fanning at injury level
Atlantoaxial dislocation
MOI: flexion, unstable
Transverse ligament rupture w/out Fx = direct blow to occiput
Dx w/ predental space:
>2mm= injury
>5mm- rupture
Bilateral Interfacetal Dislocation
MOI- flexion, unstable
Anterior, superior facet dislocation
Xray shows >50% anterior dislocation
Locked facet- neuro Sxs
Perched facet- no neuro Sxs
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
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
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
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
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
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
Burst Fx
MOI: vertical compression, unstable
Vertebrae compressed by axial load, fragments displace in all directions
Hyperextension dislocation
Extension, unstable
Extreme hyperextension tears ALL and intervetebral disc
Prevertebral swelling may be only radiographic finding
Central Cord Syndrome presentation
Hyperextension Tear Drop Fx
Extension, unstable w/ extension
ALL avulses from hyper extension
Common in older PTs w/ osteoporosis
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
Atlanto-Occipital Dissociation
High energy impact, highly unstable
UE paralysis, normal LE=
Cruciate paralysis
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
Transverse sacral Fx cause ?
Longitudinal sacral Fx cause ?
Central sacral Fxs cause ?
Cauda Equina Syndrome
Radiculopathy
Incontinence
? 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
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
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
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
Define Spinothalamic Tract
What happens when these tracts are damaged
Transmits pain, temp sensations
Contralateral loss of pain, temp
Define the Dorsal Column
What happens when these are injured?
Vibration, proprioception transmission
Ipsilateral loss of senses
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
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
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
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
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
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
? 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
Define neurogenic shock
How will PT look
Type of distributive shock- lost peripheral sympathetic tone causes vasodilation
HOTN, warm, tachy
(T1-4 compromise= brady)
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
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
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
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
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
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
? 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
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
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
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
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
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
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
What does FAST stand for
How long does this take?
Focused Assessment w/ Sonography for Trauma
4min
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
? 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
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
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
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
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
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
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
What is in a Combat Pill pack?
What other pain and anti-nausea meds may be issued?
Acetaminophen Meloxicam
Moxifloxacin
Fentanyl Ketamine Ondansetron
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%
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
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
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
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
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
Define Cold Urticaria
How is it Tx
Hypersensitivity to cold air/water, rarely anaphylaxis
Antihistamines
Epinephrine
What is the critical event of frostbite
What sequelaes can occur and increase damaged tissue?
Endothelial damage from thawing
Thrombosis Ischemia Necrosis Gangrene
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
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
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 98-102F (37-39C) x 20-30min
Tetanus
Opioid w/ elevation
Hypothermia begins at ? temp
What are the Primary and Secondary causes
<95F/35C
P: exposure
S: impaired regulation
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
Body temps below ? put PTs at risk for cardiac arrest
What EKG finding is seen at this point
<32C/89.6F
Osborn J wave
Why are PTs cooled after ROSC activity
If PT is intubated, what is the preferred location to measure body temps?
50% at 28C
19% at 18C
11% at 8* C
Lower 1/3 of esophagus
Bladder/rectal probes
What are two common DDxs of accidental hypothermia
What is the underlying cause if hyperglycemia is present after rewarming?
Intoxication
Sepsis
DKA
Pancreatitis
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
32.2C/90F and 35%
35C/95F
Hypothalamus loses ability to regulate body temps below ? or above ?
Why is there inc sweat production?
<95F or >104F
Inc cholinergic stimulation
What medications can interfere w/ body heat removal mechanisms
Anticholinergic- Benadryl Diuretics Phenothiazine BBs CCBs Sympathomimetics
PTs are at increased risk for heat injury w/out an acclamation period of ?
Define Confinement Hyperpyrexia
7days
PTs in cars/boxes
What are the 4 minor heat injuries
What is the major
Head edema
Prickly heat
Heat cramps
Exhaustion
Stoke
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
What catalyst usually presents w/ heat cramps
Deficiency of ? E+ can be cause
Fluid replacement w/ hypotonic solutions
Na K Mg Cl
Heat stress is usually due to deficiency in ?
? can be seen here
Water and Na
Rhabdo
How does heat stroke present
Since the CNS is vulnerable during this condition, what may be seen?
> 104* and AMS
Ataxia- early
Seizure- common
What is the temp goal when Tx heat stroke
All heat stroke Pts have ? disposition
102.2
Admit
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
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
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
Low BP + high ICP= ?
What HTN PE finding may not be present if pressure suddenly/rapidly increases?
Low CPP and brain injury
Papilledema
Etomidate
Propofol
Neuroprotective
Lowers ICP
Low risk for adrenal suppression
Rapid on/off
Anti-seizure
HOTN
Succinylcholine
Rocuronium
Avoid in burns/muscle injury
Safe for HyperK
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
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
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
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
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
Highly unstable neck trauma
Stable
Flexion teardrop Fx
Atlanto-occipital dislocaiton
Anterior subluxation
Simple Wedge/Compression
Spinous process avulsion
Unilateral facet dislocation
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
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
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
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
Gold is = to 30
tada
