Exam 4 Flashcards by Rodrigo N

Nexus National Emergency X-ray utilization Study

No Post. midline C-Spine Tenderness
No evidence of intoxication
Alert Mental Status
No focal Neuro deficits
No painful distracting injuries

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If a patient is obtunded what can be assumed?

Assume a cervical spine injury until proven otherwise

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Preferred study for Cervical Spine injury

CT Scan

Should not delay Urgent operative procedures

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The following warrant immediate intervention

Tension pneumothorax needle D
36 French Chest tube for hemo-pneuo thorax
Occlusive dressing to sucking chest wound

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Asymmetric or absent breath sounds in the intubated patient, what is the treatment

Partially withdraw ET tube from R main stem entubation

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If no breath sounds and massive hemothorax or vascular injury suspected, what indicates a thoracotomy or video assisted thoracic surgery?

Chest tube output of > 1,000ml or >200ml/hr of blood

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Class I Blood Loss

up to 750 ml

15%

<100 BPM

BP = Normal Pulse = Normal or increased

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Class II Blood loss

750-1,500 ml

15-30%

Pulse 100-120

BP= Normal Pulse = Decreased

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Class III Blood Loss

1,500-2,000 ml

30-40%

Pulse = 120-140

BP = Decreased Pulse Pressure = Decreased

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Class IV Blood Loss

> 2,000 ml

> 40%

> 140

BP= Decreased Pulse Pressure= Decreased

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Can Mask Early hemodynamic indicators of shock

B-Blockers

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The following transfusion treatment showed decreased mortality when using

FFP: PRBCs 1:1 10 units

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A patient with a GCS < 15 and appropriate MOI of head trauma has what?

Significant Head injury until proven otherwise

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Monitor serum glucose for euglycemia and avoid _______ in head injury patients

Prophylactic hyperventilation/ Hyperventilation

of 25mmHg or less

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Abdominal Tenderness or distention on palpation with hypotension indicates what?

Exploratory Laparotomy (Immediate OR transport)

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Strongest recommendation for ED thoracotomy is?

Patients w/ penetrating trauma with witnessed signs of life during transport & at least Electrical activity upon arrival

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Secondary survey consists of what?

Head to toe exam for injuries

Do not start until basic functions are corrected

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If Meatal blood is present or prostate is displaced, suggesting urethral injury, what should be done prior to inserting a foley?

Perform a Retrograde Urethrography

If vaginal= Bimanual exam

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Most frequently missed conditions in secondary survey?

Orthopedic Conditions

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Patients who are not rapidly transported to the OR CT after initial assessment, what can be performed?

Standard Radiography imaging of C-spine, Chest and pelvis

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FAST examination is an effective screening tool for ?

Intraperitoneal bleeding, Pericardial tamponade, and pneumo/Hemothorax

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Obtunded patients get what imaging?

Entire spine if MOI warrants it

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Routine labs for trauma include

Blood Type and screen, HgB, Urine Dipstick for blood, and ethanol level; Glucose for AMS; >55 =ECG and Cardiac markers

(HCG for child bearing age Females)

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When transferring a patient what must be completed?

A rapid but thorough primary and secondary survey prior to transferring.

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Which Injuries may not be readily apparent on initial CT? What is required?

Pancreas, Bowel and head trauma Repeated imaging and neurologic & LOC assessments

Most common herniation. Displaced Inferiorly through medial edge of tentorium Leads to compression of CNIII Parasympathetic fibers An ipsilateral fixed and dilated pupil due to unopposed sympathetic tone. Results in contralateral motor paralysis

Uncal Herniation

Less common, occurs w/ midline lesions. Lesions of the frontal or occipital lobes, or vertex Bilateral pin point pupils, Bilateral Babinski's, and increased muscle tone. (Decorticate Posturing)

Central Transtentorial Herniation

Pinpoint pupils, flaccid paralysis, and sudden death. Cerebellum portions herniates through foramen magnum. Upwards transtentorial herniation leads to conjugate downward gaze w/ absent vertical eye movements

Cerebellotonsilar Herniation

GCS classified as Severe

GCS score 3-8

GCS classified as Moderate

GCS score of 9-13

GCS classified as Mild

GCS score of 14-15

Prior to intubating a patient what needs to be recorded?

Best score of GCS

Single fixed dilated pupil indicates what?

Intracranial hematoma- Uncal Herniation

Bilateral Fixed dilated pupils indicates what?

Increased ICP with poor brain perfusion, Bilat uncal herniation, Atropine drug effect or severe hypoxia

Bilateral pinpoint pupils indicates what?

Opiate exposure or Central Pontine lesion

Presentation of upper extremity flexion and lower extremity extension is what posturing? Where is the intracranial injury?

Decorticate Above the level of the midbrain

presentation of arm extension and internal rotation with wrist and finger flexion, and extension of lower extremities is what posturing? Where is the intracranial injury?

Decerebrate More Caudal to midbrain injury

Most important prehospital interventions for head trauma are?

Airway and BP management

Optimal Airway and BP management in head trauma

Capnometry PCO2@ 35-45 | S BP> 90mmHg and Hypoxemia > 60 <90mmHg & PAO2 < 60 = mortality 150%

May decrease Baseline ICP and prevent transient rises in ICP elevation

Sedation and Analgesia

Appropriate early management of which conditions will have better outcomes ?

Hypotension, hypoxemia, Hypercarbia, and Hyperglycemia

Intubation agent may cause a lower ICP and may be neuro protective

Etomidate 0.3mg/kg IV

Intubation agent that has a rapid onset and anti-seizure properties. May cause hypotension if not adequately resuscitated

Propofol 1-3 mg/kg

Intubation agent that is short acting that may cause extensive muscle injury. Avoid in Burns

Succinylcholine 1-1.5 mg/kg

Intubation agent that is short acting and is safe in hyperkalemia

rocuronium (0.6-1.0 mg/kg

Maintain Sys BP and MAP at

> 90mmHg and MAP= 80mm Hg

hyperglycemia is associated with worse outcome. what is an adequate glycemic control?

100-180 mg/dL

Treatments that may lower ICP and improve cerebral blood flow

Elevate head 30 degrees Mannitol &/or hypertonic saline 3% NaCl (250 ml over 30 min.)

If GCS < or = 8, this treatment can be used to monitor ICP and serve as extraventricular drain What is the ICP monitoring criteria

Intracranial Bolt > 40 y/o Uni/Bilat motor posturing Sys Bp < 90mmHg

An ICP of ______ mmHg increases morbidity and mortality. Monitor will be placed by neurosurgery

>20mmHg

Scalp Laceration can be treated with what, if direct pressure is not effective?

Locally infiltrate with Lidocaine and Epinephrine and clamp or ligate bleeding vessels Galeal Lacerations tx with appropriate examination

Categorized linear fracture with an overlying laceration

Open fracture

Open or depressed skull fractures should be treated with

Vancomycin 1 Gm and Ceftriaxone 2 G

Decreased hearing or deafness and 7th nerve palsy. | Fluid collected that is sent for analysis. Found only in CSF

Basilar Skull Fx Beta Transferrin

Results from the disruptionof parenchyma and present with blood in the CSF Present with Photophobia, headache, meningeal signs MC CT abnormality

Subarachnoid Hemorrhage

have a three fold higher mortality and can be missed on early CT scans

Subarachnoid hemorrhage Repeat CT after 6-8 hrs

Blunt trauma to temporal r temporoparietal area w associated skull fx Middle meningeal arterial disruption Significant blunt trauma with loss of consciousness or altered sensorium, followed by lucid period Biconvex football shaped

Epidural Hematoma

The high-pressure arterial bleeding can lead to herniation within hours

Epidural Hematoma

Sudden acceleration-Deceleration of brain. subsequent tearing Bridging Dural veins. Tend to collect more slowly, than epidural because of venous nature. Crescent shaped lesion

Subdural Hematoma

Are more susceptible in elderly and alcoholics: < 2 y/o Acute ______ Chronic _______

Subdural hematoma W/I 14 days After 2 weeks

Caused by sudden deceleration shearing forces. Disruption of axonal fibers in the white matter and brainstem MVC and Shaken Baby Syndrome

Diffuse axonal Injury

Most frequently damaged abdominal organ

Liver

Most frequently damaged abdominal organ from sports accidents

Spleen

Most common mechanism for blunt abdominal trauma

MVC

Considered a penetrated abdominal cavity injury until proven otherwise

Lower chest, pelvis, flank, or back

Mimic intra-abdominal injury

Rectus abdominis hematomas

hemoperitoneum is quickly detected with a single view up to 90% of patients at?

Morrison's pouch

The fast cannot evaluate the______ the ______ imaging is more ideal for this area

retroperitoneum: CT

Non invasive gold standard imaging study

CT with contrast

Gold standard therapy for significant intra-abdominal injury

Laparotomy

60 minutes of resuscitative endovascular balloon occlusion is tolerated

REBOA endovascular Balloon of Aorta

Anatomically unique designed for rotation of spine, held by the transverse ligament

C1 Atlas & C2 Odontoid

Most commonly injured region of the spine

Cervical C5-C7 and C2 level | (C1-C7) most flexible--> most injured

2nd MC injured region of spine

Thoracolumbar transition zone

Rigid segment and enhanced reinforcement with rib articulation. Spinal canal also narrower--> complete transection

T1-T10

Can produce bowel or bladder dysfunction

Sacral Fractures that involve central canal

Spine injury is considered unstable when?

At least 2 columns of a particular region are involved | assume any spine fx is unstable until spine surgeon confirms it is stable

Defined as the absence of sensory and motor function below the level of injury

Complete Neurologic Lesion

Defined as sensory and motor or both functions are partially present below the neurologic level of injury

Incomplete Neurologic Lesion

Patients in spinal shock lose all reflex activities below the area of injury, lesions cannot be deemed truly complete until

Spinal shock has resolved

Damage results in ipsilateral findings muscle weakness, spasticity, increased tendon reflexes, and babinski's sign Descending motor pathway originates from the cortex and 90% cross to the opposite side of origin at medulla through the _________

corticospinal tract

Loss of pain and temperature sensory on the contralateral half of body Cross the midline immediately and ascend to thalamus via the________

spinothalamic Tract

Vibration, position loss in ipsilateral half light touch not lost unless damage to both________&______ and cross at the medulla

Dorsal columns and spinothalamic tracts

Damage to_______Can cause immediate respiratory arrest

C-3

Any patient with damage to______ or above should have their airway secured by ET tube

_______ denotes an incomplete spinal cord level injury even if patient has complete motor sensory motor loss

Anogenital Reflex

Cremasteric reflex: stoking the medial thigh with a blunt instrument causes what?

The scrotum to rise= spinal cord integrity exists

Loss of motor function ad pain temperature sensation do distal lesion. Only vibration, position and tactile sensation preserved

Anterior Cord

Decreased strength, decreased pain and temperature sensation: more in upper than lower extremities

Central cord

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

Brown sequard syndrome (Penetrating MC)

Not a true spinal cord syndrome: Bowel and Bladder dysfunction, saddle anesthesia, variable loss of lower extremity reflexes

Cauda Equina

present with warm skin, peripherally vasodilated and hypotensive bradycardia.

Neurogenic shock | HyTN Presumed to be other than Neuro R/O

Standard Radiographic ID of cervical injury includes

Lateral (90% ID) Ant-Posterior Odontoid (Swimmers view for C spine junction)

Persistent neck pain/ midline tenderness, extremity paresthesia, or neurologic findings despite normal CT or radiographs indicate what?

Ligamentous injury

SOC for Ligament injuries

MRI Reliable patients with persistent CT and normal CT= DC with firm foam collar and F/U in 3-5 days

The two type of fractures amenable to outpatient therapy

Wedge or Anterior compression fractures <40% loss of height >50% loss of height= unstable

Fractures may result in retropulsed fragments that can impinge the spinal canal

Burst fractures

SOmetimes misdiagnosed as wedge compression fractures occurs via flexion distraction mechanism- involves significant distraction of the middle and posterior ligamentous structure

Chance Fracture

Coccygeal fractures assessment do not include

Imaging