Fiser ABSITE CH. 15 Trauma Flashcards
1st peak for trauma deaths occur during what time period? Deaths due to lacerations of heart, aorta, brain, brainstem, spinal cord. Cannot really save these patients; death is too quick.
0-30 minutes
The 2nd peak in trauma deaths occurs in 30 min to 4 hrs. What classification of injury is the first and second most common cause? These are the patients you can save with rapid assessment (golden hour).
Head injury (#1) and hemorrhage (#2)
The 3rd peak for trauma deaths occurs in days to weeks. Deaths due to what two main reasons?
multisystem organ failure and sepsis
Blunt trauma accounts for 80% of all trauma; what is the most common injured organ?
liver (some texts say spleen)
What is the physics formula for kinetic entery?
1/2 mv2
What is the LD50 of height of fall.
4 stories
What is the most commonly injured organ in penetrating injury?
small bowel (some texts say liver)
What is the most common cause of death in the 1st hour of trauma?
hemorrhage
Blood pressure is usually OK until ___% of total blood volume is lost.
30
What is the most common cause of death after reaching the ER alive?
head injury
What is the most common cause of death long term in trauma patients?
infection
What is the most common cause of upper airway obstruction? and what is the tx?
tongue, perform jaw thrust
What injuries are associated with seat belts?
small bowel perforations, lumbar spine fractures, sternal fractures
What is the best site for cutdown for access?
saphenous vein
General indications for DPL or FAST?
hypotensive pt with blunt trauma
What is considered a positive DPL?
>10cc of blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500 WBC/cc
What do you do if DPL is positive?
laparotomy
What location should DPL performed if pelvic fracture is present?
supraumbilical
What 2 things can DPL miss?
retroperitoneal bleed, contained hematoma
What four places are checked for blood in FAST?
perihepatic fossa, perisplenic fossa, pelvis, pericardium
FAST can be obstructed by obesity and what amount of free fluid may not be detected?
Less than 50-80
What 2 things does FAST scan miss?
retroperitoneal bleeding, hollow viscus injury
Need a CT scan following blunt trauma in pts with ___, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria.
abdominal injury
Pt requiring DPL that turned out to be negative will need what?
abdominal CT scan
Name 2 injuries that CT scan misses.
hollow viscous injury, diaphragm injury
Peritonitis, evisceration, positive DPL, clinical deterioration, uncontrolled hemorrhage, free air, diaphragm injury, intraperitoneal bladder injury, positive contrast studies, specific renal, pancreas, and biliary tract injuries.
Need laparotomy
Possible penetrating abdominal injuries (knife or low-velocity injuries) - When would you just do local exploration and observation? What is the purpose of diagnostic laparoscopy?
fascia not violated; to see if fascia is violated
Name three situations that can cause abdominal compartment syndrome.
massive fluid resuscitation, trauma or abdominal surgery
What is the bladder pressure seen with abdominal compartment syndrome?
>25-30
What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?
IVC compression
How does abdominal compartment syndrome lead to decreased urine output?
renal vein compression
What is the treatment for abdominal compartment syndrome?
decompressive laparotomy
Pneumatic antishock garment is controversial; use in pts with SBP
50, thoracic
ER thoracotomy: In what type of trauma is it used only if pressure/pulse lost ER? What type if lost on way to ER or in ER?
Blunt; Penetrating
If ER thoracotomy is performed for cardiac injury, the pericardium is opened anterior to what structure?
phrenic nerve
In ER thoracotomy, for what type of injury is the aorta cross clamped? and what structure must you watch out for?
abdominal, esophagus
After cross clamping the aorta in ER thoractomy, at what BP level is further treatment futile?
if BP fails to reach 70 mmHg
When to catecholamines peak after injury?
24-48 hours
What is the time it takes for type specific blood? type and screen? type and crossmatch?
Less than 10 minutes 20-30 min 45-60 min
Can you give nonscreened, noncrossmatched blood (Type specific)?
can be administered relatively safely but there may be effects from antibodies to minor antigens in the donated blood
GCS
Pt with head injury and GCS less than or equal to 14 what next? and 10? and 8?
head CT, intubation, ICP monitor
What is the most common artery injured with epidural hematoma?
middle meningeal artery
Head CT shows lenticular (lens-shaped) deformity?
epidural hematoma
Operation of epidural hematoma indicated for significant neurologic degeneration or significan mass effect (shift > ___)
5 mm
Subdural hematoma is most commonly from tearing of what?
venous plexus (bridging veins) between dura and arachnoid
What is the head CT finding with subdural hematoma?
crescent-shaped deformity
Chronic subdural hematoma is usually in elderly after minor fall. Need drainage if > ___ or causing significant symptoms.
1 cm
In which 2 lobes are intracerebral hematoma usually found?
frontal, temporal
Traumatic intraventricular hemorrhage needs what procedure if causing hydrocephalus?
ventriculostomy
Diffuse axonal injury shows up better on MRI or CT?
MRI
Tx for diffuse axonal injury is supportive; may need what if ICP elevated?
craniectomy
Mean arterial pressure minus intracranial pressure = ? and what is the desired value
Cerebral perfusion pressure >60
What are the following signs of on brain imaging?: decreased ventricular size, loss of sulci, loss of cisterns
elevated ICP
ICP monitors are indicated for (2)
1) Suspected increase in ICP 2) GCS 8
Normal ICP is ___; >___ needs treatment
10; 20
Name three interventions that are tried first with elevated ICP
1) Sedation and paralysis 2) Raise head of bed 3) Relative hyperventilation
When hyperventilating a pt due to increased ICP. What is a target CO2 range? and what is the effect and what can happen if overhyperventilated?
30-35 cerebral vasoconstriction cerebral ischemia from too much vasoconstriction
What can be done with fluids to manage elevated ICP?
give hypertonic saline at times to draw fluid out of brain. (keep Na 140-150, serum Osm 295-310)
What medication can be given to pts with elevated ICP and what is the MOA?
mannitol, draws fluid from the brain
What are three procedural options for elevated ICP if other measures fail?
ventriculostomy w/CSF drainage; craniotomy decompression; Burr hole
What medication is given prophylactically to prevent seizures to most pts with traumatic brain injury?
phenytoin
Peak ICP levels occur after how long after head injury?
48-72
In traumatic brain injury, dilated pupil indicates temporal pressure on same side. Which CN is compressed?
CN III
Racoon eyes are a sign of fracture of what part of the basal skull?
anterior fossa
Battle’s sign indicates fracture of what part of the basal skull? What nerve can be injured?
middle fossa, facial
What is difference in tx for acute and delayed Battle’s sign?
if acute need exploration, if delayed, likely secondary to edema and exploration not needed
Temporal skull fractures can injure what 2 cranial nerves?
CN VII and VIII
What is the most common site of facial nerve injury with temporal skull fractures?
geniculate ganglion
Most skull fractures do not require surgical treatment. Operate if (3)
1) Significantly depressed by 8-10mm 2) Contaminated 3) CSF leak not responding to conservative therapy
What is a Jefferson fracture and what is the tx?
C-1 burst caused by axial loading. Tx: rigid collar
C-2 hangman’s fracture is caused by distraction and extension. What is the tx?
traction and halo
What are the 3 types of C-2 odontoid fractures and what is their tx?
Type I - above base, stable Type II - at base, unstable (will need fusion or halo) Type III - extends into vertebral body (will need fusion or halo)
Cervical facet fractures or dislocations can cause injury to the___; usually associated with hyperextension and rotation and with disruption of ___ .
cord; ligament/s
What are the three columns of the thoracolumbar spine?
1) anterior - anterior longitudinal ligament and anterior 1/2 of the vertebral body 2) middle - posterior 1/2 of the vertebral body and posterior longitudinal ligament 3) posterior - facet joints, lamina, spinous processess, interspinous ligament
What is the significance of more than one thoracolumbar spine column disruption.
Considered unstable
What is the difference between compression (wedge) fractures and burst fractures of the thoracolumbar spine?
Compression fractures usually involve the anterior column only and are considered stable. Burst fractures are considered unstable and require spinal fusion.
Upright fall. Look for fractures of what 3 areas?
calcaneus, lumbar, wrist/forearm
Neurologic deficits without bony injury. What injury should you consider and how to dx?
Check for ligamentous injury with MRI
The following are indications for what? fracture or dislocation not reducible with distraction; acute anterior spinal syndrome; open fractures; soft tissue or bony compression of the cord; progressive neurological dysfunction
emergent surgical spine decompression
Facial nerve injuries need repair. Fracture of what bone is most common cause of facial nerve injury?
temporal bone
Try to preserve skin and not trime edges with lacerations in what part of the body
Face
Maxillary fracture straight across is called what?
Le Fort type I
Maxillary fracture lateral to nasal bone underneath eyes, diagonal. ( / \ ) What is that called?
Le Fort type II
Fracture of lateral orbital walls ( - - ) is called what?
Le Fort type III
Nasoethmoidal orbital fractures, what percentage have a CSF leak? Try conservative therapy for how long? What can you try to decrease CSF pressure to help it close? May need surgical closure of dura to deal with leak.
70%, 2 weeks, epidural catheter
What is the difference in tx for anterior vs posterior nose bleeds?
anterior is just packing; posterior is harder to dea with; try ballon tamponade 1st; may need angioembolization of internal maxillary artery or ethmoidal artery