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4-Goldstien list > Goldenstien Trauma List 1 > Flashcards

Goldenstien Trauma List 1 Flashcards

1
Q

Components of the primary survey

A
  1. Airway with cervical spine precautions
  2. Breathing
  3. Circulation
  4. Disability
  5. Exposure
  6. Monitors (pulse oximetry, BP, ECG)
  7. Resuscitation (2 large bore IV’s, 2L warmed crystalloid, 100% O2 via non-rebreather)
  8. Investigations (trauma blood work)

(A.B.C.D.E.M.R.I.)

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2
Q

Glasgow coma scale

A

Eye opening

4 – spontaneous

3 – to speech

2 – to pain

1 – none

Best motor

6 – obeys commands

5 – localizes pain

4 – withdraws to pain

3 – abnormal withdrawal (decorticate)

2 – abnormal extension (decerebrate)

1 – none

Verbal

5 – oriented

4 – confused conversation

3 – inappropriate words

2 – incomprehensible sounds

1 – none

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3
Q

Classification of shock

A

Hypovolemic

Cardiogenic

  • Myocardial infarction
  • Mechanical defects

Obstructive

  • Cardiac tamponade
  • Massive pulmonary embolus
  • Tension pneumothorax

Distributive

  • Septic
  • Anaphylactic
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4
Q

Keys to determining types of shock

A
  1. Hypovolemic: decreased CVP (all others increased or normal)
  2. Cardiac tamponade: increased pulmonary wedge pressure
  3. Septic/anaphylactic: decreased systemic vascular resistance and increased SvO2
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5
Q

Signs of hemorrhage

A
  1. Altered level of consciousness
  2. Tachycardia
  3. Tachypnea
  4. Skin pallor
  5. Decreased capillary refill
  6. Cool skin
  7. Decreased urine output

(Proximal → distal)

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6
Q

Classification of hemorrhagic shock (4 x 3)

A

Class I: up to 15% blood volume

  • HR < 100
  • Normal BP
  • U/O > 30 ml/hr

Class II: 15-30% blood volume

  • HR > 100
  • Decreased BP
  • U/O 20-30 ml/hr

Class III: 30-40% blood volume

  • HR > 120
  • Decreased BP
  • U/O 5-15 ml/hr

Class IV: > 40% blood volume

  • HR > 140
  • Decreased BP
  • Negligible U/O
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7
Q

Types of possible blood transfusions (3)

A
  1. O-negative
  2. Type-specific
  3. Cross-matched

(Fastest → slowest)

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8
Q

Types of responses to fluid resuscitation (3)

A

Rapid

10-20% EBL

Vitals return and stay normal

Transient

20-40% EBL

Recurrent tachycardia and hypotension

Type-specific blood

Non-responders

> 40% EBL

Vitals never normalize

Crystalloid and immediate type O blood

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9
Q

Hemodynamic goals of shock resuscitation (3)

A
  1. MAP > 60-65 mmHg
  2. PWP 12-18 mmHg
  3. CI > 2.1 L/min/m2 (Cardiogenic/obstructive) or > 3-3.5 L/min/m2 (septic/hemorrhagic)
  4. U/O > 0.5 ml/kg/h
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10
Q

Oxygen delivery goals of shock resuscitation (4)

A
  1. Hb > 100
  2. SaO2 > 92%
  3. SvO2 > 60%
  4. Lactate < 2.5 mEq/L
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11
Q

Side effects of massive transfusion (5)

A
  1. ARDS
  2. Coagulopathy
  3. Electrolyte abnormalities
  4. Hypothermia
  5. Immunosuppression

(A.C.E.H.I.)

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12
Q

Consequences of hypothermia (3)

A
  1. Acid-base disturbances
  2. Coagulation abnormalities
  3. Ventricular fibrillation
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13
Q

Initiators of coagulopathy in trauma (6)

A
  1. Tissue trauma
  2. Shock
  3. Hemodilution
  4. Hypothermia
  5. Acidemia
  6. Inflammation
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14
Q

Factors affecting physiologic response to trauma (9)

A

External

  1. Type of force (blunt vs. penetrating)
  2. Kinetic energy applied
  3. Temperature exposure
  4. Chemical/gas exposure

Internal

  1. Pre-existing medical disease
  2. Diabetes
  3. Rheumatoid disease
  4. Medications
  5. Illicit drug use/EtOH
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15
Q

Definition of systemic inflammatory response syndrome (≥ 2 of 4)

A
  1. Heart rate > 90 bpm
  2. WBC count < 4 or > 10
  3. Respiratory rate > 20 with PaCO2 < 32 mmHg
  4. Temperature < 36° C or > 38° C
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16
Q

Definition of acute respiratory distress syndrome (6)

A
  1. Acute onset
  2. Arterial hypoxemia unresponsive to oxygen therapy (PaO2/FiO2 < 200 mmHg)
  3. Bilateral infiltrates on CXR
  4. Dyspnea
  5. PWP < 18 mmHg
  6. Tachypnea
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17
Q

Etiology of ARDS in trauma patients (8)

A

Direct injury (4)

  1. Aspiration
  2. Near drowning
  3. Lung contusion
  4. Toxic inhalation

Indirect injury (4)

  1. Sepsis
  2. Severe non-thoracic trauma
  3. Massive transfusion
  4. Fat embolism syndrome
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18
Q

Clinical signs of basal skull fractures (5)

A
  1. Bleeding from the ears
  2. Retroauricular ecchymosis (Battle’s sign)
  3. CSF otorrhea/rhinorrhea
  4. Cranial nerve VII palsy
  5. Periorbital ecchymosis (“raccoon eyes”)

(B.B.C.C.R.)

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19
Q

ER department management of closed head injuries (4)

A
  1. Maintain normal blood pressure
  2. Avoid hypoxia
  3. Hyperventilation to PCO2 of 25-30 mmHg
  4. Mannitol (1 g/kg of 20% solution)
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20
Q

eminently lethal chest injuries (5)

A
  1. Tension pneumothorax
  2. Open pneumothorax
  3. Massive hemothorax
  4. Flail chest
  5. Cardiac tamponade
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21
Q

Life threatening chest injuries (5)

A
  1. Simple pneumothorax
  2. Hemothorax
  3. Pulmonary contusion
  4. Tracheobronchial injury
  5. Blunt cardiac injury
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22
Q

Radiographic findings of an aortic arch injury (9)

A
  • Widening of the superior mediastinum
  1. Normal = 8 cm wide
  2. Abnormal = 8-10 cm wide
  3. Aortic Dissection = >10 cm
  • Separation of the calcified intima from the outermost portion of the aorta by more than 5 mm (the “calcium sign”)
  • Loss of aortic knob
  • Displacement of trachea or NG tube to the right
  • Downward displacement of the left mainstem bronchus
  • Disparity in the caliber of the ascending and descending aorta
  • Apical capping
  • Pleural effusion (most commonly left sided)
  • Localized bulge in the aorta
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23
Q

Clinical findings of an aortic dissection (3)

A
  1. Pulse deficit
  2. Diastolic murmur of aortic regurgitation
  3. Abnormal EKG
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24
Q

Clinical signs of a tension pneumothorax (6)

A
  1. Respiratory distress
  2. Absent breath sounds
  3. Hyperresonance to percussion
  4. Distended neck veins
  5. Tracheal deviation away from the injured side
  6. Shock with hypotension
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25
Q

CXR findings of aortic disruption (11)

A
  1. Widened mediastinum
  2. Obliteration of the aortic knob
  3. Tracheal deviation to the right
  4. Deviation of the NG to the right
  5. Depression of the left mainstem bronchus
  6. Obliteration of space between pulmonary artery and aorta
  7. Widened paratracheal stripe
  8. Widened paraspinal interfaces
  9. Pleural/apical cap
  10. Left-sided hemothorax
  11. 1st/2nd rib/scapula fractures
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26
Q

Positive findings of a diagnostic peritoneal lavage (6)

A
  1. ≥ 100,000 RBC/mm3
  2. ≥ 500 WBC/mm3
  3. Positive gram stain
  4. Amylase concentration > 175 IU
  5. > 5 ml of gross blood on initial aspiration
  6. Enteric contents on initial aspiration
27
Q

Signs of a urethral injury (5)

A
  1. Inability to void despite a full bladder
  2. Blood at the urethral meatus
  3. High-riding/mobile prostate
  4. Elevated bladder on IVP
  5. Contrast dye extravasation into the perineum
28
Q

Burn classification (3)

A
  1. First degree – superficial
  2. Second degree – partial thickness skin
  3. Third degree – full-thickness skin loss
  4. Fourth degree – through deep tissues
29
Q

Signs of inhalational injury (4)

A
  1. Facial burns
  2. Singed face and hair
  3. Carbon in the pharynx
  4. Carbonaceous sputum
30
Q

Markers of adequate resuscitation (5)

A
  1. Lactic acid < 2.5 mEq/L (#1)
  2. Base deficit < 5
  3. MAP > 60 mmHg
  4. Urine output 0.5-1 ml/kg/hr (adult)
  5. HR < 100 bpm
  6. SvO2>70
31
Q

Grading of trauma patients (4)

A
  1. Grade I: Stable (cleared for surgery)
  2. Grade II: Borderline
  3. Grade III: Unstable (SBP < 90 mmHg)
  4. Grade IV: Extremis
32
Q

Indications to perform damage control orthopedic surgery (11)

A
  1. ISS > 40 without thoracic injury
  2. ISS > 20 with thoracic injury
  3. Uncontrolled hypothermia (? 32deg vs. 35)
  4. Coagulopathy
  5. Exaggerated inflammatory response IL-6 > 800 pg/mL
  6. Arterial injury with SBP < 90
  7. Moderate/severe head injury (AIS ≥ 3)
  8. Bilateral lung contusions
  9. Multi-injured patient with abdo/pelvis with SBP < 90
  10. Bilateral femoral fractures with thoracic trauma
  11. Presumed surgery time > 6 hours

(Injury severity, vitals, blood work, injuries, surgery)

33
Q

Fat embolism syndrome findings (3)

A
  1. Petechial rash (upper/anterior body)
  2. Altered mental status
  3. ARDS (hypoxia, tachypnea, dyspnea, tachycardia)
34
Q

Diagnostic criteria for fat embolism syndrome (11)

A

Major

  1. Hypoxemia (PaO2 < 60 mmHg)
  2. CNS depression
  3. Petechial rash
  4. Pulmonary edema

Minor

  1. Tachycardia > 110 bpm
  2. Fever > 38.3° C
  3. Thrombocytopenia
  4. Decreased hematocrit
  5. Retinal emboli
  6. Fat in sputum
  7. Fat in urine
35
Q

Risk factors for fat embolism syndrome (6)

A
  1. Pelvic fractures
  2. Multiple long bone fractures
  3. Lower extremity injuries
  4. Closed fractures
  5. Young patients
  6. Reaming
36
Q

acute respiratory distress syndrome findings (5)

A
  1. Tachypnea
  2. Dyspnea
  3. Hypoxemia (despite 100% O2)
  4. Reduced lung compliance (need for PEEP)
  5. Diffuse bilateral infiltrates on CXR
37
Q

AO principles of fracture fixation (4)

A
  1. Adequate reduction of fracture fragments
  2. Stable internal fixation
  3. Preservation of blood supply to bone
  4. Early active ROM
38
Q

Purposes of splinting (5)

A
  1. Pain relief
  2. Protect extremity from additional trauma
  3. Prevent/correct deformity
  4. Provide maintenance of fracture reduction
  5. Protection during functional activities

(5 P’s)

39
Q

Fractures for which evidence exists for the use of locking plates (5)

A
  1. Humeral shaft non-unions
  2. Intraarticular distal femur, proximal tibia, distal radius
  3. Proximal humerus
  4. Periprosthetic (above TKA/below THA)
  5. Short, extraarticular metaphyseal fractures

(H.I.P.P.S.)

40
Q

Indications for external fixation (6)

A

Temporary:

  1. Grossly contaminated wound/severe soft tissue injury
  2. Pelvic fractures with hemorrhage
  3. Unresuscitated patients

Definitive:

  1. Some periarticular fractures
  2. Some intraarticular fractures (otherwise unreconstructible)
  3. Fractures with segmental bone loss
41
Q

Indications for surgical treatment of AC joint injuries (6)

A
  1. Type III injuries in young, high-demand patients
  2. Type IV-V-VI injuries
  3. Open injuries
  4. Neurovascular compromise
  5. Chronic symptoms of instability/pain after nonoperative treatment
  6. Ipsilateral SC joint dislocation
42
Q

Options for surgical treatment of AC joint injuries (5)

A
  1. Primary acromioclavicular joint fixation
  2. Coracoclavicular fixation
  3. CC ligament reconstruction
  4. Dynamic muscle transfers (historical)
  5. Distal clavicle resection (± CC fixation/ligament reconstruction)
43
Q

Complications of AC joint injuries (14)

A
  1. Skin pressure/ulceration
  2. Persistent deformity
  3. Decreased shoulder/elbow ROM
  4. Soft-tissue calcification
  5. Infection
  6. Recurrence of deformity
  7. Hardware failure/migration
  8. Clavicle/coracoid fracture
  9. Symptomatic hardware
  10. Stiffness
  11. Post-traumatic arthritis
  12. Aseptic foreign body reaction
  13. Clavicular osteolysis
  14. Brachial plexus/axillary artery injury
44
Q

Risk factors for posterior shoulder dislocation (9)

A
  1. >37 years old
  2. Voluntary Dislocation
  3. Retroverted glenoid
  4. MDI
  5. Rotator Interval Lesion
  6. Chondral Damage
  7. ETOH
  8. Seizures
  9. Electrical Shock
45
Q

Shoulder dislocation associated injuries (7)

A
  1. Axillary nerve palsy
  2. Vascular injury
  3. Labral avulsion injuries
  4. Glenoid rim fractures
  5. Rotator cuff tears
  6. Tuberosity fractures
  7. Humeral head impression fractures
46
Q

Indications for surgical treatment of shoulder dislocations (6)

A
  1. Irreducible by closed methods
  2. Vascular injury
  3. Associated fractures requiring treatment
  4. Recurrent dislocations
  5. Chronic dislocations
  6. Young, active patient with acute traumatic anterior instability
47
Q

Complications of shoulder dislocations (6)

A
  1. Recurrent instability
  2. Arthrofibrosis
  3. Post-traumatic arthritis
  4. Axillary nerve neurapraxia
  5. Axillary artery injury
  6. Rotator cuff injury
48
Q

Risk factors for recurrent instability following anterior shoulder dislocation (6)

A
  1. Young Age
  2. Bony Bankart
  3. Large HS
  4. <3 anchor fixation
  5. Inferior or Anterior GH Laxity
  6. MDI
49
Q

Risk factors for arthrofibrosis following shoulder dislocation (4)

A
  1. Age > 30
  2. Inadequate rehabilitation
  3. Poor patient compliance
  4. Increased trauma at the time of injury
50
Q

Classification of proximal humerus fractures (Neer) (3)

A

A fragment is considered a “part” if it is ≥ 1 cm displaced or 45° angulated

2-part

  1. Lesser tuberosity
  2. Greater tuberosity
  3. Surgical neck

3-part

4-part

51
Q

Proximal humerus fractures associated injuries (6)

A
  1. Subdural hematoma
  2. Neurologic injury (axillary, 60% on EMG)
  3. Vascular injury
  4. Rotator cuff injury
  5. Dislocation
  6. Other osteoporotic fractures

(Proximal → distal)

52
Q

Indications for surgical treatment of proximal humerus fractures (6)

A
  1. Open
  2. Medially translated distal fragment
  3. > 45° angulation in a 2-part surgical neck fracture
  4. Pathologic fracture
  5. 3- and 4-part fractures
  6. Head split
53
Q

Decision-making factors for surgical treatment of proximal humerus fractures (7)

A
  1. Age
  2. Activity level
  3. Patient preferences
  4. Vascularity of the humeral head
  5. Bone quality (cortical thickness < 4 mm)
  6. Fracture pattern
  7. Degree of comminution

(Patient, fracture)

54
Q

Contraindications to ORIF of proximal humerus fractures in elderly patients (4)

A
  1. Fracture-dislocation
  2. Head-splitting fractures
  3. Impression fractures involving > 40-50% of the articular surface
  4. 3- and 4-part fractures with osteoporotic bone
55
Q

Indications for locking plates in proximal humerus fractures (7)

A
  1. Displaced extraarticular and intraarticular/anatomic neck fractures
  2. Metaphyseal comminution
  3. Valgus impacted fractures
  4. Poor cortical contact/disrupted medial hinge
  5. Subcapital proximal humerus nonunion
  6. Proximal humerus osteotomy
  7. Pathologic fracture (?)
56
Q

Advantages of locking plate fixation for proximal humerus fractures (6)

A
  1. Improved stability
  2. Shorter immobilization/earlier rehabilitation
  3. Decreased rotator cuff damage
  4. Decreased need for implant removal
  5. Reduced hardware complications
  6. Potential avoidance of hemiarthroplasty
57
Q

Methods to achieve proper height of hemiarthroplasty component for proximal humerus fracture (5)

A
  1. Pull-down test (top of prosthesis at top of glenoid)
  2. One finger test (between top of prosthesis and acromion)
  3. Top of prosthesis 5 cm above superior border of pectoralis major
  4. GT is 8 ± 3 mm below top of articular segment
  5. Long head of biceps tension
58
Q

Complications of hemiarthroplasty for proximal humerus fracture (8)

A
  1. Infection
  2. Nerve injury
  3. Tuberosity malunion
  4. Heterotopic ossification
  5. Joint degeneration
  6. Disappearing tuberosities
  7. Subacromial impingement
  8. Prosthetic loosening
59
Q

Risk factors for tuberosity malunion in hemiarthroplasty for proximal humerus fracture (4)

A
  1. Age > 75
  2. Females
  3. Excessive prosthetic height/retroversion
  4. Non-anatomic reduction

(Patient, surgery)

60
Q

Factors predictive of post-operative constant score following hemiarthroplasty for proximal humerus fracture (5)

A
  1. Age
  2. Persistent neurologic deficit
  3. Need for early revision
  4. Degree of displacement of prosthetic head from centre of glenoid
  5. Degree of tuberosity displacement (> 5 mm)
61
Q

Complications of proximal humerus fractures (7)

A
  1. Nonunion
  2. Malunion
  3. Avascular necrosis
  4. Missed injury
  5. Disrupted rotator cuff
  6. Adhesive capsulitis
  7. Neurovascular injury
62
Q

Risk factors for avascular necrosis in proximal humerus fractures (7)

A
  1. Anatomic neck fracture
  2. Head split
  3. Fracture-dislocation
  4. 3- and 4-part fractures
  5. Metaphyseal head extension < 8 mm
  6. Medial hinge displacement > 2 mm
  7. ORIF
63
Q

Components of acceptable alignment of a humeral shaft fracture (4)

A
  1. ≤ 3 cm of shortening
  2. ≤ 30° varus/valgus angulation
  3. ≤ 20° anterior/posterior angulation
  4. ≤ 15° rotation
64
Q

Treatment options for humeral shaft fractures (7)

A
  1. Long arm cast
  2. Collar and cuff
  3. Hanging cast
  4. Functional bracing
  5. External fixation
  6. ORIF
  7. Intramedullary nailing

4-Goldstien list (15 decks)

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