Kaplan Surgery Trauma

Question 1

Head trauma concerns (9-10 item list)

Answer 1

Linear skull fractures
Open skull fractures 
Basilar skull fractures 
Indications for CT in head trauma
Traumatic brain injury
Epidural hematoma 
Subdural hematoma 
Chronic subdural hematoma 
Diffuse axonal injury

Question 2

Linear skull fractures: tx

Answer 2

left alone if they are closed without an overlying wound

Question 3

Open skull fractures: tx

Answer 3

Open fractures require wound closure. If comminuted or depressed, treat in the OR.

Question 4

indications for CT use in head trauma

Answer 4

Anyone with head trauma who has become unconscious or GCS < 13-14 gets a CT scan to look for intracranial hematomas. I

if negative and neurologically intact, they can go home if the family will awaken them frequently during the next 24 hours to make sure they are not going into coma.

Question 5

Basilar skull fractures

Answer 5

raccoon eyes, rhinorrhea, otorrhea or ecchymosis behind the ear (Battle’s sign).

CT scan of the head is required to rule out intracranial bleeding and should be extended to include the neck to evaluate for a cervical spinal injury

Question 6

TBI: the three components

Answer 6

Initial blow/direct blow

intracranial bleeding –> hematoma that displaces the midline structures

Later development of increased intracranial pressure (ICP) due to cerebral edema

Question 7

fixed dilated pupil, contralateral hemiparesis with decerebrate posturing, biconvex lens shaped hematoma

Answer 7

acute epidural hematoma

Question 8

CT scan shows semilunar, crescent-shaped hematoma after blunt force trauma, pt unconscious

Answer 8

acute subdural hematoma

Question 9

cerebral perfusion mmHg =

Answer 9

mean arterial mmHg - ICP mmHg

Question 10

CT scan shows diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages.

Answer 10

Diffuse axonal injury

occurs in more severe trauma. Without hematoma there is no role for surgery. Therapy is directed at preventing further damage from increased ICP.

Question 11

occurs in the very old or in severe alcoholics. Over several days or weeks, mental function deteriorates

Answer 11

Chronic subdural hematoma

A shrunken brain is rattled around the head by minor trauma, tearing venous sinuses.

Over several days or weeks, mental function deteriorates as hematoma forms.

CT scan is diagnostic, and surgical evacuation provides dramatic cure.

Question 12

Neck Trauma Zones for penetrating wounds, dx and tx

Answer 12

zone 1: clavicles to the cricoid cartilage - eval w/CTA and CT esophagram

zone 2: cricoid cartilage to the angle of the mandible - CT or surgical, depending

zone 3: angle of the mandible to the base of the skull, CTA

Question 13

Spinal cord injuries- specific conditions for exam

Answer 13

Hemisection (brown sequard)
anterior cord syndrome
central cord syndrome

Question 14

ipsilateral paralysis and loss of proprioception and contralateral loss of pain perception caudal to the level of the injury.

Answer 14

Hemisection (Brown-Sequard)

typically caused by a clean-cut injury such as a knife blade

Question 15

loss of motor function and loss of pain and temperature sensation on both sides caudal to the injury, with preservation of vibratory and positional sense.

Answer 15

Anterior cord syndrome

typically seen in burst fractures of the vertebral bodies.

Question 16

paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.

Answer 16

Central cord syndrome

typically occurs in the elderly with forced hyperextension of the neck, such as a rear-end collision.

Question 17

Rib fractures: why to treat it and how to tx it

Answer 17

pain impairs respiratory effort, which leads to hypoventilation, atelectasis, and ultimately, pneumonia.

To avoid this cycle, treat pain from rib fractures with a local nerve block or epidural catheter, in addition to oral and IV analgesics.

Question 18

Chest wounds listed for exam

Answer 18

Rib fracture 
hemothorax
pneumothorax 
blunt trauma
sucking wounds
flail chest 
pulmonary contusion 
blunt cardiac trauma 
rupture of diaphragm 
rupture of aorta 
rupture of trachea or bronchus 
rupture of esophagus
subcutaneous emphysema 
air embolism 
fat embolism

Question 19

moderate shortness of breath with absence of unilateral breath sounds and hyperresonance to percussion.

dx and tx

Answer 19

Simple pneumothorax results from penetrating trauma such as a weapon or the jagged edge of a fractured rib.

Diagnosis is confirmed with chest x-ray

Tx/management consists of chest tube placement.

Question 20

decreased breath sounds and dull to percussion on the same side

(a) dx and tx
(b) dx with lung bleeding and tx
(c) dx with intercostal a. hemorrhaging and tx

Answer 20

Hemothorax

happens the same way as pneumothorax blood can originate directly from the lung parenchyma or from the chest wall, such as an intercostal artery.

Dx confirmed with chest x-ray.

Tx: chest tube placement necessary to enable evacuation of the accumulated blood to prevent late development of a fibrothorax or empyema- surgery to stop the bleeding is sometimes required.

If lung is the source of bleeding, it usually stops spontaneously as it is a low pressure system.

significant artery or intercostal artery bleed–> thoracotomy to stop the hemorrhage.

Question 21

Indications for thoracotomy include:

Answer 21

Indications for thoracotomy include:

Evacuation of >1,500 mL when chest tube inserted

Collecting drainage of >1 L of blood over 4 hours, i.e., 250 mL/hr

Question 22

s a flap that sucks air with inspiration and closes during expiration. If untreated, it will lead to

Answer 22

Sucking chest wounds: untreated, it will lead to a deadly tension pneumothorax.

Initial management is with a partially occlusive dressing secured on 3 sides, with one open side acting as a one-way valve. This allows air to escape but not enter the pleural cavity (to prevent iatrogenic tension pneumothorax and multiple fractures within each rib).

Question 23

chest wall caves in during inspiration and bulge out during expiration (paradoxical breathing), CXR shows “white out” of lungs

Answer 23

Flail chest caused by pulmonary contusion

occurs with multiple rib fractures that allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxical breathing).

The real problem is the underlying pulmonary contusion.

Contused lung is very sensitive to fluid overload, thus treatment includes fluid restriction and pain management.

Pulmonary dysfunction may develop, thus serial chest x-rays and arterial blood gases have to be monitored.

Pulmonary contusion can show up right away after chest trauma with “white-out” of the affected lung(s) or can be delayed up to 48 hours.