Kaplan Surgery Trauma Flashcards
Head trauma concerns (9-10 item list)
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
Linear skull fractures: tx
left alone if they are closed without an overlying wound
Open skull fractures: tx
Open fractures require wound closure. If comminuted or depressed, treat in the OR.
indications for CT use in head trauma
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.
Basilar skull fractures
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
TBI: the three components
Initial blow/direct blow
intracranial bleeding –> hematoma that displaces the midline structures
Later development of increased intracranial pressure (ICP) due to cerebral edema
fixed dilated pupil, contralateral hemiparesis with decerebrate posturing, biconvex lens shaped hematoma
acute epidural hematoma
CT scan shows semilunar, crescent-shaped hematoma after blunt force trauma, pt unconscious
acute subdural hematoma
cerebral perfusion mmHg =
mean arterial mmHg - ICP mmHg
CT scan shows diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages.
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.
occurs in the very old or in severe alcoholics. Over several days or weeks, mental function deteriorates
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.
Neck Trauma Zones for penetrating wounds, dx and tx
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
Spinal cord injuries- specific conditions for exam
Hemisection (brown sequard)
anterior cord syndrome
central cord syndrome
ipsilateral paralysis and loss of proprioception and contralateral loss of pain perception caudal to the level of the injury.
Hemisection (Brown-Sequard)
typically caused by a clean-cut injury such as a knife blade
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.
Anterior cord syndrome
typically seen in burst fractures of the vertebral bodies.
paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
Central cord syndrome
typically occurs in the elderly with forced hyperextension of the neck, such as a rear-end collision.
Rib fractures: why to treat it and how to tx it
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.
Chest wounds listed for exam
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
moderate shortness of breath with absence of unilateral breath sounds and hyperresonance to percussion.
dx and tx
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.
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
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.
Indications for thoracotomy include:
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
s a flap that sucks air with inspiration and closes during expiration. If untreated, it will lead to
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).
chest wall caves in during inspiration and bulge out during expiration (paradoxical breathing), CXR shows “white out” of lungs
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.
