KC Trauma Flashcards
What is the definition of massive transfusion. What is predictive of requiring an MTP?
> 10 u of pRBCs over 24 hours
Predictive with 2+ of: penetrating injury, +ve FAST, SBP <90, HR >120
Describe a balanced transfusion protocol in adults and pediatrics?
Adults 1:1:1 ratio of pRBCs, platelets, plasma, or 2:1:1
Peds 10 ml/kg:10 ml/kg/25 ml/kg pRBC, platelets, FFP
*10 each for kids probably fine - varied sources not in Rosens
Summarize the literature used to dervive massive transfusion ratios
PROPPR (JAMA 2015)
Bottom line: Among patients with trauma suffering hemorrhagic shock, there was no difference in mortality at 24 hours or 30 days between a 1:1:1 and 1:1:2 administration of plasma, platelets, and red blood cells.
Population: 690 patients at 12 Level 1 trauma centres in NA. Multisite RCT. Inclusion: trauma from field, at least 1 u PRBC, espected to need massive transfusion. Exclusion: Trauma from another facility, expected to die within 1 hour, already received 3uPRBC, pregnant, younder than 15, thoracotomy, more than 5 mins cpr
Intervention: 1:1:1
Control: 1:1:2
Outcome: Primary 24h + 30 day mortality; no difference. Secondary outcomes of hemostasis time, vent free days, surgery, adverse events; no difference. Rate of death due to exsanguination was 9.2% in 1:1:1 vs. 14.6% in 1:1:2 which WAS statistically significant
What are the indications for trauma team activation
Note: guidelines likely differ depending on province and EMS trauma activation protocols:
- Physiologic: GCS <13, systolic <90, RR <10 or >30
- Anatomic: open or depressed skull fracture, penetrating anywhere except the distal extremities, chest wall deformity, pelvic fracture, two or more proximal long bone fractures, pulseless extremity, amputation proximal to wrist or ankle
- Mechanism: falls >20 feet (children 2-3x height of child), high risk auto crash (intrusion, ejection, death in vehicle), auto vs. pedestrian/bicyclist >30 km/hr, motorcycle crash
- Population: older adults, children, patients with bleeding disorder, burns, pregnancy
List 6 side effects of massive transfusion
Hypothermia, hypomagnesium, hypocalcemia (calcium forms complexes with citrate in blood), hypo OR hyperkalemia, alkalosis (from citrate), coagulopathy (due to hemodilution)
Summarize the CRASH 2 trial
CRASH 2 (Lancet, 2010)
Bottom line: TXA improves survival when given early in trauma with known or suspected significant hemorrhage
Population: 20,207 trauma patients with or at risk for hemorrhage, 274 hospitals in 40 countries, multicentre RCT. Exclusion: clear indication or contraindication for TXA
Intervention: TXA 1 g over 10 mins then 1g/8 hour infusion
Control: matching placebo
Outcome: Primary death in hospital at 4 weeks 14.5% in TXA vs. 16.0% in placebo STATISTICALLY SIGNIFICANT. No change in secondry outcomes, incuding VTE, surgical intervention, need for transfusion, death due to bleeding or specific causes
*What are 3 acute complications that can result from mild traumatic head injuries/repeated head injuries?
- Post-concussive syndrome
- Seizures
- Post-traumatic transient cortical blindness
- Impairment in
- physical (headache, dizziness, vertigo, nausea, fatigue, sensitivity to noise & light),
- cognitive (difficulties with attention, concentration, and memory), and
- psychosocial functioning (irritability, anxiety, depression, emotional lability)
Definition of mild traumatic brain injury
GCS 13-15 with a transient disruption in 1) loss of consciousness 2) loss of memory of the events 3) alterations in mental state at the time of accident 4) focal neurologic deficit
LOC <30 minutes, Loss of memory <24 hours, altered can be confused or “seeing stars”
Definition of moderate and severe brain injury
Moderate 9-12, severe <8
*6 Steps in return to play for an athlete suffering a concussion.
- Stage 1/ No activity: Symptom-limited physical and cognitive rest
- Stage 2/ Light aerobic exercise: Walking, stationary cycling
- Stage 3/ Sport-specific exercise: Running drills, no contact
- Stage 4/ Non-contact training drills: Passing drills in football, no contact
- Stage 5/ Full-contact practice: Normal training activities, after medical clearance
- Stage 6/ Return to play: Normal game play
*Young man falls from roof at a party. Three abnormalities on CT given 3 slices (apparently very obvious)
- epidural hemorrhage
- Skull fracture
- Midline shift / loss of ventricles
*He is muttering incomprehensible words, opens his eyes to command, and withdraws to pain. What’s his GCS
E3 V3 M4
*Head trauma, dilated pupil with contralateral paresis. What type of herniation is this?
Uncal herniation
The uncus herniates medially into the tentorial notch, causing compression on the 3rd nerve then brainstem as it progresses:
- Ipsilateral blown pupil/CN III palsy (anisocoria, ptosis, impaired extraocular movements)
- Consciousness, decreased
- Hemiparesis, contralateral
Mnemonic = ICH
Mnemonic = ICH
*Head trauma, If they had ipsilateral CN3 and paresis, describe how this could happen?
Kernohan’s notch syndrome: contralateral cerebral peduncle is forced against the opposite edge of the tentorial hiatus giving ipsilateral paresis - “false localizing”
*Four treatments for increased ICP
- Raise head of the bed (30 degrees), remove constricting devices ex. C collar
- Osmotically active agent — mannitol 1g/kg or hypertonic saline (3%) 300ml
- Intubate and hyperventilate, target PaCO2 35 (although not good evidence)
- Neurosurgical consult for decompressive craniotomy or EVD to relieve pressure
*Recognize SDH and explain pathophysiology
Bleeding between dura and brain, from acceleration-deceleration injuries (bridging vessels), often in elderly/alcoholics with brain atrophy
*Recognize EDH and explain pathophysiology
bleeding between inner skull and dura, from direct trauma (venous or arterial), usually young people
*For SDH describe the following:
i. Does this injury cross the midline
ii. What is the shape?
iii. Does it respect the suture?
- usually not (under dura can not cross falx)
- Crescent moon
- Cross sutures
Surgical indications for OR in SDH
Thickness >10 mm
Midline shift >5 mm
Worsening GSC by >2
Persistently high ICP
Pupil change
*For EDH describe the following:
i. Does this injury cross the midline
ii. What is the shape?
iii. Does it respect the suture?
- May cross midline (above the dura)
- Biconvex, lenticular
- Does not cross sutures
Surgical indications for OR in EDH
Volume >30 cm3
Thickness >15 mm
Midline shift >5mm
Pupil change + coma
Explain the Canadian CT head rule
CT head required in Minor head injury plus:
1. GCS score < 15 at 2 hrs after injury
2. Suspected open or depressed skull fracture
3. Any sign of basal skull fracture (hemotympanum, racoon eyes, CSF otorrhea/rhinorrhea, battle sign)
4. Vomiting ≥ 2 episodes
5. Age ≥ 65 years
6. Amnesia before impact ≥ 30 min
7. Dangerous mechanism ** (pedestrian, occupant ejected, fall from elevation >3 ft or 5 stairs)
Inclusion criteria: minor head injury (blunt trauma to the head with a witness LOC, amnesia, or disorientation), initial GCS => 13, injury within 24 hours
Exclusion criteria: age <16, minimal head injury (no LOC, amnesia, or disorentation), unclear hx of trauma (ex. seizure of syncope), obvious penetrating skull injury or depressed skull fracture, acute focal neurologic deficit), unstable vital signs, seizure, bleeding disorder, return for the same head injury, pregnant
List when the Canadian CT head rule does not apply
See above
What is normal ICP? What is considered high? What is our target MAP in resuscitation with a known high ICP?
5-15mmHg
Remember MAP - ICP = CPP
Between MAP of 60 and SBP of 150 brain undergoes autoregulation
CPP < 40 = lose of autoregulation
so if ICP is 20, want MAP of 80 to have CPP of 60
What are the 5 layers of the scalp?
SCALP Skin, connective tissue, aponeurosis fascia (muscles), loose connective tissue, periosteum
Alternative is dermis, subcutanous layer (hair and fat), Galea (wrinkles forhead), loose areolar tissue, periosteum
List 3 things that cause cerebral vasoconstriction, and vasodilation
Cerebral vasoconstriction: hypocarbia, alkalosis, hypertension
Cerebral vasodilation: hypercarbia, acidosis, hypotension
Which head injuries get seizure prophylaxis?
Ben says “not reccomended for late PTS. Are reccomended for early (within 7 days) if percieved benefit > risk
Penetrating, seizure
Which head injuries get antibiotics?
General indications: Penetrating injury, open or depressed skull fracture, persistent CSF leak, basiliar skull fracture with fever, complex and contaminated wound
In skull fractures: open skull fracture, involving a sinus, associated with pneumocephalus, highly contaminated
In basilar skull fractures: immunocompromised, CSF leak
Explain 6 common herniation syndromes
Supratentorial
uncal - inner most part of temporal lobe (uncus) moves downwards towards tentorium
central transtentorial - downward pressure under free edge of tentorium
transcalvarial - squuezes out of fracture subfalacine - frontal lobe under falx
Infratentorial
upward cerebrellar transtenorial downward cerebellar (tonsillar)
*Describe secondary systemic insults and goals in management. Which ones double mortality?
*Hypotension, target MAP >80
*Hypoxia, target PaO2 >60
Hyper or hypocapnia, target PaCO2 35-45 unless herniation
Anemia
Hyperpyrexia
Summarize the CRASH 3 trial
CRASH 3 (Lancet, 2019)
Bottom line: TXA did not improve mortalty in traumatic brain injury patients. In a subgroup analysis of patients with mild-moderate head injury GCS 9-15, TXA did reduce death due to head injury
Population: 12,737 patients in 175 hospitals and 29 countries. Inclusion: Adults with TBI within 3 hours of injury, GSC <= 12 or intracranial bleeding on CT, clinician was unsure whether TXA would held. Exclusion: major extracranial bleeding
Intervention: TXA 1 g over 10 mins then 1g/8 hour infusion
Control: matching placebo
Outcome: Primary head injury related death 18.5% in TXA vs. 19.8% (no difference). Secondary outcomes: head injury related deaths in patients with mild-moderate injury GCS 9-15 5.8% vs. 7.5% STATISTICALLY SIGNIFICANT. No change in other subgroups, disability, VTE, or other complications
*What six clinical findings of orbital floor fracture?
Also known as a orbital blowout fracture
- Peri-orbital bruising/swelling
- Orbital tenderness
- Orbital step-off deformity
- Orbital emphysema
- Enophthalmos
- Exophthalmos/proptosis, if associated retrobulbar hematoma
- Diplopia
- Anesthesia to mid face/upper lip due to infraorbital nerve (branch of maxillary nerve/CN V2) neuropraxia
*What are the radiologic findings of orbital floor fractures? (2)
What is the preffered XR view?
- Tear-drop sign (herniated fat +/- inferior rectus muscle)
- Eye brow sign (intra-orbital air rises to superior part, looks like an eyebrow)
- Blood in maxillary sinus
- Retro-orbital hematoma
- Orbital emphysema
Water view (looking up) or Caldwell view (looking down)
*What are the two reasons for surgical intervention of orbital floor fractures? What is the treatment
1- persistent diplopia
2- chemosis
Repair in 1-2 weeks
*Eyelid laceration - when should ophtho be involved in repair (5)
1- Fat extrusion (involvement of orbital septum)
2- Lid margin involvement
3- Levator or canthal tendon involvement
4- Canalicular system involvement
5- Laceration with tissue loss /avulsion
At what age do the sinuses develop
Ethmoid and Mastoid - Birth
Sphenoid - 3
Frontal - 6
Maxillary - 9
EM is So Fucking Messed, Birth 3,6,9
Describe the anatomy of the salivary glands
Partoid: largest, located anterior to the ear, drains via Stensen’s duct in the 2nd upper molar
Submandibular: located under the jaw, drains via Wharton’s duct on either side of the frenulum
Sublinguinal: located inb the floor of the mouth, drains via ductules
What are indicates to reduce a nasal fracture in the ED
Deformity without swelling, deformity causing difficulty breathing, significant epistaxis
Describe the classification of midface fractures
All involve the pytergoid plate
Lefort 1: transverse fracture that separate the maxilla from the pterygoid plate and nasal septum, upper alveolar ridge moves.
Lefort 2: fracture through (nasal bridge, maxilla, orbital rim, lacrimal bones) and hard palate. Midface moves.
Lefort 3: fracture through nasal bridge, posterioly along medial orbit (ethmoids), then floor or orbit (maxilla), exits through lateral orbital wall then through zygoma. Whole bottom of face moves (craniofacial dysfunction)
Le Fort 3 can also go through sphenoid and have CSF leak
*What is a tripod/trilaminar fracture? What are four complications?
AKA zygomaticomaxillary complex
Fracture of lateral orbital rim
Fracture of inferior orbital rim
Zygomatic arch
Attachment of maxilla and zygoma
Creates a mobile bony segment that is often depressed and causing:
Facial asymmetry
Endopthalmous
Malocclusion of upper teeth
Denervation of upper teeth
Teeth stuff with fracture of maxilla/ injury of dentiaveolar nerve
Describe the bones that border the orbit
Superior: frontal bone
Lateral: zygoma and sphenoid bones, Medial and anteriomedial: maxilla, lacrimal, ethmoid bone (most vulnerable)
Key here is it is NOT the nasal bone
Which facial fractures need antibiotics
Open fractures, bite wounds, evidence of devascularization, highly contaminated wounds, through and through of the buccal mucosa, involvement of the cartilage of the ears or nose
What is the significance of perioral electrical burns
Pediatric injury from biting electric cords, often result in full thickness burn. Risk of eschar that separates causing labial arter bleeding
What is cauliflower ear? and how it should be managed?
Hematoma in the subperichondrial space.
When a consultant should be called for ear laceration?
1- Significant loss of tissue
*What defines ending of spinal shock?
Return of bulbocavernous reflex
Gloved finger in patient rectum OR tug on foley OR squeze glans or clitoris -> intact reflex leads to rectal contraction
*Describe the mechanism and 4 features of central cord syndrome.
Memory aide: MUD-E Mechanism:
- Neck hyperextension
- Often in patients with degenerative arthritis of the neck who suffer neck hyperextension, leading to buckling of ligamentum flavum into cord, resulting in concussion of central gray matter.
Features: concussion of the central gray matter in the pyramidal and spinothalamic tracts. Because fibers innervating distal structures are located in the spinal cord periphery, the upper extremities are more severely affected than the lower extremities.
*Describe the mechanism and 4 features of Brown- Sequard syndrome.
Mechanism: Hemisection of the spinal cord, usually from penetrating trauma, but may also be seen after lateral mass fractures of cervical spine
Features:
- Ipsilateral motor paralysis
- Ipsilateral loss of position and vibration sense
- Contralateral loss of pain and temperature sensation one or two levels above the lesion
*Describe the mechanism and 4 features of anterior cord syndrome.
Mechanism: Flexion injury or injury to anterior spinal artery (e.g. vascular or atheroscloerotic disease in elderly, iatrogenic cross clamping of aorta)
Features:
- Proprioception and vibration intact - Bilateral loss of motor function
- Bilateral loss of temperature sensation - Bilateral loss of pain sensation
*Describe the mechanism and 4 features of complete cord transection
Mechanism: Complete transection of cord
Features:
- Bilateral loss of proprioception and vibration - Bilateral loss of motor function
- Bilateral loss of temperature sensation - Bilateral loss of pain sensation
*What is the diagnosis? *Pic of “subluxation with bilateral perched facet joints What is the mechanism?
Flexion injury
*What are 4 unstable flexion c-spine injuries?
- Atlanto-occipital dislocation
- Anterior atlantoaxial dislocation with or without fracture
- Flexion teardrop
- Bilateral facet dislocation (displaces anteriorly above lesion)
- Odontoid fracture with lateral displacement fracture (typicalyl oblique)
- Felxion-distraction injury (seatbelt, compression # with distraction of posterior elements - split open logitudenally in back)
AAFFOB
*What are 2 unstable extension c-spine injuries?
- Posterior neural arch fracture (C1) - compression of posterior elements between occiput and SP of axis
- Hangman’s fracture (C2) - bilateal pedicle # of axis
- Extension teardrop fracture (unstable in extension, broken in front)
- Posterior atlantoaxial dislocation, with or without fracture (odontoid goes behind atlas)
*List 2 mechanisms for anterior cord syndrome
- hyperflexion injuries
- ischemia of the anterior spinal artery as a result of vascular or atherosclerotic disease in the elderly, or iatrogenic secondary to cross clamping of the aorta
- Fracture fragments from vertical compression injury
*Reflexes for
□ C6
□ C7
□ L4
□ S1/S2
C6 Biceps
C7 Triceps
L4 Patellar
S1 Achilles
*Define spinal shock
Concussive injury to the spinal cord that causes total neurologic dysfunction distal to the site of injury.
*What are three high-risk criteria in the Canadian c-spine rule?
- Age older than 65 years
- Dangerous mechanism (e.g. fall from height >1 m, axial loading injury, high- speed MVC [>100 km/h], rollover, ejection, motorized recreation vehicle or bicycle collision)
- Presence of paresthesias
*7 clinical situations in which the Canadian C Spine rule does not apply?
Inclusion
- Age >16
- Stable vitals
- At risk of C spine injury because of either 1) neck pain from any mechanism of injury OR 2) no neck pain but visible injury, not yet ambulatory, dangerous mechanism
Exclusion
- GCS < 15
- Grossly abnormal vital signs
- Injured > 48 hours previously
- Penetrating trauma
- Acute paralysis
- Known vertebral disease (e.g. RA, spinal stenosis, previous C- spine injury, ankylosing spondylitis)
- Returned for re-assessment of same injury
- Pregnant
*How can you determine if a spinal cord lesion is complete or incomplete? 3 signs.
- Total loss of motor power and sensation distal to injury
- Lack of minimal cord function/sacral sparing (e.g. perianal sensation, rectal tone, flexor toe movement)
- Lack of spinal shock (e.g. bulbocavernosus reflex present)
*Describe neurogenic shock? At what level does it occur?
Neurogenic shock = distributive shock, secondary to decreased vascular resistance and increased vagal tone as a result of autonomic disruption, injury above level of T6
*After ruling out hemorrhage, they are still hypotensive and bradycardic. List two interventions you will use now.
- IV crystalloid resuscitation
- IV vasopressor support (e.g. norepinephrine, epinephrine)
*Recognize c6 teardrop picture. Is it unstable or stable?
Flexion teardrop = extremely unstable
Extension teardrop = usually stable in flexion, unstable in extension
*Fill in table of 4 c-spine injury mechanisms and 2 examples each of unstable and stable.
FLEXION
- Wedge, clay shoveler’s, transverse process (stable)
- Bilat facet dislocation, flexion teardrop, A-O dislocation (++unstable)
EXTENSION
- Extension teardrop fracture (Usually stable in flexion; unstable in extension)
- Hnagman’s, Post A-O dislocation, post neural arch (unstable)
FLEX-ROTATION
- Unilateral facet dislocation (stable)
- Rotary A-O dislocation (unstable)
VERTICAL COMPRESSION
- Isolated fractures of articular pillar and vertebral body (stable)
- Jefferson (unstable)
What are the low risk C spine criteria that will let you range the neck?
Simple rear ended MVC OR sitting position in ED OR Ambulatory at any time OR delayed onset neck pain OR absence of midline C spine tenderness
What are two radiographic findings that suggest atlanto-occipital dislocation
1) Basion-axial or basion dens distance >12mm 2) Powers ratio (basion-posterior arch of atlas/opisthion-anterior arch of atlas)>1
What is a radiographic finding that suggests atlanto-axial dislocation
Predental space >3mm in adults and >5mm in children
*Explain the anatomic landmarks in the Denis model of spinal stability
Injury to 2 or more sections suggests instability
Anterior column: anterior longitudinal ligament, anterior vertebral body + annuls
Middle column: posterior vertebral body + annulus, posterior longitudinal ligament, spinal cord, nerve roots, vertebral arteries and veins
Posterior column: ligamentum flavum, spinous processes, intraspinous ligaments, supraspinous ligament, nuchal ligament
*clarify descrepancy boys and Rosens
*Violation of which structure defines penetrating neck trauma?
Platysma
*What two anatomic structures define each zone of the neck?
Zone I : Sternal notch/clavicle to cricoid cartilate
Zone II: Cricoid cartilate to angle of mandible
Zone III: Angle of mandible to base of skull
List the vascular, neurologic, and tissue components in each zone of the neck
Zone 1: carotid, subclavian, vertebral, thoracic vessels - spinal cord - esophagus, trachea, thyorid, thoracic duct, lung apices
Zone 2: carotid, int/ext jugulars, vertebral - spinal cord, recurrent laryngeal nerve, vagus nerve - esophagus, trachea, larynx, pharynx
Zone 2: carotid, jugular, vertebral - spinal cord, cranial nerves - esophagus, trachea, salivary glands
*What are 5 hard signs of injury in penetrating neck trauma?
Hard signs equate with the need for immediate surgical or endovascular intervention.
Rapidly expanding/pulsatile hematoma
Massive hemoptysis
Air bubbling from wound
Severe hemorrhage
Shock not responding to fluids
Decreased or absent radial pulse
Vascular bruit or thrill
Stridor/hoarseness or airway compromise
Cerebral ischemia
+/− Massive subcutaneous emphysema
*Penetrating neck trauma with Normal CTA, what are three additional diagnostic tests of procedures you would do?
- Endoscopy
- Nasoparyngoscopy
- MR angiography
- Conventional angiography
*What are three additional (non-vascular) structures that can be injured in penetrating neck trauma?
- Lung apices
- Esophagus
- Trachea
- Thyroid
- Thoracic duct
- Spinal cord
*Penetrating neck trauma stem. Stab would lateral to thyroid cartilage. What zone is it?
1
*List 5 soft signs of injury in penetrating neck trauma
Minor hemoptysis
Hematemesis
Dysphonia, dysphagia
Subcutaneous or mediastinal air
Nonexpanding hematoma
Neurological findings
Proximity wound
Split into vascular and aeordigestive soft signs
Which blunt neck traumas should get CTA
Expanded Denver Criteria:
Signs
Arterial bleeding neck, nose, mouth
Expending cervical hematoma
Bruit <50
Focal neruo finding
Neuro exam does not match CT
Stroke on CT
Risk factors
Le For II or III
Complex basillar skull, occipital #
Mandible #
C-spine # or ligament injury
Upper rib #
Near hanging with anoxic brain injury
TBI with GCS <6
Seatbelt sign plus swelling/pain/altered
Scalp degloving
Thoracic vascular injury
Blunt cardic rupture
Split up signs into vascular concerns and neuroconcerns. Split up risk factors into fractures, head scenarios, chest scenarios
what are the borders of the anterior and posterior triangle of the neck?
Anterior:
(Midline anteriorly, SCM posteriorly, and mandible superiorly)
Posterior:
(SCM: anteriorly, Clavicle: inferiorly, and Trapezius: Posteriorly)
Anterior has neurovascular and aerodigestive tracts. Posterior triangle only has the spine.
List options to control bleeding from penetrating neck wound.
Direct pressure
Finger tip occlusion
Pack to facilitate compression
16-18F foley directed into wound (not vessel lumen) and inflated with sterile water until bleeding stops or moderate resistance felt
Differentiate between Judicial vs Non-judicial , Complete vs incomplete, typical vs atypical hanging.
Judicial hanging: fall from height of body
- Judicial hanging: distraction forces —> high cervical fracture, cord transection, death
Non-judicial: fall from height < the height of the body
- Non-judicial hanging: venous congestion —> cerebral vascular stasis —> unconsciousness —> further tightening —> arterial occlusion
Complete (incomplete) hanging: full (partial) suspension of body
Typical (atypical) hanging: knot midline under occiput (all other knot placements) Maximum force is opposite knot
What is the management of a venous air embolism? When should it be suspected?
Venous Air Embolism - Management: 1. Pressure on wounds with vascular injury in neck 2. Left Lateral Decubitus to allow air to accumulate in RV (Durant maneuver) 3. Head-down position (Trendelenburg) 4. If central line in situ, aspirate air 5. Needle aspiration from RV (US guided pericardiocentesis) 6. Thoracotomy for aspiration of RV air **Consider if shock or arrest not responding to fluids in patient with penetrating neck injury
*Traumatic aortic dissection after crushing chest on steering wheel column. Six clinical findings of dissection
What are 3 risk factors for blunt aortic injury?
Severe deceleration injury
Speed over 70kmh
Evidence of severe blunt force to the chest
*******
1. Hypertension
2. Harsh murmur
3. Swelling at the base of the neck caused by the extravasation of blood from the mediastinum
4. Pulsatile neck mass
5. Lower extremity pulse deficit
6. Lower extremity paresis
7. Large left sided hemothorax
*Six x-ray findings of dissection
- Wide mediastinum (>10cm AP CXR)
- Calcium sign - Ca deposit > 10mm from aorta
- Double density of aorta
- Loss of AP window
- Obliteration of the aortic knob
- cardiomegaly
- Displacement of NG tube (esophagus) to the right
- Tracheal deviation to R
- Depressed left main bronchus
- Presence of Apical cap
- Pleural effusion (usu on L)
- widening or loss of paratracheal stripe
*3 symptoms other than crushing retrosternal chest pain radiating to the back that the patient might have?
- Interscapular or retrosternal pain
- Dyspnea
- Hoarseness
- Stridor
- Dysphagia
- Extremity pain
*Trauma CXR showing left-sided sulcus sign and wide mediastinum. Immediate management:
Chest tube insertion
*Trauma case. Young person, single stab wound to epigastrium. 6 reasons for hypotension in this patient.
- Heart/pericardium (e.g. tamponade)
- Lung/pleura (e.g. pneumothorax)
- Great vessel laceration
- Spleen laceration
- Liver laceration
- Perforated viscus
*What are 4 ecg findings of blunt cardiac trauma?
- Sinus tachycardia
- Bundle branch block
- ST segment abnormalities
- T wave abnormalities
- Ectopy (e.g. PVC, PAC)
- Other arrhythmias (e.g. atrial fibrillation)
*Over what time period do dysrhythmias occur in blunt cardiac trauma?
lethal ECG usually in first 12 hours
What is most common location of cardiac injury in blunt trauma?
Right ventricle, because of its anterior position in the thorax and proximity to the sternum
*Blunt cardiac trauma patient has mildly elevated trop now and 6 hours later, and intermittent bigeminy on ECG. What is your dispo and plan?
- Admission
- Telemetry
- Repeat troponin
- Echo
*3 CXR findings of diaphragmatic injury
- elevated diaphragm
- blurred diaphragm
- pleural effusion
- lower lobe atelectasis
- gas-containing viscus in abnormally high position
- mediastinal displacement to opposite side
*List 6 life-threating thoracic injuries you would want to rule out in your initial assessment
- aortic injury
- esophageal rupture
- tension pneumothorax
- massive hemothorax
- pericardial effusion/tamponade
- myocardial/pericardial rupture
- tracheobroncheal injury
- flail chest
- dysrhythmia
*Blunt chest trauma patient ends up having a pulmonary contusion and 2 nondisplaced rib fractures. 3 delayed complications of these injuries
- Hemothorax
- Pneumothorax
- Atelectasis
- Pneumonia
- Post-traumatic neuroma
- Costochondral separation
*Define flail chest
3 or more adjacent ribs fracture at two points
*List 3 ways in which it may affect ventilation (flail chest)
i. Underlying pulmonary contusion
ii. Pain causes splinting resulting in atelectasis
iii. Paradoxical motion of chest wall (flail segment moves inward with inspiration)
iv. Pain also causes hypoxemia and decreased cardiac output
*List 3 non surgical modalities for treatment of flail chest
i. Oral Analgesia
ii. Intercostal blocks
iii. Incentive spirometry
iv. Chest physio
v. Non-invasive ventilation (avoid intubation)
*Name three indications for OR Thoracotomy?
Initial thoracostomy tube drainage is more than 20 mL of blood per kilogram. (or 1500mL)
Persistent bleeding at a rate greater than 7 mL/kg/hr is present. (or 200mLx3h)
Increasing hemothorax seen on chest x-ray films.
Patient remains hypotensive despite adequate blood replacement, and other sites of blood loss have been ruled out.
Patient decompensates after initial response to resuscitation.
For the last 3 think increase (more hemo on CXR), decrease (worse after got better) and the same (still hypotensive despite resus)
*Once the chest is opened, list 5 things that would do therapeutically?
Pericardotomy
Finger in whatever is bleeding
Suture defects
Clamp aorta
MTP
Cardiac massage
*There was a bronchial tree injury and you suspect air embolus. What would you do next?
High flow o2. Make sure patient is flat. Consider HBO.
What is the main complication of sternal fractures
Mediastinal hematoma; anyone with a suspected sternal fracture should get a CT and ECG
List three different types of pneumothorax
Simple, communication/open, tension
List specific injuries associates with rib fractures based on location
Ribs 1-3: harder to fractures, present with thoracic injuries
Ribs 4-9: tend to fracture at posterior border
Ribs 10-12: more mobile, can cause abdominal injuries ex. Splenic lac or liver lac
Who in the ED should get a CT chest?
Nexus criteria
Pain at the chest wall, sternum, scapula, or thoracic spine
Abnormal chest X ray
Concerning mechanism of injury (ex. Rapid deceleration, fall >20 feet or high speed MVC)
Distracting painful injury
Who in the ED should get a chest tube?
Pneumothorax that is: tension, large, increasing in size, bilateral, traumatic, causing symptoms, recurrence after chest tube removal, + hemothorax
Patient: on a vent, needs OR
Define massive hemothorax in adult and peds. What is the management?
Adult:
- >1500 mL of blood immediately evacuated from tube thoracostomy
- persistent bleeding from chest, >200mL/h for 2-4 hours
Pediatric: 15 mL/kg or 2 mL/kg/hr (divide the adult numbers by 100)
Management: Thoracotomy, OR
what are complications of chest tube insertion?
- HTX
- Re-expansion pulmonary edema
- Bronchopleural fistula
- Empyema
- SC emphysema
- Infection
- Contralateral PTX
- Pleural leak
- Parenchymal injury
- Intercostal artery laceration
- Diaphragm injury
- Splenic/liver injury
Which pneumothoraces can be watched conservatively?
PSP trial (NJEM 2020)
Bottom line: conservative management was non inferior to invasive management
Population: Patients with unilateral spontaneous pneumothorax <32% or 6cm
Intervention: Small bore chest tube attached to suction x 1 hour. If repeat CXR showed lung expanded the chest tube was clamped and then drain was removed
Control: No chest tube. 4 hours of observation in the ED and repeat CXR. D/C home if CXR stable and requiring no oxygen
Outcome: Primary radiographic resolution 98.5% in intervention and 94.4% in control, therefore concluding that conservative therapy was non inferior to invasive therapy. Complete resolution of symptoms was better in the control group. Serious adverse events were greater in the invasive group.
How can pulmonary contusion be distinguished from ARDS
Pulmonary contusion: focal, appears soon after injury (definitely within 6 hours)
ARDS: bilateral, appears 24-48 hours after insult
What is the most common place for an aortic injury
Isthmus
Name 6 common causes of esophageal perforation
Iatrogenic, foreign bodies, caustic burns, blunt or penetrating trauma, spontaneous rupture ex. Boehaave’s, post operative breakdown of anastomsis
Distinguish between myocardial concussion and contusion
Concussion (aka commotio cordis): Direct blow to the heart results in a non perfusion arrhythmia, there is NO structural heart damage
Contusion: direct injury to the myocardial cells, may lead to arrhythmias (most common is sinus tachycardia)
What are the indications for ER Thoracotomy in traumatic cardiac arrest?
Penetrating cardiac arrest:
Cardiac arrest at any point with initial signs of life in the field
Systolic blood pressure below 50mmHg after fluid resuscitation
Severe shock with clinical signs of cardiac tamponade
Blunt trauma:
Cardiac arrest in the emergency department
What are 4 sonographic sign of pericardial tamponade on US
RV collapse during diastole, RA collapse during systole, plethoric IVC, large effusion
What are 3 ECG findings of tamponade
Sinus tachycardia, electrical alternans, low QRS voltage
Complications of tracheobronchial injuries?
Bronchopleural fistula, Mediastinitis
What are 5 ways to determine if the peritoneum has been violated
CT, local wound exploration, laparoscopy, missile path, plain radiographs
What are signs of life in the field
BP OR Pulse OR Cardiac rhythm OR Respiratory Effort OR Echo cardiac activity or tamponade
Pupillary response + Extremity Movement [East]
What is Waddell’s triad
Triad of injuries seen in pediatric traumas: femur #, intra abdominal or intrathoracic injury, head injury
*4 windows in a FAST in trauma
• Subxiphoid pericardium
• RUQ
• LUQ
• Pelvis
*Define edge artifact (US)
Shadowing artifact caused by refraction of ultrasound waves
*Define enhancement (US)
Relative increased echogenicity after ultrasound energy passes through an anechoic structure (e.g. bladder or blood vessel)
*Define shadowing (US)
Loss of ultrasound transmission after encountering a highly dense/reflective surface
*Define anechoic (US)
without sounds (black)
*Define hyperechoic (US
with more reflected sounds than adjacent tissue (more echogenic)
*Define acoustic window (US)
area of the body that permits transmission of the ultrasound beam to an area of interest
*Define near field (US)
top of screen/closest to probe
*Trauma case. Young person, single stab wound to epigastrium. 5 reasons for urgent laparotomy in this patient.
- Hemodynamic instability (e.g. major solid visceral or vascular injury)
- Peritoneal signs
- Evisceration
- Left-sided diaphragmatic injury
- Gastrointestinal hemorrhage
- Implement in situ (e.g. knife in situ)
- Intraperitoneal air
*What 3 injuries does a CT scan miss? (Trauma, CT abdo)
- Hollow viscous injury (e.g. small bowel)
- Diaphragmatic injury
- Pancreas
- Mesentery
*List 5 limitations to the FAST in blunt abdo trauma
- does not image solid parenchyma
- does not image retroperitoneum
- does not image diaphragmatic defects
- technically compromised by: uncooperative patient, agitated patient, obese patient, bowel gas, subcutaneous air
- high false negative rate for hemoperitoneum in presence of pelvic fracture
- poor at recognizing bowel injury
- Operator dependent
*List 5 advantages to CT in blunt abdominal trauma
- noninvasive
- define injured organ and extent of injury
- “accurately discerns the presence, source and approximate quantity of intraperitoneal hemorrhage”
- demonstrate active bleeding from liver or spleen
- can be used to determine whether therapeutic angiographic embolization is needed
- evaluates retroperitoneum
- evaluates vertebral column
- can be easily extended above or below the abdomen to visualize the thorax or pelvis
- provides definitive evaluation of the urinary tract
- “CT is particularly helpful in guiding non-operative management of solid organ damage”
*List 5 limitations to CT in blunt abdominal trauma
- insensitive for injury of pancreas, diaphragm, small bowel, mesentery
- “findings on CT scan are not able to forecast well the need for operative intervention”
- complications from IV contrast
- patients need to leave the resuscitation area
- radiation risk, cost, need tech, need radiologist, need time
*What visceral organ is most likely to be injured in blunt abdominal trauma
Spleen
*Define “seatbelt sign”
Contusion or abrasion across the lower abdomen in a patient wearing a lap belt during motor vehicle collision
*What organ is most commonly injured with seatbelt sign. What are 4 other things commonly injured?
Small bowel and Mesentery (also aorta, diapghragm, pancreas, lumbar)
*List 6 causes of False positive on FAST U/S of abdo
Ascites
Physiologic free fluid (pelvis)
Peri-renal fat
Apical fat pad
Gallbladder
IVC
?Bladder rupture
VP shunt
Ovian cyst rupture
Peritoneal dialysis
*List 6 causes of False negative on FAST U/S of abdo
Adhesions
Too early
Incomplete views
Retroperitoneal bleeds
*What is the minimum amount of blood required to be + on Abdo U/S
150-200mL
Which organs are retroperitoneal
SAD PUCKER: Suprarenal (adrenal), aorta/IVC, duodenum, pancreas, ureters, colon, kidneys, esophagus, rectum
List indications for laparotomy following penetrating trauma
Emergent: HIPED hemodynamic instability, peritoneal signs, evisceration, diapghragmatic injury
Needs additional evidence: GII
GI hemorrhage, implement in situ, inbtraperitoneal air
List indications for laparotomy following blunt trauma
Emergent: hemodynamic instability, peritoneal signs, diapghragmatic injury, pneumoperitoneum, significant GI bleeding
List pros and cons of ultrasound in trauma
PROS: quick, easy to repeat, low cost, in the trauma bay, non invasive
Cons: operator dependent, affected by body habitus, limited assessment of parenchyma, diapghram, retroperinteum, bowel injury
What is the most dependent areas in FAST for adults and peds
Adults: Morrison pouch, Peds: Pelvis
*How would you manage extraperitoneal bladder rupture? What are 3 exceptions to this?
Foley catheterization, unless complicated by other intra-abdominal injuries, bladder neck injuries, bone fragments in the bladder wall, or if open reduction is performed on an associated pelvic fracture
*How would you manage intraperitoneal bladder rupture
Surgical exploration and repair
*What are THREE ways to stabilize the pelvis in the emergency department?
• Sheet and towel clamps
• Commercial circumferential compression device
• External fixation
*What are TWO definitive management strategies for pelvic bleeding?
- Angiography and embolization
- Laparotomy and pelvic packing
*What is the best imaging strategy for:
a. Renal artery
b. Ureter injury
c. Bladder rupture
d. Urethra rupture
e. Testicle/scrotum
a. Renal artery: CT with contrast +/- angiography (note, angiography not commented on in most recent version of Rosen’s)
b. Ureter injury: CT with contrast, with 10-minute delay to permit contrast to enter and pass through the ureter
c. Bladder rupture: CT cystogram, which involves diluting 30 ml of contrast in 500 ml of saline and introducing this fluid into the bladder via Foley catheter
d. Urethra rupture: Retrograde urethrography
e. Testicle/scrotum: Ultrasound
*Blunt trauma stem with bloody meatus and urine leakage. Most likely Dx?
Urtheral injury
*Technique for Performing Retrograde Urethrography
- A 16-Fr or 18-Fr Foley catheter or a hysterosalpingogram catheter is flushed with radiopaque contrast to avoid air bubbles.
- The glans penis and urethral meatus are cleaned with antiseptic.
- The catheter is inserted into the penis, and the balloon is partially
inflated (1 to 2 mL) in the fossa navicularis. - The penis is then pulled laterally to straighten the urethra under
moderate traction. - A precontrast “scout” image is obtained, because prostatic
calcifications may be confused for extravasated contrast. - Under fluoroscopic visualization, 20 to 30 mL of contrast is injected
with the goal of filling the entire urethra. - If spasm of the external sphincter prevents posterior urethral filling,
slow, gentle pressure may allow opacification. - Static images are obtained to demonstrate the identified pathologic
condition.
*Management of urethral injury in one line?
Call urology
*What are 4 findings on physical exam that suggest you should not place a Foley?
Blood at meatus (hematuria)
Urinary retention + distended bladder
High riding prostate
Swelling or ecchymosis of the perineum or penis including “butterfly bruising”
*How to Dx urethral injury?
Retrograde urethrography
*Apart from urethral injury, what is the Ddx of hematuria in trauma?
Bladder trauma
Ureter trauma
Renal injury
?Penile fracture
*In trauma, what is your management of a) microscopic hematuria b) gross hematuria
the degree of hematuria does not correlate well with the severity of injury
In the trauma patient, what 4 findings should make GU injury a consideration?
- Pelvic #
- Blood at meatus
- Gross hematuria
- Inability to void
Think 2 for urethra and 2 for bladder
What are 4 potential complications from GI trauma
Renal insufficiency, chronic HTN, incontience, sexual dysfunction
This also about strictures
What are the 4 parts to the male urethra
Prostatic, membranous, bulbous, penile/pendulous
What are the 5 grade of renal trauma
Grade 1: subscapular hematoma, no laceration
Grade 2: subscapular hematoma + laceration <1cm
Grade 3: parenchymal laceration >1cm with collecting system involvement
Grade 4: parenchymal laceration into the collecting system
Grade 5: shattered kidney with blood vessel injury that causes devascularization
What is the management of renal trauma
Grade 1-3: observation, grade 4: observation +/- repeat imaging, grade 5: repeat imaging, often need surgery
What is the clinical difference between an intraperitoneal and extraperitoneal bladder rupture
Intraperitoneum: rupture through the dome of the bladder when distended. Contrast is show outline intraperitoneal structures. Needs OR
Extraperitoneum: rupture at the bladder base, often associated with pelvic trauma. Contrast only fills the pelvic cavity. Conservatively managed with a Foley
What is the imaging of choice for bladder injury
Retrograde stress cystogram: Dilute 30 mls of water soluble contrast in 500mls of warmed NS. Introduce 300-400mls into the bladder via Foley catheter. Clamp the foley. Then CT or x ray images are taken
What are signs of a penile fracture
Immediate pain, detumescence, popping sound, ecchymosis, eggplant deformity
What are indications for CT in suspected renal injury
Gross hematuria, microscopic hematuria with hypotension, hx of rapid acceleration/deceleration injury, penetrating trauma, signs of renal trauma (bruising, tenderness)
*What are 5 hard signs of vascular injury?
Pulsatile hemorrhage
Expanding hematoma
Absent distal pulse
Thrill
Bruit
*What are 5 soft signs of vascular injury?
Decreased pulse/abnormal ABI
Non-expanding hematoma
Significant haemorrhage at scene
Peripheral nerve deficit
Bony injury or primate penetrating wound
*What are 2 clinical tests to rule out vascular injury?
ABI
US
CTA
*True or false: (6 items)
50% of peripheral vascular associated with peripheral nerve injury.
70% of penetrating trauma to extremities associated with major venous injury.
Around 50% (I don’t remember the exact %) peripheral vascular injury will have absent distal pulse.
> 90% has arterial injury if one hard sign of vascular injury is present
70% of patients with gunshot wound have associated major venous injuries
50% of peripheral vascular associated with peripheral nerve injury. TRUE
70% of penetrating trauma to extremities associated with major venous injury. ?FALSE
Around 50% (I don’t remember the exact %) peripheral vascular injury will have absent distal pulse. (Pulses absent in 30% of cases of UE injury 2/2 collateral flow)
> 90% has arterial injury if one hard sign of vascular injury is present TRUE!
70% of patients with gunshot wound have associated major venous injuries FALSE, 50% (and 80% of those have associated arterial)
List occlusive types of vascular trauma
Transection, thrombus, reversible arterial spasm
List non occlusive types of vascular trauma
Intimal flap, compartment syndrome, dissection, AV fistula, pseudoaneurysm
?potential memory aid: I Can’t Dispo Any Patients -
List the vascular injury associated with the following orthopedic injuries: 1) shoulder dislocation 2) supracondylar fracture 3) femur fracture 4) knee dislocation 5) tibial plateau fracture
1) axillary 2) brachial 3) popliteal or superficial femoral 4) popliteal 5) popliteal
Explain how to obtain an ABI and describe a significant measurement
To obtain an ABI (ankle/brachial) or API (arterial pressure) inflate a blood pressure cuff proximal to the injury and record the pressures using a handheld Doppler distal to the injury. A ratio of <0.9 when comparing the injured and injured side is significant and warrants further investigation
What is the difference between warm and cold ischemia time
Warm ischemia time 6 hours: at 6 hours 10% will have irreversible damage, at 12 hours 90%
Cold ischemia time 24 hours
List the nerve near the following arteries: 1) axillary 2) brachial 3) radial 4) ulnar 5) femoral 6) popliteal
1) brachial plexus 2) median nerve 3) median and radial nerves 4) ulnar nerve 5) femoral nerve 6) tibial nerve
List 6 delayed complications of arterial injury
Amputation, thrombosis, intermittent claudication, ulcers, aneurysm, fistula
List high risk wounds associated with occult peripheral vascular injury
Crushed extremity
Animal bites eg large dog
Penetrating wound within 1 cm of neurovascular bundle
Dislocated joints (especially knee)
Displaced fractures: clavicle (subclavian), supracondylar humerus (brachial), femoral shaft (superficial femoral, popliteal), tibial plateau (popliteal)
What is a Haddon matrix
A form of injury preventing by focusing on the environment, agents inflicting harm (host) and at-risk populations (agent)
see photo
List 5 types of artifacts you may see on US
see photo
List 5 POCUS competencies for the EM physician
[CAEP 2019 position statement]
1. FAST
2. AAA
3. IUP
4. Thoracic (pneumothorax, hemothorax, pleural effusion, ILD)
5. Cardiac (global cardiac activity, LVEF, RV size, pericardial effusion, IVC)
6. Ultrasound guided vascular access
What is permissive hypotension? When is it contraindicated? What is the clinical target [per Rosen’s]
Resuscitation to a normal BP may increased bleeding from an uncontrolled site or from a site that is tenuous but not yet bleeding
If you use a MAP of >50, reduces bleeding, blood products, less coagulopathy
Contraindicated in head trauma (risk of hypoperfusion)
When does an ACS surgeon need to come in?
Intubated on scene
Respiratory compromise requiring airway emergently
GCS <8 attributed to trauma (probably going to be intubated)
Confirmed hypotension (SBP <90)
Gunshot neck, chest, abdo, proximal extremities
Discretion of ED physician
Think of it as if they are intubated, no clinical info need surgeon expertise to weigh in OR sounds like they are super sick and might need OR
What do the different stages of the trauma triage algorithm signify ?
Vitals/ anatomy - transfer to highest level trauma center in the vicinity
Mechanism - transport to A trauma center, depending on region may not have to be highest level
Spec pop - transport to a trauma center or hospital capable of evaluating/ managing injuries. Consult medical control
*when it doubt, go to the highest level possible
Think of this as vitals/ anatomy - statistically they have injury that needs surgeon, mechanism - might have something, special pop = where they are best suited
What is the ACS classification of shock
Not in 10th edition Rosens
What are the injuries associated with handlebars?
Ask Boys
What are 3 principles of damage control resuscitation?
Hemostatic resuscitation (give blood not fluid)
Permissive hypotension
Early hemmorhage control
All three are designed to avoid trauma-induced coagulopathy
*What is the difference between coup and countercoup?
Coup: contusion occurs on same side as the impact
Countercoup: contusion occurs on opposite side of impact
*What are the intercranial components? What is internal volume?
Brain parenchyma (80%)
CSF (10%)
Blood (10%)
Fixed at 1.4-1.7L
I think this is getting at there is only so much space in cranial vault, cant just squish stuff
*What is Cushing reflex?
HTN
Bradycardia
Irregular Respirations
signifies life threatening high ICP
*only occurs in 1/3
Describe central herniation
pinpoint pupils, increased muscle tone, lose pupil reaction, yawn, tachypnea, shallow breaths
think of someone using cocaine
Describe tonsillar herniation
Irregular breathing
Cardiac (brady)
HTN
CVS collaspe
Flaccid quadripalegia
Basically cushing reflex
What CN can be tested in severe TBI?
CN 3 - pupil size
CN 5 and 7 - corneal reflex
CN 9 and 10 - gag
What is your BP target in TBI?
BP target is >100 if 50-69 years old
>110 for everyone else
Ben thinks of this as “shoulders”
*What are 6 RF for early PTS?
immediate seizure
penetrating head injury
<65 years
Chronic ETOH
SDH
EDH
ICH cortical contussion
What are 6 RF for early PTS?
immediate seizure
penetrating head injury
<65 years
Chronic ETOH
SDH
EDH
ICH cortical contussion
What are RF for PTE?
Severe TBI
Early PTS
Age >65
Depression
ICH
Cortical contussion
*What is DAI? How is it graded?
Grade 1 - mild, coma 6 to 24 hours
Grade 2 - moderate, coma >24 hours not decerebrate
Grade 3 - severe, coma > 24 hours and decerebrate or flaccid
No clinical marker tells you which it will be
*6 RF for post-concussive syndrome in MTBI
HAD SSome MMigraines
History of migraines
Anxiety
Depression
Sensitivty to light
Sensitivty to sound
Memory poor
Multiple Injuries
What are 4 delayed complications of concussion?
- Psychiatric problems
- Substance abuse problems
- Health problems
- Concurrent orthopedic/traumatic injuries
- Chronic pain
-CTE
-PTE
Which tongue lacerations need to be sutured?
Gaping
Deep
Collect food
Heal with divot or thick scar (impair eating and speaking)
Bissected tongue
What is special risk for kids with nasal fracture?
Can have premature closure of sutures, especially vomeroseptal line
Refer to plastics in 3 days not 1 week
*What are 6 complications of orbital blowout fractures?
Not including orbital compartment syndrome
Retrobulbar hematoma
Occulocardiac reflex (bradycardia)
Optic nerve injury
Traumatic Hyphema
Intracranial injuries
Globe rupture
Two Os. in complications, two eyes in associated injuries and two bleeders (hematoma and ICH)
*3 contraindications to nasal bone reduction?
(Too injured)
hemodyamically unstable
Significant swelling
Septum involved
(Fractures)
Basillar skull
Open
Orbital wall
Ehtmoid
What XR do you get for mandible fractures?
Panorex
What are LEMON predictors of a difficult airway?
L - Look externally (facial trauma, large incisors, beard or mustache, large tongue)
E - Evaluate (3-3-2 rule incisor distance, hyoid metal distance, thyroid mouth distance)
M - Mallampati (>3)
O - Obstruction (peritonsillar abcess, trauma)
N - Neck mobility (limited)
What are symptoms of a basilliar skull fracture?
Rhinorrhea
Ottorhea
Hemotypanum
Blood in external ear canal
Battle sign
Racoon eyes
CN palsy 7 + 8
Nystagmus
Tinnitus
How do you calculate Powers ratio?
BC/OC
Basion to posterior arch of atlas over
Opithsion to anterior arch of atlas
BC over ontario*
What are BDI and BAI? What do they each tell you?
BDI = Baison Dens Interval (how vertically displaced C1/C2 is
BAI = Baison Axial Interval (how horizontally displaced C1/C2 are)
What special XR view do you get if you can’t see T1?
Swimmers View
(modified lateral projection)
Why are teardrops usntable?
Flexion - chip in front, disruption of ligaments in back
What 3 flexion injuries are potentially unstable? When do they become unstable?
Wedge - nuchal ligament intact, unstable if >50% height loss or contingious
Subluxation - unstable if ligament injury
Chance # - unstable if middle and posterior coloumns involved
The patient’s name is Chance Wedge, he has a subluxation
What 2 flexion injuries are stable?
Clay-shovelers - spinous process fracture
Transverse process #
What spine injuries are associated with shearing forces?
Odontoid Frature
What are three types of odontoid fractures?
Type I - ususally stable, tip avulsion
Type II - usually unstable - fracture through base, non-union risk
Type II - Unstable, through ondontoid into lateral masses, higher surface area better union
What are two flexion-rotation injuries, stability, and how they present
Rotarory Atlanto-Axial dislocation, unstable, asymmetry of lateral masses vs odontoid (normal 1-2mm each side)
Unilateral facet dislocation - stable, dislocated articular mass locked in intervertebral foramen (traumatic torticolis)
What are 3 vertical compression injuries?
Jefferson - force from occipital condyles to lateral masses of C1 - pushes them outward. Anterior/posterior arch injuried, sum of distance to odontoid >7mm
(Unstable)
Burst - nuculous pulpousus forced into vertebral body (stable - all ligaments intact)
Isloated fracture of articular pillar/ vertebral body - stable
JIB
You have a L1 fracture but have deficits at the level of T4? How is this possible?
Greater radicular artery of Adamkiewicz - comes off the aorta and enter spinal canal at L1, goes all the way up to T4
What is WAD? How is it classified?
Whiplash Associated Disorder
Grade 0 - injury but no pain, signs or symptoms
Grade 1 - delayed pain, minor stiffness non-focal tenderness
Grade 2 - early onset pain, stiffness, focal tenderness, spasm
Grade 3 - grade 2 plus neurologic deficit
Grade 4 grade 2 or 3 plus fracture dislocation
What level of the spine is breathing affected?
Where phrenic nerve originates (C3/C4)
C3,4,5 keeps the diaphragm alive
What is Horners syndrome? At what level do you see it?
Unilateral miosis, anihydrosis, ptosis caused by disruption of sympathetic cervical chain
Usually C7 to T2
What are 5 things that can cause Horner syndrome?
(Space occupying causes)
Pancoast tumor
Pharyngeal abscess
(vascular causes)
Lateral medullary syndrome
Carotid dissection
(In the definition)
Spine injury above T2
Outline motor innervation of C5 to T1
According to ASIA
C4 - breathing, C5 shrug per Rosens
C5 - elbow flex
C6 - wrist extend
C7 - elbow extend
C8 - flex middle finger
T1 - abduct little finger
Basketball shot
Outline motor innervation L2 to S1
Per ASIA
L2 - flex hip
L3 - Extend knee
L4 - Ankle dorsiflexion
L5 - Great toe extension
S1 - Plantar felxion ankle
Rosens add spincter tone for S2-S4
L3 extend the knee, L4 foot off floor, S1 flexion and done
What is the proper way to do your sensory exam?
Once you find what they cant feel, confirm by going bottom up
It is easier to tell when something returns then when its gone
What are 3 lines and 1 measurement for bony injury on lateral C-spine Xrays?
Anterior vertebral bodies
Posterior vertebral bodies
Spinolaminar line
Predental space - anterior odontoid to posterior part of anterior C1 (space in front of odontoid)
What are the soft tissue measurements on a lateral C-spine XR?
Looking at retropharyngeal and retrotracheal space
C2 = <6mm in adults and kids
C3/C4 = <5mm or half the width of vertebral body
C6 <22mm in adults, 14mm if under 15
4 non-spine complications of spinal cord injury
Pulmonary edema
Autonomic dysreflexia
Atonic bladder/GI tract
Pressure injury
What are 5 prognostic indicators of poor fucntional recovery following Whiplash disorders?
Inital Pain >5.5/10
Inital disability - NDI >29%
Symptoms of Post Traumatic Stress
Negative Expectations of Recovery
High Pain catastrophizing
Cold hyperalgesia
Poor outcomes relate to how bad the person feels, not objective indicators (imaging, motor function, accident features i.e. speed)
What is the relevent blood supply of the neck? How does this relate to BCVI?
Aortic arch -> either L common carotid or brachiocephalic then R common carotid -> become external and internal superior to thyroid cartilage -> internal enters carotid canal of temporal bone -> Anterior and middle cerebral arteries
Hyperflexion or hyperextension, direct blow or temporal bone injury can all cause BCVI
When do you put a penetrating trauma in a C-spine collar per EAST?
If neurologic deficit - otherwise no
Who does modified Denver tend to miss? What are features to look for in this patient group?
Kids
Basillar skull #
C-spine #
Facial # or Lefort #
Clavicle #
All the fractures!!!
What are five options for defitive repair of neck trauma?
Ligation
Primary repair
End to end anastamosis
Vein grafting
Endovascular stent
Outline the grading of BCVI and each grade’s management
Grade 1 - intimal injury/ irregular intima
Anticoagulation/ Antiplatelet o/w endovascular repair
Grade 2 - Dissection with intimal flap + luminal narrowing <25%
endovascular repair o/w anticoagulant antiplatelet
Grade 3 - pseudoanneursym
Symptoms = endo, otherwise meds
Grade 4 - vessel occlusion or thrombus
Difficult, endo o/x meds
Grade 5 - vessel transection
Lethal if untreated, needs immedaite endo or surgical repair
What is your apporach to imaging potential pharyngeal espogeal injury?
Do you history physical and CTA
If low pre-test on exam, No air or wounds on CT - ruled out
If high pre-test and equivocal CTA - gastrograffin contrast study (1st), consider barium (2nd). Alt is CT esophagphy, but patient has to be cooperative
If positive CT - flexible endocscopy
How do you manage pharyngeal injury? When does it need OR ?
Admit, NPO, Pip/tazo +/- fluconazole if known contaminent
Unstable, uncontrolled contrast exstravasation, septic
What are 6 complications of pharyngeal-esphogeal injury?
NG
G tube
trach
Pneumonia
Mediastinitis
Sepsis
What are 5 mechanisms of laryngealtracheal injuries?
Stab
Gunshot
Stragulation
Sports-related (MMA Throat punch)
Clothesline
What are 3 things to look for if you find a cricoid fracture?
Airway collaspe (only circumferential ring that stents open larynx)
A second fracture (anterioir and posterior ring)
Hoarseness (recurrent laryngeal nerve injury)
What is contraindicated with LT injuries? What does Rosen’s reccomend you do if you have to intubate?
Supraglottic airway
PPV like BVM
(forcing air in will just make it come out of wounnd)
Blind intubation (no tubes in holes you cant see)
Firberoptic awake vs double set up with smaller ETT
What does pain with movement of the tongue suggest?
Hyoid bone injury
Outline the Schaefer-Fuhrman classification of laryngeal injury and its management
Grade 1 - hematoma or laceration without fracture, airway is fine. Medical management (steroids, abx, humidity, voice rest)
Grade 2 - hematoma/ edama/ laceration no exposed cartilage OR non-displaced fracture. Partial airway compromise, sometimes needs a trach.
Grade 3 - Massive edema/lac/hematoma, exposed cartialge or displaced fracture. have airway compromise. Need trachesotmy and surgical repair.
Grade 4 - 3 + anterior layrnx disruption or unstable fracture. Always needs a trachesotmy
Grade 5 - Complete LT sepereation. Temproary airway through defect then OR
What are tardieu spots?
Punctate lesions left by gravitational pressure -> capillary rupture
What are four steps to manage a hanging?
Airway management (can have LT or hyoid bone fracture)
Manage ARDS
Assume cerebral edema/ elevated ICP
Form 1
What is postural strangulation?
Occurs in peds - when body weight compresses the anterior neck against a firm object (unconscious flop onto seatbelt) zxaxa
What is postural strangulation?
Occurs in peds - when body weight compresses the anterior neck against a firm object (unconscious flop onto seatbelt) zxaxa
What is most immediate cause of death in neck trauma? What is most common delayed cause of death?
Immediate - exsanguination from vascular injury
Delayed - missed esophageal injury
What is one other organ included in LT injuries? What is RF for this? How is it managed?
Thyroid rupture
Typically pre-exsisiting goiter
Goes to ICU - edema can obstruct airway, can lead to thyroid storm
What is SCIWORA?
Spinal cord injury without radiographic abnormalitiy
(spinal cord is injured but no evidence of ligament or bony injury on imaging. misnomer in age of MRI, more common in kids)
What are clinical features for evaluation of a difficult cricothyrotomy?
SMART
Surgery
Mass
Anatomy concerns (obesity, edema)
Raditation
Tumor
What are the components of the Rotterdam score in non-contrast CT brain predicting mortality at 6 months following TBI?
MICE
Midline shift
IVH or SAH
Basal Cistern Effacement
EDH present
Think two bleeds and two signs the bleeds are bad on imaging
Outline the types of fractures based on the Fragility Fracture Classification
Type 1 - anterior pelvic ring only
Type 2 - non-displaced posterior pelvic ring
Type 3 - displaced posterior pelvic ring unilateral
Type 4 - displaced posterior pevlic ring bilateral
