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
What is the ACS classification of shock
Not in 10th edition Rosens
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)
