Pestana- 1. Trauma Flashcards
How is an airway most commonly inserted?
Orotracheal intubation
How do you visualize the airway during an orotracheal intubation?
laryngoscope
If a patient has a c-spine injury and you cannot keep the head stable for orotracheal intubation, what is your other option?
Nasotracheal intubation over a fiber optic bronchoscope
What is a sign of major traumatic disruption of the tracheobronchial tree?
subcutaneous emphysema in the neck
What is required when securing an airway in a patient with subcutaneous emphysema in the neck?
fiberoptic bronchoscope
What is required if intubation cannot be done in the usual manner and time is limited?
cricothyroidotomy
At what age do you start feeling comfortable with doing a cricothyroidotomy?
12 (due to potential need for future laryngeal reconstruction)
List the clinical signs of shock.
-Low BP (
What are the typical causes of shock in trauma?
- Bleeding (hypovolemic/hemorrhagic)
- Pericardial tamponade
- Tension pneumothorax
In what type of shock is CVP (central venous pressure) low?
hypovolemic shock (bleeding)
How may you differentiate tension pneumothorax with pericardial tamponade?
Pericardial tamponade has NO respiratory distress where tension pneumothorax has severe respiratory distress
What are some other hints that your patient has tension pneumothorax?
- Unilateral absence of breath sounds
- Unilateral hyperresonance to percussion
- Mediastinum is shifted to opposite side
What is the routine volume replacement in the treatment of hemorrhagic shock?
- 2L of Ringer lactate (without sugar)
- Blood (Packed RBCs)
When do you know to stop volume replacement in hemorrhagic shock?
- Urine output reaches 0.5-2 mL/kg/h
- CVP does NOT exceed 15mmHg
What is the preferred route of fluid resuscitation in the trauma setting?
2 peripheral IV lines, 16-gauge
What are the alternatives to the 2 peripheral IV lines in fluid resuscitation in the trauma setting?
- Percutaneous femoral vein catheter
- Saphenous vein cut-downs
What might you use to fluid resuscitate a child
Intraosseus cannulation of the proximal tibia
If the diagnosis of pericardial tamponade is not clear from clinical exam, what do you use to diagnose?
sonogram
How do you treat pericardial tamponade?
- Pericardiocentesis
- Tube
- Pericardial window
- Open thoracotomy
How do you manage tension pneumothorax?
Immediate big needle/IV catheter into affected pleural space
After inserting big needle or IV catheter into affected pleural space in a tension pneumothorax, what is the next step?
chest tube connected to underwater seal (inserted high in the anterior chest wall)
What is the CVP in cardiogenic shock?
high (see big, distended veins)
How do you treat cardiogenic shock?
circulatory support (DO NOT GIVE FLUIDS AND BLOOD)
In what 3 situations do you see vasomotor shock?
- Anaphylactic reactions
- High spinal cord transections
- High spinal anesthesia
What is the CVP in vasomotor shock?
low
What is the main therapy for vasomotor shock?
vasopressors
What do you do with a closed (no overlying wound) linear skull fracture?
leave it alone
What do you do with an open linear skull fracture?
wound closure
When do you go to the OR with a linear skull fracture?
if it is comminuted or depressed
What do you always get in a patient who had head trauma and goes unconscious?
CT scan
What are the signs of fracture to the base of the skull?
- Raccoon eyes
- Rhinorrhea
- Otorrhea or ecchymosis behind the ear
What should you always do if a patient has a fracture at the base of their skull?
assess integrity of c-spine iwth CT scan
What should you always avoid if a patient has a fracture at the base of their skull?
nasal endotracheal intubation
How do you typically manage patient’s with fractures at the base of their skulls?
expectant management
What are the 3 components of neurologic damage from trauma?
- Initial blow
- Subsequent hematoma development (displacing midline structures)
- Development of increased ICP
What shape is an epidural hematoma?
biconvex, lens-shaped
How do you treat an epidural hematoma?
emergency craniotomy
What is the typical presentation of someone with epidural hematoma?
Trauma, unconscious, lucid interval, coma (fixed dilated pupil, contralateral hemiparesis, decerebrate posture)
What shape is a subdural hematoma?
semilunar, crescent-shaped
When do you do craniotomy on a subdural hematoma?
if midline structures are deviated
How do you manage subdural hematoma?
Prevent further damage by reducing ICP:
- Monitor ICP
- Elevate head
- Hyperventilate
- Avoid fluid overload
- Mannitol or furosemide
What is the PCO2 goal when you are hyperventilating to reduce ICP?
35
What is the suggested option to decrease oxygen demand (rather than sedation) in patients wtih increased ICP?
hypothermia
What are the CT findings in diffuse axonal injury?
Diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages
True or false: hypovolemic shock cannot happen from intracranial bleeds
TRUE (not enough space in head for amount of blood needed to produce shock)
What do you do for a gunshot wound to the upper zone of the neck?
Arteriographic diagnosis and management
What do you do for gunshot wounds to the base of the neck?
arteriography, (water-soluble) esophagogram, esoghagoscopy and bronchoscopy
When can you observe a stab wound to the neck?
if it is located in the upper and middle zone and the patient is asymptomatic
What must you do in all patients with blunt trauma to the neck (who have neuro deficits or who have TTP over c-spine)?
ascertain the integrity of the cervical spine (CT)
What are the findings in a Brown-Sequard lesion?
Unilateral paralysis and loss of proprioception distal to injury; Contralateral loss of pain perception
What causes Brown-Sequard lesion?
clean knife blade, etc.
What causes anterior cord syndrome?
burst fractures of vertebral bodies
What are the findings in an anterior cord syndrome?
loss of motor function and pain/temperature bilaterally below lesion with preservation of vibration and positional sense
What causes central cord syndrome?
forced hyperextension of the neck (ex. rear end collisions)
*more common in elderly
What are the findins in central cord syndrome?
paralysis and burning pain in the upper extremities (preservation of most functions in lower extremities)
What do you do to precisely diagnose a spinal cord injury?
MRI
What do some people think may help in the management of spinal cord injury?
immediate high-dose corticosteroids
How can a rib fracture cause PNA in the elderly?
Pain –> hypoventilation –> atelectasis –> pneumonia
How do you treat rib fracture in the elderly?
local nerve block and epidural catheter
What can cause pain pneumothorax?
-Penetrating trauma (ex. jagged edge of broken rib to knife)
What are the findings in pain pneumothorax?
- Moderate SOB
- Unilateral loss of breath sounds
- Unilateral hyperresonance to percussion
How do you treat pain pneumothorax?
- CXR
- Chest tube (upper, anterior)
- Connect to underwater seal
How do you differentiate hemothorax from pain pneumothorax?
very similar to pain pneumothorax (causes/symptoms) but you will have dullness to percussion in affected side)
How do you dx a hemothorax?
CXR
Why must you evacuate the blood from a hemothorax?
to prevent the development of empyema
How do you evacuate the blood from a hemothorax?
low placed chest tube
Is surgery typically needed for hemothorax?
NO- lung is low pressure system and usually stops bleeding by itself
What are the indications for surgery with a hemothorax?
- Recovery of >/= 1500 mL of blood when chest tube is inserted
- Collecting >600 mL of tube drainage over 6 hours
What is a sucking chest wound?
Injury where there is a flap that sucks air in with inspiration and closes during expiration
What is the risk if you do not treat a sucking chest wound?
tension pneumothorax
What is the treatment for a sucking chest wound?
occlusive dressing that allows air out (taped on 3 sides) but not in
What is the name for when multiple rib fractures allow a segment of chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing)?
flail chest
What is the real problem with flail chest?
underlying pulmonary contusion
How do you treat flail chest?
fluid restriction and diuretics
What do you use if your flail chest patient needs a respiratory due to pulmonary dysfunction?
bilateral chest tubes
What is a common injury that occurs with flail chest?
traumatic transection of the aorta
When will a pulmonary contusion show up after chest trauma?
immediately to up to 48 hours later
How does a pulmonary contusion present?
deteriorating blood gases and “white out” of lungs on CXR
What should be ordered with a sternal fracture?
EKG
Troponins
What is a possible complication of sternal fracture?
myocardial contusion
How does a traumatic rupture of the diaphragm present?
bowel in chest (physical exam and CXR)
On what side will you see/hear bowel in a traumatic rupture of the diaphragm?
ALWAYS on left
How do you evaluate possible traumatic rupture of the diaphragm?
laparoscopy
Where does traumatic rupture of the aorta occur
junction of the arch and descending aorta
How do traumatic ruptures of the aorta occur?
big deceleration injuries
What type of fractures may give you a hint that the patient could have a traumatic rupture of the aorta?
first rib, scapula, sternum
“very hard to break bones”
What is the most appropriate diagnostic tool for traumatic rupture of the aorta in a trauma setting?
spiral CT (CT angio)
If a patient develops subcutaneous emphysema in upper chest and lower neck, what happened?
1) traumatic rupture of trachea or major bronchus
2) large “air leak” from a chest tube
What is the diagnostic tool for a potential traumatic rupture of the trachea/major bronchus?
fiberoptic bronchoscopy (allows for intubation to secure airway beyond the lesion)
What are the two major causes of subcutaneous emphysema?
- Rupture of the esophagus
- Tension pneumothorax
When does rupture of the esophagus generally occur?
after endoscopy
What should be suspected when sudden death occurs in a chest trauma patient who is intubated and on a respirator?
air embolism
In what situations is the subclavian vein exposed that may allow an air embolism to occur?
- Supraclavicular node biopsies
- Central venous line placement
- CVP lines that become disconnected
How do you treat air embolism?
cardiac massage (with patient placed left side down)
How do you prevent air embolism?
use Trendelenburg position when the great veins at the base of the neck are to be entered
What do you expect in a patient who has undergone multiple trauma, long bone fractures, and develops petechial rashes in the axillae/neck, fever, tachycardia and low platelets + respiratory distress?
fat embolism
What is the proper diagnostic method for diagnosing fat embolism?
fat droplets in urine
What is the treatment for gunshot wounds to the abdomen (below level of nipple line)?
exploratory laparotomy
In what cases must a stab wound be managed with exploratory laparotomy?
- Penetration (protruding viscera)
- Hemodynamic instabiity
- Peritoneal irritation
How do you treat blunt trauma to the abdomen?
- Exploratory laparotomy (if peritoneal irritation)
- Determine if there are internal injuries/bleeds
What are some signs of internal bleeding in a patient with blunt abdominal trauma?
- Drop in BP
- Fast, thready pulse
- Low CVP
- Low UOP
- Cold, pale, anxious patient who is shivering, thirsty and perspiring
How much blood is lost before signs of shock occur?
25-30% (around 1500mL in average adult)
List the only 3 places where internal bleeds leading to shock can occur in the human body?
- Abdomen
- Thighs (femur fracture)
- Pelvis
Intraabdominal bleeding diagnosis can be made most accurately with what tool?
CT scan
From where does blood usually originate in intraabdominal bleeds?
liver or spleen
What is the problem with doing CT scans on patients with intraabdominal bleeds?
patients must be hemodynamically stable
What are 2 ways to quickly diagnose intraabdominal bleeding in a patient who is hemodynamically unstable?
- Diagnostic peritoneal lavage (DPL)
- Focused Abdominal Sonogram for Trauma (FAST)
What is the most common source of significant intraabdominal bleeding in blunt abdominal trauma?
ruptured spleen
What is required if the spleen must be removed rather than repaired?
Postoperative Immunization against encapsulated bacteria (Pneumococcus, H flu, meningococcus)
What is the empiric treatment for intraoperative coagulopathy (in multiple trauma with multiple transfusions)?
10 units each of platelets and FFP
What do you do if patient develops coagulopathy, hypothermia and acidosis in the intraoperative setting?
terminate laparotomy, pack bleeding surfaces, temporary closure, resume surgery when patient is warm/ coagulopathy is treated
What is it called when prolonged surgery with many fluids/blood products are given lead to tissue swelling so that the abdominal wound cannot be closed without undue tension?
abdominal compartment syndrome
How do you manage abdominal compartment syndrome?
Place temporary cover over abdominal contents
- Absorbable mesh (later grafted over)
- Nonabsorbable plastic (removed later when closure is possible)
What should you expect in a patient on POD#2 who gets distention, hypoxia 2/2 inability to breathe, renal failure from pressure on vena cava and retention sutures cutting through tissues?
abdominal compartment syndrome (can have a later onset)
What is a damage control laparotomy?
quick laparotomy where bleeders are clamped, damaged viscera is temporarily occluded, contamination is cleaned, and patient is closed until a later date after they can be properly resuscitated (helps prevent complications like consumption coagulopathy and abdominal compartment syndrome)
How do you manage a non-expanding pelvic hematoma?
leave it alone
What organs must be evaluated in pelvic fractures?
- Rectum
- Bladder
- Vagina (women get pelvic exams)
- Urethra (men get retrograde urethrogram)
Why is surgery not an ideal option in pelvic fractures with ongoing significant bleeding?
bleeding sites are often inaccessible and opening pelvic hematoma removes tamponade effect
What is the ideal treatment for pelvic fractures with associated ongoing hematoma?
Pelvic fixators + b/l internal iliac artery angiographic embolization (by IR)
What should be suspected in a patient with hematuria after a penetrating or blunt abdominal trauma?
urologic injuries
What injury is associated with pelvic fracture and blood at the meatus (in males)?
urethral injury
What are some associated symptoms of urethral injury in a male?
- Scrotal hematoma
- Sensation of wanting to void but cannot (posterior injury)
- “High riding” prostate on rectal exam
What should be avoided/done in a patient with a suspected urethral injury?
NO FOLEY!
Do a retrograde urethrogram
How is a bladder injury diagnosed?
retrograde cystogram
How do you treat extraperitoneal leaks at the base of the bladder?
placing a Foley catheter
How do you treat intraperitoneal bladder leaks?
Surgical repair + protection with suprapubic cystostomy
What is the typical associated finding in renal injury?
lower rib fractures
What is a rare potential sequela of injuries to the renal pedicle?
development of AV fistula leading to CHF
If renovascular HTN develops after a trauma, what most likely happened?
renal artery stenosis
What should be done in the setting of a scrotal hematoma?
sonogram to be sure the testicle is not ruptured
What is “fractured” in a penis fracture?
corpora cavernosa
tunica albuginea
What must be done for a fractured penis?
emergent surgical repair
What happens if you do not fix a fractured penis?
impotence will ensure (AV shunts develop)
How do you manage a penetrating injury to the extremity that has no major vessels in the injury tract?
- Tetanus prophylaxis
- Cleaning of wound
How do you manage a penetrating injury to the extremity that has major vessels near the injury tract?
- Doppler studies or CT angiogram (if patient is asymptomatic)
- Surgical exploration and repair (if absent distal pulses, etc)
In what order should combined artery, nerve, bone injuries be repaired?
- Stabilize bone
- Vascular repair
- Nerve
- Fasciotomy (prolonged ischemia could lead to compartment syndrome)
What are potential hazards posed by crush injuries to the extremities?
- Hyperkalemia
- Myoglobinemia
- Myoglobinuria
- Renal failure
How might you prevent most of the metabolic complications of crush injuries?
- Vigorous fluid administration
- Osmotic diuretics (mannitol)
- Alkalinization of the urine
What is the very first step in managing chemical burns?
massive irrigation (ex. tap water/shower)
Which are worse, acid burns or alkaline burns?
alkaline burns
What should you always be aware of with high-voltage electrical burns?
they are always deeper and worse than they appear to be
What are some orthopedic injuries that occur secondary to massive muscle contractions in high-voltage electrical burns?
- Posterior dislocation of the shoulder
- Compression fracture of vertebral bodies
What are some later complications associated with high-voltage electrical burns?
Cataracts
Demyelinization syndromes
What is a respiratory burn?
chemical injury caused by smoke inhalation
How do you confirm the diagnosis of a respiratory burn?
fiberoptic bronchoscopy
What is the best tool to determine if respiratory support is needed with respiratory burns?
blood gases
What levels need to be monitored in someone with a respiratory burn?
carboxyhemoglobin
How do you treat elevated carboxyhemoglobin?
100% oxygen
What can be performed if a circumferential burn leads to the cutoff of blood supply (collection of edema)?
escharotomy (bedside, no anesthesia necessary)
What should be suspected if a child has scald marks on its buttocks?
child abuse
What is the most critical and life-saving component of the management of extensive thermal burns?
fluid replacement
What is the fluid that accumulates beneath a burn?
plasma lost from circulating space that is trapped at the burn site
What can occur due to the internal shift of fluids with extensive burns?
hypovolemic shock and death
What is the rule of 9s?
Head= 9% of body surface (in babies 18%)
Upper extremities= 9% X2 of body surface
Lower extremities= 18% X2 of body surface (9X1.5 in babies)
Trunk= 36% of body surface
What do you use to assess how much fluid to give a burn patient?
- Aim for hourly UOP of 1-2 mL/kg/hr
- Avoid CVP over 15 mmHg
What is the appropriate predetermined rate of fluid infusion in an adult with burns >20% of body surface area?
1000 mL/hr of RInger lactate (no sugar) then adjust
Why do you avoid sugar in Ringer lactate in burn patient?
avoid osmotic diuresis from glycosuria (invalidation of meaning of the hourly UOP)
What is the appropriate predetermined rate of fluid infusion in a baby with burns >20% of body surface area?
20 mL/kg/hr
How do baby burns differ than adult burns?
third degree burns in babies will look deep bright red instead of leathery, dry and gray
What is the standard topical agent for adult burns?
silver sulfadiazine
What is the topical agent to use if deep penetration is desired for thick eschar or cartilage?
mafenide acetate
What are the issues with using mafenide acetate over a broad surface area?
it hurts and can cause acidosis
What topical treatment is used for burns near the eyes?
triple antibiotic ointment
How long do burn patients need NG suction?
1-2 days
What type of intensive nutritional support do burn patients need?
high-calorie/high-nitrogen diets (preferably via the gut)
When do you start thinking about grafting non-regenerated burn sites?
after 2-3 weeks of wound care and general support
What are the conditions for early excision and grafting (starting on day one/in the OR)?
-Burns
What is required for all bites?
tetanus prophylaxis and wound care
When might you give rabies prophylaxis with a provoked dog bite in an animal with no obvious signs of rabies?
if the bite is to the face
What is rabies prophylaxis?
immunoglobulin + rabies vaccine
Who should get rabies prophylaxis?
those who receive unprovoked dog bites or bites from wild animals
What percent of bites from poisonous snakes are envenomated?
around 70%
What are the most reliable signs of envenomation after a snake bite?
severe local pain
swelling
discoloration
(within 30 minutes of the bite)
What labs should be taken on someone with an envenomated snake bite?
Type and cross
Coag studies
LFTs
Renal function
What is the treatment for an envenomated snake bite?
antivenin (CROFAB)
What snake has yellow and red rings touching and why is this important?
coral snakes (have neurotoxin that needs to be promptly neutralized with specific antivenin)
What is the dosage of epinephrine used to treat anaphylaxis from bee stings?
0.3-0.5 mL of 1:1000 solution
What are symptoms of black widow spider bite?
nausea
vomiting
severe generalized muscle cramps
What is the antidote for black widow spider bites?
IV calcium gluconate
What does a brown recluse spider bite look like?
skin ulcer with necrotic center and surrounding halo of erythema (often noticed the day after bite occurs)
What is the treatment for brown recluse spider bites?
Dapsone (may need surgical excision/skin grafts)
What is the classic presentation of someone with human bites?
someone with sharp cut over knuckles (after fight)
What is the antibiotic of choice for treating human bites?
Amoxicillin-clavulanate
