Pestana 1. Trauma Flashcards
Clinical signs of shock
Low BP
Fast pulse
Low urinary output (less than 0.5 mL/kg/h)
Patient is cold, pale, shivering, sweating, thirsty, apprehensive
Most common cause of shock in trauma setting?
Bleeding (hypovolemic-hemorrhagic)
CVP low or high in shock caused by bleeding
CVP low (empty veins clinically)
What causes of shock present with high CVP?
Pericardial tamponade
Tension pneumothorax
First step in treatment of hemorrhagic shock?
2 L of lactated ringers (without sugar)
Blood (packed red cells)
What CVP do you not want to exceed while stabilizing hemorrhagic shock patient
15 mm Hg
Preferred route of fluid resuscitation?
2 peripheral IV lines, 16-gauge
If diagnosis of pericardial tamponade is unclear, what test should you order?
Sonogram
When do you see vasomotor shock?
Anaphylactic reactions
High spinal cord transection
Test for anyone with head trauma who has become unconscious?
CT-look for hemorrhage
Signs of fracture affecting base of skull
raccoon eyes
Rhinorrhea
otorrhea
Sequence of trauma to side of head–unconsciousness–lucid interval–gradual lapsing into coma–fixed dilated pupil
Acute epidural hematoma
Posturing in acute epidural hematoma
Decerebrate
CT scan finding on subdural hematoma
semilunar, cresent-shaped hematoma
Biconcave, lens-shaped hematoma
Acute epidural hematoma
Drugs to give in acute subdural hematoma patient
Mannitol or furosemide (to prevent damage fro increased ICP)
PCO2 level goal in acute subdural hematoma?
35
CT findings of diffuse axonal injury
Diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages
Patients who will have chronic subdural hematoma
Very old
Alcoholics
Can hypovolemic shock happen from intracranial bleeding?
NO. not enough space inside the head for the amount of blood loss needed to produce shock
In emergency, best way to assess status of cervical spine?
CT scan
Findings of Brown-Sequard syndrome?
Paralysis and loss of proprioception distal to injury on ipsilateral side of injury
Loss of pain perception distal to injury on contralateral side
When is anterior cord syndrome seen?
Findings?
Burst fractures of vertebral bodies
Loss of motor function and loss of pain and temp sensation on both sides distal to the injury.
Vibratory and position senses are preserved.
Paralysis and burning pain in upper extremities…Diagnosis? Cause?
Central cord syndrome
Forced hyperextension of the neck in the elderly
Test of choice for precise cord diagnosis
MRI
Difference in percussion on affected side in pneumothorax vs. hemothorax?
Pneumothorax: hyperresonance
Hemothorax: dull
Traumatic rupture of diaphragm shows up with bowel always on which side of the chest?
Left
Where does traumatic rupture of the aorta occur?
Junction of the arch and the descending aorta
What type of injury causes traumatic rupture of the aorta?
Big deceleration injury
In trauma setting, what is the most practical test for detecting a ruptured aorta?
spiral CT scan (CT angio)
Why is a patient put into Trendelenburg position when subclavian vein is being opened to the air?
To prevent air embolism
Long bone fractures…increased risk of?
Fat embolism
General next step in gunshot wounds to abdomen?
Exploratory laparotomy
Signs of shock occur when what volume of blood is lost?
25-30 %…about 1.5 L in average adult
What locations could 1.5 L of blood “hide” in a blunt trauma patient who goes into shock?
Abdomen, pelvis, thighs
Dx of intra-abdominal bleeding is made most acutely with what test?
CT scan
Tests that can be used to quickly give you a “yes” or “no” regarding intraabdominal bleeding
Sonogram (FAST exam) or Diagnostic Peritoneal Lavage (DPL)
Most common source of intraabdominal bleeding?
Liver
Most common source of significant intraabdominal bleeding in blunt trauma?
Spleen
Best management for pelvic fractures with ongoing significant bleeding?
Pelvic fixators followed by angiographic embolization of both internal iliac arteries
What do you do for penetrating urologic injuries?
Surgically explore/repair
Associated injury to kidney injury via blunt trauma
Lower rib fractures
Blunt trauma to the bladder or urethra is usually associated with…what?
Pelvic fracture
When might you see a scrotal hematoma?
Urethral injury
What may be notable about the prostate for a posterior urethral injury?
“high-riding” on exam
What test is done for a suspected urethral injury
retrograde urethrogram
Rare sequela of injuries affecting renal hilum?
Development of arteriovenous fistula leading to CHF
What do you do for scrotal hematomas?
Usually don’t need intervention unless testicle is ruptured
What is the treatment when no major vessels are involved in the vicinity of a penetrating injury to an extremity?
Tetanus prophylaxis and clean the wound
What do you do if an extremity penetrating wound is near major vessels but the patient is asymptomatic?
Doppler studies or CT angio
Obvious signs of a vascular injury in an extremity?
Absent distal pulses
Expanding hematoma
What is the sequence of stabilization when there are combined injuries of arteries, nerves, and bone?
Stabilize bone first.
Then vascular repair
Lastly the nerve should be repaired.
What is done for a high-velocity gunshot wound?
Extensive debridement, potentially amputation
What are some hazardous things that can happen to a patient as a result of a crushing injury
Hyperkalemia Myoglobinemia Myoglobinuria Renal failure Potential compartment syndrome
Treatment for patient who was involved in crushing injury?
Vigorous fluids
Osmotic diuretics
Alkalinize urine
What is worse: alkaline or acid burns?
Alkaline
What type of burns are always deeper and worse than they appear to be?
high-voltage electrical burns
What type of orthopaedic injury might you see with a high-voltage electrical burn?
Posterior dislocation of shoulder
Compression fracture of vertebral body
What is a respiratory burn?
Chemical injury caused by smoke inhalation
How do you confirm diagnosis of respiratory burn?
Fiberoptic bronchoscopy
You should check a blood level of what in a patient with a respiratory burn?
Carboxyhemoglobin
What procedure provides immediate relief of circumferential burns?
Escharotomy
Classic example of scalding burn in children due to abuse?
Burns of both buttocks
What is the fluid that accumulates underneath a deep burn?
Plasma that has been temporarily lost from circulating space that gets trapped at burn site
What is the goal for hourly urinary output in a burn patient?
1 or 2 mL/kg/h
What is the appropriate predetermine rate of fluid infusion in an adult burn patient?
Start at 1000 mL/h of Ringer lactate *without sugar and adjust as needed
Why do you want to avoid using Ringer lactate with sugar in a burn patient?
So you don’t induce an osmotic diuresis from glycosuria as this would invalidate the meaning of an hourly urinary output
How does a third-degree burn differ in appearance in babies vs. adults?
Babies: deep bright red
Adult: leathery, dry, gray
What is an appropriate rate of initial fluid administration in a baby who is burned?
20 mL/kg/hour
What prophylactic vaccine should be given in burn patient?
Tetanus
What is the standard topical agent for burn care?
Silver sulfadiazine
What should you use for topical burn care if deep penetration is desired?
Mafenide acetate
Why should you not use mafenide acetate anywhere besides places with thick eschar in burn patient?
It hurts and can produce acidosis
What do you use to topically cover burns around the eyes?
Triple antibiotic ointment
What is the preferred route of feeding in burn patient?
Oral..via gut
What is the typical burn candidate for early excision and grafting? (removal of burned area in OR on day 1 with immediate skin grafting)
Limited burn…under 20 % of body
Treatment required for all bites?
Tetanus prophylaxis
Wound care
Hemorrhoids that hurt
External
Hemorrhoids that bleed
Internal
Symptoms of prolapsed internal hemorrhoids
Itch, hurt
Who does anal fissures happen to?
Young women
