Pestana Chap 1 - Trauma Flashcards
When do you know if an airway is present? How can an airway soon be lost? What should be done before the situation becomes critical?
1) An airway is present if the patient is conscious and speaking in a normal tone of voice
2) The airway will soon be lost if there is an expanding hematoma or emphysema in the neck
3) An airway should be secured before the situation becomes critical
Aside from expanding hematoma or emphysema in the neck, when is an airway needed?
If the patient is unconscious (with a Glasgow Coma Scale of 8 or under) or his breathing is noisy or gurgly, if severe inhalation injury (breathing smoke) has occurred, or if it is necessary to connect the patient to a respirator
If a patient has a cervical spine injury, do you still secure the airway?
If an indication for securing an airway exists in a patient with potential cervical spine injury, the airway has to be secured before dealing with the cervical spine injury
How is an airway most commonly inserted?
By orotracheal intubation, under direct vision with the use of a laryngoscope, assisted in the awake patient by rapid induction with monitoring of pulse oximetry, or less commonly with the help of topical anesthesia
Can orotracheal intubation be done in the presence of a cervical spine injury? What is an alternative?
1) Yes if the head is secured and not moved
2) Nasotracheal intubation over a fiber optic bronchoscope
The use of what is mandatory when securing the airway of a patient with subcutaneous emphysema in the neck? What is subcutaneous emphysema a sign of?
1) The use of a fiberoptic bronchoscope
2) Major traumatic disruption of the tracheobronchial tree
What is done if intubation cannot be done in the usual manner (laryngospasm, severe maxillofacial injuries, an impacted foreign body that cannot be dislodged, etc.) and we are running out of time? Why?
1) Cricothyroidotomy may become necessary
2) It is the quickest and safest way to temporarily gain access before the patient sustains anoxic injury
Why are we reluctant to do cricothyroidotomy in a patient before the age of 12?
There is a potential need for future laryngeal reconstruction
What establishes that breathing is okay?
Hearing breath sounds on both sides of the chest and having satisfactory pulse oximetry
What are clinical signs of shock?
1) Low BP (under 90 mm Hg systolic)
2) Fast feeble pulse
3) Low urinary output (under 0.5 mL/kg/h)
All in a patient who is pale, cold, shivering, sweating, thirsty, and apprehensive
What is shock caused by in the trauma setting?
1) Bleeding (hypovolemic-hemorrhagic, by far the most common cause)
2) Pericardial tamponade
3) Tension pneumothorax
Where must trauma occur anatomically to produce pericardial tamponade and tension pneumothorax?
Trauma to the chest
What is the CVP in shock caused by bleeding?
Low (empty veins clinically)
What is the CVP in both pericardial tamponade and tension pneumothorax?
High (big distended head and neck veins clinically)
How can you distinguish shock caused by pericardial tamponade vs. tension pneumothorax?
1) In pericardial tamponade there is no respiratory distress
2) In tension pneumothorax there is severe respiratory distress, one side of the chest has no breath sounds and is hyperresonant to percussion, and the mediastinum is displaced to the opposite side (tracheal deviation)
What is the treatment of hemorrhagic shock in the urban setting (big trauma center nearby) with penetrating injuries that will require surgery anyway? What about in any other setting?
1) It starts with the surgical intervention to stop the bleeding, and volume replacement takes place afterward
2) In all other settings, volume replacement is the first step, starting with about 2L of Ringer lactate (without sugar), and followed by blood (packed red cells) until urinary output reaches 0.5 to 2mL/kg/h, while not exceeding CVP of 15 mmHg
What is the preferred route of fluid resuscitation in the trauma setting? What are alternatives if this method cannot be inserted? What is an alternative in children under 6 years of age?
1) 2 peripheral IV lines, 16-gauge
2) Percutaneous femoral vein catheter or saphenous vein cut-downs are alternatives
3) Intraosseus cannulation of the proximal tibia
What is management of pericardial tamponade based on? What is treatment centered on? What is helpful while treatment is ongoing?
1) Clinical diagnosis (do not order x-rays-if diagnosis is unclear choose sonogram)
2) Prompt evacuation of the pericardial sac (by pericardiocentesis, tube, pericardial window, or open thoracotomy)
3) Fluid and blood administration while evacuation is being set up is helpful
What is management of tension pneumothorax based on? What does treatment start with? What is this step followed with?
1) Clinical diagnosis (do not order x-rays or wait for blood gases)
2) Start with big needle or big IV catheter into the affected pleural space
3) Follow with chest tube connected to underwater seal (both inserted high in the anterior chest wall)
What are examples of hypovolemic shock? What is the key finding on physical exam? What is treatment?
1) Bleeding or other sources of massive fluid loss (burns, peritonitis, pancreatitis, massive diarrhea)
2) Low CVP
3) Treat by stopping the bleeding and blood volume replacement
What is intrinsic cardiogenic shock caused by? What is a key physical exam finding?
1) Massive myocardial damage (massive myocardial infarction [MI] or fulminating myocarditis)
2) High CVP (big distended veins)
How is cardiogenic shock treated? Why is differential diagnosis essential?
1) Treat with circulatory support
2) Additional fluid and blood administration in this setting would be lethal
When is vasomotor shock seen? How does the patient present? What is found on physical exam?
1) Vasomotor shock is seen in anaphylactic reactions and high spinal cord transection or high spinal anesthetic
2) Circulatory collapse occurs in flushed, “pink and warm” patient
3) CVP is low
What is the treatment for vasomotor shock?
1) Pharmacologic treatment to restore peripheral resistance is the main therapy (vasopressors)
2) Additional fluids will help
What does penetrating head trauma require for treatment?
Surgical intervention and repair of the damage
What is the management of linear skull fractures if closed? If open? If comminuted or depressed?
1) They are left alone if they are closed (no overlying wound)
2) Open fractures require wound closure
3) If comminuted or depressed, they have to be treated in the OR
What test must anyone with head trauma who has become unconscious get as part of workup and why? What is next in management is this test is negative and the patient is neurologically intact?
1) Computed tomography (CT) scan to look for intracranial hematomas
2) If negative and neurologically intact, they can go home if the family will wake them up frequently during the next 24 hours to make sure they are not going into coma
What are signs of a fracture affecting the base of the skull?
1) Raccoon eyes
2) Rhinorrhea
3) Otorrhea
4) Ecchymosis behind the ear
How is a fracture of the base of the skull managed?
Expectant management
What must be assessed in a patient with a fracture of the base of the skull? How is this done?
1) The significance of a base of the skull fracture is that it indicates that the patient sustained very severe head trauma, and thus it requires that we assess the integrity of the cervical spine
2) This is best done with CT scan, usually as an extension of the scan that is done for the head
What should be avoided in patients with a fracture of the base of the skull?
Nasal endotracheal intubation
What 3 components can cause neurologic damage from trauma?
1) The initial blow
2) The subsequent development of a hematoma that displaces the midline structures
3) The later development of increased intracranial pressure (ICP)
Is there any treatment for neurologic damage from trauma?
1) There is no treatment for the initial blow
2) Surgery can relieve the hematoma that displaces midline structures
3) Medical measures can prevent or minimize increased ICP
How does acute epidural hematoma occur? How does it present?
1) It occurs with modest trauma to the side of the head
2) It has classic sequence of trauma, unconsciousness, lucid interval (with completely asymptomatic patient who returns to his previous activity), gradual lapsing into coma again, fixed dilated pupil (90% of the time on the side of the hematoma), and contralateral hemiparesis with decerebrate posture
What does CT scan of an acute epidural hematoma show?
CT scan shows biconvex, lens-shaped hematoma
What is the treatment for an acute epidural hematoma?
Emergency craniotomy produces dramatic cure
How does an acute subdural hematoma present? How serious is an acute subdural hematoma in relation to an acute epidural hematoma?
1) It occurs with modest trauma to the side of the head and it has classic sequence of trauma, unconsciousness, lucid interval (with completely asymptomatic patient who returns to his previous activity), gradual lapsing into coma again, fixed dilated pupil (90% of the time on the side of the hematoma), and contralateral hemiparesis with decerebrate posture
2) The trauma is much bigger, the patient is usually much sicker (not fully awake and asymptomatic at any point), and the neurologic damage is severe (because of the initial blow)
What will CT scan of an acute subdural hematoma show?
Semilunar, crescent-shaped hematoma
If midline structures are deviated, what treatment will help acute subdural hematoma? What is the prognosis in this case?
1) Craniotomy will help
2) However, prognosis is bad
If there is no deviation of midline structures, what is therapy centered on for acute subdural hematoma? What does therapy include? What should you avoid in your therapeutic approach?
1) Preventing further damage from subsequent increased ICP
2) Do ICP monitoring, elevate head, hyperventilate, avoid fluid overload, and give mannitol or furosemide
3) Do not diurese to the point of lowering systemic arterial pressure
When is hyperventilation recommended for acute subdural hematoma? What is the goal of PCO2?
1) When there are signs of herniation
2) PCO2 of 35
What approach can be used to decrease brain activity (and oxygen demand) in the presence of acute subdural hematoma? What is currently suggested as a better option to reduce oxygen demand?
1) Sedation
2) Hypothermia
When does diffuse axonal injury occur?
In more severe trauma
What does CT scan show in diffuse axonal injury?
Blurring of the gray-white matter interface and multiple small punctate hemorrhages
Is there role of surgery in diffuse axonal injury?
Without hematoma there is no role for surgery
What is therapy directed at in diffuse axonal injury?
Preventing further damage from increased ICP
In whom does chronic subdural hematoma occur?
In the very old or in severe alcoholics
What occurs in chronic subdural hematoma?
A shrunken brain is rattled around the head by minor trauma, tearing venous sinuses
What occurs over several days or weeks with chronic subdural hematoma?
Mental function deteriorates as hematoma forms
What test is diagnostic of chronic subdural hematoma? What is treatment
1) CT scan is diagnostic
2) Surgical evacuation provides dramatic cure
Can hypovolemic shock happen from intracranial bleeding? Why?
1) No
2) There isn’t enough space inside the head for the amount of blood loss needed to produce shock. Look for another source
When does penetrating trauma to the neck lead to surgical exploration?
In all cases where there is:
1) An expanding hematoma
2) Deteriorating vital signs
3) Clear signs of esophageal or tracheal injury (coughing or spitting up blood)
How are gunshot wounds to the upper zone of the neck managed? The base of the neck?
1) Arteriographic diagnosis and management is preferred
2) Arteriography, esophagogram (water-soluble, followed by barium if negative), esophagoscopy, and bronchoscopy before surgery help decide the specific surgical approach
How are stab wounds to the upper and middle zones of the neck in asymptomatic patients managed?
They can be safely observed
In all patients with severe blunt trauma to the neck, what must be ascertained? If there are neurologic deficits, what exam must be done? When else is this test indicated?
1) Integrity of the cervical spine
2) Radiologic examination of the neck with CT scan of the cervical spine
3) Must also be done in neurologically intact patients who have pain to local palpation over the cervical spine
What is the best way to assess the status of the cervical spine in the emergency department setting? How can this be adapted to include the neck?
1) CT scan
2) If a CT of the head is ordered secondary to head trauma, this scan can be extended to include the neck
How does complete transection of the spinal cord present?
Nothing works (sensory or motor) below the lesion
How does a hemisection (Brown-Sequard) of the spinal cord occur? How does it present?
1) Typically from clean-cut injury (knife blade)
2) Has paralysis and loss of proprioception distal to the injury on the injury side and loss of pain perception distal to the injury on the other side
How does anterior cord syndrome occur? How does it present?
1) Typically seen in burst fractures of the vertebral bodies
2) There is loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, with preservation of vibratory and positional sense
How does central cord syndrome occur? How does it present?
1) Central cord syndrome occurs in the elderly with forced hyperextension of the neck (rear-end collision)
2) There is paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities
How is precise diagnosis of cord injury best done?
Magnetic resonance imaging (MRI; CT is easier to do if we only have to look at the bone)
Are high-dose corticosteroids after a spinal cord injury recommended?
No
Why can rib fracture be deadly in the elderly? How is it treated?
1) Progression of pain to hypoventilation to atelectasis to pneumonia
2) Treat with local nerve block and epidural catheter
What does plain pneumothorax result from? How does it present?
1) Penetrating trauma (which could be the jagged edge of a broken rib or any of the more common penetrating weapons)
2) Moderate shortness of breath, and one side of the thorax has no breath sounds and is hyperresonant to percussion
What management should be done for a plain pneumothorax?
1) Get chest x-ray
2) Place chest tube (upper, anterior)
3) Connect to underwater seal
How does hemothorax occur? How does it differ from plain pneumothorax?
1) It results from penetrating trauma (which could be the jagged edge of a broken rib or any of the more common penetrating weapons)
2) The affected side will be dull to percussion
How is hemothorax diagnosed? How is it treated acutely and why? What may be required to stop the bleeding?
1) Chest X-ray
2) Blood needs to be evacuated to prevent development of empyema, thus chest tube (placed low) is needed
3) Surgery to stop the bleeding is seldom required
What is the usual bleeding source for a hemothorax? How is the bleeding stopped? In rare cases, what can the bleeding be a result of? What is required as treatment in these cases?
1) The lung
2) It will stop by itself (low pressure system)
3) A systemic vessel (typically an intercostal artery) is the source of bleeding
4) Thoracotomy is needed
What are factors that dictate the need for surgery in the event of chest tube placement?
1) Recovering 1,500 mL or more when the chest tube is inserted
2) Collecting over 600 mL in tube drainage over the ensuing 6 hours
Why should you monitor injuries in severe blunt trauma to the chest?
There may be hidden injuries that require monitoring of:
1) Blood gases and chest x-ray to detect developing pulmonary contusion
2) Cardiac enzymes [troponins] and electrocardiogram [EKG] to detect myocardial contusion
What injury would require immediate attention in severe blunt trauma to the chest?
Traumatic transection of the aorta
What are sucking chest wounds?
They are wounds with a flap that sucks air with inspiration and closes during expiration, obviously noted on physical exam
What is a flail chest?
Flail chest occurs with multiple rib fractures that allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing)
What is the real problem underlying a flail chest? How can you treat this problem?
1) The real problem is underlying pulmonary contusion
2) Contused lung is very sensitive to fluid overload, thus treatment includes fluid restriction and use of diuretics
Because pulmonary dysfunction may develop in the presence of a flail chest, what should be monitored?
Blood gases have to be monitored
If a respirator is needed for a flail chest, what must be placed in the patient and why?
Bilateral chest tubes are advisable to prevent tension pneumothorax from developing (the multiple broken ribs may have punctured the lung)
What should be actively sought as another diagnosis in a patient with a flail chest?
To get a flail chest big trauma is required, thus traumatic transection of the aorta must be actively sought
When does pulmonary contusion present, what is happening to blood gases in its presence, and what is shown on chest x-ray?
Pulmonary contusion can show up right away after chest trauma, with deteriorating blood gases and “white out” of the lungs on chest x-ray, or it can appear up to 48 hours later (thus it is one of those hidden injuries that has to be monitored for)
When should myocardial contusion be suspected? How will it be detected? What is treatment focused on?
1) Should be suspected in sternal fractures
2) EKG monitoring will detect it. Troponins are quite specific
3) Treatment is focused on the complications, such as arrhythmias
How does traumatic rupture of the diaphragm present? How should suspicious cases be evaluated? How is treatment done?
1) Bowel in the chest (by physical exam and x-rays), always on the left side
2) Evaluate with laparoscopy
3) Surgical repair is typically done from the abdomen
What is the ultimate “hidden injury”? Where does it occur, what does it require, and when does it become symptomatic?
1) Traumatic rupture of the aorta is the ultimate “hidden injury”
2) It happens at the junction of the arch and the descending aorta, requires big deceleration injury, and is totally asymptomatic until the hematoma contained by the adventitia blows up and kills the patient
What should trigger suspicion of a traumatic rupture of the aorta?
The mechanism of injury (knowing that the patient suffered severe deceleration injury) or by the presence of fractures in chest bones that are “very hard to break”: first rib, scapula, or sternum, or by the presence of wide mediastinum
What are noninvasive diagnostic tests for traumatic rupture of the aorta? Which is the most practical?
1) Transesophageal echocardiography
2) Spiral CT scan
3) MRI angiography
4) In the trauma setting, the most practical of these is the spiral CT scan, which is enhanced by intravenous dye, and thus is also known as CT angio
What is traumatic rupture of the trachea or major bronchus suggested by? What confirms the presence of air in the tissues?
1) The development of subcutaneous emphysema in the upper chest and lower neck, or by a large “air leak” from a chest tube
2) Chest x-ray
What does fiberoptic bronchoscopy identify in traumatic rupture of the trachea or major bronchus? What is the treatment?
1) Identifies the lesion and allows intubation to secure an airway beyond the lesion
2) Surgical repair follows
What does differential diagnosis of subcutaneous emphysema include aside from traumatic rupture of the trachea or major bronchus?
Rupture of the esophagus (but the usual setting is after endoscopy) and tension pneumothorax (but in the latter the other findings-shock and respiratory distress-are far more alarming and deadly)
In what two scenarios should air embolism be suspected?
1) When sudden death occurs in a chest trauma patient who is intubated and on a respirator
2) It also happens when the subclavian vein is opened to the air (supraclavicular node biopsies, central venous line placement, CVP lines that become disconnected), also leading to sudden collapse and cardiac arrest
What is immediate management of air embolism?
Cardiac massage with the patient positioned with the left side down
How is air embolism prevented?
Prevention includes the Trendelenburg position when the great veins at the base of the neck are to be entered
When should one suspect fat embolism? How does the patient present?
1) It may produce respiratory distress in a trauma patient who may not have necessarily suffered chest trauma
2) The typical setting is a patient with multiple trauma, including several long bone fractures, who develops petechial rashes in the axillae and neck; fever, tachycardia, and low platelet count; and who at some point shows a full-blown picture of respiratory distress, with hypoxemia and bilateral patchy infiltrates on chest x-ray
What is the mainstay of therapy for fat embolism? What is the precise diagnosis for fat embolism and is it needed?
1) Respiratory support
2) Precise diagnosis (fat droplets in the urine) is not really needed
What do gunshot wounds to the abdomen require? Where must the bullet be located to be considered to involve the abdomen?
1) Exploratory laparotomy for repair of intraabdominal injuries (not necessarily to “remove the bullet”)
2) Any entrance or exit wound below the level of the nipple line is considered to involve the abdomen
When can conservative therapy be used for a gunshot wound to the abdomen?
In very select cases of abdominal trauma due to low caliber gunshot wounds involving the right upper quadrant, conservative therapy may be used if the patient is properly monitored with close follow-up of clinical signs and serial abdominal CT scans
When is exploratory laparotomy required for stab wounds?
1) If it is clear that penetration has occurred (protruding viscera)
2) The same is true if hemodynamic instability or signs of peritoneal irritation develop
What is done in the absence of signs indicative for exploratory laparotomy in the presence of a stab wound? What is diagnostic if this exam is equivocal?
1) Digital exploration of the wound in the ER (gentle insertion of gloved finger) and observation may be sufficient
2) If digital exploration is equivocal, a CT scan is diagnostic
When does blunt trauma to the abdomen require exploratory laparotomy? If this sign is not apparent, what three things must be determined to make the decision as to if exploratory laparotomy should be done?
1) If signs of peritoneal irritation (an acute abdomen) develop
2) Otherwise, in blunt trauma one must determine whether there are internal injuries, whether there is bleeding into the peritoneal cavity, and whether the bleeding is likely to stop by itself or will require surgical intervention
What are signs of internal bleeding in the presence of blunt trauma to the abdomen?
1) Drop in BP
2) Fast thready pulse
3) Low CVP
4) Low urinary output
5) In a cold, pale, anxious patient who is shivering, thirsty, and perspiring profusely
(Patient going into shock with low CVP and with no obvious external source of blood loss)
How much blood must be lost before signs of hypovolemic shock occur? Could such blood loss occur and not be detected within the head? The neck? The pericardial sac? The pleural cavities? The arms and lower legs? Where could such blood loss occur?
1) When 25-30% of blood volume is acutely lost (about 1,500 mL in the average size adult)
2) It cannot do it in the head (a much smaller amount would produce lethal neurologic damage by compression and displacement of the brain)
3) The neck could accomodate a large hematoma, but gross deformity would be obvious on physical exam
4) Blood in the pericardial sac would lead to pericardial tamponade
5) The pleural cavities could easily accommodate several liters of blood, with relatively few local symptoms, but that blood could not hide from an x-ray machine (a few hundred milliliters show up on chest x-ray)
6) By virtue of their size, the arms and lower legs would also show gross deformity if they were the site of a 1,500-mL hematoma
7) That leaves the abdomen, thighs (secondary to femur fractures), and pelvis (in pevlic fractures) as the only 3 places where 1,500 mL of blood could “hide” in a blunt trauma patient who has developed shock
What two parts of the body below the chest are always checked for fractures in the initial survey of a trauma patient and how is this done?
1) The femurs and pelvis
2) By physical exam, with x-rays if needed
In what patient should you be especially suspicious of intraabdominal bleeding if he or she goes into hypovolemic shock for no obvious reason?
The multiple trauma patient who has a normal chest x-ray and no evidence of pelvic or femur fracture
How is the diagnosis of intraabdominal bleeding most accurately made? What will this test show? In conjunction with the patient’s response to fluid administration, what can it help to make a decision about?
1) CT scan
2) The presence of blood, the injury from where the blood is coming (most frequently liver or spleen), and will even give an idea of how bad that injury is
3) Surgery or expectant therapy
Does a patient with minor internal injuries who responds promptly to fluid resuscitation need surgery?
No
Does a patient with major injuries and vital signs that do not improve with fluid resuscitation require surgery?
Yes
What are two ways of diagnosing intraabdominal bleeding in a patient who is hemodynamically unstable? What is required if they are positive?
1) Sonogram - “FAST” (Focused Abdominal Sonogram for Trauma)
2) Diagnostic peritoneal lavage (DPL)
3) Prompt exploratory laparotomy
What is the most common source of significant intraabdominal bleeding in blunt abdominal trauma?
A ruptured spleen (If all patients are counted-significant and insignificant-the liver is a more common source)
What is a diagnostic hint of a ruptured spleen in the presence of blunt abdominal trauma?
Fractures of lower ribs on the left side
In the presence of a ruptured spleen causing intraabdominal bleeding in blunt abdominal trauma, is the spleen salvaged or removed? What is done if removal is unavoidable?
1) Given the immunologic function of the spleen, every effort will be made to repair it rather than remove it-particularly in children
2) If removal is unavoidable (truly smashed to pieces, or there are many other life-threatening injuries that preclude the use of operative time for repair), post operative immunization against encapsulated bacteria is mandatory (Pneumococcus, Haemophilus influenza B, and meningococcus)
How is intraoperative development of coagulopathy during prolonged abdominal surgery for multiple trauma with multiple transfusions treated? If in addition to coagulopathy there is hypothermia and acidosis, what must be done?
1) It is treated empirically with platelet packs and fresh-frozen plasma, approximately 10 units of each
2) The laparotomy has to be promptly terminated, with packing of bleeding surfaces and temporary closure
When does abdominal compartment syndrome occur?
When lots of fluids and blood have been given during the course of prolonged laparotomies, so that by the time of closure all the tissues are swollen and the abdominal wound cannot be closed without undue tension
How is abdominal compartment syndrome managed?
A temporary cover is placed over the abdominal contents, either:
1) An absorbable mesh (that can later be grafted over)
2) Nonabsorbable plastic to be removed at a later date when closure might be possible
How does abdominal compartment syndrome present post-operatively? In this setting, what must be done?
1) On the second posteroperative day in a patient, he or she subsequently goes on to develop distention, with the sutures cutting through the tissues, hypoxia secondary to inability to breathe, and renal failure from pressure on the vena cava
2) In that setting, the abdomen must be opened and a temporary cover provided
When is damage control laparotomy done (in what patient)? How is it done?
1) It has become the standard concept that now guides management of the severely traumatized patient, who is subject to consumption coagulopathy, hypothermia, and the abdominal compartment syndrome
2) Clamp all bleeders, temporarily occlude damaged viscera, clean up all the contamination, and get out of there. Then do the rest of the resuscitation, and at a later date go back in and finish the job
How are pelvic hematomas managed if they are not expanding?
They are left alone
What injuries have to be ruled out in any pelvic fracture and what test should be done for each?
Associated injuries, such as:
1) Rectum (do rectal exam and proctoscopy)
2) Bladder in both sexes
3) Vagina in women (do pelvic exam)
4) Urethra in men (do retrograde urethrogram)
How is diagnosis of hypovolemic shock due to pelvic trauma made in someone with ongoing significant bleeding and a pelvic fracture?
It is based on evidence of hypovolemic shock in someone with a pelvic fracture who is not bleeding elsewhere (Typically a negative DPL or abdominal sonogram-or a CT scan that shows no intraabdominal injuries and a huge pelvic hematoma)
What is the treatment for pelvic fractures causing hypovolemic shock?
1) Blood replacement
2) External fixation
3) Arteriographic embolization for arteries (does not work for venous bleeding)
What is a product of opening a pelvic hematoma?
Opening a pelvic hematoma loses the tamponade effect
What is the best treatment for pelvic fractures with ongoing significant bleeding?
Pelvic fixators followed by IR angiographic embolization of both internal iliac arteries
What is the hallmark of urologic injuries?
Blood in the urine in someone who has sustained penetrating or blunt abdominal trauma
What is always the workup of a penetrating urologic injury?
Surgical exploration and repair
What type of fracture as a result of blunt urologic injury affects the kidneys? Which type affects the bladder or urethra?
1) Lower rib fractures
2) Pelvic fracture
Does a urethral injury occur in men or women? What type of fracture is it typically associated with? What does it present with? What is a more complete clinical picture of urethral injury?
1) Urethral injury occurs almost exclusively in men, is typically associated with pelvic fracture, and may present with blood at the meatus
2) A scrotal hematoma, for posterior injuries the sensation of wanting to void but not being able to do it, and a “high-riding” prostate on rectal exam
What is the key issue to avoid in a urethral injury? What would be a diagnostic clue of this issue?
1) Do not insert a foley catheter because it might compound an existing injury
2) If someone had attempted to pass a Foley catheter and met resistance, that would be another diagnostic clue suggesting urethral injury
What should be done for diagnosis of a urethral injury?
Retrograde urethrogram
Does a bladder injury occur in men or women? What type of fracture is it typically associated with? What is it diagnosed with?
Bladder injuries can occur in either sex, are usually associated with pelvic fracture, and are diagnosed by retrograde cystogram
What must an x-ray study of the bladder in a bladder injury include and why? What if a leak of the bladder is found? What if the leak is intraperitoneal?
1) An x-ray study must include postvoid films, to see extraperitoneal leaks at the base of the bladder that might be obscured by the bladder full of dye
2) If the latter are found, they can be treated simply by placing a Foley catheter
3) For intraperitoneal leaks, surgical repair is done and protected with a suprapubic cystotomy
Renal injuries secondary to blunt trauma are usually associated with what? How are they assessed? Do they require surgical intervention?
1) Lower rib fractures
2) They are assessed by CT scan
3) Most of the time they can be managed without surgical intervention
What is a rare but fascinating potential sequela of injuries affecting the renal pedicle? What is another potential sequela should renal artery stenosis develop after trauma?
1) The development of an arteriovenous fistula leading to congestive heart failure
2) Renovascular hypertension
Can scrotal hematomas become large? When do scrotal hematomas require specific intervention? How can this indication be tested for?
1) Scrotal hematomas can attain alarming size but typically do not need specific intervention unless the testicle is ruptured
2) The latter can be assessed with sonogram
When does fracture of the penis occur? What part of the penis is fractured?
1) Occurs to an erect penis, typically as an accident during vigorous intercourse (with woman on top)
2) Corpora cavernosa, tunica albuginea
How does a fracture of the penis present?
1) Sudden pain
2) Development of a large penile shaft hematoma
3) Normal appearing glans
What is required as treatment for fracture of the penis? What will happen if repair is not done promptly and why?
1) Emergency surgical repair
2) If not done, impotence will ensue as arteriovenous shunts will develop
In penetrating injuries of the extremities, what is the main issue? What provides the first clue?
1) Whether a vascular injury has occurred or not
2) Anatomic location provides the first clue
What is required in a penetrating wound of an extremity if there are no major vessels in the vicinity of the injury tract? What if the penetration is near major vessels and the patient is asymptomatic? What if there is an obvious vascular injury (absent distal pulses, expanding hematoma)?
1) Only tetanus prophylaxis and cleaning of the wound is required
2) Doppler studies or CT angio are done
3) Surgical exploration and repair are required
If there is combined injury of arteries, nerves, and bone to an extremity, what is the sequence for reparation? What should be added to repairing these structures?
1) The usual sequence is to stabilize the bone first, then do the delicate vascular repair (which would be otherwise disrupted by the rough handling needed to put together a bone), and leave the nerve for last
2) A fasciotomy should be added because the prolonged ischemia could lead to a compartment syndrome
What does a high-velocity gunshot wound (military or big-game hunting rifles) require for treatment and why?
They produce a large cone of tissue destruction that requires extensive debridements and potential amputations
What do crushing injuries of the extremities pose the hazard of developing?
1) Hyperkalemia
2) Myoglobinemia
3) Myoglobinuria
4) Renal failure
5) Potential development of compartment syndrome
What is the treatment of a crushing injury?
1) Vigorous fluid administration
2) Osmotic diuretics
3) Alkalinization of the urine
4) Fasciotomy if compartment syndrome is present
What immediate treatment do chemical burns require?
Massive irrigation to remove the offending agent at the site where the injury occurred (tap water, shower)
What is worse, an alkaline (Liquid Plumr, Drano) or acid (battery acid) burn?
Alkaline burns
What should you not try to do with a chemical burn?
Do not “play chemist” and attempt to neutralize the agent
What is characteristic of the depth and intensity of a high-voltage electrical burn?
They are always deeper and worse than they appear to be
What may be required to treat a high-voltage electrical burn?
Massive debridements or amputations
What are some concerns regarding electrical burns and how are they treated?
1) Myoglobinemia-myoglobinuria-renal failure (give plenty of fluids and osmotic diuretics like mannitol, and alkalinize the urine)
2) Orthopedic injuries secondary to massive muscle contractions (posterior dislocation of the shoulder, compression fractures of vertebral bodies)
3) Late development of cataracts and demyelinization syndromes
When do respiratory burns (inhalation injuries) occur? What are suggestive clues of a respiratory burn?
1) They occur with flame burns in an enclosed space (a burning building, car, plane) and are chemical injuries caused by smoke inhalation
2) Burns around the mouth or soot inside the throat are suggestive clues
How is diagnosis of a respiratory burn confirmed? What is the key issue in management of a respiratory burn? What is the best way of determining if this management is necessary?
1) Fiberoptic bronchoscopy
2) Whether respiratory support (a respirator) is needed or not
3) Blood gases are best to make that determination
When should intubation be done in the presence of a respiratory burn?
If there is any concern about adequacy of the airway
Levels of what molecule in particular have to be monitored in the presence of a respiratory burn? What will help to overcome intoxication with this molecule?
1) Levels of carboxyhemoglobin have to be monitored
2) If elevated, 100% oxygen will shorten its half-life
How do circumferential burns of the extremities lead to cutoff of blood supply? What may this interfere with in a circumferential burn of the chest?
1) Edema accumulates underneath the unyielding eschar
2) A similar mechanical problem may interfere with breahing
What is the treatment for immediate relief of a circumferential burn?
Escharotomies (done at the bedside, with no need for anesthesia) will provide immediate relief
What should scalding burns in children always raise the suspicion of? What is a classic example?
1) Child abuse, particularly if the pattern of the burn does not fit the description of the even given by the parents
2) A classic example is burns of both buttocks, which are typically produced by holding a small child by arms and legs, and dunking him into boiling water
In the severely burned patient, what is the most critical, life-saving component of the management of extensive thermal burns? Why?
1) Fluid replacement
2) Underneath a deep burn, a lot of fluid accumulates. This is essentially plasma that has been temporarily lost from the circulating space and trapped at the burn site. In extensive burns, this internal shift of fluids is enormous and, if untreated, leads to hypovolemic shock and death. Thus, large infusions of intravenous fluids are required
What is the formula devised to estimate how much fluid (Ringer’s lactate) is required for resuscitation in a burn patient? When is the first half infused and when is the second half infused? What other fluids can be added aside from Ringer’s lactate? Will fluids be needed on the third day of resuscitation?
1) 4 x weight in kg x % body surface burned (capped at 50%; beyond that there is no further fluid loss)
2) Infuse half of the total fluid over the first 8 hours and the second half over the next 16 hours
3) Supplement with a couple of liters of D5W every day and, if desired, by colloids on the second day
4) The expectation was that no fluids would be needed by the third day, when the plasma trapped in the burn edema would be reabsorbed and a large diuresis would ensue
How is the total involved body surface in a burn victim calculated?
The rule of 9s:
1) 9% head
2) 9% each upper extremity
3) 18% each lower extremity
4) 36% torso
5) 1% perineum
Clinically, how is fluid administration rate chosen in practice for a burn patient? What is an ideal hourly urinary output in a burn patient receiving fluid administration and what CVP must you not exceed?
1) Fluid infusion is begun at an arbitrary, predetermined rate and then adjusted as needed
2) Aim for an hourly urinary output of 1 or 2 mL/kg/h, while avoiding CVP over 15 mmHg
What is the appropriate predetermined rate of fluid infusion in the adult to start at in burn patients? Why is sugar avoided in Ringer lactate?
1) 1,000 mL/h of Ringer lactate (without sugar) on anyone whose burns exceed 20% of body surface, and then adjust as needed to produce the desired urinary output
2) Sugar is avoided in the Ringer lactate as not to induce an osmotic diuresis from glycosuria, which would invalidate the meaning of the hourly urinary output
How does estimation of fluid in burned babies differ from that in adults?
Babies have bigger heads and smaller legs; thus the “rule of 9s” for them assigns two 9s to the head, and both legs share a total of three 9s instead of four
How does the appearance of a third-degree burn differ in an adult and a baby?
In determining what is third-degree, we should remember that in babies those areas look deep bright red (rather than the leathery, dry, gray appearance in the adult)
How much more fluid do babies need than the adult in terms of rate of initial fluid administration in burn patients?
An appropriate rate of initial fluid administration is 20 mL/kg/h if the burn exceeds 20% of body surface, to be subsequently fine-tuned in response to urinary output
What is the standard topical agent for burns?
Silver sulfadiazine
What is the treatment for a burn if deep penetration is desired (thick eschar, cartilage)?
Mafenide acetate is the choice (do not use it everywhere else; it hurts and it can produce acidosis)
How are burns near the eyes treated?
They are covered with triple antibiotic ointment (silver sulfadiazine is irritating to the eyes
How is pain administered to a burn patient in the early period?
Intravenously
After an initial day or two of NG suction, what is provided for nutritional support in a burn patient?
Preferably via the gut, high-calorie/high-nitrogen diets are given
After 2 or 3 weeks of wound care and general support, what is done to the burned areas that have not regenerated in a burn patient?
Grafting. Rehabilitation starts on day 1
When is the concept of early excision and grafting used and why? What is this concept?
1) It is used whenever possible to save costs and minimize pain, suffering, and complications
2) It implies removal in the OR (on day one) of the burned areas, with immediate skin grafting
For what type of burns can early excision and grafting be done?
This can be done only for fairly limited burns (under 20%) that are obviously third-degree
When it required for all bite wounds?
Tetanus prophylaxes and wound care
What is considered a provoked dog bite? Is rabies prophylaxis required in this setting? What if the bite is of the face?
1) A bite if the dog was petted while eating or otherwise teased
2) No rabies prophylaxis is required, other than observation of the dog for developing signs of rabies
3) Because bites to the face are very close to the brain, it might be prudent to start immunization and then discontinue it if observation of the dog is reassuring
What do unprovoked dog bites or bites from wild animals raise the issue of? How can this issue be determined? What if it cannot be?
1) Potential rabies
2) If the animal is available, it can be killed and the brain examined for signs of rabies
3) Otherwise, rabies prophylaxis is mandatory (immunoglobulin plus vaccine)
Do snakbites by crotalids (rattlesnakes) always result in envenomation?
Even if the snake is poisonous, up to 30% of bitten patients are not envenomated
What are the most reliable signs of envenomation from a snake bite? What tests should be done in this setting?
1) Severe local pain, swelling, and discoloration of developing within 30 minutes of the bite
2) If present, draw blood for typing and crossmatch (they cannot be done later if needed), coagulation studies, and liver and renal function
What is treatment for envenomation from a snake bite?
Antivenin. The currently preferred agent for crotalids (rattlesnakes) is CROFAB, of which several vials are usually needed
What does antivenin dosage related to in the event of a snake bite? Are surgical excision of the bite site or fasciotomy needed? What is the only valid first aid needed during transportation?
1) It is related to the size of envenomation, not size of the patient (children get the same dosages as adults)
2) Very rarely
3) Splint the extremity. Do not make cruciate cuts, suck out venom, wrap with ice, or apply a tourniquet
Which type of snake have a neurotoxin that needs to be promptly neutralized with specific antivenin? Since you should not wait for signs of envenomation to seek treatment, how can you identify a true coral snake?
1) Brightly colored coral snakes
2) True coral snakes are identified by the mnemonic “Red on yellow, kill a fellow,” meaning that red rings and yellow rings touch each other. Harmless brightly colored imitators have black rings separating yellow and red
Do more people die of snake bites or bee stings in the United States?
Bee stings because of anaphylactic reaction
How does anaphylaxis present? What is the drug of choice for treatment? How should bee stingers be removed?
1) Wheezing and rash may occur, and hypotension when present is caused by vasomotor shock (“pink and warm” shock)
2) Epinephrine is the drug of choice (0.3 to 0.5mL of 1:1,000 solution)
3) The stingers should be removed without squeezing them
What do black widow spiders look like? What symptoms to bitten patients get? What is the treatment? What other class of drug helps?
1) They are black, with a red hourglass on their belly
2) Bitten patients get nausea, vomiting, and severe generalized muscle cramps
3) IV calcium gluconate
4) Muscle relaxants help
When are brown recluse spider bites often recognized? What treatment is helpful? What procedure may be needed and when is this procedure done?
1) By the next day a skin ulcer develops, with necrotic center and surrounding halo of erythema
2) Dapsone is helpful
3) Surgical excision may be needed but should be delayed until the full extent of the damage is evident (as much as one week). Skin grafting may be needed
What are bacteriologically the dirtiest bite one can get? What do they require? What is a classic example?
1) Human bites
2) They require extensive irrigation and debridement (in the OR)
3) A classic human bite is the sharp cute over the knuckles on someone who punched someone else in the mouth and was cut by the teeth of the victim
