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Surgery > Pestana Chapter 1: Trauma > Flashcards

Pestana Chapter 1: Trauma Flashcards

1
Q

What are the five general situations when securing an airway is needed?

A
  1. When there is an expanding hematoma or emphysema of the neck
  2. when the patient is unconscious (GSC of 8 or less)
  3. If breathing is noisy or gurgly
  4. severe inhalation injury
  5. if patient needs to be connected to a respirator
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2
Q

What is the most typical route for airway insertion?

A

orotracheal (under direct visualization with a laryngoscope)

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3
Q

Orotracheal intubation is still possible with c-spine injury if the head is secured and not moved, but what is another potential option?

A

nasotracheal intubation over a fiver optic bronchoscope

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4
Q

The use of what kind of scope is mandatory when securing an airway if there is subcutaneous emphysema in the neck? Why?

A

When there is subcutaneous emphysema in the neck, because this is a sign of major traumatic disruption of the tracheobronchial tree and you need to directly visualize it.

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5
Q

What is the quickest safest way to temporarily gain airway access if intubation cannot be done in the usual manner and you’re running out of time?

A

cricothyroidotomy

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6
Q

Why should you be reluctant to do cricothyroidotomy before the age of 12?

A

there’s a risk for future laryngeal reconstruction

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7
Q

What urinary output suggests clinical shock?

A

less than 0.5 ml/kg/hr

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8
Q

What are three most likely causes of shock after trauma?

A

hemorrhage (by far the most common)
tamponade
tension pneumothorax

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9
Q

How can you differentiate clinically between shock caused by hemorrhage and shock caused by either tamponade or tension pneumo?

A

CVP will be low in hemorrhage, so veins will be empty

CVP is high in tamponade or tension pneumo, so jugular veins will be distended

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10
Q

How do you differentiate clinically between shock caused by tamponade and tension pneumo?

A

tamponade will not have respiratory distress, but tension pneumo will

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11
Q

What is the first step in hemorrhagic shock management in an urban setting? In a rural setting?

A

Urban - surgery first and then fluid resuscitation (since they’ll need surgery anyway)

Rural - fluid resuscitation first since surgery will likely be delayed based on access

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12
Q

How should you fluid rescucitate someone with hemorrhagic shock?

A

2L lactated ringers (without sugar), followed by packed RBCs until urinary output reaches 0.5 to 2 ml/kg/hr

use two peripheral IV lines, 16-gauge

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13
Q

If you can’t get access with two peripheral 16-g IV lines, what are your options?

A

percutaneous femoral vein catheter or saphenous vein cut-downs

or IO, especially in kids under 6

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14
Q

Pericardial tamponade is a clinical diagnosis, but what imaging modality is best if the clinical picture is unclear?

A

US

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15
Q

What are the two general causes of intrinsic cardiogenic shock?

A

massive MI or fulminating myocarditis

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16
Q

What is the management for cardiogenic shock?

A

vasopressors - NOT fluid resuscitation, which would be lethal in this setting

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17
Q

What are some causes of vasomotor shock?

A

anaphylactic reactions, high spinal cord transections or high spinal anesthetic

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18
Q

What is the management for vasomotor shock?

A

vasopressors and additional fluids will help

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19
Q

What is the management for linear skull fractures?

A

they’re left alone if they’re closed (without overlying wound), but open fractures require closure. If they’re comminuted or depressed, they need to be treated in the OR

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20
Q

Anyone with head trauma and LOC should get what kind of imaging?

A

head CT

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21
Q

What are some signs that a basal skull fracture has occurred?

A

raccoon eyes, rhinorrhea, otorrhea, or ecchymosis behind the ear (Battle sign)

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22
Q

What should be the next step in management for a patient when you suspect basal skull fracture?

A

they need CT imaging of both the head and C-spine since it suggests the patient sustained severe head trauma

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23
Q

What kind of intubation should be avoided in patients with basal skull fracture?

A

nasal endotracheal

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24
Q

What is the clinical presentation of an acute epidural hematoma?

A

trauma to the side of the head followed by immediate unconsciousness, then a lucid interval, followed by a gradual lapse into coma again

fixed dilated pupil on the same side ofe the hematoma and contralateral hemiparesis with decerebrate posture

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25
Q

What will CT scan show in acute epidural hematoma?

A

biconvex lens-shaped hematoma that doesn’t cross suture lines

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26
Q

What is the management for acute epidural hematoma?

A

emergency craniotomy

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27
Q

What will a CT scan show in an acute subdural hematoma?

A

a semilunar, crescent-shaped hematoma.

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28
Q

What is the management for acute subdural hematoma?

A

if midline structures are deviated, craniotomy will help but the prognosis is bad.

if there is no deviation, management is centered on avoiding increased ICP (elevate head, hyperventilate, give mannitol or furosemide). Can also do sedation or hypothermia to decreased brain activity/O2 demand

29
Q

What is the pCO2 goal when you’re hyperventilating someone with signs of herniation?

A

35

30
Q

Diffuse axonal injury occurs in more severe injury. What will CT show?

A

blurring of the gray-white matter interface with multiple small punctate hemorrhages

31
Q

What is the management for diffuse axonal injury?

A

avoid elevated ICP

32
Q

What’s the usual etiology of a chronic subdural hematoma?

A

tearing of the venous sinuses in an elderly or alcoholic patient (small brain rattled around in the head during minor trauma)

33
Q

True or false: hypovolemic shock cannot happen from intracranial bleeding.

A

true - there isn’t enough space in the head for the amount of blood loss needed to produce shock

34
Q

When should a patient undergo surgery after penetrating neck trauma?

A

when there is:

  1. expanding hematoma
  2. deteriorating vital signs
  3. clear signs of esophageal or tracheal injury like coughing or spitting up blood
  4. maybe gun shot sounds to the middle zone regardless of symptoms (although this may be changing)
35
Q

What is the appropriate first step for a gun shot wound to the upper zone of the neck?

A

arteriographic diagnosis and management is preferred

36
Q

What is the appropriate first step for a gun shot wound to the base of the neck?

A

arteriography, asophagogram (water-soluble followed by barium if negative), esophagoscopy and bronchosocpy before surgery to help decide the specific surgical approach

37
Q

True or false: stab wounds to the upper and middle zones in asymptomatic patients can be safely observed.

A

true

38
Q

When do you need to order a CT scan of the c-spine with blunt trauma to the neck?

A

(realistically always, but….)

if there are neurologic deficits

if there is local pain to palpation over the c-spine in a neurologically intact patient.

39
Q

Describe the clinical presentation of Brown-Sequard syndrome.

A

ipsilateral paralysis and loss of proprioception distal to the injury (corticospinal and dorsal columns)

contralateral loss of pain perception distal to the injury (STT)

40
Q

What is the typical etiology of anterior cord syndrome?

A

burst fractures of the vertebral bodies

41
Q

What is the clinical presentation of anterior cord syndrome?

A

loss of motor function and loss of pain and temperature sensation on both sides distal of the injury with preservation of vibratory and positional sense (dorsal columns preserved)

42
Q

What is the typical etiology of central cord syndrome?

A

in an elderly patient with forced hyperextension of the neck (like in a rear-end collision)

43
Q

What is the clinical presentation of central cord syndrome?

A

paralysis and burning pain in the UPPER extremities with preservation of most functions in the lower extremities

44
Q

Precise diagnosis of cord injury is best done with what kind of imaging?

A

MRI

45
Q

What medications may help if given immediately after the spinal injury?

A

high-dose corticosteroids

46
Q

Why can rib fracture be deadly in the elderly? How can you avoid this?

A

pain leads to hypoventilation which leads to atelectasis which leads to pneumonia

avoid with a nerve block

47
Q

How will a pneumothorax and hemothorax differ on exam?

A

pneumothorax will be hyperresonant to percussion, while hemothorax will be dull to percussion

48
Q

What is the management of pneumothorax?

A

chest tube and connect to underwater seal

49
Q

WHat is the management for hemothorax?

A

evacuate with chest tube

surgery is rarely needed because the source of bleeding is usually the lung and typically stops on its own

50
Q

What are some factors that would make surgerical thoracotomy necessary in hemothorax?

A

if there is a systemic vessel that’s causing the bleeding, which will be suggested by recovering 1500 ml or more when the chest tube is inserted or collecting over 600 ml in the tube drainage over the ensuing 6 hours

51
Q

In severe blunt trauma, how do you monitor for pulmonary and cardiac contusions?

A

blood gases, chest x-ray, cardiac enzymes and EKG

52
Q

What is the first aid management of a sucking chest wound to avoid tension pneumo?

A

occlusive dressing that allows air out but not in.

53
Q

What does flail chest mean?

A

it means there are multiple rib fractures that allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxical breathing)

54
Q

What is the real problem in flail chest?

A

It’s not the paradoxical breathing, it’s actually the underlying pulmonary contusion. A contused lung is very sensitive to fluid-overload (so treat with fluid restriction and diuretics)

55
Q

Since big trauma is necessary to cause flail chest, what other injury should you actively rule out?

A

traumatic transection of the aorta

56
Q

What will a pulmonary contusion look like on CXR?

A

“white out” of the lungs

57
Q

What type of fracture is especially likely to cause a cardiac contusion?

A

sternal fractures, so always get troponins

58
Q

How will you diagnose a traumatic rupture of the diaphragm?

A

bowl in the chest noted on either physical exam or CXR

59
Q

Which side does a traumatic rupture of the diaphragm happen?

A

left

60
Q

When does traumatic rupture of the aorta usually happen?

A

at the junction of the arch and the descending aorta

61
Q

How does a traumatic rupture of the aorta usually present?

A

Usually asymptomatic (!!!!) until the hematoma contained by the adventitia blows up and kills the patient

62
Q

What is the typical injury necessary for traumatic rupture of the aorta?

A

severe deceleration injury or if someone breaks bones that are usually hard to break, like the first rib, scapula or sternum

63
Q

What is the typical imaging modality for traumatic aortic rupture in the trauma setting?

A

spiral CT (also known as CT angio if enhanced with contrast)

64
Q

Traumatic rupture of the trachea or major bronchus is suggested by what physical exam finding?

A

subcutneous emphysema in the upper neck or lower neck

65
Q

What is the management for trachea rupture?

A

fiberoptic bronchoscopy to allow intubation, followed by surgical repair

66
Q

Esophageal rupture should be considered on the differential for subcutaneous emphysema particularly in what setting?

A

after endoscopy

67
Q

What should be suspected when sudden death occurs in a chest trauma patient who is intubated and on a respirator?

A

air embolism

68
Q

What is another situation when air embolism should be suspected?

A

when the subclavian vein is opened opened to the air (supraclavicular

Surgery (1 decks)

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