Pestana Trauma Flashcards
2 causes of airway compromise
expanding hematoma
subcuntaenous emphysema
how are airways usually secured?
orotracheal intubation under direct vision with the use of a laryngoscope
when is the use of a fiberoptic bronchoscope indicated for securing an airway?
when there is sub-cu emphysema in the neck (occurs when there is injury to the tracheobronchial tree )
when is crichothyroidtomy indicated for securing an airway? 3
in times when intubation cannot be done with an orotracheal intubation, such as
- laryngospasm
- severe maxillofacial injuries
- foreign body in the airway that cannot be dislodged
Clinical signs of shock
low BP (<90 systolic)
tachycarida
low UO (<0.5cc/kg/hr)
pale, cold, shivering, diaphoretic, thirsty and apprehnsive
in the trauma setting, what is shock usually caused by? 3
bleeding (hemorrhage)
pericardial tamponade
tension pneumothorax
How do these differ in terms of central venous pressure?
bleeding (hemorrhage)
pericardial tamponade
tension pneumothorax
- bleeding (hemorrhage) = LOW CVP (flat veins)
- pericardial tamponade = HIGH CVP (bulging veins)
- tension pneumothorax = HIGH CVP
treatment of hemrorhagic shock at a trauma setting
surgical intervention to stop bleeding, followed by volume replacement (2L of LR w/o surgar, followed by PRBC) until UO reaches at ≥ 0.5 mL/kg/h while not exceeding CVP of 15mmHg
preferred route of fluid resuscitation
2 peripheral IV lines, 16 guage
what happens if you cannot establish a peripheral IV line in:
a little old lady
children
little old lady - percutaneous femoral vein catheter or saphenous vein cut-downs
children - intraossesus cannulation of the proximal tibia
how is pericaridal tamponade typically managed?
pericardiocentesis
how is tension pneumothorax diagnosed and managed?
by physical exam: presence of a skin flap that sucks air with inspiration and closes during expiration; do not wait for an x-ray or blood gases)
big needle/cathether into the pleural space followed by chest tube to water seal (both inserted high in the anterior chest wall)
3 causes of shock
hypovolemic
cardiogenic
vasomotor
causes of hypovolemic shock
management?
anything that causes massive fluid loss:
burns
peritonitis
pancreatitis
massive diarrhea
management: blood volume replacement (2L of LR w.o sugar + PRBC until UO reaches 0.5 - 2 ml/kg/h without exceeding CVP of 15 mmHg)
Ideal blood volume replacement
2L of LR solution (w/o sugar) + PRBC until UO reaches** ≥ 0.5 - 2** mL/kg/h without exceeding **CVP of 15 mmHg **or less)
2 causes & management of cardiogenic shock?
MI or myocarditis
circulatory support - avoid giving blood + fluids since it will be lethal
3 main causes of vasomotor shock
anaphylactic reactions
high spinal cord transection
spinal anesthetic
how do pts with vasomotor shock present? 2
how should these patients be managed?
low CVP (flat veins), pink and warm patient
vasopressors + IVF
mgmt of patients with penetrating head trauma
surgical repair
mgmt of linear skull fractures
nothing if closed fracture
surgical closure if open fracture
pt with head trauma is neurologically intact
next best step in management?
can send them home only if they have family that will wake them up frequently during the next 24 hours to ensure that they’re not comatose
pt with head trauma suddenly becomes unconscious
next best step in management?
head CT (look for intracranial hematoma/bleed)
how do patients with fractures affecting the base of the skull present? 4
next best step in management of these patients? 2
what should you avoid in these patients? 1
raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind ear
Expectant management + CT H&N to assess the integrity of the cervical spine (since patients with these types of fractures typically have sustained a very severe head trauma)
avoid nasal endotracheal intubation
epidural hematoma
how to make the diagnosis?
management?
CT scan
emergency craniotomy
what happens if epidural hematomas are not treated?
fixed dilated pupil (usually ipsilateral to hematoma)
contralateral hemiparesis + decerebrate posture
subdural hematoma
how to make the diagnosis?
management?
CT scan: semi-lunar, crescent shaped hematoma
management depends if there is deviation of midline structures:
- deviation -> craniotomy
- no deviation -> decrease ICP by elevating head, hyperventilation, avoid fluid overload, give mannitol or furosemide
6 ways to decrease ICP
elevate head
hyperventilate until PCO2 = 35
(hypocapnia causes constriction/hypercapnia causes dilation of cerebral arteries/arterioles)
avoid fluid overload
Rx: mannitol or furosemide
sedation (decrease oxygen demand of the brain)
hypothermia ( “” )
CT of head shows evidence of diffuse blurring of the GW matter interface and multiple small punctate hemorrhages.
Diagnosis?
Management? 2
Diffuse axonal injury - usually occurs when there is severe head trauma
therapy - reduce ICP (there is a flashcard about this) or surgery if there is a hematoma
in which patients do chronic subdural hematomas occur? 2
how do they usually present?
how are they diagnosed and treated?
in very old or severe alcoholics
mental status deteriorates over the course of several days or weeks as the hematoma forms
CT scan
surgical evacuation
patient shows up with a penetrating trauma to the neck
when would surgery be indicated? 3
expanding hematoma
deteriorating vitals
esophageal/tracheal injury (blood)
patient presents to the ED after falling and hitting his head in a snowboard accident.
next best step in management?
CT of H&N (cervical spine)
how do patients with complete transection of the spinal cord present?
lack of sensory + motor function below the lesion
how do patients with hemisection/Brown-sequard of the spinal cord present?
ipsilateral loss of pain + proprioception
contralateral loss of temperature and pain sensation
“control temp/pain”
how do patients with anterior cord syndrome?
how does this usually develop?
loss of motor, pain, and temperature (injury to spinothalamic tracts) bilaterally and distal to the injury with preservation of vibratory and positional sense (DCML columns are intact)
typically seen in burst fractures of vertebral bodies
how do patients with central cord syndrome present?
how does this usually develop? 3
paralysis and burning pain in the upper extremities with preservation of most functions in the lower extremities (according to wiki, patients may have some evidence of bladder dysfunction/retention)
forced hyperextension of the neck (usually secondary to rear end collision), which may cause either
- bleeding into the central part of the cord
- selective axonal disruption in the lateral columns at the level of the injury to the spinal cord with relative preservation of the grey matter
- fracture dislocation -> anteroposterior compressive forces also distribute the greatest damaging effect on the central mass of the cord substance
patient presents with suspected spinal cord injury
next best steps in management? 3
get stat CT and MRI
high dose steroids (avoids swelling)
surgical reduction (if there is a vertebral subluxation)
rib fracture in elderly - what should you be concerned about?
how would you manage these patients? 2
rib fractures can be deadly because of this sequence:
rib pain -> hypoventilation -> atelectasis -> pneumonia
trmt: local nerve block + epidural cathether
pneumothorax management
CXR
chest tube placed upper + anterior lung field and connect to water seal
hemothorax causes
how is it diagnosed?
management
why is this important?
causes: lung bleed or intercostal artery
diagnosed via CXR
management depends on cause of bleed:
- lung - chest tube placed in lower lung fields and connect to water seal (usually will stop itself since the lung is a low pressure system)
- intercostal artery - thoracotomy (incision into the pleural space of the chest)
blood needs to be evacuated to prevent development of empyema
when is thoracotomy indicated for a hemothorax? 2
if > 1.5 L of blood is recovered when chest tube is recovered
or if > 600 cc in tube drainage occurs over the course of 6 hours
what is a flail chest and when does it occur?
management? 4
occurs in the setting of multiple rib fractures that allow a segment of teh chest wall to cave in during inspiration and bulge out during expiration (paradoxical breathing)
management
- fluid restriction + diuretics (contused lungs are very sensitive to fluid overload)
- ABG
- bilateral chest tubes to prevent tension pneumothorax since broken ribs can puncture the lung
- r/o transection of the aorta (since a flail chest usually occurs under the setting of a traumatic injury)
patient has deteriorating blood gases and CXR that shows “white out of the lungs”
what is your diagnosis and what is the next best step in management?
Pulmonary contusion
- fluid restriction + diuretics (contused lungs are very sensitive to fluid overload)
- ABG
- bilateral chest tubes to prevent tension pneumothorax since broken ribs can puncture the lung
- r/o transection of the aorta (since a flail chest usually occurs under the setting of a traumatic injury)
patient presents with a sternal fracture, as evidenced on a CXR
next best step in management? 2
suspect that there is cardiac injury as well, so get EKG and troponins
patient presents to ED after a head-on car crash with a truck. He was fine for the first hour, but suddenly decompensates and dies. What is your suspicion?
how can you prevent from happening the next time?
traumatic rupture of the aorta
usually occurs in the setting of a big decleration injury, where the aorta is injured resulting in a hematoma that is initially contained by the adventitia until it blows up and kills the patient
prevent by using non-invasive diagnostic tests: TEE or CT angio; and if positive, immediate surgical correction either with a prosthetic or stent graft
crepitus is palpated along the upper chest and lower neck.
diagnosis and next best steps in management 3?
subcu emphysema secondary to traumatic rupture of the trachea or major bronchus
CXR + fiberoptic bronchoscopy for intubation (secures airway), followed by surgical repair
patient with chest trauma is intubuated and placed on a respirator. Minutes later, he flatlines.
what just happened?
next steps in management?
air embolism - leads to sudden cardiac arrest
cardiac massage ASAP to try to resuscitate the patient
2 main causes of causes of air embolism
when patient with chest trauma is intubated and placed on a respirator
when subclavian vein is opened to the air, which results in sudden collapse and cardiac arrest; examples include supraclaviuclar LN biopsies, central venous line placement, CVP lines that become disconnected
Fat embolism
how do these patients usually present?
long bone fractures
petechial rash in axilla + neck
fever
tachycardia
low platelet count
respiratory distress
CXR - bilateraly patchy infiltrates
fat embolism
how is it diagnosed?
Mainstay of therapy?mu
CXR - bilateraly patchy infiltrates
respiratory support
management of gunshot wound to abdomen
exploratory laparotomy for repair of intraabdominal injuries
when is exploratory laparatomy of stab/gunshot wound to abdomen indicated? 3
- penetration (viscera protrudes from abdomen)
- hemodynamic instability (shock, low CVP with fast thready pulse, no obvious external source of blood loss, low UO, cold/pale patient who is shivering and diaphoretic)
- signs of peritoneal irritation
if any of these signs are absent, digital exploration of the wound (gentle insertion of gloved finger), CT scan, and observation is indicated
3 main places where 1.5 L of blood can “hide”
abdomen
pelvis
thigh
when do signs of shock secondary to bleeding generally occur?
what are these signs?
when there is > 25 - 30% of blood loss
shock, low CVP with fast thready pulse, no obvious external source of blood loss, low UO, cold/pale patient who is shivering and diaphoretic
patient with multiple traumas has a normal CXR and no evidence of pelvic or femur fracture suddenly undergoes hypovolemic shock for no reason.
What should you suspect? Next best step in management?
internal bleeding
get a CT (shows presence of blood)
indication of hypovolemic shock - low CVP with fast thready pulse, no obvious external source of blood loss, low UO, cold/pale patient who is shivering and diaphoretic
patient has CT scan that shows the presence of blood around the spleen (or liver) and has low CVP with a fast, thready pulse. How would you determine if this person needs surgery?
fluid bolus/resuscitation
if patient responds -> no surgery
if patient does not respond -> surgery
how do you determine if patients have intra-abdominal bleeding?
FAST - screens for blood in the in the perihepatic space, perisplenic space, pericardium, and pelvis
4 components of FAST
screens for blood in the in the
- perihepatic space (Morrison’s pouch aka hepatorenal recess)
- perisplenic space
- pericardium
- pelvis
if FAST is (+), what happens next?
exploratory laparotomy
patient presents wiht multiple lower rib fractures on the L side is hemodynamically stable
diagnosis? management?
ruptured spleen
splenectomy + post-op immunization against encapsulated bacteria (pneumococcus, H. influenza, meningococcus)
patient undergoes a prolonged abdominal laparotomy after sustaining multiple stab wounds. Intraoperatively, he receives multiple transfusions due to significant blood loss and the surgery lasts 12 hours. Post-op, his surgical sites continue to bleed and his INR is measured to be 2.
What’s going on and what is the next best step in management?
Perioperative coagulopathy
10 U of platelet packs + FFP
what is the abdominal compartment syndrome in the context of surgery?
how do these patients usually present and how are they managed?
occurs when lots of flood and blood was given during the course of prolonged laparatomy, such that by the time of closure, all of the tissues are swollen and the abdominal wound cannot be closed without significant tension
ACS develops usually during POD#2, when the patient develops
- abdominal distension with sutures cutting through the tissues
- hypoxia develops secondary to inability to breathe
- renal failure from pressure on the renal vessels
prevent by placing a temporary mesh to be removed at a later date when closure might be possible
management of a non-expanding pelvic hematoma
nothing
management of a expanding pelvic hematoma
blood replacement
arteriographic embolization of the arterial bleed (does not work for venous bleeds)
how is a pelvic hematoma diagnosed?
when patient with a pelvic fracture has evidence of hypovolemic shock without any evidence of bleeding elsewhere
how do urethral injuries usually present?
blood at meatus (urethral opening of penis)
scrotal hematoma
sensation of wanting to void, but cannot
high-riding prostate on DRE
patient comes in with a suspected urethral injury
what is the next best step in management?
what should be avoided?
retrograde urethrogram
avoid inserting a foley catheter - may compound an existing injury
man presents to the ED complaining of significant penile pain. Physical exam shows large penile shaft hematoma with normal appearing glans
Diagnosis? Management?
Penile fracture - usually occurs to an erect penis during a vigorous intercourse session
emergency surgical repair is indicated, otherwise impotence will ensue as AV shuts develop
management of a penetrating injury to the extremity without evidence of significant bleed
can safely assume that it does not involve major vessel, so tetanus prophylaxis + wound cleaning is indicated
management of a penetrating injury to the extremity wit evidence of significant bleed/expanding hematoma, and decreased pedal pulses
assume that it involves a major vessel, surgical exploration + repair
patient sustains a major fracture to his arm after trying to protect himself from an oncoming baseball bat. You suspect damage to his arteries and nerves in addition to his bone fracture.
How would you manage this?
stabilize bone first, then focus on vascular repair, and then leave the nerve for last
fasciotomy is done afterwards since the prolonged ischemia can result in a compartment syndrome
4 major concerns of crush injuries
Concerns:
- hyperkalemia
- myoglobinemia
- myoglobinuria
- renal failure
Management:
- vigorous fluid administration
- osmotic diuretics
- alkalinization
management of chemical burns
massive irrigation
management of high voltage electrical burns 4
massive debridgements +/- amputation
also concern of myoglobinemia/uria and renal failure with excess muscle injury, so give:
**vigorous fluid administration **
osmotic diuretics (mannitol)
**alkalinzation of the urine **
diagnosis 3 and management 2 of respiratory burns/inhalation injuries
diagnosis: fiberoptic bronchoscopy + ABG + carboxyhemoglobin levels
management: intubation if evidence of airway compromise, 100% oxygen (shortens carboxyhemoglobin half-life)
What is the rule of 9s in adults? How is it different than infants?
used to assess extent of burns; used to estimate fluid needs via
kg * extent of burns * 4 = mL of LR for the first 8 hours
how do you estimate fluid needs in burn patients? 2
- use the rule of 9s (see image), which is used to assess extent of burns; which is then used to estimate fluid needs via kg * extent of burns * 4 = mL of LR for the first 8 hours
- as soon as UO data was available, fluids can be fine-tuned such that an hourly UO of **1-2 cc/kg/hr while avoiding CVP > 15 mmHg **can be targeted
why are fluids usually stopped on the third day for burn patients?
because plasma trapped in the burn edema would be reabsorbed and a large diuresis would ensue
appropriate pre-determined rate of fluid infusion in an adult whose burns exceed >20% of body surface
1 L/h of LR (w.o sugar), then adjust to produce the desired UO (1 - 2 cc/kg/hr while avoiding CVP >15mmHg)
why is LR fluid without glucose indicated for burn patients or patients who require fluid resuscitation?
to avoid an osmotic diuresis secondary to glycosuria, which would cause an increase an hourly UO (remember the targeted UO is 1 - 2 cc/kg/hr, so if this is reached faster with the osmotic diuresis, then one may turn down the IVF, which is bad!)
baby with burns that cover > 20% of his body should receive IVF at an initial rate of…
20 mL/kg/hr and subsequently fine-tuned in response to urinary output
topical agents to use on burn patients and the idications for each one 3
silver sulfadiazine
mafenide acetate (for burns that are deep)
triple antibiotics (for burns near the eyes)
management of provoked dog bites (petting a dog)
no rabies prophylaxis indicated
management of wild animals
rabies prophylaxis (Ig + vaccine)
patient comes in after snake bit him; PE: signficant tenderness around bite site, swelling, discoloration
next step in management? treatment?
draw blood for:
- typing + crossmatch
- coagulation studies
- LFT/Renal function
treatment: anti-venin such as CROFAB
anaphylactic reaction develops after a bee sting. treatment?
epinephrine
removal of stingers without squeezing them
patient comes in after being bit by a black widow spider with N, V, and severe generalized muscle cramps
management?
IV gluconate + muscle relaxants
(venom acts on nerves and cause massive release of ACh, NE, and GABA)
patient presents with this lesion after being bit by a spider
what type of spider bite is this? management?
suspect bite from brown recluse spider because there is a skin ulcer with necrotic center and surrounding halo of erythema
Dapsone (abx) + surgical excision of the skin ulcer +/- skin grafting
dirtiest bite ever
human bites
management of human bites? 2
extensive irrigation + surgical debridement
