Ross Trauma 2 (up to slide 62) Flashcards
What artery are you concerned about in hyperextension of the neck with compression against transverse process?
Vertebral artery
What artery are you concerned about with hyperflexion of the neck with compression between the mandible and spine?
Carotid artery
In what circumstances of blunt and vascular injury to the neck would you consider imaging?
- Hyperextension w/ compression of art. against transverse process
- Hyperflexion w/ compression btw mandible and spine
- direct blows with mid face fx
- intra-oral trauma
- basilar skull fx
A pt presents with dizziness, vertigo, ataxia, nystagmus, dysarthria, and diplopia. What blood vessel is injured?
Vertebral a
A pt presents with bruits, TIA’s, and Horner Syndrome. What blood vessel is injured?
Carotids
What is Horner syndrome?
Disruption of sympathetic flow to eye
- Constricted pupil
- Droopy eyelid
- Eye does not sweat
*miosis, ptosis, anhidrosis
If a pt presents with a blunt injury to the neck, are asympto with no signs (hard or soft) do they need imaging?
No, imaging is low yield - can d/c home
Any penetration into the platysma needs what type of consult?
Trauma Surgeon consult
What are the 3 zones of injury for the neck?
- Clavicles to cricoid
- Cricoid to mandible
- Mandible to base of skull
Work up for penetrating neck trauma
- If platysma is not penetrated - clean and close. If yes, need consult
- Consider zone of injury - if zone 2 may go to OR (moving more toward using Hard and Soft signs)
- If can’t tell how deep - look for Hard and Soft signs
What are vascular Hard Signs in a neck injury?
- hematomas
- bleeding
- pulse deficit
- shock and neuro deficit 2/2 to art. interruption
What are l_aryngeal and tracheal_ Hard Signs in a neck injury?
- voice alteration
- airway compromise
- subQ emphysema
- crepitus
- hemoptysis
What are esophageal Hard Signs in a neck injury?
- pain
- neck tenderness
- subQ emphysema
- dysphagia
- bleeding from NGT or mouth
*MOST common missed injury
What are Soft Signs in neck injury?
- small hematoma
- mild dysphagia
- mild dysphonia
- mild subQ emphysema
- mild tenderness in neck
What are indications for a pt with penetrating neck trauma to go to surgery?
- Unstable
- Hard Signs
- Arterial bleeding
What are indications for a pt with a penetrating neck trauma to get a CT?
- Soft Signs
- Zone 1 and 3 need CT angiography
- Zone 2 Sx vs CT
*Glory CT
In a clothesline or strangulation injury what are PE findings that require further inquiry?
- hoarseness
- dysphagia
- pain below hyoid
What are the 3 Le Fort maxillofacial trauma factures?
- maxillary teeth from face: malocclusion
- become pyramid shaped, involve nose: malocclusion (infraorbital V2, CN5)
- craniofacial dysfunction: airway compromise due to edema
A pt presents with a flattened cheekbone, diplopia, and an upward gaze. What fractures are you concerned about?
- Zygomatic fx
- Orbital floor (maxillary bone) fx
In maxilofacial lacerations what potential injuries should you be aware of?
- Nerve injury: CN 5, 7
- Parotid gland esp Stenson’s duct
What signs would a pt with an orbital blow out fx possibly present with?
- enophthalmos
- diplopia w/ upward gaze
- dec eye mvmt
- MCC bone = maxillary (entrapment of inf. rectus m)
- infraorbital n entrapment (V2, CN 5)
Orbital blow out fracture management
Generally no need for emergent SX but may need repair in 7-10 days, consult maxillofacial services
What are you looking for on PE in chest trauma?
- Bruising (patterns), open wounds, subQ air, JVD, breathing patterns
- Listen to lungs, heart
- Palpate for fx or areas of tenderness
- Get CXR (don’t wait for this to tx unstable pt)
What are the “Lethal Six” of the Deadly Dozen in chest trauma?
- Airway obstruction
- Tension pneumothorax
- Cardiac tamponade
- Open pneumothorax
- Hemothorax
- Flail chest
What are the “Hidden Six” of the Deadly Dozen in chest trauma?
- Thoracic aorta injury
- Tracheal/bronch injuries
- Blunt myocardial injury
- Diaphragmatic tear
- Esophageal injury
- Pulm contusion
What is the treatment for an open pneumothorax or “sucking chest wound”
- 3 sided flap dressing (only allows air to go out)
- Or social dressing
- Repair in OR
Cardiac tamponade Sx, Dx, and Tx?
Sx: Beck’s Triad: JVD, muffled heart sounds, hypotension
Dx: FAST US
Tx: need OR but can do pericardialcentesis in emergent issue
Thoracic aorta Sx, Dx, Tx?
Sx: presents with other significant chest trauma (rib fractures), hypotension with blunt chest force
Dx: wide mediastinum on CXR - order chest CT if stable w/ AND w/o contrast if high suspicion for Dx
Tx: Surgical
Findings on a CXR for a thoracic aorta injury
- mediastinal widening 8cm
- indistinct aortic knob
- left mainstream broncus depression
- apical capping
- obliteration of distance btw pulm art. and aorta
Pulmonary Contusion MOA, Sx, Dx, and complications?
MOA: usually compression-decompression injury (high speed MVA)
Sx: edema, bleeding w/o lung tissue laceration, commonly assoc. w/ other chest trauma (rib fx) but not mandatory
Dx: CT much more sensitive - often initially silent injury, can present few hrs later
Comp: Pneumonia
What is the most common chest injury?
Rib fractures
A 1st rib fracture indicates high force so what should you be suspicious of?
More occult injury
(50% of rib fx are NOT seen on X-ray)
What is flail chest and what is the tx?
Segment of chest cavity moving paradoxically due to rib fx
Tx: need OR
What is the treatment for rib fractures?
- Rib belts…not looking good (PNA formation and higher rate of pneumothorax) but provides comfort for pt
- Internal fixation: to OR when significantly displaced and/or hemothorax
What is the work up for an elderly pt with a rib fx?
- Depends on their situation
- Admit elderly with more than 2 rib fx
- Must be able to control pain
- low threshold for admit
What are the indications for a thoracotomy in penetrating thoracic trauma?
Loss of vitals w/i 2-3 min of arrival with active CPR and penetrating trauma
What are some special circumstances to consider when it comes to trauma?
- Elderly: VERY low threshold for admit
- Intoxicated: must wait until they are sober
- Peds: cannot communicate so low threshold to admit
What are some problems to consider with abdominal trauma?
- Ruptured hollow viscus and bleeding from a solid organ are not easily recognized
- Sig. blood loss in abd cavity w/o drastic change in external appearance of abdomen
- large area from below nipple line to symphysis pubis
What solid organs are most commonly injured in blunt abdominal trauma?
Spleen MC and liver
Blunt abdominal trauma (from MVA, fall, handle bar, blasts) needs to be evaluated for what intervention?
surgical intervention
When performing a PE for a blunt abdominal trauma pt what do you not want to forget to look at?
- the back
- scrotum/labia (swelling or laceration concern for pelvic fx)
- anus
- urethral meatus (blood = clue for renal injury or bladder injury)
Blunt trauma Red Flags that have a high likelihood of abd injury
- Seat belt and handle bar sign
- Lumbar fx: chance fx
- Presence of free fluid with no known solid organ injury is a hollow viscus injury
The PE gives clues to the severity of what types of injuries?
- Handle bar injury
- Seat belt injury
- Lower rib fx
Blunt abdominal trauma work up
- FAST US
- Abd CT w and w/o contrast
- Labs: CBC, BMP w amylase, lactate
- Admit - re-eval
*Do not delay taking pt to OR or for transfer in order to obtain CT
What are indications for emergent laparotomy?
- diffuse peritonitis
- penetrating gunshot w/ peritoneal violation
- penetrating stab wound w/ evisceration
- abd tenderness w/ hypotension (blunt trauma)
In blunt abdominal trauma if tenderness is found on repeat abd exam what can this imply?
Deeper injury (Kehr’s sign, US helpful in FAST exam)
