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Surgical Recall > SR 38 - Trauma > Flashcards

SR 38 - Trauma Flashcards

1
Q

First five steps of the primary survey?

A 
Airway and C-spine stabilization
Breathing
Circulation
Disability
Exposure and environment
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2
Q

What are the steps of a cricothyroidotomy?

A

Incise the cricothyroid membrane between the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an ET or tracheostomy tube into the trachea

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3
Q

What are the parts of a good breathing assessment?

A

Inspection - air movement, respiratory rate, cyanosis, tracheal shift, JVD, asymmetric chest expansion, accessory muscle use, open chest wounds
Auscultation - breath sounds
Percussion - hyperresonance or dullness
Palpation - subcutaneous emphysema, flail chest

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4
Q

Life-threatening conditions that need to be identified and treated during the breathing stage?

A

Tension pneumothorax
Open pneumothorax
Massive hemothorax

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5
Q

Treatment of a tension pneumothorax?

A

Needle thoracostomy - 2nd ICS MCL

Followed by, tube thoracostomy in anterior/midaxillary line in 4th ICS

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6
Q

What does a pneumothorax look like on a CXR?

A

Loss of lung markings

Straight lines

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7
Q

What is the major cause of respiratory compromise with flail chest?

A

Underlying pulmonary contusion

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8
Q

What is the treatment for a flail chest?

A

Intubation with positive pressure ventilation
PEEP PRN
(Allows the ribs to heal)

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9
Q

Define Beck’s Triad

A

Hypotension
Muffled heart sounds
JVD

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10
Q

Define Kussmaul’s sign

A

JVD with inspiration

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11
Q

How do you diagnose cardiac tamponade?

A

Ultrasound - echocardiogram

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12
Q

What is the treatment of cardiac tamponade?

A

Pericardial window

If blood returns, complete median sternotomy to R/O cardiac injury

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13
Q

What is the treatment of a massive hemothorax?

A

Volume replacement
Tube thoracostomy
Removal of blood (allows apposition of parietal and virsceral pleura - seals the defect)

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14
Q

What is the initial assessment for adequate circulation?

A

Palpation of pulses
Radial - 80mmHg
Femoral/carotid - 60mmHg

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15
Q

What are the parts of a good circulation assessment?

A 
Heart rate
Blood pressure
Peripheral perfusion
Urinary output
Mental status
Capillary refill (normal
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16
Q

Who won’t mount a tachycardic response to hypovolemic shock?

A

Spinal cord injury
On B-blockers
Well-conditioned atheletes

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17
Q

What is the trauma resuscitation fluid of choice?

A

Lactated Ringer’s solution

Isotonic and the lactate helps buffer the hypovolemia-induced metabolic acidosis

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18
Q

What decompressions do trauma patient receive?

A

Gastric decompression - NGT

Bladder decompression - foley AFTER normal rectal exam

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19
Q

Contraindications to placement of a foley?

A

Signs of urethral injury:

  • Severe pelvic fracture in men
  • Blood at the urethral meatus
  • ‘High-riding’ ‘ballotable’ prostate
  • Scrotal/perineal injury/ecchymosis
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20
Q

What test do you do if urethral injury is suspected prior to placement of a foley catheter?

A 
Retrograde UrethroGram (RUG)
Dye in penis retrograde to the bladder and E-ray to look for extravasation of dye
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21
Q

How do you get gastric decompression when a patient has maxillofacial fracture?

A

Use an OGT

Because an NGT may perforate through the cribiform plate into the brain

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22
Q

What are the parts of a good disability assessment?

A

Neurological assessment

  • Mental status - GCS
  • Pupils
  • Motor/sensory
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23
Q

What are the three parts of the GCS?

A 
Eye opening (4)
Motor response (6)
Verbal response (5)
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24
Q

What are the stages in GCS - eye opening?

A

4 - opens spontaneously
3 - opens to voice command
2 - opens to painful stimuli
1 - does not open eyes

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25
Q

What are the stages in GCS - motor response?

A 
6 - obeys commands
5 - localizes to painful stimulus
4 - withdraws from pain
3 - decorticate posture
2 - decerebrate posture
1 - no movement
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26
Q

What are the stages in GCS - verbal response?

A 
5 - appropriate and oriented
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1- no sounds
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27
Q

Define decorticate posture

A

Abnormal flexion

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28
Q

Define decerebrate posture

A

Abnormal extension

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29
Q

Why do you inspect the ears in trauma?

A

Hemotympanum and otorrhea is a sign of basilar skull fracture

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30
Q

What are typical signs of basilar skull fracture?

A

Raccoon eyes
Battle’s signs
Clear otorrhea or rhinorrhea
Hemotympanum

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31
Q

What diagnosis in the anterior chamber must not be missed on the eye exam?

A

Traumatic hyphema

Blood in the anterior chamber of the eye

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32
Q

What potential destructive lesion must not be missed on the nasal exam?

A

Nasal septal hematoma

If not evacuated, it can cause pressure necrosis in the septum

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33
Q

What is the best indication of a mandibular fracture?

A

Dental malocclusion

Tell the patient to ‘bite down’ and ask if it feels normal

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34
Q

Signs of thoracic trauma are found on the neck exam?

A

Crepitus or subcutaneous emphysema from tracheobronchial disruption/PTX
Tracheal deviation - tension PTX
JVD - cardiac tamponade
Carotid bruit - carotid artery injury

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35
Q

What is the best way to diagnose or rule-out aortic injury?

A

CT angiogram

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36
Q

What must be considered in every penetrating injury of the thorax at or below the nipple?

A

Injury to the abdomen

Diaphragm extends to the level of the nipples on expiration

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37
Q

What conditions must exist to pronounce an abdominal physical exam negative?

A

Alert patient without evidence of head/spinal cord injury or intoxication

38
Q

What is the seatbelt sign?

A

Ecchymosis on lower abdomen from wearing a seatbelt

10% will have small bowel perforation

39
Q

What must be documented from the rectal exam?

A 
Sphincter tone (indication of spinal cord function)
Presence of blood (colon or rectal injury)
Prostate position (urethral injury)
40
Q

What patients can have their C-spine cleared during physical exam?

A 
No neck pain on palpation
Full range of motion
No neurological injury - GCS 15
No intoxication
No distracting injury
No pain meds
41
Q

CXR findings suggestive of thoracic aortic injury?

A 
Widened mediastinum
Apical pleural capping
Loss of aortic contour
Depression of left main stem bronchus
NGT/tracheal deviation
Clinical suspicion
High-speed mechanism
42
Q

What is the most common site of thoracic aortic traumatic tear?

A

Distal to the take-off of the left subclavian artery

43
Q

What studies do you use to evaluate intra-abdominal injury?

A

FAST (focused assessment with sonography for trauma)
CT scan
DPL (Diagnostic Peritoneal Lavage)

44
Q

What does the FAST exam look for?

A

Blood int eh peritoneal cavity

You look at Morison’s pouch, bladder, spleen and pericardial sac

45
Q

Indication for CT scan in blunt abdominal trauma?

A

Stable with abdominal pain/tenderness/mechanism

46
Q

Indication for DPL or FAST in blunt abdominal trauma?

A

Unstable

47
Q

Indicators of a positive peritoneal lavage in blunt trauma?

A

Classic:

  • Inability to read newsprint through the lavage fluid
  • RBC >100,000
  • WBC >500mm3
  • Lavage fluid drained from chest tub, foley, NGT

Less common:

  • Bile present
  • Bacteria present
  • Feces present
  • Food matter present
  • Elevated amylase level
48
Q

What must be placed before a DPL is performed?

A

NGT and foley catheter

49
Q

What injuries does CT scan miss?

A

Small bowel

Diaphragm

50
Q

What injuries does DPL miss?

A

Retroperitoneal

51
Q

What are the most emergent orthopedic injuries?

A 
Hip dislocation (needs immediate reduction)
Exsanguinating pelvic fracture (binder or external fixator)
52
Q

What findings would require a celiotomy in a blunt trauma victim?

A

Peritoneal signs
Free air on CXR/CT scan
Unstable patient with positive FAST or DPL

53
Q

Approach to GSW to the belly?

A

Exploratory laparotomy

54
Q

Evaluation of stab wound to the belly?

A

Exploratory laparotomy - peritoneal signs, heavy bleeding, shock
Otherwise, observe, or local wound exploration to rule out fascial penetration or DPL

55
Q

What depth of neck injury must be further evaluated?

A

Penetrating injury through the platysma

56
Q

Anatomy of the neck by trauma zones - zone III

A

Angele of the mandible and up

57
Q

Anatomy of the neck by trauma zones - zone II

A

Angle of the mandible to the cricoid cartilage

58
Q

Anatomy of the neck by trauma zones - zone I

A

Below the cricoid cartilage

59
Q

How do you treat penetrating neck injuries to zone III?

A

Selective exploration

60
Q

How do you treat penetrating neck injuries to zone II?

A

Dependent on status - surgical exploration vs. selective exploration

61
Q

How do you treat penetrating neck injuries to zone I?

A

Selective exploration

62
Q

What is selective exploration?

A

Based on diagnostic studies - A-gram or CT a-gram, bronchoscopy, esophagoscopy

63
Q

What are the indications for surgical exploration in all penetrating neck wounds?

A

Hard signs of significant neck damage

  • Shock
  • Exsanguinating hemorrhage
  • Expanding hematoma
  • Pulsatile hematoma
  • Neurologic injury
  • SubQ emphysema
64
Q

What is the Le Forte fracture arrangement?

A

III - orbital fracture
II - mandible/nasal
I - mandible/oral

65
Q

What is the ‘3-for-1’ rule?

A

For every 1 L blood loss - 3 L crystalloids

66
Q

How much blood can be lost into the thigh with a closed femur fracture?

A

1.5 L

67
Q

What population is a surgical cricothyroidotomy not recommended?

A

Patient younger than 12yo

Perform a needle cricothyroidotomy

68
Q

What are the signs of a laryngeal fracture?

A

SubQ emphysema in the neck
Altered voice
Palpable laryngeal fracture

69
Q

What is the treatment of a rectal penetrating injury?

A

Diverting proximal colostomy
Closure of the perforation
Presacral drainage

70
Q

What is the treatment of extraperitoneal minor bladder rupture?

A

Bladder catheter and observation

Intraperitoneal or large bladder rupture requires operative closure

71
Q

What intra-aobdominal injuries are associated with seatbelt use?

A

Small bowel injury
L2 fracture
Pancreatic injury

72
Q

Bleeding from a pelvic fracture is caused by arterial or venous bleeding?

A

Venous ~85%

73
Q

If patient has a laceration through their eyebrow - do you shave the eyebrow before suturing?

A

No - it may not grow back (20%)

74
Q

What is the treatment for extensive irreparable biliary, duodenal, and pancreatic head injury?

A

Trauma whipple

75
Q

What is the most common intra-abdominal organ injured with penetrating trauma?

A

Small bowel

76
Q

If you can only run one blood test for a trauma patient, what would you do?

A

Type and cross for blood transfusion

77
Q

What is the treatment of penetrating injury to the colon?

A

In shock - resection and colostomy

Stable - primary anastomosis/repair

78
Q

What is the treatment of small bowel injury?

A

Primary closure or resection and primary anastomosis

79
Q

What is the treatment of minor pancreatic injury?

A

Drainage

80
Q

What is the most commonly injured abdominal organ with blunt trauma?

A

Liver

81
Q

What is the treatment for significant duodenal injury?

A

Pyloric exclusion

  • Close duodenal injury
  • Staple off pylorus
  • Gastrojejunostomy
82
Q

What is the treatment for massive tail of pancreas injury?

A

Distal pancreatectom with splenectomy

83
Q

What is ‘damage control’ surgery?

A

Stop major hemorrhage and GI soilage
Pack and get out of the OR ASAP - bring patient to the ICU to warm, correct coags and resuscitate
Return patient to OR when stable, warm and not acidotic

84
Q

What is the lethal triad?

A

Acidosis
Coagulopathy
Hypothermia

85
Q

What is the diagnosis if you see a NGT in the chest on a CXR?

A

Ruptured diaphragm with stomach in the pleural cavity

Take patient to OR - ex-lap

86
Q

What finding on ABD/pelvic CT requires ex-lap in a blunt trauma patient with normal vital signs?

A

Free air

No solid organ injury with lots of free fluid - to rule out hollow viscus injury

87
Q

Can you rely on a negative FAST in the unstable patient with a pelvic fracture?

A

No - perform DPL (above the umbilicus)

88
Q

What lab tests are used to look for intra-abdominal injury in children?

A

LFT (increased AST or ALT)

89
Q

What is the only indication for MAST trousers?

A

Prehospitalization

Pelvic fracture

90
Q

What is the treatment for human and dog bites?

A

Leave wound open
Irrigation
Antibiotics

91
Q

What is sympathetic ophthalmia?

A

Blindness in one eye that results in subsequent blindness in the contralateral eye (autoimmune)

92
Q

What can present after blunt trauma with neurological deficits and a normal brain CT scan?

A

Diffuse axonal injury

Carotid artery injury

Surgical Recall (32 decks)

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