SR 38 - Trauma Flashcards by Ryan Bird

First five steps of the primary survey?

Airway and C-spine stabilization
Breathing
Circulation
Disability
Exposure and environment

How well did you know this?

Not at all

Perfectly

What are the steps of a cricothyroidotomy?

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

How well did you know this?

Not at all

Perfectly

What are the parts of a good breathing assessment?

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

How well did you know this?

Not at all

Perfectly

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

Tension pneumothorax
Open pneumothorax
Massive hemothorax

How well did you know this?

Not at all

Perfectly

Treatment of a tension pneumothorax?

Needle thoracostomy - 2nd ICS MCL

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

How well did you know this?

Not at all

Perfectly

What does a pneumothorax look like on a CXR?

Loss of lung markings

Straight lines

How well did you know this?

Not at all

Perfectly

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

Underlying pulmonary contusion

How well did you know this?

Not at all

Perfectly

What is the treatment for a flail chest?

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

How well did you know this?

Not at all

Perfectly

Define Beck’s Triad

Hypotension
Muffled heart sounds
JVD

How well did you know this?

Not at all

Perfectly

Define Kussmaul’s sign

JVD with inspiration

How well did you know this?

Not at all

Perfectly

How do you diagnose cardiac tamponade?

Ultrasound - echocardiogram

How well did you know this?

Not at all

Perfectly

What is the treatment of cardiac tamponade?

Pericardial window

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

How well did you know this?

Not at all

Perfectly

What is the treatment of a massive hemothorax?

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

How well did you know this?

Not at all

Perfectly

What is the initial assessment for adequate circulation?

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

How well did you know this?

Not at all

Perfectly

What are the parts of a good circulation assessment?

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

How well did you know this?

Not at all

Perfectly

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

Spinal cord injury
On B-blockers
Well-conditioned atheletes

How well did you know this?

Not at all

Perfectly

What is the trauma resuscitation fluid of choice?

Lactated Ringer’s solution

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

How well did you know this?

Not at all

Perfectly

What decompressions do trauma patient receive?

Gastric decompression - NGT

Bladder decompression - foley AFTER normal rectal exam

How well did you know this?

Not at all

Perfectly

Contraindications to placement of a foley?

Signs of urethral injury:

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

Use an OGT

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

How well did you know this?

Not at all

Perfectly

What are the parts of a good disability assessment?

Neurological assessment

Mental status - GCS
Pupils
Motor/sensory

How well did you know this?

Not at all

Perfectly

What are the three parts of the GCS?

Eye opening (4)
Motor response (6)
Verbal response (5)

How well did you know this?

Not at all

Perfectly

What are the stages in GCS - eye opening?

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

How well did you know this?

Not at all

Perfectly

What are the stages in GCS - motor response?

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

What are the stages in GCS - verbal response?

``` 5 - appropriate and oriented 4 - confused 3 - inappropriate words 2 - incomprehensible sounds 1- no sounds ```

Define decorticate posture

Abnormal flexion

Define decerebrate posture

Abnormal extension

Why do you inspect the ears in trauma?

Hemotympanum and otorrhea is a sign of basilar skull fracture

What are typical signs of basilar skull fracture?

Raccoon eyes Battle's signs Clear otorrhea or rhinorrhea Hemotympanum

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

Traumatic hyphema | Blood in the anterior chamber of the eye

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

Nasal septal hematoma | If not evacuated, it can cause pressure necrosis in the septum

What is the best indication of a mandibular fracture?

Dental malocclusion | Tell the patient to 'bite down' and ask if it feels normal

Signs of thoracic trauma are found on the neck exam?

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

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

CT angiogram

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

Injury to the abdomen | Diaphragm extends to the level of the nipples on expiration

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

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

What is the seatbelt sign?

Ecchymosis on lower abdomen from wearing a seatbelt | 10% will have small bowel perforation

What must be documented from the rectal exam?

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

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

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

CXR findings suggestive of thoracic aortic injury?

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

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

Distal to the take-off of the left subclavian artery

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

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

What does the FAST exam look for?

Blood int eh peritoneal cavity | You look at Morison's pouch, bladder, spleen and pericardial sac

Indication for CT scan in blunt abdominal trauma?

Stable with abdominal pain/tenderness/mechanism

Indication for DPL or FAST in blunt abdominal trauma?

Unstable

Indicators of a positive peritoneal lavage in blunt trauma?

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

What must be placed before a DPL is performed?

NGT and foley catheter

What injuries does CT scan miss?

Small bowel | Diaphragm

What injuries does DPL miss?

Retroperitoneal

What are the most emergent orthopedic injuries?

``` Hip dislocation (needs immediate reduction) Exsanguinating pelvic fracture (binder or external fixator) ```

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

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

Approach to GSW to the belly?

Exploratory laparotomy

Evaluation of stab wound to the belly?

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

What depth of neck injury must be further evaluated?

Penetrating injury through the platysma

Anatomy of the neck by trauma zones - zone III

Angele of the mandible and up

Anatomy of the neck by trauma zones - zone II

Angle of the mandible to the cricoid cartilage

Anatomy of the neck by trauma zones - zone I

Below the cricoid cartilage

How do you treat penetrating neck injuries to zone III?

Selective exploration

How do you treat penetrating neck injuries to zone II?

Dependent on status - surgical exploration vs. selective exploration

How do you treat penetrating neck injuries to zone I?

Selective exploration

What is selective exploration?

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

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

Hard signs of significant neck damage - Shock - Exsanguinating hemorrhage - Expanding hematoma - Pulsatile hematoma - Neurologic injury - SubQ emphysema

What is the Le Forte fracture arrangement?

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

What is the '3-for-1' rule?

For every 1 L blood loss - 3 L crystalloids

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

1.5 L

What population is a surgical cricothyroidotomy not recommended?

Patient younger than 12yo | Perform a needle cricothyroidotomy

What are the signs of a laryngeal fracture?

SubQ emphysema in the neck Altered voice Palpable laryngeal fracture

What is the treatment of a rectal penetrating injury?

Diverting proximal colostomy Closure of the perforation Presacral drainage

What is the treatment of extraperitoneal minor bladder rupture?

Bladder catheter and observation | Intraperitoneal or large bladder rupture requires operative closure

What intra-aobdominal injuries are associated with seatbelt use?

Small bowel injury L2 fracture Pancreatic injury

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

Venous ~85%

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

No - it may not grow back (20%)

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

Trauma whipple

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

Small bowel

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

Type and cross for blood transfusion

What is the treatment of penetrating injury to the colon?

In shock - resection and colostomy | Stable - primary anastomosis/repair

What is the treatment of small bowel injury?

Primary closure or resection and primary anastomosis

What is the treatment of minor pancreatic injury?

Drainage

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

Liver

What is the treatment for significant duodenal injury?

Pyloric exclusion - Close duodenal injury - Staple off pylorus - Gastrojejunostomy

What is the treatment for massive tail of pancreas injury?

Distal pancreatectom with splenectomy

What is 'damage control' surgery?

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

What is the lethal triad?

Acidosis Coagulopathy Hypothermia

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

Ruptured diaphragm with stomach in the pleural cavity | Take patient to OR - ex-lap

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

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

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

No - perform DPL (above the umbilicus)

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

LFT (increased AST or ALT)

What is the only indication for MAST trousers?

Prehospitalization | Pelvic fracture

What is the treatment for human and dog bites?

Leave wound open Irrigation Antibiotics

What is sympathetic ophthalmia?

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

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

Diffuse axonal injury | Carotid artery injury