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Y2 > Surgery: Trauma > Flashcards

Surgery: Trauma Flashcards

1
Q

What are the 3 main elements of the ATLS protocol?

A

(advanced trauma life support - ATLS)

  1. primary survey
  2. secondary survey
  3. definitive care
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2
Q

List the 5 steps of the primary survey

A
  1. Airway (and C spine stabilization)
  2. Breathing
  3. Circulation
  4. Disability
  5. Exposure and Environment
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3
Q

what comprises spinal immobilization

A

use a full backboard and rigid cervical collar

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4
Q

what is the quickest test for an adequate airway

A

ask a question, if the patient can speak, the airway is intact

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5
Q

If chin lift or jaw thrust are unsuccessful, what is the next maneuver used to establish an airway

A

endotracheal intubation

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6
Q

If all other methods of establishing an airway are unsuccessful, what is the definitive airway?

A

cricothyroidotomy

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7
Q

While trying to establish the airway, what 2 things must always be kept in mind?

A 
spinal immobilization
adequate oxygenation (ventilate with 100% oxygen using a bag and mask before attempting to establish airway)
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8
Q

When assessing breathing, what do you look for while inspecting?

A 
air movement
respiratory rate
cyanosis
tracheal shift
JVD
asymmetric chest expansion
use of accessory muscles
open chest wounds
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9
Q

What is heard on percussion of pneumothorax

A

hyper resonance

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10
Q

what is another term for tube thoracostomy

A

chest tube

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11
Q

diagnosis and treatment of open pneumothorax

A

dx: usually obvious with air movement through a chest wall defect and pneumothorax on CXR
tx: tube thoracostomy (chest tube), occlusive dressing over wall defect or “three sided dressing”

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12
Q

for a cricothyroidotomy, where is the incision made?

A

cricothyroid membrane: between the cricoid cartilage inferiorly and the thyroid cartilage superiorly
(then tube is placed into the trachea)

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13
Q

how is flail chest diagnosed

A

(fracture of 3 or more consecutive ribs)

flail segment of chest wall moves paradoxically

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14
Q

what is the major cause of respiratory compromise with flail chest

A

pulmonary contusion (bruised lung)

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15
Q

Tx of flail chest

A

intubation with positive pressure ventilation and positive end expiratory pressure as needed

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16
Q

what is cardiac tompanade

A

bleeding into the pericardial sac, resulting in constriction of the heart, decreasing inflow, and resulting in decreased cardiac output
(bc the pericardium does not stretch)

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17
Q

what are the signs and symptoms of cardiac tamponade

A

tachycardia/shock
Beck’s triad (hypotension, muffled heart sounds, JVD)
pulsus paradoxus (exaggerated fall in BP during inspiration, more than 10 mmHg)
Kussmaul’s sign (JVD with inspiration)

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18
Q

dx and tx of cardiac tompanade

A

dx: ultrasound
tx: pericardial window

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19
Q

dx massive hemothorax

A 
unilateral decreased or absent breath sounds
dullness to percussion
CXR
CT
chest tube output
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20
Q

tx of massive hemothorax

A

volume replacement
tube thoracostomy (chest tube)
removal of blood

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21
Q

when is emergent thoracotomy for hemothorax indicated

A

> 1,500 cc of blood on initial placement of chest tube
or
persistent >200 cc of bleeding via chest tube per hour for 4 hours
(thoracotomy = cutting between the ribs to gain access to thoracic cavity)

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22
Q

what are the goals while assessing circulation?

A

secure adequate tissue perfusion

treat external bleeding

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23
Q

what is initial test for adequate circulation

A

palpation of pulses: if radial pulse is palpable then systolic pressure is at least 80 mmHg, if femoral or carotid pulse is palpable then systolic pressure is at least 60 mmHg

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24
Q

what comprises adequate assessment of circulation

A 
heart rate
blood pressure
peripheral perfusion
urinary output
mental status
capillary refill ( N > 2 sec)
skin (cold and clammy = hypovolemia)
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25
Q

Who can be hypovolemic with normal blood pressure

A

young patients (autonomic tone maintains pressure until cardiovascular collapse is imminent)

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26
Q

Which patients may not mount a tachycardic response to hypovolemic shock

A

spinal chord injury
taking beta blockers
well-conditioned athletes

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27
Q

how are sites of external bleeding treated

A

direct pressure with or without tourniquets

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28
Q

what is the best and preferred intravenous access in the trauma patient

A

two large bore IVs (14-16 gauge), IV catheters in upper extremities (peripheral IV access)

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29
Q

what is the anatomy of the groin which helps when placing a femoral catheter

A 
lateral to medial "NAVEL"
nerve
artery
vein
empty space 
lymphatics
therefore, vein is medial to the femoral pulse
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30
Q

what is the trauma resuscitation fluid of choice in a hypotension trauma patient

A

blood and blood products

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31
Q

what is the trauma resuscitation fluid of choice in a non hypotensive trauma patient

A

lactated ringers

most use normal saline for TBI patient

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32
Q

what types of decompression do trauma patients recieve

A

gastric decompression with NG tube and foley catheter bladder decompression after normal rectal exam and no indication of urethral injury

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33
Q

what are the contraindications of placement of a foley catheter

A 
signs of urethral injury: 
severe pelvic injury in men
blood at urethral meatus
"high riding" ballotable" prostate (loss of urethral tethering"
scrotal/perineal injury/ecchymosis
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34
Q

what test should be done prior to placing a Foley catheter if urethral injury is suspected

A 
retrograde urethrogram (RUG)
(dye in penis retrograde to bladder and Xray looking for extravasation
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35
Q

how is gastric decompression achieved with a maxillofacial fracture?

A

(NOT with NG tube bc tube may perforate through cribriform plate into brain)
place oral gastric tube

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36
Q

What comprises adequate assessment of disability?

A

mental status: Glasgow Coma Scale
pupils
motor/sensory screening exam for lateralizing extremity movement, sensory deficits

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37
Q

what does a blown pupil suggest

A

ipsilateral brain mass (blood) as herniation of the brain compresses CN III

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38
Q

Describe the Glasgow coma scale

A 
eyes opening: "four eyes"
4-spontaneous
3- opens to voice
2- opens to pressure stimulus
1- does not open eyes
Motor response: "6 cylinder motor"
6- obeys commands
5- localizes painful stimulus
4- withdraws from pressure
3- decorticate posture
2- decerebrate posture
1- no movement
Verbal response: "Jackson 5"
5- appropriate and oriented
4- confused
3- inappropriate words
2- incomprehensible sounds
1- no sounds
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39
Q

what is a normal GCS score?

A

GCS 15

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40
Q

what is the GCS score of someone who is dead?

A

GCS 3

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41
Q

what is the GCS score for a patient in a coma?

A

GCS < or = 8

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42
Q

GCS score indication for intubation?

A

GCS < or = 8

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43
Q

How does scoring of GCS differ for patients that are intubated

A

verbal evaluation is omitted and replaced with a T, thus the highest score for an intubated patient is 10 T

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44
Q

what are the goals in obtaining adequate exposure

A

complete disrobing to allow a thorough visual inspection and digital palpation of the patient during the secondary survey

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45
Q

what is the “environment” of the ABCDEs

A

keep a warm environment (keep the patient warm; a hypothermic patient can become coagulopathic)

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46
Q

What principle is followed in completing the secondary survey?

A

complete physical exam, including all orifices: ears, nose, mouth, vagina, and rectum

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47
Q

Why look in the ears?

A

hemotympanum and otorrhea is a sign of basilar skull fracture

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48
Q

What are typical signs of basilar skull fracture

A

racoon eyes
Battle’s sign (bruising over the mastoid process)
clear otorrhea or rhinorrhea
hemotympanum

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49
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, often a result of penetrating or blunt force trauma to the eye and can result in permanent vision loss)

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50
Q

what potentially destructive lesion must not be missed on the nasal exam?

A

nasal septal hematoma: hematoma must be evacuated, if not, it can result in pressure necrosis of the septum

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51
Q

what is the best indication of mandibular fracture

A

dental malocclusion: tell the patient to “bite down” and ask “ does that feel normal to you?”
(malocclusion = crooked teeth or poor bite)

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52
Q

what signs of thoracic trauma are often found on the neck exam

A

crepitus or subcutaneous emphysema from tracheobronchial disruption/PTX
tracheal deviation from tension pneumothorax
JVD from cardiac tamponade
carotid bruit heard with seatbelt neck injury result in in carotid artery injury

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53
Q

what is the best physical exam for broken ribs or sternum

A

lateral and anterior-posterior compression of the thorax to elicit pain/instability

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54
Q

what is the best way to diagnose or rule out aortic injury

A

CT angiogram

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55
Q

what must be considered in every penetrating injury of the thorax at or below the level of the nipple

A

concomitant injury to the abdomen

the diaphragm extends to the level of the nipples in the male on full expiration

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56
Q

what is the significance of subcutaneous air

A

indicates pneumothorax until proven otherwise

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57
Q

what is the physical exam technique for examining the thoracic and lumbar spine

A

logrolling the patient to allow complete visualization of the back and palpation of the spine to elicit pain over fractures, step off (spine deformity)

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58
Q

what conditions must exist to pronounce an abdominal physical exam negative

A

alert patient without any evidence of head/spinal cord injury or drug/EtOH intoxication
(even then the abdominal exam is not 100% accurate)

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59
Q

what physical signs may indicate intra-abdominal injury

A 
tenderness
guarding
peritoneal signs
progressive distension (always use a gastric tube for decompression of air)
seatbelt sign
60
Q

what is the seatbelt sign

A

ecchymosis on lower abdomen from wearing a seatbelt

about 10% of patients with this sign have a small bowel perforation

61
Q

what must be documented from the rectal exam

A 
sphincter tone (as an indication of spinal cord function)
presence of blood (as an indication of colon or rectal injury)
prostate position (as an indication of urethral injury)
62
Q

what is the best physical exam technique to test for pelvic fractures

A

lateral compression of the iliac crests and greater trochanters and anterior-posterior compression of the symphysis pubis to elicit pain/instability

63
Q

what is the halo sign?

A

cerebrospinal fluid from the nose/ear will form a clear halo around the blood on a cloth

64
Q

what physical signs indicate possible urethral injury, thus contraindicating placement of a Foley catheter

A

high-riding, ballotable prostate on rectal exam
presence of blood at the meatus
scrotal or perineal ecchymosis

65
Q

what must be documented from the extremity exam

A 
any fractures or joint injuries
any open wounds
motor and sensory exam, particularly distal to any fractures
distal pulses
peripheral perfusion
66
Q

what complication after prolonged ischemia to the lower extremity must be treated immediately?

A

compartment syndrome (pressure build up due to blood collection or swelling)

67
Q

what is the treatment for compartment syndrome

A

fasciotomy (cutting the fascia)

68
Q

what injuries must be suspected in a trauma patient with a progressive decline in mental status

A

epidural hematoma
subdural hematoma
brain swelling with rising intracranial pressure
hypoxia/hypotension must be ruled out

69
Q

what are the classic blunt trauma ER xrays

A

AP chest films

AP pelvis film

70
Q

what are common trauma labs

A

blood for complete blood count, chemistries, amylase, liver function test, lactic acid, coagulation studies, and type and crossmatch
urine for urinalysis

71
Q

how can a C spine be evaluated

A

clinically by physical exam

radiographically

72
Q

what patients can have their C-spine cleared by a physical exam

A

no neck pain on palpation with full range of motion with no neurological injury (GCS 15)
no EtOH/drugs
no distracting injury
no pain meds

73
Q

How do you rule out a C-spine bony fracture

A

CT scan of the C spine

74
Q

what do you do if no bony C-spine fracture is apparent on CT scan and you cannot obtain an MRI in a comatose patient

A

this is controversial, but most centers remove the C-collar

75
Q

which xrays are used for evaluation of the cervical spine ligamentous injury

A

MRI (lateral flexion and extension C spine films also used but infrequently)

76
Q

what study is used to rule out thoracic aortic injury

A

CT scan of mediastinum looking for mediastinal hematoma with CTA

77
Q

what is the most common site of thoracic aortic traumatic tear

A

just distal to the take-off of the left subclavian artery

78
Q

what studies are available to evaluate for intra-abdominal injury

A

focused assessment with sonography in trauma
CT scan
DPL (diagnostic peritoneal lavage)

79
Q

what is a FAST exam and what does it look for

A

focused assessment with sonography for trauma

blood in the peritoneal cavity looking at Morison’s pouch, bladder, spleen, and pericardial sac

80
Q

what does DPL stand for

A

diagnostic peritoneal lavage

81
Q

what diagnostic test is the test of choice for evaluation of the unstable patient with blunt abdominal trauma?

A

FAST

82
Q

what is the indication for abdominal CT in blunt trauma?

A

normal vital signs with abdominal pain/tenderness/mechanism

83
Q

what is the indication for FAST in blunt trauma

A

unstable vital signs (hypotension)

84
Q

what injuries does CT scan miss

A

small bowel injuries and diaphragm injuries

85
Q

what study is used to evaluate the urethra in cases of possible disruption due to blunt trauma

A

retrograde urethrogram (RUG)

86
Q

what are the most emergent orthopedic injuries?

A
  1. hip dislocation (must be reduced immediately)

2. exsanguinating pelvic fracture (binder or external fixator)

87
Q

what is the treatment of a gunshot wound to the belly

A

exploratory laprotomy

88
Q

what is the evaluation of the stab wound in the belly

A

if there are peritoneal signs, heavy bleeding, shock, perform exploratory laparotomy
otherwise, many surgeons perform a CT scan and/or laparoscopy

89
Q

what depth of neck injury must be further evaluated

A

penetrating injury through the platysma

90
Q

define the anatomy of the neck by trauma zones

A

zone III: angle of the mandible and up
zone II: angle of the mandible to the cricoid cartilage
zone I: below the cricoid catilage

91
Q

how do most surgeons treat penetrating neck injuries by neck zone?

A

zone I and III: selective exploration

Zone II: surgical exploration

92
Q

what is selective exploration?

A

selective exploration is based on diagnostic studies that include A-gram or CT A-gram, bronchoscopy, esophagoscopy

93
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 (air trapped)

94
Q

what is the minimal urine output for an adult trauma patient

A

50 mL/hr

95
Q

what is the brief ATLS history?

A 
"AMPLE"
allergies
medications
PMH
last meal (when)
events (injury, etc.)
96
Q

in what population is a surgical cricothyroidotomy not recommended?

A

any patient under 12 yrs old, perform needle cricothyroidotomy instead

97
Q

what is the treatment of rectal penetrating injury

A

diverting proximal colostomy
closure of perforation (if easy, and definitely if intraperitoneal)
presacral drainage

98
Q

what is the treatment of extraperitoneal minor bladder rupture

A 
bladder catheter (foley) drainage and observation
intraperitoneal or larger bladder rupture requires operative closure
99
Q

what intra-abdominal injury is associated with seatbelt use

A

small bowel injuries (L2 fracture, pancreatic injury)

100
Q

what is the treatment of a pelvic fracture

A

+ or - pelvic binder until the external fixator is placed
IVF/blood
+ or - A gram to embolize bleeding pelvic vessels

101
Q

bleeding from pelvic fractures is most commonly caused by arterial or venous bleeding?

A

venous (85%)

102
Q

if a patient has a laceration through an eyebrow, should you shave the eyebrow prior to suturing it closed

A

no- 20% of the time, the eyebrow will not grow back if shaved

103
Q

what is the treatment of extensive irreparable biliary, duodenal, ad pancreatic head injury

A

trauma whipple

104
Q

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

A

small bowel

105
Q

how high up do the diaphragms go?

A

to the nipples (intercostal space 4)

thus, intraabdominal injury with penetrating injury below the nipples must be ruled out

106
Q

if you have only one vial of blood from a trauma victim to send to the lab, what test should be ordered

A

type and cross (for blood transfusion)

107
Q

what is the treatment of penetrating injury to the colon

A

if the patient is in shock, resection and colostomy

if the patient is stable, the trend is primary anastomosis/repair

108
Q

what is the treatment of small bowel injury

A

primary closure or resection and primary anastomosis

109
Q

what is the treatment for minor pancreatic injury

A

drainage (JP drain)

110
Q

what is the most commonly injured abdominal organ with blunt trauma

A

liver

111
Q

what is the treatment for significant duodenal injury

A

pyloric exclusion:

  1. close duodenal injury
  2. staple off pylorus
  3. gastrojejunostomy
112
Q

what is the treatment for massive tail of pancreas injury

A

distal pancreatectomy (usually perform splenectomy also)

113
Q

what is “damage control” surgery?

A

stop major hemorrhage and GI soilage
pack and get out of the OR ASAP to bring the patient to the ICU to warm, correct coags, and resuscitate
return patient to OR when stable, warm, and not acidotic

114
Q

what is the lethal triad?

A

“ACH”

  1. Acidosis
  2. Coagulopathy
  3. Hypothermia
115
Q

what comprises the workup/treatment of stable parasternal chest gunshot/stab wound?

A
  1. CXR
    2.FAST, chest tube, = or - OR for subxiphoid window
    if blood returns then sternotomy to asses for cardiac injury
116
Q

what is the diagnosis with NGT in chest on CXR

A

ruptured diaphragm with stomach in pleural cavity (go to ex lap: exploratory laparotomy)

117
Q

what films are typically obtained to evaluate extremity fractures

A

complete views of the involved extremity, including the joints above and below the fracture

118
Q

what finding on abdominal/pelvic CT scan requires ex lap in the blunt trauma patient with normal vital signs

A

free air
also strongly consider in the patient with no solid organ injury but lots of free fluid= both to rule out hollow viscus injury

119
Q

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

A

no- perform DPL (above umbilicus)

120
Q

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

A

LFTs = increased AST/ALT

121
Q

what is the treatment for human and dog bites

A

leave wound open
irrigation
antibiotics

122
Q

what is sympathetic opthalmia

A

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

123
Q

what can present after blunt trauma with neurologic deficits and a normal brain CT scan

A

diffuse axonal injury (DAI)

carotid artery injury

124
Q

what is the usually presentation of an anterior hip dislocation

A

externally rotated with anterior hip fullness

125
Q

dx: coiled NGT in the left pleural cavity after blunt trauma

A

diaphragm rupture

126
Q

Dx: blunt trauma patient with GCD <8 and otorrhea

A

basilar fracture

127
Q

Dx: 20 yr old male status post (s/p) baseball bat to his head, arrives in a coma
CT scan reveals a lens shaped (lenticular) shaped hematoma next to inner table of skull

A

epidural hematoma

128
Q

dx: 44 yr old male status post fall from a ladder presents with GCS of 5
CT scan reveals a crescent shaped hematoma next to the inner table of skull

A

subdural hematoma

129
Q

dx: trauma oatient with increasing JVD with inspiration

A

cardiac tamponade (kussmauls sign)

130
Q

dx: trauma patient with hypertension and bradycardia

A

cushings response to increased ICP

131
Q

dx: trauma patient with hypotension and bradycardia

A

spinal cord injury

132
Q

dx: 28 yr old female involved in high speed, side impact motor vehicle collision
stable vital signs
CXR revelas widened mediastinum

A

thoracic aortic injury

133
Q

dx: 21 yr old male involved in high-speed motor vehicle collision with obvious unstable pelvis, gross blood from urethral meatus, high riding prostate on rectal exam

A

urethral injury

134
Q

dx: 45 yr old female involved in high speed motor vehicle accident complains of abdominal pain and shortness of breath
decreased breath sounds on the left
CXR reveals the NGT coiled up in the left chest

A

ruptured left diaphragm

135
Q

dx: 56 yr old involved in high speed motorcycle collision complains of severe shortness of breath
on exam, the left chest wall moves inwards not outwards on inhalation

A

flail chest (paradoxic respirations)

136
Q

dx: 67 yr old involved in a high speed MVC presents with a GCS of 5, bilateral periorbital ecchymosis, left mastoid ecchymosis, and clear fluid draining from the left ear

A

basilar skull fracture- Battle’s and raccoon signs

137
Q

dx: 50 yr old female s/p high speed MVC with rib fractures and flail chest develops hypoxia 12 hours later in the ICU
CXR shows no pneumo or hemothorax but reveals pulmonary infiltrates/congestion

A

pulmonary contusion

138
Q

dx: 29 yr old s/p a MVC arrives with hypotension, sats of 83%, JVD, decreased breath sounds on left

A

tension pneumothorax

139
Q

dx: 55 yr old male s/p 3-story fall reveals NGT coiled up in chest on CXR

A

diaphragm injury

140
Q

dx: 22 yr old male s/p MVC with transection of right optic nerve
progresses to blindness in contralateral left eye 3 weeks later

A

sympathetic opthalmia

141
Q

workup: 8 yr old male s/p bicycle accident with handlebar to abdomen with duodenal hematoma

A

NGT
TPN
observe
may take weeks to open up

142
Q

dx: 30 yr old male involved in a skiing collision with a tree arrived in the ER awake (GCS 15) bit then gets confused and next goes unresponsive (GCS 3)

A

lucid interval of epidural hematoma

143
Q

47 yr old female s/p MVC with a seatbelt sign (ecchymosis) on the left neck, what test should be done?

A

CTA of cervical vessels

144
Q

22 yr old male s/p gunshot wound to umbilicus

bullet is in the spine on xrays. what test should be done

A

exploratory laparotomy

145
Q

27 yr old female with normal vital signs and stab to right flank, what test should be done

A

CT scan with triple contrast (rectal, PO, IV)

Y2 (2 decks)

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