Surgery: Trauma Flashcards
1
Q
What are the 3 main elements of the ATLS protocol?
A
(advanced trauma life support - ATLS)
- primary survey
- secondary survey
- definitive care
2
Q
List the 5 steps of the primary survey
A
- Airway (and C spine stabilization)
- Breathing
- Circulation
- Disability
- Exposure and Environment
3
Q
what comprises spinal immobilization
A
use a full backboard and rigid cervical collar
4
Q
what is the quickest test for an adequate airway
A
ask a question, if the patient can speak, the airway is intact
5
Q
If chin lift or jaw thrust are unsuccessful, what is the next maneuver used to establish an airway
A
endotracheal intubation
6
Q
If all other methods of establishing an airway are unsuccessful, what is the definitive airway?
A
cricothyroidotomy
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)
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
9
Q
What is heard on percussion of pneumothorax
A
hyper resonance
10
Q
what is another term for tube thoracostomy
A
chest tube
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”
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)
13
Q
how is flail chest diagnosed
A
(fracture of 3 or more consecutive ribs)
flail segment of chest wall moves paradoxically
14
Q
what is the major cause of respiratory compromise with flail chest
A
pulmonary contusion (bruised lung)
15
Q
Tx of flail chest
A
intubation with positive pressure ventilation and positive end expiratory pressure as needed
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)
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)
18
Q
dx and tx of cardiac tompanade
A
dx: ultrasound
tx: pericardial window
19
Q
dx massive hemothorax
A
unilateral decreased or absent breath sounds dullness to percussion CXR CT chest tube output
20
Q
tx of massive hemothorax
A
volume replacement
tube thoracostomy (chest tube)
removal of blood
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)
22
Q
what are the goals while assessing circulation?
A
secure adequate tissue perfusion
treat external bleeding
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
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)
25
Who can be hypovolemic with normal blood pressure
young patients (autonomic tone maintains pressure until cardiovascular collapse is imminent)
26
Which patients may not mount a tachycardic response to hypovolemic shock
spinal chord injury
taking beta blockers
well-conditioned athletes
27
how are sites of external bleeding treated
direct pressure with or without tourniquets
28
what is the best and preferred intravenous access in the trauma patient
two large bore IVs (14-16 gauge), IV catheters in upper extremities (peripheral IV access)
29
what is the anatomy of the groin which helps when placing a femoral catheter
```
lateral to medial "NAVEL"
nerve
artery
vein
empty space
lymphatics
therefore, vein is medial to the femoral pulse
```
30
what is the trauma resuscitation fluid of choice in a hypotension trauma patient
blood and blood products
31
what is the trauma resuscitation fluid of choice in a non hypotensive trauma patient
lactated ringers
| most use normal saline for TBI patient
32
what types of decompression do trauma patients recieve
gastric decompression with NG tube and foley catheter bladder decompression after normal rectal exam and no indication of urethral injury
33
what are the contraindications of placement of a foley catheter
```
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
```
34
what test should be done prior to placing a Foley catheter if urethral injury is suspected
```
retrograde urethrogram (RUG)
(dye in penis retrograde to bladder and Xray looking for extravasation
```
35
how is gastric decompression achieved with a maxillofacial fracture?
(NOT with NG tube bc tube may perforate through cribriform plate into brain)
place oral gastric tube
36
What comprises adequate assessment of disability?
mental status: Glasgow Coma Scale
pupils
motor/sensory screening exam for lateralizing extremity movement, sensory deficits
37
what does a blown pupil suggest
ipsilateral brain mass (blood) as herniation of the brain compresses CN III
38
Describe the Glasgow coma scale
```
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
```
39
what is a normal GCS score?
GCS 15
40
what is the GCS score of someone who is dead?
GCS 3
41
what is the GCS score for a patient in a coma?
GCS < or = 8
42
GCS score indication for intubation?
GCS < or = 8
43
How does scoring of GCS differ for patients that are intubated
verbal evaluation is omitted and replaced with a T, thus the highest score for an intubated patient is 10 T
44
what are the goals in obtaining adequate exposure
complete disrobing to allow a thorough visual inspection and digital palpation of the patient during the secondary survey
45
what is the "environment" of the ABCDEs
keep a warm environment (keep the patient warm; a hypothermic patient can become coagulopathic)
46
What principle is followed in completing the secondary survey?
complete physical exam, including all orifices: ears, nose, mouth, vagina, and rectum
47
Why look in the ears?
hemotympanum and otorrhea is a sign of basilar skull fracture
48
What are typical signs of basilar skull fracture
racoon eyes
Battle's sign (bruising over the mastoid process)
clear otorrhea or rhinorrhea
hemotympanum
49
What diagnosis in the anterior chamber must not be missed on the eye exam
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)
50
what potentially destructive lesion must not be missed on the nasal exam?
nasal septal hematoma: hematoma must be evacuated, if not, it can result in pressure necrosis of the septum
51
what is the best indication of mandibular fracture
dental malocclusion: tell the patient to "bite down" and ask " does that feel normal to you?"
(malocclusion = crooked teeth or poor bite)
52
what signs of thoracic trauma are often found on the neck exam
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
53
what is the best physical exam for broken ribs or sternum
lateral and anterior-posterior compression of the thorax to elicit pain/instability
54
what is the best way to diagnose or rule out aortic injury
CT angiogram
55
what must be considered in every penetrating injury of the thorax at or below the level of the nipple
concomitant injury to the abdomen
| the diaphragm extends to the level of the nipples in the male on full expiration
56
what is the significance of subcutaneous air
indicates pneumothorax until proven otherwise
57
what is the physical exam technique for examining the thoracic and lumbar spine
logrolling the patient to allow complete visualization of the back and palpation of the spine to elicit pain over fractures, step off (spine deformity)
58
what conditions must exist to pronounce an abdominal physical exam negative
alert patient without any evidence of head/spinal cord injury or drug/EtOH intoxication
(even then the abdominal exam is not 100% accurate)
59
what physical signs may indicate intra-abdominal injury
```
tenderness
guarding
peritoneal signs
progressive distension (always use a gastric tube for decompression of air)
seatbelt sign
```
60
what is the seatbelt sign
ecchymosis on lower abdomen from wearing a seatbelt
| about 10% of patients with this sign have a small bowel perforation
61
what must be documented from the rectal exam
```
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
what is the best physical exam technique to test for pelvic fractures
lateral compression of the iliac crests and greater trochanters and anterior-posterior compression of the symphysis pubis to elicit pain/instability
63
what is the halo sign?
cerebrospinal fluid from the nose/ear will form a clear halo around the blood on a cloth
64
what physical signs indicate possible urethral injury, thus contraindicating placement of a Foley catheter
high-riding, ballotable prostate on rectal exam
presence of blood at the meatus
scrotal or perineal ecchymosis
65
what must be documented from the extremity exam
```
any fractures or joint injuries
any open wounds
motor and sensory exam, particularly distal to any fractures
distal pulses
peripheral perfusion
```
66
what complication after prolonged ischemia to the lower extremity must be treated immediately?
compartment syndrome (pressure build up due to blood collection or swelling)
67
what is the treatment for compartment syndrome
fasciotomy (cutting the fascia)
68
what injuries must be suspected in a trauma patient with a progressive decline in mental status
epidural hematoma
subdural hematoma
brain swelling with rising intracranial pressure
hypoxia/hypotension must be ruled out
69
what are the classic blunt trauma ER xrays
AP chest films
| AP pelvis film
70
what are common trauma labs
blood for complete blood count, chemistries, amylase, liver function test, lactic acid, coagulation studies, and type and crossmatch
urine for urinalysis
71
how can a C spine be evaluated
clinically by physical exam
| radiographically
72
what patients can have their C-spine cleared by a physical exam
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
How do you rule out a C-spine bony fracture
CT scan of the C spine
74
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
this is controversial, but most centers remove the C-collar
75
which xrays are used for evaluation of the cervical spine ligamentous injury
MRI (lateral flexion and extension C spine films also used but infrequently)
76
what study is used to rule out thoracic aortic injury
CT scan of mediastinum looking for mediastinal hematoma with CTA
77
what is the most common site of thoracic aortic traumatic tear
just distal to the take-off of the left subclavian artery
78
what studies are available to evaluate for intra-abdominal injury
focused assessment with sonography in trauma
CT scan
DPL (diagnostic peritoneal lavage)
79
what is a FAST exam and what does it look for
focused assessment with sonography for trauma
| blood in the peritoneal cavity looking at Morison's pouch, bladder, spleen, and pericardial sac
80
what does DPL stand for
diagnostic peritoneal lavage
81
what diagnostic test is the test of choice for evaluation of the unstable patient with blunt abdominal trauma?
FAST
82
what is the indication for abdominal CT in blunt trauma?
normal vital signs with abdominal pain/tenderness/mechanism
83
what is the indication for FAST in blunt trauma
unstable vital signs (hypotension)
84
what injuries does CT scan miss
small bowel injuries and diaphragm injuries
85
what study is used to evaluate the urethra in cases of possible disruption due to blunt trauma
retrograde urethrogram (RUG)
86
what are the most emergent orthopedic injuries?
1. hip dislocation (must be reduced immediately)
| 2. exsanguinating pelvic fracture (binder or external fixator)
87
what is the treatment of a gunshot wound to the belly
exploratory laprotomy
88
what is the evaluation of the stab wound in the belly
if there are peritoneal signs, heavy bleeding, shock, perform exploratory laparotomy
otherwise, many surgeons perform a CT scan and/or laparoscopy
89
what depth of neck injury must be further evaluated
penetrating injury through the platysma
90
define the anatomy of the neck by trauma zones
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
how do most surgeons treat penetrating neck injuries by neck zone?
zone I and III: selective exploration
| Zone II: surgical exploration
92
what is selective exploration?
selective exploration is based on diagnostic studies that include A-gram or CT A-gram, bronchoscopy, esophagoscopy
93
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 (air trapped)
94
what is the minimal urine output for an adult trauma patient
50 mL/hr
95
what is the brief ATLS history?
```
"AMPLE"
allergies
medications
PMH
last meal (when)
events (injury, etc.)
```
96
in what population is a surgical cricothyroidotomy not recommended?
any patient under 12 yrs old, perform needle cricothyroidotomy instead
97
what is the treatment of rectal penetrating injury
diverting proximal colostomy
closure of perforation (if easy, and definitely if intraperitoneal)
presacral drainage
98
what is the treatment of extraperitoneal minor bladder rupture
```
bladder catheter (foley) drainage and observation
intraperitoneal or larger bladder rupture requires operative closure
```
99
what intra-abdominal injury is associated with seatbelt use
small bowel injuries (L2 fracture, pancreatic injury)
100
what is the treatment of a pelvic fracture
+ or - pelvic binder until the external fixator is placed
IVF/blood
+ or - A gram to embolize bleeding pelvic vessels
101
bleeding from pelvic fractures is most commonly caused by arterial or venous bleeding?
venous (85%)
102
if a patient has a laceration through an eyebrow, should you shave the eyebrow prior to suturing it closed
no- 20% of the time, the eyebrow will not grow back if shaved
103
what is the treatment of extensive irreparable biliary, duodenal, ad pancreatic head injury
trauma whipple
104
what is the most common intra-abdominal organ injured with penetrating trauma
small bowel
105
how high up do the diaphragms go?
to the nipples (intercostal space 4)
| thus, intraabdominal injury with penetrating injury below the nipples must be ruled out
106
if you have only one vial of blood from a trauma victim to send to the lab, what test should be ordered
type and cross (for blood transfusion)
107
what is the treatment of penetrating injury to the colon
if the patient is in shock, resection and colostomy
| if the patient is stable, the trend is primary anastomosis/repair
108
what is the treatment of small bowel injury
primary closure or resection and primary anastomosis
109
what is the treatment for minor pancreatic injury
drainage (JP drain)
110
what is the most commonly injured abdominal organ with blunt trauma
liver
111
what is the treatment for significant duodenal injury
pyloric exclusion:
1. close duodenal injury
2. staple off pylorus
3. gastrojejunostomy
112
what is the treatment for massive tail of pancreas injury
distal pancreatectomy (usually perform splenectomy also)
113
what is "damage control" surgery?
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
what is the lethal triad?
"ACH"
1. Acidosis
2. Coagulopathy
3. Hypothermia
115
what comprises the workup/treatment of stable parasternal chest gunshot/stab wound?
1. CXR
2.FAST, chest tube, = or - OR for subxiphoid window
if blood returns then sternotomy to asses for cardiac injury
116
what is the diagnosis with NGT in chest on CXR
ruptured diaphragm with stomach in pleural cavity (go to ex lap: exploratory laparotomy)
117
what films are typically obtained to evaluate extremity fractures
complete views of the involved extremity, including the joints above and below the fracture
118
what finding on abdominal/pelvic CT scan requires ex lap in the blunt trauma patient with normal vital signs
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
can you rely on a negative FAST in the unstable patient with a pelvic fracture
no- perform DPL (above umbilicus)
120
which lab tests are used to look for intra-abdominal injury in children
LFTs = increased AST/ALT
121
what is the treatment for human and dog bites
leave wound open
irrigation
antibiotics
122
what is sympathetic opthalmia
blindness in one eye that results in subsequent blindness in the contralateral eye (autoimmune)
123
what can present after blunt trauma with neurologic deficits and a normal brain CT scan
diffuse axonal injury (DAI)
| carotid artery injury
124
what is the usually presentation of an anterior hip dislocation
externally rotated with anterior hip fullness
125
dx: coiled NGT in the left pleural cavity after blunt trauma
diaphragm rupture
126
Dx: blunt trauma patient with GCD <8 and otorrhea
basilar fracture
127
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
epidural hematoma
128
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
subdural hematoma
129
dx: trauma oatient with increasing JVD with inspiration
cardiac tamponade (kussmauls sign)
130
dx: trauma patient with hypertension and bradycardia
cushings response to increased ICP
131
dx: trauma patient with hypotension and bradycardia
spinal cord injury
132
dx: 28 yr old female involved in high speed, side impact motor vehicle collision
stable vital signs
CXR revelas widened mediastinum
thoracic aortic injury
133
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
urethral injury
134
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
ruptured left diaphragm
135
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
flail chest (paradoxic respirations)
136
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
basilar skull fracture- Battle's and raccoon signs
137
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
pulmonary contusion
138
dx: 29 yr old s/p a MVC arrives with hypotension, sats of 83%, JVD, decreased breath sounds on left
tension pneumothorax
139
dx: 55 yr old male s/p 3-story fall reveals NGT coiled up in chest on CXR
diaphragm injury
140
dx: 22 yr old male s/p MVC with transection of right optic nerve
progresses to blindness in contralateral left eye 3 weeks later
sympathetic opthalmia
141
workup: 8 yr old male s/p bicycle accident with handlebar to abdomen with duodenal hematoma
NGT
TPN
observe
may take weeks to open up
142
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)
lucid interval of epidural hematoma
143
47 yr old female s/p MVC with a seatbelt sign (ecchymosis) on the left neck, what test should be done?
CTA of cervical vessels
144
22 yr old male s/p gunshot wound to umbilicus
| bullet is in the spine on xrays. what test should be done
exploratory laparotomy
145
27 yr old female with normal vital signs and stab to right flank, what test should be done
CT scan with triple contrast (rectal, PO, IV)
