Surgery: Trauma Flashcards
normal PCWP and what does pcwp rep
mean is 9 (preload)
normal RA pressure
mean is 4 preload
normal cardiac index
2.8-4.2
normal SVR
1,150 dyne-sec/cm5
normal MVO2
60-80%
hemodynamic changes in shock states
CO, SVR, PCWP in cardiogenic shock
CO = decreased SVR= increased PCWP = incrased
normal CO
5 L blood per minute
hemodynamic changes in shock states
CO, SVR, PCWP in hypovolemic shock
CO: decreased
SVR: increased
PCWP: decreased
hemodynamic changes in shock states
CO, SVR, PCWP in neurogenic shock
CO: decreased
SVR: decreased
PCWP: decreased
hemodynamic changes in shock states
CO, SVR, PCWP in septic shock
CO: increased
SVR: decreased
PCWP: decreased
MVO2 is only increased in what shock
septic
when is an airway considered patent
if pt is talking, coughing, or moving air
urgent airway in what situation
expanding hematoma or cutaneous emphsema
emergent airway in what situation
apneic, GCS under 8
gurgling or gasping
INTUBATE
when would you use nasotracheal intubation
if theres uncertain cervical spine disease
must be avoided in facial fractures
order of breathing and getting oxygen into shock pt
O2–>bag valve mask–> ET tube–>cricothyrotomy if ET fails–>tracheostomy (in the OR or for long term)
when do you do cricothyrotomy and where
in ED
if ET fails or mouth is not accessible
what is oxygenation influenced by
FiO2 and PEEP (bag valve mask or advanced airway techniques)
how do you measure oxygenation
pulse ox or ABG (PaO2)
what is ventilation influenced by
minute ventilation (TV X RR)
measure ABG to get serum PaCO2
has to do with amount of CO2
what is end tidal capnography used for
accurate tube placement, if it is around 40 then in right place
urine output in shock
SBP in shock
MAP in shock
<0.5 mL/kg/hr
under 90 SBP
MAP under 65
MAP equation
CO
SV
MAP = CO X SVR
CO = SV X HR
SV = preload X contractility
hemorrhagic shock treatment
dx and tx
Dx: FAST = US
plug the hole
transport to OR for surgery to close hole
on way to OR start 2 LBIV >16 G and fluids apply pressure
LR first then Blood as it becomes available
tension pneumothorax in shock
clx sx and tx
penetrating trauma has air fill pleural space and compresses the vena cava
distended neck veins
reduced lung sounds on affected side, hyperres, and tracheal deviation away from wound
normal heart sounds
emergent needle decompression (top 2nd rib then chest tube req)
tamponade in shock
cause
physio
cx sx
tx
blunt trauma
blood in pericardial space, crushing R and obstructing flow into heart, blood backs up into venous system so pt has
DISTENDED neck veins
distant heart sounds
normal lung sounds
tx: pericardiocentesis or mediastinotomy
how do you evaluate for pericardial effusion and dx
FAST exam = ECHO
clx with pulus paradoxus >10mmHg bp on inhalation
which shock has bilateral pulmonary edema and distended neck veins and treatment
cardiogeneic
inotropes is treatment
treatment for neurogenic shock
vasopressors
cause neurogenic shock and cx features
no sympathetic tone so massive vasodilation
spinal trauma and anesthesia
pink, warm, dry and low BP
treating septic shock
bx cx and treat with vasopressors and abx
what is the diagnostic test of choice always in head trauma
CT scan
sx in basilar skull fracture
clear rhinorrhea and otorrhea, racoon eyes, and hematoma behind the ears (batle sign)
managment of basilar skull fracture
cervical spine needs to be evaluated by CT
expanding hematoma in epidural hematoma causes what
syndome of the uncus
ipsilateral fixed dilated pupil and contralateral hemiparesis
treatment for epidural hematoma
craniotomy and evacuation
treatment for an acute subdural hematoma (cause first and sx)
massive trauma like MVA or shaken baby, LOC with no lucid interval
craniotomy if midline shift noticed otherwise decrease ICP by elevation, hyperventilation, and mannitol
CT shape of epidural heamtoma and subdural
epi = lens
subdural = crescent
what patients get chronic subdural hematoma?
elderly demented patients and alcoholics bc of brain atrophy and tensed bridging veins
minor trauma can cause it
clinical signs of chronic SD hematoma and tx
gradually deteriorating mental function often with HA
treat with craniotomy
Diffuse axonal injury cause, sx, dx, tx
angular trauma like spinning in a car struck on an angle
LOC—> coma
dx: CT scan and or MRI: blurring of gray white matter
- best seen on MRI
Tx: manage ICP, often fatal
treatment for concussion
home if GCS of 15 and normal CT
observe if GCS <15 and abnormal CT
what kind of amnesia in a concussion
retrograde
hard signs in neck trauma requires what
surgery bc unstable
hard signs in neck trauma
airway
vessels
digestive
airway: GAS: gurgle, apnea, stridor
vessels: expanding hematoma, pulsatile bleed, shock, stroke
digestive: mediastinitis
soft signs in neck trauma
airway
vessels
digestive
airway: dysphonia, subQ air
vessels: hematoma, oozing
digestive: dysphagia, subQ air
pt: no hard signs, but soft signs + what do you consider
CTA vs Zone method
zone method I II and III in a stable pt (if unstable always surgery)
bullet vs knife wounds
I is basal: jugular, carotids, esophagus, trachea
- get arteriogram, esophagram and bronchoscopy before surgery
II: middle: any pt with damage here gets surgery bc can explore here and other zones
III: upper: worry about carotids entering the skull
-arteriogram
all bullet wounds considered for surgery and knife conservative manage
if the ____ is disrupted its a penetrating neck injury and mech doesn’t matter
platysma
if there are no hard or soft signs then do what
observe
if soft signs then what do you do
zone based vs CTAngio based apprach
any trauma to the spinal cord will be definitively diagnosed with what
MRI
if trauma + FND it is seen as what in blunt trauma with no fracture
managment
cord syndrome (probably from edema)
high dose dexamethasone to reduce edema and preserve neuro function
then image
complete transection of cord
motor and pain and sensory are lost below site of lesion
LMN sings at level of lesion
UMN sx below lesions
bilateral lesions
lose pain and temp, sens and motor
hemisection of spinal cord segment
MC cause
sx
stabbing
ipsilateral loss of motor and sensory below lesion
loss of pain and temp contraterally below lesion
LMN sx at lesion
UMN below lesion
central cord syndrome
ALS destoryed
syrinx (chronic) or hyperextension of neck (acute)
Loss of P and T in cape like distribution and weakness
anterior cord syndrome
spinal artery occlusion (artery of adamkieqics from a AAA), infarct front half of cord (ALS and motor tract bilat)
lose pain and temp and motor but SENSATION in tact
loss of pain and temp but vibration in proprioception in tact?
anterior cord syndrome
pt: FND, erectile dysfunction and urinary/bowel incont what is and tx
cord compression
high dose dexamethasone then MRI
if you get a rib fracture in elderly pts that end up not breathing enough bc hurts can lead to what so how treat
atelectasis and pneumonia
give pain control
pneumothorax in penetrating trauma
cause
cx
dx
tx
air into plueral space and compresses lung = dyspnea
CX: lung sounds decreased on effected side with hyperressonance
CXR: vertical lung shadows
tx: thoracostomy (chest tube)
hemothorax
cause cx features dx tx f/u
penetrating trauma
decreased lung sounds and dull to percussion
xray shows horizontal lung shadow with meniscus (air fluid level)
chest tube to drain
F/U: chest tube drains
200cc/kg (1500 mL)
3 cc/kg/hr (200 mL/hr)
then surgical exploration bc bleed is peripheral and won’t stop on own like pulmonary vasculature which is low pressure system and clots easily
sucking chest wound is what
dx?
if no ___ then tx
penetrating trauma, a flap of skin forms = one way valve of air in pleural space on inhalation but not out on exhale bc trapped
visual inspection to see flap and xr for pneumo
if no tension then place occlusive dressing taped on 3 sides and chest tube
sucking chest wound can lead to what
tx
tension pneumothorax
tx: decompression then place dressing
dx and tx of flail chest
broken ribs (2 or more ribs broken in two or more places), paradoxically movement from chest
dx: visual inspect and CXR
tx: binders/weights—->plates
- monitor with pulse ox and ventilation
f/u of flail chest
pulm contusion
cardiac contusion
aortic dissection
any flail chest that has what is possible increased severity
scapular or sternal fracture
pt: huge trauma,
day 1 CR = normal but have dyspnea and leaky caps = edema
24-48 hrs later white out on chest x ray
pulmonary contusion
treatment of pulmonary contusion
avoid crystalloid
use colloids like blood and albumin
peep
diurese
what to look for in pulmonary contusion
sever trauma clues
don’t miss heart failure
possible myocardial contusion what should you do
serial EKGs and toponins, elevated from the get go
stabilize and treat arrhythmias and HF just like an MI (MONA BASH)
diurese and antiarrth too
FAST assessment when walk in door to R/O pericardial effusion
how do you get traumatic dissection of aorta
deceleration injury
full transection of aorta = what
death most often
partial transection of aorta develop what
adventitial hematoma, which are asx until they rupture and pt dies
managment of suspected dissection of aorta
XRAy = wide mediastinum
CT next, if positive then surgery
if negative and low index suspicion then stop
if pt cannot have CT angio bc of renal failure for aortic dissection then what should you use
MRI or TEE
what should you do if high index of suspicion for aortic dissection but CT scan is negative
angiogram
if shot below what dermatome then need exploratory lap
T4 (nipple line)
is it necessary to remove bullet in abdomen of gunshot wound
no
penetrating trauma of abdomen when do you go to ex lap
bullet
evisceration
peritoneal signs
hemodynamically instability
if pt has little cut and it isnt’ clear if it has penetrated into the peritoneum what are the 2 options
explore the wound with finger, be careful
second is get CT or FAST to R/o intrabdominal complicatons
if you have blunt trauma what to evaluate
FAST if positive for blood then OR
CT shows blood or air then OR (can do if stable enough to wait)
how much blood can the abdomen hold?
pelvis?
1500 mL in abdomen
2000 mL in pelvis
how much blood can head and chest hold
head 50
chest 500
what often causes liver lacerations
ligamentum teres
after abdominal trauma having bowel sounds in the chest means what and confirm how
ruptured diaphragm, XRAY (often missed) so CT
what is + kehrs sign
should pain from diaphragmatic irritation following trauma
what is the pringle maneuver
compression of the hepatoduodenal ligament, sealing the hepatic artery and portal vein
if bleed stil means transaction of hepatic vein
treating ruptured liver
mc bleed
reapair lobectomy and pringle maneuver
what else must be considered in a pelvic fracture
urologic and rectal injury
blood at meatus or high riding prostate means what injury
dx?
urethral
retrograde urethrogram prior to insertion of oley
how to look for rectal injury
proctoscope
how do dx a ureter injury?
IV pyelogram pre op
methylene blue intraop
hemodynamically stable and pelvic fracture and bleed then what
what if unstable
no exploration
external fixation and seriel hemoglobin
unstable = explore and internal fixation
diagnosing pelvic fracture
xray then ct
signs of pelvic fracture
hip rocking producing creptius, pain and mobility
what degree burn: increased pain and blisteres
2nd
full thickness burn through the dermis with m and bone exposed
what kind of pain and surrounded by what
3rd degree
no pain and surrounded by 2nd degree burn
alkaline or acid burn worse?
alkaline
treating chemical burn
dont neutralize
IRRIGATE
if ingested seriel exams and EGD
burns or soot in or around the mouth or nose consider what
inhalation injury from smoke or chems etc
treatment for respiratory burn
analyze airway with bronchoscopy but secure with intubation
if need to deterine who needs airway use ABGs
what might you see from electrical burn
arrhytmia
muscular burn leading to Rhabdo
dx electrical burn
CK for rhabdo, and Cr
Tx: IVF, mannitol (for rhabdo) to stop RFail
what kind of dislocation in lighting strike
posterior
long term sequelae to electrical burns?
demyelination syndromes and cataracts
treating circumferential burns
cut eschar
burns and parkland formula
first half of fluids given in 8 hours and the second half in 16 hours
what is important to prevent scarring in a burn
early ovement
what should you use as ppx against infection in a burn
silver sulfadizine and mafenide
parkland formula
4 x KG x % BS area burned
-give this amt of IVF in first 24 hours
first 1/2 in 8 hrs next 1/2 over the next 16
parkland formula: head, chest, pelvis, legs, genitals, arms
head = 9 chest = 9 pelvis/abdomen = 9 legs front = 9 for each leg legs back = 9 each leg each side of arm = 4.5 so one arm = 9 genital = 1
for pediatrics take one of the 9s and give to head?
treatment fo bee and wasps stings
IM epi and H1/H2 blockers and corticosteroids
features of poisonous snakes
slit like eyes, rattlers, cobra cowl
tx for snake bite
anti-venom
black spider with hourglass on belly
black widow
spider bite that cause abdominal pain or pancreatitis and tx
black widow
IV caclium gluconate to stablize muscles
pt going through attic or old boxes in south and gets bit by something
brown recluse
pt with bite that is asx day one then next day is small ulcer
is what
tx?
act now bc necrotic ulcer with ring of erythema at bite site is brown recluse
wide debridement and graft
treating human bites and it is from what behaviors
sex and fights
surgical exploration and massive irrigation
amox-clav if dirty
five tetanus shot i been over 5 years since booster
dog/cat bite treatment
irrigation, leave open, amox-clav
tetanus if been over 5 yrs since last booster
treatment for methanol overdose
ingesting what causes this?
ethanol or fomepizole
moonshine
treatment for ethylene glycol OD
ingesting what causes this?
ethanol
fomepizole
antifreeze
methanol poisoning can cause what
blindess
ethylene glycol can lead to what
kidney failure
how can you diagnose ethylene glycol ingestion
woods lamp lights up urine
what ingestion if elevation of liver enzymes in the thousands
tylenol
diagnosing tylenol overdose and treating
get acetaminophen level at 4 and 16 hrs if above line on nomogram then use NAC
if develop fulminant hepatic failure then transplant
early signs of aspirin OD
tinnitus
n/v
vertigo
resp alkalosis
late signs of aspirin OD
Anion gap acidosis
obtunded, coma,
increased hyperpyrexia
dx and treat aspirin OD
salicylate level
alkalinize urine and dirues it
SPO2 with CO poisoning
may be 100% still
dx CO poisoning and tx
ABG and carboxyhemoglobin
tx: 100% fio2 and hyperbarics
cianide tox from what
pt presents how
dx
tx diff for each way ingesting
smoke inhale or nitroprusside
SAS, cherry red skin and blood on ABG
clx diagnosis
tx: thiosulfate, can use amylnitrate with nitroprusside poisoning
