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Block 3 Surgery > Surgical Trauma > Flashcards

Surgical Trauma Flashcards

1
Q

Head on collision MVA high speed collision anticipated mechanism

A

Blunt trauma

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2
Q

MVA pertinent medical hx

A

Telemetry data
Airbag deployment
Scene timeline

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3
Q

Blunt mechanism organ trauma commonly what 2

A

Liver ; spleen [ not necessarily operative ]

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4
Q

Liver Mangement low grade to grade 4

A

Non op; angiography

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5
Q

High grade injury repeat images

A

4-8 weeks later

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6
Q

Change between stage 2 and 3 acute hemmorhage

A

Stage 3 = 1500 loss with loss of vital signs

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7
Q

GCS of a person that is intubated what can you do to check disability

A

Brain stem reflex by checking anisocoria

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8
Q

Peripheral pulses are absent indicates need for what

A

OR because the LIMB is threat ; critical beyond 6 hours

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9
Q

When a multi trauma comes in post MVA what should you start with?

A

Primary survey ABC’s

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10
Q

Pelvic instability needs what

A

Pelvic binder

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11
Q

Do TBI’s benefit from blood transfusions

A

YES it increases the MAP

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12
Q

If an unstable patient becomes stable post primary survey management what do you do next

A

Secondary survey

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13
Q

Poly trauma patient needs what type of CT

A

Pan CT

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14
Q

Are TBI’s commonly a cause of Hemodynamic instability in a trauma patient

A

NO!

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15
Q

2 things that limit exam of abdomen in a patient with

A

Distracting injuries
Altered sensorium

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16
Q

Look for what 2 things on an abdominal exam

A

Distention =
Bruising

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17
Q

In a patient with a left Subdural hematoma GCS of 9 what contributes to left subdural hematoma

A

Bp of 70/50 for approx 10 minutes order to arrival to the hospital

MAP - ICP = CPP (60-70 = normal)

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18
Q

Are diminished pulses the same as absent pulses

A

No absent indicates a critical limb ; needs OR

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19
Q

Left flank bruise ; with hematuria non op mgmt

A

IVF
U/O
Bed Rest

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20
Q

Chance fx AKA ____ fx makes the likelihood of a hollow viscous injury

A

TP - transverse process
High!

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21
Q

SubQ emphysema in the setting of PTX makes you concerned for what

A

Tracheo bronchial injury

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22
Q

Best ways to ensure intubation

A

Visualization and capnography showing normal waveform

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23
Q

Hypotensive with negative FAST what is the best mgmt

A

Blood products

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24
Q

Best control of widened medistinum wiht aortic involvement best mgmt

A

Impulse control with BB

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25
Q

Pericardial Tamponade definitive treatment

A

Sternotomy

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26
Q

U/S neg but pt would benefit from surgical intervention of pericardial Tamponade what do you do ; FAST negative

A

Pericardial window

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27
Q

Tracheo bronchial injury ; indications for this treatment

A

Thoroctomy

Blood loss exceeding limits
Esophagus injury with GI contents out the chest tube

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28
Q

ETOH after stab wound what is the Likely physical exam finding

A

Tender abdomen
Breath sounds present and equal bilaterally

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29
Q

10th intercostal space unstable is probably a what and needs what

A

Subdiaphragmtic injury
Ex lap

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30
Q

An evsiceration s/p wound injury needs what

A

OR

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31
Q

Less invasive way to check for peritoneal violations

A

Laparoscopy

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32
Q

Blunt trauma commmonly what organs and what mgmt

A

Liver spleen; non operative

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33
Q

What is the fast not sensitive for

A

Retro peritoneal structures

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34
Q

Good follow up for neg FAST imaging with high suspicion

A

CT if stable

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35
Q

Stab wound rigid and tender diffusely ; what mgmt

A

Ex Lap

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36
Q

When would you do a local wound exploration

A

Stab to abdomen alert and hemodynically normal and his abdominal examination is Normal

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37
Q

Most common hollow viscous organ injured in abdominal trauma

A

Small Bowel

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38
Q

What is the most important component of the GCS if they are in tact

A

Motor

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39
Q

Anisocoria is defined as

A

Greater than 1mm difference between pupils indicative of ICP increase

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40
Q

CSF leaks require what

A

ABX if leak persists longer than 7 days

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41
Q

Most common cervical fx in trauma

A

C1 - Jefferson and C2 - hangman

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42
Q

GCS of 8 and TBI concern injury get what

A

Endotracheal intubation

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43
Q

What is Cushings triad

A
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44
Q

If you cauterize at the level of the Galeal what happens

A

Alopecia

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45
Q

What level of midline shift is concerning in Subdural

A

5 mm shift

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46
Q

Reasons for ICP monitoring

A

Positive CT finding with mass effect

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47
Q

Na resuscitation

A

145 with normal saline

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48
Q

What is a ;good adjunct mgmt for ICP increased

A

Keppra 7 days seizure prophylaxis

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49
Q

What is worse outcome in a subdrual hematoma wiht GCS of 9

A

Any HyPOTENSION

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50
Q

Rule of 9s

A
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51
Q

Why do you perform escharotmy

A

To relive what may be a tourniquet around the leg

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52
Q

Electrical burns main concern and intervention

A

Cardiac monitoring

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53
Q

Admit to burn center criteria

A

Grater 10% TBSA in kids
Greater 40% in adults
Face hands genitalia
Electrical burns
Polytruama burns
Greater 5 % full thickness

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54
Q

Tri modal death distribution

A

Seconds to minute after injury [Massive Trauma]

Minutes to hours [Blood Loss Injuries]

Days to weeks [Sepsis]

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55
Q

IDME

A

Immediate

Delayed

Minimal

Expectant

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56
Q

Set up of triage

A

Single point good flow

Sufficient labor and traffic; with dedicated casualty recorders

No treatment in the triage

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57
Q

Four steps of field triage

A

Vital signs and LOC

Anatomic evidence of injury

Mechanism of injury

Special patients systemic considerations

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58
Q

What GCS is required for transportation ot a higher level of trauma

A

13

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59
Q

5 management priorities

A

Stop major bleeding

Secure the airway

Ventilate

Restore circulation

Assess GCS and splint obvious fractures

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60
Q

Delayed triage

Examples

A

Wounded but STABLE

Globe injuries
Facial fx
Blunt trauma - shock
Burns
Lacerations

STABLE BUT NEED HIGHER LEVEL OF CARE

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61
Q

Minimal triage

Examples

A

Minor injuries

Minor laceration
Minor burns
Small bone Fx

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62
Q

Expectant triage

A

Non salvageable injury

GSW with coma
Shock
Severe burn
High spine injury
No vital signs

No Abandoning!

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63
Q

Reassessment criteria

A

Loosen tourniquets
Bandage placement check
Check distal pulses
Assess breathing and ventilation

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64
Q

Medevac reports

A

9 Line MEDEVAC
MIST reports

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65
Q

What comes in the MIST report

A

Mechanism
Injuries
Sxs Vitals
Treatments given

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66
Q

What is the primary surgery

A

XABCDE

Address LIFE LIMB EYESIGHT

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67
Q

How do you assess breathing

A

Chest wall motion
Chest wall tenderness
Respiratory rate

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68
Q

How do you check disability

A

GCS
Pupil response

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69
Q

What are the 2 most rapid causes of death

A

Loss of airway
Massive bleeding SBP less then 90 + HR greater than 130

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70
Q

What does a portable CXR assess

A

Mediastinum
Tension PTX
Massive HTX

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71
Q

When is the primary survey performed?

A

POI

en route

Immediately in the trauma bay

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72
Q

Example of trauma imaging (4)

A

CXR
ABD X-RAY
Fx
FAST

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73
Q

3 examples of hemorrhage control

A

Tourniquets HIGH AND TIGHT

Direct pressure

Hemostatic bandages

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74
Q

4 signs of airway obstruction

A

Foreign bodies or debris

ID of facial fx or

tracheal laryngeal injury

Suction to clear secretions or blood

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75
Q

What is the requirement for a OPA tube or Supraglottic airway

A

Need to have no gag reflex

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76
Q

Endotracheal intubation :

A

Placed in trachea
Definitive
Need laryngoscope or video

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77
Q

What is a surgical airway

A

Cricothyrotomy

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78
Q

Flail chest presentation

A

At least 2 fx per rib in at least tow ribs creating a free segment

Paradox respirations
Increased pCO2 with vent difficulty

Decreased profusion

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79
Q

Tension PTX location for decompression

A

4-5 ICS AAL

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80
Q

Open PTX sucking chest wound gets what management

A

Chest seal device

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81
Q

How can we optimize o2 delivery

A

Max cardiovascular performance

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82
Q

Initial assessment of circulation (3)

A

Pulse
LOC
Skin perfusion

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83
Q

Where do you estimate pulse with SBP

A

Radial Pulse = higher than 90

Femoral pulse = higher 70

Carotid pulse = higher than 30

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84
Q

What stage of acute hemorrhage often follows a vital signs change

A

Stage 3

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85
Q

How do you begin initial rescucitation

A

Saline LOCK

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86
Q

Class 3 hemorrhage gets what Mangement

A

Early blood products in 20 mins

1:1:1

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87
Q

What type of fluid rescucitation will worsen trauma induced coagulapthy

A

Crystalloids

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88
Q

What is contained in component therapy

A

1 U PRBC
1 U PLT
1 U CRYO

COAG factors 65%

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89
Q

What is contained in a warm whole blood therapy

A

500 mL whole blood

High Hct/platelet/ COAG concentration 100%

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90
Q

Disability assessment (3)

A

Assess

GCS

AVPU

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91
Q

Symmetry of pupil exam for disability

A

Within 1 mm
Constricts with light
Dilation less than 4 mm
Corresponding dilation with same side injury
Lateral gaze + Dilated Pupil = CN3 Brain stem herniation

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92
Q

CN3 Brian stem herniation through tentorium cerebelli will manifest as what physical exam findings

A

Lateral gaze and dilated pupil

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93
Q

When can the secondary survey begin

A

After primary ABCDE
And Hemodynamics stable

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94
Q

What is a good hx to get in secondary survey

A

AMPLE

Allergies
Medications
Past illness
Last oral intake
Events / Environment

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95
Q

What are the two categories of injury in trauma

A

Penetrating injury and Blunt trauma

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96
Q

How do penetrating vs blunt trauma injuries present

A

Penetrating = local

Blunt = multi system

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97
Q

What type of trauma presents with hollow viscous injury

A

Blunt

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98
Q

What are the 3 priorities of secondary survey

A

ID wounds
ID operation requirements
Additional testing requirements

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99
Q

Where is zone 2 of the neck and what is the dispo

A

Just below the cricoid to the distal lip (ramus)

Alert and stable but no HARD injuries = expectant management

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100
Q

Stable without obvious neck injury should get what

A

CTA to r/o occult vascular structures

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101
Q

Main mgmt of chest penetrating trauma

A

THORACOSTOMY

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102
Q

If cardiac injury suspected get what?

A

ED U/S

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103
Q

What is persistent instability without evidence of intrathoracic bleeding commonly

A

Pericardial Tamponade

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104
Q

Thoracic spinal cord injury will likely cause

A

Neurogenic shock

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105
Q

If intrathoracic bleed is outside the pericardium what do you need

A

Stabilize after tube throcostomy and modest volume loading

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106
Q

Penetrating wound that violates the peritoneal cavity gets what

GSW that is suspicious needs what

A

Laparotomy

Laparoscopy

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107
Q

Where are you exploring with superficial stab wounds to rule out deep penetration in the anterior abdomen

A

Anterior fascia (should be intact)

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108
Q

Injuries to what structures are considered retroperitoneal

A

Flank back and pelvis

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109
Q

What are most retroperitoneal colon injuries identified on the basis of

A

Extraluminal gas or fluid

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110
Q

Rectal injury suspected perform what

A

Sigmoidoscopy

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111
Q

Unstable patient with iso penetrating injury to the extremity gets what

A

External compression and then prompt triage to OR

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112
Q

Example of hard signs of arterial injury (5)

A

External bleeding
Pulsatile hematoma
Absent distal pulse
Palpable thrill/bruit
Signs of distal ischemia

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113
Q

Signs of distal ischemia need what

A

OR for on table Angio

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114
Q

What 3 conditions are commonly treated with fasciotomy

A

Fractures
Burns
Snake bites

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115
Q

Indications for fasciotomy (5)

A

Arterial and Venous injury
Massive soft tissue damage
Delta between injury and repair
Prolonged hypotension
Excessive swelling or high tissue pressure

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116
Q

Most common MOI in blunt trauma (4)

A

Fall from standing
Height fall
MVC
Assault

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117
Q

Initial blunt trauma screens should focus on what areas

A

Chest
Abdomen
Pelvis

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118
Q

Most reliable screening test for intrathoracic bleeding

A

CXR

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119
Q

How much blood can be sequestered in the peritoneal cavity with minimum abdominal Distention

A

3 L

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120
Q

Most rapid reliable method of indetifying intrabdominal free blood

A

FAST

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121
Q

4 initial management interventions for unstable pelvis

A

Blood volume replacement
Application of pelvic binder
Eval the response to rescucitation
Perform U/S

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122
Q

Unstable patient wiht postieve findings on U/S should get

A

Laparotomy

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123
Q

No evidence of bleeding and unstable pelvis

A

External pelvis fixation and preperiotnela pelvic packing in the OR
Then Angio

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124
Q

Blunt trauma commonly presents with

A

Shock

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125
Q

Who should get ICP monitoring (3)

A

CT + evidence of ICP
GCS less than 9
Lateral neural injury

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126
Q

When is craniotomy considered in TBI

A

GCS score less than 9 and a lateralizing Neuro exam

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127
Q

Is hypotension assoc with closed head trauma

A

NO ; investigate for bleeding

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128
Q

Bleed vs TBI mnmgt

A

Bleed control top priority

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129
Q

Are blunt cerebral vascular injuries often sxs

A

YES

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130
Q

How do we prevent neurologic morbidity in TBI

A

Early diagnosis and therapeutic anti coagulation

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131
Q

What is gold standard initial screen in cerebral vascular injuries

A

CTA of the neck

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132
Q

3 chest injuries to be ruled out in the secondary survey

A

Rib fx
Blunt cardiac injury
Blunt aortic injury

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133
Q

If fx of 1st rib r/o what

A

Blunt cardiac injury

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134
Q

Flail chest with pulmonary contusion consider what

A

Early intubation
ADMIT
Pain control = EPIDURALS

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135
Q

What type of PTX is likely observed

A

Occult

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136
Q

Immediate treatment of tensionPTX

A

Large bore needle

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137
Q

Definitive treatment of tension PTX

A

Tube thoracostomy with

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138
Q

ECG findings for pericardial Tamponade

A

Electrical alternans

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139
Q

Persistent signs of pericardial Tamponade presentation

A

Tachycardia and distended neck veins

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140
Q

Good management regimen of blunt trauma

A

CXR
CTA

GIVE INITAL : beta blocker / operative repair

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141
Q

Rupture of the diaphragm often results in what

A

Respiratory distress

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142
Q

Hollow viscous injury often presents how?

A

Delayed

Wall thickening with free fluid

Elevated amylase a

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143
Q

Concerning unset law solid organ injury with positive FAST gets

A

OR

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144
Q

Stable patient with positive FAST gets

A

CT with IV contrast

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145
Q

Solid injuries are often managed how

A

Non op
Angio

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146
Q

What are dispo solid injuries based on

A

Grade of injury
Arterial contrast extravasion
Injury burden
Patient stability

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147
Q

Most freq GU injured organ =

A

Renal

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148
Q

GU organ injures often present with what

A

Hematuria

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149
Q

What two things are important for renal injury management

A

Must take into account MOI and probability of several kidney injury

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150
Q

After non op management what 3 things should be considered

A

Bed rest
Foley
Follow up CT

Determine foley requirements

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151
Q

Pelvic fx high suspicion for

A

Bladder or urethral injury

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152
Q

Urethral injury high suspicion

A

High riding prostate
Blood in the urethral meats
Blood during rectal exam

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153
Q

How do we r/o urethral injury before cannuilation

A

RUG with flouro

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154
Q

Blunt trauma operative intervention requirements (3)

A

CXR = wide mediastinum

ABD = free fluid

Pelvis = extravasation of contrast

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155
Q

6 reasons for early deaths with abdominal trauma

A

Airway obstruction
Flail chest
Open PTX
Massive Hemothorax
Tension PTX
Cardiac Tamponade

156
Q

What are you looking for on abdominal trauma physical exam (6)

A

Cyanosis
Subcutaneous emphysema
Flail chest
Laceration hematoma
JVD
Tracheal deviation

157
Q

What is the priority with blunt thoracic trauma

A

Airway management

158
Q

How are most chest injuries treated including penetration trauma

A

Non op

159
Q

What are 4 chest trauma surgical indications

A

Penetrating with greater than 1.5 L blood loss
Diaphragmatic rupture
Aortic transection
Cardiac Tamponade

160
Q

Best initial image of chest trauma

A

Portable CXR

161
Q

Most common wall injury resulting from blunt trauma

A

Rib fracture

162
Q

1st management after image chest trauma

A

Thoracic epidural analgesia

163
Q

Dx criteria for flail chest

A

Rib fx
+ Spont breathing

164
Q

Non op mgmt of flail chest

A

Pain control
CAN COUGH
-If not = spirometry

165
Q

Flail chest + deceased pulm fxn with dec hypoxia or hypercapnia with good pain control gets what

A

ET tube/ Mech vent

166
Q

Sternal fx result mostly from where

A

MVC’s

167
Q

Management of sternal fx

A

Initial = rescucitation and excluded life threats
Get ECG and Get chest radiograph

All normal with good PO pain response = outpatient Management

168
Q

What is the op treatment of choice if we are going to provide it for sternal fx ( not likely )

A

ORIF

169
Q

ORIF indications for sternal fx

A

Non union
Displaced with overriding segments
Severe pain and respiratory compromise
Multiple unstable rib fx
Thoracotomy

170
Q

Occult PTX may be observed how?

A

Safely

171
Q

What happens to the pleural space in Tension PTX progression from simple

A

Air accumulates in the pleural space causing increased intraplueral pressure

172
Q

What is the dx for ; unilateral decreased or absent breath sounds, tympany
on the affected side, tracheal deviation, and distention of neck veins.

A

Tension PTX

173
Q

Standard first line intervention for Tension PTX

A

Decompression of the thoracic cavity

14 gauge ; 3.25 inch long needle

174
Q

Small open pneumo’s initial treatment

A

Occlusive dressing ; then consider need fro throracostomy

175
Q

Complications of hemothorax

A

Atelectasis or Empyema

176
Q

Hemothorax imaging techniques

A

CXR then Thoracic CT

177
Q

Are bruises to the lung more commonly due to blunt trauma or penetrating

A

Blunt ; both can cause it

178
Q

Characteristic findings in bruises to the lung

A

VQ mismatch ; with right to left shunt and hypoxia

179
Q

Bruises to the lung are seen best where

A

Chest CT scan

180
Q

Bruises to the lung watch out for what

A

Pnumeonia and sepsis

181
Q

Clinical sequlae of pulm contusion

A

Simple SOB to respiratory dysfunction
Innate immune system activation

182
Q

How long should it take for pulm contusion to resolve

A

3 to 5 days

183
Q

Chylothorax injuries are an injury where

A

To the thoracic duct

184
Q

Dx of thoracic duct chylothorax

A

High levels of triglycerides in a large pleural effusion of milk
1000 mL per day = common

185
Q

Chylothorax management

A

Limit short and long chain TRIGLY
Then TPN if req’d
+/- pleural drainage and lung expansion
Operative strategies = only after conservative measures fail

186
Q

Diaphragmatic hernia mgmt

A

Decompress then laparoscopy/laparotomy

187
Q

Aortic transection mgmt

A

Control HR and BP before surgery = beta blocker agents [esmolol / propanolol]
Stent graft

188
Q

When should you suspect great vessel injury

A

Wound at base of neck or in chest

189
Q

Gold standard for great vessel injury imaging

A

Arteriogriography

190
Q

Definitive Treatment great vessel injury

A

Median sternotomy
[with or without neck extension]

191
Q

Blunt cardiac injuries commonly affect what location of the heart

A

Anterior / right ventricle injury to myocardial cells

192
Q

Becks triad

A

HYPOTN muffled heart sounds JVD

193
Q

U/S and FAST are first tests performed when

A

High risk penetrating wounds

194
Q

Cardiac Tamponade without imminent arrest =

A

OR for sternotomy or pericardial window if neg U/S

195
Q

Cardiac arrest imminent or witnessed with Pericardial Tamponade what do you do

A

Rescucitation with thoractomy with pericardiotomy

196
Q

Dont forget what test whe investigating pericardial injury

A

EKG

197
Q

Thoracomty indications

A

RAPID deterioration
Penetrating trauma / pre hospital CPR less than 15 mins
Blunt prehosi[tal CPR less than 10 mins
-Organized Rhythm REQ’d-[even PEA]

198
Q

If you suspect esophageal disruption and thoracostomy produces gastric contents what should you do

A

Thoracotomy

199
Q

3 operative injuries with delayed exploration

A

Retained hemothorax
Post traumatic Empyema
Smaller missed hemorrhages

200
Q

3 ways we avoid complications performing thoracostomy

A

Avoid NV bundle by entering above the rib
Perform 360 sweep
Controlled pleural entry

201
Q

What is the triangle of safety for thoracostomy

A

Medial = pectoral is muscle

Lateral = latissimus dorsi

Inferior Border = 4-5th intercostal space

202
Q

Where should you aim when placing the chest tube

A

Towards the apex of the lung

203
Q

When do you stop inserting the chest tube

A

After the last feast ration of the tube is in the chest

204
Q

Which side does the 2 way valve face when attaching to the tube for proper drainage

A

Blue to you!

205
Q

What helps measure drainage of chest tube

A

Pleur evac with 3 chambers

206
Q

What should happen after pleur vac attachment

A

Air leak meter bubbles violently when initially attached then settles within 1 minute

207
Q

Post placement CXR is checking for what with thoracostomy

A

Last fenestration in the chest
Break in Radiopaque line
Tube hugging chest wall
Tubes sits in the apex of the lung

208
Q

What happens inf the wall suction is placed on initially

A

Pulmonary edema refractory to diuretics

209
Q

Initial setting of the chest tube

A

Water seal then 1-2 hours later wall suction

210
Q

Mx during chest tube

A

Keep drainage system below the chest
PO ABX
Pain control

Check for leak everyday!
Measure drainage!
CXR!

211
Q

Chest tube troubleshooting pnuemonic

A

DOPE

Displaced
Obstructed
Positional
Equipment dysfunction

212
Q

If there is an air leak and the connection is okay and the insertion site is okay what is the likely cause

A

Lung injury

213
Q

When can you consider removal of chest tube

A

No air leak on water seal
Less than 200 mL drainage in 24 hours
No PTX

214
Q

What is considered anterior abdominal organs

A

Liver
Spleen
Transverse colon
Small intestine

215
Q

What are considered retroperitoneal organs

A

Duodenum
Pancreas
Kidneys
Aorta
Vena cava

216
Q

Why may penetrating injury in the abdomen need surgery

A

To eval hollow organ injury

217
Q

What is the signficance of dx laparoscopy

A

Stable patients with penetrating abdominal trauma
Establish whether peritoneal penetration has occured
Reduce number of nontherapeutic trauma lapatomies

218
Q

Three main indications for ex lap in blunt trauma

A

Peritonitis
Intrabdominla hemoorhadfe
Associated injuries : diaphragmatic rupture

219
Q

Examples of hollow organs

A

Duodenum
Bladder
Intestine
Gallbladder

220
Q

How do hollow organs typically respond to trauma

A

Spill into abdominal cavity

221
Q

How do solid organs typically respond to trauma

A

Bleed out

222
Q

What can cause an ILEUS (5)

A

Peritonitis
Hypovolemia
Tension PTX
Cardiac Tamponade
Lumbar spine injury

223
Q

Peritonitic pain indications (4)

A

Somatic pain
Distention
Obvious bruising
Sits STILL

224
Q

Percussion and palpation of the abdominal looks for what

A

Dullness = bleeding

Hypertympany = signs of intraperitoneal air

225
Q

What are grey turners cullens and seatbelt sign

A

Other signs of intraperiotneal injury

226
Q

What labs should you get with abdominal injury

A

CBC
CMP
UA
Special Tests

227
Q

What can CT imaging often miss

A

Hollow viscous injury

228
Q

What will CT show instead that indicated hollow viscous injury

A

Fat stranding
Pnuemoperitneum
Free fluid

229
Q

Seat belt sing indicates what

A

Small bowel injury

Chance fx
Hollow viscous injury

230
Q

What labs point towards hollow viscous injury

A

WBC elevations
Amylase
Lactic acid increases !

231
Q

Can U/S distinguish HVI from solid organ injury

A

NO!

232
Q

Blunt trauma abdominal injury image of choice

A

CT if stable

233
Q

What is the abdominal trauma exception to ex lap

A

Tangential GSW
Look for peritoneal penetration then +/- laparotomy

234
Q

If peritoneal penetrated do what

A

Do not force back in evisceration cover with clean dressing and laparotomy

235
Q

When is an NG tube contra

A

Cribifomr plate Fx

236
Q

Blunt abdominal injury with no hemorrhage suspected do what

A

Monitor serial abd exams with low threshold for OR

237
Q

Blunt trauma hemorrhage confirmed =

A

If KIDS + STABLE = monitor

Take to OR is unstable
Most commonly liver and spleen

238
Q

Penetrating injury + shock = what txm

A

Ex lap surgery

239
Q

Most commonly injured bowel

A

SMALL over large

240
Q

Liver damage occurs commonly from what type of trauma

A

Penetrating

241
Q

If liver injury FAST+ stable what can you do ; with active bleed

A

CT

Angio

242
Q

What is a grade 4 injury that needs repeat U/S imaging

A

Hematoma ; ruptured intraparencyhmal hematoma with active bleeding

243
Q

If ASX but grade 4 or 5 injury damage to the liver what is the management

A

CT scan repeats to r/o psuedoanuerysm

244
Q

Post discharge routine imaging for liver

A

4 to 8 weeks after injury

high grade should be Reimaged at 3 months prior to return to contact sports

245
Q

Are stab wounds likely to injure the spleen

A

NO!

246
Q

Penetrating splenic injury with hypotension or peritonitis =

A

Emergent lap

247
Q

Stable patient with spleen injury gets what

A

Infused CT scan to dx extent of injury

248
Q

Retroperitoneal location and direct blow to the epigastrium commonly injure what organs

A

Duodenum and pancreas

249
Q

Physical exam of duodenal and pancreatic trauma

A

Vague abdominal back or flank pain
Lower spine fx r/q req’d

250
Q

What labs increase suspicion for pancreatic trauma

A

Lipase! and amylase Raised

*need further eval

251
Q

Duodenum and pancreatic dx imaging of choice

A

CT

252
Q

What kind of contrast can aid in duodenal and pancreatic injury

A

Intraluminal ; to look for extravasation or retro air fat stranding and unexplained fluid ; wall thickening

253
Q

How much blood can occur with pelvic trauma

A

4 L of blood may accumulate retroperitoneal

254
Q

When is a pelvic fx usually present (special test)

A

Manual compression of the distraction of the Iliac crests = abnormal movement or pain

255
Q

If urethral injury is suspected what should you NOT do

A

Place bladder catheter (NO!!!!!!!!!!!

256
Q

Pelvic trauma + unstable get what?

A

FAST for pelvic blood
Arterial Vs Venous

257
Q

Arterial hemorrhage can be checked in pelvic trauma by what

A

Contrast CT scan

258
Q

If CT is positive in pelvic fx do what

A

Abrupt cutoff of an arter on CT = Angio embolization

259
Q

If unstable pelvic fx with venous hemorrhage mgmt?

A

Place external fixation device

260
Q

Pelvic trauma mgmt

A

Eval for hemorrhage
Skin traction
Pelvic blunder
External fixation = ortho
EVAL URETHRAL INJURY

261
Q

Positive urethral injury in pelvic fx do what

A

Consult urology -> urostomy / Suprapubic catheterization

262
Q

Why can abdominal compartment syndrome occur

A

Increased peak airway pressure
Decreased cardiac output
Systemic vascualr resistance

263
Q

What should you eval for when the abdomen is closed and you suspect compartment syndomre

A

Acidosis
Decreased u/p
Increased lactate

264
Q

Treatment of choice for abdominal compartment syndrome

A

Decompressive lap

265
Q

2 types of drains in pelvic trauma post op care

A

Jackson Pratt = closed under suction

Penrose = allows serious drainage dec wound healing no suction

266
Q

Terms :

Alert
Stupor
Obtunded
VEgetative
Comatose

A

Alert = awake and immediately responsive to all stimuli
Stupor = less alert but still responds with stimulation
Obtunded = asleep but still repspodns to noxious stimuli
VEgetative = arousal without awareness
Comatose = appears asleep and does not respond to stimuli

267
Q

Where are the bleeding scalp vessels

A

Deep to the hair follicles at the level of the galea

268
Q

Where do you want to avoid scalp cautery

A

Superficial layers = Alopecia

269
Q

Should you use an active drain over a skull fx

A

NO!

270
Q

Layers of the scalp by SCALP

A

Skin
Connective tissue
Galea (apneurosa)
Loose Areola r tissue
Pericranium

271
Q

What are the two components of consciousness

A

Arousal and awareness

272
Q

What type of skull fx needs surgery

A

Open depressed

273
Q

Basilar skull fx signs

A

Periorbital exxhymosis
Retroauricular hematoma
CSF from nose/ear
Hemotympanum

274
Q

Complications of basilar skull fx

A

Vascular epidural hematoma
CN defect it’s = 3;4;5
CSF leak = meningitis concern

275
Q

What is primary Brian injury ; sxs

A

Damage to brain parenchyma and blood vessels =

Ischemia
Hematoma
Anoxia
Shear injury

276
Q

What is secondary brain injury

A

Hypoxia
HYPOTN
Increased ICP
Hyper or Hypo glycemic
Seizures = TBI

277
Q

When are brain injuries found on the primary survey

A

Disability = ID Neuro deficit

278
Q

How often should the airway be reevaluated

A

Every 5 mins

279
Q

When is early orotracheal intubation and ventilation indicated

A

GCS score of 8 or lower
Motor score of 4 or lower

280
Q

Indications for immediate intubation

A

Loss of protective laryngeal reflexes
Ventilatory insuff.

281
Q

What defines Spont hyperventilation

A

PaCO2 less than 26

282
Q

Two of the worst secondary insults of TBI

A

Hypoxia and HYPOTN

283
Q

What is the BEST independent predictor of breathing mortality

A

In hospital oxygen desaturation

284
Q

5 signs of hypoxia

A

AMS
Coma
Peripheral vasoconstriction
Tachycardia
Tachypnea

285
Q

What can give false readings for pulse ox

A

Cold temps
Poor peripheral perfusion
CO poisoning

286
Q

Calculation of cerebral perfusion pressure

A

CPP = MAP - ICP

287
Q

Normal MAP pressure

A

80-90 = good tissue perfusion

288
Q

Normal ICP

A

= 10-15 a fxn of volume and pressure

289
Q

How do yo calc the MAP

A

Systolic + 2X diastolic // 3

290
Q

What adds up to equal ICP

A

Brain volume / CSF volume / Blood volume

291
Q

How can we manage CSF volume

A

Intraventricular catheters

292
Q

Is intracranial HTN increased pressure or increased blood flow

A

Pressure by volume increase! Of blood CSF and brain volume

293
Q

how can we increase CPP in brain trauma

A

Increase or keep the MAP high

294
Q

GCS of 3 to 8 with abnormal CT scan need

A

ICP monitoring

295
Q

Eye GCS

A

4

Spont
To command
To pain
NONE

296
Q

Verbal GCS

A

5

Oriented
Confused
Inapprorriate
Incomprehensible
NONE

297
Q

Motor GCS

A

6

Obeys
Localized to pain
Withdraws from pain
Abnml FLEX *decorrticate
Abnml EXT *decerebrate
NONE

298
Q

What it’s eh dx for blood pools in the anterior chamber of the eye

A

TBI / Hyphema

299
Q

When may pupils be constricted

A

Narcotics
Organophosphates

300
Q

What metabolic dysfunction can cause a decreased LOC

A

Thyroid dysfunction and Vit B12

301
Q

What image for TBI with acute ischemic stroke

A

MRI

302
Q

Midline shift herniation of brain stem 1st line txm

A

Elevate HOB
Mx ventilation

303
Q

Subdural; vs Epidural

A

Sub = rupture of veins elderly chronic bleed

Epidural
=middle meningeal artery
With lucid interval

304
Q

Does diffuse Axonal injury have midline shift

A

NO!

305
Q

General mgmt elevated ICP

A

Mx SBP 90-110
Mgmt of shock aggressively = phenylephrine

Fluid r2 = NS 145-155

HOB @ 30 degrees above the heart

306
Q

Hyperosmotic therapy

A

HS@ 3%
mannitol if NOT hypotensive QUICK!

307
Q

If yo administer mannitol what do you need to measure serially

A

Sodium
Serum osmolality
Renal fxn

308
Q

Agitation and seizure mgmt in reducing metabolic demand

A

Propofol + Fentanyl

Levetiracetam for 7 days

Last resort = craniectomy

309
Q

Why does hyponatremia occur with elevated ICP

A

Cerebral salt wasting by BNP release (dilation)

310
Q

What volume state is recommended in TBI patients

A

Euvolemic

311
Q

Gold standard with measurement removal of CSF causing pressure and waht is the goal ICP

A

Ventriculostomy

Less than 20

312
Q

Increased ICP can lead to Cushings triad. Explain

A

Elevated SBP Brady irregular resp patterns —-> herniation!

313
Q

Location of Uncal herniation

A

Tentorium cerebellum and same side CN 3 palsy

*dialted unrepsonsive pupil with lateral gaze

314
Q

What type of herniation can lead to respiratory depression and quick death

A

Tonsillar

315
Q

Brainstem herniation mgmt

A

Elevate the HOB
Secure airway
Ensure adequate ventilation

316
Q

Explain hyperventilation

A

Rapid decrease in PCO2
Vasoconstriction which lowers ICP
More room for brain to swell

can decrease CPP to the point of ischemia

317
Q

PCO2 goals in herniation and TBI mgmt

Hyperventilation target

A

35-45 mmHg

25-35 mmHg

318
Q

What layer of the skin integrates the epidermis and dermis

A

Basement membrane zone

319
Q

What are the three zones of thermal injury

A

Zone of coagulation = coagulated necrotic NONVIABLE

Zone of stasis = vasoconstriction and ischemia VIABLE

Zone of hyperemia = vasodilation VIABLE

320
Q

Burn depths

A

First degree

Second degree
-epidermis
-dermis

Third degree

321
Q

Why do full thickness burns require surgical closure

A

No hair follicles to repopulate with new Keratinocytes

322
Q

Are first degree burns included in burn calculation?

A

NO!

323
Q

Mgmt of 1st degree burns

A

APA NSAIDS
Hydrating lotion ETOH based

*heal in 3-4 days without SCAR

324
Q

Hallmark of second degree partial thickness burn

A

Blistering

325
Q

Superficial partial

A

Pink moist painful

326
Q

Superficial deep

A

Extend into reticular layer of dermis Zone of COAG and hyperemia

DRY +/- pain

327
Q

Superficial deep wound healing time

A

3-8 weeks ; severe scare contraction and loss of function possible

328
Q

If a partial thickness burn has not healed in ___ weeks = surgical excision and skin graft

A

3

329
Q

What is pharm management for superficial wounds

A

Cover with slivadine (ABX)

Make sure tetanus is up to date

330
Q

Do third degree burns blanch with pressure

A

NO!

331
Q

How do third degree burns heal

A

Only by contraction or migration of keratinocytes from PERIPHERY

With surgical excision of necrotic tissue

332
Q

Initial txm of third degree burn

A

Rinse
Dress
Elevate
ABX cream

Aggressive fluids

333
Q

How long do deep thickness burns take to heal

A

21-30 days

334
Q

Face burns will typically need what ABX

A

Bacitracin

335
Q

Burns to the ears require what ; to prevent what

A

Sulfamylon - PAINFUL

Chondririts

336
Q

If admin narcs for burns what type

A

IV

337
Q

How often should burn dressings be changed

A

24-48 hours ; in position of FXN

338
Q

If skin is excised from burn it needs what

A

Skin graft cover

339
Q

Skin graft from self ; same species ; from another species

A

Auto
Allo
Xeno

340
Q

What parts of the body need fuel thickness skin graft

A

Face neck and hands

341
Q

Burn patients need what consideration

A

Air way Management EARLY

342
Q

How can you monitor increased fluid loss in burn pts

A

ABG
Lactate
CPP monitor

343
Q

Describe los of intravascular fluid and protein in heat injured capillaries

A

Greatest in 6-8 hours then returns bu 36-48 hours
Edema by hypopreoteinema

344
Q

What is the burn systemic inflammatory response

A

Release of oxidants cause a decrease in cell energy and membrane potential

Sodium and water flow into the intracellular space

345
Q

Describe burn shock

A

Hypovolemic and cellular

decreased cardiac output, increased extracellular fluid, decreased plasma volume, and oliguria

346
Q

When are fluid losses most apparent in burn injury

A

First 8-12 hours

347
Q

If AKI develops from burn injury what mgmt

A

Vasopressors

348
Q

Target urine output in burn patients

A

30-50 mL / h

349
Q

If UOP increases to more than 1 mL /kg / hour during rescucitation do what to IVF?

A

Decrease by 25%

350
Q

Rule of tens for burn fluid mgmt

A

10 % TBSA > than 40kg and if greater than 80 kg + 100mL for ever 10 kg over 80

351
Q

Treatment for circumferential burns

A

Escharotomy

352
Q

Describe metabolism and cellular fxn in burn patients

A

Increase in pro inflammatory cytokines and oxidants = increaed metabolic rate

Control = beta blocker ; insulin ; GH ; testosterone

353
Q

How can you fix contracture after Burns

A

Z plasty

354
Q

Electrical burns have what type of metabolic effect

A

Myoglobinuria

355
Q

Acidic / alkalinic chem burn effects

A

Coagulation Necrosis

Liquefaction necrosis

DILUTE AND SPLINT

356
Q

Wound healing phases

A

Inflammation
Migration
Maturation

357
Q

If the inflammatory stage of wound healing is prolonged expect what

A

Abnormal wound healing

358
Q

Maturation of wounds takes how long

A

Weeks to months

*80% of tensile strength regained at 6-8 weeks

359
Q

Closure types (3) of wounds

A

Primary

Secondary

Tertiary

360
Q

Explain tertiary intention

A

Delayed primary closure
Wounds debrides 1st then close by primary intention after

361
Q

1st mgmt of hematoma

A

Direct pressure

362
Q

How long should an abrasion heal after secondary intention

A

7 to 14 days

363
Q

If abrasion debris are not removed in 24-48 hours what can occur

A

Traumatic tattooing

364
Q

Mgmt of punctures

A

Typically left open

365
Q

If a puncture presents with uncompcellulitis mgmt

A

Oral ABX

366
Q

Laceration can be mgmt how

A

Primarily if into Sub Q tissue

Secondary if contaminated

367
Q

Mgmt of crush wound

A

U/S or MRI to I’d hematoma
R/o compartment syndrome

368
Q

Compartment syndrome after crush injury should be max how

A

Restore Bp
Remove dressings
Limb at heart level

Forced mannitol alkaline diuresis

369
Q

Mgmt of extravasation wound

A

I and D / aspirate / skin graft or flap coverage

370
Q

Human bite wound ABX

A

Augmentin

Get x rays to eval fx or open joint injury

371
Q

Spider bites can result in what

A

Liquefactive necrosis

372
Q

High velocity wounds from small entry (GSW) get what txm

A

Extensive debridement
ID of injured tissue with general anesthesia

Secondary or delayed primary closure

373
Q

How can you minimize pain in secondary intention

A

Negative pressure wound dressing

374
Q

Puncture wound mgmt

A

Allow secondary intention and insert gauze packing ;

change daily

375
Q

Wound complicated discharge or could odor mgmt

A

I&D Manage with NPWD ABX

Wet to dry dressing

376
Q

2 disease states that lead to chronic wounds

A

Diabetes and obesity

377
Q

4 wound healing necessities

A

Oxygen

Nutrition

Appropriate wound bed

Wound moisture

378
Q

Main factor leading to delayed wound healing

A

Profound inflammatory state

379
Q

Pressure ulcer mgmt commonly

A

Primary closure

380
Q

6 wound dressings

A

Films

Foams

Hydrogels

Alginates

Hydrocolloids

381
Q

What wound dressing has best absorbency

A

Foams

382
Q

What wound dressing has best comfort

A

Aliganates

383
Q

What wound dressing has good comfort pain relief and debridement

A

Hydrogels

384
Q

What dressing provides best environment protection

A

Films

385
Q

Hydrogels are good but they require what

A

High follow up

386
Q

Chronic wound recommendations

A

Infection control
Debridement
Secondary wound closure x 2 weeks
—If not = top ABX

Block 3 Surgery (1 decks)

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