Surgical Trauma Flashcards
Head on collision MVA high speed collision anticipated mechanism
Blunt trauma
MVA pertinent medical hx
Telemetry data
Airbag deployment
Scene timeline
Blunt mechanism organ trauma commonly what 2
Liver ; spleen [ not necessarily operative ]
Liver Mangement low grade to grade 4
Non op; angiography
High grade injury repeat images
4-8 weeks later
Change between stage 2 and 3 acute hemmorhage
Stage 3 = 1500 loss with loss of vital signs
GCS of a person that is intubated what can you do to check disability
Brain stem reflex by checking anisocoria
Peripheral pulses are absent indicates need for what
OR because the LIMB is threat ; critical beyond 6 hours
When a multi trauma comes in post MVA what should you start with?
Primary survey ABC’s
Pelvic instability needs what
Pelvic binder
Do TBI’s benefit from blood transfusions
YES it increases the MAP
If an unstable patient becomes stable post primary survey management what do you do next
Secondary survey
Poly trauma patient needs what type of CT
Pan CT
Are TBI’s commonly a cause of Hemodynamic instability in a trauma patient
NO!
2 things that limit exam of abdomen in a patient with
Distracting injuries
Altered sensorium
Look for what 2 things on an abdominal exam
Distention =
Bruising
In a patient with a left Subdural hematoma GCS of 9 what contributes to left subdural hematoma
Bp of 70/50 for approx 10 minutes order to arrival to the hospital
MAP - ICP = CPP (60-70 = normal)
Are diminished pulses the same as absent pulses
No absent indicates a critical limb ; needs OR
Left flank bruise ; with hematuria non op mgmt
IVF
U/O
Bed Rest
Chance fx AKA ____ fx makes the likelihood of a hollow viscous injury
TP - transverse process
High!
SubQ emphysema in the setting of PTX makes you concerned for what
Tracheo bronchial injury
Best ways to ensure intubation
Visualization and capnography showing normal waveform
Hypotensive with negative FAST what is the best mgmt
Blood products
Best control of widened medistinum wiht aortic involvement best mgmt
Impulse control with BB
Pericardial Tamponade definitive treatment
Sternotomy
U/S neg but pt would benefit from surgical intervention of pericardial Tamponade what do you do ; FAST negative
Pericardial window
Tracheo bronchial injury ; indications for this treatment
Thoroctomy
Blood loss exceeding limits
Esophagus injury with GI contents out the chest tube
ETOH after stab wound what is the Likely physical exam finding
Tender abdomen
Breath sounds present and equal bilaterally
10th intercostal space unstable is probably a what and needs what
Subdiaphragmtic injury
Ex lap
An evsiceration s/p wound injury needs what
OR
Less invasive way to check for peritoneal violations
Laparoscopy
Blunt trauma commmonly what organs and what mgmt
Liver spleen; non operative
What is the fast not sensitive for
Retro peritoneal structures
Good follow up for neg FAST imaging with high suspicion
CT if stable
Stab wound rigid and tender diffusely ; what mgmt
Ex Lap
When would you do a local wound exploration
Stab to abdomen alert and hemodynically normal and his abdominal examination is Normal
Most common hollow viscous organ injured in abdominal trauma
Small Bowel
What is the most important component of the GCS if they are in tact
Motor
Anisocoria is defined as
Greater than 1mm difference between pupils indicative of ICP increase
CSF leaks require what
ABX if leak persists longer than 7 days
Most common cervical fx in trauma
C1 - Jefferson and C2 - hangman
GCS of 8 and TBI concern injury get what
Endotracheal intubation
What is Cushings triad
If you cauterize at the level of the Galeal what happens
Alopecia
What level of midline shift is concerning in Subdural
5 mm shift
Reasons for ICP monitoring
Positive CT finding with mass effect
Na resuscitation
145 with normal saline
What is a ;good adjunct mgmt for ICP increased
Keppra 7 days seizure prophylaxis
What is worse outcome in a subdrual hematoma wiht GCS of 9
Any HyPOTENSION
Rule of 9s
Why do you perform escharotmy
To relive what may be a tourniquet around the leg
Electrical burns main concern and intervention
Cardiac monitoring
Admit to burn center criteria
Grater 10% TBSA in kids
Greater 40% in adults
Face hands genitalia
Electrical burns
Polytruama burns
Greater 5 % full thickness
Tri modal death distribution
Seconds to minute after injury [Massive Trauma]
Minutes to hours [Blood Loss Injuries]
Days to weeks [Sepsis]
IDME
Immediate
Delayed
Minimal
Expectant
Set up of triage
Single point good flow
Sufficient labor and traffic; with dedicated casualty recorders
No treatment in the triage
Four steps of field triage
Vital signs and LOC
Anatomic evidence of injury
Mechanism of injury
Special patients systemic considerations
What GCS is required for transportation ot a higher level of trauma
13
5 management priorities
Stop major bleeding
Secure the airway
Ventilate
Restore circulation
Assess GCS and splint obvious fractures
Delayed triage
Examples
Wounded but STABLE
Globe injuries
Facial fx
Blunt trauma - shock
Burns
Lacerations
STABLE BUT NEED HIGHER LEVEL OF CARE
Minimal triage
Examples
Minor injuries
Minor laceration
Minor burns
Small bone Fx
Expectant triage
Non salvageable injury
GSW with coma
Shock
Severe burn
High spine injury
No vital signs
No Abandoning!
Reassessment criteria
Loosen tourniquets
Bandage placement check
Check distal pulses
Assess breathing and ventilation
Medevac reports
9 Line MEDEVAC
MIST reports
What comes in the MIST report
Mechanism
Injuries
Sxs Vitals
Treatments given
What is the primary surgery
XABCDE
Address LIFE LIMB EYESIGHT
How do you assess breathing
Chest wall motion
Chest wall tenderness
Respiratory rate
How do you check disability
GCS
Pupil response
What are the 2 most rapid causes of death
Loss of airway
Massive bleeding SBP less then 90 + HR greater than 130
What does a portable CXR assess
Mediastinum
Tension PTX
Massive HTX
When is the primary survey performed?
POI
en route
Immediately in the trauma bay
Example of trauma imaging (4)
CXR
ABD X-RAY
Fx
FAST
3 examples of hemorrhage control
Tourniquets HIGH AND TIGHT
Direct pressure
Hemostatic bandages
4 signs of airway obstruction
Foreign bodies or debris
ID of facial fx or
tracheal laryngeal injury
Suction to clear secretions or blood
What is the requirement for a OPA tube or Supraglottic airway
Need to have no gag reflex
Endotracheal intubation :
Placed in trachea
Definitive
Need laryngoscope or video
What is a surgical airway
Cricothyrotomy
Flail chest presentation
At least 2 fx per rib in at least tow ribs creating a free segment
Paradox respirations
Increased pCO2 with vent difficulty
Decreased profusion
Tension PTX location for decompression
4-5 ICS AAL
Open PTX sucking chest wound gets what management
Chest seal device
How can we optimize o2 delivery
Max cardiovascular performance
Initial assessment of circulation (3)
Pulse
LOC
Skin perfusion
Where do you estimate pulse with SBP
Radial Pulse = higher than 90
Femoral pulse = higher 70
Carotid pulse = higher than 30
What stage of acute hemorrhage often follows a vital signs change
Stage 3
How do you begin initial rescucitation
Saline LOCK
Class 3 hemorrhage gets what Mangement
Early blood products in 20 mins
1:1:1
What type of fluid rescucitation will worsen trauma induced coagulapthy
Crystalloids
What is contained in component therapy
1 U PRBC
1 U PLT
1 U CRYO
COAG factors 65%
What is contained in a warm whole blood therapy
500 mL whole blood
High Hct/platelet/ COAG concentration 100%
Disability assessment (3)
Assess
GCS
AVPU
Symmetry of pupil exam for disability
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
CN3 Brian stem herniation through tentorium cerebelli will manifest as what physical exam findings
Lateral gaze and dilated pupil
When can the secondary survey begin
After primary ABCDE
And Hemodynamics stable
What is a good hx to get in secondary survey
AMPLE
Allergies
Medications
Past illness
Last oral intake
Events / Environment
What are the two categories of injury in trauma
Penetrating injury and Blunt trauma
How do penetrating vs blunt trauma injuries present
Penetrating = local
Blunt = multi system
What type of trauma presents with hollow viscous injury
Blunt
What are the 3 priorities of secondary survey
ID wounds
ID operation requirements
Additional testing requirements
Where is zone 2 of the neck and what is the dispo
Just below the cricoid to the distal lip (ramus)
Alert and stable but no HARD injuries = expectant management
Stable without obvious neck injury should get what
CTA to r/o occult vascular structures
Main mgmt of chest penetrating trauma
THORACOSTOMY
If cardiac injury suspected get what?
ED U/S
What is persistent instability without evidence of intrathoracic bleeding commonly
Pericardial Tamponade
Thoracic spinal cord injury will likely cause
Neurogenic shock
If intrathoracic bleed is outside the pericardium what do you need
Stabilize after tube throcostomy and modest volume loading
Penetrating wound that violates the peritoneal cavity gets what
GSW that is suspicious needs what
Laparotomy
Laparoscopy
Where are you exploring with superficial stab wounds to rule out deep penetration in the anterior abdomen
Anterior fascia (should be intact)
Injuries to what structures are considered retroperitoneal
Flank back and pelvis
What are most retroperitoneal colon injuries identified on the basis of
Extraluminal gas or fluid
Rectal injury suspected perform what
Sigmoidoscopy
Unstable patient with iso penetrating injury to the extremity gets what
External compression and then prompt triage to OR
Example of hard signs of arterial injury (5)
External bleeding
Pulsatile hematoma
Absent distal pulse
Palpable thrill/bruit
Signs of distal ischemia
Signs of distal ischemia need what
OR for on table Angio
What 3 conditions are commonly treated with fasciotomy
Fractures
Burns
Snake bites
Indications for fasciotomy (5)
Arterial and Venous injury
Massive soft tissue damage
Delta between injury and repair
Prolonged hypotension
Excessive swelling or high tissue pressure
Most common MOI in blunt trauma (4)
Fall from standing
Height fall
MVC
Assault
Initial blunt trauma screens should focus on what areas
Chest
Abdomen
Pelvis
Most reliable screening test for intrathoracic bleeding
CXR
How much blood can be sequestered in the peritoneal cavity with minimum abdominal Distention
3 L
Most rapid reliable method of indetifying intrabdominal free blood
FAST
4 initial management interventions for unstable pelvis
Blood volume replacement
Application of pelvic binder
Eval the response to rescucitation
Perform U/S
Unstable patient wiht postieve findings on U/S should get
Laparotomy
No evidence of bleeding and unstable pelvis
External pelvis fixation and preperiotnela pelvic packing in the OR
Then Angio
Blunt trauma commonly presents with
Shock
Who should get ICP monitoring (3)
CT + evidence of ICP
GCS less than 9
Lateral neural injury
When is craniotomy considered in TBI
GCS score less than 9 and a lateralizing Neuro exam
Is hypotension assoc with closed head trauma
NO ; investigate for bleeding
Bleed vs TBI mnmgt
Bleed control top priority
Are blunt cerebral vascular injuries often sxs
YES
How do we prevent neurologic morbidity in TBI
Early diagnosis and therapeutic anti coagulation
What is gold standard initial screen in cerebral vascular injuries
CTA of the neck
3 chest injuries to be ruled out in the secondary survey
Rib fx
Blunt cardiac injury
Blunt aortic injury
If fx of 1st rib r/o what
Blunt cardiac injury
Flail chest with pulmonary contusion consider what
Early intubation
ADMIT
Pain control = EPIDURALS
What type of PTX is likely observed
Occult
Immediate treatment of tensionPTX
Large bore needle
Definitive treatment of tension PTX
Tube thoracostomy with
ECG findings for pericardial Tamponade
Electrical alternans
Persistent signs of pericardial Tamponade presentation
Tachycardia and distended neck veins
Good management regimen of blunt trauma
CXR
CTA
GIVE INITAL : beta blocker / operative repair
Rupture of the diaphragm often results in what
Respiratory distress
Hollow viscous injury often presents how?
Delayed
Wall thickening with free fluid
Elevated amylase a
Concerning unset law solid organ injury with positive FAST gets
OR
Stable patient with positive FAST gets
CT with IV contrast
Solid injuries are often managed how
Non op
Angio
What are dispo solid injuries based on
Grade of injury
Arterial contrast extravasion
Injury burden
Patient stability
Most freq GU injured organ =
Renal
GU organ injures often present with what
Hematuria
What two things are important for renal injury management
Must take into account MOI and probability of several kidney injury
After non op management what 3 things should be considered
Bed rest
Foley
Follow up CT
Determine foley requirements
Pelvic fx high suspicion for
Bladder or urethral injury
Urethral injury high suspicion
High riding prostate
Blood in the urethral meats
Blood during rectal exam
How do we r/o urethral injury before cannuilation
RUG with flouro
Blunt trauma operative intervention requirements (3)
CXR = wide mediastinum
ABD = free fluid
Pelvis = extravasation of contrast
6 reasons for early deaths with abdominal trauma
Airway obstruction
Flail chest
Open PTX
Massive Hemothorax
Tension PTX
Cardiac Tamponade
What are you looking for on abdominal trauma physical exam (6)
Cyanosis
Subcutaneous emphysema
Flail chest
Laceration hematoma
JVD
Tracheal deviation
What is the priority with blunt thoracic trauma
Airway management
How are most chest injuries treated including penetration trauma
Non op
What are 4 chest trauma surgical indications
Penetrating with greater than 1.5 L blood loss
Diaphragmatic rupture
Aortic transection
Cardiac Tamponade
Best initial image of chest trauma
Portable CXR
Most common wall injury resulting from blunt trauma
Rib fracture
1st management after image chest trauma
Thoracic epidural analgesia
Dx criteria for flail chest
Rib fx
+ Spont breathing
Non op mgmt of flail chest
Pain control
CAN COUGH
-If not = spirometry
Flail chest + deceased pulm fxn with dec hypoxia or hypercapnia with good pain control gets what
ET tube/ Mech vent
Sternal fx result mostly from where
MVC’s
Management of sternal fx
Initial = rescucitation and excluded life threats
Get ECG and Get chest radiograph
All normal with good PO pain response = outpatient Management
What is the op treatment of choice if we are going to provide it for sternal fx ( not likely )
ORIF
ORIF indications for sternal fx
Non union
Displaced with overriding segments
Severe pain and respiratory compromise
Multiple unstable rib fx
Thoracotomy
Occult PTX may be observed how?
Safely
What happens to the pleural space in Tension PTX progression from simple
Air accumulates in the pleural space causing increased intraplueral pressure
What is the dx for ; unilateral decreased or absent breath sounds, tympany
on the affected side, tracheal deviation, and distention of neck veins.
Tension PTX
Standard first line intervention for Tension PTX
Decompression of the thoracic cavity
14 gauge ; 3.25 inch long needle
Small open pneumo’s initial treatment
Occlusive dressing ; then consider need fro throracostomy
Complications of hemothorax
Atelectasis or Empyema
Hemothorax imaging techniques
CXR then Thoracic CT
Are bruises to the lung more commonly due to blunt trauma or penetrating
Blunt ; both can cause it
Characteristic findings in bruises to the lung
VQ mismatch ; with right to left shunt and hypoxia
Bruises to the lung are seen best where
Chest CT scan
Bruises to the lung watch out for what
Pnumeonia and sepsis
Clinical sequlae of pulm contusion
Simple SOB to respiratory dysfunction
Innate immune system activation
How long should it take for pulm contusion to resolve
3 to 5 days
Chylothorax injuries are an injury where
To the thoracic duct
Dx of thoracic duct chylothorax
High levels of triglycerides in a large pleural effusion of milk
1000 mL per day = common
Chylothorax management
Limit short and long chain TRIGLY
Then TPN if req’d
+/- pleural drainage and lung expansion
Operative strategies = only after conservative measures fail
Diaphragmatic hernia mgmt
Decompress then laparoscopy/laparotomy
Aortic transection mgmt
Control HR and BP before surgery = beta blocker agents [esmolol / propanolol]
Stent graft
When should you suspect great vessel injury
Wound at base of neck or in chest
Gold standard for great vessel injury imaging
Arteriogriography
Definitive Treatment great vessel injury
Median sternotomy
[with or without neck extension]
Blunt cardiac injuries commonly affect what location of the heart
Anterior / right ventricle injury to myocardial cells
Becks triad
HYPOTN muffled heart sounds JVD
U/S and FAST are first tests performed when
High risk penetrating wounds
Cardiac Tamponade without imminent arrest =
OR for sternotomy or pericardial window if neg U/S
Cardiac arrest imminent or witnessed with Pericardial Tamponade what do you do
Rescucitation with thoractomy with pericardiotomy
Dont forget what test whe investigating pericardial injury
EKG
Thoracomty indications
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]
If you suspect esophageal disruption and thoracostomy produces gastric contents what should you do
Thoracotomy
3 operative injuries with delayed exploration
Retained hemothorax
Post traumatic Empyema
Smaller missed hemorrhages
3 ways we avoid complications performing thoracostomy
Avoid NV bundle by entering above the rib
Perform 360 sweep
Controlled pleural entry
What is the triangle of safety for thoracostomy
Medial = pectoral is muscle
Lateral = latissimus dorsi
Inferior Border = 4-5th intercostal space
Where should you aim when placing the chest tube
Towards the apex of the lung
When do you stop inserting the chest tube
After the last feast ration of the tube is in the chest
Which side does the 2 way valve face when attaching to the tube for proper drainage
Blue to you!
What helps measure drainage of chest tube
Pleur evac with 3 chambers
What should happen after pleur vac attachment
Air leak meter bubbles violently when initially attached then settles within 1 minute
Post placement CXR is checking for what with thoracostomy
Last fenestration in the chest
Break in Radiopaque line
Tube hugging chest wall
Tubes sits in the apex of the lung
What happens inf the wall suction is placed on initially
Pulmonary edema refractory to diuretics
Initial setting of the chest tube
Water seal then 1-2 hours later wall suction
Mx during chest tube
Keep drainage system below the chest
PO ABX
Pain control
Check for leak everyday!
Measure drainage!
CXR!
Chest tube troubleshooting pnuemonic
DOPE
Displaced
Obstructed
Positional
Equipment dysfunction
If there is an air leak and the connection is okay and the insertion site is okay what is the likely cause
Lung injury
When can you consider removal of chest tube
No air leak on water seal
Less than 200 mL drainage in 24 hours
No PTX
What is considered anterior abdominal organs
Liver
Spleen
Transverse colon
Small intestine
What are considered retroperitoneal organs
Duodenum
Pancreas
Kidneys
Aorta
Vena cava
Why may penetrating injury in the abdomen need surgery
To eval hollow organ injury
What is the signficance of dx laparoscopy
Stable patients with penetrating abdominal trauma
Establish whether peritoneal penetration has occured
Reduce number of nontherapeutic trauma lapatomies
Three main indications for ex lap in blunt trauma
Peritonitis
Intrabdominla hemoorhadfe
Associated injuries : diaphragmatic rupture
Examples of hollow organs
Duodenum
Bladder
Intestine
Gallbladder
How do hollow organs typically respond to trauma
Spill into abdominal cavity
How do solid organs typically respond to trauma
Bleed out
What can cause an ILEUS (5)
Peritonitis
Hypovolemia
Tension PTX
Cardiac Tamponade
Lumbar spine injury
Peritonitic pain indications (4)
Somatic pain
Distention
Obvious bruising
Sits STILL
Percussion and palpation of the abdominal looks for what
Dullness = bleeding
Hypertympany = signs of intraperitoneal air
What are grey turners cullens and seatbelt sign
Other signs of intraperiotneal injury
What labs should you get with abdominal injury
CBC
CMP
UA
Special Tests
What can CT imaging often miss
Hollow viscous injury
What will CT show instead that indicated hollow viscous injury
Fat stranding
Pnuemoperitneum
Free fluid
Seat belt sing indicates what
Small bowel injury
Chance fx
Hollow viscous injury
What labs point towards hollow viscous injury
WBC elevations
Amylase
Lactic acid increases !
Can U/S distinguish HVI from solid organ injury
NO!
Blunt trauma abdominal injury image of choice
CT if stable
What is the abdominal trauma exception to ex lap
Tangential GSW
Look for peritoneal penetration then +/- laparotomy
If peritoneal penetrated do what
Do not force back in evisceration cover with clean dressing and laparotomy
When is an NG tube contra
Cribifomr plate Fx
Blunt abdominal injury with no hemorrhage suspected do what
Monitor serial abd exams with low threshold for OR
Blunt trauma hemorrhage confirmed =
If KIDS + STABLE = monitor
Take to OR is unstable
Most commonly liver and spleen
Penetrating injury + shock = what txm
Ex lap surgery
Most commonly injured bowel
SMALL over large
Liver damage occurs commonly from what type of trauma
Penetrating
If liver injury FAST+ stable what can you do ; with active bleed
CT
Angio
What is a grade 4 injury that needs repeat U/S imaging
Hematoma ; ruptured intraparencyhmal hematoma with active bleeding
If ASX but grade 4 or 5 injury damage to the liver what is the management
CT scan repeats to r/o psuedoanuerysm
Post discharge routine imaging for liver
4 to 8 weeks after injury
high grade should be Reimaged at 3 months prior to return to contact sports
Are stab wounds likely to injure the spleen
NO!
Penetrating splenic injury with hypotension or peritonitis =
Emergent lap
Stable patient with spleen injury gets what
Infused CT scan to dx extent of injury
Retroperitoneal location and direct blow to the epigastrium commonly injure what organs
Duodenum and pancreas
Physical exam of duodenal and pancreatic trauma
Vague abdominal back or flank pain
Lower spine fx r/q req’d
What labs increase suspicion for pancreatic trauma
Lipase! and amylase Raised
*need further eval
Duodenum and pancreatic dx imaging of choice
CT
What kind of contrast can aid in duodenal and pancreatic injury
Intraluminal ; to look for extravasation or retro air fat stranding and unexplained fluid ; wall thickening
How much blood can occur with pelvic trauma
4 L of blood may accumulate retroperitoneal
When is a pelvic fx usually present (special test)
Manual compression of the distraction of the Iliac crests = abnormal movement or pain
If urethral injury is suspected what should you NOT do
Place bladder catheter (NO!!!!!!!!!!!
Pelvic trauma + unstable get what?
FAST for pelvic blood
Arterial Vs Venous
Arterial hemorrhage can be checked in pelvic trauma by what
Contrast CT scan
If CT is positive in pelvic fx do what
Abrupt cutoff of an arter on CT = Angio embolization
If unstable pelvic fx with venous hemorrhage mgmt?
Place external fixation device
Pelvic trauma mgmt
Eval for hemorrhage
Skin traction
Pelvic blunder
External fixation = ortho
EVAL URETHRAL INJURY
Positive urethral injury in pelvic fx do what
Consult urology -> urostomy / Suprapubic catheterization
Why can abdominal compartment syndrome occur
Increased peak airway pressure
Decreased cardiac output
Systemic vascualr resistance
What should you eval for when the abdomen is closed and you suspect compartment syndomre
Acidosis
Decreased u/p
Increased lactate
Treatment of choice for abdominal compartment syndrome
Decompressive lap
2 types of drains in pelvic trauma post op care
Jackson Pratt = closed under suction
Penrose = allows serious drainage dec wound healing no suction
Terms :
Alert
Stupor
Obtunded
VEgetative
Comatose
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
Where are the bleeding scalp vessels
Deep to the hair follicles at the level of the galea
Where do you want to avoid scalp cautery
Superficial layers = Alopecia
Should you use an active drain over a skull fx
NO!
Layers of the scalp by SCALP
Skin
Connective tissue
Galea (apneurosa)
Loose Areola r tissue
Pericranium
What are the two components of consciousness
Arousal and awareness
What type of skull fx needs surgery
Open depressed
Basilar skull fx signs
Periorbital exxhymosis
Retroauricular hematoma
CSF from nose/ear
Hemotympanum
Complications of basilar skull fx
Vascular epidural hematoma
CN defect it’s = 3;4;5
CSF leak = meningitis concern
What is primary Brian injury ; sxs
Damage to brain parenchyma and blood vessels =
Ischemia
Hematoma
Anoxia
Shear injury
What is secondary brain injury
Hypoxia
HYPOTN
Increased ICP
Hyper or Hypo glycemic
Seizures = TBI
When are brain injuries found on the primary survey
Disability = ID Neuro deficit
How often should the airway be reevaluated
Every 5 mins
When is early orotracheal intubation and ventilation indicated
GCS score of 8 or lower
Motor score of 4 or lower
Indications for immediate intubation
Loss of protective laryngeal reflexes
Ventilatory insuff.
What defines Spont hyperventilation
PaCO2 less than 26
Two of the worst secondary insults of TBI
Hypoxia and HYPOTN
What is the BEST independent predictor of breathing mortality
In hospital oxygen desaturation
5 signs of hypoxia
AMS
Coma
Peripheral vasoconstriction
Tachycardia
Tachypnea
What can give false readings for pulse ox
Cold temps
Poor peripheral perfusion
CO poisoning
Calculation of cerebral perfusion pressure
CPP = MAP - ICP
Normal MAP pressure
80-90 = good tissue perfusion
Normal ICP
= 10-15 a fxn of volume and pressure
How do yo calc the MAP
Systolic + 2X diastolic // 3
What adds up to equal ICP
Brain volume / CSF volume / Blood volume
How can we manage CSF volume
Intraventricular catheters
Is intracranial HTN increased pressure or increased blood flow
Pressure by volume increase! Of blood CSF and brain volume
how can we increase CPP in brain trauma
Increase or keep the MAP high
GCS of 3 to 8 with abnormal CT scan need
ICP monitoring
Eye GCS
4
Spont
To command
To pain
NONE
Verbal GCS
5
Oriented
Confused
Inapprorriate
Incomprehensible
NONE
Motor GCS
6
Obeys
Localized to pain
Withdraws from pain
Abnml FLEX *decorrticate
Abnml EXT *decerebrate
NONE
What it’s eh dx for blood pools in the anterior chamber of the eye
TBI / Hyphema
When may pupils be constricted
Narcotics
Organophosphates
What metabolic dysfunction can cause a decreased LOC
Thyroid dysfunction and Vit B12
What image for TBI with acute ischemic stroke
MRI
Midline shift herniation of brain stem 1st line txm
Elevate HOB
Mx ventilation
Subdural; vs Epidural
Sub = rupture of veins elderly chronic bleed
Epidural
=middle meningeal artery
With lucid interval
Does diffuse Axonal injury have midline shift
NO!
General mgmt elevated ICP
Mx SBP 90-110
Mgmt of shock aggressively = phenylephrine
Fluid r2 = NS 145-155
HOB @ 30 degrees above the heart
Hyperosmotic therapy
HS@ 3%
mannitol if NOT hypotensive QUICK!
If yo administer mannitol what do you need to measure serially
Sodium
Serum osmolality
Renal fxn
Agitation and seizure mgmt in reducing metabolic demand
Propofol + Fentanyl
Levetiracetam for 7 days
Last resort = craniectomy
Why does hyponatremia occur with elevated ICP
Cerebral salt wasting by BNP release (dilation)
What volume state is recommended in TBI patients
Euvolemic
Gold standard with measurement removal of CSF causing pressure and waht is the goal ICP
Ventriculostomy
Less than 20
Increased ICP can lead to Cushings triad. Explain
Elevated SBP Brady irregular resp patterns —-> herniation!
Location of Uncal herniation
Tentorium cerebellum and same side CN 3 palsy
*dialted unrepsonsive pupil with lateral gaze
What type of herniation can lead to respiratory depression and quick death
Tonsillar
Brainstem herniation mgmt
Elevate the HOB
Secure airway
Ensure adequate ventilation
Explain hyperventilation
Rapid decrease in PCO2
Vasoconstriction which lowers ICP
More room for brain to swell
can decrease CPP to the point of ischemia
PCO2 goals in herniation and TBI mgmt
Hyperventilation target
35-45 mmHg
25-35 mmHg
What layer of the skin integrates the epidermis and dermis
Basement membrane zone
What are the three zones of thermal injury
Zone of coagulation = coagulated necrotic NONVIABLE
Zone of stasis = vasoconstriction and ischemia VIABLE
Zone of hyperemia = vasodilation VIABLE
Burn depths
First degree
Second degree
-epidermis
-dermis
Third degree
Why do full thickness burns require surgical closure
No hair follicles to repopulate with new Keratinocytes
Are first degree burns included in burn calculation?
NO!
Mgmt of 1st degree burns
APA NSAIDS
Hydrating lotion ETOH based
*heal in 3-4 days without SCAR
Hallmark of second degree partial thickness burn
Blistering
Superficial partial
Pink moist painful
Superficial deep
Extend into reticular layer of dermis Zone of COAG and hyperemia
DRY +/- pain
Superficial deep wound healing time
3-8 weeks ; severe scare contraction and loss of function possible
If a partial thickness burn has not healed in ___ weeks = surgical excision and skin graft
3
What is pharm management for superficial wounds
Cover with slivadine (ABX)
Make sure tetanus is up to date
Do third degree burns blanch with pressure
NO!
How do third degree burns heal
Only by contraction or migration of keratinocytes from PERIPHERY
With surgical excision of necrotic tissue
Initial txm of third degree burn
Rinse
Dress
Elevate
ABX cream
Aggressive fluids
How long do deep thickness burns take to heal
21-30 days
Face burns will typically need what ABX
Bacitracin
Burns to the ears require what ; to prevent what
Sulfamylon - PAINFUL
Chondririts
If admin narcs for burns what type
IV
How often should burn dressings be changed
24-48 hours ; in position of FXN
If skin is excised from burn it needs what
Skin graft cover
Skin graft from self ; same species ; from another species
Auto
Allo
Xeno
What parts of the body need fuel thickness skin graft
Face neck and hands
Burn patients need what consideration
Air way Management EARLY
How can you monitor increased fluid loss in burn pts
ABG
Lactate
CPP monitor
Describe los of intravascular fluid and protein in heat injured capillaries
Greatest in 6-8 hours then returns bu 36-48 hours
Edema by hypopreoteinema
What is the burn systemic inflammatory response
Release of oxidants cause a decrease in cell energy and membrane potential
Sodium and water flow into the intracellular space
Describe burn shock
Hypovolemic and cellular
decreased cardiac output, increased extracellular fluid, decreased plasma volume, and oliguria
When are fluid losses most apparent in burn injury
First 8-12 hours
If AKI develops from burn injury what mgmt
Vasopressors
Target urine output in burn patients
30-50 mL / h
If UOP increases to more than 1 mL /kg / hour during rescucitation do what to IVF?
Decrease by 25%
Rule of tens for burn fluid mgmt
10 % TBSA > than 40kg and if greater than 80 kg + 100mL for ever 10 kg over 80
Treatment for circumferential burns
Escharotomy
Describe metabolism and cellular fxn in burn patients
Increase in pro inflammatory cytokines and oxidants = increaed metabolic rate
Control = beta blocker ; insulin ; GH ; testosterone
How can you fix contracture after Burns
Z plasty
Electrical burns have what type of metabolic effect
Myoglobinuria
Acidic / alkalinic chem burn effects
Coagulation Necrosis
Liquefaction necrosis
DILUTE AND SPLINT
Wound healing phases
Inflammation
Migration
Maturation
If the inflammatory stage of wound healing is prolonged expect what
Abnormal wound healing
Maturation of wounds takes how long
Weeks to months
*80% of tensile strength regained at 6-8 weeks
Closure types (3) of wounds
Primary
Secondary
Tertiary
Explain tertiary intention
Delayed primary closure
Wounds debrides 1st then close by primary intention after
1st mgmt of hematoma
Direct pressure
How long should an abrasion heal after secondary intention
7 to 14 days
If abrasion debris are not removed in 24-48 hours what can occur
Traumatic tattooing
Mgmt of punctures
Typically left open
If a puncture presents with uncompcellulitis mgmt
Oral ABX
Laceration can be mgmt how
Primarily if into Sub Q tissue
Secondary if contaminated
Mgmt of crush wound
U/S or MRI to I’d hematoma
R/o compartment syndrome
Compartment syndrome after crush injury should be max how
Restore Bp
Remove dressings
Limb at heart level
Forced mannitol alkaline diuresis
Mgmt of extravasation wound
I and D / aspirate / skin graft or flap coverage
Human bite wound ABX
Augmentin
Get x rays to eval fx or open joint injury
Spider bites can result in what
Liquefactive necrosis
High velocity wounds from small entry (GSW) get what txm
Extensive debridement
ID of injured tissue with general anesthesia
Secondary or delayed primary closure
How can you minimize pain in secondary intention
Negative pressure wound dressing
Puncture wound mgmt
Allow secondary intention and insert gauze packing ;
change daily
Wound complicated discharge or could odor mgmt
I&D Manage with NPWD ABX
Wet to dry dressing
2 disease states that lead to chronic wounds
Diabetes and obesity
4 wound healing necessities
Oxygen
Nutrition
Appropriate wound bed
Wound moisture
Main factor leading to delayed wound healing
Profound inflammatory state
Pressure ulcer mgmt commonly
Primary closure
6 wound dressings
Films
Foams
Hydrogels
Alginates
Hydrocolloids
What wound dressing has best absorbency
Foams
What wound dressing has best comfort
Aliganates
What wound dressing has good comfort pain relief and debridement
Hydrogels
What dressing provides best environment protection
Films
Hydrogels are good but they require what
High follow up
Chronic wound recommendations
Infection control
Debridement
Secondary wound closure x 2 weeks
—If not = top ABX
