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Trauma 1 Flashcards

1
Q

What is stage 3 shock?
EBL
HR
BP
RR

A

When you’re unstable - RULE of 3s

EBL = 30% blood volume (2000cc)
HR >130
BP decreased (can’t compensate)
RR 30
Resus with cystalloid and blood

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2
Q

Whats the ratio of blood products for an MTE? What is an adverse reaction of giving pRBC

A

1:1:1
RBC:platelets:FFP

pRBC w/ citrate (preservative) - cause hypoCa

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3
Q

Describe stable vs unstable values for:
Lactate
pH
Base deficit

A

NORMAL
Lactate <2.5
pH > 7.2
Base deficit < -5.5

ABNORMAL
Lactate >4
pH <7.2
Base deficit > -6

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4
Q

What is a time goal for femur fracture fixation if concomitant abdominal injury?

A

> 12hrs - if appropriate

1 study that shows >50% risk reduction of complications when femur definitively fixed >12hrs from severe abdominal injury present

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5
Q

Is organ failure after trauma faster for kids or adults

A

Kids

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6
Q

What is independently associated w/ complications in poly trauma pt w/ pelvis frx

A

Severe chest injury

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7
Q

List the GA classification + abx required

A

1 = <1cm
- Cephalosporin
2 = <10cm
- “ “
3 = >10cm, significant periosteal stripping even with small wound
- “ “ + aminoglycoside / OR 3rd gen cephalosporin alone (ceftriaxone)

3A = primary closure
3B = flap
3C = vascular injury requiring repair

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8
Q

3 most important interventions for decreasing infection with open fractures

A

TIMING IV abx
Time to thorough I&D (not time to definitive surgery)
Time to transfer to a definitive trauma center (LEAP/Pollak data!)

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9
Q

What is goal for ST coverage for open frx

A

<7 days - longer is associated w/ infx

Increase by 16% per day after this

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10
Q

What abx do you add to open frx prophylaxis for:
1. Water contamination
2. Farm contents or bowel/ischemia

A
  1. Quinolone
  2. Penicillin
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11
Q

Findings of FLOW

A

No benefit pulse lavage (increased cost)
High reop if you use soap (vs saline alone)

AKA saline on gravity!!!

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12
Q

What are the options for bone defects in open frx
<5cm
5-10cm
>10cm

A

<5cm - autograft +/- Masquelet
5-10cm - graft or transport
>10cm - bone transport (1mm/day)

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13
Q

What was the initial finding for LEAP at 2 years - amp vs salvage?
How did the finding hold at 7 years?

A

2 yrs
No difference in functional outcomes
No diff return to work
Salvage had more
- Complications
- Reop / readmission

7yrs - no difference again, both groups worsened

Aka clinical outcomes more related to social/personal/economic resources that injury management

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14
Q

What is the metabolic changes for the following amp levels
- Syme
- BKA vs short BKA
- AKA

A
  • Syme 15%
  • BKA 10%
    vs short BKA 40%
  • AKA 70%

Through knee worse than AKA

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15
Q

What is the rate of MRSA in ortho trauma pts

A

3%
Think not that common in the world, so shouldn’t be in wounds initially

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16
Q

Compartment pressure dx for compartment syndrome

A

Measured pressure within 30mmHg of DBP

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17
Q

Nerve at risk with dual vs single incision lower leg compartment release

A

Single = CPN
Dual = SPN

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18
Q

3 thigh compartments

A

Lateral = quads
Medial = adductors
Posterior = hamstrings

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19
Q

How many foot compartments are there? 2 options for release

A

9 compartments
Single medial vs 2 dorsal incisions

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20
Q

Wound vacs - what is the data for:
- Open tibias
- Post fasciotomy
- At risk wounds (calc, pilon, etc)
- STSG

A
  • Open tibias = less infx
  • Post fasciotomy = better wound perfusion
  • At risk wounds (calc, pilon, etc) = less infection and wound breakdown
  • STSG = NO diff in healing, more $$
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21
Q

What factor is most important when considering surgical treatment of bullet wounds

A

Low vs high velocity bullet
E = M V^2

Low velocity can leave alone
High velocity - treat like open frx, serial debridement

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22
Q

OTA recs for DVT (pre-PCLOT)
- Initial DVT choice
- Mechanical DVT?
- Duration of AC?
- IVC filters?
- Which fractures may not need AC?

A
  • Initial DVT choice = LMWH (enoxaparin) within 24h of MSK injury
    NOW PCLOT ASA 81 BID
  • Mechanical DVT? YES strong rec
  • Duration of AC? unclear, limited data
  • IVC filters? Against unless PE/DVT on appropriate prophylaxis strong rec
  • Which fractures may not need AC?
    Below knee and able to mobilize
    No diff for Lovenox vs placebo RCT
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23
Q

What is the mechanism of action/reversal if applicable
ASA
Warfarin
Heparin
Xabans
Dabigatran

A

ASA - irreversible thromboxane A2 on platelets

Warfarin - vit K antagonist
- Reverse vit K, FFP

Heparin - increase AT3 (indirect thrombin inhibition)
- Heparin faster onset that LMWH bc also inhibits X1 and IIa
- Reverse heparin w/ protamine

Xabans - factor Xa inhibitor
- Eliquis (apixaban), Xarelto (rivaroxaban)

Dabigatran - direct thrombin inhibitors

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24
Q

Major criteria for dx fat embolism syndrome / trt

A

Hypoxia (PaO2<60) - presents as:
- CNS confusion
- Petechial rash
- Pulm edema

Trt = ventilation support (aka nothing)

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25
Diagnose ARDS
Bilateral CXR infiltrates Less lung compliance PaO2/FiO2 < 200
26
How should you position a pregnant patient if need surgery
Left lat decub - prevent aorta/IVC compression
27
What is the most injury domestic violence? RFs?
Facial frx RF - F - 19-29 - Pregnant NOT race or SE status
28
What are the 2 main posterior SI joint ligaments
Sacrotuberous - resist vertical shear (ischium to sacrum) Sacrospinous - resist ER because more horizontal
29
Tile classification pelvis
A = stable frx (avulsions) B = rotationally unstable (IR/ER) C = rotation + vertically unstable
30
What is the Young Burgess classification pelvis Does this classification predict mortality?
LC - IR forces LC 1 - ramus frx, incomplete vs complete sacral frx (complete = 1.5) 2 - crescent ilium frx 3 - LC with CL ER = windswept pelvis APC - ant-post or ER forces AP 1 <2.5 opening 2 >2.5cm (open book) - anterior SI torn, hinging on the intact post SI lig 3 - everything torn, vertical and rotation unstable Vertical shear Does not directly predict mortality Unstable patterns have higher mortality risk than stable
31
Associated injuries for LC 1/2 LC 3 APC 3 Vertical shear
LC 1/2 - brain LC 3 - bowel injury APC 3 - shock (vascular), ARDS Vertical shear - shock (vascular) Vascular injuries - think about angio, embolization - Superior glut MOST COMMON - Obturator - 2nd most common for LC - Internal pudendal, if injured bilaterally impotence
32
Describe an inlet vs outlet XR
Inlet = true ring XR, sacrum flat Outlet = sacrum vertical
33
What do you see on obturator outlet XR
Supra acetabular pins ("LC-2 screw") - Sup-inf placement - Are you out of the joint
34
What do you see on a teardrop XR? What is a teardrop XR?
Teardrop = OO w/ more outlet Start point for supra acetabula screws
35
What are the Judet XRs? What do you see on each?
Iliac oblique = IOWA - Wall anterior - Post col Obturator oblique - Post wall - Ant col
36
What do you use an obturator inlet XR for
Looking down the iliac wing See if pins are contained in the ilium "See passage of screws through supra-acetabular corridor from AIIS to PSIS"
37
What do you use an obturator outlet XR for?
Iliac crest pins Vertical look at the crest
38
What are the pros/cons for supra acetabular vs crest pins for pelvic ex fix? XRs you need for each
Crest - less C arm dependent, potentially weaker bone - Obturator inlet XR make sure in the wing Supra-tab - strong bone - Teardrop for starting point (OO) - OI to see down the wing and make sure contained in ilium - iliac oblique to keep the pin out of the hip joint and sciatic notch
39
What 2 risks with supra-tab pins
30% LFCN palsy (from compression on outside when sitting) - also see with the in-fix 9% HO
40
What plate for anterior ring
Always 4-6 hole, never 2
41
Iliosacral screws - nerve at risk
L5 > S1 Iliac cortical density shows you L5 - Lateral XR - Stay behind the ICD
42
Why look for sacral dysmorphism
S1 likely hard to use S2 easier
43
What are the 3 zones of sacral frx
1 = lateral to foramen - Neuro rare - If displaced, can be unstable 2 = foramen - Neuro = uniL radiculopathy 3 = involves canal - bilateral radiculopathy or cauda!!
44
Diagnose: - Kyphotic sacrum on sag CT - Bilateral sacral rfx - Paradoxical inlet XR (what does this mean)
Spinopelvic dissociation Paradoxical inlet = you can see S1 on the AP pelvis
45
How do you fix spinopelvic dissociation
Triangular osteosynthesis Iliosacral screw Unilateral lumbopelvic fixation
46
Which bladder injuries do you have to fix with pelvic frx
Intraperitoneal - look for contrast in bladder tracking up into abdomen
47
Best XR for vertical shear
Outlet
48
How treat medial physeal clavicle fractures (vs SC joint dislocation)
Physeal frx - Posterior can observe because remodeling occurs
49
Absolute indications ORIF clavicle
Open / threatened skin Vascular injury Scapulothoracic dissociation being treated operatively
50
RF clavicle nonunion Nonunion rate for nonop clavicles? What is the NNT surgically for displaced clavicle fractures to prevent nonunion? Biggest comp of op management
RF - 100% displacement - Older - Female - Smoking 15% nonunion NNT to prevent 1 nonunion = 7 Presenters conclude not cost effective for health care system Comp = reop for sx hardware
51
ORIF clavicles - Which construct is less symptomatic hardware - Which construct is best to resisting rotational forces - Which construct is best to resisting bending forces
Op clavicle, will likely present Q stem with 100% displacement, >2cm shortening Ant plating = least sx hardware Anterosup plating = resist rotational forces Ant = resist bending forces
52
What is the benefit of AC joint reconstruction
CONTROVERSIAL Cots - no lasting clinical advantage Metanalysis - earlier return to work, worse cosmesis with OR
53
Indications for scapula frx ORIF
Coracoid/acromion >1cm displaced Glenoid displaced >2-5mm (articular frx) Glenoid frx causing GH instability Glenopolar angle = glenoid face relation to lateral angle scaupla - Op <20 - aka face becomes almost parallel to lat border - Normal 30-45 Scap body angle >45 (sagittal cuts) Lateral border displaced >2cm from rest body
54
Associated injury scapulothoacic dissociation
Neurologic injury - most common, 1ary det outcome Subclavian rupture - why you'll DIE, always get CTA
55
Imaging findings for scapulothoracic dissociation
Distance between medial border of scapulae on CXR wide Distracted clavicle fracture SC or AC separation
56
What is metaphyseal extension a predictor for non op treatment prox hum frx - what are the numbers
Metaph ext <8mm poor predictor Does the head piece have metaphysis on it or not Aka does the medial calcar stay with the articular frag or the shaft - Stays with head (aka >8mm of extension into metaphysis) = GOOD - Stays with shaft = bad
57
What was finding of PROFHER for displaced 2 part fractures
No sig diff between op/non op 2yrs
58
For deltoid split, how far down is the axillary nerve off the edge of the acromion
4-7cm
59
Most common complication of ORIF prox hum frx
Screw cut out (fixed angle in bad bone) Also 2/2 AVN Some suggest strong calcar screw to prevent this
60
Op vs non op algorithm for the test - GT frx - 2 pt prox hum - 3+ prox hum: young vs old
GT >5mm displaced = op 2 pt prox hum = nonop everyone 3+ prox hum young = ORIF " " old = RSA (vs nonop if sick)
61
What is the distance from top of the pec tedon to the top of articular head
5.5cm
62
Acceptable alignment parameters nonop humeral shaft frx
20 deg A/P 30deg V/V 15deg malrotation 3cm short
63
CI bracing for hum shaft frx
BMI too high NM injury NOT comminution
64
What are 2 risks of using IMN for humeral shaft frx What structures are at risk with the distal locking bolts
1. Higher rates shoulder stiffness.... duh 2. Iatrogenic radial nerve injury - Why people harp about opening for reduction regardless of instrumentation choice Distal locking screws: - Lat to med screw = radial n - Ant to post screw = MSC
65
Humerus approaches: - Anterior: which muscle has dual innervation - Lateral: what nerve at risk - Posterior: what structure limits extension proximally
Ant: deep interval is brachialis split - MCNn medial - Radial n lateral Lat: triceps post, BR ant - Radial n Post: mobilize triceps off medial (not triceps split) - Ax n limits proximal - See ABCn and radial n directly
66
When do you get the EMG for radial n injury with hum shaft? How long wait to operate? What muscle comes back first with radial n recovery
EMG 6wks 6ish mo minimum nonop BR 1st to return
67
What is the advantage to parallel vs orthogonal plating distal hum frx
BIOMECH STUDIES ONLY Parallel plates = increased torsional stiffness
68
What is the Milch classification distal hum condyle frx
Medial or lateral condyles - doesn't matter 1: Trochlea intact 2: Frx through trochlea Think like an articular frx, anything displaced needs OR
69
Structure at risk if your olecranon tension band wires push out anterior
AIN
70
Name 2 lateral approaches to elbow
kAplan = Ant - ECRL/ECRB - Anterior so protects LUCL - Closer to PIN (going through supinator - This is the answer for any radial head/neck fracture that needs fixation extension onto the shaft Kocher - Anconeus (radial) / ECU (PIN) - More risk LUCL
71
What is an Essex Lopresti? What must you address in OR?
IO membrane disruption Need to create length stability - either ORIF or replace radial head
72
3 parts of MCL
Post bundle - what you can resect to get more flexion Ant bundle *** most impt Transverse ligament
73
Name parts of the lateral elbow ligamentous complex
Annular LUCL Radial colat
74
What structures are disrupted? Valgus laxity in supination vs Valgus laxity in pronation
Supination: LUCL +/- MCL - splint in pronation Pronation: proven MCL disruption - splint in supination Pronation will only improve PL instability when the MCL is intact

Millers (29 decks)

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