Trauma 101 Flashcards
(imaging) in patients with penetrating injuries to the thorax or abdomen; ALWAYS
CXR
Imaging for hemodynamically unstable patients
FAST exam
Imaging for hemodynamically stable patient
`CT scan
Any penetrating wound below the nipple requires a(n)
______
exploratory laparotomy
High-energy trauma + widened mediastinum on CXR →
Next best step in management?
CT Angiography for aortic injury
Blunt trauma + subcutaneous emphysema →
Next best step in management?
Bronchoscopy for tracheal injury
Signs of peritonitis (abdominal tenderness, rebound, guarding, rigidity) → Next best step in management?
exploratory laparotomy
Pt with Blood at the urinary meatus → Next best step in management?
Retrograde URETHRO-gram
might be bladder injury, but need to r/o urethral injury first
Pt presents with no blood at the urinary meatus, but has hematuria in the Foley catheter → Next best step in management?
Retrograde CYSTO-gram to r/o bladder injury
Pt presents with hematuria in Foley catheter.
Retrograde urethrogram and cystogram have been normal → Next best step in management?
CT scan to r/o kidney injury
why not retrograde pyelography?
Pts pupils are fixed (non-reactive to light) and dilated.
What 2 things can result in this finding?
Brain bleeds & herniation
Pt presents with narrowing Pulse Pressure (SBP–DBP) list one possible cause
Hemorrhage
→ cause SBP to drop & DBP to rise
→ this helps maintain MAP >65 for adequate perfusion
MAP = CO x TPR → DBP + 1/3 (PP)
Pt needs fluid resuscitation. What IVs are used?
2 large bore (16 gauge) peripheral IVs
Patient needs transfusion for massive hemorrhage what is given to the patient?
Whole blood
1:1:1 of pRBC, Plasma, Platelets
Most common injuries in trauma (5)
[SPLUGeD in trauma]
Splenic injury/rupture Pancreatic injury (handlebar injury) Liver injury/rupture Genital trauma Urinary trauma Duodenal rupture/ hematoma (kids mostly–Handlebar injury)
Handlebar injury should raise concerns for what 3 injuries?
Pancreatic injury
Splenic
Duodenal
Patient with Ecchymoses over the right chest &
pain in the right shoulder
should raise concerns for what injury?
Liver hematoma
Patient with Hematuria, Pain, bruising, &
Flank discoloration/ecchymoses
should raise concerns for what injury?
Renal hematoma
Blunt chest trauma should be considered in patients with what physical exam finding?
JVD
Best initial test for all blunt chest trauma patients?
Chest x-ray
and FAST, ECG, Troponin
Pt presents with flail chest injury and begins to have dyspnea with dropping oxygen saturations. What is the next best step in management before bridging pt to surgery for rib fixation with plate?
Flail chest: 3+ ribs are broken in 3+ places creating 1 floating segment
Intubate on PPV
1st line: Oxygen, analgesia, and monitoring vitals/pulmonary edema →
If showing signs of impending respiratory failure → Intubate on PPV
2nd line: Once on PPV → surgical rib fracture fixation via Rib cage Plate (sx indicated if rib is very displaced even in the absence of RF)
Trauma pt presents has CXR showing Ipsilateral diaphragmatic elevation.
Diagnosis and next best step in management?
Phrenic (C3–C5) nerve paralysis → Intubate
*Unilateral paralysis → Asymptomatic/ exertional dyspnea
Bilateral paralysis → severe dyspnea
Pulmonary contusion on CXR → Patchy alveolar infiltrates (White out or diffuse opacity)
Next best step in management?
Monitor blood gasses (ABG)
*Cx → ARDS
Trauma pt presents with:
subcutaneous emphysema w/o tracheal midline shift nor distended neck veins
Next best step in management?
CXR
Tracheobronchial injury
Pt in ED with chest pain, dyspnea Subcutaneous emphysema crepitus on chest auscultation synchronous to the heartbeat \+/- hoarse voice Dx & next best step in management?
*List 3 possible causes of this presentation?
- Pneumomediastinum: presence of gas (usually air) in the mediastinum
- Get a CXR
- Causes:
Rupture of pulmonary blebs
Boerhaave (esophageal rupture)
Iatrogenic (post-procedure: endoscopy)
*(Hamman’s crunch: crepitus w/ heart beat)
Pt in ED with recent h/o
Strangulation, intubation, or penetrating trauma to neck or chest
who presents with
Hoarseness, Dyspnea, Hemoptysis, Palpable crepitus, Hamman’s sign (crepitus on chest auscultation)
Diagnosis & Next best step in management?
Tracheal Rupture
Chest x-ray → Bronchoscopy→ Chest CT
(if you think it might be Pneumomediastinum the answer is still get a CXR)
Tracheal Rupture: Partial or complete puncture or laceration of the trachea or the main bronchi (bronchial disruption)
Management for stable versus unstable patient?
In stable patients: conservative management → Neck immobilization.
Unstable patient (vascular injury, hard signs) → Surgery
Presents with the all/some of the following:
unequal leg length w/ reduced ROM
Labial/Scrotal, flank, or inguinal hematomas
Urethral injury
Pelvic Fractures
(Tilted/ Unstable pelvis)
Diagnostics: Pelvic X-ray → CT (in stabilized patients)
Trauma pt with a high-riding or nonpalpable prostate, perineal swelling, & hematuria.
Concerns for ____
Urethral injury
( blood at urethral meatus)
*If suspected injury of the urinary tract → Retrograde urethrogram, cystogram, & pyelourethrogram
(Contrast is injected into the ureters to make the ureters & kidneys easily seen on the x-ray)
If pt has confirmed urinary injury on imaging what is the next best step in management?
Suprapubic catheterization
not transurethral
Management of Pelvic Fractures includes:
Prompt ____
If, stable fracture →
If open, unstable fracture, or urological injury →
pelvic stabilization with an external binder/brace
Conservative treatment → stable
Surgical treatment → unstable/open/urologic injury
Pt with pelvic fracture is hemorrhaging →
Next best step in management?
Angiography w/ Embolization
+/- external fixation
List 2 possible complications of pelvic fractures:
Hemorrhagic shock → intra/retroperitoneal bleeding
Abdominal compartment syndrome → blood filling peritoneal spaces
Extremity Pain Worse with passive stretching or extension of muscles
Very tight, wood-like muscles that are extremely tender out of proportion to the extent of injury
Paresthesia & Soft tissue swelling
Diagnosis & Next best step in management?
Acute compartment syndrome (ACS)
Bedside fasciotomy
Acute limb ischemia presents with what 4 early sxs and what 2 late sxs?
Early:
Pain, Pallor, Paresthesias & Poikilothermia (cold)
Late:
Pulselessness & Paralysis
*Pulse is usually still palpable but pulselessness is a very bad sign
How to tell apart acute compartment syndrome from acute limb ischemia?
ACS: extreme pain worse with passive flexion, rock hard muscles, WARM, swelling
ALI: moderately painful, Pale & COLD
Both: paresthesia & late paralysis
(consider pt hx)
____ can turn a simple pneumothorax into a life-threatening tension pneumothorax.
Positive pressure ventilation
In Penetrating abdominal trauma, surgical repair is done after ___
hemodynamic stabilization
IVFs, blood, pressors
Can present with cutaneous crepitus (4)
Pneumomediastinum/pneumothorax
Tracheobronchial Rupture
Esophageal Rupture
Hemothorax
Trauma pt presents with FLAT neck veins, dullness on percussion, Decreased tactile fremitus
+/-Crepitus on palpation
+/-Paradoxical chest wall movement
Diagnosis & Next best step in management?
Traumatic hemothorax
(blood within the pleural space)
Get CXR
(Looks like pleural effusion; blunting of the costophrenic angle, tracheal deviation/ mediastinal shift)
*Ultrasound (can detection of smaller amounts of fluid/blood)
CXR shows hemothorax what is the next best step in management?
Chest tube insertion
In Hemothorax a Thoracotomy is indicated if (2)
Initial chest tube output is > 1500 mL
or
chest tube output is >200 mL/hour for 2–4 hours
What is the main complication associated with Hemothorax
Pleural empyema
Thoracentesis
