TRAUMA Flashcards
First peak for trauma deaths (0-30 min)
lacs of heart, aorta, brain, brainstem or spinal cord
2nd peak for trauma deaths (30 min-4 hrs)
head injury (#1) and hemorrhage (#2) –> can be saved with rapid assessment (golden hr!)
2 biggest predictors of fall survival
age and body orientation
LD 50 for falls
4 stories
MCC death in first hour
hemorrhage
BP usually ok until how much blood volume is lost
30%
MCC upper airway obstruction
tongue
best cutdown site for venous access if large bore IV and central access not possible
saphenous vein
hemostatic resuscitation indications
> or = 4 units PRBC in 1st hour or >/= 10U prbc in 24 hrs
Positive DPL
>10 cc blood >100,000 RBCs/cc food particles bile bacteria >500 WBC/cc
If pelvic fx present where to do DPL?
supra umbilical
2 things missed by DPL
retroperitoneal bleed
contained hematoma
FAST scan may not detect free fluid < what amt
50-80 mL
final common pathway for decreased CO in ACS
IVC compression
When do catecholamines peak after injury
24-48 hours
Universal donor blood
type O
GCS : M3
flexion with pain (decorticate)
GCS : M2
extension with pain (decerebrate)
head CT if GCS = to
10
most important prognostic indicator on GCS
motor
when to perform crani in epidural hematoma
shift > 5 mm or significant neurologic deteroiation
CPP =
MAP - ICP
ICP monitors indicated for
GCS < or = 8
suspected increased ICP
or pts with moderate to severe head injury and inability to follow clinical exam
Want CPP > ??
60 to improve MAP
ICP > what needs tx
20
Peak ICP occurs how long after injury
48-72 hrs
Sign of impending herniation
intermittent bradycardia
dilated pupil could be due to pressure on which cranial nerve
III (oculomotor)
raccoon eyes can be due to fracture of
anterior fossa
battle sign may be due to fracture of? what nerve can be injured
middle fossa
facial nerve
avoid nasotracheal intubation in pts with fractures where
basal skull
MC site of facial nerve injury
geniculate ganglion
temporal skull fx can lead to injuries in which CN
VII and VIII (vestibulocochlear)
Indications to operate for skull fx
significant depression >1 cm
contaminated
persistent CSF leak not responding to conserv tx (close dura)
Coagulopathy with TBI is due to
release of tissue thromboplastin
tx for C1 burst fx
Jefferson fracture
rigid collar
Tx for C2 hangmans fx
traction and halo
Tx for C2 odontoid fracture above base
type 1, stable
Tx for C2 odontoid fracture at base
Type II, unstable (will need fusion or halo)
Tx for C2 odontoid fracture extending into vertebral vody
Type III, fusion or halo rarely
dens =
odontoid process
compression fx usually involve which column of spine
anterior column
when does bradycardia a/w spinal cord injury typically resolve
2-5 weeks
indications for emergent surgical spine decompression
fx or dislocationf not reducible with distraction
open fx
soft tissue or bony compression of cord
progressive neurologic dysfunction
tx of type I & II lefort
reduction, stabilization, intramaillary fixation +/- circumzygomatic and orbital rim suspension wires
tx of type III lefort
suspension wiring to stable frontal bone; may need external fixation
Tx of nasoethmoidal orbital fx
70% have CSF leak
conservative tx up to 2 weeks
can try epidural catheter to decrease CSF pressure and help it close
May need surgical closure of dura to stop leak
Anterior nosebleed tx
packing
Posterior nosebleed tx
try balloon tamponade 1st
may need angioembolization of internal maxillary artery or ethmoidal artery
1 indicator of mandibular injury
malocclusion
zone I of neck
clavicle to cricoid cartilage
if surgery required for zone 1 what kind of incision is made
median sternotomy
zone II of neck
cricoid to angle of mandible
zone III of neck
angle of mandible to base of skull
RLN injury tx
repair or reimplant in cricoarytenoid muscle
can ligate vertebral artery?
yes
relative indications for thoracotomy
1000-1500 cc after initial
>250 cc/h for 3 hours
>2500 cc/24 hrs
Incision: lower thoracic aorta
left anterior thoracotomy
Typically, it is begun at the sternal edge in the fourth or fifth intercostal space in a sharp arc to the axilla.
incision: left lung
left anterior thoracotomy
Typically, it is begun at the sternal edge in the fourth or fifth intercostal space in a sharp arc to the axilla.
incision: r lung parenchyma
right anterior thoracotomy
injury to great vessels - incision?
median sternotomy
Access to R lung including hilum
R posterolat thoracotomy
Access to right trachea
R posterolat thoracotomy
Access to aortic arch
L posterolat thoracotomy
Access to descending thoracic aorta
L posterolat thoracotomy
Access to distal thoracic esophagus
L posterolat thoracotomy
Pericardial incision should be made where in relation to left phrenic n
longitudinal and anterior
Bronchus injuries MC on which side
Right
Reapir indications after tracheobronchial injury
large air leak and respiratory compromise
2 weeks of persistent air leak
cant get the lung up
injury >1/3 diameter of trachea
access t oright mainstem
right thoracotomy
access to proximal left mainstem injuries
right thoracotomy (avoids aorta)
access to distal left mainstem
left thoracotomy
when to do transabdominal approach for diaphragm injury
<1 week
when to do chest approach for diaphragm injury
> 1 week out
What kind of mesh used in diaphragm injury
PTFE (gore tex)
Where is the usual tear in aortic transection
ligamentum arteriosum just distal to left subclavian takeoff
access to distal left subclavian
left posterolateral thoracotomy
access to distal right subclavian
midclavicular incision and resection of medial clavicle
access to proximal left subclavian artery
trap door through left 2nd intercostal space
access to proximal left CCA
median sternotomy
MC arrhythmia in myocardial contusion
SVT
airway pressures in tension ptx
increased
1st and 2nd rib fx are high risk for
aortic transection
anterior pelvic fx: more likely to have venous or arterial bleeding
venous
pelvic venous plexus most common
posterior pelvic fx: more likely to have venous or arterial bleeding
arterial
tx of intra op penetrating injury pelvic hematoma
open (or go to IR)
tx of isolated anterior ring fx with minimal sacral iliac displacement
wbat
MC assoc injury with pelvic fx
head injury
MC area of duodenum injured
2nd portion (descending near ampulla)
Major source of morbidity in duodenal trauma
Fistula
If injury in 2nd portion of duodenum and can’t get primary repair
place jejunal serosal patch over hole
need pyloric exclusion and GJ
consider feeding and draining J
repair small bowel injuries in what direction
transversely to avoid stricture
paracolonic hematoma - open or leave alone
open
high rectal extra peritoneal injury
primary repair usual (laparotomy, mobilize rectum). if LAR needed, place diverting loop colostomy
middle rectal extra peritoneal injury
if repair not easily feasible, place end colostomy only.
can common hepatic artery be ligated
yes with collaterals through GDA
pringle maneuver does not stop bleeding from?
hepatic vv
retrohepatic IVC injury, what kind of shunt can you use
aatriocaval
portal triad hematoma - explore or leave alone
explore
contained subcapsular liver hematomas - explore or leave alone
leave alone
Portal vein injury
need to repair via lateral venorrhaphy
will need to perform distal panc with that maneuver
ligation of portal vein –> how much mortality?
50%
grade VI liver injury
hepatic avulsion, likely not compatible with lfie
pancreatic hematoma - explore or leave alone
explore
anterior shoulder dislocation a/w injury to
axillary nerve
posterior shoulder dislocation a/w injury to
axillary artery
proximal humerus fx a/w injury to
axillary nerve, posterior circumflex humeral artery
midshaft humerus fx a/w injury to
radial nerve and profunda brachii artery
distal humerus fx a/w injury to
brachial artery
elbow dislocation a/w injury to
brachial artery
distal radius fx a/w injury to
median nerve
anterior hip dislocation a/w injury to
femoral artery
posterior hip dislocation a/w injury to
sciatic nerve
distal femur fx a/w injury to
popliteal artery
scapula fx a/w injury to
pulm contusion
aortic transection
best indicator of renal trauma
hematuria
which renal vein can be ligated
left. ligate near IVC, has adrenal and gonadal vein collaterals
penetrating renal injury with hematoma
open unless pre op CT/IVP shows good function without significant urine extrav
best indicator of bladder trauma
hematuria
blood supply of ureter
medial in upper 2/3
lateral in lower 1/3
uterine rupture more liekly to occur where
posterior fundus
PaCO2 in pregnancy
decreased (25-30 mmHg) due to increased minute ventilation
Normal PaCO2 may indicate impending respiratory failure
One of the only indications to leave alone a penetrating injury
retrohepatic location
tx black widow spider bite
IV calcium gluconate, muscle relaxants
what spider bite cdauses nausea, vomiting, muscle cramps
black widow
what spide bite causes skin ulcer with necrotic center and surrounding erythema
brown recluse
tx brown recluse spider bite
dapsone
bilateral pinpoint pupils
pontine hemorrhage
bolt is placed where
intraparenchymal
main regulator of CPP
PaCO2
Neurogenic shock vs spinal shock which impacts hemodynamics?
neurogenic (hypotensive and brady)
spianl shock will have which reflexes absent
bulbocavernosus and cremasteric
intact reflexes in spinal shock
indicates deficits are likely permanent
MC site for BCVI
distal internal carotid
post endovascular repair of blunt aortic injury develops left hand ischemia
carotid t osubclavian bypass as subclavian routinely covered during endovascular repair of BAI
If low angle on TEG
give cryo (this is how fast they are forming a strong clot)
if amplitude low on TEG
platelets
if LY30 high on TEG
give TXA
if prolonged R time on TEG
FFP (how long it takes to start clot)
anterior cord syndrome
The patient presents with loss of motor function as well as a loss of pain and temperature sensation below the level of the injury. Proprioception and the ability to sense vibration are preserved.
central cord syndrome
hyperextension injury (esp with prev existing spondylosis) The patient presents with bilateral upper extremity loss of sensation and weakness.
posterior cord syndrome
This causes loss of proprioception and vibration, although motor function is preserved.
age of viability
23 weeks
what is the relative anemia of pregnancy
Red blood cell mass increases approximately 30%, but blood volume increases 40 to 50%. As a result, there is a relative anemia of pregnancy.
Average Hgb 10.9 +/- 0.8 in 2nd trimester and 12.4 +/- 1.0 at term
risk factors for failure of non operative mgmt splenic trauma
age older than 40, grade III or higher injury, or injury severity scores of at least 25.
if bleeding decreases after pringle maneuver likely origin is
portal vein or hepatic artery
if bleeding continues after pringle maneuver likely origin is
hepatic veins behind liver
complic of hepatic a ligation
hepatic abscess or biloma
grade III pancreatic injury
distal transection or parenchymal with duct injury
proximal duct transection or injury involving ampulla - grade and tx?
grade IV
left of SMV: distal panc
right of SMV: closed suction drainage
tx of grade V pancreatic injury
whipple or drainage + pyloric exclusion
time frame when ureteral injury should be immed repaired vs delayed
<5 days vs 10-14 days
how can open PTX lead to rapid death
significant vq mismatch –> hypoxia
phase 1 of cardiac tamponade
increaing pericardial pressure restricts ventricular diastolic filling, reduces subendocardial flow
pericardial pressures remain below R and L ventricular pressures
how is CO maintained in phase 1 of cardiac tamponade
compensatory tachycardia, increased SVR and elevated ventricular filling pressure
when do initial signs of shock show in cardiac tamponade
second phase
phase 2 of cardiac tampoande
rising pericardial pressure exceeds right ventricular pressure and compromises diastolic filling, stroke volume, and coronary perfusion
when does cardiac output decrease in cardiac tamponade
second phase
what is third phase of cardiac tamponade
intrapericardial pressures approach LV filling pressures
compensatory mechanisms fail
cardiac arrest results as profound coronary hypoperfusion occurs
what factor must be taken into account when using Broselow tape
obesity
MC fx patterns assoc with bladder injuries
obturator ring and pubic diastasis
gold standard for bladder injuries
CT cystography
contra indications to left subclavian artery coverage (4)
aberrant left vertebral
dominant left vertebral artery blood supply to basilar system
previous CABG with patent left IMA
functioning AVF in LUE
MC complication of liver injury
biliary fistula
access to distal trachea
R posterolateral thoracotomy
empiric abx for human bite
cefoxitin
empiric abx for dog bite
augmentin
empiric abx for cat bite
augmentin
clear or milky white blister formation a/w frostbite - which degree?
second
hemorrhagic blisters with frostbite - what degree?
third
tx of blisters a/w frostbite
drainage to remove potentially harmful prostaglandins with needle aspiration and/or debridement
tx of hemorrhagic blisters a/w frostbite
leave intact
consider applying aloe vera gel
difference between 3rd and 4th degree frostbite
3rd degree full thickness, hemorrhagic blisters and may have black eschar
4th degree extends to bone and tissues are black/mummified at presentation!
capsular laceration <1 cm deep - what grade splenic injury
grade I
grade II splenic injury
subcapsular hematoma 10-50% or intraparenchymal hematoma <5 cm diameter
laceration 1-3 cm deep
grade III splenic injury
subcapsular hematoma >50% area or intraparenchymal hematoma >5 cm
laceration >3 cm deep or involving trabecular vessels
expanding hematoma OR ruptured hematoma
grade IV splenic injury
lac involving hilar vessels with major devascularization
why is CT oftne repeated after non operative mgmt of splenic injuries
At many institutions repeated at 48 hours as there is 7% chance of pseudoaneurysm
failure rate of grade III splenic injury
20%
failure rate of grade V splenic injury
75%
success rate of non operative mgmt in adults vs children
60-80% adults
>90% children
what is phalens test
wrists in flexion for 1 minute
what is durkan test
place pressure across proximal palm for approx 30 seconds
what is tinel’s sign
tap across distal wrist crease and proximal palm
contraindications to left subclavian artery coverage
absent R vertebral a
Dominant L vertebral a blood supply to basilar system
Previous CABG with patent left IMA
Functioning AVF in LUE
WBC in pregnancy
5-12K, although counts as high as 20K have been observed in last trimester
>29K should alwyas be concerning
Hematopoietic changes in pregnancy
Hypercoagulability – increased levels of factors VII, VIII, IX, X, and XII, as well as DECREASED fibrinolytic activity (due to increase in plasminogen activator inhibitor type 2)
Grade B postoperative pancreatic fistula
B1: persistent drainage over 3 weeks with clinical mx but no intervention
B2: persistent drainage managed by pharm tx (e.g., octreotide)
B3: persistent drainage managed by interventional procedures
Grade C postoperative pancreatic fistula
aggressive changes in clinical mgmt needed, involving ICU admission
Usually reoperate and/or suffer from MSOF
Grade D postoperative pancreatic fistula
mortality due to fistula
suopracondylar humerus fracture a/w injury to
brachial artery, median nerve
fracture of medial epicondyle of humerus a/w injury to
ulnar n., ulnar collateral a
