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ACNP Final > Trauma > Flashcards

Trauma Flashcards

1
Q

Skull Base Fx

Path:

S/Sx:

Dx:

Tx:

A

Skull Base Fx

Path:

  • Temporal: most common; inj CN VII, CVIII, carotid a., epidural hematoma
  • Frontal sinus: inj CN I
  • Central: inj CN III, IV, V, VI, carotid a.
  • Posterior: inj CN IX-XII, cervical spine, vertebral a.; paraplegia

S/Sx:

  • Battle’s Sign (post-auricular)
  • Racoon eyes (periorbital)
  • Rhinorrhea / otorrhea

Dx:

  • CT scan
  • CSF (+) glu, halo sign
  • Test vision, CN fct, mental status

Tx:

  • C-Spine precautions until proven otherwise
  • Consult neurosurg, ENT, plastics, opthal, audiology
  • Abx: Use if prolonged CSF -> meningitis, brain abscess: Ceph, FQ, B-lactam
    • NOT recommended empirically in most cases
  • Surg: displaced fx stabilization; CN decompression, repair
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2
Q

Epidural Hematoma

Path:

S/Sx:

Dx:

Tx:

A

Epidural Hematoma

Path:

  • Baseball to the temple -> middle meningeal a. shear -> blood btwn skull and dura

S/Sx:

  • LOC -> lucency -> rapid neuro decline

Dx:

  • Head CT

Tx:

  • Surgical emergency if >30mL or GCS <9 w/ pupillary changes
  • Observation + freq neuro checks if small, min. ML shift, no focal sx, GCS > 8
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3
Q

Subdural Hematoma

Path:

S/Sx:

Dx:

Tx:

A

Subdural Hematoma

Path:

  • MVA / major trauma -> tear bridging veins -> blood btwn dura mater and subarachnoid membrane

S/Sx:

  • Knocked out, stays out
  • N/V, confusion, lethargy, focal deficit
  • Chronic: seizures, personality change, dementia, aphasia

Dx:

  • Head CT

Tx:

  • If >1cm width, (+) ML shift = craniotomy/surgery +/- Burr hole/evacuation
  • If small, (-) ML shift = Decrease ICP w/ elevation, hyperventilation, manitol
  • Monitor for post-op seizures
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4
Q

What is different about a traumatic subarachnoid hematoma vs. SAH d/t aneurysm rupture?

What about traumatic intraparenchymal hematoma?

A

With traumatic subarachnoid hematoma, you are not concerned with reducing vasopasm risk. You will allow the traumatic SAH to resolve on its own.

Likewise, traumatic intraparenchymal hemorrhage is less concerning than hemorraghic stroke, with decent outcomes if the traumatic hematoma is small.

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5
Q

Traumatic Brain Injury

Path:

S/Sx:

Dx:

Tx:

A

Traumatic Brain Injury

Path:

  • MVC most common; falls; ETOH 50%

S/Sx:

  • LOC, short term mem loss, GCS < 14 at time of injury
  • +/- craniofacial trauma, C-spine injury, focal neuro deficit
  • HA, seizure, N/V
  • Poor prognosis: Hematoma >30mL; ML shift > 10mm; swirl sign (active bleed)

Dx:

  • CT Head
  • ICP monitor (EVD gold standard)

Tx:

  • Protect airway; preoxygenate; fentanyl & etomidate good; propofol allows neuro exam but may cause hotn
  • Treat ICP: osmolar therapy and avoid hypotonic IV fluids
    • Maintain CPP > 60 (CPP = MAP - ICP)
    • Prevent secondary brain injury: cerebral edema, seizures, fevers, hypoxia, hypercarbia, hotn, hypertherma
  • Monitor Na
    • Central DI: tx with DDAVP and IV fluid
    • Cerebral salt wasting: Tx with Na and fluids
    • SIADH: Urine Na > 40, urine osm > 100; Tx with fluid restriction + vaptan if severe
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6
Q

Cervical Spine Trauma

Path:

S/Sx:

Dx:

Tx:

A

Cervical Spine Trauma

Path:

  • Blunt injury (MVC) > GSW / stab
  • Edema -> airway compromise
  • C3,4,5 keep the diaphragm alive

S/Sx:

  • Difficult breathing
  • Neurogenic shock if inj above T6 (d/t unopposed parasympathetic activity)
    • Normal CO but decreased SVR

Dx:

  • MRI

Tx:

  • Suspect C-Spine inj w/ head or facial trauma -> immobilize, lay flat, log roll
  • Neurogenic shock:
    • Fluids (MAP > 85)
    • HD Monitoring
    • Consider vasoactive (Alpha Agonist) / inotropic (Beta agonist) drip
      • Norepi OK but less direct cardiac action
      • Avoid phenylephrine in bradycardia
    • +/- Midrodrine
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7
Q

Central Cord Syndrome

Path:

S/Sx:

Dx:

Tx:

A

Central Cord Syndrome

Path:

  • Hyperextension injury -> dmg to centrally located fibers serving upper limb motor & spinothalamic function -> incomplete SCI
  • Usually in older adults w/ hx spondylosis / spinal stenosis

S/Sx:

  • Spinal cord bruising
  • Transient deficits upper extremities > lowers for < 48h
  • Loss of pain and temp sensation in cape like distribution (hands/arms > feet) +/- weakness

Dx:

  • MRI: ligamentous inj if AMS preventing C-Spine clearance
  • CT cervical spine

Tx:

  • C-Spine Clearance: take off collar; check movement; check pain; check MS; document
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8
Q

Nasal Fx

Path:

S/Sx:

Dx:

Tx:

A

Nasal Fx

Path: Most common mid-facial injury

S/Sx: Nasal congestion, epistaxis, septal hematoma

Dx: Inspection of internal & external nares; plain films if isolated nasal fx suspected

Tx: Address epistaxis / hematoma first; closed reduction is option; wait until edema resolves before surgical repair

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9
Q

Zygomatic Complex Fx

Path:

S/Sx:

A

Zygomatic Complex Fx

Path: Lateral blow -> Tripod fx, 2nd most common facial fx

S/Sx:

  • Pain over cheekbone
  • Depression / step-off on palpation
  • Local ecchymosis or edema
  • Assymetrical orbits
  • Exopathalmos / enopthalmos
  • Proptosis, diplopia
  • Subconjunctival hemorrhage
  • Impaired EOM movement
  • Infraoribital nerve paresthesia
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10
Q

Maxillary Fx

S/Sx:

A

Maxillary Fx

S/Sx:

  • Pain w/ jaw movement
  • Intraoral bleeding
  • Epistaxis
  • Loose / missing teeth
  • Inability to chew, malocclusion of teeth
  • Elongated face
  • Displaced maxilla (lateral)
  • Infraorbial nerve paresthesia
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11
Q

Orbital Floor Fx

Path:

S/Sx:

A

Orbital Floor Fx

Path: ‘Blowout Fx’ d/t anterior-posterior force

S/Sx:

  • Enopthalmos +/- autoimmune rxn
  • Diplopia
  • Loss of extraocular eye movement or (+) diplopia -> muscle entrapment
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12
Q

Mandibular Fx

S/Sx:

Dx:

A

Mandibular Fx

S/Sx:

  • Step-off deformity
  • Crepitus
  • Pain w/ jaw movement
  • Malocclusion of teeth
  • Dysphagia
  • Paresthesias of lip and chin
  • Trismus
  • Loose / broken / missing teeth
  • Intraoral bleed

Dx: Plain films NOT preferred; may need Panorex films

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13
Q

What are your broad considerations for ANY facial trauma in terms of…

Dx:

Tx:

A

General Facial Trauma

Dx:

  • ABC, assume c-spine inj, mental status exam, full visual acuity ecam, CN testing
  • Imaging: Maxillofacial CT w/o contrast; CT head/face for surg planning

Tx:

  • Gentle pressure to stop bleed
  • Do not nasally intubate, avoid NGT
  • May need Surgical airway/cric depending on bleed and deformity
  • Empiric Abx: CONTROVERSIAL
    • Defer to surgeon
    • High risk fx SHOULD get abx: open facial fx, communication with sinus, communication with oral flora and mouth
  • Oral care with CHG if wired jaw
  • Tetanus vax
  • Ocular trauma precautions: sneeze w open mouth, no straws, etc
  • Consult appropriately
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14
Q

All Thoracic and Lumbar Spinal Trauma

Tx:

D/c considerations:

A

All T & L Spinal Trauma

Tx:

  • DVT ppx; IVC filter
  • Bowel & bladder training; I/O; bowel regimen
  • Corticosteroids CONTROVERSIAL in blunt trauma, Ø in penetrating
  • Prevent secondary morbidity: VAP, HAP, CAUTI, DVT, PE, neuropathic pain, spasticity, decubity, depression

D/c:

  • 85% those who survive 24h will survive 10 years
  • Low level injury and specialized SCI rehab best predictors of survival
  • Home modifications, ADL assistance, home care, transport, follow up
  • Complications: decubiti, UTI, resp infxn, injury, contrractures, depression
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15
Q

Thoracic Fx

Path:

Epi:

Thoracolumbar Junction Fx

Path:

A

Thoracic Fx

Path:

  • Tremendous force -> flexion/axial loading -> T2-T10 fx

Epi:

  • Vertebral compression fx most common
  • Burst fx: retropulsed fragments into spinal canal -> Complete Spinal Cord Injury

Thoracolumbar Junction Fx

Path:

  • Flexion -> Vertebral body wedging -> Compression fx to T11-L1
  • Chance Fx d/t seatbelt injury -> unstable pt -> a/w bowel +/- iliac a. inj
  • Burst Fx -> unstable
  • Usually no spinal cord injury
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16
Q

Lower Lumbar & Sacral Fx

Path:

S/Sx:

Dx:

A

Lower Lumbar & Sacral Fx

Path:

  • Hyperflexion & axial loading -> longitudinal sacral fx -> radiculopathy
  • Transverse sacral fx -> cauda equina syndrome
  • Uncommon

S/Sx:

  • May have sacral sparing -> retain potential for motor recovery, continence
    • Physiologic continuity of long-tract fibers within sacral spinal cord
    • Will define complete vs incomplete SCI

Dx:

  • Test for sacral sparing
    • Saddle sensation
    • Bulbocavernosus reflex
    • Anal wink
    • Urination / defecation
17
Q

Cauda Equina Syndrome

Path:

S/Sx:

Dx:

A

Cauda Equina Syndrome

Path:

  • Compression on S3, S4, S5 nerve roots

S/Sx:

  • Saddle anesthesia
  • Severe low back pain
  • Motor weakness & sensory loss to BLEs
  • Reflex loss
  • Bladder & bowel incontinence, sexual dysfunction

Dx:

  • Sensory Grading
    • 0 absent
    • 1 altered
    • 2 normal
    • NT not testable
  • ASIA Impairment Scale
  • Strength Exam (0/5 - 5/5)
18
Q

Bony Thorax Fracture

Path:

S/Sx:

Dx:

Tx:

A

Bony Thorax Fracture

Path: Blunt or penetrating trauma

S/Sx: Decreased breathing

Dx: CXR

Tx:

  • Analgesia: APAP, NSAID, opioid
  • Prevent & tx Atelectasis
    • i.s. q1h while awake
    • HOB up
  • Sternal precautions: no heavy push/pull
19
Q

Flail Chest

Path:

S/Sx:

Dx:

Tx:

A

Flail Chest

Path: Huge blunt trauma -> 2+ broken ribs in 2+ places

S/Sx:

  • Paradoxical rise/fall with insp/expiration
  • Severe pain +/- Pulmonary contusion

Dx: Visual inspection, CXR

Tx:

  • May require MV
  • Thoracic epidural
  • Binder potentially
20
Q

Pulmonary Contusion

Path:

S/Sx:

Dx:

Tx:

A

Pulmonary Contusion

Path: Huge blunt or penetrating trauma -> Bruise of lung parenchyma

S/Sx:

  • Normal then -> Evolves over 24-48h s/p trauma
  • Progressive tachypnea, hypoxia, hypercarbia
  • BL or severe –> ARDS

Dx: CXR 24-48h later

Tx:

  • Treat like ARDS
  • Use colloids
  • PEEP, O2 monitoring & supplementation
  • I.S.
  • +/- MV up to 3wks
  • +/- Diuresis
21
Q

Pneumothorax

Path:

S/Sx:

Dx:

Tx:

Complications:

A

Pneumothorax

Path:

  • Air trapped btwn lung and chest wall often d/t rib fx or penetrating trauma
  • 3 Types:
    • Closed (symptomatic)
    • Open (sucking chest, penetrating -> do NOT occlude)
    • Tension (tracheal shift from midline away from injury)

S/Sx:

  • Dyspnea
  • Obstructive shock -> Low CO -> HD instability
  • Air leak: should diminish as lung tissue heals

Dx:

  • CXR
    • Ptx vertical shadow
    • Hemotx horizontal shadow

Tx:

  • Chest tube required
  • Emergent needle decompression if chest tube not available
  • Drain hemothorax:
    • If >1500mL/day or 200mL/h or unstable s/p drain -> surgical thoracotomy to identify and stop bleeding
  • 3 sided dressing for sucking chest wound
  • After chest tube placement:
    • Check CXR to verify improvement
    • Assess subq emphysema
    • Note degree of air leak

Complications:

  • New airleak: check tubing connection; make sure tube still in chest wall; CXR to evaluate position of hole
  • Recurrent ptx: place 2nd chest tube
22
Q

Ureteral Trauma

Path:

S/Sx:

Dx:

A

Ureteral Trauma

Path: Pelvic fx

S/Sx:

  • Flank, abd pain
  • Flank mass
  • Prolonged ileus d/t retention
  • UTI
  • Hydronephrosis
  • AKI / azotmemia

Dx:

  • CT urogram: specific
    • CT red flags:
      • Perinephric hematoma +/- stranding
      • Ureteral dilation
      • Ureter not visible
  • Retrograde Pyelogram: most accurate
    • Do if CT is inconclusive
23
Q

Bladder Injuries

Patho:

Tx:

Urethral Trauma

S/Sx:

Dx:

Tx:

Pelvic Fx

S/Sx:

A

Bladder Injuries

Patho: Low seatbelt -> extraperitoneal vs intraperitoneal injury

Tx: Extraperitoneal = NON surgical; Intraperitoneal = SURG repair

Urethral Trauma

S/Sx: Blood at urethral meatus

Dx: Blood at urethral meatus

Tx:

  • Don’t do anything yet - consult urology
  • Partial Trauma: foley vs. suprapubic cath +/- surgical repair
  • Complete Trauma: Suprapubic cath & delayed surgical/endo repair

Pelvic Fx

S/Sx: Can exsanguinate; can cause vaginal/rectal injuries

24
Q

Muscular Compartment Syndrome

Path:

Epi:

S/Sx:

Dx:

Tx:

A

Muscular Compartment Syndrome

Path: Injury, dz, or fluid compress surrounding structures -> increased pressure -> tissue damage, hypoxia

Epi:

  • High risk: tibial fx; venous ligation; dislocation; burns; venom

S/Sx:

  • Pain out of proportion
  • Paresthesias (anesthesia in first web space, inability to dorsiflex)
  • Pallor
  • Paralysis
  • Pulselessness
  • Poikilothermia

Dx:

  • >30-45mmHg = high pressure = frequent monitoring
  • >45mmHg = very high = surgical release needed
  • Clinical suspicion

Tx:

  • Remove constrictive device, elevate extremity, ice
  • Fasciotomy - multiple incisions through skin extended to fascia
  • Wound vac -> promotes granulation
  • Post Op: compartment syndrome can recur in skin / dressing
  • Wound mgmt: Wet to dry, xeroform, continued elevation +/- Jacob’s ladder
  • Complications: Infxn, venous insufficiency, chronic edema
25
Q

Abdominal Hemorrhage

S/Sx:

Dx:

Tx:

A

Abdominal Hemorrhage

S/Sx:

  • Kerh’s sign: L shoulder pain referred d/t diaphragm irritation 2/2 blood accumulating
  • +/- Peritoneal signs
  • Hemorrhagic Shock: AMS -> Decreased UO -> Tachypnea (with pulse pressure narrowing throughout)
    • Bradycardia -> Arrest -> Death

Dx:

  • BMP, Mg, Phos, Coags, CBC, Type & Cross, CK, Amylase, Lipase, Toxicology, HcG, Lactate, ABG
  • FAST Exam

Tx:

  • Hem Shock
    • I: Normal, anxious -> give fluids
    • II: 15-30% (.75-1.5L) total blood volume loss +/- decreased pulse pressure -> give fluids
    • III: Decreased CO, tachypnea, decreased UO, 2L EBL, confusion -> give blood
    • IV: >2L EBL, no UO, HoTN, Lethargy -> give blood
  • Resuscitation
    • Begin with 1L warmed isotonic crystalloid
      • NS -> hyperchloremic acidosis
    • Mass txfn policy - continue until parameters met
  • Non-Operative:
    • NPO, bedrest, serial CBC, serial abd exam
    • Txfn PRN
  • Operative:
    • Peritoneal signs -> surg vs IR embolization
26
Q

Abdominal Compartment Syndrome

Path:

S/Sx:

Dx:

Tx:

A

Abdominal Compartment Syndrome

Path:

  • Increased intra-abdominal HTN > 12mmHg -> decreased organ perfusion
    • Depends on compliance = Vol/Pres
  • Primary: retroperitoneal bleeding (ruptured AAA) vs. visceral (intestinal edema) vs. peritoneal fluid (ascites) vs. trauma packing
  • Secondary: Burns, massive resuscitation

S/Sx:

  • Triad:
    • Inc ventilatory pressure (diaphragm pushed up)
    • Dec urine output (kidneys compressed)
    • HoTN (venous compression
  • High index of suspicion:
    • Hx abd surg; HoTN with reperfusion; resuscitation > 10L fluid or 6L blood
    • Clinical triad (hotn, low UO, high ventilatory pressure) +/- firm, distended abd

Dx:

  • Pressure measurements: bladder pressure
    • Grading: I (15mmHg) through IV (>25mmHg)
    • Normal IAP < 10
  • DDx: mesenteric ischemia, ruptured AAA, toxic megacolon, acute appendicitis, acute diverticulitis

Tx:

  • Limit fluid resuscitation
  • Freq monitor: IAP >30 mmHg
    • Decompress stomach, bladder; Evac bowel contents; improve abd wall compliance +/- NMB; optimize fluid & tissue perfusion
  • Surgical Decompression: IAP > 45 mmHg
    • Open laparotomy
      • Visceral herniation = diagnostic
      • Resolution of problems = diagnostic
    • Post Op: wound vac dressing for open abdomen
    • Complications: Fistula, evisceration, hgernia, IA abscess, metabolic drain
      • Will need increased protein and calories
27
Q

Blunt Cardiac Injury

Path:

S/Sx:

Dx:

Tx:

A

Blunt Cardiac Injury

Path:

  • Compression of heart btwn sternum & vertebral column
  • Upward force from lower trauma

S/Sx:

  • Chest wall bruise, rib/sternal fx
  • Sinus tach, PACs, PVCs (d/t irritated myocardial cells)
  • Retrosternal pain (MI-like) 2/2 trauma, unrelieved by O2, rest
  • S/sx cardiogenic shock (decreased contractility -> decreased CO)
  • Hematoma, hemopericardium, ventricular aneurysm, thromboembolism, constrictive pericarditis, traumatic MI d/t coronary a. inj, spasm -> necrosis & rupture

Dx:

  • Vitals, ECG, Trop, Echo, CT/MRI

Tx:

  • ECG & Trop I
    • (-) ECG and (-) trop: r/o BCI
    • (+) ECG or (+) Trop I: Admit w/ continuous ECG 24-48h and serial Trops
  • HD Unstable: 2D Echo vs TEE
  • If abnormal ECG, trop, echo:
    • Cardiac CT vs MRI: determine need for cardiac cath +/- anticoagulation
28
Q

Traumatic Cardiac Tamponade

Path:

S/Sx:

Tx:

A

Traumatic Cardiac Tamponade

Path: Rapid tampondae with less fluid than in ‘medical’ tamponade

S/Sx:

  • Increased CVP
  • Decreased Pulse Pressure
  • Decreased CO
  • Less reliable:
    • Beck’s Triad (muffled heart sounds, inc JVD, HoTN) more common in ‘medical’ tamponade, only in 10% of BCI
    • Kussmaul’s sign (JVD with inspiration)
    • Pulsus paradoxus
    • FAST exam (+) massive hemothorax

Tx:

  • Pericardial window: evacuate blood and clot; eval heart and vessels; surgical repair possible
  • NO pericardiocentesis: will not remove blood, will increase injury, will increase risk of false negative
29
Q

Traumatic Valvular Injury

Path:

S/Sx:

Tx:

A

Traumatic Valvular Injury

Path: Mitral valve injured and heart does not have time to compensate

S/Sx: Pulm edema (MVR) -> fluid into L atrium -> Vascular congestion

Tx: Early surgical intervention if possible; tx cardiogenic shock if occurs

ACNP Final (5 decks)

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