Trauma Flashcards
1
Q
What is the correct procedure to perform for trauma patients that are unable to be intubated?
A
cricothyroidotomy
2
Q
Describe the soft tissue anatomy pertinent to a cricothyroidotomy.
A
the cricothyroid membrane which is to be incised is bordered by the thyroid cartilage superiorly, the cricoid cartilage inferiorly, and the cricothyroid muscles laterally
3
Q
What component of GCS has the most prognostic significance?
A
motor score
4
Q
Describe the GCS system.
A
- eyes (4): spontaneous, to speech, to pain, no response
- verbal (5): oriented, confused, inappropriate words, incomprehensible sounds, no response
- motor (6): obeys commands, localizes to pain, withdraws from pain, abnormal flexion, abnormal extension, no response
5
Q
What GCS is an indication for intubation?
A
less than 8
6
Q
What is the significance and pathophysiology of a unilateral fixed and dilated pupil on neuro exam?
A
suggests a unilateral space occupying lesion with compression of the optic nerve
7
Q
What is the significance of bilateral pinpoint pupils on neuro exam?
A
pontine hemorrhage
8
Q
What are the two main types of ICP monitors?
A
- bolt: an intraparenchymal monitor
- ventriculostomy: a drain placed in the ventricle (i.e. diagnostic and therapeutic of increased ICP)
9
Q
What is the golden rule of head trauma?
A
avoid hypotension and hypoxia to avoid secondary brain injury
10
Q
What is Cushing’s reflex?
A
a triad of altered respirations, hypertension, and bradycardia suggestive of impending herniation
11
Q
What is the most common kind of brain bleed in trauma patients?
A
intraparenchymal
12
Q
How is cerebral perfusion pressure calculated?
A
CPP = MAP - ICP
13
Q
What are goals for ICP and CPP?
A
- CPP > 60
- ICP < 20
14
Q
What is the main factor regulating CPP?
A
PaCO2
15
Q
Why is CPP extremely sensitive to MAP in patients with TBI?
A
because TBI results in a loss of arterial autoregulation
16
Q
What interventions are available to reduce ICP?
A
- elevate the head of bed
- remove the c-collar or anything around the neck
- hyperventilation
- hypertonic saline (preferred over mannitol in trauma patients due to possible hypotension)
- sedation/paralysis
17
Q
What are three adjuncts in the treatment of head injury?
A
- seizure ppx for one week
- early enteral feeding within 1-2 days
- correction of coagulopathy
18
Q
How are the following reversed:
- warfarin
- dabigatran
- apixaban
- rivaroxaban
A
- warfarin: PCC for rapid reversal, FFP and vitK are slower
- dabigatran: dialysis or praxbind (idarucizumab)
- apixaban: PCC gives partial reversal
- rivaroxaban: PCC gives partial reversal
19
Q
Who is a candidate for clinical c-collar clearance?
A
those with no distracting injury, a GCS of 15, no indication of intoxication, and no midline tenderness or neurologic deficts
20
Q
What is the typical presentation of central cord syndrome?
A
upper extremity weakness in an elderly patient with spinal stenosis
21
Q
What is the typical presentation for Brown Sequard syndrome?
A
- ipsilateral motor deficits
- contralateral pain and temperature deficits
- typically from penetrating trauma
22
Q
What is the typical presentation for anterior cord syndrome?
A
- motor deficit below the level of the injury
- typically from vascular injury to the anterior spinal artery
23
Q
What are the typical vitals for patients in neurogenic shock?
A
bradycardic and hypotensive
24
Q
What are the zones of neck trauma?
A
- zone 1 is the clavicles to the cricoid cartilage
- zone 2 is the cricoid cartilage to the angle of the mandible
- zone 3 is the angle of the mandible to the skull base
25
How should penetrating neck injuries be managed?
- if hypotensive or with hard signs of vascular injury, patient should go the OR
- otherwise patients should get a CT angio neck
26
How are suspected esophageal injuries diagnosed and then managed?
- evaluate with an esophagram or EGD
- if an injury is seen, extend the myotomy to evaluate the extent of the mucosal injury and then repair in 2 layers, buttress, and drain
- if an injury can't be located, widely drain
27
What are the indications for CTA of the neck?
- hyperextension/rotation or hyperflexion mechanism
- neuro exam unexplained by brain imaging
- diffuse axonal injury
- skull base fractures involving the foramen lacerum or cervical spine fracture
- LeFort II or III facial fractures
- blunt head trauma with GCS < 8
- cervical bruit or hematoma
28
What is the most common site for blunt cerebrovascular injury?
distal internal carotid
29
What are the indications for OR in patient's with a chest tube?
> 1500cc at initial placement or > 200cc/hr for 4 hours
30
What is a flail chest?
three consecutive ribs fractured in two places
31
What causes hypoxia in patients with flail chest?
the underlying pulmonary contusion
32
How is flail chest managed?
pain control, rib plating, positive-pressure ventilation PRN
33
Flail Chest
- three or more consecutive ribs broken in two or more places
- hypoxia secondary to underlying pulmonary contusion
- treated with analgesia, rib plating, and positive pressure ventilation as needed
34
What is the concern in patients with sternal fracture? How is this evaluated?
- concern is for blunt cardiac injury
- EKG is required for all
- normal EKG and troponins rule out injury
- echo is indicated for patients with hemodynamic instability or persistent new arrhythmia
35
What is the most common EKG abnormalities for patients with sternal fractures?
- sinus tachycardia
| - PVCs
36
What is the most common site of blunt aortic injury and why?
the proximal descending aorta where the relatively mobile arch can move against the fixed descending aorta
37
How is blunt aortic injury diagnosed?
CXR can be a screening tool but with low sensitivity while CT angiography of the chest is the study of choice
38
How are aortic injuries classified?
- type I: intimal tear
- type II: intramural hematoma
- type III: pseudoaneurysm
- type IV: rupture
39
Describe the management of blunt aortic injury.
- diagnosed with CTA of the chest
- initially managed with SBP control < 120 using esmolol +/- nitroprusside
- endovascular repair
40
Post endovascular repair of blunt aortic injury goes on to develop left hand ischemia?
- subclavian is routinely covered during endovascular repair of BAI
- requires a carotid to subclavian bypass
41
Blunt Aortic Injury
- most likely at the proximal descending aorta where the mobile arch connects to the fixed descending aorta
- presents with hypotension, upper extremity hypertension or unequal pressures
- possible CXR abnormalities but CTA of the chest is preferred diagnostic method
- type I are intimal tears, II are mural hematomas, III are pseudoaneurysms, and IV are ruptures
- initially manage with SBP control using esmolol +/- nitroprusside
- definitively managed with endovascular repair
42
What are the two most missed intra-abdominal injuries following blunt trauma?
hollow viscus or pancreatic
43
Seat belt sign is concerning for what injuries?
small bowel or pancreatic
44
What are indications for a trip to the OR following abdominal stab wound?
hemodynamic instability, evisceration, or evidence of peritonitis
45
How should abdominal stab wounds be managed?
- hemodynamic instability, evisceration, or peritonitis are immediate indications for the OR
- anterior stab wounds should be explored to look for violation of the anterior rectus sheath, if found and alert for exams then CT is acceptable but if unable to examine then consider CT versus diagnostic laparoscopy
- flank wounds should be evaluated with triple contrast CT scan
46
How are diaphragmatic injuries best evaluated?
sensitivity of CT is low so best method is diagnostic laparoscopy
47
How is a bowel injury (small or large bowel) managed in the trauma setting?
- if destructive (> 50% circumference or devascularization) then the segment should be resected
- primary repair if not
- in damage control cases, can staple off the bowel and leave in discontinuity
48
What is a bucket handle injury?
when the mesentery of bowel is torn from the bowel which was left intact
49
How are the following pancreatic injuries managed:
- distal with no ductal injury
- distal with ductal injury
- head with no ductal injury
- head with ductal injury
- distal with no ductal injury: leave drains
- distal with ductal injury: distal pancreatectomy +/- splenectomy depending on hemodynamics
- head with no ductal injury: drainage
- head with ductal injury: drainage
50
What are the three zones of retroperitoneal injury?
- 1: central (aorta, cava)
- 2: lateral (renals)
- 3: pelvis (iliacs)
51
Which retroperitoneal zones should be explored in blunt and penetrating abdominal trauma?
- penetrating: all three
- blunt: explore zone 1, explore zone 2 only for explanding/pulsatile hematomas, zone 3 don't explore but pack and do an angio
52
How are open book fractures managed?
- first step is a binder
- if stable: angiography
- if unstable: OR for preperitoneal packing
53
For the following classes of hemorrhagic shock, how much blood is lost and what are the signs?
- class I
- class II
- class III
- class IV
- class I: 0-15%, no signs
- class II: 15-30%, tacky with narrowed pulse pressure
- class III: 30-40% with hypotension
- class IV: greater than 40%
54
What are the earliest signs of shock?
narrowed pulse pressure and tachycardia
55
What is the "triad of death"?
cold, coagluopathic, and acidotic
56
What are the four principles of damage control?
- control sepsis and spillage
- control hemorrhage
- temporary closure
- resuscitation
57
What is the preferred mechanism for abdominal compartment syndrome decompression in burn patients?
- high risk of mortality for laparotomy
| - therefore the preference is for drainage
58
What is the proper dose for TXA and what does it do? When is it indicated?
- it decreases fibrinolysis
| - give 1g within 3hrs of injury with subsequent 1g over 8 hrs
59
What do the following measure on a TEG and what is the best method for correction:
- Reaction Time (R)
- Clot Formation Time (K)
- Alpha Angle
- Max Amplitude
- LY30
- R Time, time until clot formation starts, give FFP
- K Time, time to reach fixed strength, give cryo
- Alpha Angle, speed of fibrin formation, give cryo
- Amplitude, size of clot, give platelets
- LY30: fibrinolysis, give TXA
60
How is a traumatic bladder injury managed?
- intraperitoneal: OR repair
| - exztraperitoneal: foley drainage
61
How are ureteral injuries managed?
- mid injuries: spatulate ends, primary anastomosis over double K with fine absorbable suture
- distal: re-implant into bladder +/- psoas hitch
62
What are considered hard signs of vascular injury?
pulsatile bleeding, expanding hematoma, absent pulses, bruit/thrill
63
What are considered soft signs of vascular injury?
non-expanding hematoma, decreased pulses (ABI < 0.9), proximity to neuromuscular structures
64
How should hard and soft signs of vascular injury be managed?
- hard: OR
| - soft: CT angiogram
65
What is the appropriate size of bolus for pediatric trauma patients?
20cc/kg of crystalloid, 10cc/kg of blood
66
How can you improve venous return in pregnant patients?
roll them onto their left side to take pressure off the IVC
67
Which pregnant trauma patients need fetal monitoring?
those with a viable pregnancy > 24 weeks
68
What is the best next step for a patient who sustains a left thoracoabdominal stab injury and has negative imaging and a normal abdominal exam?
diagnostic laparoscopy looking for diaphragmatic injury
69
What is the diagnosis and treatment for a TBI patient who is hypernatremia and fluid overloaded?
diabetes insipidus, treat with DDAVP
70
What should you suspect if liver bleeding is uncontrolled by a Pringle?
hepatic vein or retrohepatic vena cava injury
71
What vessel is most likely injured if you encounter major arterial bleeding posterior in the neck?
vertebral artery
72
What is the gateway structure to the carotid bifurcation?
the common facial vein
73
What is the gateway structure for the great vessels during median sternotomy?
innominate vein
74
What is the diagnosis and treatment for hematemesis 2 weeks after an MVC with high grade liver laceration?
haemobilia, treat with angioembolization
75
What surgery should be offered to those with an open pelvic fracture and complex perineal wound?
diverting colosomty
76
What surgery should be offered to a patient with GSW to the pelvis with a rectal wall hematoma seen on rigid proctoscopy?
diverting colostomy
