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BTK Book Review > Trauma > Flashcards

Trauma Flashcards

1
Q

What is the correct procedure to perform for trauma patients that are unable to be intubated?

A

cricothyroidotomy

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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

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3
Q

What component of GCS has the most prognostic significance?

A

motor score

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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
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5
Q

What GCS is an indication for intubation?

A

less than 8

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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

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7
Q

What is the significance of bilateral pinpoint pupils on neuro exam?

A

pontine hemorrhage

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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)

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9
Q

What is the golden rule of head trauma?

A

avoid hypotension and hypoxia to avoid secondary brain injury

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10
Q

What is Cushing’s reflex?

A

a triad of altered respirations, hypertension, and bradycardia suggestive of impending herniation

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11
Q

What is the most common kind of brain bleed in trauma patients?

A

intraparenchymal

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12
Q

How is cerebral perfusion pressure calculated?

A

CPP = MAP - ICP

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13
Q

What are goals for ICP and CPP?

A
  • CPP > 60

- ICP < 20

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14
Q

What is the main factor regulating CPP?

A

PaCO2

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15
Q

Why is CPP extremely sensitive to MAP in patients with TBI?

A

because TBI results in a loss of arterial autoregulation

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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
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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
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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
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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

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20
Q

What is the typical presentation of central cord syndrome?

A

upper extremity weakness in an elderly patient with spinal stenosis

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21
Q

What is the typical presentation for Brown Sequard syndrome?

A
  • ipsilateral motor deficits
  • contralateral pain and temperature deficits
  • typically from penetrating trauma
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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

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23
Q

What are the typical vitals for patients in neurogenic shock?

A

bradycardic and hypotensive

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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
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25
Q

How should penetrating neck injuries be managed?

A
  • if hypotensive or with hard signs of vascular injury, patient should go the OR
  • otherwise patients should get a CT angio neck
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26
Q

How are suspected esophageal injuries diagnosed and then managed?

A
  • 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
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27
Q

What are the indications for CTA of the neck?

A
  • 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
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28
Q

What is the most common site for blunt cerebrovascular injury?

A

distal internal carotid

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29
Q

What are the indications for OR in patient’s with a chest tube?

A

> 1500cc at initial placement or > 200cc/hr for 4 hours

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30
Q

What is a flail chest?

A

three consecutive ribs fractured in two places

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31
Q

What causes hypoxia in patients with flail chest?

A

the underlying pulmonary contusion

32
Q

How is flail chest managed?

A

pain control, rib plating, positive-pressure ventilation PRN

33
Q

Flail Chest

A
  • 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
Q

What is the concern in patients with sternal fracture? How is this evaluated?

A
  • 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
Q

What is the most common EKG abnormalities for patients with sternal fractures?

A
  • sinus tachycardia

- PVCs

36
Q

What is the most common site of blunt aortic injury and why?

A

the proximal descending aorta where the relatively mobile arch can move against the fixed descending aorta

37
Q

How is blunt aortic injury diagnosed?

A

CXR can be a screening tool but with low sensitivity while CT angiography of the chest is the study of choice

38
Q

How are aortic injuries classified?

A
  • type I: intimal tear
  • type II: intramural hematoma
  • type III: pseudoaneurysm
  • type IV: rupture
39
Q

Describe the management of blunt aortic injury.

A
  • diagnosed with CTA of the chest
  • initially managed with SBP control < 120 using esmolol +/- nitroprusside
  • endovascular repair
40
Q

Post endovascular repair of blunt aortic injury goes on to develop left hand ischemia?

A
  • subclavian is routinely covered during endovascular repair of BAI
  • requires a carotid to subclavian bypass
41
Q

Blunt Aortic Injury

A
  • 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
Q

What are the two most missed intra-abdominal injuries following blunt trauma?

A

hollow viscus or pancreatic

43
Q

Seat belt sign is concerning for what injuries?

A

small bowel or pancreatic

44
Q

What are indications for a trip to the OR following abdominal stab wound?

A

hemodynamic instability, evisceration, or evidence of peritonitis

45
Q

How should abdominal stab wounds be managed?

A
  • 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
Q

How are diaphragmatic injuries best evaluated?

A

sensitivity of CT is low so best method is diagnostic laparoscopy

47
Q

How is a bowel injury (small or large bowel) managed in the trauma setting?

A
  • 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
Q

What is a bucket handle injury?

A

when the mesentery of bowel is torn from the bowel which was left intact

49
Q

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
A
  • 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
Q

What are the three zones of retroperitoneal injury?

A
  • 1: central (aorta, cava)
  • 2: lateral (renals)
  • 3: pelvis (iliacs)
51
Q

Which retroperitoneal zones should be explored in blunt and penetrating abdominal trauma?

A
  • 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
Q

How are open book fractures managed?

A
  • first step is a binder
  • if stable: angiography
  • if unstable: OR for preperitoneal packing
53
Q

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
A
  • 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
Q

What are the earliest signs of shock?

A

narrowed pulse pressure and tachycardia

55
Q

What is the “triad of death”?

A

cold, coagluopathic, and acidotic

56
Q

What are the four principles of damage control?

A
  • control sepsis and spillage
  • control hemorrhage
  • temporary closure
  • resuscitation
57
Q

What is the preferred mechanism for abdominal compartment syndrome decompression in burn patients?

A
  • high risk of mortality for laparotomy

- therefore the preference is for drainage

58
Q

What is the proper dose for TXA and what does it do? When is it indicated?

A
  • it decreases fibrinolysis

- give 1g within 3hrs of injury with subsequent 1g over 8 hrs

59
Q

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
A
  • 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
Q

How is a traumatic bladder injury managed?

A
  • intraperitoneal: OR repair

- exztraperitoneal: foley drainage

61
Q

How are ureteral injuries managed?

A
  • mid injuries: spatulate ends, primary anastomosis over double K with fine absorbable suture
  • distal: re-implant into bladder +/- psoas hitch
62
Q

What are considered hard signs of vascular injury?

A

pulsatile bleeding, expanding hematoma, absent pulses, bruit/thrill

63
Q

What are considered soft signs of vascular injury?

A

non-expanding hematoma, decreased pulses (ABI < 0.9), proximity to neuromuscular structures

64
Q

How should hard and soft signs of vascular injury be managed?

A
  • hard: OR

- soft: CT angiogram

65
Q

What is the appropriate size of bolus for pediatric trauma patients?

A

20cc/kg of crystalloid, 10cc/kg of blood

66
Q

How can you improve venous return in pregnant patients?

A

roll them onto their left side to take pressure off the IVC

67
Q

Which pregnant trauma patients need fetal monitoring?

A

those with a viable pregnancy > 24 weeks

68
Q

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?

A

diagnostic laparoscopy looking for diaphragmatic injury

69
Q

What is the diagnosis and treatment for a TBI patient who is hypernatremia and fluid overloaded?

A

diabetes insipidus, treat with DDAVP

70
Q

What should you suspect if liver bleeding is uncontrolled by a Pringle?

A

hepatic vein or retrohepatic vena cava injury

71
Q

What vessel is most likely injured if you encounter major arterial bleeding posterior in the neck?

A

vertebral artery

72
Q

What is the gateway structure to the carotid bifurcation?

A

the common facial vein

73
Q

What is the gateway structure for the great vessels during median sternotomy?

A

innominate vein

74
Q

What is the diagnosis and treatment for hematemesis 2 weeks after an MVC with high grade liver laceration?

A

haemobilia, treat with angioembolization

75
Q

What surgery should be offered to those with an open pelvic fracture and complex perineal wound?

A

diverting colosomty

76
Q

What surgery should be offered to a patient with GSW to the pelvis with a rectal wall hematoma seen on rigid proctoscopy?

A

diverting colostomy

BTK Book Review (13 decks)

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