trauma Flashcards
Hard Signs of Penetrating Neck Trauma
Expanding or pulsatile hematoma
Loss of airway
Stridor or hoarse voice
Audible bruit or palpable thrill
Massive subcutaneous emphysema
Wound bubbling
Shock refractory to resuscitation
Soft signs of penetrating neck trauma
Mild hemoptysis
Dysphonia
Dysphagia
Subcut or mediastinal air, non-expanding hematoma
Spinal Levels and Loss of Function
C2- occiput
C3 - Thyroid Cartilage
C4 - Breathing / Sternal notch
C5 - Shrugging / Below the clavicles
C6 - Elbow flexion / Thumb
C7 - Extension / middle finger
C8 -Finger Flexion
Anterior Spinal Column Contents
Anterior: Anterior spinal ligament, ant vertebral body and disc
Middle Spinal Column Contents
posterior annulus of disc, posterior vertebral wall, posterior longitudinal ligament, spinal cord, laminae and pedicles, articulating facets, transverse process, nerve roots, vertebral arteries and veins
Posterior Spinal Column Contents
Posterior: spinous process, nuchal ligament, interspinous and supraspinous ligaments, and ligamentum flavum
Corticospinal Tract Location and Function
Postero-lateral and anterior cord. Ipsilateral motor.
Spinothalmic Tract Location and Function
Anterolateral. Pain and temperature.
Posterior Columns Locations and Function
Posterior central. Light touch Vibration and proprioception ipsilateral.
Canadian C-Spine Rule High Risk Features
1) Age > 65
2) High Energy Mechanism
- Fall > 3 ft, axial load, high speed MVC, ATVs, bicycle hit by car
3) Parasthesias in extremities
Canadian C-Spine Low Risk Features
1) Ambulated at any point
2) Seated in ED
3) Simple rearend MVC
4) Delayed onset of neck pain
5) Absence on C-spine tenderness
Canadian C-Spine Inclusion
GCS 15
Stable vital signs
Age > 16
No paralysis
No known vertebral disease
Previous c-spine surgery
Canadian CT Head Inclusion
LOC, definite amnesia or witnessed disorientation in GCS 13-15
Age >= 16
No anticoags
Canadian CT Head Rule High Risk
1) GCS < 15 @ 2 hrs
2) Suspected open or depressed #
3) Any sign basal skull #
4) Vomiting > 2 episodes
5) Age > 65
Canadian CT Head Medium Risk
Amnesia > 30 minutes before impact
Dangerous mechanism
Cervical Spine Injuries and Stability - Flexion
1) Wedge - Stable
2) Flexion Tear Drop - Anterior vertebral body teardrop with interspinous ligament disruption. VERY unstable
3) Clay Shoveler’s - Spinous process #. Stable
4) Subluxation - Atlantooccipital misalignment. Possibly unstable
5) Bilateral Facet Dislocation - Unstable
6) Anterior atlantoaxial dislocation w or w/o # - Unstable
7) A-A dislocation - stable
8) Odontoid # - Unstable
9) Fracture of transverse process - stable.
C-Spine Injuries Flexion - Rotation
Unilateral Facet Dislocation - stable
Rotary A-A dislocation - unstable
C-Spine Injuries Extension
Posterior Neural Arch (C1) - Unstable
Hangman’s (C2) - # of bilateral pars interarticularis
Extension teardrop - Unstable in extension
Proper A-A dislocation w or w/o # - unstable
All extension injuries unstable
C-Spine Injuries Compression
Bursting - stable
Jefferson (C1) - Extremely unstable if ligamentous injury
Isolated # of articular pillar and vertebral body
Types of Odontoid Fractures
Type 1: Uncommon - tip of the dens. Avulsion of alar ligaments
Type 2: Most common - Waist of the dens near the ligament insertion
Type 3: Base of dens into the body
Type go in order from superior to inferior
Central Cord Syndrome Mechanism and Symptoms
Hyperextension in an already narrowed canal. ?Ligamentum flavum protrusion into cord and injures central portion of cord.
- Weakness more in upper than lower.
- Variable sensory changes
Anterior Cord Syndrome
Hyperflexion injury with disc protrusion into anterior cord.
- Motor paralysis below level
- Pain affected, fine touch and prioprioception spared
- Worst prognosis of partial cord injuries
Define Spinal Shock vs Neurogenic Shock
Spinal shock is reversible impairment of spinal cord injury - can lead to neurogenic shock. Often leads to loss of f’n below the level of the injury.
Neurogenic Shock: Uncontrolled parasympathetic activation in complete spinal cord injury above T6 (location of sympathetic chain), bradycardia and vasodilation. Can see priapism as well.
Brown Sequard / Hemi Cord Syndrome
Penetrating injury or lateral masses fracture
Weakness or paralysis with contralateral loss of sensation.
Myocardial Concussion
Think commotio cordis - blunt trauma during repol. Can lead to asystole or vfib. No structural damage.
Myocardial Contusion
Chest trauma with heart compressed by sternum. ECG abnormalities, tachy, PVCs, heart block, ischemia, arrhythmia, trop elevation.
- N ECG and N trop = rule out
Rib Fractures
If 3 or more - Consider admission. Treat pain to avoid splinting and atelectasis
WEST Guidelines for Traumatic Arrest
If no signs of life:
Blunt > 10 min
Penetrating > 15 min
= Dead
If < time limit Consider resuscitative thoracotomy
Pneumothorax Mgmt
If small < 2cm to chest wall then conservative
If > 3 cm chest tube.
Signs of Tension Pneumo
Deviated Trachea
Hypotension
Tachycardia, tachypnea
Altered LOC
Hypoxia
Indications for laparotomy following penetrating trauma
Evisceration
Diaphragm injury
Hemodynamic Instability
Peritoneal signs
OR:
Intraperitoneal air
Implement in situ
Gastrointestinal hemorrhage
Diaphragm Injury Assess
can be missed on CT
If L thoracoabdo penetrating trauma - need thoracoscopy or laparoscopy with N CT.
Indications for laparotomy after blunt trauma
Hemodynamic Instability with suspected abdomen injury
Peritonitis (Unequivocal)
Pneumoperitoneum
Diaphragmatic injury
GI bleeding
If multisystem trauma, hemodynamic unstable, with unstable pelvis and N CXR - next steps
If FAST + : laparotomy with packing and fixation
If FAST - : Usually* angiography embolization and pelvic fixation. THEN look for intraabdominal injury on CT +/- laparotomy
If combined blunt head with lateralizing and blunt abdo trauma
BRAIN TRUMPS EVERYTING:
- Consider CT head and craniotomy
then laparotomy vs angiography with pelvic fixation
Types of brain herniation
Subfalcine
Transalar / transphenoidal
Transtentorial uncal
Central transtentorial
Cerebellar Tonsillar Herniation
Transcalvarial
Tentorial (Uncal) Symptoms
3 nerve palsy - unilateral fixed, blown
Contralateral hemiparesis
Brain stem compression
Subfalcine (midline shift) herniation Signs
Papilledema
Contralateral leg paralysis
Central (tentorial) herniation Signs
Pupils fixed, mid-dilated.
Decerebrate posturing
(Similar to transtent)
Upward transtentorial signs
Hydrocephalus and increased ICP
N/V, headache and ataxia
Progressive LOC and brain stem reflexes
Ataxia and dysarthria
Respiratory irregularities
Tonsillar Herniation Sign (cerebellar tonsil)
Acute hydrocephalus with impaired consciousness, headache vomiting, and meningismus,
Dysconjugate gaze and nystagmus
Death
massive transfusion def’n
Massive transfusion has been defined as transfusion of ≥10 units of whole blood (WB) or packed red blood cells (pRBCs) in 24 hours, ≥3 units of pRBCs in one hour, or ≥4 blood components in 30 minutes
risks / adverse events of massive transfusion
coagulopathy
Zone 1 Neck Anatomy
Base of neck to cricoid cartilage
- Prox carotid artery
- Vertebral artery
- Subclavian
- Mediastinal vessels
- Apices of lungs
- Esophagus
- Trachea
- Thyroid
- Thoracic Duct
- Spinal Cord
Zone 2 Neck Anatomy
Base of cricoid to angle of jaw
- Carotid artery
- Vertebral artery
- Larynx
- Pharynx
- Jugular Vein
- Esophagus
- Trachea
- Vagus Nerve
- Recurrent Laryngeal Nerve
- Spinal Cord
