Trauma Flashcards
Between what two structures is the circothyroid membrane?
the thyroid and cricoid cartilages
What volume of blood from a chest tube in a trauma patient should prompt thoracotomy?
- 200cc/hr for four hours
- 1500cc at placement
What are hard signs of vascular injury?
- pulsatile bleeding
- absent pulse
- rapidly expanding or pulsatile hematoma
- bruit/thrill
What are the soft signs of vascular injury?
- history of significant bleeding
- decreased pulses (ABI < 0.9)
- non-expanding hematoma
- proximity to neuromuscular structures
What are the key portions of the “disability” exam in the CCB?
GCS and pupillary exam
What are the four classes of shock?
I: < 15%
II: 15-30%
III: 30-40%
IV: > 40%
The first sign of shock is what?
tachycardia
In what class of shock is altered mental status typically seen?
class III-IV
How is GCS scored?
Eye
- 4: spontaneous
- 3: to voice
- 2: to pain
- 1: none
Verbal
- 5: oriented
- 4: confused
- 3: inappropriate
- 2: incomprehensible
- 1: none
Motor
- 6: obeys commands
- 5: localizes to pain
- 4: withdraws from pain
- 3: flexion
- 2: extension
- 1: none
What component of GCS has the most prognostic value?
motor
Bilateral pinpoint pupils can be a sign of what neurologic injury?
a pontine hemorrhage
A unilateral, fixed, dilated pupil can be a sign of what neurologic injury?
an ipsilateral space occupying lesion compressing the optic nerve
What are the components of a TEG and how are they corrected?
- R time: FFP
- K time: cryo
- a-angle: cryo
- MA: plts, DDAVP
- LY30: TXA
What is the most common type of intra-cranial hemorrhage in trauma patients?
intra-parenchymal hematoma
ICP monitors are indicator for which trauma patients?
GCS < 8 with an abnormal head CT
What is the “golden rule” of head trauma?
avoid secondary injury by avoiding hypotension, hypoxia, fever, and hypo/hyperglycemia
What is Cushing’s reflex? What does it indicate?
- hypertension
- bradycardia
- altered respirations
- indicative of impending herniation
What is the target goal for ICP and CPP?
- ICP < 20
- CCP > 60
How is CPP calculated?
CPP = MAP - ICP
What are the reversal options for the following medications:
- warfarin
- dabigatran
- rivaroxaban
- apixaban
- warfarin: vit K, FFP, PCC
- dabigatran: dialysis or praxbind (idarucizumab)
- rivaroxaban: andexanet alfa or PCC
- apixaban: andexanet alfa or PCC
What is idarucizumab?
aka praxbind, an antibody used to reverse dabigatran
What antibody is used to reverse dabigatran?
idarucizumab (aka praxbind)
Describe the physiology of neurogenic shock?
injury to the sympathetic efferent signals leading to hypotension and bradycardia
What is the general rule for defining an unstable spinal fracture?
two or more columns are disrupted
What are the zones of the neck?
- I: clavicle to cricoid cartilage
- II: cricoid cartilage to angle of mandible
- III: angle of mandible to skull base
What is the best first test if concerned for a traumatic esophageal injury?
water-soluble esophagram
If an esophageal injury is not amenable to primary repair, how should it be managed?
- close over a large T-tube to create a controlled fistula
- or complete diversion with a cervical esophagostomy, wide drainage, and gastrostomy
What are the principles of repairing an esophageal injury?
- decried devitalized tissue
- control the leak
- buttress
- drain widely
- antibiotics
- keep NPO with distal feeding access
What is the most common site for BCVI?
distal internal carotid
What is the grading scale for BCVI?
- grade I: mild intimal irregularity
- grade II: > 25% stenosis due to dissection with raised flap, intramural hematoma, intraluminal thrombosis
- grade III: pseudoaneurysm
- grade IV: vessel occlusion
- grade V: vessel transection with active extrav
How should zone I vascular neck injuries be approached?
- typically best approached endovascularly in a stable patient
- sternotomy is the best open approach
How should zone II vascular neck injuries be approached?
usually through an anterior SCM incision
What are the most common EKG abnormalities in those with blunt cardiac injury?
sinus tach and PVCs
What is the appropriate screening for BCI?
trops and an EKG
What is the proper way to repair a blunt cardiac injury?
- a pledgeted, 3-0 permanent monofilament taking muscular bites (not full thickness)
- consider horizontal mattress sutures for friable tissue
What is Beck’s triad?
a collection of symptoms including jugular distention, muffled hear sounds, and hypotension which suggest cardiac tamponade
What clinical exam finding distinguishes cardiac tamponade from pneumothorax?
breath sounds, heart sounds, and midline trachea
What is the most common location for a blunt aortic injury?
the ligamentum arteriosum
How are blunt aortic injuries graded?
- type I: intimal tear
- type II: intramural hematoma
- type III: pseudoaneurysm
- type IV: rupture
What is the most commonly missed blunt abdominal injury?
pancreatic or hollow viscus injury
How are the zones of RP injury managed?
- explore all zones for penetrating trauma
- explore zone I for blunt
- explore zone II for blunt if expanding or pulsatile
- don’t explore zone III for blunt
How long of a trial should you give for non-operative management of a duodenal hematoma?
21 days
How should a duodenal hematoma be managed if patients fail non-operative repair?
drainage and then seromuscular closure over a T-tube
What is the preferred method for drainage of an injured duodenum?
a post-pyloric NGT rather than a duodenostomy tube
How should a duodenal injury be managed if there is > 50% tissue loss?
- can’t perform primary repair
- should instead perform duodenoduodenostomy or RNY duodenojejunostomy
How are traumatic rectal injuries managed?
with diversion (drainage and irrigation are insufficient)
How are traumatic pancreatic injuries graded?
I: superficial contusion/laceration not involving duct
II: major contusion/laceration not involving duct
III: distal transection or parenchymal injury with duct injury
IV: proximal transection or parenchymal injury with ampulla involvement
V: massive disruption of pancreatic head
How are traumatic pancreatic injuries managed?
- generally speaking, suck the head and bite the tail
- can drain the tail if there is no ductal injury
How are splenic injuries graded?
I: subcapsular hematoma < 10% or capsular tear < 1cm
II: subcapsular hematoma 10-50%, capsular tear 1-3cm
III: subcapsular hematoma > 50% or ruptured subcapsular hematoma or laceration > 3cm
IV: laceration involvement segmental or hilar vessels producing > 25% devascularization
V: completely shattered or with hilar vascular injury
What organism is the most common cause of OPSI?
Streptococcus pneumoniae
How are traumatic liver injuries graded?
Same as spleen for 1-3
I: subcapsular hematoma < 10% or tear < 1cm depth
II: subcapsular hematoma 10-50% or tear 1-3cm depth and < 10cm in length
III: subcapsular hematoma > 50%, ruptured subcapsular hematoma with active bleed, tear > 3cm
IV: lac disrupting 25-75% of lobe or 1-3 segments within 1 lobe
V: > 75% of lobe or > 1 segments in one lobe, or juxtahepatic venous injury
VI: hepatic avulsion
What is the most common intra-abdominal organ to be injured in blunt trauma?
the liver
What is the most common part of the liver to be injured in blunt trauma?
the right posterior segments
Hematemesis that occurs one week after a blunt traumatic injury to the liver is suggestive of what pathology? How is it treated?
an arterial-biliary fistula which requires embolization
What are the indications for hepatic necrosectomy after trauma?
uncontrolled pain or PO intolerance
What type of suture should be used for a ureterouretal anastomosis?
a fine, absorbable suture
How should the bladder be repaired?
in a two-layered fashion using absorbable suture
Hip dislocation is most likely to injure which nerve?
sciatic
Humeral shaft fracture is most likely to injure which nerve?
radial
Knee dislocation is most likely to injure which nerve?
common peroneal nerve, leading to loss of dorsiflexion (deep peroneal) and to foot eversion (superficial peroneal)
What are the objective criteria for diagnosing compartment syndrome?
a compartment pressure within 30mmHg of diastolic pressure
How does a pediatric airway differ from an adult?
narrower, shorter, and more anterior
Direct laryngoscopy is likely to trigger what in the pediatric population?
bradycardia
What med should you have ready when preparing for direct laryngoscopy of a child?
atropine given the higher risk for inducing bradycardia
What is different about ETT selection in pediatrics?
intubate with uncuffed tubes in infants
How should you select ETT size for pediatric patients?
- pinky bed width
- age/4 + 4
What physiologic respiratory changes are present in a pregnant woman?
- increased TV
- decreased FRC
- increased O2 consumption
Which trauma patients should succinylcholine not be used in?
burn patients, those with crush injuries (think hyperK+), and those with significant spinal cord trauma
What operation should you perform for someone with an open pelvic fracture and complex perineal wound?
diverting colostomy
What operation should you perform for someone who sustains a GSW and is found to have a rectal wall hematoma on rigid proctoscopy?
diverting colostomy
