Trauma Flashcards
most common causes of death in trauma pt?
hemorrhage and head in ury
thing to not forget before paralyzing trauma pt?
quick neuro exam: pupils, GCS, gross motor
run through primary survey
ABCDE
GCS
E4: spont, voice, pain, nothing
V5: oriented, confused, inappro words, sounds, nothing
M6: follows commands, localizes pain, withdraws from pain, flexor, extensor, none
dose and timing of TXA
2g, less than 3 hrs from injury
classes of hemorrhage
class 1: Hr < 100 (<15% blood)
class 2: 100-120 (15-30%)
class 3: 120-140 (30-40%)
class 4: >140 (>40%)
who gets O+ in trauma
everyone, except females of childbearing age get O-
ED thoracotomy indications/contraindications for penetrating trauma
Prehospital/hospital signs of life
-Eco evidence of cardiac activity with tamponade
-unresponsive hypotension [SBP less than 70] despite resuscitation
-Availability of surgeon and or operating room for definitive management
Contraindications:
-pre hospital CPR greater than 15 minutes without response
-asystole as presenting rhythm and no evidence for cardiac tamponade on bedside ultrasound
-Significant head trauma
ED thoracotomy indications/contraindications for blunt trauma
-unresponsive hypotension [SBP less than 70] despite resuscitation 3
-Prehospital signs of life with lots of life less than 10 minutes
-Rapid exsanguination from chest tube , greater than 1500 ML output upon insertion
–Availability of surgeon and or operating room for definitive management
Contraindications:
-pre hospital CPR greater than 10 minutes without response
-asystole as presenting rhythm and no evidence for cardiac tamponade on bedside ultrasound
-Significant head trauma
Secondary survey ample history mnemonic
all, meds, pmhx, last meal, events
CPP equation and ideal values for each
CPP= MAP - ICP
CPP > 60, MAP >80, ICP <15
Uncal herniation syndrome
blown/down and out pupil… temporal lobe swelling, uncus pushed on brainstem, compresses ipsilateral CN 3
CT can CT head rules
go
PECARN head rules
dose of hyperosmolar agents in adults and kids
NaCl: 3% NaCl 3 mL/kg over 10 mins, max 250 mL, repeat once prn. adults 250 mL
mannitol: 1g/kg, max 100 g
head trauma cushing reflex
bradycardia, hypertension, irreg resps
things to avoid in head injury
hypotension, hypoxemia, hypoglycemia, hyperpyrexia
mgmt of severe TBI
HOB > 30 deg, neuroprotective RSI (exam first), SBP > 90, MAP 80, optimize vitals to reduce secondary injury, rapid CT HEAD, reverse anticoagulation
age group, location, CT finding, common cause and classic symptoms of: Epidural hematoma
age group: young (rare in elderly and in less than 2)
location: potential space between dura and skull
CT finding: convex lesion, lemon-shaped
common cause: lateral blow with skull # and tear of MMA
classic symptoms: immediate LOC, then lucid period then deterioration (only in 20%)
age group, location, CT finding, common cause and classic symptoms of: subdural hematoma
age group: elderly
location: sace between dura and arachnoid
CT finding: concave, banana shaped lesion
common cause: shearing force on bridging VEINS from accel/decel, more common in elderly d/t smaller brain
classic symptoms: rapid LOC in acute, progressive HA, progressive aLOC/behavior changes in chronic
age group, location, CT finding, common cause and classic symptoms of: subarachnoid (traumatic)
age group: any with trauma
location: between arachnoid and pia
CT finding: blood in basal cisterns or hemispheric sulci and fissure
common cause: accel/decel with tearing of aub arachnoid vesseles
classic symptoms: mild, mod or severe TBI with MENINGEAL signs/symptoms
age group, location, CT finding, common cause and classic symptoms of: contusion/intraparenchymal
age group: any with trauma
location: usually anterior temporal lobs or posterior frontal lobe
CT finding: intraparenchymal blood, can also be normal initially.
common cause: severe or penetrating trauma, shaken baby
classic symptoms: normal to LOC
In context of had trauma: persistent dec LOC and normal CT head, consider
DAI, better dx’d on MRI
timeline grading of subdural bleeds
acute <24hr, subacute < 14 days, chronic > 14 days
surgery usually for acute or subacute hemm and bleeds with midline shift/aLOC
basal skull # presenting s/s
hemotympanum, CSF rhinorrhea (target lesion on filter paper), hearing difficulty, vertigo, 7th nerve palsy, Battle Sign, raccoon eyes.
mgmt of basal skull #
generally, pain mgmt, antiemetics and observation. no consensus on prophylactic abx
how to classify # of skull convexity
location and type (linear, comminuted, depressed)
operative repair if depressed beyond one full thickness of skull
causes of pharyngeoesophageal injury
Boerhave, penetrating trauma, caustic or foreign body ingestion
rarely blunt trauma
mechanisms of blunt cerebrovascular injury
-direct impact (seatbelt, strangulation, etc)
-hyperextension with lateral rotation –> carotid lacerates on lateral process
-intraoral trauma
-basal skull #
signs of cerebrovascular injury from blunt neck trauma, including hard signs
most have initial NORMAL neuro exam, often only symptom is pain in neck… need high index of suspicion.. get CTA if mechanism concerning.
HARD signs: expanding hematoma, bruits, active bleeding, stroke/TIA, airway compromise (?)
HARD signs of major injury in penetrating neck trauma (8)
-airway compromise
-air bubbling from wound
-shock
-severe active bleeding
-expanding/pulsatile hematoma
-neuro deficit
-hematemesis
-massive SQ emphysema
if wound does not violate ______ it can be closed
platysma
zone 1 of neck: landmarks
clavicles to cricoid cartilage
zone 2 of neck: landmarks
cricoid to mandible
zone 3 of neck: landmarks
mandible to base of skull
work up of neck zone injuries
zone 1 and 3 –> CTA
zone 1 also consider bronch and endoscopy to look for tracheal and esophgeal injury respectively
zone 2: if hard sings –> explore surgically, if no hard signs, treat like zone (as above)
NEXUS for c-spine
validated 16 and over
NSAID
neuro deficit
spinal tenderness (midline), NOT pain
alert
intoxicated
distracting injury
3 lines on lateral c spine xr
anterior contour line
posterior contour line
spinolaminar line
soft tissues values for later c spine xr:
> 7 mm at c2 or > 21 mm at c6 is abn
c-spine #: wedge
stable vs unstable
mechanism
notes
stable
flexion
multiple wedge or >50% loss of height may be unstable
c-spine #: transverse process
stable vs unstable
mechanism
notes
stable
flexion
benign
c-spine #: clay shoveler
stable vs unstable
mechanism
notes
stable
flexion against contracted posterior neck muscle
usually c7
c-spine #: unilateral facet
stable vs unstable
mechanism
notes
stable
flexion+rotation
anterior displacement <50% of width
c-spine #: burst
stable vs unstable
mechanism
notes
stable
vertical compression
can be unstable if fragments enter canal
c-spine #: jefferson
stable vs unstable
mechanism
notes
unstable
axial load/vertical compression
seen on odontoid view (asymmetry and widening of lateral masses)
c-spine #: bilateral facet dislocation
stable vs unstable
mechanism
notes
unstable
flexion
anterior displacement >50%
c-spine #: odontoid 2&3
stable vs unstable
mechanism
notes
unstable
flexion
usually high energy, look for other injuries
c-spine #: antlantooccipatal dislocation
stable vs unstable
mechanism
notes
unstable
flexion or extension
usually results in immediate death
c-spine #: hangmans
stable vs unstable
mechanism
notes
unstable= bilat c2 pedicle with C2 displace anteriorly on c3
extension
c-spine #: teardrop
stable vs unstable
mechanism
notes
unstable
flexion or extension
anteroinferior portion of vertebrae
3 types of odontoid fractures
T1= tip = stable
t2= junction of body of c2 and base of odontoid = unstable = most common
t3= fracture at base of dens
T spine: wedge
mechanism
xr findings
unstable/major
flexion injury
= loss of anterior vetebral body height
T spine: chance #
mechanism
xr findings
flexion around anterior axis (SEATBELT)
horizontal # through vert body and all posterior elements, unstable,
T spine: burst #
mechanism
xr findings
vertical compression
loss of height through whole vert body
T spine: flexion-distraction injury
mechanism
xr findings
compression of anterior & distraction of posterior
fanning = increased posteior interspinous space
T spine: translational #
mechanism
xr findings
shear force
shift of vertebral body causing disruption
anterior- cord
-poor prognosis
-loss of pain/temp and motor, preservation of vib and prop
brown sequard
-hemisection of cord from penetration, -best prognosis
-ipsilateral motor, vib/prop
-contralteral pain/temp
posterior cord
-loss of vib and prop, preservation of motor
complete SCI
everything is fucked
central cord syndrome
-hyperextension injury, most comon incomplete SCI
-numbness/weakness > in arms than legs
neurogenic shock=
hypotension due to lack of sympathetic tone. pt is warm, vasodilated and bradycardic, type of distributive shock
think sepsis but brady
spinal schock
transient depression of all spinal function below level of injury, can make incomplete SCI look complete. usually resolves in 24-48 hrs.
SCIWORA
neuro deficits with normal XR and CT, often MRI findings. most common in kids
upright cxr findings of PTX in trauma
absent lung markings, subQ emphysema, depressed diaphragm on injured side
finding of PTX on supine CXR
deep sulcus sign
simple traumatic pneumo TX
if less than 15-25%, can tx with NRB and rpt cxr
if large or any hemodynamic compromis–> chest tube (size depends on if there is blood or not, 24F is a good size for hemothor!), consider chest tube if intubating (can convert to tension on PPV)
findings in tension pneumo
distended neck veins, decreased/absent breath sounds, shifted mediastinum, tracheal deviation (to oppo side)
hypotension and neck veins happen with tamponade too, use POCUS
chest tube size and settings
historically, 22-24F for pneumo and 32F for hemo, however just use 24F for both. can use seldinger and smaller if only pneumo, ie use 14F
set to water seal and 20 cm H2O of suction.
open pneumo (aka sucking chest wound) mgmt
three sided occlusive dressing
if chest tube required, dont put it through wound
what injuries implied with pneumomediastinum
larnygeal, tracheal, major bronchi, pharynx or esophagus (NEED TO R/O eso, scope or xr with oral contrast)
exam findings pneumomedistiunm
subQ emphysema in neck, Hammans crunch (crunch during systole)
4 causes of lung opacification in trauma
massive hemo
diaphragmatic rupture with herniation
lung collapse
pulm contusion
where do hemothorax bleed from, how many also have pneumo
lung parnechyma, intercostals, less commonly great vessls/hilar vessesls
25%
massive hemothorax criteria: (indicated need for thoracotomy)
initial output >1500 mL (or 20 mL/kg kids)), or subsequent output of 200 mL/hr (3 ml/kg/hr in kids), or persistent hypotension
how visible are rib # on cxr
about 50%
peds vs adult chest trauma
peds less likely to break ribs, more likely to injure inner structures
initial concerns/associate dinjuries in rib #
pneumo/hemo
brachial plexus,
liver/spleen lac
rib # mgmt
pain mgmt, pulm hygiene, admit if 3 or more, admit ICU if 6 or more and >65 yoa
define flail chest
2 or more breaks in 3 or more adjacent ribs causing paradoxical movement of chest
flail chest mgmt
same as rib # +, CPAP if stable, early ventilation if needed
3 reasons for hypoxemia in flail chest
pain, hypoexapansion and pulm contusion
sternal fracture best seen on?
lateral cxr
does isolated sternal fracture predict blunt cardiac injury? do they need cardiac monitoring? should you do initial ECG and troponin?
NO, Not if ecg & trop normal, YES
findings of pulmonary contusion
hemoptysis 50%, opacity on cxr, dyspnea, tachypnea, tachycardia, chest wall bruising usually present
cxr findings and timeline of pulm contusion
pathcy infiltrates within minutes to hours.
mgmt of pulm contusion
intubate for failure of oxygenation or ventilation, admit for monitoring/pulmonary hygiene, no abx or steroids prophylactically.
2 complications of pulm contusion
ARDS, pma
test for blunt myocardial injury
normal ECG and trop rule it out.
beck triad for tamponade
muffled HS, hypotension, distended neck veins
what is pulsus parodoxus
<10 in SBP with inspiration (sign of tamponade)
walk through pericardiocentesis
go
where do most blunt aortic injuries occur
aortic isthmus (between Lt subclav and ligamentum arteriosum)
cxr findings of traumatic aortic injury
widened mediastinum
loss of aortic knob
eso/trach deviation
widened paraspinous interface
widened right paratracheal stripe
left apical cap
left hemothorax
depression of lt mainstem bronchus
mgmt of traumatic aortic injury
operative repair, labetalol to keep SBP <120, control pain, no valasalva
should you probe a penetrating chest wound or remove fb?
no, can dislodge clot and cause massive hemm
3 types of blunt abdo trauma
diaphragmatic, hollow viscus, solid organ
which diaphragm is usually injured in blunt injury
left (not protected by liver)
imaging in diaphragmatic injury
they all suck, unless there is herniation (doesnt always happen).. gold standard d is laparoscopy or thorascopy
mgmt of diaphragmatic hernia
NG decompression of the stomach (URGENTLY in ED), then OR
blunt hollow viscus injury often associated with what L spine fracture
Chance fracture
presentation of hollow viscus injury
tend to present with delayed peritoneal signs… if abdo wall contusion, seatbelt sign, serial exams.. ie period of obs is appropriate if normal CT, but concerning mechanism
three blunt abdo injuries that are difficult to diagnose on CT
diaphragm, pancreas (a solid organ) and bowel (unless full thickness perf, which presents like free air)
most commonly injured organ in abdo trauma
spleen, then liver
most commonly injured organs in abdo stabbings
liver then small bowel
most commonly injured organs in abdo GSW
small bowel, then colon, then liver
indications for surgery in blunt trauma
+ FAST and hypotension
evisceration of abdo contents
peritonitis
free air
diaphragm or aortic injury
rena injury with urine outside gerota fascia
persistent blood from NGT, rectum or vagina
indications for surgery in penetrating trauma
injury with hypotension
peritonitis
evisceration of abdo contents
+ FAST and hypotension
any GSW that has violated peritoneum
foreign body in abdomen
suspected diaphragm injury
blood from rectum, NGT or vagina
what GA is uterues/bladder no longer in pelvis, what GA is abruption a concern
12 wks
16 wks
what is normal FHR
120-160
vital sign changes in pregnancy
baseline HR inc by 10-15
baseline BP dec in first or second trim
RR inc later in pregnancy
why does Lt lat decubitus work in preg
decompresses IVC
GA that confers possible viability
24 weeks (dome of uterus above umbilicus)
indications for perimortem c-section
maternal arrest with no ROSC in 4 minutes and GA >24 weeks
if performed <5 min = excellent outcomes, 5-10 mins good, > 15 mins poor
indications for emergent c-section
GA >24 weeks, signs of fetal distress, uterine rupture, placental abruption, preterm labour with signs of malpresentaton and mom can tolerate it.
changes to blood gas in later pregnancy
baseline bicarb 21
baseline pco2 30 (pco2 40 is hypoventilation)
3 broad categories of pelvic fractures
major ring, acetabular, avulsion/single bone
mechanism of acetabular # (one for young and one for old)
young= high energy MVC - knee into dashboard
old= fall
*mgmt depends on pt and fracture factors
mgmt of most avulsion fracture
non-op
most common complication of major pelvic ring #s
retroperitoneal bleeding fom injury to low pressure veins
what is destot sign
hematoma over inguinal ligament or scrotum, indicates major pelvic ring #s
3 types of major pelvic ring #s and their classification system, (mechanically unstable)
Young-Burges system.
lateral comprssion, anteroposterior compression (open book), vertical shear
mgmt of unstable pelvis
binder placed at GTs
important consideration in major pelvic fracture
look for open fracture with rectal perineal and vaginal exam.
lateral compression fracture: incidence, mechanism, findings
50%, T bone MVC or pedstruck, transverse pubis rami with sacroiliac fracture
anteroposterior fracture (open book): incidence, mechanism, findings
25%, head on MVC, pubic symphysis and SI joint disruption
vertical shear: incidence, mechanism, findings
5%, fall/jump from height, fracture fragments/symphysis displaced vertically.
most associated with severe hemm
biggest complication if hip dislocation if not reduced quickly
AVN of fem head
types of hip dislocation and what is most common, then think through reductin techniqques
posterior (80-90%), anterior and central
Mechanisms of urethral injury
Straddle injury, direct blow, instrumentation, penile fracture
signs of urethral injury and test to order
blood at meatus, inability to void, high riding prostate, perineal hematoma, vaginal bleeding,
need to get RUG before placing foley
3 grades of bladder injury and mgmt
contusion –> nothing
extraperitoneal rupture –> foley for 10-14 days
intraperitoneal rupture -> operative
test for ?bladder rupture
retrograde cystogram –> often need RUG first
signs, test and mgmt of ureteric injuries
flank pain/hematuria, CT IVP or regular CT with contrast, most need operative mgmt
imaging test in ?testicular injury
doppler u/s
how to repair simple lacerations to penis?
4-0 absorbable, if fracture (laceration of tunica albuginea)–> need uro
3 causes of pain out of proportion to exam
nec fasc, compartment syndrome, mesenteric ischemia
causes of compartment syndrome
circumferential cast or burns, swelling within compartment (hematoma, fracture, crush, injection, ischemia/reperfusion injury
what is first structure affected by compartment syndrome
nerves, leads to loss of 2-point discrimination
normal compartment pressure
0-10, greater than 20 is concerning, >30 is diagnostic
5 p’s of compartment syndrome
and two earlier findings
pain, pain, pain, pain, pain
pain with passive extension, loss of 2 point discrimination
Hard signs of arterial injury (90% chance of injury, straight to OR)
pulsatile bleeding, audible bruit, rapidly expanding hematoma, obvious arterial occlusion, decreased temperature
soft signs of arterial injury (get CTA)
history of arterial bleeding, proximity to major artery, diminished pulses, peripheral nerve injury, small non-pulsatile hematoma, ABI <0.9)
in penetrating extremity injury always perform bilateral _______?
ABI
how to perform ABI
doppler SBP below injury / doppler SBP uninjured limb
what to do with amputated extremities
wash with sterile saline, wrap in saline soaked gauze, put in ziplock bag and then on ice .
4 zones of fingertip amputation
1: bone and nail bed intact
2. exposed bone
3. entire nail bed gone
4. amp near DIP jt
high pressure injection injuries, mgmt?
injuries are often grease or paint
surgical debridement, in ther meantime give abx, tetanus, elevate and splint limb, often look benign at outset.
parkland formula
4 mL of LR* TBSA * weight = fluid over 1st 24hrs and then give half in first 8 hours
use 3mL in kids
Add 5% dextrose if wt < 20 kg
use in kids with >10% TBAS and adults with >20% TBSA,
**titrate to UO of 0.5-1 mL/kg/hr
rule of 9’s and palm rule
palm (including fingers) = 1% TBSA
9 for face/head, 9 for each arm, 18 for each leg, 18 each for front and back of torso, 1 for perineum
superficial burns: depth, findings prognosis
-epidermal layer only
-red painful, tender, non blistering ie sunburn
-heals without scarring in 1 wk
superficial partial thickness: depth, findings prognosis
-epidermis and superficial dermis, blood vessels, sweats glands, hair follicles ok
-red, painful, blistering, BLANCHING,
-heals with minimal scarring in 2-3 weeks
deep partial thickness: depth, findings prognosis
-epidermis and superficial dermis but deeper
-red to pale white/yellow, less painful, NO BLANCHING,
-3-8 weeks with scarring and some contracture
full thickness: depth, findings prognosis
-epidermis and all dermis
-white/black/charred, painless, leathery
-require surgical grafting, unless <1 cm
with burn patient always think about??
CO and cyanide
Major, moderate or minor burn criteria, and disposition for the classifications. Should mostly know major criteria.
burn dressing/debridement
polysporin or Silvadene cream (antimicrobial cream) then mepilex Ag or non stick like adaptic/bactigras
can de-roof blisters and debride dead skin, initial debridement just soak a 4X4 gauze pad in sterile water and scrub burn.
subdermal: depth, findings prognosis
-muscles, bones
-looks horrible
-life and limb threatening.
in nasal trauma alwasy look for?
septal hematoma
describe septal hematoma drain
-anesthetize the septum with topical our atomised anesthetic -
-make elliptical incision over the hematoma
-evacuate the clot with pressure or suction
-place a small Penrose drain and pack the nares as an anterior epistaxis bilaterally
-follow up E NT in 48 hours
dx of nasal fracture
clinical! no need for xrays or CT, CT only if concern for other facial fracture
nasal fracture mgmt
if alignment is acceptable, no septal hematoma, no epistaxis and pt can breathe through both nares, do nothing, no f/u
-if alignment terrible, try and reduce (lidocaine soaked pledgets to bilat nares is often enough) or refer to see ENT within 5-7 days
what are orbital blowout fractures and how do they happen
orbital floor fracture, from direct blunt force to globe (fist, ball etc)
what are medial orbital fracture
fracture through the lamina papyracea into the ethmoid sinus
complications of orbital fracture
extraocular nerve entrapement, most often inf rectus, leads to DIPLOPIA and abn EOM
orbital # mgmt
prophylactic abx to cover sinus pathogens (controversial), if diplopia, muscle entrapement urgent referral to ophtho, ENT, plastics for f/u within 24 hrs. other non-urgent referral.
test for mandibular fracture
tongue blade test: bite on tongue blade and if can break it once twisted by dr, 95% neg predictive value,
mgmt of mandible fracture:
if open ( ie blood in mouth) give abx and urgent referral
-if closed, non-displaced fractured with analgesia, soft diet and ENT/plastics/OMS f/u in 1-2 days
mechanisms of mandible fracture
forced occlusion (breaks condyle), lateral blow (breaks body or angle). most are multifocal but 40% unifocal (bc of U shape)
what causes mandible dislocation and where does it dislocate?
excessive mout openening, anterior and superior
what 3 bones make up the tripod
zygomatic, maxillary, orbital
aka zygomatico-maxillary-orbital complex
classification for midface fractures? name and explain
Lefort 1: break through maxilla (bilat or unilat) just above roots of teeth, dental arch is mobile
Lefort 2: bilat through maxill and through inferior orbit and nasal bridge, dental arch and nose move together
lefort 3: rare, maxilla, orbit, nasal bridge, zygoma, often has CSF leak, whole face moves.
where do you pull to test for lefort fracture
pull anteriorly on central incisors
Signs of life? (Context of thoracotomy indication)
consideration in flash or flame burn re toxins?
Administer 100% oxygen if there is concern for burns resulting from flash or flame in a closed space. Consider co-oximetry testing and
the administration of Cyanokit (hydroxocobalamin) for any potential carbon monoxide and/or cyanide exposure.
Is determination of burn depth of clinical judgment, or are there objective measures?
Clinical judgment. Using commonly observed wound features.
Who should be referred to a burn unit? This is different than people who should be treated in one.
Burn depth chart
Difference between superficial partial and deep partial is blanching
What do you infuse in the Parkland formula?
RL
Went to add dextrose to paediatric Parkland formula?
Add D5 if their weight is less than 20 kg
ED care of minor burns
