trauma

Question 1

principles of trauma

Answer 1

-Broadly classified by the mechanism
-Multidisciplinary approach
-Teams are often ATLS certified
-Defined roles and positions
-!Simultaneous assessment and treatment

Question 2

critical dx in the polytrauma pt

Answer 2

-INCRACRANIAL INJURIES:
-Subdural hemorrhage
-Epidural hemorrhage
-Subdural Hemorrhage
-Epidural Hemorrhage
-Subarachnoid Hemorrhage
-Intraparenchymal Hemorrhage
-Intraventricular Hemorrhage
-Traumatic Brain Injury
-Blunt Cerebrovascular Injury

-INTRATHORACIC INJURIES:
-blunt cardiac injury
-traumatic aortic injury
-pneumothorax
-cardiac tamponade

-INTRA-ABDOMINAL or GU:
-splenic injuries
-renal injuries
-liver injuries
-urethral/bladder injuries

-MSK INJURIES:
-Spinal Cord Injury
-Spinal Ligamentous Injury
-Vertebral Fractures
-Displaced Fractures/Dislocations
-Pelvic Fractures
-Compartment Syndrome

-VASCULAR INJURIES:
-Aortic Rupture / Dissection
-Carotid/Vertebral Artery Dissection
-Extremity Vascular
-Laceration/Dissection

Question 3

5 causes of hypotension in trauma

Answer 3

-hemorrhagic!! MC cause of death
-tamponade- EFAST
-tension pneumothorax- listen
-neurogenic- spinal cord injury
-toxicologic

Question 4

trauma overview

Answer 4

-history: MOI

-Primary survey:
-Detect and prevent life threatening injuries
-ABCDE
-C-collar -> Log roll video
-Adjuncts: Monitors, XRAYs, E-FAST exam, Labs

-Secondary survey:
-Head to toe exam- further injuries
-AMPLE- allergies, meds, PMH, last meal event, environment

-Imaging:
-advanced imaging once stabilized

-Disposition:
-OR
-IR
-Observation
-Transfer

Question 5

trauma- airway + C-spine

Answer 5

-Look for:
-Incoherence (GCS<8)
-Stridor
-Drooling
-Facial burns
-Facial / neck injuries, edema
-Blood or other airway obstruction
-Penetrating neck trauma -> expanding hematoma

-Protect:
-Suction to clear
-Jaw thrust, chin lift
-C-spine collar immobilization
-!Intubation
-Backup: Surgical airway (cric)

Question 6

trauma- breathing

Answer 6

-Oxygen sat (goal>94%) and RR
-Listen for !equal bilateral breath sounds!
-Deviated trachea
-Chest wall wounds + motion
-Crepitus at neck or chest

-Pneumothorax (simple, tension, hemo)

-Flail chest:
-Fractures of ≥2 consecutive ribs in ≥ 2 places
-Paradoxical movement of the chest wall

-Contusion:
-Pulmonary or cardiac contusion
-Takes 24 hours to develop on XRAY

Question 7

trauma- circulation

Answer 7

-IV access
-!!2 large bore IVs, IO, Central line (Cordis)

-Check PULSES, blood pressure

-Fluid resuscitation
-IV crystalloids
-Massive transfusion protocol (MTP)
-GOAL MAP ≥80 to maintain CPP

-Control bleeds
-direct pressure
-Pressure dressing
-Pelvic binder
-Tourniquet

-Position: LLD if 3rd trimester pregnancy

Question 8

trauma- disability and dextrose

Answer 8

-!Pupil size and reactivity

-!Neuro assessment:
-GCS – Eye opening
-GCS – Verbal response
-GSC – Motor response

-4 extremity movement
-Brain or spinal cord injury

-Altered mental status
-Traumatic until proven otherwise
-Assess for: hypoglycemia!!, ETOH, narcotics

-Neurological life threats on primary survey:
-Penetrating cranial injury
-Intracranial hemorrhage- Subdural hematoma, Epidural hematoma, Subarachnoid hemorrhage, Intraparenchymal or intraventricular hemorrhage
-Diffuse axonal injury
-High spinal cord injury

-If indicated and stable:
-!CT-head non contrast
-CT- c spine non contrast

Question 9

trauma- exposure/environment

Answer 9

-!!Trauma patients = Trauma naked

-Avoid hypothermia
-Exacerbates bleeding in trauma
-Warm blankets

-Look for burns / toxic exposures etc.
-Examine the axillae, perineum , head/neck, urethral meatus
-A finger in every orifice

-Examine the back (C-spine, thoracic spine, flank, back, buttocks)
-C collar
-Log roll requires 4 people

Question 10

22 year old male is brought to the ED via EMS after a MVC.
He was the unrestrained driver in a rollover vehicle traveling approximately 50 mph.
Another passenger died on scene
Patient require prolonged extrication

HR 120, BP 90/60, O2 90% on NRB, RR 30, Temp 98.6F

Answer 10

Immediately: IV access, Oxygen, Monitor, C-collar

-AIRWAY: Speaking in full sentences. No expanding hematoma. No soot in oropharynx.
-BREATHING: Decreased breath sounds on right anterior chest with tracheal deviation to the left
-STOP- Chest tube for pneumo/hemothorax -> SPO2 improved to 96% and RR 20
-bc its a hemothorax needle decompression wont really do much

-CIRCULATION: Radial and femoral pulses 1+. Sluggish cap refill. Pale and diaphoretic
-STOP- 1L fluid bolus -> HR 130, BP 90/60 (no improvement) -> blood transfusion -> HR 110, BP 95/65

Question 11

FAST and E-FAST

Answer 11

-FAST (Focused Assessment with Sonography in Trauma) examination

-Looks for the presence of fluid—presumed to be blood in the appropriate clinical setting—visualizing 10 structures or spaces in four areas:
-RUQ (hepatorenal space)
-LUQ (splenorenal space)
-Subxiphoid (cardiac space)
-Suprapubic region (pouch of Douglas)

-E-FAST (Extended FAST)
-Adds anterior and lateral pleural spaces (thoracic view)
-Evaluate for pneumothorax or pleural effusion (assumed to be a hemothorax)

-A negative FAST does NOT exclude intraabdominal or intrathoracic injury
-It helps us better triage a patient

-pelvic fracture and retroperitoneal bleed require CTA for dx- all the others can see on efast

Question 12

When do we perform a FAST

Answer 12

-Evaluation of injury, hypotension and/or shock in trauma
-Evaluation of unexplained hypotension in non-trauma patient
-Identify rupture of ectopic pregnancy

Question 13

why does FAST work in certain locations of the abdomen

Answer 13

Fluids in the abdomen tend to accumulate in certain areas, this is where the FAST exam focuses

Question 14

EFAST- RUQ

Answer 14

-2 places to look for fluid in the RUQ:​
-Between the liver and kidney​
-Hemothorax

-MC place where blood goes to
-check here first

-right pic- shark fin sign- between liver and kidney is black = blood

-Lobules on the left of the kidney -> liver

Question 15

EFAST- LUQ

Answer 15

-3 places to look for fluid in the LUQ
-Between the kidney and spleen
-Between the spleen and diaphragm
-Hemothorax

-No blood between spleen and kidney (white = good)
-diaphragm is under the spleen -> diaphragm isn’t adheresd to the spleen here -> blood between diaphragm and spleen = bad

Question 16

EFAST- pelvic

Answer 16

-Get a good view of the bladder
Look for free fluid around the bladder

-between uterus and colon = douglas pouch

Question 17

EFAST- subxiphoid

Answer 17

-bottom photo- black fluid between pericardium and heart

-top photo- normal

Question 18

cardiac tamponade- rapid recap

Answer 18

-Sx:dyspneaand chest pain
-PE:muffled heart sounds,JVD,hypotension(Beck triad),pulsusparadoxus
-ECG: low-voltageQRS,electricalalternans

-Bedside Echocardiography (E-FAST)
-Pericardial fluid
-Diastolic collapse of RV(less sensitive but very specific)
-Early systolic collapse of RA(highly sensitive and specific)
-Plethoric IVC

-Tx:pericardiocentesis or delayed pericardial window

Question 19

EFAST- fluid in lungs on RUQ/LUQ

Answer 19

-TOP PIC:
-Normal RUQ ultrasound
-Spine should only extend up until the lung border
-Lung should have mirror artifact
-Air is mucking the view of the spine above the diaphragm -> spine sign

-BOTTOM PIC:
-Large pleural effusion in RUQ
+Spine sign = can see the spine above the diaphragm due to pleural fluid allowing sound waves to penetrate
-black between the lung and diaphragm = pleural effusion maybe

Question 20

Pulmonary views: NORMAL LUNG vs pathologic PTX

Answer 20

-GOAL:
-Obtain views of lung slide to assess for pneumothorax
-Pleural slide “Ants on a log” -M-Mode “Sea-shore” (bottom pic)

-The following signs are can be found in a pneumothorax
-No Pleural slide “Dead ants on a log”
-M-Mode “Barcode” (top pic)

Question 21

tension pneumo- rapid recap

Answer 21

-Sx:dyspneaand chest pain
-PE:unilateral absent breath sounds, tracheal deviation, obvious chest trauma
-E-FAST- No lung sliding
-Tx can be performed prior to imaging in unstable patients with suggestive clinical signs of hemothorax or tension pneumothorax
-Needle decompression
-Chest tube placement

Question 22

secondary survey

Answer 22

-After primary survey and resuscitation
-AMPLE history

-Head-to-toe
-Identify and control scalp wound bleeding with direct pressure, sutures, or surgical clips.
-Identify facial instability and potential for airway instability.
-Identify hemotympanum.
-Identify epistaxis or septal hematoma; consider tamponade or airway control if bleeding is profuse.
-Identify avulsed teeth or jaw instability.
-Evaluate for abdominal distention and tenderness.
-Identify penetrating chest, back, flank, or abdominal injuries.
-Assess for pelvic stability; consider pelvic wrap or sling.
-Inspect perineum for laceration or hematoma.
-Inspect urethral meatus for blood.
-Consider rectal examination for sphincter tone and gross blood.
-Assess peripheral pulses for vascular compromise.
-Identify extremity deformities, and immobilize open and closed fractures and dislocations.

-Frequent reassessment

Question 23

trauma investigations

Answer 23

-EFAST = extended focused assessment stenography for trauma
-Trauma Panel: CBC, BMP, lactate, T&S + cross match, PT/PTT/INR, UA, HCG, Utox, Ethanol, Serum osm, Troponin (blunt cardiac injury), POC glucose

-If stable, perform imaging (x-rays, CT, CT angiography)
-CXR
-Pelvic XR
-CT: head, C-spine, chest, abdomen, pelvis PRN -> Only stable patients go to the CT scan

-CTA: Neck, chest, abdomen, pelvis
-If you suspect aortic or blunt cerebrovascular injury
-IV contrast, no oral contrast needed

-MRI

Question 24

70 year old female from home reports a trip and fall while walking about one hour ago. She reports hitting her head, but denies any loss of consciousness. She reports mild tenderness where she hit her head but otherwise feels fine. She has not vomited or feels nauseous. She is not on anticoagulation. She denies any distal weakness or numbness.

Question 25

c-spine injuries

Answer 25

-Cervical spine is more mobile than rest of spine -Less support = susceptible for more injury mechanisms -Cervical sprain/strain is common -Serious c-spine injuries <2% of all imaging -Devastating complications: Quadriplegia, death -On plain radiograph, there should be a smooth line along the -Anterior contour line -Posterior contour line -Spinolaminar lines -Misalignment suggests ligamentous disruption or fracture -Cervical collar immobilization is often placed in the pre-hospital setting -*Pre-hospital placement of C-collar does not mandate imaging!* -Obtain C spine image if: -Neuro deficits -GCS depressed -What validated risk stratification rules exist for everyone else? -NEXUS criteria -Canadian CT-spine rules

Question 26

canadian c-spine rules

Answer 26

-Well-validated decision rule that can be used to safely rule out cervical spine injury (CSI) in alert, stable trauma patients without the need to obtain radiographic images. -Requires -GCS=15 (intoxication is OK if alert and cooperative) -Vital signs are stable -Neuro exam is normal -No known c-spine disease or prior surgery -Sensitivity 99-100% -Specificity 40%

Question 27

spinal cord injury (SCI)

Answer 27

-Bony tenderness -Motor function: 5/5 is active against full resistance -Sensory function: -Position, Vibration, and light touch = Dorsal columns -Pain (pinprick) and temperature = Ventral columns -Impaired mentation: -Pinprick or deep painful stimuli -Press very hard with your thumb under the bony superior roof of the orbital cavity -Press a pen hard on one of the patient’s fingernails -Spinal reflexes = DTR

Question 28

spinal imaging

Answer 28

-Plain radiography: -C spine: Lateral, AP, open mouth odontoid view -Thoracic, lumbar: Lateral, AP, oblique -Not recommended as first line imaging modality for adults  -!!!!!CT is first line imaging for moderate-high risk patients for cervical injury -!!CT non-contrast of cervical spine -MRI is especially helpful for soft tissue, cord, and ligamentous injury -Note: Normal imaging does NOT exclude SCI -!SCIWORA = spinal cord injury without obvious radiographic abnormalities -Occurs in children d/t elasticity of ligaments and spinal cord -Neurologic symptoms without radiographic findings

Question 29

CT c-spine imaging

Answer 29

-If CT scan is negative, and you still have a high suspicion, get an MRI -If positive fracture or unstable injury: -Move to padded cervical immobilization -Neurosurgery / Ortho consult -Obtain MRI to evaluate for soft tissue injuries -If negative CT and cleared: -Removal of C-collar -Symptomatic treatment (NSAIDs, Muscle relaxers) -Discourage bed rest -Discourage soft collars -Return to work/sports when symptoms resolve

Question 30

A trauma is called overhead: a young woman was thrown from a horse onto her head and back… You run to the trauma bay where the young woman has been brought in by EMS. The trauma PA is evaluating her ABCs. You see that the patient is awake, has a GCS score of 15, and is answering questions appropriately, but she appears uncomfortable. Her blood pressure on the monitor is 80/48 mm Hg. As the resident finishes the primary survey, you note that the patient is unable to lift her lower extremities on command. Her grip strength is weak, and she has gross loss of sensation in the bilateral upper extremities. You wonder whether this is a head or a spine injury, and how best to treat her hypotension. Should she receive corticosteroids?

Answer 30

You suspected a spinal injury and neurogenic shock; however, you wanted to avoid anchoring bias. You placed 2 large-bore IVs and called for blood. An E-FAST exam was negative, the pelvis felt stable on exam, and radiographs were negative. Sinus bradycardia, HR 56/min and a BP of 82/38 mm Hg. The patient’s riding partner arrived and was able to tell you that she was thrown from the horse, landed directly on her head, had no apparent thoracoabdominal injury, and was unable to move. The patient had weak grip and no movement in her lower extremities. You decided that this was most consistent with neurogenic shock and started norepinephrine at 5 mcg/hr. Her blood pressure improved to 125/90 mm Hg. CT scan demonstrated C5/C6 bilateral locked facets without evidence of hemorrhage. Your neurosurgical colleagues rapidly came to the bedside and performed closed reduction. In discussion with the neurosurgical team, you ultimately decided not to administer methylprednisolone, as there is not strong evidence supporting improved outcomes.

Question 31

spinal cord injury (SCI): neurogenic shock

Answer 31

-Injury in the brain or spinal cord at or above T6 can cause neurogenic/distributive shock -Diagnosis of exclusion: think hemorrhagic first -Presentation: -Hypotension usually refractory to IVF -Bradycardia -Hypothermia -Management: -IV fluids -Pressors (norepinephrine) to keep MAP 85-90mmHg -Consider atropine for bradycardia -Steroids are no longer recommended for minimizing neurologic injury

Question 32

A 24-year-old male presents with abdominal pain after being involved in a moderate-mechanism motor vehicle accident. He also reports some right shoulder pain. His blood pressure is 106/77 mm Hg, his pulse is 108 bpm, and his respiratory rate is 20 breaths/minute. The patient has abdominal pain that is diffuse without guarding or rebound. His shoulder is normal.

Question 33

blunt abdominal trauma

Answer 33

-Abdomen, flank, back trauma -MVC, falls, assaults, and recreational activities -Ranges: No pain -> peritonitic abdomen, rebound, guarding -Intraabdominal injury: -Solid organ injury and hemorrhage -Hollow viscus -Vascular shearing -Signs strongly associated with intra-abdominal injury: -Seat belt sign -Rebound tenderness, distension, guarding -Hypotension SBP < 90mmHg -Concomitant femur fracture -Other exam findings: Tachycardia, pelvic pain, scrotal bruising, blood at the urethral meatus , blood on rectal exam -Unique abdominal injury patterns -Seatbelt sign -Linear bruise -Neck, chest, abdomen -Associated with intra-abdominal injury in 30% of patients

Question 34

blunt abdominal trauma

Answer 34

-Handlebar sign -Increased rate of solid organ injury or viscus injury in pediatrics -Grey turner and Cullen sign -Ecchymosis over the flank and periumbilical area respectively -Suggest retroperitoneal hemorrhage -Blood at the urethra -Requires retrograde urethrogram to evaluate for urethral injury -Blood on digital rectal exam -Suggests rectal laceration from pelvic fracture -Ultrasound (E-FAST) is a good, quick bedside study -Fluid -> suggests hemoperitoneum/hemothorax/hemopericardium -High specificity (95%) -Low sensitivity (68%) -CT abdomen pelvis with IV contrast -Highly sensitive and specific (~97%) -Do not send an unstable patient to CT scan -Disposition -Positive or suspicious findings for intraabdominal injury require surgical consultation for exploratory laparotomy

Question 35

cullen sign

Answer 35

grey turner sign

Question 36

trauma algorithmic

Answer 36

Question 37

A 35-year-old female with no significant past medical history is brought to the emergency department (ED) by emergency medical services (EMS) from the scene of an apartment fire, where she jumped six stories out of a window to the pavement below. Her initial vital signs are blood pressure 76/54 mmHg, heart rate 128 bpm, temperature 37.0˚ C, respiratory rate 20 breaths per minute, and oxygen saturation 95% on room air. The presenting fingerstick glucose is 108 mg/dL. Her airway is intact, and she has equal bilateral breath sounds. Pulses in all four extremities are weak but intact and symmetric. Her Glasgow Coma Scale (GCS) is 14 (3E-5V-6M), and she arrives in a cervical collar placed pre-hospital. A focused assessment with sonography for trauma (FAST) exam is negative, and her secondary survey is notable for a pelvis that is significantly tender to gentle anterior and lateral compression.

Question 38

unstable pelvic

Answer 38

-Pelvic ring is held together by many ligaments -Requires high energy MOI = multiple injuries -Pain, movement, or crepitus with gentle AP compression or lateral compression is highly concerning for a pelvic fracture -Unstable pelvic fracture: -Resuscitate -Pelvic binding - can hold up to 6L -CTA -IR or Surgical consult for repair -pic- Open book pelvic fracture. Note the significant diastasis of the pubic symphysis.

Question 39

vascular extremity trauma

Answer 39

-MSK problems are usually lowest on priority list -Neurovascular >>>> Bone/Muscle -Control hemorrhage (do not blind clamp): -DIRECT PRESSURE -PROXIMAL PRESSURE -TOURNIQUETS -PRESSURE DRESSINGS -HEMOSTATIC DRESSINGS -“Hard signs” of vascular injury reflectr vascular injury requiring surgical repair in the OR (no pulses, no cap refill, no senses) -“Soft signs” are equivocal findings and require CTA or ABI for further assessment, may still require OR (some signs of flow)

Question 40

head injuries

Answer 40

-Men > women -Trimodal: Ages 0-4, 15-24, >75 years old -Minorities -Falls and MVC = most common mechanisms -Traumatic brain injury (TBI) is defined as brain function impairment as a result of external force -Severe traumatic brain injury (TBI) is more common at extremes of age -Clinical manifestations are broad: brief confusion, coma, disability, death

Question 41

traumatic brain injury pathophysiology

Answer 41

-Primary phase -Occurs at the time of impact -Due to bleeding or direct trauma -Includes: -Hematoma (EDH/SDH) -SAH -Contusion -Diffuse axonal injury -Secondary phase -Days/hours later -Caused by impaired cerebral blood flow ! -Causes: -Edema / ↑ ICP -Small vessel bleed -Inflammation -Physiologic dysfunction -Often cause cognitive difficulties

Question 42

TBI severity

Answer 42

-GCS is used to categorize severity and determine the work up! -GCS ≤12 -Neurologic deficits -Post-traumatic seizures -Anticoagulated -≥ 65 with LOC, amnesia, confusion

Question 43

canadian head CT rules

Answer 43

-Only applies to patients with a GCS 13-15 and at least one of the following: -LOC -Amnesia to the head injury event -Witnessed disorientation -Exclusion criteria -Age <16 years old -Blood thinners -Seizures after injury, or, anticoagulation use -CT head rules -HIGH sensitivity 83-100% for clinically important brain injuries -HIGH sensitivity 100% for injury requiring neurosurgery -No false negatives for serious injury!

Question 44

PERCARN- pediatric head CT rules

Answer 44

-PECARN was developed to determine which patients do not require a CT scan -PECARN screening tool for pediatric patients -One for children less than 2 years -One for children 2-16 years old -CT head recommended if: -GCS<15  -AMS -Signs of skull fracture (basilar skull fx >2) -Observation versus CT if: -LOC from head trauma -Non-frontal hematoma or acting differently and <2 yo -Vomiting from head trauma -Severe headache -Severe mechanism: -MVC + [Ejection, rollover, vs. pedestrian, death at scene ] -High impact object -Fall >3ft (<2yo) or >5ft (>2yo)

Question 45

negative head CT after trauma

Answer 45

-mild concussion-

Question 46

mild TBI management

Answer 46

-Expect slight cognitive impairment for up to days-weeks -BRAIN REST -PREVENT REINJURY -Symptom control (headache, nausea, insomnia etc. refer to last weeks lecture) -Return to play -> cleared by neurologist -Return to ED if worsening signs or symptoms: -Worsening headache -Vomiting -Deteriorating altered mental status -Bruising around the eyes or ears -Seizures

Question 47

33-year-old man who was drinking heavily and got into a bar room fight, sustaining several blows to his head with a stool. He was knocked out for a couple of minutes but then woke up. He was taken to his sister’s house, where he walked with assistance from the car into the house. Once inside, he developed nausea, vomited, and then fell face down onto the floor. Paramedics found him groggy, with equal and reactive pupils and an intact gag reflex; he was placed in a c-spine collar and secured to a backboard.

Question 48

traumatic brain bleeds (severe)

Answer 48

headache -neck pain -seizure -focal neuro deficits -low LOC

Question 49

epidural hematoma

Answer 49

-Classic presentation -!Initial brief LOC -!“Lucid interval” -!Progressive obtundation (↓ LOC, HA, N/V) -Unequal pupils (dilated on side of clot) -Most patients: -Decreased alertness, severe headache, dizziness, n/v -Usually associated with acute trauma (MVA, falls, assaults) -Symptoms often evolve rapidly -Rapid expansion can cause a Cushing’s reflex (↑ BP, ↓ HR, irregular respirations), herniation, cardiac arrest -Blood between the skull and dura mater -MC artery ruptured is the middle meningeal artery (linear skull fracture) -Results in elevated ICP -CT Head findings: -Hyperdense (white) -Biconvex / lens shaped / lenticular -Does not cross suture lines -Mass effect is common -Heterogenous appearance may indicate active bleeding -Neuro consult, often needs surgery (hematoma evacuation)

Question 50

subdural hematoma

Answer 50

-Blood in the subdural space (between brain and dura) -Shear force from trauma disrupts the bridging veins -May cause brain compression and elevated ICP -Higher morality rate than epidural -CT findings -Acute: Hyperdense (white) -Subacute: Iso- or hypodense (gray) -Chronic: Hypodense (dark gray, to black) -!Crescent shaped (follows contour of cortex) -Crosses suture lines -Does NOT cross falx -Mass effect may occur -!Elderly and anticoagulated , alcoholics -Clinical presentation -Pediatric: HA, vomiting, ↓ LOC, focal deficits, bulging fontanelles, seizures. Consider abuse! -Younger people, trauma: Headache, LOC, neuro deficits -Elderly: Slow, chronic personality changes, increase in falls and confusion, focal deficits -Usually associated with mild/subacute trauma -Deceleration that shears the veins Symptoms often evolve slowly over time -Management: -Large/acute/neurologic deterioration: Surgical evacuation -Small/subacute/neuro intact: observation

Question 51

traumatic subarachnoid hemorrahge

Answer 51

-Mechanism of traumatic SAH: -Cerebral contusion causing diffusion of blood into the SA space -Vascular injury from rotational/shearing forces -Can increase intracranial pressure through 2 mechanisms: -Hemorrhage into the intracranial cavity -Hydrocephalus through obstruction of the ventricular system -Clinical presentation -Mild to severe trauma -Volume of blood correlates with initial GCS prognosis -Associated with subdural or epidural bleeds -Dx: Non-contrast head CT -Most sensitive (98-100%) within 6 hours of symptom onset -CT findings: -Hyper density (blood) in basilar cisterns or sulci -Can be localized, or diffuse -Blood in the 3rd ventricle/aqueduct may obstruct CSF and cause hydrocephalus -Management -R/O aneurysmal cause! -> aneurysmal require surgery -!Reverse coagulopathy -Warfarin reversal: PCC, FFP, Vit K -UFH, LMWH: Protamine sulfate -Thrombocytopenia: Platelets -Blood pressure systolic goal < 160mmHg -Reduce ICP to maintain CPP- Hypertonic saline (consult a neurologist) -Prevent cerebral vasospasm- Nimodipine 60mg PO q4h -Dispo: Neuro ICU

Question 52

intraparenchymal hemorrahge

Answer 52

-Blood within the brain tissue -Vascular injury from direct, severe, acute trauma -Non-traumatic cause = malignant hypertension -Often evolves over time due to small vessels -Associated with neurologic deterioration -CT findings: -Demarcated hyperdense (white) collections deep inside the brain tissue -May be seen immediately, but often evolve over hours/days -Mass effect common -Management -Definitive airway, Reverse anticoagulation, control BP (do not allow hypotension) -Prevent ↑ ICP

Question 53

cerebral edema/ICP elevation

Answer 53

-Cerebral edema = swelling of the brain -Can occur due to several causes: -Head trauma, vascular ischemia, intracranial lesions, obstructive hydrocephalus -Munro-Kellie doctrine: -Cranial cavity is a fixed space with fixed proportion of matter -Brain (1400ml), Blood (150ml), CSF (150ml) -Increased in a component = ↑ ICP -To decrease ICP, must decrease either brain, blood, or CSF -Clinical evidence of elevated ICP or impending herniation -Deepening coma (worsening GCS) -Lateralizing signs (fixed, dilated pupil or gaze deviation) -Neurologic deterioration -ICP medical management is often a bridge to definitive treatment -Management: -ABC stabilization -Seizure control with benzodiazepines -Stop bleeding (reverse coagulopathy as previously mentioned) -Lower ICP (next slides) -Blood pressure regulation -Hypotension is associated with poor outcomes and mortality, aggressively treat with fluids/pressors -Hypertension may aid cerebral perfusion if ICP elevated, but excessive hypertension may worsen bleeding -> Goal SBP for hypertension is ~160mmHg

Question 54

interventions to lower ICP

Answer 54

Question 55

uncal herniation

Answer 55

-Cushings reflex (HTN, bradycardia) = sign of impending herniation -Innermost temporal lobe is compressed and moves towards the brainstem, causing pressure on CN III -Classic presentation of uncal herniation: ipsilateral fixed dilated pupil + contralateral hemiplegia !!

Question 56

31 year old man presenting to the ED after falling from the roof of a three story building Blood covering the head/face, obvious compound femur fracture Eyes closed, large left periorbital contusion Moans and thrashes in response to sternal rub Pulls away when you press on his nailbeds

Answer 56

A healthy man presenting to the ED after falling from the roof of a 3 story building GCS 7 Vitals: Pulse 124bpm RR 28 BP 88/44 SPO2 94% A healthy man presenting to the ED after falling from the roof of a 3 story building ABCs: C collar placed, IV access obtained GCS was 7 , now 6 Eyes closed (1), silent (1), weak withdrawal to pain (4) New Vitals after intervention (intubation, fluids, binder): Pulse 88bpm RR 20 BP 118/64 SPO2 98% Eyes are now anisocoric A healthy man presenting to the ED after falling from the roof of a 3 story building CT showed large subdural hematoma with signs of impending herniation ABCs: Intubate, IV access Neurosurgical consult for definitive management ICP reduction: elevate HOB, hypertonic saline, hyperventilate BP is adequate at 118/64, monitor Check coags

Question 57

facial trauma

Answer 57

-Usually due to BLUNT trauma, MVA, athletic injuries -Best imaging: -!CT facial bones no contrast -Obtain if: -Bony tenderness -Step-off -Crepitus -Evidence of entrapment -R/o bad injuries: brain bleeds, c-spine fx, CSF leak, entrapment syndrome, airway -Majority of traumas: -Nasal fractures (49%) -Mandible (18%) -Maxilla (13%) -Concomitant injuries are common! -Orbital floor "blowout" fractures = evaluate for ocular entrapment -Isolated fractures treated differently: -Mid-facial fracture = consult surgeon -Nasal fracture = ENT follow up -Dental fracture = dental follow up

Question 58

orbital fracture

Answer 58

-History and symptoms; -Blunt or penetrating trauma -Orbital pain, pain with eye movement! -Orbital floor: Diplopia! and/or nausea -Orbital roof: Forehead numbness -Physical exam -Periorbital edema, ecchymosis, diplopia -Proptosis or enophthalmos -Widened intercanthal distance -Bradycardia: oculocardiac reflex causes ↓ HR when pressure is applied to extraocular muscles

Question 59

orbital blow out fracture

Answer 59

-Fracture of the orbital floor -May entrap the !inferior rectus muscle ! -Causes vertical strabismus ! -Numbness of the middle face (maxillary branch of the trigeminal nerve runs through the inferior orbital groove)

Question 60

orbital fractures

Answer 60

-Ocular exam -Pupils -Visual acuity -Visual field examination -Extraocular movements -IOP -Slit lamp (retinal damage) -Diagnosis: !CT facial bones w/o contrast! is gold standard -General Management: -ABCs, other trauma evaluation -Do NOT blow nose -Cold compresses for periorbital edema -Call ophthalmology for any concerning findings such as: -Globe injury -↓ visual acuity -Widened intercanthal space (fx) -Orbital compartment syndrome (rock hard eyelids) -CSF leakage -Entrapment esp if causing oculocardiac reflex

Question 61

basilar skull fracture

Answer 61

-Skull base fracture -Serious and life-threatening complications -Signs and symptoms: -Hemotympanum – 1st sign -Raccoon eyes - delayed -Battle sign - delayed -“Halo” sign -Anosmia -EOM defects -Hearing loss, loss of balance -Carotid artery or vertebral artery injury -Cervical spine injury

Question 62

LeFort fracture (mid-face)

Answer 62

-Mid-face = area b/w the outer corners of the eye and corners of the mouth -Le Fort fractures; a group of mid-face fractures classified into 3 types -Involve partial or complete separation of midface from the skull -Typically caused by blunt trauma such as MVA -Typically involve the pterygoid plates of the sphenoid bones, which form the base of the skull, extending behind the eye and below the front part of the brain. -May cause an obstruction of the airway

Question 63

lefort fracture (mid-face)

Answer 63

-Possible physical exam findings -!!Severe facial bleeding/edema/ecchymosis -!!Mobility of different bone segments “Does your bite feel normal?” -CSF rhinorrhea -Hemotympanum -Anosmia -Paresthesia's -Elongation of the face -Exophthalmos- Check visual acuity -Raccoon eyes or widening between eyes- Type II, III -> emergent ophtho eval -Auricular hematoma -Pupil asymmetry -Dental injuries -Sinking over the anterior face (dish face, Type III)

Question 64

lefort fracture (midface) tx

Answer 64

-ABCs first! -Intubation is extremely difficult (esp in II and III) -Severe bleeding -> anterior packing -C-spine stabilization with c-collar -Other life-threatening trauma or hemorrhage? -Hemodynamically stable? -CSF leak -> elevate HOB 40-60 degrees -Check their face while stabilizing forehead: -Le Fort I: Move the hard palate -Le Fort II: Move the maxilla/nose -Le Fort III: Move the maxilla/nose/zygomas -Diagnosis: CT facial bones non-con -Add a CT head, CT C-spine for concomitant injuries -No role for XRAY -Transfer to trauma center -Definitive management: surgical

Question 65

nasal fracture

Answer 65

-MC facial fracture -Blunt trauma, IPV -Nasal fracture = Bone (bridge, upper part) -Cartilage break is much easier to fix -Mostly clinical diagnosis -Rock the bridge of the nose for crepitus/deformity -Best imaging = CT facial bones -Often associated with nasal septum injury, orbital blow out fx, maxilla fracture -Management: -Elevate HOB, ice, analgesics -Isolated nasal fracture -Aligned/Non-displaced: usually no intervention -Sometimes if within 4-6 hours can attempt closed reduction -Usually, ENT will reduce in 3-7 days after swelling goes down

Question 66

septal hematoma

Answer 66

-Worst morbidity from nasal trauma -Blood between the perichondrium and cartilage -Presents as: fluctuant mass inside the nose on septal side -Complication: -Septal abscess -Septal necrosis -saddle nose deformity -septal perforation -Management: -I&D with bilateral packing (NOT PACKING) -Augmentin -ENT to removal 2-3 days

Question 67

dental review

Answer 67

-3 layers of our teeth -Enamel is the outer most -Dentin is the cushion -Pulp is the neurovascular bundle- Fracture to pulp is PAINFUL -Know the names of teeth (molars, incisors, canines) -12 years old = usually no more baby teeth

Question 68

dental fracture

Answer 68

-Ellis classification -I - usually non painful and enamel -II - dentin which is more yellow -III - pulp, painful, red -Dry it out and dermabond for 60 seconds to protect from air/hot/cold temporarily -Alveolar fracture - socket fracture -Avulsion fracture - totally pulled out -Can replace an adult tooth if pulled for <2 hours (place in milk, saliva, Hanks soln) -Doxycycline antibiotics -Subluxation - in place but loose -24 hour dental follow up, dental brace as temporary measure

Question 69

mandible fracture

Answer 69

-MOI: Assault, Fall on chin -Unilateral or bilateral -Signs: -Trismus -Abnormal bite -Floor of mouth hematoma -Preauricular tenderness (condylar fx) -Consider: salivary gland, ducts, blood vessel involvement -Admit all open and unstable fractures -Maintain soft diet -Perioperative antibiotics -Often require ORIF

Question 70

mandibular dislocation

Answer 70

-Uncommon -Occurs in TMJ, trauma, extra-wide yawning, seizures -Bilateral anterior displacement -Rare: Unilateral displacement with rotated jaw -Chief complaint: Cannot close their mouth -Atraumatic TMJ dislocations are often reduced in the ED with procedural sedation -Put pads on the teeth or your fingers -Push mandible down and back

Question 71

ear trauma

Answer 71

-Can have traumatic TM perforation -MUST CHECK for signs of basilar skull fracture -Hemotympanum -Battle sign -CSF leak (halo sign) -Basilar skull fractures…. -Can cause meningitis -Often missed in CT heads (50%) -CT temporal bones (missed 15%) -Call surgeon if high suspicion

Question 72

auricular hematoma

Answer 72

-Sudden collection of blood between ear cartilage and perichondrium resulting from trauma -Pressure from blood clot can cause cartilage necrosis and cause cauliflower ear -Cauliflower ear -> hearing loss due to loss of shape, and cosmesis -Management: -Tx goals: Prompt drainage, prevention of reaccumulating -Inject local anesthesia -Perform regional block - 1cc subq injections at the root of the helix and the mastoid bone -Perform I&D -If small (<2cm) and less than 48 hours -Early needle aspiration and PRESSURE dressing -Nonsurgical dressing: Padding behind and on top of the ear and wrap the gauze -> Stay on 12- 48 hours -Bolsters! are an alternative -Two rolls of tefla dressing covered in antibacterial ointment -3-0 nylon, prolene or silk -If larger (>2cm) or present for longer (2-7 days) -I&D , ENT referral -If longer than 7 days, refer to ENT

Question 73

man who over trained

Answer 73

A. Renal ultrasound B. CT scan C. IV fluids! D. Observation and wait for the patient to metabolize illicit substances E. Phlebotomy and chloroquine

Question 74

complications: rhabdomyolysis

Answer 74

-Defined as acute breakdown and necrosis of MUSCLE -Causes -TRAUMA/COMPRESSION: -Prolonged immobilization (s/p fracture found lying on the floor) -Crush injuries (direct muscle trauma) -Overexertion (marathon runners) -Seizures -Burns -Compartment syndrome -Can also be caused by medications (STATINs MC), substance abuse (amphetamines), infections (influenza), metabolic or genetic factors -Signs and symptoms -Classic triad of muscle pain, weakness and dark urine -Additional symptoms are usually non-specific fever, malaise, nausea/vomiting, tachycardia, abdominal pain, oliguria -AMS may occur from underlying cause (drugs, toxins, lyte abnl)

Question 75

complications: rhabdomyolysis

Answer 75

-Diagnosis -LABS: -↑ CPK (>20,000) ** -↑ LDH -!Hyperkalemia, phos -Hypocalcemia -+/- AKI -U/A: MYOGLOBINURIA ** -Red/Brown/Pink/Dark urine that is heme (+) but no RBCs on microscopy!!!!! -EKG: +/- hyperkalemia if severe -Management -IV hydration to flush out myoglobin -Treat any hyperkalemia* -Severe -> dialysis -Complications -ACUTE KIDNEY INJURY and ATN due to excess myoglobin

Question 76

A 25-year-old male with a tibial shaft fracture after a high-speed motor vehicle accident with excruciating lower leg pain despite appropriate analgesia. Pressing on the muscles of the lower leg, there is a firmness to the compartments without swelling. He also has extreme pain with passive stretching. What would you do?

Question 77

compartment syndrome

Answer 77

-Increased pressure within a confined compartmental space  CRITICAL reduction in blood flow to tissue -Can occur in any fascial compartment -More common in lower limbs -Treatable but often missed! -Late or missed presentation: -Myonecrosis -Rhabdomyolysis -Contracture -Sensory loss -Infection -Non-union -Amputation -Death

Question 78

extremity compartment syndrome

Answer 78

-Initiating event -MC: Long bone fractures (MC Tibia) -Crush injuries -High energy trauma -Circumferential thermal burns -Tight casts -Signs of compartment syndrome: -Pain out of proportion is the first and most reliable finding -Absolute compartment pressure > 30 mmHg or -Delta pressure < 30 mm Hg (delta = diastolic BP – compartment pressure) -Presents within hours or within 48 hours of insult -SEVERE PAIN that is disproportionate to the injury -Unrelieved with initial measures -!!Worse with passive stretching -Paresthesia's -!!Tense compartments -Not usually swollen -The 6 P’s as it progresses -May be associated with fracture, bleeding, hypovolemia, rhabdomyolysis -!!Consult orthopedics, trauma, or acute care surgery for emergency surgical fasciotomy of all involved compartments. -OPEN fractures can get compartment syndrome -CAN occur in low-energy or atraumatic injuries (drug overdose) -Bleeding disorders or anticoagulation are at risk for compartment syndrome. -Perform and document serial exams (every 30 minutes) to differentiate equivocal findings as they evolve over time.

Question 79

compartment syndrome management

Answer 79

-Management -Early recognition -Consult orthopedics, trauma, or acute care surgery for emergency surgical fasciotomy -Prior to surgical intervention: -Remove all dressings / splints / casts -Keep limb at neutral level -High flow oxygen -Improve BP with IV fluids -Give opioid analgesics! -Fasciotomy incisions are often left open to allow a recheck in 24-48 hours, to assess the need for any debridement of dead tissue. Monitor for rhabdomyolysis and renal injury

Question 80

A 10 year-old boy placed in a thumb spica cast for a scaphoid fracture presents complaining of forearm and hand pain that is not relieved with pain medication and elevation. Which of the following is the earliest physical exam sign for his current condition? A. Slow capillary refill B. Loss of two-point discrimination C. Absent peripheral pulses D. Pain with passive stretch