Trauma Flashcards
Pt w/ multiple stab wounds, fully conscious, normal voice, expanding hematoma in neck. Next step?
Intubation to protect against imminent airway compromise.
Pt w/ multiple stab wounds, fully conscious, normal voice, subcutaneous emphysema in neck and upper chest. Next step?
Intubation to protect against imminent airway compromise AND fiberoptic bronchoscopy.
Pt unconscious, breathing spontaneously, breathing sounds gurgled and noisy. Next step?
Orotracheal intubation
Most common indication for intubation in trauma?
Altered mental status (unconscious patients can’t protect an airway)
Airway protection in potential cervical spine injury?
Orotracheal intubation with manual in-line cervical immobilization or over a flexible bronchoscope. Nasotracheal intubation an option if not precluded by facial injury.
Extensive facial fractures, bleeding briskly into the airway, voice masked by gurgling sounds. Next step?
Cricothyroidotomy is the best option. Percutaneous transtracheal ventilation (IV catheter in trachea with high-pressure O2 delivery) is a possibility. NOT emergency tracheostomy.
Unconscious pt with multiple facial fractures, brisk bleeding into the mouth and throat, gurgling, irregular, labored breathing. Next step?
Cricothyroidotomy. NOT percutaneous transtracheal ventilation (does not eliminate CO2 well, and need to avoid hypoventilation in unconscious head trauma for fear of increased ICP)
Three conditions that might produce inadequate breathing in trauma
Plain pneumothorax, tension pneumothorax, flail chest with underlying pulmonary contusion
Most common causes of shock in trauma?
Bleeding (hypovolemic) most common, followed by pericardial tamponade and tension pneumothorax (both require chest involvement).
“Picture of shock”
Diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water, low blood pressure, fast weak pulse
Management of hypovolemic shock in trauma
Big-bore IV lines, Foley catheter, IV antibiotics (if abdominal trauma) in preparation for ex-lap, then fluid and blood administration (i.e. control the bleeding site first if surgery is called for)…if no surgery needed, fluid resuscitation first in part as a diagnostic test.
Approach to shock in multiple gunshot wound pt in the field?
Don’t attempt to start an IV on site–time is better spent getting the patient to a trauma center for ex lap (“scoop and run”)…unless center is very far away from center, then start fluid resuscitation with Ringer’s lactate (a couple of liters in the first 20-30 minutes).
Groin gunshot wound, BP 90/70, HR 105, bright red blood squirting from wound. First step?
Direct local pressure (gloved finger or sterile pressure dressing), NOT tourniquet or blind clamping. Volume restoration later.
Car accident victim, unconscious, spontaneous but noisy breathing, BP 80/60, HR 95. No vein distention. First steps?
Intubation, central line for CVP measurement, chest/abdomen exam, two large peripheral lines pouring in Ringer’s lactate (can also use percutaneous femoral vein catheter or saphenous vein cut-down)
Child shot in arm, bleeding controlled by local pressure, hypotensive and tachycardic, peripheral IVs unsuccessful. Next step?
Intraosseous cannulation in proximal tibia, then bolus of Ringer’s lactate (20 mL/kg)
Multiple gunshot wounds to chest and abdomen, diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. BP 60/40, HR 150, pulse barely perceptible. Next steps?
Likely hypovolemic shock, but can’t rule out pericardial tamponade or tension pneumothorax. Look for distended neck veins (or high CVP) in both, and respiratory distress, tracheal deviation, and absent breath sounds on a hyperresonant hemithorax in tension pneumo.
Management of suspected pericardial tamponade?
Clinical diagnosis, no x-rays needed, find and evacuate the blood in the pericardial space via pericardiocentesis, tap, tube, or pericardial window. If positive, follow with thoracotomy and then ex-lap. Fluid resuscitation or blood transfusion helps tamponade as a temporizing measure.
Stab wound with 6-inch blade, entry wound left of sternal border at 4th intercostal space. BP 80/50, HR 110, cold, pale, perspiring heavily. Distended neck and facial veins, normal breathing and breath sounds. Next steps?
This is pericardial tamponade, need median sternotomy to open the pericardial sac and relieve the tamponade (can skip pericardiocentesis or pericardial window)
Management of suspected tension pneumothorax?
Immediate big-bore needle or IV catheter placed into the pleural space, followed by a chest tube to the affected side. No time for chest x-ray.
Automobile collision, pt in coma with fixed, dilated pupils and multiple obvious fractures in both upper extremities and right lower leg. BP 70/50, barely perceptible pulse of 140. Where is the bleeding?
Obvious head injury present, but the shock here is caused by bleeding which cannot be intracranial. Need to lose a liter and a half to go into shock.
Pt with severe chest pain, cold, diaphoretic, BP 80/65, irregular, feeble pulse at a rate of 130, neck and forehead veins distended, short of breath. Management?
Cardiogenic shock from massive MI. Need to verify high CVP, ECG, enzymes, coronary care unit, thrombolytic therapy. Don’t “drown” with fluids.
Characteristics, examples, and management of vasomotor shock?
Massive vasodilation, loss of vascular tone; pt warm and flushed, CVP low; can occur in anaphylaxis, spinal block; management is vasoconstrictors and volume replacement.
Management of penetrating wounds?
As a rule, internal damage will need to be repaired surgically. Do not remove embedded “weapon” at scene of accident or in ER.
Management of skull fractures?
Closed, asymptomatic = leave alone; open, not comminuted or depressed = clean and close laceration in ER; open, comminuted or depressed = OR for cleaning, repair, and possible craniotomy
Management of head trauma with transient loss of consciousness?
Head CT to look for hematoma; if CT and neuro exam are normal, pt can go home as long as someone can wake them up frequently to make sure they are not going into coma
4 signs of basal skull fracture
Raccoon eyes, clear fluid dripping out the nose, clear fluid dripping from the ear, ecchymosis behind the ear (all individually diagnostic)
Management of basal skull fracture
Pt may be in a coma…needs head CT. CSF leak will stop by itself, nothing done about fractures. Be sure to evaluate cervical spine as well.
Signs of acute epidural hematoma?
Head trauma, transient LOC, recovery, recurrent LOC after ~1 hr, unilateral pupil fixation and dilation, signs of contralateral hemiparesis
Diagnosis and management of acute epidural hematoma?
CT scan (lens-shaped hematoma and deviation of midline structures); management is emergency surgical decompression (craniotomy)
Automobile collision, pt unconscious at scene, regains consciousness briefly in ambulance, arrives in ER in coma with fixed, dilated right pupil and contralateral hemiparesis. Next diagnostic and management steps?
Could be acute epidural hematoma but more likely subdural (sicker pt). Diagnosis is by CT scan. Management is emergency craniotomy, but prognosis is usually poor due to parenchymal injury. Don’t forget to check the cervical spine!
Pt in coma with no lateralizing signs. CT shows crescent-shaped hematoma without deviation of midline structures. Management?
Subdural hematoma, surgery not indicated without lateralizing signs or midline displacement. Management should be aimed at controlling ICP.
Pt in deep coma with bilateral fixed, dilated pupils. CT shows diffuse blurring of gray-white mass interface and multiple small punctate hemorrhages. No single large hematoma or displacement of midline structures. Diagnosis and treatment?
Diffuse axonal injury. Prognosis is terrible, surgery cannot help. Need to lower ICP. First line is head elevation, hyperventilation, and avoidance of fluid overload. Second line is mannitol and furosemide (but don’t go too far and produce hypotension, which would decrease brain perfusion). Lowered oxygen demand may help (hypothermia).
Pt becomes senile over 3-4 weeks after possible head trauma. Diagnosis and management?
Chronic subdural hematoma, diagnosed by CT scan, managed with surgical decompression (craniotomy)
Management of penetrating neck wounds in an unstable patient (deteriorating vital signs)?
Immediate surgical exploration
Gunshot wound to neck, entrance wound in anterior left side at level of thyroid cartilage, bullet embedded in right scalene muscle. Pt is spitting and coughing blood and has an expanded hematoma. BP responds promptly to fluid administration and pt is stable. Management?
Penetrating wound in the middle of the neck (zone II) needs surgical exploration even though pt is stable.
Gunshot wound to neck, entrance and exit wounds above the level of the angle of the mandible. Steady trickle of blood from both wounds, not responding to local pressure. Pt drunk and combative but otherwise stable. Management?
Angiography is best choice for diagnosis and potential embolization. No tracheal or esophageal involvement possible this high in the neck, pharyngeal injuries inconsequential. Vascular injuries possible, but not easy to explore surgically.
Gunshot wound to neck, entrance and exit wounds above the clavicles but below cricoid cartilage. Pt is hemodynamically stable. Management?
Standard workup includes angiography, soluble-contrast esophagogram (followed by barium if negative), esophagoscopy, and bronchoscopy, even in asymptomatic patients. Surgical repair probably indicated.
Stab wound to neck in front of sternocleidomastoid at level of thyroid cartilage. Pt asymptomatic, vital signs normal. Management?
Observation for 12 hours (only true for stab wounds of upper and middle zones without symptoms)
Pt thrown from vehicle, multiple facial lacerations but otherwise stable, persistent neck pain and tenderness to palpation over posterior midline, neuro exam normal. Management?
AP/lateral cervical spine films (including T1) along with odontoid views. If negative and suspicion remains, then CT scan.
Brown-Sequard syndrome (spinal cord hemisection)
Paralysis and loss of proprioception distal to injury on the ipsilateral side to injury, loss of pain perception distal to injury on contralateral side.
Burst fracture of vertebral body can produce?
Anterior cord syndrome (loss of motor function and loss of pain and temperature sensation on both sides distal to injury with preservation of vibratory sense and position)
Neck hyperextension can produce?
Central cord syndrome (paralysis and burning pain on both upper extremities while maintaining good motor function in legs)
Diagnosis and management of spinal cord injuries?
X-rays and CT for looking at cervical bones, MRI for looking at spinal cord, high dose corticosteroids may help minimize permanent damage.
