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Surgery > Trauma 2/28/17 > Flashcards

Trauma 2/28/17 Flashcards

1
Q 
zones approach (old approach) to neck trauma
how new approach updates
A

III - toward head - worried about arteries - but tough to explore - get arteriogram
II - middle - arteries, trach, espophagus - go to surgery, easy to explore
I - toward thorax - arteries, trach, esophagus - scary to operate as things can retract / fall into thorax - get arteriogram, esophogram, bronchoscope

the above if pt stable
if unstable, to surgery regardless of zone

new approach - OR if unstable, CT angiogram if stable but symptomatic (evals arteries, esoph, trach), observe if asymptomatic or CT angio negative, to OR if CT angio positive, repeat CT angio if asymptomatic becomes symptomatic
…. all regardless of zone.

so basically CT angiogram changed things and is the first step in eval if stable symptomatic… to OR if unstable still… use zone method if CT angio unavailable

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2
Q

define penetrating neck injury

A

platysma has been disrupted

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3
Q

hard signs vs soft signs of instability w neck trauma

A

hard

  • airway gurgle, stridor, loss of airway
  • vascular expanding hematoma, pulsatile (arterial) bleeding, stroke, frank shock

soft
-signs of air digestive or vascular injury that are not that bad - dysphonia dysphasia, subq emphysema / crepitus, non-pulsatile bleeding non-expanding hematoma

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4
Q

dorsal columns medial lemniscus system

where in spinal cord transverse cut
where decussate

function

A

posteromedial
decussates up in… brain or brainstem… not spinal cord

proprioception
(fin feels the way)
vibratory sense
(shivers down the back)

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5
Q

ALS
aka aka aka

where in spinal cord transverse cut
where dessucate

function

A

anterolateral system
ventrolateral system
spinothalamic tract

anterolateral (and MEDIAL - DECUSSATES anterior to spinal canal)

pain
temperature
(vent the pain and temperature)
(spinoThermometer tract .. put thermometer in spine it will be painful)

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6
Q

corticospinal tract

where in spinal cord transverse cut

function

A

lateral
(decussates way up in pyramids i think… not in spinal cord)

motor

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7
Q

DCML
STT
CST

where in transverse cut of spinal cord
where decussate
what function

A

DCML posteromedial, up in brain/stem whatever not in spine, proprioception (fin) vibratory sense (chills)

STT anterolateral/ventrolateral but decussates at the level - pain and temp (put spinothermometer into spine will get pain and temp)

CST lateral slightly dorsal - decussates up in pyramids - motor

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8
Q

brown sequard syndrome

A

hemisection of spinal cord
(almost always knife trauma to neck)

contralateral pain/temp loss below level, bilateral at level (STT/ALS/VLS)
ipsilateral motor loss… flaccid LMN at level, spastic UMN below level… (CST)
ipsilateral vib and prop loss below level (DCML)

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9
Q

cord compression
sx
dx
tx

A

fnd
ed (erectile dysfunction)
u/b incontinence

dexamethasone (to reduce inflammatory edema, which is the cause of the compression… not the trauma itself)

MRI AFTER dex because want to treat asap, MRI takes a while uncomfortable maybe dangerous

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10
Q

anterior cord syndrome

A

dcml spared (prop and vib)

LMN at level, UMN below level (CST)

loss of pain temp below (STT ALT VLT)

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11
Q

central cord syndromes

A

syringomyelia (swelling of central canal)
hyperextension in elderly

Loss of pain/temp, LMN AT THE LEVEL ONLY…eg usually CAPE-LIKE distribution down back and arms from cervicle spine lesion
(other syndromes affect below the level too)

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12
Q

posterior cord syndrome

A

lose dcmls
(sensation below the level)

motor (cst) pain and temp (stt als vls) preserved

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13
Q

evaluate airway patency in emergency situation

A

speaking full sentences
no accessory muscle use
bilateral breath sounds
-patent

can see expanding hematoma
cutaneous emphysema
-urgent airway

GCS less than 8, intubate
gurgling, gasping, stridor
-emergent airway - INTUBATE

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14
Q

what is the significance of inspiratory stridor

A

entrance to entire airway is collapsing

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15
Q

evaluate breathing in emergency situation

A

full breaths, satting well on pulse-ox, probably ok

deeper look:

pCO2 on ABG measures ventilation (MV = TVxRR)

pO2 on ABG (or pulse ox is almost as good really) measures oxygenation (controlled with PEEP, FiO2)

*don’t be fooled by ETCO2 endotracheal capnography (40 is normal) just tells you that ET tube is in the right place, assists in ET tube placement

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16
Q

eval for circulation in emergency situation

A

pale cold diaphoretic

SBP v90 MAP v65 not absolutely scary but should get antenna going

U output v.5cc/kg/hr

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17
Q

manage airway in trauma

A 
jaw thrust
finger sweep
O2 nc, face tent, non-rebreather
bag valve mask
intubate
cric (done in ed)
trach (done in or in more controlled circumstances for longer placement)
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18
Q

MAP =

A 
MAP = CO x SVR
MAP = HRxSV x SVR
MAP = HR x PreloadxContractility x SVR
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19
Q

General concepts that can contribute to shock

A

HR too fast or slow

Preload down… via volume (hemorrhage) or obstruction (tension pneumo, pericardial tamponade, PE)

contractility down (MI, CHF, contusion)

SVR down (sepsis anaphylaxis, anesthesia, spinal trauma)

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20
Q

tf

hemorrhage picked up by Hb being low

A

careful

Hb is a concentration, don’t pick it up until fluid shift eg after giving fluids that anemia becomes evident on lab

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21
Q

abdominal bleed in trauma bay, how to dx, manage

A

FAST US to dx
apply pressure
take to OR - put in IVs, type and cross, IVF, Blood as necessary on the way over

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22
Q

pericardial tamponade in trauma bay, how to dx, manage

A

FAST - ECHO

pericardiocentesis

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23
Q

Warm vs cold hypotension ddx

A

Warm svr problem
-sepsis anaphylaxis anesthesia spinal trauma

Cold a cardiac output (hr sv contractility) problem, svr contracts in reponse
-hemorrhage tension pneumo tamponade chf mi contusion

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24
Q

Normal tidal volume

A

500cc

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25
Q

High tidal volume, ventilator, hypotension, think…

A

Pneumothorax

In general, keep tidal volumes lower (500cc is normal) and respiratory higher if necessary to prevent pneumothorax

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26
Q

Pulsus paradoxus

A

Deeper drop in sbp w inspiration than normal (more than 10mmhg, so radial pulses may disappear during inspiration)

From pressure around hear preventing expansion for more venous return, r heart expands into left heart, increasing afterload and dec stroke volume so sbp lower

Eg in tamponade pericarditis copd osa

(Normally sbp drops a little from pooling in pulm vasculture)

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27
Q

Define massive PE

A

Causes hypotension

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28
Q

S1Q3T3

A

deep s wave in lead 1
Deep q wave lead 3
Inverted t wave lead 3

Sign of acute r heart strain
Eg PE (only 10% pe’s will have s1q3t3)
Similar to pattern in left posterior fascicular block

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29
Q 
Lung and heart sounds
Pneumothorax
Pericardial tamponade
PE
MI
A

Pneumo reduced lung normal heart

Tamponade normal lung distant heart

PE normal both

MI normal both if R sided
Pulm edema normal heart if L sided

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30
Q

In emergency, order of attempts at venous access

A

Peripheral venous line x3 attempts
(or at least Say you tried 3 times per some veteran medics)

IO intraosseous line (good for 24 hours if need right now, can get fluid up and get more definitive peripheral line later)

….

Central line (jugular, subclavian, femoral)

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31
Q

Is jugular venous access considered central or peripheral?

A

Internal jugular is central

External jugular is peripheral

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32
Q

When is ng tube with enteral hydration typically called for

A

For ICU pt getting meds and fluids but not drinking, develops hypernatremia - enteral ng tube hydration for gradual restoration of fluid balance

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33
Q

Sites for central venous access

A

Internal jugular
Subclavian
Femoral

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34
Q

When is a PICC line typically placed

A

In non-emergent situation for Pt who needs long term abx, chemo, or becomes difficult to stick (sickle cell pt in 30’s or 40’s)

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35
Q

What is a saphenous vein cutdown and when will it be used

A

Peripheral venous access via dissecting out saphenous ant to medial malleolus and ligating it, using proximal end to insert a catheter

Not used in too many emergency situations

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36
Q

TF

In tachycardic hypotensive pt w story consistent w hemorrhage, wait for low hb before transfusing

A

F
Hb will be normal in acute blood loss because it is a concentration. Give fluids, give blood

“Don’t transfuse above 7 or 8 because worse outcomes” does not apply to acutely hemorrhaging pt

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37
Q

Typical situations to expect hemoconcentration (high hb)

A

Dehydration
Insensible water loss (severe sepsis)

Insensible water loss = evaporated from skin or airway

38
Q

What is insensible water loss

A

Eveporated from skin or airway

39
Q

3 key signs and sx of aortic dissection

A

Chest pain radiating to back
Widened mediastinum
Pressures different between arms

40
Q

Mechanism of traumatic aortic dissection

A

Ligamentum arteriosum tacks aorts down, but free to move on either side, shear

41
Q

What does blood pressure over palp mean

A

Measured via cuff and palpation, not auscultation, eg in emergency situation

42
Q

Reflex treatment of hemodynamically unstable chf

A

Furosemide and dobutamine

43
Q

TF

Peritoneum does not like blood and blood there presents as acute abdomen

A

T

44
Q

Vasomotor shock
Define
Signs and symptoms

A

Vasodilation from neurogenic origin

45
Q

Why check rectal tone in pt hypotensive after fall from height

A

May be neurogenic shock, looking for neurologic deficits to support

46
Q

When is 1-2 L blood loss in OB cool vs not cool

A

can be cool in childbirth as plasma and rbc volumes have expanded

Not cool in elective procedure, 1-2 L is 20-40% of circulating blood volume

47
Q

When to consider vasopressors in pt in shock

A

When due to SVR

-sepsis anaphylaxis anesthesia vasomotor/neurogenic

48
Q

What does flushing a foley attempt to do

A

Unobstruct, unkink

49
Q

Gunshot wound through and through lower third of neck, pt stable, how to proceed?

A

Need to go to surgery to make sure structures intact (airway, esophagus, vasculature), but difficult to explore structures near thoracic inlet so get diagnostic studies first as pt is stable
-angiogram esophogram bronchoscopy vs ct angiogram

50
Q

Knife vs through-and-through bullet to lower neck, pt stable, how to proceed

A

Bullet gets surgical exploration, arteriogram esophogram bronchoscopy vs ct angio first ad pt stable and near thoracic inlet complicated surgery can do more harm than good

Knife wound if superficial Can be observed in Stable pt

51
Q

When to intubate bullet neck wound guy holding it shouting

A

If airway compromised (difficulty speaking, breathing(
Expanding hematoma
Coughing up blood

52
Q

Spinal trauma with FND’s

What is Always the next step

A

IV methylprednisolone

53
Q

Spinal trauma w FND’s,

give steroids, get ct, or get mri?

A

All of the above, in that order

54
Q

When can you uncollar a major trauma pr

A

When on physical exam:
No FNDs
No tenderness to palpation
No spinal pain with movement

55
Q

Major trauma pt w neck pain, xr negative, get ct?

A

Yes
If history concerning enough for fracture, or tenderness, especially pinpoint spinal tenderness, persists

Get ct so don’t miss unstable fracture or edema that may soon cause FND’s

56
Q

TF

IV methylprednisolone for spine trauma w FND’s will decrease usefulness of subsequent diagnostic MRI

A

F

Give the IV steroids to reduce edema and further spinal injury, MRI will still be diagnostic

57
Q

Mild trauma, no loss of consciousness, progressive decline in cognitive function without fnd’s

Diagnosis

Who is at risk

A

Subacute or Chronic Subdural Hematoma

Alcoholics
Elderly
Anticoagulated

58
Q

Intraparenchymal hematoma is caused by

A

Hypertension

59
Q

Grade and treat a concussion

A

Grade I, ouchie, no loc or amnesia
- sit out the Game. rest, analgesics, observation at Home

Grade II, Bam, loc no amnesia
- sit out the Week. rest, analgesics, observation at home or in hospital depending on family reliability to make sure doesn’t slip into coma

Grade III, POW, loc and amnesi
- sit out the Season. CT to rule out a deadly bleed like an elidural hematoma. rest, analgesics, observation more likely in Hospital

60
Q

MVA trauma patient with GCS 3 intubated unresponsive but vitals otherwise normal and CT showing blurring of gray/white junction consistent with diffuse axonal injury

Manage

Prognosis

A

Elevate head of bed
Hyperventilate
IV mannitol

If that doesn’t help then craniotomy

(Decrease ICP, try conservative measures first)

this pt not likely to recover

61
Q

Choose imaging for trauma pt with LOC, Racoon eyes (periorbital ecchymoses)
and/or Battle sign (retro auricular hematomas) consistent with basilar skull fracture

A

CT Head AND C-Spine

chance of neck trauma is high

62
Q

2 causes of acute hypotensio from blunt chest trauma

A

Tension pneumothorax

Aortic transection

63
Q

TF

Tracheal deviation, hypotension, and subcutaneous air in the neck and chest in trauma pt think esophageal rupture

A

F
Esophageal rupture usually in setting of wretching

Think pneumothorax or aortic dissection in acute hypotension in trauma pt

Think pneumothorax when you add tracheal deviation and subcutaneous emphysema, also look for decreased breath sounds

64
Q

TF

Both arterial and venous pulmonary vasculature is considered low pressure

A

T

65
Q

Indications for thoracotomy to resolve hemothorax

What to do if these criteria not met

A

^1500cc 1.5L drained from chest tube
or
More than 100cc/hr over 6 hours
(Probably from a systemic arterial bleed, pulmonary arteries and veins are all low pressure)

Observe chest tube for resolution of bleed if below these amounts

66
Q

In penetrating trauma, consider the start of the abdomen to be at ______, so do an ex lap if penetrating trauma below this

A

In penetrating trauma, consider the start of the abdomen to be at T4 NIPPLE LEVEL, so do an ex lap if penetrating trauma below this

67
Q

TF

It is necessary to retrieve bullet fragments in the body

A

False

You leave them in

68
Q

When does a pneumothorax require thoracostomy vs needle decompression

A

Thoracostomy (chest tube) for pneumothorax

Emergent needle decompression if tension pneumo with HYPOTENSION

69
Q

Pneumothorax

Get cxr or just place chest tube?

A

Hust place chest tube (on test)

ED may get cxr in real life

70
Q

In chest trauma pt especially with rib, sternal, scapular fractures, be on lookout for aortic _____, and ____ and ____ contusions _____ hours after trauma

A

In chest trauma pt especially with rib, sternal, scapular fractures, be on lookout for aortic DISSECTION, and PULMONARY and CARDIAC contusions 48-72 hours after trauma

71
Q

Why avoid agressive fluid resuscitation with sternal, rib, scapular fractures in chest trauma patient

A

High risk of pulmonary contusion which is sensitive to fluid administration and will leak right into alveoli and white out lungs

72
Q

ECG changes and elevated trops and heart failure with pulmonary edema on cxr but clean coronaries on heart cath in trauma pt
Dx

A

Cardiac contusion

73
Q

Pathology of ARDS in an adult

A

Sepsis with circulating cytokines causing inflammation in lungs and stiffness with low compliance

74
Q

Compliance and PaO2/FiO2 ratio in ARDS

A

Low compliance

PaO2/FiO2 v200

75
Q

What does ventilator associated pneumonia look like on cxr

A

Pulmonary consolidation

76
Q

Treat pelvic fracture with hematoma, hemodynamically stable after IVF resuscitation

A

External fixation and allow hematoma to tamponade itself off

(Pelvic bleeds usually venous)
(IF hemodynamically unstable options include angiography with embolization, ORIF, last ditch pelvic exploration, but test will not give hemodynamically instable pelvic trauma bleed because course of action not standardized

77
Q

Caustic ingestion with oropharyngeal erythema and drooling

Next steps

A

Admit for observation for stridor/laryngeal involvement/airway compromise

EGD to assess damage

Day 1 NPO, day 2 CLD if low severity edema erythema shallow ulcers

NPO 72 hours if high severity deep ulcers circumferential burns black necrosis

78
Q

Electrical burn pt with normal EKG started on fluids and morphine, next step?

Later sequelae?

A

Check for thermal burns under the skin (bones heat up, sustained contraction causes rhabdo) with serum CK, urine myoglobin, or blood in urine without RBCs

Later sequelae
Compartment syndrome, cataracts and demyelination syndromes

79
Q

Parkland formula, how much is an arm or a leg worth

A

9% for a Whole arm or leg, 4.5% for just the front or the back

80
Q

Anaphylaxis with wheezing, first step IM Epinephrine or intubate?

After steps?

A

First step IM Epinephrine

Anaphylaxis – IM Epinephrine

Diphenhydramine, Cimetidine, fluids to support blood pressure, steroids, consider intubation

81
Q

What are the risks of treating rabies

A

Cost and injection

So give IVIG and Vaccine if possibly exposed and don’t have animal to observe

82
Q

Treat a human bite

A

Surgical debridement / irrigation

Leave open to close by secondary intention

Consider abx vs just monitor for abscess

83
Q

Treat possible rabies exposure when animal not available to monitor

A

IVIG and Vaccine

84
Q

In acetaminophen toxicity, _____ is depleted

A

In acetaminophen toxicity, GLUTATHIONE is depleted

85
Q

In acetaminophen toxicity, hepatic toxicity occurs after _____ is depleted

A

In acetaminophen toxicity, hepatic toxicity occurs after GLUTATHIONE is depleted

from toxic metabolite build up

86
Q

Manage acetaminophen toxicity

A

N-acetyl cysteine

Liver transplant if all else fails

87
Q

For all toxic ingestions, give ____

For all recent toxic ingestions within 1 hour, give ____ and ____

A

For all toxic ingestions, give ACTIVATED CHARCOAL

For all recent toxic ingestions within one hour, give ACTIVATED CHARCOAL and GASTRIC LAVAGE

88
Q

Ethylene glycol (antifreeze) is converted to _____ when ingested, which causes _____ and _____
Confirm dx by observing blue _____ under _____
Treat with _____ or _____ and potentially _____

A

Ethylene glycol (antifreeze) is converted to OXALIC ACID when ingested, which causes RENAL FAILURE and METABOLIC ACIDOSIS
Confirm dx by observing blue URINE under WOOD’S LAMP
Treat with ALCOHOL or FOMEPIZOLE and potentially HEMODIALYSIS if renal failure occurs

89
Q

Typical setting of methanol toxicity

How to diagnose

Complications

A

Kentucky Moonshine home fermented alcohol

Fundoscopic exam for hyperemic optic disks

metabolic acidosis, blindness and death

90
Q

TF

Consider syrup of ipecac for a toxic ingestion

A

F
NEVER syrup of ipecac, we don’t do it anymore – makes you vomit, risk aspiration, re-burn esophagus if caustic. We now prefer nasogastric lavage

91
Q

Side effects of N-acetyl cysteine

Threshold for giving in possible acetaminophen overdose

A

None. Very well tolerated. Low threshold for administration in possible acetaminophen overdose

Surgery (22 decks)

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