Trauma 2/28/17 Flashcards
zones approach (old approach) to neck trauma how new approach updates
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
define penetrating neck injury
platysma has been disrupted
hard signs vs soft signs of instability w neck trauma
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
dorsal columns medial lemniscus system
where in spinal cord transverse cut
where decussate
function
posteromedial
decussates up in… brain or brainstem… not spinal cord
proprioception
(fin feels the way)
vibratory sense
(shivers down the back)
ALS
aka aka aka
where in spinal cord transverse cut
where dessucate
function
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)
corticospinal tract
where in spinal cord transverse cut
function
lateral
(decussates way up in pyramids i think… not in spinal cord)
motor
DCML
STT
CST
where in transverse cut of spinal cord
where decussate
what function
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
brown sequard syndrome
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)
cord compression
sx
dx
tx
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
anterior cord syndrome
dcml spared (prop and vib)
LMN at level, UMN below level (CST)
loss of pain temp below (STT ALT VLT)
central cord syndromes
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)
posterior cord syndrome
lose dcmls
(sensation below the level)
motor (cst) pain and temp (stt als vls) preserved
evaluate airway patency in emergency situation
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
what is the significance of inspiratory stridor
entrance to entire airway is collapsing
evaluate breathing in emergency situation
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
eval for circulation in emergency situation
pale cold diaphoretic
SBP v90 MAP v65 not absolutely scary but should get antenna going
U output v.5cc/kg/hr
manage airway in trauma
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)
MAP =
MAP = CO x SVR MAP = HRxSV x SVR MAP = HR x PreloadxContractility x SVR
General concepts that can contribute to shock
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)
tf
hemorrhage picked up by Hb being low
careful
Hb is a concentration, don’t pick it up until fluid shift eg after giving fluids that anemia becomes evident on lab
abdominal bleed in trauma bay, how to dx, manage
FAST US to dx
apply pressure
take to OR - put in IVs, type and cross, IVF, Blood as necessary on the way over
pericardial tamponade in trauma bay, how to dx, manage
FAST - ECHO
pericardiocentesis
Warm vs cold hypotension ddx
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
Normal tidal volume
500cc
High tidal volume, ventilator, hypotension, think…
Pneumothorax
In general, keep tidal volumes lower (500cc is normal) and respiratory higher if necessary to prevent pneumothorax
Pulsus paradoxus
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)
Define massive PE
Causes hypotension
S1Q3T3
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
Lung and heart sounds Pneumothorax Pericardial tamponade PE MI
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
In emergency, order of attempts at venous access
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)
Is jugular venous access considered central or peripheral?
Internal jugular is central
External jugular is peripheral
When is ng tube with enteral hydration typically called for
For ICU pt getting meds and fluids but not drinking, develops hypernatremia - enteral ng tube hydration for gradual restoration of fluid balance
Sites for central venous access
Internal jugular
Subclavian
Femoral
When is a PICC line typically placed
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)
What is a saphenous vein cutdown and when will it be used
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
TF
In tachycardic hypotensive pt w story consistent w hemorrhage, wait for low hb before transfusing
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
Typical situations to expect hemoconcentration (high hb)
Dehydration
Insensible water loss (severe sepsis)
Insensible water loss = evaporated from skin or airway
What is insensible water loss
Eveporated from skin or airway
3 key signs and sx of aortic dissection
Chest pain radiating to back
Widened mediastinum
Pressures different between arms
Mechanism of traumatic aortic dissection
Ligamentum arteriosum tacks aorts down, but free to move on either side, shear
What does blood pressure over palp mean
Measured via cuff and palpation, not auscultation, eg in emergency situation
Reflex treatment of hemodynamically unstable chf
Furosemide and dobutamine
TF
Peritoneum does not like blood and blood there presents as acute abdomen
T
Vasomotor shock
Define
Signs and symptoms
Vasodilation from neurogenic origin
Why check rectal tone in pt hypotensive after fall from height
May be neurogenic shock, looking for neurologic deficits to support
When is 1-2 L blood loss in OB cool vs not cool
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
When to consider vasopressors in pt in shock
When due to SVR
-sepsis anaphylaxis anesthesia vasomotor/neurogenic
What does flushing a foley attempt to do
Unobstruct, unkink
Gunshot wound through and through lower third of neck, pt stable, how to proceed?
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
Knife vs through-and-through bullet to lower neck, pt stable, how to proceed
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
When to intubate bullet neck wound guy holding it shouting
If airway compromised (difficulty speaking, breathing(
Expanding hematoma
Coughing up blood
Spinal trauma with FND’s
What is Always the next step
IV methylprednisolone
Spinal trauma w FND’s,
give steroids, get ct, or get mri?
All of the above, in that order
When can you uncollar a major trauma pr
When on physical exam:
No FNDs
No tenderness to palpation
No spinal pain with movement
Major trauma pt w neck pain, xr negative, get ct?
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
TF
IV methylprednisolone for spine trauma w FND’s will decrease usefulness of subsequent diagnostic MRI
F
Give the IV steroids to reduce edema and further spinal injury, MRI will still be diagnostic
Mild trauma, no loss of consciousness, progressive decline in cognitive function without fnd’s
Diagnosis
Who is at risk
Subacute or Chronic Subdural Hematoma
Alcoholics
Elderly
Anticoagulated
Intraparenchymal hematoma is caused by
Hypertension
Grade and treat a concussion
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
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
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
Choose imaging for trauma pt with LOC, Racoon eyes (periorbital ecchymoses)
and/or Battle sign (retro auricular hematomas) consistent with basilar skull fracture
CT Head AND C-Spine
chance of neck trauma is high
2 causes of acute hypotensio from blunt chest trauma
Tension pneumothorax
Aortic transection
TF
Tracheal deviation, hypotension, and subcutaneous air in the neck and chest in trauma pt think esophageal rupture
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
TF
Both arterial and venous pulmonary vasculature is considered low pressure
T
Indications for thoracotomy to resolve hemothorax
What to do if these criteria not met
^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
In penetrating trauma, consider the start of the abdomen to be at ______, so do an ex lap if penetrating trauma below this
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
TF
It is necessary to retrieve bullet fragments in the body
False
You leave them in
When does a pneumothorax require thoracostomy vs needle decompression
Thoracostomy (chest tube) for pneumothorax
Emergent needle decompression if tension pneumo with HYPOTENSION
Pneumothorax
Get cxr or just place chest tube?
Hust place chest tube (on test)
ED may get cxr in real life
In chest trauma pt especially with rib, sternal, scapular fractures, be on lookout for aortic _____, and ____ and ____ contusions _____ hours after trauma
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
Why avoid agressive fluid resuscitation with sternal, rib, scapular fractures in chest trauma patient
High risk of pulmonary contusion which is sensitive to fluid administration and will leak right into alveoli and white out lungs
ECG changes and elevated trops and heart failure with pulmonary edema on cxr but clean coronaries on heart cath in trauma pt
Dx
Cardiac contusion
Pathology of ARDS in an adult
Sepsis with circulating cytokines causing inflammation in lungs and stiffness with low compliance
Compliance and PaO2/FiO2 ratio in ARDS
Low compliance
PaO2/FiO2 v200
What does ventilator associated pneumonia look like on cxr
Pulmonary consolidation
Treat pelvic fracture with hematoma, hemodynamically stable after IVF resuscitation
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
Caustic ingestion with oropharyngeal erythema and drooling
Next steps
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
Electrical burn pt with normal EKG started on fluids and morphine, next step?
Later sequelae?
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
Parkland formula, how much is an arm or a leg worth
9% for a Whole arm or leg, 4.5% for just the front or the back
Anaphylaxis with wheezing, first step IM Epinephrine or intubate?
After steps?
First step IM Epinephrine
Anaphylaxis – IM Epinephrine
Diphenhydramine, Cimetidine, fluids to support blood pressure, steroids, consider intubation
What are the risks of treating rabies
Cost and injection
So give IVIG and Vaccine if possibly exposed and don’t have animal to observe
Treat a human bite
Surgical debridement / irrigation
Leave open to close by secondary intention
Consider abx vs just monitor for abscess
Treat possible rabies exposure when animal not available to monitor
IVIG and Vaccine
In acetaminophen toxicity, _____ is depleted
In acetaminophen toxicity, GLUTATHIONE is depleted
In acetaminophen toxicity, hepatic toxicity occurs after _____ is depleted
In acetaminophen toxicity, hepatic toxicity occurs after GLUTATHIONE is depleted
from toxic metabolite build up
Manage acetaminophen toxicity
N-acetyl cysteine
Liver transplant if all else fails
For all toxic ingestions, give ____
For all recent toxic ingestions within 1 hour, give ____ and ____
For all toxic ingestions, give ACTIVATED CHARCOAL
For all recent toxic ingestions within one hour, give ACTIVATED CHARCOAL and GASTRIC LAVAGE
Ethylene glycol (antifreeze) is converted to _____ when ingested, which causes _____ and _____
Confirm dx by observing blue _____ under _____
Treat with _____ or _____ and potentially _____
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
Typical setting of methanol toxicity
How to diagnose
Complications
Kentucky Moonshine home fermented alcohol
Fundoscopic exam for hyperemic optic disks
metabolic acidosis, blindness and death
TF
Consider syrup of ipecac for a toxic ingestion
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
Side effects of N-acetyl cysteine
Threshold for giving in possible acetaminophen overdose
None. Very well tolerated. Low threshold for administration in possible acetaminophen overdose
