Trauma Flashcards
1
Q
What is the golden hour of trauma?
A
Period immediately following trauma in which rapid assessment, diagnosis, stabilization must occur.
2
Q
What should happen in prehospital phase of trauma management?
A
Control of airway and external hemorrhage.
Immobilization.
Rapid transport to hospital.
3
Q
What should a trauma history include?
A
AMPLE: Allergies Medications/Mechanism of injury PMH/Pregnant Last meal Events surrounding mechanism of injury
4
Q
What are the ABCs of trauma care?
A
Airway (w/ cervical spine precautions) Breathing and ventilation Circulation/Control of hemorrhage Disability (neuro status) Exposure/Environment control Foley
5
Q
Describe airway and C-spine management.
A
Assess patency.
Use jaw thrust or chin lift to open airway.
Clear foreign bodies.
Insert oral or nasal airway when necessary.
6
Q
Describe breathing and ventilation management.
A
Inspect, auscultate, palpate chest.
Identify and treat injuries that may impair (e.g. pneumothorax, flail chest, pulmonary contusion, massive hemothorax).
All receive O2.
7
Q
Describe control of hemorrhage.
A
Assess circulatory status (e.g. cap refill, pulse, skin color).
Place 2 large-bore IVs (always draw blood).
Use direct pressure.
8
Q
Describe assessment of disability.
A
Rapid neuro exam.
Establish pupillary size, reactivity.
Assess level of consciousness (e.g. AVPU, GCS).
9
Q
What is AVPU?
A
Assesses level of consciousness:
Alert, Verbal, Pain, Unresponsive.
10
Q
What should you do before placing a Foley?
A
Examine prostate and genitalia for injury (mainly, urethral transection).
First perform retrograde urethrogram if suspected.
11
Q
What are signs of urethral transection?
A
Blood at the meatus.
High-riding prostate.
Perineal or scrotal hematoma.
12
Q
What is appropriate initial fluid therapy?
A
Bolus of < 2L of isotonic crystalloid solution.
Pediatrics: 20 cc/kg.
13
Q
What is a crystalloid?
A
Na-based solution that provides transient increase in intravascular space (2/3 quickly distributes to EV and interstitial spaces).
Ex. saline, Ringer’s lactate.
14
Q
What is a colloid?
A
Blood product-based solution that remains in intravascular space longer.
Costly, riskier (transfusion rxn, viruses), not superior in volume resuscitation.
Ex. RBCs, albumin.
15
Q
What is the 3-to-1 rule?
A
Rough estimate of the total volume of crystalloid needed to replace blood loss.
16
Q
What is a trauma series?
A
Radiographs of C-spine, chest, pelvis.
Usually occurs concurrently with early resuscitation.
17
Q
What are the layers of the scalp?
A
SCALP. Skin Connective tissue Aponeurosis (galea) Loose areolar tissue Pericranium
18
Q
How is a galeal laceration treated?
A
Single-layer, interrupted 3.0 non-absorbable sutures through the skin, subcutaneous tissue and galea.
19
Q
The brain is partially compartmentalized by reflections of which dural layers?
A
Falx cerebri
Tentorium cerebelli
20
Q
Where is CSF produced?
A
Choroid plexus.
21
Q
What is the rate of production of CSF?
A
500 cc/day (150 cc circulating at any given time).
22
Q
What is CPP?
A
CPP = cerebral perfusion pressure = MAP - ICP.
23
Q
What is the Monro-Kellie hypothesis?
A
The sum of the volume of brain, blood and CSF within the skull must remain constant. (Thus increased ICP may result in cerebral herniation or cessation of cerebral blood flow.)
24
Q
What is the Cushing reflex?
A
The brain’s attempt to maintain CPP. May present as hypertension and bradycardia in the setting of increased ICP.
25
What are indications for a head CT?
Neurologic deficit.
Persisting depression or worsening of mental status.
Moderate/severe mechanism of injury.
Depressed fracture.
Linear fracture overlying dural venous sinus or meningeal artery groove.
26
After discharge for head trauma, what signs and symptoms should family look out for?
```
Persistant or worsening headache
Dizziness
Vomiting
Inequality of pupils
Confusion
```
27
What measures are used to lower ICP?
```
HIVED:
Hyperventilation
Intubation w/ pretreatment and sedation
Ventriculostomy
Elevation of head
Diuretics (mannitol, furosemide)
```
28
What is the anterior triangle of the neck?
Bordered by midline, posterior border of SCM, mandible.
| Contains majority of vital structures of neck.
29
What is the posterior triangle of the neck?
Bordered by trapezius, posterior border of SCM, clavicle.
| Lower zone contains subclavian vessels, brachial plexus, apices of lungs.
30
What are the anatomical markers for the zones of the neck?
Cricoid cartilage.
| Angle of mandible.
31
What are possible complications of penetrating injuries to the neck?
Exsanguination.
Airway compromise (e.g. hematoma, thyroid cartilage fracture, tracheal cartilage dislocation).
CVA (e.g. transection of carotid, air embolus).
Esophageal injury.
32
What procedure is performed in event of laryngotracheal separation?
Tracheostomy.
33
What are indications for surgical exploration in neck trauma?
```
Expanding hematoma.
Subcutaneous emphysema.
Tracheal deviation.
Change in voice quality.
Air-bubbling through wound.
Deteriorating vitals.
```
34
What exploratory techniques for neck trauma are used in lieu of surgery?
```
C-spine film and CXR.
Arteriography.
Esophagogram (water-soluble --> barium).
Esophagoscopy.
Bronchoscopy.
CT.
```
35
What region of the spine is most vulnerable?
Cervical.
36
What are the vertebral regions of the spine?
Cervical (7), Thoracic (12), Lumbar (5), Sacral (5), Coccygeal (4).
37
At what vertebral level does the spinal cord end?
L2.
38
What is spinal shock?
State of flaccidity, absent reflexes, absent autonomic control (uninhibited parasympathetic) occurring after spinal injury.
Does signify permanent damage.
39
What is the difference between a complete and incomplete spinal cord injury?
Complete means no preservation of neurologic function distal to injury. (Note: DTRs and sacral reflexes may be preserved.)
40
What is sacral sparing?
Preservation of perianal sensation, voluntary sphincter contraction, or voluntary toe flexion in a spinal cord injury.
41
What are the 3 major spinal cord tracts?
```
Corticospinal tract (ipsilateral motor).
Spinothalamic tract (contralateral pain/temp).
Dorsal column (ipsilateral position/vibration).
```
42
If penetrating spinal cord injury is diagnosed, what medication is used?
High-dose methylprednisolone within 8 hr.
43
What are indications for a C-spine film?
```
Tenderness along C-spine.
Neurologic deficit.
Good mechanism of injury.
Presence of distracting injury.
Patients with altered sensorium.
```
44
Why are thoracic spinal fractures more devastating?
The spinal canal through this region is relatively narrow and the blood supply is in a water-shed area.
45
What is the most common injury to the thoracic spine?
Wedge or compression fracture 2/2 hyperflexion.
46
What is Beck's tamponade triad?
Hypotension
JVD
Muffled heart sounds
47
What is electrical alternans?
Alternating heights of R wave in QRS complexes.
| Sign of pericardial tamponade.
48
What are complications of tube thoracostomy?
SubQ placement.
Bleeding from intercostal vessels.
Injury to intercostal nerves, lung, diaphragm, or liver.
49
What are some iatrogenic causes of great vessel injury?
CVP line or chest tube placement.
IABP.
Non-vascular clamp during thoracotomy.
Overinflation of Swan-Ganz balloon.
50
What are 2 reasons a gunshot wound is worse than a stab wound?
Fragmentation of bullet.
| Injury from resultant shock wave.
51
What are the 3 mechanisms of injury in blunt trauma?
Injury from direct blow.
Crush injury.
Deceleration injury.
52
Where are the 3 openings in the diaphragm?
T8: IVC
T10: esophagus, vagus nerves
T12: aorta, thoracic duct, azygos vein
53
What is the blood supply for the diaphragm?
```
Pericardiophrenic arteries (from internal thoracic)
Phrenic arteries (from thoracic, abdominal aorta)
Intercostal arteries (from thoracic aorta, internal thoracic)
```
54
What are the peritoneal abdominal viscera?
```
Liver
Spleen
Stomach
Small bowel (except for proximal 3/4 of duodenum)
Transverse and sigmoid colon
```
55
What are the retroperitoneal abdominal viscera?
```
Proximal 3/4 of duodenum
Ascending and descending colon
Pancreas
Kidneys
Ureters
Major vessels (aorta, IVC, renal and splenic vessels)
```
56
What are the pelvic viscera?
```
Bladder
Urethra
Ovaries and uterus (women)
Prostate (men)
Rectum
Iliac vessels
```
57
What is the seat-belt sign?
Ecchymotic area found in the distribution of the lower anterior abdominal wall.
Associated with perforation of bladder, bowel, seat-belt fracture.
58
What is Cullen's sign?
Periumbilical ecchymosis.
| Indicates intraperitoneal hemorrhage.
59
What is Grey-Turner's sign?
Flank ecchymoses.
| Indicates retroperitoneal hemorrhage.
60
What is Kehr's sign?
Left shoulder or neck pain secondary to left diaphragm irritation (splenic rupture).
Pain increases when in Trendelenburg or on LUQ palpation.
61
What is FAST?
FAST = Focused abdominal sonography for trauma.
| EMBU for free fluid (blood) in the abdomen.
62
What are the 4 dependent areas assessed in FAST?
Morrison's pouch (between liver, L kidney)
Splenorenal recess.
Pouch of Douglas (above rectum).
Subxiphoid and parasternal (hemopericardium).
63
What is DPL?
DPL = diagnostic peritoneal lavage.
64
What are the rules for contrast use in abdominal CTs?
Non-contrast: Intra-parenchymal hematomas.
PO contrast: Location, integrity of upper GI tract.
IV contrast: Organ, vascular injury.
65
What is the blood supply for the liver?
```
Portal vein (from SMV and splenic vein).
Hepatic artery (from common hepatic branch of celiac artery).
```
66
What is the venous drainage of the liver?
Left, middle and right hepatic veins (into IVC).
67
What is the criteria for a trial of observation in traumatic injury to the liver?
Stable or stabilizes with fluids.
No peritoneal signs.
Injury precisely delineated and graded by CT.
No associated injury requiring laparotomy.
No need for excessive blood transfusions.
68
What is the Pringle maneuver?
Occlusion of the portal triad manually or w/ an atraumatic vascular clamp.
Should not exceed 20 minutes.
69
What are the steps in trauma liver surgery?
Laparotomy.
Pringle maneuver.
Finger fracture of liver to expose damaged vessels and bile ducts.
Debridement of nonviable tissue.
Placement of omental pedicle (w/ blood supply) at site of injury.
Closed suction drainage.
70
What are complications of trauma liver surgery?
```
Hemorrhage.
Hemobilia.
Hyperpyrexia.
Abscess.
Biliary fistula.
```
71
What are the major and minor ligaments of the spleen?
Major: gastrosplenic, splenorenal.
Minor: splenophrenic, presplenic fold, pancreaticosplenic, phrenicolic, pancreaticocolic.
72
Between which layers does breast tissue lie?
Within superficial pectoral fascia.
73
What does a mammary gland consist of?
15-20 lobules opening on the areola via a single lactiferous duct.
74
What are Cooper's ligaments?
Separate and support mammary glands, extending from the deep pectoral fascia to the superficial dermal fascia.
75
What is the tail of Spence?
The portion of breast tissue that extends into the axilla.
76
What is the blood supply to the breast?
Lateral thoracic artery (from axillary).
Internal thoracic artery.
Anterior and posterior intercostal arteries.
77
What is the venous drainage of the breast?
Axillary vein.
Internal thoracic vein.
Intercostal veins.
78
What is the lymphatic drainage of the breast?
Axillary lymph nodes mainly.
| Parasternal lymph nodes (medial quadrants).
79
What neural structures may be encountered during major breast surgery?
Long thoracic nerve.
Thoracodorsal nerve.
Medial and lateral pectoral nerves.
Intercostobrachial nerves.
80
What follows damage to the long thoracic nerve?
Winging of the scapula (serratus anterior).
81
What follows damage to the thoracodorsal nerve?
Inability to push oneself up from a sitting position (latissimus dorsi).
82
What is the initial approach to a breast mass in a woman under 30?
Serial PE w/ observation for 2-4 weeks or until next menstrual period.
83
See pg. 137 for approach to breast mass in woman over 30.
See it.
84
What is the differential diagnosis for a breast mass?
1) Inflammatory: mastitis, fat necrosis, Mondor's disease.
2) Benign: fibroadenoma, fibrocystic changes, mammary duct ectasia, cystosarcoma phyllodes, intraductal papilloma, gynecomastia.
3) Premalignant: DCIS, LCIS.
4) Malignant: infiltrating ductal, infiltrating lobular, or inflammatory carcinoma, Paget's disease.
85
Which tumors are most likely to metastasize to bone?
```
Tumors Running and Leaping Promptly to Bone.
Thyroid
Renal
Lung
Prostate
Breast
```
86
What are risk factors for breast cancer?
1) Estrogen exposure (e.g. menarche 55, nulliparity, 1st pregnancy >30, postmenopausal ERT).
2) Premalignancy (e.g. DCIS, LCIS, atypical ductal or lobular hyperplasia).
3) Genetics (e.g. BRCA1-2, Li-Fraumeni, prior cancer, breast cancer in mother or sister).
4) Other (white, old, radiation).
87
What is done for a pregnant woman with breast cancer?
1) Modified radical mastectomy (no radiation).
2) If lymph nodes are positive, delay chemo to 2nd trimester.
3) Suppress lactation after delivery.
4) Termination does not improve survival.
88
What are risk factors for breast cancer in males?
Klinefelter's syndrome.
Estrogen therapy or elevated endogenous estrogen.
Radiation.
Breast trauma.
89
Which genetic syndromes are associated with breast cancer?
```
Li-Fraumeni syndrome.
Muir-Torre syndrome.
BRCA1 and BRCA2 (Cowden's syndrome).
Peutz-Jeghers syndrome.
Ataxia telangiectasia.
```
90
Which gene mutations are associated with breast cancer?
p53: tumor suppressor (Li-Fraumeni).
BRCA1: Chr17, also ovarian cancer.
BRCA2: Chr13.
Rb.
91
When should mammograms begin?
At age 35 or 10 years before the age at which 1st-degree relative was diagnosed.
92
Why are mammograms better for older women (over age 30)?
Younger women have more fibrous breast tissue, making mammograms more difficult to interpret.
93
What constitutes a suspicious finding on mammogram?
A stellate, speculated mass with associated microcalcifications.
94
What is a radical mastectomy?
Resection of all breast tissue, axillary lymph nodes, pectoralis major and minor.
95
What is a modified radical mastectomy?
Resection of all breast tissue and axillary lymph nodes. (Preferred to radical mastectomy)
96
What is a simple mastectomy?
Resection of all breast tissue.
97
What is a sentinel node biopsy?
1) Lymph nodes identified on pre-op scintigraphy.
2) Blue dye injected in periareolar area.
3) Axilla opened and inspected for blue "sentinel" nodes by gamma probe.
4) If sentinel nodes are positive, axillary dissection.
5) If negative, no dissection (unless lymphadenopathy).
98
What chemotherapeutic drugs are used for breast cancer?
CAF (cyclophosphamide, adriamycin, 5-FU).
| CMF (cyclophosphamide, methotrexate, 5-FU).
99
What is tamoxifen?
A selective estrogen receptor modulator (SERM) that blocks uptake of estrogen by target tissues.
Used as hormonal therapy in breast cancer, esp. ER+ tumors.
100
What are side effects of tamoxifen?
Hot flashes.
Irregular menses.
Thromboembolism.
Risk of endometrial cancer.
