Trauma Flashcards
T/F: An airway has to be secured before dealing with a potential cervical spine injury.
True (keep head secured and not moved; can use nasotracheal intubation over a fiberoptic bronchoscope)
Subcutaneous emphysema in the neck is a sign of _________, and mandates use of a ________________ when securing an airway.
“major traumatic disruption of the tracheobronchial tree;” mandates use of a fiberoptic bronchoscope
Shock is blood pressure under __ mm Hg systolic
90
Shock is urinary output under _______
0.5 mL/kg/hr
How do you distinguish between shock caused by bleeding, by pericardial tamponade, or by tension PTX?
CVP!
high = pericardial tamponade/PTX
low = hemorrhag
Respiratory distress!
great = PTX
none = pericardial tamponade
In fluid resuscitation, you must use “large bore” peripheral IV needles. This is ____ gauge.
14-16
In adults, if PIVs can’t be secured, femoral vein catheters or saphenous vein cut-downs are alternatives. In children under 6, __________ is the alternate route.
intraosseous cannulation of the proximal tibia
What is Beck’s triad?
Pericardial tamponade =
1) low arterial BP
2) distended neck veins
3) muffled heart sounds
What is a comminuted fracture?
A fracture in which the bone has broken into several pieces.
Which head fractures are treated in the OR?
comminuted or depressed head fractures (note: open fractures require wound closure, but linear skull fractures are left alone if closed)
What is the next step in patients with raccoon eyes, rhinorrhea and otorrhea, or ecchymosis behind the ear?
Expectant management with CT scan to assess integrity of cervical spine
What type of intubation should be avoided in patients with Battle’s sign?
nasotracheal intubation
Battle’s sign = mastoid ecchymosis, evidence of fracture along the middle cranial fossa and extravasion of blood along posterior auricular artery.
Acute epidural hematoma results in a fixed dilated pupil that is on the (same/opposite) side of the trauma 90% of the time.
SAME side
What is decerebrate and which is decorticate posturing? Which is worse?
Decerebrate = extension of the arms, toes pointed down
Decorticate = arms protecting core (flexed across chest), toes pointed down
DeCERebrate is more SERious
A semilunar crescent shaped hematoma on CT is indicative of
subdural hematoma
A biconvex, lens shaped hematoma on CT is indicative of
epidural hematoma
To lower ICP in signs of herniation, hyperventilation is recommended to a goal of PCO2 of
35
T/F: Hypovolemic shock cannot happen from intracranial bleeding
True! There isn’t enough space!
When does penetrating trauma to the neck lead to surgical exploration?
1) expanding hematoma
2) deteriorating vital signs
3) clear signs of esophageal or tracheal injury
What are the 3 zones of the neck, and what is the treatment of trauma to them?
zone 1: thoracic inlet to cricothyroid membrane. Gunshot wounds –> arteriography, esophogram, esophagoscopy, bronchoscopy
zone 2: cricothyroid membrane to mandible. Stab wounds in asx patients can be observed
zone 3: madible and up. Arteriographic diagnosis of gunshot wounds; asx stab wounds can be observed
T/F: You have to do a CT of the C-spine of someone who is neurologically intact but has pain to local palpation over the C spine.
True
Findings often seen due to clean-cut injury (knife blade) to spinal cord:
Brown-Sequard: paralysis and loss of priproception to distal to injury distal ipsilaterally; contralateral loss of pain perception distal to injury
Findings seen due to burst fractures of vertebral bodies:
anterior cord syndrome: loss of motor function and loss of pain and temperature sensation on both sides distal to injury with preservation of vibratory and positional sense
Findings seen due to forced hyperextension of the neck (rear-end collision in elderly):
central cord syndrome: paralysis and burning pain in upper extremities, with preservation of most functions in lower extremities
Treatment of rib fracture:
local nerve block and epidural catheter (don’t want hypoventilation –> atelectasis –> PNA)
What is the difference in where a chest tube is placed in PTX vs hemothorax?
PTX = upper, anterior hemothorax = lower, to avoid development of empyema
T/F: Hemothorax does not usually require surgical intervention to stop the bleeding, because it’s a low pressure system.
True.
However, if >1500 mL or more blood is collected initially, or over 600 mL over the ensuing 6h, then thoracotomy is indicated (systemic vessel like intercostal artery usually the source of bleeding in these cases)
Work up of severe blunt trauma to chest:
1) blood gases, CXR (white out) for pulmonary contusion
2) cardiac enzymes and EKG (arrythmias) for myocardial contusion
T/F: Contused lung is very sensitive to fluid overload.
True. Treatment includes fluid restriction and use of diuretics.
How are sucking chest wounds (flap that sucks air with inspiration and closes during expiration) treated?
occlusive dressing that allows airs out but not in
What do you look for on CXR for pulmonary contusion?
“white out” of the lungs on CXR; can show up immediately or up to 48 h later
What increases suspicion of traumatic rupture of the aorta?
1) big deceleration injury
2) fractures of chest bones that are “hard to break”: sternum, scapula, first rib
3) wide mediastinum
What are noninvasive diagnostic tests for rupture of aorta?
1) TEE
2) spiral CT (CT angio!)
3) MRA
What is the differential of subq emphysema?
1) rupture of trachea or major bronchus
2) rupture of esophagus (as in after esophagus)
3) tension PTX
Sudden death occurring in a chest trauma patient who is intubated and on a respirator is suspicious for:
air embolism
This also happens with subclavian vein is exposed to air (CVP placement, supraclavicular node biopsies, etc). Avoid this by Trendelenburg patient when placing
What is the treatment of air embolism?
cardiac massage, patient placed left side down
Fat droplets in urine helps aid a precise diagnosis of
fat embolism
Any entrance or exit wound of a bullet below the level of _______ is considered to involve the abdomen
nipple line (T4)
In the case of blunt trauma to the abdomen, what indicates exploratory lap?
signs of internal bleeding (shock, low CVP, no obvious external source of blood loss, peritoneal irritation)
Where are the only places where 1500 mL–25-30% of blood volume– of blood (the amount of blood loss to start signs of shock) could hide?
abdomen
thigh (secondary to femur fracture)
pelvis (pelvic fractures)
**femur and pelvic fractures are checked in trauma patients
(lungs could accommodate, but would show up on Xray)
If patient develops hypothermia and acidosis during laparotomy, what are the steps?
laparotomy has to be terminated promptly! Pack bleeding surfaces and temporary close; resume when patient is warmed and coagulopathy is treated (patient already receives 10u of FFP and platelets ppx for laparotomies for multiple trauma with multiple transfusions)
What is abdominal compartment syndrome? How do you treat it?
When lots of fluids and blood have been giving during the course of laparotomy so all tissues are swollen and abdominal wound cannot be closed–or 2 days later, distention develops with hypoxia (can’t breath) and renal failure (pressure on IVC). Must be reopened and temporary cover is placed (absorbable mesh or nonabsorbable plastic)
When are pelvic hematomas left alone?
When they are not expanding
What is the treatment of an expanding pelvic hematoma?
Pelvic fixators, followed by a visit to IR for both internal iliac arteries
Scrotal hematoma, a sensation of wanting to void but not being able to do it, and a high riding prostate on rectal exam indicate:
pelvic fracture with urethral injury
How are bladder injuries diagnosed?
retrograde cystogram
What is a potential sequelae of injuries affecting the renal pedicle?
1) development of AV fistula leading to CHF
2) renal artery stenosis leading to renovascular HTN
Large penile shaft hematoma with normal appearing glans think:
Treatment?
fracture of penis. Requires emergency surgical repair otherwise impotence will develop (as AV shunts will develop)
In an injury to the extremity that is not near major vessels, what is the treatment?
tetanus prophylaxis and cleaning of the wound
Asymptomatic extremity injury near major vessels: treatment?
tetanus ppx, cleaning of wound, AND Doppler studies or CTA
What is repaired first in combined injuries of arteries, nerves, and bone?
1) bone
2) vascular repair
3) nerve
* *also due a fasciotomy!! Prolonged ischemia could leave to compartment syndrome
In an arterial injury 5 cm?
5: venigraft
Treatment of crush injuries:
1) Hydration of IVF
2) Alkalinization of urine (IV bicarb)
3) mannitol diuresis
Treatment of chemical burns:
massive irrigation
Treatment of high-voltage electrical burns:
like those of crush injuries: hydration of IVF, alkalinization of urine with IV bicarb, mannitol diuresis; treatment of orthopedic injuries
Which type of burn is associated with late development of cataracts and demyelinization syndromes?
high-voltage electrical burns
Burns aroudn the mouth or soot inside the throat indicate what kind of burn?
respiratory burn (inhalation injur)
How is respiratory burn confirmed?
fiberoptic bronchoscopy; blood gases to determine if respiratory support is needed
What is the treatment of circumferential burns?
Escharotomies (to prevent cutoff of blood supply as edema develops)
How is the extent of burns in an adult calculated?
Rule of 9s; head and each upper extremity = 9%; lower extremity = 2 9%; torso = 4 9%
How should fluid be replaced as rule of thumb?
To hourly urinary output of 1-2 mL/kg/h, while avoiding CVP over 15 mm Hg
If greater than 20% BSA burn, start at _________ mL/h or Ringer lactate and then adjust for urinary output
1,000 mL/h (1 L); NO sugar (to avoid osmotic diuresis)
What is the fluid replacement in babies burned as a rule of thumb?
20 mL/kg/h if burn exceeds 20% of body surface
What are the degrees of burn, 1-4?
1st: just epidermis
2nd: epidermis and some dermis
3rd: epidermis and all dermis (no pain)
4th: bone and muscle
Besides fluid replacement, what are other aspects of burn care?
1) tetanus ppx
2) cleaning of burn areas
3) topical agents (silver sulfadiazine, or mafenide acetate for deep penetration–eschars and cartilage)
4) IV pain medication
5) NG suction x2d, then aggressive high-calorie/high nitrogen diet
What topical agents should be used in burn care?
usually silver sulfadiazine; mafenide acetate for deep penetration (eschars, cartilage), but it can produce acidosis and hurt
Burns near eyes = triple antibiotic ointment (silver sulfadiazine irritates the eyes)
How long after the burn are wounds that have not regenerated grafted, generally?
2-3 weeks
What type of patient is a candidate for early excision and grafting (removal in OR of burned areas on day one with immediate skin grafting)?
very limited burns (under 20%) that are obviously third degree
T/F: Tetanus ppx is required for all bites.
True
T/F: In both provoked and unprovoked dog bites, rabies ppx is mandatory (Ig and vaccine)
False. Just unprovoked dog bites or wild animal bites
What is the treatment of snake bites (if signs of envenomation)?
1) tetanus ppx and wound care
2) draw blood for typing and crossmatch
3) coag studies
4) liver and renal function
5) antivenin (CROFAB for crotalids)
T/F: Antivenin dosage in snakebites is based on the size of the patient.
False. The size of the envenomization!! chilrend and adults receive same dosage
What is the only valid first aid to snake bites?
Splint the extremity during transportation
What is the treatment of black widow spider bites? What are the symptoms?
Symptoms: n/v, generalized muscle cramps
antidote: IV calcium gluconate; muscle relaxants can help
Brown recluse spider bites are often not recognized at the time. A skin ulcer develops with a necrotic center and surrounding halo of erythema. What is the treatment?
Dapsone; surgical excision..but delay one week.
What is the treatment of a sharp cut over the knuckles following a bar altercation?
Human bite!! Extensive irrigation and debridement in the OR; leave wound open; antibiotics
