Trauma Flashcards
What are 5 traumatic injuries missed on CT Abdo/Pelvis?
- Holoviscous/ bowel injury
- Pancreatic injuries
- Bladder injuries (need retrograde urethrogram)
- Diaphramatic injuries (need diagnostic laparoscopy)
- Mesenteric injuries - small vessel may not reveal bleeding
What is considered high velocity vs low velocity GSW?
High velocity: military and hunting weapons (>2000 ft/s)
- direct pathway/predictable
Low velocity: smaller caliber hand guns and airguns. speed ~300 ft/sec for 0.22 caliber pistols.
- erratic pathway can bounce around.
What are the triangles of the neck?
Anterior (high risk neurovascular and GI injuries)
- Midline, Ant. border SCM, angle of mandible superiorly.
Posterior (more favorable prognosis)
- Post edge SCM, Clavicle and Trapezius m.
What are the zones of the neck?
Zone I: sternal notch and clavicles (thoracic outlet) to cricoid cartilage
Zone II: Cricoid cartilage to angle of mandible
Zone III: Angle of mandible to base of skull
What structures lie in Zone I?
Vascular
- Proximal carotid a.
- Vertebral a.
- Subclavian a.
- Major vessels of upper mediastinum (SVC, arch of aorta, pulmonary a.)
Airway
- Lung apicies
- Trachea
- Thoracic duct
GI
- Esophagus
- thyroid
Neurologic
- Spinal cord
What are the structures in zone II?
Vascular
- Common carotid a.
- Vertebral a.
- Jugular vein
Airway
- Larynx
- Trachea
GI
- Pharynx
- Esophagus
Neurologic
- Vagus n.
- Recurrent laryngeal n.
- Spinal cord
What is in zone III?
Vascular
- Distal carotid a.
- Vertebral a.
- Distal jugular vein
GI
- Salivary and parotid glands
Neurologic
- Cranial n. 9-12
- Spinal cord
What are 8 soft signs of penetrating neck trauma?
Pursue investigations
Soft (8): Think complications that deal with blood, air, nerves.
- Hemoptysis, hematemesis
- Oropharyngeal blood
- Non-expanding hematoma
- Dyspnea
- Dysphonia, dysphagia
- SQ or mediastinal air
- Chest tube leak
- focal neurologic deficits
What are 7 Hards signs of penetrating neck trauma?
needs emergent surgical intervention
Hard (7): Think airway, vascular and bleeding. Go from head down to be systematic
- Airway obstruction
- Cerebral ischemia (stroke)
- Thrill or bruit
- Decr. radial pulse
- Pulsatile bleeding
- Expanding hematoma
- Shock refractory to fluids.
With penetrating neck trauma what are a few ways to theoretically avoid an air embolism?
- Cautious BVM - can introduce air into disrupted vessels
- Trandeleburg
- Immediately occlude bubbling wound.
What do you immediately do when suspecting a venous air embolism?
(senerio: patient has profound shock unresponsive to fluids or cardiopulmonary arrest unresponsive to ED thoracotomy)
- Head down - trandelenberg
- Left lateral decubitus
- cause intra-cardiac air to accumulate to apex of right ventricle
If above doesnt work…
- Attempt to aspirate air embolism from apex of right ventricle AFTER the aorta has been cross clamped..
What are contra-indications for Nasotracheal intubation? (3)
- Basilar skull # (risk of penetrating into brain)
- Midface #
- Laryngeal injury
In the neck trauma patient, what is a major concern with respect to: BVM, Endotracheal intubation and a surgical airway?
BVM: can worsen SQ emphysema and cause an air embolism
Intubation: can transform a partial LT tear into a complete one
Surgical
- Anatomy distorted
- Can potentially disrupt a cervical hematoma that has tamponaded and result in exsanguination.
Which area of the esophagus is more prone to injury in neck trauma?
The cervical portion
Esophageal injuries are very difficult to diagnose. Physical exam is unreliable, which 2 Ix are indicated?
- Barium swallow
- Endoscopy
- Not good enough on its own, misses proximal injuries.
CT is not sensitive enough to dx esophageal injuries. But can show trajectory of penetrating object…
What is the most serious laryngeal injury?
Criocoid cartilage fracture because it can result in complete airway obstruction.
- The criocoid is the only complete ring in the larynx.
What are 10 signs of Larygnotracheal injury (LT)?
- Air leaking through a neck wound (bubbling)
- Only hard sign. - Subcutaneous emphysema
- Dyspnea
- Hemoptysis
- Dysphonia, Aphonia
- Stridor
- Cough
- Larygneal Crepitus
- Tender over larynx
- Large Neck wound
Pain with tongue movement suggests injury to what 3 potential areas?
- Largyneal cartilage
- Epiglottis
- Hyoid bone
Patient with neck trauma has horner’s syndrome. What injury do they have?
Carotid a. dissection.
In context of trauma we accept permissive hypotension. Why is 80 mmHg a common target?
Dont want to go over 80 mmHg SBP because arteries with complete transection tend to spasm and stop bleeding with pressures below 80mmHg.
- Also, higher pressures can dislodge a clot from vasculature and result in further exsangunation.
What pressure is indicative of immediate fasciotomy in compartment syndrome?
Pressures >30 mmHg indicates immediate fasciotomy.
- At this pressure, capillary flow is compromised.
- The patient can still have a strong pulse at this point but will have microvascular ischemia.
what are the indications for an EDT (ED thoracotomy)?
- Penetrating trauma + cardiac arrest
- better prognosis if narrow complex PEA - Blunt trauma with vital signs in the field.
- Nontraumatic hypothermic cardiac arrest
What are 4 contraindications for an EDT?
- Blunt trauma arrest patients without vital signs in the field (there is no chance of survival)
- Trauma patients with open cranial wounds
- Initial rhythm of asystole
- CPR ongoing >15 minutes
What is the survival rate of patients undergoing EDT for blunt trauma?
about 2%
What is the survival rate of patients undergoing EDT for penetrating trauma?
~16%
But this depends on the situation also.
What 5 factors need to be considered when determining the benefit of an EDT?
- Mechanism of injury (penetrating better)
- Location (thorax > abdomen)
- Initial cardiac rhythm (narrow complex PEA)
- Resuscitation time
- Signs of life (objective physiologic parameters)
- Pupillary response
- Extremity movement
- cardiac electrical activity
- Pulse
What are 5 indications for CTA in H+ N blunt trauma?
- Arterial hemorrhage from H+ N
- Cervical hematoma
- Focal or lateralizing neurologic deficit
- Evidence of infarct on imaging.
- Mechanism
a. Displaced midface (leForte II, III)
b. Complex mandibular #
c. Closed HI with DAI - Near hanging resulting in anoxic brain injury
- Unexplained neurodeficts.
- Physical signs
a. Seatbelt neck abrasion of other neck - Basil skull # in proximity to ICA or VA
a. Vertebral artery
b. ICA - carotid canal - Any C-spine fracture.
Protocol in Calgary is that CTA be done in the first 24 hours. Communicate to admitting service..
What is the difference between judicial (complete) and non-judicial (incomplete) hanging?
- Judicial/complete: Full body suspended. Death by high cervical fracture, complete cord transaction.
- Non-judicial/incomplete: part of body is still touching ground
- Rope around neck causes venous congestion and LOC. Once pt limp, ligature can tighten more causing complete arterial occlusion –> brain death
- Death by vascular occlusion
What is the difference between typical and atypical hanging?
- Typical: Knot is in midline occiput. Death from arterial occlusion more likely.
- Atypical: Knot anywhere else.
List 6 complications of near hanging (incomplete/non-judicial) and strangulation?
- Pulmonary edema
- Neurogenic (poor prognosis)
- Post obstructive - Bronchopneumonia
- ARDS
- Vascular damage
- Laryngeal injuries
- Thyroid cartilage fractures
What are the 6 anatomical spaces of the deep neck fascia?
- Viceral (also pretracheal) fascia
- connects to mediastinum - Anterior cervical space
- Carotid Space
- Retropharygneal space
- connects to posterior mediastinum
Danger space: between retropharyngeal space to perivertebral space
- connects to diaphragm - Posterior cervical space
- Perivertebral space
- posterior aspect connects to coccyx
How long does it take to heal rib #’s
3-6 weeks
What other injuries are associated with left and right sided rib #’s
Left: hepatic lac
Right: splenic lac
Both: hemo/pneumothorax, intercostal artery injury.
With central chest blunt trauma, why do adults typically have less severe injury than children?
Sternum will absorb force where in children the force is not dissipated and transferred to mediastinal structures
What is the incidence of myocardial contusion with sternal #?
1.5-6%
- there is NO assoc with aortic rupture or related injuries.
BUT if there is a mediastinal hematoma, pay attention - potentially lethal – can exsanguinate.
How much fluid is required to blunt the costophrenic angles of a CXR?
200-300mL
What are the landmarks for a chest tube insertion?
Triangle of safety
- Lateral border of latissimus dorsi
- Border pect muscle
- Nipple line
OR
4th or 5th intercostal space, anterior axillary line.
- in men: nipple
- in women: inframammary fold.
What are the landmarks for an anterior chest tube?
2nd intercostal space, midclavicular line.
What are 9 CXR findings of aortic injury?
1. widened mediastinum greater than 8cm supine AP film greater than 6 cm erect PA Sn 50-90% sp 10% 2. Loss of AP window 3. Left apical pleural cap 4. L sided hemothorax 5. Double calcium sign (ring sign) 6. Widened paratracheal stripe 7. Depression of Left mainstem bronchus below 40 degrees from horizontal 8. Deviation of trachea to the right 9. Deviation of NG tube to the right. 10. Multiple rib #
In blunt aortic trauma, where is the most common location of rupture of the aorta?
The isthmus of the aorta, just distal to the left subclavian.
It is tethered by the ligamentum arteriosum and the intercostal arteries.
This is because the descending aorta is fixed and proximal part more mobile so sudden deceleration can cause a tear at that location.
