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General Surgery > Trauma > Flashcards

Trauma Flashcards

1
Q

5 W’s causing fever

A
  1. Wind (atelectasis)
  2. Water (UTI)
  3. Wound (infection)
  4. Walking (DVT)
  5. Wonder-drugs (meds)
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2
Q

How treat cardiac tamponade?

A

Drain with needle immediately: insert needle at tip of xiphoid process, aiming toward left shoulder.
* know blood is pericardial if does NOT clot

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3
Q

Major causes of hemodynamic instability & shock (4)

A
  1. Hemorrhagic (massive blood loss = > 10%, or at least 1 L)
  2. Cardiogenic (ie: cardiac tamponade)
  3. Neurogenic
  4. Septic
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4
Q

Most likely locations of massive blood loss in trauma patient

A
  1. scalp
  2. chest
  3. abdomen
  4. pelvis
  5. extremities (esp. from long bones)
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5
Q

Indications for “Damage control laparotomy” and empiric transfusion of FFP & platelets

A

“Bloody vicious cycle” (or PostInjury Coagulopathy) = triad of signs:
coagulopathy (INR or PTT >50% normal), core hypothermia (<7.2)

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6
Q

Order of initial assessment of trauma patient (5 steps)

A
  1. primary survey & 2. concurrent resuscitation
  2. secondary survey (take history)
  3. diagnostic evaluation
  4. definitive care
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7
Q

What to look for when checking “ABCs”

A

A: airways obstruction or injury
B: Tension/open pneumothorax, flail chest + contusion
C (Circulation): massive hemothorax or hemoperitoneum, unstable pelvic fracture, cardiac tamponade.
(also: shock, C-spine injury, limb loss)
D (disability): intracranial hemorrhage/mass lesion

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8
Q

Be wary of impending airway obstruction in trauma patients, even if able to talk, IF:
(elective intubation indicated right away)

A
  1. penetrating injuries to neck => expanding hematoma;
  2. chemical or thermal injury to mouth/nares/hypopharynx;
  3. extensive subcutaneous air in the neck;
  4. complex maxillofacial trauma;
  5. airway bleeding
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9
Q

Indications for Endotracheal intubation

A
  1. apnea or inability to sufficiently oxygenate;
  2. inability to protect the airway bc altered mental status; 3. impending airway compromise bc inhalation injury;
  3. hematoma, facial bleeding, or soft tissue swelling;
  4. aspiration
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10
Q

Options for Endotracheal intubation:

A
  1. Nasotracheal *must be breathing spontaneously
  2. Orotracheal (most common)
    • need neuromuscular blockage if conscious
  3. Surgical route (cricothyroidotomy) *not if <8 yrs old
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11
Q

Signs of tension pneumothorax

A
  1. hypotension, 2. respiratory distress,
  2. a) tracheal deviation AWAY from affected side,
    b) decreased/no breath sounds on affected side
    c) subcut. emphysema on affected side
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12
Q

regular vs. tension pneumothorax vs. open

A

Regular & Tension: both bc hole in lung –> air to pleural space; all same signs/Sxs except = tension if hypotension.
Open pneumo = hole through chest wall

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13
Q

treatment for tension pneumothorax

A

tube thoracostomy along midaxillary line at 4th or 5th intercostal space. *above the rib (bc neurovascular bundle = below)

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14
Q

treatment for open pneumothorax

A

Emergently: gauze over defect, taped on 3 sides (lets air out => prevent conversion to tension pneumo)
Definitively: surgical closure of wound w/ chest tube (not at wound site)

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15
Q

Flail chest (defns, Sxs/signs)

A

= fracture of 3+ contiguous ribs in 2+ locations
Sxs: hypoventilation, hypoxemia.
*Initial CXR usually underestimtes damage, see contusion in later CXR

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16
Q

Minimal systolic BP for palpable pulses

A

Carotid: 60 mmHg
Femoral: 70 mmHg
Radial: 80 mmHg

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17
Q

1st steps in restoring adequate circulatory volume

A
  1. place TWO peripheral catheters (short w/ large diameter – 16 gauge)
  2. manual compression of open wounds
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18
Q

Location of the saphenous vein

A

1 cm anterior and 1 cm superior to the medial malleolus
(use for venous catheter if groin or ankle doesn’t work)
OR intraosseous needle if child >6 yo

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19
Q

“FAST” exam

A

“Focused Abdominal Sonography for Trauma”

  1. Morison’s pouch (btwn R kidney & Liver)
  2. LUQ of abdomen (btwn L kidney & spleen)
  3. Pelvis
    (4. pericardium (xiphoid process))
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20
Q

Causes of massive hemothorax from trauma types

A

blunt trauma –> severed intercostal aa from rib fractures

penetrating trauma –> systemic or pulmonary hilar vessel injury

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21
Q

Treatment for massive hemothorax

A

(“massive” = > 1500 mL or 1/3 of blood volume)

tube thoracostomy emergently to quantify, then surgery

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22
Q

Beck’s triad

A

= signs of cardiac tamponade

  1. dilated neck veins (JVD)
  2. muffled heart sounds
  3. decreased arterial pressure
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23
Q

Dx & Tx for cardiac tamponade

A

Dx: pericardial ultrasound
Tx: Pericardiocentesis (drain via needle)

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24
Q

Glascow coma scale… ranges:

A 
(assessment of level of consciousness, assoc. w/ degree of injury to brain)
3-8 = severe injury
9-12 = moderate injury
13-15 = mild injury
* CT scan indicated for any GCS <14
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25
Q

Steps for fluid resuscitation of patient in shock

if persistent hypotension

A
  1. 2 L IV isotonic crystalloid (ie: Ringer’s lactate)
  2. try again (total of 2x for adults or 3x for kids)
  3. give RBCs
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26
Q

Adequate urine output in adults, kids, infants

A

sufficient volume levels IF
0.5 mL/kg/hr in adults
1.0 mL/kg/hr in kids
2 mL/kg/hr in infants

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27
Q

Hemorrhagic vs. Cardiogenic shock

A

Hemorrhagic: flat neck vv, CVP 15

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28
Q

DDx for cardiogenic shock

A
  1. tension pneumothorax (most common)
  2. pericardial tamponade
  3. blunt cardiac injury
  4. myocardial infarction
  5. bronchovenous air embolism
29
Q

Typical presentation & Tx for bronchovenous air embolism

A

Presentation: hemodynamically stable until intubated, then cardiac arrest.
Tx: 1. place in Trendelenberg position
2. emergency thoracotomy
3. cross-clamp pulmonary hilum on side of injury
4. Aspirate air from LV, then Aortic root, then RCA

30
Q

“AMPLE” history

A 
For secondary survey of trauma patient, ask about
A - Allergies
M - medications
P - Past illness, pregnancy
L - Last meal (when)
E - Events related to injury
31
Q

Contraindications to immediate foley catheterization

A

a) blood at meatus, b) perineal/scrotal hematomas,
c) high-riding prostate
…in these cases, wait until after urologic examination
(bc likely bladder rupture!)

32
Q

“The Big Three” tests to order for blunt trauma cases

A
  1. Lateral cervical spine xray
  2. CXR (chest)
  3. pelvic xray
33
Q

organs most likely injured by blunt trauma

A

Liver, spleen, kidneys (solid organs, lack elastic give)

34
Q

organs most likely injured by penetrating trauma

A

Small bowel, liver, colon (largest ventral surface area)

35
Q

Signs of basilar skull fracture (4)

A

Otorrhea, rhinorrhea, raccoon eyes, and Battle’s sign (ecchymosis behind the ear)
* => slightly increased risk of meningitis

36
Q

Signs/Sxs of larynx fracture

A

hoarse voice, subcutaneous emphysema, palpable fracture, air tracking around fracture visible on CT

37
Q

imaging options for possible C-spine injuries

A

a) CT

b) 5 plain films: Lat w/ C7-T1, AP, transoral odontoid, & bilateral oblique views.

38
Q

Partial spinal cord injury syndromes

A

a) Central cord: decreased motor/pain/temp sens. in upper extremities only (usually from hyper-extension)
b) Anterior cord: decreased motor/pain/temp sens. BELOW lesion
c) Brown-sequard: from penetrating injury, = hemisection

39
Q

Indications for immediate operation on Cervical spine injury

A

Absolute: hemodynamic instability/significant external hemorrhage
Relative: precise Dx for Zone I or III injuries, symptomatic penetrating injuries or transcervical GSW to zone II

40
Q

“Zones” for cervical injuries

A

I: btwn clavicles & cricoid cartilage
II: btwn cricoid cartilage & angle of mandible
III: above angle of mandible

41
Q

most common location of torn aorta (from high-impact trauma)

A

95% of cases (survive to ED): just distal to L subclavian a.

Others: ascending arch, transverse arch, or @ diaphragm

42
Q

Signs of thoracic descending aorta tear:

A

widened mediastinum, abnormal aortic contour, Tracheal shift, NG tube shift, L apical cap, L/R paraspinal stripe thickening, depression of L main bronchus, obliteration of AorticoPulmonary window, L pulm hilar hematoma

43
Q

Indications for Exploratory/diagnostic laparotomy

A

a) any GSW to abdomen, EXCEPT if isolated to liver;

b) stab wound to abdomen if penetrates fascia

44
Q

Signs of bowel injury from trauma

A
  1. Thickened bowel wall
  2. Streaking of mesentery
  3. free fluid w/o solid organ injury
  4. free intraperitoneal air
45
Q

Indications for surgery in case of peripheral arterial injuries

A

Hard/Absolute: pulsatile hemorrhage, absent pulse, acute ischemia
Soft/Need further work-up: hematoma, nerve injury, bruit, AA-index <0.9, close proximity to major vessel(s)

46
Q

Indications for giving specific blood products

4 components

A
  1. packed RBCs: Hb <100 mg/dL
47
Q

Factors that increase risk of (early) venous thromboembolism

A

a) multiple fractures of the pelvis and lower extremities
b) coma or spinal cord injury,
c) ligation of large veins in the abdomen/legs
d) Morbidly obese patients
e) over 55 years of age

48
Q

Location of incision for midline neck exploration

A

“Collar incision” = two finger breadths above the sternal notch; *can vary depending on injury

49
Q

Location of incision for Anterolateral thoracotomy

A

with patient supine, incision along inframammary line in 5th intercostal space
*if need access to L subclavian: median sternotomy or 4th interspace incision

50
Q

Presentation of epidural hematoma

A

Initial loss of consciousness, Lucid interval, LOC again w/ ipsilat. fixed dilated pupil, then cardiac arrest.

51
Q

Calculating Cerebral perfusion pressure (CPP)

A 
CPP = MAP - ICP 
(MAP = mean arterial pressure, ICP = intracranial P)
52
Q

Immediate post-injury care for head trauma

A
  • Maintain cerebral perfusion (by lower ICP or increase BP)
  • maintain PCO2
    *may temporarily hyperventilate => cerebral vasoconstriction
  • prophylactic anticonvulsant meds
    +/- moderate hypothermia
53
Q

Indications for emergent operation on C-spine injuries

A

Neurologic deterioration and/or INcomplete deficit (quadri/tetra-plegia)

54
Q

Indication for angiography in case of hepatic hemorrhage

A

Hemodynamically stable, but requiring

a) 4 units of RBCs in 6 hrs or
b) 6 units of RBCs in 24 hrs

55
Q

Pringle maneuver

A

clamping (with device or manually) of portal triad.
If hemorrhage continues, = from hepatic vv or retrohepatic vena cava
(If stops, = from hepatic a. or portal v)

56
Q

Risk of splenic re-bleed

A

Risk delayed hemorrhage/rupture for 2 weeks after initial trauma

57
Q

Common fracture & vessel injury combos

A
  • clavicle/first rib fracture + subclavian a. injury
  • dislocated shoulder/proximal humerus + axillary a.
  • supracondylar fractures/elbow dislocations + brachial a.
  • femur fracture + superficial femoral a.
  • knee dislocation + popliteal vessel injury
58
Q

causes of compartment syndrome

A
  1. arterial hemorrhage into a compartment,
  2. venous ligation or thrombosis,
  3. crush injuries,
  4. ischemia and reperfusion
59
Q

When is Fasciotomy indicated (to prevent/Tx compartment syndrome)?

A

a) Diastolic BP - compartment P < 35 mmHg
b) ischemic period(s) for >6 hrs
c) combined aa & vv injuries

60
Q

Criteria for successful resuscitation before “semi-elective” procedures (after damage-control operation):

A
  1. core temp >35 C
  2. base deficit <6 mmol/L
  3. normal coag levels (INR, PTT)
61
Q

Trick to identifying secondary abdominal compartment syndrome

A

measure intra-peritoneal pressure indirectly via bladder pressure (in mm H2O, using 3-way foley)
BUT unreliable IF:
bladder rupture, extra P from pelvic packing, neurogenic bladder or abdominal adhesions

62
Q

Symptoms of abdominal compartment syndrome

A

(= intra-abdominal hypertension)

  • decreased urine output
  • increased pulmonary inspiratory pressures
  • decreased cardiac preload & increased cardiac afterload
63
Q

Considerations for pregnant women in trauma cases

normal vs. abnormal stats/lab values

A
  • increased HR & decreased BP during pregnancy
  • relative hypervolemia and anemia
  • decreased FRC => slight resp. alkalosis
  • more rapid de-saturation (of oxygen)
  • increased risk aspiration
  • alk phos = 2 x normal
  • relative hypercoagulable state
64
Q

procedures to be wary of in pregnant women w/ trauma

A

chest tube & diagnostic peritoneal lavage

bc want to go around gravid uterus

65
Q

Can you put pregnant trauma patient through radiation? what is the safe limit of exposure?

A

YES if necessary. “Safe” is <1 rad; and abdominal CT = 3.5 rad)

66
Q

Most common causes of pediatric trauma cases by age

A

infant (< 1 yr): falls
Child: bike riding
Adolescent: motor vehicle accidents

67
Q

Differences between adult and pediatric airway anatomy

A

the airway in kids is…

  1. more cephalad (acute angle, less curved)
  2. smaller size
  3. funnels-shaped larynx (vs. cylindrical in adults)
68
Q

Noteworthy differences in overall physiology btwn kids and adults (to be wary of w/ trauma)

A
  • bones more pliable (=> organ damage w/o bone fractures)
  • higher oxygen need (2x adult)
  • lack outward signs of hypovolemia (up to 25% blood loss)

General Surgery (4 decks)

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