Trauma Flashcards
5 W’s causing fever
- Wind (atelectasis)
- Water (UTI)
- Wound (infection)
- Walking (DVT)
- Wonder-drugs (meds)
How treat cardiac tamponade?
Drain with needle immediately: insert needle at tip of xiphoid process, aiming toward left shoulder.
* know blood is pericardial if does NOT clot
Major causes of hemodynamic instability & shock (4)
- Hemorrhagic (massive blood loss = > 10%, or at least 1 L)
- Cardiogenic (ie: cardiac tamponade)
- Neurogenic
- Septic
Most likely locations of massive blood loss in trauma patient
- scalp
- chest
- abdomen
- pelvis
- extremities (esp. from long bones)
Indications for “Damage control laparotomy” and empiric transfusion of FFP & platelets
“Bloody vicious cycle” (or PostInjury Coagulopathy) = triad of signs:
coagulopathy (INR or PTT >50% normal), core hypothermia (<7.2)
Order of initial assessment of trauma patient (5 steps)
- primary survey & 2. concurrent resuscitation
- secondary survey (take history)
- diagnostic evaluation
- definitive care
What to look for when checking “ABCs”
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
Be wary of impending airway obstruction in trauma patients, even if able to talk, IF:
(elective intubation indicated right away)
- penetrating injuries to neck => expanding hematoma;
- chemical or thermal injury to mouth/nares/hypopharynx;
- extensive subcutaneous air in the neck;
- complex maxillofacial trauma;
- airway bleeding
Indications for Endotracheal intubation
- apnea or inability to sufficiently oxygenate;
- inability to protect the airway bc altered mental status; 3. impending airway compromise bc inhalation injury;
- hematoma, facial bleeding, or soft tissue swelling;
- aspiration
Options for Endotracheal intubation:
- Nasotracheal *must be breathing spontaneously
- Orotracheal (most common)
- need neuromuscular blockage if conscious
- Surgical route (cricothyroidotomy) *not if <8 yrs old
Signs of tension pneumothorax
- hypotension, 2. respiratory distress,
- a) tracheal deviation AWAY from affected side,
b) decreased/no breath sounds on affected side
c) subcut. emphysema on affected side
regular vs. tension pneumothorax vs. open
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
treatment for tension pneumothorax
tube thoracostomy along midaxillary line at 4th or 5th intercostal space. *above the rib (bc neurovascular bundle = below)
treatment for open pneumothorax
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)
Flail chest (defns, Sxs/signs)
= fracture of 3+ contiguous ribs in 2+ locations
Sxs: hypoventilation, hypoxemia.
*Initial CXR usually underestimtes damage, see contusion in later CXR
Minimal systolic BP for palpable pulses
Carotid: 60 mmHg
Femoral: 70 mmHg
Radial: 80 mmHg
1st steps in restoring adequate circulatory volume
- place TWO peripheral catheters (short w/ large diameter – 16 gauge)
- manual compression of open wounds
Location of the saphenous vein
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
“FAST” exam
“Focused Abdominal Sonography for Trauma”
- Morison’s pouch (btwn R kidney & Liver)
- LUQ of abdomen (btwn L kidney & spleen)
- Pelvis
(4. pericardium (xiphoid process))
Causes of massive hemothorax from trauma types
blunt trauma –> severed intercostal aa from rib fractures
penetrating trauma –> systemic or pulmonary hilar vessel injury
Treatment for massive hemothorax
(“massive” = > 1500 mL or 1/3 of blood volume)
tube thoracostomy emergently to quantify, then surgery
Beck’s triad
= signs of cardiac tamponade
- dilated neck veins (JVD)
- muffled heart sounds
- decreased arterial pressure
Dx & Tx for cardiac tamponade
Dx: pericardial ultrasound
Tx: Pericardiocentesis (drain via needle)
Glascow coma scale… ranges:
(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
Steps for fluid resuscitation of patient in shock
if persistent hypotension
- 2 L IV isotonic crystalloid (ie: Ringer’s lactate)
- try again (total of 2x for adults or 3x for kids)
- give RBCs
Adequate urine output in adults, kids, infants
sufficient volume levels IF
0.5 mL/kg/hr in adults
1.0 mL/kg/hr in kids
2 mL/kg/hr in infants
Hemorrhagic vs. Cardiogenic shock
Hemorrhagic: flat neck vv, CVP 15
DDx for cardiogenic shock
- tension pneumothorax (most common)
- pericardial tamponade
- blunt cardiac injury
- myocardial infarction
- bronchovenous air embolism
Typical presentation & Tx for bronchovenous air embolism
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
“AMPLE” history
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
Contraindications to immediate foley catheterization
a) blood at meatus, b) perineal/scrotal hematomas,
c) high-riding prostate
…in these cases, wait until after urologic examination
(bc likely bladder rupture!)
“The Big Three” tests to order for blunt trauma cases
- Lateral cervical spine xray
- CXR (chest)
- pelvic xray
organs most likely injured by blunt trauma
Liver, spleen, kidneys (solid organs, lack elastic give)
organs most likely injured by penetrating trauma
Small bowel, liver, colon (largest ventral surface area)
Signs of basilar skull fracture (4)
Otorrhea, rhinorrhea, raccoon eyes, and Battle’s sign (ecchymosis behind the ear)
* => slightly increased risk of meningitis
Signs/Sxs of larynx fracture
hoarse voice, subcutaneous emphysema, palpable fracture, air tracking around fracture visible on CT
imaging options for possible C-spine injuries
a) CT
b) 5 plain films: Lat w/ C7-T1, AP, transoral odontoid, & bilateral oblique views.
Partial spinal cord injury syndromes
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
Indications for immediate operation on Cervical spine injury
Absolute: hemodynamic instability/significant external hemorrhage
Relative: precise Dx for Zone I or III injuries, symptomatic penetrating injuries or transcervical GSW to zone II
“Zones” for cervical injuries
I: btwn clavicles & cricoid cartilage
II: btwn cricoid cartilage & angle of mandible
III: above angle of mandible
most common location of torn aorta (from high-impact trauma)
95% of cases (survive to ED): just distal to L subclavian a.
Others: ascending arch, transverse arch, or @ diaphragm
Signs of thoracic descending aorta tear:
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
Indications for Exploratory/diagnostic laparotomy
a) any GSW to abdomen, EXCEPT if isolated to liver;
b) stab wound to abdomen if penetrates fascia
Signs of bowel injury from trauma
- Thickened bowel wall
- Streaking of mesentery
- free fluid w/o solid organ injury
- free intraperitoneal air
Indications for surgery in case of peripheral arterial injuries
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)
Indications for giving specific blood products
4 components
- packed RBCs: Hb <100 mg/dL
Factors that increase risk of (early) venous thromboembolism
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
Location of incision for midline neck exploration
“Collar incision” = two finger breadths above the sternal notch; *can vary depending on injury
Location of incision for Anterolateral thoracotomy
with patient supine, incision along inframammary line in 5th intercostal space
*if need access to L subclavian: median sternotomy or 4th interspace incision
Presentation of epidural hematoma
Initial loss of consciousness, Lucid interval, LOC again w/ ipsilat. fixed dilated pupil, then cardiac arrest.
Calculating Cerebral perfusion pressure (CPP)
CPP = MAP - ICP (MAP = mean arterial pressure, ICP = intracranial P)
Immediate post-injury care for head trauma
- Maintain cerebral perfusion (by lower ICP or increase BP)
- maintain PCO2
*may temporarily hyperventilate => cerebral vasoconstriction - prophylactic anticonvulsant meds
+/- moderate hypothermia
Indications for emergent operation on C-spine injuries
Neurologic deterioration and/or INcomplete deficit (quadri/tetra-plegia)
Indication for angiography in case of hepatic hemorrhage
Hemodynamically stable, but requiring
a) 4 units of RBCs in 6 hrs or
b) 6 units of RBCs in 24 hrs
Pringle maneuver
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)
Risk of splenic re-bleed
Risk delayed hemorrhage/rupture for 2 weeks after initial trauma
Common fracture & vessel injury combos
- 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
causes of compartment syndrome
- arterial hemorrhage into a compartment,
- venous ligation or thrombosis,
- crush injuries,
- ischemia and reperfusion
When is Fasciotomy indicated (to prevent/Tx compartment syndrome)?
a) Diastolic BP - compartment P < 35 mmHg
b) ischemic period(s) for >6 hrs
c) combined aa & vv injuries
Criteria for successful resuscitation before “semi-elective” procedures (after damage-control operation):
- core temp >35 C
- base deficit <6 mmol/L
- normal coag levels (INR, PTT)
Trick to identifying secondary abdominal compartment syndrome
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
Symptoms of abdominal compartment syndrome
(= intra-abdominal hypertension)
- decreased urine output
- increased pulmonary inspiratory pressures
- decreased cardiac preload & increased cardiac afterload
Considerations for pregnant women in trauma cases
normal vs. abnormal stats/lab values
- 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
procedures to be wary of in pregnant women w/ trauma
chest tube & diagnostic peritoneal lavage
bc want to go around gravid uterus
Can you put pregnant trauma patient through radiation? what is the safe limit of exposure?
YES if necessary. “Safe” is <1 rad; and abdominal CT = 3.5 rad)
Most common causes of pediatric trauma cases by age
infant (< 1 yr): falls
Child: bike riding
Adolescent: motor vehicle accidents
Differences between adult and pediatric airway anatomy
the airway in kids is…
- more cephalad (acute angle, less curved)
- smaller size
- funnels-shaped larynx (vs. cylindrical in adults)
Noteworthy differences in overall physiology btwn kids and adults (to be wary of w/ trauma)
- bones more pliable (=> organ damage w/o bone fractures)
- higher oxygen need (2x adult)
- lack outward signs of hypovolemia (up to 25% blood loss)
