Trauma 3

Question 1

Classification and management of retroperitoneal hematomas?

Answer 1

Zone 1 – central hematoma – abdominal exploration (preoperative angiogram it’s unstable)

Zone 2 – kidney hematoma – no exploration unless hematoma expanding or patient with penetrating trauma

Zone 3 – pelvic hematoma – no expiration with a blunt trauma. Angiographic embolization and pelvic fracture reduction are appropriate. Exploration if penetrating trauma to exclude vascular injuries.

Question 2

Patient presents after a head injury in MVA. Evaluation?

Answer 2

1. ABC’s
2. Rapid neurologic exam (pupillary, cranial nerves, peripheral motor/sensory function)
3. Assess consciousness – Glasgow coma scale
4. Examine head for depressed skull fracture or scalp laceration
5. Determine state of consciousness during accident

Question 3

Signs that suggest a basal skull fracture?

Answer 3

#Loss of consciousness
#sinus fractures
#local hematoma
#Blood from ear, (raccoon) eyes, mastoid bone (Brattle's sign)

Question 4

Patient presents after trauma. Change that warrants CT scan? Normal CT scan of head and the kids?

Answer 4

Any neurologic change

Normal CT virtually eliminates possibility of serious head injury and patient can be discharged

Question 5

Danger of severe head injury?

Temporary, immediate Maneuvers to mitigate this?

Answer 5

Edema of the brain, increasing ICP and decreasing cerebral perfusion

#Elevation of head to 30°
#Hyperventilation 26-28 PCO2 (Stop hyperventilation after CT scan and neurologic evaluation)
#Manitol to dehydrate brain

Question 6

Use of hyperventilation in brain injury?

Answer 6

Useful immediately after injury and for patients with signs of impending brain herniation

Routine hyperventilation they worsen neurologic outcome

Question 7

Signs of impending brain herniation?

Answer 7

Blown pupil or lateralizing

Question 8

Management of patient with Glasgow coma scale less than 8?

Answer 8

#Intubation
#Maneuvers to minimize cerebral edema (elevate head, limits, hyper)
#CT scan and if necessary, evacuation

Question 9

Patient posttrauma with Glasgow coma scale of 10 and dilated right pupil that sluggishly reacts to light – Suspected diagnosis? Management?

Answer 9

Space occupying lesion (epidural hematoma, Temporel lobe intracerebral hematoma)

Emergency evacuation

Question 10

Patient post, develops sodium level of 125 – suspected diagnosis? Could lead to? Management? Overcorrection may lead to? To avoid this?

Answer 10

SIADH from brain injury

cerebral edema

water restriction or hypertonic saline

Central Pontine Myelinosis; correct half of Na deficit over 24 hours

Question 11

Patient post trauma presents with sodium level of 160 – suspected diagnosis? Mechanism? Treatment?

Answer 11

Diabetes insipidus; failure of release of ADH

subcutaneous vasopressin and free water

Question 12

Importance of postoperative body temperature? Temperature can affect what lab values?

Answer 12

Hypothermia is a predictor of poor outcome (leads to coagulopathy from platelet dysfunction and prolongation of PT and PTT)

Question 13

When to transfuse platelets in postoperative patient with continuing hemorrhage?

Answer 13

Keep platelet count above 60,000

Question 14

Effect of multiple injuries on fluid management?

Answer 14

Increased injuries = increased inflammation = more fluid loss into third space

Need greater fluid replacement

Question 15

High PCWP indicates?

Low PCWP?

Answer 15

Pulmonary edema fluid overload caused by left heart failure or overhydration

Hypovolemia and decreased preload