Trauma Flashcards
When do you need to secure an airway?
Expanding hematoma or emphysema in neck Unconscious pt Breathing is noisy or gurgly Severe inhalation injury Respirator needed. Pts with cervical spine injuries need an airway before dealing with the spine.
How to tell if airway is present?
Pt conscious and speaking with normal tone.
Methods of airway creation.
Orotracheal intubation using laryngoscope.
Nasotracheal intubation over fiber optic bronchoscope.
When must you use fiberoptic bronchoscope?
When securing airway in pt with subcutaneous emphysema in neck.
What is subcutaneous emphysema in the neck a sign of?
Major traumatic disruption of tracheobronchial tree.
When to do cricothyroidotomy?
Laryngospasm, severe maxillofacial injury, impacted foreign body.
If under 12 years, will need laryngeal reconstruction so it is last resort.
Signs of shock.
Low BP (under 90), feeble pulse, low urinary output (under 0.5 mL/kg/hr). Pt is cold, pale, shivering, sweating, thirsty, apprehensive.
Causes of shock in trauma.
Bleeding: CVP is low
Pericardial tamponade: from blunt or penetrating trauma, CVP is high with distended head and neck veins, no respiratory distress.
Tension pneumothorax: from blunt or penetrating trauma, CVP is high with distended head and neck veins, severe respiratory distress, one side hyperresonant with no breath sounds, tracheal deviation and displaced mediastinum.
Tx of hemorrhagic shock.
In trauma center: start with surgery if needed to stop bleeding, then do volume replacement.
Other setting: volume replace,net with 2L ringer lactate then PRBCs until urinary output is 0.5-2 mL/kg/hr. CVP no higher than 15.
Route of fluid resuscitation.
2 16 gauge peripheral IV lines.
Alternates: per cutaneous femoral vein catheter, saphenous vein cut downs.
If under 6yr, can do IO of proximal tibia.
Tx of pericardial tamponade.
Dx clinically, US if needed.
Tx: pericardiocentesis, tube, pericardial window, open thoracotomy.
Give blood and fluids.
Tx of tension pneumothorax.
Dx clinical.
Tx: big needle or big IV catheter into pleural space, connect chest tube to underwater seal (high in anterior chest wall).
Hypovolemic shock.
Cause: bleeding, burns, peritonitis, pancreatitis, diarrhea.
Key finding: low CVP.
Tx: stop bleeding, blood volume replacement.
Intrinsic cardiogenic shock.
Cause: massive MI, fulminating myocarditis.
Key finding: high CVP (distended veins).
Tx: circulatory support.
Vasomotor shock.
Cause: anaphylactic rxn, high spinal cord transection, high spinal anesthesia.
Findings: flushed, pink, warm pt, low CVP.
Tx: vasopressors, fluids.
Tx of penetrating head trauma.
Surgery.
Tx of linear skull fractures.
Closed fracture: leave alone.
Open fracture: wound closure.
Comminuted or depressed: fix in OR.
When to get a CT in head trauma.
If pt lost consciousness.
Looking for intracranial hemorrhage.
If negative, send home and wake up frequently over 24 hrs.
Signs of basal skull fracture.
Raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind ear.
Need to assess integrity of spine via CT.
Avoid nasal endotrachial intubation.
Neurologic damage from trauma.
Cause: initial blow, hematoma displacing midline structures, increased ICP.
Tx: surgery for hematoma, medically relieve ICP.
Acute epidural hematoma.
Cause: modest trauma to side of head.
Sequence: trauma, unconscious, lucid interval, lapse into coma, fixed dilated pupils, contra lateral hemiparesis with decerebrate posture.
Dx: CT shows bi convex, lens shaped hematoma.
Tx: emergency craniotomy.
Acute subdural hematoma.
Cause: Bigger trauma to head.
Sequence: big trauma, unconscious, sick and doesn’t regain full consciousness, severe neurological damage, lapse into coma, fixed dilated pupils, contralateral hemiparesis with decerebrate posture.
Dx: CT shows semilunar crescent-shaped hematoma.
Tx: with midline deviation = craniotomy, bad prognosis.
Without deviation = monitor ICP, elevate head, hyperventilate, avoid fluid overload, give mannitol or furosemide. Goal PCO2 35. Potential hypothermia to reduce O2 demand.
Diffuse axonal injury.
Cause: severe trauma.
Dx: CT showing diffuse blurring of gray-white matter interface, multiple small punctuate hemorrhages.
Tx: monitor ICP.
Chronic subdural hematoma.
In very old and severe alcoholics.
Cause: tearing of venous sinuses from rattling of shrunken brain.
Sequence: mental deterioration over days to weeks.
Dx: CT
Tx: surgery
Tx if penetrating neck trauma.
Surgical exploration when have expanding hematoma, deteriorating vitals, esophageal or tracheal injury (coughin/spitting up blood).
Pt of gunshot to neck.
Upper zone: dx and tx by arteriograph.
Base: perform arteriograph, esophogram, and bronchoscopy before surgery.
Tx of stab wounds to neck.
If asymptomatic and in upper or middle, observe.
Severe blunt trauma to neck.
Assess cervical spine.
If there are neuro deficits or pain to local palpation of cervical spine, get CT.
Transection of spinal cord.
Nothing works below transection.
Brown-Sequard Syndrome
Hemisection of spinal cord. Cause: knife injury. Features: ipsilateral paralysis and loss of proprioception, contralateral loss of pain distal to lesion. Dx: MRI Tx: potential high dose corticosteroids
Anterior cord syndrome
Cause: burst fractures of vertebral bodies.
Features: loss of motor/pain/temp distal to lesion. Vibratory and positional sensation preserved.
Dx: MRI
Tx: potential high dose corticosteroids.
Central cord syndrome
In elderly.
Cause: forced hyperextension or neck (rear-end collision).
Features: paralysis and burning pain in upper extremities, preserved function of lower extremities.
Dx: MRI
Tx: potential high dose corticosteroids
Rib fracture in elderly.
Can cause: pain ➡️ hypoventilation ➡️ atelectasis ➡️ pneumonia
Tx: local nerve block, epidural catheter.
Pneumothorax
Cause: penetrating trauma.
Features: mod SOB, no breath sounds and hyperresonant on one side.
Dx: chest x-ray
Tx: chest tube (upper, anterior) with underwater seal.
