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.
Hemothorax
Cause: penetrating trauma. Bleeding usually from lung, sometimes from intercostal arteries.
Dx: chest x-ray
Tx: chest tube (low), surgery (thoracotomy) to stop bleeding if not from lung.
Need surgery if recover >1500mL blood from chest tube insertion of >600mL over next 6hrs.
Monitoring for hidden injuries after severe blunt trauma to chest.
Get blood gases, chest x-ray, cardiac enzymes, EKG
Sucking chest wounds.
Flap that sucks air with inspiration and closes during expiration.
Can lead to tension pneumothorax.
Tx: occlusive dressing taped on 3 sides.
Flail chest
Cause: multiple rib fractures ➡️ wall caves with inspiration, bulges with expiration. Have pulmonary contusion.
Look out for transection of aorta.
Tx: fluid restriction, diuretics, blood gases, chest tubes if need respirator.
Pulmonary contusion
Dx: deteriorating blood gases, white out on chest x-ray.
Tx: fluid restriction, diuretics.
Myocardial contusion
Cause: trauma with sternal fracture.
Dx: EKG, troponins.
Tx: handle arrhythmias.
Traumatic rupture if diaphragm
Dx: chest X-ray with bowel in thorax on left side. Evaluate with laryngoscopy.
Tx: surgery via abdomen.
Traumatic rupture of aorta.
At junction of arch and descending aorta.
Cause: deceleration injury, suspect if have breaks in 1st rib/scapula/sternum or wide mediastinum.
Asymptomatic until hematoma in adventitia blows.
Dx: transesophageal Echo, spiral CT (CT angio if has dye)**, MRI angiography
Traumatic rupture of trachea or bronchus
Suspect with subcutaneous emphysema in upper chest and lower neck or a lot of air from chest tube.
Dx: chest X-ray with air in tissues, fiberoptic bronchoscopy.
Tx: surgery
Ddx of subcutaneous emphysema
Rupture of trachea or bronchus Rupture of esophagus (after endoscopy) Tension pneumothorax (with shock and resp distress)
Air embolism
Sudden death in chest trauma pt who is intubation and on respirator.
Also when subclavian vein opened during CVP line placement and supraclavicular node biopsies.
Tx: cardiac massage with left side down.
Prevention: Trendelenburg position when great veins entered.
Fat embolism
Features: multiple trauma pt with long bone fractures who gets petechial rashes in axilla and neck, fever, tachycardia, low plt count, respiratory distress with hypoxemia and bilateral patchy infiltrates on chest X-ray.
Dx: bone fractures, low plt count, bilateral patchy infiltrates on chest X-ray, fat droplets in urine***.
Tx: respiratory support
Gunshot to abdomen
Any gunshot below nipple line.
Tx: exploratory laparotomy to repair intraabdominal injuries.
Stab wound to abdomen
If hemodynamically unstable or viscera protruding = exploratory laparotomy
Otherwise explore wound with finger, CT if needed.
Blunt trauma to abdomen
Acute abdomen = exploratory laparotomy
Otherwise look for signs of internal bleeding or injury and the severity.
Signs of internal bleeding.
Drop in BP, fast threads pulse, low CVP, low urinary output in pt who is pale, cold, anxious, thirsty, sweating.
Usually appear around 25% blood loss.
Blood loss usually in abdomen, thighs, pelvis.
Dx: check for pelvic and femur fracture.
Intraabdominal bleeding
Hemodynamically stable pt:
Dx: CT
Hemodynamically unstable pt:
Dx: DPL, FAST
Tx: Responds to fluids = no surgery
Doesn’t respond to fluids = surgery
Ruptured spleen
Most common source of intraabdominal bleeding in blunt trauma.
Pt typically has broken left lower ribs.
Tx: repair spleen, remove if necessary and immunize against pneumococcus, HiB, meningococcus.
Intraoperative coagulopathy
Tx: transfusions of platelets and FFP (10 each).
If develop hypothermia and acidosis, stop laparotomy, pack, close.
Abdominal compartment syndrome
Cause: too much administered fluid and blood causes swollen tissues and abdomen cannot be closed without undue tension.
Tx: cover abdominal contents with absorbable mesh or non-absorbable plastic, close later.
If pt was closed and this develops with sutures cutting through skin, hypoxia, renal failure from pressure on IVC, open and cover abdomen.
Pelvic hematoma
Leave alone if not expanding
Injuries associated with pelvic hematoma
Rectal Dx: rectal exam, protoscopy Bladder Vaginal Dx: pelvic exam Urethra Dx: retrograde urethrogram
Pelvic fracture with bleeding
Dx: hypovolemic shock, neg DPL or FAST, neg abdominal CT
Tx: pelvic fixators, interventional radiology for angiographic embolization of internal iliac arteries.
Hallmark or urologic injury
Hematuria after abdominal trauma.
Penetrating urologic injury
Tx: surgical exploration and repair
Blunt urologic injury
Affect kidney = look for rib fracture
Affect bladder or urethra = pelvic fracture
Urethral injury
In men with pelvic fracture, blood at meatus.
May have scrotal hematoma, wants to void but can’t, “high-riding” prostate
Dx: retrograde urethrogram
Bladder injury
Associated with pelvic fracture
Dx: retrograde cystogram, postvoid X-ray
Tx: leak at base = Foley catheter
Intraperitoneal leak = surgery with suprapubic cystostomy
Renal injury
Associated with lower rib fractures.
Dx: CT scan
Rarely causes AV fistula at renal pedicle ➡️ CHF.
If get renal artery stenosis may ➡️ renovacular HTN.
Scrotal hematoma
No intervention unless testicle is ruptured.
Check testicle with US.
Fracture of penis
Fracture of corpora cavernosa or tunica albuginea
From vigorous intercourse with woman on top.
Features: sudden pain, large penile shaft hematoma, normal glans.
Tx: emergency surgery
Untreated ➡️ AV shunts ➡️ impotence.
Penetrating injury of extremity
No major vessels affected = tetanus prophylaxis, clean wound.
Near major vessel and asymptomatic = Doppler or CT angio
Symptomatic (absent distal pulse, expanding hematoma) = surgery and repair.
Combined injury of artery, bone, and nerve.
1st stabilize bone.
2nd vascular repair.
3rd nerve.
Fasciitis you to prevent compartment syndrome.
High velocity gunshot wounds
Cause large cone if tissue destruction.
Tx: debridement, amputation.
Crushing injury
Can cause hyoerkalemia, myoglobinemia, myoglobinuria, renal failure, compartment syndrome.
Tx: fluid administration, osmotic diuretics, alkalinize urine. Fasciotomy.
Chemical burns
To: irrigation
Worse with bases.
High-Voltage electrical burn
Tx: massive debridement or amputation.
Concerns for: myoglobinemia-myoglobinuria-renal failure, posterior dislocation of shoulder, compression of vertebral bodies, cataracts, demyelination syndromes.
Inhalation injury
Features: burns around mouth, soot in throat.
Dx: fiberoptic bronchoscopy, blood gases, monitor carboxyhemoglobin levels.
Tx: intubate if airway is concerning.
Circumferential burns
Cause edema under eschar that can cut off blood or if on chest can affect breathing.
Tx: escharotomy
Scalding burn in kid
Think child abuse.
Fluid needs after burns
Initial 1L an hour adult and adjust by urine output. Start at 20% burn.
Keep urine output between 1-2 mL/kg/hr.
Burn looks leathery, gray, dry.
Rule of nines for burns
Head = 9%
Each arm = 9%
Each leg = 2x9 =18%
Trunk = 4x9 = 36%
Fluid needs burned babies
Head = 2x9 =18% Both legs = 3x9 = 27% Each arm = 9% Trunk = 4x9 = 36% Burn looks bright red. Initial fluids after 20% burn = 20mL/kg/hr, tune by urinary output.
Burn care
Tetanus prophylaxis
Cleaning
Topical agents (silver sulfadiazine, if deep use mafenide)
Burn around eyes gets triple antibiotic ointment
Pain meds
High calorie nitrogen diet
If not regenerated by 2-3wks, graft.
Early excision and grafting of burns
For 3rd degree that are less than 20%
Dog bite
Provoked if while feeding = no rabies.
Unprovoked = rabies prophylaxis.
Snake bite
30% not envenomated.
Signs of venom: severe local pain, swelling, discoloration within 30 min.
Dx: blood type and match, coag studies, renal function tests, liver function tests.
Tx: splint for transportation, antivenin (CROFAB)
Bee sting
Can cause anaphylaxis.
Signs: warm and pink shock, wheezing, rash, hypotension.
Tx: epinephrine, remove stinger
Black widow spider bite
Features: nausea, vomiting, severe generalized muscle cramps
Tx: IV calcium gluconate, muscle relaxants.
Brown recluse spider bite
Features: by day 2 have skin ulcer with necrotic center, halo of erythema.
Tx: dapsone, excision but not until fully affected, skin graft.
Human bite
Tx: irrigation, debridement in OR.
