Trauma Flashcards
Definition of Massive Hemothorax (Indications for op management)
>1500 mL blood upon chest tube placement
or
200 mL/h X 4h
Needle Thoracostomy
14G needle, 2nd ICS midclavicular line
Indications for chest tube placement
Hemothorax > 200-300 mL
Pneumothorax > 1.0 cm wide or not confined to upper 1/3 of chest
Landmark for chest tube placement
Triangle of safety: Lateral border of pec major, anterior border of lat dorsi, 5th ICS AKA anterior axillary line, 5th ICS
Procedure of inserting chest tube
Occlude prox (away form pt) end of tube with clamp. Grasp distal end with other clamp.
Oblique incision 1-2 cm below intended ICS.
Large clamp to dissect IC muscles to level above incision, enlarge to 1.5-2,0 cm.
Insert finger along top of clamp to make sure lung not adhered to chest wall.
Grasp tube by side hole with clamp and advance until at least the last side hole is 2.5-5.0 cm inside the chest wall.
For pneumo aim anteriorly, for hemo aim posterolaterally.
Simple interrupted 1-0 ethilon, wrap ends around tube & tie.
Petroleum gauze dressing –>sterile gauze dressing –>pressure dressing.
Connect to pleur-evac –>unclamp free end.
20-30 cm H20 suction
Xray - if last hole not in pleural space, replace tube, do not advance (not sterile)
How to remove chest tube
Pull on end-expiration or inspiration, can be during valsalva. Cover with petroleum gauze –>sterile gauze–>pressure dressing. CXR 12-24h post.
What to do with a sucking chest wound?
Cover immediately with sterile petrolatum gauze dressing secured on three sides. Chest tube at a separate site (do not insert through wound site as will follow knife tract into lung or diaphragm).
Indications for removing chest tube.
24h after air leaks stop or drainage serous and <200 mL/24h.
Do not remove while on vent.
What size of chest tube to use?
Pneumo: 24-28 F
Hemo: 32-40 F
Classes of Hemorrhage
Class I: <15% (750 mL) Slightly anxious
Class II: 15-30% (750-1500 mL) HR 100-120, narrow PP, RR 20-30, u/o 20-30 ml/h
Class III: 30-40% (1500-2000 mL) HR 120-140, BP low, RR 30-40, u/o 5-15 ml/h
Class IV: >40% (>2000 mL) HR >140, RR >35, very low u/o, decreased LOC
Class III, IV, consider starting blood right away
Canadian C-Spine Rules
1. Stable + GCS 15 + Trauma
2. Any HR features?
Age >=65, fall >=3ft/5stairs, axial load to head, MVC >100 km/h, rollover, ejection, motorized rec vehicle, bicycle struck/collision, paresthesias in extremities
3. Any LR features?
Simple rear-end MVC (not pushed into oncoming traffic, no bus/truck, no rollover, <100 km/h), sitting in the ED, ambulatory at any time, delayed onset (>30 min) neck pain, no midline c-spine tenderness
If no HR, and at least one LR then turn head 45 deg either way.
TIG Dosage and Indications
For contaminated wounds with < 3 injections in series of Td vaccinations (2, 4, 6 18 months, 4-6 years, 16 years, or unknown status).
250 IU IM X 1 (give at separate site from Td) for age >7
For age <7, dose is 4 IU/kg up to max of 250 IU
Sources of blood loss
“On the floor and four places more”
- chest
- abdo
- pelvis
- femur
Definition of massive transfusion
More than 10 units/24h
Becks’ Triad
Hypotension
JVD
Muffled Heart Sounds
Findings of traumatic aortic disruption on CXR
- widened mediastinum
- obliteration of aortic knob
- tracheal deviation (RIGHT)
- depression of LEFT mainstem bronchus
- elevation of RIGHT mainstem bronchus
- obscuration of aortopulmonary window
- deviation of esophagus/NG tube RIGHT
- widened paratracheal stripe
- widened paraspinal interfaces
- pleural/apical cap
- LEFT hemothorax
- 1st/2nd rib or scapular #s
Signs of Esophageal Rupture
Treatment
LEFT haemo/pneumothorax without rib # following severe blow to lower sternum/epigastrium and pain out of proportion to injury
Treatment: chest tube & early repair
Uncal Herniation
CN III (oculomotor) runs along edge of tentorium and gets compressed with temporal lobe (uncal) herniation. Also compresses corticospinal (pyramidal) tract in midbrain. Ipsilateral pupillary dilation with contralateral hemiparesis.
Signs of basilar skull #
Raccoon/Battle’s, CSF leakage, 7th, 8th nerve palsies
Normal & High ICP
Normal is ~10 mm Hg, >20 mm Hg is high.
Contusion/intracerebral hematomas
Usually in frontal and temporal lobes. 20% evolve to need NSx. Need repeat CT within 24h.
Hyperventilation in Traumatic Brain Injury
Reduces PCO2, causes cerebral vasoconstriction, decreases edema, but also CPP. Only for short time (i.e. if herniating/deteriorating) to 25-30 mm Hg.
Dose of mannitol in IICP, contraindications
20% (20 g/100 mL), do not give if hypotensive (osmotic diuretic), give if signs herniation/deterioration. 1 g/kg over 5 minutes
Dose of hypertonic saline in IICP (adults)
150 mL 3% over 5-10 minutes
Spinal cord tracts
Central Cord Syndrome
Arms weaker than legs. Usually from hyperextension in elderly. Thought to be from vascular compromise of anterior spinal artery.
Anterior Cord Syndrome
Paraplegia, loss of pain/temperature, intact dorsal column function (position, vibration). Poor prognosis for recovery.
Brown-Sequard Syndrome
Hemisection of cord, usually from penetrating trauma. Ipsilateral motor loss and positional loss with contralateral loss of pain/temp one to two levels below level of injury.
C1 Rotary Subluxation
Can occur from minor injury, esp in kids. Neck stuck in rotation. Odontoid not equidistant on open mouth view. Do not force.
Hangman’s #
This fracture is virtually never seen in suicidial hanging. Indeed it was not even seen in many of those who were judicially hanged; asphyxiation being the usual mode of death. Major trauma in hyperextension, such as a high speed motor vehicle accident, is in fact the most common association – especially in fatal cases.
X of both pars interarticularis (pedicles) of C2
Nexus Criteria for C-Spine Imaging
- (Apply to Age 1-100)
- Focal Neuro Deficit
- Midline Spinal Tenderness
- Altered LOC
- Intoxication
- Distracting Injury
Name for Vfib arrest secondary to blunt chest trauma
commotion cordis
How to perform delayed wound closure?
Pack.
Close 4-10 days later.
When to remove sutures on face?
5 days
When to remove sutures on scalp?
7-10 days
When to remove sutures on torso?
7-10 days
When to remove sutures on extremities?
7-10 days
When to remove sutures on high-tension areas?
10-14 days
Which sutures to use in mouth?
Chromic gut
Vicryl
Silk
Which sutures to use on hands?
Plain gut
Which sutures to use on face?
Rapid gut or Monofil/Ethilon
GCS (Adult)
E4
1: None 2: Pain 3: Voice 4: Spontaneous
V5
1: None 2: Incomprehensible 3: Inappropriate 4: Confused 5: Oriented
M6
1: None 2: Extension to pain 3: Flexion to Pain 4: Withdraws from pain 5: Localizes pain 6: Obeys commands
Indication for TXA in Trauma
Dose of TXA in Trauma
(Adult)
Trauma with significant bleeding (SBP 110)
1 g IV over 10 minutes then 1 g over 8 hours
Name of Trial for TXA in Trauma
Sites, number of patients, findings
In CRASH-2, a trial spanning 274 hospitals in 40 countries, over 20,000 trauma patients with or at risk of significant hemorrhage were randomly assigned within eight hours of injury to treatment with the antifibrinolytic agent tranexamic acid (n = 10,096) or placebo (n = 10,115) [88]. Overall mortality was lower in the tranexamic acid group (14.5 versus 16 percent; relative risk [RR] 0.91, 95% CI 0.85-0.97), as was death from hemorrhage (4.9 versus 5.7 percent; relative risk [RR] 0.85, 95% CI 0.76-0.96). No differences in complications from vascular occlusion (eg, pulmonary embolism, myocardial infarction) were noted between the two groups.
Increased harm after 3h from trauma!
First Degree Burns
- Red, painful, no blisters. Not included in TBSA calculations. Heals 7d.
- Moisturize, no dressings needed
Superficial partial-thickness (superficial second degree) burns
- Blistering, wet, painful, blanches, heals 14-21 d, no scar.
- jelonet –> wet to dry gauze, wash daily with soap + water and change dressings daily
- no silver (slows healing), no polysporin (no better than vaseline), no need for antimicrobial dressings
Deep partial-thickness (deep second degree) burns:
- Pale white to yellow, painless, does not blanch, heals 3-8 weeks, permanent scar.
- may use acticoat (silver) dressing but need to put intrasite gel to keep it hydrated, or flamazine, or same jelonet –> wet to dry combo.
Full thickness (third degree) burns
- charred, white, leathery, painless, needs skin grafts
- may use acticoat (silver) dressing but need to put intrasite gel to keep it hydrated, or flamazine, or same jelonet –> wet to dry combo.
Fourth Degree Burns
- bone, fat, muscle.
Wound Care for Burns
- Rinse with warm tap water, cover warm, clean, dry linens.
- may cover small burns with saline soaked gauze
- flamazine (sulfasalazine)
- good for third degree burns, but inhibits healing in second-degree, stains gray (don’t use on face)
- any combination of antimicrobial +- gels/synthetics can be used, no clear evidence of benefit of one over another
TBSA needing fluids
- 20% (not counting 1st degree)
Fluid Resuscitation in Burns
- adjust to u/o 0.5-1 mL/kg/h
-
adult
- LR 4 mL/kg x % BSA (PT + FT)
- 1/2 over 8 h, 1/2 over 16 h
-
child
- LR 3 mL/kg x % BSA (PT + FT) + maintenance
- 1/2 over 8 h, 1/2 over 16 h
- Add D5W to kids < 20 kg
- LR 3 mL/kg x % BSA (PT + FT) + maintenance
Burns Transfer Criteria (Read-Through)
-
Criticall major burn (transfer to burn centre) criteria:
- ≥ 20% TBSA partial and/or full thickness at any age
- ≥ 10% TBSA partial and/or full thickness for ages ≤ 10 and ≥50
- Full thickness burns ≥ 5% TBSA at any age
- Burns to hands, face, feet, joints, genitalia, perineum
- Electrical burns
- Chemical burns
- Inhalation injury
- Burns with comorbidity
- Burns with patients who require special social, emotional, or rehabilitation care
-
Criticall consider transfer to minor burn centre
- Burns >10% but <20% TBSA in adults
-
Remain at base site
- Burns <10% TBSA in adults who do not require transfer but seek medical advice or an ambulatory burns clinical referral for assessment
Orbital #
Types
SSx
- pure
- blow-out # through inferomedial wall
- unpure
- orbital ridge #, usually occurs through other facial #
- ssx
- enopthalmos
- diplopia on upward gaze
- infraorbital anesthesia
Le Fort #
- Le Fort I: transverse # separating body of maxilla from pterygoid plate and nasal septum. Only hard palate and teeth move (like loose upper denture).
- Le Fort II: pyramidal # through central maxilla and hard palate. Nose + hard palate move, eyes don’t move.
- Le Fort III: # through frontozygomatic suture line, across the orbit and through base of nose and ethmoids, entire face separated from skull, eyes held only by optic nerve.
- Le Fort IV: Le Fort III + Frontal Bone
Mandible # (Read-through)
- consider bilateral until proven otherwise
- r/o open #, alveolar ridge # intraorally, examine ears for TM perforation
- Panorex if low suspicion
- CT if suspected condyle, complex, or multiple facial #’s
- peds # require 1-2 day f/u as difficult to repair late
Uncal Herniation
- lesion: temporal love or lateral middle fossa
- signs: ipsilateral mydriasis + contralateral paralysis
central transtentorial herniation
- lesion: midline lesions (e.g. frontal, occipital lobes)
- signs: bilateral miosis, bilateral Babinski’s, increased muscle tone
cerebellotonsillar herniation
- lesion: cerebellar tonsils herniate through foramen magnum
- signs: bilateral miosis, flaccid paralysis, sudden death
upward transtentorial
- lesion: posterior fossa
- signs: conjugate downward gaze, miosis
Sternum #
- CT, ECG, serial troponin +- cardiac monitoring for 6h
- DC Home if all normal
Management of Blunt Abdominal Trauma
- FAST, CT if high suspicion
Management of Penetrating Abdominal Trauma
- CT all GSW
- CT non-GSW near liver/spleen, otherwise CT not helpful for bowel injury
- admit for observation for 12h with serial exams, vitals, WBC count
- may probe wound with sterile finger even though not officially recommended (Inaba)
Management of Penetrating Flank Injuries
- vertically between iliac crest & 6th rib, AP by anterior and posterior axillary line
- kidneys, colon, retroperitoneal structures at risk
- all should get triple-contrast CT (IV, PO, PR) and admit for observation
Management of Penetrating Gluteal Injuries
- explore, if through muscle then
- triple-contrast CT +- cystourethrogram
Urethral Trauma
- posterior urethra
- prostatic + membranous portion
- blunt trauma, pelvic fractures
- anterior urethra
- fixed bulbar + pendulous (penile) segments
- straddle injuries, penile fracture
- diagnose both with cystourethrogram after CT done if CT needed
Management of Scrotal Trauma
- emergent US to r/o testicular rupture, dislocation
- traumatic epididymitis may occur several days later, treat symptomatically
Management of Blunt Cardiac Trauma
- serial trop, ECG ~100% sensitive
- admit to tele for 24-48h + formal echo if any abnormalities
Management of Pentrating Extremity Trauma
-
Hard Signs = consult Vascular Sx immediately
- diminished pulses
- arterial bleeding
- expanding pulsatile hematoma
- audible bruit
- palpable thrill
- distal ischemia
-
Soft Signs or ABI <0.9 = CT Angio
- small, stable hematoma
- injury to anatomically related nerve
- unexplained hypotension
- history of hemorrhage
- proximity of injury to majour vascular structures
- complex fracture
- Doppler US not acceptable
Management of Blunt Laryngotracheal Injury
- rare
- may have quiescent phase
- CT, np scope
Management of Neck Trauma (Blunt + Penetrating)
Review Evernote “Neck Trauma”
Acceptable Upper Limits of Soft Tissues on Lateral C-Spine Films
- 10 mm @ C1
- 5 mm @ C2
- 7 mm @ C3
- 20 mm @ C5-C7
C-Spine Trauma Approach
See Evernote “Spine Trauma”
Pelvic Fractures
Review Evernote
Indications for ED Thoracotomy
- within 10 minutes of arrest from penetrating trauma to chest –> definitely yes
- within 10 minutes of arrest from blunt trauma to chest –> probably (consider US to see if cardiac activity and if tamponade)
- unresponsive hypotension with chest trauma (<60 mm Hg) –> maybe
- rapid exsanguination from chest tube (i.e. > 1.5L)?
Dose of hypertonic saline in IICP
3 mL/kg of 3% over 3 min, repeat x 3 PRN
Dental Trauma
Review Evernote
Nasal Fracture
- refer peds within 2-4 days ENT re: rapid healing
- adults within 6-10 days
- reduce if immediately post-injury, before edema distorts landmarks
Nasal Septal Hematoma
- cartilage blood supply from perichondrium
- lifts off with NSH
- leads to abscess, necrosis, saddle deformity
- horizontal incision, evacuate clot, bilat anterior nasal packing
- ENT within 24h
Closed Fist Injuries
- do not close
- assume all are from bites
- explore with tourniquet, any damage to tendon/sheath/intraarticular should be seen by plastics in ED
- otherwise wash out 100-300 mL NS
- bulky dressing –> splint in position of safety x 2-3 d
- need to re-evaluate at 24h
- clavulin, 1st dose in ED
- clinda + cipro/septra if pen allergic x 3-5 days
-
if infected
- Pip/Tazo or Clinda + Cipro
- plastics to see in ED
BP Targets in Trauma (Controlled Resuscitation)
- Target SBP 70 mm Hg systolic and central pulses in penetrating, peripheral pulses in blunt trauma
- increase for severe head injuries, elderly with HTN at baseline, spinal shock
- for HI, MAP >80, SBP >110, SBP < 140
