Trauma

Question 1

At what GCS score does an airway need to be secured?

Answer 1

8 or under

Question 2

What signs/symptoms necessitate an airway?

Answer 2

Noisy/gurgly breathing, severe inhalational (smoke) injury, need to connect to a respirator

Question 3

If needed, should an airway be secured before or after addressing a C-spine injury?

Answer 3

Before (ABCs, airway first!)

Question 4

If needed, can orotracheal intubation be done in the presence of a C-spine injury?

Answer 4

Yes, if head is secured and not moved

Question 5

What is an alternative option to orotracheal intubation in the setting of C-spine injury?

Answer 5

Nasotracheal intubation over fiber optic bronchoscope

Question 6

In securing an airway, when is the use of a fiberoptic bronchoscope mandatory?

Answer 6

If there is subcutaneous emphysema in the neck, a sign of major traumatic disruption of the tracheobronchial tree

Question 7

If intubation cannot be done in the usual manner, what is the quickest and safest way to temporarily gain access to an airway?

Answer 7

Cricothyroidotomy

Question 8

Before what age is it inadvisable to perform a cricothyroidotomy? Why?

Answer 8

Before age 12, due to potential need for future laryngeal reconstruction

Question 9

What are the clinical signs of shock?

Answer 9

Hypotension (sBP

Question 10

What are the 3 most common causes of shock in traumatic setting?

Answer 10

Hypovolemic-hemorrhagic (most common)
Pericardial tamponade
Tension pneumothorax

Question 11

There must be blunt or penetrating trauma to the chest in order for which two causes of shock to occur?

Answer 11

Pericardial tamponade

Tension pneumothorax

Question 12

In a patient with sBP 85, HR 110 and weak, urine output of 0.4 ml/kg/hr, and CVP 2 mmHg, what is the most likely cause of his shock?

Answer 12

Hypovolemic

Question 13

In what types of shock is CVP elevated?

Answer 13

Pericardial tamponade
Tension penumothorax
Cardiogenic

Question 14

What clinical signs indicate an elevated CVP?

Answer 14

Distended head and neck veins

Question 15

A patient with trauma to the chest, in shock, with notable JVD and respiratory distress, what other signs would indicate tension pneumothorax?

Answer 15

One side of chest has no breath sounds and is hyperresonant to percussion, and mediastinum is displaced to the opposite side (tracheal deviation)

Question 16

In an urban setting with trauma center, what is first in treatment of hemorrhagic shock from penetrating injury, surgery or fluids?

Answer 16

Surgery

Question 17

In volume repletion for hemorrhagic shock, what is the first fluid used? What next? What is the target urine output? What is the maximum CVP?

Answer 17

First, 2L of lactated Ringer’s (no sugar). Then, PRBC until UOP is 0.5-2 ml/kg/h. CVP not to exceed 15 mmHg

Question 18

What is the preferred route of fluid resuscitation?

Answer 18

2 peripheral 16g IVs

Question 19

What is the alternative to peripheral IVs in fluid resuscitation?

Answer 19

Adults: femoral vein catheter or saphenous vein cut-down

Children

Question 20

What is the preferred imaging technique for pericardial tamponade?

Answer 20

Ultrasound

Question 21

Where to insert needle catheter and chest tube in tension pneumothorax?

Answer 21

High in the anterior chest wall

Question 22

What are two causes for cardiogenic shock?

Answer 22

Massive MI, fulminating myocarditis

Question 23

What are some non-hemorrhagic causes of hypovolemic shock?

Answer 23

Burns, peritonitis, pancreatitis, massive diarrhea

Question 24

What are some causes of vasomotor shock?

Answer 24

Anaphylactic reaction, high spinal cord transection or anesthetic

Question 25

What type of skull fracture should be left alone? What requires wound closure? Which ones go to the OR?

Answer 25

Left alone: closed linear skull fractures
Wound closure: open linear skull fractures
OR: comminuted or depressed skull fractures

Question 26

Which head trauma patients get a CT?

Answer 26

Unconscious patients, to look for intracranial hemorrhage.

Question 27

If a CT head is negative and patient is neurologically intact, what home care is needed for them to be discharged?

Answer 27

Someone must be willing to wake them up frequently in the next 24 hours to check for comatose

Question 28

What are some signs of a fracture of the base of the skull?

Answer 28

Raccoon eyes, rhinorrhea, otorrhea, or ecchymosis behind the eyes (Battle signs)

Question 29

What are 3 causes of neurological damage from trauma?

Answer 29

Initial blow, then hematoma (mass effect), finally increased ICP

Question 30

What is the classic clinical sequence seen with acute epidural hematoma?

Answer 30

Initial blow, then unconsciousness, then lucid interval, then gradual lapse into coma with ipsilateral fixed dilated pupil and contralateral hemiparesis with decerebrate posture

Question 31

What is decerebrate posture? Decorticate?

Answer 31

Decerebrate: abnormal extension
Decorticate: abnormal flexion

Question 32

Is prognosis worse for epidural or subdural hematoma?

Answer 32

Subdural

Question 33

What is the treatment for acute subdural hematoma?

Answer 33

Craniotomy if midline is shifted
ICP monitoring
Elevate head
Hyperventilate (to pCO2 35)
Avoid fluid overload
Mannitol or furosemide (do not lower systemic arterial pressure)
Sedation or hypothermia to lower metabolic demand

Question 34

What is seen on CT in diffuse axonal injury?

Answer 34

Diffuse blurring of gray-white matter interface, multiple small punctate hemorrhages

Question 35

CT scan showing diffuse blurrin of gray-white matter interface and multiple small punctate hemorrhages after severe trauma, suggests what sequelae?

Answer 35

Diffuse axonal injury

Question 36

When is there a role for surgery in diffuse axonal injury?

Answer 36

With hematoma

Question 37

What patient populations get chronic subdural hematomas?

Answer 37

Very old or severe alcoholics

Question 38

With penetrating trauma to the neck, what cases would lead to surgical exploration?

Answer 38

Expanding hematoma, deteriorating vitals, or clear signs of esophageal or tracheal injury (coughing or spitting up blood)