Trauma Flashcards
1
Q
subcutaneous emphysema = ?
A
trapped air or gas in layer under the skin
2
Q
trapped air or gas in layer under the skin =?
A
subcutaneous emphysema
3
Q
pt unconscious is what on GCS?
A
GCS of 8 or less
4
Q
airway should be secured when (5)?
A
- pt is unconscious (GCS 8 or less)
- breathing is noisy or gurgly
- severe inhalation injury
- if pt needs a respirator
- B4 it becomes critical
5
Q
pt w/ cervical spine injury + noisy breathing – what do you do first?
A
Secure airway first, then deal w/ cervical spine injury
6
Q
Can orotracheal tube be inserted if pt has cervical spine injury?
A
Yes as long as can be done w/ head secured and not moved.
Another option is nasotracheal tube over a fiber optic bronchoscope
7
Q
When do you use a nasotracheal tube over a fiber optic bronchoscope?
A
MANDATORY: when securing airway if there is subQ emphysema in the neck
Can be done for pts w/ cervical spine injury as well
8
Q
what is a sign of major traumatic disruption of the tracheobronchial tree?
A
SubQ emphysema
9
Q
SubQ emphysema is a sign of what?
A
major traumatic disruption of the tracheobronchial tree
10
Q
Need airway but intubation not possible?! what next?
A
cricothyroidotomy!
11
Q
why reluctant to do cricothyroidotomy before age 12?
A
bc of potential need for future laryngeal reconstruction
12
Q
Satisfactory breathing or airway =?
A
Breathing: breath sounds bilaterally + good pulse ox
Airway: conscious, speaking w/ normal tone of voice
13
Q
Clinical signs of shock
A
- low BP (
14
Q
Main 3 causes of shock in trauma setting?
A
1) Bleeding (hypovolemic-hemorrhagic shock most common)
2) pericardial tamponade
3) tension pneumothorax
15
Q
maj separator b/t shock caused by bleeding vs pericardial tamponade or tension pneumo?
A
Bleeding: Central venous pressure low –> veins flat
Peri/pneumo: CVP high (big distended head and neck veins)
16
Q
shock caused by pericardial tamponade –> what signs?
A
- chest trauma
- CVP high (big distended head and neck veins)
- NO resp distress (diff from tension pneumo)
17
Q
shock caused by tension pneumo –> what signs?
A
- chest trauma
- CVP high (big distended head and neck veins)
- Resp distress (diff from pericardial tamponade) –> one side of chest has no breath sounds and is hyperresonant to percussion
- mediastinum displaced to opp side of pneumo (tracheal deviation)
18
Q
maj separator b/t shock caused by pericardial tamponade vs tension pneumo?
A
Pericardial tamp: NO RESP DISTRESS
Pneumo: resp distress w/ dec breath sounds 1 side + hyperresonant to percusion + tracheal deviation
19
Q
Initial treatment for hemorrhagic shock w/ penetrating injuries ?
A
Surgical intervention to stop bleeding - since they are going to need surgery anyway, THEN volume replace
20
Q
Hemorrhagic shock initial treatment usually?
A
Volume replace!!!!
VR w/ about 2L of Ringer lactate w/o sugar THEN PRBC until urinary output reaches 0.5 to 2mL/kg/h - while not exceeding CVP of 15mmHg
21
Q
Hemorrhagic shock, what do you volume replace w/ first fluids or PRBC?
A
FLUIDS! about 2L of Ringer lactate w/o sugar then PBRC
22
Q
In hemorrhagic shock volume replace w/ fluids and blood until what?
A
until urinary output reaches 0.5 - 2mL/kg/h – w/o exceeding CP of 15mmHg
23
Q
In hemorrhagic shock volume replace w/ fluids and blood conscious not to exceed what?
A
CVP of 15mmHg
24
Q
What is the preferred route of fluid resuscitation in the trauma setting?
A
2 peripheral IV lines - 16 gauge
25
If can't get peripheral IV lines in what are alternatives for adults in trauma setting?
- percutaneous femoral vein catheter
| - saphenous vein cut downs
26
If can't get peripheral IV lines in what are alternatives for Children
Intraosseus cannulation of the proximal tibia
27
What imaging to diagnosis pericardial tamponade is ordered?
SONOGRAM! not xrays
28
Management of pericardial tamponade based on?
clinical diagnosis! then prompt evacuation of pericardial sac
29
Ways to treat pericardial tamponade?
- pericardiocentesis
- tube
- pericardial window
- open thoracotomy
30
What is helpful to do while evacuation of pericardial sac in treatment of pericardial tamponade is ocurring?
Fluid and blood administration!
31
Is volume replacing w/ fluid and blood during evacuation of pericardial sac in treatment of pericardial tamponade helpful or hurtful?
HELPful!
32
Management of tension pneumothorax based on?
clinical diagnosis! do NOT wait on xrays or blood gases
33
Treat tension pneumo by?
- Needle thoracostomy
| - Chest tube placement - will take more time
34
Intrinsic cardiogenic shock caused by?
myocardial damage (massive MI or fulminating myocarditis)
35
Cardiogenic shock will present w/ high or low CVP?
High!
36
Treatment of cardiogenic shock?
circulatory support!
37
volume resus in cardiogenic shock?
NO! no additional fluid or blood administration or could be lethal!
38
When is vasomotor shock seen?
- anaphylatic reactions
- high spinal cord transections
- high spinal anesthetic
39
anaphylatic rxn can lead to what type of shock?
vasomotor shock
40
high spinal cord transections can lead to what type of shock?
vasomotor shock
41
Vasomotor shock --> what symptoms/what pt look like?
circulatory collapse in flushed "pink and warm" pt. CVP low.
42
vasomotor shock has high or low CVP?
low
43
what is main treatment of vasomotor shock?
pharm treatment to restore peripheral resistance (vassopressors)
44
Will additional fluids help or hurt in vasomotor shock?
HELP
45
list shocks that have low CVP (2)
1) hemorrhagic
| 2) vasomotor
46
list shock types/causes of shock that have high CVP (3)
1) tension pneumo
2) pericardial tamponade
3) cardiogenic shock
47
penetrating head trauma requires?
surgical intervention and repair of the damage
| Skull fractures sustained from penetrating trauma are considered open and patients are also treated with IV antibiotics.
48
linear skull fracture treatment?
Closed (no overlying wound) --> leave alone
Open fractures --> wound closure
Comminuted or depressed --> surgically treated
49
linear skull fracture is?
A linear skull fracture is a single fracture that most often extends through the entire thickness of the calvarium. They occur most often in the temporoparietal, frontal, and occipital regions. very rarely if vessels damaged --> hemorrhage.
50
Depressed skull fracture is?
Depressed skull fractures occur when trauma of significant force drives a segment of the skull below the level of the adjacent skull. These fractures often involve injury to the brain parenchyma and place patients at significant risk for central nervous system infection, seizures, and death if not identified early and managed appropriately (ie surgery)
51
Open skull fracture means?
Open (or compound) skull fractures exist when a scalp laceration lies over or adjacent to the fracture site.
52
Closed skull fracture means?
Closed (or simple) skull fractures exist when no scalp laceration is present over or adjacent to the fracture.
53
Pt w/ head trauma and is now unconscious --> what imaging study and looking for what?
CT head looking for intracranial hematomas
54
Pt w/ head trauma and has become unconscious --> CT scan which is neg for intracranial hematoma. Pt apepars neurologically intact. Next steps?
Pt can go home if family will wake them up frequently during next 24 hrs to make sure not going into coma
55
Signs of fracture affecting the base of the skull:?
- Raccoon eyes
- rhinorrhea
- otorrhea
- ecchymosis behind the ear
56
Pt w/ raccoon eyes, rhinorrhea, otorrhea, and ecchymosis behind the ear is suggestive of?
fracture affecting the base of the skull
57
imaging and treatment of pts w/ fracture affecting base of skull?
- CT scan to assess head AND cervical spine
| - Expectant management (watchful waiting)
58
what do you AVOID in pts w/ fracture affecting base of the skull?
nasal endotracheal intubation
59
neurological damage from trauma can be caused by 3 components: ?
1) initial blow
2) subsequent dev of a hematoma that displaces midline structures
3) later dev increased intracranial pressure
60
Acute epidural hematoma classic sequence = ?(6)
1) trauma (often modest trauma to side of head)
2) unconsciousness
3) lucid interval (asymp --> return to activity)
4) gradual lapse into coma
5) fixed dilated pupil (90% on side of hematoma)
6) contralateral hemiparesis w/ decerebrate posture*
*Decerebrate posture is an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. The muscles are tightened and held rigidly.
61
CT scan of acute epidural hematoma looks like?
biconvex, lens-shaped hematoma
62
biconvex, lens-shape image on head CT = ?
epidural hematoma
63
treatment for epidural hematoma?
emergency craniotomy
64
Diff b/t epidural and subdural hematomas
1) CT scan: epi: biconvex shape, sub: screscent shape
2) Severity: sub>>>epi
3) Epi has lucid period, none in sub
65
Acute subdural hematoma seen on CT looks like?
Semilunar, crescent shaped hematoma
66
Semilunar crescent shaped hematoma = ?
subdural hematoma
67
subdural hematoma w/ midline structures deviation --> treatment? prognosis?
Treat w/ craniotomy, but prognosis is still bad
68
subdural hematoma w/ NO midline deviation what do you do?
- ICP monitoring
- elevate head
- Hyperventilate
- Avoid fluid overload
- Give mannitol or furosemide --> but do not diurese to point of lowering systemic arterial pressure
69
What is the main focus of treatment of subdural hematoma w/ no midline deviation?
Focus: prevent further damage by decreasing/stop inc of ICP
70
When do you hyperventilate a pt w/ a subdural hematoma?
Signs of herniation
71
What is the hyperventilation goal for a pt w/ a subdural hematoma and sign of herniation?
PCO2 of 35mmHg
72
Additional options used to decrease O2 demand for pts w/ subdural hematoma =? (2)
1) Hypothermia (main rec)
| 2) Sedation bc dec brain activity (previously used, not as common)
73
CT scan shows what w/ diffuse axonal injury?
diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages
74
diffuse axonal injury indicated w/o hematoma --> Treatment?
NO SURGERY! Focus on preventing further damage from ICP.
75
Chronic subdural hematoma seen w/ what populations?
- very old
| - severe alcoholics
76
Pathophysiology chronic subdural hematoma
shrunken brain rattled around head --> minor trauma --> tearing venous sinuses --> over several days or wks mental func dec as hematoma forms
77
duration of chronic subdural hematoma?
mental func will deteriorate over several days to week while hematoma forms
78
Chronic subdural hematoma diagnosed by?
CT scan
79
Treatment of chronic subdural hematoma?
Surgical evacuation
80
Chronic subdural hematoma symptoms
The insidious onset of headaches, light-headedness, cognitive impairment, apathy, somnolence, and occasionally seizures, may occur as a consequence of chronic SDH, and symptoms may not become evident until weeks after the initial injury.
81
Imaging on CT differences b/t acute vs chronic subdural hematoma
Acute: high-density crescentic collection across the hemispheric convexity
Subacute/Chronic: sodense or hypodense crescent-shaped lesions that deform the surface of the brain.
82
Can hypovolemic shock occur from intracranial bleeding?
NOOOOOOO!
There isn't enough space in the head for the amt of blood loss necessary for shock --> look for another source
83
What cases of penetrating neck trauma lead to surgical exploration?
- expanding hematoma
- deteriorating vital signs
- clear signs of esophageal or tracheal injury (coughing/spitting up blood)
84
zone 1/base of neck has what anatomical boundaries?
sternal notch and clavicles to the cricoid cartilage
85
zone 2/middle of neck has what anatomical boundaries?
Contains what major items?
Cricoid cartilage to the angle of the mandible
- jugular veins
- vertebral and common carotid arteries
- internal and external branches of the carotid arteries
- trachea
- esophagus,
- larynx
- spinal cord
86
arteriography ? ?
Angiography, or arteriography, is an x-ray examination of the arteries, which are blood vessels. To make the arteries visible on x-ray, a type of dye called “contrast” is injected.
87
zone 3/upper neck has what anatomical boundaries?
Contains what major items?
Region above the angle of the mandible up to the base of the skull
- pharynx
- jugular veins
- vertebral arteries
- distal portion of the internal carotid arteries
88
gunshot wound to each of 3 diff zones has what treatments?
USUALLY SELECTIVE APPROACHES - debatable
Zone 3/upper = arteriographic diagnosis and management
Zone 2/mid = toss up b/t selective and surgical exploration
Zone 1/base = arteriography, esophagogram, esophagoscopy, and bronchoscopy b4 surgery
89
Stab wound to upper and middle zone in asymptomatic pt treated by?
observation
90
What must do if pt w/ severe blunt trauma to neck?
ascertain integrity of cervical spine!
91
Who gets CT scans post severe blunt trauma to neck?
- pt w/ neurological deficits
| - neurologically intact pt w/ pain to local palpation over cervical spine
92
In ED setting best radiographic way to assess status of cervical spine is?
CT scan
93
Signs of complete spinal cord transection?
nothing works (sensory or motor) below site/lesion
94
Hemisection of spinal cord aka ?
Brown-Sequard
95
brown-sequard aka =?
Hemisection of spinal cord
96
Typical cause of hemisection of spinal cord?
Clean-cut injury (ie knife blade)
97
Hemisection of spinal cord has what symptoms?
Paralysis and loss of proprioception DISTAL to injury on the INJURED SIDE.
Loss of pain perception DISTAL to injury on CONTRALATERAL SIDE.
98
Anterior cord syndrome seen when?
Typically seen in BURST FRACTURES of vertebral bodies
99
Anterior cord syndrome results in?
Loss of motor func, loss of pain, loss of temp sens on BOTH SIDES DISTAL to injury
Vibration and proprioception PRESERVED.
100
Loss of motor func, loss of pain, loss of temp sens on BOTH SIDES DISTAL to injury
Vibration and proprioception PRESERVED.
Anterior cord syndrome
101
Paralysis and loss of proprioception DISTAL to injury on the INJURED SIDE.
Loss of pain perception DISTAL to injury on CONTRALATERAL SIDE.
Hemisection of spinal cord
102
BURST FRACTURES of vertebral bodies -->?
Anterior cord syndrome
103
Clean-cut injury (ie knife blade) to back -->?
hemisection of spinal cord
104
Main population that central cord syndrome occurs in?
Elderly
105
central cord syndrome caused by
Forced hyperextension of the neck (ie rear-end collision)
106
Elderly man is rear-ended, likely spinal cord injury is?
Central cord syndrome
107
Presentation of central cord syndrome?
Paralysis and burning pain in UPPER EXTREMITIES
Most func intact in lower extremities
108
Elderly man is rear-ended, has paralysis and burning pain in upper extremities, which likely spinal cord injury is this?
Central cord syndrome
109
Best diagnosis readiographic study for spinal cord injury?
MRI
110
What do some consider helpful immediately after spinal cord injury?
High-dose corticosteroids
111
Rib fracture treatment?
Nerve block and epidural catheter
112
Why is pain control in setting of rib fracture esp in elderly important?
B/c can cause following: PAIN --> hypOventilation --> atelectasis --> PNA (which can kill the elderly!)
113
Plain pneumothorax results from?
Penetrating trauma to chest
114
Clinical presentation of plain pneumothorax?
- Moderate SOB
- dec/no breath sounds unilaterally
- Hyperresonant to percussion on side w/o breath sounds
115
Treatment of plain pneumothorax?
Get chest x ray, place chest tube (upper, anterior), connect to underwater seal
116
Maj diff b/t clinical presentation of pneumothorax and hemothorax?
Hemothorax will be DULL to percussion on side of injury, pneumothorax will be HYPERRESONANT
117
Difference in placement of chest tube in pneumohorax vs hemothorax?
Pneumo - high and anterior placement
| hemothorax - low
118
Blood needs to be evacuated from a hemothorax to avoid what developing?
Empyema
119
What is a sign surgery is needed post chest tube placement in hemothorax setting?
1) recover 1500mL or more when chest tub inserted
| 2) Collecting > 600mL in drainage over 6hrs
120
Hemothorax + chest tube, is surgery necessary?
Usually no, bc bleeding from lung which will stop on own
Rare cases from systemic vessel (ie intercostal artery) - thoracotomy may be needed
Need surgery when:
1) recover 1500mL or more when chest tub inserted
2) Collecting > 600mL in drainage over 6hrs
121
thoractomy = ?
A thoracotomy is an incision into the pleural space of the chest.
122
Sucking chest wound =?
Flap that sucks air IN w/ INSPIRATION and CLOSES during EXPIRATION
123
Sucking chest wound untreated --> ?
tension pneumothorax
124
Treat sucking chest wound w/?
Occlusive dressing that allows air out (taped on 3 sides) but not in.
125
Flail chest =?
Seen w/ multiple rib fractures that allow a segment of the chest wall to cave in during INSPIRATIon and bulge out during EXPIRATIOn (paradoxic breathing)
126
flail chest --> ?
chest contusion
bad b/c contused lung very sensitive to fluid overload
127
Medical aspect of treatment of flail chest?
fluid restrict and use diuretics - b/c contused lung of results and is sensitive to fluid overload
128
what labs need to be monitored in flail chest?
blood gases - bc pulm dysfunction often dev
129
if respirator needed, what is different in pt w/ flail chest?
need BILATERAL CHEST TUBES to prevent tension pneumothorax dev
130
If pt has flail chest, must also check for what?
Traumatic transection of the aorta
131
Pulmonary contusion will cause what on labs and xray?
Deteriorating blood gases
| "white out" of lungs on CXR
132
Pulm contusion time course?
Can appear immediately or up to 48 hours post trauma
133
Pulm contusion treatment:
Fluid restrict + use diuretics, pain control and pulmonary toilet/hygiene (methods used to clear mucus and secretions from the airways)
usually resolves in 1 wk
134
Sternal fracture --> suspect what type of injury?
Myocardial contusion
135
Myocardial contusion seen in what type of injury?
sternal fractures
136
what should be ordered in presence of sternal fracture?
troponins and EKG
137
Treatment of myocardial contusion focuse on?
Complications arising from arrhythmias
138
Traumatic rupture of diaphragam seen as what on exam and xray ?
Bowel in the chest (seen on phys exam and xray) on LEFT SIDE
139
Treatment of traumatic rupture of diaphragam?
Needs surgery - depending on extent and other injuries either laparoscopy or laparotomy (open)
140
traumatic rupture of aorta usually occurs where anatomically?
junction of the arch and descending aorta
141
What often causes traumatic aorta ruptures?
big deceleration injury
142
big deceleration injury --> what maj injury
traumatic rupture of the aorta
143
Path/timeline of traumatic rupture of aorta
1) asymptomatic --> unknown bleeding
2) hematoma forms but is contained by adventitia
3) adventitia cannot contain any longer --> tears open --> pt dies
144
Suspicion for traumatic rupture of aorta is high in what cases: (3)
1) Deceleration injury
2) Presence of fractures in chest bones that are "very hard to break" (ie 1st rib, scapula, sternum)
3) presence of wide mediastinum
145
In trauma setting what is the most practical imaging?
CT angio (aka spiral CT scan enhanced by intravenous dye)
146
Non invasive diagnostic test for rupture of aorta
- spiral CT (most practical in trauma setting)
- transesophageal echo
- MRI angio
147
What clinical findings is suggestive of traumatic rupture of trachea or major bronchus?
- SubQ emphysema in upper chest and lower neck
| - large "air leak' from a chest tube
148
Treatment for rupture of trachea or maj bronchus?
1) CXR confirms presence of air in tissue
2) fiberoptic bronchoscopy identifies lesion --> can intubate and secure airway beyond lesion
3) SURGICAL REPAIR
149
DDx for subQ emphysema = ? (3)
- rupture of esophagus (often post endoscopy)
- tension pneumo(worry about shock + resp distress)
- gas producinng infx
150
chest trauma pt who is intubated and on a repirator suddenly dies, most likely?
air embolism
151
What vein when open to air --> air embolism --> sudden collapse and cardiac arrest?
subclavian vein
152
Instances subclavian vein may be exposed to air (bad)
- supraclavicular node biopsies
- central venous line placement
- CVP lines become disconnected
153
Immediate management of air embolism?
cardiac massage w/ pt positioned w/ L side down
154
Prevention of air embolism when veins at base of neck are being entered is by what mechanism?
Put pt in Trendelenburg
155
Resp distress in pt w/ trauma but not chest trauma, most likely?
Fat embolism, esp if setting of long bone fractures
156
Fat embolism treatment?
- Respiratory support
157
Signs of fat embolism:
multiple trauma esp long bone fractures who dev:
- petechial rashes in axillae and neck
- fever
- tachycardia
- low platelet count
At some pt dev resp distress w/ hypoxemia + bilateral patchy infiltrates on CXR
158
Pt w/ multiple trauma esp long bone fractures who dev:
- petechial rashes in axillae and neck
- fever
- tachycardia
- low platelet count
dev resp distress w/ hypoxemia + bilateral patchy infiltrates on CXR
Likely?
Fat embolism
159
What seen on CXR w/ pt w/ fat embolism and resp distress?
bilateral patchy infiltrates on CXR
