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Surgery > Trauma > Flashcards

Trauma Flashcards

1
Q

ABCs

A

Airway (with C spine precautions - assume C spine injury until proven otherwise)

Breathing and vent

Circulation/Control of hemorrhage

Disability (neuro status)

Exposure/Environment control

Foley

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2
Q

Airway and C-spine

A

Assess patency

use jaw thrust or chin lift initially to open it up

Clear foreign bodies

Insert oral or nasal airway when needed

Intubate obtunded/unconscious patients

Surg airway = cricothyroidotomy - when unable to intubate

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3
Q

Patent airway

A

speaks in full sentences
B/l breath sounds

Just give O2

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4
Q

Urgent airway

A

Has patent airway now but maybe not forever. Will need intervention soon

Expanding hematoma

Cutaneous emphysema (rice crispies in skin)

Give BVM

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5
Q

Emergent airway

A

GCS

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6
Q

Breathing and ventilation

A

Do they need ventilations or a ventilator?

Monitor SpO2 and End tidal CO2 (for intubated patients should be about 40)

What might alter ventilation?
Hemothorax, pneumothorax, flail chest, pulm contusion

Normal RR 12-20

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7
Q

Control of hemorrhage

A

2 large bore IVs (14 or 16 gauge)

Draw blood samples at time of IV catheter placement

Assess cap refill, pulse, skin color

Control life-threatening bleeds using direct pressure

Are they in shock?
- sys BP

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8
Q

Disability

A

Rapid neuro exam

Establish pupillary size and reactivity and level of consciousness using AVPU or GCS

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9
Q

AVPU

A

Alert
Verbal
Pain
Unresponsive

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10
Q

Exposure/Environment/Extra

A

Undress the patient

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11
Q

Foley

A

Contraindicated when transection of urethra is suspected like in pelvic fracture. If suspected get retrograde urethrogram first

Examine prostate and genitals before foley insertion

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12
Q

Gastric intubation

A

NGT or OGT may reduce aspiration risk. If cribiform is fractured used OGT

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13
Q

IV fluid

A

Start with up to 2L of isotonic crystalloid (NS or LR)

Peds should get IV bolus 20cc/kg

3:1 rule. Total amount of crystalloid volume needed acutely to replace blood loss.

Use warm fluids whenever possible

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14
Q

Shock in the trauma setting

A 
Hemorrhage
Tension Pneumo
Pericardial Tamponade
Contractility issues
Vasomotor
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15
Q

Hemorrhage signs

A

Bleeding patient with flat neck veins. Low Hgb/Hct. High HR (compensation)

Dx: May beed to do FAST

Tx: 2 large bore IV
Dump fluid and blood into them (T/C, IVF, Blood). Fix the hole. All on the way to the OR

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16
Q

Tension pneumo signs

A

1 - needle decompression in 2nd IC space (goal is to relieve IVC not re-inflate lung). This is NOT a chest tube.

Hole in pleura creates a flap. When pt breathes in, air gets into pleural space. When they exhale it gets trapped

Affected lung collapses. Replaced inside the space with air.

Air compresses IVC

Engorged neck veins
Absent lung sounds on affected side
Hyperresonant
Induces tracheal deviation away from affected side

F/u with chest tube (thoracostomy)

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17
Q

Pericardial tamponade signs

A

RV is looser/floppier than LV so it collapses. We cannot fill. Basically a diastolic HF.

Engorged neck veins
Clear lung sounds

Beck’s triad = distant heart sounds, JVD, hypotension

Dx: FAST

Tx: Pericardialcentesis

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18
Q

Contractility issues signs

A

Pt will have engorged neck veins

Also with pulm edema

Dx = Echo or FAST

Tx = medically manage

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19
Q

Vasomotor shock signs

A

Normal response to shock is to increase SVR therefore preload, HR, contracility issues generally cause cold extremities

HERE, we get vasodilation leading to warm extremities despite low BP.

Dx: depends on mechanism

TX: give back what they’re lacking (ANS tone) with vasopressors

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20
Q

Secondary survey

A

Stage in trauma eval after all the ABC business

Get trauma history (AMPLE history)

Allergies
Meds/Mechanism of injury
PMH/Pregnant?
Last meal
Events surrounding mechanism of injury

Head to toe eval

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21
Q

How is body water distributed?

A

2/3 intracellular
1/3 extracellular
- 1/4 intravascular
- 3/4 extravascular

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22
Q

Basilar skull fracture

A

Look for Battle sign - bruising around eyes and behind ears

Runny nose - that’s CSF actually coming out!

Get CT

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23
Q

Epidural hematoma

A

MMA breaks and starts to bleed. Space btw skull and dura fills with blood. Will get big enough and push on brain.

Initial LOC
Lucid period
Death

“Walk, talk, and die syndrome”

Dx: Get CT (lens-shaped)
Tx: Craniotomy

“Epi was a horrible class that I thought would be easy. I’m glad I can look at it through the lens of time now.”

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24
Q

Acute subdural

A

Young patient. May be sign of abuse in baby.

Usually need a HUGE trauma like MVAs.

Blood fills btw brain and dura

Course = trauma then coma then death

Dx: CT (crescent shaped).
Tx: Keep ICP low (hypervent, raise bed head, mannitol). Pray.

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25
Q

Chronic subdural

A

Older patients or alcoholics

Shrunken brain = stretched veins. Tearing of bridging veins from minor trauma or an old trauma maybe weeks ago.

HA then progressive dementia.

Dx: CT (crescent shaped)
Tx: Craniotomy

This is why all patients with dementia should get a CT

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26
Q

Why should all patients with dementia get a CT?

A

Could just be chronic subdural hematoma

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27
Q

Ways to reduce ICP

A

Hyperventilation
Raise head of bed
Mannitol

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28
Q

Concussion

A

Sports injury
LOC
Amnesia (retrograde)

CT is normal

Tx: Go home but only if patient has family to keep them up. Keep them awake for 24 hrs

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29
Q

Diffuse Axonal Injury

A

Patient who had angular trauma like a car accident where car spun a lot

Presents with coma

CT shows blurring of grey-white junction

Tx = pray

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30
Q

Neck zones

A

Zone 1 = lowest. Below cricoid and above clavicle (most conservative)

Zone 2 = middle (lots of surgery here)

Zone 3 = above angle of mandible (some surgery)

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31
Q

When does penetrating trauma to the neck always lead to surgical exploration?

A

All cases where there is:
Expanding hematoma

Deteriorating vitals

Clear signs of esophageal or tracheal injury (coughing or spitting blood)

GSW to middle neck

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32
Q

GSW to middle neck (zone 2)

A

surgery always

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33
Q

GSW to lower neck (zone 1)

A

Arteriography, esophagogram (water soluble then barium if negative), esophogoscopy, and bronchoscopy before surgery to decide approach

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34
Q

GSW to upper neck (zone 3)

A

Arteriogram. If abnormal then surgery

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35
Q

Stab wounds to all zones

A

Arteriogram and U/S

Looking for expanding hematoma or active bleeding

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36
Q

Why is surgery uncommon for zones 1 and 3?

A

Blood supply is hard to control in these regions.

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37
Q

ALS (tract)

A

Pain and temperature.

lateral spinal cord, anterior

Crosses over before ascending

38
Q

DCML

A

Vibration/Position

Dorsal, medial

Crosses over in brainstem

39
Q

Motor tracts

A

Upper extremity more medial than lower extremity. Lateral spinal cord.

40
Q

Cord Syndrome

A

Patient with FND
- ED, urine/fecal incont, erection that doesn’t stop

Dx = MRI

Initial trauma doesn’t do the damage. It’s the edema around it. Therefore, you can really skip the MRI and just give them dexamethasone (decadron)

41
Q

Complete transection of spinal cord

A

At the site of the lesion you lose LMNs - paralysis

Below the site you lose UMNs - upgoing Babinsky and hyperreflexia

All sensory is lost and all pain/temp is lost.

Basically nothing works below the lesion

42
Q

Hemisection

A

Ipsilateral loss of motor and sensory (vib/position)

Contralateral loss of pain/temp

Sharp knife trauma

43
Q

Anterior Cord lesion

A

Burst fractures of the vertebral bodies.

Loss of motor function and loss of pain/temp on both sides distal to injury

Preserved vibration/position sense

44
Q

Central Cord Syndrome

A

Patient is elderly with forced hyperextension of the neck (rear-end collision). There is paralysis and burning pain in upper extremities with preserved functions in lower extremities

Sort of like syrinx - cape-like distribution. May expand to include ALS.

45
Q

management of spinal cord injuries

A

MRI: CT is easier to do if we only need to see bones.

Some think high dose steroids right after the injury may help

46
Q

Pericardial tamponade - more detail

A

Usually seen with penetrating thoracic trauma, but blunt can cause it too.

Tachycardia, muffled heart sounds, JVD, hypotension and electrical alternans on ECG (alternating heights of R in QRS complexes)

Dx with cardiac U/S as part of FAST

Requires immediate decompression via needle pericardiocentesis, pericardial window or thoracotomy with manual decompression

Clinically apparent tamponade may result from 60-100ml of blood

47
Q

Blunt cardiac trauma

A

Usually secondary to MVAs, fall from heights, crush injury, blast injury, direct violent trauma

Get a screening ECG

48
Q

How should pericardium be opened?

A

anterior and parallel to phrenic nerve (longitudinally)

49
Q

Pneumothorax

A

Can be from penetrating trauma or blunt trauma that caused a rib fracture

Air in pleural space

Usually asymptomatic. Maybe Chest pain.

Dyspnea
Hyperresonance of affected side
Decreased breath sounds of affected side

Dx: upright CXR - absence of lung markings where the lung has collapsed. Vertical lung shadow.

Tx: Tube thoracostomy in upper lung. Confirm placement with CXR

50
Q

Tension pneumothorax

A

Air enters pleural space and cannot escape. Causes total ipsilateral lung collapse and mediastinal shift, impairing venous return and thus decreasing cardiac output resulting in shock

Same signs as pneumothorax PLUS tracheal deviation away from affected side

Dx should be clinical - don’t wait on the CXR to start treatment

Tx: immediate needle decompression followed by tube thoracostomy

51
Q

Hemothorax

A

Dyspnea
Dullness to percussion
Reduced breath sounds

Lung compressed upward so there is an air-fluid level.

Dx: CXR shows horizontal air-fluid level

Tx: Thoracostomy in lower lung.

We need to figure out if bleed is from peripheral or pulmonary artery. Pulm vasculature is lower pressure and stops on its own.

Look at chest tube output - If 1500cc initial drainage OR 600cc in 6hrs go to surgery (thoracotomy)

25% of hemothorax cases have associated pneumothorax

75% of hemothorax cases are associated with extrathoracic injuries

52
Q

Indications for thoracotomy

A

1500cc initial drainage from chest tube

200cc/hr for 4hrs continued drainage

  • Thoracic great vessel injury
  • Esophageal injury
  • Patients who decompensate after initial stabilization
53
Q

Sucking chest wound

A

ONLY from penetrating trauma from the outside (not ribs)

Breathe in: air enters
Exhale: flap closes. Air gets stuck

May get a tension pneumo

Pt = trauma, dyspnea, tension pneumo

Dx: Visual inspection

Tx: Occlusive dressing taped on 3 sides to create our own valve. THEN chest tube to drain whatever air is left.

54
Q

Rib fracture

A

Blunt trauma usually

Can induce ANY of the penetrating traumas

CP that makes them splint - won’t breathe much. Reduced breathing leads to higher risk for atelectasis and pneumonia

Dx = CXR
Tx = pain control (avoid tons of opiates) balanced with breathing
55
Q

Flail chest

A

Flail chest is an indication for looking for problems inside the chest

HUGE blunt trauma - requires 2+ ribs broken in 2+ places

Paradoxical movement

Dx = visual inspection and CXR
Tx = weights/binders to align it. Maybe surgical placement of a plate
56
Q

What are the indications for investigating for problems WITHIN the chest?

A

Flail chest
Sternal fracture
Scapular fracture

Investigate for: Aortic dissection, pulmonary contusion and myocardial contusion

57
Q

Pulmonary contusion

A

Get CXR - normal initially. All of a sudden the pt gets dyspnea and pulm edema

Takes 48h from trauma for CXR to show b/l whiteout

This is a non-cardiogenic pulmonary edema - a lot like ARDS

Tx = avoid crystalloids. Give colloids BUT really we treat with PEEP (push fluid back into leaky capillaries)

58
Q

Myocardial contusion

A

Dx: prophylactic EKG and troponin

Tx: Control HF and arrythmias with MONA BASH

59
Q

Aortic dissection

A

High speed MVAs. Torn at ligamentum arteriosum due to inertia

Patient is either DOA (total tear) or if tear is incomplete there is an adventitial hematoma

Dx: CXR - This determines index of suspicion
- If widened mediastinum, tearing CP radiating to back or dif BPs on exam then index is very high.

THEN do CT. If index is high and CT is negative do angiogram. If index is low and CT negative stop.

Tx = surgical repair. Get systolic BP as low as you can first.

60
Q

Seat-belt sign

A

ecchymotic area found in distribution of lower anterior abdominal wall and can be associated with perforation of bladder or bowel as well as lumbar distraction fracture (Chance Fracture)

61
Q

Cullen’s sign

A

Periumbilical ecchymosis is indicative of intraperitoneal hemorrhage

62
Q

Grey-Turner sign

A

Flank ecchymosis indicative of retroperitoneal hemorrhage

63
Q

Kehr’s sign

A

L shoulder or neck pain secondary to splenic rupture

Increases in trandelenburg position or with LUQ palpation

Caused by irritation of diaphragm

64
Q

GSW to abdomen

A

All go to ex-lap

65
Q

Knife to abdomen treatment

A

If you see:
Evisceration
Peritoneal signs
Shock

GO TO EX-LAP

If you probe the wound and cannot enter peritoneum then watch/wait. If you can enter then GO TO EX-LAP

66
Q

How much blood can each compartment hold?

A 
Head = 50cc
Chest = 500cc
Abdomen = 1500cc
Pelvis = 2000cc
Thighs = 1000cc each
Ankles = 200cc each
Arms = 100cc each
Forearms = 50cc each

Anything below nipple and above knee then can kill you

67
Q

Blunt trauma to abdomen

A

We need to know if patient is bleeding or not

Get FAST or CT

If bleeding then Ex-Lap

68
Q

FAST

A

Positive if free fluid is demonstrated in abdomen

4 views used to search for free fluid (presumed to be blood in trauma patient) that collects in dependent areas and appears as hypoechoic on US

1) Morrison’s pouch (RUQ) - btw liver and kidney
2) Splenorenal recess (LUQ) - btw spleen and kidney
3) Pouch of Douglas - above rectum “bladder view”
4) Subxiphoid and parasternal views - looks for hemopericardium

69
Q

Pros/Cons to FAST

A

Pros: Fast, noninvasive, 80-95% sensitive for intra-abdominal blood

Cons: user dependent, low specificity for individual organ injury

70
Q

What are some potential iatrogenic causes of great vessel injuries?

A

CVP line or CP placement

Intra-aortic balloon pump placement

Overinflation of Swan-Ganz

71
Q

What is the mortality associated with traumatic aortic rupture?

A

90% die at scene

another 50% die within 24h

72
Q

How can you detect an injury to innominate or subclavian arteries?

A

Absent/low upper extremity pulses and BP

Increased lower extremity pulses

73
Q

What are some possible sources of bleeding detected by FAST?

A

1 = ruptured liver

  • ligamentum teres tears from inertia
  • Tx = repair or lobectomy. Can do pringle (grab hepatoduodenal ligament and cut off hepatic artery/portal vein)

Ruptured spleen

  • massive bleed
  • has a capsule so repair is pretty easy
  • if you can fix it save it
  • if not sacrifice it - remember to vaccinate against encapsulated organisms

Ruptured diaphragm

  • BS in thorax
  • Kehr’s sign
  • Get CXR
  • Tx = surg
74
Q

Pelvic trauma

A

Major MVA/Fall to break a pelvis

Use hip-rocking maneuver - will always be broken in 2 places. Can move it in 2 directions at once with extreme pain

Look for urethral injuries - high riding prostate, blood at meatus. Get an IV pyelogram and avoid foley.

May require prophylactic protoscopy to rule out rectal injury

Dx = CT (the same one we got during FAST)

Tx = give them blood and track H/H
Do NOT operate. Let the hip heal first.

75
Q

25 yo F presents after high speed MVA with dyspnea and tachycardia. Local bruising over right side of chest. CXR shows a right upper lobe consolidation.

A

Pulmonary contusion.

76
Q

First degree burn

A

Like a sunburn

Erythema, warm, tender

No blisters

77
Q

Second degree burn

A

Erythema, warm, tender

Blisters

78
Q

Third degree burn

A

Deeper than dermis (into fascia or muscle)

Painless

Surrounded by 2nd degree burns

White/charred lesions

79
Q

Chemical burn

A

Alkali or acidic

Alkali are worse

Either on the skin - never buffer. just irrigate a ton

OR swallowed - never vomit. CAN buffer here bc it’s in stomach

80
Q

Respiratory burns

A

Closed fire/explosion

Chemicals/smoke inhaled and may burn larynx.

Eventual edema can block the airway

Look for soot on nostrils/mouth

Dx = bronchoscopy

Tx = intubation

81
Q

Electrical burns

A

Lightning strikes or touching high voltage wires

Entrance and exit wounds

Can cause arrhythmias

Can burn muscle in contact with bone (bones conduct electricity well). This can cause rhabdo.

Can act on nerves as well and generate muscle contractions that can cause posterior dislocation of shoulder

Dx = check CK. If positive get creatinine

Tx = IVF and mannitol

82
Q

Circumferential burns

A

No matter the source

Initially blood vessel is patent. THEN cut off by eschar

Watch for signs of vascular compromise.

Dx = clinical
Tx = cut the eschar at bedside (it's 3rd degree so it won't hurt)
83
Q

Parkland formula

A

Tells us how much fluid we need to give burn patients

(%BSA involved)(kg body weight)(4cc) = fluids lost

Add that number of cc’s of LR to 2000cc of D5W

Replace the total as: 50% in first 8hrs. 50% in next 16hrs.

84
Q

Rule of 9s

A

ONLY count 2nd/3rd degree burns

Whole head = 9%
Chest front = 9%
Upper back = 9%
Abdomen front = 9%
Lower back = 9%
Leg front = 9% x 2
Leg back = 9% x 2
Arm = 9% x 2

Total = 99%

Genitalia = 1%

85
Q

Rabies algorithm

A

Animal bite… was it a wild animal?

Wild: Capture it and kill it. Look at its brain. If you see signs of rabies or you couldnt catch the animal then vaccinate (vaccine + IgG)

Domestic: Observe the animal. If you see signs of rabies then vaccine + IgG

If never see signs of rabies then nothing needs to be done

86
Q

bee sting

A

Anaphylaxis?

Yes: SubQ Epi 1:1000 + H1/H2 blockers

No: remove stinger

87
Q

Snake bite

A

Signs it’s venomous: slit-like eyes, cobra cowl, rattlers

Patient will have skin changes, erythema and lots of PAINNN if it’s venomous.

Dx = clinical
Tx = anti-venom
88
Q

Black widow bite

A

Pt has bite and abdominal pain OR enzymatic evidence of pancreatitis**

Dx = it's pretty much too late
Tx = IVF and IV Calcium to treat the pancreatitis
89
Q

Brown recluse bite

A

Attic. Old boxes. Southern USA.

Starts off with small dot of erythema

Progresses to necrotic ulcer with ring of erythema

Dx = clinical
Tx = debridement over and over. Skin grafting when toxin has resolved
90
Q

Human bite

A

WORST ONE

Sex act or fist fight
Shady story

Dx = clinical and shady story

Tx = Debride, explore wound and irrigate a ton THEN give Abx (amoxicillin or augmentin)

Surgery (27 decks)

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