Trauma

Question 1

Mortality associated with thoracic trauma requiring exploration?

Answer 1

Operative mortality of patients requiring emergency thoracotomy:

• 67% of patients blunt injury
• 17% of patients with penetrating injury

Question 2

Overall mortality of thoracic trauma

Answer 2

10%

Question 3

Extent of the diaphragm

Answer 3

Skin margin:

Anterior: umbilicus and nipple (fourth intercostal space)

posterior: inferior tip of the scapula posteriorly.

Bony:

The bony landmarks for the diaphragm extend from T8 to L1.

With expiration, the diaphragm rises to the level of the nipple and T5.

Question 4

Superior margin of the chest

Answer 4

zone 1 of the neck :

cricothyroid membrane to the sternal notch

Question 5

Volume which the pleura can accommodate

Answer 5

In the adult, each pleural space can accommodate as much as 3 L of blood. This large volume loss will cause rapid progression to class IV hemorrhagic shock and exsanguination

Question 6

Volume which the pericardium can accommodate

Answer 6

In contrast, the pericar- dium can only acutely accommodate an additional 100 to 200 mL of blood before venous return and diastolic filling are impaired, causing cardiac tamponade and shock.

Question 7

Class I hemorrhage - volume of blood loss

Answer 7

Class I:

Blood Volume Loss <15%

Adult blood loss <750 ml

Question 8

Class II hemorrhage - volume of blood loss

Answer 8

Blood Volume Loss: 15-30%

Adult: 750-1500 ml of blood loss

Question 9

Class III hemorrhage - volume of blood loss

Answer 9

Blood Volume Loss: 30-40%

Adults: 1500-2000 ml blood loss

Question 10

Class IV hemorrhage - volume of blood loss

Answer 10

>40%

>2L

Question 11

Class I hemorrhage -Characteristics

• Blood Volume Loss: % & ml
• Cardiovascular:
• pH
• Respiratory
• Neurologic
• Skin
• Delayed Capillary Refill
• Renal

Answer 11

Characteristics

Blood Volume Loss <15%

Adult blood loss <750 ml

Cardiovascular

• Heart Rate normal or mild increase
• Pulses normal
• Blood Pressure normal

pH normal

Respiratory: Rate normal

Neurologic: Slightly anxious

Skin

• Warm and pink
• Capillary Refill brisk (<2 seconds)

Renal: Normal urine output

Adults: >0.5 ml/kg/hour (>30 cc/hour)

Children: >1 ml/kg/hour

Infants <1yo: >2 ml/kg/hour

Question 12

Class II hemorrhage - Characteristics

• Blood Volume Loss:% / ml
• Cardiovascular
• pH
• Respiratory
• Neurologic
• Skin
• Renal

Answer 12

Characteristics

• Blood Volume Loss: 15-30%
• Adult: 750-1500 ml of blood loss
• Cardiovascular
  
  • Tachycardia
  • Diminished peripheral pulses
  • Blood Pressure normal
• Normal pH
• Respiratory
  
  • Mild Tachypnea
• Neurologic
  
  • Irritable
  • Confused
  • Combative
• Skin
  
  • Cool extremities
  • Mottling
  • Delayed Capillary Refill
• Renal
  
  • Oliguria
  • Increased specific gravity

Question 13

Class I hemorrhage % volume blood loss

Answer 13

class I 40%

Question 14

Class IV Shock: % volume blood loss

Answer 14

>40%

Question 15

Among severely traumatized patients, __of deaths are thought to be secondary to chest trauma.

Answer 15

25%

Question 16

?% of unrestrained individuals in MVC sustain chest trauma

Answer 16

50%

Question 17

Initial management of tracheobronchial injury

Answer 17

Intervention will be directed initially toward the pneumo- thorax, as the tracheobronchial injury (TBI) is often not yet suspected. Persistent pneumothorax or air leak after placement of a chest tube should alert the physician to the possibility of a TBI. Insertion of a second chest tube is required in these cases. TBI must be suspected if a patient deteriorates rapidly following endotracheal intubation. Because of positive pressure ventilation and loss of negative intrathoracic pressure on inspiration, air leak is increased, followed by increasing difficulties with oxygenation and ventilation.

Question 18

Anatomy of most tracheobronchial injuries

Answer 18

most within 2 cm of the carina most within the right mainstream bronchus followed by lower trachea

Question 19

Tension Pneumothorax presentation (two ways)

Answer 19

• An awake patient:
  
  • Able to mount a compensatory response increasing his respiratory rate, tidal volume, negative inspiratory pressure, and chest expansion. –> The physiologic insult: primarily hypoxic with progressive respiratory decompensation; hypotension is the terminal event of hypoxic cardiac failure or respiratory arrest.
• Sedated and ventilated patients:
  
  • cannot compensate, and show a greater degree of impeded venous return from both the intrapleural pressure and the PPV. The deterioration is much more rapid, resulting in more rapid cardiogenic shock once the central venous pressure equals the intrapleural pressure, and causing complete obstruction of venous return.

Question 20

how often is a classic tension ptx seen in an awake vs intubated patient

Answer 20

TPTX show that tracheal devi- ation, oxygen desaturation, and hypotension are actually INCONSISTENT findings in (awake) spontaneously ventilating patients (

Question 21

warning signs of tension ptx on ventilated patient

Answer 21

PPV who suddenly deteriorates with falling SaO2, rapidly becomes hypotensive without a clear reason, becomes difficult to bag, or shows raised peak inspiratory pressures on a ventilator

Question 22

Indications for immediate needle decompression

Answer 22

1. Traumatic arrest 2. Loss of blood pressure or pulse during resuscitation 3. Increased difficulty to bag/raising peak ventilatory pressures combined with hypotension 4. Hypotension or hypoxia/respiratory distress with decreased/absent breath sounds on one side or palpable subcutaneous emphysema.

Question 23

% of lung contusion which requires mech ventilation

Answer 23

18-30%

Question 24

Rib fractures consistent with lower abdominal injuries

Answer 24

9-12th

Question 25

How much blood need be in the chest to see on cxr

Answer 25

150-200ml

Question 26

comparison of sensitivity of E-Fast and cxr in showing blood in the pleurae

Answer 26

Many CXRs done in trauma are performed on the supine patient,–> portable CXR on a supine patient has a sensitivity of 40% to 60% in ruling out hemothorax. E-FAST can identify as little as 20 mL of fluid in the pleural cavity, and has shown sensitivities of greater than 96% in detecting hemothorax.

Question 27

Massive hemothorax

Answer 27

A massive hemothorax is defined as the presence of 1500 mL or more of blood in the thoracic cavity, and is the classic indication to proceed with an urgent thoracotomy.

Question 28

The most common complication after pericardiotomy for trauma is

Answer 28

postpericardiotomy syndrome.

Question 29

___% of caustic injections occur in children __ years old

Answer 29

80% of caustic ingestion occurs in children

Question 30

how long until the caustic effects of a swallowed battery

Answer 30

Severe injury results within 1 hour of ingestion from the extravasation of highly toxic potassium or sodium hydroxide contained in the battery

Question 31

important difference in accidental ingestions vs suicide attempts

Answer 31

volume - accidental are significantly less

Question 32

factors which determine the severity of the effect of a caustic ingestion

Answer 32

1. pH of the ingested substance 2. Whether the substance is solid or liquid 3. Duration of exposure 4. Quantity ingested

Question 33

Anatomically, where in the esophagus are caustic injuries the most severe

Answer 33

at areas of the greatest narrowing, with the greatest narrowing

Question 34

time course of esophageal injury to the esophagus

Answer 34

However in the ensuing 24 to 48 hours the damaged layers begin to degenerate and become infi ltrated with lymphocytes. Angiogenesis and migration of fi broblasts begin between the second and fourth day after injury. By 1 week, the necrotic tissue has sloughed off and ingrowth of granulation tissue begins. The wound is clearly demarcated by this time, and the risk of perforation is probably the highest owing to the low tensile strength of the collagen deposited in the wound.

Question 35

Gastric lavage with corrosive injury to esophagus

Answer 35

Gastric lavage is also contraindicated, owing to the risk of esophageal perforation and aspiration of gastric contents.

Question 36

First degree mucosal injury to esophagus - depth

Answer 36

Mucosal

Question 37

First degree mucosal injury to esophagus - endoscopic appearance

Answer 37

Mucosal hyperemia and edema

Question 38

Second degree mucosal injury to esophagus - depth

Answer 38

Transmucosal, with or without involvement of muscularis.

Question 39

Second degree mucosal injury to esophagus - endoscopic appearance

Answer 39

Hemorrhagic, exudative, ulcerative pseudomembranes

Question 40

Third degree esophageal injury - depth

Answer 40

Full-thickness injury with extension into periesophageal Complete obliteration of esophageal lumen by massive tissue. May involve mediastinal or intraperitoneal organs.

Question 41

when should endoscopy be fist performed after caustic ingestion

Answer 41

early because the risk of rupture increases at 24 to 72 hours

Question 42

Steps to address potential sytemic air embolization?

Answer 42

(1) Ventilation :
(a) Positive pressure ventilation should be avoided if possible.
(b) If intubation and assisted breathing is required, pressures should be minimal.

1. Vigorous hyperventilation is not desirable.
2. Selective lung ventilation with a double-lumen tube or endobronchial blocker can exclude the damaged lung.–>

(c) stopping ongoing gas entrainment.
(d) Cross-contamination of the other lung by blood is also arrested.

(2)Oxygenation & Gas

(a)Oxygen:

1. 100% oxygen administration is good, irregardless of measured oxygen saturation.
2. Room air (80% nitrogen) is essentially insoluble in blood.
3. Intravascular oxygen bubbles will resolve much faster than air emboli.

(b) Nitrous oxide:
1. increases bubble sizeà should be avoided
(3) Intravascular Volume Status
(a) should be kept generous _within lim_its
(b) volume depletion enhances the pressure gradient from airway to pulmonary veins, potentially worsening this complication.
(4) If Hemotypsis is present:
(a) prompt bronchoscopy may exclude large airway injury.
(5) Thoracotmy:
(a) Emergency thoracotomy with mass hilar clamping may be necessary if:

1. cardiac tamponade cannot be excluded
2. lung bleeding continues.

(b)Intracoronary Air

1. should lead to Trendelenberg positioning
2. aspiration of air from the left ventricular apex.
3. Institution of cardiopulmonary bypass has also been advocated..

(c) Hyperbaric therapy?
1. After hemodynamics have been stabilized hyperbaric therapy may be of benefit if cerebral air embolism has occured.

Question 43

Emergency thoracotomy - steps if intracoronary air is seen?

Answer 43

• Intracoronary Air
• should lead to Trendelenberg positioning
• aspiration of air from the left ventricular apex.
• Institution of cardiopulmonary bypass has also been advocated..