Trauma Flashcards
Need airway but subcutaneous emphysema in neck? What to do?
Fiberoptic bronchoscope mandatory.
Clinical signs of shock?
Low BP (under 90 mmHg systolic), fast feeble pulse, and low urinary output (
Types of Trauma Shock
Hypovolemic hemorrhagic
- Central venous pressure is low.
Pericardial tamponade, or tension pneumothorax.
- CVP is high.
- Blunt and penetrating trauma to chest.
- Respiratory distress will distinguish these two.
Tx of Hemorrhagic Shock
Surgical intervention and volume replacement.
- 2 L of LR followed by blood until UO is > 0.5 to 2 mL/kg/h, while not exceeding CVP of 15 mmHg.
Preferred Route of Fluid Resuscitation
2 peripheral IV lines, 16 gauge, or femoral or saphenous catheter.
Management of Pericardial Tamponade
Pericardial centesis, tube, pericardial window, or open thoracotomy.
Tension Pneumothorax
Needle into affected space, followed by chest tube connected to underwater seal.
Intrinsic cardiogenic shock
Tx with circulatory support.
Vasomotor Shock
Seen in anaphylactic rxns, high spinal cord transection, high spinal anesthetic.
Tx: Restore peripheral resistance (vasopressors); additional fluids will help.
Linear Skull Fractures
- Left alone if closed.
- Wound closure if open.
- OR if comminuted or depressed.
Head Trauma with Unconsciousness
1) CT scan to look for intracranial hematoma.
2) If none and neurologically intact, can go home as long as someone looks over them for the next 24 hours.
Signs of fractures affecting base of skull
Raccoon eyes, rhinorrhea, otorrhea, or ecchymosis.
Assess integrity of cervical spine.
Nasal endotracheal intubation should be avoided in these patients.
Insertion of Airway Types
Orotracheal via laryngoscope or nasotracheal intubation over fiber optic bronchoscope.
Acute Epidural Hematoma
Trauma, unconsciousness, lucid interval, gradually lapsing into coma again, fixed dilated pupil (on same side of hematoma), and contralateral hemiparesis.
- Biconvex, lens shaped hematoma on CT
- Tx: Emergency craniotomy
Acute Subdural Hematoma
Presents same as acute epidural hematoma. Pt much sicker.
- Semilunar, crescent shaped hematoma.
- Midline structures deviated.
- Prevent increase in ICP by elevating head, hyperventilate, mannitol, furosemide, sedation and hypothermia to reduce oxygen demand on the brain.
Diffuse Axonal Injury
Severe Trauma
- Diffuse blurring of gray-white matter interface and multiple small punctate hemorrhages on CT.
- Prevent increase in ICP.
Chronic Subdural Hematoma
Old and alcoholics; tearing of venous sinus (bridging veins).
- Surgical evacuation of hematoma. Sx worse when hematoma grows.
Can hypovolemic shock happen from intracranial bleeding?
No! Not enough space.
Neck Trauma
- GSW to upper neck: arteriography and management is preferred.
- GSW to base of neck: arteriography, esophagogram, esophascopy, and bronchoscopy to decide surgery approach.
- Blunt trauma to neck: CT to check cervical spine.
Hemisection (Brown-Sequard)
Ipsilateral paralysis and loss of proprioception distal to injury. Contralateral loss of pain perception.
Anterior Cord Syndrome
Seen in burst fractures of vertebral bodies.
Loss of motor function, pain, and temperature sensations bilateral.
Vibratory and positional sense is preserved.
Central Cord Syndrome
In elderly from forced hyperextension of neck.
Paralysis and burning pain in upper extremities.
Best imaging for spinal cord injuries?
MRI
Rib Fracture
Pain, hypoventilation, atelectasis, pneumonia. Tx with local nerve block and epidural catheter.
Plain Pneumothorax
Shortness of breath, no breath sounds on one side, hyperresonant to percussion.
-Tx: Chest Xray and chest tube placement, upper and anterior, and connect to water seal.
Hemothorax
- Chest tube needs to be placed low.
- Lung is usual bleeding source and will stop by itself.
- If systemic vessel, thoracotomy. Surgery needed if
Severe Blunt Trauma to Chest- Need to check for what?
- Blood gases and chest xray to detect pulmonary contusions.
- Cardiac enzymes (tropinins) and EKG to detect myocardial contusions.
- Check for traumatic transection of aorta.
Sucking Chest Wounds
Has flap that sucks air with inspiration and closes during expiration.
Can lead to deadly tension pneumothorax.
Tx: Occlusive dressing that allows air out but not in.
Flail Chest
Paradox breathing. Pulmonary contusion.
- Fluid restriction and use of diuretics. Pulmonary dysfunction may develop, and blood gases have to be monitored.
- If respirator needed, then need bilateral chest tubes to prevent tension pneumothorax.
- Also check for aortic transection.
Pulmonary Contusion
Deteriorating blood gases and white out of the lungs on chest xray.
Tx like flail chest.
Myocardial Contusion
EKG and Troponins
Tx is focused on complications, such as arrhythmias.
Traumatic Rupture of Aorta
- @ Junction of arch and descending aorta, requires big deceleration injury. Hematoma contained by the adventitia blows up and kills the patients.
- Suspect when broken first rib, scapula, or sternum, or by presence of wide mediastinum. CT angio best for imaging.
Traumatic rupture of trachea or major bronchus.
Suggested by developing subcutaneous emphysema in upper chest and lower neck, or by large “air leak” from a chest tube.
- Fiberoptic bronchoscopy; surgical repair follows.
Differential for Subcutaneous Emphysema
Rupture of trachea or bronchus, esophagus, or tension pneumothorax.
Air embolism
Sudden death occurs in chest trauma patient. Happens when subclavian vein is opened to air.
- Supraclavicular node biopsies, central venous line placement, CVP lines that becomes disconnected.
- Management: cardiac massage, patient positioned with left side down. Trendelenburg position.
Fat Embolism
Long bone fractures who develops petechial rashes in the axillae and neck, tachycardia, and low platelet count, respiratory distress with hypoxemia and bilateral patchy infiltrates on chest xray.
Tx: respiratory distress.
GSW to Abdomen (Anywhere below nipple line)
Exploratory laparotomy.
Stab Wounds
If protruding viscera, then exploratory laparotomy.
Blunt Trauma to Abdomen
If acute abdomen, exploratory laparotomy.
Need to also determine if there is internal bleeding.
Signs of Internal Bleeding in a Patient with Blunt Trauma
Low BP, high pulse, low CVP, low urinary output in cold, pale, anxious patient who is shivering, thirsty, and perspiring perfusely. Must lose about 1500 mL (only in abdomen, thigh, and pelvis)
Dx of Intraabdominal Bleeding
- CT scan will show presence of blood. Get only in hemodynamically stable patient.
- If hemodynamically unstable, diagnostic peritoneal lavage or newer sonogram (blood in cavity or not). If positive, prompt exploratory laparotomy.
Ruptured Spleen
Fractures of lower ribs on left side. Repair over removal otherwise postoperative immunization against Pneumococcus, haemophilus influenza B, and meningococcus.
Intraoperative Development of Coagulopathy
If also presence of hypothermia and acidosis, laparotomy has to be promptly stopped and returned to later.
Abdominal Compartment Syndrome
Occurs when lots of fluids and blood has been given during prolonged course of laparotomy, so by time of closure, abdominal wound cannot be closed without undue tension.
- May not occur until 2nd postoperative day.
- Distention, hypoxia, and renal failure from pressure of vena cava.
Pelvic Fracture
Associated injuries need to be ruled out.
- Rectal exam and protoscopy to rule our injury to rectum and bladder.
- Pelvic exam for vagina in women and retrograde urethrogram for urethra in men.
Pelvic Fractures with Ongoing Significant Bleeding
Tx: Pelvic fixators followed by IR for angiographic embolization of both internal iliac arteries.
Hallmark of Urologic Injuries
Blood in urine in someone who has sustained penetrating or blunt abdominal trauma.
Penetrating Urologic Injuries
Needs to be surgically explored and repaired.
Urethral Injury
Occurs almost exclusively in men. Blood present at meatus.
- Sx: Scrotal hematoma, posterior injuries- sensation of wanting to void but not being able to do it, and high-riding prostate on rectal exam.
- Avoid Foley catheter until retrograde urethrogram.
Bladder Injuries
Dx via retrograde cystogram. Xray must include postvoid films
If extraperitoneal leak, catheter. If intraperitoneal leak, surgical repair is done and protected with suprapubic cystostomy.
Renal Injuries
CT scan. Can be managed without surgical intervention.
- Complications: development of an arteriovenous fistula leading to congestive heart failure. Renal stenosis - renovascular hypertension.
Scrotal Hematomas
Typically do not need intervention unless testicle is impaired (assessed via sonogram).
Fracture of Penis
Fracture of Corpora Cavernosa and Tunica Albuginea
Sudden pain and development of large penile shaft hematoma, with normal appearing glans.
Tx: emergency surgical repair
Penetrating Injuries of Extremities
If near major vessels, doppler and CT angio are done. If there is obvious vascular injury, surgical exploration and repair are required.
Combined Injuries of Arteries, Nerves, and Bones
Stabilize bone first, delicate vascular repair, and leave nerve for last.
Possibly fasciotomy b/c prolonged ischemia could lead to compartment syndrome.
High Velocity GSW
Produces large cone of tissue destruction that requires extensive debridements and potential amputations.
Crushing Injuries
Hazard of hyperkalemia, myoglobinemia, myoglobinuria, and renal failure, and potential for compartment syndrome.
- Tx: Fluid administration, osmotic diuretics, and alkalinization of urine are good preventive measures. Fasciotomy may be required.
Chemical Burns
Massive irrigation. Alkaline burns are worse than acid burns. Irrigation must begin as soon as possible.
High-voltage electrical burns
Always deeper and worser than they appear. Massive debridements or amputations may be required.
- Myoglobinemia-myoglobinuria-renal failure, ortho injuries due to muscle contraction, and late development of cataracts and demyelinization syndromes.
Respiratory Burns (Inhalation Injuries)
- Burns around mouth or soot inside throat is suggestive. Dx confirmed with fiberoptic bronchoscopy. Respirator needed or not? Check blood gas levels.
Circumferential Burns
Escharotomies
Scalding Burns in Children
child abuse
Fluid Replacement in Severely Burned Patients
Aim for hourly UO of 1 to 2 mL/kg/hr, while avoiding CVP over 15mmHg.
Adjust fluid resuscitation accordingly.
Appropriate Predetermined Rate of Fluid Infusion in Adult
Start at 1000 mL/h of Ringer lactate (without sugar; would invalidate it) on anyone whose burns exceeds 20% of body surface, and adjust as needed to produce appropriate urinary outcome.
Fluid Needs in Burn Babies
Third degree burns: areas look deep bright red, rather than gray and leathery dry appearance.
- Initial rate should be 20mL/kg/hr if burn exceeds 20% of body surface.
Aspects of Burn Care
Tetanus prophylaxis, cleaning of burned areas, and use of topical agents.
Silver sulfadiazine. If deep penetration is required, mafenide acetate is choice.
Triple antibiotic ointment for burn near eyes.
Early excision and skin grafting for burn patients
Done only for fairly limited burns (under 20%) that are obviously third-degree.
Snakebites and Venom
Tx: CROFAB (antivenin); valid first aid is to splint the extremity during transportation.
Bee Stings
Death caused by vasomotor shock.
Epinephrine is DOC; stingers should be removed without squeezing.
Black Widow Spiders
N/V and severe generalized muscle cramps. Antidote is IV calcium gluconate. Muscle relaxants can also help.
Brown Recluse Spider Bites
Day after bite- skin ulcer develops with necrotic center and surrounding halo of erythema.
Dapsone is helpful.
Surgical excision when full extent of damage is evident.
Human Bites
Really dirty. Require extensive irrigation and debridement. Need specialized orthopedic care.
