Trauma Flashcards
management of hemodynamically unstable trauma patient with FAST positive
urgent laparotomy
management of hemodynamically stable trauma patient with Grade I-III (low grade) splenic injury
may observe as long as without any evidence for other intra-abdominal injuries, active contrast extravasation, or a blush on CT
management of splenic injury with contrast extravasation or vascular blush on CT
splenic artery embolization
management of high grade IV, V splenic injury
may consider embolization in grave IV, controversial
splenectomy for some IV, and V
absolute indications for laparotomy in blunt abdominal trauma
Anterior abdominal injury with hypotension
Abdominal wall disruption
Peritonitis
Free air under diaphragm on chest radiograph
Positive FAST or DPL in hemodynamically unstable patient
CT-diagnosed injury requiring surgery
absolute indications for laparotomy in penetrating abdominal injury
Injury to abdomen, back, and flank with hypotension
Abdominal tenderness
GI evisceration
High suspicion for transabdominal trajectory after gunshot wound
CT-diagnosed injury requiring surgery
relative indications for laparotomy in blunt abdominal injury
Positive FAST or DPL in hemodynamically stable patient
Solid visceral injury in stable patient
Hemoperitoneum on CT without clear source
relative indications for laparotomy in penetrating abdominal trauma
Positive local wound exploration after stab wound
signs and symptoms of gastric outlet obstruction develop (abdominal pain, distention, and vomiting) in patient with abdominal trauma suggestive of
duodenal hemorrhage
what side does diaphragmatic rupture usually happen on
left
management of hemodynamically stable patients with liver injury who demonstrate pooling of intravenous contrast on initial or subsequent abdominal CT scan
hepatic embolization
management of hemodynamically stable patients with liver injury with no other indication for abdominal exploration
observation
monitored care, serial abdominal examination, and serial hemoglobin assessment and potentially hepatic embolization
contraindications to non-operative management of liver injury
●Hemodynamic instability after initial resuscitation.
●Other indication for abdominal surgery (eg, peritonitis).
●Gunshot injury (relative contraindication if extrahepatic injury is suspected).
●Absence of an appropriate clinical environment to provide monitoring, serial clinical evaluation, or availability of facilities and personnel for hepatic embolization or urgent abdominal exploration should the need arise.
management of grade VI liver injury
hepatic avulsion - by nature are hemodynamically unstable and require operative management
indication for surgical management of liver injury
hemodynamically unstable patients
nonoperatively managed patients who continue to bleed (ongoing blood transfusion, hemodynamic instability), and in some patients who manifest a persistent systemic inflammatory response (ileus, fever, tachycardia, oliguria)
ipsilateral fixed and dilated pupil due to unopposed sympathetic tone, further herniation compresses pyramidal tract which results in contralateral motor paralysis - caused by which herniation syndrome
uncal herniation
bilateral pinpoint pupils, bilateral Babinski’s signs and increased muscle tone —> fixed midpoint pupils follow along with prolonged hyperventilation and decorticate posturing - caused by which herniation syndrom
central transtentorial herniation
pinpoint pupils, flaccid paralysis, and sudden death - caused by which herniation syndrome
cerebellar tonsillar herniation
conjugate downward gaze with absence of vertical eye movements and pinpoint pupils - caused by which herniation syndrome
upward transtentorial herniation
inclusion criteria for CT head rule
minor head injury with LOC, amnesia, or disoriented, GCS 13-15
indications for CT head as per rule
- signs of basilar skull fracture - CSF otorrhea, rhinorrhea, racoon eyes or battle sign
- vomiting 2 or more times after injury
- GCS < 15 at 2 hours after injury
- age over 65
med risk: amnesia before impact > 30 mins, dangerous mechanism (pedestrian, occupant ejected, fall from elevation)
exclusion criteria for CT head rule
- Age under 16
- Minimal head injury with no LOC, amnesia, or disorientation
- Unclear history of trauma as the primary event (ie primary seizure or syncope)
- Obvious penetrating skull injury or depressed fracture
- Acute focal neurological deficit
- Unstable vital signs associated with major trauma
- Seizure prior to ED assessment
- Anticoagulation or bleeding disorder
- Pregnancy
Quick Confusion Scale
Quick Confusion Scale year?-2 month? -2 short key phrase, patient repeat time? 2 count backward from 20 to 1 - 2 say months in reverse -2 repeat key phrase - 5
-abnormal if 11 or less score
primary treatment for mTBI
rest
avoid asa and NSAIDs
checklist for management of head trauma in ED
- C-spine precautions
- airway: maintain, intubate for GCS <8 or PRN- induction agents: etomidate, propofol, six, roc
- oxygenation and ventilation: SpO2 > 90, PCO2 35-45 - do not hyperventilate prophylactically (Prolonged (>6 hours) hypocapnia causes cerebral vasoconstriction and worsens cerebral ischemia)
- BP: SBP >90, MAP 80, give NS, blood products PRN; no permissive hypotension
- exam and GCS: before paralytics given
- stat head CT and C-spine CT
- repeat exam: check GCS for changes and signs of impending herniation/deterioration
- check glucose: treat hypo and hyperglycaemia - keep from 5.5 to under 10
- control temp: maintain between 36-38.3
- seizure prophylaxis: give antiepileptic drug if GCS <10, acute seizure with injury, or abnormal head CT - use dilantin, fosphenytoin or keppra
- identify and treat elevated ICP, herniation: head of bed at 30 degrees, ensure goo`d BP, ventilation and temp control, give mannitol 1g/kg IV bolus, urgent neurosurgical consult, consider hypertonic saline bolus in refractory ICP
- neurosurgery referral/transfer: ICP monitoring, ventriculostomy for ICP management surgery
what wounds need tetanus immunoglobulin
tetanus prone wound (wounds >6h old, >1cm deep, puncture wounds, avulsions, wounds resulting from missiles, crush wounds, burns, frostbite, wounds contaminated with dirt, faces, soil or saliva) AND uncertain or less than 3 doses of tetanus toxoid vaccine
what to do with any wound, no tetanus toxoid booster within past 10 years/ or uncertain immune status
tetanus toxoid booster
what do with dirty wound, last booster more than 5 years ago
tetanus toxoid booster
what to do with any wound, last booster less than 5 years ago
nothing !
high risk factors for wound infection
puncture wounds
wounds > 12h old
hand or foto wounds
immunocompromised
patient age >50
prosthetic joints or valves (risk of endocarditis)
suture size and duration for face
6-0, 5 days
suture use and duration for skin, not joint
4-0, 7 days
suture size and duration for joint skin
3-0, 10 days
suture choice for mucous membrane
absorbable (vicryl)
X ray features of aortic tear
ABC WHITE Xray features of Aortic tear Bronchus (left main) depressed Cap (pleural cap) Wide mediastinum Hemothorax Indisctinct aortic knuckle Tracheal deviation to right side Esophagus (NG tube) deviated to the right
hard signs of vascular injury in neck trauma
shock unresponsive to initial fluid therapy active arterial bleeding pulse deficit pulsatile or expanding hematoma thrill or bruit
hard signs fo rlarygnotracheal injury in neck truama
stridor hemoptysis dysphonia air or bubbling in wound airway obstruction
soft signs of vascular injury in neck trauma
hypotension in field
history of arterial bleeding
nonpulsatile or non expanding hematoma
proximity wounds
soft signs for laryngotracheal injury in neck trauma
hoarseness neck tenderness subQ emphysema cervical ecchymosis or hematoma tracheal deviation or cartilaginous step-off larygenal deem or hematoma restricted vocal cord mobility
soft signs for pharyngoesophageal injury in neck trauma
odynophagia subcutaneous emphysema dysphasia hematemesis blood in the mouth saliva draining form wound severe neck tenderness prevertebral air transmidline trajectory
