Trauma Flashcards
head on collision mechanism of injury associated with which potential injuries
facial injuries
lower extremity injuries
aortic injuries
rear end collision mechanism of injury associated with which potential injuries
hyperextension of C spine
C spine fractures
central cord syndrome
lateral T bone collision mechanism of injury associated with which potential injuries
thoracic injuries
abdominal injuries- spleen, liver
pelvic injuries
clavicle, humerus, rib fractures
rollover MVC mechanism of injury associated with which potential injuries
crush injuries
compression fractures of the spine
*significant mechanism of injury
MVC - ejected from vehicle mechanism of injury associated with which potential injuries
spinal injuries
*significant mortality
MVC with windshield damage (likely unrestrained) mechanism of injury associated with which potential injuries
closed head injuries, coup/contrecoup injuries
facial #s
skull #s
C-spine #s
MVC with steering wheel damage mechanism of injury associated with which potential injuries
thoracic injuries sternal and rib #s, flail chest cardiac contusion aortic injuries hemothorax, pneummothorax
MVC with dashboard involvement or damage
pelvic and acetabular injuries
dislocated hip
MVC proper seat belt use associated wtih
sternal, rib #, pulmonary contusion
MVC use of lap belt only associated wtih
Chance fractures, abdominal injuries, head and facial injuries and #s
MVC use of shoulder belt only associated with
C spine injuries, and #s, “submarine” out of restraint devices, possible ejection
MVC with airbag deployment associated with
upper extremity soft tissue injuries and #s
lower extremity injuries and #s
not effect for lateral impacts, less severe head and upper torso injuries, more severe in children
trauma pedestrian vs. automobile at low speed mechanism of injury associated with which potential injuries
tibia and fibula fractures, knee injuries
trauma pedestrian vs. automobile at high speed mechanism of injury associated with which potential injuries
Waddels triad: tibia and fibula or femur #s, truncal injuries, craniofacial injuries
thrown pedestrians at risk for multi system trauma
bicycle vs. automobile trauma mechanism of injury associated with which potential injuries
closed head injuries
handlebar injuries: spleen or liver lac, additional intra-abdominal injuries, consider penetrating injuries
bicycle trauma - non-automobile related mechanism of injury associated with which potential injuries
extremity injuries
handlebar injuries
what height of fall has an LD50
36-60ft
fall trauma with vertical impact associated with what injrueis
calcanea and lower extremity #s pelvic #s closed head injuries C spine #s renal and renal vascular injuries
fall trauma with horizontal impact associated with what injuries
craniofacial fractures
hand and wrist fractures
abdominal and thoracic visceral injuries
aortic injuries
what components of airway exam important in primary survey in trauma
neck or maxillofacial injuries- sub Q emphysema, expanding hematoma, burns/signs of inhalation injury GCS > 9 sufficient respirato effort no active vomiting no significant oropharyngeal bleeding
what components of breathing exam important in primary survey in trauma
assess for signs of injury that may compromise ability to oxygenate or ventilate
look for increased work of breathing, tachypnea, penetrating wounds, subQ emphysema, chest wall instability, flail segments, tracheal deviation and distended neck veins, equal breath sounds, O2 sat, cyanosis, tracheal deviation
identify and treat flail chest, cardiac injury, pulmonary contusion, tension pneumothorax, open or massive pneumothorax
what components of circulation exam important in primary survey in trauma
mental status, skin color and temp, heart rate, BP, capillary refill
2 large bore 14 or 16G IVs
if patient in shock – non hemorrhagic: tension pneumothorax, cardiac tamponade, cariogenic, neurogenic, septic vs. hypovolemic: hemorrhagic or fluid loss
locate hemorrhage: physical exam: external, thoracic, abdomen, pelvis, long bone
what history is important in secondary survey
AMPLE
allergies medications PMHX last meal environment and events leading up to trauma
treatment/workup of trauma patient with shock
resuscitation: 1-2L isontic funds, 1:1:1 ratio of PRBCs, platelets FFP
prevent hypothermia
TXA 1g IV bolus, followed by 1g infusion over 8 hours
direct pressure/tourniquet for localized hemorrhage
reduce/splint long bone #s
wrap pelvis, angioembolization in pelvic #
internal hemorrhagE: laparotomy or thoracotomy
airway considerations for blunt trauma patients
severe maxillofacial injuries
maintain C spine in line immobilization, consider awake intubation for C spine injuries
assess for laryngeal / tracheal injury
anticipate blood/emesis in the airway
airway considerations in penetrating trauma
watch for expanding hematoma
anticipate significant bleeding
impaired video/fiberoptic techniques
breathing considerations in blunt trauma
chest contusions
flail segment
bowel sounds in chest
breathing considerations in penetrating trauma
chest injury
significant bleeding
sucking chest wound
circulation considerations in blunt trauma
positive FAST
unstablie pelvis
long bone #
signs of retroperitoneal bleeding
circulation considerations in penetrating trauma
obvious vascular injury
external hemorrhage
confounding factors to consider which may be causing altered mental status other than head injury in trauma
hypoglycemia
hypertension meds can cause bradycardia/hypotension
use of diuretics/anticholinergics can cause hyponatremia
seizure/postictal
anticoagulants - neuroimaging needed
intoxication - drugs or alcohol
laboratory evaluation of the trauma patient
lytes, liver function, INR, UA, blood type and screen, lactate levels or base deficit
B-hCG in females
what test is used in massive transfusion or extensive bleeding in trauma patents to aid in early diagnosis of coagulopathies
TEG - thrombestrography
ROTEM - thromboelasometry
important examination/ diagnoses to pick up during trauma secondary survey - general
exam: LOC, GCS, any specific complaints
critical diagnoses: GCS < 8, focal motor deficit
important examination/ diagnoses to pick up during trauma secondary survey - head
exam: pupils, visual fields, contusions, lacerations evidence of skull fracture (hemotympanum, racoon eyes, battle sign, palpable defects)
critical diagnoses: herniation syndrome
emergent diagnoses: globe rupture, open skull fracture, CSF leak
important examination/ diagnoses to pick up during trauma secondary survey - face
exam: contusions, lacerations, midface instability, malocclusion
critical diagnosis: airway obstruction due to bleeding
emergent diagnoses: facial fractures, mandibular fracture
important examination/ diagnoses to pick up during trauma secondary survey - neck
exam: penetrating injury, lacs, JVD, subQ emphysema, hematoma, midline cervical tenderness
critical diagnoses: carotid injury, pericardial tamponade, tracheal/laryngeal fracture, vascular injury, cervical fracture, dislocation
important examination/ diagnoses to pick up during trauma secondary survey - chest
exam: resp effort, excursion, contusions, lacerations, focal tenderness, crepitus, subQ emphysema, heart tones, breath sounds
critical diagnoses: impending respiratory failure, flail chest, cardiac tamponade, tension pneumothorax
emergent diagnoses: cardiopulmonary injury, intrathoracic injury, rib #s, pneumothorax, hemothorax
important examination/ diagnoses to pick up during trauma secondary survey - abdomen, flank
exam: contusions, penetrating injury, lacerations, tenderness, peritoneal signs
critical diagnoses: intra-abdomainl hemorrhage, abdominal catastrophe
emergent diagnoses: solid, hollow viscous injury
important examination/ diagnoses to pick up during trauma secondary survey - pelvis, GU
contusions, lacerations, stability, symphyseal tenderness, blood (urethral meatus, vaginal bleeding, hematuria), rectal exam
critical diagnoses: pelvic hemorrhage, unstable pelvic fracture, colorectal injury (bleeding), urethral injury
important examination/ diagnoses to pick up during trauma secondary survey - neuro/spinal cord
exam: midline bony spinal tenderness, mental status, paresthesias, sensory level, motor function, including sphincter tone
critical diagnoses: spinal fracture, dislocation, epidural or subdural hematoma
emergent diagnoses: cerebral contusions, shear injury, SCI, contusion, nerve root injury
important examination/ diagnoses to pick up during trauma secondary survey - extremities
exam: contusions, lacerations, deformity, focal tenderness, pulses, cap refill, eval of compartments
critical diagnoses: compartment syndrome, vascular injury, neurovascularinjury, arterial injury, hemorrhage shock
emergent diagnoses: rhabdomyolysis, fracture
what imaging needed in patients with blunt trauma with significant chest pain, sternal tenderness, or abnormal thoracic US or CXR findings
CT chest
recommended imaging in patients with penetrating chest trauma, after normal CXR and thoracic US, asymptomaticc
repeat CXR in 1 hour, does not need a CT
do you need pelvic Xray on alert, hemodynamically stable stables who are asymptomatic
no
who in blunt trauma gets a CT abdo
abdo pain or tenderness significant mechanism of injury abnormal eFAST gross hematuria unreliable exam (altered, distracting injury, head injury)
seat belt sign associated with internal abdominal injury
who in blunt trauma can forego abdominal CT
GCS 15, normal abdominal physical exam, negative eFAST, normal laboratory results
in blunt trauma patients not getting an abdominal CT, what monitoring do they need
repeat FAST and Hb
surgeon should be present in ED on trauma patient within 15 mins of arrival if any of the following criteria
confirmed hypotension (SBP < 90) +GSW to neck, chest, abdo, or proximal extremities OR intubated patents transferred from scene
respiratory compromised requiring emergent airway
penetrating GSW to neck, chest abdo or pelvis
GCS < 8 attributed to trauma
define flail chest
three or more adjacent ribs are fractured at 2 points, allowing free segment of chest wall to move in paradoxical motion with flail moving inward on inspiration and outward with expiration
which ribs are less likely to fracture
1-3 are short and protected
9-12 are longer and more mobile at anterior end
4-8 most likely to fracture
findings suggestive of clinical diagnosis of rib fracture
severe point tenderness, bony crepitus, ecchymosis, muscle spasm over the rib
bimanual compression of thoracic cage remote from injury produces pain at site of fracture
NEXUS CT rule for CT chest after blunt trauma
if does not meet any of this criteria, do not need CT chest
abnormal CXR rapid deceleration mechanism (fall >20 feet or MVC > 65km/h) distracting painful injury chest wall tenderness sternal tenderness Tspine tenderness scapular tenderness
indicatins for operative fixation of flail chest
pts unable to wean from ventilator secondary to mechanics of flail chest, persistent t pain, severe chest wall instability, progressive decline in pulmonary function
treatment of flail chest
pulmonary physiotherapy
effective analgesia
selective use of ETT and mechanical ventilation
close observation for respiratory compromise
what work up needed if suspect sternal fracture
if minimal trauma e.g. fall to ground or punch to chest, CXR
if more significant trauma, or when CXR shows displaced # or evidence of intrathoracic injury - CT chest
clinical manifestatiosn of pulmonary contusion
dyspnea, tachypnea, cyanosis, tachycardia, hypotension, and chest all bruising -rales or absent breath sounds on asucultation
diagnosis of pulmonary contusion
CXR- patchy, irregular alveolar infiltrate
ABG- widening A-a gradiane tindicates decreasing pulmonary diffusion capacity of patient’s contused lung
what is difference between pulmonary contusion and ARDS
contusion occurs within minutes of initial injury, isolated to segment or lobe
ARDS develops 48-72 hours later, more diffuse
treatment of pulmonary contusion
IV fluids restricted to maintain intravascular volume withn strict limits and comprehensive supportive care consisting of tracheobroncial toilet, suctioning, pain relief
avoid intubation because increase morbidity
if 1 lung severely contused and causing significant hypoxemia can intubate and ventilate lungs separately
types of pneumothorax
simple
communicating
tension
occult
indications for tube thoracostomy
traumatic cause (expect asymptomatic, apical pneumothorax)
moderate to large size
resp Symptoms regardless of sitze
increase size of pneumothorax after conservative therapy
recurrence of pneumothorax after removal of initial chest tube
patient requires ventilator support
pt requires GA
associated hemothorax
bilateral pneumothorax regardless of siez
tension pneumothraox
complications of tube thoracostomy
formation of hemothorax, pulmonary edema, bronchopleural fistula, pleural leaks, empyema, subQ emphysema, infection, intercostal artery laceration, contralateral pneumothorax, and parenchyma injury
placement site for tube thoracostomy
4th or 5th intercostal space at midaxillary line
causes of hemothorax
hemorrhage for injured lung parenchyma body vommon
intercostal, internal mamary arteries more often than hilarious or great vessels
indicaitons for thoracotomy
initial thoracotomy drainage more than 20cc/kg of blood or more than 1500mL or 200mL/hr for 3 hours
persistent bleeding more than 7cc/kg/hr
increasing hemothorax on CXR
pt remains hypotensive despite adequate blood replacement and other sites of bleeding have been ruled out
pt decompensated after initial response to resuscitation
clinical features suggestive of tracheobronchial injury
massive air leak through a chest tube, hemoptysis, or increasing subQ emphysema
Hamman’s crunch if air tracks to mediastinum
continuous bubbling into chest tube hooked to suction
what diagnostic test used if tracheobronchial injury suspected
bronchoscopy
which patients may be okay with conservation mgmt for tracheobronchial injury
tracheal tears less than 2cm without esophageal prolapse, mediasitnitis, or massive air leakage
CT findings consistent with diaphragmatic injury
diaphragmatic discontinuity, intrathoracic herniation of abdominal contents, waist-like constriction of abdominal viscera (collar sign)
treatment of diaphragmatic injury
surgery
potential complications after blunt cardiac trauma
life threatening dysrhythmias, conduction abnormalities, CHF, cardiogenic shock, hemopericardiaum with tamponade, cardiac rupture, valvular rupture, intraventricular thrombi, thromboembolic phenomena, coronary artery occlusion, ventricular aneurysms and constrictive pericarditis
what is myocardial concussion
commotio cordis
acute form of blunt cardiac trauma usually produced by sharp, direct blow to mid anterior chest that stuns the myocardium and results in brief dysrhythmia, hypotension and LOC
no structural heart damage
recommended monitoring of patient after commotio cords who are not found mohave more severe traumatic cardiac injury
observe 6-12 hours on telemetry
when D/C, no return to play until additional outpatient cardiac testing performed if indicated
part of heart most likely to get myocaridal contusion
RV - anterior position and close to sternum
how to assess for myocaridal contusion
if negative 12 lead ECG + negative troponin, can rule out myocardial contusion
treatment of suspected myocardial contusion
similar to MI saline lock IV if fluids not otherwise indicated cardiac monitoirng O2 if hypoxic analgesic agents
dysrhythmias usually transient adndont require tx; if VT or A Flutter treat as per ACLS guidelines
treat and prevent any conditions that increase myocardial irritability
lytics & asa contradincated in trauma
disposition of pt with myocardial contusion
telemetry observation or in-hospital monitoring, depending in patients other injuries
markedly abnormal ECG, troponin elevation or hypotension warrant echocardiography and cardiology consult
proposed mechanisms of myocardial rupture in trauma
- deceleration stearin stresses on fixed attached of IVC and SVC to RA
- upward displacement of blood and abdominal viscera from blunt abdominal injury causes sudden increase in intracardiac pressure
- direct compression of the heart between sternum and vertebral bodies
- laceration from a fractured rib or sternum
- complications of a myocardial contusion, necrosis, and subsequent cardiac rupture
what determines survival in patients with cardiac rutpuree
if pericardium remains in tact, protected from immediate exsanguination
auscultation revealing harsh murmur known as bruit de moulin
pneumopericardium - seen in rupture
imaging in myocardial rupture
FAST bedside US reveals pericardial effusion
CXR may be helpful to note the presence of other intrathoracic injuries (eg. hemothorax, pneumothorax, and signs of possible aortic dissection)
indications for ED thoracotomy
penetrating traumatic cardiac arrest
- cardiac arrest at any point with initial signs of life in the field (less than 10 mins of CPR)
- SBP < 50 after fluid resus
- severe shock with clinical signs of cardiac tamponade
blunt trauma
-cardiac arrest in the ED
indications for central line
(1) IV access (especially if difficult peripheral access)
(2) CVP monitoring
(3) ScvO2 monitoring/sampling
(4) Infusions of irritant substances (e.g. vasoactive agents, chemotherapy or TPN administration)
(5) Renal replacement therapy, olasmapheresis and apheresis
(6) Transvenous pacing
contraindications for central line
CONTRAINDICATIONS
coagulopathy
respiratory failure
raised ICP (cannot tilt head down)
-> can use femoral approach in all the situations above
obstructed vein (e.g. thrombus, or tumour)
overlying skin infection, burn or other disease process
hemorrhage from target vessel
uncooperative patient
