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Surgery Clerkship > Trauma > Flashcards

Trauma Flashcards

1
Q

What is shock?

A

A state in which there is inadequate tissue perfusion and delivery for O2 needed for aerobic metabolism

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2
Q

What is hypotension in trauma due to?

A

Hemorrhagic shock until proven otherwise

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3
Q

What is mechanism of cardiogenic shock?

A

Failure of myocardial pump or decreased preload

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4
Q

What is mechanism of neurogenic shock?

A

Autonomic dysfunction (loss of SNS tone) with peripheral vasodilation

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5
Q

What is mechanism of hypovolemic shock?

A

Decreased blood and plasma volume

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6
Q

What are clinical manifestations of hypovolemic shock?

A 
Tachycardia
Hypotension
Pale/cool extremities
Weak pulses
Prolonged capillary refill
Low urine output
AMS
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7
Q

What is the caution about young patients in hypovolemic shock?

A

They can maintain normal BP due to strong vascular tone until CV collapse is imminent

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8
Q

What is significance of blood at urethral meatus?

A

Urethral blunt trauma - DO NOT place foley. Do retrograde urethrogram to evaluate if urethra intact

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9
Q

What is significance of gross hematuria?

A

Injury to kidney or bladder

  • R/o renal injury with CT abdomen pelvis w/ contrast
  • R/o bladder injury with CT cystogram or retrograde cystogram
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10
Q

How much blood loss is necessary to cause hypotension in supine position?

A

30-40% of blood volume lost = 1.5-2L

Class III shock

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11
Q

5 main sources of major blood loss in trauma?

A 
Chest
Abdomen
Pelvis/retroperitoneum
Long bones
External
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12
Q

Most likely cause of blood loss in chest?

A

hemothorax from lung or torn intercostal arteries

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13
Q

Most likely cause of blood loss in abdomen?

A

splenic rupture

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14
Q

Most likely cause of blood loss in retroperitoneum?

A

1 pelvic fractures - tear small arterial branches off of internal iliac artery
renal 2 trauma

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15
Q

Most likely cause of blood loss in long bones?

A

femur fracture - loss of 1-2 units of blood (500ml each)

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16
Q

Most likely cause of blood loss in skin?

A

scalp lacerations

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17
Q

What can rapid deceleration injuries cause?

A

descending aortic transection (distal to ligamentum arteriosum) - often fatal.
- If survived, injury usually contained in mediastinum (less likely to cause massive blood loss)

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18
Q

What cavity should NOT be considered source of hemorrhagic shock?

A

Closed head injury - cannot lose that much blood into cranium!

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19
Q

What is the cushing response and why are we concerned?

A

Hypertension and bradycardia

  • Often in patients with increased ICP
  • Often heralds brain herniation
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20
Q

What are ABCDE of trauma patient management?

A 
Primary survey
A: Airway w/ C spine precaution
B: Breathing
C: Circulation
D: Disability: neuro eval with GCS score
E: exposure: look for discrete injuries
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21
Q

What is in secondary survey?

A 
AMPLE:
Allergies
Medications
PMH
Last Meal
Events before trauma
\+ PE
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22
Q

What is recommended technique of airway in trauma?

A

Orotracheal intubation

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23
Q

What are the two types of surgical airways? Which is appropriate in emergent trauma setting?

A

Cricothyrotomy - preferred: easier and faster w/ fewer complications
Tracheostomy - better for long term management

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24
Q

Why do we not use nasotracheal intubation in trauma?

A

Due to facial or basilar skull fractures - can lead to inadvertent intracranial passage of NT tube

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25
Q

How to confirm proper intubation?

A

1 End tidal CO2 determination: capnography

2 CXR to make sure tube is not past carina

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26
Q

What is important for C of primary survey?

A

Establishment of 2 large bore peripheral IVs (14 best)

- Then draw blood and do labs

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27
Q

What do you do if cannot obtain peripheral access in kids?

A

Place line in interosseous location (tibial)

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28
Q

Where to place peripheral IV lines?

A

1 each in antecubital fossa ideally, but be mindful of where trauma is

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29
Q

When is central line indicated?

A

if peripheral access is problematic or patient is hemodynamically unstable - place in femoral vein

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30
Q

When evaluating proper endotracheal tube placement - when can we not use end-tidal CO2 determination?

A

If patient in cardiac arrest

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31
Q

How much fluid to give in rapid resuscitation, of what?

A

1-2L of lactated ringers (130 meq/L Na, Cl, lactate, K, Ca).

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32
Q

Why donā€™t we give lots of K to trauma pt?

A
  • Pt may be in shock w/ decreased renal perfusion, decreased GFR, decreased ability to excrete K.
  • Risk of hyperK due to crush injuries
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33
Q

What if patient does not respond to 2L of fluid?

A

= Non or transient responder = patient still actively bleeding!
GIVE BLOOD with FFP!

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34
Q

After fluid resuscitation started, what next?

A
  1. Peritonitis: go to OR for exploratory laparotomy
    2: If unresponsive/not peritonitis: do FAST scan and if positive: OR for exploratory laparotomy, plus due CXR for hemothorax
    3 Pelvic sray to look for fracture
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35
Q

What is role of diagnostic peritoneal lavage?

A

FAST has replaced it - use only equivocal fast scan or fast is not available

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36
Q

How do we manage intra-abdominal bleeding due to splenic injury?

A

Hemodynamically stable: splenic embolization

Unstable: surgical exploration and splenectomy or repair

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37
Q

What is important to test for 2 weeks after splenectomy?

A

Encapsulated bacteria

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38
Q

What is Kehrā€™s sign?

A

acute referred pain in L shoulder due to splenic injury

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39
Q

What is most commonly injured organ after blunt trauma?

A

Liver

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40
Q

What to do if liver is bleeding?

A

Stable: Embolization via IR
unstable: surgical exploration

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41
Q

How to temporarily control bleeding from hepatic artery or portal venous sources?

A

Pringle maneuver: clamp portal triad

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42
Q

What if pringle maneuver doesnā€™t work? Where is bleeding?

A

Bleeding is coming from hepatic veins

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43
Q

What are first steps of management of pelvic fracture?

A

Pelvic volume: reduced by wrapping pelvic binder or sheet around greater trochanters of femurs

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44
Q

What is significance of free fluid in abdomen after trauma?

A
  • usually due to bleeding, usually an injury to spleen or liver.
  • Without major organ injury - free fluid may be bleeding from occult source (mesenteric artery), enteric contents or urine from bladder rupture
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45
Q

What is threshold for hypotension in elderly patients?

A

SBP < 90-100 for people 20-49
SBP < 120 for people 50-69
SBP < 140 for patients 70+

DUE to hypertension at baseline for older people

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46
Q

How to manage pelvic fracture in hemodynamically unstable patient?

A

1 Angiographic embolization
BUT if pt in severe shock - may not be able to wait for IR. SO take pt to OR for preperitoneal packing ā€“> angiographic embolization
ANother option: ligate bilateral internal iliac arteries

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47
Q

What causes neurogenic shock?

A

High cervical spine injury - patient will have well perfused extremities

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48
Q

What is role of colloids in fluid resuscitation?

A

None

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49
Q

After primary survey, what do we do for unstable and stable patients?

A

Stable: CT scan
Unstable: FAST scan

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50
Q

How to manage pelvic fracture?

A

Pelvic angiography and embolization if ongoing bleeding

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51
Q

What is MIVT prehospital report?

A

Mechanism
Injuries
Vitals
Treatment

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52
Q

What are 2 most common types of penetrating trauma?

A

Stab wounds and gunshot wounds

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53
Q

What 3 findings independently mandate immediate operative intervention in patients with penetrating abdominal trauma?

A

1 Hypotension
2 Peritonitis
3 Evisceration (ejection of organs)

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54
Q

What is a tangential GSW and what workup does it warrant?

A

Injuries with identifiable entry and exit wounds, without clinical evidence of injury to deeper structures

Look for blast effect or fragmentation via X-rays or serial physical exam

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55
Q

What 3 structures comprise the internal abdomen?

A

peritoneal cavity, pelvis and retroperitoneum

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56
Q

Why is it hard to find injuries to retroperitoneal organs in trauma patients?

A
  • Decreased symptoms/signs of peritonitis due to protected location
  • FAST notorious for missing retroperitoneal bleeding
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57
Q

What is the zone classification for retroperitoneal hematoma?

A

Reminds surgeon of structures that might be injured
- Ultimately, decide to explore retroperitoneal hematoma based on:
1 Hemodynamic status
2 Mechanism of injury
3 Zone location

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58
Q

Most common organs injured following penetrating abdominal injury?

A

1 Small bowel

2 liver

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59
Q

Transpelvic GSW: what structures must be ruled as safe? How do we eval?

A

Ureters, bladder, iliac vessels, rectum, vagina
1 Proctoscopy for rectum
2 CT scan for abdomen and pelvis
3 females: vaginal exm

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60
Q

Without hypotension, peritonitis or evisceration, what do we do to evaluate penetrating abdominal trauma?

A

CT abdomen pelvis with IV contrast

Do CT chest too if concern for multi-cavitary torso trauma

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61
Q

Do we use FAST exam for penetrating trauma? If so, when?

A

More useful for blunt
Used in penetrating to rule out cardiac tamponade
Not very helpful to identify retroperitoneal structure injuries

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62
Q

When do we use local wound exploration?

A

For hemodynamically stable patient with anterior abdominal stab wound

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63
Q

What are first steps in management of penetrating trauma patient?

A

Primary survey of ABCDEs, especially identifying presence and location of all entry and exit wounds

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64
Q

What is massive transfusion protocol and when do we use it?

A

Provide blood component therapy (packed RBCs, plasma, platelets)
Use in all hemodynamically unstable patients with major suspected food loss

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65
Q

What is permissive hypotension? When is it used?

A

For penetrating torso trauma - keep the blood pressure intentionally low to avoid ā€œpopping the clotā€.
do NOT use in blunt trauma, especially in head injury

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66
Q

Do we use prophylactic antibiotics/analgesics in all penetrating trauma patients?

A

No: can mask signs and symptoms

If patient has clear signs/symptoms for surgical intervention: yes: get preoperative AB for bowel flora

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67
Q

When do we administer tetanus prophylaxis?

A

1 Pts with < 3 doses tetanus toxoid
2 Pts with unknown immunization status
+ tetanus prone wound (obvious soil contamination, > 6 hours old)

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68
Q

How to manage patients presenting with impalement?

A

Assessed as other penetrating trauma patients

Do not remove until in OR or after imaging studies have been done

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69
Q

Where are trauma patients prepped in the OR?

A

Chin to knees - make sure access to chest (thoracotomy?), groins (for saphenous graft)

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70
Q

What is surgical management for patients presenting with penetrating abdominal trauma?

A

exploratory laparotomy

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71
Q

When do we use laparoscopy in penetrating abdominal trauma?

A
  • Pt with no hypotension, peritonitis, evisceration, use laparoscopy to determine if penetrating injury has penetrated the peritoneum
  • If needed, then do laparotomy: avoids negative/nontherapeutic laparotomy: associated with 5% mortality and 20% morbidity
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72
Q

What is the lethal triad of death in a trauma patient?

A

Acidosis, Hypothermia and coagulopathy

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73
Q

What is damage control surgery?

A

Patient with hemorrhage, multiple injuries shows hypothermia, coagulopathy and acidosis intraoperatively: surgeon stops surgery (even if all injuries arenā€™t fixed), transport patient to ICU and correct lethal triad
Plan to re-explore patient after correction

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74
Q

What criteria must be met for nonoperative management in patients with penetrating abdominal trauma?

A

Hemodynamically stable
No peritonitis
Evaluable (normal AMS)
CT scan showing no intraabdominal injury

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75
Q

How long to continue prophylactic antibiotics after trauma laparotomy?

A

24 hours

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76
Q

What is a stoma, and is it needed for small bowel or colon injuries?

A

Pouch

RARELY needed for small bowel/colon injuries: can be repaired primarily

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77
Q

Patients with injury to colon and/or common iliac artery are at increased risk for damage to what structure?

A

ureter

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78
Q

What signs make you suspect abdominal compartment syndrome?

A
  • Decreased urine output
  • Increasing peak pressures on ventilator
  • increasing vasopressor support
    in absence of another identifiable cause in a patient with multiple traumatic injuries
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79
Q

What is treatment for abdominal compartment syndrome?

A

take patient to OR: decompressive laparotomy: open abdominal fascia and leave wound open

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80
Q

What are hard and soft signs of vascular injury?

A

Hard: specific, overt PE exam findings - require immediate operative intervention
Soft: increase index of suspicion for vascular injury

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81
Q

What are 6 Pā€™s of limb ischemia, and what do they apply to?

A

pain, pallor, paresthesias, paralysis, pulselessness, poikilothermic
Acute and chronic limb ischemia!

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82
Q

What does an audible bruit or palpable thrill near an artery suggest in trauma?

A

traumatic AV fistula

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83
Q

What are the hard signs of vascular injury?

A 
Arterial/pulsatile bleeding
Persistent hemorrhage with shock
Expanding or pulsatile hematoma
palpable thrill
audible bruit
absent pulse
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84
Q

What are the components of physical exam of injured extremity?

A

Vascular
Neuro
MSK
Soft tissue

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85
Q

What is the mechanism of popliteal artery injury?

A

Traction and transection injuries due to fixed course across knee joint

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86
Q

What is most common presentation of popliteal artery injury?

A

thrombosis with acute distal limb ischemia

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87
Q

Why do we promptly reduce a dislocation?

A
  • Otherwise, associated with poorer long term outcomes
  • Short term: assoc with significant pain/discomfort: improved with reduction
  • Will allow for normal range of motion/use
  • Dislocations assoc with arterial injuries increase risk of osteonecrosis of bone
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88
Q

What do we do AFTER reduction of dislocation?

A

Re-examine vascular and neuro status

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89
Q

What is minimal vascular injury?

A

Clinically silent injuries that are discovered on radiographic studies like angio.

90
Q

What do we do if hard signs of vascular imaging are present?

A

Go immediately to OR

91
Q

Without hard signs present, how to evaluate for vascular injury at bedside?

A

Ankle brachial index: compare SBP of ankle to brachial. Normal is 1-1.2, < 0.9 = sensitive and specific for arterial injury

92
Q

Without hard signs of vascular injury and if ABI is abnormal, what next?

A

CTA is best: available, quick and noninvasive

93
Q

What other imaging is needed for posterior knee dislocation, other than vascular testing?

A

plain film joint x-ray

94
Q

Do angiogram in penetrating trauma if ABI is normal and no hard signs of vascular injury?

95
Q

What is the mangled extremity severity score and how is it used?

A

Quantifies injury severity in patients with severe trauma of extremities: helps surgeon to determine if limb should be saved or amputated
Higher risk limb loss: longer duration ischemia, patient age, hemodynamic status, severity of neurovasc injury and severity of soft tissue injury

96
Q

What is role of tourniquets in patients with life threatening extremity hemorrhage?

A

early application of tourniquets prior to onset of shock is associated with improved outcomes

97
Q

What is the order of steps of management in knee dislocation?

A
  1. Immediate reduction of knee with ischemic limb
  2. Recheck neurovascular status
  3. Start heparin if no pulse.
  4. If ABI < 0.9, obtain CTA - if arterial injury ā€“> OR
98
Q

Where does graft come from to replace injured artery?

A

Greater saphenous vein from contralateral leg

99
Q

If there is combined orthopedic and vascular injury, which is repaired first?

A
  1. Place intravascular shunt
  2. Orthopedic stabilization
  3. Definitive vascular repair
100
Q

Why does heparin help vascular injury?

A

Reduces amputation rate: preventing microvascular thrombosis in setting of low-flow arterial circulation

101
Q

If patient has palpable pulses, do they have an arterial injury?

A

they may! Important to do ABI with pulse exam to confirm normal blood flow

102
Q

When is endovascular repair a good option?

A

Hemodynamically stable patients with wound location that is difficult to assess surgically (e.g. proximal limb injuries with extension into chest/abdomen = junctional injuries)

103
Q

Who is not a good candidate for endovascular repair?

A

Patients at risk for compartment syndrome or those requiring embolectomy

104
Q

What are the most important parts of H&P for neck injury?

A

Mechanism of injury
Location
Clinical Exam findings

105
Q

What is significance of stridor?

A

Sign of upper airway obstruction

Warrants immediate attention, usually in form of endotracheal intubation

106
Q

How do we name the zones of the neck?

A

I-III in direction of blood flow of carotids

107
Q

What is the significance of whether or not the injury has penetrated the platysma?

A

Injuries that do not penetrate the platysma are by definition nonpenetrating neck injuries and do not require further workup

108
Q

How do we tell the difference between pseudoaneurysm and hematoma?

A

Pseudoaneurysm: artery sustains full thickness injury that is temporarily tamponaded by surrounding soft tissue (not surrounded by media or adventitia). Can still feel pulsatile quality.
Hematoma: no active or ongoing hemorrhage from vessels

109
Q

What is the differential of a pulsating mass? (3)

A

AV fistula
aneurysm
pseudoaneurysm

110
Q

How does phrenic nerve damage present?

A

It causes ipsilateral hemidiaphragm paralysis which may be seen on CXR: elevation of the diaphragm on the affected side

111
Q

In penetrating neck trauma, after primary survey, if no hard signs are present, what is the next step?

A

Helical CT angiography

112
Q

In penetrating neck trauma, if helical CT angiography shows concern for injury in zone 1 or 3, what is the next step?

A

Catheter angiography (arterial) and/or triple endoscopy (if aerodigestive tract)

113
Q

In penetrating neck trauma, if helical CT angiography shows concern for injury in zone 2, what is the next step?

A

Surgical exploration (if vascular), triple endoscopy if aerodigestive tract

114
Q

What do you do in the ED if there is brisk arterial bleeding that cannot be controlled by direct pressure?

A

Place foley catheter into wound and advance, followed by inflation of balloon and clamping - provides tamponade effect on bleeding vessel

115
Q

Why do we more readily explore zone 2 vs. 1 and 3?

A

Zone 2 is readily accessible via standard neck incision

116
Q

What should we look for in patients with penetrating injury above the clavicle?

A

Pneumothorax

117
Q

What is the general principle for operative exposure of vascular injuries?

A

Obtain proximal and then distal control of injured artery so that bleeding is controlled before exploration

118
Q

In setting of major vascular injury, what other part of the body should be preppred?

A

one or both thighs in anticipation of need to harvest greater saphenous vein

119
Q

How to manage repair of pseudoaneurysm?

A

Surgical repair: inherently unstable and can rupture/cause massive blood loss in trauma setting

120
Q

How to manage AV fistula?

A

Needs open surgical repair: low resistance vein means it will rarely close

121
Q

How to manage intimal injury?

A

Usually stable: may remodel and heal spontaneously

122
Q

Why is routine use of CTA recommended in patient with GSW?

A

Multiple bullet fragments may be created inside the neck or bullets ricocheting off bony structures

123
Q

How do we evaluate for blunt carotid injury? If present, how to treat?

A

Ct angiogram. Usually anticoagulation only

124
Q

What is zone 1?

A

Clavicles/sternal notch to cricoid cartilage

125
Q

What is zone 2?

A

cricoid cartilage to angle of mandible

126
Q

What is zone 3?

A

Angle of mandible to base of skull

127
Q

What is the concern with bilateral vocal cord paralysis?

A

complete upper airway obstruction

128
Q

What should we be thinking about in the back of our heads for patient with penetrating neck injury?

A

Airway compromise from expanding hematoma - low threshold for intubation!

129
Q

When should we expect blunt carotid injury?

A

FND that is not explained in head CT

130
Q

What is the maximum amount of artery that can be removed and still allow for primary anastomosis?

A

2cm - do not perform under tension

131
Q

What are considered the lethal 6 injuries of thoracic trauma?

A 
Airway obstruction
Tension pneumothorax
Open pnemothorax
Massive hemothorax
Flail chest
Cardiac tamponade
132
Q

Whatā€™s the most common cause of airway obstruction in patients with diminished airway reflexes?

A

Relaxed tongue falls back against the rear of the pharynx

133
Q

What are considered the ā€œhiddenā€ 6 injuries of thoracic trauma?

A 
Blunt aortic injury
Esophageal injury
Tracheobronchial injury
Diaphragmatic rupture
Blunt cardiac injury
Pulmonary contusion
134
Q

What causes diaphragmatic rupture?

A

1 Sudden rise in intraabdominal pressure - stomach and colon are most frequently herniated structures
2 Penetrating thoracoabdominal injury

135
Q

What makes up the deadly dozen of thoracic trauma?

A

Lethal 6 + hidden 6

136
Q

What is the differential diagnosis for combative trauma patient?

A
  • Intoxication

- Underlying physiologic derangement: hypoxia, hypovolemic or cardiogenic shock, hypoglycemia

137
Q

What is the preferred central line location in trauma?

A

femoral line

138
Q

How to establish diagnosis of tension pneumothorax?

A

Clinical: suspect with hypotension, dyspnea, tachypnea, JVD, unilateraly absent breath sounds, deviated trachea to unaffected side

139
Q

How to establish diagnosis of cardiac tamponade?

A

Clinical: Beckā€™s triad: hypotension, distended neck veins, muffled heart sounds.
- Can support with FAST scan: fluid in pericardial sac

140
Q

What is the differential for absent breath sounds on left?

A

pneumothorax

massive hemothorax

141
Q

What is the implication of a penetrating injury to the chest that is above vs. below the nipple?

A

Above nipple: thoracic structures

Below: thoracic structures, abdominal contents or diaphragm itself

142
Q

Why is it important to know type of weapon used in penetrating injury?

A

Bullet injuries: unpredictable paths: must find entry and exit wound. If canā€™t find exit, find bullet radiographically

143
Q

What is the concern when pulse pressure is low?

A
  • Pulse pressure < 30 = low.

- Implies reduced stroke volume

144
Q

What is the differential for narrow pulse pressure in trauma? (< 30 mm Hg)

A

Pericardial tamponade
Hypovolemic shock
Cardiogenic shock

145
Q

What is the significance of air bubbling from a chest wound?

A

Sucking chest wound: type of open pneumothorax. Chest wall defect is so large (>2/3 of trachea diameter) that inspired air takes path of least resistance and enters into the chest cavity through wound instead of through trachea

146
Q

What is the difference between open, simple and tension pneumothorax in trauma patients?

A

Open: free communication between atmosphere and pleural space through open chest wall wound
Simple: jagged rib fracture punctures lung (stab or gunshot wound)
Tension: lung injury creates one-way valve

147
Q

After putting in a central line, what is needed next and why?

A

CXR to confirm you did not cause an iatrogenic pneumothorax

148
Q

Why is a tension pneumothorax dangerous?

A

the injury creates a one-way valve effect: each inspiration: air leaks out of lung and into pleural cavity: leads to compression of superior and inferior vena cavae - decreased preload and

149
Q

What happens with tension pneumothorax in setting of positive pressure ventilation?

A

Tension pneumothorax will be exacerbated! Decompress as soon as suspected with chest tube BEFORE PPV

150
Q

What is the mechanism of an air embolism?

A

Traumatic creation of fistula between injured bronchus and pulmonary vein

151
Q

In a patient with suspected tamponade, why do we not intubate and institute PPV?

A

PPV causes reduced cardiac filling, which can exacerbate already compromised cardiac output seen in cardiac tamponade

152
Q

What is a needle thoracostomy? Where is it placed?

A

allows for immediate thoracic decompression in tension pneumothorax. needle placed in 2nd or 3rd intercostal space, just above rib at midclavicular line - advanced until air is aspirated into syringe
* Location ideal as it minimizes risk to heart or collapsed lung

153
Q

What is function of needle thoracostomy?

A

Convert tension pneumothorax into simple/closed pneumothorax. Provides immediate decompression

154
Q

What else do patients who receive needle thoracostomy need?

A

Tube thoracostomy (chest tube) for definitive management. Would take too much time in setting of tension pneumothorax

155
Q

What is a tube thoracostomy? Where does it go?

A

Chest tube insertion: place hollow plastic tube between 4th or 5th intercostal space at midaxillary line into chest to decompress a hemothorax and/or pneumothorax

156
Q

When does a chest tube need to go to the operating room?

A

If massive hemothorax encountered (>1.5L immediately or >150-200mL/hour over 3 hours) - immediate transport to OR needed!

157
Q

What is tube thoracostomy vs. thoracotomy?

A

Tube thoracostomy: treats pneumothorax
Thoracotomy: often performed by surgeon in emergency setting to perform lifesaving/invasive resuscutation measures (internal cardiac massage, hemorrahge control)

158
Q

What is initial and chronic management of cardiac tamponade?

A
  1. IV fluids: increase preload

2. Definitive: Median sternotomy to release tamponade in OR: not pericardiocentesis

159
Q

Why is pericardiocentesis not recommended in trauma?

A

Unreliable since blood is clotted in pericardial sac, fluid is usually viscous enough in non-trauma settings.
Can be used in certain clinical circumstances if necessary.

160
Q

Are vasopressors recommended in management of traumatic cardiac tamponade? Why or why not?

A

No: they increase SVR which exacerbates myocardial dysfunction

161
Q

What should be ordered on all patients that are combative? (3)

A
  1. finger stick glucose
  2. pulse ox
  3. complete vitals
162
Q

How much pleural fluid can the diaphragm hide in upright CXR?

A

up to 500cc

163
Q

How do we look for a leak in a chest tube drainage system?

A

Check the water seal chamber on suction: large leaks will be obvious with bubbles passing through water seal fluid.

164
Q

What is a necessary for a hemothorax patient who requires general anesthesia?

A

A chest tube! PPV may convert simple pneumothorax into tension pneumothorax

165
Q

Why do we put patients with pneumothorax on 100% O2?

A

To increase O2 into vascular system and gradually wash out nitrogen. Increased pressure gradient between alveolar capillaries and pneumothorax space = accelerated absorption from pleural space

166
Q

How do we treat a sucking chest wound?

A

Occlusive dressing and chest tube

167
Q

How to treat flail chest with respiratory compromise?

A

1 Analgesics

2 Intubation / mechanical ventilation

168
Q

What is the most dangerous complication after pericardiocentesis?

A

Laceration of coronary vessel

169
Q

What nerve is at risk when opening the pericardium?

A

L phrenic nerve: passes longitudinally over posterior aspect of pericardium of L ventricle

170
Q

How do we treat persistent hemothorax, if patient already had a chest tube?

A

1 Repeat chest tube
2 VATS
3 Thoracotomy

171
Q

What is a long term sequelae of a patient with L diaphragm injury?

A

Acquired diaphragmatic hernia with incarcerated bowel in the chest: patient presented with chest pain and SOB with remote history of trauma

172
Q

If patient has penetrating wound just below nipple, what is next diagnostic step and why?

A

CXR: rule out intra-abdominal injury due to high risk of bowel injury and blood loss

173
Q

Is FAST appropriate for penetrating trauma? If so, when?

A

Limited evidence

Use in cardiac tamponade and pneumothorax

174
Q

Do chest tube placement patients get prophylactic antibiotics?

175
Q

When do we remove chest tubes that were placed for traumatic pneumo/hemothorex?

A

No air leaks present and lung fully expanded on CXR

176
Q

What is main risk during chest tube removal?

A

Air being reintroduced into pleural cavity

177
Q

What is most important factor in cardiac tamponade?

A

Rapid accumulation of fluid

178
Q

What are indications for ED thoracotomy?

A
  1. Penetrating trauma: < 15 min of prehospital CPR
  2. Blunt trauma with < 5 min of prehospital CPR
  3. Persistent severe postinjury hypotension (SBP < 60) due to cardiac tamponade, air embolism or hemorrhage
179
Q

What are the 5 degrees of burn and what levels of skin do they correlate to?

A

1st: Epidermis only
2nd: Epidermis and some dermis
3rd: All skin (epidermis and dermis)
4th: all skin, underlying bone, tendon, adipose or muscle

180
Q

How do we differentiate between 2nd degree burns of superficial vs. deep partial thickness?

A

Superficial: with pain
Deep: without pain

181
Q

How do we determine severity of burn injury?

A 
Rule of nines:
Head 9%
Each arm 9%
Ant torso: 18%
Post torso: 18%
Each leg: 18%
182
Q

What percent of skin is the palm?

183
Q

What does carbonaceous sputum indicate?

A

Possible inhalation injury

184
Q

What are the 3 components of inhalation injury?

A

1 Upper airway edema
2 Acute respiratory failure (pneumonitis from products of combustion)
3 CO poisoning

185
Q

What do we look for when concerned about burn wound sepsis?

A 
1 2nd degree burn --> 3rd degree burn in hospital
2 Discolored burn
3 Eschar with green pigment
4 Black necrotic skin
5 Skin separation
6 signs of sepsis
186
Q

What is the significance of circumferential burn in the extremity?

A

Significantly increased risk for compartment syndrome

187
Q

What is the significance of circumferential burn in the chest?

A

Can compromise respiratory efforts

188
Q

What are the different causes of burns?

A

Thermal (scalding hot water)
Chemical (alkali: liquefactive necrosis)
Electrical (can cause cardiac arrhythmia)

189
Q

What are the risks of:

a) DC current?
b) AC current?

A

a) Asystole

b) V fib

190
Q

What is a long term complication of electrical injury?

191
Q

Why are burn patients at increased risk for dehydration?

A

Lose the integrity of skin layer for fluid and temp regulation which can lead to fluid loss, lack of temperature control ā€“> hypovolemic shock

192
Q

Why are burn patients at increased risk for GI ulcers?

A

Decreased perfusion from decreased intravascular volume ā€“> subsequent ischemic necrosis of gastric mucosa

193
Q

What is the burn called in severe burns patients, and where is it?

A

Curlingā€™s ulcer in duodenum

194
Q

What are the most common organisms involved in burn wound infections?

A
  1. Pseudomonas
  2. S. aureus
  3. S. pyogenes

if fungal: candida
if viral: HSV

195
Q

What are risk factors for mortality of burn injury?

A

Increased age
Total burn surface area
Inhalational injury

196
Q

How do we diagnose inhalation injury?

A

1 Clinically: facial burns, singed nasal hairs and history of injury in an enclosed space

2 Fiberoptic bronchoscopy for definitive diagnosis

197
Q

How do we diagnose burn wound infection?

A

Punch biopsy: > 10^5 bacteria / g

198
Q

How do we determine fluids for burn patients?

A

Parkland formula for patients with > 20% TBSA

Total fluid volume = 4 cc/kg x weight (kg) x TBSA (%)

Titrate to urine output 0.5 mL/kg/hour in adults, 2-4mL/kg/h in kids

199
Q

What type of fluid do burn patients get?

A

Lactated Ringerā€™s

200
Q

What is key management principle for patients with electrical burns?

A

Cardiac monitoring: 12-24 hours to look for arrhythmia

201
Q

What medication should all burn patients be started on?

HINT: to prevent ulcers

A

PPI or H2 blocker

202
Q

How do we manage a burn wound?

A
  1. Resuscitate
  2. Cleanse and debride
  3. Antimicrobial agents and dressings
  4. Skin graft after the wound is clean
203
Q

What do you do for patients with circumferential chest burn and deteriorating respiratory status?

A

chest escarotomy

204
Q

Which electrolytes do we track in burn patients?

A

Na and K
Na: hyponatremia from fluid loss
K: hyperkalemia from cell and tissue destruction

205
Q

How do you manage a patient with inhalation injury?

A

Early intubation: prevent sudden loss of airway due to thermal injury/upper airway edema

206
Q

What are the Pā€™s of compartment syndrome, and how do they differ from acute limb ischemia?

A

pain, paresthesia, pallor, paralysis, pulselessness and poikilothermia

Pulselessness is a LATE sign, vs. early sentinel event in acute limb ischemia

207
Q

What are early signs of compartment syndrome?

A
  1. Pain (during passive range of motion)
  2. Nerve ischemia (sensory before motor)
  3. Cap refill diminishes: pallor, paralysis
208
Q

How many compartments are there in the upper leg vs. lower leg?

A

Upper: 3: anterior, medial, posterior
Lower: 4: anterior, lateral, superficial posterior, deep posterior

209
Q

How many compartments are there in upper arm vs. forearm?

A

Upper arm: 2: anterior and posterior

Forearm: 3: dorsal, volar, mobile wad

210
Q

What are the 2 categories of causes of compartment syndrome?

A
  1. Decreased compartment size

2. Increased compartment volume

211
Q

What is pathophys of compartment syndrome?

A
  1. Injury: crush, burn, fracture or reperfusion
  2. Inflammation: accumulation of fluid/bleeding
  3. Pressure exceeds normal - venues collapse and venous HTN results
  4. Arterial-venous pressure gradient falls, limiting capillary perfusion pressure ā€“> tissue ischemia
212
Q

What sequelae can tissue damage secondary to compartment syndrome lead to?

A

Hyperkalemia, acidosis and myoglobinuria which may cause kidney failure

213
Q

What is the significance of first web space numbness in compartment syndrome?

A

Deep peroneal nerve courses through anterior lower leg compartment.

Nerve ischemia within anterior compartment produces numbness between 1st and 2nd toes

214
Q

What is abdominal compartment syndrome?

A

Abdominal cavity is a fixed compartment: susceptible to elevated pressures causing mass effect to intra-abdominal organs

215
Q

What is the main risk factor for abdominal compartment syndrome?

A

Trauma patients that receive massive fluid resuscitation

216
Q

What are the clinical manifestations of abdominal compartment syndrome?

A

Clinical: tense, tender, swollen compartments with pain on passive motion

217
Q

When do we measure compartment pressures in suspected extremity compartment syndrome?

A

1 When suspicion is low to provide confirmatory documentation
2 when patient is obtunded and accurate PE cannot be performed

218
Q

How to diagnose abdominal compartment syndrome?

A

Measure bladder pressure: > 25-30 mmHg suggests abdominal compartment syndrome

219
Q

What is treatment of extremity compartment syndrome?

A

Immediate decompressive fasciotomy

220
Q

What compartment in lower leg is most often missed during fasciotomy and why is this compartment important?

A

Deep posterior

Important for foot function: contains both posterior tibial and peroneal arteries and tibial nerve

221
Q

What is treatment for abdominal compartment syndrome?

A

Urgent decompressive laparotomy

Surgery Clerkship (16 decks)

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