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
2
Q
What is hypotension in trauma due to?
A
Hemorrhagic shock until proven otherwise
3
Q
What is mechanism of cardiogenic shock?
A
Failure of myocardial pump or decreased preload
4
Q
What is mechanism of neurogenic shock?
A
Autonomic dysfunction (loss of SNS tone) with peripheral vasodilation
5
Q
What is mechanism of hypovolemic shock?
A
Decreased blood and plasma volume
6
Q
What are clinical manifestations of hypovolemic shock?
A
Tachycardia Hypotension Pale/cool extremities Weak pulses Prolonged capillary refill Low urine output AMS
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
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
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
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
11
Q
5 main sources of major blood loss in trauma?
A
Chest Abdomen Pelvis/retroperitoneum Long bones External
12
Q
Most likely cause of blood loss in chest?
A
hemothorax from lung or torn intercostal arteries
13
Q
Most likely cause of blood loss in abdomen?
A
splenic rupture
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
15
Q
Most likely cause of blood loss in long bones?
A
femur fracture - loss of 1-2 units of blood (500ml each)
16
Q
Most likely cause of blood loss in skin?
A
scalp lacerations
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)
18
Q
What cavity should NOT be considered source of hemorrhagic shock?
A
Closed head injury - cannot lose that much blood into cranium!
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
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
21
Q
What is in secondary survey?
A
AMPLE: Allergies Medications PMH Last Meal Events before trauma \+ PE
22
Q
What is recommended technique of airway in trauma?
A
Orotracheal intubation
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
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
25
How to confirm proper intubation?
1 End tidal CO2 determination: capnography
| 2 CXR to make sure tube is not past carina
26
What is important for C of primary survey?
Establishment of 2 large bore peripheral IVs (14 best)
| - Then draw blood and do labs
27
What do you do if cannot obtain peripheral access in kids?
Place line in interosseous location (tibial)
28
Where to place peripheral IV lines?
1 each in antecubital fossa ideally, but be mindful of where trauma is
29
When is central line indicated?
if peripheral access is problematic or patient is hemodynamically unstable - place in femoral vein
30
When evaluating proper endotracheal tube placement - when can we not use end-tidal CO2 determination?
If patient in cardiac arrest
31
How much fluid to give in rapid resuscitation, of what?
1-2L of lactated ringers (130 meq/L Na, Cl, lactate, K, Ca).
32
Why don't we give lots of K to trauma pt?
- Pt may be in shock w/ decreased renal perfusion, decreased GFR, decreased ability to excrete K.
- Risk of hyperK due to crush injuries
33
What if patient does not respond to 2L of fluid?
= Non or transient responder = patient still actively bleeding!
GIVE BLOOD with FFP!
34
After fluid resuscitation started, what next?
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
35
What is role of diagnostic peritoneal lavage?
FAST has replaced it - use only equivocal fast scan or fast is not available
36
How do we manage intra-abdominal bleeding due to splenic injury?
Hemodynamically stable: splenic embolization
| Unstable: surgical exploration and splenectomy or repair
37
What is important to test for 2 weeks after splenectomy?
Encapsulated bacteria
38
What is Kehr's sign?
acute referred pain in L shoulder due to splenic injury
39
What is most commonly injured organ after blunt trauma?
Liver
40
What to do if liver is bleeding?
Stable: Embolization via IR
unstable: surgical exploration
41
How to temporarily control bleeding from hepatic artery or portal venous sources?
Pringle maneuver: clamp portal triad
42
What if pringle maneuver doesn't work? Where is bleeding?
Bleeding is coming from hepatic veins
43
What are first steps of management of pelvic fracture?
Pelvic volume: reduced by wrapping pelvic binder or sheet around greater trochanters of femurs
44
What is significance of free fluid in abdomen after trauma?
- 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
45
What is threshold for hypotension in elderly patients?
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
46
How to manage pelvic fracture in hemodynamically unstable patient?
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 --> angiographic embolization
ANother option: ligate bilateral internal iliac arteries
47
What causes neurogenic shock?
High cervical spine injury - patient will have well perfused extremities
48
What is role of colloids in fluid resuscitation?
None
49
After primary survey, what do we do for unstable and stable patients?
Stable: CT scan
Unstable: FAST scan
50
How to manage pelvic fracture?
Pelvic angiography and embolization if ongoing bleeding
51
What is MIVT prehospital report?
Mechanism
Injuries
Vitals
Treatment
52
What are 2 most common types of penetrating trauma?
Stab wounds and gunshot wounds
53
What 3 findings independently mandate immediate operative intervention in patients with penetrating abdominal trauma?
1 Hypotension
2 Peritonitis
3 Evisceration (ejection of organs)
54
What is a tangential GSW and what workup does it warrant?
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
55
What 3 structures comprise the internal abdomen?
peritoneal cavity, pelvis and retroperitoneum
56
Why is it hard to find injuries to retroperitoneal organs in trauma patients?
- Decreased symptoms/signs of peritonitis due to protected location
- FAST notorious for missing retroperitoneal bleeding
57
What is the zone classification for retroperitoneal hematoma?
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
58
Most common organs injured following penetrating abdominal injury?
1 Small bowel
| 2 liver
59
Transpelvic GSW: what structures must be ruled as safe? How do we eval?
Ureters, bladder, iliac vessels, rectum, vagina
1 Proctoscopy for rectum
2 CT scan for abdomen and pelvis
3 females: vaginal exm
60
Without hypotension, peritonitis or evisceration, what do we do to evaluate penetrating abdominal trauma?
CT abdomen pelvis with IV contrast
| Do CT chest too if concern for multi-cavitary torso trauma
61
Do we use FAST exam for penetrating trauma? If so, when?
More useful for blunt
Used in penetrating to rule out cardiac tamponade
Not very helpful to identify retroperitoneal structure injuries
62
When do we use local wound exploration?
For hemodynamically stable patient with anterior abdominal stab wound
63
What are first steps in management of penetrating trauma patient?
Primary survey of ABCDEs, especially identifying presence and location of all entry and exit wounds
64
What is massive transfusion protocol and when do we use it?
Provide blood component therapy (packed RBCs, plasma, platelets)
Use in all hemodynamically unstable patients with major suspected food loss
65
What is permissive hypotension? When is it used?
For penetrating torso trauma - keep the blood pressure intentionally low to avoid "popping the clot".
do NOT use in blunt trauma, especially in head injury
66
Do we use prophylactic antibiotics/analgesics in all penetrating trauma patients?
No: can mask signs and symptoms
| If patient has clear signs/symptoms for surgical intervention: yes: get preoperative AB for bowel flora
67
When do we administer tetanus prophylaxis?
1 Pts with < 3 doses tetanus toxoid
2 Pts with unknown immunization status
+ tetanus prone wound (obvious soil contamination, > 6 hours old)
68
How to manage patients presenting with impalement?
Assessed as other penetrating trauma patients
| Do not remove until in OR or after imaging studies have been done
69
Where are trauma patients prepped in the OR?
Chin to knees - make sure access to chest (thoracotomy?), groins (for saphenous graft)
70
What is surgical management for patients presenting with penetrating abdominal trauma?
exploratory laparotomy
71
When do we use laparoscopy in penetrating abdominal trauma?
- 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
72
What is the lethal triad of death in a trauma patient?
Acidosis, Hypothermia and coagulopathy
73
What is damage control surgery?
Patient with hemorrhage, multiple injuries shows hypothermia, coagulopathy and acidosis intraoperatively: surgeon stops surgery (even if all injuries aren't fixed), transport patient to ICU and correct lethal triad
Plan to re-explore patient after correction
74
What criteria must be met for nonoperative management in patients with penetrating abdominal trauma?
Hemodynamically stable
No peritonitis
Evaluable (normal AMS)
CT scan showing no intraabdominal injury
75
How long to continue prophylactic antibiotics after trauma laparotomy?
24 hours
76
What is a stoma, and is it needed for small bowel or colon injuries?
Pouch
| RARELY needed for small bowel/colon injuries: can be repaired primarily
77
Patients with injury to colon and/or common iliac artery are at increased risk for damage to what structure?
ureter
78
What signs make you suspect abdominal compartment syndrome?
- Decreased urine output
- Increasing peak pressures on ventilator
- increasing vasopressor support
in absence of another identifiable cause in a patient with multiple traumatic injuries
79
What is treatment for abdominal compartment syndrome?
take patient to OR: decompressive laparotomy: open abdominal fascia and leave wound open
80
What are hard and soft signs of vascular injury?
Hard: specific, overt PE exam findings - require immediate operative intervention
Soft: increase index of suspicion for vascular injury
81
What are 6 P's of limb ischemia, and what do they apply to?
pain, pallor, paresthesias, paralysis, pulselessness, poikilothermic
Acute and chronic limb ischemia!
82
What does an audible bruit or palpable thrill near an artery suggest in trauma?
traumatic AV fistula
83
What are the hard signs of vascular injury?
```
Arterial/pulsatile bleeding
Persistent hemorrhage with shock
Expanding or pulsatile hematoma
palpable thrill
audible bruit
absent pulse
```
84
What are the components of physical exam of injured extremity?
Vascular
Neuro
MSK
Soft tissue
85
What is the mechanism of popliteal artery injury?
Traction and transection injuries due to fixed course across knee joint
86
What is most common presentation of popliteal artery injury?
thrombosis with acute distal limb ischemia
87
Why do we promptly reduce a dislocation?
- 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
88
What do we do AFTER reduction of dislocation?
Re-examine vascular and neuro status
89
What is minimal vascular injury?
Clinically silent injuries that are discovered on radiographic studies like angio.
90
What do we do if hard signs of vascular imaging are present?
Go immediately to OR
91
Without hard signs present, how to evaluate for vascular injury at bedside?
Ankle brachial index: compare SBP of ankle to brachial. Normal is 1-1.2, < 0.9 = sensitive and specific for arterial injury
92
Without hard signs of vascular injury and if ABI is abnormal, what next?
CTA is best: available, quick and noninvasive
93
What other imaging is needed for posterior knee dislocation, other than vascular testing?
plain film joint x-ray
94
Do angiogram in penetrating trauma if ABI is normal and no hard signs of vascular injury?
No
95
What is the mangled extremity severity score and how is it used?
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
What is role of tourniquets in patients with life threatening extremity hemorrhage?
early application of tourniquets prior to onset of shock is associated with improved outcomes
97
What is the order of steps of management in knee dislocation?
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 --> OR
98
Where does graft come from to replace injured artery?
Greater saphenous vein from contralateral leg
99
If there is combined orthopedic and vascular injury, which is repaired first?
1. Place intravascular shunt
2. Orthopedic stabilization
3. Definitive vascular repair
100
Why does heparin help vascular injury?
Reduces amputation rate: preventing microvascular thrombosis in setting of low-flow arterial circulation
101
If patient has palpable pulses, do they have an arterial injury?
they may! Important to do ABI with pulse exam to confirm normal blood flow
102
When is endovascular repair a good option?
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
Who is not a good candidate for endovascular repair?
Patients at risk for compartment syndrome or those requiring embolectomy
104
What are the most important parts of H&P for neck injury?
Mechanism of injury
Location
Clinical Exam findings
105
What is significance of stridor?
Sign of upper airway obstruction
| Warrants immediate attention, usually in form of endotracheal intubation
106
How do we name the zones of the neck?
I-III in direction of blood flow of carotids
107
What is the significance of whether or not the injury has penetrated the platysma?
Injuries that do not penetrate the platysma are by definition nonpenetrating neck injuries and do not require further workup
108
How do we tell the difference between pseudoaneurysm and hematoma?
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
What is the differential of a pulsating mass? (3)
AV fistula
aneurysm
pseudoaneurysm
110
How does phrenic nerve damage present?
It causes ipsilateral hemidiaphragm paralysis which may be seen on CXR: elevation of the diaphragm on the affected side
111
In penetrating neck trauma, after primary survey, if no hard signs are present, what is the next step?
Helical CT angiography
112
In penetrating neck trauma, if helical CT angiography shows concern for injury in zone 1 or 3, what is the next step?
Catheter angiography (arterial) and/or triple endoscopy (if aerodigestive tract)
113
In penetrating neck trauma, if helical CT angiography shows concern for injury in zone 2, what is the next step?
Surgical exploration (if vascular), triple endoscopy if aerodigestive tract
114
What do you do in the ED if there is brisk arterial bleeding that cannot be controlled by direct pressure?
Place foley catheter into wound and advance, followed by inflation of balloon and clamping - provides tamponade effect on bleeding vessel
115
Why do we more readily explore zone 2 vs. 1 and 3?
Zone 2 is readily accessible via standard neck incision
116
What should we look for in patients with penetrating injury above the clavicle?
Pneumothorax
117
What is the general principle for operative exposure of vascular injuries?
Obtain proximal and then distal control of injured artery so that bleeding is controlled before exploration
118
In setting of major vascular injury, what other part of the body should be preppred?
one or both thighs in anticipation of need to harvest greater saphenous vein
119
How to manage repair of pseudoaneurysm?
Surgical repair: inherently unstable and can rupture/cause massive blood loss in trauma setting
120
How to manage AV fistula?
Needs open surgical repair: low resistance vein means it will rarely close
121
How to manage intimal injury?
Usually stable: may remodel and heal spontaneously
122
Why is routine use of CTA recommended in patient with GSW?
Multiple bullet fragments may be created inside the neck or bullets ricocheting off bony structures
123
How do we evaluate for blunt carotid injury? If present, how to treat?
Ct angiogram. Usually anticoagulation only
124
What is zone 1?
Clavicles/sternal notch to cricoid cartilage
125
What is zone 2?
cricoid cartilage to angle of mandible
126
What is zone 3?
Angle of mandible to base of skull
127
What is the concern with bilateral vocal cord paralysis?
complete upper airway obstruction
128
What should we be thinking about in the back of our heads for patient with penetrating neck injury?
Airway compromise from expanding hematoma - low threshold for intubation!
129
When should we expect blunt carotid injury?
FND that is not explained in head CT
130
What is the maximum amount of artery that can be removed and still allow for primary anastomosis?
2cm - do not perform under tension
131
What are considered the lethal 6 injuries of thoracic trauma?
```
Airway obstruction
Tension pneumothorax
Open pnemothorax
Massive hemothorax
Flail chest
Cardiac tamponade
```
132
What's the most common cause of airway obstruction in patients with diminished airway reflexes?
Relaxed tongue falls back against the rear of the pharynx
133
What are considered the "hidden" 6 injuries of thoracic trauma?
```
Blunt aortic injury
Esophageal injury
Tracheobronchial injury
Diaphragmatic rupture
Blunt cardiac injury
Pulmonary contusion
```
134
What causes diaphragmatic rupture?
1 Sudden rise in intraabdominal pressure - stomach and colon are most frequently herniated structures
2 Penetrating thoracoabdominal injury
135
What makes up the deadly dozen of thoracic trauma?
Lethal 6 + hidden 6
136
What is the differential diagnosis for combative trauma patient?
- Intoxication
| - Underlying physiologic derangement: hypoxia, hypovolemic or cardiogenic shock, hypoglycemia
137
What is the preferred central line location in trauma?
femoral line
138
How to establish diagnosis of tension pneumothorax?
Clinical: suspect with hypotension, dyspnea, tachypnea, JVD, unilateraly absent breath sounds, deviated trachea to unaffected side
139
How to establish diagnosis of cardiac tamponade?
Clinical: Beck's triad: hypotension, distended neck veins, muffled heart sounds.
- Can support with FAST scan: fluid in pericardial sac
140
What is the differential for absent breath sounds on left?
pneumothorax
| massive hemothorax
141
What is the implication of a penetrating injury to the chest that is above vs. below the nipple?
Above nipple: thoracic structures
| Below: thoracic structures, abdominal contents or diaphragm itself
142
Why is it important to know type of weapon used in penetrating injury?
Bullet injuries: unpredictable paths: must find entry and exit wound. If can't find exit, find bullet radiographically
143
What is the concern when pulse pressure is low?
- Pulse pressure < 30 = low.
| - Implies reduced stroke volume
144
What is the differential for narrow pulse pressure in trauma? (< 30 mm Hg)
Pericardial tamponade
Hypovolemic shock
Cardiogenic shock
145
What is the significance of air bubbling from a chest wound?
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
What is the difference between open, simple and tension pneumothorax in trauma patients?
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
After putting in a central line, what is needed next and why?
CXR to confirm you did not cause an iatrogenic pneumothorax
148
Why is a tension pneumothorax dangerous?
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
What happens with tension pneumothorax in setting of positive pressure ventilation?
Tension pneumothorax will be exacerbated! Decompress as soon as suspected with chest tube BEFORE PPV
150
What is the mechanism of an air embolism?
Traumatic creation of fistula between injured bronchus and pulmonary vein
151
In a patient with suspected tamponade, why do we not intubate and institute PPV?
PPV causes reduced cardiac filling, which can exacerbate already compromised cardiac output seen in cardiac tamponade
152
What is a needle thoracostomy? Where is it placed?
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
What is function of needle thoracostomy?
Convert tension pneumothorax into simple/closed pneumothorax. Provides immediate decompression
154
What else do patients who receive needle thoracostomy need?
Tube thoracostomy (chest tube) for definitive management. Would take too much time in setting of tension pneumothorax
155
What is a tube thoracostomy? Where does it go?
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
When does a chest tube need to go to the operating room?
If massive hemothorax encountered (>1.5L immediately or >150-200mL/hour over 3 hours) - immediate transport to OR needed!
157
What is tube thoracostomy vs. thoracotomy?
Tube thoracostomy: treats pneumothorax
Thoracotomy: often performed by surgeon in emergency setting to perform lifesaving/invasive resuscutation measures (internal cardiac massage, hemorrahge control)
158
What is initial and chronic management of cardiac tamponade?
1. IV fluids: increase preload
| 2. Definitive: Median sternotomy to release tamponade in OR: not pericardiocentesis
159
Why is pericardiocentesis not recommended in trauma?
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
Are vasopressors recommended in management of traumatic cardiac tamponade? Why or why not?
No: they increase SVR which exacerbates myocardial dysfunction
161
What should be ordered on all patients that are combative? (3)
1. finger stick glucose
2. pulse ox
3. complete vitals
162
How much pleural fluid can the diaphragm hide in upright CXR?
up to 500cc
163
How do we look for a leak in a chest tube drainage system?
Check the water seal chamber on suction: large leaks will be obvious with bubbles passing through water seal fluid.
164
What is a necessary for a hemothorax patient who requires general anesthesia?
A chest tube! PPV may convert simple pneumothorax into tension pneumothorax
165
Why do we put patients with pneumothorax on 100% O2?
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
How do we treat a sucking chest wound?
Occlusive dressing and chest tube
167
How to treat flail chest with respiratory compromise?
1 Analgesics
| 2 Intubation / mechanical ventilation
168
What is the most dangerous complication after pericardiocentesis?
Laceration of coronary vessel
169
What nerve is at risk when opening the pericardium?
L phrenic nerve: passes longitudinally over posterior aspect of pericardium of L ventricle
170
How do we treat persistent hemothorax, if patient already had a chest tube?
1 Repeat chest tube
2 VATS
3 Thoracotomy
171
What is a long term sequelae of a patient with L diaphragm injury?
Acquired diaphragmatic hernia with incarcerated bowel in the chest: patient presented with chest pain and SOB with remote history of trauma
172
If patient has penetrating wound just below nipple, what is next diagnostic step and why?
CXR: rule out intra-abdominal injury due to high risk of bowel injury and blood loss
173
Is FAST appropriate for penetrating trauma? If so, when?
Limited evidence
| Use in cardiac tamponade and pneumothorax
174
Do chest tube placement patients get prophylactic antibiotics?
No
175
When do we remove chest tubes that were placed for traumatic pneumo/hemothorex?
No air leaks present and lung fully expanded on CXR
176
What is main risk during chest tube removal?
Air being reintroduced into pleural cavity
177
What is most important factor in cardiac tamponade?
Rapid accumulation of fluid
178
What are indications for ED thoracotomy?
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
What are the 5 degrees of burn and what levels of skin do they correlate to?
1st: Epidermis only
2nd: Epidermis and some dermis
3rd: All skin (epidermis and dermis)
4th: all skin, underlying bone, tendon, adipose or muscle
180
How do we differentiate between 2nd degree burns of superficial vs. deep partial thickness?
Superficial: with pain
Deep: without pain
181
How do we determine severity of burn injury?
```
Rule of nines:
Head 9%
Each arm 9%
Ant torso: 18%
Post torso: 18%
Each leg: 18%
```
182
What percent of skin is the palm?
1%
183
What does carbonaceous sputum indicate?
Possible inhalation injury
184
What are the 3 components of inhalation injury?
1 Upper airway edema
2 Acute respiratory failure (pneumonitis from products of combustion)
3 CO poisoning
185
What do we look for when concerned about burn wound sepsis?
```
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
What is the significance of circumferential burn in the extremity?
Significantly increased risk for compartment syndrome
187
What is the significance of circumferential burn in the chest?
Can compromise respiratory efforts
188
What are the different causes of burns?
Thermal (scalding hot water)
Chemical (alkali: liquefactive necrosis)
Electrical (can cause cardiac arrhythmia)
189
What are the risks of:
a) DC current?
b) AC current?
a) Asystole
| b) V fib
190
What is a long term complication of electrical injury?
Cataracts
191
Why are burn patients at increased risk for dehydration?
Lose the integrity of skin layer for fluid and temp regulation which can lead to fluid loss, lack of temperature control --> hypovolemic shock
192
Why are burn patients at increased risk for GI ulcers?
Decreased perfusion from decreased intravascular volume --> subsequent ischemic necrosis of gastric mucosa
193
What is the burn called in severe burns patients, and where is it?
Curling's ulcer in duodenum
194
What are the most common organisms involved in burn wound infections?
1. Pseudomonas
2. S. aureus
3. S. pyogenes
if fungal: candida
if viral: HSV
195
What are risk factors for mortality of burn injury?
Increased age
Total burn surface area
Inhalational injury
196
How do we diagnose inhalation injury?
1 Clinically: facial burns, singed nasal hairs and history of injury in an enclosed space
2 Fiberoptic bronchoscopy for definitive diagnosis
197
How do we diagnose burn wound infection?
Punch biopsy: > 10^5 bacteria / g
198
How do we determine fluids for burn patients?
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
What type of fluid do burn patients get?
Lactated Ringer's
200
What is key management principle for patients with electrical burns?
Cardiac monitoring: 12-24 hours to look for arrhythmia
201
What medication should all burn patients be started on?
HINT: to prevent ulcers
PPI or H2 blocker
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How do we manage a burn wound?
1. Resuscitate
2. Cleanse and debride
3. Antimicrobial agents and dressings
4. Skin graft after the wound is clean
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What do you do for patients with circumferential chest burn and deteriorating respiratory status?
chest escarotomy
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Which electrolytes do we track in burn patients?
Na and K
Na: hyponatremia from fluid loss
K: hyperkalemia from cell and tissue destruction
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How do you manage a patient with inhalation injury?
Early intubation: prevent sudden loss of airway due to thermal injury/upper airway edema
206
What are the P's of compartment syndrome, and how do they differ from acute limb ischemia?
pain, paresthesia, pallor, paralysis, pulselessness and poikilothermia
Pulselessness is a LATE sign, vs. early sentinel event in acute limb ischemia
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What are early signs of compartment syndrome?
1. Pain (during passive range of motion)
2. Nerve ischemia (sensory before motor)
3. Cap refill diminishes: pallor, paralysis
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How many compartments are there in the upper leg vs. lower leg?
Upper: 3: anterior, medial, posterior
Lower: 4: anterior, lateral, superficial posterior, deep posterior
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How many compartments are there in upper arm vs. forearm?
Upper arm: 2: anterior and posterior
| Forearm: 3: dorsal, volar, mobile wad
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What are the 2 categories of causes of compartment syndrome?
1. Decreased compartment size
| 2. Increased compartment volume
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What is pathophys of compartment syndrome?
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 --> tissue ischemia
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What sequelae can tissue damage secondary to compartment syndrome lead to?
Hyperkalemia, acidosis and myoglobinuria which may cause kidney failure
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What is the significance of first web space numbness in compartment syndrome?
Deep peroneal nerve courses through anterior lower leg compartment.
Nerve ischemia within anterior compartment produces numbness between 1st and 2nd toes
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What is abdominal compartment syndrome?
Abdominal cavity is a fixed compartment: susceptible to elevated pressures causing mass effect to intra-abdominal organs
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What is the main risk factor for abdominal compartment syndrome?
Trauma patients that receive massive fluid resuscitation
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What are the clinical manifestations of abdominal compartment syndrome?
Clinical: tense, tender, swollen compartments with pain on passive motion
217
When do we measure compartment pressures in suspected extremity compartment syndrome?
1 When suspicion is low to provide confirmatory documentation
2 when patient is obtunded and accurate PE cannot be performed
218
How to diagnose abdominal compartment syndrome?
Measure bladder pressure: > 25-30 mmHg suggests abdominal compartment syndrome
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What is treatment of extremity compartment syndrome?
Immediate decompressive fasciotomy
220
What compartment in lower leg is most often missed during fasciotomy and why is this compartment important?
Deep posterior
Important for foot function: contains both posterior tibial and peroneal arteries and tibial nerve
221
What is treatment for abdominal compartment syndrome?
Urgent decompressive laparotomy
