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Absite Behind the Knife > Trauma > Flashcards

Trauma Flashcards

1
Q

Primary Survey

A 
A: Airway
B: Breathing
C: Circulation
D: Disability
E: Exposure
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2
Q

Disability

A

2 parts:
GCS
Pupillary exam
Looking for inc ICP

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3
Q

What component of GCS is most predictive?

A

Motor score

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4
Q

When to intubate based on GCS

A

<8

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5
Q

One pupil fixed and dilated

A

ipsilateral intracranial hemorrage -> compressing

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6
Q

Bilateral pinpoint pupils from brain injury

A

Pontine hemorrhage

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7
Q

Candidate for ICP monitor

A

GCS < 8 w/ abnormal head CT

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8
Q

Types of ICP monitor

A

Interventricular drain - ventriculostomy - allows to drain CSF
Bolt -> intraparenchymal

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9
Q

Which factor most affects outcome in brain injury?

A

Hypotension
Hypoxia
(Keep BP elevated and avoid desat)

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10
Q

Signs of inc ICP

A

Pupil dilatation
Cushing’s Triad - HTN, bradycardia, low RR
Motor posturing
Treat ICP based on exam

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11
Q

Treatment of inc ICP

A

1) Elevate head of bed, neck free of anything compressing flow
2) Ventilate to PCO2 of 35
3) Sedation and paralysis
Meds:
4) Mannitol and hypertonic saline (resuscitates while helping lower ICP, b/c osmotic diuretics -> hyperosmotic state
Then imaging and neurosurg

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12
Q

Epidural hematoma

A

MMA
hit in side of head
Lenticular shape
Lucid interval

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13
Q

Subdural hematoma

A

Bridging veins

Crescent shape

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14
Q

Does epidural or subdural have better outcome?

A

Epidural

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15
Q

Went through windsheild

A

Intraparenchymal contusion

Avoid secondary brain injury -> generally don’t go to surgery

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16
Q

Subarachnoid

A

Worst headache of life

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17
Q

CPP formula

A 
Cerebral perfusion pressure: MAP - ICP, adopt to any compartment
Tells amount of blood reaching cells
want 70 or better (60 is minimum)
Surrogate for blood flow to brain
Want ICP < 20
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18
Q

Major regulator of cerebral perfusion

A

pCO2 -> based on arterial dilatation (hyperventilate patient causes vasoconstriction of artery and decreased ICP)
If pCO2 rises -> hypoperfusion of brain due to vasodilation and inc ICP

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19
Q

Severe TBI can they autoregulate

A

No

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20
Q

Seizure prophylaxis

A

Give to trauma patient

Dilantin or keppra -> short term, 1 wk post injury, prevents early seizures

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21
Q

Feeding TBI pts?

A

Early feeding in 24-48 hours

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22
Q

Steroids in TBI pts?

A

NO! no benefit

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23
Q

Reversing coagulopathy

A 
Inc INR from coumadin:
PCC - prothrombin complex concentrate
Vitamin K
FFP
Pradaxa:
Dialysis
Epixaban/Rivaroxaban:
PCC - partial reversal
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24
Q

Clear spine clinically`

A 
No distracting injuries - no other significantly painful injury distracting them
Must be examinable (GCS 15)
Not intoxicated
Not on sedating meds
No neurologic findings
No bony or midline tenderness
25
Q

Clear c-spine imaging

A

CT scan

not x-ray in adults, but possibly in kid

26
Q

Central cord syndrome

A

old lady, weakness in arms, maybe legs (cape and gloves), normal motor exam
Spinal stenosis due to spinal cord contusion

27
Q

Brown-sequard

A

Ipsilateral motor deficit, contralateral pain and temp loss below level of injury
Hemidissection of cord - stab wound

28
Q

Anterior cord syndrome

A

After aortic case
Malperfusion to spine
Exclusively motor deficits

29
Q

SCIWRA -

A

Peds, can’t move legs, normal imaging

30
Q

Spinal shock vs neurogenic shock

A

Spinal - lose motor reflexes, dx by testing reflexes (bulbocavernosis, cremasteric) if not present then in spinal shock, will come back -> bad if they come back and have no other functioning
Neurogenic - bradycardia, hypotension (hemodynamic), presents as warm extremities as well

31
Q

Spinal shock vs neurogenic shock

A

Spinal - lose motor reflexes, dx by testing reflexes (bulbocavernosis, cremasteric) if not present then in spinal shock, will come back -> bad if they come back and have no other functioning (out of spinal shock whatever they have is permanent)
Neurogenic - bradycardia, hypotension (hemodynamic), presents as warm extremities as well

32
Q

Management of spinal injury

A

Stabilization

NO STEROIDS

33
Q

Stability of fracture?

A

3 columns- 2/3 disrupted are unstable

Blunt injuries not penetrating

34
Q

Respiratory issues with spinal cord injury

A

C 3,4,5 diaphragm alive
High spinal cord injury but breathing okay not in distress -> using accessory muscles
Will need to be intubated above C4

35
Q

Zones of neck - ant/lateral

A

Zone 3: Angle of mandible to skull
Zone 2: Cricothyroid to angle of mandible (carotid, esophagus, trachea)
Zone 1: Sternum to cricothyroid

36
Q

What structures to worry about in neck

A

Esophagus
Carotids
Jugulars
Trachea

37
Q

Hypotensive w/ penetrating neck injury managment

38
Q

Hard signs of vascular injury

39
Q

No hard signs of vascular injury

A

If has violated platysma:
Full exam
Other signs of injury - Motor deficit, hematoma nonexpanding, crepitus, air coming from wound, hemoptysis/hematemesis
Need further eval - CT neck angio

40
Q

If suspicion of esophageal injury

A

Esophagram or esophagoscopy

41
Q

How to explore neck

A

Large incision on anterior border of SCM, base of ear to sternal notch

42
Q

What do you explore

A

Vessels
Trachea
Esophagus - easier to explore on L

43
Q

Swallow study with small leak of contrast, explore, no esophageal injury

A

Widely drain area and leave drains

44
Q

Swallow study with small leak of contrast, explore, Find 4 cm laceration in esophagus

A

Extend myotomy to see entire mucosal defect then close in 2 layers

45
Q

Which esophageal injuries can you manage non op

A

Small contained, not septic, endoscopic (dilation injury) to cervical, thoracic, flow back into lumen of esophagus, no connection to pleural space
Tx: NPO, abx, non op management
Cannot manage intraabdominal non op

46
Q

High speed MVA, normal head CT, have altered mental status

A

Blunt cerebrovascular injury - Carotids, vertebrals

47
Q

Who to screen for blunt head injury who has NO symptoms

A 
Cervical spine, base of skull, mandible fractures (Le Fort)
Seat belt sign above clavicle
GCS < 8
Bruit or thrill
Screen: CTA
48
Q

Blunt cerebrovascular injurys

A

Distal carotid - hard to reach in OR

Tx: Antiplatelet or anticoagulation, possible stent esp if AV fistula

49
Q

Flail chest

A

3 consecutive ribs with fractures in 2 places

50
Q

Cause of hypoxia

A

Pain -> decreased respiration due to underlying pulmonary contusion, not the paradoxical motion

51
Q

Tx of flail segment

A 
Manage pain
#1 Epidural
If significant contusion -> intubation
If signficant paradoxical motion -> consider plating
52
Q

Car crash -> slam into steering wheel, hypotensive, sternal fracture w/ PVCs, no bleed

A

Blunt cardiac injury
MC finding EKG abnormality (GET AN EKG)
Dx: EKG then echo

53
Q

Pulmonary contusion hx

A

Day 24-48 hrs blossoms w/ fluid mobilizing -> become hypoxic, like ARDS

54
Q

Blunt aortic injury

A

Chest trauma, widened mediastinum, hemathorax, recurrent laryngeal nerve injury
CXR finding
Widened mediastinum
Aortic knob obscured
Apical cap
Compress L mainstem bronchus
R deviation of mediastinum
Dx: CTA
Tear is distal to L subclavian artery
Tx: BP control w/ beta-blockers
Options for repair: TEVAR, open thoracic graft
Open repair, L posterolateral thoracotomy w/ L Heart Bypass
Big risks of surgery = paralysis, worse w/ open

55
Q

Who to repair endovascularly

A

Adequate inflow vessels

Stable

56
Q

POD 1 from endovascular repair

A

L hand cold and turning dusky
(Covered L subclavian)
Tx: Carotid to subclavian bypass

57
Q

Chest tube for trauma patient reason for OR

A

Hemodynamic instability
Initial output > 1500
200 cc/hr for 4 hours, or 100cc/hr for 8 hours

58
Q

Elderly, fell with 5 rib fractures

A

Admit to ICU

Rib block vs. Epidural

59
Q

Thoracic trauma pt with diaphragmatic ruputre

A

Stabilize
LAPAROTOMY, fix with permanent sutures
May have a concomitant spleen injury

Absite Behind the Knife (11 decks)

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