Trauma

Question 1

When do you intubate? (GCS)

Answer 1

GCS of 9 or less requires intubation

Question 2

What leads to hypotension in a tension pneumothorax

Answer 2

Increased intrathoracic pressure decreasing preload
Loss of left heart blood flow due to loss of pulmonary vasculature to affected lung
Compression of mediastinum
Tension pneumothorax is a CLINICAL diagnosis and Xrays are not appropriate in this setting. If tension pneumothorax is suspected, immediate needle decompression is undertaken

Question 3

Treatment for tension pneumothorax

Answer 3

needle decompression using 14-16 gauge long angiocath inserted at midclavicular line in the second intercostal space, over the rib to avoid the neurovascular bundle

Question 4

Massive hemothorax

Answer 4

Consider a massive hemothorax in patients in shock with no breath sounds and/or percussion dullness.

Question 5

Treatment of a hemothorax

Answer 5

placing a large (36 f) chest tube and possibly a trip to the operating room (OR) for hemorrhage control.

Question 6

How high is the blood pressure if the femoral or carotid are palpable?

Answer 6

If the femoral or carotid are palpable, these suggest a systolic blood pressure of at least 60 mm Hg

Question 7

How high is the blood pressure if the radial is palpable?

Answer 7

suggests a systolic blood pressure of at least 80 mm Hg.

Question 8

Not all patients in shock or with circulatory problems are tachycardic. Examples?

Answer 8

Neurogenic shock to sympathetic cord disruption
Beta blockade, Calcium channel blockade
Elderly
Children and young adults
Conditioned athletes start with a lower basal level. Doubling their resting heart rate of 45-50 shows a falsely reassuring heart rate of 90-100.

Question 9

Classifications of hemorrhagic shock

Answer 9

Class I: Normal BP, Normal to fast HR, <15% blood loss, treat with NS
Class II: Normal to fast HR, Normal to low BP, 15-30% blood loss, treat with NS. Narrowed Pulse Pressure
Class III: Fast HR, Low BP, 30-40% blood loss, treat with NS and blood. Altered Mentation.
Class IV: Fast HR, Low BP, >40% blood loss, treat with NS and Blood. Obtunded.

Question 10

Disability Neurological check. What does AVPU stand for?

Answer 10

Alert – a fully awake patient.
Voice – the patient responds when verbally addressed. Response to voice can be verbal, motor, or with eyes.
Pain – the patient makes a response on any of the three component measures only when pain stimulus is delivered.
Unresponsive – If the patient does not give any Eye, Voice or Motor response to voice or painful stimuli.

Question 11

Glasgow Coma Scale

Answer 11

Eyes: 
4 – Spont
3 – Loud voice
2 – To Pain
1 - None
Verbal:
5 – Oriented
4 – Confused
3 – Inapprop words
2 – Incomprehensible sounds
1 – No Sounds
Motor:
6 – Obeys
5 – Localizes to pain
4 – Withdraws to pain
3 – Abnormal flexion posturing
2 – Abnormal extension posturing
1 – None

Question 12

If a patient has evidence of fluid on FAST exam and is unstable, do you get a CT or go to OR straight?

Answer 12

If the patient is unstable,they should go to OR and NOT to CT scanner

Question 13

What is the battle sign?

Answer 13

left, ecchymosis behind ear indicative of basilar skull fracture

Question 14

What is the raccoon’s eyes?

Answer 14

right, periorbital ecchymosis without edema indicative of basilar skull fracture.

Question 15

Motor Strength

Answer 15

0: Total paralysis
1: Palpable/visible contraction
2: FROM w/gravity eliminated
3: FROM against gravity
4: FROM, less than normal strength
5: Normal strength

Question 16

In order to clear cervical spine

Answer 16

Alert, not intoxicated
Absence of neck pain
Absence of midline neck tenderness
Absence of distracting injury
Absence of sensory or motor complaint

Question 17

Penetrating trauma to the neck may result in

Answer 17

injury to major vascular structures, pharynx, larynx, trachea, esophagus

Question 18

Blunt trauma to the neck may result in

Answer 18

crushed larynx, tracheal disruption, expanding hematoma, esophageal leak.

Question 19

A tracheobronchial tree disruption presents as

Answer 19

present on physical as subcutaneous emphysema. You may notice that after placing a chest tube, the lung refuses to inflate. There may be a persistent air leak. You may need to place a second chest tube, and if this fails, the patient needs to go to the OR.

Question 20

A pulmonary contusion presents as

Answer 20

may initially present as mild hypoxia but after fluid resuscitation, the corresponding pulmonary edema worsens and so does the hypoxia. This can be diagnosed on chest x-ray (or CT) and is treated by proper oxygenation and ventilation (often with intubation), and maintaining normovolemia.

Question 21

A blunt cardiac injury presents as

Answer 21

Often the only sign may be an abnormal ECG or tracing on the cardiac waveform. Echocardiography may show a hypokinetic heart. Treatment consists of medicating dysrhythmias that effect hemodynamics.

Question 22

Traumatic aortic disruption

Answer 22

caused by a rapid acceleration (or deceleration) causing a tear in the aorta. Normally this is immediately fatal, but those who survive may show a widened mediastinum on CXR. This can be confirmed with CT scan or angiography of the aorta and requires prompt surgical correction.

Question 23

Flail chest

Answer 23

caused by two or more fractures in 2+ contiguous ribs creating a free-floating segment of chest wall. This segment will move in the opposite direction of the rest of the chest wall during inspiration and expiration and disrupts the normal negative-pressure ventilatory mechanics.

Question 24

What does diminished sphincter tone indicate?

Answer 24

spinal cord injury

Question 25

What does a high riding prostate indicate?

Answer 25

Pelvic fracture or urethra injury

Question 26

What are the 5 P’s of compartment syndrome?

Answer 26

Pallor, Pain, Paresthesia, Poikilothermic, Pulseless (late finding

Question 27

What injuries can lead to compartment syndrome?

Answer 27

forearm and tibial injuries, tight dressings with underlying increasing swelling, prolonged external pressure or crush injuries, or circumferential burns

Question 28

Treatment of compartment syndrome?

Answer 28

fasciotomy

Question 29

What is a diagnostic positive peritoneal lavage?

Answer 29

Gross blood (10 ml)
100,000 RBCs/mm3
More than 500 WBCs/mm3
Positive Gram stain
Food fibers
Bacteria, bile, feces