Trauma Flashcards
NEXUS criteria
midline tenderness, neuro deficits distracting injury AMS or intoxication
Normal blood volume, adults, kids
7% of body weight = 5 L
8-10% in kids
Palpable pulse cut offs
Radial pulse = BP > 80 Femoral pulse = BP > 70 Carotid pulse = BP > 60
Traumatic hemothorax, thoracotomy indication
>1,500 mL initially
Shock classes
Class I: <15% blood loss = no significant changes
Class II: 15-30% blood loss = dec cap refill, dec heart rate, narrow pulse pressure Class III: 30-40% blood loss = shock, low BP, altered mental status
Class IV: >40% blood loss = preterminal
Blood replacement timing for various blood products
When to administer (peds)
Full crossmatch preferred (takes 1 hour) Type-specific ABO + Rh compatible (10 mins) If type-specific unavailable Type O neg (universal donor) Type O pos can be used in males
Persistent shock after 20 mL/kg bolus, titrate to UOP 1 mL/h
Early head injury interventions (3)
Relative hyperventilation (pC02 30-35) ICP monitor (GCS 3-8 & intracranial lesion) Early surgical decompression/craniotomy
GCS
Thoracotomy Indications
•Absolute indication
–Penetrating chest trauma + signs of life (pre-hospital or ED) + cardiac activity in ED
•Liberal indications
–Abdominal trauma and cardiac activity requiring aortic cross clamping to get to operating room
–Blunt chest trauma with loss of vital signs in ED
Trauma epidemiology
Kids% of deaths and 1-2 cause of fatal injury
Adults
Elderly, leading causes (2)
50%, Head trauma then burns
50% Head trauma
Elderly MVC, falls
Pediatric airway considerations
–Large occiput tends to flex neck
–Obligate nose breathers <6 months
–Increased tongue size
–Anterior larynx
–Narrow subglottic area
Peds ETT formula
– ET size (mm) = (age + 16) / 4
IO lines complications (5)
- Growth plate injury
- Fluid leakage
- Fat emboli
- Osteomyelitis
- Compartment syndrome
Kids bolus and PRBC dose
–Crystalloid 20 ml/kg bolus (x 2 if poor response)
–PRBC 10 ml/kg
SCIWORA diagnosed by
MRI
Shaken baby syndrome pathophysiology
Diffuse cerebral injury with edema
Retinal hemorrhages, poor prognosis
Pathognomonic fracture for child abuse
Metaphysial deformity (bucket handle) due to shearing / rotational forces
Pregnancy and trauma
•Uterus rises out of pelvis at
Penetrating vs blunt trauma
12 weeks
•Penetrating trauma
– Maternal mortality is low
– Fetal mortality is high
Blunt trauma:
Leading cause
of maternal death
Uterine rupture signs
–Presentation may be non-specific: loss of uterine contour, palpable fetal parts
–Shock, abdominal pain, fetal demise
Abruption
mechanism pearl
tests (2)
management
–Can be Minor fall, airbag deployment, bump into counter
–Check Kleihauer-Betke (fetal nucleated RBCs in maternal circulation) (controversial)
- Fetal monitoring
–RhoGAM if Rh negative
Abruption fetal monitoring indications and guidelines
- External fetal monitoring is indicated for all blunt trauma patients >20 weeks gestation
- Frequent uterine activity is more predictive of abruption than ultrasound
–>8 contractions/hr x 4 hrs: Risk for abruption
–3-7 contractions/hr x 4 hrs: Extend monitoring for 24 hrs
–<3 contractions/hr x 4 hrs: Safe for discharge
•Fetal distress (>23 weeks)
–Tachycardia, bradycardia, and decelerations
–May indicate emergent C-section
Cerebral perfusion pressure
Abnormal is
(CPP) = MAP-ICP
Increased ICP: CSF pressure > 15 mm Hg
Epidural and Subdural
Secondary or primary
Epidural - Coup
Subdural - Contrecoup
Diffuse Cerebral Edema
Skull fracture treatment
Linear non-depressed fracture
Temporal skull fracture (middle meningeal artery) associated with
Open skull fracture (2)
Depressed skull fracture needs NSG when
Occipital skull fracture actions (4)
Linear non-depressed fracture - no treatment
Temporal skull fracture (middle meningeal artery) associated with epidural hematoma
Open skull fracture: Antibiotics and neurosurg
Depressed skull fracture (one bone-table width): Neurosurgery for elevation
Occipital skull fracture: Rule out SAH, contrecoup injury, posterior fossa hematoma, cranial nerve injury
Ring test for CSF
Halo of clear fluid beyond blood-tinged fluid / CSF fluid is glucose-positive
Basilar Skull Fracture CT findings and caveat
CSF leaks
Air-fluid level in sphenoid sinus, air in the posterior fossa, air around TMJ
Caveat - Skull x-rays and CT are often negative
Most CSF leaks resolve spontaneously within a week
Clinical dx: can cause CSF oto- or rhinorrhea, bleeding from the ear canal, ecchymosis of the mastoid area or orbital area, cranial nerve deficits (V, VI, VII and VIII [hearing loss, nystagmus, ataxia])
SDH vs EDH (3) - severity, frequency, mortality
SDH - often more severe underlying injury
Six times more common than epidurals
Higher mortality rate than epidurals
SDH time classification, CT appearance
– Acute: <24 hours (white on CT)
– Subacute: 24 hours-2 weeks (isodense on CT)
– Chronic: >2 weeks (dark on CT)
Herniation Syndromes - transtentorial
Mechanism/location
Neuro deficit
–Mass effect (hemorrhage, edema) pushes medial temporal lobe (uncus) through the tentorial notch
–Compression of CN III causes ipsilateral fixed, dilated pupil
–Compression of ipsilateral corticospinal tract causes contralateral hemiplegia
•Sometimes the opposite corticospinal tract is compressed producing ipsilateral hemiplegia
–Brainstem compression causes coma
Herniation Syndromes - Central
Mechanism/location
Neuro deficit
–Mass effect causes downward displacement of entire brainstem
–Earliest sign is CN VI (lateral rectus) palsy
–Bilateral uncal herniation
Herniation Syndromes -Tonsillar
Mechanism/location
Neuro sx
–Cerebellar tonsils herniate through foramen magnum
–Respiratory arrest and death
Increased ICP Treatment
Airway/breathing
Meds and dose
- Intubate if GCS ≤ 8, Elevate HOB
- Hyperventilation is controversial
–Decreased pCO2, increased pH, decreased ICP, vasoconstriction
–Goal: pCO2 30-35 mm Hg
–Avoid excessive hyperventilation
•Mannitol
–Osmotic diuretic (1 g/kg)
–Controversial in children
•Steroids not beneficial
Peds head trauma vs adults
Autoregulation
Injury types
GCS
Skull
- Poor pressure/volume curve
- More non-surgical lesions
– Diffuse cerebral edema
– Diffuse axonal shear
– Contusions
– Peds concussion syndrome (diffuse cerebral hyperemia)
- GCS may wax and wane
- Skull is much weaker
Growing skull fracture - peds
What/another name
Exam
Symptoms
Tx
Prophylaxis
•Growing fractures” = Leptomeningeal cyst that enlarges over time, associated with a tear of the underlying dura and initially have > 4mm fragment separation
–May feel a skull defect or local swelling, seizures, neuro deficits
–Median age 18 months /most require surgical repair
–All fractures are advised to be re-x-rayed in two months to evaluate for signs of a growing fracture
Growing fracture - peds
Penetrating Neck Injury
Definition
Zones and most common
Management principal
Complication and treatment
•Most injuries occur in Zone ll
–Vascular > CNS
–Peripheral nerves > brachial plexus
- Vascular injuries need proximal and distal control
- Death from CNS injury, exsanguination, airway compromise (intubate early)
- Air embolism is potentially fatal complication
–Machinery murmur
–Trendelenburg + left lateral decubitus position to prevent bubble migration
Penetrating Neck Injury
Hard signs (8)
–Hypotension
–Arterial bleeding
–Expanding hematoma
–Thrill, bruit
–Focal deficits
–Hemothorax >1,000 mL
–Bubbling wound
–Hemoptysis, hematemesis
Soft signs
(require full diagnostic evaluation)
–Stridor
–Hoarseness
–Vocal cord paralysis
–Subcutaneous air
–Facial nerve injury
Penetrating Neck Injury with hard signs
management by zone
•Hard signs: Unstable require surgical exploration
–Zone I: Requires thoracic surgical approach
–Zone II: Exploration technically least difficult
–Zone III: May require disarticulation of mandible
Penetrating Neck Injury with soft signs
management by zone
–Zone I: Angiogram, esophagram, endoscopy, bronchoscopy
–Zone II: Exploration or angiogram, esophagram, endoscopy, bronchoscopy
–Zone III: Angiography
Pentrating neck injury - zones
Blunt Neck Trauma
Evaluation
Injury types
CT with contrast
- Laryngotracheal and pharyngoesophageal injuries can be subtle; require diagnostic imaging
- Carotid/vertebral artery injury: Pseudoaneurysm or dissection
–Mechanism: Hyperextension, hyperflexion, direct blow, intraoral trauma, basilar skull fracture
–Neurologic symptoms may be delayed
Triad: Neck trauma + TIA, stroke, or Horner’s syndrome
Carotid artery dissection
Hypotension + blunt trauma
Leading cause
•Pelvic fracture > intraabdominal injury > intrathoracic injury
Hypotension + penetrating trauma
Leading causes
Lung > heart > great vessels
Occlusive dressing in tension PTX caveat
Application of occlusive
dressing can cause
tension pneumothorax
Open thoracotomy
Technique (3)
Most commonly injured structures
Incision at 5th ICS, open pericardium vertically, anterior to phrenic nerve
Because of their anterior location, the right
ventricle and right atrium are most commonly
injured in penetrating trauma
1st and 2nd Rib Fractures, Scapular fx
–Myocardial contusion
–Bronchial tear
Vascular injury (consider angiogram
Flail Chest, treatment
Direct pressure, intubation, consider chest tube
Tracheobronchial Injury
Most common location
Treatment (3)
Sign and sx review
within 2 cm of carina
oxygenation, ventilation, chest tube
•Symptoms / signs
–Chest pain
–Dyspnea
–Hypoxemia
–Hamman’s crunch
(mediastinal friction rub w/ heart beat)
–Hemoptysis
–Subcutaneous emphysema
•CXR
–Pneumothorax
–Pneumomediastinum
–Tension pneumothorax
–Rib fracture
Continuous bubbling a chest tube is a sign of
Hamman’s crunch, description, suggests
•bronchopleural fistula
mediastinal friction rub w/ heart beat suggestive of tracheobronchial tree injury
caused by pneumomediastinum or pneumopericardium
Hemothorax
most common etiology
dx and caveats (2)
- Intercostal artery injury is a common cause
- Upright CXR: Blunting of CPA (200-300 mL)
–Volumes of up to 1000 mL may be missed on supine CXR
•Beware of right mainstem intubation with white-out of opposite lung (don’t confuse with hemothorax)
Hemothorax - Thoracotomy indications
– Unstable
– Initial output >1500 mL
– >100 mL/ hr x 6 hours
– Persistent air leak
Open PTX initial treatment and caveat
–3-sided petrolatum gauze, one-way valve, chest tube
–Dressing can create a tension pneumothorax; remove dressing if patient has increased SOB
Diaphragm: Traumatic Injuries
Caveats
Natural history
dx often missed, especially if on R (masked by liver)
- DPL, CT, ultrasound may not be diagnostic
- Often diagnosed at laparotomy
- Treatment: Surgical repair
- Small injuries will continue to enlarge
- Small injuries will continue to enlarge
Diaphragm injury Blunt mechanism vs Penetrating
Side
Body habitus
Aspect
Size
Typical diagnostic time
Dx
Translocation
Blunt Mechanism
- L > R (1% bilateral)
- Obese person
- Anterior aspect
- Large rent (6-10cm)
- Delayed diagnosis (by 48 hours)
- L hemothorax
- Translocation 50%
- CXR abnormal but not diagnostic
Penetrating Mechanism
- L > R
- Thinner habitus
- Posteriorly (SW in L flank)
- Small tear (2-3 cm)
- Delayed diagnosis (by years until herniation)
- Normal CXR (ptx, htx)
- Translocation rare
- Late herniation and strangulation
Traumatic Ruptured Aorta (TRA)
Most common location/outcome
Survivors usual location
Sx
Signs
- Most often, tear at isthmus 2°to deceleration (victims die immediately at scene)
- Survivors who reach ED usually have tear at the ligamentum arteriosum
Traumatic Ruptured Aorta (TRA)
Sx
Signs
- Retrosternal pain, dyspnea, stridor, dysphagia
- Harsh systolic murmur (aortic valve)
- Pulse difference between upper and lower extremities
Traumatic Ruptured Aorta (TRA)
CXR findings and most sensitive and specific (6)
•X-ray findings
– widened mediastinum (best S&S)
– Left apical cap
– Blurred aortic knob
– Left hemothorax, trachea deviated to right; NG tube deviated to right
– Depressed left mainstem bronchus
– Loss of aortic-pulmonary window
Traumatic aortic rupture
Cardiac Tamponade
3 eponyms
- Beck’s triad: Hypotension, JVD, muffled heart sounds
- Pulsus paradoxus (weaker pulse, lower systolic pressure with inspiration)
- Electrical alternans: Alternating QRS direction
Myocardial contusion
Conduction abnormalities
Dx
- EKG: Slowed conduction, ectopy, ST-T wave changes, and tachycardia
- Diagnosis: Echocardiogram (wall motion defect), increased (Troponins not rec’d in ATLS)
Abdominal seatbelt sign
associated injuries
Mesenteric laceration, hollow viscus tear, ruptured diaphragm, Chance fracture
Abdominal trauma - Laparotomy indications
–Evisceration, GSW, impalement, gross blood by NG, rectal or DPL, positive FAST scan if unstable
Anterior stab wounds
Rule of thumb
–Rule of thumb: 1/3 no penetration, 1/3 penetration and no surgery, 1/3 require surgery
Only patient’s with findings need repair
Could be chest or abdomen wound
Abdominal trauma - CT weaknesses
Gross hematuria tests (2)
Insensitive to hollow organ injury, pancreas, and diaphragm
CT or cystourethrogram
Positive DPL (4)
–Aspiration of 10 mL of free-flowing blood (DPA)
–>100,000 RBCs/mL in lavage fluid (BAT)
–10,000 RBCs/mL is threshold for laparotomy in penetrating trauma
–Bile, feces, urine
Abdominal sign eponyms
Grey Turner’s sign
Kehr’s sign
Cullen’s sign
Rovsing’s sign
- Grey Turner’s sign: Flank discoloration (late sign of retroperitoneal hematoma; seen in hemorrhagic pancreatitis)
- Kehr’s sign: Referred left shoulder pain due to subdiaphragmatic irritation or splenic rupture
- Cullen’s sign: Periumbilical ecchymosis (in hemorrhagic pancreatitis, ectopic pregnancy)
- Rovsing’s sign: RLQ pain with LLQ palpation (due to peritoneal irritation e.g. acute appendicitis)
Post splenectomy vaccinations
Pancreas and Small intestine injury presentation
Colon - most common injury location
pneumococcas and HiB
delayed presentation, labs/CT often normal initially, a/w lap belt and LS spine injuries
Transverse
Urethral trauma
Dx: retrograde urethrogram -> RUG
Complications (4)
Rupture Anterior vs posterior, def and location of extrav
Dx: retrograde urethrogram -> RUG
Complications: fistula, stricture, fistula (anterior), impotence, incontinance (posterior)
Posterior - at or above level of prostate in pelvis so extrav into the pelvis -> needs OR
Testicular trauma
dx (2)
Renal Injury
dx caveat and dx (2)
Vascular injury dx and timing
US or direct exploration
Renal injuries can present without hematuria
Gross hematuria: IVP, contrast CT urogram
Renal vascular injury requires angiogram
dx - angiogram, repair within 12 hours
Tetanus
US epi
High risk wounds (7)
60 cases/year, esp elderly and neonatal 3-10 days after birth
–>24 hrs old, crush injury, devitalized tissue
–Burns, IVDA, early postpartum wounds
–Soil in wounds
Tetanus vaccine guidelines
Clean minor wounds
All other wounds
- If less than three prior immunizations in the past or unknown – give Tdap
- If three prior immunizations – give Tdap only if prior immunization more than 10 years previously
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- If less than three prior immunizations or unknown, Tdap and tetanus immune globulin (TIG)
- If three prior immunizations, give Tdap if last prior immunization more than 5 years prior
Local anesthetic pearls
2 types and ID pearl
max dose/kg without/with epi
Avoid irrigation with:
–“Amides” and “esters”
–Most “reactions” due to the methylparaben preservative (resembles antigenically “esters”)
–One “i” in generic name: Ester. Two “i”s: Amide
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Lido: 4.5/7; 70 kg person 30 mL of 1% (1% solution has 1 gram in 100 mL)
Bupivicaine: 2/3
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Avoid: Detergents, peroxide and povidone iodine at full strength is not advised in wounds (tissue toxic)
Abx wound prophylaxis (8)
– High risk sites (hands, feet)
– Puncture wounds, foreign bodies
– Contaminated wounds, bites
– Extensive soft tissue injury
– Through-and-through mouth lacerations
– Open fractures, exposed joints and tendons
– Prosthetic valves (endocarditis prophylaxis)
– Immunocompromised
Gas Gangrene
Etiologic agent + virulence cause
px Pearls (2)
tx (5)
C. perfringens produces exotoxin
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- Pain out of proportion to physical findings
- Dusky, brawny, “woody” edema with crepitance
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Treatment: fluids, high dose penicillin, debridement, hyperbaric O2
Necrotizing Fasciitis
Agents (3)
Px pearls (2)
Lab pearl
abx
- Anaerobes, group A Strep, Staph aureus
- very painful, crepitance
low sodium
Abx: imipenem-cilastatin
Complications of massive transfusion (3)
Decreased clotting factors, decreased platelets, decreased temperature (the most common sequelae of massive transfusion is hypothermia)
Machinery sounding “Mill wheel” murmur and management
with neck vascular inury -> air embolism
LLD and trendelenburg
