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EM Board exam > Trauma > Flashcards

Trauma Flashcards

1
Q

NEXUS criteria

A

midline tenderness, neuro deficits distracting injury AMS or intoxication

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2
Q

Normal blood volume, adults, kids

A

7% of body weight = 5 L

8-10% in kids

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3
Q

Palpable pulse cut offs

A

Radial pulse = BP > 80 Femoral pulse = BP > 70 Carotid pulse = BP > 60

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4
Q

Traumatic hemothorax, thoracotomy indication

A

>1,500 mL initially

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5
Q

Shock classes

A

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

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6
Q

Blood replacement timing for various blood products

When to administer (peds)

A

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

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7
Q

Early head injury interventions (3)

A

Relative hyperventilation (pC02 30-35) ICP monitor (GCS 3-8 & intracranial lesion) Early surgical decompression/craniotomy

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8
Q

GCS

A
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9
Q

Thoracotomy Indications

A

•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

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10
Q

Trauma epidemiology

Kids% of deaths and 1-2 cause of fatal injury

Adults

Elderly, leading causes (2)

A

50%, Head trauma then burns

50% Head trauma

Elderly MVC, falls

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11
Q

Pediatric airway considerations

A

–Large occiput tends to flex neck

–Obligate nose breathers <6 months

–Increased tongue size

–Anterior larynx

–Narrow subglottic area

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12
Q

Peds ETT formula

A

– ET size (mm) = (age + 16) / 4

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13
Q

IO lines complications (5)

A
  • Growth plate injury
  • Fluid leakage
  • Fat emboli
  • Osteomyelitis
  • Compartment syndrome
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14
Q

Kids bolus and PRBC dose

A

–Crystalloid 20 ml/kg bolus (x 2 if poor response)

–PRBC 10 ml/kg

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15
Q

SCIWORA diagnosed by

A

MRI

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16
Q

Shaken baby syndrome pathophysiology

A

Diffuse cerebral injury with edema

Retinal hemorrhages, poor prognosis

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17
Q

Pathognomonic fracture for child abuse

A

Metaphysial deformity (bucket handle) due to shearing / rotational forces

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18
Q

Pregnancy and trauma

•Uterus rises out of pelvis at

Penetrating vs blunt trauma

A

12 weeks

•Penetrating trauma

– Maternal mortality is low

– Fetal mortality is high

Blunt trauma:

Leading cause

of maternal death

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19
Q

Uterine rupture signs

A

–Presentation may be non-specific: loss of uterine contour, palpable fetal parts

–Shock, abdominal pain, fetal demise

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20
Q

Abruption

mechanism pearl

tests (2)

management

A

–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

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21
Q

Abruption fetal monitoring indications and guidelines

A
  • 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

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22
Q

Cerebral perfusion pressure

Abnormal is

A

(CPP) = MAP-ICP

Increased ICP: CSF pressure > 15 mm Hg

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23
Q

Epidural and Subdural

Secondary or primary

A

Epidural - Coup

Subdural - Contrecoup

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24
Q
A

Diffuse Cerebral Edema

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25
Q

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)

A

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

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26
Q

Ring test for CSF

A

Halo of clear fluid beyond blood-tinged fluid / CSF fluid is glucose-positive

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27
Q

Basilar Skull Fracture CT findings and caveat

CSF leaks

A

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])

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28
Q

SDH vs EDH (3) - severity, frequency, mortality

A

SDH - often more severe underlying injury

Six times more common than epidurals

Higher mortality rate than epidurals

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29
Q

SDH time classification, CT appearance

A

– Acute: <24 hours (white on CT)

– Subacute: 24 hours-2 weeks (isodense on CT)

– Chronic: >2 weeks (dark on CT)

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30
Q

Herniation Syndromes - transtentorial

Mechanism/location

Neuro deficit

A

–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

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31
Q

Herniation Syndromes - Central

Mechanism/location

Neuro deficit

A

–Mass effect causes downward displacement of entire brainstem

–Earliest sign is CN VI (lateral rectus) palsy

–Bilateral uncal herniation

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32
Q

Herniation Syndromes -Tonsillar

Mechanism/location

Neuro sx

A

–Cerebellar tonsils herniate through foramen magnum

–Respiratory arrest and death

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33
Q

Increased ICP Treatment

Airway/breathing

Meds and dose

A
  • 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

34
Q

Peds head trauma vs adults

Autoregulation

Injury types

GCS

Skull

A
  • 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
35
Q

Growing skull fracture - peds

What/another name

Exam

Symptoms

Tx

Prophylaxis

A

•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

36
Q
A

Growing fracture - peds

37
Q

Penetrating Neck Injury

Definition

Zones and most common

Management principal

Complication and treatment

A

•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

38
Q

Penetrating Neck Injury

Hard signs (8)

A

–Hypotension

–Arterial bleeding

–Expanding hematoma

–Thrill, bruit

–Focal deficits

–Hemothorax >1,000 mL

–Bubbling wound

–Hemoptysis, hematemesis

39
Q

Soft signs

A

(require full diagnostic evaluation)

–Stridor

–Hoarseness

–Vocal cord paralysis

–Subcutaneous air

–Facial nerve injury

40
Q

Penetrating Neck Injury with hard signs

management by zone

A

•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

41
Q

Penetrating Neck Injury with soft signs

management by zone

A

–Zone I: Angiogram, esophagram, endoscopy, bronchoscopy

–Zone II: Exploration or angiogram, esophagram, endoscopy, bronchoscopy

–Zone III: Angiography

42
Q

Pentrating neck injury - zones

A
43
Q

Blunt Neck Trauma

Evaluation

Injury types

A

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

44
Q

Triad: Neck trauma + TIA, stroke, or Horner’s syndrome

A

Carotid artery dissection

45
Q

Hypotension + blunt trauma

Leading cause

A

•Pelvic fracture > intraabdominal injury > intrathoracic injury

46
Q

Hypotension + penetrating trauma

Leading causes

A

Lung > heart > great vessels

47
Q

Occlusive dressing in tension PTX caveat

A

Application of occlusive

dressing can cause

tension pneumothorax

48
Q

Open thoracotomy

Technique (3)

Most commonly injured structures

A

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

49
Q

1st and 2nd Rib Fractures, Scapular fx

A

–Myocardial contusion

–Bronchial tear

Vascular injury (consider angiogram

50
Q
A
51
Q

Flail Chest, treatment

A

Direct pressure, intubation, consider chest tube

52
Q

Tracheobronchial Injury

Most common location

Treatment (3)

Sign and sx review

A

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

53
Q

Continuous bubbling a chest tube is a sign of

Hamman’s crunch, description, suggests

A

•bronchopleural fistula

mediastinal friction rub w/ heart beat suggestive of tracheobronchial tree injury

caused by pneumomediastinum or pneumopericardium

54
Q

Hemothorax

most common etiology

dx and caveats (2)

A
  • 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)

55
Q

Hemothorax - Thoracotomy indications

A

– Unstable

– Initial output >1500 mL

– >100 mL/ hr x 6 hours

– Persistent air leak

56
Q

Open PTX initial treatment and caveat

A

–3-sided petrolatum gauze, one-way valve, chest tube

–Dressing can create a tension pneumothorax; remove dressing if patient has increased SOB

57
Q

Diaphragm: Traumatic Injuries

Caveats

Natural history

A

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
58
Q

Diaphragm injury Blunt mechanism vs Penetrating

Side

Body habitus

Aspect

Size

Typical diagnostic time

Dx

Translocation

A

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
59
Q

Traumatic Ruptured Aorta (TRA)

Most common location/outcome

Survivors usual location

Sx

Signs

A
  • Most often, tear at isthmus 2°to deceleration (victims die immediately at scene)
  • Survivors who reach ED usually have tear at the ligamentum arteriosum
60
Q

Traumatic Ruptured Aorta (TRA)

Sx

Signs

A
  • Retrosternal pain, dyspnea, stridor, dysphagia
  • Harsh systolic murmur (aortic valve)
  • Pulse difference between upper and lower extremities
61
Q

Traumatic Ruptured Aorta (TRA)

CXR findings and most sensitive and specific (6)

A

•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

62
Q
A

Traumatic aortic rupture

63
Q

Cardiac Tamponade

3 eponyms

A
  • Beck’s triad: Hypotension, JVD, muffled heart sounds
  • Pulsus paradoxus (weaker pulse, lower systolic pressure with inspiration)
  • Electrical alternans: Alternating QRS direction
64
Q

Myocardial contusion

Conduction abnormalities

Dx

A
  • EKG: Slowed conduction, ectopy, ST-T wave changes, and tachycardia
  • Diagnosis: Echocardiogram (wall motion defect), increased (Troponins not rec’d in ATLS)
65
Q

Abdominal seatbelt sign

associated injuries

A

Mesenteric laceration, hollow viscus tear, ruptured diaphragm, Chance fracture

66
Q

Abdominal trauma - Laparotomy indications

A

–Evisceration, GSW, impalement, gross blood by NG, rectal or DPL, positive FAST scan if unstable

67
Q

Anterior stab wounds

Rule of thumb

A

–Rule of thumb: 1/3 no penetration, 1/3 penetration and no surgery, 1/3 require surgery

Only patient’s with findings need repair

68
Q
A

Could be chest or abdomen wound

69
Q

Abdominal trauma - CT weaknesses

Gross hematuria tests (2)

A

Insensitive to hollow organ injury, pancreas, and diaphragm

CT or cystourethrogram

70
Q

Positive DPL (4)

A

–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

71
Q

Abdominal sign eponyms

Grey Turner’s sign

Kehr’s sign

Cullen’s sign

Rovsing’s sign

A
  • 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)
72
Q

Post splenectomy vaccinations

Pancreas and Small intestine injury presentation

Colon - most common injury location

A

pneumococcas and HiB

delayed presentation, labs/CT often normal initially, a/w lap belt and LS spine injuries

Transverse

73
Q

Urethral trauma

Dx: retrograde urethrogram -> RUG

Complications (4)

Rupture Anterior vs posterior, def and location of extrav

A

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

74
Q

Testicular trauma

dx (2)

Renal Injury

dx caveat and dx (2)

Vascular injury dx and timing

A

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

75
Q

Tetanus

US epi

High risk wounds (7)

A

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

76
Q

Tetanus vaccine guidelines

Clean minor wounds

All other wounds

A
  • 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

______________________________________________________________

  • 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
77
Q

Local anesthetic pearls

2 types and ID pearl

max dose/kg without/with epi

Avoid irrigation with:

A

–“Amides” and “esters”

–Most “reactions” due to the methylparaben preservative (resembles antigenically “esters”)

–One “i” in generic name: Ester. Two “i”s: Amide

____________________________________________________

Lido: 4.5/7; 70 kg person 30 mL of 1% (1% solution has 1 gram in 100 mL)

Bupivicaine: 2/3

_________________________________________________________

Avoid: Detergents, peroxide and povidone iodine at full strength is not advised in wounds (tissue toxic)

78
Q

Abx wound prophylaxis (8)

A

– 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

79
Q

Gas Gangrene

Etiologic agent + virulence cause

px Pearls (2)

tx (5)

A

C. perfringens produces exotoxin

___________________________________

  • Pain out of proportion to physical findings
  • Dusky, brawny, “woody” edema with crepitance

____________________________________

Treatment: fluids, high dose penicillin, debridement, hyperbaric O2

80
Q

Necrotizing Fasciitis

Agents (3)

Px pearls (2)

Lab pearl

abx

A
  • Anaerobes, group A Strep, Staph aureus
  • very painful, crepitance

low sodium

Abx: imipenem-cilastatin

81
Q

Complications of massive transfusion (3)

A

Decreased clotting factors, decreased platelets, decreased temperature (the most common sequelae of massive transfusion is hypothermia)

82
Q

Machinery sounding “Mill wheel” murmur and management

A

with neck vascular inury -> air embolism

LLD and trendelenburg

EM Board exam (18 decks)

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