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Surgery: Pestana's > Trauma > Flashcards

Trauma Flashcards

1
Q

what can block an airway s/p trauma

A

expanding hematoma or emphysema

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2
Q

main way to secure airway; another option?

A

orotracheal intubation guided by use of laryngoscope; nasotracheal intubation over fiber optic bronchoscope

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3
Q

when is the use of fiberoptic bronchoscope mandatory?

A

when there is subq emphysema in the neck, which is a sign of major traumatic disruption of the tracheobronchial tree.

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4
Q

indication for cricothyroidotomy?

A

any reason intubation cannot be done in the usual manner and time is running out; some examples being: laryngospasm, severe maxillofacial injuries, an impacted foreign body that cannot be dislodged.

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5
Q

treatment of hemorrhagic shock in an urban setting (w/ big trauma center nearby) compared to everywhere else

A

surgical intervention to stop bleeding and THEN volume replacement
VS
volume replacement as the first step in all other settings

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6
Q

how to replace volume in traumatic setting?

A

2L lactate ringers (or NS) followed by Packed Red cells until urinary output reaches 0.5-2mL/kg/h; DO NOT EXCEED CVP OF 15mmHg

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7
Q

can’t get access to veins in arms? next step…

A

femoral vein catheter or saphenous vein cutdowns (when you expose a vein surgically and then a cannula is inserted to the vein) as alternatives.

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8
Q

management of pericardial tamponade

A

prompt evacuation of pericardial sac (pericardiocentesis, tube, pericardial window, or open thoracotomy)

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9
Q

Management of tension pneumothorax

A

big needle or IV catheter into pleural space. Follow w/ chest tube connected to underwater seal

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10
Q

signs of vasomotor shock

A

ciruclatory collapse occurs in flushed, “pink and warm” patient. CVP is low.

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11
Q

Dealing with vasomotor shock

A

pharmacologic treatment to restore peripheral resistance.

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12
Q

how to deal with linear skull fractures?

A

left alone if they are closed (no overlying wound); if fragmented or depressed, they have to be treated in the OR

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13
Q

indication for CT following head trauma; what happens if negative?

A

Head trauma + loss of consciousness; to check for intracranial hematomas; if negative and neurologically intact, pt can go home if the family will wake them up frequently during the next 24 hours to make sure they are not going into coma

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14
Q

signs of fracture affecting base of skull; next step?

A

raccoon eyes, rhinorrhea, otorrhea or ecchymosis behind the ear; main concern when we see this is cspine integrity so we get CT to assess integrity of cervical spine

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15
Q

evidence of acute epidural hematoma

A

sequence of trauma, unconsciousness, lucid interval, gradual lapsing into coma again, fixed dilated pupil (usually on the side of the hematoma) and contralateral hemiparesis with decerebrate posture.

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16
Q

subdural hematoma ct image?

A

http://drarunlnaik.com/yahoo_site_admin/assets/images/subduralhaematoma.111141517_std.jpg….semilunar, crescent shaped hematoma

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17
Q

epidural hematoma ct image?

A

http://classconnection.s3.amazonaws.com/33/flashcards/602033/jpg/epidural_hematoma_21346694332707.jpg….biconvex, lens shaped

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18
Q

signs of subdural hematoma

A

trauma is much bigger than epidural and pts have severe neurologic damage from initial blow of traumatic event.

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19
Q

management of epidural hematoma

A

emergency craniotomy

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20
Q

management of subdural hematoma

A

to deal with cranial deviations, can do craniotomy, w/o deviation, treatment is aimed at reducing ICP w/ mannitol/furosemide, hyperventilate (increase CO2)

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21
Q

recognizing diffusing axonal injury on CT; management?

A

blurring of the gray-white matter interface and multiple punctate hemorrhages. just prevent further damn from increased ICP

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22
Q

chronic subdural hematoma more likely in what kind of pts?

A

occurs in very old and severe alchy’s.

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23
Q

causes of chronic subdural hematoma? symptoms?

A

shrunken brain rattled around the head by minor trauma, tearing venous sinuses; over several days or weeks, mental function deteriorates as hematoma forms

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24
Q

management of gunshot wounds to the neck

A

upper zone involvement: arteriographic diagnosis and management is preferred.
base of neck: arteriography, esophagogram (water-soluble, then barium if negative) esophagoscopy and bronchoscopy before surgery can help decide specific surgical approach

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25
Q

management of stab wounds to the neck

A

damage to the upper and middle zones in asymp pt.s can be safely observed

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26
Q

how can hemisection of spinal cord present

A

paralysis and loss of proprioception distal to the injury on the injury sdide and loss of pain perception distal to the injury contralaterally

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27
Q

Anterior cord syndrome; usually seen in burst fractures of vetebral bodies

A

loss of motor function and loss of pain and temp on both sides distal to injury, with preservation of vibratory positional sense.

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28
Q

central cord syndrome…what is it and what population does it occur in?

A

There is paralysis and burning pain in the upper extremities, w/ preservation of most functions in the lower extremities; elderly w/ forced hyperextension of the neck

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29
Q

Progression of symptoms seen in elderly pt with chest trauma; how to treat it?

A

pain, hypoventilation, atelectasis, pneumonia; w/ local nerve block and epidural cath.

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30
Q

management of a pneumothorax

A

Chest xray, place chest tube and connect underwater seal

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31
Q

hemothorax diagnosis and management

A

diagnosis: dullness to percussion on affected side and chest xray.
management: place chest tube to evacuate chest…usually bleeding is caused by lung vessels so bleeding should stop quickly (low pressure)…sometimes can occur 2/2 systemic vessels and bleed a lot….THORACOTOMY necessary if: >1500mL evacuated first time or >250ml/hr evacuated over the following 4-5hrs

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32
Q

flail chest management

A

Concern for underlying pulmonary contusion which is sensitive to volume–> fluid restriction and use of diuretics; if a respirator is needed, B/L chest tubes are advisable to prevent tension pneumothorax from developing

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33
Q

pulmonary contusion diagnosis

A

right after chest trauma can show up as deteriorating blood gases and “white out” of the lungs on chest x-ray, or it can appear up to 48 hrs later.

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34
Q

diagnosis and management of rupture of diaphragm

A

diagnosis: bowel in the chest (through exam and xray) always on the left side…suspicious cases should undergo laparoscopy
management: surgical repair, done usually from the abdomen

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35
Q

Suspicion for rupture of the aorta should be triggered with what scenario?

A

History of severe deceleration injury, by the presence of fractures in chest bones that are “very hard to break” (first rib, scapula, sternum), or by presence of a widened mediastinum.

-presence of large flail chest

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36
Q

most practical diagnostic test for ruptured aorta in trauma setting? other viable options in nontrauma setting?

A

CT angiogram; TEE or MRI angiography.

37
Q

signs of rupture of the trachea or major bronchus

A

development of subq emphysema in the upper chest and lower neck or by a large “air leak” from a chest tube.

38
Q

what diagnostic imaging can you use to confirm damage to trachea or main bronchus? how to intubate in this type of patient?

A

Chest xray can show air in the tissue; intubate with fiberoptic bronchoscopy as a guide to identify the lesion and secure an airway beyond the lesion

39
Q

differential diagnosis for subq emphysema?

A

tracheal/bronchus damage, rupture of the esophagus (usually happens after endoscopy) and tension pneumothorax

40
Q

pt dies suddenly after Central venous line placement…top diagnosis? mechanism of action?

A

air embolism; subclavian vein is opened to the air causing an air embolism to form leading to sudden collapse and cardiac arrest.

41
Q

management of air embolism? good way to prevent them in the first place?

A

cardiac massage (internal vs external), with the pt positioned with the left side down. Trendelenburg position when the great veins at the base of the neck are to be entered.

42
Q

fat embolism typically seen in what setting?

A

a pt. w/ multiple trauma, including several long bone fractures, who develops petechial rashes in the axillae and neck; fever, tachycardia, and low platelet count; and who at some point shows a full-blown picture of respiratory distress.

43
Q

therapy for fat embolism

A

mainstay of therapy is respiratory support; precess diagnosis is not needed to start therapy.

44
Q

management of gunshot wounds to the abdomen; only exception?

A

exploratory laparotomy; in specific cases of low caliber gunshot wounds involving the right upper quadrant, conservative therapy may be used if the patient is properly monitored w/ close follow-up of clinical signs and serial abdominal CT scans.

45
Q

management of stab wounds to abdomen

A

clear penetration (protruding viscera)?- exploratory lap.
hemodynamic instability or signs of peritoneal irritation develop?- ex. lap
hemodynamically stable w/o signs of penetration/peritonitis?- digital (finger) exploration of the wound and observation may be fine….if digital exploration is equivocal then CT scan.

46
Q

management of blunt trauma to abdomen?

A

peritoneal irritation?-ex. lap
no peritoneal irritation?- determine whether internal injury/bleeding and whether bleeding will stop on its own or will require surgical intervention

47
Q

signs of internal bleeding in blunt trauma? how much blood is lost before signs of shock occur?

A

drop in BP, w/ fast thready pulse, low CVP, and low urine output, in a cold, pale, anxious patient who is shivering thirsty, and perspiring profusely…pt. must have no evidence of excessive external blood loss; 25-30% of blood volume needs to be acutely lost.

48
Q

imaging tool for diagnosis of intraabdominal bleeding; main limitation of this tool in a traumatic setting?

A

CT scan; can’t be used in hemodynamically unstable pt (b/c pt has to be transported down to get machine scan)

49
Q

management of intraabdominal bleeding?

A

s/p CT scan: fluid resuscitation and if this isn’t enough, pt will require surgery
s/p lavage or sonogram: prompt ex. lap

50
Q

diagnosis of intraabdominal bleeding in pt who is hemodynamically unstable?

A

Diagnostic peritoneal lavage or sonogram

51
Q

two most common sources of significant intraabdominal bleeding in blunt trauma?

A

spleen and liver

52
Q

diagnostic signs of spleen rupture?

A

suspicion of intraab. bleeding, and fractures of lower ribs on the left side.

53
Q

management of ruptured spleen

A

try to repair it first (especially in children)…if it must be removed, administer postop immunization against meningicoccal, pneumococcus, and H. influenza.

54
Q

how does abdominal compartment syndrome develop; signs of this in a pt. who’s been closed up already

A
  • lots of fluid and blood given to pt. during the course of prolonged laparotomies so that by the time of closure, all the tissues are swollen and the abdominal wound can’t be closed w/o undue tension.
  • evidence of distention and tissue being cut into by suture scissors, with hypoxia (from inability to breathe), and renal failure from pressure on vena cava.
55
Q

management of abdominal compartment syndrome

A

temporary cover placed over abdominal contents, either absorbable mesh (that can later by grafted over) or nonabsorbable plastic to be removed at a later date when closure might be possible.

56
Q

managment of pelvic hematomas?

A

typically left alone if they are not expanding

57
Q

first thing to do in a situation of pelvic fracture?

A

assess damage in rectum (rectal exam and protoscopy), bladder, vagina (pelvic exam), or urethra in men (retrograde urethrogram)

58
Q

diagnosis of intrapelivc bleeding

A

based on evidence of internal bleeding w/o evidence of any other source and negative DPL or abdominal sonogram….or a CT scan that shows no intrabdominal injuries and huge pelvic hematoma

59
Q

management of pelvic bleeding from fractures

A
  • external fixation to diminish bleeding from venous source

- external fixation doesn’t work then possibly arterial so use arteriographic embolization

60
Q

hallmark of urologic injuries is…

A

blood in the urine

61
Q

how are penetrating urologic injuries are managed?

A

surgical exploration and repair

62
Q

some common signs of urethral injury?

A

blood in the meatus, scrotal hematoma, “high-rising” prostate on rectal exam, and sensation of wanting to void but not being able to.

63
Q

how to diagnose bladder injury

A

retrograde cystogram (w/ dye) w/ postvoid films included in order to see extraperitoneal leaks at the base of the bladder that might be obscured by the bladder full of dye.

64
Q

management of intraperitoneal bladder leak vs extraperitoneal bladder leak

A
  • intra: surgical repair is done w/ a suprapubic cystostomy

- extra: placing foley cath.

65
Q

management of scrotal hematomas

A

do not need specific intervention unless the testicle is ruptured (which can be assessed w/ sonogram)

66
Q

management of penile fracture; complications of delayed management?

A

emergency surgical repair; impotence due to the formation of AV shunts

67
Q

management of penetrating injuries of the extremities

A
  • depends on if vascular injury has occurred;
  • –if not then only tetanus prophylaxis and cleaning of the wound is required.
  • –if penetration is near major vessels and the pt. is asymp., then Doppler studies or CT angio is done.
  • –if there is obvious vascular injury (absent distal pulses, expanding hematomas) surgical exploration and repair is required
68
Q

management of combined injuries of arteries, nerves, and bone

A
  • repair bone first, then deal w/ vasculature and leave the nerve for last
  • a fasciotomy can be added b/c prolonged ischemia could lead to a compartment syndrome.
69
Q

crushing injuries of the extremities can lead to what complications? prevention of these complications?

A
  • hyperkalemia, myoglobinemia, myoglobinuria and renal failure (and possible compartment syndrome)
  • management: vigorous fluids, osmotic diuretics and alkanization of the urine. (possible fasciotomy for compartment syndrome)
70
Q

dealing w/ chemical burns

A

massive irrigation

71
Q

management of high-voltage electrical burns

A

usually deeper than they appear to be so you might require debridements and amputations.

72
Q

diagnosis of respiratory burns

A

likely with evidence of burns around the mouth or soot in the throat. diagnosis confirmed by fiberoptic bronchoscopy

73
Q

management of respiratory burns

A

if blood gases show hypoxia then intubation should be done

74
Q

complications of circumferential burns in extremities and chest; management?

A
  • of the extremities: can lead to cutoff of the blood supply as edema accumulates under eschar (full thickness burn scars)
  • of the chest: can interfere w/ breathing
  • escharotomies provide immediate relief
75
Q

fluid management of burns in adults

A

w/in first 48 hrs: initial rate of infusion of 1L/hr of lactate ringers (w/o sugars) in an adult w/ extensive burns (>20% of body burned), and then adjust fluids on basis of urinary output (1 or 2mL/kg/h), while avoiding CVP over 15 mmHg.

76
Q

fluid management in burned babies

A

Initial fluid of 20 mL/kg/hr w/ extensive burns (>20% of body) and then fine tuned in response to urinary output.

77
Q

overall burn management

A
  • fluid resuscitation, tetanus prophylaxis, cleaning of burn areas and use of topical agents (standard=silver sulfadiazine; if deep penetration is needed over places of thick eschar, then use mafenide acetate)
  • burns near eyes are given triple antibiotic ointment (silver sulf. is irritating to eyes)
  • IV pain meds
  • 1-2 days of NG suction, then intensive nutritional support of high calorie/high nitrogen diets
  • after 2-3 weeks of wound care, burned areas that have not regenerated are grafted.
  • for very limited burn («20% of body), can do early excision of burns and then grafting to minimize pain/complications.
78
Q

generalized management of all bites

A

tetanus prophylaxis and wound care

79
Q

management of dog bite and bites from wild animal

A

provoked dog bites: observation of dog for signs of rabies; bites close to the face can receive immunization and be discontinued if observation is reassuring

unprovoked dog bites/wild animal bites: if animal is available it can be killed and brain examined for signs of rabies…otherwise rabies prophylaxis (IgG and vaccine)

80
Q

management of snake bites

A

if swelling and pain occurs w/in 30 mins at site of bite, then get type and screen, coag studies, LFTs and RFTs; then give CROFAB (or other antivenin)

81
Q

management of bee stings

A

give epinephrine (because of ensuing anaphylaxis)…remove stingers w/o squeezing em

82
Q

management of black widow spider bite

A

-spider looks black w/ red hourglass on belly…give IV calcium gluconate or muscle relaxants

83
Q

management of human bites

A

irrigation and debridement of wound

84
Q

What types of things can cause vasomotor shock?

A
  • anaphylactic rxns

- spinal cord transection

85
Q

What is the Doppler threshold of peripheral pulses required to justify completing an escharotomy?

A

25-40mmHg

86
Q

Penetrating wounds to neck are take to or if these conditions are present

A
  • unstable vitals
  • expanding hematoma
  • clear evidence of esophageal or tracheal injury–coughing or spitting out blood
87
Q

Diagnosis of intraabdominal bleeding can be made most accurately with what imaging modality

A

Ct

88
Q

s/p trauma: how to check if an airway is present

A

conscious and speaking in a normal tone of voice

Surgery: Pestana's (13 decks)

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