trauma Flashcards
extreaperitoneal bladder injury
contusion or rupture of the neck, anterior wall or anterolateral wall of the bladder –> extravasation of urine into adjacent tissues causes localised pain in the lower abd and pelvic)
pelvis fracture is almost always present with, and sometimes a bony fragment can directly puncture and rupture the bladder
gross hematuria is also usually present, urinary retention may occur (esp if in the neck)
how can bladder injury causes peritonitis
rupture of the dome (upper, in contact with peritoneum) –> urine leaking into the peritoneal cavity –. chemical peritonitis
ureteral injury
The mcc is iatrogenic
- rare from trauma
MC site: uteropelvic junctio
- hematuria, fever, flank pain, renla mass (hydronephrosis)
urethral injury - characteristics
- almost exclusively in men
- suspect if blood seen at urethral meatus/ motile prostate
- urethral catheterization is relatively contraindicated
- perform retrograde urethrogram (x-ray during injection) –> extravasasion of inability to reach bladder confirm it
posterior urethra (membranous) trauma
prone to injury from pelvic fracture –> injury can cause urine to leak into retropubic space
anterior urethra bulbar and penile trauma
at risk of damage due to perineal straddle injury –> urine leak beneath deep fascia of Buck –> if fascia is torn, urine escapes into superficial perineal space
4% of patients with spinal cord injuries will develop
post-traumatic syringomyelia –> impaired strength and pain pain/Q sensation in the upper extremities
(MRI is diagnostic)
PCWP in tenstion pneumothorax
normal/low
PCWP in PE
normal/low
Bronchial rupture - manifestation
persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma
other findings: pneumodiastinum + subcuteaneous emphysema
Nowadays - indication of perit lavage
unstable patient with inconclusive FAST
prehospital management of cervical spine truma
- spinal immobilization
- careful helmet removal
- airway oxygenation
emergency department management of cervical spine trauma
- orotracheal incubation preferred unless significant facial trauma present
- rapid-sequence intubation added for unconscious patients who are breathing but need ventilator support
- in-line cervical stabilization suggested inless if interferes with intubation
- Monitoring for neurogenic shock from spinal cord injury
how to carry amputated parts
wrapped in saline-mostiened gause, sealed in a plastic bag, placed on ice and brought to emergency department
Glascow coma scale - eye opening
spontaneous: 4
to verbal command: 3
to pain: 2
none: 1
Glascow coma scale - verbal response
oriented: 5 disoriented/confused: 4 inapprorpiate words: 3 incomprehensible sounds: 2 none: 1
Glascow coma scale - motor response
obeys: 6
localizes: 5
withdraws: 4
felxion posturing (dcorticate): 3
extension posturing (decerebrate: 2
none: 1
blunt trauma and unstable - management
FAST:
(+) –> laparotomy
(-) –> signs of extraabdominal hemor (pelvic bone, long bone fracture): yes: stabilize, no: stabilize and then CT of abdomen
(-) inconclusive –> diagnostic perit lavage (if + laparatomy, if negative go to the negative pathway)
penetrating abd trauma - indications for urgent exploratory laparotomy
- unstable
- peritonitis
- evisceration (eg. externally exposed intestines)
- blood from NT tube or on rectal examination
(Any penetrating trauma below the nipples or 4th intercostal)
suspected splenic injury (blunt abd trauma, Left sided abd pain, anemia) - evaluation and management
- stable: and alert –> FAST: if normal but high risk features (anemia or guarding) –> CT scan of abdomen
- stable with altered mental status –> CT
flail chest findings
paradoxiccal chest wall motion with respiration
chest pain, tachypnea, rapid shallow breaths
CXR: rib fractures +/- contusion/hemothorax
Management of flail chest
pain control, O2
positive pressure ventilation if resp failure
spontaneous pneumothorax - management
2 cm or smaller: observation + O2
large + stable: needle aspiration or chest tube
positive pressure mechanical ventilation in a patient with hemor shock
increased intrathoracic pressure –> further decreased Venous return –> cardiac arrest
Diaphragmatic rupture?
more common in the lest
- resp distress and can have deviation of the mediastinal contents to the opposite side, elevation of the hemidiaphragm on the chest x-ray might be the only abnormal finding
- also nasogastric tube in the pulm cabity is diagnostic
important step in the management of ribs fracture
adequate analgesia –> prevent hypoventilation (and so atelectasis or pneumonia)
pulm contusion - management
pain control
pulm hygiene (eg. nebulizer treatment, chest PT)
O2 + ventilatory support
avoid fluids / use diuretics
chest xray suggestive for diaphragmatic rupture - next step
chest and abdominal CT
management of blunt abdominal trauma in hemodynamically stable patients
antered mental status?
NO: serial abd exams +/- CT
YES: FAST: if negative –> serial abd exams (+/- CT scan), if (+) do CT
blunt trauma and unstable - management
FAST:
(+) –> laparotomy
(-) –> signs of extraabdominal hemor (pelvic bone, long bone fracture): yes: stabilize, no: stabilize and then CT of abdomen
(-) inconclusive –> diagnostic perit lavage (if + laparatomy, if negative go to the negative pathway)
cricothriroidotomy - pediatrics
avoid if under 12
when to uss fiberotpic bronchoscope
when securing an airway if there is subcutaneous emphysema in the neck (sign of disruption of the tracheobronchial tree)
urinary output at shock
under 0.5 ml/Kg/h
air embolism - management
cardiac massage with the patient positioned with the left side down
Trendelenburg position when the great veins at the base of the neck are to be entered
coagulopathy,hypothermia + acidosis during laparotomy - next step
the laparotomy has to be promptly terminated, with packing of bleeding surfaces and temporary closrue 00> resume latter when the patient has been warmed and the coagulopathy treated
contraindications of nasotracheal intubation
- basilar skull fractures
2. apneic/hypopneic
CT in AAA rupture?
only if it is stable
confirm with U/S
all burn victims should be treated initially with
high flow O2
clinical signs of basilar skull fractures
- hemamatomas of the mastoid process or periauricular hematomas (Battle sing)
- Bilateral peri-orbital hematomas (raccoon eyes)
- hemotympanum
- CSF otorrhea
- CN palsies (anosmia, vertigo, tinnitus, hearing loss)
