trauma

Question 1

extreaperitoneal bladder injury

Answer 1

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)

Question 2

how can bladder injury causes peritonitis

Answer 2

rupture of the dome (upper, in contact with peritoneum) –> urine leaking into the peritoneal cavity –. chemical peritonitis

Question 3

ureteral injury

Answer 3

The mcc is iatrogenic
- rare from trauma
MC site: uteropelvic junctio
- hematuria, fever, flank pain, renla mass (hydronephrosis)

Question 4

urethral injury - characteristics

Answer 4

1. almost exclusively in men
2. suspect if blood seen at urethral meatus/ motile prostate
3. urethral catheterization is relatively contraindicated
4. perform retrograde urethrogram (x-ray during injection) –> extravasasion of inability to reach bladder confirm it

Question 5

posterior urethra (membranous) trauma

Answer 5

prone to injury from pelvic fracture –> injury can cause urine to leak into retropubic space

Question 6

anterior urethra bulbar and penile trauma

Answer 6

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

Question 7

4% of patients with spinal cord injuries will develop

Answer 7

post-traumatic syringomyelia –> impaired strength and pain pain/Q sensation in the upper extremities
(MRI is diagnostic)

Question 8

PCWP in tenstion pneumothorax

Answer 8

normal/low

Question 9

PCWP in PE

Answer 9

normal/low

Question 10

Bronchial rupture - manifestation

Answer 10

persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma
other findings: pneumodiastinum + subcuteaneous emphysema

Question 11

Nowadays - indication of perit lavage

Answer 11

unstable patient with inconclusive FAST

Question 12

prehospital management of cervical spine truma

Answer 12

1. spinal immobilization
2. careful helmet removal
3. airway oxygenation

Question 13

emergency department management of cervical spine trauma

Answer 13

1. orotracheal incubation preferred unless significant facial trauma present
2. rapid-sequence intubation added for unconscious patients who are breathing but need ventilator support
3. in-line cervical stabilization suggested inless if interferes with intubation
4. Monitoring for neurogenic shock from spinal cord injury

Question 14

how to carry amputated parts

Answer 14

wrapped in saline-mostiened gause, sealed in a plastic bag, placed on ice and brought to emergency department

Question 15

Glascow coma scale - eye opening

Answer 15

spontaneous: 4
to verbal command: 3
to pain: 2
none: 1

Question 16

Glascow coma scale - verbal response

Answer 16

oriented: 5
disoriented/confused: 4
inapprorpiate words: 3
incomprehensible sounds: 2
none: 1

Question 17

Glascow coma scale - motor response

Answer 17

obeys: 6
localizes: 5
withdraws: 4
felxion posturing (dcorticate): 3
extension posturing (decerebrate: 2
none: 1

Question 18

blunt trauma and unstable - management

Answer 18

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)

Question 19

penetrating abd trauma - indications for urgent exploratory laparotomy

Answer 19

1. unstable
2. peritonitis
3. evisceration (eg. externally exposed intestines)
4. blood from NT tube or on rectal examination
   (Any penetrating trauma below the nipples or 4th intercostal)

Question 20

suspected splenic injury (blunt abd trauma, Left sided abd pain, anemia) - evaluation and management

Answer 20

1. stable: and alert –> FAST: if normal but high risk features (anemia or guarding) –> CT scan of abdomen
2. stable with altered mental status –> CT

Question 21

flail chest findings

Answer 21

paradoxiccal chest wall motion with respiration
chest pain, tachypnea, rapid shallow breaths
CXR: rib fractures +/- contusion/hemothorax

Question 22

Management of flail chest

Answer 22

pain control, O2

positive pressure ventilation if resp failure

Question 23

spontaneous pneumothorax - management

Answer 23

2 cm or smaller: observation + O2

large + stable: needle aspiration or chest tube

Question 24

positive pressure mechanical ventilation in a patient with hemor shock

Answer 24

increased intrathoracic pressure –> further decreased Venous return –> cardiac arrest

Question 25

Diaphragmatic rupture?

Answer 25

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

Question 26

important step in the management of ribs fracture

Answer 26

adequate analgesia –> prevent hypoventilation (and so atelectasis or pneumonia)

Question 27

pulm contusion - management

Answer 27

pain control
pulm hygiene (eg. nebulizer treatment, chest PT)
O2 + ventilatory support
avoid fluids / use diuretics

Question 28

chest xray suggestive for diaphragmatic rupture - next step

Answer 28

chest and abdominal CT

Question 29

management of blunt abdominal trauma in hemodynamically stable patients

Answer 29

antered mental status?
NO: serial abd exams +/- CT
YES: FAST: if negative –> serial abd exams (+/- CT scan), if (+) do CT

Question 30

blunt trauma and unstable - management

Answer 30

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)

Question 31

cricothriroidotomy - pediatrics

Answer 31

avoid if under 12

Question 32

when to uss fiberotpic bronchoscope

Answer 32

when securing an airway if there is subcutaneous emphysema in the neck (sign of disruption of the tracheobronchial tree)

Question 33

urinary output at shock

Answer 33

under 0.5 ml/Kg/h

Question 34

air embolism - management

Answer 34

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

Question 35

coagulopathy,hypothermia + acidosis during laparotomy - next step

Answer 35

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

Question 36

contraindications of nasotracheal intubation

Answer 36

1. basilar skull fractures

2. apneic/hypopneic

Question 37

CT in AAA rupture?

Answer 37

only if it is stable

confirm with U/S

Question 38

all burn victims should be treated initially with

Answer 38

high flow O2

Question 39

clinical signs of basilar skull fractures

Answer 39

1. hemamatomas of the mastoid process or periauricular hematomas (Battle sing)
2. Bilateral peri-orbital hematomas (raccoon eyes)
3. hemotympanum
4. CSF otorrhea
5. CN palsies (anosmia, vertigo, tinnitus, hearing loss)