Trauma Flashcards
The first step in the eval. of trauma is ___ and ___
The first step in the evaluation of a trauma patient is airway and protection
A airway is considered protected if the patient is ____ and _____ in a normal voice
An away is protected if the patient is conscious and speaking in a normal voice
An airway is considered unprotected if there is an expanding ____ or subcutaneous ___ in the neck, noisy or gurgly breathing or a Glasgow coma scale of ___
An airway is considered unprotected if there is an expanding hematoma or subcutaneous emphysema in the neck, noisy or gurgly breathing or GGC of <8.
An airway should be secured before the situation becomes critical. In the field, the airway can be secured by ___ or ___
Can be secured by intubation or cricothyroidectomy. This is called the definitive airway.
In the ED, airway securing can be done by rapid sequence induction and __ __, with monitoring of pulse oximetry.
In the ED, airway securing can be done by rapid sequence induction and orotracheal intubation, with monitoring of pulse oximetry.
In the presence of cervical spinal injury, orotracheal intubation can still be done, as long as the ____ is secured and in-line stabilization is maintained during the procedure.
In the presence of cervical spinal injury, orotracheal intubation can still be done, as long as the head is secured and in-line stabilization is maintained during the procedure.
Another option in that setting is nasotracheal intubation over a ___ bronchoscope.
Another option in that setting is nasotracheal intubation over a fiberoptic bronchoscope.
If maxillofacial injuries preclude the use of intubation or intubation is unsuccessful, ____ may become necessary.
If maxillofacial injuries preclude the use of intubation or intubation is unsuccessful, cricothyroidectomy may become necessary.
In pediatric patients, under age ____, tracheostomy is preferred over cricothyoidotomy, due to the high risk of airway stenosis, as the cricoid is much smaller than in the adult.
In pediatric patients, under age 12, tracheostomy is preferred over cricothyoidotomy, due to the high risk of airway stenosis, as the cricoid is much smaller than in the adult.
Breath sounds indicate satisfactory ventilation; an absence or decrease of breath sounds may indicate ____ and/or hemothorax and necessitate chest tube placement.
Breath sounds indicate satisfactory ventilation; an absence or decrease of breath sounds may indicate pneumothorax and/or hemothorax and necessitate chest tube placement.
What are the three clinical signs of shock?
- Low BP (<90)
- Tachy (>100)
- Low urinary output (<0.5 mL/kg/hr
Patients in ___ will be pale, cold, shivering and apprehensive.
Patients in shock will be pale, cold, shivering and apprehensive
In the trauma setting, shock is either ____, secondary to ___, or ___, secondary to ____
In the trauma setting, shock is either hypovolemic (secondary to hemorrhage and the most common scenario), or cardiogenic (secondary to pericardial tamponade or tension pneumothorax due to chest trauma).
Hemorrhagic shock tends to cause _____ neck veins due to ___ central venous pressure.
Cardiogenic shock tends to cause ___ CVP with ___ venous distension. Both processes may occur simultaenously.
Hemorrhagic shock tends to cause collapsed neck veins due to low central venous pressure.
Cardiogenic shock tends to cause elvated CVP with jugular venous distension. Both processes may occur simultaenously.
In ___ ____, there is typically no respiratory distress, while in ___ pneumothorax there is significant dyspnea, loss of unilateral breath sounds and tracheal deviation.
In pericardial tamponade, there is typically no respiratory distress, while in tension pneumothorax, there is significant dyspnea, loss of unilateral breath sounds and tracheal deviation.
Treatment of hemorrhagic shock includes:
- Volume resuscitation with what?
- Control of bleeding
Volume resus with 2L of Lactated Ringer’s solution, unless blood products are immediately available.
In the setting of trauma, transfusion of blood products should be in an ___ ratio, between: ____, ____ and ___.
In the setting of trauma, transfusion of blood products should be in an 1:1:1 ratio, between packed RBCs, FFP, platelets.
Resuscitation should be continued until BP is normalized, and HR normalized and urine output reaches ____
Urine output has to reach 0.5-1 mL/kg/hr
In the setting of uncontrolled hemorrhage, permissive hypotnesion is recommended to prevent further blood loss while awaiting definitive surgical repair, but a mean arterial pressure (>__ mmHg) should be maintained to ensure adequate ____.
In the setting of uncontrolled hemorrhage, permissive hypotension is recommended to prevent further blood loss while awaiting definitive surgical repair, but a mean arterial pressure (>60 mmHg) should be maintained to ensure adequate cerebral perfusion.
The preferred route for fluid resuscitation in the trauma setting up ___ IV lines, __-guage or greater. If this cannot be contained, what can you do? What if you cannot do this second alternative?
What do you do in kids under age 6?
The preferred route for fluid resuscitation in trauma is setting up 2 large bore peripheral IV lines, 16-guage or greater.
If this cannot be obtained, percutaneous subclavian or femoral vein catheters should be insrted. An acceptable alternative is a saphenous vein-cut-down. In children age <6, intraosseous cannulation of the proximal tibia or femur is the alternate route.
Pericardial tamponade is generally a clinical diagnosis and can be confirmed with ___.
Management requires evacuation of the pericardial space by pericardiocentesis, subxiphoid pericardial window or thoracotomy. Fluid and blood administration while evacuation is being set up is helpful to maintain an adequate cardiac output.
Pericardial tamponade is generally a clinical diagnosis and can be confirmed with U/S. Management requires evacuation of the pericardial space by pericardiocentesis, subxiphoid pericardial window or thoracotomy. Fluid and blood administration while evacuation is being set up is helpful to maintain an adequate cardiac output.
Tension pneumothorax is a clinical diagnosis, based on ____
Management requires immediate ____ of the pleural space, initially with a large bore needle which converts the ___ to a ____ pneumothorax and followed by ____
Tension pneumothorax is a clinical diagnosis, based on physical exam.
Management requires immediate decompression of the pleural space, initially with a large bore needle which converts the tension to a simple pneumothorax and followed by chest tube placement.
In the non-trauma setting, shock can also be ____ because of massive fluid loss such as bleeding, burns, peritonitis, pancreatitis, or massive diarrhea. The clinical picture is similar to trauma, with hypotension, tachycardia, and oliguria ith a low CVP. Stop the bleeding and replace the blood volume.
In the non-trauma setting, shock can also be hypovolemic because of massive fluid loss such as bleeding, burns, peritonitis, pancreaitis, or massive diarrhea. The clinical picture is similar to trauma, with hypotension, tachycardia, and oliguria ith a low CVP. Stop the bleeding and replace the blood volume.
Intrinsic cardiogenic shock is caused by ____ damage. The clinical picture is hotn, tachy, oliguria with ___ CVP (presenting as ___ neck veins). DDx is essential, because additional fluid and blood administration in this setting could be lethal, as the failing heart becomes easily overlooked.
Intrinsic cardiogenic shock is caused by myocardial damage. The clinical picture is hotn, tachy, oliguria with high CVP (presenting as distended neck veins). DD is essential, because additional fluid and blood administration in this setting could be lethal, as the failing heart becomes easily overlooked.
____ shock from anaphylaxis, high spinal anesthesia, or spinal cord transection, causes circulatory collapse. Patients are flushed, “pink and warm” with a ___ CVP. Tx is with ____ and fluids is aimed at filling dilated veins and restoring peripheral resistance.
Vasomotor shock from anaphylaxis, high spinal anesthesia, or spinal cord transection, causes circulatory collapse. Patients are flushed, “pink and warm” with a low CVP. Tx is with phenylephrine and fluids is aimed at filling dilated veins and restoring peripheral resistance.
After the ABC’s have been evaluated, and any immediate life-threatening emergencies addressed, the trauma eval. continues with the secondary survey which is composed of a complete physical exam to evaluate for occult injuries followed by __ and __ xray. The secondary survey may be augmented with further imaging studies, depending on the mechanism of injury and findings on exam. Ay change that occurs requires complete re-eval.
After the ABC’s have been evaluated, and any immediate life-threatening emergencies addressed, the trauma eval. continues with the secondary survey which is composed of a complete physical exam to evaluate for occult injuries followed by chest and pelvic xray. The secondary survey may be augmented with further imaging studies, depending on the mechanism of injury and findings on exam. Ay change that occurs requires complete re-eval.
Head trauma, as a rule, requires surgical intervention and repair of the damage.
Linear skull fractures are ____ _____ if they are closed (no overlying wound).
Open fractures require ____ closure. If comminuted or depressed, treat in the ___
Anyone with head trauma who has become unconscious gets a ___ to look for ___ ___. If negative and neurologically intact, they can go home if the family will ____ them frequently during the next 24 hours to make sure they are not going into coma.
Head trauma, as a rule, requires surgical intervention and repair of the damage.
Linear skull fractures are left alone if they are closed (no overlying wound).
Open fractures require wound closure. If comminuted or depressed, treat in the OR.
Anyone with head trauma who has become unconscious gets a CT scan to look for intracranial bleeding. If negative and neurologically intact, they can go home if the family will awaken them frequently during the next 24 hours to make sure they are not going into coma.
____ of the skull fracture:
- Raccoon eyes, rhinorrhea, otorrhea, or ecchymosis behind the ear (Battle’s sign).
CT scan of the head is required to rule out ___ __ and should be extended to include the neck to evaluate the ___ ____ injury. Expectant management is the rule and ____ are not usually indicated.
Base of the skull fracture:
- Raccoon eyes, rhinorrhea, otorrhea, or ecchymosis behind the ear (Battle’s sign).
CT scan of the head is required to rule out intracranial bleeding and should be extended to include the neck to evaluate the cervical spinal injury. Expectant management is the rule and antibiotics are not usually indicated.
Neurological damage from trauma can be caused by 3 components:
- Initial blow
- Subsequent development of a ____ that ___ the midline
- Later development of increased intracranial pressure (ICP) due to cerebral edema.
Neurological damage from trauma can be caused by 3 components:
- Initial blow
- Subsequent development of a hematoma that displaces the midline
- Later development of increased intracranial pressure (ICP) due to cerebral edema.
________
- occurs with modest trauma to the side of the head, and has a classic sequence of trauma, unconsciousness, a lucid interval (a completely asymptomatic patient who returns to his previous activity), gradual lapsing into coma again, fixed dilated pupil (90% of the time on the side of the hematoma), and contralateral hemiparesis with decerebrate posturing. CT shows bioconvex, lens-shaped hematoma.
Emergency ___ produced a dramatic cure. Because every patient who has been unconscious gets a CT scan, the full-blown picture with the ___ pupil and ___ hemiparesis is seldom seen.
Acute epidural hematoma
- occurs with modest trauma to the side of the head, and has a classic sequence of trauma, unconsciousness, a lucid interval (a completely asymptomatic patient who returns to his previous activity), gradual lapsing into coma again, fixed dilated pupil (90% of the time on the side of the hematoma), and contralateral hemiparesis with decerebrate posturing. CT shows bioconvex, lens-shaped hematoma.
Emergency craniotomy produced a dramatic cure. Because every patient who has been unconscious gets a CT scan, the full-blown picture with the fixed pupil and contralateral hemiparesis is seldom seen.
_______
- force of trauma is typically much larger then acute epidural hematoma and the patient is usually much sicker (not fully awake and asymptomatic at any point), due to more severe neurologic damage. CT scan will show semi-lunar, crescent-shaped hematoma. If midline structures are deviated, craniotomy will help. Prognosis is ____.
If there is no deviation, therapy is centered on preventing further damage from subsequent _____
Acute subdural hematoma
- force of trauma is typically much larger then acute epidural hematoma and the patient is usually much sicker (not fully awake and asymptomatic at any point), due to more severe neurologic damage. CT scan will show semi-lunar, crescent-shaped hematoma. If midline structures are deviated, craniotomy will help. Prognosis is bad.
If there is no deviation, therapy is centered on preventing further damage from subsequent increased ICP.
Invasive ICP monitoring, head elevation, modest hyperventilation, avoidance of fluid over-load and diuretics such as mannitol or furosemide can decrease ICP. However, do not over diurese. This can lower systemic arterial pressure, as cerebral perfusion pressure = MAP - ICP. Hyperventilation is recommended when there are signs of herniation, and the goal is PCO2 35 mmHg.
Sedation is used to decrease brain activity and oxygen demand. Moderate hypothermia is currently recommended to further reduce cerebral oxygen demand.
Invasive ICP monitoring, head elevation, modest hyperventilation, avoidance of fluid over-load and diuretics such as __ or __ can decrease ICP. However, do not over diurese. This can ___ systemic arterial pressure, as cerebral perfusion pressure = MAP - ICP. Hyperventilation is recommended when there are signs of herniation, and the goal is PCO2 35 mmHg.
____ is used to decrease brain activity and oxygen demand. Moderate ___thermia is currently recommended to further reduce cerebral oxygen demand.
Invasive ICP monitoring, head elevation, modest hyperventilation, avoidance of fluid over-load and diuretics such as mannitol or furosemide can decrease ICP. However, do not over diurese. This can lower systemic arterial pressure, as cerebral perfusion pressure = MAP - ICP. Hyperventilation is recommended when there are signs of herniation, and the goal is PCO2 35 mmHg.
Sedation is used to decrease brain activity and oxygen demand. Moderate hypothermia is currently recommended to further reduce cerebral oxygen demand.
Diffuse axonal injury occurs in more severe trauma.
CT scan will show diffuse ___ of the gray-white matter interface and multiple small ____ hemorrhages. Without hematoma, there is no role surgery. Therapy is directed at preventing further damage from ____ ICP.
Diffuse axonal injury occurs in more severe trauma.
CT scan will show diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages. Without hematoma, there is no role surgery. Therapy is directed at preventing further damage from increased ICP.
Neck trauma
- For the purpose of evaluating penetrating neck trauma, the neck has been divided into three zones:
What are they?
Zone 1: Clavicles to cricoid cartilage
Zone 2: Cricoid cartilage to the angle of the mandible
Zone 3: Angle of mandible to the base of the skull.
For injuries to zone 1:
- Evaluate with angiography, esophagram (water-soluble, followed by barium if negative), esophagoscopy, bronchoscopy to help decide if surgical exploration is indicated and to determine the ideal surgical approach.
Injuries to Zone 2:
- All penetrating traumas to zone 2 require ____ ____, which a recent trend toward selective exploration based on physical exam.
Inuries to Zone 3:
- evaluate with ___ for vascular injury.
For injuries to zone 1:
- Evaluate with angiography, esophagram (water-soluble, followed by barium if negative), esophagoscopy, bronchoscopy to help decide if surgical exploration is indicated and to determine the ideal surgical approach.
Injuries to Zone 2:
- All penetrating traumas to zone 2 require surgical exploration, which a recent trend toward selective exploration based on physical exam.
Inuries to Zone 3:
- evaluate with angiography for vascular injury.
In all patients with severe blunt trauma to the neck, the integrity of the ___ ___ has to be ascertained.
Unconscious patients and conscious patients with ___ tenderness to palpation should be evaluated initially with ___ and potentially followed with __, depending on findings.
Conscious patients with no symptoms (are not intoxicated, have not used drugs, or have no distracting injuries) can be ____ evaluated for a cervical spinal injury; however, if CT scan of the head is being obtained, it is generally acceptable to extend the study to include the ___ ___.
In all patients with severe blunt trauma to the neck, the integrity of the cervical spine has to be ascertained.
Unconscious patients and conscious patients with midline tenderness to palpation should be evaluated initially with CT scan and potentially followed with MRI depending on findings.
Conscious patients with no symptoms (are not intoxicated, have not used drugs, or have no distracting injuries) can be clinicaly evaluated for a cervical spinal injury; however, if CT scan of the head is being obtained, it is generally accpeted to extend the study to include the cervical spine.
Brown-Sequard syndrome
- typically caused by clean cut injury such as knife blade, and results in ____ paralysis and loss of proprioception and____ loss of pain perception caudal to the level of the injury.
Brown-Sequard syndrome
- typically caused by clean cut injury such as knife blade, and results in ipsilateral paralysis and loss of proprioception and contralateral loss of pain perception caudal to the level of the injury.
___ ___ syndrome
- typically seen in burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temp sensation on both sides caudal to the injury, with preservation of vibratory and positional sense.
Anterior cord syndrome
- typically seen in burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temp sensation on both sides caudal to the injury, with preservation of vibratory and positional sense.
__ __ syndrome.
- occurs in the elderly with forced hyperextention of the neck, such as a rear-end collision. There is paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
Central cord syndrome.
- occurs in the elderly with forced hyperextention of the neck, such as a rear-end collision. There is paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
Traumatic rupture of the aorta is the ultimate “___ ___”.
It most commonly occurs at the __ and __ where the relatively mobile aorta is tethered by the ligamentum arteriosum.
Such an injury requires significant ___ injury and is totally _____ until the hematoma contained by the ___ ruptures resulting in rapid death. Suspicion should be triggered by one of the following:
- Mechanism of injury
- ____ mediastium
- Presence of atypical fractures such as the ___ rib, ___, or ___, which requires great force to fracture.
Dx is made by ____. Surgical repair is indicated once the patient has been stabilized and more immediate life-threatening injuries have been managed. This can be done in an open or endovascular fashion.
Traumatic rupture of the aorta is the ultimate “hidden injury.”
It most commonly occurs at the junction of the arch and the descending aorta, where the relatively mobile aorta is tethered by the ligamentum arteriosum.
Such an injury requires significant deceleration injury and is totally asymptomatic until the hematoma contained by the adventitia ruptures resulting in rapid death. Suspicion should be triggered by one of the following:
- Mechanism of injury
- Widened mediastium
- Presence of atypical fractures suuch as the first rib, scapula, or sternum, which requires great force to fracture.
Dx is made by CT angiogram. Surgical repair is indicated once the patient has been stabilized and more immediate life-threatening injuries have been managed. This can be done in an open or endovascular fashion.
Fracture of the penis (fracture of the ___ ___), fracture of the tunica albuginea) occurs to an erect penis, typically as an accident during __ __. There is sudden pain and development of a large penile shaft hematoma, with a normal appearing glans.
Emergency surgical repair is needed. If not done, impotence will ensue as either AV shunts or painful erections.
Fracture of the penis (fracture of the corpora cavernosa), fracture of the tunica albuginea) occurs to an erect penus, typically as an accident during vigorous intercourse. There is sudden pain and development of a large penile shaft hematoma, with a normal appearing glans.
Emergency surgical repair is needed. If not done, impotence will ensue as either AV shunts or painful erections.
