Trauma Flashcards
What initial actions should you take to care for the trauma patient?
- Assess the primary survey, with focus on ABCDE’s.
Address problems with any portion of the survey before moving on - Log roll the patient
- Xray and FAST Exam
- Secondary Survey
- Resuscitation and stabilization
What does the D of ABCDE stand for?
Disability - neurologic status
Which of the ABCDEs involves a hemorrhage/shock assessment?
C - circulation
What does the E of ABCDE stand for?
Exposure/environmental control
How do you judge if the airway is patent in the trauma pt?
- Have the patient speak, evaluating for voice change and stridor
- Look for evidence of pooling secretions or cyanosis
Consider some traumatic signs that might indicate a future need to intubate.
- Facial injury causing obstruction or bleeding
- Laryngeal fractures
- Expanding hematomas
What are some actions to take if you feel a trauma pt’s airway is not intact?
- ALWAYS MAINTAIN C-SPINE IMMOBILIZATION
- Consider performing jaw thrust to establish patency of the airway.
- Consider use of a naso or oro-pharyngeal airway during bag-valve mask ventilations (BVM)
- Rapid Sequence intubation if needed for airway stabilization or protection (e.g. for GCS of 9 or less)
- Evaluate neck for landmarks associated with cricothyroidotomy and to assess the patient for subcutaneous emphysema or tracheal deviation.
List 2 emergent cardiothoracic conditions where you might see JVD?
tension pneumothorax or cardiac tamponade
How would PTX sound on percussion?
How would hemothorax sound on percussion?
- Hyperresonat
2. Dull
Paradoxical chest wall movements are seen in this condition.
What is flail chest?
two or more fractures in 2+ contiguous ribs
Crepitence & point tendnerness of the chest wall may be seen in: (1)
Rib fx
In tension PTX, where is the needle (14 or 16 gauge) inserted?
- Over or under the rib?
Midclavicular line in the 2nd ICS
- Over the rib to avoid the neurovascular bundle
In a patient in shock with no breath sounds and/or percussion dullness, what dx should you strongly consider?
Hemothorax
Tx of hemothorax?
Placing a large (36 f) chest tube and possibly a trip to the OR for hemorrhage control.
- If the hemothorax is retained despite the chest tube then a VATS is recommended
*If a ________ pulse is palpable, it suggests a systolic blood pressure of at least 80 mm Hg. If the _________ or _________ are palpable, these suggest a systolic blood pressure of at least 60 mm Hg.
radial
femoral or carotid
What types of pts may not show a strong tachycardic response in shock?
- Neurogenic shock to sympathetic cord disruption
- Beta blockade, Calcium channel blockade
- Elderly
- Children and young adults
- Conditioned athletes start with a lower basal level. Doubling their resting heart rate of 45-50 shows a falsely reassuring heart rate of 90-100.
What type of shock are the ATLS Classifications for?
Hemorrhagic
How many classes are there in the ATLS Classifications system of hemorrhagic shock?
- Which is most severe?
4
IV is most severe
Describe class I of the ATLS Classification of hemorrhagic shock.
- HR
- BP
- % Blood loss
- Tx:
Nl/fast HR
Nl BP
<15% blood loss
Tx: nl saline
Describe class II of the ATLS Classification of hemorrhagic shock.
- HR
- BP
- % Blood loss
- Tx:
Nl/fast HR
Nl/low BP
15-30% blood loss
Tx: nl saline
Describe class III of the ATLS Classification of hemorrhagic shock.
- HR
- BP
- % Blood loss
- Tx:
Fast HR
Low BP
30-40% blood loss
Tx: NS + blood products
Describe class IV of the ATLS Classification of hemorrhagic shock.
- HR
- BP
- % Blood loss
- Tx:
Fast HR
Low BP
>40% blood loss
Tx: NS + blood products
In which stage of the ATLS Classification system of hemorrhagic shock will you begin to see narrowed pulse pressure?
Stage II (15-30% blood loss)
In which stage of the ATLS Classification system of hemorrhagic shock will you begin to see AMS?
Stage III (30-40% blood loss)
In which stage of the ATLS Classification system of hemorrhagic shock will the pt likely become obtunded?
Stage IV (>40% blood loss)
True or false: a full neuro exam is done during the primary survey of a trauma pt.
False- during secondary survey
just do gross neuro exam, eg “wiggle your toes”
Uncal herniation will present as a “blown pupil.” What is the mechanism behind this?
Paralysis of parasympathetic fibers of pupillary constrictors of CN III (unopposed symp activity)
What are the 3 GCS categories, and how much are each worth?
EVM
Eyes-Verbal-Motor
4-5-6
*What are the possible outcomes of the “Eyes” category of GCS?
Eyes open... 4 – Spontaneously 3 – To loud voice 2 – To Pain 1 – Not at all
*What are the possible outcomes of the “Verbal” category of GCS?
5 – Oriented 4 – Confused 3 – Inappropriate words 2 – Incomprehensible sounds 1 – No Sounds
*What are the possible outcomes of the “Motor” category of GCS?
6 – Obeys commands
5 – Localizes to pain
4 – Withdraws to pain
3 – Abnormal flexion posturing (decorticate)
2 – Abnormal extension posturing (decerebrate)
1 – No movements
Why would you “log roll” a pt during trauma assessment?
Under which of the ABCDEs is this done?
Log roll the patient using spinal immobilization to palpate the spine for step-offs or pain.
D - disability (neuro)
What is done to satisfy the E of ABCDEs?
Completely disrobe patient to assess for any hidden injury. Keep patient warm to prevent coagulopathy.
What radiographic studies can be done during the primary survey of a trauma pt?
X-ray
US
What US views are taken during the FAST exam?
- sub-xiphoid cardiac view
- spleno-renal view
- hepato-renal view
- bladder view
What’s an important historical question to ask the trauma pt, in case they have to go to the OR?
Last meal?
What are Battle sign and Raccoon eyes, and what are they indicative of?
- Battle’s sign: ecchymosis behind ear indicative of basilar skull fracture
- Raccoon’s eyes: periorbital ecchymosis without edema indicative of basilar skull fracture
Recall the grading of strength categories.
0: Total paralysis
1: Palpable/visible contraction
2: FROM w/gravity eliminated
3: FROM against gravity
4: FROM, less than normal strength
5: Normal strength
In order to clear the cervical spine and remove the patient’s collar, they must have the following findings:
Alert, not intoxicated Absence of neck pain Absence of midline neck tenderness Absence of distracting injury Absence of sensory or motor complaint
*Will the following p/w nspiratory or expiratory stridor?
Traumatic supraglottic injury
Traumatic subglottic injury
Traumatic supraglottic injury: inspiratory
Traumatic subglottic injury: expiratory
___% of brain injuries have associated C-spine injury
5%
___% spinal injuries are cervical
55%
___% of patients with C-spine fx will have a second noncontiguous vertebral fracture
10%
A tracheobronchial tree disruption will present on physical as ____________________.
subcutaneous emphysema
- You may notice that after placing a chest tube, the lung refuses to inflate (2nd chest tube vs. go to OR).
How might a pulmonary contusion present on exam?
May initially present as mild hypoxia but after fluid resuscitation, the corresponding pulmonary edema worsens and so does the hypoxia.
- On exam tachypnea, tachycardia, hypoxia is common. In severe cases ecchymosis can be evident over chest wall and decreased breath sounds on auscultation.
*How is pulmonary contusion diagnosed and treated?
This can be diagnosed on chest x-ray (or CT –> better) and is treated by proper oxygenation and ventilation (often with intubation), and maintaining normovolemia.
What test would reveal a traumatic aortic disruption from an acceleration or deceleration injury?
- Is surgery indicated?
This can be confirmed with CT scan or angiography of the aorta
- Requires prompt surgical correction.
What are Cullen’s sign and Grey-Turner’s sign, and what are they a/w?
- Cullen’s sign of periumbilical bruising
- Grey-Turner’s sign of flank bruising
- Both associated with retroperitoneal hemorrhage
How much blood can the pelvis hold during trauma?
5L (lots)
What are some tx’s for pelvic trauma?
Treatment involves stabilizing the pelvis by wrapping a sheet around it (to compress), longitudinal traction, pelvic binders, MAST trousers (falling out of favor).
Tx of compartment syndrome?
fasciotomy
What would a high-riding prostate on trauma exam possibly be a sign of?
Can be sign of a pelvic fracture or urethral injury
Why do you examine sphincter tone during a trauma exam?
Diminished sphincter tone which can be a sign of a spinal cord injury
Review the labs you should order in a trauma pt.
- Type and cross
- CBC to check hemoglobin, hematocrit and platelets
- ABG and Lactate to screen for shock
- Chemistry panel
- Urinalysis
- EtOH
- EKG if indicated
What study might you order if concerned for urethral injury?
Retrograde-urethrogram
When might a diagnostic peritoneal lavage be used?
May be used for a hypotensive, unstable patient that neesds CT for hollow viscous organ but too HDUS to make it
- It is 98% sensitive for bleeding and is used to detect bowel injury (often missed on CT).
When is a diagnostic peritoneal lavage considered positive?
Gross blood (10 ml) 100,000 RBCs/mm3 More than 500 WBCs/mm3 Positive Gram stain Food fibers Bacteria, bile, feces
What are the downsides of diagnostic peritoneal lavage?
- Invasive
- Misses retroperitoneal injuries
What should you scream out loud at the beginning of every trauma case?
ABC’s, IV, O2, Monitor!
What is “blunt trauma”?
Mechanisms causing increased intrathoracic pressure such as car collisions (most common cause of thoracic trauma), and falls.
*The injuries to be identified and treated during the primary survey are: (6)
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Flail chest and pulmonary contusion
- Massive hemothorax
- Cardiac tamponade
For motor vehicle accidents (MVAs), what are some important questions to ask in the hx?
speed of collision, position of colliding car to each other, position of patient in the car, seatbelt use, extent of car damage (intrusion, wind shield damage, difficulty of extrication, air bag deployment)
With respect to falls, what is an important question to ask in the hx?
Height?
With respect to gun shot wounds, what are some important questions to ask in the hx?
kind of gun,
distance from the shooter,
number of shots heard
In chest trauma, any injury within the “box” results in injury to underlying organs. What is the “box”?
Region in between the nipple lines, inferior neck line and diaphragm
What is an “open” PTX?
- What sx does it p/w?
A sucking chest wall wound from penetrating injury, usually with a big defect in the chest wall.
- P/w chest pain, SOB with sonorous breath sounds, sucking air from wound and shallow respirations.
How is an OPEN PTX treated?
- What can happen if treated improperly?
Treated by placement of a square dressing tape on 3 sides to create an escape valve.
- If this is not performed, this injury can turn into a tension PTX.
Ultimately a chest tube is placed ipsilateral to the side of the wound but at a different anatomic location than the wound.
How would you dx hemothorax?
US
___________________ is a frequent complication of flail chest.
Pulmonary contusion
*What is the goal of flail chest tx (and how is this achieved)?
The treatment goal is to re-expand the lung with CPAP (positive pressure) or physiotherapy, and to avoid atelectasis.
What is the tx of mild flail chest?
Pain control and incentive spirometry
more severe: CPAP or physiotherapy to re-expand lung and avoid ATX
Severe blunt chest trauma causes leakage of blood and proteins into alveoli causing ______________ and that can lead to ARDS.
atelectasis
Patients with pulmonary contusions can be occasionally asymptomatic but often present with these sx:
SOB, chest pain, hemoptysis and cough
What side of the heart is most often injured in blunt chest trauma? (R vs L)
Right atrium/ventricle
- Injury is closely associated with sternal fractures.
What radiographic test (1) should all pts with suspected cardiac contusions get?
2D-ECHOs for evaluation of EF
Why do you need to observe cardiac contusion pts for 24 hours? (2)
Development of arrhythmia / cardiogenic shock
In cardiac contusion pts, if the subsequent 2D-ECHO shows a reduced EF (new from prior), patients should undergo a ___________________.
dobutamine stress test
What sx does a pt in tamponade p/w?
Chest pain, SOB with air hunger, frequently AMS
- What is triad is seen with tamponade?
- What additional sx are somewhat pathognomonic?
- Beck’s
- JVD
- Hypotension
- Distant heart sounds
- Pulsus paradoxus
- Narrowing of pulse pressure
How is dx of tamponade made?
Clinically
- US can help, though
What is the tx for tamponade if the pt is HDS?
If HDUS?
- HDS: pericardiocentesis
- HDUS: emergent surgery
What thoracic traumatic injury is often seen with deceleration injuries (e.g. 30 MPH car crash or 40 ft fall)?
Blunt aortic injury
Review the 3 possible results of blunt aortic injury in (1) dead on scene, (2) HDUS, and (3) HDS pts.
A) dead on scene: presumed complete aortic transection on impact.
B) HDUS: full thickness transection with active hemorrhage from aorta (look for non sustained improvement in BP on fluid bolus).
C. HDS: partial thickness transection with possibility of pseudoaneurysm aorta with vague complaints including chest/back pain and lower extremity complaints.
What test is diagnostic for blunt aortic injury in stable pts?
Unstable?
CT Angio (if stable enough) - Otherwise TEE can be used for unstable patients however they need to be intubated prior to this test.
- CXR can help
What is the tx of blunt aortic injury in HDUS pts?
- Stable?
Emergent surgery (cross-clamp aorta) - If stable, BP control and then surgery
What are considered the “great vessels”? (3)
aorta, vena cava and pulmonary trunk
Most pts w/trauma tot he great vessels present in this condition:
Shock
Review some PE signs for great vessel trauma/injury.
- expanding hematoma,
- acute superior vena cava syndrome,
- hematoma compressing trachea
Great vessel trauma is treated similarly to what other type of trauma?
Blunt aortic trauma
*In a traumatic arrest from penetrating chest injury (e.g. 2/2 great vessel or aortic injury) leading to massive hemorrhage, how is the airway/breathing managed? (3)
Management requires stabilization of airway via endotracheal intubation, bilateral chest tubes and ED thoracotomy which allows open heart CPR, pericardiotomy and cross clamping of the aorta.
In a traumatic arrest from penetrating chest injury, patients with a penetrating injury and PEA within 5 minutes of arrival are appropriate candidates for ______________.
thoracotomy
Summarize the tx (simply) for the following conditions:
- HDUS pts:
- PTX:
- Open PTX:
- Hemothorax:
- Flail chest
- Pulmonary contusion
- Cardiac contusion
- Tamponade
- Blunt aortic injury
- Great vessel injury
- HDUS patients: Packed RBC (O-Neg) transfusion), consideration of STAT OR for surgical intervention.
- PTX: Tube thoracostomy
- Open PTX: Tape wound and tube placement at site separate from injury
- Hemothorax: As above, except if greater than 1500 cc of blood obtained on initial chest tube placement or more than 150-200cc/hr x 4 hours, patient needs to go to the OR under Cardiothoracic surgery.
- Flail Chest: Symptomatic Support, intubate and ventilate as needed. Incentive spirometry. In extreme cases patient may need cardiothoracic surgical intervention.
- Pulmonary Contusion: Symptomatic support, high flow oxygen, early intubation if needed, incentive spirometry.
- Cardiac Contusion: Monitoring if any significant changes in ejection fraction
- Cardiac Tamponade: Pericardiocentesis followed by OR thoracotomy.
- Blunt Aortic Injury: If stable blood pressure control followed by close observation and delayed aortic repair. If unstable, massive transfusion protocol, transfuse pRBC and stat emergency aortic repair by Cardiothoracic and Vascular surgery.
- Great Vessel Injury: Typically unstable shock like presentation: Massive transfusion with concurrent OR thoracotomy.
*In chest trauma, who are considered candidates for resuscitative thoracotomy?
Traumatic arrest secondary to penetrating chest trauma only
List some possible outcomes of BLUNT laryngeal trauma.
- crushed larynx,
- tracheal disruption,
- expanding hematoma,
- esophageal leak.
Which spinal cord region results in paraplegia?
Quadriplegia?
Para: thoracic
Quadra: cervical
Describe the 3 zones of penetrating neck trauma presentations.
Zone III-Above angle of mandible
Zone II-Angle of mandible
Zone I-below cricoid cartilage
What study should be done/ordered in Zone III neck trauma? (above angle of mandible)
Angiography
What study should be done/ordered in Zone II neck trauma? (angle of mandible to cricoid cartilage)
Explore, observe, growing role for CTA
What study should be done/ordered in Zone I neck trauma? (below cricoid cartilage)
Angiography, EGD, esophagoscopy
Which of the 3 neck zones of penetrating trauma has the highest mortality?
Zone I (below cricoid cartilage)
The majority of blunt laryngeal trauma is due to __________.
MVC
Penetrating laryngeal trauma typically results from ______________.
gunshot or stab wound
What basic labs would be considered part of a “trauma panel”?
CBC Chemistry pane PT/INR Type and screen VBG/ABG
True or false:
A chest X-ray should be obtained in all circumstances of neck trauma.
True
especially if the platysma has been penetrated
Cervical spine radiography is indicated for all trauma patients who have:
- midline neck pain
- tenderness on palpation
- neurologic deficits referable to the cervical spine
- ALOCs
- a significant mechanism with a distracting injury
- suspect is intoxicated
Besides CT, what can be used to assess the esophagus in neck trauma?
endoscopy with contrast
Besides CT, what can be used to assess the larynx in neck trauma?
Fiberoptic laryngoscopy
- An excellent way to evaluate the supraglottic and glottic larynx; has limitations in evaluating the subglottic area.
What sx might prompt you to order angiography for suspected vascular neck trauma injury?
- GI blood
- hoarseness
- subcutaneous air
- respiratory distress
In neck trauma, if attempts at oral intubation fail or are unsafe due to significant trauma, ______________ is required.
a surgical airway
If indicated, what type of surgical airway is suggested in neck trauma? (2)
Formal tracheotomy is preferred over cricothyrotomy but if patient is unstable, a cricothyrotomy should be attempted
True or false:
Laryngeal mask airways are often useful in neck trauma patients.
False, contra’d
- can occlude the airway and may also ventilate air through mucosal defects in the larynx to the neck
Review some causes of immediate surgical intervention in neck trauma pts.
- Uncontrolled hemorrhage,
- shock not responding to resuscitation,
- expanding or pulsatile hematoma,
- airway compression,
- airway communication with wound (as evidenced by bubbling)
Name the components of c-spine immobilization.
- semi-rigid cervical collar
- head immobilization
- backboard
- tape
- straps
What is deglutition?
Swallowing
- Nearly 90% neck trauma pts are able to swallow in future
*Spine injuries above __-___ can result in partial or total loss of respiratory function.
C6
3 kinds of forces are seen with blunt abdominal trauma:
- Sheering (rapid decel)
- Crushing
- External compression (rapid pressure rise)
True or false:
A cervical collar is rarely necessary and may hinder treatment in penetrating abdominal trauma victims.
True
What things should you think about in the E of ABCDE?
Environment/exposure
- Completely expose the patient. Rectal tone? Gross blood per rectum?
*In the setting of hypotension, free fluid on the eFAST exam suggests ________________________.
hemoperitoneum
- Necessitates emergent surgical intervention
What types of findings could potentially present on an abdominal trauma pt’s rectal exam?
high riding prostate, lack of rectal tone, or heme-positive stools
With blunt abdominal trauma, ________________ is the most common injury followed by _______________.
- splenic rupture
- liver lacerations
- Bladder rupture can also be encountered
- Can also lead to diaphragmatic rupture especially on the left side.
- Pelvic fracture is another common injury
Blunt aortic injuries especially from deceleration injury can also occur however majority of these patients die from traumatic transection of the aorta at the scene of the accident. In the minority who survive, judicious _______________ and emergent operative intervention is indicated.
BP control
Review the most commonly injured GI organs by GSW.
- small bowel
- colon
- liver
- vasculature
Read the most commonly injured GI organs by stab wound
- Liver
- Small bowel
- Diaphragm
- Colon
____________________ is the standard of care when evaluating patients with blunt abd trauma.
beside US
- Limited use for penetrating abd trauma
For stable patients the cornerstone of diagnosis of abdominal trauma is _____________.
CT Scan with IV contrast
In abdominal trauma, ____________ (lab) levels can illustrate any theoretical injury to the pancreas although the evidence behind this is not substantial.
lipase
Why get a UA in abdominal trauma pts?
Check for signs of hematuria, as this can indicate injury to the GU system
What is a principle to keep in mind when controlling the BP of an abdominal trauma pt?
Permissive hypotension
- The thought is that any increases in BP or excessive crystalloid administration further exacerbates the lethal trauma triad
- What is permissive hypotension?
- What is the goal MAP?
- Avoiding aggressive crystalloid resuscitation of trauma patients, in favor of blood product resuscitation to a specific defined Mean Arterial Pressure (MAP) of 65.
*What is the lethal “trauma triad”?
- coagulopathy
- acidodis
- hypothermia
(all beget each other and leads to death spiral)
Pelvic fractures with concurrent pelvic vessel injury warrant a stat _____________ consult for emergent ____________ (procedure).
interventional radiology
arterial embolization
*When can ED thoracotomies possibly be indicated during abdominal trauma, penetrating or blunt injuries?
PENETRATING if leads to cardiac arrest
* Never in blunt injuries!
True or false:
Neck trauma patients present with deceptively unimpressive physical exams.
False – abdominal do, though
Where is Morrison’s pouch?
Hepato-renal recess
In head trauma with hypotension, Current guidelines recommend maintenance of a mean arterial pressure >___ mm Hg to maintain adequate CPP.
80 mmHg
- via fluid boluses or vasopressors if necessary
True or false:
All subdural hematomas are, by definition, chronic.
False
- Can be acute as well (from trauma)
Sudden deceleration can result in this type of brain injury:
What is diffuse axonal injury?
What is the classic CT reading of diffuse axonal injury?
Classically display punctate hemorrhages along the gray-white junction of the cerebral cortex and in deep structures of the brain
What’s a complication of diffuse axonal injury that can develop rapidly and requires prompt intervention?
Edema
*What are some PE signs of skull fx?
- CSF otorrhea or rhinorrhea
- hemotympanum
- periorbital or retroauricular ecchymosis (“raccoon eyes” and Battle signs)
- deafness
- 7th nerve palsy
What is uncal herniation?
- Signs?
When the uncus of the medial temporal lobe is displaced inferiorly through the tentorium.
- *ipsilateral fixed and dilated pupil and contralateral motor paralysis.
What is central transtentorial herniation?
- Signs?
Occurs from midline lesions of the frontal or temporal lobes with downward displacement of the parenchyma through the tentorium
- bilateral pinpoint pupils, bilateral Babinski’s signs, and *increased muscle tone.
What is cerebellotonsillar herniation?
- Signs?
The cerebellar tonsils are displaced through the foramen magnum
- bilateral pinpoint pupils, *flaccid paralysis, and *sudden death.
What is upwards transtentorial herniation?
- Signs?
Results from posterior fossa lesions,
- conjugate downward gaze with *lack of vertical eye movements and pinpoint pupils.
A mild TBI, also known as a _____________, is defined as a GCS score of 14 or 15 with associated signs or symptoms after a blunt force or acceleration-deceleration head injury.
concussion
Sx of concussion may include:
headache, vomiting, weakness, numbness, dizziness, decreased concentration, memory problems, sleep disturbance, irritability, fatigue, visual disturbances, depression, or anxiety
Repeat concussion during the vulnerable healing period following an initial concussion can result in this syndrome.
second impact syndrome
What is the worst possible consequence of second impact syndrome following concussion?
rapid onset of cerebral edema and death
The New Orleans Criteria and the Canadian CT Head Rules have a sensitivity of ___%
100%
If there is concern for impending brain herniation, what temporary intervention could be used as a last resort?
a temporary course of hyperventilation may be instituted, with a goal PaCO2 of 30-35 mm Hg.
List measures useful for decreasing ICP in a closed head injury?
- Raise head of bed to 30 degrees
- Mannitol may be used as an osmotic diuretic if the patient is not hypotensive, or hypertonic saline if hypotension is present.
- If not done previously, the patient should be intubated and adequately sedated to prevent agitation and increase in ICP
Recall: Patients with head injury require higher MAP goals (>___ mm Hg) than typical trauma patients.
80 mmHg
Have a low threshold for ordering head CT in these 3 demographics:
- The elderly
- chronic alcoholics
- those with coagulopathies or on anticoagulants
