Trauma

Question 1

most common causes of death in trauma patients? relative timing?

Answer 1

1st peak (0-30 minutes) – basically dead on scene; 2nd peak (30 minutes-4 hours) – death due to head injury #1, hemorrhage #2, these pt can be saved w/ rapid assessment (golden hour); 3rd peak (days-weeks) death due to multisystem organ failure and sepsis

Question 2

injuries associated with seatbelts

Answer 2

small bowel perforation, lumbar spine fractures, sternal fractures

Question 3

FAST scan misses….

Answer 3

retroperitoneal bleeding, hollow viscus injury

Question 4

indications for ED thoracotomy? blunt? penetration?

Answer 4

blunt trauma, use only if pulses lost in the ED – penetrating trauma can use if pulses are lost on the way to the ED

Question 5

in trauma who gets type O+ blood? O- blood?

Answer 5

O+ blood goes to males and older females – otherwise O- to females who are prepubscent or of childbearing age

Question 6

explain the GCS scale

Answer 6

E4V5M6 – eyes: 4 opens spontaneously 3 opens to voice 2 opens to painful stimuli 1 does not open, voice: 5 talks normally 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no response, motor: 6 moves spontaneously / follows commands 5 localizes to pain 4 withdraws to pain 3 flexes to pain (decorticate) 2 extends to pain (decerebrate) 1 no response – gcs less than 8, intubate

Question 7

cause of epidural hematoma, CT findings, indication for surgery

Answer 7

bleeding from middle meningeal artery, CT shows lens-shaped deformity, have lucid interval, operate for midline shift > 5 mm, or symptomatic

Question 8

cause of subdural hematoma, CT findings, indication for surgery

Answer 8

bleeding from bridging veins (venous plexus) that cross from dura and arachnoid, CT shows crescent shaped deformity, operate for symnptomatic shift > 1 cm

Question 9

indication for ICP monitoring (BTF) in head trauma

Answer 9

moderate -> severe head injury who can’t be serially neurologically assessed; severe head injury (GCS < 8) + abnormal CT scan; severe head injury (GCS < 8) + normal CT if 2 of the following are present: (1) Age > 40 yrs (2) BP < 90mmHg (3) Abnormal motor posturing (brain trauma foundation guidelines)

Question 10

what is cerebral perfusion pressure? what are goal CPPs? ICPs?

Answer 10

CPP = MAP - ICP, goal CPP >60; normal ICP is 10, needs intervention if >20

Question 11

most common site of facial nerve injury?

Answer 11

geniculate ganglion, temporal skull fx

Question 12

indication for surgical management of skull fx

Answer 12

significantly depressed (>1 cm), contaminated, or persistent CSF leak

Question 13

what is a Jefferson fracture? general tx?

Answer 13

C1 burst fracture, caused by axial loading i.e. diving headfirst into a shallow pool; tx w/ rigid collar

Question 14

what is a hangman’s fracture? general tx?

Answer 14

C2 fracture caused by distraction/extension injury; tx w/ traction and halo

Question 15

definition of an unstable thoracolumbar spine fracture?

Answer 15

fracture that involves 2 or more column disruption

Question 16

describe the Le Fort classification of facial fractures

Answer 16

type 1 ( - ) maxillary fx straight across, type 2 ( / \ ) lateral to nasal bone, underneath eyes, diagonal towards maxilla, type 3 ( - - ) lateral orbital walls

Question 17

define the anatomic neck zones, general management in penetrating trauma

Answer 17

zone 1 clavicle to circoid cartilage (may need angio, bronch, esophagoscopy, barium swallow, may need median sternotomy to reach these lesions), zone 2 cricoid to angle of mandible (may need neck exploration in OR), zone 3 angle of mandible to base of skull (may need angiography and laryngoscopy – would need jaw subluxation, muscle release to reach vascular injuries here)

Question 18

indication for thoracotomy after inital chest tube placement

Answer 18

chest tube output >1.5L initially; OR >250ml/hr for 3 hours, OR >2.5L within 24 hrs

Question 19

operative approach for diaphragm injuries?

Answer 19

transabdominal approach if <1 week, otherwise consider thoracic approach if > 1 week (may have adhesions that would need to take down from chest)

Question 20

most common location of aortic transection? operative approach?

Answer 20

ligamentum arteriosum (just distal to subclavian artery takeoff) – approach w/ L thoracotomy

Question 21

approach for left subclavian artery injury? right subclavian artery injury?

Answer 21

left subclavian approach via left thoracotomy, right subclavian approach via median sternotomy if proximal, if distal may need a midclavicular incision with possible resection of the clavicle

Question 22

approach to injury to inominate artery?

Answer 22

median sternotomy

Question 23

what type of bleeding is associated with anterior pelvic fractures? posterior pelvic fractures?

Answer 23

anterior pelvic fracture associated with venous bleeding, posterior pelvic fractures associated with arterial bleeding

Question 24

which portion of duodenum most frequently injured?

Answer 24

2nd portion

Question 25

order of structures in the renal hilum?

Answer 25

VAP (anterior-posterior) vein -> artery -> pelvis

Question 26

ureteral injury with large segment missing (>2cm) management?

Answer 26

upper 1/3 / middle 1/3 -> temporize with perc nephrostomy (tie off both ends of the ureter), go for ileal interposition or trans-ureteroureterostomy later -- lower 1/3 -> reimplant in bladder, may need bladder hitch (psoas hitch)

Question 27

ureteral injury with small segment missing (<2 cm) management?

Answer 27

upper 1/3 / middle 1/3 -> mobilize ends of ureter and perform primary repair over stent; lower 1/3 reimplant into bladder

Question 28

explain the retroperitoneal zones and associated injuries -- which ones do we leave alone?

Answer 28

zone 1 = central (pancreaticoduodenal injuries, aorta/vaca), zone 2 = flank or perinephric (injuries to GU tract or colon), zone 3 = pelvis (pelvic, fx usually leave these alone)

Question 29

what is 1st 2nd 3rd 4th degree burns?

Answer 29

1st - epidermis (sunburn), 2nd (there is superficial and deep -- superficial has blebs/blisters, hair follicles intact, no skin graft needed; deep there is decreased sensation w/ loss of hair follices, need skin graft), 3rd - leathery 'charred parchment' down to subcutaneous fat; 4th down to bone, into adjacent adipose or muscle

Question 30

criteria for admission in burns patients?

Answer 30

TBSA >10% for young <10 or older >50 patients; TBSA >20% for everyone, burns to sensitive areas (hands, face, feet, genitalia, perineum), 3rd degree burns >5% in any age, any electrical/chemical, concominant inhalation injury

Question 31

what is parkland's formula

Answer 31

volume of resuscitation needed = 4 cc/kg x weight x %TBSA -- give 1/2 in first 8 hours

Question 32

STSG vs FTSG

Answer 32

STSG more likely to survive, graft not as thick so easier imbibition and refvascularization; FTSG have less wound contraction (good for palms / back of hand)

Question 33

silvadene characteristics

Answer 33

can't use in pt w/ sulfa allergy, limited eschar penetration, ineffective against pseudomonas, can lead to neutropenia and thrombocytopenia - painless classification

Question 34

silver nitrate characteristics

Answer 34

limited eschar penetration, ineffective against some pseudomonas, causes electrolyte inbalances (think nitrates = electrolytes -- can lead to hyponatremia, hypochloremia, hypocalcemia, hypokalemia), can cause methemoglobinemia - painful application

Question 35

sulfamylon characteristics

Answer 35

mafenide sodium -- good eschar penetration, broadest spectrum against pseudomonas and GNRs, can cause metabolic acidosis due to it being a carbonic anhydrase inhibition

Question 36

what is a Curling's ulcer?

Answer 36

gastric ulcer that occurs with burns

Question 37

what is a Marjorlin's ulcer?

Answer 37

highly malignant squamous cell Ca that arises in chronic non healing burn wounds

Question 38

most common cause of death in trauma patients in the 1st hour

Answer 38

hemorrhagic shock

Question 39

anterior abdominal stab wounds: what percentage actually penetrate the peritoneal cavity? and cause injury?

Answer 39

1/3 do not penetrate peritoneal cavity, 1/3 penetrate peritoneal cavity w/o injury, 1/3 penetrate peritoneal cavitiy w/ sig intraabdominal injury

Question 40

why is the PA wedge pressure high in abdominal compartment syndrome?

Answer 40

intra-abd pressure leads to increased intrathoracic pressure which increases your pulm capillary wedge pressure and central venous pressure (however overall there is less preload and lower stroke volume); systemic vascular resistance is also increased (increased afterload)

Question 41

bacitracin characteristics?

Answer 41

painless, limited eschar penetration, poor gram negative coverage

Question 42

characteristics of electrical burns - DC vs AC, fat vs skinny people, cause of death, management

Answer 42

DC (car battery) results in single large muscle contraction, throw pt far away, vs AC (outlet) which can cause flexion/gripping and increased exposure; fat people have higher resistance to electricity, leading to more burn and damage; cause of death early is cardiac arrythmia; treat with cardiac monitoring, IVF to maintain high urine output

Question 43

stages of frostbite?

Answer 43

1st degree - hyperemic, no necrosis, 2nd degree hyperemia, partial thickness necrosis, 3rd degree hemorrhagic bullae and full thickness necrosis, 4th degree frank gangrene w/ involvement of underlying muscle/bone

Question 44

what is a Chance fracture?

Answer 44

flexion-distraction type injuries of the spine with significant asosciation with intraabdominal injuries (most commonly hollow viscus and pancreas ~33% chance),

Question 45

what to do with C-collar in pt's with negative ct c spine who are obtunded?

Answer 45

remove them according to East guidelines

Question 46

most common electrolyte abnormality in burn patient?

Answer 46

hypernatremia -- due to insensible water loss through burn wound, also can have hyperglycemia, hypocalcemia, hypomagnesia

Question 47

grades of kidney lacerations?

Answer 47

grade 1 - subcapsular, non expanding hematoma, grade 5 completely shattered or avulsion of renal hilum -- grade 3 is deep laceration that doesnt involve collecting duct, grade 4 laceration extends into collecting system or main renal artery -- 90% managed non-operatively, most urinary extravasation resolves

Question 48

most common organisms found in wounds isolated from human bites

Answer 48

#1 strep, #2 staph -- other common include eikenella, fusobacterium, prevotella, porphyromonas

Question 49

treatment of retained hemothorax in trauma?

Answer 49

do not place second chest tube, go straight to early VATS - shorter hospital stay, lower hospital cost

Question 50

hard signs of vascular injury?

Answer 50

shock, pulsatile bleeding, expanding/pulsatile hematoma, palpable thrill, absent distal pulses

Question 51

soft signs of vascular injury

Answer 51

diminished pulses, proximity to vessels, hematoma, and reports of significant blood loss

Question 52

what are the components of PCC? when do we use it?

Answer 52

PCC (prothrombin complex concentrate) inactivated concentrate of protein C, S, factors 2, 7, 9, 10 (4 factor vs 3 factor which has less 7) -- very fast reversal of warfarin

Question 53

preferred sites for intraosseus access - children / adults?

Answer 53

children - proximal tibia (anteromedial tibia 2-3 cm below tibial tuberosity), then distal femur; adults preferred at sternum, followed by tibia

Question 54

indications for internal fixation in flail chest?

Answer 54

patients already undergoing thoracotomy for intrathoracic injury, flail chest without pulm contusion, noticeable paradoxial movement of a chest wall segment while a pt is being weaned from respirator, and severe deformity of the chest wall

Question 55

best way to identify blunt cardiac injury?

Answer 55

NOT sternal fractures apparently -- monitor with ECG, troponins - normal ECG has negative predictive value of 95%

Question 56

Describe the Cattell maneuver

Answer 56

right medial visceral rotation of the cecum and ascending colon; incise the peritoneal reflection at the white line of Toldt -- useful for exposing R retroperitoneal structures such as the IVC and R ureter

Question 57

Describe the Kocher maneuver

Answer 57

mobilization and medial rotation of the duodenum

Question 58

Describe the Mattox maneuver

Answer 58

left medial rotation of the descending colon at the line of Toldt, spleen and/or kidney towards the midline

Question 59

why is it OK to ligate the L renal vein? (e.g. trauma, AAA repair)

Answer 59

because of outflow via the adrenal, gonadal and iliolumbar veins

Question 60

which patients should you consider primary amputation on in trauma?

Answer 60

hemodynamic unstable and profound ischemia of >6 hours

Question 61

compartments of the lower leg? most commonly affected? first symptom?

Answer 61

anterior/lateral superficial/deep posterior - most common anterior, deep peroneal nerves runs in it, numbness in 1st web space is early finding

Question 62

how to decompress the posterior compartment during a lower extremity fasciotomy?

Answer 62

need to detach the soleus muscle from the tibia to decompress the deep posterior compartment (which contains the tibial nerve)

Question 63

principles in management of a retrohepatic IVC injury

Answer 63

will bleed despite Pringle maneuver -- damage control packing attempt, however if still ongoing bleeding, will need to take down hepatic ligaments, perform Kocher maneuver, direct compression of the retrohepatic space -- can proceed with ICU/resusc or total vascular exclusion of the liver done -- can also consider atriocaval (Schrock) shunt or start venovenous bypass

Question 64

when is resection and duodenoduodenostomy appropriate in duodenal trauma

Answer 64

for >50% circumfrential injury to the 1st, 3rd or 4th portion of the duodenum

Question 65

onset of vomiting after blunt abdominal trauma, more often in children

Answer 65

duodenal hematoma - managed non operatively -- can occur in pt w/o trauma in hemophilia

Question 66

management of rectal injuries

Answer 66

intra vs extraperitoneal - intraperitoneal = treat like colon injury, repair primarily; extraperitoneal need to decide on primary repair vs diverting colostomy, which depends on how accessible the injury is