Trauma Flashcards
most common causes of death in trauma patients? relative timing?
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
injuries associated with seatbelts
small bowel perforation, lumbar spine fractures, sternal fractures
FAST scan misses….
retroperitoneal bleeding, hollow viscus injury
indications for ED thoracotomy? blunt? penetration?
blunt trauma, use only if pulses lost in the ED – penetrating trauma can use if pulses are lost on the way to the ED
in trauma who gets type O+ blood? O- blood?
O+ blood goes to males and older females – otherwise O- to females who are prepubscent or of childbearing age
explain the GCS scale
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
cause of epidural hematoma, CT findings, indication for surgery
bleeding from middle meningeal artery, CT shows lens-shaped deformity, have lucid interval, operate for midline shift > 5 mm, or symptomatic
cause of subdural hematoma, CT findings, indication for surgery
bleeding from bridging veins (venous plexus) that cross from dura and arachnoid, CT shows crescent shaped deformity, operate for symnptomatic shift > 1 cm
indication for ICP monitoring (BTF) in head trauma
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)
what is cerebral perfusion pressure? what are goal CPPs? ICPs?
CPP = MAP - ICP, goal CPP >60; normal ICP is 10, needs intervention if >20
most common site of facial nerve injury?
geniculate ganglion, temporal skull fx
indication for surgical management of skull fx
significantly depressed (>1 cm), contaminated, or persistent CSF leak
what is a Jefferson fracture? general tx?
C1 burst fracture, caused by axial loading i.e. diving headfirst into a shallow pool; tx w/ rigid collar
what is a hangman’s fracture? general tx?
C2 fracture caused by distraction/extension injury; tx w/ traction and halo
definition of an unstable thoracolumbar spine fracture?
fracture that involves 2 or more column disruption
describe the Le Fort classification of facial fractures
type 1 ( - ) maxillary fx straight across, type 2 ( / \ ) lateral to nasal bone, underneath eyes, diagonal towards maxilla, type 3 ( - - ) lateral orbital walls
define the anatomic neck zones, general management in penetrating trauma
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)
indication for thoracotomy after inital chest tube placement
chest tube output >1.5L initially; OR >250ml/hr for 3 hours, OR >2.5L within 24 hrs
operative approach for diaphragm injuries?
transabdominal approach if <1 week, otherwise consider thoracic approach if > 1 week (may have adhesions that would need to take down from chest)
most common location of aortic transection? operative approach?
ligamentum arteriosum (just distal to subclavian artery takeoff) – approach w/ L thoracotomy
approach for left subclavian artery injury? right subclavian artery injury?
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
approach to injury to inominate artery?
median sternotomy
what type of bleeding is associated with anterior pelvic fractures? posterior pelvic fractures?
anterior pelvic fracture associated with venous bleeding, posterior pelvic fractures associated with arterial bleeding
which portion of duodenum most frequently injured?
2nd portion
order of structures in the renal hilum?
VAP (anterior-posterior) vein -> artery -> pelvis
ureteral injury with large segment missing (>2cm) management?
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)
ureteral injury with small segment missing (<2 cm) management?
upper 1/3 / middle 1/3 -> mobilize ends of ureter and perform primary repair over stent; lower 1/3 reimplant into bladder
explain the retroperitoneal zones and associated injuries – which ones do we leave alone?
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)
what is 1st 2nd 3rd 4th degree burns?
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
criteria for admission in burns patients?
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
what is parkland’s formula
volume of resuscitation needed = 4 cc/kg x weight x %TBSA – give 1/2 in first 8 hours
STSG vs FTSG
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)
silvadene characteristics
can’t use in pt w/ sulfa allergy, limited eschar penetration, ineffective against pseudomonas, can lead to neutropenia and thrombocytopenia - painless classification
silver nitrate characteristics
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
sulfamylon characteristics
mafenide sodium – good eschar penetration, broadest spectrum against pseudomonas and GNRs, can cause metabolic acidosis due to it being a carbonic anhydrase inhibition
what is a Curling’s ulcer?
gastric ulcer that occurs with burns
what is a Marjorlin’s ulcer?
highly malignant squamous cell Ca that arises in chronic non healing burn wounds
most common cause of death in trauma patients in the 1st hour
hemorrhagic shock
anterior abdominal stab wounds: what percentage actually penetrate the peritoneal cavity? and cause injury?
1/3 do not penetrate peritoneal cavity, 1/3 penetrate peritoneal cavity w/o injury, 1/3 penetrate peritoneal cavitiy w/ sig intraabdominal injury
why is the PA wedge pressure high in abdominal compartment syndrome?
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)
bacitracin characteristics?
painless, limited eschar penetration, poor gram negative coverage
characteristics of electrical burns - DC vs AC, fat vs skinny people, cause of death, management
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
stages of frostbite?
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
what is a Chance fracture?
flexion-distraction type injuries of the spine with significant asosciation with intraabdominal injuries (most commonly hollow viscus and pancreas ~33% chance),
what to do with C-collar in pt’s with negative ct c spine who are obtunded?
remove them according to East guidelines
most common electrolyte abnormality in burn patient?
hypernatremia – due to insensible water loss through burn wound, also can have hyperglycemia, hypocalcemia, hypomagnesia
grades of kidney lacerations?
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
most common organisms found in wounds isolated from human bites
1 strep, #2 staph – other common include eikenella, fusobacterium, prevotella, porphyromonas
treatment of retained hemothorax in trauma?
do not place second chest tube, go straight to early VATS - shorter hospital stay, lower hospital cost
hard signs of vascular injury?
shock, pulsatile bleeding, expanding/pulsatile hematoma, palpable thrill, absent distal pulses
soft signs of vascular injury
diminished pulses, proximity to vessels, hematoma, and reports of significant blood loss
what are the components of PCC? when do we use it?
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
preferred sites for intraosseus access - children / adults?
children - proximal tibia (anteromedial tibia 2-3 cm below tibial tuberosity), then distal femur; adults preferred at sternum, followed by tibia
indications for internal fixation in flail chest?
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
best way to identify blunt cardiac injury?
NOT sternal fractures apparently – monitor with ECG, troponins - normal ECG has negative predictive value of 95%
Describe the Cattell maneuver
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
Describe the Kocher maneuver
mobilization and medial rotation of the duodenum
Describe the Mattox maneuver
left medial rotation of the descending colon at the line of Toldt, spleen and/or kidney towards the midline
why is it OK to ligate the L renal vein? (e.g. trauma, AAA repair)
because of outflow via the adrenal, gonadal and iliolumbar veins
which patients should you consider primary amputation on in trauma?
hemodynamic unstable and profound ischemia of >6 hours
compartments of the lower leg? most commonly affected? first symptom?
anterior/lateral superficial/deep posterior - most common anterior, deep peroneal nerves runs in it, numbness in 1st web space is early finding
how to decompress the posterior compartment during a lower extremity fasciotomy?
need to detach the soleus muscle from the tibia to decompress the deep posterior compartment (which contains the tibial nerve)
principles in management of a retrohepatic IVC injury
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
when is resection and duodenoduodenostomy appropriate in duodenal trauma
for >50% circumfrential injury to the 1st, 3rd or 4th portion of the duodenum
onset of vomiting after blunt abdominal trauma, more often in children
duodenal hematoma - managed non operatively – can occur in pt w/o trauma in hemophilia
management of rectal injuries
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
