Trauma

Question 1

Frostnip

1) Definition
2) Pathophysiology
3) Symptoms
4) Treatment

Answer 1

1) very brief exposure to freezing cold results in the formation of ice crystals on the surface of the skin
2) intense and painful vasoconstriction
3) Numbness and pallor
4) rewarming (no long-term damage occurs)

Question 2

Frostbite

How many degrees?

Answer 2

4 degrees

Question 3

Numbness and edema which forms a firm plaque…

What degree of frostbite? Treatment? How long to heal?

Answer 3

First-degree frostbite

Treatment:

Healing time: spontaneous after 1 to 4 weeks

Question 4

Milky-white blister formation…partial-thickness..

What degree of frostbite? Treatment? How long to heal?

Answer 4

Second-degree frostbite

Treatment:

Healing time: atrophic (2-4 weeks)

Question 5

Hemorrhagic blister formation…full-thickness damage … black eschar forms with possible limb/tissue loss…
What degree of frostbite? Treatment? How long to heal if it does heal?

Answer 5

Third-degree frostbite

Healing time: 1 to 3 months to heal

Question 6

Extends to the bone…tissues are black or mummified on presentation…
What degree of frostbite? Treatment? How long to heal if it does heal?

Answer 6

Fourth-degree frostbite

Healing time: Does not heal

Question 7

Describe the 5 Grades in the AAST Kidney Injury Scale?

Answer 7

Grade I:

• Contusion: Microscopic or gross hematuria with normal urologic studies
• Hematoma: Subcapsular, non-expanding without parenchymal laceration

Grade II:

• Hematoma: Non-expanding perirenal hematoma confined to retroperitoneum
• Laceration: < 1.0 cm parenchymal depth of renal cortex without urinary extravasation

Grade III:
- Laceration: >1.0 cm parenchymal depth of renal cortex without urinary extravasation

Grade IV:

• Laceration: Parenchymal laceration involving renal cortex, medulla, collecting system
• Vascular injury: Injury of the main renal artery or main renal vein with contained hemorrhage

Grade V

• Laceration: Shattered kidney
• Vascular injury: Renal hilum avulsion (causing devascularization of the kidney)

Question 8

How does bilateral injuries change the Grading for AASTI Kidney Injury scale?

Answer 8

Add one grade, up to Grade III.

Question 9

How you calculate nitrogen balance?

Answer 9

= [g of protein / 6.25] - (total urinary nitogren +2)

or

= [g of protein/6.25] - (urinary urea nitrogen+4)

Question 10

70-kg man is receiving 125 grams of protein via total parenteral nutrition following a 30% body surface area burn. His 24-hour urinary nitrogen excretion is 30 gm. What is the nitrogen balance of this patient?

Answer 10

-14 g

Calculation:
125/6.25 - (30+4) = -14

Question 11

What is the definition of hypothermia?
Difference between mild vs. moderate vs. severe vs profound?

Treatment for each?

Answer 11

hypothermia: < 35C or 95F

mild hypothermia: (90-94F): shivering and mild mental changes. +tachycardia. Treatment = active movement

moderate hypothermia (84-89F): agitated/combative, muscle spasticity, dilated pupils, slowing of respiration, a.fib, hypotension. Treatment = passive warming (thermal pack/forced air, heaed blankets, warm IVF)

severe hypothermia (70-84F): prolonged QRS/Osborn wave, flaccid, comatose… v.fib…? death? Treatment: active rewarming (ECMO, cardiopulmonary bypass, thoracic lavage, peritoneal lavage)

Profound hypothermia (<70F): loss of vitals, cardiac activity and EEG tracing

Question 12

In a hypothermic patient with asystole… what are indications to stop CPR and ACLS?

Answer 12

Temperature warmed to 32C (or 90F)

OR

Serum potassium > 12 mmol/L

Question 13

What is the difference between primary vs. secondary hypothermia?

Answer 13

Primary hypothermia: prolonged environmental exposure to col temperature overwhelms the body’s natural heat-generating ability

Secondary Hypothermia: body’s normal metabolic responses are impaired by illness or substance abuse

Question 14

Full thickness skin grafts:

• designed elliptically or as a rectangular?
• heal by primary closure or secondary intent?

Answer 14

• Elliptical

- Heal by primary closure

Question 15

Large internal jugular vein injury with actively bleeding carotid injury… how do you treat the internal jugular vein?

Answer 15

ligate internal jugular vein then address carotid injury exposure.

Question 16

23-year-old male fell off his motorcycle and was brought to the trauma bay. He is unable to abduct his shoulder and move his elbow and wrist joints, but his grip is normal. Sensation is preserved along the medial side of the extremity and the 4th and 5th digits. What is the most likely pattern of injury?

Answer 16

Avulsion of C5, C6, C7 nerve roots

C5-C6 nerve root = unable to abduct his shoulder and move his elbow

C7 nerve root = unable to abduct shoulder, deficit in flexion AND extension at elbow and wrist joints.

Question 17

What is Erb-Duchenne palsy?

Answer 17

Avulsion of C5 and C6 roots causing deficit in shoulder abduction, elbow FLEXION, and sensory deficit along lateral arm and 1st/2nd digits

Question 18

What is Klumpke palsy?

Answer 18

C8-T1 root injurty = intrinisic hand muscle and sensory deficit in 4th and 5th digits + Horner syndrome (miosis, ptosis and anhidrosis)

Question 19

What is the most common pattern of brachial plexus injury?

Answer 19

pan plexus injury (Avulsion of all brachial plexus roots (C5-T1) = flail arm and insensate hand

Question 20

What is the timing for sharp vs. blunt brachial plexus injury?

Answer 20

Sharp/open injury = repaired urgently

Blunt/Closed brachail plexu sinjury = 3-6 weeks post-injury work up (MRI/nerve conduction) every 4 weeks with repair before 1 year. (@18 months, motor end plate degeneration occur)

Question 21

During tracheostomy in OR after tracheostomy placed… balloon ruptures and there is a fire .. what do you do?

Answer 21

Decrease FIO2 –> remove tracheostomy –> oral intubate –> smother with saline

Question 22

What are the components of the Mangled Extremity Severity Score (MESS)?

Answer 22

1) Limb ishcemia > 6 hours
2) Limb ischemia [reduced pulse, but normal perfusion = 1; pulseless/parasthesias/slow capillary refill = 2; cool/numb/paralysis/insensate = 3]
3) age (<30; 30-50; >=50)
4) Shock (SBP > 90mmHg = 0; transient hypotension = 1; persistent hypotension = 2)
5) Injury mechanism (stab/GSW/simple fx [low energy] = 1; dislocation/open fx[medium energy] = 2; high speed MVA/rifle [high energy] = 3; high speed trauma with gross contamination [very high energy ] = 4

Question 23

For TEG, what is normal:

• R time?
• K time?
• Alpha angle?
• Maximum amplitude?
• LY30?

What do you give for each if their abnormal?

Answer 23

• R time: 5 to 10 minutes [FFP]
• K time: 1 to 3 minutes [cryo]
• Alpha angle: 53 to 72 degrees [cryo]
• Maximum amplitude: 50 to 70 mm [platelets/DDAVP]
• LY30: 0 to 8% [TXA or Aminocaproic acid]