Trauma Flashcards
3 zones of the neck?
1 - thoracic inlet to cricoid
2- cricoid to angle of mandible
3- ankle of mandible to base of skull
Best imaging test for penetrating neck injury?
CT-angiography
OR if hard signs (HARD Bruit)
Hard signs of neck injury?
Hypotension Arterial bleed Rapidly expanding hematoma Deficit - neuro of vascular Bruit or thrill
+ stridor, hoarseness
4 types of important structures in the neck?
- airway
- vessel
- esophagus
- spinal cord
Indications for cricothyrotomy in trauma
severe facial or other neck injuries that preclude intubation from above
Triad that suggests laryngeal injury in trauma?
triad of dyspnea, stridor and hemoptysis
Sx consistent with esophageal injury?
neck tenderness, pain, dysphagia, odyniphagia, drooling, crepitus, subcutaneous emohysema, fever, mediastinitis
Most common area for c-spine injury in young kids
higher fulcrum - C1-C4
High risk conditions for c-spine injury
Syndromes ( T21, Maroteaux-Lamy, Klippel-Feil, achondroplasia, congenital cervical stenosis, Chiari malformation, rheumatoid disease, acute soft tissue or bony infection/infiltration)
What are the NEXUS low-risk c-spine criteria?
What age can you use NEXUS criteria?
If meet all 5 criteria - can clear clinically and do not need c-spine xrays:
Alert No districting injury No intox No neuro deficit No midline pain
Use in > 8 yo (younger kids weren’t included in the study)
What are the PECARN c-spine risk factors?
any one of: - altered mental status - neuro deficit - neck pain - substantial torso injury - torticollis - high risk MVC - diving If any 1 factor present --> higher risk --> need imaging. Good for all ages of children
Risk of hard spinal board for a prolonged time?
Pressure sores / skin breakdown
Pain
Respiratory compromise
How to clear the c-spine (rules for each age range)?
Canadian C Spine Rules ( > 16)
Nexus ( > 8 year olds)
PECARN C spine risk factors ( all ages)
< 3 year olds: use clinical exam
Name 3 high-risk criteria in the Canadian c-spine rule
Rule only validated > 16 years old:
- Dangerous mechanism
- Parasthesias
- Unable to actively rotate neck 45 degrees L and R
- age > 65
- Not ambulatory
- Midline C spine tenderness
4 lines on lateral c-spine xray
- anterior vertebral
- posterior vertebral (anterior margin spinal canal)
- spinolaminar line (posterior margin spinal canal)
- spinous process tips
“ABC’s” of c-spine xray interpretation?
A-alignment B- bones C- cartilage S-soft tissues Ensure C1-T1 included
What is the line of Swischuk?
Draw spinolaminar line - drawn from spinous process of C1 to C3, if C2 > 2mm from line, suggests real pathology (vs. psuedosubluxation)
What is a Jefferson fracture?
Burst of C1 from axial load (C1 laterally ofset > 1 mm from C2 on xray)
What is a pseudo-Jefferson fracture?
Not a real fracture. Normal xray finding in up to 90% of 2 year old - looks like lateral offset of C1 on C2 but really just due to radiolucent cartilage artifact (would need CT to tell the difference)
What is a Hangman’s fracture?
Due to neck hyperextension - spondylolisthesis of C2 (differentiate from psuedosubluxation with Swischuk’s line C1 to C3)
What is atlanto-axial subluxation?
Movement between C1 and C2 because of transverse ligament rupture OR fractured dens
What are some causes of atlanto-axial subluxation?
tonsillitis, cervical adenitis, pharyngitis, arthritis or connective tissue disorders, T21
What type of fracture is a Chance fracture?
flexion-distraction fracture
2 main causes of traumatic torticollis?
- muscular spasm (of SCM)
- rotary subluxation
- (also c-spine #, ligamentous injury, clavicle #)
4 infection causes of torticollis?
- RPA
- cervical LN
- Lemierre’s
- meningitis
- osteomyelitis
- upper lobe pneumonia
Label parts of the spinal cord and what they do?
Dorsal columns = vibration and proprioception
Lateral corticospinal = motor control
Spinothalamic (more anterior/lateral) = pain and temperature
What is Brown-Sequard syndrome?
hemi section of cord: contralateral loss of pain and temp with ipsilateral motor findings (weakness or paralysis, below level of the lesion)
What is central cord syndrome?
Most severe damage in the center, arms weakest, legs okay. From hyper flexion injury
What is anterior cord syndrome?
Bilat loss of motor, pain, and temperature. Dorsal columns (vibration and proprioception) are okay
What are the 3 most commons causes of mortality in teenagers ages 15-19y in North America?
- Accidental (MVC most common)
- Suicide
- Homicide
Physiological differences in children related to trauma? (5)
- multisystem trauma more likely
- hypotension is a late finding
- greater BSA: inc heat and insensible losses
- fluid and nutrition requirements vary by age and stage of growth
- Developmental stages = challenges in assessments
6 components of the pediatric trauma score?
Size (weight) Airway SBP Neuro Skin MSK
High score (12 max) is good, lower score = worse prognosis
What four things would you want to find out from EMS for a trauma patient?
ATMIST:
- age
- timing
- mechanism
- injuries identified
- Signs/symptoms
- Tx provided
What do you want to know from the EMT’s about what the scene/car looked like?
- Significant intrusion into vehicle, which part of vehicle
- Airbags deployed
- Presence of car seat
- Extrication
- Anyone dead on scene
- Speed
- Exam on scene (GCS, focal neuro deficits, seizures)
What MVC conditions are associated with a high-risk of significant trauma?
Roll-over Ejection Prolonged extrication Fatalities at the scene High-speed
6 steps EMS needs to take to stabilize his c-spine before getting him to hospital
- Provide in-line manual C-spine stabilization and lower patient to ground/supine position
- Place in a hard cervical collar
- Straighten upper and lower extremities against body (palms inward)
- Rolled onto center of spine board with in-line stabilization
- Trunk, pelvis and lower extremities appropriately secured to board.
- Patient’s head and neck position are secured with tape across the forehead and cervical collar
2 Complications of hard board?
- Pain/discomfort
- Pressure sores
- Potential respiratory insufficiency
What is Waddell’s Triad?
Child hit by car
- TBI
- Intra-abdominal and or intra thoracic injury
- Femoral shaft fracture
Most common solid organ injured in blunt abdo trauma?
Spleen > Liver
3 indications for laparotomy in blunt abdominal trauma?
- Hemodynamically unstable with suspected intra-abdominal injury
- Multisystem injuries requiring craniotomy with intraperitoneal blood identified or strong history or physical examination findings to indicate intra-abdominal injury
- Abdominal distension with hypotension
- Peritoneal irritation on exam
- Bowel perforation evident/ pneumoperitoneum
- Penetrating wound to abdomen
- GSW
- Rectal or vaginal laceration
5 sources of occult blood loss during trauma?
on the floor and 4 more:
(Scalp) - infant Chest (Hemothorax) Retroperitoneal Abdominal Pelvis Femur
Injury sustained from bicycle handlebars?
- pancreatic injury/ pseudocyst
- duodenal hematoma
What is the lap belt complex?
Seat belt sign on abdomen/ flank
Hollow viscous injury (ie. bowel)
Chance vertebral fracture
What is the mechanism of a chance fracture?
flexion-distraction of the lumbar spine (Findings: anterior wedge fracture of the vertebral body with a horizontal fracture through the posterior elements or distraction of the facet joints and spinous processes)
CT abdomen has low sensitivity for which intra-abdominal injury?
hollow viscus injuries
pancreatic injuries
4 things in the history that would be suspicious for NAI?
- History inconsistent with developmental stage
- No explanation offered by caregiver
- Explanation provided by caregiver changes
- Different explanations offered by different caregivers
- Injury inconsistent with mechanism described by caregivers
- unexpected delay in seeking care
3 intra-abdominal injuries that often present late?
- pancreatic pseudocyst
- duodenal hematoma (gastric outlet obstruction)
- hematobilia (upper GI bleed+ abdo pain)
5 areas of the mandible?
symphysis, body, angle, ramus and condyle
2 renal injuries that present WITHOUT hematuria?
Vascular pedicle injuries
Penetrating injuries
5 grades of renal injuries
1 - subcapsular hematoma 2- lac < 1 cm, or retroperitoneal 3- cortical lac > 1 cm 4- injuries into renal cortex/collecting system 5- shattered/fractured kidney
When to pursue imaging to r/o kidney injury?
1) Gross hematuria or significant microscopic hematuria ( > 50 rbc/hpf) with or without shock
2) Associated injury or suspicious mechanism ( rapid deceleration, high velocity strike, fall from > 15 feet or direct blow to abdomen or flank) regardless of presence of hematuria
3) Clinically stable child with penetrating abdominal or pelvic trauma
Best imaging test for renal injuries?
CT abdomen with contrast and 10-minute delayed phase
6 clinical findings suggestive of renal injury?
- Flank Hematoma
- Hematuria
- Flank mass
- Flank tenderness
- Hypovolemic shock
- Generalized abdominal tenderness
- Rigid abdomen
When to obtain a pelvic xray in the trauma room?
1) sustained pelvic or lower abdominal trauma + gross hematuria
2) inability to void
3) abnormal external GU exam
4) multiple associated injuries
You are seeing a trauma patient with a possible urethral injury (teen with ATV injury and possible pelvic #). List three clinical features of urethral injury?
- Blood at the urethral meatus
- Hematuria
- Difficulty voiding
- Perithral and perineal edema/ecchymosis ( butterfly shape)
- High riding prostate/displacement on exam
- Perineal hematoma
What test to confirm urethral injury?
Retrograde urethrogram
Name 3 high risk criteria in the Canadian C-spine rule
- Dangerous mechanism
- Paresthesias
(3. Age > 65)
Types of vertebral fractures (5)?
- wedge
- chance (flexion-distraction)
- burst
- shear
- slice
2 most common causes of torticollis after trauma, and how to differentiate between the 2?
- Muscular torticollis - chin points towards the unaffected side. SCM spasm usually occurs on the affected side
- Rotary Subluxation: C spine injury
Can be spontaneous or after URTI or traumatic event
Rarely present with abnormal neuro findings
Chin will point to the same side as the SCM spasm (typical “cock robin” position)
Xrays or CT to differentiate. Rotary subluxation needs c-spine collar, analgesia, and neurosurg follow-up.
Spinal shock vs. neurogenic shock?
- Neurogenic shock: hypotension, bradycardia, due to loss of sympthathetic tone
- Spinal shock: flaccid paralysis, loss of sensation, reflexes, loss of anal tone, usually temporary, “concussion” - peripheral neurons become temporarily unresponsive to brain stimuli
3 features of Cushing’s triad?
hypertension, bradycardia and periodic breathing
How to treat TBI with Cushing’s triad?
- Positioning: HOB 30 degrees, head in neutral position, C spine precautions
- Ventilation to maintaining PaCO2 35-40 mm Hg (hyperventilate 30-35 if unequal pupils)
- Sedation
- Hyperosmolar therapy: Hypertonic saline or Mannitol
- Neurosurgery consultation - Urgent
CATCH 2 rule?
High risk = WIGS: worsening headache, irritability, GCS < 15 at 2 hours, suspected open or depressed skull #
Med risk = SDH + V: Suspected basal skull #, dangerous mechanism, boggy hematoma, vomiting 4+ times
Appearance of epidural vs. subdural hematoma on CT?
Epidural = lens shaped Subdural = crescent shaped
Write out the formula for cerebral perfusion pressure (CPP) calculation
CPP= MAP-ICP
What are 4 causes of secondary injury in severe traumatic brain injury
seizures, hyperthermia, hypotension, hypoglycemia
4 categories of signs and sx after a concussion
- physical symptoms (ie. dizzyness, headache)
- cognitive (difficulty concentrating)
- sleep
- emotional ie. mood
Features of complicated skull fractures?
complex, burst, cross suture lines, depressed, diastatic,bilateral, *multiple or open
Basal skull fracture - signs/symptoms?
battle sign, periorbital ecchymosis, hemotympanum, CSF otorrhea, rhinorrhea
3 indications for a skull xray?
- Work up for non accidental trauma in < 2 year old
- Initial assessment for craniosynostosis
- Presence of a large, boggy hematoma in child < 2 years of age
- Penetrating lesion in scalp
- Depressed skull fracture ( in an older patient) - will need CT regardless
- No access to CT
How to treat an open pneumothorax?
place occlusive dressing while pt is in full expiration + chest tube at a site different than the open wound
Thoracotomy for Hemothorax - 3 indications?
- Bleeding at a rate of 1-2 ml/kg/hr
- Inability to expand lung
- Retained blood within pleural cavity
6 possible complications of chest tube insertion:
Bleeding (laceration of intercostal vessel)
injury to the intercostal neurovascular bundle
infection (empyema)
site infection
intraparenchymal lung placement
organ perforation ( diaphragm, cardiac, intraabdominal), malpositioning
re-expansion pulmonary edema
tension pneumothorax
recurrent pneumothorax ( usually on removing)
What is Beck’s triad?
JVP distention, hypotension, muffled heart sounds (pericardial tamponade)
4 conditions that must be present for commotio cordis to occur:
- Blow to the heart
- By object with significant mass
- Ventricles must have a large enough mass
- Strikes during ventricular vulnerable period (T wave)
How to assess for blunt cardiac trauma?
ECG (ST-T wave changes, arrythmias), serum cardiac enzymes, echocardiography, continuous cardiac monitoring
How to perform pericardiocentesis?
Insert 20G spinal needle below the xyphoid process at a 45 degree angle towards the left shoulder
Can use US to guide, should also have continuous ECG monitoring (
Most common injury mechanism for aortic injuries?
severe deceleration forces (ie MVCs) causing shearing stress
Clinical signs of aortic injury?
difference in pulse between arms or arms/legs, thoracic ecchymosis, thoracic and back tenderness, paraplegia, anuria
(can be misdiagnosed as a spinal cord injury)
4 findings of aortic injury / rupture on CXR
Imaging test of choice?
widened mediastinum
blurred aortic knob
pleural cap
tracheal/NG deviation
Test of choice = CT angiography (or TEE in the OR if unstable)
Clinical presentation of rib fractures?
splint and hypoventilate (secondary to pain), point tenderness and crepitus (if pneumothorax present)
+/- flail chest
Management of flail chest?
place injured side down to improve TV, ventilation. Intubate, PPV to optimize lung expansion and splinting of the injured segment. Monitor for pneumothorax
Define what is meant by flail chest?
i. Fracturing a segment of 2 or more ribs on same side resulting in chest wall losing continuity with the thoracic cage and becoming subject to the intrathoracic pressures (unlike the thoracic cage)
1. Sucks in when inspiring
2. Blows out when expiring
4 causes of hypoxemia in flail chest?
Shallow breathing or splinting -> atelectasis
Low tidal volume
Underlying lung contusions
Underlying pneumothorax / hemothorax
5 immediately life threatening injuries to the thorax?
- tension pneumothorax
- traumatic aortic rupture
- commotio cordis
- massive hemothorax
- diaphragmatic rupture
- cardiac tamponade
- ventricular/atrial rupture
What test to do if proximal clavicle fracture or dislocation is seen on CXR?
CT angiography of the chest - r/o mediastinal injury from posteriorly displaced fragment
Indication for ED thoracotomy in penetrating trauma?
Penetrating trauma with vital signs but loses them during transport or acutely deteriorates during ED resuscitation
NOT indicated if: no pulse or BP in the field, asystole is the presenting rhythm and there is no pericardial tamponade, prolonged pulselessness ( > 15 minutes) during resuscitation, massive, non survivable injuries have occurred, no trauma surgeon available within 45 minutes
List 6 cardio/thoracic injuries that require operative intervention?
- Cardiac tamponade
- atrial/ventricular damage
- diaphragmatic hernia
- massive hemothorax
- traumatic aortic rupture
- esophageal rupture/ damage
- tracheal/bronchial rupture
- Laceration of lung parenchyma, internal mammary artery or intercostal artery
15 year old struck in the center of his chest by a baseball bat. Extensive bruising. Sp02 95%, normal vitals.
3 investigations you would like in the initial management of this patient?
Most common intrathoracic injury in blunt chest trauma?
Initial tests? CXR, ECG, POCUS
Most common injury: lung contusions
4 clinical features of traumatic asphyxia?
- petechiae / ecchymosis in SVC distribution
- Subconjunctival hemorrhages
- Facial edema and cyanosis
- Hemoptysis
- altered mental status
What is the ISS score?
ISS = (AIS1)2 + (AIS2)2 + (AIS3)2
ISS >15 has traditionally been considered a marker for severe injuries
