Trauma Flashcards
Trauma is most common cause of death in what age groups?
1-44 yrs old
Primary survey in trauma is used for what?
identify and treat conditions that constitute immediate threat to life
First priority in primary survey?
AIRWAY
When is endotracheal intubation needed?
someone is apneic
AMS and can’t protect airway
inhalational injury, expanding hematomas etc
can’t oxygenate
Nasotracheal intubation can only be performed in pts that?
are breathing spontaneously
Preferred intubation route?
orotracheal; can see the vocal cords directly, can use bigger sized ETT
can be used to apneic pts
How do we confirm ETT?
direct laryngoscopy
wave capnography
b/l breath sounds
xray
In emergent surgical airway management, what is preferred?
cricothyroidotomy
For kids less than 11, why is a circothyroidotomy not done?
relative contraindication due to fear of subglottic stenosis
tracheostomy is thus preferred
These are some conditions that are an immediate threat to life and should be picked up and addressed during primary survey?
tension pneumo
flail chest
open pneumo
massive air leak
If a pt comes in with respiratory distress, hypotension, tracheal deviation away from affected side, decreased breath sounds on affected side, subQ emphysema, what do they have?
tension pneumo
Treatment for tension pneumo?
needle decompression with 14 gauge needle in 2nd intercostal space, mid clavicular line performed in field
tube thoracostomy done in the trauma bay before chest xray done
Where do we put a chest tube in, anatomically?
mid axillary line
4-5th intercostal space
chest tube directed superior/posterior
How does a tension pneumo work?
tear in lung acts as a one way valve
allows more air to go into chest, making chest filled with positive pressure
diaphragm gets depressed
mediastinum gets shifted to contralateral side
heart starts twisting around SVC and IVC
decreased venous return and decreased CO
What is an open pneumo?
sucking chest wound
free communication between pleural space and atmosphere
(atm and pleural pressures equilibrate)
Tx for an open pneumothorax?
tape wound on three sides, create one-way valve
definitive tx–> closure of wound, chest tube at different site
What’s flail chest?
when three or more contiguous ribs fractured in at least 2 different locations
In flail chest what is the source of the respiratory failure?
underlying pulmonary contusion
Massive air leaks can be due to tracheobronchial injuries, what are the two types:
I–> within 2 cm on carina, not assc with pneumo
II–> mor distal in tracheobronchial tree, assc with pneumo
For the carotid, femoral or radial pulses to be felt, what must be systolic bp be?
carotid; 60
femoral; 70
radial; 80
IV access for fluid resuscitation, what is preferred?
2 16 gauge catheters or larger in adults
Preferred sites for IO access?
proximal tibia
What’s massive hemothorax?
> 1500 cc of blood in chest on xray
in kids; 25% of circulating blood volume
Acutely, how much blood is needed to cause cardiac tamponade?
less than 100 cc needed
Beck’s triad of cardiac tamponade?
JVD
muffled heart sounds
low arterial BP
How does cardiac tamponade cause problems?
pericardium is fibrous sac, does not distend acutely
pericardial pressure will exceed right atrial pressure, so we get reduced filling
RV output is reduced
Tx for cardiac tamponade?
pericardiocentesis successful in 80% of pts
most failures due to clotted blood in pericardium
In someone with cardiac tamponade and SBP <60 mmHg, what do we do next?
resuscitative thoracotomy
Indications for ED thoracotomy;
penetrating trauma to torso with <15 mins of pre-hospital CPR
blunt trauma with <10 mins of pre-hospital CPR
penetrating trauma to neck or extremities with < 5 mins of CPR pre-hospital
SBP <60 mmhg due to;
cardiac tamponade
hemorrhage
air embolism
Contraindications to ED thoracotomy?
penetrating trauma; CPR > 15 mins and no signs of life
blunt trauma; CPR > 10 mins and no signs of life
How do we perform a pericardiocentesis for cardiac tamponade?
subxiphoid approach
needle 45 degrees from chest wall, aimed at left shoulder
Survival rates of resuscitative thoracotomy?
highest for isolated cardiac injuries; 35% for pts in shock, and 20% in pts without vital signs
for all other penetrating wounds; survival is 15%
for pts with abdominal trauma; survival <2 %
Incision for resuscitative thoracotomy?
generous left antero-lateral incision
longitudinal pericardiotomy performed anterior to phrenic nerve
After RT, what SBP must a pt maintain to transport to OR for further management;
SBP 70 mmHg
Mild, moderate, severe GCS:
<8 severe
moderate; 9-12
mild; 13-15
This is a quantifiable determination of neur function useful for triage, treatment and prognosis;
GCS
What are the IV classes of hemorrhagic shock?
class 1; EBL 750 (15%); vitals normal, slightly anxious
class 2; EBL 750-1500 (15-30%), >100 HR, mildly anxious
class 3; EBL 1500-2000 (30-40%), >100 HR, anxious, confused
class 4; EBL >2000, >40%, HR >140, decreased BP, confused and lethargic
EBL 750, 15% loss of EBV, vitals normal, slightly anxious, what class of hemorrhagic shock?
1
EBL >2000, EBV >40%, HR >140, BP decreased, confused and lethargic, what class of shock?
4
EBL 1500-2000, EBV 30-40%, anxious, confused, HR >100, what class shock?
3
What is class 2 hemorrhagic shock?
EBL 750-1500
EBV 15-30%
mildly anxious
What is adequate urine output in an adult, a child, and infant less than 1 yrs old?
adult; 0.5 cc/kg/hr
child; 1 cc/kg/hr
infant; 2cc/kg/hr
Earliest sign of ongoing blood loss?
tachycardia
Why is decreased SBP not a good indicator of early hypovolemia?
you don’t see changes in BP until about 30% of EBV is lost
also; younger pts maintain their BP due to increased sympathetic tone until they are on the verge of collapse
also: pregnant pts have increased circulating blood volume, they need to lose a lot of blood before BP decreases
Hypovolemic pts can be triaged into three categories:
responders; respond to volume and vitals normalize
transient responders; respond initially, then deteriorate
non-responders; no matter what we do they don’t respond and persist with hypovolemia
what are the 4 categories of shock?
hemorrhagic
cardiogenic
septic
neurogenic
What’s an air embolism?
can occur after blunt/penetrating trauma
air from an injured bronchus enters adjacent injured pulmonary vein and returns air to left side of heart
air accumulates in LV, during systole air is pumped into coronary arteries
**typically this is a pt with a penetrating thoracic injury who gets intubated with positive pressure ventilation and suffers a cardiac arrest
How do we treat an air embolism?
place pt trendelenburg, head down
trap air in apex of LV
emergency thoracotomy done
cross-clamp pulmonary hilum on affected side to prevent further air from going into heart
air then aspirated from LV apex, aortic root and right coronary artery, with 18 gauge needle
How much blood loss does each rib fracture produce?
100-200 cc
How much blood loss does a tibial fracture produce?
300-500 cc
How much blood loss does a femur fracture produce?
800-1000 cc
How much blood loss does a pelvic fracture produce?
> 2L
Organs more likely to be injured due to blunt trauma;
liver, spleen, kidneys
Organs more likely to be injured due to penetrating trauma:
SB, liver, colon
For MVC, variables assc with life-threatening injuries are:
>20 MPH death of another occupant in the vehicle extraction time >20 mins lack of a seatbelt lateral impact
What’s Battle’s sign?
ecchymoses behind ears
suggestive of a basilar skull x
When is an epidural hematoma?
blood accumulates between skull and dura
rupture of middle meningeal artery
convex on imaging
What is a subdural hematoma?
hematoma between dura and cortex
due to venous disruptions, or lacerations of brain parenchyma
concave on imaging
Which has a worse prognosis, epidural vs subdural?
SDH
because of the associated brain parenchymal injury
What’s diffuse axonal injury?
due to high speed deceleration injuries
axons damaged directly due to shear forces
What is central cord syndrome?
motor, pain, temperature are preserved in the LE but diminished in the UE
usually seen in older pts with hyperextension injuries
What is anterior cord syndrome?
decreased motor, pain, temp below level of injury
position, vibration and crude touch are maintained
THis results from penetrating injury in which half of spinal cord transected;
Brown-Sequard syndrome
ipisilateral loss of motor, proprioception, vibration
contralateral loss of pain/temp
Zones of the neck:
1–> up to level of clavicles
2–> up to level of angle of mandible
3–> above angle of mandible
What do you suspect in pts who have persistent pneumothorax, persistent air leaks after chest tube placement, or difficulty ventilating?
need to assess for tracheo-bronchial injury
What is a persistent hemothorax not drained by 2 chest tubes called?
caked hemothorax
needs thoracotomy
On chest xray, a mediastinal hematoma on left and right is suggestive of what?
L side hematoma; descending aortic injury
R side hematoma; innominate A injury
Where is aortic injury most common?
distal to left subclavian A, where it’s tethered to ligamentum arteriosum
For GSW to abdomen, between 4th intercostal space and pubic symphysis, what do we do?
ex-lap
What are the grades of liver injuries?
1–> <10 % of surface area, <1 cm deep
2–> 10-50% surface area, 1-3 cm deep
3–> >50 % surface area, >10 cm deep
4–> 25-75% of a hepatic lobe
5–> 75% of a hepatic lobe
6–> hepatic avulsion
What are the grades of a splenic injury?
1–> <10 % surface area, <1 cm deep
2–> 10-50% surface area, 1-3 cm deep
3–> >50 % surface area, >10 cm deep
4–> >25 % devascularization, hilum lac
5—> shattered spleen, complete devascularization
When doing an A-A index for extremity injuries, when do we perform a CTA?
if there is >10 % difference between the two extremities
Brief loss of consciousness, followed by a lucid interval, , during which time the hematoma is expanding, describes what?
Epidural hematoma
due to rupture of middle meningeal artery
These brain bleeds due to tearing of bridging veins between dura and cerebral cortex:
SDH
have associated brain parenchymal injury, thus more serious than EDH
How do we see diffuse axonal injury on CT?
scattered punctate hemorrhages on parenchyma
loss of interface between gray and white matter
Of the three components of GCS, which is most telling of neurological function?
motor component
How to gain access to a proximal tracheobronchial injury vs distal tracheobronchial injury?
proximal–> r-thoracotomy ( have access to trachea and proximal b/l mainstem bronchi)
distal–> l-thoracotomy wound be for distal L-mainstem bronchus injury
When is C-section performed in trauma settings?
where surgical exposure for maternal injuries is not possible due to large uterus
c-section should only be considered for fetus at 23-24 weeks
perimortem c-section should only be performed 4 minutes after maternal cardiac arrest
After an esophageal repair you want to ensure there is no leak, so you order an esophagram, what kind of contrast do you use?
water-soluble contrast is better, safer
barium causes an inflammatory response with fibrosis
Positive findings on a DPL?
for abdominal trauma; >100K WBC, >500 WBC
for thoracoabdominal stab wounds; >10K WBC, >500 WBC
if frank blood is aspirated on initial entry into the peritoneal cavity–> + exam
if no blood encountered initially, 1 L of warm saline infused into belly, and suctioned back up
if food, feces, or bowel content encountered, it’s a + DPL.
Contraindications to placement of tracheostomy via percutaneous dilational method?
requires bronchoscopy to prevent damage to nearby structures, esophagus
Fio2>60 or PEEP > 12 should not undergo this method, they can have respiratory decompensation
not done in pediatric pts due to mobile and collapsable trachea, coagulopathic pts, BMI >30, pts w/midline neck masses
Toxin from a brown recluse spider can cause what hematologic problems?
coagulopathy and DIC
aside from causing a skin lesions with central necrosis
Whats the Cattell-Brasch maneuver?
right medial visceral rotation
right colon is mobilized medially/superiorly
duodenum is Kocherized
exposes the R-kidney, its vasculature, and IVC
Right medial visceral rotation, where the kidney is mobilized medially/superiorly is called?
Cattell-Braasch maneuver
exposed R-kidney, its vessels and IVC
Mattoxx maneuver AKA?
left medial visceral rotation
exposes L-kidney and aorta
What do you do with a pregnant pt who has sustained trauma, in terms of Rh iso-immunization?
all Rh negative mothers should receive a dose of Rh immunoglobulin within 72 hrs
(Kleihauer-Betke test–> detects occult placental hemorrhage)
When is a thoracotomy indicated after chest tube placement?
1500 cc initial return
300 cc/hr for 3 consecutive hrs
How do we manage a distal ureteral injury?
ureteroneocystostomy
psoas hitch/boari flap, tension free
Hard signs of vascular injury?
absent distal pulse
palpable thrill/audible bruit
expanding hematoma
active pulsatile bleeding.
Failure of non-operative management of splenic laerations increases with what?
increasing age
increases twofold in pts above 55
***as the grade of splenic lac increases, so does the rate of failure of non-operative management from 1% for grade 1 to 75% for grade V
Someone comes in with TBI, head bleed, on warfarin, INR 5, GCS 7, what reversal agent do you use?
PCC–> faster onset of action compared to FFP
Soft signs of a vascular injury?
hx of significant bleeding
injury with proximity to a named vessel
diminished pulses
neurological deficits
Parkland formula;
4 cc/kg x % body surface area
(ex; 80kg male with 80% burns)
4x 80=> 320
320 x 80 => 25,600
half of this is given in first 8 hrs; 12800/8 hrs-> 1600 cc/hr
other half given in next 16 hrs
How long after a splenic injury, say a grade II splenic lac, that is managed non-operatively, can someone return to contact sports?
6 weeks
What is the Mattox maneuver?
mobilizing the spleen, pancreas, left colon and moving them medially to expose left retroperitoneum and aorta
Whats a Kocher and extended Kocher maneuver?
kocher–> mobilization of the duodenum to visualize duodenum and head of pancreas
extended Kocher–> exposes the aorta between the celiac axis and SMA
For unilateral neck exploration, an incision can be made from mastoid process to clavicle along anterior edge of SCM, to access the internal carotid artery, what structure is ligated?
facial vein is ligated
- *marks bifurcation of carotid arteries
- *ansa cervicalis and posterior belly of digastric also ligated to gain exposure of carotid sheath contents
Where do we perform an antero-lateral thoracotomy if needed?
pt supine
5th intercostal space, infra-mammary line
When doing a clamshell thoracotomy, what needs to be ligated after?
internal mammary arteries need to ligated on undersurface of sternum (proximally and distally)
What kind of incision do we access the proximal left subclavian artery?>
trap door incision
anterio-lateral thoracotomy
extend superiorly on sterum
extend via left supraclavicular incision
**can also be accessed with a sternotomy with supraclavicular extension
When do we perform a median sternotomy with cervical extension:
proximal subclavian, innominate, or proximal carotid artery injuries
When is a postero-lateral thoracotomy used?
when you have damage to trachea or mainstem bronchus injuries near carina
For vascular abdominal injuries, we need to know if it’s a supracolic or infracolic injury, for supracolic injuries what vessels are involved how do we access them>?
supracolic–> aorta, celiac, proximal SMA, left renals
can do a left medial visceral rotation; Mattox maneuver to access them
How do you perform a left medial visceral rotation; Mattox?
begin dissecting along white line of Toldt at descending colon and carrying dissection all the way up splenic flexure, behind gastric fundus, ending up by esophagus
Suspected IVC injuries are accessed how?
right medial visceral rotation; cattell-braasch
In cases where we need to expose the bifurcation of the IVC and visualize the right iliac vein, what vessels can we ligate?
can ligate the right common iliac artery to gain expose the IVC bifurcation underneath
has to be repaired after venous injury is addressed
What are some named arteries that usually tolerate ligation?
right and left hepatic arteries
celiac artery
What major veins can be ligated?
> 80% of pts will survive SMV ligation
left renal vein–> can be ligated next to IVC due to collaterals
portal vein can be ligated in extreme cases
When do we use autogenous grafts vs PTFE for arterial repairs?
for vessels <6 mm in diameter; internal carotid, SFA, popliteal arteries–> autogenous contralateral saphenous vein graft
vessels > 6 mm; aorta, innominate, subclavian–> PTFE
In a damage control laparotomy, venous injuries can be ligated with impunity, except;
supra-renal IVC
popliteal vein
What’s an abnormal ICP?
10 is considered upper limit of normal
therapy usually not initiated until ICPs >20 mmHg
In someone who needs Burr holes for decompression due to an epidural hematoma, where do we make the Burr holes?
on side of dilated pupil
What is CPP?
MAP - ICP
goal is > 50 mmHg
**CPP can be increased by lowering ICP or increasing MAP
In TBI pts why do we have an initial hyperventilation stage?
cerebral vasoconstriction occurs when pCO2 is less than 30
What is the indication for angiography for hepatic hemorrhage?
4 units of pRBCs in 6 hrs
or 6 units of pRBCs in 24 hrs
How can the Pringle maneuver help elucidate source of liver bleeding?
once the triad is clamped, bleeding from hepatic artery and portal vein will stop
if liver continues to bleed, it’s probably from hepatic veins or IVC posterior to liver
Liver avulsion is considered what grade of liver injury?
grade VI
How do we repair diaphragmatic injuries?
debridement of non-viable tissue
tension free repair with a large monofilament, permanent suture (polypropolene)
To gain control of a proximal common carotid artery injury what incision do we make?
median sternotomy
How do you distinguish cardiac tamponade vs tension pneumo clinically?
tamponade; hypotension, JVD, b/l breath sounds
tension pneumo; hypotension, JVD, absent breath sounds
What are the different segments of the vertebral artery?
V1–> from origin to C6
V2–> from C6 to C2
V3–> From C2 to dura
V4—> from dura to confluence of basilar artery
In an unstable pt, can you ligate the external carotid artery if it is transected due to an injury?
yes. with limited morbidity
Rule of 9s for TBSa;
each arm is 9 head is 9 each leg is 18 anterior trunk is 18 posterior trunk is 18 genitalia is 1
How do you expose the supra-renal vs infra-renal aorta?
supra-renal aorta; exposed via a Mattox maneuever; left medial visceral rotation
infra-renal aorta; reflecting T-mesocolon cephalad, eviscerating pts small bowel towards the right, midline infracolic retroperitoneum is opened up until left renal vein seen
What are some risk factors for post-op delirium?
transfusion of > 1L in OR
age >70
ASA risk stratification >4
BMI < 18
What are the two types of hepatorenal syndrome?
type 1–> rapid onset, acute, doubling of Cr within 2 weeks, cr has to be at least 2.5
type 2–> slow progression, w/diuretic resistant ascites
Most reliable method of identifying VAP?
BAL
MCC of acute liver failure in the US?
acetaminophen tox
Berlin criteria for ARDS?
resp failure can’t be due to cardiac failure or fluid overload
b/l pulm opacities on xray
PEEP >5
onset can be a week after clinical insult
What electrolyte derangements do we see with pts with central diabetes insipidus due to TBI?
we have decreased vasopressin production
this leads to a lot of dilute urine
Na >145 (hypernatremie)
urine osm; <300 (low)
low urine specific gravity
Whats the anaphylaxis dose of epinephrine?
- 3 mg (1:1000) IM
0. 5 mg (1:10,000) IV
Feared complication of rapid correction of severe hyponatremia is?
central pontine myelinosis
What arrhythmia can be associated with hypomagnesemia?
polymorphic V-tach
wide QRS complex, prolonged PR
transition from peaked T wave to flattened T waves
What is a positive apnea test?
PCO2 of 60 mmHg or a rise in PCO2 of at least 20 over baseline
Difference between hypoxemia and hypoxia;
hypoxemia—> low O2 content in the blood (due to low O2 transfer from alveoli to pulmonary circulation)
hypoxia—> O2 supply is not congruent with demand (can have tissue hypoxia vs global hypoxia)
What’s the 30 day mortality of endoscopic vs open AAA repair?
Endoscopic repair; 1.6% mortality
open repair; 4.8 %; statistically significant
**long term mortality benefit has not been shown for EVAR vs open
