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Appendix > Trauma > Flashcards

Trauma Flashcards

1
Q

Trauma is most common cause of death in what age groups?

A

1-44 yrs old

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2
Q

Primary survey in trauma is used for what?

A

identify and treat conditions that constitute immediate threat to life

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3
Q

First priority in primary survey?

A

AIRWAY

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4
Q

When is endotracheal intubation needed?

A

someone is apneic

AMS and can’t protect airway

inhalational injury, expanding hematomas etc

can’t oxygenate

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5
Q

Nasotracheal intubation can only be performed in pts that?

A

are breathing spontaneously

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6
Q

Preferred intubation route?

A

orotracheal; can see the vocal cords directly, can use bigger sized ETT
can be used to apneic pts

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7
Q

How do we confirm ETT?

A

direct laryngoscopy
wave capnography
b/l breath sounds
xray

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8
Q

In emergent surgical airway management, what is preferred?

A

cricothyroidotomy

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9
Q

For kids less than 11, why is a circothyroidotomy not done?

A

relative contraindication due to fear of subglottic stenosis

tracheostomy is thus preferred

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10
Q

These are some conditions that are an immediate threat to life and should be picked up and addressed during primary survey?

A

tension pneumo
flail chest
open pneumo
massive air leak

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11
Q

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?

A

tension pneumo

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12
Q

Treatment for tension pneumo?

A

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

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13
Q

Where do we put a chest tube in, anatomically?

A

mid axillary line

4-5th intercostal space

chest tube directed superior/posterior

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14
Q

How does a tension pneumo work?

A

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

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15
Q

What is an open pneumo?

A

sucking chest wound

free communication between pleural space and atmosphere

(atm and pleural pressures equilibrate)

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16
Q

Tx for an open pneumothorax?

A

tape wound on three sides, create one-way valve

definitive tx–> closure of wound, chest tube at different site

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17
Q

What’s flail chest?

A

when three or more contiguous ribs fractured in at least 2 different locations

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18
Q

In flail chest what is the source of the respiratory failure?

A

underlying pulmonary contusion

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19
Q

Massive air leaks can be due to tracheobronchial injuries, what are the two types:

A

I–> within 2 cm on carina, not assc with pneumo

II–> mor distal in tracheobronchial tree, assc with pneumo

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20
Q

For the carotid, femoral or radial pulses to be felt, what must be systolic bp be?

A

carotid; 60

femoral; 70

radial; 80

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21
Q

IV access for fluid resuscitation, what is preferred?

A

2 16 gauge catheters or larger in adults

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22
Q

Preferred sites for IO access?

A

proximal tibia

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23
Q

What’s massive hemothorax?

A

> 1500 cc of blood in chest on xray

in kids; 25% of circulating blood volume

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24
Q

Acutely, how much blood is needed to cause cardiac tamponade?

A

less than 100 cc needed

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25
Q

Beck’s triad of cardiac tamponade?

A

JVD

muffled heart sounds

low arterial BP

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26
Q

How does cardiac tamponade cause problems?

A

pericardium is fibrous sac, does not distend acutely

pericardial pressure will exceed right atrial pressure, so we get reduced filling

RV output is reduced

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27
Q

Tx for cardiac tamponade?

A

pericardiocentesis successful in 80% of pts

most failures due to clotted blood in pericardium

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28
Q

In someone with cardiac tamponade and SBP <60 mmHg, what do we do next?

A

resuscitative thoracotomy

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29
Q

Indications for ED thoracotomy;

A

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

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30
Q

Contraindications to ED thoracotomy?

A

penetrating trauma; CPR > 15 mins and no signs of life

blunt trauma; CPR > 10 mins and no signs of life

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31
Q

How do we perform a pericardiocentesis for cardiac tamponade?

A

subxiphoid approach

needle 45 degrees from chest wall, aimed at left shoulder

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32
Q

Survival rates of resuscitative thoracotomy?

A

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 %

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33
Q

Incision for resuscitative thoracotomy?

A

generous left antero-lateral incision

longitudinal pericardiotomy performed anterior to phrenic nerve

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34
Q

After RT, what SBP must a pt maintain to transport to OR for further management;

A

SBP 70 mmHg

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35
Q

Mild, moderate, severe GCS:

A

<8 severe

moderate; 9-12

mild; 13-15

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36
Q

This is a quantifiable determination of neur function useful for triage, treatment and prognosis;

A

GCS

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37
Q

What are the IV classes of hemorrhagic shock?

A

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

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38
Q

EBL 750, 15% loss of EBV, vitals normal, slightly anxious, what class of hemorrhagic shock?

A

1

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39
Q

EBL >2000, EBV >40%, HR >140, BP decreased, confused and lethargic, what class of shock?

A

4

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40
Q

EBL 1500-2000, EBV 30-40%, anxious, confused, HR >100, what class shock?

A

3

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41
Q

What is class 2 hemorrhagic shock?

A

EBL 750-1500

EBV 15-30%

mildly anxious

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42
Q

What is adequate urine output in an adult, a child, and infant less than 1 yrs old?

A

adult; 0.5 cc/kg/hr

child; 1 cc/kg/hr

infant; 2cc/kg/hr

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43
Q

Earliest sign of ongoing blood loss?

A

tachycardia

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44
Q

Why is decreased SBP not a good indicator of early hypovolemia?

A

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

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45
Q

Hypovolemic pts can be triaged into three categories:

A

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

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46
Q

what are the 4 categories of shock?

A

hemorrhagic
cardiogenic
septic
neurogenic

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47
Q

What’s an air embolism?

A

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

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48
Q

How do we treat an air embolism?

A

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

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49
Q

How much blood loss does each rib fracture produce?

A

100-200 cc

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50
Q

How much blood loss does a tibial fracture produce?

A

300-500 cc

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51
Q

How much blood loss does a femur fracture produce?

A

800-1000 cc

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52
Q

How much blood loss does a pelvic fracture produce?

A

> 2L

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53
Q

Organs more likely to be injured due to blunt trauma;

A

liver, spleen, kidneys

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54
Q

Organs more likely to be injured due to penetrating trauma:

A

SB, liver, colon

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55
Q

For MVC, variables assc with life-threatening injuries are:

A 
>20 MPH
death of another occupant in the vehicle
extraction time >20 mins 
lack of a seatbelt
lateral impact
56
Q

What’s Battle’s sign?

A

ecchymoses behind ears

suggestive of a basilar skull x

57
Q

When is an epidural hematoma?

A

blood accumulates between skull and dura

rupture of middle meningeal artery

convex on imaging

58
Q

What is a subdural hematoma?

A

hematoma between dura and cortex

due to venous disruptions, or lacerations of brain parenchyma

concave on imaging

59
Q

Which has a worse prognosis, epidural vs subdural?

A

SDH

because of the associated brain parenchymal injury

60
Q

What’s diffuse axonal injury?

A

due to high speed deceleration injuries

axons damaged directly due to shear forces

61
Q

What is central cord syndrome?

A

motor, pain, temperature are preserved in the LE but diminished in the UE

usually seen in older pts with hyperextension injuries

62
Q

What is anterior cord syndrome?

A

decreased motor, pain, temp below level of injury

position, vibration and crude touch are maintained

63
Q

THis results from penetrating injury in which half of spinal cord transected;

A

Brown-Sequard syndrome

ipisilateral loss of motor, proprioception, vibration
contralateral loss of pain/temp

64
Q

Zones of the neck:

A

1–> up to level of clavicles

2–> up to level of angle of mandible

3–> above angle of mandible

65
Q

What do you suspect in pts who have persistent pneumothorax, persistent air leaks after chest tube placement, or difficulty ventilating?

A

need to assess for tracheo-bronchial injury

66
Q

What is a persistent hemothorax not drained by 2 chest tubes called?

A

caked hemothorax

needs thoracotomy

67
Q

On chest xray, a mediastinal hematoma on left and right is suggestive of what?

A

L side hematoma; descending aortic injury

R side hematoma; innominate A injury

68
Q

Where is aortic injury most common?

A

distal to left subclavian A, where it’s tethered to ligamentum arteriosum

69
Q

For GSW to abdomen, between 4th intercostal space and pubic symphysis, what do we do?

A

ex-lap

70
Q

What are the grades of liver injuries?

A

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

71
Q

What are the grades of a splenic injury?

A

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

72
Q

When doing an A-A index for extremity injuries, when do we perform a CTA?

A

if there is >10 % difference between the two extremities

73
Q

Brief loss of consciousness, followed by a lucid interval, , during which time the hematoma is expanding, describes what?

A

Epidural hematoma

due to rupture of middle meningeal artery

74
Q

These brain bleeds due to tearing of bridging veins between dura and cerebral cortex:

A

SDH

have associated brain parenchymal injury, thus more serious than EDH

75
Q

How do we see diffuse axonal injury on CT?

A

scattered punctate hemorrhages on parenchyma

loss of interface between gray and white matter

76
Q

Of the three components of GCS, which is most telling of neurological function?

A

motor component

77
Q

How to gain access to a proximal tracheobronchial injury vs distal tracheobronchial injury?

A

proximal–> r-thoracotomy ( have access to trachea and proximal b/l mainstem bronchi)

distal–> l-thoracotomy wound be for distal L-mainstem bronchus injury

78
Q

When is C-section performed in trauma settings?

A

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

79
Q

After an esophageal repair you want to ensure there is no leak, so you order an esophagram, what kind of contrast do you use?

A

water-soluble contrast is better, safer

barium causes an inflammatory response with fibrosis

80
Q

Positive findings on a DPL?

A

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.

81
Q

Contraindications to placement of tracheostomy via percutaneous dilational method?

A

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

82
Q

Toxin from a brown recluse spider can cause what hematologic problems?

A

coagulopathy and DIC

aside from causing a skin lesions with central necrosis

83
Q

Whats the Cattell-Brasch maneuver?

A

right medial visceral rotation
right colon is mobilized medially/superiorly
duodenum is Kocherized

exposes the R-kidney, its vasculature, and IVC

84
Q

Right medial visceral rotation, where the kidney is mobilized medially/superiorly is called?

A

Cattell-Braasch maneuver

exposed R-kidney, its vessels and IVC

85
Q

Mattoxx maneuver AKA?

A

left medial visceral rotation

exposes L-kidney and aorta

86
Q

What do you do with a pregnant pt who has sustained trauma, in terms of Rh iso-immunization?

A

all Rh negative mothers should receive a dose of Rh immunoglobulin within 72 hrs

(Kleihauer-Betke test–> detects occult placental hemorrhage)

87
Q

When is a thoracotomy indicated after chest tube placement?

A

1500 cc initial return

300 cc/hr for 3 consecutive hrs

88
Q

How do we manage a distal ureteral injury?

A

ureteroneocystostomy

psoas hitch/boari flap, tension free

89
Q

Hard signs of vascular injury?

A

absent distal pulse

palpable thrill/audible bruit

expanding hematoma

active pulsatile bleeding.

90
Q

Failure of non-operative management of splenic laerations increases with what?

A

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

91
Q

Someone comes in with TBI, head bleed, on warfarin, INR 5, GCS 7, what reversal agent do you use?

A

PCC–> faster onset of action compared to FFP

92
Q

Soft signs of a vascular injury?

A

hx of significant bleeding
injury with proximity to a named vessel
diminished pulses
neurological deficits

93
Q

Parkland formula;

A

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

94
Q

How long after a splenic injury, say a grade II splenic lac, that is managed non-operatively, can someone return to contact sports?

A

6 weeks

95
Q

What is the Mattox maneuver?

A

mobilizing the spleen, pancreas, left colon and moving them medially to expose left retroperitoneum and aorta

96
Q

Whats a Kocher and extended Kocher maneuver?

A

kocher–> mobilization of the duodenum to visualize duodenum and head of pancreas

extended Kocher–> exposes the aorta between the celiac axis and SMA

97
Q

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?

A

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
98
Q

Where do we perform an antero-lateral thoracotomy if needed?

A

pt supine

5th intercostal space, infra-mammary line

99
Q

When doing a clamshell thoracotomy, what needs to be ligated after?

A

internal mammary arteries need to ligated on undersurface of sternum (proximally and distally)

100
Q

What kind of incision do we access the proximal left subclavian artery?>

A

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

101
Q

When do we perform a median sternotomy with cervical extension:

A

proximal subclavian, innominate, or proximal carotid artery injuries

102
Q

When is a postero-lateral thoracotomy used?

A

when you have damage to trachea or mainstem bronchus injuries near carina

103
Q

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>?

A

supracolic–> aorta, celiac, proximal SMA, left renals

can do a left medial visceral rotation; Mattox maneuver to access them

104
Q

How do you perform a left medial visceral rotation; Mattox?

A

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

105
Q

Suspected IVC injuries are accessed how?

A

right medial visceral rotation; cattell-braasch

106
Q

In cases where we need to expose the bifurcation of the IVC and visualize the right iliac vein, what vessels can we ligate?

A

can ligate the right common iliac artery to gain expose the IVC bifurcation underneath

has to be repaired after venous injury is addressed

107
Q

What are some named arteries that usually tolerate ligation?

A

right and left hepatic arteries

celiac artery

108
Q

What major veins can be ligated?

A

> 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

109
Q

When do we use autogenous grafts vs PTFE for arterial repairs?

A

for vessels <6 mm in diameter; internal carotid, SFA, popliteal arteries–> autogenous contralateral saphenous vein graft

vessels > 6 mm; aorta, innominate, subclavian–> PTFE

110
Q

In a damage control laparotomy, venous injuries can be ligated with impunity, except;

A

supra-renal IVC

popliteal vein

111
Q

What’s an abnormal ICP?

A

10 is considered upper limit of normal

therapy usually not initiated until ICPs >20 mmHg

112
Q

In someone who needs Burr holes for decompression due to an epidural hematoma, where do we make the Burr holes?

A

on side of dilated pupil

113
Q

What is CPP?

A

MAP - ICP

goal is > 50 mmHg

**CPP can be increased by lowering ICP or increasing MAP

114
Q

In TBI pts why do we have an initial hyperventilation stage?

A

cerebral vasoconstriction occurs when pCO2 is less than 30

115
Q

What is the indication for angiography for hepatic hemorrhage?

A

4 units of pRBCs in 6 hrs

or 6 units of pRBCs in 24 hrs

116
Q

How can the Pringle maneuver help elucidate source of liver bleeding?

A

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

117
Q

Liver avulsion is considered what grade of liver injury?

A

grade VI

118
Q

How do we repair diaphragmatic injuries?

A

debridement of non-viable tissue

tension free repair with a large monofilament, permanent suture (polypropolene)

119
Q

To gain control of a proximal common carotid artery injury what incision do we make?

A

median sternotomy

120
Q

How do you distinguish cardiac tamponade vs tension pneumo clinically?

A

tamponade; hypotension, JVD, b/l breath sounds

tension pneumo; hypotension, JVD, absent breath sounds

121
Q

What are the different segments of the vertebral artery?

A

V1–> from origin to C6

V2–> from C6 to C2

V3–> From C2 to dura

V4—> from dura to confluence of basilar artery

122
Q

In an unstable pt, can you ligate the external carotid artery if it is transected due to an injury?

A

yes. with limited morbidity

123
Q

Rule of 9s for TBSa;

A 
each arm is 9
head is 9
each leg is 18
anterior trunk is 18
posterior trunk is 18
genitalia is 1
124
Q

How do you expose the supra-renal vs infra-renal aorta?

A

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

125
Q

What are some risk factors for post-op delirium?

A

transfusion of > 1L in OR

age >70

ASA risk stratification >4

BMI < 18

126
Q

What are the two types of hepatorenal syndrome?

A

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

127
Q

Most reliable method of identifying VAP?

A

BAL

128
Q

MCC of acute liver failure in the US?

A

acetaminophen tox

129
Q

Berlin criteria for ARDS?

A

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

130
Q

What electrolyte derangements do we see with pts with central diabetes insipidus due to TBI?

A

we have decreased vasopressin production

this leads to a lot of dilute urine

Na >145 (hypernatremie)

urine osm; <300 (low)

low urine specific gravity

131
Q

Whats the anaphylaxis dose of epinephrine?

A
  1. 3 mg (1:1000) IM

0. 5 mg (1:10,000) IV

132
Q

Feared complication of rapid correction of severe hyponatremia is?

A

central pontine myelinosis

133
Q

What arrhythmia can be associated with hypomagnesemia?

A

polymorphic V-tach

wide QRS complex, prolonged PR

transition from peaked T wave to flattened T waves

134
Q

What is a positive apnea test?

A

PCO2 of 60 mmHg or a rise in PCO2 of at least 20 over baseline

135
Q

Difference between hypoxemia and hypoxia;

A

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)

136
Q

What’s the 30 day mortality of endoscopic vs open AAA repair?

A

Endoscopic repair; 1.6% mortality

open repair; 4.8 %; statistically significant

**long term mortality benefit has not been shown for EVAR vs open

Appendix (39 decks)

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