Trauma Flashcards
What component of GCS has most prognostic ability?
motor score
GCS at which intubation is warranted
GCS < 8 = intubate
What information does a unilateral fixed and dilated pupil give you?
ipsilateral space occupying lesion with compression on optic nerve
What information does bilateral pinpoint pupils give you?
Pontine hemorrhage, or narcotic overdose
what patient’s need ICP monitor?
GCS < 8 with intracranial abnormality on CT
what is the difference between a bolt and a ventriculostomy?
ventriculostomy - in ventricle and can drain CSF
bolt - in parenchyma
what is cushing’s reflex? and what does it indicate?
hypertension, bradycardia and altered respirations
indicates impending herniation
initial management of patient with cushing’s reflex
sedate, elevate HOB, PaCO2 <35, mannitol or 3%, paralytic
classic presentation of epidural hematoma
head injury with lucid interval with rapid GCS decline
describe the CTH of epidural hematoma
lenticular lucency contained by suture lines
describe CTH of SDH
crescent shaped lucency that crosses suture lines
CPP = ?
goal CPP and ICP
CPP = MAP - ICP
CPP >60 and ICP < 20
interventions to reduce ICP? (5 examples)
- elevate HOB
- hyperventilate
- remove C collar
- 3% or mannitol
- sedate or paralyze
reversal agent for coumadin in the trauma setting
PCC for rapid reversal
FFP is okay
Vitamin K
reversal agent for pradaxa (dabigatran)
dialysis or praxbind (idarucizumab)
reversal agent for apixaban/rivaroxaban
PCC gives partial reversal, dialysis
andexanet alpha
clinical clearance for spine trauma (3 criteria)
- no distracting injuries
- no intoxication and GCS 15
- no midline tenderness or neuro deficits
injury pattern for central cord syndrome?
upper extremity weakness and burning - ‘cape and gloves’
ex. elderly with spinal stenosis
injury pattern for brown sequard?
ipsilateral motor deficit and contralateral pain/temp deficit below injury
ex. stab wound
injury pattern for anterior cord syndrome?
motor deficit below the level of injury
ex. vascular injury to anterior spinal artery
difference between neurogenic shock and spinal shock
neurogenic shock - hemodynamics affected
spinal shock - sensory/motor affected. no bulbocavernosus or cremasteric reflex. some functions may return.
what constitutes an ‘unstable’ spinal cord injury
when 2/3 ligamentous columns are disrupted - need operative fixation
borders of zones of the neck ?
Zone 1 - clavicles to cricoid
Zone 2 - cricoid to angle of mandible
Zone 3 - mandible to skull base
next best step in management: penetrating neck injury with unstable hemodynamics
OR
next best step in management: penetrating neck injury with hard sign of vascular injury
OR
What are hard signs of vascular injury? (4 examples)
- Observed pulsatile bleeding.
- Arterial thrill (ie, vibration) by manual palpation.
- Bruit over or near the artery by auscultation.
- Visible expanding hematoma.
NBS penetrating neck injury without hard sign of vasc injury?
CT neck with angiogram
-if concerned for esophageal injury - esophagram or EGD
how to repair esophageal injury?
extend myotomy to see mucosal injury extend, repair in 2 layers, buttress, drain
Who to consider for CTA for BCVI?
hanging mechanism neuro exam not explained by brain imaging DAI skull base fx involving foramen lacerum Horner syndrome LeFort II or III C1-C3 fracture cervical bruit cervical seatbelt sign
most common site for BCVI
distal internal carotid artery
Tx for BCVI
mostly heparin vs antiplatelet therapy
endovascular approach for some grade III injuries
coil embolization for grade IV and V
Chest tube output where going to OR is indicated?
initial output >1500cc or >200 cc/hr for 4 hours
definition of flail chest
3 or more consecutive ribs fractured in two locations
tx for flail chest
pain control, PPV, rib plating?
Initial workup for blunt cardiac injury
EKG - look for Tachycardia or PVCs
troponins are controversial…negative EKG and troponins effectively rule out cardiac injury
NBS patient with blunt cardiac injury with hemodynamic instability or persistent new arrhthmia?
Echocardiogram
location for most blunt aortic injuries?
proximal descending aorta just distal to ligamentum arteriosum
Tx for retained hemothorax despite tube thoracostomy?
Early VATS superior to placing second tube
initial Tx for aortic dissection?
anti-hypertensive regimens to maintain <120 mmHg
esmolol +/- nitroprusside
is open or endovascular repair of blunt aortic injury preferred?
endovascular
Tx for hemodynamically stable patient with solid organ blush on CT?
angioembolization
clinical indications to go to the OR for penetrating injuries? (3 of them)
hemodynamic instability, peritonitis, evisceration
imaging test of choice to get for flank stab wounds?
triple contrast CT (oral, rectal, IV) - controversial
best way to assess thoracoabdominal stab wounds?
diagnostic laparoscopy. this injury is frequently missed on CT
how do you repair sm bowel injury if >50% of circumference is damaged?
resect and anastomosis
how do you repair sm bowel injury if segment is devascularized?
resection and anastomosis
Tx of <50% sm bowel injury without devascularization
primary repair
how do you repair large bowel injury if >50% of circumference is damaged?
primary repair
how do you repair large bowel injury if segment is devascularized or >50% circumferential injury ?
resection and anastomosis
what is a bucket handle injury?
mesentery of bowel torn from bowel. bowel intact
Tx for bucket handle injury?
resect
Tx distal pancreatic injury without duct disruption?
leave drains
Tx distal pancreatic injury with duct disruption?
distal pancreatectomy with splenectomy
Tx injury to head of pancreas with duct disruption
drainage only
Tx injury to head of pancreas withOUT duct disruption
drainage only
where is zone 1 of the retroperitoneum
centrally located - aorta and vena cave
where is zone 2 of the retroperitoneum
kidneys
where is zone 3 of the retroperitoneum
pelvis (iliac)
penetrating injury to what retroperitoneal zones mandates exploration
ALL 3 zones need to be explored in penetrating injury
Tx blunt zone 1 injury?
explore
Tx blunt zone 2 injury?
explore only if pulsatile or expanding hematoma
Tx blunt zone 3 injury?
do not explore. pack and angiography
Next step in open book pelvic fx with hypotension?
place abdominal binder
definitive Tx in stable patient with pelvic fx and hemorrhage?
angioembolization
Next step, open book pelvic fx, with binder, unstable?
OR for preperitoneal packing
Blood loss needed for Class I hemorrhage?
0-15%
no physiologic changes
Blood loss needed for Class II hemorrhage?
15-30%
tachycardia, narrowed pulse pressure
Blood loss needed for Class III hemorrhage?
30-40%
hypotension
Blood loss needed for Class IV hemorrhage?
> 40%
what is the earliest sign of shock ?
tachycardia and narrow pulse pressure
what is the triad of death?
coagulopathy, hypothermia, acidosis
principal of damage control surgery?
control sepsis/spillage and hemorrhage
temporary abdominal closure
resuscitation
return to OR when more physiologically stable
First signs of abdominal compartment syndrome? (2)
decreased UOP
increased peak pressures on vent
how to diagnose abdominal compartment syndrome?
bladder pressure >20
Tx abdominal compartment syndrome?
decompressive laparotomy
except in burn patients - place drains to drain ascites
Adjunct to give bleeding trauma patient requiring MTP?
TXA 1g within 3 hours of injury then 1g over the next 8hr
ROTEM/TEG
What product to give if clot formation time (CFT) prolonged?
FFP
ROTEM/TEG
What product to give if alpha angle low?
cryoprecipitate
ROTEM/TEG
What product to give if amplitude of clot is low?
platelets
ROTEM/TEG
What product to give if LY30 (lysis) is high?
TXA
tx intraperitoneal bladder injury?
operative repair
Tx extraperitoneal bladder injury?
foley drainage
tx mid ureteral injury?
primary anastomosis over double J stent with absorbable suture
tx distal ureteral injury?
reimplant into bladder
tx distal ureteral injury if not enough length to reach bladder?
psoas hitch
Dx for urethra injury?
retrograde urethrogram
hard signs of vascular injury?
pulsatile bleeding, expanding hematoma, absent pulses, bruit/thrill
soft signs of vascular injury
non expanding hematoma, decreased ABI <0.9
Dx for soft signs of vascular injury?
CT angiogram
Tx extremity arterial trauma ?
typically reverse saphenous vein graft
Tx extremity venous injury?
primary repair if possible or ligate
What do you need to do after popliteal artery and vein repair?
fasciotomy
crystalloid bolus amount for pediatric?
20cc/kg
blood bolus for pediatrics?
10cc/kg
