Trauma and emergency Flashcards
Signs og basical skull fracture
- Raccoon eyes
- Battle sign (hematoma behind the ear)
- Clear otorrhea
- Clear rhinorrhea
Next step: CT scan of head and neck
Patient with righ head trauma who then presents LOC, followed by a lucid interval and then coma. On exam presents right fixed dilated pupil and left hemiparesis.
Dx, Next step, tx?
Epidural hematoma + herniation syndrome
Next step: CT scan will show a lens shaped hematoma
Tx: craniotomy
Adolescent who had a massive head trauma and then LOC with no licid period.
Dx, Next step, tx?
Acute subdural hematoma
Next step: CT scan showing a crescent shaped hematoma
Tx: ↓ intracranial pressure (ICP)
- Hyperventilate once intubated
- Elevate head of bed
- Manitol
Old patient who 6 months ago fell from his bed. His daughter says that his is having more headaches ever since and she has notice a decreased cognitive function.
Dx, next step, tx?
Chronic subdural hematoma
Dx: CT scan showing a crescent shaped hematoma
Tx:
- Craniotomy
- Anticoagulation adjustment if needed
Patient who was playing football and had head trauma, followed by LOC. He is now lucid bud doesn’t remember the event.
CT is normal
Dx?
Concussion
Close observation at home with alarm signs
Patient who in a car accident had angular trauma (the car spun). Since the accident is is in coma.
CT scan showing grey/white blurring
Diffuse axonal injury
Tx: Really poor prognosis, basically manage the ICP
ABCs, patient presentation when airway is patent
o Speaks full sentences
o No use of accessory muscles
o Bilateral breath sounds
ABCs, patient presentation when airway is urgent or emergent
Urgent airway (may need to be intubated):
o Expanding hematoma
o Cutaneous emphysema
Emergent airway:
o Apnea
o GCS < 8
o Gurgling/gasping
Parameters that manage problems with ventilation
Ventilation (CO2)
• Assessed with ABG = pCO2
• Managed with Minute ventilation = Tidal volume x RR
ABCs (breathing)
Parameters that manage problems with oxygenation
Oxygenation (O2)
• Assessed with SatO2 / pO2
• Managed with PEEP, FiO2
Patient presentation of someone with shock
- Syst BP < 90 / (MAP < 65)
- Urinary output < 0.5 cc/kg/hr
- Pale, cool, diaphoretic, sense of impending doom
Patient in shock (hypotension) and warm extremities. Differentials?
Problems in systemic vascular resistance, e.g.,
- Sepsis
- Anaphylaxis
- Anesthesia
- Spinal trauma
Patient with Flat neck veins, Normal lungs, ↑HR, Hypotension, Cold extremities.
Dx, next step, tx?
Hemorrhage
Next step: FAST (U/S)
Tx: pressure, surgery
- Large bore IV, type and cross, IVF, transfusion on their way to the OR
JVD, ↓ breath sounds, hyperresonance, Traqueal deviation, Hypotension, Cold extremities.
Dx, next steps?
Tension pneumo
Next steps:
- Needle decompression, i.e., thoracostomy (not a chest tube) with a 14G needel in the 2nd costal space
- Then, get the CxR and put the chest tube
Patient with: • JVD • Distant heart sound • Hypotension • Paradoxal pulse (↓Systolic BP during inspiration > 10 mmHg) • Cold extremities • Normal lung sounds
Dx, next steps, tx?
Pericardial tamponade
Next step: Pericardiocentesis guided by U/S (FAST)
Beck’s triad?
- JVD
- Distant heart sound
- Hypotension
Definition of paradoxal pulse
↓ pulse amplitud and ↓Systolic BP of > 10 mmHg during inspiration
Patient who was bitten by a raccoon.
Tx?
Capture the animal, kill it and Bx the brain to see if there is rabies. If rabies, give immunoglobulin and vaccine
Patient who was stung by a wasp and now is hypotensive and has bronchospasm.
Tx?
- IM epinephrine 1:1,000
* H1 + steroids (alternative)
Patient who was bitten by a snake.
How to know if he need the anti-venom?
Snake Likely poisonous if
- Slit-like eyes
- Cobra cowl
- Rattler
Patient risk fx:
- Skin changes
- Erythema
- Pain out of proportion
Patient who was bitten by a spider with hourglass on the belly. The patient refers abdominal pain.
Dx? What do you have to keep an eye on?
Black widow bite
Calcium levels. Give IV calcium
Patient who was in florida and was bitten by spider in a attic. He had initially a bite, but now it is a necrotic ulcer.
What type of spider and tx?
Brown recluse
Tx: debride–> grafting
Patient who was bitten by his domestic dog.
Microorganism? Tx?
Pasteurella
Tx:
- Irrigation
- Leave the wound open (heal by secondary intention)
- Amoxicillin/clavulanate
- Tetanus Ig + toxoid if > 5 years since immunization
Management of human bites?
Tx (same as dog/cat bite):
- Irrigation
- Leave the wound open (heal by secondary intention)
- Amoxicillin/clavulanate
- Tetanus Ig + toxoid if > 5 years since immunization
Patient with penetrating neck trauma and unstable (Gurgling, Stridor, Loss of airway, Vascular, Expanding hematoma, Pulsatile bleeding, Stroke, Shock).
Next step?
Surgery
Patient with penetrating neck trauma, but stable and otherwise ASx.
Next step?
Observe, if worsens perform a CT angio
Patient with penetrating neck trauma and stable. However, presents soft signs (Dysphonia, Dysphagia, Subcutaneous emphysema, hematoma).
Next step?
CT angio, if (+)–> surgery. If (-) observe
If proximal third involved, it could be replaced with a arteriogram.
If distal third involved, it could be replaced with esophagram, bronchogram, and arteriogram
Patient with trauma of neck. He has Ipsi lateral proprioception/vibration loss, Ipsi lateral motor loss (Flaccid paralysis and Hyporeflexia at the level with Spastic paralysis and Hyperreflexia bellow the level), and contra lateral pain/temp loss.
Dx?
Hemi section
Patient with trauma of neck. No sensory, no motor, no pain/temp on both sides. Flaccid paralysis and Hyporeflexia at the level with Spastic paralysis and Hyperreflexia bellow the level.
Dx?
Complete transection
Patient with trauma of neck. Bilateral motor loss, Bilateral pain/temp loss, Proprioception/vibration normal.
Dx?
Anterior cord lesion
Patient with Loss of pain/temp in a cape-like distribution during the last months.
Dx?
Chronic Central cord lesions (syringomyelia)
Patient with trauma of neck for hyperextension. • Loss of pain/temp and motor in a cape-like distribution
Dx?
Central cord lesions
Patient with trauma of neck. Bilateral Proprioception/vibration loss, Normal motor, Normal pain/temp.
Dx?
Posterior cord lesion
Patient who tried to kill himself by taking 30 pills of acetaminophen. AST and ALT are > 1,000
Next step, tx?
Acetaminophen levels at 4 and 16 hours from ingestion
Tx:
- N-acetyl cysteine if above lab limits
- Observe if below
Patient who tried to kill himself by taking 60 pills of aspirin. Tinnitus, N/V, Vertigo, Primary respiratory alkalosis, anion gap acidosis, Hyperpyrexia.
Next step, tx?
Next step: Salicylate levels
Tx:
- Alkalization urine (to trap the acids of salicylates), then
- Forced diuresis
Patient who was on a fire and has headache, N/V.
SpO2 100%
Dx, next step, tx?
Carbon monoxide intoxication
Next step:
- ABG
- Carboxy hemoglobin
Tx: Increase wear off of CO
- 100% FiO2
- Hyperbaric
Patient who was on a fire, in a poor state with chery-red skin.
Dx, tx?
Cyanide intoxication
Tx: Thiosulfate
Farmer who has Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis, Bronchoconstriction.
Dx, tx?
Organophosphate toxicity
Tx: Atropine and pralidoxime
Patient who is drunk with either alcoholic beverage or robbing alcohol.
Tx?
IVF, protect airway
Patient who drank antifreeze.
Type of alcohol and tx?
Ethylene glycol
Tx:
Fomepizole (inhibit conversion of toxic metabolites) or EtOH
Patient who drank moonshine and went blind.
Type of alcohol and tx?
Methanol
Tx:
Fomepizole (inhibit conversion of toxic metabolites) or EtOH
Patient with blunt chest trauma, who has chest pain, and decrease res movements.
CxR shows one rb fractured.
Tx?
Pain control
Patient who had penetrating chest trauma. Dyspnea, Hyperresonance, ↓ breath sounds, ↓ fremitus.
CxR: vertical shadow
Dx, tx?
Pneumothorax
Tx: Thoracostomy
Patient who had penetrating chest trauma. Dyspnea, Dullness on percussion, ↓ breath sounds, ↓ fremitus.
CxR showing horizontal shadow; air-fluid level
Dx, tx?
Hemothorax
Tx: Thoracostomy
When to operate an hemothorax?
> 20 cc/kg upon tube placement or > 3 cc/kg/h drainage
Patient who had chest trauma, and has a sucking chest wound. Tx?
Occlusive dressing (taped on 3 sides) + chest tube
Definition of flail chest and tx?
2 or more ribs fracture in 2 or more places
Tx:
Blinders and weights
If binders fail–> surgery
F/U: consider also pulmonary contusion, myocardial contusion, traumatic dissection of aorta
Patient who had blunt chest trauma.
Nomal CxR on day 1 but lung is white out lung on CxR on 2nd day.
Dx and tx?
Pulmonary contusion
Tx:
- Avoid crystalloids
- Use calloids (coloides)
- PEEP
- Diuresis
Patient who had blunt chest trauma who has high troponins and changes on the EKG.
Dx, tx?
Myocardial contusion
Tx: MONABASH + Diuretics for CHF +/- antiarrhythmic
F/U: FAST to look for pericardial tamponade
Patient who had blunt chest trauma who has discordant BP between right and left sides and a wide mediastinum on the CxR.
Dx, next step, tx?
Traumatic dissection of the aorta
Next step: CT angiogram or TEE or MRI
Tx: emergent surgery
- ↓ BP with betablockers
Patient who was shot under T4 level.
Tx?
Exploratory laparoscopy
Patient who had a penetrating abdominal trauma with a knife. He has peritoneal signs and evisceration.
Tx?
Exploratory laparoscopy
Patient who had a penetrating abdominal trauma with a knife. He has no peritoneal signs or evisceration.
Tx?
Probe the lesion to see if it’s penetrating.
Patient with blunt abdominal trauma. Negative FAST, negative CT scan, but you still have a high suspicion of internal hemorrhage.
Next step?
diagnostic peritoneal lavage
Tx of rupured live?
Exploratory laparoscopy
- Pringle maneuver during sx (compress the hepatoduodenal ligament, hepatic artery and porta)
- Sx repair vs lobectomy
Patient with blunt abdominal trauma which cause a ruptured spleen. The patient underwent splenectomy.
Next step?
Vaccinate against encapsulated organism (e.g., strep and Neisseria)
Patient with blunt abdominal trauma whose CT scan shows diaphragmatic hernia.
Dx, tx?
Diaphragm rupture
Exploratory laparoscopy
Patient with blunt abdominal trauma whose CT scan shows free air at the top of the scan. The KUB shows air under diaphragm.
Dx, tx?
Ruptured hollow viscus
Exploratory laparoscopy
Patient who was in a car accident. He has pain during the hip-rock maneuver.
Dx, next step, tx?
Pelvic fracture
Next step: CT scan and retrograde urethrogram
Tx: external fixation might be sufficient
- If blood goes into the peritoneum then surgery, otherwise generally not needed
F/U: urethral trauma, rectal injury
Patient who was in a car accident, who has a pelvic fracture. On digital rectal exam you identify a High-riding prostate. You also see Blood at the meatus.
Dx, next step, tx?
Urethral trauma
Next step: retrograde urethrogram
Tx: suprapubic cath
Patient who was in a car accident in whom you suspect rectal injury and ureter injury.
Next steps?
Proctoscope and intravenous pyelogram
Patient with a chemical burn.
Tx?
- Irrigate and irrigate and irrigate and irrigate
* NEVER buffer (because it created heat and burns more)
Patient who ingested and acid or alkali
Tx?
- Observation, series of CxR and call IG for an EGD
- NEVER induce emesis
- NEVER NG tube
- NEVER buffer
Patient who was on a fire and has Soot/singed nares and stridor.
Next steps?
- ABG, SPO2, peak-flow
- Bronchoscopy
- Close monitor
- If deterioration –> prophylactic intubation
Patient who was stricken by a lightning.
Next steps, tx?
CK, creatinine to rule out radbomiolisis
And monitor for arrhythmias
Tx: IVF, mannitol to treat rabdo
Patient with circumferential burn.
Tx?
Cut the eschar and refer
Rule of 9s to determine % of body surface?
Head= 9% Front chest= 9% Back of chest= 9% Front abdomen= 9% Back of adbomen= 9% Entire arm= 9% Front of leg= 9% Back of leg= 9% Genitalia= 1%
Parkland formuka
(%BSA burned with 2nd and 3rd degree x kg x 4cc) of LR
Give 50 % in 8 hrs
Give 50% in the next 16 hrs
Tx of burns
o IVF o Early movement o Early graft o Pain control o Infection prophylaxis: Topical mupirocin or silver sulfadiazine
When to refer a burned patient
o Face o Hands o Genitals o Circumferential o More than 10%
Class of drugs that may cause syndrome of muscle rigidity, hyperthermia, autonomic instability, and extrapyramidal symptoms.
Antipsychotics (neuroleptic malignant syndrome).
Side effects of corticosteroids.
Acute mania, immunosuppression, thin skin, osteoporosis, easy bruising, myopathies.
Treatment for DTs.
Benzodiazepines.
Treatment for acetaminophen overdose.
N-acetylcysteine.
Treatment for opioid overdose.
Naloxone.
Treatment for benzodiazepine overdose. .
Flumazenil
Treatment for neuroleptic malignant syndrome and malignant hyperthermia.
Dantrolene.
Treatment for malignant hypertension.
Nitroprusside.
Treatment of atrial fibrillation.
Rate control, rhythm conversion, and anticoagulation.
Treatment of supraventricular tachycardia.
If stable, rate control with carotid massage or other vagal stimulation; if unsuccessful, consider adenosine.
Causes of drug-induced SLE.
INH, penicillamine, hydralazine, procainamide,
chlorpromazine, methyldopa, quinidine.
Macrocytic, megaloblastic anemia with neurologic
symptoms.
B12 defi ciency.
Macrocytic, megaloblastic anemia without neurologic symptoms.
Folate deficiency.
A burn patient presents with cherry-red fl ushed skin and coma. SaO2 is normal, but carboxyhemoglobin is elevated. Treatment?
Treat CO poisoning with 100% O2 or with hyperbaric O2 if poisoning is severe or the patient is pregnant.
Blood in the urethral meatus or high-riding prostate.
Bladder rupture or urethral injury.
Test to rule out urethral injury.
Retrograde cystourethrogram.
Radiographic evidence of aortic disruption or dissection.
Widened mediastinum (> 8 cm), loss of aortic knob, pleural cap, tracheal deviation to the right, depression of left main stem bronchus.
Radiographic indications for surgery in patients with acute abdomen.
Free air under the diaphragm, extravasation of contrast, severe bowel distention, space-occupying lesion (CT), mesenteric occlusion (angiography).
The most common organism in burn-related infections.
Pseudomonas.
Method of calculating fluid repletion in burn patients.
Parkland formula.
Acceptable urine output in a trauma patient.
50 cc/hr.
Acceptable urine output in a stable patient.
30 cc/hr.
Cannon “a” waves.
Third-degree heart block.
Signs of neurogenic shock.
Hypotension and bradycardia.
Signs of ↑ ICP (Cushing’s triad).
Hypertension, bradycardia, and abnormal respirations
↓ Cardiac output (CO), ↓ pulmonary capillary wedge pressure (PCWP), ↑ peripheral vascular resistance (PVR).
Hypovolemic shock.
↓ Cardiac output (CO), ↑ pulmonary capillary wedge pressure (PCWP), ↑ peripheral vascular resistance (PVR).
Cardiogenic (or obstructive) shock.
↑ Cardiac output (CO), ↓ Pulmonary capillary wedge pressure (PCWP), ↓ peripheral vascular resistance (PVR).
Septic or anaphylactic shock.
Treatment of septic shock.
Fluids and antibiotics.
Treatment of cardiogenic shock.
Identify cause; pressors (e.g., dopamine).
Treatment of hypovolemic shock.
Identify cause; fl uid and blood repletion.
Treatment of anaphylactic shock.
Diphenhydramine or epinephrine 1:1000.
Supportive treatment for ARDS.
Continuous positive airway pressure.
Signs of air embolism.
A patient with chest trauma who was previously stable suddenly dies.
Trauma series.
AP chest, AP/lateral C-spine, AP pelvis.
