Trauma and Orthopedic Surgery: PART II Flashcards
What is this sign called?
Cullen sign, it is periumbilical ecchymosis that can be a sign of retroperitoneal injury
A physical examination finding of flank ecchymosis due to retroperitoneal bleeding that dissects through fascial planes.
Flank ecchymosis (Grey Turner sign)
Can be a sign of retroperitoneal injury
A crunching, rasping sound in sync with the heartbeat that is caused by the heart beating against air-filled tissues. Associated with pneumomediastinum, pneumopericardium, and tracheobronchial injury.
Hamman’s Sign
How might a pt with
Patients with pneumothorax usually present with sudden-onset dyspnea, ipsilateral chest pain, diminished breath sounds, and hyper-resonant percussion on the affected side
What are major manifestations of a tension pneumothorax?
manifests with distended neck veins, tracheal deviation, and hemodynamic instability.
What do we mean by primary and secondary spontaneous pneomothorax?
Primary spontaneous pneumothorax: occurs in patients without clinically apparent underlying lung disease
Secondary spontaneous pneumothorax: occurs as a complication of underlying lung disease
What are signs of ureter trauma?
Nonspecific, they may show hematuria on labs. These injuries tend to be concommitant with other multisystem injuries like a motor vehicle accident
Where would urine accumulate in an extraperitoneal bladder rupture?
retropubic space
Where would urine accumulate in an intraperitoneal bladder rupture?
intraperitoneal
Where would blood accumulate in a posterior urethral injury? (Male)
Injuries of the posterior urethra typically result in bleeding from the external urethral meatus, difficulty voiding, and suprapubic pain and tenderness. Urine and blood may collect in the retropubic and deep perineal spaces. Rupture of the puboprostatic ligament and the collection of blood and urine may cause a high-riding prostate.
How would an injury of the anterior urethra present? (Male)
Injuries of the anterior urethra typically result in bleeding from the external urethral meatus, difficulty voiding, and perineal pain and tenderness. If the Buck fascia is also ruptured, urine and blood may collect around the scrotum and in the superficial perineal space. The prostate is normal on digital rectal examination.
In urethral injuries, what is your first step in managment?
DRAIN THE BLADDER!
Pts who have a urethral rupture should probably not get transurethral catherturization. They will end up getting a suprapubic catherterization.
What is the pathophys of compartment syndrome?
External or internal forces as initiating event → increased compartment pressure→ obstruction of venous outflow and collapse of arterioles→ decreased tissue perfusion → lower oxygen supply to muscles → irreversible tissue damage (necrosis) to muscles and nerves after 4–6 hours of ischemia
6 Ps of acute limb ischemia
Pain, Pallor, Paresthesias, Poikilothermia, Pulselessness, and Paralysis
COMPARTMENT SYNDROME
What is the differential for compartment syndrome?
Acute Compartment Syndrome
Deep Vein Thrombosis
Acute Limb Ischemia
Rhabdomyolysis
How do we diagnose acute compartment syndrome?
Diagnosis is based on clinical findings but is typically confirmed with early measurement of compartment pressures.
Change in pressure ≤ 30 mm Hg
What burn degree: Superficial layers of the epidermis
First degree burn
What burn degree: Epidermis and upper layers of the dermis (papillary dermis)
Second A: superficial and partial thickness
What burn degree: Deeper layers of the dermis (papillary and reticular dermis)
Second b (deep partial thickness burn)
What burn degree: Epidermis, dermis, and subcutaneous tissue
3rd
At what degree does a burn stop blanching?
2b, deep partial thickness burn and onward
What burn patients don’t feel pain?
Pts who have 3rd and onward
What burn degree: Epidermis, dermis, and deeper structures (muscles, fat, fascia, and bones)
4th/deeper injury burn
What burns have blistering?
second
Tissue necrosis with black, waxy-white, or gray leather-like skin (eschar) is characterstic of what kind of burn?
3rd degree
What is the rule of nines?
Its the approximation we use in order to calculate total body surface area burned. NOTE: The rule of nines does not accurately account for pediatric proportions in children.
How do we calculate burn surface area in childre?
This is what amboss has, there are mixed things
Most common causes of death from burns
Shock, sepsis, and respiratory failure
Common causative organisms of sepsis in burns include
Staphylococcus aureus (including MRSA), Enterococcus (including VRE), and Pseudomonas.
What is our major concern with circumferential burns?
Compartment syndrome
Circumferential eschars (burns that fully encircle the chest, neck, abdomen, and/or an extremity) → loss of skin elasticity → impaired blood flow and/or compartment syndrome (caused by an accumulation of fluids) → acute ischemia distal to the eschar
A pt with significant eschar on the chest or neck, what would we be concerned for?
Asphyxia
Significant eschar on chest or neck → restriction of chest excursion → asphyxia
What layer of the skin does second degree involve?
up to dermis
What layer of skin does third degree burns involve?
Past the dermis to subq
What formulas do we use to calculate fluid rescusitation in burn patients?
Parkland or Brooke formulas. They do have a consensus formula.
What is the consensus formula for fluid resuscitation in the first 24 hours in a burn pt?
2–4 mL lactated Ringer’s × body weight (Kg) × %TBSA burns = total fluid for the first 24 hr
How much fluid should be given in the first 8 hours?
Half of the total should be given within the first 8 hours after the burn.
The consensus formula for burn patients is 2–4 mL of Ringers Lactate multiplied by weight in kilograms (kg) multiplied by percent total body surface area burned (%TBSA) divided by 24 hours, which equals the milliliters (mLs) of fluid to be given in the first 24 hours. Half of the total should be given within the first 8 hours after the burn. The amount of fluid to use depends on the patient’s age and the type of burn injury:
Adults: Use 2 mL
Pediatrics: Use 3 mL
Electrical injuries: Use 4 mL
Children: May need more fluid because they have a larger %TBSA relative to their weight
In a burn pt, how do you monitor the adequacy of their fluid rescusiatation?
URINE OUTPUT
0.5cc per kilo per hour
A 2 yo is brought in for accidental scald injury. Child has zebra striping and donut hole sparing, what are you concerned for?
Abuse
What is the indication for escharotomy?
A 19 year old woman working at a fast food restaurant slips and falls, immersing her entire left hand and forearm in a vat of hot grease. On evaluation less than an hour later, the burned hand is tightly swollen, cool, dry and waxy white. She cannot move her fingers, and complains only of a deep ache in the limb. You cannot palpate a radial pulse.
Lost pulses
Hamman’s sign
A crunching, rasping sound in sync with the heartbeat that is caused by the heart beating against air-filled tissues. Associated with pneumomediastinum, pneumopericardium, and tracheobronchial injury ( like a bronchial rupture).
High speed MVA, GCS 14, Normal cardiac exam, LUQ TTP, RR 33, Pulse 103, O2 94. Xray as shown.
Diaphragmatic rupture
Mediastinal shift can be seen in…
tension pneumo
thoracus aortic rupture
A widened mediastinum, esophageal deviation, depression of the left main bronchus, and hemothorax (suggested by left pleural effusion) are consistent with …
A widened mediastinum, esophageal deviation, depression of the left main bronchus, and hemothorax (suggested by left pleural effusion) are consistent with thoracic aortic rupture (TAR). TAR can be traumatic (e.g., due to high-velocity blunt chest wall trauma) or spontaneous (e.g., following aortic dissection).
blunt injury to the chest wall and patchy infiltrate on chest x-ray shoudl raise concern for
Pulmonary contusion
Pulmonary contusion is the most common lung injury following blunt injury to the chest wall (e.g., during a motor vehicle accident). Damage to the capillaries in the lung parenchyma results in pulmonary edema and/or bleeding within contused lung tissue, which appears as a patchy infiltrate on chest x-ray. Excessive fluid administration worsens pulmonary edema, as the damaged capillaries leak fluid into the lungs.
What would you expect on percussion for a pneumothorax?
hyperresonance on the affected side
Parkland formula
4 milliliters of lactated Ringer’s (LR) solution per kilogram of body weight, per percent of TBSA burned
The patient sustained a deceleration injury and has mediastinal widening on chest x-ray, suggesting blunt thoracic aortic injury. They are hemodynamically stable, what test are you going to order next? What if they were hemodynamically unstable?
Contrast enhanced CT A for stable, unstable should be urgently evaluated with transesophageal echocardiography in the operating room.
In a pt who was in a MVA w/ a negative FAST exam but has hypotension, arrythmua, vassopressor resistant hypotension, lung crackles, and elevated JVP, what should you be thinking?
Cardiac contusion leading to cardiogenic shock
Stable patients with penetrating neck injuries should be evaluated for possible injuries to the trachea, larynx, and neck vessels. What modality would you use to eval?
CT angio
Note that Immediate intubation and surgical exploration are indicated in patients with hemodynamic instability, expanding hematoma, or clear signs of tracheal/esophageal injury.
The presence of dyspnea and tachypnea with decreased breath sounds and hyperresonance to percussion after a penetrating chest wound with bubbling of blood indicates an open pneumothorax. With no signs of a tension pneumo, what would we do next?
Partially occlusive dressing
______________________is the standard treatment option for second-degree burns (i.e., deep partial-thickness burns) affecting the periorbital area.
Topical antibiotic ointment (e.g., neomycin, erythromycin) with nonadherent dressing
Why should we avoid silver sulfa or chlorhexidine for a pt with periorbital second degree burns?
Topical antimicrobial agents that are typically used for the management of deep partial-thickness burns (e.g., silver sulfadiazine, chlorhexidine) are toxic to the eyes and should be avoided in patients with periorbital burns.
What topical antimicrobial agents do we use for the managment of deep partial thickness burns?
Things like silver sulfadiazine, chlorhexidine
JVD, tachy, hypotensive, tense and distended abdomen, and low urine output with high creatinine and no signs of infection following a surgery for liver lac and pt had to get massive volume resuscitation should make you think of…
Abdominal compartment syndrome!!
Rising IAP causes a tense and distended abdomen and leads to abdominal compartment syndrome if the pressure continues to rise (especially ≥ 20 mm Hg, even less in children). This condition prevents blood in the inferior vena cava from reaching the heart (↓ preload), thereby causing a reduction in cardiac output that leads to hypotension, reactive tachycardia, and prerenal kidney injury due to reduced perfusion (causes oliguria and BUN:Cr > 20). In some cases, elevated IAP extends into the thoracic compartment, which causes jugular venous distention.
How do we manage a flail chest?
positive pressure ventilation, we may do surgical ixation once we stabilize patients breathing
In a patient with a gunshot wound that you want to send to get a CTa which would normally be the right answer, what would be a contraindication that tripped you up before?
Type 1 diabetic with renal insufficiency will not be able to tolerate contrast, youll end up with contrast induced nephropathy
A 37-year-old woman is brought to the emergency department 15 minutes after falling down a flight of stairs. On arrival, she has shortness of breath, right-sided chest pain, right upper quadrant abdominal pain, and right shoulder pain.
A liver hematoma commonly results from blunt abdominal trauma such as falls. This patient has the typical features of liver injury, including ecchymoses over the right chest, pain in the right upper quadrant and the right chest, referred pain to the right shoulder (due to diaphragmatic irritation), and hemodynamic instability. After stabilizing this patient, a focused assessment with sonography in trauma (FAST) should be performed to assess for free fluid in the abdomen.
Impaled foreign bodies should be removed under direct visualization __________________________
in the operating room
What confirms the diagnosis of a bladder rupture?
Extravasation of contrast on retrograde cystography confirms the diagnosis.
The initial treatment for chemical burns is the same regardless of the chemical’s pH. What do we do FIRST?
Irrigate the shit out of it
Any penetrating trauma located anteriorly below the nipple line (fourth intercostal space) is considered a potential trauma of both the thorax and the abdomen. What do we do in a hemodynamically unstable pt?
Ex laparotomy
In hemodynamically stable patients the next best step is almost always some form of…
CT!
Dont do a CTa on diabetics with bad renal function though unless you would like to precipitate contrast nephropathy
Empiric antibiotic that covers MRSA
Vancomycin
What empiric antibiotic do we give to help cover pseudomonas?
Cefepime
Common alternative regimens for Pseudomonas coverage include piperacillin/tazobactam or carbapenems (e.g., imipenem or meropenem).
Duodenal wall thickening on CT in the clinical context of MVA should increase your suspicion of…
intramural duodenal hematoma which can lead to gastric outlet obstruction (nausea, vomiting, gastric distention with a large gastric bubble)
