Trauma and shock Flashcards
a teenage boy falls from his bicycle and is run over by a truck. on arrival in the ED, he is awake and laert and appears frightened but in no distress. the CXR suggests an air-fluid level in the LLL field and the NGT seems to coil upward into the L chest. which of the following is the next best step in his management?
a. placement of a L chest tube
b. thoracotomy
c. laparotomy
d. esophagogastroscopy
e. diagnostic peritoneal lavage
C
diaphragmatic rupture
- -> immediate laparotomy & diaphragmatic repair
1) examination of abdomen for associated injuries
2) possible incarceration fo hernia (esp. w/ negative thoracic pressure)
dx = hx of abdominal trauma, air fluid level in LL chest, NGT entering into chest wall.
10yo boy was the backseat belted passenger in a high speed MVA. on presentation to the ED, he is awake, alert and hemodynamically stable. he is complaining of abdominal pain and has an ecchymosis on his anterior abdominal wall where the seatbelt was located. which of the following is the best next step in his management?
a. discharge him home w/out any other workup
b. discharge him home if his amylase level is normal
c. discharge him home if his abdominal plain films are negative for the presence of free air.
d. discharge him home if an abdominal CT is negative
e. observe him regardless of negative test results.
E
“seatbelt sign” —> concerns for enteric / mesenteric injury
Complications
- worsening abdominal pain, fevers, signs of sepsis
Dx
- CT - free air, thickening of SB wall / mesentery; free fluid in the absence of solid organ injury
- WBC > 500, high amylase, bile/bacteria/food fibers.
65yo man who smokes cigarettes and has COPD falls and fractures the 3rd, 4th, and 5th ribs in the L anterolateral chest. CXR is otherwise normal. which of the following would be the most appropriate next step in his management?
a. strapping the chest with adhesive tape
b. admission to the hospital and treatment with oral analgesia.
c. tube thoracostomy
d. placement of an epidural for pain management
e. surgical fixation of the fractured ribs
D. don’t fix ribs
to observe that this doesn’t cause further insult to COPD = atelectasis, pneumonia, respiratory fiailure
1) Eval = US, CT, peritoneal lavage
2) Pain management = epidural catheter (MAJOR), oral meds (MINOR)
36yo man who was hit by a car presents to the ED with hypotension. On exam, he has tenderness and bruising over his L lateral chest below the nipple. an US exmaination is performed and reveals free fluid in the abdomen. what is the most likely organ to have been injured in this pt? a. liver b kidney c. spleen d. intestine e. pancreas
C
= most likely to be damaged in blunt abdominal trauma
Dx = abd US / FAST
52yo man is pinned against a loading dock. the pt has a fractured femur, a pelvic fracture, a tender abdomen, and no pulses in the R foot with minimal tissue damage to the R leg. angiography discloses a popliteal artery injury with obstruction. at surgery, the popliteal vien is also transected. his BP is 85/60. which of the following is the best management strategy for his vascular injuries?
a. repair of the popliteal vein with simple closure
b. repair of the popliteal vein with saphenous vein patch
c. repair of the popliteal vein with a synthetic interposition graft
d. ligation of the popliteal vein
e. amputation of the R Le above the knee.
D
hemodynamically unstable ==> Ligate the vein
hemodynamically stable ==> ?venous repair - proximal veins should be repaired to avoid chornic venous insufficiency
27yo man sustains a single gunshot wound to the L thigh. in the ED, he is noted to have a large hematoma of his medial thigh. he complains of paresthesias in his L foot. on exam, there are weak pulses palpable distal to the injury and the pt is unable to move his foot. which of the following is the most appropriate initial management of this pt?
a. angiography
b. immediate exploration and repair in the OR
c. fasciotomy of the anterior compartment of the calf
d. observation for resolution of spasm
e. local wound exploration at the bedside
B
large hematoma –>
diffdx:
- compartment syndrome = nerve damage, arterial damage.
- acute arterial insufficiency = hematoma, pulsatile bleeding, audible bruit, palpable thrill, absent distal pulses / distal ischemia
25yo woman arrives in the ED following an automobile accident. she is acutely dyspneic with a RR of 60. breath sounds are markedly diminished on the R side. which of the following is the best first step in the management of this pt?
a. take a CXR
b. draw arterial blood for blood gas determination
c. decompress the R pleural space
d. perform pericardiocentesis
e. administer IV fluids
C
tension pneumothorax –> best first step = decompress
17yo adolescent boy is stabbed in the L 7th intercostal space, midaxillary line. he presents to the ED with a HR of 86, BP 125/74, and O2 sat of 98%. breath sounds are equal b/l. which of the following is the most appropriate next step in his workup?
a. local exploration of the wound
b. L tube thoracostomy
c. diagnostic laparoscopy
d. CT scan of the abdomen
e. Echocardiography
C
lung/spleen –> exploration of the thorax or abdomen
local wound exploration can lead to pneumothorax
your hospital is conducting an ongoing research study involving the hormonal response to trauma. blood is drawn regularly (with IRB approval) for various studies. which of the following values are likely to be seen after a healthy 36yo man is hit by a bus and sustains a ruptured spleen and a lacerated small bowel?
a. increased secretion of insulin
b. increased secretion of thyroxine
c. decreased secretion of vasopressin (ADH)
d. decreased secretion of glucagon
e. decreased secretion of aldosterone
A
increased insulin (b/c increased glucose from cortisol), aldosterone; ADH (b/c hypovelemic), catecholamines, glucagon
decreased
18yo man who sustained a R sided cervical laceration during a gang fight. your intern suggests nonoperative management and observation. which of the following is a relative, rather than an absolute, indication for neck exploration?
a. expanding hematoma
b. dysphagia
c. dysphonia
d. pneumothorax
e. hemoptysis
D. pneomotorax doesn’t necessarily mean something in the throat (more the thorax)
hematoma - from carotid
dysphonia - pressure on trachea
dysphagia = pressure on esophagus
hemoptysis - damage to esophagus –> bleeding into GI system
following blunt abdominal trauma, 12yo girl develops upper abdominal pain, N&V. an upper GI series reveals a total obstruction of the duodenum with a coiled spring appearance in the 2nd & 3rd portions. in the absence of other suspected injuries, which of the following is the most appropriate management of this pt?
a. gastroejejunostomy
b. NG suction & observation
c. duodenal resection
d. TPN to increase the size of the retroperitoneal fat pad
e. duodenojejunostomy
B
1) NGT & fluids = see if it will go away
2) ex-lap = if after 2 weeks of persistent sxs
45yo man presents after a high speed MVA. he has a seatbelt sign across his neck and chest with an ecchyosis over his L neck. he is hemodynamically stable and neurologically intact. CTA shows a L carotid dissection. in the absence of other significant injuries, what is the next step in his management?
a. antiplatelet therapy
b. systemic anticoagulation with heparin
c. neck exploration and L carotid artery repair
d. neck exploration & L intra-extracranial bypass
e. angiography & L carotid artery stenting
B
carotid dissection or type B aortic dissection = lifetime anticoagulation
18yo man was assaulted and sustained significant head and facial trauma. which of the following is the most common initial manifestation of increased intracranial pressure?
a. change in level of consciousness
b. ipsilateral (side of hemorrhage) pupillary dilation
c. contralateral pupillary dilation
d. hemiparesis
e. HTN
A
Closed head injuries
1) change in mental status / level of consciousness
2) cushing triad = hypotension, bradycardia, irregular respiration
3) laterlizing signs –> focal intracranial lesion
28yo man is brought to the ER for a severe heard injury after a fall. he was intubated in the field for his decreased level of consciousness. he is tachycardic and hypotensive. on exam, he is noted to have an obvious skull fracture and his R pupil is dilated. which of the following is the most appropriate method for initially reducing his ICP?
a. elevation of the head of the bed
b. saline-furosemide (lasix) infusion
c. mannitol infusion
d. IV dexamethasone (Decadron)
e. hyperventilation
E. hyperventilation, mannitol
steroids - reduce edema
hyperosmotic solution - 3% saline
45yo man was an unhelmeted motorcyclist involved in a high speed collision. he was ejected from the motorcycle and was noted to be apneic at the scene. after being intubated, he was brought to the Er, where he is noted to have a L dilated pupil that responds only sluggishly. what is the pathophysiology of his dilated pupil?
a. infection within the cavernous sinus
b. herniation of the uncal process of the temporal lobe
c. laceration of the corpus callosum by the falx cerebri
d. occult damage to the superior cervical ganglion
e. cerebellar hypoxia
B
pressing on the CN3 - ipsilateral compression of nerve & its parasympathetic fibers
31yo man is brought to the ED following an automobile accident in which his chest struck the steering wheel. exam reveals stable vital signs and no evidence of respiratory distress, but the pt exhibits multiple rib fractures and paradoxical movement of the R side of the chest. CXR shows no evidence of pneumothorax or hemothorax. which of the following is the most appropriate initial management of this pt?
a. intubation, mechanical ventilation and PEEP
b. stabilization fo the chest wall with sandbags
c. stabilization with towel clips
d. immediate operative stabilization
e. pain control, chest physiolotherapy, and close observation
E
“flail chest”
even for flail chest - don’t fix the ribs (unless doing a thoracotomy for another reason)
- mechanical ventilation if needed.
30 yo man is stabbed in the arm. there is no evidence of vascular injury, but he cannot flex his 3 radial digits. which of the following structures has he most likely injured?
a. flexor policis longus & flexor digitus medius tendons
b. radial nerve
c. median nerve
d. thenar and digital nerves at the wrist
e. ulnar nerve
C
median nerve.
no such thing as flexor digitus medius
following a 2h firefighting episode, a 36yo fireman begins complaining of a throbbing HA, nausea, dizziness, and visual disturbances. he is taken to the ED, where his carboboxyhemoglobin level is found to be 31%. which of the following is the most appropriate next step in his treatment?
a. begin an immediate exchange transfusion
b. transfer to pt to a hyperbaric O2 chamber
c. begin bicarbonate infusion & give 250mg acetazolamide (diamox) IV
d. administer 100% O2 by mask
e. perform flexible bronchoscopy with further therapy determined by findings
D. breathing in the CO from the fire
unlikely to be inhalational injury b/c likely had protective equipment on.
75yo man with a hx of coronary artery disease, HTn, and DM undergoes a R hemocolectomy for colon cancer. on POD2, he complains of SOB and chest pain. he becomes hypotensive with depressed mental status and is immediately transferred to the ICU . after intubation and placement on mechanical ventilation, an echo confirms cardiogenic shock. a central venous catheter is placed that demonstrates a central venous pressure of 18mmHg. which following is the appropriate initial management strategy?
a. additional liter fluid bolus
b. inotropic support
c. mechanical circulatory support with intra-aortic balloon pump (IABP)
d. cardiac catheterization
e. heart transplant
B. give pressors
probably from an MI
CVP = 5
1) supplemental O2
2) limit fluids - b/c already fluid overloaded
3) pressors (dopamine) (dobutamine - increased HR, minimal increased BP)
4) mechanical circulatory support - intra-aortic balloom pump (decreased afterload; increased diastolic perfusion pressure)
18yo man climbs up a utility pole to retrieve his younger brother’s kite. an electrical spark jumps from the wire to his metal belt buckle and burns his abdominal wall, knocking him to ground. which of the following should guide your treatment of this pt?
a. injuries are generally more superficial than those from thermal burns
b. IV fluid replacement is based on percentage of body surface area burned.
c. electric burns often result in a transient traumatic optic neuropathy
d. evaluation for fracture of the other extremities and visceral injury is indicated
e. cardiac conduction abnormalities are unlikely.
D
thermal burn –> IV fluid replacement
TX = debridement , skin grafting, amputation of extremities
electrical burn –> more internal, esp. cardiac
- myonecrosis w/ myoglobinuria, renal damage
- cardiac / respiratory arrest
- compartment syndrome
- cataract development
TX = debridement , skin grafting, amputation of extremities, AND fasciotomy
22yo man is examined following a MVA. he has a R knee dislocation which is reduced in hte ED. he has palpable pedal pulses and is neurologically intact. which of the following is an appropriate next step in his workup and management?
a. measurement of ankle brachial indices
b. angiography of the R LE
c. prophylactic below knee 4 compartment fasciotomies
d. surgical exploration of the R popliteal artery
e. observation with serial pulse checks.
A
complications of knee dislocations
- popliteal artery transection ==> but he has palpable pulses
- popliteal artery injuries
DX –> ankle-brachial index< 0.9; CTA
- compartment syndrome d/t ischemia-reperfusion injury
23yo previously healthy man presents to the ED after sustaining a single gunshot wound to the L chest. the entrance wound is 3cm inferior to the nipple and the exit wound is just below the scapula. a chest tube is placed that drains 400mL of blood and continues to drain 50-75mL/h during the initial resuscitation. initial BP of 70/0mmHg has responded to a 2L crystalloid and is now 100/70. abdominal examination is unremarkable. CXR reveals a reexpanded lung and no free air under the diaphragm. which of the following is the best next step in his management?
a. admission and observation
b. peritoneal lavage
c. exploratory thoracotomy
d. exploratory celiotomy
e. local wound exploration
D
Complications of gunshot wounds to the lower chest (below T4)
- intra-abdoinal injury ==> abdominal exploration
- less likely pulmonary injury ==> b/c most parenchymal lung injuries will stop bleeding & heal spontaneously with tube thoracostomy (no need for exploratory thoracotomy)
a pt is brought to the Ed after a MVA. he is unconscious and has a deep scalp laceration and one dilated pupil. his HR is 120, BP 80/40, and RR is 35. despite rapid administration of 2L normal saline, the pt’s vital signs do not change significantly. which of the following is the most appropriate next step in the w/up of his hypotension?
a. neurosurgical consultation for emergent ventriculostomy to manage his ICP.
b. neurosurgical consultation for emergent craniotomy for suspected subdurral hematoma
c. emergent burr hole drainage at the bedside for suspected epidural hematoma
d. administration of mannitol and hyperventilation to treat his elevated ICP
e. abdominal US (focused assessment with sonography in trauma [FAST]).
E
image first !
nothing else on exam that would necesarily say increased ICP.
usually due to hypovolemia
25yo man is involved in a gang shoot-out and sustains an abdominal gunshot wound from a .22 pistol. at laparotomy, it is discovered that the L transverse colon has incurred a through and through injury with minimal fecal soilage of the peritoneum. which of the following is the most appropriate management of the pt?
a. a colostomy should be performed regardless of the pt’s hemodynamic status to decrease the risk of an intraabdominal infection.
b. primary repair should be performed, but only in the absence of hemodynamic instability
c. primary repair should be performed with placement of an intra-abdominal drain next to the repair
d. primary repair should be performed and IV antibiotics administered for 14d.
e. the pt should undergo a 2-stage procedure with resection of the injured portion and reanastomosis 48h later when clinically stabilized.
B
no evidence that abx > 24h in the setting of immediate repair or placement of a drain reduces postoperative infectious complicaitons