Trauma and Wound Management Flashcards
4-2-1 rule
- For maintenance fluids in kids
- 4 mL for first 10 kg
- 2 mL for next 10 kg
- 1 mL for each kg thereafter
Parkland formula
- For fluid bolus
- F x % of body covered by 2 or 3rd degree x body weight kg
- For kids, F = 3
- For adults, F = 2
- 2/3 in first 16 hours, 1/3 in next 8 hours
Contusion
a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise
Four stages of wound healing
- First 2 weeks
- Exudative (Day 1)
- Resorptive (Day 1-3)
- Proliferation (Day 3-7)
- 2 weeks - months/years
- Maturation
Phases of wound healing – detail
Exudative Phase diagram
Resorptive Phase diagram
Proliferative Phase diagram
Maturation Phase diagram
DID NOT HEAL mnemonic
- Drugs (steroids, cytotoxics, immunosuppressives)
- Ischemia/infarcton
- Diabetes
- Nutritional deficiency (iron, copper, zinc, vitamin C)
- Oxygen (hypoxia)
- Toxins (alcohol consumption, smoking)
- Hypothermia/hyperthermia
- Excessive tension on the wound edges
- Acidosis/Another wound
- Local anesthetics
Vitamin C deficiency and wound healing
Delays wound healing in the proliferative phase due to inability to adequately synthesize collagen (terminally mature, cross-linked)
Copper deficiency and wound healing
Delays wound healing in the proliferative phase due to inability to adequately synthesize collagen (terminally mature, cross-linked)
Co-factor for lysl oxidase
Zinc deficiency and wound healing
- Can delay wound healing because the collagenases responsible for collagen remodeling require zinc to function properly
Disease of excessive scarring
- Occurs in dysregulation of the proliferative phase of one of the following:
-
Excess:
- PDGF
- TGFb
- CTGF (connective-tissue growth factor)
- TIMPs
-
Insufficient:
- FGF
- Metalloproteinase (eg collagenase)
- IL-10
-
Excess:
Difference between hypertrophic scar and keloid
-
Hypertrophic scar:
- Cutaneous condition characterized by high fibroblast proliferation and collagen production that leads to a raised scar that does not grow beyond the boundaries of the original lesion.
-
Keloid:
- Lesions grow beyond the original wound margins, leading to a ”claw-like” appearance.
Pathology of contractures
- Excessive proliferation in myofibroblasts during proliferative and maturation phases leads to contraction of the wound.
- Excessive contraction can reduce the functionality of the injured limbs or organs.
-
Wounds that cross a joint are at high risk for causing functional deficits from contracture.
- like Dupuytren’s contracture
Decubitus ulcer
Another name for pressure ulcers
A condition of localized tissue damage due to pressure that obstructs blood flow to the skin and subcutaneous tissue. Most commonly develops over bony prominences, such as the sacrum, heel, hip, and back of the head.
Things patients with multiple wounds should be screened for
- Rhabdomyolysis
- Compartment syndrome
- DVT / VTE
1000 foot management of open wounds
- Cleaning
- Removal of devitalized tissues
- If feasible, wound closure
- Glue
- Wound closure strips
- Suturing
1000 foot management of closed wounds
- Manage according to POLICE principal
- A strategy to minimize inflammation and encourage healing of closed wounds, such as contusions and sprains:
- (P) protection,
- (OL) optimal loading,
- (I) ice,
- (C) compression,
- (E) elevation.
- A strategy to minimize inflammation and encourage healing of closed wounds, such as contusions and sprains:
1000 foot management for chronic wounds
Chronic wounds and ulcers can often be treated conservatively;
however, in severe or nonhealing wounds, surgical intervention, including debridement and skin grafting, may be necessary. Management of the underlying cause (e.g., diabetes, chronic venous disease) is imperative to enable healing of chronic wounds
Managing complete traumatic fingertip amputation
- Control bleeding by placing direct pressure on the wound and raise the injured area.
- Gently clean the amputated part with sterile saline solution.
- Cover with gauze dampened with saline.
- Place in a watertight bag.
- Place the bag in an ice bath in a sealed container.
- Head to hospital for urgent assessment.
Stump ulcer
- Complication of digit amputation
- Etiology: most commonly develops due to friction and repetitive pressure from a prosthesis with a suboptimal fit
- Risk factors: conditions associated with poor wound healing (e.g., diabetes, peripheral neuropathy, poor circulation)
- Management of noninfected stump ulcer: pressure relief, skin care and frequent wound checks, and ensuring a proper prosthetic socket fit
Considerations for bite wounds
- More likely to be infected:
- Common pathogens: Streptococci, Staphylococci, H. influenzae, Pasteruella multicoda, Capnocytophaga canimorsus, anaerobes
- Rabies
- Tetanus
- Will need irrigation and debridement
- Broad spectrum abx: beta lactam - beta lactamise inhibitor OR 2nd or 3rd generation cephalosporin
Rabies ppx for bite wounds with suspicious or unclear history
- Immediate passive AND active immunization
WBite wounds eligible for primary surgical closure
- Clinically uninfected
- <12 hours old (<24 if on face)
- Location other than hand or foot
Considerations for stab wounds
- Do not remove foreign body from wound when performing first aid – this would reduce the beneficial tamponade effect
- Removal in a hospital setting with staff prepared for immediate surgical intervention
Achieving primary wound hemostasis
- Mechanical hemostasis: Apply pressure
- Pharmacologic hemostasis: Local hemostatics (epinephrine, fibrin) or systemic antifibrinolytics (tranexamic acid)
- Surgical hemostasis: Electrocautery or ligation
- Interventional radiology: Angiographic embolization
Risk factors for Clostridium tetani infection of a wound
Penetrating wounds, open fractures, and wounds with extensive devitalized tissue
Assessing wounds for associated damage of peripheral structures
- Vascular injuries: Examine pulses and capillary refill time distal to the wound; assess the 6 Ps for signs of acute limb ischemia
- Peripheral nerve injuries: Examine sensation and motor function distal to the wound before administering anesthesia
- Bone, cartilage, or meniscal injury: Assess for signs of fracture and range of motion (active and passive) of the underlying joint or bone
- Tendon injuries: Assess movement and range of motion of the respective muscles
Basic procedure for primary wound closure
Primary wound closure = wound closure with intent to heal by primary intention
Basic procedure for secondary wound closure
Secondary wound closure = wound closure with intent to heal by secondary intention
Indications for secondary wound closure
- Infected wounds or wounds at high risk of infection
- Wounds with foreign bodies
- Large wounds with irregular edges that cannot be approximated without tension
Primary vs Secondary closure - key points
-
Primary
- Low inflammation, minimal scarring
- Closed
- Tetanus prophylaxis rarely indicated
- Must be done within certain timeframe
-
Secondary
- High inflammation, significant scarring
- Remains open
- Tetanus prophylaxis often indicated
- No specific timeframe, but can change to tertiary closure after 3-5 days in uncomplicated cases
Basic procedure for tertiary wound closure
- Clean the wound and debride any areas of devitalized tissue.
- Close the wound using the methods for primary wound closure outlined above.
Definition of tertiary wound closure and indications
Surgical closure of a wound after healing by secondary intention has already begun; also known as healing by tertiary intention
Indicated for:
- Clean wounds with healthy edges in patients presenting after the time frame within which primary closure can be safely performed.
- Contaminated wounds left to heal by secondary intention and with no signs of infection after 3–5 days
Timeframe for safe primary wound closure
- Within 6–10 hours of injury on the extremities
- Within 10–12 hours of injury on the scalp and face
In otherwise healthy individuals, the timing of suture/staple removal depends on . . .
. . . the location of the wound
Can remove after 3-5 days for face, but 10-14 days for extremities
When are skin grafts contraindicated?
- Contaminated wound
- Insufficient blood supply
Treatment of hematomas and seromas
- Small or asymptomatic: manage expectantly
- Large or symptomatic: exploration and drainage, followed by wound packing until granulation tissue is formed, then closed by delayed primary intention or by secondary intention
In blunt trauma patients, ___ is assumed until proven otherwise
In blunt trauma patients, cervical spine injury is assumed until proven otherwise
That is why we have a very low threshhold for giving people cervical collars in the field (EMS)
The primary survery
- Airway
- Breathing
- Circulation
- Disability (Glasglow coma assessment)
- Exposure (full body exam)
Glasglow coma scale
- If GCS < 8, you need to intubate
Stable vertebral fracture
- Fracture of the anterior column of the spine, in which the structural stability of the spine remains intact
- Clin: Local pain on pressure, compression, unevenness in vertebral process alignment, sometimes paravertebral hematoma, sometimes kyphosis
- No neurologic involvement
- Dx: Detailed neuro exam to r/o involvement, x-ray or CT
- Tx: analgesics, physical therapy, external bracing/orthotic for 8-12 weeks
Unstable vertebral fracture
- Fracture of the mid or posterior columns of the spine, in which the structural stability of the spine is compromised
- Clin: Local pain on pressure, compression, unevenness in vertebral process alignment, sometimes paravertebral hematoma
- May be neurologic involvement, including neurogenic shock
- Dx: Detailed neuro exam, x-ray or CT
- Tx: spinal fusion (spondylodesis)
Crush syndrome
- Rhabdomyolysis w/ AKI
- Hyperkalemia
- Sometimes hypotension
Spinal shock
- Caused by acute traumatic spinal cord injury
Myocardial contusion
- Presents just like CHF, but is in healthy individual in the setting of trauma
Identifying acute intraabdominal hemorrhage
FAST Scan is key here
Telling the difference between pericardial tamponade and tension pneumothorax
- Lung sounds (hyperresonance, one-sided breath sounds in tension pneumo, normal in tamponade)
- Heart sounds (distant in tamponade)
Beck’s triad
- For pericardial tamponade:
- Distant heart sounds
- Hypotension
- Distended neck veins
Diagnosing pericardial tamponade
- Dx:
- Clinical w/ pulsus paradoxus > 10 mm Hg
- FAST/Echo useful for surveilance and may aid Dx, BUT almost never indicated in the acute setting. Instead, you do pulsus as above and then proceed to pericardiocentesis with ultrasound guidance.
CHF vs tamponade on exam
CHF will have lung crackles, since it is a problem with LVEDP
Tamponade will not, since it is a problem with RVEDP (not enough fluid in pulmonary circulation in the first place!)
Hypotension and cold is a __ problem.
Hypotension and warm is a __ problem.
Hypotension and cold is a cardiac output problem.
Hypotension and warm is a SVR problem.
When to suspected basilar skull fracture and what to do
- “Raccoon eyes” / hematomas around eyes
- “Battle sign” / hematoma behind the ear
- Clear otorrhea / clear rhinorrhea
- What to do: Noncontrast CT to look for intracranial hematoma
Most likely bleeder in epidural hematomas
Middle meningeal artery
Acute vs chronic subdural hematomas
- Acute:
- Pres: Shaken baby syndrome, adolescent/adult with massive trauma
- Loss of consciousness -> death
- Dx: CT showing crescent-shaped hematoma
- Tx: Reduce intracranial pressure – elevated head of bed to 30 degrees, hyperventilate, IV mannitol. Extremely poor prognosis.
- Chronic:
- Pres/Path: Elderly individual w/ dementia or chronic EtOH use -> shrunken brains -> bridging veins expand -> veins burst in setting of minor trauma
- Chronic SDH may contribute to their dementia and may be reversible.
- Dx: CT showing crescent-shaped hematoma
- Tx: Craniotomy
Diffuse axonal injury
- Pres: History of angular trauma (spinning), LOC, no recovery -> into coma/brain death
- Dx: CT scan showing gray-white blurring. Brain death testing.
- Tx: Basically none. This is essentially brain death.
Rib fracture
- Etiology: Blunt trauma, but can itself cause penetrating trauma
- Presentation: Chest pain, decreased breathing due to pain on deep inspiration
- Note: Because they don’t breathe deeply, they have atelectasis. This atelectasis can precipitate pneumonia.
- Dx: CXR, see fractures
- Tx: DO NOT USE BINDERS. Instead, you want just pain control and supportive care.
- Complications: Penetrating trauma syndromes of the chest (pneumothorax, etc)
Pneumothorax caused by rib fracture is essentially always going to be ___ and ___
Pneumothorax caused by rib fracture is essentially always going to be open and non-tension
Treatment for traumatic open pneumothorax
- Large pneumothorax:
- Thoracostomy tube placement in upper region of pleura
- Small pneumothorax (< 1 cm):
- Consider high flow oxygen and conservative care vs above
Hemothorax
- Etiology: Penetrating chest trauma
- Pres: Dyspnea in setting of chest trauma
- Dx: CXR showing air-fluid level w/ meniscus and lung collapsed to the upper region of the chest (as shown), dullness to percussion over area (not hyperresonance)
- Tx:
- To address hemothorax: Thoracostomy in bottom of pleura
- To address blood source:
- If pulmonary vasculature bleeding (less than 20 cc/kilo at once OR 3cc/kilo/hr), conservative care.
- If peripheral arterial vasculature bleeding (more than 20 cc/kilo at once OR 3 cc/kilo/hr), surgical ligation.
- Note: for average adult, 20cc/kilo = 1500, 3 cc/kilo = 200
Sucking chest wound
- Etiology: Penetrating trauma from outside (not rib fractures)
- Pres: Dyspnea
- Path: Injury site forms a one-way valve sucking air in over time. Results in gradual pneumothorax and tesion pneumothorax.
- Dx: Clinical, CXR
- Tx: First, occlusive dressing w/ 3/4 seal (make the opposite one-way valve). Then, thoracostomy for tension pneumothorax.
Signs of very severe chest trauma
- Signs:
- Scapular fracture
- Sternal fracture
- Flail chest
- If you see any of these, then the organs of the chest are probably impacted as well. This is where you see lung and heart contusions, transection of the aorta.
Flail chest
- Path: Huge blunt trauma with >2 ribs broken in >2 places
- Pres: Paradoxical breathing motion (part of chest is sucked in when you breathe)
- Dx: Visual inspection, but you will also get CXR since they had massive trauma (look for pulm/cardiac contusions, etc)
- Tx: Binders/weights. If that fails, operate and put in plates.
Pulmonary contusion
- Etiology: Huge blunt trauma
- Pres: In context of scapular fracture, sternal fracture, or flail chest. CXR normal on presentation, but gradually develops profound dyspnea.
- Pathology: Leaky capillaries from “lung bruising”. Non-cardiogenic pulmonary edema.
- Dx: CXR when dyspnea develops (24-48 hours after injury) will show white-out
- Tx: Treat like ARDS. Give colloids for fluid resuscitation, PEEP, and diurese if patient will tolerate.
Myocardial contusion
- Etiology: Huge blunt trauma
- Pres: In context of scapular fracture, sternal fracture, or flail chest.
- Path: Essentially a “heart attack” that is induced by trauma.
- Dx: 12 lead EKG, troponin , FAST scan (to rule out pericardial tamponade)
- Note: These tests should be run prophylactically in anyone with massive trauma like this to screen for this condition.
- Tx: Can’t “reperfuse”, but you can treat the CHF with diuretics and the arrhythmias with antiarrhythmics. Give standard pharmacologic MI therapy (MONABASH)
- Complications: Pericardial tamponade
MONABASH
- Standard MI series of drugs
- Morphine
- Oxygen
- Nitroglycerin
- Aspirin
- Beta blockers
- Statin
- Heparin
Traumatic aortic dissection
- Etiology: Huge blunt trauma
- Pres: In context of scapular fracture, sternal fracture, or flail chest.
- Path: Complete or incomplete dissection and intramediastinal or adventitial hematoma
- Will be incomplete on exams, because complete = death
- Dx: Unequal blood pressures L vs R, CXR showing widened mediastinum are screening. CT angiogram is definitive diagnostic
- Note: If renal failure, MRI or TEE can be used to diagnose
- Tx: Decrease blood pressure with IV beta blockers. Then, emergent surgery.
Thoracotomy vs thoracostomy
Thoracostomy = straw
Thoracotomy you just open it up.
Zone method of penetrating neck trauma management
- Zone I:
- Lower neck
- Risk of contents falling into chest during surgery
- Due to risks of surgery, if hemodynamically stable, get arteriogram, esophogram, and bronch.
- If unstable, go to surgery
- Zone II:
- Mid neck
- Least complicated region to operate on, go straight to surgery whether or not they are stable.
- Zone III:
- Upper neck
- Risk of intraoperational stroke from vessel trauma during surgery
- Due to risks of surgery, if hemodynamically stable, get arteriogram.
- If unstable, go to surgery
Modern neck trauma algorithm
Cardinal rule of abdominal trauma
If the peritoneum has been perforated, they need an exploratory laporotomy
Always assume that a gunshot wound to the abdomen. . .
. . . has penetrated the peritoneum
In other words, 100% of the time these invidiuals need surgery.
AND, for the purposes of gunshot wounds, anything below nipple line (T4) is considered potentially abdominal
Signs that a knife wound has clearly entered the peritoneum (and therefore the patient needs surgery)
- Classic peritoneal signs (guarding, rebound tenderness)
- Shock
- Evisceration
If you see an abdominal knife wound and there are no clear signs of peritoneal involvement on exam, the next step is to. . .
. . . probe the wound
If you enter the peritoneum, then you go to surgery.
If you don’t, you can initiate supportive care and hold back on operating.
Blunt abdominal trauma management
- First step: FAST
- If positive for blood (hematoma/hemoperitoneum), go to OR
- Second step: CT scan
- If positive for blood OR air, go to the OR
- You should NOT order a KUB. But if you are given one, then you are looking for air under the diaphragm, which is an indication for surgery.
In the setting of an unstable patient who you are pretty sure is bleeding with a negative FAST exam, another thing you can do is. . .
. . . diagnostic peritoneal lavage looking for blood
This is not commonly done and more likely CT will be the way to go, it is a very specific and rare scenario where you would use lavage, but it may show up on exams.
Which compartments of the body can hold enough blood to kill you before they tamponade themselves shut?
- Bilateral chest injury
- Abdominal injury
- Pelvic injury
- Injury to either thigh
Most common source of bleeding following abdominal trauma
The liver
Ruptured liver
- Etiology: blunt trauma
- Path: Liver may shear itself around the falciform ligament
- Tx: Pringle maneuver upon laporotomy. If repairable, repair it. If not, lobectomy of the bleeding lobes.
Ruptured spleen
- Path: blunt trauma (2nd most common cause of bleed following blunt trauma)
- Tx: Repair if spleen only damaged organ. If there are multiple bleeders (ex, including liver), resection of the spleen to save time/blood may be necessary.
- Follow-up for resection: Vaccinate against encapsulated organisms
Ruptured diaphragm
- Etiology: blunt trauma
- Dx: Bowel sounds in chest. CXR showing bowel in chest. If hemodynamically stable, diagnosis must be confirmed with CT and concomitant injuries ruled out.
- Tx: Exploratory laporotomy.
Ruptured hollow viscus
- aka ruptured intestinal tract
- Dx: CT scan showing free air
- Tx: Exploratory laporotomy to find hole in intestinal tract.
Free abdominal air on imaging
KUB: Will appear under the diaphragm
CT: Will appear at the anterior-most surface (since patients are laying down supine for CT!)
Pelvic fracture
- Etiology: Enormous trauma (ex, hit by car)
- On exam: Extreme pain with hip rock, able to push hip in both directions at once
- Dx: CT scan
- Once identified, you must look for related injuries: Urethral injury, rectal injury, ureteral injury
- Tx:
- External fixation and transfusion (if indicated) sufficient for most cases.
Urethral injury
- Etiology: Enormous trauma, usually in setting of pelvic fracture
- Pres: High-riding prostate, blood at urethral meatus
- Dx: Retrograde urethrogram
- Tx: DO NOT use Foley catheter. Suprapubic catheter when necessary.
Rectal injury
- Etiology: Enormous trauma, usually in setting of pelvic fracture
- Dx: Proctoscopy
Ureteral injury
- Etiology: Enormous trauma, usually in setting of pelvic fracture
- Dx: CT abdomen and pelvis is now the diagnostic study of choice, NOT IV pyelogram
Generally speaking in the setting of abdominal trauma, if FAST is positive. . . .
. . . the next step depends upon the status of the patient.
Unstable: OR
Stable: CT scan to determine need for exploratory laporotomy
Degrees of burn
- 1st degree: Like a sunburn. Epidermis intact, just a little redness, warmth, pain. Don’t treat apart from pain management instructions.
- 2nd degree:Presence of blisters. Partial thickness through dermis. More painful than first degree. Risk of infection and fluid loss.
- 3rd degree: Full thickness through dermis. Skin is burned away. Muscle and bone exposed. However, there is no pain since skin is burned away – just charred white flesh. Will always be surrounded by 2nd degree.
Chemical burns
- Etiology: Acid, alkali, detergent
- Skin: NEVER BUFFER. This will cause an exothermic reaction and convert the chemical burn into a thermal burn. Instead, irrugate and irrugate and irrugate to oblivion.
- Ingested: NEVER BUFFER. NEVER induce emesis (gives chemical a second pass). NG tubes induce emesis, so don’t do those either. Keep NPO and monitor with serial exams, eventually get endoscopy to grade.
- Complications: Esophageal rupture
Respiratory burns
- Etiology: Closed fire, smoke, explosions, inhaled chemicals
- Pres: May not be bad at first, but will develop edema over time which may close off the airway.
- Warning signs: Soot at the nares, singed nares, stridor.
- Dx: Monitor closely with ABG/SpO2, peak flows. If stable and not deteriorating, you can do bronchoscopy to assess swelling. If it is there, intubate. If not, you are good to manage with supportive care and continued monitoring.
- Tx: When above is deteriorating, prophylactically intubate.
Electrical burns
- Etiology: Touched high voltage wires, struck by lightning
- Pres: Will have an entrance and exit wound (as electricity follows path of least resistance). Skin may look fine, but periosteal muscle may be burned.
- Path: Bones heat up and burn muscles next to them (rhabdomyolysis). Produces arrhythmia if it passes through heart. Muscle jerk precipitated by electricity posteriorly dislocates shoulder.
- Dx: CK to look for rhabdo. Cr for kidney function if CK is positive.
- Tx: If rhabdo, give fluids and mannitol, monitor kidney function.
If you see posterior shoulder dislocation, you should think . . .
. . . seizure vs electrocution
Posterior dislocations are caused by forceful, noncoordinated muscle contraction. These are the two situations that can precipitate this.
Circumferential burn
- Path: Compromise of vascular supply
- Dx: Clinical
- Tx: Cut the eschar. Remove the pressure, remove the disease. Since eschar will be painless, no need for anesthesia.
- Complications: If not treated, necrosis of limb.
Principles of widespread burn management
- Parkland’s formula (w/ Rule of 9’s for %BSA), 50 in 8 - 50 in next 16
- Early movement
- Early grafting
- IV analgesics (also encourages movement)
- Infection prophylaxis with abx and debridement IF INDICATED (topical mupirocin or silver sulfadiazine, if involving the eyes: neomycin or erythromycin ointment)
- Oral abx are not sufficient, stick to the above
- Regarding indication: If burns are simple and umcomplicated, you don’t need to do this – emollients and cleanliness will be sufficient. Only if things are bad do you need to prophylax.
Acute Lung Injury
- Clinical definition:
- Acute onset respiratory insufficiency
- PaO2 / FiO2 < 300
- Nonsegmental pulmonary infiltrates on CXR
- PCWP < 18
- On the same spectrum as ARDS, which is a very severe ALI.
- Can be induced by trauma, similar to pulmonary contusion
Most likely injuries in high speed motor vehicle accident with successful airbag activation and seatbelts
- Blunt chest wall injury (rib frx)
- Pulmonary contusion
- Myocardial contusion
- Aortic dissection
- Traumatic brain injury
- Facial trauma
- Diapgragmatic injury
- Cervical and thoracic spine injury
- Lower extremity fractures
Occult pneumothorax
- Small pneumothorax not visualized on CXR, but seen in CT
- Seen in up to 10% of blunt trauma cases
- 6% will go on to develop more severe symptoms and require chest tube placement if the tube is not placed immediately
- PPV helps mitigate this risk
What don’t you want to do in the treatment of pulmonary contusions?
Give tons of fluids
This will make the situation worse. Give fluids sparingly and smartly.
Leading causes of death associated with blunt chest injury
- Tension pneumothorax
- Massive hemothorax
- Blunt cardiac injury (myocardial contusion)
- Thoracic aortic rupture
Presence of a left lower rib fracture should raise concern for. . .
. . . splenic rupture
Patients over age ___ with multiple rib fractures are at high risk of developing complications, and should be admitted to the hospital for observation even if apparently asymptomatic.
Patients over age 45 with multiple rib fractures are at high risk of developing complications, and should be admitted to the hospital for observation even if apparently asymptomatic.
Isolated sternal fracture
Patients with just sternal fracture (ie, no associated rib injuries) are actually at very low risk for other complications and can be safely managed as outpatients.
When do you take a tube placed for tube thoracostomy out?
48 hours after resolution of the pneumothorax
If air persists or re-expands despite placement of chest tube and suction, __ must be considered
If air persists or re-expands despite placement of chest tube and suction, major tracheobronchial injury must be considered
This requires operative management.
Indications for surgical intervention following chest tube placement in hemothorax
- >1500 mL initial output
- >200 mL/hr output for >4 hours
Management of retained hemothorax (by volume)
- < 300 mL: Low risk for complications. Observe.
- > 300 mL: High risk for complications (empyema, fibrosis). Surgical evacuation is indicated.
Cardiac workup for blunt trauma patients
- Everyone with blunt trauma gets an ECG
- If abnormal, monitor rhythm and pump function for 24 hours
- If normal AND troponin < 0.4 ng/mL, discharge is safe from cardiac perspective
In the case of blunt aortic injury, how should you titrate beta blockers?
Titrate to 100 mm Hg systolic blood pressure
Intervention of choice for diagnosed traumatic aortic dissection
Endocascular repair
Cutoff for DTaP vs Tdap for tetanus prophylaxis
Younger than 7, give DTaP
Older than 7, give Tdap
Order of operations for injury management
- Issues of oxygenation/ventilation
- Issues of blood loss
- Other blunt injuries
If there is high clinical suspicion of pneumothorax in the context of hypotension. . .
. . . you can just go ahead and do a thoracostomy.
No need for CXR. You could save their life by relieving a tension pneumo.
Management of major orthopedic injuries in the acute setting
Unless they are associated with significant bleeding, their management can be deferred for 24-48 hours.
Treating tetanus
- Intubation and sedation
- Muscle relaxants
- Metronidazole
Treating a wound concerning for development of tetanus
-
< 3 lifetime doses of Tdap
- Clean wound: Tdap only
- Diry wound: Tdap + Tetanus Ig
- Note: Timing does NOT matter here – only # of lifetime doses so far
-
> 3 lifetime doses of Tdap
- Clean wound, > 10 years: Tdap
- Clean wound, < 10 years: No treatment
- Dirty wound, > 5 years: Tdap
- Dirty wound, <5 years: No treatment
- Note: Timing DOES matter here
Traumatic central cord syndrome
- May see in cases of injury to cervical spine of an elderly patient with cervical spondylosis
- Often involves acute hyperextension
- Dx: Non-contrast MRI of cervical spine
Non-depressed skull fractures
- Asymptomatic patients with relatively small (< 3 mm) linear, nondepressed skull fractures may be sent home without further management
- If symptomatic (ie, headache, Cushing’s triad), they should be monitored as an inpatient
- Note: Non-depressed skull fracture means there is low risk of injury to brain parenchyma
While in non-emergent cases you want to ensure that the cervical spine is safe before intubating, for emergencies. . .
. . . you intubate before obtaining imaging of the cervical spine
Protecting their breathing is more important. This is especially true if the cervical spine itself is injured, because cervical fractures may lead to immediate or delayed cervical spinal cord compression and/or phrenic nerve paralysis and subsequent respiratory failure.
Anterior cranial fossa fracture vs temporal fracture
-
Anterior crania fossa:
- Raccoon eyes
- CSF rhinorrhea
-
Temporal fracture:
- Postauricular ecchymosis / Battle sign
- CSF otorrhea
In addition to the ABCs, whenever you are doing a primary survey of a truama patient you should also. . .
. . . insert a Foley catheter and two large bore IVs
Also an NG tube, if necessary
When is it appropriate to get a CT to assess bullet trajectory in a gunshot victim?
When the patient is hemodynamically stable and has low suspicion for vital torso injury
In the setting of hemorrhagic trauma, the ideal resuscitation fluid is. . .
. . . blood products in a ratio of 1:1:1.
Survival is better than with crystalloid!!!
Reversing warfarinization in the emergency setting
Factor IX prothrombin concentrate is the preferred agent
First-line therapy for a bleeding extremity in a patient with shock
Apply pressure
Then, place a tourniquet proximally
Patients with fracture to the calcaneus are also at risk for . . .
. . . fractures of the femoral neck and lumbar spine
Therefore, an X-ray of the thoracolumbar spine is required.
For the purposes of the ABCDE approach to the primary survey, cervical collar placement falls under. . .
. . . A
In fact, it should be the first thing you do even if you suspect pneumothorax. It is that important to protection of the airway.
Anyone who presents with spinal shock or diffuse spinal paralysis in the lower extremities needs a ___
Anyone who presents with spinal shock or diffuse spinal paralysis in the lower extremities needs a Foley
They may develop acute urinary retention if they are not catheterized
Renal injury
- Suspected when there is posterior abdominal / costovertebral trauma and urinary changes (oliguria, anuria, hematuria)
- Hemodynamically stable: CT abdomen and pelvis with contrast.
- Hemodynamically unstable: Emergent surgical exploration
- Tx: Less severe trauma usually self-resolves without intervention. Rarely, renal trauma can lead to life-threatening hemorrhage or expanding retroperitoneal hematomas, both of which are indications for surgical exploration.
“Child wearing adult seatbelt in car accident” injuries
- Lumbar spinal fracture
- Duodenal hematoma
- Treat w/ NG tube decompression and TPN
Pancreatic ductal injury
- Occurs in blunt abdominal trauma in which the pancreas is compressed against the vertebral bodies posterior to it
- Most commonly from seatbelt or handlebar injuries in car or motorcycle accidents
- Signs and symptoms of ductal injury may resemble those of acute pancreatitis and may likewise take several days to manifest.
- CT is has poor sensitivity for pancreatic ductal injuries
Low-grade splenic hematomas can be managed. . .
. . . expectantly with serial ultrasounds
These would be for sub-capsular hematomas with little or no intraperitoneal bleeding, < 10% of spleen surface area, penetrating < 1 cm
When performing a cricothyrotomy, do you aim up or down the trachea?
DOWN
If you aim up, you may hit the vocal cords
Site of decompression for needle thoracostomy
What properties of an IV are ideal for trauma cases?
Wide, and short
For lowest flow friction
First step in workup of truama with pelvic fracture
Pelvic binder
DO THIS BEFORE you investigate for pelvic organ injury. The idea with pelvic binder is to prevent hematoma expansion in pelvic bleed by promoting tamponade.
Differentiating anterior bladder wall rupture from bladder dome rupture
The bladder dome shares a wall with the peritoneum. So, if the bladder dome is the part of the bladder that is ruptured, you will have peritonitis
The anterior bladder wall will not necessarily involve peritonitis
Appropriate dressings for infected/necrotic vs healthy wounds
- Infected wounds OR wounds with necrotic tissue: Wet-to-dry dressings
- Healthy granulation tissue: Nonadherent, moisture-retaining dressings
