Trauma, Burns and Sepsis Flashcards
1
Q
what do you do in a patient with decreased breath sounds on one side but otherwise stable?
A
order CXR and pulse oximetry
2
Q
tx. of spontaneous PTX in trauma pt
A
insertion of large diameter chest tube
- insert finger into pleural space prior to inserting the tube to make sure its in the right place
3
Q
where do you direct a chest tube?
A
toward the posterior, apical aspect of the pleural space
4
Q
what is the correct location to insert a chest tube?
A
bw 4th and 5th intercostal spaces in the midaxillary line
5
Q
what should happen after insertion of a chest tube correctly?
A
the lung should re-expand
6
Q
after insertion of a chest tube, a large amt of air continues to leak into the chest tube over next few hours and lung is still only partially inflated
A
injury to major bronchus or trachea
- requires partial lung resection to repair
7
Q
when is observation of a small PTX appropriate?
A
- not enlarging
- no free fluid in pleural space (i.e. no hemothorax)
- pt is asymptomatic
- pt has not other injuries requiring surgery
8
Q
if pt has small PTX and requires surgery why must a chest tube be inserted?
A
assisted ventilation puts positive pressure in lungs which increases the risk of converting a small PTX to a larger one
9
Q
what signs/symptoms point to tension PTX?
A
decreased breath sounds on one side
hypotension
JVD
10
Q
tx. of tension PTX
A
immediate needle aspiration followed by insertion of chest tube
- get CXR after, not BEFORE
11
Q
what else can cause hypotension and JVD in a trauma patient?
A
pericardial tamponade
- do emergent ultrasound and pericardiocentesis and then send patient to OR
12
Q
initial management of patient with hypotension?
A
two large bore IV lines with rapid infusion of 1-2 L of NS
13
Q
can a closed head injury be the cause of severe hypotension?
A
no.. there is not enough space for the head to hold that much blood and due to the Cushing reflex
14
Q
when putting in a urinary catheter, you notice blood at the urethral meatus..
A
do not insert the catheter
- instead assess for possible causes of urethral injury (DRE for prostate); definitive diagnosis with retrograde cystourethrogram
15
Q
how do you properly assess cervical spine?
A
- stabilize neck with collar/board
- palpate alone posterior aspect for tenderness or any deformity
- ask patient to move his fingers and toes and to tell you if they can feel you touch them
- order CT scan to R/O injury
16
Q
what do you do if after insertion of a chest tube, there is 1500 ml of blood evacuated?
A
thoracotomy - to evaluate for lung hilar injury or injury to the heart
- also do this is rate of blood loss is > 200ml/hr for 3 hrs
17
Q
what are you worried about with a stab wound just below the clavicle? how should you evaluate?
A
subclavian artery or venous injury
- if pt is stable do an angiogram
- if pt is unstable, urgent exploration
18
Q
what are you worried about if there is a penetrating injury below the nipple?
A
diaphragmatic injury
- need abdominal exploration
19
Q
pt who was in an MVA has a widened mediastinum on AP CXR - what do you suspect and what test should you order next if pt is stable?
A
suspect thoracic aortic transection
- order normal PA CXR
20
Q
what is the next step once you find a widened mediastinum on CXR?
A
order aortic angiography (gold standard) or CT scan
21
Q
next step in management in gunshot wound to the abdomen
A
preoperative radiograph followed by abdominal exploration
22
Q
when is surgical exploration of the abdomen justified?
A
- obvious, penetrating injuries
- unstable pts with rapidly distending abdomen or severe abdominal pain
23
Q
what test should you do next in someone with suspected abdominal injuries but no justification for abdominal exploration who is unstable?
A
diagnostic peritneal lavage
24
Q
“positive” diagnostic peritoneal lavage
A
- > 10 ml gross blood
- > 100 000/ml RBC in lavage fluid
- appearance of vegetable matter or bile
25
what test do you use to investigate abdominal trauma in a stable pt?
CT scan w/ contrast
26
pt with suspected adbominal trauma complains of severe, diffuse abdominal pain - what do you do?
sign of irritation of peritoneum - indication for exploration w/o further tests
27
a patient comes in but is comatose..how do you examine their abdomen?
physical is useless
| - order either DPL, CT or FAST if necessary
28
pt with suspected abdominal trauma has a CXR; it shows the stomach in the left chest
diaphragm rupture - should be repaired in OR
29
how do you assess for pelvic bleeding as a cause of hypotension?
pelvic angiogram
| - will show significant bleeding from branch of internal iliac artery and can be controlled by embolization
30
If you feel a radial pulse, the systolic BP is atleast .... (1)
If you feel a femoral or carotid pulse, the systolic BP is atleast (2)
1. 80 mmHg
| 2. 60 mmHg
31
Who may not mount tachycardic response to hypovolemic shock
Pts with spinal cord injuries
Pts on beta blockers
Well conditioned athletes
32
Contraindications to Foley catheter placement (4)
Pelvic fracture in men
Blood at urethral meatus
High riding ballotable prostate
Scrotal/perineal injury or ecchymosis
33
What is a quick way to assess airway?
Ask patient a question, if patient can speak airway is intact
34
Signs if airway obstruction
Stridor, hoarseness, respiratory retractions, use of accessory muscles
35
What can the gag reflex tell you about the airway?
If present, the airway is clear
| If absent, should inspect airway digitally for foreign bodies
36
Indications for intubation in a trauma patient
Expanding hematoma
Subcutaneous emphysema (injury to major bronchus)
Pt unconscious - GCS < 8 or severely depressed mental status
Extensive facial fracture
Laryngeal edema - hoarseness, stridor, change in voice
Inadequate respiratory effort
37
What test do you need to do in a pt with subcutaneous emphysema before intubation?
Fibreoptic bronchoscopy - advance beyond injured segment under direct visualization.
38
An unconscious pt is brought in with spontaneous but noisy and labored breathing; prior to losing consciousness he complained of neck pain and was unable to move extremities - what should you be considering and doing?
Consider cervical spinal injury
- airway needs to be protected first: perform intubation with manual inline cervical immobilization or over a flexible bronchoscope
39
Pt in severe MVA is fully awake and alert but he has extensive facial fractures and he is bleeding briskly into his airway - next step?
Secure airway - orotracheal route is probably impossible
| - do cricothyroidotomy or percutaneous thyroidostomy
40
What three things indicate good 'breathing'
Spontaneous breathing
Bilateral breath sounds
Pulse oximetry over 95
41
MCC of hypovolemic shock (3)
Bleeding - chest not involved
Pericardial tamponade
Tension PTX
42
How do you distinguish shock caused by bleeding from tension PTX/ tamponade?
Bleeding has low CVP, tension PTX/tamponade have high CVP and distended neck veins
43
Tx of hypovolemic shock due to bleeding
Big bore IV lines, Foley catheter and IV antibiotics
Immediate exploratory laparotomy
Fluids and blood administration come AFTER stopping bleeding
44
Pt comes to ER in state of shock after a gunshot to the groin; he is squirting bright red blood from the wound - what so you do?
Control bleeding by local pressure (gloved finger or sterile pressure dressing) then fluids
45
A car accident victim is brought in to ER with obvious signs of hypovolemic shock due to bleeding; however, non source of bleeding can be identified - what do you do?
Two large peripheral lines with infusion of Ringer lactate (1-2 L in first 20 minutes followed by blood products
- percutaneous femoral vein catheter if peripheral iv is hard to start
46
If you are unable to start a peripheral line on a child under age 6, where can you do it?
Intra osseous cannulation of proximal tibia
| In children this small, give 20ml/kg of ringers lactate
47
Signs of pericardial tamponade
```
Hypotension
Muffled heart sounds
JVD
Pulses paradoxus
Kussmauls' sign: JVD with inspiration
```
48
Tx of pericardial tamponade
Need to evacuate pericardium - do pericardiocentesis or pericardial window
Follow with thoracotomy and exploratory laparotomy
49
how do you manage a case of pericardial tamponade in a patient with a stab wound to the chest?
median sternotomy -> no need to do pericardiocentesis first because sternotomy will open the pericardial sac
50
you suspect tension PTX in pt.. what is your management approach?
immediate big-bore IV needle or IV catheter decompression (2nd IC space, midclavicular line) followed by chest tube in 4th IC space in ant/midaxillary line (at level of nipple in men)
51
pale, cold, clammy pt with low CVP in a non-trauma setting
internal bleeding
52
pale, cold clammy pt with high CVP in non-trauma setting
cardiogenic shock
53
warm, flushed pt with low CVP in non-trauma setting
anaphylactic shock (vasomotor shock)
54
what do you do in a situation where a weapon or object is impailed in a patient?
never remove it in ER or at scene of crime - should be removed in controlled setting in OR
55
pt in ER has a scalp laceration and a CT scan showing an underlying linear skull fracture; he is neurologically intact and has no history of LOC - management?
laceration cleaned and closed in ER
| - no further action for skull fracture
56
tx. of a comminuted and depressed skull fracture
cleaning and repair (possible craniotomy) in OR
57
pt brought in who was hit by a car; he was unconscious at the scene but is now lucid; he does not recall how the accident happened - management?
CT scan
| - anyone who became unconscious should have a CT scan
58
pt is hit by a car and arrives in ER in a coma with ecchymosis around both eyes (raccoon eyes)
basal skull fracture
59
how can a basal skull fracture present? (3)
ecchymosis around both eyes
clear fluid dripping out of nose/ear
ecchymosis behind the ear
- in addition to pt usually being in a coma
60
14 yo boy is hit over head with baseball bat, he loses consciousness and recovers prompty and continues to play; one hour later he is found unconscious in the locker room; his right pupil is fixed and dilated and there are signs of contralateral hemiparesis - what test should be done?
CT scan - to diagnose epidural hematoma
61
tx. of acute epidural hematoma
emergency surgical decompression
| - craniotomy
62
how can you distinguish an acute epidural from subdural hematoma clinically?
epidural hematoma usually has more prominent lucid interval and more trivial injury (vs. big trauma and sicker patient in subdural bleeds)
63
management of subdural hematoma
if signs of midline shift - emergency craniotomy
| if no signs of displacement - monitor ICP, ICU medical tx.
64
CT scan of head shows diffuse blurring of gray-white mass interface and multiple small punctate hemorrhages; pt is in a deep coma, with bilateral fixed dilated pupils - dx? management?
dx. diffuse axonal injury
| tx. want to prevent further increases in ICP
65
therapy aimed at decreasing ICP
elevation of the head
hyperventilation
avoiding fluid overload
sometimes, mannitol and furosemide
66
when is hyperventilation indicated for ICP?
signs of brain herniation
| when you want PaCO2 of 35 mmHg
67
how do you lower the oxygen demand in traumatic brain injury patients?
sedation
| hypothermia - better option
68
tx of chronic subdural hematoma
surgical decompression
69
pt has been shot in the neck and his BP is rapidly dropping...what do you do?
penetrating wounds anywhere in the neck need immediate surgical exploration if pt is unstable
70
what are the indications for surgery in a penetrating neck injury?
below mandible to cricoid cartilage (middle of the neck, zone II)
coughing/splitting blood
expanding hematoma
unstable vitals
71
what is the next best step for a neck injury above the level of the mandible?
angiography with possible embolization
| - vascular injuries are only possible problem but difficult to get to surgically in this area
72
what is the approach to management for an injury to the neck below the cricoid cartilage (above clavicles)?
```
if pt stable do W/U:
- angiography
- soluble contrast esophagogram and barium
- esophagoscopy
- bronchoscopy
THEN SURGERY
```
73
management of an asymptomatic pt with a stab wound in the upper or middle zone of neck?
can be safely observed for 12 hours w/o workup or surgical exploration
74
what is the proper approach to a cervical spinal injury?
1. immobilize
2. palpate for tenderness over posterior midline
3. assess motor and sensory function
4. imaging (usually lateral XR)
75
best test for suspected cervical spine injury?
CT scan of head/neck
76
what signs/sx prompt you to consider a cervical spine injury?
neurological deficits
imaging abnormalities
local tenderness
77
pt gets stabbed in the back, right side of midline; he has paralysis and loss of proprioception distal to injury on RIGHT and loss of pain perception distal to injury on LEFT
spinal cord hemisection - Brown-Sequard syndrome
78
pt in a car accident sustains burst fracture of vertebral body; he has loss of motor function and pain/temp sensation on both sides distal to injury while shows preserved vibratory and position sense - dx?
anterior cord syndrome
79
pt in car accident has a neck hyperextension injury; he develops paralysis and burning pain in both upper extremities while maintaining good motor function in legs - dx?
central cord syndrome
80
best test to look at spinal cord
MRI
81
tx. of rib fracture
local pain relief - best achieved by nerve block or epidural catheter
82
pt is stabbed in the chest; he is mildly SOB but stable. there is decreased breath sounds on the right side and is hyperresonant to percussion - dx? management?
dx. plain PTX
| tx. CXR to confirm; chest tube to underwater seal and suction
83
pt is stabbed in the chest; he is mildly SOB but stable; the base of the right chest has no breath sounds and is dull to percussion with faintly distant breath sounds at the apex - dx? tx?
hemothorax - dx w/ XR
| - treat with chest tube on right at base of pleural cavity
84
you put a chest tube in a recover > 1000-1500 ml of blood - next step in management?
surgical intervention
| - will need thoracotomy or thoracoscopy to ligate the bleeding vessel
85
what artery is most likely responsible for bleeding in a large hemothorax?
intercostal artery
86
chest tube for tx. of hemothorax turns up > 600 ml of fluid over 6 hours?
surgical intervention required
87
CXR shows multiple air fluid levels in the chest - dx?
diaphragmatic injury with bowel up in chest
88
pt with stab wound to chest has no breath sounds on the right, hyperresonant to percussion at apex, dull to percussion at base; CXR shows one, large single air fluid level
hemopneumothorax
| - insert chest tube at base to drain fluid, can also put one in at apex for air
89
tx of a sucking chest wound
large occlusive dressing with Vaseline gauze with 3 secured sides; chest tube
90
pt with multiple rib fractures presents with a segment of the chest wall that caves when she inhales and bulges out when she exhales...dx?
flail chest
| - 2+ fractures in 3+ consecutive ribs
91
tx of flail chest
positive pressure ventilation w/ PEEP
| bilateral chest tubes to prevent tension PTX
92
2 days after sustaining multiple rib fractures on both sides the pt presents with respiratory distress; CXR shows lungs "white out" - dx?
pulmonary contusion
93
tx. of pulmonary contusion
fluid restriction, diuretics and respiratory support with mechanical ventilation and PEEP
94
what kind of injury can cause traumatic transection of aortia?
deceleration injury
95
pt in MVA has multiple bruises over the chest and is very tender over sternum; palpation of sternum elicits a gritty feeling of bone grating on bone...
sternal fracture
96
how do you confirm a sternal fracture?
lateral CXR
97
what are you afraid of with a sternal fracture?
myocardial contusion - check ECG, troponins
| aortic transection - order CT scan
98
an NG tube curling up in the left chest is an indication of?
traumatic diaphragmatic rupture
| - tx. surgical repair
99
what location is transection of the aorta usually in?
isthmus - junction of arch and descending aorta
100
diagnostic test to check for aortic transection/
spiral CT (with angiography)
101
pt with severe blunt trauma due to MVA begins to develop progressive subcutaneous emphysema all over her upper chest and lower neck - what 3 things concern you
1. rupture of esophagus
2. tension PTX
3. rupture of trachea or major bronchus
102
how do you confirm rupture of trachea or major bronchus?
fibreoptic bronchoscopy
- also helps secure airway
- surgery follows
103
a chest tube for a traumatic PTX is putting out a very large amt of air through the tube and the collapsed lung is not expanding - dx/
major bronchial injury
104
pt with penetrating injury of chest is intubated and placed on respirator and a chest tube has been placed; he is stable and then suddenly goes into cardiac arrest - dx?
air embolism - from injured bronchus to nearby injured pulmonary vein and to LV
105
tx of sudden cardiac arrest from air embolism
cardiac massage - pt on Left side down
| thoracotomy
106
causes of air embolism
chest trauma (intubation)
supraclavicular LN biopsy
CVP placement
CV lines that are disconnected
107
management of a penetrating gunshot wound to the abdomen
foley catheter/ large bore IV lines
broad spec antibiotics
tetanus prophylaxis
EXPLORATORY LAPAROTOMY
108
what do you do for a gunshot wound just below the nipple?
below the nipple is considered both abdomen and chest
| - need exploratory laparatomy and CXR/chest tube
109
when do you do an exploratory laparotomy for a stab wound or blunt trauma to the abdomen?
protruding viscera
hemodynamically unstable
sx. of peritoneal irritation
110
how much blood must you lose in order to go into hypovolemic shock?
25-35% (about 1.5 L in avg size adult)
111
what areas most commonly have "hidden" internal bleeding leading to hypovolemic shock?
pelvic fractures
multiple femur fractures
intra-abdominal bleeding
112
Dx. of major intra-abdominal bleeding
stable pt? - CT scan
| unstable? - diagnostic peritoneal lavage or sonogram
113
what is the most likely cause of major intra-abdominal bleeding?
ruptured spleen
114
how do you tx. ruptured spleen?
efforts to repair it >> removal
| if removed, must immunize with pneumovax, H.fluB and meningococcus (encapsulated bacteria)
115
multiple trauma pt being operated on requires multiple blood transfusions; he develops coagulopathy evidenced by blood oozing from all dissected surfaces and IV lines - tx?
FFP and platelet packs - 10 units of each
116
during course of laparotomy for multiple trauma, patient develops significant coagulopathy, hypothermia and refractory acidosis - management?
abdomen needs to be closed immediately (with packing) and no further operating can be done
117
in a multiple trauma patient undergoing surgery with multiple blood transfusions and several liters of Ringers lactate, the surgeons are unable to close the abdomen bc they find the wound edges cannot be pulled together without undue tension; the abdominal wall and contents seems to be swollen - dx?
abdominal compartment syndrome
118
tx of abdominal compartment syndrome
close the wound with absorbable mesh over which formal closure can be done later or with a non-absorbable plastic cover that will be removed later
119
trauma patient POD1 develops a tense and distended abdomen; the retention sutures are cutting through abdominal wall; he also develops hypoxia and renal failure - dx?
abdominal compartment syndrome that developed a bit later
| - tx. involves decompression by opening the incision
120
patient with a crush injury to pelvis arrives hypotensive but responds to fluid resuscitation; CT scan shows no intra-abdominal bleeding and a pelvic hematoma - how do you manage this patient?
non-expanding pelvic hematomas in pt who is stable can be left alone; must R/O other associated injuries to rectum, bladder and vagina
121
pt with crush injuries is determined to have a pelvic fracture; she is hemodynamically unstable - management?
- not surgery (difficult to access)
- arteriography with embolization (if arterial)
- external pelvic fixation
122
male pt with a pelvic fracture has blood at the meatus - what does this mean? what is the first test you run?
1. bladder or urethral injury
| 2. eval. starts with retrograde urethrogram
123
characteristics of a posterior urethral injury
blood at meatus
scrotal hematoma
sensation of wanting to urinate but cannot
high-riding prostate on DRE
124
characteristics of anterior urethra injury
blood at meatus and scrotal hematoma
125
a pt after MVA with a pelvis fracture has no blood at the meatus but when trying to insert a foley catheter, a medical student feels resistance...
urethral injury! stop catheterizing and order retrograde urethrogram
126
insertion of a foley catheter in a woman reveals gross hematuria - dx?
likely bladder injury
127
how do you diagnose bladder injury?
retrograde cystogram
- may see intraperitoneal extravasation (rupture at dome)
- do post-void films to assess retroperitoneal extravasation (rupture at trigone)
128
gross hematuria on catheterization in a patient with multiple rib fractures...
think kidney injury and order CT scan
129
tx. of traumatic hematuria due to blunt kidney trauma
no surgery, even if kidney is smashed
| - operate only if renal pedicle is avulsed or patient is exsanguinating
130
some time after sustaining kidney injuries during trauma, a patient presents with acute SOB and a flank bruit - dx?
AV fistula formed at renal pedicle with subsequent heart failure
131
tx. of AV fistula at renal pedicle after trauma
arteriogram and surgical correction
132
approach to adult with traumatic microhematuria
no work-up required
| - if it were gross traumatic hematuria or hematuria unrelated to trauma a workup would be needed
133
approach to traumatic microhematuria in a child
always investigate - usually means a congenital anomaly
| - start with sonogram
134
young boy presents with scrotal hematoma - what do you do next?
order an USG to assess whether testicle is ruptured or not
| - if ruptured = surgery; if not = symptomatic tx
135
man comes in reporting that he slipped in the shower and fell; on exam he has a large penile shaft hematoma with normal appearing glans - dx?
fracture of tunica albuginea/corpora cavernosa - only happens to erect penis
136
tx. of fracture of penis
urologic emergency
| - surgical repair or importence will ensue due to formation of AV shunts
137
gunshot wound to anterolateral thigh with bullet lodged in muscles posterolateral to femur - management?
no important anatomy in this area
- clean wound
- tetanus prophylaxis
- bullet can remain in there
138
what is the next step if a bullet wound is in an area of close proximity to an area where vascular injury is likely?
Doppler or CT-angio
139
normal order of repair in a patient with shattered bone, ruptured vessel and torn nerve?
stabilize bone first, then vascular repair and lastly nerve repair; in such cases, fasciotomy is mandatory
140
what are the main concerns with crush injuries of extremities?
1. myoglobinemia-acute renal failure
2. delayed swelling and compartment syndrome
3. hyperkalemia
141
tx. of electrical burns
extensive surgical debridement
IVF
osmotic diuretics
alkalinization of urine
142
complications of electrical burns:
- posterior dislocation of shoulder
- compression fracture of vertebral body
- cataracts
- demyelinazation syndromes
143
man rescued from burning building it noted to have burns around mouth and nose and inside of his mouth/throat look like inside of chimney - what are you concerned about?
CO poisoning
| respiratory burns
144
how do you manage CO poisoning
- measure carboxyhemoglobin levels
| - administer 100% O2
145
diagnosis of respiratory burns
bronchoscopy - confirms injury
| need for therapy and actual degree of damage is revealed by monitoring blood gases
146
management of circumferential burns
compulsive monitoring of Doppler signals of peripheral pulses and capillary filling - if circulation compromised, escharotomy must be performed
147
how fast should infusion of IVF be after burn injury?
1000 ml/hour (of Ringer's lactate)
148
Parkland formula (old)
4 ml RL x kg x %BSA (+ 2L D5W for maintenance)
| - give 1/2 in first 8 hours, 2nd half in next 16 hrs
149
how do you calculate fluid replacement in babies for burns?
rate in first hour = 20 ml/kg
| 24-hour calculations = 4-6 ml/kg/%
150
management of 2nd/3rd degree burns after fluid resuscitation....
```
tetanus prophylaxis
topical agent - silver sulfadiazine
mafenide acetate - if deep penetration required
pain meds IV
intensive nutritional support
```
151
tx. for small, contained, clearly third degree burn (white, leathery, dry and anesthetic)
early excision and grafting
152
provoked dog bite (i.e. child tried to pet domestic dog while it is eating) - management
tetanus prophylaxis and standard wound care
| - if bite near face, rabies tx. may be needed
153
unprovoked bite by an animal that may have rabies, but you are unable to capture it - tx?
rabies prophylaxis is mandatory (IVIG plus vaccine)
154
reliable signs of envenomation by a poisonous snake
excruciating local pain
swelling
discoloration
- usually w/in 30 minutes
155
tx. of snake bite that has signs of envenomation
- draw blood for crossmatch, coag studies, renal and LFTs
- antivenin: CroFab
- surgical excision and fasciotomy in severe cases
156
dose of Epinephrine for anaphylactic shock
0.3-0.5 ml of 1:1000 solution
157
lady is bit by a spider that is black with red hourglass mark on its belly; pt has NV and severe generalized muscle cramps
black widow spider bite
| tx. IV calcium gluconate and muscle relaxants
158
pt comes in with a "bug bite"; the ulcer is 1 cm in diameter with a necrotic centre and surrounding halo of erythema
brown recluse spider bite
tx. dapsone
local excision and skin grafting may be needed
159
tx. of human bite
surgical exploration by orthopedic surgeon with extensive irrigation and debridement
