Trauma, Burns and Sepsis Flashcards
what do you do in a patient with decreased breath sounds on one side but otherwise stable?
order CXR and pulse oximetry
tx. of spontaneous PTX in trauma pt
insertion of large diameter chest tube
- insert finger into pleural space prior to inserting the tube to make sure its in the right place
where do you direct a chest tube?
toward the posterior, apical aspect of the pleural space
what is the correct location to insert a chest tube?
bw 4th and 5th intercostal spaces in the midaxillary line
what should happen after insertion of a chest tube correctly?
the lung should re-expand
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
injury to major bronchus or trachea
- requires partial lung resection to repair
when is observation of a small PTX appropriate?
- not enlarging
- no free fluid in pleural space (i.e. no hemothorax)
- pt is asymptomatic
- pt has not other injuries requiring surgery
if pt has small PTX and requires surgery why must a chest tube be inserted?
assisted ventilation puts positive pressure in lungs which increases the risk of converting a small PTX to a larger one
what signs/symptoms point to tension PTX?
decreased breath sounds on one side
hypotension
JVD
tx. of tension PTX
immediate needle aspiration followed by insertion of chest tube
- get CXR after, not BEFORE
what else can cause hypotension and JVD in a trauma patient?
pericardial tamponade
- do emergent ultrasound and pericardiocentesis and then send patient to OR
initial management of patient with hypotension?
two large bore IV lines with rapid infusion of 1-2 L of NS
can a closed head injury be the cause of severe hypotension?
no.. there is not enough space for the head to hold that much blood and due to the Cushing reflex
when putting in a urinary catheter, you notice blood at the urethral meatus..
do not insert the catheter
- instead assess for possible causes of urethral injury (DRE for prostate); definitive diagnosis with retrograde cystourethrogram
how do you properly assess cervical spine?
- 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
what do you do if after insertion of a chest tube, there is 1500 ml of blood evacuated?
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
what are you worried about with a stab wound just below the clavicle? how should you evaluate?
subclavian artery or venous injury
- if pt is stable do an angiogram
- if pt is unstable, urgent exploration
what are you worried about if there is a penetrating injury below the nipple?
diaphragmatic injury
- need abdominal exploration
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?
suspect thoracic aortic transection
- order normal PA CXR
what is the next step once you find a widened mediastinum on CXR?
order aortic angiography (gold standard) or CT scan
next step in management in gunshot wound to the abdomen
preoperative radiograph followed by abdominal exploration
when is surgical exploration of the abdomen justified?
- obvious, penetrating injuries
- unstable pts with rapidly distending abdomen or severe abdominal pain
what test should you do next in someone with suspected abdominal injuries but no justification for abdominal exploration who is unstable?
diagnostic peritneal lavage
“positive” diagnostic peritoneal lavage
- > 10 ml gross blood
- > 100 000/ml RBC in lavage fluid
- appearance of vegetable matter or bile
what test do you use to investigate abdominal trauma in a stable pt?
CT scan w/ contrast
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
a patient comes in but is comatose..how do you examine their abdomen?
physical is useless
- order either DPL, CT or FAST if necessary
pt with suspected abdominal trauma has a CXR; it shows the stomach in the left chest
diaphragm rupture - should be repaired in OR
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
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)
- 80 mmHg
2. 60 mmHg
Who may not mount tachycardic response to hypovolemic shock
Pts with spinal cord injuries
Pts on beta blockers
Well conditioned athletes
Contraindications to Foley catheter placement (4)
Pelvic fracture in men
Blood at urethral meatus
High riding ballotable prostate
Scrotal/perineal injury or ecchymosis
What is a quick way to assess airway?
Ask patient a question, if patient can speak airway is intact
Signs if airway obstruction
Stridor, hoarseness, respiratory retractions, use of accessory muscles
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
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
What test do you need to do in a pt with subcutaneous emphysema before intubation?
Fibreoptic bronchoscopy - advance beyond injured segment under direct visualization.
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
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
What three things indicate good ‘breathing’
Spontaneous breathing
Bilateral breath sounds
Pulse oximetry over 95
MCC of hypovolemic shock (3)
Bleeding - chest not involved
Pericardial tamponade
Tension PTX
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
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
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
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
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
Signs of pericardial tamponade
Hypotension Muffled heart sounds JVD Pulses paradoxus Kussmauls' sign: JVD with inspiration
Tx of pericardial tamponade
Need to evacuate pericardium - do pericardiocentesis or pericardial window
Follow with thoracotomy and exploratory laparotomy
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
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)
pale, cold, clammy pt with low CVP in a non-trauma setting
internal bleeding
pale, cold clammy pt with high CVP in non-trauma setting
cardiogenic shock
warm, flushed pt with low CVP in non-trauma setting
anaphylactic shock (vasomotor shock)
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
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
tx. of a comminuted and depressed skull fracture
cleaning and repair (possible craniotomy) in OR
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
pt is hit by a car and arrives in ER in a coma with ecchymosis around both eyes (raccoon eyes)
basal skull fracture
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
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
tx. of acute epidural hematoma
emergency surgical decompression
- craniotomy
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)
management of subdural hematoma
if signs of midline shift - emergency craniotomy
if no signs of displacement - monitor ICP, ICU medical tx.
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
therapy aimed at decreasing ICP
elevation of the head
hyperventilation
avoiding fluid overload
sometimes, mannitol and furosemide
when is hyperventilation indicated for ICP?
signs of brain herniation
when you want PaCO2 of 35 mmHg
how do you lower the oxygen demand in traumatic brain injury patients?
sedation
hypothermia - better option
tx of chronic subdural hematoma
surgical decompression
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
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
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
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
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
what is the proper approach to a cervical spinal injury?
- immobilize
- palpate for tenderness over posterior midline
- assess motor and sensory function
- imaging (usually lateral XR)
best test for suspected cervical spine injury?
CT scan of head/neck
what signs/sx prompt you to consider a cervical spine injury?
neurological deficits
imaging abnormalities
local tenderness
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
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
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
best test to look at spinal cord
MRI
tx. of rib fracture
local pain relief - best achieved by nerve block or epidural catheter
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
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
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
what artery is most likely responsible for bleeding in a large hemothorax?
intercostal artery
chest tube for tx. of hemothorax turns up > 600 ml of fluid over 6 hours?
surgical intervention required
CXR shows multiple air fluid levels in the chest - dx?
diaphragmatic injury with bowel up in chest
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
tx of a sucking chest wound
large occlusive dressing with Vaseline gauze with 3 secured sides; chest tube
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
tx of flail chest
positive pressure ventilation w/ PEEP
bilateral chest tubes to prevent tension PTX
2 days after sustaining multiple rib fractures on both sides the pt presents with respiratory distress; CXR shows lungs “white out” - dx?
pulmonary contusion
tx. of pulmonary contusion
fluid restriction, diuretics and respiratory support with mechanical ventilation and PEEP
what kind of injury can cause traumatic transection of aortia?
deceleration injury
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
how do you confirm a sternal fracture?
lateral CXR
what are you afraid of with a sternal fracture?
myocardial contusion - check ECG, troponins
aortic transection - order CT scan
an NG tube curling up in the left chest is an indication of?
traumatic diaphragmatic rupture
- tx. surgical repair
what location is transection of the aorta usually in?
isthmus - junction of arch and descending aorta
diagnostic test to check for aortic transection/
spiral CT (with angiography)
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
- rupture of esophagus
- tension PTX
- rupture of trachea or major bronchus
how do you confirm rupture of trachea or major bronchus?
fibreoptic bronchoscopy
- also helps secure airway
- surgery follows
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
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
tx of sudden cardiac arrest from air embolism
cardiac massage - pt on Left side down
thoracotomy
causes of air embolism
chest trauma (intubation)
supraclavicular LN biopsy
CVP placement
CV lines that are disconnected
management of a penetrating gunshot wound to the abdomen
foley catheter/ large bore IV lines
broad spec antibiotics
tetanus prophylaxis
EXPLORATORY LAPAROTOMY
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
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
how much blood must you lose in order to go into hypovolemic shock?
25-35% (about 1.5 L in avg size adult)
what areas most commonly have “hidden” internal bleeding leading to hypovolemic shock?
pelvic fractures
multiple femur fractures
intra-abdominal bleeding
Dx. of major intra-abdominal bleeding
stable pt? - CT scan
unstable? - diagnostic peritoneal lavage or sonogram
what is the most likely cause of major intra-abdominal bleeding?
ruptured spleen
how do you tx. ruptured spleen?
efforts to repair it»_space; removal
if removed, must immunize with pneumovax, H.fluB and meningococcus (encapsulated bacteria)
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
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
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
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
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
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
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
male pt with a pelvic fracture has blood at the meatus - what does this mean? what is the first test you run?
- bladder or urethral injury
2. eval. starts with retrograde urethrogram
characteristics of a posterior urethral injury
blood at meatus
scrotal hematoma
sensation of wanting to urinate but cannot
high-riding prostate on DRE
characteristics of anterior urethra injury
blood at meatus and scrotal hematoma
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
insertion of a foley catheter in a woman reveals gross hematuria - dx?
likely bladder injury
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)
gross hematuria on catheterization in a patient with multiple rib fractures…
think kidney injury and order CT scan
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
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
tx. of AV fistula at renal pedicle after trauma
arteriogram and surgical correction
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
approach to traumatic microhematuria in a child
always investigate - usually means a congenital anomaly
- start with sonogram
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
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
tx. of fracture of penis
urologic emergency
- surgical repair or importence will ensue due to formation of AV shunts
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
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
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
what are the main concerns with crush injuries of extremities?
- myoglobinemia-acute renal failure
- delayed swelling and compartment syndrome
- hyperkalemia
tx. of electrical burns
extensive surgical debridement
IVF
osmotic diuretics
alkalinization of urine
complications of electrical burns:
- posterior dislocation of shoulder
- compression fracture of vertebral body
- cataracts
- demyelinazation syndromes
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
how do you manage CO poisoning
- measure carboxyhemoglobin levels
- administer 100% O2
diagnosis of respiratory burns
bronchoscopy - confirms injury
need for therapy and actual degree of damage is revealed by monitoring blood gases
management of circumferential burns
compulsive monitoring of Doppler signals of peripheral pulses and capillary filling - if circulation compromised, escharotomy must be performed
how fast should infusion of IVF be after burn injury?
1000 ml/hour (of Ringer’s lactate)
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
how do you calculate fluid replacement in babies for burns?
rate in first hour = 20 ml/kg
24-hour calculations = 4-6 ml/kg/%
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
tx. for small, contained, clearly third degree burn (white, leathery, dry and anesthetic)
early excision and grafting
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
unprovoked bite by an animal that may have rabies, but you are unable to capture it - tx?
rabies prophylaxis is mandatory (IVIG plus vaccine)
reliable signs of envenomation by a poisonous snake
excruciating local pain
swelling
discoloration
- usually w/in 30 minutes
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
dose of Epinephrine for anaphylactic shock
0.3-0.5 ml of 1:1000 solution
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
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
tx. of human bite
surgical exploration by orthopedic surgeon with extensive irrigation and debridement
