Trauma, C38 P226-246 Flashcards
What widely accepted
protocol does trauma care
in the United States follow?
P226
Advanced Trauma Life Support (ATLS)
precepts of the American College of
Surgeons
What are the three main
elements of the ATLS
protocol?
P226
- Primary survey/resuscitation
- Secondary survey
- Definitive care
How and when should the
patient history be obtained?
P227
It should be obtained while completing
the primary survey; often the rescue
squad, witnesses, and family members
must be relied upon
PRIMARY SURVE
What are the five steps of
the primary survey?
P227
Think: “ABCDEs”: Airway (and C-spine stabilization) Breathing Circulation Disability Exposure and Environment
PRIMARY SURVE What principles are followed in completing the primary survey? P227
Life-threatening problems discovered
during the primary survey are always
addressed before proceeding to the
next step
AIRWAY
What are the goals during
assessment of the airway?
P227
Securing the airway and protecting the
spinal cord
AIRWAY In addition to the airway, what MUST be considered during the airway step? P227
Spinal immobilization
AIRWAY
What comprises spinal
immobilization?
P227
Use of a full backboard and rigid cervical
collar
AIRWAY In an alert patient, what is the quickest test for an adequate airway? P227
Ask a question: If the patient can speak,
the airway is intact
AIRWAY
What is the first maneuver
used to establish an airway?
P227
Chin lift, jaw thrust, or both; if successful,
often an oral or nasal airway can be
used to temporarily maintain the airway
AIRWAY If these methods are unsuccessful, what is the next maneuver used to establish an airway? P227
Endotracheal intubation
AIRWAY If all other methods are unsuccessful, what is the definitive airway? P228 (picture)
Cricothyroidotomy, a.k.a. “surgical airway”: Incise the cricothyroid membrane between the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an endotracheal or tracheostomy tube into the trachea
AIRWAY What must always be kept in mind during difficult attempts to establish an airway? P228
Spinal immobilization and adequate oxygenation; if at all possible, patients must be adequately ventilated with 100% oxygen using a bag and mask before any attempt to establish an airway
BREATHING
What are the goals in
assessing breathing?
P228
Securing oxygenation and ventilation
Treating life-threatening thoracic injuries
BREATHING
What comprises adequate
assessment of breathing?
P228
Inspection—for air movement, respiratory rate, cyanosis, tracheal shift, jugular venous distention, asymmetric chest expansion, use of accessory muscles of respiration, open chest wounds Auscultation—for breath sounds Percussion—for hyperresonance or dullness over either lung field Palpation—for presence of subcutaneous emphysema, flail segments
BREATHING What are the life-threatening conditions that MUST be diagnosed and treated during the breathing step? P228
Tension pneumothorax, open
pneumothorax, massive hemothorax
BREATHING
What is it?
P229
Injury to the lung, resulting in release of air
into the pleural space between the normally
apposed parietal and visceral pleura
BREATHING
How is it diagnosed?
P229
Tension pneumothorax is a clinical
diagnosis: dyspnea, jugular venous
distention, tachypnea, anxiety, pleuritic
chest pain, unilateral decreased or absent
breath sounds, tracheal shift away from
the affected side, hyperresonance on the
affected side
BREATHING
What is the treatment of a
tension pneumothorax?
P229
Rapid thoracostomy incision or immediate decompression by needle thoracostomy in the second intercostal space midclavicular line, followed by tube thoracostomy placed in the anterior/ midaxillary line in the fourth intercostal space (level of the nipple in men)
BREATHING
What is the medical term for
a “sucking chest wound”?
P229
Open pneumothorax
BREATHING
What is a tube thoracostomy?
P229
“Chest tube”
BREATHING How is an open pneumothorax diagnosed and treated? P229
Diagnosis: usually obvious, with air movement through a chest wall defect and pneumothorax on CXR Treatment in the ER: tube thoracostomy (chest tube), occlusive dressing over chest wall defect
BREATHING
What does a pneumothorax
look like on chest X-ray?
P229 (picture
Loss of lung markings (Figure shows a
right-sided pneumothorax; arrows point
out edge of lung-air interface)
Flail Chest
What is it?
P230 (picture)
Two separate fractures in three or more
consecutive ribs
Flail Chest
How is it diagnosed?
P230
Flail segment of chest wall that moves
paradoxically (sucks in with inspiration
and pushes out with expiration opposite
the rest of the chest wall)
Flail Chest What is the major cause of respiratory compromise with flail chest? P230
Underlying pulmonary contusion!
Flail Chest
What is the treatment?
P230
Intubation with positive pressure
ventilation and PEEP PRN (let ribs heal
on their own)
Cardiac Tamponade
What is it?
P230
Bleeding into the pericardial sac, resulting
in constriction of heart, decreasing inflow
and resulting in decreased cardiac output
(the pericardium does not stretch!)
Cardiac Tamponade
What are the signs and
symptoms?
P230
Tachycardia/shock with Beck’s triad,
pulsus paradoxus, Kussmaul’s sign
Cardiac Tamponade
Define the following:
Beck’s triad
P231
- Hypotension
- Muffled heart sounds
- JVD
Cardiac Tamponade
Define the following:
Kussmaul’s sign
P231
JVD with inspiration
Cardiac Tamponade
How is cardiac tamponade
diagnosed?
P231
Ultrasound (echocardiogram)
Cardiac Tamponade
What is the treatment?
P231
Pericardial window—if blood returns
then median sternotomy to rule out and
treat cardiac injury
Massive Hemothorax
How is it diagnosed?
P231
Unilaterally decreased or absent breath
sounds; dullness to percussion; CXR, CT
scan, chest tube output
Massive Hemothorax
What is the treatment?
P231
Volume replacement
Tube thoracostomy (chest tube)
Removal of the blood (which will allow
apposition of the parietal and visceral
pleura, sealing the defect and slowing
the bleeding)
Massive Hemothorax What are indications for emergent thoracotomy for hemothorax? P231
Massive hemothorax 1. >1500 cc of blood on initial placement of chest tube 2. Persistent >200 cc of bleeding via chest tube per hour x 4 hours
CIRCULATION
What are the goals in
assessing circulation?
P231
Securing adequate tissue perfusion;
treatment of external bleeding
CIRCULATION
What is the initial test for
adequate circulation?
P231
Palpation of pulses: As a rough guide,
if a radial pulse is palpable, then systolic
pressure is at least 80 mm Hg; if a
femoral or carotid pulse is palpable, then
systolic pressure is at least 60 mm Hg
CIRCULATION
What comprises adequate
assessment of circulation?
P231
Heart rate, blood pressure, peripheral
perfusion, urinary output, mental status,
capillary refill (normal <2 seconds), exam
of skin: cold, clammy = hypovolemia
CIRCULATION
Who can be hypovolemic
with normal blood pressure?
P232
Young patients; autonomic tone can
maintain blood pressure until
cardiovascular collapse is imminent
CIRCULATION Which patients may not mount a tachycardic response to hypovolemic shock? P232
Those with concomitant spinal cord
injuries
Those on -blockers
Well-conditioned athletes
CIRCULATION
How are sites of external
bleeding treated?
P232
By direct pressure; / tourniquets
CIRCULATION What is the best and preferred intravenous (IV) access in the trauma patient? P232
“Two large-bore IVs” (14–16 gauge),
IV catheters in the upper extremities
(peripheral IV access)
CIRCULATION
What are alternate sites of
IV access?
P232
Percutaneous and cutdown catheters in
the lower leg saphenous; central access
into femoral, jugular, subclavian veins
CIRCULATION For a femoral vein catheter, how can the anatomy of the right groin be remembered? P232
Lateral to medial “NAVEL”: Nerve Artery Vein Empty space Lymphatics Thus, the vein is medial to the femoral artery pulse (Or, think: “venous close to penis”)
CIRCULATION
What is the trauma
resuscitation fluid of choice?
P232
Lactated Ringer’s (LR) solution
(isotonic, and the lactate helps buffer the
hypovolemia-induced metabolic acidosis)
CIRCULATION
What types of decompression
do trauma patients receive?
P232
Gastric decompression with an NG tube
and Foley catheter bladder decompression
after normal rectal exam
CIRCULATION What are the contraindications to placement of a Foley? P232
Signs of urethral injury: Severe pelvic fracture in men Blood at the urethral meatus (penile opening) “High-riding” “ballotable” prostate (loss of urethral tethering) Scrotal/perineal injury/ecchymosis
CIRCULATION What test should be obtained prior to placing a Foley catheter if urethral injury is suspected? P233
Retrograde UrethroGram (RUG): dye in
penis retrograde to the bladder and x-ray
looking for extravasation of dye
CIRCULATION How is gastric decompression achieved with a maxillofacial fracture? P233
Not with an NG tube because the tube
may perforate through the cribriform
plate into the brain; place an oral-gastric
tube (OGT), not an NG tube
DISABILITY
What are the goals in
assessing disability?
P233
Determination of neurologic injury
Think: neurologic disability
DISABILITY
What comprises adequate
assessment of disability?
P233
Mental status—Glasgow Coma Scale (GCS) Pupils—a blown pupil suggests ipsilateral brain mass (blood) as herniation of the brain compresses CN III Motor/sensory—screening exam for lateralizing extremity movement, sensory deficits
DISABILITY
Describe the GCS scoring
system.
P233
Eye opening (E) 4—Opens spontaneously 3—Opens to voice (command) 2—Opens to painful stimulus 1—Does not open eyes (Think: Eyes = “four eyes”) Motor response (M) 6—Obeys commands 5—Localizes painful stimulus 4—Withdraws from pain 3—Decorticate posture 2—Decerebrate posture 1—No movement (Think: Motor = “6-cylinder motor”) Verbal response (V) 5—Appropriate and oriented 4—Confused 3—Inappropriate words 2—Incomprehensible sounds 1—No sounds (Think: Verbal = “Jackson 5”)
DISABILITY
What is a normal human GCS?
P234
GCS 15
DISABILITY
What is the GCS score for a
dead man?
P234
GCS 3
DISABILITY
What is the GCS score for a
patient in a “coma”?
P234
GCS ⩽8
DISABILITY
How does scoring differ if
the patient is intubated?
P234
Verbal evaluation is omitted and replaced
with a “T”; thus, the highest score for an
intubated patient is 11 T
EXPOSURE AND ENVIRONMENT
What are the goals in
obtaining adequate exposure?
P234
Complete disrobing to allow a thorough
visual inspection and digital palpation of
the patient during the secondary survey
EXPOSURE AND ENVIRONMENT
What is the “environment”
of the E in ABCDEs?
P234
Keep a warm Environment (i.e., keep the
patient warm; a hypothermic patient can
become coagulopathic)
SECONDARY SURVEY What principle is followed in completing the secondary survey? P234
Complete physical exam, including all
orifices: ears, nose, mouth, vagina,
rectum
SECONDARY SURVEY
Why look in the ears?
P234
Hemotympanum is a sign of basilar skull
fracture; otorrhea is a sign of basilar skull
fracture
SECONDARY SURVEY Examination of what part of the trauma patient’s body is often forgotten? P234
Patient’s back (logroll the patient and
examine!)
SECONDARY SURVEY
What are typical signs of
basilar skull fracture?
P234
Raccoon eyes, Battle’s sign, clear otorrhea
or rhinorrhea, hemotympanum
SECONDARY SURVEY What diagnosis in the anterior chamber must not be missed on the eye exam? P234
Traumatic hyphema = blood in the
anterior chamber of the eye
SECONDARY SURVEY What potentially destructive lesion must not be missed on the nasal exam? P235
Nasal septal hematoma: Hematoma must
be evacuated; if not, it can result in
pressure necrosis of the septum!
SECONDARY SURVEY
What is the best indication
of a mandibular fracture?
P235
Dental malocclusion: Tell the patient to
“bite down” and ask, “Does that feel
normal to you?”
SECONDARY SURVEY What signs of thoracic trauma are often found on the neck exam? P235
Crepitus or subcutaneous emphysema from
tracheobronchial disruption/PTX; tracheal
deviation from tension pneumothorax;
jugular venous distention from cardiac
tamponade; carotid bruit heard with
seatbelt neck injury resulting in carotid
artery injury
SECONDARY SURVEY
What is the best physical exam
for broken ribs or sternum?
P235
Lateral and anterior-posterior compression
of the thorax to elicit pain/instability
SECONDARY SURVEY What physical signs are diagnostic for thoracic great vessel injury? P235
None: Diagnosis of great vessel injury requires a high index of suspicion based on the mechanism of injury, associated injuries, and CXR/radiographic findings (e.g., widened mediastinum)
SECONDARY SURVEY What is the best way to diagnose or rule out aortic injury? P235
CT angiogram
SECONDARY SURVEY What must be considered in every penetrating injury of the thorax at or below the level of the nipple? P235
Concomitant injury to the abdomen:
Remember, the diaphragm extends to the
level of the nipples in the male on full
expiration
SECONDARY SURVEY
What is the significance of
subcutaneous air?
P235
Indicates PTX, until proven otherwise
SECONDARY SURVEY What is the physical exam technique for examining the thoracic and lumbar spine? P235
Logrolling the patient to allow complete
visualization of the back and palpation
of the spine to elicit pain over fractures,
step off (spine deformity)
SECONDARY SURVEY What conditions must exist to pronounce an abdominal physical exam negative? P235
Alert patient without any evidence of
head/spinal cord injury or drug/EtOH
intoxication (even then, the abdominal
exam is not 100% accurate)
SECONDARY SURVEY What physical signs may indicate intra-abdominal injury? P236
Tenderness; guarding; peritoneal signs;
progressive distention (always use a
gastric tube for decompression of air);
seatbelt sign
SECONDARY SURVEY
What is the seatbelt sign?
P236
Ecchymosis on lower abdomen from
wearing a seatbelt (10% of patients with
this sign have a small bowel perforation!)
SECONDARY SURVEY
What must be documented
from the rectal exam?
P236
Sphincter tone (as an indication of spinal
cord function); presence of blood (as an
indication of colon or rectal injury); prostate
position (as an indication of urethral injury)
SECONDARY SURVEY What is the best physical exam technique to test for pelvic fractures? P236
Lateral compression of the iliac crests
and greater trochanters and anteriorposterior
compression of the symphysis
pubis to elicit pain/instability
SECONDARY SURVEY
What is the “halo” sign?
P236
Cerebrospinal fluid from nose/ear will form
a clear “halo” around the blood on a cloth
SECONDARY SURVEY What physical signs indicate possible urethral injury, thus contraindicating placement of a Foley catheter? P236
High-riding ballotable prostate on
rectal exam; presence of blood at the
meatus; scrotal or perineal ecchymosis
SECONDARY SURVEY
What must be documented
from the extremity exam?
P236
Any fractures or joint injuries; any open
wounds; motor and sensory exam,
particularly distal to any fractures; distal
pulses; peripheral perfusion
SECONDARY SURVEY What complication after prolonged ischemia to the lower extremity must be treated immediately? P236
Compartment syndrome
SECONDARY SURVEY
What is the treatment for
this condition?
P236
Fasciotomy (four compartments below
the knee)
SECONDARY SURVEY What injuries must be suspected in a trauma patient with a progressive decline in mental status? P236
Epidural hematoma, subdural hematoma, brain swelling with rising intracranial pressure But hypoxia/hypotension must be ruled out!
TRAUMA STUDIES
What are the classic blunt
trauma ER x-rays?
P237
- AP (anterior-to-posterior) chest film
2. AP pelvis film
TRAUMA STUDIES
What are the common
trauma labs?
P237
Blood for complete blood count,
chemistries, amylase, liver function tests,
lactic acid, coagulation studies, and type
and crossmatch; urine for urinalysis
TRAUMA STUDIES Will the hematocrit be low after an acute massive hemorrhage? P237
No (no time to equilibrate)
TRAUMA STUDIES
How can a C-spine be
evaluated?
P237
- Clinically by physical exam
2. Radiographically
TRAUMA STUDIES What patients can have their C-spines cleared by a physical exam? P237
No neck pain on palpation with full range
of motion (FROM) with no neurologic
injury (GCS 15), no EtOH/drugs, no
distracting injury, no pain meds
TRAUMA STUDIES
How do you rule out a
C-spine bony fracture?
P237
With a CT scan of the C-spine
TRAUMA STUDIES What do you do if no bony C-spine fracture is apparent on CT scan and you cannot obtain an MRI in a COMATOSE patient? P237
This is controversial; the easiest answer is
to leave the patient in a cervical collar
TRAUMA STUDIES Which x-rays are used for evaluation of cervical spine LIGAMENTOUS injury? P237
MRI, lateral flexion and extension
C-spine films
TRAUMA STUDIES What findings on chest film are suggestive of thoracic aortic injury? P237
Widened mediastinum (most common finding), apical pleural capping, loss of aortic contour/KNOB/AP window, depression of left main stem bronchus, nasogastric tube/tracheal deviation, pleural fluid, elevation of right mainstem bronchus, clinical suspicion, high-speed mechanism
TRAUMA STUDIES
What study is used to rule
out thoracic aortic injury?
P238
Spiral CT scan of mediastinum looking
for mediastinal hematoma with CTA
Thoracic arch aortogram (gold standard)
TRAUMA STUDIES What is the most common site of thoracic aortic traumatic tear? P238
Just distal to the take-off of the left
subclavian artery
TRAUMA STUDIES What studies are available to evaluate for intra-abdominal injury? P238
FAST, CT scan, DPL
TRAUMA STUDIES
What is a FAST exam?
P238
Ultrasound: Focused Assessment with
Sonography for Trauma = FAST
TRAUMA STUDIES
What does the FAST exam
look for?
P238
Blood in the peritoneal cavity looking at
Morison’s pouch, bladder, spleen, and
pericardial sac
TRAUMA STUDIES
What does DPL stand for?
P238
Diagnostic Peritoneal Lavage
TRAUMA STUDIES What diagnostic test is the test of choice for evaluation of the unstable patient with blunt abdominal trauma? P238
FAST
TRAUMA STUDIES What is the indication for abdominal CT scan in blunt trauma? P238
Normal vital signs with abdominal
pain/tenderness/mechanism
TRAUMA STUDIES What is the indication for DPL or FAST in blunt trauma? P238
Unstable vital signs (hypotension)
TRAUMA STUDIES
How is a DPL performed?
P238
Place a catheter below the umbilicus (in
patients without a pelvic fracture) into
the peritoneal cavity
Aspirate for blood and if <10 cc are
aspirated, infuse 1 L of saline or LR
Drain the fluid (by gravity) and analyze
TRAUMA STUDIES
What is a “grossly positive” DPL?
P238
⩾10 cc blood aspirated
TRAUMA STUDIES Where should the DPL catheter be placed in a patient with a pelvic fracture? P239
Above the umbilicus Common error: If you go below the umbilicus, you may get into a pelvic hematoma tracking between the fascia layers and thus obtain a false-positive DPL
TRAUMA STUDIES
What constitutes a positive
peritoneal tap?
P239
Prior to starting a peritoneal lavage, the DPL catheter should be aspirated; if >10 mL of blood or any enteric contents are aspirated, then this constitutes a positive tap and requires laparotomy
TRAUMA STUDIES What are the indicators of a positive peritoneal lavage in blunt trauma? P239
Classic: Inability to read newsprint through lavaged fluid RBC ⩾100,000/mm WBC ⩾500/mm (Note: mm, not mm) Lavage fluid (LR/NS) drained from chest tube, Foley, NG tube
Less common: Bile present Bacteria present Feces present Vegetable matter present Elevated amylase level
TRAUMA STUDIES
What must be in place
before a DPL is performed?
P239
NG tube and Foley catheter (to remove
the stomach and bladder from the line
of fire!)
TRAUMA STUDIES
What injuries does CT scan miss?
P239
Small bowel injuries and diaphragm
injuries
TRAUMA STUDIES
What injuries does DPL
miss?
P239
Retroperitoneal injuries
TRAUMA STUDIES What study is used to evaluate the urethra in cases of possible disruption due to blunt trauma? P239
Retrograde urethrogram (RUG)
TRAUMA STUDIES
What are the most emergent
orthopaedic injuries?
P240
- Hip dislocation—must be reduced
immediately - Exsanguinating pelvic fracture (binder
or external fixator)
TRAUMA STUDIES
What findings would require
a celiotomy in a blunt trauma victim?
P240
Peritoneal signs, free air on CXR/CT
scan, unstable patient with positive FAST
exam or positive DPL results
TRAUMA STUDIES
What is the treatment of a
gunshot wound to the belly?
P240
Exploratory laparotomy
TRAUMA STUDIES
What is the evaluation of a
stab wound to the belly?
P240
If there are peritoneal signs, heavy bleeding, shock, perform exploratory laparotomy; otherwise, many surgeons either observe the asymptomatic stab wound patient closely, use local wound exploration to rule out fascial penetration, or use DPL
PENETRATING NECK INJURIES
What depth of neck injury
must be further evaluated?
P240
Penetrating injury through the platysma
PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone III
P240
Angle of the mandible and up
PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone II
P240
Angle of the mandible to the cricoid
cartilage
PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone I
P240 (picture)
Below the cricoid cartilage
PENETRATING NECK INJURIES How do most surgeons treat penetrating neck injuries (those that penetrate the platysma) by neck zone: Zone III P241
Selective exploration
PENETRATING NECK INJURIES How do most surgeons treat penetrating neck injuries (those that penetrate the platysma) by neck zone: Zone II P241
Surgical exploration vs. selective
exploration
PENETRATING NECK INJURIES How do most surgeons treat penetrating neck injuries (those that penetrate the platysma) by neck zone: Zone I P241
Selective exploration
PENETRATING NECK INJURIES
What is selective
exploration?
P241
Selective exploration is based on diagnostic
studies that include A-gram or CT A-gram,
bronchoscopy, esophagoscopy
PENETRATING NECK INJURIES What are the indications for surgical exploration in all penetrating neck wounds (Zones I, II, III)? P241
“Hard signs” of significant neck damage: shock, exsanguinating hemorrhage, expanding hematoma, pulsatile hematoma, neurologic injury, subQ emphysema
PENETRATING NECK INJURIES How can you remember the order of the neck trauma zones and Le Forte fractures? P241 (picture)
In the direction of carotid blood flow
MISCELLANEOUS TRAUMA FACTS
What is the “3-for-1” rule?
P241
Trauma patient in hypovolemic shock
acutely requires 3 L of crystalloid (LR)
for every 1 L of blood loss
MISCELLANEOUS TRAUMA FACTS
What is the minimal urine
output for an adult trauma patient?
P241
50 mL/hr
MISCELLANEOUS TRAUMA FACTS How much blood can be lost into the thigh with a closed femur fracture? P242
Up to 1.5 L of blood
MISCELLANEOUS TRAUMA FACTS Can an adult lose enough blood in the “closed” skull from a brain injury to cause hypovolemic shock? P242
Absolutely not! But infants can lose
enough blood from a brain injury to
cause shock
MISCELLANEOUS TRAUMA FACTS
Can a patient behypotensive
after an isolated head injury?
P242
Yes, but rule out hemorrhagic shock!
MISCELLANEOUS TRAUMA FACTS
What is the brief ATLS history?
P242
“AMPLE” history: Allergies Medications PMH Last meal (when) Events (of injury, etc.)
MISCELLANEOUS TRAUMA FACTS In what population is a surgical cricothyroidotomy not recommended? P242
Any patient younger than 12 years; instead
perform needle cricothyroidotomy
MISCELLANEOUS TRAUMA FACTS
What are the signs of a
laryngeal fracture?
P242
Subcutaneous emphysema in neck
Altered voice
Palpable laryngeal fracture
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
rectal penetrating injury?
P242
Diverting proximal colostomy; closure of perforation (if easy, and definitely if intraperitoneal); and presacral drainage
MISCELLANEOUS TRAUMA FACTS What is the treatment of EXTRAperitoneal minor bladder rupture? P242
“Bladder catheter” (Foley) drainage and
observation; intraperitoneal or large
bladder rupture requires operative closure
MISCELLANEOUS TRAUMA FACTS
What intra-abdominal injury is
associated with seatbelt use?
P242
Small bowel injuries (L2 fracture,
pancreatic injury)
MISCELLANEOUS TRAUMA FACTS
What is the treatment of a
pelvic fracture?
P242
+/- pelvic binder until the external
fixator is placed; IVF/blood; +/- A-gram
to embolize bleeding pelvic vessels
MISCELLANEOUS TRAUMA FACTS Bleeding from pelvic fractures is most commonly caused by arterial or venous bleeding? P242
Venous (≈85%)
MISCELLANEOUS TRAUMA FACTS If a patient has a laceration through an eyebrow, should you shave the eyebrow prior to suturing it closed? P242
No—20% of the time, the eyebrow will
not grow back if shaved!
MISCELLANEOUS TRAUMA FACTS What is the treatment of extensive irreparable biliary, duodenal, and pancreatic head injury? P243
Trauma Whipple
MISCELLANEOUS TRAUMA FACTS What is the most common intra-abdominal organ injured with penetrating trauma? P243
Small bowel
MISCELLANEOUS TRAUMA FACTS
How high up do the
diaphragms go?
P243
To the nipples (intercostal space #4);
thus, intra-abdominal injury with
penetrating injury below the nipples
must be ruled out
MISCELLANEOUS TRAUMA FACTS Classic trauma question: “If you have only one vial of blood from a trauma victim to send to the lab, what test should be ordered?” P243
Type and cross (for blood transfusion)
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
penetrating injury to the colon?
P243
If the patient is in shock, resection and
colostomy
If the patient is stable, the trend is
primary anastomosis/repair
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
small bowel injury?
P243
Primary closure or resection and primary
anastomosis
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
minor pancreatic injury?
P243
Drainage (e.g., JP drains)
MISCELLANEOUS TRAUMA FACTS What is the most commonly injured abdominal organ with blunt trauma? P243
Liver (in recent studies)
MISCELLANEOUS TRAUMA FACTS
What is the treatment for
significant duodenal injury?
P243
Pyloric exclusion:
- Close duodenal injury
- Staple off pylorus
- Gastrojejunostomy
MISCELLANEOUS TRAUMA FACTS
What is the treatment for
massive tail of pancreas injury?
P244
Distal pancreatectomy (usually perform splenectomy also)
MISCELLANEOUS TRAUMA FACTS
What is “damage control” surgery?
P244
Stop major hemorrhage and GI soilage Pack and get out of the O.R. ASAP to bring the patient to the ICU to warm, correct coags, and resuscitate Return patient to O.R. when stable, warm, and not acidotic
MISCELLANEOUS TRAUMA FACTS
What is the “lethal triad”?
P244
“ACH”: 1. Acidosis 2. Coagulopathy 3. Hypothermia (Think: ACHe = Acidosis, Coagulopathy, Hypothermia)
MISCELLANEOUS TRAUMA FACTS What comprises the workup/ treatment of a stable parasternal chest gunshot/ stab wound? P244
- CXR
- FAST, chest tube, / O.R. for subxiphoid
window; if blood returns, then
sternotomy to assess for cardiac injury
MISCELLANEOUS TRAUMA FACTS
What is the diagnosis with
NGT in chest on CXR?
P244 (picture)
Ruptured diaphragm with stomach in pleural cavity (go to ex lap)
MISCELLANEOUS TRAUMA FACTS What films are typically obtained to evaluate extremity fractures? P244
Complete views of the involved extremity,
including the joints above and below the
fracture
MISCELLANEOUS TRAUMA FACTS
Outline basic workup for a victim of severe blunt trauma In ER:
Airway, physical exam. IV X 2, labs, type and cross, OGT/NGT, Foley, chest tube PRN
X-rays: CXR, pelvic, femur
(if femur fracture is suspected)
[Note: AP = anteroposterior; Ext = extremity; OGT = orogastric tube;
FAST = Focused Assessment Sonogram for Trauma; lat = lateral; C = cervical.]
P245 (Table)
(see table
MISCELLANEOUS TRAUMA FACTS What finding on ABD/pelvic CT scan requires ex lap in the blunt trauma patient with normal vital signs? P245
Free air; also strongly consider in the
patient with no solid organ injury but lots
of free fluid = both to rule out hollow
viscus injury
MISCELLANEOUS TRAUMA FACTS Can you rely on a negative FAST in the unstable patient with a pelvic fracture? P245
No—perform DPL (above umbilicus)
MISCELLANEOUS TRAUMA FACTS What lab tests are used to look for intra-abdominal injury in children? P246
Liver function tests (LFTs) = ↑AST
and/or ↑ALT
MISCELLANEOUS TRAUMA FACTS
What is the only real indication
for MAST trousers?
P246
Prehospitalization, pelvic fracture
MISCELLANEOUS TRAUMA FACTS
What is the treatment for
human and dog bites?
P246
Leave wound open, irrigation, antibiotics
MISCELLANEOUS TRAUMA FACTS What percentage of pelvic fracture bleeding is exclusively venous? P246
85%
MISCELLANEOUS TRAUMA FACTS
What is sympathetic
ophthalmia?
P246
Blindness in one eye that results in
subsequent blindness in the contralateral
eye (autoimmune)
MISCELLANEOUS TRAUMA FACTS What can present after blunt trauma with neurological deficits and a normal brain CT scan? P246
Diffuse Axonal Injury (DAI), carotid
artery injury