Trauma: Chapter 1 Flashcards
Patient with cervical spine injury and airway problem. What do you deal with first?
airway
What are indications for securing an airway?
- unconscious
- noisy or gurgly breathing
- severe inhalation injury (smoke)
- need to connect to respirator
What are tools you need for orotracheal intubation?
- laryngoscope
- rapid induction (on awake pt)
- pulse oximetry
What is another of intubating a patient?
- nasotracheal intubation with fiber optic bronchoscope
When do you HAVE to use a fiberoptic bronchoscope?
When there’s subcutaneous emphysema in the neck.
What’s major sign of traumatic disruption in the tracheobronchial tree?
subcutaneous emphysema
What are situations when you need to do a cricothyroidotomy?
- laryngospasm
- severe maxillofacial injuries
- impacted foreign body that can’t be dislodged
At what ages would you be reluctant to do a cricothyroidotomy?
Before the age of 12
Why would you avoid doing cricothyroidotomy in kids?
to avoid the potential for future laryngeal
How do you test for in breathing?
- listen for breath sounds on both sides of the chest
2. pulse oximetry
What are the clinical signs of shock?
- low blood pressure (bp)- under 90mmHg
- fast feeble pulse
- lower urinary output (under 0.5 mL/kg/h)
- pale
- cold
- shivering
- sweating
- thirsty
- apprehensive
How can you distinguish shock from bleeding vs. tamponade or pneumothorax?
Bleeding= low CVP
Tamponade or tension pneumothorax= high CVP (big distended head and neck veins pneumothorax)
How do you distinguish shock from tamponade vs. pneumothorax?
pneumothorax has severe respiratory distress
no breath sounds on one side
hyperresonant to percussion
mediastinum displaced to the opposite side (tracheal deviation)
Hemorrhagic shock what do you do first? volume resusc. vs stopping the bleeding
urban setting (trauma center)= stop the bleeding first then volume all others= start with volume replacement
What do you volume replace people with?
- 2 L of Ringer lactate (without sugar)
- Then packed red cells
When do you stop giving fluids?
When urinary output = 0.5-2 cc/kg/h
What’s the preferred route of fluid resuscitation?
2 peripheral IV lines, 16-gauge
What do you do when you can’t insert peripheral ivs?
- percutaneous femoral vein catheter
- saphenous vein cut-down
What do you do when you can’t inserts ivs in kids under age 6?
intraosseous cannulation of the proximal tibia
What are the different ways to treat tamponade?
- pericardiocentesis
- tube
- pericardial window
- open thoracotomy
When do you get vasomotor shock?
- anaphylactic reactions
- high spinal cord transection
- high spinal anesthetic
What are physical exam signs of vasomotor shock?
pink, flushed
warm
CVP is low
What’s the main therapy for vasomotor shock?
pharmacologic treatment
…additional fluids will help
what kind of head trauma requires surgical intervention?
penetrating
How do you manage linear skull fractures?
leave them alone if they’re closed
- open fractures require wound closure
- comminuted or depressed fracture
What is the first thing you do when you have a patient w a head trauma who has become unconscious?
CT
If the CT is negative, what is the next step in management?
They can go home if the family wakes them up frequently during the next 24 hours to make sure they’re not going into a coma
signs of fracture of the base of the skull?
- raccoon eyes
- rhinorrhea
- otorrhea
- ecchymosis
When a patient has signs of a base of the skull fracture, what else must you check?
C-spine injury
What are the 3 components of neurologic damage from trauma?
- initial blow
- development of a hematoma that displaces the midline structures (surgical treatment)
- later development of increased ICP (intracranial pressure)–medical measures can prevent or minimize the third
How can you treat subdural hematoma WITH midline shift?
Craniotomy
bad prognosis
What are some strategies for lowering ICP?
- elevate head
- hypothermia (to reduce oxygen demand)
- hyperventilate (goal of a pCO2 of 35)
- avoid fluid overload
- give mannitol
- or furosemide
Signs of diffuse axonal injury?
- blurring of gray-white interface
2. multiple punctate hemorrhages
Populations that get subdural hematomas?
very old
alcoholics
how long does it take for signs of subdural hematoma to manifest?
several days or weeks- see deterioration of mental funciton and hematoma formation
In what cases must you surgically explore a penetrating neck trauma?
- expanding hematoma
- deteriorating vitals
- clear signs of esophageal or tracheal injury (coughing/spitting up blood)
Diagnoses and management of gunshot wound to the UPPER ZONE of the neck?
arteriographic
gsw BASE OF THE NECK?
diagnostic:
1. arteriography
2. esophagogram (water-soluble first, THEN barium if negative)
3. esophagoscopy and bronchoscopy before surgery (help decide the surgical approach)
Mngmt of stab wounds to the upper and middle zones of the neck?
if asymptomatic, observation only
Brown -Sequard Hemisection
- typically from knif blade
- ipsilateral paralysis and loss of proprioception distal to the injury
- contralateral loss of pain percepition distal to the injry
Anterior Cord Syndrome
- typical of burst fractures of the vertebral bodies
- loss of motor function on both sides distal to the injury
- loss of pain and temp on both sides distally
- proprioception preserved on both sides distally
Central Cord syndrome
- occurs in elderly w forced hyperextension of the neck (rear-end collision)
- paralysis and burning pain in upper extremities
- preservation of most functions in lower extremities
Rib fracture in the elderly treatmetn
- local nerve block
2. epidural catheter
do you need to find the bleeding source in Hemothorax?
No, the lung is usually the source and will stop by itself?
When do you need a thoracotomy with a hemothorax?
when there is a systemic bleeder (intercostal artery)
How do you know you need surgery in a hemothorax?
- when you recover more than 1500 cc or more of blood when the chest tube is inserted
- when you collect over 600 mL over ensuing 6 hrs
How do you assess for hidden injuries in blunt trauma?
- blood gas and chest x-ray (for pulmonary contusion)
2. cardiac troponins and ekg (for cardiac contusion)
Treating a sucking chest wound?
Occlusive dressing (allows air out, taped on 3 sides) but not in
Flail Chest Signs
- occurs when there are multiple rib fractures
- paradoxic breathing (chest wall caves in during inspiration and bulge out during expiration)
- pulmonary contusion
Pulmonary Contusion in Flail Chest Mngmt
- it’s very sensitive to fluid overlaod
- treat with fluid restriction and use of diuretics
- monitor blood gases
- If need respirator, must insert bilateral chest tubes to prevent tension pnthx
- also need to check for TRAUMATIC transection of the aorta
Radiographic sign of pulmonary contusion?
white out of the lungs on CXr–can happen up to 48 hrs later
Myocardial contusion?
- when you have a sternal fracture
- EKG monitoring detects it
- Order troponins
- worry about complications like arryth.
Traumatic rupture of the diaphragm
- bowel in the chest (can detect on exam and xray)
- Always on the left side
- If you suspect it, must do laparoscopy
- repair from the abdomen
Traumatic Aortic Rupture
- junction of arch and descending aorta most common site
- ULTIMATE “hidden injury”–asymptomatic until the hematoma blows up
.
How to detect a traumatic aortic rupture?
- DECELERATION injury
2. Presence of fractures in chest bones that are “very hard to break”– first rib, scapula, or sternum
Tests for aortic rupture?
- transesophageal echo
- spiral ct scan (most practical in trauma setting)
- MRI angiographaph
Subcutaneous Emphysema
- traumatic rupture in trachea or major bronchus
2. surgical repair follows
DDx fro subcutaneous emphysema
- rupture of the esophagus
2. tension pneumo
Air embolism causes:
- chest trauma pt who is intubated or on a respirator
- when subclavian vein is opened to the air (supraclavicular node biopsy, central venous line placement, CVP lines become disconnected )
Air embolism immediate trmt:
cardiac massage w left side down
Air embolism prevention?
trendelenburg
Fat embolism physical exam signs?
- petechial rashes in axillae and neck
- fever
- tachy
- low platelet count
- eventual respiratory distress
- hypoxemia and bilateral patchy CXR infiltrates
…in setting of multiple trauma (including long bone fracture)..
Precise diagnosis of fat embolism?
fat droblets in the urine
Fat embolism main therapy?
respiratory support
Mgmt. of gunshot wound to abdomen?
exploratory laparotomy for repair of intraabdominal injuries
When do you not need ex lap in abdomen gsw?
- low caliber gunshot
- RUQ
- pt is being properly monitored
- there’s close follow up of clinical signs
- you’re ordering serial abdominal exams
Abdominal stab wound mgmt?
- viscera is protruding—-> ex lap
- hemodynamic instab, periotneal irritation—> ex lap
- none of the above–> digital exploration of the wound in the ER (gentle insertion of gloved finger and observation —> then CT if needed
Blunt abd trauma?
- signs of peritoneal irritation—–> ex lap
2. establish whether there is internal bleeding and whether it might stop on its own & internal injuries
Signs of bleeding into the abdomen?
- drop in blood pressure
- low CVP
- low urinary output
- cold, pale, anxious pt who is shivering, thirsy and perspiring profusely —> occur when 25-30% of blood is lost ~1500 ccs
Sites where you can bleed out?
- Thorax: pleural cavity
- abdomen
- thighs
- pelvis
- retroperitoneum
Hypovolemic shock in the setting of a normal chest x-ray and no evidence of pelvic or femur fracture?
suspect intraabdominal bleeding
most accurate way of detecting intraabdominal bleeding?
CT
What is required to take a trauma pt to CT?
hemodynamic stability
Quick way to diagnose intraabodominal bleeding in pt who is hemodynamically unstable?
- diagnositc peritoneal lavage (DPL)
2. sonogram in the ER or OR
If you find there is blood in the abdomen, next ste?
prompt ex lap
What’s the most common cause of all intrabodominal bleeding in blunt abdominal trauma?
liver trauma
What’s the most common cause of SIGNIFICANT intrabdominal bleeding in abdominal trauma?
spleen rupture
What population should you avoid removing the spleen in?
children
Mgmt for intraoperative development of coagulopathy during prolonged abdominal surgery?
Multiple transfusions of:
- platelet packs
- fresh-frozen plasma
empirical treatment
Treatment for arterial pelvic bleeding?
arteriographic embolization
Best treatment option for significant bleeding after pelvic fractures?
- external pelvic fixation
+ 2. angiographic embolization of both internal iliac arteries
most common cause of urological injury involving the kidney?
lower rib fractures
most common cause of urologic injuries involving the bladder or urethra?
pelvic fracture
Blood in the urethral meatus in men?
pelvic fracture
Complete picture of urethral injury in men:
- blood in the urethral meatus
- scrotal hematoma
- the sensation of wanting to void but not being able to do it
- “high riding” prostate on rectal exam
what should you NOT do in the case of urethral injury?
insert a foley catheter
what should you do to treat a urethral ijury?
retrograde urethrogram
How to diagnose bladder injury?
retrograde cystogram
what must you also get in the case of bladder injury?
postvoid xray films to look for extraperiotoneal leaks at the base of the bladder
Treatment for extraperiotoneal leaks at the base of the bladder?
place a foley catheter
treatment for INTRAperitoneal leaks of the bladder?
- sugical repair
2. protect with suprapubic cystostomy
Modality used to assess renal injury?
CT scan
Mgmt for renal injury?
no surgical intervention needed most of the time
Rare sequela of renal injury?
AV fistula leading to congestive heart failure
2. renal artery stenosis–> renovascular htn
Trmt for scrotal hematoma?
usually doesn’t need specific intervention
How to test for testicle rupture?
sonogram
Structures that get fractured in penile fracture?
- corpora cavernosa
2. tunica albuginea
How does a fractured penis look?
sudden pain + large penile shaft hematoma + normal glans
Trtmt for penile fractures?
surgical repair
complications: impotence and AV fistulas
Penetrating injury to the extremity w NO majory vessels in vicinity?
tetanus prophylaxis + wound cleaning
Penetrating injury to the extremity WITH major vessels nearby but NO symptomos
doppler study or CT angio
Signs of vascular injury?
- absent distal pulses
2. expanding hematoma
Mgmt of vascualr injury?
- surgical exploration
2. surgical repair
Mgmt combined artery + nerve + bone injury?
Sequence:
- stabilize bone
- do delicate vascular repair
- nerve done last
- fasciotomy prophylactically (prolonged ischemia could lead to compartment syndrome)
High-velocity (military or big-game hunting rifle) gun-shot wound?
- large cone of tissue destruction
- extensive debridement required
- potential amputation
5 concerns in crushing injury?
- hyperkalemia
- myoglobinemia
- myoglobinuria
- renal failure
- compartment syndrome
3 treatments for preventing hyperkalemia-myoglobinemia-myoglobinuria-renal failure?
- vigorous fluid administration
- osmotic diuretic
- alkalinization of urine
Treatment of chemical burns?
- massive irrigation
(tap water, shower as soon as possible) do NOT try to neutralize the wound
Which are wors alkaline burns (liquid plumr, drano) or acid burn (battery acid)?
alkaline burns
Concerns with high-voltage electrical burns?
- debridement/amputation
- myoglobinemia-myoglobinuria-renal failure (give fluids, mannitol, alkalinize the urine )
- massive muscle contractions (posterior dislocation of the shoulder, compression fracture of vertebral bodies)
- cataracts develop later
- demyelinization syndromes
Respiratory burns?
chemical injuries caused by smoke inhalation (breathing in flames from a burning building, car, plane)
Signs of respiratory burns?
- burns around the mouth
2. soot inside the throat
How can you confirm that there is a respiratory burn?
fiberoptic bronchoscopy
How can you confirm that a respirator is needed?
blood gases
Mgmt of respiratory burns?
- make sure airway is adequate- intubate if needed
- monitor level of carboxyhemoglobin
- if carboxyhemoglobin is elevated–> give 100% oxygen to lower half-life of carboxy-hemogloin
Circumferential burns of the extremities danger
cut-off of the blood supply as edema accumulates under unyielding eschar
-same mechanism can cause breathing issues in case of circumferential burns of the chest
How to restore blood supply in case of circumferential burns?
escharotomy (no need for anesthesia )
Scalding burns on both bottocks of children?
- child abuse
Fluid resuscitation post-burn algorithm?
- initial rate of 1 L/hr
2. Then adjust fluid administration on basis of urinary output
“Rule of Nines” : How to estimate extent of burns in an adult?
“RULE OF NINES”
- head and each of th eupper extremities= 9%
- Each lower extremity= 2x 9%
- Trunk= 4 x 9%
- –for both 2nd and 3rd degree burns–
Target hrly urinary output in burn pts who are receiving fluid resuscitation?
1-2mL/kg/h
*avoid a CVP of over 15 mmHg
Appropriate [redetermined fluid infusion in an adult?
1000 mL/h of Ringer Lactate (w/o sugar) in anyone whose burns exceed 20% of body surface, then adjust to produce desired urinary output
Why do you avoid sugar in Ringer lactate?
so as not to induce osmotic diuresis from glycosuria
Rule of 9s in Babies?
- head= 2 x 9%
2. both legs= 3 x 9%
Difference bw look of a 3rd degree burn in a baby vs adult?
In babies, 3rd degree burns look deep, bright red (rather than leathery, dry, gray as in an adult)
Post-burn fluid administration in babies
20mL /kg/h if the burn exceeds 20% of body surface and then fine-tune in response to urinary output
Burn Care:
- tetanus prophylaxis
- clean of burn area
- use of topical agent (silver sulfadiazine is standard topical agent) …mafenide acetate locally for deeper penetration(eschar, cartilage)..triple antibiotic ointment for burns near the eyes bc silver sulfadiazine is irritating to the eyes
- give all meds IV for the first couple of days
- 1-2 days of NG suction followed by intensive high-calorie/high-nitrogen diet via GI ideally
- after 2-3 weeks of wound care, burned areas that haen’t regenerated are grafted
- rehab starts on day ONE
Who is eligible for early excision and grafting?
limited burns (under 20% of body)
Required prophylaxis for all bites?
tetanus prophylaxis
What kind of dog bites are provoked?
- petting dog while eating
2. teased dog
Mgmt of dog bite?
- start rabies immunization
2. stop if observation of dog is reassuring
Issue with unprovoked dog bites or bites from wild animals:
- potential rabies
- can kill animal and examin brain for signs of rabies
- rabies prophylaxis is MANDATORY (Ig + vaccine)
Signs of envenomation following snake bite?
- severe local pain
- swelling
- discoloration within 30 minutes of bite
Snake bite with envenomation, do ASAP:
Draw blood for:
- typing and crossmatch
- coag studies
- liver and renal function
Snake bite treatment?
antivenin- dosage relates ot size of envenomation (not size of pt)
What dosage of antivenin do children get relative to adults/
same dosage
Preferred agent for crotalids (viper)?
CROFAB
Mgmt of snake bite in the field?
only valid first aid is to splint the extremitiy during transplantation
Dose of epinephrine to use in bee anaphylactic reactions?
- 3-0.5 mL of 1/1000 solution
- avoid squeezing stinger when removing it
Sx after black widow spider bite?
- nause
- vomiting
- generalized muscle cramps
Antidote for black widow spider bite?
IV calcium gluconate
-muscle relaxants can help-
Brown recluse spider bite:
- often presents next day as a skin ulcer with necrotic center and surrounding halo of erythema
Trmt for brown recluse spider bite?
dapsone
+ surgical excision w/ post-op skin grafting may be needed but should bot be delayed until the full extent of damage is evident
Human bite treatment?
- extensive irrigation and debridement in the OR
- need specialized orthopedic care
- most often appear as a sharp cut over the knuckles on someone who punched someone
