Trauma & ED Flashcards
ECG changes for thrombolysis or
percutaneous intervention
ST elevation of >2mm (2 small
squares) in 2 or more consecutive
anterior leads (V1-V6) OR
ST elevation of greater than 1mm
(1 small square) in greater than 2
consecutive inferior leads (II, III,
avF, avL) OR
New Left bundle branch block
Scoring system used for ACS +
purpose
GRACE
calculates predicted 6 month
mortality
Indications for thoracotomy in hemothorax
Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours
How to prevent thromboembolism in Pregnant women?
Treatment with low molecular weight heparin throughout pregnancy and 4-6 weeks after childbirt
Aortic dissection.in pregnancy
*In 3rd trimester
*Predispose by HTN,Marfan and congenital heart diseases
*Sharp shooting pain of chest
*Cold and clammy extremities with high blood pressure
* involvement of right coronary artery causing inferior wall MI
* aortic regurgitation murmur which is early diastolic
What is Beck’s Triad?
Used in Cardiac Tamponade
Beck’s triad:
elevated venous pressure
reduced arterial pressure
reduced heart sounds
GCS with severe brain injuries
Severe brain injuries are generally associated with GCS <8.
Formula.for Fluid resuscitation in burns in adults
2ml crystalloid x weightinkg x% TBSA for second- and third-degree burns.
Half in 1st 8 hours and other half in next 16 hours
The efficacy of fluid replacement in adult burn patients is determined by
Urine output 0.3-0.5ml/kg/hr OR 30-50ml per hour
Maintenance fluid in burn patience
Maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight
Vit C as antioxidant
Electrical burns
Electrical injury in All ages
4 ml Hartmanns x kg x % TBSA until urine clears
1-1.5 ml/kg/hr output until urine clears
Burnt nose hair and soot inoro pharynx
Intubate asap
Some side effects of burns
Fluid loss
bacterial translocation from gut
immunosuppressio
Transfer to burn centre if:I
Need burn shock resuscitation
Face/hands/genitals affected
Deep partial thickness or full thickness burns
Significant electrical/chemical burns
Burn affecting extremes of age
Inhalational injury
Any burn >2% and >3% in children and adults respectively
Depth of burn assessment
Bleeding on needle prick
Sensation
Appearance
Blanching to pressure
Fluid resuscitation indication in burns patient
> 15% total body area burns in adults (>10% children)
Escharotomies are done in which situation
cutting of whole band of burn around torso or Limbs to regulate ventilation and prevent compartment syndrome
Percentage burn estimation
- Lund Browder chart: most accurate even in children
- Wallace rule of nines
- Palmar surface: surface area palm = 0.5% burn(in irrregular burnt aareas)
Sickle Cell anaemia with sudden anemia with
low and
high reticulocyte count
High reticulocyte count in acute sequestration
low reticulocyte count in parvo virus infection
What is sickle crisis
Sickle crises
Bone pain
Pleuritic chest pain: acute sickle chest syndrome commonest cause of death
CVA, seizures
Papillary necrosis
Splenic infarcts
Priapism
Hepatic pain
Management of messive Pulmonary embolism
Thrombolysis is 1st line for massive PE (ie circulatory failure) and may be instituted on clinical grounds alone if cardiac arrest is imminent; a 50 mg bolus of alteplase is recommended
Pulmonary Embolism EKG
S1, Q3, T3
Tall R waves: V1
Ppulmonale (peaked P waves): inferior leads
Right axis deviation, Right bundle branch block
Atrial arrhythmias
Twave inversion: V1, V2, V3
Emergency Thoracotomy
wide bore needle inserted in the fourth intercostal space in the mid axillary line.
Most commonSalter and Harris #
Type2 in which growthplate and
metaphysis both are involved
Cushing response. is
Cushing responseis due to increase intracranial pressure
Hypertension
Bradycardia
Respiratory depression
Normal Cerebral per fusion pressure
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.
Painful 3rd nerve palsy is due to
Painful third nerve palsy = posterior communicating artery aneurysm
Grafts for large and small areas
Large: Split thickness skin graft
Small: Full thickness skin graft
Compartment syndrome tricky question
Paresthesia with present pulse
Pulse goes last in compartment syndrome and it’s the worst prognostic sign
Massive transfusion defined as
More than patient’s total blood volume in 24 hours and half of estimated blood volume in an hour
Criteria of blood component replacement invasive hemorrhage is
Platelet ffp and pcv in ratio of 1:1:1
Local anesthetic toxicity anti dote
Intralipid 20%
Prilocaine toxicity antidote
Methylene Blue
Splenic trauma grade 3 treatment with mild hypotension
Conservativ4 treatment
Classic dishpan/flattened facial appearance 8n which fracture
Lefort 2 or 3
Which site fracture indicates compartment syndrome
Tibial shaft
Supracondylar fracture
Pressure In compartment to diagnose compartment syndrome
20mm abnormal
>40 diagnostic
Pain on passive stretching of toes
Compartment syndrome
Beck’s triad
Muffled heart sounds
Raised jvp
Hypotension
Fluid r4commmended in burns
Hartmann solution
Diaphragmatic rupture findings on CXR
Bowel loops in chest
Invisible hemidiaphragm
Displaced mediastinum
Mos common type of injury after lateral car crash
Diaphragmatic rupture
Fastscan in pregnancy
Not reliable
CT scan in pregnancy criteria
If suspicion of organ injury then perform it after major trauma
If suspected placental rupture
Aortic dissection points
Aortic regug murmur like early diastolic murmur
Inf wall MI(II, III and AVF)
COMMon in 3rd trimester of pregnancy, CT disorders like marfan, Ehler, bicuspid valve
Pneumothorax and chest drain
If traumatic always place drain no matter the size
If spontaneous and stable than no need but if unstable and tachypneic or decrease spo2 then place drain
Oculogyric crisis
Acute distonia
Sec to antipsychotics or metaclopromide
Extrapyrimidal disorder
Short gut syndrome
Caus3s Hypomagnesemia with broad complex tachycardia (Torsa de pointes)
Head injury and opiates
Give it
As by doing this we will decrease pressu4e to prevent raised icp
Ruptured anterior cruciate ligament
Ruptured posterior cruciate ligament
Menisceal tear
Dislocation of the patella
Differentiation point
Ruptured anterior cruciate ligament
Sport injury
Mechanism: high twisting force applied to a bent knee
Ruptured posterior cruciate ligament
Mechanism: hyperextension injuries
Menisceal tear
Rotational sporting injuries
Dislocation of the patella
severe contraction of quadriceps with knee stretched in valgus and external rotation
Gritti - Stokes amputation
Gritti - Stokes amputation. During a Gritti - Stokes operation the patella is conserved and swung posteriorly to cover the distal femoral surface.
Palmer Method of Burn
Palmar surface—The surface area of a patient’s palm (including fingers) is roughly 0.8% of total body surface area. Palmar surface are can be used to estimate relatively small burns (< 15% of total surface area) or very large burns (> 85%, when unburnt skin is counted).
Thoracotomy indication in hemothorax
In massive hemothorax which means
> 1.5 lit of blood in initial drain
Continued bleeding of over 200ml/hr for next 2 to 4 hours
Multiple transfusions are required to maintain hemodynamic stability
After how much time a nose # should be reduced
After 5days
Complications of basil skull fracture
Facial palsy
meningitis
and isolated 6th nerve palsy
What is battle sign
Periauricular bruising
Present in basal skull #
Features of zygomatic Arch fracture
Cause due to direct blow to the face
causes
diplopia, enophthalmus, extra ocular muscle Entrapment, Cosmetic deformity, depression of the Malar eminence, facial widening, malocclusion and neurosensary disturbance of Infra orbital nerve
Ebb Phase
24-48 hours post trauma
Hypovolaemia
dec Cardiac output
dec BMR
hypothermia
lactic acidosis
The main physiological role of the ebb phase
The main physiological role of the ebb phase is to conserve both circulating volume and energy stores for recovery and repair.
The predominant hormones regulating the ebb phase
The predominant hormones regulating the ebb phase are catecholamines, cortisol and aldosterone
flow phase is divided into
The flow phase may be subdivided into an initial catabolic phase, lasting approximately 3–10 days, followed by an anabolic phase, which may last for weeks
Features of flow phase
increase B MR
inc 02 consumption
_ ve nitrogen balance
inc stress homore levels
hyperglycemia
gluconeogenesis
proteinlysis
Lipolysis
immunosuppression
Hormones of flowphase
catecholamines, cortisol, insulin and glucagon
Colles’ Fracture
Colles’ Fracture
A Colles’ fracture* describes an extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface. This type of fracture typically occurs as a “fragility fracture” in osteoporotic bone.
It occurs when a person falls forwards and plants their outstretched hand in front of them. The transfer of load as their body falls forces the wrist into supination (Fig. 2A).
Smith’s Fracture
Smith’s Fracture
This describes the volar angulation of the distal fragment of an extra-articular fracture of the distal radius (the reverse of a Colles fracture), with or without volar displacement.
This type of fracture is caused by falling backwards and planting the outstretched hand behind the body, causing a forced pronation type injury (Fig. 2B). These are less common.
Barton’s Fracture
Barton’s Fracture
This is an intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint.
A Barton fracture can be described as volar (more common) or dorsal (less common), depending on whether the volar or dorsal rim of the radius is involved.
Only shock which has bradycardia and warm peripheries
Neurogenic shock
method is most effective at raising the core temperature?
Instillation of warm intraperitoneal and intrapleural fluid
haemodialysis or
Cardiac bypass
Drug for arrhythmia during hypothermia
bretylium toslyte
Superficial dermal burns features
Erythematous
Do not extend beyond the upper part of the dermal papillae
Capillary return and blisters are both usually present.
urgent burn fluid resuscitation
> 15% body surface area burns in adults
Necrosis after acid vs alkali
Acid Results in coagulation necrosis to affected tissues
Alkali Results in liquefaction necrosis to affected tissues
Kehr’s sign
Free blood can irritate the diaphragm and cause a radiating left shoulder pain
Which antibiotic post splenectomy
prophylactic Penicillin V
Complication of splenic conservative surgery or embolectomy
Ongoing bleeding
Splenic necrosis
Splenic abscess or cyst formation
Thrombocytosis*
Need of urgent splenectomy) criteria
Patients who are haemodynamically unstable* or with a grade 5 injury (a shattered spleen or major hilar vascular injury) need urgent laparotomy.
Urine output limit after burn
> 0.5mL/kg/hr.
CXR findings of Diaphragmatic rupture
non visible diaphragm, bowel loops in the hemithorax and displacement of the mediastinum.
common cause of diaphragmatic rupture.
A lateral blunt injury during a road traffic accident
J waves are pathognomonic of
hypothermia.
Features of an addisonian crisis:
Hyponatraemia
Hyperkalaemia
Hypoglycaemia
Drug not to give in addisonian crisis
Fludrocortisone
Features of Total anterior circulation infarcts
Hemiparesis/hemisensory loss
Homonymous hemianopia
Higher cognitive dysfunction
Weber’s syndrome
Ipsilateral III palsy
Contralateral weakness
Disconnection syndrome
If ant cerebral artery is affeced
Aphasia (Wernicke’s) in which artery injury
Middle cerebral artery
Pontine palsy
VI nerve: horizontal gaze palsy
VII nerve
Contralateral hemiparesis
Todd’s Paresis =
Unilateral motor paralysis following a seizure
Hormones increased during hypothermia
Glucagon
TSH
Aldosterone
Corticosterone
Isolated homonymous hemianopia in which areas lesion and which artery involvement
Occipital lobe lesion
Post Cerebral artery involvemen
Carotid end arterectomy not done in
Post cerebral artery occlusion
All patients with Mediastinal traversing wound should undergo
CT angiogram and oesophageal contrast swallow.
haemoptysis and surgical emphysema suspect
Tracheobronchial tree injur
What kind of chess drains should be used for hemothorax
a wide bore 36F chest drain.
Risk ofarrhythmias falls after how many hours post ca4diac contusion
24 hours
Commonest cause of death after RTA or falls
Traumatic aortic disruption
If GCS <8 or = to 8,
consider stabilising the airway
Full spine immobilisation until assessment if:
GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
If a c-spine injury is suspected ,what test to perform
C spine xray
CT only if some conditions are present
CT c-spine is preferred if:
Intubated
- GCS <13
- Normal x-ray but continued concerns regarding c-spine injury
- Any focal neurology
- A CT head scan is being performed
- Initial plain films are abnormal
Contact neurosurgeon if:
Persistent GCS < 8 or = 8
Unexplained confusion > 4h
Reduced GCS after admission
Progressive neurological signs
Incomplete recovery post seizure
Penetrating injury
Cerebrospinal fluid leak
The typical therapeutic end points include after massive transfusions
Hb: 8-10 g/dl
Platelets > 100
PT (INR) and APTT < 1.5
Fibrinogen > 1.0 g/l
Ca2+ > 1 mmol/l
pH: 7.35-7.45
BE: +/- 2
ToC > 36 °C
What occurs in initial ztage of rhabdomyolysis
Hypocalcemia
If suspected nasal # then how to asses
Within 10 days after swelling gets down
Altered sensation from forehead to vertex
Damage to
frontal branch of trigeminal nerve)
What muscle relaxant and more perfuser of area after trauma to face
Papaverine 40mg smooth muscle relaxant
Dextran 40 500mls IV improves perfusion
Orbital apex syndrome
extension of superior orbital fissure syndrome and includes compression of the optic nerve
Ventricular tachycardia - which drug is contraindicated
verapamil is contraindicated
Drugs for VT
Amiodarone
Lidocaine
Procainamide
Adenosine(in trial)
When to perform immediate cardioversion
If patient has adverse signs systolic BP < 90 mmHg, chest pain, heart failure or rate > 150 beats/min)
combination of a crush injury, limb swelling and inability to move digits
Diagnosis
compartment syndrome
perform fasciotomy
Why aggressive IV hydration in compartment syndrome
Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
Congenital causes of Torsades de pointes
Jervell-Lange-Nielsen syndrome,
Romano-Ward syndrome
sick euthyroid syndrome
Due to any systemic illness
All 3 thyroid parameters are low
Vertigo and dysarthria with vision loss
Posterior circulation stroke
most common is basilar artery stroke
CXR features of Tension Pneumothorax
Lung collapse towards the hilum
Diaphragmatic depression Increased rib separation
Increased thoracic volume
Ipsilateral flattening of the heart border
Contra lateral mediastinal deviation
Aortic dissection Rx inpregnant
If <28 then operate with inutero
IF >32 then C-sec then repair
Rx of miteral stenosis in pregnancy
Ballon valvuloplasty
Warfarin in pregnancy
is contraindicated
Rx of oculogyric crisis
Procyclidine
Causes of oculogyric crisis
Phenothiazines
Haloperidol
Metoclopramide
Postencephalitic Parkinson’s disease
Aortic dissection usually occur in
Deceleration injuries
when to give unfractionated heparinin ACS patients
If angiography is likely within 24 hours or a patients creatinine is > 265 umol/l
If angiography is likely within 24 hours not to give which antithrombin
Low molecular weight heparin
Criteria to give clopidogrel in ACS
•Predicted 6 month mortality of more than 1.5%
•Patients who may undergo percutaneous coronary intervention within 24 hours of admission to hospital.
Crjteria .of Intravenousglycoprotein IIb/IIIa receptor antagonists(eptifibatide or tirofiban)in ACS
•Predicted 6-month mortality above 3.0%), and
•Who are scheduled to undergo angiography within 96 hours of hospital admission.
glycoprotein IIb/IIIa receptor antagonists
eptifibatide or tirofiban)
Coronary angiographyshould be done within
Coronary angiographyshould be considered within 96 hours of first admission
Cxr of thoracic aortic rupture
Widened mediastinum
Trachea/Oesophagus to right
Depression of left main stem bronchus
Widened paratracheal stripe/paraspinal interfaces
Space between aorta and pulmonary artery obliterated
Rib fracture/left haemothorax
PTFE in trauma for vascular injury
Causes infection
Lateral medullary syndrome
ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss
Penetrating thoracic trauma that is then followed by cardiac arrest is an indication of
ER thoracotomy
Anticoagulation effect on compartment syndrome.
Anticoagulation will worsen compartment syndrome.
Chest pain, hypoxia and clear chest on auscultation in pregnancy
Diagnosis
pulmonary embolism
Rx of Anaphylaxis
1:1000 0.5ml INTRAMUSCULARLY (not IV). Repeat after 5 mins if no response
Rx of flail chest it sats L 90%
Intubation and ventilation
Clamshell thoracotomy
Clamshell thoracotomy (also known as bilateral anterolateral thoracotomy) is a technique used to provide complete exposure of the thoracic cavity (heart, mediastinum and lungs)
If access to lungs, heart and mediastinum is needed at the same time then what incision tomade
Clamshell thoracotomy
Test to check for CSF in a fluid like rhinorrhea
Beta 2 transferrin assay
Colloid to be started in burns after and of what kind
5% albumin in R/L
After 18 to 24 hours of burn
Which agent helps in clearance of myoglobin
Bicarbonate
Narrow complex tachycardia vs broad Rx
Adenosine and vagal for narrow
Adenosine for broad
