Trauma/ Extremity Trauma

Question 1

What is the leading cause of accidental deaths in the US? What is a factor?

Answer 1

MVAs

Alcohol

Question 2

What is the 2nd leading cause of accidental death for ages 45-75 yrs?

Answer 2

Falls
#1 cause of unintentional death for those age 75 and older

Question 3

First peak of death

Answer 3

Seconds-minutes
Brain injury, high spinal cord injuries, large vessels, cardiac arrest
Best treated by prevention

Question 4

Second peak of death

Answer 4

Minutes-hours
Sub/epidural bleeds, HTX/PTX, spleen/liver lac
Best treated by ATLS principles
“Golden hour”

Question 5

Third peak of death

Answer 5

Days-weeks
Sepsis, multi-organ failure
Directly correlated to earlier tx

Question 6

Primary trauma evaluation

Answer 6

Airway maintenance with C-spine control 
Breathing and ventilation
Circulation with hemorrhage control
Disability or neurological status
Exposure and environmental control

Question 7

Airway

Answer 7

Control with basic to advanced maneuvers
Suction
100% oxygen
Hyperventilation
Prepare to intubate
Paralyze the pt
Use appropriate tx
-HTN, hyperkalemia, elevated ICP
Intubate: maintiain in-line traction

Question 8

Circulation

Answer 8

Control exsanguinating hemorrhage
Control external bleeding promptly
2 large-bore IV (14-16 g)
-Blood draw for type and cross
Add pressure bags if needed
-Nl saline/LR
-Blood 
-No pressors

Question 9

Class I circulation

Answer 9

Up to 15% blood loss (750 mL)

Question 10

Class II circulation

Answer 10

15-30% blood loss (750-1500 mL)

Question 11

Class III circulation

Answer 11

30-40% blood loss (1500-2000 mL)

Question 12

Class IV circulation

Answer 12

> 40% loss (>2L)

Question 13

GCS- eye opening

Answer 13

4-spontaneous
3-to speech
2-To pain
1-none

Question 14

GCS- verbal response

Answer 14

5-oriented
4-confused
3-inappropriate
2-incomprehensible
1-none

Question 15

GCS- motor response

Answer 15

6-obeys commands
5-localizes to pain
4-withdraws from pain
3-flexion to pain
2-extension to pain
1-none

Question 16

Exposure/environmental control

Answer 16

Get them naked
Cut off clothes for ease/keeping pt immobilized
Assess entire body
Rectal/vaginal exam
Cover with blankets/bear hugger to prevent hypothermia

Question 17

Adjuncts to primary survey

Answer 17

ECG/monitor
Pulse ox
CXR
Urinary/gastric catheters

Question 18

Secondar survey

Answer 18

Complete head-to-toe exam with detailed hx
Reassess vital signs
Fully examine each body region/system
Complete neuro exam (GCS if not already done)
FAST exam

Question 19

Hx

Answer 19

Allergies
Medications
Past illnesses/pregnancy
Last meal
Environments/events related to the injury

Question 20

What criteria are used to determine whether to get films to determine whether to release from C-spine?

Answer 20

NEXUS criteria
Focal neurological deficit
MIdline spinal tenderness
Altered level of consciousness
Intoxication
Distracting injury
If none present, C-spine can be cleared clinically. No radiographs needed.

Question 21

Trauma in pregnancy

Answer 21

Hemodynamical differences
-Decreased SVR and VR
-CO is ~25% higher
-HR is 15-20% higher than nl
So...avoid prolonged supine position
Left lateral decubitus prevents supine hypotensive syncrome

Question 22

Blunt trauma in pregnancy

Answer 22

Placental abruption
Uterine rupture
Amniotic fluid embolism
-80% mortality
Fetomaternal hemorrhage
-Rh neg mothers (Rhogam)

Question 23

Penetrating trauma in pregnancy

Answer 23

More intentional

Work up the same as blunt

Question 24

Evaluation of trauma in pregnancy

Answer 24

Hx
ABCs
Secondary survey
Fetal monitoring
-Variability
-Accelerations/decelerations
U/s

Question 25

Causes of compartment syndrome

Answer 25

Crush injuries
Burns
Overly tight bandages
Prolonged compression
Surgery
Thrombus

Question 26

What are the Ps of compartment syndrome?

Answer 26

Pain
Paresthesia
Pallor 
Paralysis
Pulselessness
Poikilothermia

Question 27

Dx of compartment syndrome

Answer 27

High degree of suspicion
Frequent reassessments
-Distal neurovascular status
Doppler flow does not exclude diagnosis
Definitive dx
-Direct measurement of pressure in the compartment

Question 28

Compartment pressures as high as _______ require surgical intervention

Answer 28

30-45 mm Hg

Question 29

Orthopedic tests

Answer 29

ACL
-Lachman
-Anterior drawer
Meniscal injuries
-McMurray 
-Apley
Achilles tendon injury
-Thompson
Allen's

Question 30

Displacement

Answer 30

Distal fragment moves laterally away from the proximal fragment but maintains alignment along the long axis

Question 31

Angulation

Answer 31

Deranged orientation of long axis of the bone

Expressed in degrees and direction noted

Question 32

Salter-Harris classification

Answer 32

Type I: growth plate
Type II: growth plate and metaphysis
Type III: growth plate and epiphysis
Type IV: metaphysis, growth plate, and epiphysis
Type V: growth plate crush injury

Question 33

When to consult on extremity injuries

Answer 33

In the ED, every possible fx
Compound
Intra-articular
Septic joints
-Red/hot/swollen/pain
Salter-Harris 3, 4, 5

Question 34

Tx options for extremity fxs

Answer 34

Sedation
-Versed
-Etomidate
Passive weight reduction
Active reduction
-Abduct arm 45. Elbow at 90%
-Externally rotate
-Downward traction
-Abduct shoulder if necessary
-Immobilize shoulder