Trauma indications CC

Question 1

Cervical spine clearance in trauma - CT scan indications

Answer 1

• Age >65 yrs
• Fall >3 ft or 5 stairs
• Motor vehicle crash at high speed
• Motor vehicle rollover or ejection
• Bicycle crash
• Motorcycle crash
• Motorized recreational vehicle crash

Question 2

Cervical spine clearance in trauma - conditions for cervical collar

Answer 2

• Altered mental status
• Intoxication with drugs or alcohol
• Traumatic brain injury
• Midline cervical tenderness
• Focal neurologic deficit
• Numbness or paresthesia of any extremity without direct injury
• Painful distracting injury

Question 3

Relative contraindications to pharmacologic VTE prophylaxis in trauma patients

Answer 3

• High risk of bleeding
• Pelvic or retroperitoneal hematoma
• Ocular injury with hemorrhage
• Some traumatic brain injuries (acute phase)
• Solid organ injury
• Systemic anticoagulation
• International normalized ratio (INR) ≥1.5, or activated prothrombin time (aPTT) ratio ≥1.3
• Platelet count <50,000
• Allergy
• History of heparin-induced thrombocytopenia

Question 4

IVC filters in trauma patients

Answer 4

• Recurrent PE despite full anticoagulation
• Proximal DVT & contraindications to full anticoagulation
• Proximal DVT & major bleeding while on full anticoagulation
• Progression of iliofemoral clot despite anticoagulation (rare)

Question 5

Emergent thoracotomy (emergency department thoracotomy) - indications

Answer 5

• Penetrating thoracic injury: (+) signs of life & pulseless → strongly recommended
• Penetrating thoracic injury: (−) signs of life & pulseless → conditionally recommended
• Penetrating extrathoracic injury: (+) signs of life & pulseless → conditionally recommended
• Penetrating extrathoracic injury: (−) signs of life & pulseless → conditionally recommended
• Blunt injury: (+) signs of life & pulseless → conditionally recommended

Another source:

• more than 1500 mL blood immediately evacuated by tube thoracostomy;
• persistent bleeding from the chest, defined as 150 mL/hr to 200 mL/hr for 2 to 4 hours;
• persistent blood transfusion required to maintain hemodynamic stability.
• persistent air-leak on post-injury day 3

Note: indications to consider operative intervention rely on patient physiology rather than any absolute numbers.

Question 6

Emergent thoracotomy (emergency department thoracotomy) - contraindications/considerations

Answer 6

• Blunt injury: (−) signs of life & pulseless → conditionally NOT recommended

Be mindful of blood-borne pathogen exposure

Question 7

Indications for ICP monitoring in traumatic brain injury

Answer 7

• Any moderate-to-severe TBI (GCS < 12) who cannot be serially neurologically assessed, for example if sedated
• Any severe TBI (GCS < 8) with an abnormal CT head scan
• Any severe TBI (GCS < 8) with a normal CT head scan if 2 of the following are present:
  
  • Age > 40 years,
  • SBP < 90,
  • Abnormal motor posturing

Question 8

Indications to repeat imaging in blunt solid organ injury

Answer 8

hemodynamic instability,
persistent systemic inflammatory
response,
increasing abdominal pain, jaundice, or
unexpected decrease in hemoglobin.

Question 9

Indications for CT head after head injury

Answer 9

• GCS less than 13 at any point since the injury
• GCS equal to 13 or 14 at two hours after the injury
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid otorrhoea, Battle’s sign)
• Vomiting > 2 episodes
• > 65 years of age
• Post traumatic seizure
• Focal neurological deficit
• Amnesia before impact > 30 minutes
• Dangerous mechanism of injury

MCQs