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Surgery > Trauma Methods > Flashcards

Trauma Methods Flashcards

1
Q

If a patient has head trauma and CT scan indicates a crescent shaped hematoma, what are methods to minimize oxygen demand of the brain?

A

– Sedation
– Hypothermia
+ Mannitol and Furosemide (to reduce ICP)
Additionally, elevate head and hyperventilate to ensure maximium oxygen to tissues

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2
Q

Why can’t hypovolemic shock occur if there is an ICH?

A

There is not enough room in the skull to lose enough blood from circulation to cause hypovolemic shock

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3
Q

If there is a knife wound to the spinal cord at T4 causing hemisection, what physical exam findings?

A

Loss of motor and proprioception on the injury side, then loss of pain and tempurature on the opposite side.

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4
Q

What is a typical causation of central cord syndrome and clinical findings?

A

Usually from hyperextension of the neck in elderly individuals, typically from being rear-ended

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5
Q

How should a cord injury be definitively diagnosed and what should be given?

A

MRI for diagnosis

– Corticosteriods immediately

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6
Q

How are the physical exam findings different between a pneumothorax compared to hemathorax?

A

Pneumothorax – absent breath sounds and hyperresonant to percussion (chest tube – upper+anterior)
Hemathorax – absent breath sounds, but dull to percussion (chest tube – placed low in chest)

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7
Q

What bone fractures if present should cause your suspicion for aortic rupture be elevated?

A

Very hard to break bones, require significant force to break

    • 1st rib
    • scapula
    • sternum
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8
Q

If a patient is intubated and on a respirator after blunt chest trauma, then suddenly dies, what is most common cause?

A

Air Embolism
– reverse trenclelenburg and cardiac massage
Other causes: subclavian vein exposed to air (central line placement, supraclavicular node biopsy, CVP lines disconnected)

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9
Q

What must be present in a trauma patient in order for CT scan to be an option?

A

hemodynamically stable

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10
Q

What are the differences in treatment of anterior vs posterior urethral injuries in men?

A

Anterior – surgical repair at time of occurance

Posterior – treated with suprapubic urine drainage and delayed repair

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11
Q

For crush injuries and electrical burns, what are ways to prevent significant renal damage?

A

Muscle will be damaged and releasing myoglobin, thus need significant fluids +osmotic diuretics and alkalinzation of urine to trap the myoglobin to prevent obstruction and reabsorption

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12
Q

What kind of burn patients are candidates for excision and grafting?

A

Typically under 20% and 3rd degree, limited/focal burns

– can occur on Day 1 of burn in the OR

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13
Q

What is the most common agent used for topical burn care and deep burn care?

A

silver sulfadiazine

– deep is mafenide acetate, but only at those sites can cause acidosis and pain

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14
Q

How do you know if a snake injected venom into the patient or not? (up to 30% are not envenomated)

A

If venom injected: severe local pain, swelling, and discoloration within 30 minutes in the bite area.

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15
Q

What must be done first if envenomation is suspected in a patient from snake bite?

A

blood draw for typing, coagulation studies, liver, and renal function – even if not needed at the time due to being unable to have reliable tests if blood draws wait

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16
Q

What is the treatment for a black widow spider bite? (red hourglass on belly)

A

IV calcium gluconate + muscle relaxants

– symptoms nausea/vomiting and generalized muscle cramps.

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17
Q

What organs are highest risk for injury from a blunt trauma to the abdomen?

A

Spleen and Liver

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18
Q

What is a complicating factor for chest and abdominal trauma injuries?

A

Rib Fractures – can be the cause of the liver/spleen injuries
– patients won’t breath as deeply to keep the lungs open increasing their risk of pneumonia and death

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19
Q

What is the goal of the primary survey of the patient when initially presenting to the trauma bay?

A

Identify Life Threatening Injuries

– Airway, Breathing, Circulation, Disability (Neuro), and Exposure

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20
Q

What should be performed initially in the ED with blunt abdominal trauma and abdominal pain?

A

– FAST scan
Focused Abdominal Sonography for Trauma
Looks for blood accumulated in the abdomen

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21
Q

If there is any evidence on FAST exam of blood collection in the peritoneum, what should be done?

A

CT Scan of the Abdomen

– answers the question of where the bleeding is coming from and pathology occurring. Assists in planning surgery.

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22
Q

What are complications that can arise from trauma to the liver and spleen?

A

Hypovolemic Shock, Diaphragmatic rupture, Hematoma rupture, abscess formation, bowel obstruction and abdominal compartment syndrome.

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23
Q

After abdominal trauma what should be done while in the hospital?

A

Hemodynamic monitoring

Serial Abdominal Exams

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24
Q

If a patient is experiencing shoulder pain after abdominal trauma, which was not present on primary or secondary survey, what might be the cause?

A

Diaphgram Irritation – spleen injury or liver that is causing diaphgram inflammation
– Phrenic nerve referred pain

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25
Q

What should be done FIRST in trauma resuscitation?

A

Secure Airway

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26
Q

How is an airway determined upon primary assessment?

A

GCS of 8 or below

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27
Q

How do you secure an airway in a patient with a possible C-spine injury?

A
    • stabilize the C-spine (in-line stabilization)

- - fiberoptic intubation

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28
Q

What are the methods of securing an airway?

A
    • Orotracheal intubation
    • Cricothyroidotomy
    • Percutaneous Tracheostomy
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29
Q

How do you know if the ET tube was placed properly?

A
    • There are breath sounds BILATERALLY
    • Positive color change indicating CO2
    • Normal pulse Oximetry
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30
Q

What is the indication for CT Head and head trauma?

A

Everyone gets a CT Head if they were unconscious for any amount of time

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31
Q

What are the criteria for outpatient management of head injury that includes a period of unconscious time?

A
  • No intracranial bleeding on CT Head
  • Neurologically intact
  • Someone to check on them for the next 24 hours
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32
Q

What are the signs that a patient with a close head injury should return to the hospital for concern for significant traumatic brain injury?

A
  • Headache
  • Vomiting
  • Dizziness
  • Confusion
  • Decreasing mental status
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33
Q

When is it indicated to repair a skull fracture?

A

Only if the skull fracture is comminuted or depressed

– if its open with overlaying wound, close the wound, not the skull fracture

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34
Q

What are the signs of a base of the skull fracture?

A
  • Periorbital Ecchymosis
  • Rhinorrhea (could be CSF)
  • Otorrhea (could be CSF)
  • Ecchymosis behind the ear
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35
Q

If a base of skull fracture is suspected in a patient that is conscious, what should be used to assess the patient?

A
  • Only need a C-spine CT Scan

If the patient is unconscious need to include CT Head with C-spine

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36
Q

What is the timeline of events for a epidural hematoma?

A

The patient with have a head injury typically on the side of the head with initial loss of consciousness, then the patient will have a “lucid” interval, then once the dura ruptures from the suture lines of the skull there is rapid deterioration.

37
Q

If you see a biconvex shaped hematoma in the head, then which artery most likely was ruptured.

A

Epidural Hematoma – middle meningeal artery

– lens-shaped hematoma

38
Q

What is the management of epidural hematoma once identified on CT Head?

A

– rapid craniotomy with hematoma evacuation

39
Q

What is a complication that can arise from an untreated epidural hematoma?

A

Subfalcine herniation compression of cerebral cortex and brainstem

    • compression of CN3 – fixed dilated pupil on that side
    • contralateral hemiparesis with decerebrate posturing
40
Q

What demographic of patients most commonly get subdural hematomas and why?

A

– Elderly and Alcoholics due to brain atrophy and more easily able to tear the bridging veins of the subdural space

41
Q

What is normally present during a subdural hematoma and what are indications for craniotomy?

A

Semilunar crescent shaped hematoma in the head

- if midline shift is present and brain structures displaced

42
Q

If a patient is found to have a subdural hematoma without midline shift, what is most concerning and how is the patient managed?

A

Managed medically for tight control over the intracranial pressure

    • ICP Monitoring
    • Elevate the head of the bed (to help blood flow out)
    • Hyperventilate the patient
    • gently diurese with Mannitol or Furosemide
43
Q

Why is it important to hyperventilate a patient with an intracranial hemorrhage?

A

– Decrease the pCO2, which generally maintains blood flow to the head, thus if it is lower then there is no stimulation from the brain to influence more blood flow to the head, in theory reducing ICP

44
Q

If a patient is known to have head trauma and CT scan indicates no mass lesions but multiple small lesions of the grey matter, what might be diagnosis?

A

Diffuse Axonal Injury – due to severe trauma

45
Q

What are the boundaries to Zone 1 of the neck in penetrating trauma?

A

Zone 1: Inferior to the cricoid cartilage
Zone 2: Between the cricoid cartilage and angle of the mandible
Zone 3: Superior to the angle of mandible

46
Q

What are the indications for exploration of penetrating trauma to the neck?

A
    • patients vitals are deteriorating
    • expanding hematoma
    • signs of tracheal or esophageal injury (hemoptysis or subQ emphysema)
47
Q

In a patient with a penetrating neck trauma, what need to be performed in order to rule out (or in) surgical intervention if the patient is stable otherwise?

A
    • Arteriogram of vessels
    • Esophagogram (water soluble, then barium if negative)
    • Esophagoscopy
    • Bronchoscopy
48
Q

What is an indication for CT scan of the C-spine in blunt or deacceleration injuries?

A

If the patient has any C-spine point tenderness at all, or evidence of neurologic compromise or fracture on examination

49
Q

What are the most common causes of shock? (Hypotension and cardiac decompromise)

A
    • Hypovolemia/Hemorrhage
    • Pericardical Tamponade
    • Tension Pneumothorax
    • Neurogenic
50
Q

How can you immediately tell between hypovolemic shock and tension pneumo/pericardial tamponade?

A

Hemorrhagic Shock – Low Central Venous Pressure
– Flat Neck Veins
Restrictive Shock – Elevated CVP, veins should be distended since there is difficulty for the blood to get into the heart

51
Q

What is the first step in management of a patient with hypovolemic shock?

A

– VOLUME REPLACEMENT with IV fluids

2 Liters of NS/Ringers as fast as possible, then packed RBCs

52
Q

What is the general rule for resuscitation of a patient in hypovolemic shock?

A

3 to 1 Rule – 3 mL of fluid per 1mL of blood loss

53
Q

How do you know a patient is sufficiently resuscitated?

A

Urine output – 0.5-2mL/kg/h

– Increased CVP pressure, but not above 15 mmHg

54
Q

What is Beck’s Triad for pericardial tamponade?

A

– Hypotension
– Increased JVD
– Muffled distant heart sounds
(Most commonly from penetrating check trauma)

55
Q

How is a pericardial tamponade diagnosed?

A

Typically clinical suspicion is enough to warrant intervention
– Ultrasound can diagnose if clinical picture is unclear

56
Q

What is the intervention needed once a diagnosis of pericardial tamponade is established?

A

Immediate pericardial sac evacuation via:

    • pericardialcentesis
    • chest tube
    • pericardial window
    • open thoracotomy
57
Q

What is the most common clinical picture of a tension pneumothorax?

A
    • Trauma to the chest
    • Distended CVP (JVD appreciated)
    • Hypotension
    • Respiratory Distress
58
Q

What is absolutely contraindicated in pericardial tamponade?

A

Chest X-ray — WASTES TIME and is NOT NEEDED for Diagnosis

59
Q

What are the physical exam findings on a tension pneumothorax?

A

– No breath sounds (one or both sides)
– hyperresonate to percussion (due to air)
CXR is CONTRAINDICATED – clinical diagnosis is all that is needed

60
Q

What is the immediate treatment needed for tension pneumothorax?

A

Emergent insertion of a large bore needle or catheter into the pleural space
– high on anterior chest 2nd intercostal space
Then after relieving initial pressure, insert Chest Tube high on anterior chest wall with an underwater seal

61
Q

What is are the unique features of neurogenic shock?

A

– Hypotension
– Bradycardia
– Flushing from cutaneous vasodilation
Loss of sympathetic outflow
— can have paralysis if spinal cord is severely lesioned

62
Q

What is the preferred management of rib fractures and why?

A

Local Rib Blocks – local anesthetic
– broken ribs prevent full inspiration and patients breath less, but giving the patient large doses of narcotics causes further respiratory depression

63
Q

How can tension pneumothorax and cardiac tamponade be differentiated from hypovolemic shock?

A

Distended Neck Veins (Indicative of increased venous pressure)

64
Q

If a patient has a “sucking” chest wound and developing a tension pneumothorax, what should be the immediate management?

A

Occlusive Dressing Taped at 3 Points

– this allows air to flow OUT, but prevents air from coming into the wound any further

65
Q

What are the immediate steps in management of tension pneumothorax?

A
  1. Emergent decompression with a large gauge needle in the 2nd intercostal space anteriorly
  2. Chest tube in the 5th intercostal space
  3. Intubated
66
Q

What would be the clinical findings for a hemathorax?

A
  • decreased breath sounds
  • dullness to percussion on chest wall (unique)
    Management – chest tube
67
Q

When is intervention needed on a hemathorax?

A

If after the chest tube(s) placed continue to drain 100s of mLs per hour, then thoracotomy needs to be performed to ligate the vessel (most likely not a simple intercostal artery, but thoracic artery)

68
Q

What is the best initial management of a flail chest?

A
  • paradoxical respiratory mechanics due to the flail chest can be corrected by PEEP
  • PAIN CONTROL + OXYGEN
    (in order to maximize excursion and oxygenation)
69
Q

If a patient with flail chest is intubated, what else should be done during their management?

A
    • Intubated with PEEP utilized

- - PROPHYLACTIC CHEST TUBES on the side of the chest where the fractures are at to prevent a pneumothorax

70
Q

What injures if present warrant an active investigation for another lurking injury?

A
    • Sternum Fracture
    • 1st Rib Fracture
    • Scapula Fx
    • Flail Chest
71
Q

If a patient has one of the significant force trauma injuries, how much you evaluate them and what are you looking for?

A

– CXR, EKG, Cardiac Enzymes

Looking for:

  • Pulmonary or Cardiac Contusion
  • Aortic Damage / Rupture
72
Q

What might you be worried about if you see a widened mediastinum on CXR after a high force trauma?

A

– Traumatic Aortic Rupture

73
Q

If a patient has high concern for aortic injury, but CXR is inconclusive, what might be used for further evaluation?

A
    • CT Chest

- - Transesophageal Echocardiogram

74
Q

If you have a suspicion for aortic damage in a patient and the CXR is positive, but further eval TEE is unremarkable suspicion, what do you do next?

A

Perform an Angiogram of the Aorta

– CTA Chest

75
Q

When and what do pulmonary contusions look like on CXR?

A

Initial CXR are usually normal, but over time CXR can develop a “white out” appearance of the area and can cause acute hypoxia. — Similar to ARDS

76
Q

Once you have diagnosed a patient with a pulmonary contusion, how do you manage the patient?

A
    • Similar to ARDS, increased permeability of the alveolar membranes
    • fluid restriction and diuretics
77
Q

What side do diaphgrams typically rupture causing air fluid levels in the abdomen?

A

Usually on the left, since the right side is protected by the liver

78
Q

If after chest tube placement and stabilization measures there is a pneumothorax that is persistant, what might be the cause?

A

Tracheobronchial injury

Evaluation via – Bronchoscopy

79
Q

What kind of injuries are most concerning for a urologic injury?

A
    • straddle injury
    • penetrating injury to lower abdomen
    • fall from height
    • gross hematuria
    • pelvic fracture
80
Q

What should be indications of urethral injuries?

A
  • blood at the urethral meatus
  • ecchymosis in the perineum or scrotum
  • “high riding” prostate upon exam
  • difficulties voiding after injury
81
Q

If there is any indication of a urethral injury, what should be done first?

A

DO NOT PLACE A FOLEY

– Perform a retrograde urethrogram

82
Q

How are managements of anterior and posterior urethral injuries managed differently?

A

Anterior – immediate surgery

Posterior – suprapubic cystostomy placement and delayed repair

83
Q

What is the most common cause of bladder rupture or injury?

A

Pelvic Fracture

– immediate surgery to repair the bladder

84
Q

If a bladder is injured / ruptured from an external force not from a pelvic shard, then what is the management?

A

Extraperitoneal bladder rupture

– nonsurgical management by Foley drainage or suprapubic

85
Q

What is the best modality to diagnose renal or urethral injuries?

A

CT Abd/Pelvis with Contrast

– Intravenous pyelogram can be used to diagnose ureter damage

86
Q

What is the typical management of renal injuries and when does surgical intervention occur?

A

– Renal injuries are managed medically most of the time
However if there is vascular compromise or laceration extending through the cortex and collecting system, then surgical intervention

87
Q

When do penile fractures usually occur? What are the symptoms?

A

Typically during vigorous sex when the female is on top, fracture of the tunica albuginea / corpus cavernosa

  • Sudden pain
  • Hematoma development
  • Normal appearing glans otherwise
88
Q

What needs to be done to manage a penile fracture, what happens if it goes untreated?

A

– Urethrogram and surgical intervention

If untreated development of an AV shunt can occur and permanent impotence

Surgery (7 decks)

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