Traumatic Disorders Flashcards
What defines a positive diagnostic peritoneal aspiration?q
Aspiration of >10mL of frank blood
*x-ray from 369368
Diagnosis?
Patellar tendon rupture
Clinical features of patellar tendon rupture
Classically patient falls while descending a staircase or stepping down from a curb
Exam shows superior displacement of patella with inferior pole tenderness and swelling
Inability to actively extend the affected knee or to maintain the passively extended knee against gravity
ED management of patellar tendon rupture?
Immobilize knee in extension with knee immobilizer and apply ice and a compressive dressing
Causes for knee extensor mechanism injury
- Quadriceps tendon rupture
- Patellar tendon rupture
- Patellar fracture
- Tibial tuberosity avulsion
Retroperitoneum contents
- Adrenal glands
- Kidney
- Aorta
- Duodenum (except proximal segment)
- Pancreas (except tail)
- Ascending and descending colon
- Rectum
- Ureter
- Esophagus
What are Grey-Turner and Cullen signs?
Late findings
Grey-Turner: flank ecchymosis
Cullen: periumbilical ecchymosis
What is Bryant sign?
Unilateral scrotal ecchymosis secondary to tracking blood
Common mechanism for anterior urethral injuries
Direct trauma to the perineum such as straddle injuries, but also seen with penile fractures
Symptoms of urethral injury
- Blood at penile meatus
- Inability to void
- Gross hematuria
- Perineal pain
- Perineal swelling or ecchymosis
- Absent, high-riding, or boggy prostate on exam
Differences between anterior and posterior urethral injury
Physical exam findings are different
Classically for anterior: perineal hematoma or penile swelling
posterior: absent, high-riding, or boggy prostate
Diagnosis of urethral injuries
Retrograde urethrogram
What is the most common dysrhythmia seen in blunt cardiac injury outside of sinus tachycardia?
Atrial fibrillation
Disposition for tympanic membrane perforation?
If involves <25%, can discharge with otic antibiotics
Keep ear dry
90% heal in few months; if not may require surgery
What organ is the most common site of injury for gunshots to the abdomen?
Small intestine
What organ is the most common site of injury in abdominal stab wounds?
Liver
Signs of better prognosis in amputation injuries
- Distal > Proximal
2. Guillotine-like > avulsion or crush
Digit amputations can tolerate a maximum of what amount of ischemic time prior to replantation?
12-24 hrs
What is the proper method for preservation of amputation?
Wrap clean amputated part in saline-moistened gauze and seal in a dry plastic bag, then place on ice. Stump should be wrapped in moist gauze, kept elevated to reduce bleeding, and cooled with ice packs
Zones of fingertip amputations
Zone I - amputation isolated to pulp and distal nail (healing by secondary intention)
Zone II - exposed bone
Zone III - involve eponychium
Contraindications to replantation in amputation injuries
- Amputations in unstable patients
- Multiple-level amputations
- Self-inflicted
- Single-digit amputations proximal to flexor digitorum superficialis insertion
- Serious underlying dz like vascular, complicated DM, CHF
- Extremes of age
Indications for replantation of amputation injuries
- Multiple digits
- Thumb
- Wrist and forearm
- Sharp amputations with minimal to moderate avulsion proximal to the elbow
- Single digits amputated between PIP and DIP
Patients with persistent PTX following tube thoracostomy should be evaluated for what?
Possible bronchial injury
What is a hangman fracture?
Spondylolysis of C2
- Caused by extreme hyperextension from abrupt deceleration
- Bilateral fractures of the pedicles of the axis (C2)
Q#977263
What are the clinical manifestations of Brown-Sequard Syndrome?
Ipsilateral loss of motor strength, vibratory sensation, and proprioception
Contralateral loss of pain and temperature
Which incomplete spinal cord syndrome has the best prognosis of full recovery?
Brown-Sequard syndrome
Perilunate vs. lunate dislocation
Both from FOOSH
Perilunate: MC carpal dislocation, palpable dorsal wrist fullness. X-ray shows dorsal displacement of capitate
Lunate: palpable volar wrist fullness, volar displacement of lunate with spilled teacup or piece of pie sign
What nerve is at risk of being compressed in a perilunate dislocation?
Median nerve
What is the most commonly injured visceral organ in blunt trauma?
Spleen
When to consult oculoplastic specialist for eyelid lacerations
- Within 6-8mm of medial canthus
- Involves lacrimal duct or sac
- Involves inner surface of the lid
- Involves lid margins
- Associated with ptosis
- Involves the tarsal plate or levator palpebrae muscle (if visible fat protrusion, this is likely)
Indications for intubation in flail chest
- Shock
- Severe head injury
- Comorbid pulmonary disease
- Fx of 8+ ribs
- Age >65
- O2 sat <95% despite O2 supplementation
- Pulmonary contusion
Most commonly injured organ in adult blunt abdominal trauma?
Spleen
Most common cause of lethal hemorrhage in blunt abdominal trauma in pediatrics?
Severe liver injury (spleen is still more frequently injured)
Neck zones
Zone 3 - above angle of mandible and anterior to mastoid air cells
Zone 2 - Above cricoid cartilage and below angle of mandible
Zone 1 - Below cricoid cartilage to sternum
Blunt trauma to carotid artery may lead to injury to the sympathetic chain. What is the name of the syndrome associated with this and its components?
Horner Syndrome - ptosis, miosis, anhidrosis
Hard signs in penetrating neck trauma
- Expanding hematoma
- Diminished pulse
- Paralysis
- Hemorrhage
- Stroke
Management of tuft fracture (partially amputated open distal phalanx fx)
- Reattach partially amputated fragment
- Make sure nail bed is exposed and realigned properly to prevent abnormal nail growth
- Discharge for follow-up with hand surgeon
Best location for placement of a chest tube in pregnancy?
Third intercostal space at the anterior axillary line
Diaphragm rises an extra 4cm with compensatory flaring of the ribs
In penetrating abdominal trauma in a pregnant patient, what is at greatest risk of injury?
Bowel
Hard evidence of vascular injury
- Absent distal pulses
- Distal ischemia
- ABI <0.8
- Expanding or pulsatile hematoma
-> surgical exploration
What is a “dimple” sign?
Seen on physical exam in posterolateral knee dislocation
Nerve and artery complications from knee dislocations
Nerve: Common peroneal nerve - can note hypoesthesia in first web space or loss of dorsiflexion of the foot
Artery: Popliteal
Clinical presentation of anterior cord syndrome
- Loss of motor function below lesion
- Loss of pain and temperature below lesion
- Preservation of position and vibratory function
Nexus criteria
- No c-spine midline tenderness
- No focal neuro deficit
- No AMS
- No intoxication
- No distracting injury
Ellis Classification of tooth injuries and their management
I. Fracture of enamel -> smooth edge with file and discharge with dental follow-up
II. Fracture through dentin and enamel (ivory-yellow appearance) -> smooth edge with file and apply calcium hydroxide covering over exposed dentin with dental follow-up
III. Fracture through pulp, dentin, and enamel -> dental consult for pulpotomy to prevent infection
Most common location for blunt aortic injury
Left subclavian artery origin - aorta is anatomically fixed at this point by ligamentum arteriosum
How are partial-thickness traumatic aortic injuries medically managed?
Similar to aortic dissections with BP and HR control
Parkland Formula
Volume of LR = 4 x TBSA x Weight (kg)
First half over first 8 hours; second half over next 16 hours
Rule of Nines in Burn
Q180115
Differences between first, second, third, fourth degree burns
- First-degree: only affect epidermis; erythema, pain, blanching of skin
- Second-degree: epidermis and the dermis; severe pain and blistering
- Third-degree: full involvement of epidermis and dermis; pale, leathery, insensate
- Fourth-degree: all third-degree burns that involve fat, muscle, or bone
Target UOP in burns
0.5-1 mL/kg/hr in adults
1-2 mL/kg/hr in children
How might duodenal hematoma present?
Hematoma can lead to partial or complete luminal obstruction which results in gastric distention and vomiting
Vomiting can be delayed up to 48 hours
Examine for ecchymosis, seat belt sign, peritoneal signs, abdominal distension, presence of bowel sounds, presence of palpable abdominal mass
Management for duodenal hematoma
Most cases resolve without operative intervention
- Observation with NG decompression, bowel rest, parenteral nutrition
What are indications for operative fixation of a flail chest segment?
- Inability to wean patient from ventilator
- Severe chest wall instability
- Persistent pain
- Progressive pulmonary function decline
What is the most commonly reported gastric injury associated with blunt abdominal trauma in children?
Gastric perforation
What is Beck triad?
For pericardial effusion with tamponade
- Hypotension
- JVD
- Muffled heart sounds
Initial management of pericardial effusion resulting in tamponade
- Preload dependent - IVF
Pericardiocentesis, pericardial window
What is C1 burst fracture?
Also a “Jefferson” fracture
Q313552 for image
Presentation and Mechanism for C1 burst fracture
- Axial compression injury such as fall onto head or dive into shallow pool
- Rarely with immediate neurologic impairment; only finding may be midline tenderness
What is the most common location and cause of spinal column injuries in children?
Cause: MVC
Vast majority involve cervical spine
Management of C1 Burst Fracture
Immobilization with semipermanent device such as Halo traction brace
- unstable fracture
Minimum MAP goal for neurogenic shock?
85
Treatment for neurogenic shock?
Appropriate fluid resuscitation
Levophed; if still refractory -> Phenylephrine
Methylprednisolone possibly for nonpenetrating traumatic spinal cord injury, but controversial and speak with spine surgeon first
Spinal cord injuries above what level can result in neurogenic shock?
At or above T5
What is the most common cause of perforated bowel in MVC
Sudden deceleration injury -> shear forces
What organ is most often damaged from a handlebar injury?
Duodenum - classically delayed 48-72 hours
What is Kehr’s sign?
Acute pain in tip of shoulder due to presence of blood or other irritants in peritoneal cavity when patient is laying down and legs are elevated. Classic symptom of ruptured spleen
Within how many minutes should a perimortum c-section be performed?
Ideally within 4 minutes of loss of maternal pulses to allow for delivery within 5 minutes of start of maternal resuscitation
CPR should continue during procedure
Describe procedure of perimortem c-section
Midline vertical incision from pubis symphysis to epigastrium followed by midline vertical incision of uterus
What is minimum gestational age for perimortem c-section?
Somewhat controversial; most guidelines only if >/= 20 weeks gestation (uterus at level of umbilicus or higher)
If patient hypotensive, tachycardic, FAST negative and retroperitoneal hemorrhage suspected, what is the best next step in diagnosis?
?CT scan was answer. “Hemodynamically resuscitated and CT obtained”
Characteristics of toddler fracture
- Nondisplaced spiral fracture of the tibia
- Age 9 months and 3 years
- Mechanism = twisting of leg during a fall as a low-energy fracture
- Fx can take up to 7 days to appear on radiographs
Tx for toddler fracture
Immobilization in controlled ankle movement boot and follow-up with orthopedist within a week. If boot unavailable, can be placed in short leg cast
- Preferred over casting as similar outcomes without risks involved with casting such as skin breakdown and longer duration of immobilization
In the case of hemothorax, what is an indication for operative management?
Chest tube bleeding > 2-3 mL/kg/hr or hypotension unresponsive to transfusion
Tx for nasal septal hematoma
I&D
- Anesthetize with lidocaine-soaked pledgets
- Small horizontal incision through hematoma and perichondrium (lateral) and any clots evacuated
- Pack hematoma with a gauze wick and bilateral nares should be packed to prevent reaccumulation
Complications of nasal septal hematoma
Necrosis of septum leading to saddle nose deformity and associated nasal obstruction which would require operative repair
What is the “lover’s triad”?
Name associated with injuries that may occur after jumping from an upper floor window
- Calcaneal fracture
- Vertebral compression fracture
- Forearm fracture
Indications for ophthalmology consult for eyelid laceration
Involves:
- Lid margin
- Canalicular system
- Tarsal plate
- Orbital septum
Indications for surgery in traumatic hemothorax
More than 20 mL/kg or 1500 mL initial drainage
Persistent bleeding of more than 200mL/hr for 3 hours
Persistent bleeding of 7 mL/kg/hr at any time
Refractory shock
Increasing hemothorax seen on CXR
Most commonly fractured facial bones
- Nasal bone
2. Mandible
What type of injury typically causes central cord syndrome?
Forced hyperextension
What is the most common type of incomplete spinal cord syndrome?
Central Cord Syndrome
Indications for renal imaging in trauma
- Penetrating trauma (abdomen, flank, lower chest)
- Blunt abdominal trauma and gross hematuria
- Blunt abdominal trauma, microhematuria (>5 red blood cells per high-power field), and hemodynamic instability
- High index of suspicion for injury based on mechanism
In cases of blunt renal injury where the patient is hemodynamically stable and only microscopic hematuria present, patient can be safely observed in ED without further imaging
What are complications of basilar skull fractures?
- Cranial nerve palsies 2-3 days after injury
- Bacterial meningitis (rare but increases if leaking CSF for greater than 7 days)
What is the first step to perform if a patient deteriorates during trauma evaluation?
Repeat primary survey to identify and treat any new problems that may have arisen
What is the most common complication of penetrating neck trauma in children?
Vascular injury
What is the most consistent physical exam finding in patients with compartment syndrome?
Loss of two-point discrimination
ED management of high-pressure injection injuries (commonly to finger)
Urgent hand surgery consultation
Initiation of broad-spectrum abx
Splinting affected extremity
What material is associated with highest rate of amputations in high-pressure injection injuries?
Paint and paint thinner produce a large early inflammatory response
Management of auricular hematoma
- Acute (<48 hrs) and small (<2cm): needle aspiration
- Large (>2cm) or 48hrs-7days: I&D
- Pressure dressing (suturing a pledget to both sides of ear using through-and-through sutures or by packing the helix and ear cavity and wrapping the ear and head with compressive wrap) to prevent recurrence of hematoma
- > 7 days: referral to ENT/plastics
What paralytic might be avoided if patient with globe trauma needs intubation?
Succinylcholine may increase intraocular pressure
Complications from petrous temporal bone fracture
Middle ear structures (ossicles, stapedius muscle, semicircular canals, vestibulocochlear nerve)
Internal carotid artery
Facial Nerve Branches
Venous structures
Timing of reimplanting completely avulsed teeth
Up to 60 minutes, after that soak in citric acid/fluoride and consult oral surgeon
