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Emergency Medicine > Traumatology > Flashcards

Traumatology Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

leading cause of death in patients <45 yr

A

trauma

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2
Q

Trimodal distribution of death in trauma

A

■ minutes: death usually at the scene from lethal injuries
■ early: death within 4-6 h – “golden hour” (decreased mortality with trauma care)
■ days-weeks: death from multiple organ dysfunction, sepsis, etc

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3
Q

Categories of trauma injuries

A

■ blunt (most common): MVC, pedestrian-automobile impact, motorcycle collision, fall, assault, sports

■ penetrating (increasing in incidence): gunshot wound, stabbing, impalement

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4
Q

Considerations for traumatic injury

A
  • important to know the mechanism of injury to anticipate traumatic injuries
  • always look for an underlying cause (alcohol, medications, illicit substances, seizure, suicide attempt, medical problem)
  • always inquire about HI, loss of consciousness, amnesia, vomiting, headache, and seizure activity
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5
Q

What is the cardiac box

A

sternal notch, nipples, and xiphoid process; injuries inside this area should increase suspicion of cardiac injury

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6
Q

High risk injuries

A
  • MVC at high speed, resulting in ejection from vehicle
  • Motorcycle collisions
  • Vehicle vs. pedestrian crashes
  • Fall from height >12 ft (3.6 m)
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7
Q

What is Waddle’s triad

A

Vehicle vs. Pedestrian Crash

In adults look for triad of injuries (Waddle’s triad)

  • Tibia-fibula or femur fracture
  • Truncal injury
  • Craniofacial injury
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8
Q

MVC special considerations

A

Vehicle(s) involved: weight, size, speed, damage

Location of patient in vehicle

Use and type of seatbelt

Ejection of patient from vehicle

Entrapment of patient under vehicle

Airbag deployment

Helmet use in motorcycle collision

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9
Q

MVC associated injuries

A

Head-on collision: head/facial, thoracic (aortic), lower extremity

Lateral/T-bone collision: head, C-spine, thoracic, abdominal, pelvic and lower extremity

Rear-end collision: hyper-extension of C-spine (whiplash injury)

Rollover

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10
Q

Pedestrian-automobile impact special considerations

A

High morbidity and mortality

Vehicle speed is an important factor

Site of impact on car

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11
Q

Pedestrian-automobile impact associated injuries

A

Children at increased risk of being run over
(multisystem injuries)

Adults tend to be struck in lower legs (lower extremity injuries), impacted against car (truncal injuries), and thrown to ground (HI)

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12
Q

Falls special considerations

A

1 storey = 12 ft = 3.6 m

Distance of fall: 50% mortality at 4 storeys and 95% mortality at 7 storeys

Landing position (vertical vs. horizontal)

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13
Q

Falls associated injuries

A

Vertical: lower extremity, pelvic, and spine fractures; HI

Horizontal: facial, upper extremity, and rib fractures; abdominal, thoracic, and HI

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14
Q

60% of MVC related deaths are due to

A

HI

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15
Q

Signs of basal skull fracture

A
  • Battle’s sign (bruised mastoid process)
  • Hemotympanum
  • Raccoon eyes (periorbital bruising)
  • CSF rhinorrhea/otorrhea
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16
Q

How to diagnose head fracture

A

non-contrast head CT

physical exam

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17
Q

Types of skull fractures

A

■ vault fractures
linear, non-depressed
– most common – typically occur over temporal bone, in area of middle meningeal artery (commonest cause of epidural hematoma)
◆ depressed
– open (associated overlying scalp laceration and torn dura, skull fracture disrupting paranasal sinuses or middle ear) vs. closed

■ basal skull fractures
◆ typically occur through floor of anterior cranial fossa (longitudinal more common than transverse)
◆ clinical diagnosis superior as poorly visualized on CT

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18
Q

Types of facial fractures

A

■ neuronal injury

■ beware of open fracture or sinus fractures (risk of infection)

■ severe facial fractures may pose risk to airway from profuse bleeding

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19
Q

Scalp laceration management

A

■ can be a source of significant bleeding

■ achieve hemostasis, inspect and palpate for skull bone defects ± CT head (rule-out skull fracture)

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20
Q

Types of neuronal injury

A

A. diffuse
■ mild TBI = concussion
◆ transient alteration in mental status that may involve loss of consciousness
◆ hallmarks of concussion: confusion and amnesia, which may occur immediately after the trauma or minutes later
◆ loss of consciousness (if present) must be less than 30 min, initial GCS must be between 13-15, and post-traumatic amnesia must be less than 24 h
■ diffuse axonal injury
◆ mild: coma 6-24 h, possibly lasting deficit
◆ moderate: coma >24 h, little or no signs of brainstem dysfunction
◆ severe: coma >24 h, frequent signs of brainstem dysfunction

B. focal injuries
■ contusions
■ intracranial hemorrhage (epidural, subdural, intracerebral)

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21
Q

Warning signs of severe head injury

A
  • GCS <8
  • Deteriorating GCS
  • Unequal pupils
  • Lateralizing signs

N.B. Altered LOC is a hallmark of brain injury

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22
Q

Assessment of brain injury physical exam

A

• assume C-spine injury until ruled out

• vital signs
■ shock (not likely due to isolated brain injury, except in infants)
■ Cushing’s response to increasing ICP (bradycardia, HTN, irregular respirations)

• severity of injury determined by
1. LOC
◆ GCS ≤8 intubate, any change in score of 3 or more = serious injury
◆ mild TBI = 13-15, moderate = 9-12, severe = 3-8
2. pupils: size anisocoria >1 mm (in patient with altered LOC), response to light
3. lateralizing signs (motor/sensory)
◆ may become subtler with increasing severity of injury
• reassess frequently

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23
Q

Assessment of brain injury investigations

A
  • labs: CBC, electrolytes, PT/PTT or INR/PTT, glucose, toxicology screen
  • CT scan head and neck (non-contrast) to exclude intracranial hemorrhage/hematoma
  • C-spine imaging
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24
Q

Canadian CT head rule

A

CT Head is only required for patients with minor HI with any one of the following

High Risk (for neurological intervention)
• GCS score <15 at 2 h after injury
• Vomiting ≥2 episodes
• Age ≥65 yr
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (hemotympanum, “raccoon” eyes, CSF otorrhea/rhinorrhea, Battle’s sign)

Medium Risk (for brain injury on CT) 
• Amnesia before impact >30 min (i.e. cannot recall events just before impact) 
• Dangerous mechanism (pedestrian struck by MVC, occupant ejected from motor vehicle, fall from height >3 ft or five stairs)

Minor HI is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patient with a GCS score of 13-15.

NB: Canadian CT Head Rule does not apply for nontrauma cases, for GCS<13, age <16, for patients on Coumadin® and/or having a bleeding disorder, or having an obvious open skull fracture.

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25
Q

Brain injury management

A

• goal in ED: reduce secondary injury by avoiding hypoxia, ischemia, decreased CPP, seizure

• general  
■ ABCs  
■ ensure oxygen delivery to brain through intubation and prevent hypercarbia  
■ maintain BP (sBP >90) 
■ treat other injuries

• early neurosurgical consultation for acute and subsequent patient management

• seizure treatment/prophylaxis
■ benzodiazepines, phenytoin, phenobarbital
■ steroids are of no proven value

• treat suspected raised ICP, consider if HI with signs of increased ICP:
■ intubate
■ calm (sedate) if risk for high airway pressures or agitation
■ paralyze if agitated
■ hyperventilate (100% O2) to a pCO2 of 30-35 mmHg
■ elevate head of bed to 20º
■ adequate BP to ensure good cerebral perfusion
■ diurese with mannitol 1g/kg infused rapidly (contraindicated in shock/renal failure)

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26
Q

Head injury disposition

A
  • neurosurgical ICU admission for severe HI
  • in hemodynamically unstable patient with other injuries, prioritize most life-threatening injuries and maintain cerebral perfusion
  • for minor HI not requiring admission, provide 24 h HI protocol to competent caregiver, follow-up with neurology as even seemingly minor HI may cause lasting deficits
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27
Q

Mild traumatic brain injury severity correlate

A

Extent of retrograde amnesia correlates with severity of injury

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28
Q

Mild traumatic brain injury clinical features

A
  • somatic: headache, sleep disturbance, N/V, blurred vision
  • cognitive dysfunction: attentional impairment, reduced processing speed, drowsiness, amnesia
  • emotion and behaviour: impulsivity, irritability, depression
  • severe concussion: may precipitate seizure, bradycardia, hypotension, sluggish pupils
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29
Q

Mild traumatic brain injury investigations

A
  • neurological exam
  • concussion recognition tool (see thinkfirst.ca)
  • imaging – CT as per Canadian CT Head Rules, or MRI if worsening symptoms despite normal CT
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30
Q

Mild traumatic brain injury management

A
  • close observation and follow-up; for patients at risk of intracranial complications, give appropriate discharge instructions to patient and family; watch for changes to clinical features above, and if change, return to ED
  • hospitalization with normal CT (GCS <15, seizures, bleeding diathesis), or with abnormal CT
  • early rehabilitation to maximize outcomes
  • pharmacological management of pain, depression, headache
  • follow Return to Play guidelines
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31
Q

Mild traumatic brain injury prognosis

A

• most recover with minimal treatment
■ athletes with previous concussion are at increased risk of cumulative brain injury

• repeat TBI can lead to life-threatening cerebral edema or permanent impairment

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32
Q

Every Patient with One or More of the Following Signs or Symptoms should be Placed in a C-Spine Collar

A
  • Midline tenderness
  • Neurological symptoms or signs
  • Significant distracting injuries
  • HI
  • Intoxication
  • Dangerous mechanism
  • History of altered LOC
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33
Q

Spine trauma most important film

A

the lateral C-spine x-ray is the single most important film; 95% of radiologically visible abnormalities are found on this film

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34
Q

Cauda Equina Syndrome cause and presentation

A

Cauda Equina Syndrome can occur with any spinal cord injury below T10 vertebrae. Look for incontinence, anterior thigh pain, quadriceps weakness, abnormal sacral sensation, decreased rectal tone, and variable reflexes

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35
Q

Spinal trauma physical exam

A
  • ABCs
  • abdominal: ecchymosis, tenderness
  • neurological: complete exam, including mental status

• spine: maintain neutral position, palpate C-spine; log roll, then palpate T-spine and L-spine, assess rectal tone
■ when palpating, assess for tenderness, muscle spasm, bony deformities, step-off, and spinous process malalignment

• extremities: check capillary refill, suspect thoracolumbar injury with calcaneal fractures

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36
Q

assume cord injury with

A

significant falls (>12 ft), deceleration injuries, blunt trauma to head, neck, or back

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37
Q

when to maintain spinal immobilization until

A

until spinal injury has been ruled out

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38
Q

does a normal neuro exam exclude spinal injury

A

vertebral injuries may be present without spinal cord injury; normal neurologic exam does not exclude spinal injury

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39
Q

can you injury cord despite normal c spine xray

A

cord may be injured despite normal C-spine x-ray (spinal cord injury without radiologic abnormality)

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40
Q

types of spinal cord injuries

A

complete/incomplete transection

cord edema

spinal shock

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41
Q

spinal trauma investigations

A

• bloodwork: CBC, electrolytes Cr, glucose, coagulation profile, cross and type, toxicology screen

• imaging
■ full C-spine x-ray series for trauma (AP, lateral, odontoid)

• thoracolumbar x-rays
■ AP and lateral views

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42
Q

thoracolumbar xrays indications

A

◆ C-spine injury
◆ unconscious patients (with appropriate mechanism of injury)
◆ neurological symptoms or findings
◆ deformities that are palpable when patient is log rolled
◆ back pain
◆ bilateral calcaneal fractures (due to fall from height) – concurrent burst fractures of the lumbar or thoracic spine in 10% (T11-L2)
◆ consider CT (for subtle bony injuries), MRI (for soft tissue injuries) if appropriate

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43
Q

The Canadian C-Spine Rule

A

For Alert GCS=15 and Stable Trauma Patients where C-Spine injury is a concern

  1. Any high -risk factor that mandates radiography
Dangerous Mechanism 
or 
Age 65+ 
or 
Paresthesias in extremities

If yes then radiography
If no the go to 2

  1. Any low-risk factors that allows safe assessment of ROM?
Simple rear end MVC 
or 
No midline C-spine tenderness 
or 
Ambulatory at any time 
or 
Delayed onset of neck pain 
or 
Sitting position in ED

If no then radiography
If yes then go to 3

  1. Able to actively rotate neck >45o left and right?

Unable then radiography
Able then no radiography

Dangerous mechanism: 
Fall from 1 m/5 stairs + 
Axial load to head (ex. diving) 
MVC high speed (>100 km/h), rollover, ejection 
Motorized recreational vehicles 
Bicycle collision 
Simple rear end MVC excludes 
Pushed into oncoming traffic 
Hit by bus/large truck 
Rollover 
Hit by high speed vehicle
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44
Q

When to complete CT for C spine

A
  • Inadequate plain film survey
  • Suspicious plain film findings
  • To better delineate injuries seen on plain films
  • Any clinical suspicion of atlanto-axial subluxation
  • High clinical suspicion of injury despite normal x-ray
  • To include C1-C3 when head CT is indicated in head trauma
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45
Q

Clearing C-spine

A
  • oriented to person, place, time, and event
  • no evidence of intoxication
  • no posterior midline cervical tenderness
  • no focal neurological deficits
  • no painful distracting injuries (e.g. long bone fracture)

Normal films ->
Neck pain ->
Normal flexion/extension films = cleared

Normal films ->
Abnormal neuro exam ->
Normal MRI = cleared

If abnormal flexion/extension films or MRI then remain immobilized and consult spine service

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46
Q

Management of cord injury

A

• immobilize
• evaluate ABCs
• treat neurogenic shock (maintain sBP >100 mmHg)
• insert NG and Foley catheter
• high dose steroids: methylprednisolone 30 mg/kg bolus, then 5.4 mg/kg/h drip, start within 6-8 h of injury (controversial and recently has less support)
• complete imaging of spine and consult spine service if available
• continually reassess high cord injuries as edema can travel up cord
• if cervical cord lesion, watch for respiratory insufficiency
■ low cervical transection (C5-T1) produces abdominal breathing (phrenic innervation of diaphragm still intact but loss of innervation of intercostals and other accessory muscles of breathing)
■ high cervical cord injury (above C4) may require intubation and ventilation
• treatment: warm blanket, Trendelenburg position (occasionally), volume infusion, consider vasopressors

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47
Q

Lines of contour on lateral c-spine x-ray

A
  1. Anterior vertebral line
  2. Posterior vertebral line (anterior margin of spinal canal)
  3. Posterior border of facets
  4. Laminar fusion line (posterior margin of spinal canal)
  5. Posterior spinous line (along tips of spinous processes)
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48
Q

Sensitivity of prevertebral soft tissue selling for injury

A

49%

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49
Q

Approach to C-spine x-rays

A

• 3-view C-spine series is the screening modality of choice

  1. lateral C1-T1 ± swimmer’s view
    ◆ lateral view is best, identifies 90-95% of injuries
  2. odontoid view (open mouth or oblique submental view)
    ◆ examine the dens for fractures – if unable to rule out fracture, repeat view or consider CT or plain film tomography
    ◆ examine lateral aspects of C1 and spacing relative to C2
  3. AP view
    ◆ alignment of spinous processes in the midline
    ◆ spacing of spinous processes should be equal
    ◆ check vertebral bodies and facet dislocations
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50
Q

Interpretation of lateral c-spine xray

A

A Adequacy and Alignment

Must see C1 to C7-T1 junction; if not, downward traction of shoulders, swimmer’s view, bilateral supine obliques, or CT scan needed
Lines of contour in children <8 yr of age, can see physiologic subluxation of C2 on C3, and C3 on C4, but the spino-laminal line is maintained
Fanning of spinous processes suggests posterior ligamentous disruption
Widening of facet joints
Check atlanto-occipital joint
Line extending inferiorly from clivus should transect odontoid
Atlanto-axial articulation, widening of predental space (normal: <3 mm in adults, <5 mm in children) indicates injury of C1 or C2

B Bones
Height, width, and shape of each vertebral body
Pedicles, facets, and laminae should appear as one – doubling suggests rotation

C Ca tilage
Intervertebral disc spaces – wedging anteriorly or posteriorly suggests vertebral compression

S Soft Tissues
Widening of retropharyngeal (normal: <7 mm at C1-4, may be wide in children <2 yr on expiration) or
retrotracheal spaces (normal: <22 mm at C6-T1, <14 mm in children <5 yr)

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51
Q

Acute phase of spinal cord injury

A

■ spinal shock: absence of all voluntary and reflex activity below level of injury
◆ decreased reflexes, no sensation, flaccid paralysis below level of injury, lasting days to months

■ neurogenic shock: loss of vasomotor tone, SNS tone
◆ watch for: hypotension (lacking SNS), bradycardia (unopposed PNS), poikilothermia (lacking SNS so no shunting of blood from extremities to core)
◆ occurs within 30 min of SCI at level T6 or above, lasting up to 6 wk
◆ provide airway support, fluids, atropine (for bradycardia), vasopressors for BP support

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52
Q

Chronic phase of Spinal cord injury

A

■ autonomic dysreflexia: in patients with an SCI at level T6 or above
◆ signs and symptoms: pounding headache, nasal congestion, feeling of apprehension or anxiety, visual changes, dangerously increased sBP and dBP
◆ common triggers – GU causes: bladder distention urinary tract infection, and kidney stones – GI causes: fecal impaction or bowel distension
◆ treatment: monitoring and controlling BP, prior to addressing causative issue

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53
Q

Utility of supine oblique views of the c spine

A
  • Rarely used
  • Beter visualization of posterior element fractures (lamina, pedicle, facet joint)
  • Good to assess patency of neural foramina
  • Can be used to visualize the C7-T1 junction
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54
Q

what needs to be r/o before proceeding to OR for C-spine fracture

A

20% of C-spine fractures are accompanied by other spinal fractures, so ensure thoracic and lumbar spine x-rays are normal befo e proceeding to OR

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55
Q

What account for 50% of all trauma deaths

A

chest trauma

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56
Q

Airway obstruction physical exam

A 
Anxiety 
Stridor 
Hoarseness
Altered mental status 
Apnea 
Cyanosis
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57
Q

Airway obstruction investigations

A

Do not wait for ABG to intubate

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58
Q

Airway obstruction management

A

Definitive airway management
intubate early
remove foreign body if visible with laryngoscope prior to intubation

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59
Q

Tension pneumothorax how to diagnose

A

clinical diagnosis

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60
Q

tension pneumothorax pathophysiology

A

one way valve causing accumulation of air in pleural space

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61
Q

tension pneumothorax physical exam

A

Respiratory distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion

Tracheal deviation away from pneumothorax

Percussion hyperresonance

Unilateral absence of breath sounds

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62
Q

tension pneumothorax investigations

A

Non-radiographic diagnosis

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63
Q

tension pneumothorax management

A

Needle thoracostomy – large bore needle, 2nd ICS mid clavicular line, followed by chest tube in 5th ICS, anterior axillary line

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64
Q

open pneumothorax pathophysiology

A

air entering chest from wound rather than trachea

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65
Q

open pneumothorax physical exam

A

wound (hole >2/3 tracheal diameter) ± exit wound

Unequal breath sound

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66
Q

open pneumothorax investigations

A

ABG: decreased pO2

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67
Q

open pneumothorax management

A

Air-tight dressing sealed on 3 sides (prevents tension pneumo)

Chest tube

Surgery

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68
Q

Pulsus paradoxus

A

a drop in BP of >10 mmHg with inspiration. Recall that BP normally drops with inspiration, but what’s “paradoxical” about this is that it drops more than it should

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69
Q

Massive hemothorax definition

A

> 1,500 cc blood loss in chest cavity

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70
Q

Massive hemothorax physical exam

A

Pallor, flat neck veins, shock

Unilateral dullness

Absent breath sounds, hypotension

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71
Q

Massive hemothorax investigations

A

Usually only able to do supine CXR – entire lung appears radioopaque as blood spreads out over posterior thoracic cavity

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72
Q

Massive hemothorax management

A

Restore blood volume

Chest tube

Thoracotomy if:
>1,500 cc total blood loss
≥200 cc/h continued drainage

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73
Q

Flail chest definition and common associated diagnosis

A

Free-floating segment of chest wall due to >2 rib fractures, each at 2 sites

Underlying lung contusion (cause of morbidity and mortality)

74
Q

Flail chest physical exam

A

Paradoxical movement of flail segment

Palpable crepitus of ribs

Decreased air entry on affected side

75
Q

Flail chest investigations

A

ABG: decreased pO2, increased pCO2

CXR: rib fractures, lung contusion

76
Q

Flail chest management

A

O2 + fluid therapy + pain control

Judicious fluid therapy in absence of systemic hypotension

Positive pressure ventilation ± intubation and ventilation

77
Q

Cardiac tamponade diagnosis

A

clinical

78
Q

Cardiac tamponade pathophysiology

A

Pericardial fluid accumulation impairing ventricular function

79
Q

Cardiac tamponade physical exam

A

Penetrating wound (usually)

Beck’s triad: hypotension, distended neck veins, muffled heart sounds

Tachycardia, tachypnea Pulsus paradoxus Kussmaul’s sign (increased JVP with inspiration)

80
Q

Cardiac tamponade investigations

A

Echo

FAST

81
Q

Cardiac tamponade management

A

IV fluids

Pericardiocentesis

Open thoracotomy

82
Q

Ruptured diaphragm more commonly diagnosed what side

A

Ruptured diaphragm is more often diagnosed on the left side, as liver conceals right side defect

83
Q

Pulmonary contusion physical exam

A

Blunt trauma to chest

Interstitial edema impairs compliance and gas exchange

84
Q

Pulmonary contusion investigations

A

CXR: areas of opacification of lung within 6h of trauma

85
Q

Pulmonary contusion management

A

Maintain adequate ventilation

Monitor with ABG, pulse oximeter, and ECG

Chest physiotherapy

Positive pressure ventilation if severe

86
Q

Ruptured diaphragm physical exam

A

Blunt trauma to chest or abdomen (e.g. high lap belt in MVC)

87
Q

Ruptured diaphragm investigations

A

CXR: abnormality of diaph agm/lower lung fields/ NG tube placement

CT scan and endoscopy: sometimes helpful for diagnosis

88
Q

Ruptured diaphragm management

A

Laparotomy for diaphragm repair and associated intra-abdominal injuries

89
Q

Esophageal injury physical exam

A

Usually penetrating trauma (pain out of proportion to degree of injury)

90
Q

Esophageal injury investigations

A

CXR: mediastinal air (not always)

Esophagram (Gastrograffin®)

Flexible esophagoscopy

91
Q

Esophageal injury management

A

Early repair (within 24 h) improves outcome but all require repair

92
Q

Aortic tear location and prognosis

A

90% tear at subclavian (near ligamentum arteriosum), most die at scene

Salvageable if diagnosis made rapidly

93
Q

Aortic tear physical exam

A

Sudden high speed deceleration (e.g MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent)

Decreased femoral pulses, differential arm BP (arch tear)

94
Q

Aortic tear investigations

A

CXR, CT scan, transesophageal echo, aortography (gold standard)

95
Q

Aortic tear management

A

Thoracotomy (may treat other severe injuries first)

96
Q

Blunt Myocardial Injury (rare) physical exam

A

Blunt trauma to chest (usually in setting of multi-system trauma and therefore difficult to diagnose)

Physical exam: overlying injury, e.g. fractures, chest wall contusion

97
Q

Blunt Myocardial Injury (rare) investigations

A

ECG: dysrhythmias, ST changes

Patients with a normal ECG and normal hemodynamics never get dysrhythmias

98
Q

Blunt Myocardial Injury (rare) management

A

O2
Antidysrhythmic agents
Analgesia

99
Q

Aortic tear xray features

A

ABC WHITE
X-ray features of Aortic tear
Depressed left mainstem Bronchus
pleural Cap

Wide mediastinum (most consistent) 
Hemothorax 
Indistinct aortic knuckle 
Tracheal deviation to right side 
Esophagus (NG tube) deviated to right (Note: present in 85% of cases, but cannot rule out)
100
Q

Penetrating neck trauma management

A

management: injuries deep to platysma require further evaluation by angiography, contrast CT, or surgery

• do not explore penetrating neck wounds except in the OR

101
Q

If penetrating neck trauma present DON’T

A
  • Clamp structures (can damage nerves)
  • Probe
  • Insert NG tube (leads to bleeding)
  • Remove weapon/impaled object
102
Q

3 zones of neck

A

Zone 1: Base of neck (thoracic inlet to cricoid cartilage)

Zone II: Midportion of neck (cricoid to angle of the mandible)

Zone III: Superior aspect of neck

103
Q

Larynx injury history

A

strangulation, direct blow, blunt trauma, any penetrating injury involving platysma

104
Q

Larynx injury triad and other symptoms

A

hoarseness, subcutaneous emphysema, palpable fracture

hemoptysis, dyspnea, dysphonia

105
Q

Larynx injury investigations

A

CXR, CT scan, arteriography (if penetrating)

106
Q

Larynx injury management

A

◆ airway: manage early because of edema

◆ C-spine may also be injured, consider mechanism of injury

◆ surgical: tracheotomy vs. repair

107
Q

Trachea/bronchus injury history

A

deceleration, penetration, increased intra-thoracic pressure, complaints of dyspnea, hemoptysis

108
Q

Trachea/bronchus injury examination

A

Subcutaneous air

Hamman’s sign (crunching sound synchronous with heart beat)

109
Q

Trachea/bronchus injury CXR

A

Mediastinal air

Persistent pneumothorax or persistent air leak after chest tube inserted for pneumothorax

110
Q

Trachea/bronchus injury management

A

Surgical repair if >1/3 circumference

111
Q

Seatbelt injuries may cause what

A
  • Retroperitoneal duodenal trauma
  • Intraperitoneal bowel transection
  • Mesenteric injury
  • Lspine injury
112
Q

Indications for foley and NG tube in abdominal trauma

A

Foley catheter: unconscious or patient with multiple injuries who cannot void spontaneously or is unconscious

NG tube: used to decompress the stomach and proximal small bowel. Contraindicated if suspected facial or basal skull fractures

113
Q

Types of abdominal trauma and common organ injury that they cause

A

■ blunt: usually causes solid organ injury (spleen = most common, liver = 2nd)

■ penetrating: usually causes hollow organ injury or liver injury (most common)

114
Q

Blunt trauma results in what two types of hemorrhage

A

Intra-abdominal

Retroperitoneal

115
Q

Abdominal trauma physical exam

A

• often unreliable in multi-system trauma, wide spectrum of presentations
■ slow blood loss not immediately apparent
■ tachycardia, tachypnea, oliguria, febrile, hypotension
■ other injuries may mask symptoms
■ serial examinations are required

• abdomen
■ inspect: contusions, abrasions, seat-belt sign, distention
■ auscultate: bruits, bowel sounds
■ palpate: tenderness, rebound tenderness, rigidity, guarding
■ DRE: rectal tone, blood, bone fragments, prostate location
■ placement of NG, Foley catheter should be considered part of the abdominal exam

• other systems to assess: cardiovascular, respiratory (possibility of diaphragm rupture), genitourinary, pelvis, back/neurological

116
Q

Abdominal trauma investigations

A

labs: CBC, electrolytes, coagulation, cross and type, glucose, Cr, CK, lipase, amylase, liver enzymes, ABG, blood EtOH, β-hCG, U/A, toxicology screen

117
Q

Xray in abdominal trauma strengths and limitations

A

Chest (looking for free air under diaphragm, diaphragmatic hernia, air-flud levels), pelvis, cervical, thoracic, lumbar spines

Soft tissue not well visualized

118
Q

CT scan in abdominal trauma strengths and limitations

A

Most specific test

Radiation exposure 20x more than x-ray Cannot use if hemodynamic instability

119
Q

Diagnostic peritoneal lavage (rarely used) in abdominal trauma strengths and limitations

A

Most sensitive test
Tests for intra-peritoneal bleed

Cannot test for retroperitoneal bleed or diaphragmatic rupture
Cannot distinguish lethal from trivial bleed
Results can take up to 1 h

120
Q

Ultrasound FAST in abdominal trauma strengths and limitations

A

Identifies presence/absence of free fluid in peritoneal cavity
RAPID exam: less than 5 min
Can also examine pericardium and pleural cavities

NOT used to identify specific organ injuries
If patient has ascites, FAST will be falsely positive

121
Q

Criteria for positive lavage

A
  • > 10 cc gross blood
  • Bile, bacteria, foreign material
  • RBC count >100000 x 106/L
  • WBC >500 x 106/L,
  • Amylase >175 IU
122
Q

When must imaging be completed in abdominal trauma

A

■ equivocal abdominal examination, altered sensorium, or distracting injuries (e.g. head trauma, spinal cord injury resulting in abdominal anesthesia)

■ unexplained shock/hypotension

■ patients have multiple traumas and must undergo general anesthesia for orthopedic, neurosurgical, or other injuries

■ fractures of lower ribs, pelvis, spine

■ positive FAST

123
Q

Laparotomy is mandatory if penetrating trauma and

A
  • Shock
  • Peritonitis
  • Evisceration
  • Free air in abdomen
  • Blood in NG tube, Foley catheter, or on DRE
124
Q

Abdominal trauma management

A
  • general: ABCs, fluid resuscitation, and stabilization
  • surgical: watchful waiting vs. laparotomy
  • solid organ injuries: decision based on hemodynamic stability, not the specific injuries
  • hemodynamically unstable or persistently high transfusion requirements: laparotomy
  • hollow organ injuries: laparotomy
  • even if low suspicion of injury: admit and observe for 24 h
125
Q

Penetrating trauma high risk of what

A

gastrointestinal perforation and sepsis

126
Q

Penetrating trauma history

A

size of blade, calibre/distance from gun, route of entry

127
Q

How to rule out peritoneal penetration

A

local wound exploration under direct vision may determine lack of peritoneal penetration (not reliable in inexperienced hands) with the following exceptions:
• thoracoabdominal region (may cause pneumothorax)
• back or flanks (muscles too thick)

128
Q

Rule of thirds for stab wounds

A
  • 1/3 do not penetrate peritoneal cavity
  • 1/3 penetrate but are harmless
  • 1/3 cause injury requiring surgery
129
Q

Penetrating trauma management

A
  • general: ABCs, fluid resuscitation, and stabilization

* gunshot wounds always require laparotomy

130
Q

GU tract injuries etiology

A

• blunt trauma: often associated with pelvic fractures
■ upper tract
◆ renal – contusions (minor injury – parenchymal ecchymoses with intact renal capsule) – parenchymal tears/laceration: non-communicating (hematoma) vs. communicating (urine extravasation, hematuria)
◆ ureter: rare, at uretero-pelvic junction
■ lower tract
◆ bladder – extraperitoneal rupture of bladder from pelvic fracture fragments – intraperitoneal rupture of bladder from trauma and full bladder
◆ urethra – posterior urethral injuries: MVCs, falls, pelvic fractures – anterior urethral injuries: blunt trauma to perineum, straddle injuries/direct strikes
■ external genitalia

• penetrating trauma
■ damage to: kidney, bladder, ureter (rare), external genitalia

• acceleration/deceleration injury
■ renal pedicle injury: high mortality rate (laceration and thrombosis of renal artery, renal vein, and their branches)

• iatrogenic
■ ureter and urethra (from instrumentation)

131
Q

GU tract injuries history

A
  • mechanism of injury
  • hematuria (microscopic or gross), blood on underwear
  • dysuria, urinary retention
  • history of hypotension
132
Q

GU tract injuries physical exam

A
  • abdominal pain, flank pain, CVA tenderness, upper quadrant mass, perineal lacerations
  • DRE: sphincter tone, position of prostate, presence of blood
  • scrotum: ecchymoses, lacerations, testicular disruption, hematomas
  • bimanual exam, speculum exam
  • extraperitoneal bladder rupture: pelvic instability, suprapubic tenderness from mass of urine or extravasated blood
  • intraperitoneal bladder rupture: acute abdomen
  • urethral injury: perineal ecchymosis, scrotal hematoma, blood at penile meatus, high riding prostate, pelvic fractures
133
Q

GU tract injuries investigations

A
  • urethra: retrograde urethrography
  • bladder: U/A, CT scan, urethrogram ± retrograde cystoscopy ± cystogram (distended bladder + postvoid)
  • ureter: retrograde ureterogram
  • renal: CT scan (best, if hemodynamically stable), intravenous pyelogram
134
Q

GU tract injuries management

A

• urology consult

• renal
■ minor injuries: conservative management
◆ bedrest, hydration, analgesia, antibiotics
■ major injuries: admit
◆ conservative management with frequent reassessments, serial U/A ± re-imaging
◆ surgical repair (exploration, nephrectomy): hemodynamically unstable or continuing to bleed >48 h, major urine extravasation, renal pedicle injury, all penetrating wounds and major lacerations, infections, renal artery thrombosis

• ureter
■ ureterouretostomy

• bladder  
■ extraperitoneal 
◆ minor rupture: Foley drainage x 10-14 d  
◆ major rupture: surgical repair  
■ intraperitoneal 
◆ drain abdomen and surgical repair

• urethra
■ anterior: conservative, if cannot void, Foley or suprapubic cystostomy and antibiotics
■ posterior: suprapubic cystostomy (avoid catheterization) ± surgical repair

135
Q

Gross hematuria suggests what GU tract injury

A

Bladder injury

136
Q

In the case of gross hematuria the GU system is investigated in what order

A

distal to proximal (ie urethrogram, cystogram, etc)

137
Q

Description of fractures

A

SOLARTAT

Site 
Open vs. closed 
Length 
Articular 
Rotation 
Translation 
Alignment/Angulation 
Type e.g. Salter-Harris, etc.
138
Q

Fracture physical exam

A
  • look (inspection): “SEADS” swelling, erythema, atrophy, deformity, and skin changes (e.g. bruises)
  • feel (palpation): all joints/bones for local tenderness, swelling, warmth, crepitus, joint effusions, and subtle deformity
  • move: joints affected plus those above and below injury – active ROM preferred to passive
  • neurovascular status: distal to injury (before and after reduction)
139
Q

Life threatening orthopedic injuries

A

Major pelvic fractures

Traumatic amputations

Massive long bone injuries and associated fat emboli syndrome

Vascular injury proximal to knee/elbow

140
Q

Limb threatening orthopedic injuries

A

Fracture/dislocation of ankle (talar AVN)

Crush injuries

Compartment syndrome

Open fractures

Dislocations of knee/hip

Fractures above knee/elbow

141
Q

Open fractures increase risk of what complication

A

osteomyelitis

142
Q

Open fracture management

A
  • remove gross debris, irrigate cover with sterile dressing – formal irrigation and debridement often done in the OR
  • control bleeding with pressure (no clamping)
  • splint
  • antibiotics (1st generation cephalosporin and aminoglycoside) and tetanus prophylaxis
  • standard of care is to secure definitive surgical management within 6 h, time to surgery may vary from case-to-case
Remember “STAND” 
Splint 
Tetanus prophylaxis 
Antibiotics 
Neurovascular status (before and after) 
Dressings (to cover wound)
143
Q

How to manage orthopedic injuries with vascular injuries associated

A
  • realign limb/apply longitudinal traction and reassess pulses (e.g Doppler probe)
  • surgical consult
  • direct pressure if external bleeding
144
Q

Compartment syndrome pathophysiology

A

when the intracompartmental pressure within an anatomical area (e.g. forearm or lower leg) exceeds the capillary perfusion pressure, eventually leading to muscle/nerve necrosis

145
Q

Compartment syndrome diagnosis and clinical presentation

A

clinical diagnosis: maintain a high index of suspicion

■ pain out of proportion to the injury

■ pain worse with passive stretch

■ tense compartment

■ look for “the 6 Ps” (note radial pulse pressure is 120/80 mmHg while capillary perfusion pressure is 30 mmHg, seeing any of the 6ps indicates advanced compartment syndrome, therefore do not wait for these signs to diagnose and treat)
Pulse discrepancies
Pallor
Paresthesia/hypoesthesia
Paralysis
Pain (especially when refractory to usual analgesics)
Polar (cold)

146
Q

Compartment syndrome management

A

requires prompt decompression: remove constrictive casts, dressing ; emergent fasciotomy may be needed

147
Q

Nerves at risk with anterior shoulder dislocation

A

axillary nerve (lateral aspect of shoulder) and musculocutaneous nerve (extensor aspect of forearm) at risk

148
Q

What should be ruled out with forceful anterior shoulder dislocation

A

fracture

149
Q

Anterior shoulder dislocation management

A

reduce (traction, scapular manipulation), immobilize in internal rotation, repeat x-ray, out-patient follow-up with orthopedics

150
Q

Colles’ fracture description

A

distal radius fracture with dorsal displacement from “Fall on Outstretched Hand” (FOOSH)

151
Q

Colles’ fracture plain film

A

■ AP film: shortening, radial deviation, radial displacement

■ lateral film: dorsal displacement, volar angulation

1. Dorsal tit 
2 Dorsal displacement 
3. Ulnar styloid fracture 
4. Radial displacement 
5. Radial tilt 
6. Shortening
152
Q

Colles’ fracture management

A

■ reduce, immobilize with splint, out-patient follow-up with orthopedics or immediate orthopedic referral if complicated fracture

■ if involvement of articular surface, emergent orthopedic referral

153
Q

Scaphoid fracture presentation

A

tenderness in anatomical snuff box, pain on scaphoid tubercle, pain on axial loading of thumb

154
Q

Scaphoid fracture management

A

negative x-ray: thumb spica splint, repeat x-ray in 1 wk ± CT scan/bone scan

positive x-ray: thumb spica splint x 6-8 wk, repeat x-ray in 2 wk

■ outpatient orthopedics follow-up

155
Q

Scaphoid fracture risk if no immobilization

A

■ risk of AVN of scaphoid if not immobilized

156
Q

Mechanism of avulsion of base of 5th metatarsal

A

occurs with inversion injury

157
Q

avulsion of base of 5th metatarsal management

A

supportive tensor or below knee walking cast for 3 weeks

158
Q

calcaneal fracture history

A

fall from height

159
Q

calcaneal fracture associated injuries

A

may involve ankles, knees, hips, pelvis, lumbar spine

160
Q

Ottawa Knee Rules

A

A knee xray examination is required only for acute injury patients with one or more of:

Age 55 years or older

Tenderness at head of fibula

Isolated tenderness of patella

Inability to flex to 90o

Inability to weight bear both immediately and in the ED (four steps)

161
Q

Ottawa ankle and foot rules

A

An ankle radiographic series is required only if there is any pain in malleolar zone and any of these findings

  1. Bony tenderness at posterior edge or tip of lateral malleolus
  2. Bony tenderness at posterior edge or tip of medial malleolus
  3. Inability to bear weight both immediately and in ED (four steps)

A radiographic series is required only if there is any pain in midfoot zone and any of these findings:

  1. Bony tenderness at base of 5th metatarsal
  2. Bony tenderness at navicular
  3. Inability to bear weight both immediately and in ED (four steps)
162
Q

Acute treatment of contusions

A 
RICE 
Rest 
Ice 
Compression 
Elevation
163
Q

Tetanus prophylaxis in pregnancy

A

Both tetanus toxoid (Td) and immunoglobulin (TIG) are safe in pregnancy

164
Q

High risk factors for infection

A 
Wound Factors 
• Puncture wounds 
• Crush injuries 
• Wounds >12 h old 
• Hand or foot wounds

Patient Factors
• Age >50 yr
• Prosthetic joints or valves (risk of endocarditis)
• Immunocompromised

165
Q

Guidelines for tetanus prophylaxis for wounds

A

Unknown or fewer than 3 doses vaccination history
with Tdap or Td
with clean minor wounds
YES

Unknown or fewer than 3 doses vaccination history
with TIG
with clean minor wounds
NO

Unknown or fewer than 3 doses vaccination history
with Tdap or Td
with not clean, minor wounds
YES

Unknown or fewer than 3 doses vaccination history
with TIG
with not clean, minor wounds
YES

Vaccination history of 3+ doses 
with Tdap or Td  
with clean, minor wounds 
NO 
Yes if more than 10 years since the last tetanus toxoid-containing vaccine dose

Vaccination history of 3+ doses
with TIG
with clean, minor wounds
NO

Vaccination history of 3+ doses 
with Tdap or Td  
with non clean, minor wounds 
NO 
Yes if more than 5 years since the last tetanus toxoid-containing vaccine dose

Vaccination history of 3+ doses
with TIG
with non clean, minor wounds
NO

  • note that non clean, minor wounds include contaminated with dirt, feces, coil and saliva, puncture wounds, avulsions, wounds resulting from missiles, crushing, burns and frostbite
166
Q

Tetanus vaccination options

A

Tdap is preferred to Td for adults who have never received Tdap.
Single antigen tetanus toxoid (TT) is no longer available in the United States

167
Q

Types of bruises and things to check for

A
  • non-palpable = ecchymosis
  • palpable collection (not swelling) = hematoma following blunt trauma
  • assess for coagulopathy (e.g. liver disease), anticoagulant use
168
Q

Abrasion management

A

■ clean thoroughly with brush to prevent foreign body impregnation ± local anesthetic antiseptic ointment (Polysporin® or Vaseline®) for 7 d for facial and complex abrasions

■ tetanus prophylaxis

169
Q

Suture to face type and duration

A

Close with Nylon or Other Non-absorbable Suture 6-0

5 days

170
Q

Suture to not joint type and duration

A

Close with Nylon or Other Non-absorbable Suture 4-0

7 days

171
Q

Suture to joint type and duration

A

Close with Nylon or Other Non-absorbable Suture 3-0

10 days

172
Q

Suture to scalp type and duration

A

Close with Nylon or Other Non-absorbable Suture 4-0

7 days

173
Q

Suture to mucous membrane type and duration

A

Absorbable (vicryl)

N/A duration

174
Q

Who may require sutures for longer than standard periods of time

A

Patients on steroid therapy

175
Q

Lacerations physical exam

A

■ think about underlying anatomy

■ examine tendon function actively against resistance and neurovascular status distally

■ clean and explore under local anesthetic; look for partial tendon injuries

176
Q

Lacerations imaging

A

■ x-ray or U/S wounds if a foreign body is suspected (e.g. shattered glass) and not found when exploring wound (remember: not all foreign bodies are radioopaque), or if suspect intra-articular involvement

177
Q

Lacerations management

A

■ disinfect skin/use sterile techniques

■ irrigate copiously with normal saline

■ analgesia ± anesthesia

■ maximum dose of lidocaine
◆ 7 mg/kg with epinephrine
◆ 5 mg/kg without epinephrine

  • evacuate hematomas, debride non-viable tissue, remove hair and foreign bodies
  • ± prophylactic antibiotics (consider for animal/human bites, intra-oral lesion, or puncture wounds to the foot)
  • suture unless: delayed presentation (>6-8 h), puncture wound, mammalian bite, crush injury, or retained foreign body
  • take into account patient and wound factors when considering suturing
  • advise patient when to have sutures remove
178
Q

What are the most important factors in decreasing infection risk in lacerations

A

Early wound irrigation and debridement are the most important factors in decreasing infection risk

179
Q

Agents for sedation and amnesia in children

A

in children, topical anesthetics such as LET (lidocaine, epinephrine, and tetracaine), and in selected cases a short-acting benzodiazepine (midazolam or other agents) for sedation and amnesia are useful

180
Q

Alternatives to sutures

A

tissue glue

steristrips

staples

Emergency Medicine (6 decks)

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