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absite trauma1

QuestionAnswer
3 peaks of trauma mortality and cause <30min: lac heart/Ao, brain/brainstem/spinal cord. Can't save; 30m-4h: #1head injury, #2 hemorrh; days-wks: MOF, sepsis
MC blunt trauma organ injured liver (some say spleen)
MC organ injured penetrating trauma small bowel (some say liver)
LD50 hgt 4 stories
MC cause death 1hr hemorrhage
how much vol loss until BP decrsd 30%
MC cause of death after making to ED alive head trauma
MC cause of death in trauma in longterm infxn
MC cause of upper airway obstruction tongue
3 injuries 2/2 seat belt small bowel perf, lumbar spine fx, sternal fx
when is diagnostic peritoneal lavage positive 10cc blood, 100K RBC/cc, food particles, bile, bac, >500WBC/cc
what does diagnostic peritoneal lavage miss retroperitoneal bleed, contained hematoma
where does FAST scan? perihep fossa, perisplenic, pelvis, pericardium
what amt of vol does FAST miss? <50-80cc (also misses retroperitoneal bldg)
when get CT in blunt trauma abd pain, need for gen anesthesia, closed head injury, intoxicants, paraplegia, distracting injury, hematuria
what does CT scan miss hollow viscous injury, diaphragm injury
when need ex lap peritonitis, evisceration, positive DPL or FAST, clinical deterioration, uncontrolled hemorrh, free air, diaph injury, intraperitoneal bladder injury, specific renal/pancreas/biliary injury
mgmt penetrating abd injury if knife/low velocity can do local exploration and observation if fascia not violated
abd compression syndrome, what P >25-30
physiology of abd compartment syndrome isch IVC compression decreases CO, gut malperfusion, renal vein compression -> decrsd UOP, then upward diaphragm
tx abd compartment syndrome decompressive laparotomy
when is ER thoracotomy indicated in blunt trauma if pressure/pulse lost IN ER
where go in for ER thoracotomy anterolateral 4th/5th intercostal space and open pericardium anterior to phrenic n; if abd injury XC desc Ao if SBP>70 transport to OR (if SBP doesn't incrs then futile)
when do catecholamines peak 24-48h s/p injury
what emergent blood transfusions can be used and risks type O (univesal donor) males can get Rh+ and females childbearing age Rh-; type specific non screened/non crossmatched but can have Abs to minor Ags
Glasgow motor scale 6 command, 5 localize pain, 4 wdrw pain, 3 flex (decort) pain, 2 extend w pain (decereb), 1 no response
Glasgow verbal scale 5 oriented, 4 confused, 3 inapprop words, 2 incomprehensible, 1no response
Glasgow eye scale 4 spon opening, 3 opens to commands, 2 opens to pain, 1 no response
cut offs Glasgow scale and actions 11-14 head CT, 9-10 intubate, 8 or below need ICP monitor
epidural hematoma, MC cause, s/s MC m meningeal artery, lens shaped, LOC then lucid then sudden deterioration
tx epidural hematoma surgery if signif neurol deterioration of mass shift >5mm
subdural hematoma, MC cause, s/s tearing bridging veins bw dura and arachnoid, crescent shaped (usu in elderly after minor fall)
tx subdural surgery if signif mass effect, in chronic drain if >1cm or signif sympt
imaging for diffuse axonal injury shows up better MRI than CT
mgmt diffuse axonal injury supportive, may need craniectomy if ICP elevated. Very poor px
how is cerebral perfusion pressure calculated and what goal MAP-ICP, goal >60
CT signs of incrsd ICP decrsd ventricular size, loss of sulci, loss of cisterns
when ICP monitoring Glasgow 8 or less, suspected incrsd ICP, mod or severe head injury and inability to follow clinical exam (ie intubated)
tx if elevated ICP sedation/paralysis, hypervent (CO2 30-35 for vasoconstrict), Na 140-150 and Osm 295-310, mannitol, phenytoin (ppx sz),
when is peak ICP s/p injury 48-72h
what happens to pupils w incrsd ICP dilated pupil same side (CN III compression)
s/s basal skull fx raccoon eyes (anterior fossa), battle's sign (middle fossa, can involve facial n), hemotympanum, CSF rhinorrhea/otorrhea
temporal skull fx can injure which 2 cranial nerves CN7,8
MC site of facial nerve injury, location of blow geniculate ganglion, from temporal/lateral skull and orbital blows
tx of facial n injury usu conservative, surgery if depressed 8-10mm, contaminated, or persistent CSF leak
mgmt CSF leak usu expectantly
axial loading spine causes what type of fx C1 burst (Jefferson fx)
tx of C1 burst fx rigid collar
how does hangman fx occur? Which bone? Tx? extension, C2, need fusion and halo
types of odontoid fx I=above base, stable, II=at base need fusion or halo, III goes into vertebral body need fusion or halo
when is thoracolumbar spine considered unstable 3 columns in thoracolumbar spine (Ant, middle, posterior), if >1 disrupted then unstable
compression thoracolumbar spine fx involves what? Tx? anterior, tx=stable so don't need fusion
burst fx-considered unstable? Tx? >1column unstable, need fusion
indications for emergent spine decompression fx or dislocation not reducible w distraction, acute anterior spine syndrome, open fx, cord compression, progressive neural deficit
what are the 3 columns of the thoracolumbar spine anterior=ant longit lig and ant 1/2 vertebral body, middle=posterior 1/2 vertebral body and posterior longit lig; posterior=facet joints, lamina, spinous processes, interspinous lig
types of Le Fort facial fx I=straight across maxilla, tx=reduction, stabilize, intermaxillary fix; II=like I but includes nasal bone under eyes /\ shaped, tx=same as I; III=includes orbit walls, tx=suspension wire
what cxn commonly seen w nasoethmoidal orbital fx; tx 70% CSF leak; conservative therapy 2wks, can try epidural cath to decrs CSF P to help close or may need surgical closure of dura
tx of nosebleeds; ant v posterior; arteries causing ant=packing of anterior ethmoidal a (Kisselbach's plexus), post=try balloon tamponade, may need angioemboliz of internal maxillary artery or ethmoidal
signs of orbital blowout; tx impaired upward gaze or diplopia w upward vision; need repair w resoration of orbital floor
how tell mandibular fx; dx; tx malocclusion (teeth not lining up); dx w panorex or fine cut CT; tx=intramax fixation w wires or ORIF
tx of tripoid fx? Which bone is it? zygomatic bone, ORIF
pt w maxillofacial fx are at high risk for what other injury cervical spine injury
w/u of asympt blunt neck trauma neck CT
w/u asympt penetrating neck injury by zone I (bw clavicle and cricoid)=angio, bronch, esophag, Ba swallow, +/- pericardial window/sternotomy; II (cricoid to angle of mandible):explore in OR; II (angle of mandible to base of skull): angio, laryngoscopy
how evaluate eso injury rigid esophagoscopy and esophagogram
how w/u contained eso injury observe
how tx noncontained injury if small, <24h, no contamination and pt stable -> 1ry closure; otherwise spit fistula and drain w chest tube
if repair esophageal do you need drain yes, 20% leak rate
how approach esophageal injury neck L side, upper 2/3 thoracic use R thoraco, lower 1/3 L thoraco
tx laryngeal and tracheal injury secure airway w tracheostomy (not nasotracheal or orotracheal airway or cric); then primary repair can use strap mscl for airway support
how manage thyroid injury control bleeding and drain
how to deal w gun injuries to neck (not according to zone) need angio, neck CT, evaluate eso and trachea
how manage vertebral artery bleeds? Carotids? can ligate or embolize w/o sequela; can't ligate carotid (stroke 20%)
what are indications for going to OR s/p chest tube 1.5L after insertion, 250/h for 3 hrs, 2.5L/24h or bleeding instability
why impt to drain all blood w chest tube prevent fibrothorax, pulmonary entrapment, infectd hemothorax--so if not all drained s/p chest tubes will need thoracoscopic or open drainage
tx sucking chest wound tape on 3 side (needs to be 2/3 dia of trachea to be significant)
diaphragm injury MC on which side? How dx? L, laparoscopy
what approach used for repair diaphragm (depending on time s/p injury) <1wk=trans abd, >1wk chest
when do you need to evaluate Ao for transection MVA >45mph, fall >15ft
med mgmt Ao transection nipride and esmolol
if Ao transection and other life threatening injuries, what do you do first? life threatening ones and deal w Ao later
how access R subclavian injury mid clavicular incision and resxn of medial clavicle
when do you use median sternotomy v L thoracotomy to access Ao/vascular injuries median sternotomy for Asc Ao, innom, prox LCCA and R subcl; L thoracotomy for L subclav and desc Ao
what w/u if suspect myocardial contusion ECG most impt (bc death is due to arrythmia, ie Vtach and Vif <24h); also CKMB
what are borders of box chest injuries clavicles, xiphoid, nipples
w/u penetrating injuries inside chest box pericardial window, bronch, eso, Ba swallow
w/u penetrating injuries outside chest box chest tube if intubated, otherwise serial CXR
Created by: ehstephns on 2013-01-22



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