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Surg 2 Trauma

Surgery 2

Trauma PE: Head scalp lacerations, contusions; skull fractures; rhinorrhea, otorrhea (CSF); hemotympanum (blood behind eardrums or in external auditory canal); visual acuity; pupil equality and reactivity; facial fractures
Trauma PE: Neck tracheal deviation; spinal tenderness or stepoffs (MAINTAIN MIDLINE IMMOBILIZATION DURING EXAM)
Trauma PE: Chest clear and equal breath sounds, symmetric chest rise; rib and sternal fractures; clear heart sounds
Trauma PE: Abdomen bowel sounds, distension, tenderness, contusions (e.g., seat-belts)
Trauma PE: Pelvis instability on rocking; rectal exam (on everyone) for blood, sphincter tone, high-riding prostate; blood at urethral meatus
Trauma PE: Back spinal tenderness or stepoffs; ecchymoses, lacerations (LOGROLL)
Trauma PE: Extremities deformities, joint mobility, pulses, lacerations, contusions
Trauma PE: Neurologic Glasgow Coma Scale (GCS); motor/sensory deficits
3 reasons to intubate a trauma pt Impaired level of consciousness, a mechanically compromised airway, or ventilatory problems
True/False: Dx tension PTX can be made by chest X-ray. False
Tension PTX: Sx: tracheal deviation (away from side of PTX), increased JVD, decreased breath sounds, tympany to percussion, hypotension.
Tension PTX: Rx: needle decompression followed by chest tube insertion
Beck’s Triad (reflecting cardiac tamponade) Muffled HS, increased JVD, hypotension
GCS ≥13 = mild brain injury
GCS of 9-12 = moderate injury
GCS ≤8 = severe injury
How can you evaluate the stable trauma patient with abdominal pain? Observation w/ serial exam is an option only for stable pts w/ a reliable PE (no drugs or head injury)
Abdominal CT is used for: stable pts w/ equivocal exams or with high-risk mechanisms.
Advantage of abdominal CT over DPL is: ability to evaluate the retroperitoneum (aorta, IVC, pancreas, kidneys, and portions of duodenum and colon).
Ultrasound in trauma pt eval: non-invasive but can be performed anywhere; can detect free intraperitoneal fluid as well as many solid organ injuries
Diagnostic Peritoneal Lavage (DPL) is for: unexplained hypotension or for equivocal exam in a multiply injured pt. DPL can be performed anywhere & in less than 5 min
A positive DPL = aspiration of gross blood or >100,000 rbc/ml on lab exam of lavage fluid. DPL is 98% sensitive for intraperitoneal bleeding.
Immediate exploratory laparotomy is indicated for: most penetrating trauma or for the unstable patient with obvious evidence of abdominal injury on physical exam.
Unstable pts with pelvic fractures should undergo: emergent external fixation
Closed head injury: CPP = Cerebral perfusion pressure = MAP-ICP
Closed head injury: Rx: Intubate, ICP monitoring, keep CPP >70 to prevent secondary injury; No steroids, Ventilate to keep CO2 30-35
3 types of shock most commonly seen in surgery: Cardiogenic, hypovolemic, neurogenic
Hypovolemic Shock: <20% Decreased pulse pressure; Ortho hypotension; Flat neck veins; increased Hct
Hypovolemic Shock: 20-40% Thirst; Tachycardia; Oliguria; Mod hypotension
Hypovolemic Shock: >40% MS changes; Severe hypotension; EKG-ischemic arrhythmias
Most significant cause of morbidity in pts w/ traumatic brain injuries: DAI (diffuse axonal injury)
Closed head injury = Intracranial hemorrhage
Closed head injury: Epidural arterial bleed assoc w/ skull fx requiring immediate surg intervention; assoc w/ lucid interval following LOC
Closed head injury: Subdural venous bleed btw cortex & dura requiring surg evacuation depending on severity
Closed head injury: Intracerebral hemorrhage within the parenchyma, often associated with other injuries
Closed head injury: Subarachnoid frequently missed on CT and rarely requiring immediate treatment
Hemothorax: Tx if drains >1500cc blood, insert chest tube; if >200cc/hr: to OR for thoracotomy to r/o great vessel injury
Cardiac tamponade: Tx OR or ED Thoracotomy (classic answer: pericardiocentesis) [ED thoracotomy: Subxyphoid, substernal notch, 45 degree angle, shoulder]
Intra-abdominal Injuries: must R/O: hemoperitoneum
Created by: Adam Barnard Adam Barnard