absite trauma1
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| 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
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| MC blunt trauma organ injured | liver (some say spleen)
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| MC organ injured penetrating trauma | small bowel (some say liver)
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| LD50 hgt | 4 stories
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| MC cause death 1hr | hemorrhage
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| how much vol loss until BP decrsd | 30%
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| MC cause of death after making to ED alive | head trauma
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| MC cause of death in trauma in longterm | infxn
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| MC cause of upper airway obstruction | tongue
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| 3 injuries 2/2 seat belt | small bowel perf, lumbar spine fx, sternal fx
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| when is diagnostic peritoneal lavage positive | 10cc blood, 100K RBC/cc, food particles, bile, bac, >500WBC/cc
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| what does diagnostic peritoneal lavage miss | retroperitoneal bleed, contained hematoma
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| where does FAST scan? | perihep fossa, perisplenic, pelvis, pericardium
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| what amt of vol does FAST miss? | <50-80cc (also misses retroperitoneal bldg)
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| when get CT in blunt trauma | abd pain, need for gen anesthesia, closed head injury, intoxicants, paraplegia, distracting injury, hematuria
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| what does CT scan miss | hollow viscous injury, diaphragm injury
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| 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
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| mgmt penetrating abd injury if knife/low velocity | can do local exploration and observation if fascia not violated
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| abd compression syndrome, what P | >25-30
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| physiology of abd compartment syndrome isch | IVC compression decreases CO, gut malperfusion, renal vein compression -> decrsd UOP, then upward diaphragm
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| tx abd compartment syndrome | decompressive laparotomy
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| when is ER thoracotomy indicated | in blunt trauma if pressure/pulse lost IN ER
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| 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)
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| when do catecholamines peak | 24-48h s/p injury
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| 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
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| Glasgow motor scale | 6 command, 5 localize pain, 4 wdrw pain, 3 flex (decort) pain, 2 extend w pain (decereb), 1 no response
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| Glasgow verbal scale | 5 oriented, 4 confused, 3 inapprop words, 2 incomprehensible, 1no response
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| Glasgow eye scale | 4 spon opening, 3 opens to commands, 2 opens to pain, 1 no response
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| cut offs Glasgow scale and actions | 11-14 head CT, 9-10 intubate, 8 or below need ICP monitor
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| epidural hematoma, MC cause, s/s | MC m meningeal artery, lens shaped, LOC then lucid then sudden deterioration
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| tx epidural hematoma | surgery if signif neurol deterioration of mass shift >5mm
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| subdural hematoma, MC cause, s/s | tearing bridging veins bw dura and arachnoid, crescent shaped (usu in elderly after minor fall)
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| tx subdural | surgery if signif mass effect, in chronic drain if >1cm or signif sympt
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| imaging for diffuse axonal injury | shows up better MRI than CT
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| mgmt diffuse axonal injury | supportive, may need craniectomy if ICP elevated. Very poor px
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| how is cerebral perfusion pressure calculated and what goal | MAP-ICP, goal >60
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| CT signs of incrsd ICP | decrsd ventricular size, loss of sulci, loss of cisterns
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| when ICP monitoring | Glasgow 8 or less, suspected incrsd ICP, mod or severe head injury and inability to follow clinical exam (ie intubated)
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| tx if elevated ICP | sedation/paralysis, hypervent (CO2 30-35 for vasoconstrict), Na 140-150 and Osm 295-310, mannitol, phenytoin (ppx sz),
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| when is peak ICP s/p injury | 48-72h
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| what happens to pupils w incrsd ICP | dilated pupil same side (CN III compression)
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| s/s basal skull fx | raccoon eyes (anterior fossa), battle's sign (middle fossa, can involve facial n), hemotympanum, CSF rhinorrhea/otorrhea
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| temporal skull fx can injure which 2 cranial nerves | CN7,8
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| MC site of facial nerve injury, location of blow | geniculate ganglion, from temporal/lateral skull and orbital blows
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| tx of facial n injury | usu conservative, surgery if depressed 8-10mm, contaminated, or persistent CSF leak
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| mgmt CSF leak | usu expectantly
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| axial loading spine causes what type of fx | C1 burst (Jefferson fx)
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| tx of C1 burst fx | rigid collar
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| how does hangman fx occur? Which bone? Tx? | extension, C2, need fusion and halo
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| types of odontoid fx | I=above base, stable, II=at base need fusion or halo, III goes into vertebral body need fusion or halo
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| when is thoracolumbar spine considered unstable | 3 columns in thoracolumbar spine (Ant, middle, posterior), if >1 disrupted then unstable
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| compression thoracolumbar spine fx involves what? Tx? | anterior, tx=stable so don't need fusion
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| burst fx-considered unstable? Tx? | >1column unstable, need fusion
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| indications for emergent spine decompression | fx or dislocation not reducible w distraction, acute anterior spine syndrome, open fx, cord compression, progressive neural deficit
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| 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
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| 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
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| 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
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| 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
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| signs of orbital blowout; tx | impaired upward gaze or diplopia w upward vision; need repair w resoration of orbital floor
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| 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
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| tx of tripoid fx? Which bone is it? | zygomatic bone, ORIF
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| pt w maxillofacial fx are at high risk for what other injury | cervical spine injury
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| w/u of asympt blunt neck trauma | neck CT
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| 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
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| how evaluate eso injury | rigid esophagoscopy and esophagogram
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| how w/u contained eso injury | observe
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| how tx noncontained injury | if small, <24h, no contamination and pt stable -> 1ry closure; otherwise spit fistula and drain w chest tube
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| if repair esophageal do you need drain | yes, 20% leak rate
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| how approach esophageal injury | neck L side, upper 2/3 thoracic use R thoraco, lower 1/3 L thoraco
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| 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
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| how manage thyroid injury | control bleeding and drain
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| how to deal w gun injuries to neck (not according to zone) | need angio, neck CT, evaluate eso and trachea
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| how manage vertebral artery bleeds? Carotids? | can ligate or embolize w/o sequela; can't ligate carotid (stroke 20%)
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| 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
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| 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
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| tx sucking chest wound | tape on 3 side (needs to be 2/3 dia of trachea to be significant)
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| diaphragm injury MC on which side? How dx? | L, laparoscopy
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| what approach used for repair diaphragm (depending on time s/p injury) | <1wk=trans abd, >1wk chest
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| when do you need to evaluate Ao for transection | MVA >45mph, fall >15ft
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| med mgmt Ao transection | nipride and esmolol
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| if Ao transection and other life threatening injuries, what do you do first? | life threatening ones and deal w Ao later
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| how access R subclavian injury | mid clavicular incision and resxn of medial clavicle
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| 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
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| what w/u if suspect myocardial contusion | ECG most impt (bc death is due to arrythmia, ie Vtach and Vif <24h); also CKMB
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| what are borders of box chest injuries | clavicles, xiphoid, nipples
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| w/u penetrating injuries inside chest box | pericardial window, bronch, eso, Ba swallow
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| w/u penetrating injuries outside chest box | chest tube if intubated, otherwise serial CXR
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