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absite trauma1
| Question | Answer |
|---|---|
| 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
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