1
Q
Skull Base Fx
Path:
S/Sx:
Dx:
Tx:
A
Skull Base Fx
Path:
- Temporal: most common; inj CN VII, CVIII, carotid a., epidural hematoma
- Frontal sinus: inj CN I
- Central: inj CN III, IV, V, VI, carotid a.
- Posterior: inj CN IX-XII, cervical spine, vertebral a.; paraplegia
S/Sx:
- Battle’s Sign (post-auricular)
- Racoon eyes (periorbital)
- Rhinorrhea / otorrhea
Dx:
- CT scan
- CSF (+) glu, halo sign
- Test vision, CN fct, mental status
Tx:
- C-Spine precautions until proven otherwise
- Consult neurosurg, ENT, plastics, opthal, audiology
- Abx: Use if prolonged CSF -> meningitis, brain abscess: Ceph, FQ, B-lactam
- NOT recommended empirically in most cases
- Surg: displaced fx stabilization; CN decompression, repair
2
Q
Epidural Hematoma
Path:
S/Sx:
Dx:
Tx:
A
Epidural Hematoma
Path:
- Baseball to the temple -> middle meningeal a. shear -> blood btwn skull and dura
S/Sx:
- LOC -> lucency -> rapid neuro decline
Dx:
- Head CT
Tx:
- Surgical emergency if >30mL or GCS <9 w/ pupillary changes
- Observation + freq neuro checks if small, min. ML shift, no focal sx, GCS > 8
3
Q
Subdural Hematoma
Path:
S/Sx:
Dx:
Tx:
A
Subdural Hematoma
Path:
- MVA / major trauma -> tear bridging veins -> blood btwn dura mater and subarachnoid membrane
S/Sx:
- Knocked out, stays out
- N/V, confusion, lethargy, focal deficit
- Chronic: seizures, personality change, dementia, aphasia
Dx:
- Head CT
Tx:
- If >1cm width, (+) ML shift = craniotomy/surgery +/- Burr hole/evacuation
- If small, (-) ML shift = Decrease ICP w/ elevation, hyperventilation, manitol
- Monitor for post-op seizures
4
Q
What is different about a traumatic subarachnoid hematoma vs. SAH d/t aneurysm rupture?
What about traumatic intraparenchymal hematoma?
A
With traumatic subarachnoid hematoma, you are not concerned with reducing vasopasm risk. You will allow the traumatic SAH to resolve on its own.
Likewise, traumatic intraparenchymal hemorrhage is less concerning than hemorraghic stroke, with decent outcomes if the traumatic hematoma is small.
5
Q
Traumatic Brain Injury
Path:
S/Sx:
Dx:
Tx:
A
Traumatic Brain Injury
Path:
- MVC most common; falls; ETOH 50%
S/Sx:
- LOC, short term mem loss, GCS < 14 at time of injury
- +/- craniofacial trauma, C-spine injury, focal neuro deficit
- HA, seizure, N/V
- Poor prognosis: Hematoma >30mL; ML shift > 10mm; swirl sign (active bleed)
Dx:
- CT Head
- ICP monitor (EVD gold standard)
Tx:
- Protect airway; preoxygenate; fentanyl & etomidate good; propofol allows neuro exam but may cause hotn
- Treat ICP: osmolar therapy and avoid hypotonic IV fluids
- Maintain CPP > 60 (CPP = MAP - ICP)
- Prevent secondary brain injury: cerebral edema, seizures, fevers, hypoxia, hypercarbia, hotn, hypertherma
- Monitor Na
- Central DI: tx with DDAVP and IV fluid
- Cerebral salt wasting: Tx with Na and fluids
- SIADH: Urine Na > 40, urine osm > 100; Tx with fluid restriction + vaptan if severe
6
Q
Cervical Spine Trauma
Path:
S/Sx:
Dx:
Tx:
A
Cervical Spine Trauma
Path:
- Blunt injury (MVC) > GSW / stab
- Edema -> airway compromise
- C3,4,5 keep the diaphragm alive
S/Sx:
- Difficult breathing
- Neurogenic shock if inj above T6 (d/t unopposed parasympathetic activity)
- Normal CO but decreased SVR
Dx:
- MRI
Tx:
- Suspect C-Spine inj w/ head or facial trauma -> immobilize, lay flat, log roll
- Neurogenic shock:
- Fluids (MAP > 85)
- HD Monitoring
- Consider vasoactive (Alpha Agonist) / inotropic (Beta agonist) drip
- Norepi OK but less direct cardiac action
- Avoid phenylephrine in bradycardia
- +/- Midrodrine
7
Q
Central Cord Syndrome
Path:
S/Sx:
Dx:
Tx:
A
Central Cord Syndrome
Path:
- Hyperextension injury -> dmg to centrally located fibers serving upper limb motor & spinothalamic function -> incomplete SCI
- Usually in older adults w/ hx spondylosis / spinal stenosis
S/Sx:
- Spinal cord bruising
- Transient deficits upper extremities > lowers for < 48h
- Loss of pain and temp sensation in cape like distribution (hands/arms > feet) +/- weakness
Dx:
- MRI: ligamentous inj if AMS preventing C-Spine clearance
- CT cervical spine
Tx:
- C-Spine Clearance: take off collar; check movement; check pain; check MS; document
8
Q
Nasal Fx
Path:
S/Sx:
Dx:
Tx:
A
Nasal Fx
Path: Most common mid-facial injury
S/Sx: Nasal congestion, epistaxis, septal hematoma
Dx: Inspection of internal & external nares; plain films if isolated nasal fx suspected
Tx: Address epistaxis / hematoma first; closed reduction is option; wait until edema resolves before surgical repair
9
Q
Zygomatic Complex Fx
Path:
S/Sx:
A
Zygomatic Complex Fx
Path: Lateral blow -> Tripod fx, 2nd most common facial fx
S/Sx:
- Pain over cheekbone
- Depression / step-off on palpation
- Local ecchymosis or edema
- Assymetrical orbits
- Exopathalmos / enopthalmos
- Proptosis, diplopia
- Subconjunctival hemorrhage
- Impaired EOM movement
- Infraoribital nerve paresthesia
10
Q
Maxillary Fx
S/Sx:
A
Maxillary Fx
S/Sx:
- Pain w/ jaw movement
- Intraoral bleeding
- Epistaxis
- Loose / missing teeth
- Inability to chew, malocclusion of teeth
- Elongated face
- Displaced maxilla (lateral)
- Infraorbial nerve paresthesia
11
Q
Orbital Floor Fx
Path:
S/Sx:
A
Orbital Floor Fx
Path: ‘Blowout Fx’ d/t anterior-posterior force
S/Sx:
- Enopthalmos +/- autoimmune rxn
- Diplopia
- Loss of extraocular eye movement or (+) diplopia -> muscle entrapment
12
Q
Mandibular Fx
S/Sx:
Dx:
A
Mandibular Fx
S/Sx:
- Step-off deformity
- Crepitus
- Pain w/ jaw movement
- Malocclusion of teeth
- Dysphagia
- Paresthesias of lip and chin
- Trismus
- Loose / broken / missing teeth
- Intraoral bleed
Dx: Plain films NOT preferred; may need Panorex films
13
Q
What are your broad considerations for ANY facial trauma in terms of…
Dx:
Tx:
A
General Facial Trauma
Dx:
- ABC, assume c-spine inj, mental status exam, full visual acuity ecam, CN testing
- Imaging: Maxillofacial CT w/o contrast; CT head/face for surg planning
Tx:
- Gentle pressure to stop bleed
- Do not nasally intubate, avoid NGT
- May need Surgical airway/cric depending on bleed and deformity
- Empiric Abx: CONTROVERSIAL
- Defer to surgeon
- High risk fx SHOULD get abx: open facial fx, communication with sinus, communication with oral flora and mouth
- Oral care with CHG if wired jaw
- Tetanus vax
- Ocular trauma precautions: sneeze w open mouth, no straws, etc
- Consult appropriately
14
Q
All Thoracic and Lumbar Spinal Trauma
Tx:
D/c considerations:
A
All T & L Spinal Trauma
Tx:
- DVT ppx; IVC filter
- Bowel & bladder training; I/O; bowel regimen
- Corticosteroids CONTROVERSIAL in blunt trauma, Ø in penetrating
- Prevent secondary morbidity: VAP, HAP, CAUTI, DVT, PE, neuropathic pain, spasticity, decubity, depression
D/c:
- 85% those who survive 24h will survive 10 years
- Low level injury and specialized SCI rehab best predictors of survival
- Home modifications, ADL assistance, home care, transport, follow up
- Complications: decubiti, UTI, resp infxn, injury, contrractures, depression
15
Q
Thoracic Fx
Path:
Epi:
Thoracolumbar Junction Fx
Path:
A
Thoracic Fx
Path:
- Tremendous force -> flexion/axial loading -> T2-T10 fx
Epi:
- Vertebral compression fx most common
- Burst fx: retropulsed fragments into spinal canal -> Complete Spinal Cord Injury
Thoracolumbar Junction Fx
Path:
- Flexion -> Vertebral body wedging -> Compression fx to T11-L1
- Chance Fx d/t seatbelt injury -> unstable pt -> a/w bowel +/- iliac a. inj
- Burst Fx -> unstable
- Usually no spinal cord injury
16
Q
Lower Lumbar & Sacral Fx
Path:
S/Sx:
Dx:
A
Lower Lumbar & Sacral Fx
Path:
- Hyperflexion & axial loading -> longitudinal sacral fx -> radiculopathy
- Transverse sacral fx -> cauda equina syndrome
- Uncommon
S/Sx:
- May have sacral sparing -> retain potential for motor recovery, continence
- Physiologic continuity of long-tract fibers within sacral spinal cord
- Will define complete vs incomplete SCI
Dx:
- Test for sacral sparing
- Saddle sensation
- Bulbocavernosus reflex
- Anal wink
- Urination / defecation
17
Q
Cauda Equina Syndrome
Path:
S/Sx:
Dx:
A
Cauda Equina Syndrome
Path:
- Compression on S3, S4, S5 nerve roots
S/Sx:
- Saddle anesthesia
- Severe low back pain
- Motor weakness & sensory loss to BLEs
- Reflex loss
- Bladder & bowel incontinence, sexual dysfunction
Dx:
- Sensory Grading
- 0 absent
- 1 altered
- 2 normal
- NT not testable
- ASIA Impairment Scale
- Strength Exam (0/5 - 5/5)
18
Q
Bony Thorax Fracture
Path:
S/Sx:
Dx:
Tx:
A
Bony Thorax Fracture
Path: Blunt or penetrating trauma
S/Sx: Decreased breathing
Dx: CXR
Tx:
- Analgesia: APAP, NSAID, opioid
- Prevent & tx Atelectasis
- i.s. q1h while awake
- HOB up
- Sternal precautions: no heavy push/pull
19
Q
Flail Chest
Path:
S/Sx:
Dx:
Tx:
A
Flail Chest
Path: Huge blunt trauma -> 2+ broken ribs in 2+ places
S/Sx:
- Paradoxical rise/fall with insp/expiration
- Severe pain +/- Pulmonary contusion
Dx: Visual inspection, CXR
Tx:
- May require MV
- Thoracic epidural
- Binder potentially
20
Q
Pulmonary Contusion
Path:
S/Sx:
Dx:
Tx:
A
Pulmonary Contusion
Path: Huge blunt or penetrating trauma -> Bruise of lung parenchyma
S/Sx:
- Normal then -> Evolves over 24-48h s/p trauma
- Progressive tachypnea, hypoxia, hypercarbia
- BL or severe –> ARDS
Dx: CXR 24-48h later
Tx:
- Treat like ARDS
- Use colloids
- PEEP, O2 monitoring & supplementation
- I.S.
- +/- MV up to 3wks
- +/- Diuresis
21
Q
Pneumothorax
Path:
S/Sx:
Dx:
Tx:
Complications:
A
Pneumothorax
Path:
- Air trapped btwn lung and chest wall often d/t rib fx or penetrating trauma
- 3 Types:
- Closed (symptomatic)
- Open (sucking chest, penetrating -> do NOT occlude)
- Tension (tracheal shift from midline away from injury)
S/Sx:
- Dyspnea
- Obstructive shock -> Low CO -> HD instability
- Air leak: should diminish as lung tissue heals
Dx:
- CXR
- Ptx vertical shadow
- Hemotx horizontal shadow
Tx:
- Chest tube required
- Emergent needle decompression if chest tube not available
- Drain hemothorax:
- If >1500mL/day or 200mL/h or unstable s/p drain -> surgical thoracotomy to identify and stop bleeding
- 3 sided dressing for sucking chest wound
- After chest tube placement:
- Check CXR to verify improvement
- Assess subq emphysema
- Note degree of air leak
Complications:
- New airleak: check tubing connection; make sure tube still in chest wall; CXR to evaluate position of hole
- Recurrent ptx: place 2nd chest tube
22
Q
Ureteral Trauma
Path:
S/Sx:
Dx:
A
Ureteral Trauma
Path: Pelvic fx
S/Sx:
- Flank, abd pain
- Flank mass
- Prolonged ileus d/t retention
- UTI
- Hydronephrosis
- AKI / azotmemia
Dx:
- CT urogram: specific
- CT red flags:
- Perinephric hematoma +/- stranding
- Ureteral dilation
- Ureter not visible
- CT red flags:
- Retrograde Pyelogram: most accurate
- Do if CT is inconclusive
23
Q
Bladder Injuries
Patho:
Tx:
Urethral Trauma
S/Sx:
Dx:
Tx:
Pelvic Fx
S/Sx:
A
Bladder Injuries
Patho: Low seatbelt -> extraperitoneal vs intraperitoneal injury
Tx: Extraperitoneal = NON surgical; Intraperitoneal = SURG repair
Urethral Trauma
S/Sx: Blood at urethral meatus
Dx: Blood at urethral meatus
Tx:
- Don’t do anything yet - consult urology
- Partial Trauma: foley vs. suprapubic cath +/- surgical repair
- Complete Trauma: Suprapubic cath & delayed surgical/endo repair
Pelvic Fx
S/Sx: Can exsanguinate; can cause vaginal/rectal injuries
24
Q
Muscular Compartment Syndrome
Path:
Epi:
S/Sx:
Dx:
Tx:
A
Muscular Compartment Syndrome
Path: Injury, dz, or fluid compress surrounding structures -> increased pressure -> tissue damage, hypoxia
Epi:
- High risk: tibial fx; venous ligation; dislocation; burns; venom
S/Sx:
- Pain out of proportion
- Paresthesias (anesthesia in first web space, inability to dorsiflex)
- Pallor
- Paralysis
- Pulselessness
- Poikilothermia
Dx:
- >30-45mmHg = high pressure = frequent monitoring
- >45mmHg = very high = surgical release needed
- Clinical suspicion
Tx:
- Remove constrictive device, elevate extremity, ice
- Fasciotomy - multiple incisions through skin extended to fascia
- Wound vac -> promotes granulation
- Post Op: compartment syndrome can recur in skin / dressing
- Wound mgmt: Wet to dry, xeroform, continued elevation +/- Jacob’s ladder
- Complications: Infxn, venous insufficiency, chronic edema
25
**Abdominal Hemorrhage**
S/Sx:
Dx:
Tx:
**Abdominal Hemorrhage**
S/Sx:
* Kerh's sign: L shoulder pain referred d/t diaphragm irritation 2/2 blood accumulating
* +/- Peritoneal signs
* Hemorrhagic Shock: AMS -\> Decreased UO -\> Tachypnea (with pulse pressure narrowing throughout)
* Bradycardia -\> Arrest -\> Death
Dx:
* BMP, Mg, Phos, Coags, CBC, Type & Cross, CK, Amylase, Lipase, Toxicology, HcG, Lactate, ABG
* FAST Exam
Tx:
* Hem Shock
* I: Normal, anxious -\> give fluids
* II: 15-30% (.75-1.5L) total blood volume loss +/- decreased pulse pressure -\> give fluids
* III: Decreased CO, tachypnea, decreased UO, 2L EBL, confusion -\> give blood
* IV: \>2L EBL, no UO, HoTN, Lethargy -\> give blood
* Resuscitation
* Begin with 1L warmed isotonic crystalloid
* NS -\> hyperchloremic acidosis
* Mass txfn policy - continue until parameters met
* Non-Operative:
* NPO, bedrest, serial CBC, serial abd exam
* Txfn PRN
* Operative:
* Peritoneal signs -\> surg vs IR embolization
26
**Abdominal Compartment Syndrome**
Path:
S/Sx:
Dx:
Tx:
**Abdominal Compartment Syndrome**
Path:
* Increased intra-abdominal HTN \> 12mmHg -\> decreased organ perfusion
* Depends on compliance = Vol/Pres
* Primary: retroperitoneal bleeding (ruptured AAA) vs. visceral (intestinal edema) vs. peritoneal fluid (ascites) vs. trauma packing
* Secondary: Burns, massive resuscitation
S/Sx:
* Triad:
* Inc ventilatory pressure (diaphragm pushed up)
* Dec urine output (kidneys compressed)
* HoTN (venous compression
* High index of suspicion:
* Hx abd surg; HoTN with reperfusion; resuscitation \> 10L fluid or 6L blood
* Clinical triad (hotn, low UO, high ventilatory pressure) +/- firm, distended abd
Dx:
* Pressure measurements: bladder pressure
* Grading: I (15mmHg) through IV (\>25mmHg)
* Normal IAP \< 10
* DDx: mesenteric ischemia, ruptured AAA, toxic megacolon, acute appendicitis, acute diverticulitis
Tx:
* Limit fluid resuscitation
* Freq monitor: IAP \>30 mmHg
* Decompress stomach, bladder; Evac bowel contents; improve abd wall compliance +/- NMB; optimize fluid & tissue perfusion
* Surgical Decompression: IAP \> 45 mmHg
* Open laparotomy
* Visceral herniation = diagnostic
* Resolution of problems = diagnostic
* Post Op: wound vac dressing for open abdomen
* Complications: Fistula, evisceration, hgernia, IA abscess, metabolic drain
* Will need increased protein and calories
27
**Blunt Cardiac Injury**
Path:
S/Sx:
Dx:
Tx:
**Blunt Cardiac Injury**
Path:
* Compression of heart btwn sternum & vertebral column
* Upward force from lower trauma
S/Sx:
* Chest wall bruise, rib/sternal fx
* Sinus tach, PACs, PVCs (d/t irritated myocardial cells)
* Retrosternal pain (MI-like) 2/2 trauma, unrelieved by O2, rest
* S/sx cardiogenic shock (decreased contractility -\> decreased CO)
* Hematoma, hemopericardium, ventricular aneurysm, thromboembolism, constrictive pericarditis, traumatic MI d/t coronary a. inj, spasm -\> necrosis & rupture
Dx:
* Vitals, ECG, Trop, Echo, CT/MRI
Tx:
* ECG & Trop I
* (-) ECG and (-) trop: r/o BCI
* (+) ECG or (+) Trop I: Admit w/ continuous ECG 24-48h and serial Trops
* HD Unstable: 2D Echo vs TEE
* If abnormal ECG, trop, echo:
* Cardiac CT vs MRI: determine need for cardiac cath +/- anticoagulation
28
**Traumatic Cardiac Tamponade**
Path:
S/Sx:
Tx:
**Traumatic Cardiac Tamponade**
Path: Rapid tampondae with less fluid than in 'medical' tamponade
S/Sx:
* Increased CVP
* Decreased Pulse Pressure
* Decreased CO
* Less reliable:
* Beck's Triad (muffled heart sounds, inc JVD, HoTN) more common in 'medical' tamponade, only in 10% of BCI
* Kussmaul's sign (JVD with inspiration)
* Pulsus paradoxus
* FAST exam (+) massive hemothorax
Tx:
* Pericardial window: evacuate blood and clot; eval heart and vessels; surgical repair possible
* NO pericardiocentesis: will not remove blood, will increase injury, will increase risk of false negative
29
**Traumatic Valvular Injury**
Path:
S/Sx:
Tx:
**Traumatic Valvular Injury**
Path: Mitral valve injured and heart does not have time to compensate
S/Sx: Pulm edema (MVR) -\> fluid into L atrium -\> Vascular congestion
Tx: Early surgical intervention if possible; tx cardiogenic shock if occurs
ACNP Final
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