Trauma

Question 0

Three clinical signs of shock?

Answer 0

1. Low BP
2. Fast, feeble pulse
3. Low urinary output (under .5 mL/kg/hr)

Question 1

Ways to secure an airway in the presence of the cervical spine injury (In order of preference)?

Answer 1

1. Orotracheal intubation
2. Nasotracheal intubation over fiber-optic bronchoscope
3. Cricothyroidotomy if over 12

Question 2

In trauma setting, shock is caused by? (CVP?)

Answer 2

1. Hypovolemic-hemorrhagic (low)
2. Pericardial tamponade (high)
3. Tension pneumothorax (high)

Question 3

Unlike other causes of shock, no respiratory distress in?

Severe respiratory distress in?

Answer 3

Pericardial tapenade

Tension pneumothorax

Question 4

2 alternative ways to treat shock?

Answer 4

1. If trauma center nearby – first stop bleeding, then replace volume
2. Otherwise first replace volume,

Question 5

How to replace volume in trauma patient?

Answer 5

1. 2 L ringers lactate
2. Packed red cells until urinary output reaches .5-2 mL/kg/hr
3. Do not exceed CVP of 15

Question 6

Preferred route of fluid resuscitation? Other methods? Other methods on child under six?

Answer 6

2 16-gauge peripheral IV lines

Percutaneous femoral vein catheter or saphenous vein cut-downs

Intraosseous cannulation of proximal tibia

Question 7

Pericardial tamponade – diagnosed by? If diagnosis is uncertain? Treatment options?

Answer 7

Clinical diagnosis – if unclear choose sonogram, not CXR

Pericardiocentesis, pericardial window, or open thoracotomy

Question 8

Tension pneumothorax – diagnosis? Management?

Answer 8

Clinical – do not order CXR or wait for blood gases

1. Needle into pleural space
2. Follow with chest tube

Question 9

Causes of shock in nontraumatic setting?

Answer 9

1. Hypovolemic – bleeding, burns, peritonitis, pancreatitis, message diarrhea
2. Intrinsic cardiogenic shock – MI, myocarditis
3. Vasomotor (neurogenic) shock – anaphylaxis, high spinal cord transection, high spinal anesthetic

Question 10

Penetrating head trauma – management?

Answer 10

Surgical intervention

Question 11

Linear skull fractures – management?

Answer 11

1. Is closed (no overlying wound), leave alone
2. If open, wound closure
3. If depressed or comminuted, OR

Question 12

Patient with head trauma who becomes unconscious – management?

Answer 12

1. CT scan to look for intracranial hematomas
2. If negative and neurologically intact, can go home if family is willing to wake him up frequently over next 24 hours to make sure they don’t go into a coma

Question 13

Fracture affecting base of skull – signs/symptoms? Management?

Answer 13

1. Raccoon eyes
2. Rhinorrhea
3. Otorrhea or Bruising behind ear
4. CT scan of cervical spine for integrity or especially if unconscious (to rule out intracranial bleeding)
5. Expectant management (no antibiotics)

Question 14

Causes of neurologic damage from trauma? Corresponding treatments?

Answer 14

1. Initial blow – no treatment
2. Hematoma that displaces midline structures – surgery
3. Increased ICP – medical measures

Question 15

Epidural hematoma – natural history? Imaging shows? Management?

Answer 15

1. Trauma
2. Unconsciousness
3. Lucid interval (completely asymptomatic)
4. Gradual lapsing into coma
5. Fixed dilated pupil (mostly ipsilateral) with contralateral hemiparesis

CT scan shows biconvex, Lens-shaped hematoma

Craniotomy produces cure

Question 16

Acute subdural hematoma (versus epidural hematoma)? Imaging shows? Management?

Answer 16

bigger trauma and no lucid interval

CT scan shows semi-lunar, crescent shaped hematoma

1. Craniotomy if midline structures are deviated (but prognosis is bad)
2. If no deviation, prevent increased ICP

Question 17

Medical management for patient with risk of increased ICP?

Answer 17

1. Elevate head
2. Hyperventilate to PCO2 of 35, if signs of herniation
3. Mannitol or furosemide to avoid overload (but do not decrease the systemic arterial pressure)
4. Hypothermia/Sedation to decrease oxygen demand

Question 18

Diffuse axonal injury – suggested by? Management?

Answer 18

CT scan shows:

2. diffuse blurring of gray-white matter interface
3. Multiple small punctate hemorrhages

No surgery without hematoma – just prevent increased ICP

Question 19

Chronic subdural hematoma – typical patient? Mechanism? Diagnosis? Management?

Answer 19

Very old or severe alcoholics

1. Shrunken brain moved around by minor trauma, tearing penis sinuses
2. Mental function deteriorates as hematoma forms

CT scan

Surgical evacuation provides cure

Question 20

Can intracranial bleeding lead to hypovolemic shock?

Answer 20

No,not enough space