Trauma

Question 0

Signs of laryngeal edema?

Answer 0

Hoarseness, changing voice, Strider

Question 1

Importance of gag reflex in trauma patient?

Answer 1

Indicates airway is most likely clear; if absent, inspect airway digitally

Question 2

Indications for intubation in trauma patient?

Answer 2

1. Severely depressed mental status
2. Glasgow coma score under nine
3. Inability to protect airway or tracheal/laryngeal trauma
4. Severely compromised respiratory mechanics (multiple rib fractures)

Question 3

Glasgow coma scale – categories? (Maximum points?)

Answer 3

Eye-opening (4 points)
Verbal response (5 points)
Motor response (6 points)

Question 4

A simple pneumothorax from trauma is usually due to? Management?

Answer 4

Open fracture that lacerates the visceral pleura and underlying lung parenchyma

Insertion of a large diameter chest tube

Question 5

Patient with pneumothorax. Chest tube properly placed, but lung is not reinflating. Possible causes of this pneumothorax? Treatment?

Answer 5

1. Traumatic diaphragmatic hernia (must go to OR)

2. Lung adherent to parietal pleura with adhesions (place tube toward posterior, apical aspect of pleural space)

Question 6

Where to place chest tube?

When to take out a chest tube?

Answer 6

Between fourth and fifth rib

When lung is fully inflated and no further air leak is apparent

Question 7

Patient with pneumothorax. After insertion of chest tube, air continues to leak into chest tube over six hours. Lung only partially inflated. Likely Cause? Management?

Answer 7

Major airway injury with disruption of a bronchus or trachea

1. Bronchoscopy
2. Thoracotomy and partial lung resection

Question 8

Patient with pneumothorax – when is a chest tube not necessary?

Answer 8

1. Not enlarging
2. No free fluid in the plural space
3. Patient is asymptomatic and has no other significant injuries (chest injuries, other fractures, trauma)

Question 9

Patient with small pneumothorax – if goes to OR, what procedures can increase size of pneumothorax? How?

Answer 9

General anesthesia, intubation, assisted ventilation

Increases positive pressure in tracheobronchial tree

Question 10

Patient presents post trauma. Absent breath sounds in right chest and blood pressure of 80/60. Distended neck veins. Suspected diagnosis? Mechanism resulting in hypotension? Management?

Answer 10

Tension pneumothorax

Air enters plural space, but can’t leave – increasing pressure. Increased pressure inhibits minutes return, cardiac output drops, resulting in hypotension

1. Insertion of chest tube
2. If not possible, needle aspiration
3. After chest tube/needle aspiration, CXR

Question 11

42-year-old man presents posttrauma. Ventilating/oxygenating well. Blood-pressure 80/60, heart rate 110, distended neck veins. Suspected diagnosis? Other expected signs? Management?

Answer 11

Cardiac tamponade (Not pneumothorax because good ventilation)

1. Optionally: pericardial ultrasound examination
2. Emergent pericardiocentesis (subxiphoid approach)
3. After initial drainage, pericardial window and examination in OR for source of bleeding

Question 12

Physical exam signs in pericardial tamponade (not necessarily detectable in trauma patients)

Answer 12

1. Muffled heart sounds
2. Pulsus paradoxus (decrease in systolic BP of more than 10 mm on inspiration)
3. Kussmaul sign (increase in JVP during inspiration)

(JVP usually detectable)

Question 13

Signs of myocardial contusion? Confirm with?

Answer 13

Arrhythmias and acute ECG changes

Cardiac enzymes/imaging

Question 14

General physiologic changes from hemorrhages

Answer 14

Under 15% – few changes (Class I)

15-30% – tachycardia/increased pulse pressure (Class II)

30-40% – hypotension, tachycardia, decreased mentation (Class III)

Question 15

Fracture associated with with several liters of blood loss into tissue?

Answer 15

Femur

Question 16

Patient continues to remain hypotensive and unstable despite adequate fluid recitation – possible causes? next step?

Answer 16

1. Thoracic injury
2. Pelvic fracture
3. Long bone injury

Laparotomy or thoracotomy

Question 17

Cushing reflex?

Answer 17

1. Injury causes brain swelling.
2. Brain swelling results in brain ischemia.
3. Ischemia leads to SNS stimulation, causing vasoconstriction (to maintain blood pressure and perfusion)
4. Vagus nerve is unaffected, and respond to increased blood pressure with PSN this simulation, causing Bradycardia

Question 18

Hemodynamic effects to consider during pregnancy? and how to correct for them?

Answer 18

#Heart rate increases (20 BPM higher than third trimester)
#Uterus can compress vena cava causing hypotension (Evaluate blood pressure when patient is lying on left side)
#Plasma volume increases, hematocrit 31-35% is normal

Question 19

Causes of bloody urine when attempting to put in foley?

Answer 19

#Urethral injury
#High riding  prostate gland
#Penile/scrotal hematoma

Question 20

What should you do before placing catheter in the male trauma patient? Why? Other test?

Answer 20

Perform rectal exam for prostatic injury

Catheter may complete a partially transected urethra and worsen trauma

Retrograde cystourethrogram