Rosen's 10th > Trauma > Flashcards

Trauma Flashcards

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1
Q

Indications of lower urinary tract trauma?

A

Gross hematuria
Scrotal hematoma
Perineal hematoma
High riding prostate on DRE

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2
Q

List 6 situations that make abdominal physical exam less reliable

A

Altered mental status
Head trauma
Intoxication (EtOH or drugs)
Developmental delay
Psychiatric illness
SCI

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3
Q

List 4 indications for emergent laparotomy in stab and GSW wounds

A
  • hemodynamic compromise
  • peritoneal signs
  • evisceration
  • left-sided diaphragmatic injury
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4
Q

What clinical feature determines the next best intervention in hemodynamically unstable patients with pelvic fractures?

A
  • Presence of active intraperitoneal hemorrhage

If YES on eFAST, CT or peritoneal aspiration –> go to OR for laparotomy

If NO –> get diagnostic and/or therapeutic angiography

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5
Q

List 3 abdominal organs likely to sustain injury with penetrating trauma

A

Stab:
Liver
Small Intestine

GSW:
Small intestine
Colon
Liver

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6
Q

List 3 most likely abdominal organs to sustain injury with blunt trauma

A

Spleen
Liver
Intestine

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7
Q

What anatomy defines the Low Chest?

A
  • Nipple line or 4th ICS anteriorly
  • Inferior scapular tip or 7th ICS posteriorly
  • Extends down to the inferior costal margins
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8
Q

What anatomy defines the Anterior Abdomen?

A

Anterior axillary lines from the costal margins to the groin creases

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9
Q

What anatomy defines the Flank?

A

Anterior and posterior axillary lines bilaterally from the inferior scapular tip to the iliac crest

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10
Q

What anatomy defines the Back?

A

Posterior axillary lines, beginning at the inferior scapular tip and extending down to the iliac crest

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11
Q

Describe simple physics of ballistic injuries

A

Magnitude of the injury is proportional to the amount of kinetic energy imparted by the bullet to the victim

Projectile velocities:
low (slower than 1100 ft/s)
medium (1100 to 2000 ft/s)
high (faster than 2000 to 2500 ft/s).

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12
Q

List 8 internal injuries associated with inappropriate seatbelt use or “seatbelt sign”

A
  • Rib fractures
  • Contusion of intestines
  • Perforation of intestines
  • Tear of mesentery
  • Hemoperitoneum
  • Jejunal injury
  • Diaphragm rupture
  • Abdo aortic dissection
  • Lumbar spine injuries
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13
Q

List 8 interventions/procedures that can cause iatrogenic abdominal trauma

A
  • CPR
  • Heimlich maneuver
  • chest tube insertion
  • peritoneal lavage
  • paracentesis
  • peritoneal dialysis
  • liver biopsy
  • GI tract endoscopy
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14
Q

What is the triad of injury with ped vs MVC?

A

Craniofacial
Torso
Lower leg

  • if 2/3 present, pay attn to see if there is 3rd
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15
Q

What are 4 ‘categories’ or mechanisms of motorcycle crashes?

A

frontal
lateral
angular ejection
“laying the bike down”

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16
Q

Acute hypotension resulting from hemorrhage in abdominal trauma is usually what 2 things?

A

Solid visceral organ injury
Vascular injury

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17
Q

2 clinical exam findings of retroperitoneal hemorrhage?

A

1) Ecchymotic discoloration of the flanks (Gray-Turner sign)
2) Ecchymotic discoloration of the umbilicus (Cullen sign)

*these findings can be delayed for 12 hours to several days

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18
Q

List 4 causes of abdominal distension in penetrating trauma

A
  • hemoperitoneum
  • pneumoperitoneum
  • gastric dilation
  • ileus secondary to peritoneal irritation
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19
Q

What are the 3 limitations of eFAST for trauma patients?

A

Limited visualization of:
- Solid parenchymal damage
- Retroperitoneum
- Diaphragmatic defects

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20
Q

When & Why do you place an NG for abdo trauma pt?

A

When:
- intubated
- massively distended abdomen
- high concern for stomach or duodenal injury

Why:
- decompress the abdomen
- decrease the likelihood of aspiration
- determine whether blood is present

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21
Q

When to place an OG over an NG for trauma pts?

A

Midface or Skull base fractures

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22
Q

What are the 3 big questions for Anterior Abdominal Stab Wounds, and walk thru the algorithm

A

1) Surgeon has clear reason to do emergent laparotomy?
2) Peritoneal entry?
3) Internal injury?

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23
Q

List Clinical Indications for Laparotomy Following Penetrating Trauma

A

Emergent Laparotomy Indicated:
- Hemodynamic instability
- Peritoneal signs
- Evisceration
- Lt-sided diaphragmatic injury

Laparotomy Requires Additional Clinical Evidence:
- GIB
- Knife in situ
- Intraperitoneal air

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24
Q

5 ways to assess if the peritoneum has been violated?

A
  • evisceration
  • intraperitoneal air
  • local wound exploration
  • U/S
  • laparoscopy & thoracoscopy
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25
What are the 2 most frequently missed injuries on CT scan?
- Hollow viscus injury - Occult diaphragmatic injury
26
What are the 3 big questions for Anterior Abdominal GSWs, and walk thru the algorithm
1) Surgeon has clear reason to do emergent laparotomy? 2) Peritoneal entry? 3) Internal injury?
27
List 5 Clinical Indications for Laparotomy After Blunt Trauma
Emergent Laparotomy Indicated: - Unstable w/ strongly suspected abdominal injury - Obvious peritonitis - Pneumoperitoneum - Evidence of diaphragmatic injury - Significant GIB
28
List 4 pitfalls of expectant approach in abdominal trauma
- closed head trauma/ altered mental status can make abdominal exam unreliable - delayed findings of hollow viscera injury - increased use of blood products - injuries may not be amenable to therapeutic angio and embolization
29
Work thru algorithm for Blunt Abdominal Trauma
30
Work thru algorithm for Pelvic Fractures & Blunt Abdominal Trauma
31
List 2 Indications for REBOA placement
- Life-threatening noncompressible hemorrhage unresponsive to resuscitation - Traumatic arrest in place of resuscitative thoracotomy
32
List 3 Complications of REBOA placement
- acute kidney injury - bowel ischemia - lower extremity ischemia
33
List 2 indications in abdominal trauma pts for therapeutic angioembolization
Unstable pts w/ Blunt trauma & Pelvic fractures Solid visceral organ hemorrhage
34
What is the goal of a primary survey?
To rapidly identify and initiate the treatment of critical, and life-threatening injuries
35
Outline indication for TXA in trauma pts, including dosing
- Indicated for patients with significant hemorrhage or shock - 1g IV bolus, then 1g IV infusion over 8h - Results best if given within 1 hr of injury, still benefit if within 3 hr
36
List 5 co-morbidities that can lead to 2x mortality risk in trauma pts age >65
Coagulopathy Cirrhosis COPD CAD DM
37
List 3 likely injuries seen in head-on collisions
- Facial injuries - LE injuries - Aortic injuries
38
List 3 likely injuries seen in rear end collisions
- C spine hyperextension injuries - C spine #s - Central cord syndrome
39
List 4 likely injuries seen in T-bone (lateral) collisions
- Thoracic injuries - Abdominal injuries (liver & spleen) - Pelvic injuries - Clavicle, Humerus, Rib #s
40
List 2 likely injuries seen in vehicle rollovers
- Crush injuries - Spinal compression #s *Risk of ejection, significant mechanism
41
List 1 likely injury seen in pts ejected from vehicles
Spinal injuries *Likely unrestrained, significant mortality
42
List 4 likely injuries seen in MVC trauma pts when there has been windshield damage
Closed head injuries (coup-countercoup) Facial #s Skull #s C-spine #s *Likely unrestrained
43
List 5 likely injuries seen in MVC trauma pts when there is steering wheel damage
Thoracic injuries Sternal + rib #s = Flail chest HTX + PTX Cardiac contusion Aortic injuries
44
List 3 likely injuries seen in MVC trauma pts w/ dashboard involvement or damage
- Pelvic injuries - Acetabular injuries - Hip dislocation
45
List 3 likely injuries seen in MVC trauma pts with PROPER 3-point seatbelt restraint
- Sternal #s - Rib #s - Pulmonary contusion
46
List 3 likely injuries seen in MVC trauma pts with LAP BELT only restraint
- Chance #s - Abdominal injuries - Head + Facial injuries/fractures
47
List 2 likely injuries seen in MVC trauma pts with SHOULDER BELT only restraint
- C spine injuries/fractures - 'Submarine' ejection out of restraint
48
List 3 likely injuries seen in MVC truama pts with airbag deployment
- UE soft tissue injuries - UE fractures - LE injuries/fractures
49
Airbag deployment causes more severe injuries in whom?
Children, improperly in the front seat
50
List 2 likely associated injuries seen in pedestrians hit at low speed/braking?
- Tib/Fib fractures - Knee injuries
51
List 3 likely associated injuries seen in pedestrians hit at high speed?
Waddel's Triad - Tib/Fib or Femur #s - Truncal injuries - Craniofacial injuries *Likely thrown and at risk for multisystem injuries
52
List 3 likely traumatic injuries seen in cyclists with handlebar injuries
- Spleen or Liver lacerations - Intra-abdominal injuries - May have penetrating injuries
53
List 6 likely associated injuries seen in pts falling with vertical impact?
- Closed head injuries - C spine #s - Spinal compression #s - Renal + renal vascular injuries - Pelvic #s - Calcaneal + LE #s
54
List 5 likely injuries seen in trauma pts falling with horizontal impact
- Craniofacial #s - Hand + Wrist #s - Thoracic injuries - Abdomional visceral injuries - Aortic injuries
55
List 4 ways that GSWs cause trauma to surrounding tissue
- Direct laceration - Crush injury - Shock waves - Cavitation (displacement of tissue forward + radially)
56
List 8 clinical exam findings which suggest traumatic injuries that may compromise pt's oxygenation + ventilation
Agitation Restlessness Somnolence Inc WOB Tachypnea Tracheal deviation Subcut emphysema Penetrating wounds Chest wall instability Flail segments Distended neck veins
57
List 6 clinical indicators of adequate perfusion
Normal mental status Skin colouring Temperature HR BP Cap refill
58
What are the 2 goals of a secondary survey?
(1) Obtain pertinent historical data about patient and injury (2) Identify and manage all significant injuries by performing a systematic, complete examination
59
List 4 examples of significant 'distracting' traumatic injuries
Traumatic amputations Gaping wounds Complex open fracture-dislocations Combative patient behaviour
60
What are 7 criteria for obtaining thoracic imaging in blunt trauma patients with otherwise very low risk of thoracic injury?
(1) age >60 yrs (2) rapid deceleration mechanism (3) chest pain (4) drug or alcohol intoxication (5) abnormal alertness and mental status (6) distracting painful injury (7) tenderness to chest wall palpation
61
List 6 American College of Surgeons Requirements for the Presence of a Surgeon in Major Resuscitations
Surgeon should be present in ER on trauma patient arrival or within 15 min if any of the following major criteria are found: - hTN = SBP <90 mmHg - GSW to the neck, chest, abdomen, pelvis or proximal extremities - Intubated patients transferred from the scene - Respiratory compromise requiring an emergent airway - GCS <8 attributed to trauma - At discretion of the emergency clinician
62
Outline arterial O2 concentration goal in brain trauma
PaO2 > 60mmHg
63
List 1 contraindication to permissive hypotension in trauma pts
Traumatic brain injuries
64
Rather than MAP, what is the clinically relevant endpoint in the resuscitation of a trauma patient?
*Restoration of adequate tissue perfusion = normal mentation OR = normalization of tissue oxygen saturation
65
What is the MAP goal for permissive hypotension, and what are 3 benefits?
MAP >50mmHg - Less blood product use - Less bleeding - Lower incidence of coagulopathy
66
What are the 4 'National Association of EMS Physicians' and 'ACS Committee on Trauma' guidelines for preventing transport of trauma pts NOT likely to benefit from ED thoracotomy?
- Blunt trauma w/out vital signs at scene - Apneic or Pulseless Penetrating trauma w/out other signs of life - >15mins pre-hospital CPR - Transport times >15mins after arrest
67
List 6 signs of life in trauma
- Pulse - Measurable BP - Respiratory effort - Cardiac rhythm - Echo cardiac activity or Tamponade - (Pupillary response)
68
Define: 1) Head Injury 2) Brain Injury
1) Clinically evident injury on physical examination ex) ecchymosis, lacerations, deformities 2) Injury to the brain itself
69
What component of the GCS is the strongest predictor of outcome following TBI?
Motor
70
List 2 medications that should be given to pts with penetrating brain trauma
1) Anti-epileptics - Phenytoin - Keppra 2) Broad spec ABX *for 7 days
71
Define mild traumatic brain injury?
- GCS 13 to 15 - with trauma-induced physiologic disruption of brain fnc * manifested as 1 or more of following: 1. Loss of consciousness < 30 min 2. Amnesia to events immediately before or after the accident (post-traumatic amnesia should last <24 h) 3. Any altered mental status at time of accident (dazed, disoriented, foggy, seeing stars or confused) 4. Focal neurologic deficit(s) that may or may not be transient (weakness, loss of balance, change in vision, sensory loss)
72
What are layers of the scalp?
- Skin - Connective tissue (subcutaneous) - Aponeurosis (galea) - Loose areolar connective tissue - Periosteum /Pericranium
73
List factors promoting cerebral vasoconstriction (3) & cerebral vasodilation (4)
Vasoconstriction: - HTN - alkalosis - hypocarbia Vasodilation: - hTN - acidosis - hypercarbia - hypoxia
74
List 3 factors that promote vasogenic brain edema
Brain injury with: - Inc cerebral blood flow - Vascular dilation - Disrupted BBB
75
What is normal ICP range?
5 - 15 mmHg
76
What is normal CPP range?
60 - 70 mmHg
77
What is equation for cerebral perfusion pressure (CPP)?
CPP = MAP - ICP
78
List 6 ways to lower ICP
HOB >30 Neutral neck position (remove tight C-collar) Mannitol Hypertonic saline EVD *Hyperventilation * may have harm, and only temporizing measure
79
What is the Cushing reflex?
HTN Bradycardia Irregular respiration
80
Outline 3 broad categories of TBI
Mild - GCS 13-15 Moderate - 9-12 Severe - <8
81
List 6 physiologic events that cause secondary insults to the brain after traumatic injury
- Inflammatory response activation - Electrolyte abnormalities - Increase in excitatory amino acids (glutamate) - Dysregulation of neurotransmitter synthesis & release - Imbalance in mitochondrial fnc & energy metabolism - Free radicals production
82
List 6 clinical factors associated with mortality in penetrating head trauma
Increasing age Suicide attempt Decreased GCS Bilateral mydriasis Dural penetration Bi-hemispheric & multi-lobar injury
83
List 4 clinically significant features of skull fractures
- intracranial air - overlying scalp laceration (open skull fracture) - depression below level of skull’s inner table - location over a major dural venous sinus or middle meningeal artery
84
List 4 examples each of extra-axial & intra-axial brain bleeds/injuries
Extra = within the skull but outside of the brain tissue - EDH - SDH - SAH - SDHG (subdural hygroma) Intra = within the brain tissue itself - TAI/DAI - cerebral contusions - cerebral hematomas - cerebellar contusions - cerebellar hematomas
85
Describe epidural hematoma
- btwn inner table of skull and dura *forceful direct-impact injury - usually temporoparietal region - blood assoc. w/ fracture occurs over middle meningeal artery/vein or dural sinus
86
Describe subdural hematoma
- btwn dura and brain * acceleration-deceleration injuries - common in those with brain atrophy (old or EtOH use), bridging veins at risk
87
Describe subarachnoid hemorrhage
- blood within CSF and meningeal intima
88
Describe subdural hygroma
- collection of clear, xanthochromic blood-tinged fluid in dural space - immed. after trauma or delayed
89
Outline 2 steps of how traumatic axonal injury (DAI) occurs
Primary insult = Axons torn, form axon retraction balls Secondary insult = disrupted extra-cell brain matrix + inflamm mediator influx --> Axon swelling & Axon death
90
What are the clinical grades of diffuse TAI?
Grade I (mild) = coma for 6 - 24 hrs Grade II (moderate) = coma >24 hrs but not decerebrate Grade III (severe) = coma >24 hrs + decerebrate or flaccid
91
List 5 systemic conditions that worsen outcome after TBI
Hyperpyrexia (>38.5) Hypoxia (PaO2 < 60) Hypotension (SBP < 90) Anemia (HCT <30%) Hypo + Hypercarbia
92
List 12 Clinical Characteristics of Basilar Skull Fractures
- Blood in ear canal - Hemotympanum - Rhinorrhea - Otorrhea - Battle’s sign (retroauricular hematoma) - Raccoon sign (periorbital ecchymosis) - Cranial nerve deficits - Facial paralysis - Decreased auditory acuity - Dizziness - Tinnitus - Nystagmus
93
List out the GCS score
94
Differentiate decorticate & decerebrate posturing
Decorticate = injury above midbrain - abnormal flexion of arm, elbow, wrist - arm adducts - LE extends and IR, plantar flex Decerebrate = midbrain lesion - abnormal extension or arm - flexion of wrist, fingers - arm IR, adducts - neck extends, teeth clenched - LE extends and IR, plantar flexed
95
List 6 ways to assess integrity of the brainstem
- Respiratory pattern - Pupil size - Oculocephalic response (dolls eye) - Oculovestibular response (cold water) - Pupil response - Corneal reflex - Gag reflex +/- Facial symmetry if grimaces
96
Outline 4 components of Rotterdam Score of initial non-con CT brain for predicting 6mo mortality after TBI
1 ≤ 0% 2 ≤ 7% 3 ≤ 16% 4 ≤ 26% 5 ≤ 53% 6 ≤ 61% --> Basal cistern effacement 0 = none 1 = compressed 2 = absent --> Midline shift 0 = none or <5 mm 1 = >5 mm --> EDH 0 = present 1 = absent --> IVH or SAH 0 = both absent 1 = either present *Add 1 to every score
97
Describe appearance of SDGHs on CT
- Crescent shaped in extra-axial space - density is same as CSF - Bilateral SDHGs are common
98
What is the SBP goal for pts with head trauma?
SBP > 110 or SBP >100 if age 50-69yrs
99
List and give dosing for 2 different hyperosmolar therapies in adults
Mannitol 0.25-1g/kg IV q6h 23.4% Saline 30-60ml IV q6h or 3% Saline 250ml IV
100
List complications of mannitol and hypertonic saline use
Mannitol - renal failure - hTN - paradoxical increased bleeding HTS - renal failure - central pontine myelinolysis - rebound ICP elevation
101
List 3 ways to reverse vitamin K antagonists?
IV Vitamin K FFP PCC
102
List 4 ways to reverse dagbigatran
Idarucizumab = 2.5g IV bolus over 5-10 mins + additional 2.5g given within 15 mins of first dose PCC FFP Hemodialysis
103
List 3 ways to reverse Factor Xa (DOACs) inhibitors
Andexanet alfa PCC FFP
104
Define 3 different acute seizures as a result of TBIs
Early Post-traumatic seizure = w/in 7days of injury Late PTS = more than 7 days after injury Post-traumatic epilepsy is recurrent seizures more than 7 days following injury
105
List empiric ABX for penetrating craniocerebral trauma or open skull fractures
CTX 2g q12h + Vancomycin 1g q12h Cefepime 2g IV q8h (for Pseudo) Ampicillin 2g IV q4h (for Listeria) Gentamycin 80mg q8h (large open #) Metronidazole 500mg q6h
106
List 4 ways to close scalp lacerations
Sutures Staples Tissue glue Hair apposition technique
107
What is the disposition for patients with linear skull fractures?
No underlying brain injury = ED observation 4-6 hours, then d/c home Any suspicion or clinical evidence of brain injury, should be admitted for observation + have NeuroSx consult
108
Patients with open cranial fractures depressed greater than the thickness of the cranium may be treated nonoperatively if: (8)
- NO clinical or radiographic evidence of dural penetration - NO significant ICH - NO depression >1cm - NO frontal sinus involvement - NO gross cosmetic deformity - NO wound infection - NO pneumocephalus - NO gross wound contamination
109
List 4 indications for urgent surgical evacuation of EDH?
- EDHs >30cm ^3 area - Clot thickness >15mm - Midline shift >5mm - Comatose + Anisocoria
110
List 5 indications for surgical evacuation of acute SDH?
- Thickness >10 mm - Midline shift >5mm - Worsening GCS score (-2 points or more from time of injury to hospital admission) - Asymmetric or fixed + dilated pupils - Persistent elevated ICP
111
When can post-traumatic vasospasm occur in traumatic SAH?
- occurs approx 48hrs after injury - can persist for 2 weeks
112
List 10 risk factors for EARLY post-traumatic seizures
Age <65yr Chronic AUD GCS <10 Immediate seizures Posttraumatic amnesia >30min Linear or depressed skull fracture Penetrating head injury SDH EDH ICH Cortical contusion
113
List 6 risk factors for post-traumatic EPILEPSY
Age >65 Hx of MDD Severe TBI Acute ICH or contusion Temporal lobe bleeds Posttraumatic amnesia >24h Early PTS prior to d/c
114
List 8 medical systemic complications that can occur after TBI
DIC VTE Neurogenic Pulmonary Edema Acute lung injury Cardiac dysrhythmias: - SVT - upright T or TWI - prolonged QT - STD or STE - U waves
115
Outline 2 clinical features associated w/ mild TBI (aka concussion)
(1) Pt sustained blunt force mechanism or whiplash type acceleration-deceleration event (2) At any point after injury, any AMS, disorientation, confusion, amnesia, or disordered awareness, +/- LoC *symptoms can resolve by time they get to ED
116
Outline 4 general symptom categories in concussion / mild TBI
Somatic symptoms: - HA, dizziness, diminished balance, vertigo, tinnitus, photo- & phonophobia, N/V Cognitive symptoms: - impaired memory or concentration, delayed language comprehension, slowed or repetitive speech. Emotional disturbances: - irritability, sadness, anxiety, depression. Sleep-related disturbances: - spectrum btwn insomnia & fatigue.
117
List High and Medium risk features of the CDN CT Head Rule
High Risk = May Require Neurologic Intervention 1. GCS score <15 at 2h after injury 2. Suspected open or depressed skull fracture 3. Any sign of basal skull fracture 4. Vomiting >2 episodes 5. Age >65yr Medium Risk = May Have Important Brain Injury on CT 6. Amnesia before impact >30min 7. Dangerous mechanism (ped vs MVC, occupant ejected from vehicle, fall >3ft [5 stairs])
118
List 8 NEXUS II Criteria for CT Head
Adults AND Children require CT if ANY of following are present: 1. Evidence of significant skull fracture 2. Scalp hematoma 3. Neurologic deficit 4. Altered level of alertness 5. Abnormal behaviour 6. Coagulopathy 7. Persistent vomiting 8. Age >65 years
119
List 7 types of head & neck trauma associated with vascular injuries
- Penetrating trauma - High impact blunt injury - Skull base fractures - Blunt neck trauma - C-spine fractures - C-spine facet subluxation/dislocation - Fracture lines approaching artery
120
List 8 complicating factors for recovery from mTBI / concussion
- Psychiatric concerns - SUD - Health problems - Concurrent orthopedic or traumatic injuries - Chronic pain - Lack of family & social support - Unemployment - Litigation
121
Compare timing of traumatic intracranial hemorrhage in pts taking anti-coagulation vs anti-platelets?
Antiplatelets = more likely IMMEDIATE bleeding Anticoagulation = more likely to have delayed bleeding
122
Define zones of the neck
Zone 1 = sternal notch to cricoid cartilage Zone 2 = cricoid cartilage to angle of mandible Zone 3 = angle of mandible to skull base
123
List 3 complications of mild TBI / concussion
- Post-concussive Syndrome - Seizures - Post-traumatic Transient Cortical Blindness
124
Define Anterior & Posterior triangles of neck
Anterior = midline, SCM, mandible lower edge Posterior = SCM, Trap, clavicle
125
List 4 ways that blunt trauma can occur to carotid arteries
- Hyperextension-rotation mechanisms - Hyperflexion - Direct blow to vessel intraorally or externally - Damage to carotid canal of temporal bone
126
List 3 ways that blunt trauma can occur to vertebral arteries
- Damage to transverse foramina - C1-C3 Fractures or Facet Dislocations - Stretch + Compression around Atlanto-Axial & Atlanto-Occipital joints
127
List 4 possible vascular injuries 2/2 penetrating neck trauma
Partial or Complete vascular transection Puncture wounds AV fistula Pseudoaneurysm
128
List 3 possible vascular injuries 2/2 blunt neck trauma
Vascular occlusion Dissection Intimal flaps
129
List 6 Hard & 3 Soft signs of Vascular Injury in Penetrating Neck Trauma
HARD: 1) Severe, uncontrolled hemorrhage 2) Refractory shock/hypotension 3) Large or expanding or pulsatile hematoma 4) Unilateral pulse deficit 5) Bruit or thrill (new or age <40) 6) Neurologic deficit consistent with stroke SOFT: 1) Minor bleeding 2) Small, non-expanding hematoma 3) Proximity wound
130
List 5 Hard & 5 Soft signs of Aerodigestive Injury in Penetrating Neck Trauma
HARD: - Airway compromise/distress - Air bubbling through wound - Extensive subcutaneous emphysema - Stridor - Hoarse voice SOFT: - Mild hemoptysis - Mild hematemesis - Dysphonia - Dysphagia - Odynophagia - Mild subcutaneous emphysema
131
List 11 presenting signs of BCVI
- Arterial hemorrhage of neck, nose, or mouth - Cervical bruit, especially age <50 - Expanding cervical hematoma - Neuro deficits not consistent w/ CT exam - Focal neuro deficit - Stroke on initial CT or MRI - Ipsilateral HA - Neck pain - Pulsatile tinnitus - Transient blindness - Partial Horner syndrome
132
List the 11 expanded Denver Criteria for BCVI
- LeFort 2 or 3 - Complex skull fracture/basilar skull fracture/occipital condyle fracture - Severe TBI (GCS <6) - C-spine fracture, subluxation or ligamentous injury at any level - Near hanging with anoxic brain injury - Seat belt abrasion w/ significant swelling, pain, or altered mental status - TBI w/ thoracic injury - Scalp degloving - Thoracic vascular injury - Blunt cardiac rupture - Upper rib fracture (ribs 1–6)
133
List 10 associated s/s of LaryngoTracheal injuries in Blunt Trauma
- subcut emphysema - air escape - external bleeding or bruising - dyspnea - hypopnea - stridor - cough - hoarseness - dysphonia - dysphagia - hemoptysis - tracheal deviation - cyanosis - nerve injury
134
List 6 clinical features of BCVI
- Arterial hemorrhage from neck, nose, or mouth - Cervical bruit (Age <50) - Expanding cervical hematoma - Focal neuro deficit: TIA, Horner syndrome, vertebrobasilar symptoms, hemiparesis - Stroke findings at CT or MRI - Neurologic deficit inconsistent w/ head CT findings
135
List 5 sequelae of hanging injuries
Hypoxic-ischemic brain injury Neurogenic pulmonary edema w/ massive sympathetic discharge Negative intrapleural pressure generated pulm edema (forceful inspiratory effort against extrathoracic obstruction) Cardiogenic pulmonary edema Hanging-associated Takotsubo cardiomyopathy
136
What used to be GOLD STANDARD for dx'ing neck vascular injuries?
DSA = digital subtraction angiography - can be positive even if negative CTA
137
List 5 long term complications of penetrating laryngotracheal trauma
Vocal cord dysfunction Voice changes Laryngeal or Tracheal Stenosis Chronic aspiration Tracheoesophageal fistulas
138
Outline Biffl Scale Grading & Treatment of BCVI
GRADE 1 = Intimal injury or irregular intima > AC or APT (endovascular repair if not candidate) GRADE 2 = Dissection with an intimal flap causing luminal narrowing of less than 25% > Endovascular repair if symptoms; o/w APT or AC GRADE 3 = Pseudoaneurysm formation > Endovascular repair if symptoms; o/w APT or AC GRADE 4 = Vessel occlusion or thrombosis > Difficult to manage, injured vessel often thromboses + cannot be recanalized. Endovascular repair if sx; o/w APT or AC GRADE 5 = Vessel transection > Lethal if left untreated; Immediate endovascular intervention or surgical repair
139
Describe medical mgmt of BCVI?
* Antithrombotic therapy is indicated in grade 1-4 injuries AC = heparin 10u/kg/hr IV infusion PTT 40-50s APT = ASA 75-325 mg/day (3-5mg/kg in kids) - Repeat CTA at 7 days - 3-6 months duration of therapy
140
What ppx ABX should be given for traumatic esophageal injuries?
PipTazo IV or High dose Fluconazle IV
141
List 6 traumatic injuries of the larynx that require surgical repair
Disruption of anterior commissure Major endolaryngeal lacerations Vocal cord tear Immobile vocal cord Cartilage exposure Displaced cartilage fractures
142
Outline conservative mgmt for largynotracheal mucosal injuries
*Must be mucosal lacerations < 2-3 cm length Humidified air Elevate HOB Vocal rest Clear diet Analgesia ABX Steroids PPI
143
What is dx test of choice for blunt aortic trauma?
CTA CHEST * even if normal CXR
144
List 10 complications of rib fractures
- PTX - HTX - Pneumomediastinum - Cardiac contusion - Pulmonary contusions - Atelectasis - PNA - Empyema - Diaphragm injury - Liver laceration - Spleen laceration - Pneumoperitoneum - Aortic injury - Post-traumatic neuroma - Non-union - Costochondral separation
145
Define flail chest
1) 3+ adjacent ribs fractured at 2 points - free segment of chest wall moves in paradoxical motion - flail segment moving inward w/ inspiration, outward w/ expiration 2) Costochondral separation w/ rib #s 3) Vertical sternal fracture w/ rib #s
146
Outline the 7 NEXUS-Chest CT Criteria after Blunt Trauma
NO CT is NONE of criteria present: - Abnormal CXR - Rapid deceleration mechanism (fall >20 feet or MVC >40 mph) - Distracting painful injury - Chest wall tenderness - Sternal tenderness - Thoracic spine tenderness - Scapular tenderness Good sensitivity BAD specificity
147
List 3 types of PTX
Simple Communicating Tension
148
Define simple PTX
No communication with atmosphere + No shift of mediastinum or hemi-diaphragm resulting from accumulation of air
149
Define communicating PTX
Defect in chest wall "Sucking chest wound" = loss of chest wall integrity causes involved lung to paradoxically collapse on inspiration and expand slightly on expiration, forcing air in and out of wound
150
Define tension PTX
progressive accumulation of air under pressure within pleural cavity, with shift of mediastinum to opposite hemithorax and compression of contralateral lung and great vessels
151
List 5 cardinal signs of tension PTX
- tachycardia - hypotension - oxyhemoglobin desaturation - jugular venous distention (JVD) - absent breath sounds
152
List 10 indications for Chest Tube insertion in PTX
Traumatic cause (except asymptomatic, apical PTX) Moderate to large PTX Respiratory symptoms regardless of size of PTX Increasing size of PTX after initial conservative therapy Recurrence of PTX after removal of an initial chest tube Patient requires ventilator support Patient requires general anesthesia Associated hemothorax Bilateral PTX regardless of size Tension PTX
153
List 8 serious complications of tube thoracostomy in trauma?
- Formation of HTX - Pulmonary edema - Bronchopleural fistula - Pleural leaks - Empyema - Subcutaneous emphysema - Infxn - Intercostal artery laceration - Contralateral PTX - Parenchymal injury
154
List 3 ABX options to be given w/ chest tube insertion to prevent PNA or empyema
Ancef 1-2g IV (w/in 1 hour of insertion) or Vancomycin 1g IV or Clindamycin 600mg IV
155
In needle thoracostomies - where can you place a needle and with what equipment?
Large bore 14g or larger catheter, at least 5cm in length Anterior 2 or 3 ICS Lateral 4 or 5 ICS
156
How much fluid is required to blunt the costophrenic angles on upright CXR?
at least 200-300cc
157
List 5 Indications for Urgent Thoracotomy in Trauma
Initial chest tube drainage >20 mL blood/kg ~ 1.5L Persistent bleeding >7 mL/kg/hr ~ 200ml/hr Increasing HTX on CXR Pt remains hypotensive despite adequate blood replacement + other sites of blood loss ruled out Pt decompensates after initial response to resuscitation
158
List 2 types of tracheobronchial disruption + 6 radiographic signs of TB disruption
1) Wound open to pleural space = large PTX 2) Complete transection of TB tree w/out pleural space communication = initially open airway, but delayed luminal obstruction from granulation tissue Radiographic Signs: - PTX - Pneumomediastinum - Extensive subcut emphysema - Fracture ribs 1-5 - Air surrounding bronchus - Obstruction in course of air-filled bronchus
159
List 10 'fatal' complications of blunt myocardial injury
Dysrhythmias Conduction abnormalities Cardiac rupture Valvular rupture CHF Cardiogenic shock Pericardial tamponade Constrictive pericarditis Intraventricular thrombi Thromboembolic phenomena Coronary artery occlusion Ventricular aneurysms
160
Outline spectrum of blunt cardiac trauma
- myocardial concussion - myocardial contusion - myocardial infarction - myocardial rupture
161
Describe Commotio Cordis (myocardial concussion)
- produced by a sharp, direct blow to the midanterior chest - stuns the myocardium and results in brief dysrhythmia, hypotension, and loss of consciousness
162
List 5 mechanisms of myocardial rupture
(1) Deceleration Shearing stresses on “fixed” attachment of SVC+IVC on RA (2) Sudden increase in intracardiac pressure 2/2 upward displacement of blood & abdominal viscera from blunt abdominal injury (3) Direct Compression of heart btwn sternum + VBs (4) Laceration from fractured rib or sternum (5) Complications of myocardial contusion, necrosis, and subsequent cardiac rupture
163
What is the harsh murmur heard in cardiac rupture?
"bruit de moulin" = described as sounding like a “splashing mill wheel.” - caused by pneumopericardium
164
List "Rosens" 4 Indications for ED Thoracotomy
Penetrating Trauma: - Cardiac arrest at any point w/ initial SoL in field - SBP <50 mmHg after fluid resuscitation - Severe shock w/ clinical signs of tamponade Blunt Trauma: - Cardiac arrest in ED
165
Describe Beck's triad
Findings of pericardial tamponade - hTN - JVD - muffled heart sounds
166
Define pulsus paradoxus
Excessive drop in systolic blood pressure during the inspiratory phase of the normal respiratory cycle
167
Describe EAST guidelines for ED thoracotomy
168
Describe 6 WEST guidelines for ED thoracotomy
169
What are the 2 most common sites of blunt aortic injury?
1. Aortic isthmus 2. Ascending aorta just proximal to origin of brachiocephalic vessels
170
List 7 clinical signs of aortic rupture
- HTN - Harsh systolic murmur - Swelling at base of neck - Pulsatile neck mass - LE pulse deficit - LE paralysis - Initial chest tube output >750cc (esp if Lt sided HTX)
171
List 8 traumatic injuries that cause a wide mediastinum on CXR
- Aortic rupture - Bleeding from clavicle # - Bleeding from sternal # - Bleeding from T spine # - Pulmonary contusions - Previous mediastinal mass - Misplaced CVP catheter - Magnification by AP & supine XRs
172
Which diagnostic imaging is gold standard for blunt aortic injury?
Chest CTA
173
What defines "Minimal Aortic Injury"?
- Intimal flap <1cm - None-minimal periaortic mediastinal hematoma
174
List 4 common areas of esophageal perforations/ruptures
Areas of anatomic narrowing 1. Cricopharyngeal muscle near esophageal introitus 2. Crossing @ Lt mainstem bronchus 3. Crossing @ Aortic Arch 4. GE jnc
175
List 6 Common Causes of Esophageal Perforation
- Iatrogenic - Foreign bodies - Caustic burns - Blunt or Penetrating trauma - Spontaneous rupture (post emetic or Boerhaave syndrome) - Postoperative breakdown of anastomosis
176
List 9 Clinical Conditions That May Mimic Esophageal Perforation
Spontaneous Pneumomediastinum Aortic Dissection PE PNA PTX MI Perforated PUD Cholecystitis Pancreatitis Mesenteric thrombosis
177
List 6 XR findings in esophageal perforation
- Pneumomediastinum - Subcut emphysema - Lt pleural effusion - PTX - Wide mediastinum - Air/fluid in retropharyngeal space (lat XR)
178
List 4 CT findings in esophageal perforation (that would not be on CXR)
- Extraluminal air - Periesophageal fluid - Esophageal thickening - Extraluminal contrast
179
Outline 3 columns of Denis spine classification
Anterior Column: - Anterior longitudinal ligament - Anterior 2/3 VB + disk Middle Column: - Posterior 1/3 VB + disk - Posterior vertebral wall - Posterior longitudinal ligament Posterior Column: - Spinal cord - Laminae + pedicles, articulating facets, spinous & transverse processes - Interspinous & Supraspinous ligaments, ligamentum flavum Injury to the MIDDLE COLUMN is inherently unstable
180
List 6 STABLE FLEXION spinal injuries
- Wedge fracture - Clay shoveler's - Subluxation - Transverse process fracture - Chance fracture (when posterior) - Unilateral facet dislocation
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List 7 UNSTABLE FLEXION spinal injuries
- Flexion teardrop - Bilateral facet dislocation - Atlanto-Occipital dislocation - Anterior Atlanto-Axial dislocation +/- fracture - Rotary Atlanto-Axial dislocation - Odontoid fracture w/ lateral displacement - Flexion-distraction injury
182
Outline 3 types of odontoid fracture
Type I: Tip avulsion Type II: Fracture through base of odontoid Type III: Through odontoid, extends into lateral masses *Can extend laterally into articular facet
183
List 1 STABLE EXTENSION spine fracture
Extension teardrop fracture
184
List 3 UNSTABLE EXTENSION spine fractures
- Posterior neural arch fracture (C1) - Hangman's (C2) - Posterior Atlanto-Axial dislocation +/- fracture
185
List 2 STABLE VERTICAL compression spine fractures
- VB burst fracture - Isolated fractures of articular pillar & VB
186
List 1 UNSTABLE VERTICAL compression spine fracture
Jefferson fracture (C1)
187
What measurement is suggestive of atlantoaxial joint dislocation?
The basion-axial interval (BAI) and basion-dens interval (BDI) are normally <12 mm. >12mm SUGGESTS DISLOCATION
188
List 3 'mechanism' types of primary spinal cord injury
1. Transection of neural elements 2. Compression of spinal cord 3. Primary vascular damage
189
Outline the Quebec Task Force Classification of Whiplash-Associated Disorders (WADs)?
0 = Whiplash injury but no pain + no s/s 1 = Delayed neck pain, minor stiffness, nonfocal tenderness only, no physical signs 2 = Early onset of neck pain, focal neck tenderness, spasm, stiffness, radiating symptoms 3 = Early onset of neck pain, focal neck tenderness, spasm, stiffness, radiating symptoms, + signs of neurologic deficit 4 = Neck complaint (Gr 2 or 3) + fracture dislocation
190
What does presence or absence of deep tendon reflexes help as localizing diagnostic aid?
Upper Motor Neuron (Spinal Cord) Lesion: - muscle paralysis with INTACT deep tendon reflexes Lower Motor Neuron (Nerve Root or Cauda Equina) Lesion: - paralysis with ABSENT deep tendon reflexes
191
List the Level of Lesion + Resulting Loss of Reflex for C6/C7/L4/S1
C6 Biceps C7 Triceps L4 Patellar S1 Achilles
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List the Level of Lesion + Resulting Level of Loss of Sensation
C2 Occiput C3 Thyroid cartilage C4 Suprasternal notch C5 Below clavicle C6 Thumb C7 Index finger C8 Small finger T4 Nipple line T10 Umbilicus L1 Femoral pulse L2–L3 Medial aspect of thigh L4 Knee L5 Lateral aspect of calf S1 Lateral aspect of foot S2–S4 Perianal region
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What 2 findings EXCLUDE a complete cord syndrome?
1. Sacral Sparing - perianal sensation - preserved rectal sphincter tone - flexor toe movement 2. Spinal Shock = concussive injury to the spinal cord - END of spinal shock = RETURN of bulbocavernosus reflex
194
List 3 Incomplete Spinal Cord Lesions
- Central cord syndrome - Brown-Séquard syndrome - Anterior cord syndrome
195
Describe Central Cord Syndrome
= Hyperextension buckles ligamentum flavum, concussion of central cord - Spinothalamic + Pyramidal tracts affected - Bilateral UE > LE weakness - LOSS of pain + temperature sense
196
Describe Brown-Séquard Syndrome
= Hemisection of cord usually from penetrating injury - Ipsilateral loss of motor, position, + vibration - Contralateral loss of pain + temperature
197
Describe Anterior Cord Syndrome
= Hyperflexion causing cord contusion from bone fragment or herniated disk, or anterior spinal artery injury - Motor paralysis and hypoalgesia below level of injury - Intact position, light touch, + vibration
198
Describe traumatic Posterior Inferior Cerebellar Artery Syndrome
= Extreme Hyperextension causes vertebral artery injury -> ischemia to lateral medulla - Dysphagia + dysphonia from ipsilateral paralysis of pharynx + larynx - hiccups - N/V - vertigo - cerebellar ataxia - Contralateral loss of pain + temperature
199
List the 5 NEXUS Low Risk Criteria for C-Spine Imaging
- No midline spinal tenderness present - No focal neurologic deficit present - Normal alertness - No intoxication present - No painful distracting injury
200
What 3 questions make up the Canadian C-Spine Rule?
1. Are there any high-risk factors that mandate radiography? 2. Are there any low-risk factors that allow safe assessment of range of motion? 3. Is the patient able to rotate his or her neck actively 45 degrees to the left and to the right? = patients with no high-risk factors, any low-risk factor, and the ability to rotate the neck do not require radiographic evaluation
201
Outline the Canadian C-Spine Rule
1) High Risk Mandating Radiography - Age > 65 - Sensory deficit in extremities - Dangerous mechanism of injury: * Fall from ≥ 1 meter or five stairs * Axial load * MVA ≥ 100 km/hr, rollover or ejection * MVC involving recreational vehicle * Bicycle collision 2) Low Risk Factors Allowing for Range of Motion Assessment: - Simple rear-end MVC - Sitting position in ED - Ambulatory at scene - Delayed onset of neck pain - Absence of midline cervical spine tenderness - Able to rotate neck 45 degrees to L+R
202
List the 3 continuous spinal lines
- Anterior vertebral body margins - Posterior vertebral body margins - Spinolaminal line: spinous process bases
203
What is the normal Predental Space in adults + children, and what might abnormality suggest?
= distance btwn anterior odontoid and posterior aspect of anterior C1 ring ≤3mm in adults ≤5mm in children Widening of predental space may indicate Jefferson fracture of C1
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What are the normal measurements for retropharyngeal spaces?
= measured from anterior vertebral body to airspace C2: ≤6 mm in all C3–C4: ≤5 mm, or < half width of VB C6: ≤22 mm in adults, ≤14 mm in age <15
205
What are s/s of Spinal Shock?
- flaccid paralysis - loss of sensation - loss of deep tendon reflexes - bradycardia - hypotension - hypothermia - urinary retention - intestinal ileus
206
List 6 Prognostic Indicators of Poor Functional Recovery Following Whiplash-Associated Disorders
- Initial pain levels > 5.5/10 - Initial disability levels: NDI > 29% - Symptoms of posttraumatic stress - Negative expectations of recovery - High pain catastrophizing - Cold hyperalgesia
207
Outline 4 major types of TL injuries in Denis spine classification
1) Compression > Anterior flexion + Axial load - Anterior column VB fractures - Middle intact 2) Burst > Axial compression - Anterior + Middle compressed +/- Posterior 3) Flexion-Distraction > Flexion of middle & posterior columns w/ Distraction posteriorly - All 3 columns involved 4) Fracture-Dislocation > Variable mechanisms: shear, rotation, compression, and tension - All 3 columns involved
208
What is SBP goal for aortic injury? 2 medications for mgmt?
SBP 100-120 - Esmolol 0.5mg/kg IV bolus over 1 min, then 0.05mg/kg/min - Hydralazine
209
List 8 indications for imaging after pt has been strangled
- Facial petechiae - LoC - Incontinence of bladder or bowel - CVA like symptoms - dysphonia - dyspnea - dysphagia - subconjunctival hemorrhage
210
List 5 sequelae of Intimate Partner Violence
- chronic pain - mental health issues (depression, PTSD, substance abuse) - STIs - unintended pregnancy - worsening of medical illnesses
211
Outline 4 steps in caring for pts affected by IPV
1. Identification (asking the patient) 2. Treatment (supporting messages and medical issues) 3. Documentation (regarding violent actions and threats) 4. Referral (community, social services, legal)
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Outline 5 questions in a "Danger Assessment" in regards to IPV
1. Has the physical violence increased in frequency or severity over the past 6 months? 2. Have they ever used a weapon or threatened you with a weapon? 3. Do you believe they are capable of killing you? 4. Have you ever been beaten by them while you were pregnant? 5. Are they violently and constantly jealous of you?
213
List 8 psychosocial complications of facial trauma
Unemployment Drug abuse EtOH abuse Incarceration Relationships difficulties Anxiety Depression PTSD Poor self esteem
214
Outline LeFort classification for midface fractures
*All types involve pterygoid plate - Injuries can be U/L, B/L or both Type I = horizontal fracture - transverse fracture through maxilla above roots of teeth - maxilla may be mobile when gripping upper teeth Type II = pyramidal fracture - fractures of nasal bridge, maxilla, lacrimal bones, orbital floor, and rim Type III = craniofacial dysjunction - fractures thru nasal bones, medial, inferior & lateral walls of orbit, and zygomatic arches
215
Outline 5 bony borders of the orbit
Frontal bone - superior, majority Zygoma - lateral Maxilla - inferior Lacrimal & Ethmoid - medial
216
What special test has a 95% NPV for mandibular fracture?
Patient's ability to crack a wooden tongue blade by biting on both sides of mouth = highly unlikely to have mand #s
217
Which kind of mouth lacerations should be given ppx ABX tx?
Significant through and through lacerations of the mouth have decreased risk of infections w/ penicillins
218
Which kind of ear lacerations should be given ppx ABX tx?
Cartilage of pinna requiring repair - give ABX ppx covering typical skin flora + Pseudomonas
219
List 2 facial hematomas that require aspiration/drainage
Nasal septal hematoma Ear cartilage hematoma = Cauliflower ear
220
List 4 features of lacerations near/involving the eye that require a specialist to repair them
Deep structures involved Loss of tissue Lid margin involved Lacrimal duct
221
List 3 types of nose/nasal injuries that should be given ppx ABX
Broad spectrum ABX for: - any sinus involvement - violation of maxillary bone - violation of floor of orbit
222
Outline bones involved in tripod (trimalar) fractures of the face
Lateral orbit Zygoma Maxilla
223
Describe this finding
Halo sign = double ring of blood then CSF Concern for CSF leak in facial trauma, when seeing rhinorrhea or otorrhea
224
A trauma patient has avulsed/missing teeth. What investigation do they need, and what mgmt afterwards?
CXR to look for teeth - if below diaphragm, no retrieval - if in bronchus or esophagus, need retrieval (bronch or EGD)
225
List 4 indications for Panorex XRs in trauma
1st episode TMJ dislocation Isolated mandibular fractures Dental fractures Alveolar ridge fractures
226
What 4 injuries can be seen w/ ocular U/S?
Lens dislocation Vitreous hemorrhage Retinal detachment Globe rupture
227
List 1st and 2nd most common facial fractures in trauma
1. Nasal bone 2. Mandible
228
List 4 presenting clinical features of frontal bone injury
1. Significant traumatic mechanism 2. AMS 3. Tenderness & edema over frontal bone 4. CSF rhinorrhea
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List 3 presenting clinical features of orbital (bone) injury
1. Ocular deformity (exophthalmos) 2. Limited ocular movements 3. Visual symptoms
230
List 3 presenting clinical features of nasal (bone) injury
1. Deformity 2. Swelling & tenderness 3. Epistaxis
231
List 5 presenting clinical features of mandibular injury
1. Trismus 2. Bleeding 3. Ecchymosis 4. Fractured or loose teeth, abnormal bite 5. Paresthesia
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List 5 presenting clinical features of midface injury
1. Tenderness 2. Deformity 3. Bleeding 4. Malocclusion of teeth 5. Paresthesias
232
List 3 clinical indications for Retrograde Urethrography (RUG)
Pelvic fractures & Hematuria Perineal ecchymosis or swelling Urethral meatus blood *need imaging prior to any bladder catheterization
233
List 5 reasons renal traumatic injuries more common in peds than adults
More mobile Relatively larger Less perinephric adipose tissue Weaker abdo muscles Less rigid chest wall
234
Outline grading scale for classification of renal trauma
II-V = High grade GRADE I - Contusion w/ microscopic or gross hematuria - Nonexpanding subcapsular hematoma - No parenchymal injury GRADE II - Nonexpanding perirenal hematoma, confined to retroperitoneum - Parenchymal laceration <1cm into cortex - No urinary extravasation GRADE III - Parenchymal laceration >1cm into cortex - No collecting system rupture or urinary extravasation GRADE IV - Parenchymal laceration extending through cortex, medulla, collecting system - Main renal artery or vein injury w/ contained hemorrhage GRADE V - Completely shattered kidney OR - Avulsion of renal hilum, devascularization
235
Outline intraperitoneal vs extraperitoneal bladder ruptures
Intraperitoneal - usually from rupture of distended bladder at weakest point = dome - urine into peritoneal cavity Extraperitoneal - direct compression, shear force, pelvic fractures - urine into pelvic cavity 10% injuries have both
236
List 9 possible trauma injuries of testicles
Testicular rupture Scrotal hematoma Hematocele Spermatic cord injuries Testicular contusions Testicular fractures Testicular dislocations Traumatic testicular torsion Traumatic epidydymitis
237
List 6 indications for renal imaging in trauma
- Gross hematuria - Hemodynamic instability SBP <90 - Lower rib fractures - Significant flank ecchymosis - Evidence of intraperitoneal injury - Specific mechanisms like rapid decelerations, significant blow to flank, or penetrating injuries
238
Name gold standard imaging for evaluating renal injury
Multidetector CT w/ IV contrast In BOTH peds + adults
239
List 6 clinical features in blunt renal trauma that predict need for surgical intervention
- Grade V injuries - Deceleration mechanisms - Persistent hemorrhage - Fevers - Multiple comorbid injuries - Initial angioembolization
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List 5 early complications of renal trauma
Persistent bleeding Infection - UTIs - Perinephric abscesses - Uroepsis Persistent urinary extravasation Persistent urinoma Transient HTN
241
List 4 long term complications of renal trauma
CKD HTN Urinary fistulae AVMs
242
List 4 injuries associated w/ ureteral trauma
Lumbar transverse process fractures Pelvic fractures Bowel injuries Vascular damage - commonly iliac vessels given proximity to ureters
243
List 4 complications of (missed) ureteral injuries
Urosepsis (from urine extravasation) Hydronephrosis (from obstruction) Urinary fistula Strictures
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Name best imaging for dx'ing ureteral injury
CT urogram with IV contrast - reqs 10min delay from injection of contrast dye
245
List 5 CT findings of ureteral injury
Contrast extravasation Delayed pyelogram Hydronephrosis Low-density retroperitoneal fluid (b/c urinary extravasation) Lack of contrast distal to ureteral injury
246
List 8 clinical features of bladder trauma
Hematuria (usually gross) Abdo tenderness Abdo distension Blood at urethral meatus Inability to void Ecchymosis Entrance & Exit wounds in the perineum, thigh, or abdomen High energy pelvic fractures - symphysis diastasis - displaced obturator ring fractures
247
Briefly describe best imaging modality for ruling out bladder injury
MUST have Retrograde Cystography - CT w/ IV contrast is not enough to r/o Dissolve 30cc of water soluble contrast into 500cc bag of warm NS - Instil 300cc into bladder via Foley using gravity. - Continue past 300cc if pt is not in discomfort/pain Need XRs (fluoroscopy) in 3 views - AP - Lateral - post drainage Need only 'full' distended view if using CT
248
Name injury that must be ruled out prior to cystography imaging (and insertion of Foley to do so)
URETHRAL injury! Need urethrogram FIRST, if high enough suspicion, prior to cystography
249
List 3 pelvic fractures that should raise high suspicion for bladder injury, and therefore cystography consideration
Pubic symphysis diastasis Significantly displaced obturator ring fractures Significantly displaced pubic rami fractures
250
Outline differences in mgmt of Intraperitoneal & Extraperitoneal bladder ruptures
Contusions & EBRs: - 2/2 blunt injury, manage conservatively w/ Foley catheter - operative mgmt if other intra-abdo sx happening, bladder neck injuries, bony fragments in bladder wall IBRs: - OR for exploration + repair
251
List 4 complications of penetrating rectal injuries w/ bladder involvement
Abscess Bladder stones Urethral strictures Fistulae Sepsis
252
List clinical features of urethral trauma
*Posterior urethral trauma most common Blood at urethral meatus Distended bladder/ Urinary retention High riding prostate (not sensitive) Swelling & Ecchymoses of perineum, vagina, penis Complex perineal laceration (including vaginal lac)
253
Outline Technique for Performing Retrograde Urethrography (RUG)
1) 16-18-Fr Foley catheter or hysterosalpingogram catheter is flushed w/ radiopaque contrast to avoid air 2) Urethral meatus (+ glans penis/vulvar area) cleaned w/ antiseptic 3) Catheter is inserted into urethral opening, balloon is partially inflated (1–2mL) in fossa navicularis 4) If pt has a penis, pull it laterally to straighten urethra under moderate traction 5) Precontrast “scout” image is obtained b/c prostatic calcifications may be confused for extravasated contrast 6) Under fluoroscopic visualization, 20–30mL of contrast is injected w/ goal of filling entire urethra 7) If spasm of external sphincter prevents posterior urethral filling, slow, gentle pressure may allow opacification 8) Static images are obtained to demonstrate any pathologic condition
254
Outline mgmt of confirmed urethral injury
Place suprapubic urinary catheter - under U/S guidance - prevents infection if urine continued to drain/extravasate out of injury
255
List 3 complications of urethral injuries
Urethral stricture Urinary incontinence - stress incont Erectile dysfunction
256
Define true penile fracture
Rupture of tunica albuginea surrounding any of the three corpora of the penis
257
Outline clinical features of penile fracture
Usually during intercourse, or forcible pushing down of erect penis Immediate pain Audible 'pop' Rapid detumescence Penile swelling, hematoma, ecchymosis Deviation away from damaged side
258
Outline clinical features of female genitalia injuries
Labial swelling or ecchymosis Vulvar + Perineal hematoma, swelling
259
Name best imaging test for testicular and penile trauma
U/S
260
List 5 findings/complications of delayed/missed arterial injuries
Thrombosis Pseudoaneurysm AV fistula formation Compartment syndrome Intermittent claudication
261
Name most common blunt trauma cause of popliteal artery injury
Posterior knee dislocation
262
Outline 2 main types of vascular injury from trauma
Occlusive injuries - transections - thromboses (acute or delayed) - reversible spasm Nonocclusive injuries - intimal flaps - dissections - arteriovenous fistulas - pseudoaneurysms
263
List 4 factors that increase the risk of compartment syndrome after vascular injuries
Prolonged ischemia time Combined arterial & venous injuries After ligation or repair of major artery or vein Significant soft tissue injury, frequently w/ a long bone fracture
264
List 5 'hard' & 4 'soft' signs of peripheral vascular injury
HARD: Pulsatile hemorrhage Expanding hematoma Absent distal pulses Palpable thrill Audible bruit SOFT: Hx of significant hemorrhage at scene Nonexpanding hematoma Diminished pulse or ABI of injured extremity Peripheral nerve deficit of injured extremity Bony injury or proximate (close by) penetrating wound --------------------- *DELAYED CAP REFILL in isolation is NOT a hard or soft sign
265
Contrast timing of primary vs secondary neuropathy
Primary Nerve injury will have IMMEDIATE signs Neuropathy 2/2 vascular compression, or compartment syndrome, will develop over MINS to HRS
266
Outline approach to asymptomatic high risk wounds, when evaluating for potential neurovascular injury
Penetrating wounds w/in 1cm of a major neurovascular bundle, or w/ assumed trajectory w/in 1cm, should have FREQUENT q30-60min checks x4-6hr (warm ischemia time) to catch any potential developing vascular injury
267
List 6 Major Neurovascular Bundles (4 UE & 2 LE) to consider in trauma pts
Axillary artery & Brachial plexus Brachial artery & Median nerve Radial artery & Median + Radial nerves Ulnar artery & Ulnar nerve Femoral artery & Femoral nerve Popliteal artery & Tibial nerve
268
List 5 traumatic injuries that may have initially asymptomatic vascular injuries
Penetrating wounds w/in 1cm of a major neurovascular bundle, or w/ assumed trajectory w/in 1cm Bites from large dogs or other animals Displaced fractures Crush injuries Major joint dislocations (esp. knee dislocation)
269
Outline Arterial Pressure Index or Ankle-Brachial Index ratio that is cut-off of concern
>1.0 is normal 0.9-0.99 should be observed for 12-24hr for development <0.9 is abnormal and indicates need for more investigation
270
Outline diagnostic imaging techniques for peripheral arterial injuries
Conventional catheter-based angiography Duplex ultrasound CT angiogram = gold standard MRA
271
List 4 advantages & 3 disadvantages of CTA over conventional angiogram for peripheral arterial injuries
ADVANTAGES: - noninvasive - readily available - less costly - provides information on other injuries in the region DISADVANTAGES: - metallic artifact from bullets, orthopedic hardware, or other penetrating objects may obscure visualization - may miss venous injuries - contrast timing may miss arterial injuries
272
Outline pt criteria to go straight to OR w/ popliteal artery injury suspicions
Penetrating trauma and 1+ hard sign of arterial injury Can go straight to OR instead of CTA first
273
Outline safe tourniquet time
Up to 6hr
274
Outline technique to 'extend' warm ischemia time in vascular trauma pts
Cool the ischemic limb to avoid exceeding critical 6hr warm ischemia time, if concerns for prolonged transport, etc. Wrap extremity in towels Place ice bags around the limb
275
Outline mgmt of forearm arterial injuries
Can manage non-op - as there is collateral flow UNLESS: - ischemia in hand - hard signs of arterial injury (expanding hematoma, pseudoaneurysm, AVF) - injury to both radial & ulnar arteries
276
List 3 factors that place patients at higher risk of amputation after LE arterial injury
- Severe soft tissue injury of extremity - Presence of multiple fractures - Major venous repair - Delay in repair >6hr warm ischemia time
277
List 6 Late Complications of Arterial Injury
Delayed Thrombosis - most common Delayed amputation Intermittent claudication Chronic pain to limb Chronic edema of limb Aneurysm formation in the graft
278
List 6 criteria for minor nonocclusive vascular injuries that can be managed expectantly
Low-velocity missile wounds Intact distal circulation Absence of active hemorrhage Minimal arterial wall disruption noted on angiography Intimal flaps extending <5mm Pseudoaneurysms <5mm
279
List 10 risk factors for wound infections
1. Location: - Leg & Thigh - then Arms - then Feet - then Chest - then Back - then Face - then Scalp 2. Contamination w/ - devitalized tissue - saliva, feces - soil or foreign matter 3. Blunt Crush mechanism 4. Presence of subcutaneous sutures 5. Type of repair: Risk greatest w/ sutures > staples > tape 6. Anesthesia w/ epinephrine 7. High-velocity missile injuries 8. Diabetes - Prolonged time since injury - Long >5 cm deep penetrating wounds - Advanced age
280
Outline most effective intervention to decrease wound bacterial counts and infection
Thorough cleansing! - w/ use of NS or tap water irrigation at ~8psi - Attaching an 18g needle to 30mL syringe creates irrigant force of 8psi
281
Outline 3 instances when tissue adhesive (glue) is not recommended for wound closure
- Lacerations >4 cm - High-tension wounds - Areas subject to frequent repetitive movements (joints & hands)
282
List 6 traumatic wounds that should get ABX tx
- Through-and-through intraoral lacerations - Cat bites - Some dog & human bites - Puncture injuries to foot in high-risk individuals - Open fractures - Wounds involving exposed tendons or joints - Immunocompromised patient - High-velocity open fractures (GSWs)
283
List imaging techniques to use to locate FBs in wounds
XR U/S CT
284
List 3 benefits of topical anesthetics
- Reduce repair time - Preserve landmarks - Improve patient (& family) satisfaction - and reduce pain if additional anesthesia needed to be injected
285
Outline max dose of LET gel
If child <17kg 0.175mL/kg of LET is safe
286
Which 'family' of local anesthetics is most common to have true allergy?
Ester family - Procaine - Tetracaine - Benzocaine
287
List 3 wound closure timing options
1. Closed primarily in traditional fashion 2. Closed in 4-5 days (delayed primary closure) 3. Left open & allowed to heal on its own
288
List 6 dog bite features that require ABX tx
- Hand injuries - Deep puncture wounds - Bite in extremities w/ underlying venous or lymphatic compromise - Wounds near or in a prosthetic joint - Pts w/ DM - Wounds in older or immunocompromised patients
289
Outline ABX tx for intraoral 'thru & thru' lacerations
Penicillin VK 500mg PO BID x5d
290
List 6 s/s of wound infections to tell patients to look for
Redness Increasing pain Swelling Fever Pus Red streaks progressing up an extremity
291
Outline suture removal dates for various wound sites
Face = 5d (always replace w/ Steri-Strips) Scalp = 7–10d Trunk = 7–10d Arms & Legs = 10–14d Joints = 14d
292
Outline Proper Tetanus Prophylaxis for All Patients w/ All Wounds
293
List 5 clinical indications of inhalation injury
Facial burns Hoarseness Drooling Carbonaceous sputum Singed nasal hairs
294
List 3 indications for immediate intubation after inhalation injury
Worsening hoarseness Worsening edema Soot in the supraglottic region
295
Outline size/area of burns that require admission to a burn centre
>20% for adults >10% for peds and elderly Or deep burns
296
List 3 clinical features that increase risk of death from burns
Advanced age Increased burn size Presence of inhalation injury
297
Outline classical 3 zones of burn injury to skin
1) Central zone of coagulation or irreversible necrosis 2) Intermediate & potentially reversible zone of stasis or ischemia 3) Peripheral reversible zone of hyperemia or inflammation
298
List 3 phases of wound healing
Inflammatory phase Proliferative phase Remodeling phase
299
Outline 6 delayed/late complications of inhalation injuries
- Ventilation/Perfusion mismatch - Decreased lung compliance - Obstruction - Barotrauma - Increased dead space ventilation - PNA
300
Outline classification of burns by depth
1) Superficial (first-degree) - epidermis only - erythematous, dry - blanch w/ pressure - like sunburn 2) Superficial partial-thickness & Deep partial-thickness (second-degree) - Superficial = separation of epidermis & dermis w/ blister formation, WET, blanch w/ pressure - Deep = damage to dermal structures like hair follicles, WET or DRY, red or white or mottled 3) Full-thickness (third-degree) - entire dermis - inelastic burn eschar, waxy & white, gray, or black w/out blisters - INSENSATE 4) Deep full-thickness (fourth-degree) - involve muscle, tendon, ligament, or bone and may result in amputation 5) Fifth-degree (tissue destruction resulting in amputation)
301
Outline Rule of Nines for estimating TBSA burns
302
Name gold standard imaging test for evaluation of inhalation injury
Flexible bronchoscopy
303
Outline initial first aid care for burns
Remove jewelry and clothes Rinse burns w/ room temp water and cover w/ clean dressing Run RL @ 500cc/hr in age >14 - 125cc/hr in age <5 - 250cc/hr ages 6-13 Maintain O2 sats >92 Analgesia
304
List 10 clinical features that may indicate early intubation after burns
Exposure in an enclosed space Suspected smoke inhalation Moderate to severe facial or oropharyngeal burns Circumferential neck burns Visible injury on laryngoscopy or bronchoscopy Cognitive impairment Hemodynamic stability Dysphagia Hoarseness Oropharyngeal soot Singed nasal or facial hair Larger burns ≥ 40% TBSA Stridor Impaired oxygenation or ventilation
305
Outline Recommended Initial Ventilator Settings in Burn patients
Vt = 6–8 mL/kg RR = 8–12 in adults - 12–45 in children PlatP = <35cm H2O I/E ratio 1:1 to 1:3 Flow rates = 40–100L/min PEEP = 8cm H2O
306
List adjunct medications for intubated burn pts
Ventolin nebulized Heparin 5000 to 10,000 IU nebulized NAC nebulized Can all reduce duration of mechanical ventilation
307
Outline Parkland formula for burn IVF resuscitation
4cc/kg/TBSA of RL Half over first 8hrs since injury! Half in next 16hr
308
Outline Modified Brooke formula for burn IVF resuscitation
2cc/kg/TBSA of RL in adults 3cc/kg/TBSA of RL in children Half over first 8hrs since injury! Half in next 16hr
309
Outline goal urine output in burn pts
1cc/kg/hr
310
List indications for escharotomy in burn pts
Pain Pallor Paresthesia Paralysis Poikilothermia Pulselessness Decreased or absent oximetry signals, Increased compartment pressures for eschar over limbs >30 mmHg Increased intraocular pressures for peri-orbital eschar >30 mmHg Resp & Hemodynamic dysfnc (inc airway pressure, dec Vt, dec preload, tachycardia) for escharotomy over chest Poor respiratory compliance, Hemodynamic instability, Tube feed intolerance, Decreased U/O, or Increased bladder pressure >25 mmHg for abdominal escharotomy
311
List 10 Criteria for Referral to a Burn Center
Partial thickness burns >10% TBSA Burns that involve face, hands, genitalia, perineum, or major joints Full thickness burns in any age group Electrical burns, including Lightning Chemical burns Inhalation injury Burn injury in patients w/ preexisting medical disorders that could complicate mgmt, prolong recovery, or affect mortality Any patient w/ burns & concomitant trauma, in which burn injury poses greatest risk of morbidity or mortality Burned children in hospitals w/out qualified personnel or equipment for care of children Burn injury in patients who will require special social, emotional, or rehabilitative intervention
Rosen's 10th
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