Trauma

Question 1

What is Shock

Answer 1

Inadequate perfusion that leads to inadequate oxygen delivery and leads to metabolic acidosis

Question 2

Compensated Shock

Answer 2

Shock where vital organ function is maintained and blood pressure remains normal

Question 3

Hypovolemic Shock & S/S

Answer 3

Loss of fluid from intravascular space
-Tachycardia
-Alterations of peripheral perfusion
-Early: bounding pulses & alert, rapid CRT & some UOP
-Late: CRT delayed, extremities cool & mottled, hypotension & vasoconstriction.

Question 4

Uncompensated Shock

Answer 4

Untreated compensated shock left untreated where hypotension develops and organ/cellular function deteriorates.

Question 5

Distributive Shock & S/S

Answer 5

Abnormalities in distribution of blood flow ex: sepsis.
-Tachycardia
-Tachypnea
-Liver enlargement
-Gallop
-Oliguria & peripheral edema r/t poor renal blood flow

Question 6

Obstructive Shock & S/S

Answer 6

Mechanical obstruction of ventricular outflow: Cardiac tamponade, tension pneumonia, pericardial effusion, PE
-Tachycardia
-Alteration in stroke volume
-Pulse pressure narrow
-Weak pulses
-Delayed CRT
-Liver enlargement
-JVD

Question 7

Cardiogenic Shock & S/S

Answer 7

Abnormality in myocardial function with depressed myocardial contractility & CO that leads to poor perfusion.
Ex: myocarditis & heart failure
-Tachycardia
-Tachypnea
-Liver enlargement
-Gallop
-JVD-
-Oliguria & peripheral edema

Question 8

Hypercarbia

Answer 8

PaCO2 >50mm Hg with/without hypoxemia <60.
From inadequate alveolar ventilation 2nd to decreased minute ventilation
(tidal volume x RR)
or increased dead space ventilation. In trauma this occurs 2nd to depressed sensorium.
Leads to neurologic depression & coma

Question 9

Trauma Primary Survey (A)

Answer 9

Airway:
Younger children’s airways are anatomically different from adults
Assess for obstruction: foreign body, dental, facial, mandibular, tracheal, or laryngeal fractures
Crying attests to patent airway
Chin lift maneuver for depressed LOC
Jaw thrust maneuver when not able to move patient’s neck

Question 10

Trauma Primary Survey (B)

Answer 10

Breathing (ventilation, oxygenation)
Because children are diaphragmatic breathers, any compromise to the diaphragm limits the ability to ventilate
Inspection, auscultation and percussion
“Look first and touch last” for the awake patient
Observe for: respiratory effort, mechanics of breathing, air entry, JVD, abdominal contour and skin color
Note the position of the trachea- midline or shifted

Question 11

Trauma Primary Survey (C)

Answer 11

Circulation
Earliest sign of hypovolemia is tachycardia
Clinical signs of shock: mental status change, resp compromise, weak or absent peripheral pulse, delayed cap refill, skin pallor and hypothermia
Can maintain normal systolic BP until loss of 30% of circulatory blood

Question 12

Trauma Primary Survey (D)

Answer 12

Disability (neurologic)
Glasgow Coma Scale (3 is deep unconsciousness and 15 is alert and intact)
GCS of 8 or less requires emergent securement of airway
Examine pupils for position, size, equality and reactivity
Emergent radiographs for altered mental status

Question 13

Trauma Primary Surgery (E)

Answer 13

Exposure
Brief look for any injuries
IN LINE STABILITY of the vertebrae should be maintained at all times.
Log roll maneuver
Create warm environment to combat hypothermia

Question 14

Football injury with spearing helmet injury

Answer 14

most spinal cord injuries are caused by axial loading of the cervical spine during head-down contact, often because of “spear tackling,” a method in which the athlete lowers his head, thereby lining up the vertebral bodies, and uses his body as a battering ram to deliver a blow to another player with the crown of his head
high risk for c-spine injury and Neurogenic shock: blood flow low with unstable BP, HR and Temp

Question 15

ACL injury

Answer 15

occur often during sports that involve sudden stop/change in direction, jumping or landing: soccer, basketball, football, skiing
Generally report “cutting” and knee popping and giving out. Swelling common

Question 16

Blunt abdominal injury- liver S/S

Answer 16

diffuse abdominal tenderness
localized tenderness to RUQ
referred right shoulder pain
ecchymosis or abrasion to RUQ
penetrating wound to right torso
right sided rib pain or tenderness
hypotension, tachycardia
pelvic or rib fractures
Liver Injury Scale: Grade 1-6 (see table below)

Question 17

Blunt trauma abdominal S/S

Answer 17

diminished bowel sounds, tenderness to palpation, guarding, rebound tenderness and peritoneal irritation

Question 18

Blunt trauma treatment and diagnostics

Answer 18

Penetrating abdominal injuries require surgical exploration immediately.
Massive liver disruption & intractable bleeding need surgery consult
CT scan is preferable for both blunt and penetrating trauma especially for pt’s with concerning history or exam. CT with IV contrast must be done. Helps determine grade of injury

Question 19

Blunt Chest Trauma

Answer 19

Lung contusion/laceration
Pneumothorax/hemothorax
Rib and sternal fractures
Myocardial contusion
Cardiac tamponade
Diaphragm rupture
Aortic disruption
Tracheobronchial tears
CT scan can be done if above diagnosis are suspected and help to diagnose the degree of the injury

Question 20

Beck’s Triad

Answer 20

hypotension, JVD, muffled heart sounds.
(pulses paradoxus: SBP drops during inspiration).
Indicates Cardiac tamponade.

Question 21

MVA skull fracture S/S

Answer 21

Battle sign, raccoon eyes, ring signs indicated CSF leaking
Lethargy, seizure, presence of scalp hematoma, palpable skull defect or crepitus.
Headache, localized pain or soft tissue swelling, vomiting, confusion, altered mental status
-CT scan first line to diagnose

Question 22

Orbital Wall Fracture

Answer 22

Pain with possible diplopia and blurred vision
Eyelid edema
Ecchymosis occasionally with subcutaneous or conjunctival emphysema
Hypoesthesia over the inferior orbital rim can be present if the infraorbital nerve has been involved
Bradycardia that occurs with eye movement secondary to the oculocardiac reflex can be present in the setting of muscle entrapment - require immediate surgical intervention

Question 23

Orbital blowout fracture

Answer 23

Fractures of the floor of the orbit, sometimes known as orbital blowout fractures, typically occur when a medium sized round hard object stroke the eye
Injury to this nerve caused decreased sensation to the cheek, upper lip, and upper gingiva on the affected side;
N/V, pain, diplopia, blurred vision, eyelid edema/ecchymosis, emphysema, hypesthesia.
Exophthalmos (sunken globe).
Bradycardia with eye movement: 2nd to oculocardiac reflex from muscle entrapment.

Question 24

Compartment syndrome S/S and treatment

Answer 24

S/S: the 5 Ps (Pain, pallor, pulselessness, paresthesia, & paralysis). Pain is the earliest sign!
-THREE A’s IN KIDS: Anxiety, Agitation, Analgesics (receiving more often than they should)
-Decompressive laparotomy

Question 25

Criteria for admission to burn unit

Answer 25

Partial thickness burns >10% TBSA require fluid resuscitation (warm fluids) and urinary catheter Partial thickness burns involving face, hands, feet, genitalia, perineum, or major joints Full thickness burns in any age group Electrical burns including lightening Chemical burns Inhalation injury Burn injury in patients with pre-existing medical conditions that would complicate management Burn with concomitant trauma in which burn poses greatest risk Not qualified personnel or equipment for peds care Burn injury in pts requiring special support (child abuse)

Question 26

Burns with abuse versus accidental

Answer 26

Hx that is inconsistent with the physical exam or conflicting histories are sufficient reasons to launch deeper investigations Well defined lines of demarcation between burned and unburned skin in a scald burn and the absence of splash burns can also be seen Sparing of areas of skin particularly when extremity held in flexion and the area around joint is protected and spared Contact burns with well defined margins, object that cause injury can also be determined by the outline of the wound

Question 27

what to watch for with circumferential burns -treatment in severe cases?

Answer 27

compromised blood flow to other viable tissue Threshold for performing an escharotomy to release subeschar pressure should be low - approx >30mmHg compartment syndrome: occur in the chest or abdomen in pts with circ full thickness burns Escharotomy of the chest will often decrease the inspiratory pressures required to maintain tidal volume Abdominal compartment syndrome may be relieved by escharotomy, drainage of peritoneal fluid, or decompressive lap

Question 28

Secondary Trauma Survey SAMPLE

Answer 28

S: symptoms A: allergies M: medications P: past illnesses L: last meal E: events and environment

Question 29

Pulmonary Contusion/Laceration

Answer 29

most common injury in ?? Alveolar hemorrhage, consolidation, edema hemoptysis, SQ emphysema, hypoxemia & Resp distress. Usually resolve 7-10 unless infection or aspiration present

Question 30

Hemopneumothorax

Answer 30

High with penetrating trauma cover any open injury insert chest tube may need surgical intervention

Question 31

Myocardial Contusion

Answer 31

S/S: tachycardia, dysthymia, gallop rhythm, chest pain, myocardial dysfunction, cardiogenic pulmonary edema, elevated enzymes. Supportive care

Question 32

Cardiac Tamponade

Answer 32

Increased pericardial pressures obstructs venous return & CO. See Beck triad Need intravascular volume expansion Pericardiocentesis

Question 33

Rupture of Diaphragm

Answer 33

Most common on left side Cannot see diaphragm on X-ray or is abnormally elevated. Needs surgical repair

Question 34

Aortic disruption

Answer 34

from severe deceleration injury and extreme height falls S/S: back pain, machinery type heart murmur radiating to back, hemorrhagic shock widened mediastinum, loss of aortic knob, right tracheal deviation

Question 35

Abdominal Compartment Syndrome

Answer 35

from blunt trauma, burns or massive fluid resuscitation. Increasing abdominal pressure decreases abdominal organ perfusion & venous return. See oliguria & respiratory distress Needs decompressive laparotomy

Question 36

Non-accidental Trauma

Answer 36

Unexplained delay in treatment Hx not compatible with injury SBS: intracranial & intraocular hemorrhages. poor skin hygiene, malnutrition, FTT, hematomas & petechiae of various healing stages, bite marks, burn injuries, abrasions, strap/belt injuries, soft tissue swelling.

Question 37

Corneal abrasions

Answer 37

S/S: pain, redness, tearing, photosensitivity, blurred vision, foreign body sensation. See with stain & blue light. topical antibiotic drops Do not use steroids or anesthetics.

Question 38

Traumatic Iritis

Answer 38

Blunt trauma pain, redness, photosensitivity, tearing, blurred vision, conjunctival hyperemia. Constrictive, poorly reactive pupil cycloplegia eye drops & referral to ophthalmology.

Question 39

Traumatic Hyphema

Answer 39

blunt trauma pain, redness, blurred vision. see layered blood between cornea & iris. Eight ball hyphema: blood fills entire anterior chamber & black: needs emergent referral to ophthalmology for ruptured globe. Needs visual and Sickle cell test. start cycloplegia & intraocular pressure lowering drops. Use metal shield to cover eye & 24 hr strict bedrest. HOB at 30 degrees. No surgical intervention needed.

Question 40

Orbital blowout fracture treatment

Answer 40

Needs CT scan Seidel test for open globe Cephalexin or broad spectrum abx. Oral prednisone. Avoid nose blowing, Cold pack for 1st 48 hours Optho involvement is Extraocular muscle involvement.

Question 41

Ruptured globe

Answer 41

S/S: pain, tearing, n/v, decreased vision, positive Seidel test. Get CT scan. cover eye with metal shield or cup with tape. never soft patch. IVF's, NPO, strict bedrest & hosp admit. Antiemetics, broad spec abx & tetanus.

Question 42

Burn injury workup

Answer 42

Do with all burns > 15%. BMP, pre albumin. Carboxyhemoglobin for smoke inhalation (>20% means injury). ABG/VBG: metabolic acidosis is common. UA for electrical burn (acidosis). Baseline EKG

Question 43

Burn injury fluid resuscitation TBSA

Answer 43

<5% : po challenge 5-10%: IVF at daily main rate 10-15%: 1-1.5x daily rate. >15%: careful large volume fluid resuscitation.

Question 44

Parkland Formula for Major Burn Fluid resuscitation

Answer 44

4ml x wt(kg) x % TBSA=LR vol in 24 hr 1/2 of fluid in 1st 8 hr after injury 1/2 of fluid over next 16 hr. Under 30 kg, use dextrose containing fluids. UOP goal: <30kg is 0.5-1ml/kg/hr >30 kg is 1-2ml/kg/hr If low, titrate IVF up by 1/2. If high, titrate IVF down by 1/2.

Question 45

Splenic Laceration

Answer 45

Most common abdominal injury in childhood. Typically, from blunt trauma to upper abdomen or lower thorax * Spleen is not adequately protected by rib cage Sx's: pain in left shoulder, LUQ, or left part of chest, bruising, abrasions,N/V, mass may be palpable in LUQ Labs: decreased hemoglobin/hematocrit. Dx: CT,CXR may show fractures to left lower ribs or a pleural effusion

Question 46

Splenic Laceration

Answer 46

If splenectomy required * prophylactic antibiotics for children < 4 years of age * in some cases, children > 4 years of age * Post-op splenectomy * monitor for bleeding, thrombosis, infection, fistula formation * Vaccination importance

Question 47

Liver Laceration

Answer 47

Major cause of death in children with blunt trauma, highest risk for injury. Associated with significant blood loss/exsanguination, right lobe more prevalent than left lobe Sx's: acute abdominal tenderness,hemoperitoneum, pain in right shoulder or RUQ tenderness, bruising, seatbelt markings, and abrasions, hypotension and tachycardia, if bleeding,fractured ribs, associated pelvic or rib fractures

Question 48

Liver Laceration Evaluation & Management

Answer 48

Dx: CBC, liver function tests, ultrasound, CT, Non-operative management,same as spleen, NPO,serial hemoglobin/hematocrit (every 4 – 6 hours), blood products if indicated Can ambulate after AST and ALT are normal Operative management if hemodynamically unstable often to control bleeding

Question 49

Pancreatic Injury/Laceration

Answer 49

Associated with high morbidity and mortality Sx's: soft tissue contusion in upper quadrant, handlebar marking, tenderness to lower ribs and costal margins, epigastric tenderness, lower thoracic spine fracture, signs of peritonitis,vomiting Dx: CT with grading of injury, amylase, and lipase

Question 50

Kidney Laceration

Answer 50

Sx's: contusion,hematoma, bruising of flank or back, abdominal or flank, tenderness, palpable mass, stab wounds posterior to anterior axillary line. Dx: CT,urinalysis for hematuria,intravenous pyelogram

Question 51

Abdominal Compartment Syndrome

Answer 51

Life-threatening complication of abdominal trauma. Coagulopathies, acidosis, hypothermia, bowel edema Monitor bladder pressures

Question 52

Chest/Thoracic Trauma

Answer 52

Most common:Pneumothorax *Hemothorax * Tension Pneumothorax * Pulmonary contusion * Rib fractures * Tracheobronchial tree disruptions * Cardiac trauma Symptoms: * tachypnea * hypoxia * unequal breath sounds * muffled or displaced cardiac sounds

Question 53

Pulmonary Contusion

Answer 53

A ’bruise’ of the lung/lung parenchyma Associated with alveolar lung injury without frank, pulmonary laceration results from chest trauma Sx's: tachypnea, respiratory distress, hypoxia * Initial chest radiograph may be normal * ~ 24 hours after injury CXR demonstrates ill-defined geographic consolidation that is not specific to contusion * *can appear as aspiration, atelectasis, infection * Improvement over several days as blood is absorbed * may improve in 24-48 hours * most resolved in 7-10 days * Treatment: Supportive

Question 54

Rib Fractures

Answer 54

Children have more pliable chests than adults rib fractures are less common in children * ALWAYS raises suspicion of maltreatment Risk of mortality increases with each linear rib that is fractured Often associated with trauma/injury in other parts of the body, head, thoracic, solid organ TX: Evaluate for other injuries, evaluate for signs of abuse, consider diseases of bone (uncommon!), pain management

Question 55

ABCs of Burns

Answer 55

Airway Assessment:facial burns,singed eyebrows,stridor or wheezing, Hypoxia, carbon sputum, hoarseness,mucous membrane and tongue swelling Breathing and Circulation: Particle aspiration and CO inhalation causes hypoxia and difficulty breathing. Laboratory and radiological evaluation: carboxyhemoglobin,CBC, CMP with albumin,ABG, urine pH and myoglobin (for children with electrical burns) + EKG * Primary and Secondary Survey * Burn surgeon

Question 56

The most important management of a stabilized child who experienced a liver laceration from a bicycle accident includes: a. Serial hemoglobin and hematocrit monitoring b. Serial abdominal CT c. Coagulation therapy d. Emergent surgical intervention

Answer 56

a. Serial hemoglobin and hematocrit monitoring Monitoring hgb & hct is a conservative way to evaluate persistent bleeding.

Question 57

A 15-year-old has suffered a pulmonary contusion after being involved in a motor vehicle accident. Which chest radiograph finding would you expect on presentation? A. Normal chest radiograph B. Kerly B lines C. Diffuse opacities on the affected side D. Pleural effusion on affected side

Answer 57

A. Normal chest radiograph

Question 58

An 8-year-old is admitted with a suspected abdominal injury after a fall from an ATV (all terrain vehicle). The BEST mode of diagnosis for a suspected splenic laceration is: a. Bedside ultrasound b. Abdominal CT with IV contrast c. Abdominal CT with oral contrast d. Abdominal x-ray

Answer 58

b. Abdominal CT with IV contrast US has low sensitivity to splenic injury.

Question 59

Superficial burn 1st degree

Answer 59

outer layer epidermis with pain & erythema. Tissue intact. Heal without scarring.

Question 60

Superficial partial-thickness 2nd degree

Answer 60

epidermis & superficial layer of dermis. Blistering, erythema, blanching, pain. minimal scarring

Question 61

Deep partial-thickness 2nd degree

Answer 61

epidermis & > 50% of dermis with destruction of nerve endings; erythematous, moist, non blanching, less painful.

Question 62

Full-thickness 3rd degree

Answer 62

entire epidermis & dermis. appears Dry, leathery, stiff, or charred (black, white, or brown). insensate due to destroyed nerve fibers.