question

Kehr's sign

answer

Referred left shoulder pain, usually indicates a splenic injury

question

Base deficit

answer

Base deficit more than -6 indicates the need for agressive resuscitation and determination of the etiology

question

CXR

answer

Most important tool providing useful information in the early minutes. Can identify major sources of blood loss from injuries in the chest or elevated diaphragm with displacement of abdominal organs

question

Tracheobronchial injury

answer

Should be suspected if after chest tube placement a significant air leak is present

question

Diagnostic Peritoneal Lavage

answer

Alternative to FAST scan to detect abd bleeding. A urinary catheter and gastric tube should be in place prior to procedure.

question

FAST

answer

Focused Assessment with Sonography in Trauma. Used to detect free fluid in peritoneum or hemoperitoneum. Free fluid appears "black" on the screen. Has replaced DPL when available.

question

Positive FAST scan

answer

Hemodynamically unstable trauma patient with a positive fast are taken directly to the OR for laparotomy

question

Ultrasound abd exam

answer

Not useful to detect injuries to the diaphragm, intestine and pancreas. In patients with obesity, ascites and/or subQ emphysema the accuracy is reduced.

question

CT scan

answer

Hemodynamically stable patients may be taken to CT

question

Angiography

answer

Embolization is useful in treating patient with unstable pelvic fractures, liver and splenic hemorrhage. Use of hybrid OR suites to allow for surgical and interventional radiology methods of treatment simultaneously.

question

Diagnostic laparoscopy

answer

Can be used to detect or exclude finding so f hemoperitoneum, organ injury, intestinal spillage or peritoneal penetration. Most useful in evaluating possible diaphragmatic injuries, espectially in penetrating thoracoabdominal injuries on the left site

question

Diaphragmatic injuries

answer

Usually resultant of penetrating throacoabdominal injuries on the left side, including 11-12 rib fractures on the left.

question

Small intestine injuries

answer

Result from shearing forces in MVC or direct blows that crush intestine between force and the vertebrae. Most commonly intra-abd injury in penetrating trauma. Occurs often with spinal injury. Pancreatic/solid organ injury are predictive of increased risk for hollow viscus injury. Signs of peritonitis develop. Any blow to the abd/penetrating injury to the lower chest/abd should increase suspicion of injury

question

Treatment of small intestine injury

answer

Control bleeding prior to exploration. Debridement and closure and ligation of bleeders. Resection for multiple defects. Observe for wound infection/abscess development

question

Cause of duodenum injuries

answer

Penetrating trauma most frequent cause. Usually conconcurrent mult-organ injuries. Usually found intraoperatively, commonly missed during exlap. Blunt force injury cause by vetebral compression.

question

Duodenal injury treatment

answer

Identification with CT scan. Commonly patients have midepigastric or back pain with evolving peritoneal signs 6-24 hrs after injury. Primary closure in OR, closed drainage system. Goals are to control hemorrhage, debride devitalized tissue and provide drainage. Non operative management requires close observation for expanding or ruptured hematomas causing bleeding or peritoneal contamination.

question

Jejunum and ileum injuries

answer

Jejunum lies in umbilical region, ileum lies in the hypogastric/pelvice regions. Lap belt can cause bowel to be crushed between the vertebrae and a solid object. Incorrect wearing of seatbelt increases chance for injury

question

Stomach injury

answer

Rare, more common in children. Penetrating trauma most common cause. May find free air on cxr/fua. Pain to epigastric/abd area, tenderness, signs of peritonitis. Bloody output from gastric tube. Surgical intervention, is gastric content leakage, copious peritoneal irrigation and delayed primary closure

question

Large intestine

answer

Rectal injuries may be associated with severe pelvic fracture. Lethal due to sepsis related to fecal contamination. Most are due to penetrating trauma. Transverse colon most often injured. Most injuries are contusions. Laparotomy with primary repair and colostomy is performed when perforation to the colon or rectum is suspected. Abscesses can be percutaneously drained.

question

Liver injuries

answer

Commonly injured due to size and location. Cause of injury is blunt and penetrating trauma. MVC most common cause. Greatest mortality risk is hemorrhage. High velocity GSW cause more widespread damage that creates massive hemorrhage. Suspect liver injury in any patient with blunt injury to right side. FAST scan to rule out free fluid. CT scan in hemodynamically stable patient. Graded I to IV.

question

Treatment of liver injuries

answer

Nonoperative in select patient. OR for complex lacerations/arterial blush. Angioembolization for patients with contrast pooling or arterial blush. Pack and stabilize bleeding and return to OR 24-36 hours later for removal of packing and definitive management of liver/possible closure. Aggressive intraoperative resuscitation to prevent hypothermia, coagulopathy and hemodynamic stability. Damage control surgery.

question

Hemobilia

answer

In patients with liver injury RUQ pain and jaundice may present days and weeks post injury so follow up care is important

question

Splenic injuries

answer

Most commonly injured intra-abd organ. 25% of all blunt visceral injuries. LUQ trauma, lower rib fractures to left. Kehr's sign is caused by blood irritation to the phrenic nerve that causes referred pain to the left shoulder. CT scan is the imagining of choice for stable patients.

question

Acute splenic rupture triad

answer

left hemidiaphragm elevation, left lower lobe atelectasis and pleural effusion not commonly present and not a reliable sign

question

Treatment of splenic injury

answer

Nonoperative management, splenectomy/partial splenectomy, possible damage control. More focused on salvage of spleen. If patient has a splenectomy patient must receve vaccinations prior to discharge for H influenza/meningococcal/pneumococcal vaccine

question

Overwhelming Postsplenectomy Sepsis

answer

Rare, more common in children. 1-5 years after surgery. Flu like symptoms, shock from sepsis and DIC followed by death. Preventative measures include vaccinations and education.

question

Pancreas

answer

uncommon injury. If ductal tears, digestive enzymes invade. Major therapeutic challenge for clinical team. Most are associated with intra-abdominal injury and are found intraoperatively. GSW/Stab wounds are frequently the cause.

question

Retroperitoneal injury

answer

Associated with blunt trauma involving pelvic fractures

question

Abdominal vascular injury

answer

Usually occur with pelvic, thoracic or visceral injury. Retroperitoneal hematoma in conjunction with pelvic or spine trauma can contain up to 4 L of blood.

question

Pitfalls of abdominal trauma

answer

failure to suspect intra-abdominal injury from mechanism of injury, failure to fully evaluate complaints of abdominal pain following blunt abdominal injury, failure to perform timely operative intervention, failure to recognize hemodynamic compromise and delay surgery for further diagnostic tests

question

Blood loss hypovolemia: class I

answer

< 750 ml/15% of blood volume, HR < 100, normal B/P, normal PP, RR 14-20, CNS slightly anxious

question

Blood loss hypovolemia: class II

answer

750-1500/15-30%, >100, normal BP, decreased PP, RR 20-30, Mildly anxious

question

Blood loss hypovolemia: class III

answer

1500-2000/30-40%, HR >129, decreased b/p, decreased PP, RR 30-40, anxious/confused

question

Blood loss hypovolemia: class IV

answer

>2000/>40%, HR > 140, decreased b/p, PP decreased, RR >35, confused and lethargic

question

Compartment syndrome

answer

Common areas for compartment syndrome include: lower leg, forearm, foot, hand, gluteal region and thigh

question

Burn formula

answer

Adult and Chemical burns > 20% TBSA resuscitate at 2 ml LR x kg x TBSA in the first 24 hrs.

question

High voltage electrical injuries

answer

4 ml LR x kg x % TBSA in the first 24 hours

question

Peds Burn formula (14 and under and < 40 kgs)

answer

3 ml LR x kg x % TBSA in the first 24 hours

question

Inhalation injury

answer

Do not wait to intubate, swelling will increase then increase the difficulty of placing an ETT. Stridor or horseness is a late sign.

question

Compartment syndrome signs and symptoms

answer

Pain out of proportion for the injury, weak or absent distal pulses, delayed cap refil, firmness on palpation of muscle/soft tissue in surrounding area, distal skin cool to touch, distal skin pale or cyanotic, decrase in patient sensation

question

Hypovolemia in childresn

answer

children can be hemodynamically stable up to a 40% blood loss but only have a blood volume of 7-8% of their body weight

question

Hypovolemic shock

answer

chaning mentation, tachycardia, >120 HR greatest concern, cool, clammy skin, prolonged cap refill, narrowed pulse pressure (normal 40-50), decrased urine output, hypotension

question

Hypotension in shock

answer

Systolic blood pressure does not fall until 30% blood loss in adults

question

SIRS

answer

Systemic Inflammatory Response Syndrome. Severe physiologic reaction to injury characterized by systemic release of inflammatory cytokines and chemokines. Two or more of the following: temp > 38 or 90, RR > 20 or PaCO 12 or 10% bands

question

MODS

answer

After SIRS becomes stage 3 and severe hypotension refractory to fluid and ionotropic support ischemic insult progresses. Dysfunction of at least two organ systems from inflammatory insult, trauma or sepsis.

question

Causes of secondary brain injury

answer

hypoxia, hypotension, hypocapnea or hypercapnea

question

Secondary brain injury

answer

Leads to cerebral edema, mass effect, ischemia, cellular death

question

Optimizing oxygenation, ventilation and hemodynamics

answer

Intubate with RSI, maintain O2 sat > 90%, optimally 98%, ETCO2 monitoring to keep around 35 - provides information about adequacy of circulatory flow, hyperventilation causes vasoconstriction and reduces PaCO2 and causes ischemia, PaCo2 < 30

question

Monroe-Kellie doctrine

answer

Pressure volume relationships within the intracranial cavity, the craium is a non-expandable vault, increasing iCP is a warning that contents under pressure will try to relieve pressure by finding an exit in the area of least resistant - brain herniation

question

Normal ICP

answer

0-15, > 20 requires intervention

question

8 Cranium bones

answer

ethmoid, parietal, sphenoid, temporal, occipital

question

Dura

answer

Outermost layer-firmly adhered to the inner skull with fixed attachments of the cranial sutures

question

Arachnoid

answer

Loosely adhered to the pia mater, which makes the potential arachnoid space

question

Pia

answer

closely associated with grey matter of the brain, is the innermost layer

question

CSF circulates

answer

Between the pia and the arachnoid in the subarachnoid space, cushions and protects the brain and spinal cord

question

Middle meningeal artery

answer

Key cause of epidural bleeds

question

cerebrum

answer

right and left hemispheres of the brain

question

ventricular system

answer

approx 500 ml of CSF is produced in the choroid plexus of the lateral ventricles each day

question

third cranial nerve

answer

brainstem is the origin for the CNIII - CNX and CNXII

question

GCS 10

answer

Eye opening to voice, confused verbal response, withdraws to pain

question

GCS < 8

answer

intubate, accepted definition of coma - categorized as severe brain injury

question

GCS 9-12

answer

moderate brain injury

question

GCS >12

answer

minor brain injury

question

CPP

answer

cerebral perfusion pressure, maintain 60-70 mmHg

question

Avoid hypotension in ICH

answer

Solitary and multiple episodes of hypotension have been shown to increase the morbidity and mortality associated with brain injury

question

Cushings Triad

answer

hypertension, bradycardia and irregular respirations - ominous signs of herniation and require immediate attention and possible surgical intervention

question

ICP monitoring

answer

Placed in all salvageable head injury patients with GCS < 8 after resuscitation with an abnormal CT scan, GCS < 8 after resuscitation with a normal CT scan and at least two of the following findings: over 40 yo, systolic <90, bi or unilateral posturing

question

CPP/brain tissue oxygenation

answer

assessed through the use of devices such as the brain tissue oxygen monitoring catheter to monitor cerebral perfusion, oxygenation and oxygen carrying capacity

question

Cerebral contusion

answer

capillaries within the brain tissue are damaged and cause hemorrhage infarction or necrosis

question

Intracerebral

answer

deeper in the brain tissue, may be single or multiples, can create mass effect, increased ICP, neurologic deterioration, headache, incrased ICP, pupil changes, abn posturing, hemiparesis, hemipalegia

question

SDH

answer

Venous bleeding, acute < 72 hours old, subactue 3-7 days after acute injury, chronic - 21 days or older

question

Herniation

answer

Abdnormal protrusionof brain tissue through an opening when there is incrased intracranial pressue

question

Brown-Sequard

answer

Hemisectionof cord from penetrating injury, loss of motor on side of injury, loss of sensation on opposite side

question

Temporal lobe herniation

answer

oculomotor nerve runs along the edge of the tentorium and may becomme compressed against it during temporal lobe herniation, compression can cause a blown pupil

question

Uncal herniation

answer

common herniation through the tentorial notch is the medial part of the temporal lobe the motor tract crosses the opposite side of the foramen magnum and results in contralateral hemiparesis

question

GCS that is assymetric

answer

take the highest score

question

Neurogenic shock

answer

results from impairment of the descending sympathetic pathways, results in loss of vasomotor tone and in sympathetic innervation to the heart. Rare in injury below T6. Loss of vasomotor tone cause vasodilation of lower extremities, visceral organs, blood pools in lower extremities. Bradycardia. Vasopressors are required, atropine for symptomatic bradycardia

question

Inability to perceive pain in the spinal cord injured patient

answer

can mask a potentially serious injury elsewhere in the body, such as the usual signs of an acute abd

question

Bony level of injury

answer

the veterbra at which the bones are damaged, causing injury to the spinal cord

question

Neurologic level of injury

answer

determined primarily by clinical exam. Frequently discrepancy between the bony and neurologic levels because of the nerve innervation points

question

Central cord syndrome

answer

disproportionately greater loss of motor strength in the upper extremities than in the lower extremities, with varying degress of sensory loss. Common with hyperflexion injury

question

Anterior cord syndrome

answer

parapalegia and a dissociated sensory loss with a loss of pain and temporature sensation

question

C 1 - C 4

answer

require intubation, below C 4 consider for increased work of breathing secondary to muscle innervation changes

question

Poikilothermic

answer

Thermoregulartion is impaired and patient will take the temp of the room, adversely impacts bradycardic patients

question

Spinal Shock

answer

flaccid paralysis, loss of autonomic function, abscence of cutaneous and/or proprioceptive sensation, cessation of all reflex activity below site of injury

question

C2 dens fracture

answer

Common in geriatric patients, hyperextension injury

question

Compression fractures

answer

axial loading injury, degree of compression affects stability, thoracic and lumbar spine usually affected

question

Burst fracture

answer

fracturing in outward pattern, may impinge cord, can have compression and cord compression

question

Chance fracture

answer

Usually L1-2, teardrop fracture, may result in paraplegia, and small bowel injury from lap belt compression and lumbar spine

question

SCIWORA

answer

spinal cord injury without radiographic abnormality, common in PEDS, dislocation with spontaneous relocation, cord injury evident, imaging negative

question

Autonomic dysreflexia

answer

uncontrolled, massive sympathetic reflex to noxious stimuli, below level of lesion

question

Hyphema

answer

blood in anterior chamber of eye, prevent rebleeding, bedrest, limited activity, HOB elevated, cycloplegic agents - atropine gtts, may need patch

question

Open Globe

answer

minimize additional damage, shield w/o pressure, eye patches contraindicated, anticipate need for OR

question

Orbital blowout fracture

answer

Diplopia, can cause eye to look upward secondary to muscle/nerve impigement, emergency surgical repair indicated, delays increase risk of vision loss

question

LeFort I

answer

transverse fx between maxillary and orbital floor, may include maxillary sinuses. Lower maxilla and teeth are mobile or floating but nose and midface stable. May have trismus, malocclusion. Check for mandible fx.

question

Lefort II

answer

includs central maxilla, nasal area, ethmoid bones, tripod shape, grasping front teeth and palate causes movement to nose and upper lip w/o movement to orbital complex, caved in appearance, edema, subconjunctival hemorrhage and epistaxis, early intubation for airway protection. CSF presence - rhinorrhea suggests open skull fx

question

LeFort III

answer

complete craniofacial dysfunction, associated with massive soft tissue, ocular injuries, TBI, skull injuries, cribiform plate and dural tears, rocking mxillar moves the entire face

question

Tripod fx

answer

separation of all three major attachments of the zygoma to the rest of the face

question

Orbigozygomatic fracture

answer

complex fractures of zygoma and orbital floor, pain, trismus, diplopia, numbness to upper lip, lower lid and bilateral nasal area, surgical repair indicated

question

Neck trauma

answer

internal jugular vein and internal carotid artery most commonly injured

question

Zone I neck trauma

answer

highest mortality, angle of mandible to base of skull, difficult to assess, and exploration can increase mortality

question

Zone II neck trauma

answer

mid portion of neck, injuries apparent on exam, most carotid injuries occur here, manage by observation.

question

Zone III Neck trauma

answer

clavicles and sternal notch to cricoid cartilage. hard to assess surgically as so high at skull base. Diagnosis essential as infection can occur and impact mortality after 24 hours. Embolization very valuable, exploration can damage cranial nerves. Angiography to delineate site of injury

question

S/S of emergency intervention in neck trauma

answer

airway obstruction, pulsatile bleeding, expanding hematoma, unresponsive, extensive subcutaneous emphysema

question

s/s of neck trauma needing more diagnostics

answer

voice change, wide mediatstinum, hemoptysis, hematemesis, dysphonia/dysphagia, drooling, bloody sputum, horner's syndrome, pain with turning neck

question

Horner's syndrome

answer

a contracted pupil, drooping upper eyelid, and local inability to sweat on one side of the face, caused by damage to sympathetic nerves on that side of the neck

question

Neck trauma treatment

answer

stabiltize airway, pressure control for bleeding, subclavial injury needs IV on opposite site, consider permissive hypotension, repair vs ligation, shunting, embolization, ligation, antithrombotic

question

Neck trauma diagnostic testing

answer

CXR mandated for zone I, CT most accepted, CT angiogram - excellent for laryngeal and tracheal injuries, as reliable as arteriography. Arteriogram - considered gold standard, invasive with risk of complications, contast load but embolization can happen at the same time.

question

Associated injuries with neck trauma

answer

LeFort fractures, basilar skull fracture involving carotid canal, diffuse axonal injury with GCS < 6, cervical fracture, near hanging/anxoic brain injury, seatbelt abrasion with significant swelling/altered mental status/ TBI, necrotizing infections

question

Frontal impact

answer

Suspected injuries: Capone do, anterior flail chest, myocardial contusion, pneumothorax, traumatic aortic disruption, fracturednspleennornkiver, posterior fracture/dislocation of hip and/or knee

question

Side impact

answer

Suspect injuries: contra lateral neck sprain, Capone go, lateral flail chest, pneumothorax, traumatic aortic disruption, diaphragmatic disruptive, fractured spleen liver or kidney, fix Pelvis or scetabulum

question

Rear impact

answer

Cspine injury or soft tissue to neck

question

Pedestrian struck

answer

Head injury, traumatic aortic disruption, and visceral injury, fractured lower extremity or pelvis

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