Em Test 4.20; Essentials Of Trauma; Kek

Front 1

what are the earliest signs of hemorrhagic shock?

Back 1

tachycardia and vasoconstriction

Front 2

name the general initial tx in hemorrhagic shock.

Back 2

volume resuscitation using warmed crystalloids: ringers lactate and saline

Front 3

what solution is normally not used in trauma to replace volume loss?

Back 3

dextrose - sugars are not good in trauma (unless diabetic needed it)

Front 4

How many classes of hemorrhagic shock are there and what are they based on?

Back 4

4 classes; based on amount of blood loss and symptoms

Front 5

Name the Class of hemorrhagic shock. Person loses 30-40% (1500-2000cc = 1.5-2L of blood); Symptoms: tachypnic, tachycardia HR>120; decrease in systolic P; Change in mental status.

Back 5

Class III Hemorrhage (use blood products and crystalloids, typed if possible)

Front 6

Name the Class of hemorrhagic shock. Person loses 0-15% (0-750cc); HR<100; Tx with cystalloids, no blood products.

Back 6

Class I Hemorrhage

Front 7

Name the Class of hemorrhagic shock. Person loses >40% = >2L; tachycardia HR>140; decreased BP, confusion, lethargy.

Back 7

Class IV Hemorrhage (use blood warmers, 2L cyrstalloid and Type O Rh- for women, Rh- or Rh+ for men

Front 8

Name the Class of hemorrhagic shock. Person loses 15-30% loss (750-1500cc), Tachypnic, HR>100; narrow pulse pressure.

Back 8

Class II hemorrhage (tx. with crystalloids, then blood products if needed)

Front 9

name the universal scale used to measure the neurological state of a patient and what are its components?

Back 9

Glascow Coma Scale (3-15); Elements: Eye(1-4), Verbal(1-5), and Motor(1-6) Responses (all added together)

Front 10

At what GCS # is not a head trauma no longer considered minor?

Back 10

GCS <13 is no longer a head injury and requires a CT

Front 11

Define a concussion.

Back 11

any brief neurological deficit after a head injury (LOC is not required); hallmark: amnesia and confusion

Front 12

What GCS number is considered severe head trauma?

Back 12

GCS<8

Front 13

What is the immediate management for a severe Head trauma?

Back 13

intubate, ventilate to normocapnia (hyperventilation is the last resort to decrease ICP)

Front 14

What 2 variables must you control in a severe head trauma and have the greatest effect on outcome?

Back 14

BP and O2 (most trauma pts are hypotensive S<90 and hypoxic, PaO2<60)

Front 15

Define Cerebral Perfusion pressure and what level should be maintained?

Back 15

CPP is the net pressure of blood flow to the brain; narrow limits, too little (ischemia), too much (raised ICP); Measured as CPP=MAP(mean arterial P) - ICP; should be b/w 70-90mmHg in an adult; <70 will cause ischemia

Front 16

what is a normal person's ICP?

Back 16

resting ~8-10; if you sneeze it could go up to 13-15

Front 17

what ICP should be maintained in a severe head trauma pt?

Back 17

ICP<20mmHg

Front 18

what is the MAP and what # should be maintained in a severe head trauma?

Back 18

Mean Arterial Pressure describes the average BP; its the average arterial P during a single cardiac cycle; should be kept >90mmHg in severe head Trauma

Front 19

extra: what is the normal pO2, pCO2, and HCO3- in an arterial blood gas?

Back 19

pO2: 75-100mmHg; pCO2: 35-45mmHg; HCO3-: 22-30mmol/L

Front 20

describe a subdural hematoma on CT.

Back 20

due to disruption of the bridging veins; blood flows into dura and appears semi-lunar (aka crescentic) and does NOT respect suture lines.

Front 21

Describe the density of subdurals on CT in regard to days after injury.

Back 21

Day 1-3: hyperdense; Day 3-14 (isodense - may need contrast to see); Day >14: hypodense

Front 22

Desbribe and define an epidural hematoma on CT.

Back 22

due to a tear in a vascular structure (many times its the middle meningeal artery under the pterion on the temple); blood accumulates b/w the dura and the skull; blood respects suture lines and appears elliptical/lenticular in shape; 75% are associated with skull fractures; and 1/3 present with LOC, lucid interval, the rapid decompensation

Front 23

what is the most common type of intracranial hemorrhage in trauma?

Back 23

subarachnoid hemorrhage - will see SH in trauma and aneurysm

Front 24

describe a Subarachnoid hemorrhage on CT.

Back 24

blood follows the brain surfaces, in the fissures and sulci; will see white areas lining the brain surfaces, in the ventricles (if fresh - will be white)

Front 25

_____ coalesce into intracerebral hematomas over time and may be single or multiple on CT.

Back 25

Contusions - parenchymal contusions with direct injury

Front 26

Describe the classic appearance of contusions on CT.

Back 26

salt and pepper like appearance. (see hyperdense blood with black (edema) around it)

Front 27

what lobes are more commonly affected by contusions -> intracerebral hematomas?

Back 27

frontal and temporal lobes

Front 28

if you are seeing a pt that is clinically severe but the CT is not in correlation with the severity of their injury, what should you think of?

Back 28

Diffuse Axonal Injury or Carotid or vertebral artery problem

Front 29

what is a DAI?

Back 29

diffuse axonal injury is a shearing injury secondary to acceleration and deceleration occuring at different rates across the brain during impact; usually occurs at grey/white junctions on CT; DAI is the cause of many vegetative cases, disabilities, and institutionalizations

Front 30

The CT of DAI looks alot like what other brain injury? what makes them different?

Back 30

DAI CT looks alot like contusions, but in diffuse axonal injury the patients injuries are severe and are usually unconscious/vegetative

Front 31

These skull fractures are not clincally significant except in children.

Back 31

Linear skull fractures; all peds get CT to look for underlying brain injury

Front 32

____ skull fractures are linear fractures that run thru the base of the skull often through the petrous temporal bone or anterior cranial fossa.

Back 32

Basilar - look for CSF leak - usually tx with Antibiotics

Front 33

If the basilar fracture is through the petrous bone, what may be present on the pt?

Back 33

ecchymosis over the mastoid bone and otorrhea. may also present with

Front 34

If the basilar linear fracture is through the anterior cranial fossa it may present how on the pt?

Back 34

raccoon eyes and rhinorrhea

Front 35

A kid gets hit with a baseball bat on the frontotemporal region. His skull is pushed down in the area. what is it called and what is the management?

Back 35

Depressed Skull fracture; if the skull is depressed >1cm it requires surgical reduction/elevation

Front 36

What is commonly seen on CT with a depressed skull fracture?

Back 36

pneumocephalus - air pocket near fracture

Front 37

If a patient has hydrocephalus and a shunt is put in, what must you becareful of and why?

Back 37

draining too fast can cause the brain to collapse and get subdurals - need to drain fluid slowly

Front 38

this head injury is generally uncomplicated; the area is well vascularized and hemostasis is generally achieved with staples or suture.

Back 38

Scalp lacerations

Front 39

Name the 5 layers of the scalp.

Back 39

1)Skin, 2)Subcutaneous tissue, 3)Galea aponeurosis, 4)Loose areolar tissue, 5)Skull periosteum

Front 40

neck traumas are divided up into 3 zones, each zone is managed differently; name the zones from inferior to superior.

Back 40

Zone 1: Clavicle to cricoid cartilage; Zone2: cricoid to mandible; Zone3: mandible to skull base

Front 41

If the platysma is intact, what is the management of a neck injury?

Back 41

local exploration is sufficient

Front 42

What characteristic in a neck injury would cause you to send the pt. directly to the OR?

Back 42

if the pt. were hemodynamically unstable

Front 43

Name the treatments done for a zone 1 injury?

Back 43

angiography + esophogram, and if there is a problem with breathing, do a bronchoscopy

Front 44

Name the treatments done for a zone 2 injury?

Back 44

angiography + esophogram, and if there is a problem with breathing, do a bronchoscopy or OR exploration

Front 45

Name the treatments done for a zone 3 injury?

Back 45

angiography

Front 46

If the trauma is a ____ wound, assume the worse.

Back 46

gun shot - can't tell the extent of injury

Front 47

how does a pt. get a cardiac contusion and what is the management?

Back 47

usually steering wheel injury to the chest; usually can see steerling wheel bruise/imprint; if the EKG is abnormal or dysrhythmias occur: admit; if hemodynamically unstable, do an echocardiogram

Front 48

which is more fatal, a contusion with a tear to the ascending or descending aorta and why?

Back 48

a contusion with a tear on the ascending aorta is more fatal because you will lose blood flow to the coronary arteries and death will be around the corner

Front 49

patient comes into the ER with a flail chest and obvious abrasions from a MVA, what vital structures should you be concerned with?

Back 49

Cardiac and pulmonary contusions

Front 50

Pulmonary contusions will lead to ____ gas exchange, ___ compliance, and __ pulmonary vasculature resistance. (use increase or decrease for answers).

Back 50

decrease gas exchange; decrease compliance and increase pulmonary resistance

Front 51

Name the declining prognosis that often develops with pulmonary contusions.

Back 51

pulmonary contusions often lead to pneumonia --> Adult respiratory distress syndrome (contusions often cause edema, hemorrhage, and atelectasis to form; also rib fractures will cause the person to breath shallower: all these factors will set up for pneumonia)

Front 52

what should you keep in mind in a pulmonary contusion pt. in terms of O2 saturation?

Back 52

be aware that hypoxia is not always apparent right away but is often delayed

Front 53

What type of imaging studies do you perform on pulmonary contusions and which is more sensitive?

Back 53

CXR is often 1st, but the contusions often become more visible after 24 hours; CT Scan is much more sensitive and will show up earlier

Front 54

How do you manage Pulmonary contusion pts and what is significant about intubation?

Back 54

MANAGEMENT: O2, pain killers for rib fractures (maybe they'll breath better if they can't feel the pain in their chests) "supportive care";; INTUBATION should be avoided unless neccessary - these pts tend to get ventilator dependent

Front 55

describe how a pt would present in the ER with a sternal fracture.

Back 55

obvious injury (takes alot to fracture a sternum); localized pain, dyspnea or palpitations, soft tissue injuries are not always present because there is little soft tissue over the sternum

Front 56

What modalities help in your diagnosis of a sternal fracture?

Back 56

CXR (PA/AP/lateral) and if clinical suspicion is high - sternal view; CT may help but sensitivity is unclear; EKG - do on all pts with sternal injury to evaluate for concomitant cardiac contusion

Front 57

how would you manage a sternal fracture and who gets admitted?

Back 57

Stable and non-displaced sternum with normal exam - discharge with analgesics; ADMISSION goes to: elderly with cardiac dz, significant pain or unstable fractures; New EKG changes; all pts with retractable pain, sign. pain, or other significant injury (displaced fractures warrant consultation with orthopedics)

Front 58

What is the most common chest wall injury?

Back 58

Rib fractures

Front 59

how do rib fractures present?

Back 59

tenderness, crepitus, ecchymosis, pain (diagnose with CXR)

Front 60

Subcutaneous air is consistent with underlying ____ and should prompt further evaluation.

Back 60

pneumothorax

Front 61

if the pt has a lower rib fracture (8-12) it should alert you to what?

Back 61

intra-abdominal injury to liver, spleen, etc

Front 62

How do you manage/Tx rib fractures?

Back 62

analgesia, possible nerve blocks for multiple fractures, make sure patient is breathing adequately to prevent pneumonia with an incentive spirometer for home use

Front 63

When should you admit rib fracture pts?

Back 63

elderly with >3 fractures or significant underlying pulmonary disease (high mortality); pts with intractrable pain or dyspnea; unable to comply with pulmonary toilet; 2 fractures >55age

Front 64

how does one get a pneumothorax?

Back 64

blunt trauma, penetrating trauma, or non-traumatic (ie. spontaneous- from a bleb or bullae rupturing; lung infections; mechanical ventilation with high pressures)

Front 65

(extra) describe a tension pneumo.

Back 65

Tension pneumothorax is a life-threatening emergency. It is caused when air enters the pleural space during inspiration but cannot exit during exhalation. The positive pressure results in collapse of the involved lung and a shift of the mediastinal structures to the contralateral side. This causes a decrease in cardiac output as a consequence of decreased venous return and leads to rapidly progressive shock and death if not treated

Front 66

(extra)a pneumothorax can be either simple or complicated. what is the difference?

Back 66

In a simple pneumothorax, air in the pleural space does not build up significant pressure but allows the lung to collapse 10-30% without further expansion of the pneumothorax. A complicated pneumothorax is progressive and consists of continued air leakage into the pleural space and progressive lung collapse. This continued air leak results in positive pressure within the hemithorax and displacement of the mediastinum (ie, tension pneumothorax).

Front 67

describe how a pt would present with a SIMPLE and describe a pt with a COMPLICATED/TENSION pneumothorax.

Back 67

SIMPLE: pleurtic chest pain or SOB; decreased breath sounds, may have decreased O2 sats but the BP is normal; COMPLICATED or TENSION pneumo: the pt is in obvious distress with decreased breath sounds, hyperresonance to percussion and may have tracheal deviation, hypotension, tachycardia, hypoxia may be present

Front 68

how do you manage a tension pneumo that presents to your ER?

Back 68

this is a clinical diagnosis and there is no time for a CXR; do emergency thoracostomy (either in the 2nd intercoastal space midclavicular or do a lateral in the midaxillary line) with a 14 gauge needle (to decompress) then follow with a chest tube

Front 69

how do you manage a suspected simple pneumothorax?

Back 69

do a CXR as long as the pt is hemodynamically stable then do a thoracostomy followed by a standard 32-36 French chest tube

Front 70

when viewing an upright CXR what would you notice if you suspected pneumothorax?

Back 70

normal side - you'd see lung markings; pneumothorax (deflated)side you'd see black space (air)

Front 71

What is an occult pneumothorax?

Back 71

the presence of pneumothorax on computed tomography of the chest or abdomen but absence on chest x-ray

Front 72

what is the term for blood in the chest cavity and how is a simple one managed?

Back 72

Hemothorax; Simple hemothoraces should be treated with posteriorly directed chest tubes (size: at least 32 French in adults) to drain the blood

Front 73

What diagnostic modality is most sensitive for hemothorax?

Back 73

CT Scan (shows amount and location); CXR-AP upright will show fluid levels but CT is most sensitive

Front 74

when do you put in an anterior chest tube vs. a posterior chest tube?

Back 74

anterior goes in hemo/pneumothoraces and those thought to require positive pressure ventilation; Posterior chest tubes go in simple hemothoraces

Front 75

this trauma is also caused by blunt or penetrating trauma and is due to a ruptured heart or leak or aortic disruption where blood surrounds the heart in its sac.

Back 75

pericardial effusion

Front 76

describe the clinical findings in pericardial effusions.

Back 76

Hypotension (classic but uncommon); neck vein distention, muffled heart sounds, Low voltage EKG

Front 77

in an suspected pericardial effusion it is too dangerous to send the pt for a CT, what is the best tool to help diagnosis?

Back 77

FAST ultrasound - Focused Assessment with Sonography Trauma

Front 78

How do you manage a pericardial effusion?

Back 78

bolus with IV fluids, drainage via the pericardial window is best, needle aspiration

Front 79

how does a pericardial effusion look on CXR?

Back 79

looks like a big fluffy boot

Front 80

blunt trauma to the abdomen is more likely to cause injury to ____ _____.

Back 80

solid organs; liver>spleen

Front 81

This trauma is rare in blunt trauma, requires extensive evaulation, has a high (24%) mortality and may be associated with dissections, thrombosis, or rupture.

Back 81

Vascular Abdominal Trauama - presents with intrabdominal pain, mass, bruits or with neurologic or distal vascular findings - concern for great vessels (abdominal aorta, iliacs)

Front 82

___is the 2nd leading cause of death in abuse cases.

Back 82

abdominal trauma caused by child abuse

Front 83

this trauma is more commonly seen in penetrating trauma than blunt and is usually repaired surgically. most are left-sided because the right is protected by the liver.

Back 83

Diaphragm Injuries - pt with respiratory distress, bowel sounds in chest

Front 84

Describe the possibilities that Diaphragmatic injuries present on CXR.

Back 84

may be: normal, elevated hemi-diaphragm, poorly defined hemi-diaphragm; hemothorax/pneumothorax; bowel in the chest cavity/air fluid levels in chest

Front 85

What technique is usually done with a diaphragmatic injury to cleanse the abdominal cavity and name some things that are found.

Back 85

Diagnostic Peritoneal Lavage: find gross blood, RBC, WBC, Food, bile, feces

Front 86

(eMed) what is a hollow viscus injury?

Back 86

Viscus injuries to hollow organs (eg, stomach, intestine, bladder) remain the nemesis of the trauma surgeon and are a risk of the nonoperative management strategies adopted for solid organ injuries. Repeat clinic examinations, a high index of suspicion, and follow-up imaging help detect these injuries early to minimize associated morbidity. Increasing abdominal pain or distention may indicate a hollow visceral injury. Free intraperitoneal fluid on CT scan without evidence of an associated solid organ injury may be the result of a hollow organ injury. The presence of a handlebar mark or lower abdominal wall ecchymosis in a lap belt–restrained child (seat belt sign) should raise concerns for hollow viscus injury.

Front 87

Name the organs that are most common in hollow viscus injuries.

Back 87

small bowel>large bowel>stomach

Front 88

what is the best imaging to diagnose retroperitoneal injuries?

Back 88

CT is test of choice

Front 89

This type of injury is the most common of the blunt injury types; the spleen is effected more than the liver, and it is managed conservatively.

Back 89

Solid organ injury

Front 90

What is the Study of Choice for solid organ injuries.

Back 90

CT (99%NPV- 99% are True Negatives)

Front 91

What does F.A.S.T. ultrasound stand for?

Back 91

Focused Assessment by Sonography in Trauma

Front 92

What is its primary intention?

Back 92

detect free intraperitoneal blood

Front 93

When using FAST name and describe the 4 common views.

Back 93

1)Left Upper Quadrant (Morison' Pouch); 2)RUQ (Splenorenal Space); 3)Subxiphoid; and 4)Suprapubic/Pouch of Douglas

Front 94

If a person has 1 L of fluid inside the abdominal cavity, what is the FAST's sensitivity?

Back 94

97-98%