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94 Cards in this Set

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what are the earliest signs of hemorrhagic shock?
tachycardia and vasoconstriction
name the general initial tx in hemorrhagic shock.
volume resuscitation using warmed crystalloids: ringers lactate and saline
what solution is normally not used in trauma to replace volume loss?
dextrose - sugars are not good in trauma (unless diabetic needed it)
How many classes of hemorrhagic shock are there and what are they based on?
4 classes; based on amount of blood loss and symptoms
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.
Class III Hemorrhage (use blood products and crystalloids, typed if possible)
Name the Class of hemorrhagic shock. Person loses 0-15% (0-750cc); HR<100; Tx with cystalloids, no blood products.
Class I Hemorrhage
Name the Class of hemorrhagic shock. Person loses >40% = >2L; tachycardia HR>140; decreased BP, confusion, lethargy.
Class IV Hemorrhage (use blood warmers, 2L cyrstalloid and Type O Rh- for women, Rh- or Rh+ for men
Name the Class of hemorrhagic shock. Person loses 15-30% loss (750-1500cc), Tachypnic, HR>100; narrow pulse pressure.
Class II hemorrhage (tx. with crystalloids, then blood products if needed)
name the universal scale used to measure the neurological state of a patient and what are its components?
Glascow Coma Scale (3-15); Elements: Eye(1-4), Verbal(1-5), and Motor(1-6) Responses (all added together)
At what GCS # is not a head trauma no longer considered minor?
GCS <13 is no longer a head injury and requires a CT
Define a concussion.
any brief neurological deficit after a head injury (LOC is not required); hallmark: amnesia and confusion
What GCS number is considered severe head trauma?
GCS<8
What is the immediate management for a severe Head trauma?
intubate, ventilate to normocapnia (hyperventilation is the last resort to decrease ICP)
What 2 variables must you control in a severe head trauma and have the greatest effect on outcome?
BP and O2 (most trauma pts are hypotensive S<90 and hypoxic, PaO2<60)
Define Cerebral Perfusion pressure and what level should be maintained?
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
what is a normal person's ICP?
resting ~8-10; if you sneeze it could go up to 13-15
what ICP should be maintained in a severe head trauma pt?
ICP<20mmHg
what is the MAP and what # should be maintained in a severe head trauma?
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
extra: what is the normal pO2, pCO2, and HCO3- in an arterial blood gas?
pO2: 75-100mmHg; pCO2: 35-45mmHg; HCO3-: 22-30mmol/L
describe a subdural hematoma on CT.
due to disruption of the bridging veins; blood flows into dura and appears semi-lunar (aka crescentic) and does NOT respect suture lines.
Describe the density of subdurals on CT in regard to days after injury.
Day 1-3: hyperdense; Day 3-14 (isodense - may need contrast to see); Day >14: hypodense
Desbribe and define an epidural hematoma on CT.
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
what is the most common type of intracranial hemorrhage in trauma?
subarachnoid hemorrhage - will see SH in trauma and aneurysm
describe a Subarachnoid hemorrhage on CT.
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)
_____ coalesce into intracerebral hematomas over time and may be single or multiple on CT.
Contusions - parenchymal contusions with direct injury
Describe the classic appearance of contusions on CT.
salt and pepper like appearance. (see hyperdense blood with black (edema) around it)
what lobes are more commonly affected by contusions -> intracerebral hematomas?
frontal and temporal lobes
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?
Diffuse Axonal Injury or Carotid or vertebral artery problem
what is a DAI?
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
The CT of DAI looks alot like what other brain injury? what makes them different?
DAI CT looks alot like contusions, but in diffuse axonal injury the patients injuries are severe and are usually unconscious/vegetative
These skull fractures are not clincally significant except in children.
Linear skull fractures; all peds get CT to look for underlying brain injury
____ skull fractures are linear fractures that run thru the base of the skull often through the petrous temporal bone or anterior cranial fossa.
Basilar - look for CSF leak - usually tx with Antibiotics
If the basilar fracture is through the petrous bone, what may be present on the pt?
ecchymosis over the mastoid bone and otorrhea. may also present with
If the basilar linear fracture is through the anterior cranial fossa it may present how on the pt?
raccoon eyes and rhinorrhea
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?
Depressed Skull fracture; if the skull is depressed >1cm it requires surgical reduction/elevation
What is commonly seen on CT with a depressed skull fracture?
pneumocephalus - air pocket near fracture
If a patient has hydrocephalus and a shunt is put in, what must you becareful of and why?
draining too fast can cause the brain to collapse and get subdurals - need to drain fluid slowly
this head injury is generally uncomplicated; the area is well vascularized and hemostasis is generally achieved with staples or suture.
Scalp lacerations
Name the 5 layers of the scalp.
1)Skin, 2)Subcutaneous tissue, 3)Galea aponeurosis, 4)Loose areolar tissue, 5)Skull periosteum
neck traumas are divided up into 3 zones, each zone is managed differently; name the zones from inferior to superior.
Zone 1: Clavicle to cricoid cartilage; Zone2: cricoid to mandible; Zone3: mandible to skull base
If the platysma is intact, what is the management of a neck injury?
local exploration is sufficient
What characteristic in a neck injury would cause you to send the pt. directly to the OR?
if the pt. were hemodynamically unstable
Name the treatments done for a zone 1 injury?
angiography + esophogram, and if there is a problem with breathing, do a bronchoscopy
Name the treatments done for a zone 2 injury?
angiography + esophogram, and if there is a problem with breathing, do a bronchoscopy or OR exploration
Name the treatments done for a zone 3 injury?
angiography
If the trauma is a ____ wound, assume the worse.
gun shot - can't tell the extent of injury
how does a pt. get a cardiac contusion and what is the management?
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
which is more fatal, a contusion with a tear to the ascending or descending aorta and why?
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
patient comes into the ER with a flail chest and obvious abrasions from a MVA, what vital structures should you be concerned with?
Cardiac and pulmonary contusions
Pulmonary contusions will lead to ____ gas exchange, ___ compliance, and __ pulmonary vasculature resistance. (use increase or decrease for answers).
decrease gas exchange; decrease compliance and increase pulmonary resistance
Name the declining prognosis that often develops with pulmonary contusions.
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)
what should you keep in mind in a pulmonary contusion pt. in terms of O2 saturation?
be aware that hypoxia is not always apparent right away but is often delayed
What type of imaging studies do you perform on pulmonary contusions and which is more sensitive?
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
How do you manage Pulmonary contusion pts and what is significant about intubation?
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
describe how a pt would present in the ER with a sternal fracture.
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
What modalities help in your diagnosis of a sternal fracture?
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
how would you manage a sternal fracture and who gets admitted?
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)
What is the most common chest wall injury?
Rib fractures
how do rib fractures present?
tenderness, crepitus, ecchymosis, pain (diagnose with CXR)
Subcutaneous air is consistent with underlying ____ and should prompt further evaluation.
pneumothorax
if the pt has a lower rib fracture (8-12) it should alert you to what?
intra-abdominal injury to liver, spleen, etc
How do you manage/Tx rib fractures?
analgesia, possible nerve blocks for multiple fractures, make sure patient is breathing adequately to prevent pneumonia with an incentive spirometer for home use
When should you admit rib fracture pts?
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
how does one get a pneumothorax?
blunt trauma, penetrating trauma, or non-traumatic (ie. spontaneous- from a bleb or bullae rupturing; lung infections; mechanical ventilation with high pressures)
(extra) describe a tension pneumo.
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
(extra)a pneumothorax can be either simple or complicated. what is the difference?
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).
describe how a pt would present with a SIMPLE and describe a pt with a COMPLICATED/TENSION pneumothorax.
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
how do you manage a tension pneumo that presents to your ER?
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
how do you manage a suspected simple pneumothorax?
do a CXR as long as the pt is hemodynamically stable then do a thoracostomy followed by a standard 32-36 French chest tube
when viewing an upright CXR what would you notice if you suspected pneumothorax?
normal side - you'd see lung markings; pneumothorax (deflated)side you'd see black space (air)
What is an occult pneumothorax?
the presence of pneumothorax on computed tomography of the chest or abdomen but absence on chest x-ray
what is the term for blood in the chest cavity and how is a simple one managed?
Hemothorax; Simple hemothoraces should be treated with posteriorly directed chest tubes (size: at least 32 French in adults) to drain the blood
What diagnostic modality is most sensitive for hemothorax?
CT Scan (shows amount and location); CXR-AP upright will show fluid levels but CT is most sensitive
when do you put in an anterior chest tube vs. a posterior chest tube?
anterior goes in hemo/pneumothoraces and those thought to require positive pressure ventilation; Posterior chest tubes go in simple hemothoraces
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.
pericardial effusion
describe the clinical findings in pericardial effusions.
Hypotension (classic but uncommon); neck vein distention, muffled heart sounds, Low voltage EKG
in an suspected pericardial effusion it is too dangerous to send the pt for a CT, what is the best tool to help diagnosis?
FAST ultrasound - Focused Assessment with Sonography Trauma
How do you manage a pericardial effusion?
bolus with IV fluids, drainage via the pericardial window is best, needle aspiration
how does a pericardial effusion look on CXR?
looks like a big fluffy boot
blunt trauma to the abdomen is more likely to cause injury to ____ _____.
solid organs; liver>spleen
This trauma is rare in blunt trauma, requires extensive evaulation, has a high (24%) mortality and may be associated with dissections, thrombosis, or rupture.
Vascular Abdominal Trauama - presents with intrabdominal pain, mass, bruits or with neurologic or distal vascular findings - concern for great vessels (abdominal aorta, iliacs)
___is the 2nd leading cause of death in abuse cases.
abdominal trauma caused by child abuse
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.
Diaphragm Injuries - pt with respiratory distress, bowel sounds in chest
Describe the possibilities that Diaphragmatic injuries present on CXR.
may be: normal, elevated hemi-diaphragm, poorly defined hemi-diaphragm; hemothorax/pneumothorax; bowel in the chest cavity/air fluid levels in chest
What technique is usually done with a diaphragmatic injury to cleanse the abdominal cavity and name some things that are found.
Diagnostic Peritoneal Lavage: find gross blood, RBC, WBC, Food, bile, feces
(eMed) what is a hollow viscus injury?
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.
Name the organs that are most common in hollow viscus injuries.
small bowel>large bowel>stomach
what is the best imaging to diagnose retroperitoneal injuries?
CT is test of choice
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.
Solid organ injury
What is the Study of Choice for solid organ injuries.
CT (99%NPV- 99% are True Negatives)
What does F.A.S.T. ultrasound stand for?
Focused Assessment by Sonography in Trauma
What is its primary intention?
detect free intraperitoneal blood
When using FAST name and describe the 4 common views.
1)Left Upper Quadrant (Morison' Pouch); 2)RUQ (Splenorenal Space); 3)Subxiphoid; and 4)Suprapubic/Pouch of Douglas
If a person has 1 L of fluid inside the abdominal cavity, what is the FAST's sensitivity?
97-98%