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244 Cards in this Set

  • Front
  • Back
Important trauma epidemiology facts.
Trauma is the leading cause of death in ages 1-44. In ages 4-34, trauma causes more deaths than all other diseases combined. MVA causes 50,000 deaths per year, and half involve etoh.
What is the mortality distribution of trauma.
Occurs in three peaks: PRE HOSPITAL: devastating head and vascular injuries. FIRST HOURS: Major chest head and abdominal injuries. ICU: Sequelae of organ hypoperfusion—MOSF
What level of govt is responsible for designating trauma centers?
The states.
What are the essential components for designation of Level I trauma centers?
1. 24/7 availability of all surgical subspecialties
2. Neurosurg and hemodialysis 24/7
3. Injury prevention, education programs
4. Trauma research program
What are the three bases of trauma triage?
Trauma triage is supposed to be based on physiology, anatomy and mechanism.
What are the life-threatening injuries that should be identified on the primary survey?
1. Airway obstruction
2. Tension pneumo
3. massive hemothorax
4. massive hemorrhage
5. open pneumothorax
6. flail chest
7. cardiac tamponade
Give a very broad outline of the ATLS initial approach.
1. Primary survey
2. rapid resusc
3. secondary survey
4. diagnostic tests
5. ultimate disposition
What is the intubation procedure of choice under ATLS?
RSI with c-spine stabilization.
When is intubation indicated per ATLS?
GCS < 8 or extreme agitation.
What are the NEXUS criteria (briefly)?
If no midline tenderness, neuro deficits, distracting injury, AMS or intoxication, C-spine xrays are not indicated.
What is the most common cause of traumatic airway obstruction?
The tongue.
What are the traumatic contraindications to nasotracheal intubation?
Maxillofacial trauma, basilar skull fracture, apnea.
On the ATLS approach, what interventions are indicated under “A”?
Airway and C-spine control.
On the ATLS approach, what interventions are indicated under “B”?
1. Occlusive dressing for sucking chest wound.
2. Repositionin of ET tube.
3. Chest tube to relieve hemo/pneumothorax; if >1500 ml initially, thoracotomy is indicated.
On the ATLS approach, which interventions are indicated uncer “C”?
1. Obtain IV access.
2. Evaluate circulation.
3. Control blood loss.
4. Replace bloos loss: 3mL crystalloid = 1 mL blood. Whole blood or PRBCs can be used.
How do pulses correlate with blood pressure?
Radial = BP > 80
Femoral = BP > 70
Carotid = BP > 60
Normal blood volume = ____% of body weight = ____ L
Normal blood volume = 7% of body weight = 5 L.
What is the typical blood loss from a femur fracture?
500-1000 cc.
What is the typical blood loss from a pelvic fracture?
1500 – 2000 cc.
What is to be done about blood replacement in trauma when type-specific blood is unavailabe?
Type O neg is universal donor blood, but remember that O pos can be used in males.
Full crossmatch blood is preferred in trauma, but it takes an hour. Is there another option besides Oneg?
Type-specific ABO + Rh-compatible can be used (takes about 10 min).
ATLS hemorrhage classification.
CLASS I: < 15% blood loss; no significant changes.
CLASS II: 15-30% blood loss = dec cap refill, inc heart rate, narrow pulse pressure.
CLASS III: 30-40% blood loss = shock, dec BP.
CLASS IV: >40% blood loss = preterminal.
What are the most important things to remember about the “D” (disability) step of ATLS?
AMS requires early head CT. Intoxication is not the cause of AMS, except as a diagnosis of exclusion.
The (way overhyped) GCS.
EYES:
spont-4,
command-3,
pain-2,
none-1

VERBAL:
oriented-5,
confused-4,
inappropriate-3,
unintelligible-2,
none-1.

MOTOR: obeys-6,
localizes-5,
withdraws-4,
flexion-3,
extension-2,
flaccid-1.
What are the absolute indications for ED thoracotomy?
Penetrating chest trauma + signs of life prehosp or ED + cardiac electrical activity in ED.
What are the liberal indications for ED thoracotomy?
Abdominal trauma and cardiac activity requiring aortic cross-clamping to get to the OR. Blunt trauma with loss of vitals in the ED. All the absolute indications.
Trauma causes ___% of all pediatric deaths.
50% (!)
In Pediatric trauma, how do evaluation and treatment priorities differ from those for adults?
They don’t.
The most common lethal injury in pediatric populations is_____.
Head injury.
Airway anatomy considerations in kids.
1. Large occiput tends to flex neck.
2. Obligate nose breathers < 6 months.
3. Increased tongue size.
4. Anterior larynx.
5. Narrow subglottic area.
6. Uncuffed ET tube fo age < 8.
What is the age cutoff for cuffed ET tubes?
Age <8.
Technical considerations in pediatric trauma airway management.
1. Straight blade
2. ET size (mm) = (age + 16)/4 = size of the pinky.
3. Depth of insertion = 3x tube size.
4. No cricothyrotomy if < 8 years old.
5. Avoid blind nasal intubation.
What is the age cutoff of cricothyrotomy?
No cric if < 8 yearsold.
Discuss transtracheal jet ventilation.
Used if ET intubation impossible. Allows oxygenation, but ventilation is poor. Strictly a temporizing measure.
What is the most important contraindication to interosseous line placement.
DON’T put that sucker in a broken limb.
Complications of interosseous line placement are rare. What are they?
1. Growth plate injury.
2. Compartment syndrome
3. Fluid leakage
4. Fat emboli
5. Osteomyelitis.
True or False: although interosseious lines can be used for fluid resuscitation and drug administration, they cannot be used for giving blood.
False. Interosseous lines CAN be used for blood product administration.
What is the treatment for hypovolemic shock in the pediatric patient?
1. Crystalloid 20 ml/kg bolus (X2 if poor resopnse)
2. PRBC 10mL/kg
3. Avoid hypothermia: warm fluids to 40C
T or F: in kids, abdominal injuries are often managed nonoperatively.
True.
Discuss C-spine fractures in children.
They’re rare, with c1-c4 most common < 8 yo. Most result from flexion injury. Remember, cord injury is more common than fracture—think SCIWORA, which requires MRI for imaging.
What is the second most common cause of traumatic death in kids < 5yo.
Burns. And remember—many have inhalation injuries.
Things to remember about pediatric head trauma:
1. Poor pressure/volume curve
2. More nonsurgical lesions (diffuse cerebral edema, diffuse axonal shear, contusions, and peds concussion syndrome).
3. GCS may wax and wane.
What are the characteristics of a child abuser?
Young, unemployed, stressed-out substance abuser with a history of prior abuse.
What are suspicious fractures for child abuse?
1. Any < 1 year.
2. Rib (posterior).
3. Skull, spine, sternum.
4. Bilateral, multiple, various stages of healing.
5. Long bone.
6. Metaphyseal.
What are the characteristics of shaken baby syndrome?
Diffuse cerebral injury with edema, retinal hemorrhages, and poor prognosis.
T or F: most falls in geriatric populations involve short heights, such as falling from a stool or chair or a short flight of stairs.
False! Most falls in the elderly occur ON A LEVEL SURFACE, because of environmental hazards, or because Ginger bought Granma a pair of Nikes.
T or F: a metaphysial bucket handle fracture is highly suspicious for child abuse.
Technically false. This injury results from rotational and shearing forces, and it’s PATHOGNOMONIC for child abuse.
What are the historical features that make a presentation suspicious for domestic violence?
1. Inconsitencies in history
2. Injury and history do not correlate
3. Delay in seeking treatment
4. Pregnancy
5. May present as depression or suicide attempt
T or F: Most states do not have mandatory reporting of domestic violence.
False. Most states do.
What factors increase the risk of a lethal outcome in domestic violence?
1. Firearms
2. Child abuse
3. Public displays of violence
4. Sexual assault
5. Abused partner ends relationship
What are the common injuries and findings victims of domestic abuse?
Pregnancy Injuries to head, neck, abdomen and thorax Injuries in different stages of healing Fingernail scratches cigarette burns rope burns bites defensive injuries fractures and bruising
Uterus rises out of the pelvis at ____
12 weeks.
What is the mortality of penetrating trauma in pregnancy?
Maternal mortality is relatively low. Fetal mortality is relatively high.
What are signs of post-traumatic fetal demise?
Loss of movement, absent heart tones, and extended extremities.
In the setting of trauma, what is the most important factor in preventing fetal demise?
Maternal stabilization.
Is maternal mortality higher in blunt trauma or penetrating trauma?
Blunt.
What are the most common causes of maternal trauma?
MVCs, falls, and assaults.
What method ofDPL is used in pregnancy?
The open supraumbilical approach.
What is the fetal mortality in traumatic uterine rupture.
Almost 100% (maternal mortality is lower).
What is the presentation of post-traumatic uterine rupture?
Uncommon Late 2d/3d trimester previous C-section abdominal pain loss of uterine contour palpable fetal parts shock fetal demise
What is the leading cause of maternal death in trauma?
Abruptio placentae
What is the 2d leading cause of fetal death in trauma?
Abruptio placentae
What is the leading traumatic cause of maternal death?
Blunt trauma
True or false: abruptio placentae can occur in the setting of relatively innocuous trauma and minor falls.
True. So don’t fuck up.
True of false: abruptio placentae frequently presents without vag bleed.
Abso-fuckin’-lutely true.
T or F: DIC is an uncommon complication of abruptio placentae.
False. DIC is a common complication in this setting.
What is the name of the test that checks for fetal cells in the maternal circulation?
The Kleihauer-Betke.
When should RhoGAM be given in the setting of trauma in pregnancy?
If the mom is Rh negative.
When is external fetal monitoring indicated in trauma in pregnancy?
All patients at > 20 weeks gestation.
T or F: Ultrasound is the most sensitive predictor of aburption after blunt trauma.
False. Frequent uterine activity is more predictive of abruption than ultrasoud.
What are the toconometric signs of abruption?
>8 cotnractions/hr x 4 hrs: risk for abruption. 3-7 contractions/hr X 4 hoursextend monitoring for 24 hours. <3 contractoins/hr for four hours—safe for dc. You may have noticed the bottom line here: montioring for four hours or more is mandatory.
One single injury accounts for half of all trauma deaths. What is it?
Head bonk.
What is the most significant thing about a finding of hypotension in a head-injured patient.
It means there’s something going on beside the head injury. Look for the open faucet.
What is the formula for cerebral perfusion pressure??
CPP = MAP – ICP
In serious head injury, it is mandatory to rule out fracture of the __________
Cervical spine.
What are the signs of basilar skull fracture?
Hemotympanun Battle’s sign: mastoid area ecchymosis Raccoon eyes CSF otorrhea CSF rhinorrhea positive ring test
What are CT findings of basilar skull fracture
The fracture itself air in the posterior fossa air-fluid level in the sphenoid sinus
Stellate, complex fractures mandate an investigation to rule out _______
Abuse/assautl
Which skull fracture is associated with epidural hematoma?
Temporal bone
What is the treatment approach to a patient with a depressed or open skull fracture?
Antibiotics + neurosurgery
When are Gardner-Wells tongs for c-spine fracture contraindicated in the setting of skull fractures?
Always, dummy.
A finding of occipital skull fracture should prompt a search for which associated injuries?
SAH, contrecoup injury, posterior fossa hematoma, cranial nerve injury.
What are the symptoms of post-concussive syndrome?
Headache (weeks to years) dizziness insomnia anxiety decreased concentration change in mental function
What is the presentation of “concussion?”
Transient loss of consciousness or function amnesia no focal deficits nausea, vomiting, dizziness
Which is worse, and epidural or a subdural?
Subdural
T or F: epidural hematoma is associated with less udnerlying brain injury than a subdural hematoma.
True!
What is the temporal classification of subdural hematoma, and how does it correspond to radiographic appearance?
Acute: <24 hours, white on CT Subacute: 24h – 2 weeks, isodense on CT Chronic: > 2weeks, dark on CT
What are the exam findings in transtentorial uncal herniation? Where do they come from?
Ipsilateral fixed, dilated pupil from compression of CNII against the brainstem Coma from brainstem compression Contralateral hemiplegia from brainstem compression
What is Kernohan’s notch and what is its clinical significance in the setting of trauma?
Kernohan’s notch is a groove in the cerebral peduncle. The presence of this groove may allow the herniated uncus to compress the contralateral peduncle, causing ipsilateral hemiplegia.
What is central herniation?
Mass effect causes downward displacement of the entire brainstem
What is the earliest sign of central herniation?
CNVI (lateral rectus) palsy
What is tonsillar herniation?
A rare form of herniation in which the cerebellar tonsils herniate through the foramen magnum. Death results.
What is the treatment of increased ICP?
Intubate if GCS<8. Hyperventilation is controverisal: shoot for 30-35mmHg. Mannitol, 1g/kg (controverisal in children). Steroids are NOT beneficial in children.
What is the significance of an immediate, brief seizure with a nonfocal exam after trauma?
Nil. Such seizures are usually benign.
What are the risk factors for post-traumatic seizures?
ICH and depressed fracture.
When do postraumatic seizures occur?
Most occur within the first year.
What is the treatment for posttraumatic seizures?
phenytoin
What is a penetrating neck injury?
Any wound which violates the platysma.
Where do most penetrating neck injuries occur?
Zone II
What are the causes of death in the setting of penetrating neck injury?
CNS injury, exsanguination, airway compromise (intubate early).
A patient with a penetrating neck injury develops hypotension and a “machinery murmur.” What’s going on and what should you do?
This is air embolism. The patient should be placed in Trendelenburg + L lat decub position
What are the indications for cricothyrotomy in neck injury?
Concommitant maxillofacial trauma CNI, CNV Uncontrolled upper airway bleeding or swelling
What are the “hard signs” in neck injury that indicate a significant injury probably exists?
hypotension arterial bleeding expanding hematomoa thrill, bruit focal deficits hemothorax >1000 bubbling wound hemoptysis, hematemesis
What are the “soft signs” in neck injury that prompt a full dx evaluation?
Stridor hoarseness vocal cord paralysis sub-cue air facial nerve injury
What are the neck zones?
Zone I: below the cricoid Zone II: betwenn the cricoid and the angle of the mandible Zone III: above the angle of the mandible
What is the treatment for an unstable patient with neck injury and “hard” signs?
Surgery. Zone I requries thoracic approach, zone III may require diarticulation of the mandible. Zone II is technically the least difficulat.
What is the approach to stable patients with penetrating neck injury?
Zone I: angio, esophagram, endoscopy, bronch Zone II: explore or angio, esophagram, endoscopy, bronch Zone III: angio
Thoracic trauma causes ____ of trauma deaths.
1/4
What are the causes of hypotension in blunt trauma, in decreasing order of incidence?
Pelvic fracture>intra-abdominal injury>intrathoracic injury
Where does one perform a needle thoracostomy?
2d intercostal space on the mid-clavicular line
Which heart chambers are most frequently injured in penetrating trauma?
Right ventricle and right atrium
When should rib fractures be admitted?
Multiple rib fxs + elderly, ptx, pre-existing lung dz, etc.
What are the most important injuries associated with fractures of the first and second ribs?
Mycocardial contusion, bronchial tear, vascular injuiry (consider arteriogram)
What is a flail chest?
A segmental fracture of three or more ribs, characterized by paradoxical chest wall movement.
What are the primary pathophysiologic processes underlying a flail chest injury?
Decreased ventilation and decreased venous return
What is the treatment of a flail chest?
Direct pressure, intubation. Consider chest tube.
What is the main cause of hypoxemia in flail chest injury?
Pulmonary contusion.
What is the most common cause of sternal fracture.
MVA (steering wheel, seat belt).
What is the pathophysiology of pulmonary contusion?
Capillary damage, interstitial edema, bleeding, leadingto decreased compliance, atelectasis, hypoxemia, VQ mismatch.
What is the treatment of pulmonary contusion?
Aggressive luid resuscitation can be HARMFUL. Treatment is with oxygen, ventilation, PEEP, treatment of underlying injury.
From a diagnostic perspective, what is the most treacherous thing about pulmonary contusion?
Xray findings can be delayed by up to 6 hours.
Most tracheobronchial injuries occur where?
Within 2cm of the carina.
What are the signs and symptoms of tracheobronchial injury?
Chest pain dyspnea hypoxemia Hamman’s crunch hemoptysis sub-Q emphysema
What are the cxr findings associated wth tracheobronchial injury?
Pneumothorax pneumomediastinum tension pneumo rib fracture
A patient has persistent bubbling in a chest tube—an air leak. What is your first diagnostic thought?
Bronchopleural fistula.
What are the signs of hemothorax?
Decreased breath sounds, dullness to percussion, hypotension, hypoxemia, respiratory distress
What are thoracotomy indications in the setting of hemothorax?
Unstable initial chest tube output >1500 mL >100 ml/hr x 6 hours persistent air leak
What is the treatment for an open pneumothorax?
3-sided petrolatum gauze, one-way valve, chest tube
What is the big problem with petrolatum gauze for a sucking chest wound (open pneumo)?
Can create a tension pneumo; remove dressign if patient has increased dib.
What is the classic triad for tension pneumo?
Tracheal deviation to contralateral side, hyperresonance, no breath sounds
What are the causes of pneumomediastinum?
Mechanical ventilation Valsalva sneezing emesis ruptured bleb drug use (marijuana, crack)
What is the treatment of tension pneumomediastinum
Decompression via neck dissection
What is the most common location for diaphragmatic injury?
Left posterolateral (right-handed assailant). But it’s the right side that’s most often missed (masked by liver).
What is the best test for diaphragmatic injury?
Probably thoracoscopy, laparoxcopy, laparotomy or thoracotomy. CXR, CT, US and DPL can all miss this injury.
T or F: Small diaphragmatic tears are frequently missed, gradually heal, and do well.
FALSE. Small injuries will continue to enlarge.
What is the usual location for traumatic ruptured aorta?
At the isthmus, just beyond the arch. Victims die at the scene.
Patients with aortic rupture who arrive in the ED alive usually have a tear at the _____________
Ligamentum arteriosum
T or F: Pre-existing vascular disease does not predispose to traumatic aortic injury.
True! It does NOT.
What are the signs and symptoms of traumatic aortic rupture?
Retrosternal pain dyspnea stridor dysphagia hypotension harsh systolic murmur pulse difference between upper and lower extremities
What is the most sensitive and specific x-ray finding associated with traumatic aortic rupture?
Widened mediastinum
T or F: 1st and 2nd rib fractures are associated with traumatic aortic rupture.
Probably true, but controversial
What xray findings are associated with traumatic aortic rupture?
Wide mediastinum left apical cap blurred aortic knob left hemothorax tracheal deviation (to R) NG deviation to right depressed left mainstem loss of aortic-pulmonary window
What is Beck’s triad?
Hypotension, JVD, muffled heart sounds – cardiac tamponade
What is the best diagnostic test for cardiac tamponade in the ED?
Ultrasound
T or F: cardiac tamponade is actually more common in blunt than in penetrating trauma.
False. More common in penetrating.
What is the treatment for cardiac tamponade?
Pericardiocentesis, thoracotomy.
What is the presentation of cardiac rupture?
Death. Most die at the scene. Some people who are too dumb to die at the scene make it to the hospital with tamponade and shock. Mortality is virtually 100%
What is the presentation of myocardial contusion?
Blunt trauma Chest pain, sternal or rib fx dyspnea tachycardia
What are EKG findings consistent with myocardial contusion:
Slowed conduction, ectopy, ST-T wave changes
What is the best test for myocardial contusion?
Echo! CK-MBs and troponins have poor sensitivity, especially early on.
What is the natural history of myocardial contusion.
Usually benign. Complications are rare.
What are the complications of myocaridal contusion?
Effusion Infarction Dysrhythmia Aneurysm Thrombosis
What is the distribution of blunt vs. penetrating abdominal trauma?
2/3 or more blunt, 1/3 or more penetrating. (Depending, one assumes, on geographic location and prevailing socio-political-economic variables.)
What are the most frequent seatbelt-associated injuries?
Mesenteric laceration hollow viscus tear ruptured diaphragm Chance fracture
What are indications for laparotomy in the setting of abdominal trauma?
Evisceration GSW impalement gross blood by NG, DPL or rectal, positive FAST
What is the rule of 3s for stab wounds to the abdomen?
A rule of thumb: 1/3 no penetration, 1/3 penetration and no surgery, 1/3 require surgery.
When can patients with SWs to the abdomen be managed conservatively?
Normal vitals, no evisceration, benign abdomen—patients may be observed.
When are routine plain abdominal films indicated in abdominal trauma>?
They aren’t.
What are the strengths and weaknesses of CT in the setting of abdominal trauma?
INSENSITIVE to hollow viscus injury, pancreas, and diaphragm. SENSITIVE to retroperitoneum, solid organs, bony structures.
What are appropriate imaging studies for evaluation of post-traumatic hematuria?
CT and cystourethrogram.
What constitutes a positive DPL?
Aspirate 10 ml free-flowing blood >100,000 RBC in fluid (blunt) >10,000 RBC (penet) Bile, feces, urine
T or F: in a stable patient without peritonitis, a positive DPL may be managed conservatively.
True.
What are the relative contraindications to DPL?
Obesity, pregnancy, previous abdominal surgery, pelvic fracutre
What is the most important cause of false positive DPL?
Pelvic fracture
What trauamtic processes can result in false negative DPL?
Pancreas, bowel, or retroperitoneal injuries, or splenic hematoma without free bleeding.
What is Gray Turner’s sign?
Flank discoloration, a late sign of retroperitoneal hematoma seen in hemorrhagic pancreatitis.
What is Kehr’s sign?
Referred left shoulder pain due to subdiaphragmattic irritation or splenic rupture.
What is Cullen’s sign?
Periumbilical ecchymosis seen in hemorrhagic pancreatitis and ectopic pregnancy.
What is Rovsing’s sign?
RLQ pain with LLQ palpation due to peritoneal irritation as in appy.
What is the most commonly injured organ in blunt abdominal trauma?
The spleen.
What is the presetnation of splenic trauma?
Shock, LUQ pain, Kehr’s sign.
What are the best tests for splenic trauma?
FAST or CT
What is the treatment of acute splenic trauma?
Consider nonoperative management for low-grade injuries. Pneumovax, HIB vax: post-splenectomy sepsis has HIGH mortality.
What is the most common organ injured in penetrating abdominal trauma?
The liver. Watch out for sub-capsular hematoma: negative DPL, positive CT!
T or F: the pancreas is commonly injured in blunt trauma.
True.
What is the classic mechanism for blunt injury to the pancreas?
Handlebar and steering-wheel injuries.
T or F: presentation of pancreatic trauma is often delayed.
True, because it takes a while for the enzymes to leak and cause irritation.
T or F: in pancreatic trauma, the serum amylase will almost always be elevated.
False. Often normal.
What is the best diagnostic test for pancreatic trauma?
CT, serial exam.
Most dudoenal injuries have an associated ___________ injury.
Liver.
What are the two injuries to seriously consider in handlebar injuries?
Pancreatic trauma, duodenal injury.
Which part of the colon is usually injured?
Transverse.
What is the presentation of urethral trauma?
Blood at meatus boggy prostate perineal bruising
What is the diagnostic test of choice in urethral trauma?
Retrograde urethrogram (before Foley)
What is the presentation of anterior urethral trauma?
Usually a straddle injury, fractured penis, or result of foreign body insertion. Presents with hematuria and requires urethrogram.
What is the treatment of anterior urethral injury?
Primary repair.
What are the complications of anterior urethral injury?
Fistula, stricture, pain.
What is the presentationof posterior urethral injury?
Pelvic fracture, bladder distention, lower abdominal pain, dysuria, blood at meatus, scrotal hematoma.
What are the complications of posterior urethral trauma?
Impotence, incontinence.
A retrograde urethrogram is performed. How do the results distinguish between anterior or posterior urethral injury?
If extravasation of contrast occurs below the urogenital diaphragm, outside the pelvis (usually in the scrotum and around the penis), the injury is anterior. IF above the diaphram and in the pelvis, it is posterior.
You need to draihn the bladder but you can’t pass a Foley. What to do?
Suprapubic cystostomy. Also indicated for urethral stricture, urethral transection, and severe GU burns.
How is a suprapubic cystosomy performed?
The seldinger technique is used to gain access to the bladder, and a central line is used to drain the organ.
What are contraindications to suprapubic cystostomy?
Empty bladder (wait, use ultrasound) Higher risk of bowel injury (abdominal surg, radiation treatement) Pregnancy is NOT a contraindication.
What are the complications of suprapubic cystostomy?
Bowel injury, extravasation, infection, urethral injury.
What are the mechanisms associated with renal trauma?
Rapid deceleration, compression, penetrating trauma
What injuries are most associated with renal injury?
Lower rib fractures, L1-L2 transverse process fractures
What is the most important thing to remember about the finding of hematuria in renal trauma?
Just this: RENAL TRAUMA CAN PRESENT WITHOUT HEMATURIA.
What is the evaluation of gross hematuria in the setting of trauma?
IVP or CT or both. Angiogram may be required in the setting of renal vascular injury.
What is the time limit for revascularization of a kidney?
12 hours.
In which area would lido with epi be contraindicated for anesthesia? a. ears b. penis c. dorsum of hand d. fngers e. nose f. all of the above
c. dorsum of the hand
What is the most important consideration for treatment of abscess.
Get the pus out.
Where are staples contrainidicated?
Face, hand, feet, neck, deep wounds, curved, irregular wounds.
Where is Dermabond contraindicated?
Near eyes and joints.
What is the preferred treatment for deep wounds > 12 hours old
Irrigate, pack, delayed closure.
When is primary wound closure contraindicated?
Puncture wounds, animal bites, human bites, deep or complex wounds > 12 hours old, grossly contaminated wounds.
When should sutures be removed?
Face: 3-5 days Body: 7-10 days Over joints and areas under stress: 10-14 days
T or F: for larger areas/wounds, use of lower concentration anesthetic is contrainidciated.
FALSE. This is precisely when low-conc IS indicated, to anesthetize a wider area while avoiding risk of toxicity.
What’s the recipe for buffered lidocaine?
1 ml HCO3 10 ml lidocaine without epi Mix all ingredients serve immediately
What are the Amide anesthetics?
Lidocain, bupivicaine, mepivacaine. Amides all have two “i”s in the name.
Which are more allergenic, amide anesthetics or esther anesthetics?
Esters.
What are the ester anesthetics?
Tetracaine, procaine
What are the max does of lidocaine?
Plain: 4mg/kg With epi: 7 mg/kg
What is TAC?
Tetracaine, adrenaline, cocaine
What is LAT anesthesia?
Lidocaine, adrenaline, tetracaine
What is EMLA anesthesia?
Eutectic Mixtue of Local Anesthetics = lido + prilocaine. Takes an hour to work, but prevents pain from blood drawing, IV, LP.
When is it acceptable to use braided monofilament on skin?
Never.
How long does it take to achieve complete wound strength? And how long do absorbable sutures last?
Wound strength takes at least 3 weeks. Gut in oral mucosa lasts 3-5 days. Chromic lasts 7-10 days. Vicryl lasts 60-70 days.
What are the indications for wound management with tissue adhesive?
Linear wounds with little tension. Face and abdomen. Elderly with weak tension. Steristrips may be used in conjuction.
What are the contrainications to wound treatment with adhesive?
Wounds near eyes, bites, heavy contamination, stellate wounds, crush injuries, long wounds, bites, deep wounds.
What are the complications of tissue adhesive?
Dehiscense (<15% wound strength of sutures, topical antibiotic loosens bonds), ocular exposure, allergic reaction
When should one consider antibiotic wound prophylaxis?
High risk sites (hands, feet) puncture wounds foreign bodies contaminated wounds bites extensive soft tissue injury through-and-through mouth lacs open fractures exposed joints or tendons prosthetic valves (endocarditis prophylaxis) immunocompromise
What is the organism that causes tetanus?
Clostridium tetani, an anaerobic Gr neg bacillus
What is the toxin produced by C. tetani?
Tetanospasmin
What is the epidemiology of tetanus?
60 cases/year in the US, mostly elderly and immigrants.
What wounds are at increased risk for tetanus?
>24 hours old, crush, devitalized tissue, burns, IVDA, early postpartum wounds, soil in wounds.
What is the presentation of tetanus?
Muscle spasm, rigidity, risus sardonicus, opisthotonos, fever, unexplained tachycardia. Often occurs after minor wounds or no known injury.
What is the prestnation of neonatal tetanus?
3-10 days after birth, poor prognosis.
What is the treatment for tetanus?
Debridement, benzodiazepines, paralysis, intubation, pencillin, HTIG (30 u/kg).
What are tetanus-prone wounds?
Wounds that are prone to tetanus, stupid: stellate, >6 hours old, crush, burn, contaminated, puncture, devitalized tissue.
What are the indications for tetanus prophylaxis?
Clean wound > 10 years. Dirty wound: > 5 years.
Is tetanus prophlaxis safe in preganacy?
Yes.
What is the causative organism for gas gangrene?
C. Perfringens.
What is the presetnation of gas gangrene?
Pain out of proportion to physical findings. Dusky, brawny, “woody” edema with crepitance. Low grade fever, tachycardia. Air in tissues on x-rays.
What is the treatment of gas gangrene?
Fluids, high-dose penicillin, debridement, hyperbaric 02.
What are the causative organisms for necrotizing fasciitis?
Anaerobes, Group A Strep, staph aureus.
What are the risk factors for necrotizing fasciitis?
CRF, diabetes, vascular disease, alcohol, immunosuppression
What is the presentation of nec-fasc?
Tachycardia, high fever, toxicity, erythema, edema, very painful and tender site, crepitance
What is the treatment of nec-fasc?
Fluid resuscitation, imipenem-cilastin, surgical debridement, luck.
T or F: in flail chest, hypoxemia is due to impaired ventilation.
False. Hypoxemia is due to lung contusion and a-v mismatch.
What is the triad for Neurogenic shock?
Flaccid paralysis, hypotension, absence of tachycardia.
What are the easiest dermatomes to remember?
Clavicle =C4, thumb =C6, little finger = C8, nipple = T4, umbilicus + T10.
What is the most common sign of the so-called myocardial contusion?
Tachycardia.
What are the contraindications to nasal intubation?
Apnea, basilar skull fracture, midface frracture.
What is the fluid resuscitation of pediatric trauma patients in shock?
20ml/kg crystalloid X 2, then 10ml/kg blood. Maintain urine output at 1 ml/kg,/hr.