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129 Cards in this Set
- Front
- Back
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What could lead to metabolic acidosis and loss of peripheral vasoconstriction and CV collapse?
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Shock
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Differential Diagnosis of Shock?
list 7 |
Tamponade
Pneumothorax Pulmonary contusion or Hemothorax MI or contusion Spinal Cord Injury Toxic agents Fat/Air embolism |
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5 locations of possible LARGE scale bleeding
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External Hemorrhage
Thoracic Cavity Peritoneal Cavity Retroperitoneal space Muscle of Subcutaneous Tissue |
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death related to trauma within minutes to hours of trauma?
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ruptured spleen
liver laceration epidural hematoma |
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death related to trauma within seconds to minutes of trauma?
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High spinal cord injury
cardiac lacerations aortic tears |
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Earliest sign of hemorrhagic shock?
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Tachycardia
Vasoconstriction |
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Initial treatment of Hemorrhagic shock?
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warm crystalloids
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blood loss 0-15%? (0-750cc)
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Class I
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blood loss 15-30%? (750-1500cc)?
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Class II
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blood loss 30-40%? (150-2000cc)?
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Class III
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blood loss >40%? (>2L) ?
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Class IV
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Class of hemorrhage with HR <100?
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class I
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Class of hemorrhage with HR >100, tachypnea, and narrow pulse pressure?
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Class II
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Class of hemorrhage with HR >120, tachypnea, decrease in systolic BP, and change in MS?
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Class III
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Class of hemorrhage with HR >140, decreased BP, confusion, lethargy?
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Class IV
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Class I hemorrhage trx?
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crystalloids
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Class II hemorrhage trx?
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Crystalloids, then may use blood products
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Class III hemorrhage trx?
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Crystalloids, blood products (typed blood if possible)
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Class IV hemorrhage trx?
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2L crystalloid
Blood warmers Women: Type 0 Rh Neg. Men: Type 0 |
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What makes up 50% of all injuries that lead to death?
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Head Trauma
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What is descriptive and prognostic of head trauma, and has a max score of 15?
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GCS
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Best Eye reponse score?
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4
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Best Verbal Response score?
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5
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Best Motor response score?
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6
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no eye opening + inappropriate words + extension to pain. WHat is the GCS score?
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0 + 3 + 3= 6
(since <8 pt. has SEVERE head trauma) |
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eye opens to verbal command + Confused + flexion to pain. what is the GCS score?
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3 + 4 + 5= 12
(patient is GSC <13 so indicative for CT and is NOT minor head injury) |
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Eye reponses according to GSC scale?
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no eye opening
opening to pain opening to verbal command open spontaneously |
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verbal responses according to GSC scale?
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no verbal response
incomprehensible sounds inappropriate words confused oriented |
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Motor responses according to GSC scale?
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no motor response
localizing to pain extension to pain obeys commands flexion to pain withdrawal from pain |
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GSC 13-15?
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Minor Head trauma
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GCS <13?
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indicative of CT
NOT minor head injury |
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hallmarks of Concussion
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confusion & Amnesia
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brief neurological deficit after head injury?
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Concussion
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GCS <8?
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Severe head trauma
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What should you do with a patient with severe head trauma (<8)?
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intubate and ventilate to normocapnia
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What has the greatest effect on outcome of a patient with severe head injury?
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Hypotension (syst. BP<90)
Hypoxia (PaO2 <60, apnea, cyanosis) |
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Presence of ____________with severe head injury will double your mortality.
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HYPOtension
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How do you calculate the Cerebral Perfusion Pressure?
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CPP= MAP- ICP
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Normal value of Cerebral Perfusion Pressure?
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>70
(50 for kids) |
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MAP should be kept at ____________thru out resuscitation of severe brain injury. What about the ICP?
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>90= MAP
<20= ICP |
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Severe Head trauma diagnosis?
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GCS, Rapid CT scan, neurosurgical consult
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Trx for Severe Head injury?
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Mild Hyperventilation (PaO2 32-35mmHg)
mannitol for impeding transtentorial herniation CSF drainage preferable to mannitol |
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disruption of bridging veins between brain and dura?
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Subdural Hematoma
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Intracranial injury that DOES NOT respect suture lines?
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Subdural Hematoma
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Which has a worse long term outcome and indicates brain injury, subdural or epidural hematoma?
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Subdural Hematoma (makes sense b/c it is closest to the brain)
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Intracranial damage causing a tear in middle meningeal artery and middle fossa?
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Epidural Hematoma
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Fractured skull with LOC then a lucid interval, then rapid decompensation?
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Epidural Hematoma
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Most common type of Intracranial Hemorrhage in trauma?
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Subarachnoid Hemorrhage
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Intracerebral Hematoma?
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parenchymal contusions with direct injury to the brain
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Contusions that coalesce into hematoma over time?
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Intracerebral Hematoma
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Intracerebral Hematomas commonly occur in ________ and ___________.
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frontal & temporal lobes
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salt & pepper appearance on CT?
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Intracerebral Hematoma
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shear injury secondary to acceleration and deceleration?
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Diffuse Axonal Injury
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Where does diffuse axonal injury usually occur?
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Gray/White Jxn
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Specific areas in brain that demonstrate characteristic lesions of Diffuse Axonal Injury?
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Corpus Callosum
Centrum Semiovale Dorsal Lateral Quad.of Pons Periventricular |
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Pt. appears worse than the CT findings show?
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Diffuse Axonal Injury
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What is a significant cause of vegetitative cases and long term disability and institutionalization?
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Diffuse Axonal Injury
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Multiple Punctuate Hemorrhages?
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Diffuse Axonal Injury
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All pediatric patients with a skull frx get __________.
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CT
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linear fractures that run thru base of skull (often thru Petrous Temporal Bone or Anterior Cranial Fossa)?
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Basilar Skull Fractures
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Ecchymosis over mastoid bone (battle sign) + Otorrhea?
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Petrous Bone Fracture
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Racoon Eyes + Rhinorrhea?
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Anterior Cranial Fossa Frx
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CSF leak with a skull fracture is treated???
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with ABX
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depressed skull fractures _________, often require surgical reduction/elevation.
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>1 cm
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Intracranial Air (Pneumocephalus) and Necrotic edges require ________.
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surgical debridement and repair
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MOA of Depressed Skull Frx?
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Acceleration-Deceleration Injury
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5 layers of the scalp
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skin
subcut. tissue galea aponeurosis loose areolar tissue skull periosteum |
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What is the decision point when examining a neck injury?
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Is platysma interrupted? DEPTH is of concern
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What is used in neck trauma to localize the wound?
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Zones
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neck zone 1?
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clavicles to cricothyroid membrane (above C6)
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neck zone 2?
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cricothyroid membrane to angle of mandible?
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what neck zone is contiguous with thorax and vital structures contained within?
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Zone 1
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What neck zone extends from angle of mandible to skull base?
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Zone 3
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Hemothorax/Hemopneumothorax is seen with Zone _____injury.
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Zone 1
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Hard signs of penetrating neck trauma presents in zone ___.
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Zone 2
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Treatment for zone 1 neck trauma?
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angiography
Esophagram +/- Bronchoscopy |
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Trx for Zone 2 neck trauma?
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Angiography
Esophagram +/- Bronchoscopy OR exploration |
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Trx for Zone 3 neck trauma?
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Angiography
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Zone for Gunshot wounds?
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can NOT be assessed by zone, assume the worst
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MC location of traumatic aortic rupture?
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isthmus
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MOA of Traumatic Aortic Rupture?
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deceleration (most are Frontal or side impact MCV or fall from height)
crush injuries |
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Most patients with traumatic aortic rupture present to the ER with ___________.
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partia thickness tears
pseudoaneurysms |
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large hemothorax or a hemothorax draining arterial blood?
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suspect Blunt Aortic Injury
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primary screening for Blunt Aortic Injury?
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CXR.
normal CXR + low/moderate suspension= rule out Negative CXR + high suspension= get a CT |
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Most reliable sign on a CXR of Blunt Aortic Injury?
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Widened Mediastinum
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Diagnostic test of choice in Aortic Injury?
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CT (sensitvity 100%)
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CT findings of Aortic Injury?
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aortic pseudoaneurysm
intimal flat luminal clot active bleeding from aorta |
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What diagnostic tests can be done for Aortic Injury if CT is unable?
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Transesophageal Echocardiography
Angiography |
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Managment of Hemo. stable pt. with Aortic Injury?
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Beta Blocker- lowers HR (target is 60-80 bpm)
Nitroprusside (target SBP 120mmHg) or Labetolol |
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What should be obtained in all patients with sternal injury?
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EKG- to evaluate for concomitant cardiac contusion
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Management for Sternal frx that is stable and non-displaced?
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analgesia
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Sternal Frx with new EKG changes?
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admit to hospital
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MC chest wall injury?
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Rib Fractures
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Rib Fracture + Subcutaenous Air=
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PNEUMOTHORAX
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Lower rib fractures (8-12) should alert clinician to the potential for _____________.
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Intraabdominal injury (spleen, liver)
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Treatment for Rib Fractures?
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Analgesics
Nerve Blocks if multiple fractures Pulmonary Toilet |
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Admission Criteria for Rib Fractures?
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1. Elderly >3 frx or underlying pulmonary dx
2. intractable pain or dyspnea 3. unable to use comply w/pulmonary toilet 4. 2 fractures > 55 yeaars old |
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Simple pneumothorax presentation?
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Pleuritic chest pain or SOB
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Tension Pneumothorax presentation?
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decreased breath sounds
hyperresonance tracheal deviation |
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explain the CXR positioning for pt with possible pneumothorax?
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Upright Chest w/ expiratory views
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CXR of a patient with isolated lateral chest wounds?
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2 upright CXRs 6 hours apart will RULE OUT pneumothorax
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When can a patient be discharged from the ED, if worried about pneumothorax?
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2 negative xrays
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Treatment for Tension Pneumothorax?
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Immediate Decompression with 14 gauge needle in 2nd intercostal space, midclavicular line or laterally. Use 32-36 French chest tube for traumatic for potential hemothorax
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Treatment of Simple Pneumothorax?
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standard 32-36 french chest tube POSTERIORLY directed
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Hemothorax Primary Diagnostic Tool?
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CXR-AP upright- fluid level with meniscus on affected side. need approx. 400-500 cc to obscure diaghram on an AP film.
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__________tubes should be placed in patients with hemo/pneumothoraces and in thoses that may require positive pressure ventilation.
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Anterior Tubes
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When is a Thoracotomoy indicative for Hemothoraces?
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persistent bleeding of 200-250ml for 4 hours
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Treatment of Hemothorax for transmediastinal injuries or mediastinal findings?
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Esophagoscopy/Bronchoscope
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How much blood can lead to pericardial tamponade?
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150 cc
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Hypotension, Neck Vein Distention, and Muffled Heart sounds?
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Pericardial Tamponade
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best way to diagnose pericardial Tamponade?
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FAST
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Treatment of Pericardial Tamponade?
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Bolus with IVF, drainage via pericardial window is BEST trx
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You can locally explore a low energy wound. What is a low energy wound example?
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stabbing
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Example of a HIGH energy wound?
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Gun shot
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trend in blunt solid organ injury treatment?
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NONoperative management
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Grade I spleen injury?
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laceration <1 cm deep, subcapsular hematoma <1 cm diameter
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Grade II spleen injury?
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Laceration 1-3 cm deep, subcapsular or central hematoma 1-3 cm deep
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Grade III spleen injury?
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Lacerations 3-10 cm deep, subcapsular or central hematoma 3-10 cm diam.
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Grade IV spleen injury?
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Lacerations >10 cm deep, subcapsular or central hematoma >10cm
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Grade 5 spleen Injury?
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Spleenic tissue maceration or devascularization
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Microscopic Hematuria is defined as ___________.
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>5 RBC/HPF
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Is imaging required for Microscopic Hematuria?
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NO! rarely signifies severe injury
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Which side of diaphram is most susceptible to penetrating trauma?
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LEFT! (right is partially protected by liver). 24-42%
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what % of patients from a blunt abdominal trauma have hollow viscous injury?
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1-5%
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What is the most common organ to suffer from Hollow Viscous Injury?
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Small bowel> Large bowel> stomach
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Test of choice for Retroperitoneal injury?
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CT (amylase will be increased)
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Hollow Viscuous Injury:_________
Solid Organ Injury:__________ |
penetrating trauma
blunt trauma (SPLEEN) |
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Primary intention of Ultrasound FAST exam?
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detect free intraperitoneal blood
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what should you do if you find free fluid in hypotensive pt?
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laparotomy
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