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129 Cards in this Set

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