Trauma

Front 1

physical signs of airway obstruction (4)? one sign that gives assurance that airway is patent?

Back 1

stridor, hoarseness, retractions, accessory muscle use; talking (sign that airway patent

Front 2

options (which one chose will vary depending upon situation) that are awailable to secure airway / ventilation?

Back 2

intubation, tracheostomy, cricothyroidotomy

Front 3

indications for intubation (5)?

Back 3

laryngeal edema, inadeuqate respiratory status, comnpromised respiratory mechanics (e.g. multiple rib fractures), Galsgow coma scale of 8 or less, depressed mental status

Front 4

treatment for smple penuomothorax?

Back 4

large diameter chest tube

Front 5

management of patient with chest tube in for pneumo?

Back 5

serial CXRs, tube to suction, take out chest tube when lung is fully inflated and no air leak detected in tube

Front 6

sucking chest wound - what is it and management?

Back 6

laceration to chest wall to lung - sucks air out during respiration; management: seal wound and chest tube insertion in different location

Front 7

lung expansion not responding and continual air leakage into chest tube after chest tube insertion - what is suggested?

Back 7

major injury/disruption to trachea or bronchus

Front 8

when is observation acceptable management in simple pneumo?

Back 8

small pneumothorax/ not enlarging, asymptomatic patient,no free fluid in pleural splace

Front 9

why must a pneumo, regardless of size, have chest tube, if patient going to OR?

Back 9

general anasthesia and assisted ventilation place airway at positive pressure, increasing risk of enlarging pneumo

Front 10

hypotension and dec breath sounds on one side with distended neck veins - what should be suspected?

Back 10

tension pneumothorax (lung laceration that acts as one way valve)

Front 11

what is pathophysiology of hypotension in tension pneumo?

Back 11

intrapleural pressure inc above that of CVP (and right heart pressure) --> drop in venous return and cardiac output

Front 12

if immediate chest tube not possible, what should be first step in treatment of tension pneumo?

Back 12

needle thoracostomy on affected side

Front 13

MVA patient with hypotension, distended neck veins and normal breath sounds - most likely diagnosis and immediate treatment?

Back 13

pericardial effusion; emergent pericardiocentesis

Front 14

after emergent pericardiocentesis, next step in treatment of pericardial effusion?

Back 14

to OR for pericardial window and pericardial exploration to stop bleeding

Front 15

Initial management of MVA accident patient hypotension with normal breath sounds and without distended neck veins - diagnosis? initial management?

Back 15

hypovolemia; two large bore IV lines followed by rapid infusion (1-2L) of NS

(assess for blood loss: large lacerations, arterial injuries, major fractures)

Front 16

how much blood loss must there be for mild VS changes versus severe VS changes (inluding mentation change)?

Back 16

mild: 15-30% EBL
severe:30-40% EBL

Front 17

with what amt of blood loss (indicated by what VS changes) do you transfuse plus normal saline in resuscitating patient?

Back 17

severe blood loss = >30%, HR>120 with dec in BP;

Front 18

assessement of adequate initial volume resuscitation in hypovolemia? 4 methods

Back 18

acceptable urine output. improvements in HR, BP and mental status

Front 19

with continued hypotension despitefluid/blood replacement, what should management inlude?

Back 19

central line placement (might be done earlier as well to allow large-bore catheter for reuscitation) as well as CVP monitoring

Front 20

how is underlying cause explored in continued hypotensive despite aggressive fluid resuscitation?

Back 20

urgent laparatomy or thoracotomy

Front 21

if long bone fracture and thoracic injury excluded as cause of hypotnesion, what are most likely injuries leading to blood loss (name 2)

Back 21

intra-abdominal injury or pelvic bone injury

Front 22

why does hypotension usually not occur in closed head injury?

Back 22

Cushing reflex; brain swelling --> ischemia --> increased sympathetic response --> vasoconstriction to get blood to brain

Front 23

before placing urinary catheter in any male trauma patient, what must be performed first?

Back 23

rectal exam to rule out prostate injury/trauma

Front 24

cervical spine injury precautions? next step in evaluation after initial precaution?

Back 24

neck immobilization with collar or board, in-line stabilization until collar/board is available; palpation of posterior neck to detect tenderness or abnormalities, and basic motor/sensory exam

Front 25

when can cervical spine precautions be discontinued?

Back 25

after normal physical exam, no radiologic abnormalities, and no cerivcal spin tenderness (any of three alone indicate possibility of cervical spine injury)

Front 26

initial treatment/management of cervical spine traumatic injury?

Back 26

Initiate c-spine precautions:
1. neck immobilizaton c collar/board
2. palpation of neck for tenderness or deformities
3. assessment of neuro function
4. lateral c spine xray

Front 27

Possible distinct finding in a patient with fresh spinal cord injury?

Back 27

priapism (also possible: loss of anal sphincter tone, bradycardia)

Front 28

what is done initially if high suspicion of suspected thoracic injury?

Back 28

thoracostomy (5th interscostal space); if putting continuous blood, thoracotomy indicated

Front 29

hypotension with penetrating thorax injury - what is indicated and why?

Back 29

chest tube insertion on affected side; most likely cause of hypotension is blood loss from left chest (although tension pneumo still possibility)

Front 30

injury immediately inferior to clavicle - suspected problem and evaluation?

Back 30

subclavian artery/vein injury; evaluation via angiogram

Front 31

widened mediastinum on A-P CXR post- MVA? next steps? gold standard for diagnosis?

Back 31

repeat CXR with posteriolateral CXR (anteroposterior unreiable); if ;posteroanterior CXR is consistent, suspect thoracic aortic injury
gold standard: aortic angiogram

Front 32

injuries that likely require further eval based upon mechanism of injury (even without other findings). name 3-4.

Back 32

unprotected trauma (e.g. pedestrian hit by MV), high-energy trauma (e.g. high speed MVA, falls>15ft), minor trauma to elderly,immunosuppressed

Front 33

indications for abdominal expoloration in trauma patients?

Back 33

gunshot/deep laceration to abdomen, severe abd pain, +DPL/CT

Front 34

pre-emptive options to surgical abdominal exploration? Name 3.

Back 34

1. DPL - diagnostic peritoneal lavage
2. CT with contrast
3. abdominal ultrasound (FAST trauma U/S check to look at four quadrants quickly to check for presence of blood)

Front 35

Positive DPL? If DPL is positive, then what?

Back 35

>100,000/ml RBCs in laveged fluid; surgical abd exploration

Front 36

In abdominal trauma cases, CT scanning should be reserved for only which patients?

Back 36

stable patients

Front 37

tappropraite next step in following situations?
1. flat, nontender abdomen
2 severe diffuse abd pain
3. severe direct trauma
4. coma on admission
5. CXR showing stomach in left chest
6. CXR showing free air
7 hypotensive patient with no obvious blood loss
8. hypotensive with distended abdomen

Back 37

1. observation
2. to OR
3. to OR
4. FAST or DPL or CT
5. to OR (ruptured diaphragm)
6. perforated viscus (to OR)
7. FAST, DPL (no CT inn unstable patients)
8. to OR for x-lap
9. FAST, abd exploration, pelvic angiogram (likely sig bleeding from internal iliac) - controlled with emblization

Front 38

55 yo M in CVA, hypotensive with obvious hip fracture
1. next steps (3)?
2. therapy if suspected bleed is there

Back 38

1. FAST, abd exploration, pelvic angiogram (likely sig bleeding from internal iliac) -
2. embolization

Front 39

18 yo with islated major closed head injury in MVA - Once ABCs assessed, next step is neuro exam. What are the 4 important components of initial neuro exam?

Back 39

Neuro exam:
1. pupillary responses
2. cranial nerve exam
3. peripheral motor and sensory exam
4. level of consciousness

Front 40

18 yo with islated major cleared head injury in MVA - observed are change in consciousness leve with echymoses visible over mastoid bone. diagnosis?

Back 40

basal skull fracture

Front 41

18 yo with isolated closed head injury in MVA - patient reponses to verbal stimuli, opens eyes to on command, and moves all four extremities. Glasgow coma scale?

Back 41

15

Front 42

what imaging modality virtuall eliminated the possibility of a major head injury?

Back 42

CT-head

Front 43

39 yo man in ED, isolated head injury and loss of consciousness. Neurosurrgical eval is performed.
1. what is #1 concern?
2. maneuvers to lessen brain edema / IC pressure (3)?

Back 43

1. severe head injury with inc IC pressure
2. elevation of head to 30 degrees, hyperventilation (dec co2), mannitol

Front 44

usually, hyperventilation reserved for patient in which patients?

Back 44

impending brain herniation (e.g. blown pupil, lateralizing signs)

Front 45

Glasgow coma scale <8 equals?

Back 45

comatose patient

Front 46

49 yo in MVA - lucid interval followed by glasgow score of 10 and dilated right pupil that constricts sluggishly to light - likely general diagnosis and example?

Back 46

space occupying CNS lesion (e.g. epidural hematoma - middle meningeal artery)

Front 47

different physical signs indicating possible basal skull fracture? name 3-4

Back 47

tympanic echymoses, otorrhea, rhinorrhea, echymoses around eyes (raccoon eyes)

Front 48

post-MVA, sodium of 125, what is going on? management?

Back 48

siADH (due to stim of hypothalamic osmoreceptors) --> inc cerebral edema; water restruction

Front 49

complication of correcting sodium too quickly? correcting formula?

Back 49

central pontine myelinosis; 1/2 deficit over 24 hrs

Front 50

severe head trauma post-MVA. Unconscious patient is severely dehydrated and sodium drawn is found to be 160. Diagnosis? managements (2)?

Back 50

diabetes insipidus (failure of ADH releasel ; vasopressin (ddAVP) and free water

Front 51

hypothermia is associated with poor prognosis in trauma patients, why?

Back 51

associated with platelet dysfunction, prolongation of PT and PTT

Front 52

platelet counts can be dec in trauma for various reasons (e.g. DIC, transfusions rxns, sepsis). need to keep platelt count above what value approx?

Back 52

60,000 platelets

Front 53

metabolic acidosis in trauma patient usually secondary to what?

Back 53

hypovolemia with tissue hypoperfusion/ischemia

Front 54

25 yo M ruptures spleen in MVA - requires splenectomy, EBL of 500 cc in OR. Multiple injuries being dealt with even post-op
1. two choices for replacement?
2. 48 hrs post-op, BP 105.60, UOP 10 ml over 4 hrs, what going on, requiring what?
3. patient gets 2L fluid bolus and UOP does not increase, what is indicated?

Back 54

1. 500 cc pRBCs or 1500cc NS
2. 3rd spacing (due to multiple injuries); more aggressive resuscitation
3. CVP measurement (via central line)

Front 55

CVP measured in hypotensive/low UOP patient post-trauma surgery; with continuous resuscitation, CVP=10, still hypotensive, oliguric. Likely going on, and method of confirming?

Back 55

LV dysfunction or continued volume depletion with low cardiac output; Swan-Ganz catheter to measure PCWP (if this is low, know its hypovolemia)

Front 56

normal CVP with high PCWP, and hypotension - what is going on?

Back 56

CHF with likely pulmonary edema

Front 57

describe state:
1. PCWP 3, CO 2.5L, High SVR
2. PCWP 20, CO 2.0L, High SVR
3. PCWP 15, CO 9.5, SVR 300
4. PCWP 20, CO 15, SVR 300

Back 57

1. hypovolemia
2. cardiogenic shock
3. septic schock (high output)
4. high output failure (e.g. A-V fistula)

Front 58

innhypovolemia, resuscitate to PCWP of approximately what?

Back 58

15 mmH

Front 59

management of patient in septic shock?

Back 59

antibiotics and elim of infectious site (as well as resuscitation and pressors, if needed)

Front 60

what type of shock does not respond to fluid resuscitation?

Back 60

cardiogenic shcock

Front 61

what is etiology of neurogenic shock (e.g. typically in trauma patients)? management, and what usually not necessary (counterinititive)?

Back 61

impairment of sympathetic nervous system; fluids, vasoconstrictors and cardiac drugs not necessary

Front 62

25 uo with acute SOB progressive, hx of stab wound to left groin 5 yrs ago, BP 120/80, HR 125, bilateral rales, JVD, ejection murmur, S3 gallop.
1. why hx of hernia surgery important?
2. look for on physical exam (2)?
3. what sign can be elicited to help confirm suspicion?
4. repair involves what?

Back 62

1. AV fistula growing over time
2. bruit and palpable thrill
3. HR dec of >10 bpm with occlusion of fistula (called Branham's sign)
4. surgically occluding artery

Front 63

management in following situatiions? 30yo woman post-MVA, multiple rib fractures, right pneumo. Post-chest tube:
1. rib pain
2. pulse ox 90%, RR 28 (2-3)

Back 63

1. analgesics (prevents atelectasis, PNA)
2. oxygen, ABG, check to make sure no leak in chest tube (Pleurovac is bubbling correctly)

Front 64

post-MVA with pneumo and rib fractures. On morphine drip. ABG CO2 = 55, large, pain anterior area of chest that fails to move and expand with inspiration? Two problems what are they(?

Back 64

1. hypoventilation (likely secondary to oversedation)
2. flail chest (cause paradoxical chest movements)

Front 65

patient with flail chest and rib painreceiving oygen, but still not ventilating adquately. options (3)?

Back 65

1)intubation; 2)thoracic epidural catheter (for rib pain), 3)PCA

Front 66

patient with flail chest and rib pain with pneumo and chest tube. pulse ox = 86% on 4L, RR 44. next step?

Back 66

intubation

Front 67

intubated patient with following findings / conditions; whats going on and management?
1. PCO2 55 on ABG
2. PCO2 25 on ABM
3. FiO2 60, then 80%, patient serum O2 at 56 mm hg

Back 67

1. underventilated; increase vent rate/volume
2. overventilated; dec vent rate/volume
3 likely ARDS or mucous plug; need PEEP, CXR, and arterial line

Front 68

patient with post-MVA. intubated with PEEP due to low O2 sats, 1st night in ICU becomes extremely hypoxic and hypotensive.
1. most likely diagnosis (need to rule out)?
2. short term treatment?
3. long term treatment?

Back 68

1. tension pneumo
2. needle thoracostomy with angiocath
3. thoracostomy tube (chest tube)

Front 69

neck hematoma post-op - management?

Back 69

to OR for evacuation

Front 70

air bubling from neck woundl what is suspected? management?

Back 70

airway injury (eg. subQ emphysema of neck); bronchoscopy or laryngoscopy

Front 71

suggestion of laryngeal trauma - symptom? management?

Back 71

hoarseness; direct laryngoscopy