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114 Cards in this Set

  • Front
  • Back
Tension pneumothorax is a clinical diagnosis reflecting air under pressure in the affected pleural space. When should treatment occur?
immediately upon diagnosis

do not wait for radiologic conformation

signs/sx: CP, resp distress, tachy, hypotension, tracheal deviation, unilateral absence of breath sounds
where does the needle get placed in needle decompression of PTX?
second intercostal space, midclavicular line
tx for open pneumothorax?
close the defect with a sterile occlusive dressing that is large enough to overlap the wounds edges

tape it securely on three side to provide a flutter type valve effect

both Tension pnuemothorax and massive hemothorax are assoc w decreased breath sounds on auscultation. How can you differentiate?

PTX: Hyperressonance

Massive hemothorax: dullness

note- trachea is also deviated in PTX
Thoracotomy is not indicated unless ______ is present
a surgeon

qualified by training and experience is present

(just what the book says...)

there is even another part in red that reads:
A qualified surgeon must be present at the time of the patients arrival to determine the need and potential success of a resuscitative thoracotomy in the ED
what defines a massive hemothorax?
rapid accumulation of more than 1500 mL of blood or one-third or more of the pts blood volume in the chest

Pericardocentesis is the definitive treatment for cardiac tamponade

If surgical intervention is not possible, pericardiocentesis can be diagnostic as well as therapeutic, but is NOT definitive

surgical intervention is
Neither general anesthesia nor positive pressure ventilation should be administered in a pt who has sustained a traumatic pneumothorax or who is at risk for unexpected intraoperative tension PTX until what is done?
A chest tube is inserted

a simple PTX in a trauma pt should not be ignored or overlooked. It may progress to...
a tension PTX

a simple hemothorax that is not fully evacuated can result in a retained, clotted hemothorax with lung entrapment, or can develop into...
an empyema

if infected

never underestimate the severity of blunt pulmonary injury. _____ _____ may present as a wide spectrum of clinical signs that are often not well correlated with CXR findings.
Pulmonary contusion

Penetrating objects that traverse the mediastinum may injure the major mediastinal structures such as...
the heart, great vessels, tracheobronchial tree, and esophagus

the dg is made when careful examination and a CXR reveal an entrance wound in one hemithorax and an exit wound or a missle lodged in the contralateral hemithorax. Wounds in which metallic fragments from the missile are in proximity to medialstinal structures also should raise suspicion of a mediastinal traversing injury

surgical consultation is mandatory

Delayed or extensive evaluation of ____ ____ without cardiothoracic surgery capabilities can result in early in-hospital ruptureof the contained hematoma and rapid death from exsanguination
wide Mediastinum

xray findings suggestive of aortic disruption should be transferred to a facility capable of rapid definitve dg and tx

What is the key management principle in rib fractures?
Pain control without respiratory depression
The assessmentt of circulation during the primary survey includes early evaluation of the possibility of hemorrhage in the ____ and _____ in any pt who has sustained blunt truama
abdomen and pelvis
given an example of an abdominal deceleration injury
Bucket handle injury to small bowel

(tear or avulsion of mesentery)

Airbag deployment does NOT preclude abdominal injury


Hypothermia contributes to coagulopathy and ongoing bleeding
when are abdominal ausculatory findings most usefull?
When they are normal initally and then change over time
When present, no additional evidence of rebound tenderness should be sought

(just flip this one)

it may cause the pt further unnecessary pain
How often should testing for pelvic instability be done?

it can result in further hemorrhage

do not do it to pts with shock or obvious pelvic facture
_____ should not be placed in pts with a perineal hematoma or high-riding prostate
Foley cath

get a retrograde urethrogram
If severe facial fractures exist or basilar skull fracture is suspected, the gastric tube should be inserted where? Why?
Through the mouth

prevent passage of the tube through the cribiform plate INTO YOUR PATIENTS BRAIN....whoops
give a few examples that necessitate a retrograde urethrogram to confirm an intact urethra before inserting a cath
Inability to void
Unstable pelvic fracture
blood at the meatus
scrotal hematoma
perineal ecchymoses
high riding prostate

note- absence of hematuria does not rule out injury to GU tract
What are 2 rapid tests that can be done in pts with hemodynamic abnormalities
Free aspiration of blood, GI contents, vegetable fibers or bile thorugh the lavage catheter in pts wiht hemodynamic abnormalities mandates...?
CT is a time consuming procedure that should be used only in _____ _______ pts in whom there is no indication for laparotomy
hemodynamically normal
CT can miss some GI, diaphragmatic, and pancreatic injuries

In the absence of hepatic or spleinc injuries, pthe presence of free fluid in the abdominal cavity suggests an injury to the GI tract and/or its mesentary...what do most surgeons find this to be?
an indication for early operative intervention

bad card I know...
If there is early or obvious evidence that a pt will be transfered to another facility, time consuming tests including ___ should NOT be performed

aka if the pt is unstable, only consider FAST or DPL
Most gunshot wounds to the abdomen are managed by?
exploratory laparotomy

the incidence of significant intraperitoneal injury approaches 98% when peritoneal penetration is present (SNAP!)
Remember a negative FAST does not exclude the possiblity of significant inraabdominal injury producing small volumes of fluid
so dont completely rely on them when negative
AN early noraml srum amylase lvl does not exclude major pancreatic trauma.

flip card
Conversely, the amylase lvl can be elevated from nonpancreatic sources
Cocomitant hollow viscus injury occurs in less than __% of pts initially thought ot have isolated solid organ injury
At what level of the pelvis is a sheet/pelvic binder applied in order to sufficiently stabilize an unstable pelvis?
Level of the greater trochanters
Give the 3 most common forms of pelvic fracutes
1: Closed fracture (lateral compression): 60-70%

2. Open book ( anterior posterior compression): 15-20%

3. Vertical shear: 5-15%
Since significant resources are required to care for pts with severe pelvic fractures, what should be considered early?
transfer to trauma center

JPS ONE, what what!?
Initial management of pelvic fracture includes surgical consult and a pelvic wrap.

What factor determines if a pt should go to laparotomy or angiography?
Inraperitoneal gross blood
Initial management of pelvic fracture includes surgical consult and a pelvic wrap.

What should be done if Inraperitoneal gross blood is found? If not?
If present: Lapartomy

if not: Angiography

What are the 3 distinct regions of the abdomen?
Peritoneal cavity

Retroperitnoeal space

Pelvic cavity

note- pelvic cavity contains components of both pertioneal and retroperitoneal

hemodynamically abnormal pts with multiple blunt injuries should be rapidly assessed for intrabadominal bleeding or contamination form the GI tract by performing?

Asymptomatic pts with flank or back stab wounds that are not obviously superficial are evaluated by serial physical exams or contrast enhanced CT
Exploratory lap is an acceptable option with these pts as well
1. T/F obtaining a CT scan should not delay pt transfer to trauma center that is capable of immediate and definitive neurosurgical intervention
2. What is the classic sign of uncal herniation?
a. Ipsilateral pupillar dilation associated with contralteral hemiparesis
3. What are 3 efforts that can be made to enhance cerebral perfusion
a. Reduce elevated ICP
b. Maintain normal intravascular volume
c. Maintaining a normal MAP
d. Resotre normal oxygenation and normocapnia
4. GCS score of what is the generally accepted definition of coma or severe brain injury
a. 8 or less
5. When there is a right/left and upper/lower asymmetry, GCS should be scored how?
a. Using the BEST motor response
when should a pt with a contusion undergo repeat CT scanning?
within 24 hours

evaluate for changes in the pattern of injury
What should be obtained in all pts with suspected brain injury who have a clinically suspected open skull fracture, any sign of basilar skull fracture, more than 2 episodes of vomiting, or pts who are older than 63
a CT

but it should never delay transfer (it says this like 10 times)
what should be performed early in comatose pts?
endotracheal intubation

Hypotension is usually a result of a brain injury itself

only in terminal stages
What must be ruled out before doing Dolls' Eyes testing?
c-spine injury
make sure to do a GCS and pupillary exam prior to doing what?
giving sedation or paralyzation
what size midline shift (mass effect) is often indicative of the need of surgery to evacuate the clot/contusion
5mm or greater
at what GCS is a neurosurgery evaluation required?
12 and below
What effect do anticonvulsants have on brain recovery?
may inhibit it

avoid them unless you have to
what GCS is brain death?

other things:

nonreactive pupils
absent brainstem reflexes
no spontaneous ventilatory effor
Approximately 10% of pts with a cervical spine fracture have a second noncontiguous _______?
vertebral column fracture
When can evaluation of the spine and exclusion of spinal injury be safely deffered?
if the spine is protected

espeically in the presence of systemic instability
what is the function of the corticospinal tract?
controls motor power on the same side of the body
what is the function of the spinothalamic tract
transmits pain and temp from the opposite side of the body
what is the function of the dorsal column

carreis proprioception, vibration, and light tough from same side of body
give the spinal nerve segment for the following

middle finger:
perianal region:
middle finger: C7
nipple: T4
umbilicus: T10
perianal region: S4-5
when is neurogenic shock rare? (what level)

below the lvl of T6

note: this results in the loss of vasomotor tone and in sympathetic innervation to the heart

pt gets in accident

presents with hypotension and bradycardia


neurogenic shock

loss of vasomotor tone and sympathetic innervation to heart
what does Spinal shock refer to?

flaccidity (loss of muscle tone) and loss of reflexes seen after spinal cord injury
what is a neurologic level in spine injury?

Sensory level?

Motor Level?
neurologic level: most caudal lvl that has normal sensory and motor function on both sides of the body

Sensory level: same but with only sensory

Motor Level: same but with only motor
What spinal cord syndrome is this?

disproportionately greater loss of motor strenght in the upper extremities than in lower extremities with varying degrees of sensory loss (hands and arms worst)

Central Cord syndrome

usually after hyperextension in jury with preexisting cervical canal stenosis

hx is commonly forward fall that resulted in facial impact

due to vascular compromise of the cord (anterior spinal artery)

lower extremity will recover first, then climbs up
What spinal cord syndrome is this?

paraplegia and dissociated sensory loss with a loss of pain and temp sensation. Position, vibration , and pressure sense are intact

Anterior cord syndrome

poorest prognosis
What spinal cord syndrome is this?

ipsilateral motor loss, loss of position sense, and contralateral loss of pain and temp two levels below the level of injury
Brown-Sequard syndrome

usually from penetrating trauma

effects corticospinal tract, dorsal column, and spinothalmic tract
what is the big difference btw anterior cord and brown-sequard syndrome?
in anterior cord, the dorsal column is spared
what leads to death in shaken baby syndrome related to the spinal cord
atlanto-occipital dislocation
posterior elements of C2 aka the pars interarticularis fracture = ?
hangmans fracture
anterior loading with flexion produces what kind of thoracic spine fracture?
anterior wedge compression
vertical axial compression produces what kind of thoracic spine fracture?
burst injury
transverse fractures though the vertebral body produces what kind of thoracic spine fracture?
Chance fractures
patients with throacolumbar fractures are particular vulnerable to what kind of movement?
rotational movement

so be careful when log rolling
after how long of staying on a backboard is a pt at high risk for pressure ulcer?
2 hours
c spine injuries above what level can result in partial or total loss of respiratory function?

remember C3,4,5 keep the diaphragm alive
remember the thing about splints and why they help
long bone fractures may cause significant bleeding into the thigh

splinting helps to reduce the available volume to bleed into
what should be used in the presnese of ongoing hemorrhage that is uncontrolled by direct pressure (on a limb)
T/F the absence of a palpable distal pulse usually is an uncommon or late finding in compartment syndrome and should not be relied upon to diagnose compartment syndrome
T/F Traction should still be applied in femur fracture when there is a concomitant ipsilateral lower leg fracture

avoid it
transfer to a burn center is indicated if there is inhalation injury, but if the transport time is prolonged, what should be done before transport?

stridor occurs late and is an indication for immediate intubation

circumferential burns of the neck can lead to swelling of the tissues around the airway; therefore early intubation is also indicated
what represents 1% of a patients body surface?
their hand
does the following describe 1st degree, partial thickness, or full thickness burn?

erythema, pain, absence of blisters
first degree

does the following describe 1st degree, partial thickness, or full thickness burn?

red or mottled appearance with associated swelling and blister formation
partial thickness
does the following describe 1st degree, partial thickness, or full thickness burn?

dark and leathery, painless and dry,
full thickness


there is NO indicatoin for prophylactic antibiotics in early post burn period
When should an escharotomy be done
when you have compartment syndrome following a burn

circumferential burn
give the rule of 9s for an adult
9 for each arm total
9 for each side of each leg
18 for chest
9 for whole head
1 for the penis/vag
what type of burn may be associated with extensive occult myonecrosis?
how should an oral airway in a child be placed?
DO NOT insert it backwards then turn 180

it can cause trauma with hemorrhage into soft tissues

just put it straight in
most likely cause of sudden deteroiration in the intubated ped patient?
transfer from one bed to another
DOPE is a mnemonic for deterioration in kids with ET tubes...what is it
Obstruction (clot, secretions)
Equipment failure
in abscense of adequate ventilation and perfusion, attempting to correct an acidosis with sodium bicarb will result in what?
further hypercarbia

worsened acidosis
failure to improve hemodynamic abnormalities with first bolus of fluid raises suspicion of what?
continuing hemorrhage
hwat is the bolus dosage for kiddos?
20mL/kg of isotonic fluid
why are kids more susceptible to tension PTX? (the most common immediately life threatening injury in kids)
mobility of mediastinal structures
should an ED doc do a DPL on a kid?
no only the surgeon
discrepant history, delayed presentation, frequent prior injuries, perineal injuries in kids are all signs of
65 and older are more likely to have what kind of injuries

remember even simple falls can kill old folk
if you are intubating an old person with dentures what should you do?
leave them in place if they are intact and well fitting

only get rid of them if broken
remember that in old folk that "normal" BP and HR do not necessarily indicate normovolemia
early monitoring is needed
when an elderly pt is on diruetics, what electrolyte imbalance must be considered?
Serum K deficit

be careful giving crystalloid
hypothermia not attributable to shock or exposure should alert the physician to what in old people?
occult dz

think sepsis, endocrine, or pharmacologic
remember pts on B-blockers or CCBs may have issues
i dont know, im running out of the will to care
what is the best inital tx for the fetus?
optimal resuscitation of mom

note, look after baby before the secondary survey of mom
if mom has abrupt decrease maternal intravolume loss, what can you expect of her vital signs? what does this mean for baby?
mom will likely look fine on VS

baby will have decreased O2
a PaCO of ___ to ____ mm Hg may indicate impending resp failure during pregnancy

this is normal... so look out, may show impeding resp failure
How should the uterus be displaced? why?

manually to the LEFT SIDE to relieve pressure on the IVC

do this in a hypotensive preggo
fetal ocodynamometer should be used beyond how many weeks gestation

fetus may be in jeopardy even with apparently minor maternal injury

All pregnant Rh-negative moms should get Rh immunoglobulin therapy unless the injury is remote from the uterus (like an isolated distal extremity injury)

this was a practice Q
as pregnancy increases in time, the internal viscera are relatively protected from penetrating injury
but the uterus becomes more exposed