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114 Cards in this Set
- Front
- Back
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Tension pneumothorax is a clinical diagnosis reflecting air under pressure in the affected pleural space. When should treatment occur?
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immediately upon diagnosis
do not wait for radiologic conformation signs/sx: CP, resp distress, tachy, hypotension, tracheal deviation, unilateral absence of breath sounds |
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where does the needle get placed in needle decompression of PTX?
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second intercostal space, midclavicular line
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tx for open pneumothorax?
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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 |
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PITFALL
both Tension pnuemothorax and massive hemothorax are assoc w decreased breath sounds on auscultation. How can you differentiate? |
Percussion
PTX: Hyperressonance Massive hemothorax: dullness note- trachea is also deviated in PTX |
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Thoracotomy is not indicated unless ______ is present
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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 |
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what defines a massive hemothorax?
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rapid accumulation of more than 1500 mL of blood or one-third or more of the pts blood volume in the chest
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T/F
Pericardocentesis is the definitive treatment for cardiac tamponade |
FALSE
If surgical intervention is not possible, pericardiocentesis can be diagnostic as well as therapeutic, but is NOT definitive surgical intervention is |
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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?
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A chest tube is inserted
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PITFALL
a simple PTX in a trauma pt should not be ignored or overlooked. It may progress to... |
a tension PTX
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PITFALL
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 |
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PITFALL
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
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PITFALL
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 |
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PITFALL
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 |
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PITFALL
What is the key management principle in rib fractures? |
Pain control without respiratory depression
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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
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abdomen and pelvis
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given an example of an abdominal deceleration injury
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Bucket handle injury to small bowel
(tear or avulsion of mesentery) |
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T/F
Airbag deployment does NOT preclude abdominal injury |
True
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PITFALL
T/F Hypothermia contributes to coagulopathy and ongoing bleeding |
TRUE
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when are abdominal ausculatory findings most usefull?
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When they are normal initally and then change over time
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When present, no additional evidence of rebound tenderness should be sought
(just flip this one) |
DUH
it may cause the pt further unnecessary pain |
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How often should testing for pelvic instability be done?
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ONLY ONCE
it can result in further hemorrhage do not do it to pts with shock or obvious pelvic facture |
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_____ should not be placed in pts with a perineal hematoma or high-riding prostate
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Foley cath
get a retrograde urethrogram |
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If severe facial fractures exist or basilar skull fracture is suspected, the gastric tube should be inserted where? Why?
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Through the mouth
prevent passage of the tube through the cribiform plate INTO YOUR PATIENTS BRAIN....whoops |
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give a few examples that necessitate a retrograde urethrogram to confirm an intact urethra before inserting a cath
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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 |
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What are 2 rapid tests that can be done in pts with hemodynamic abnormalities
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FAST
DPL |
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Free aspiration of blood, GI contents, vegetable fibers or bile thorugh the lavage catheter in pts wiht hemodynamic abnormalities mandates...?
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Laparotomy
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CT is a time consuming procedure that should be used only in _____ _______ pts in whom there is no indication for laparotomy
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hemodynamically normal
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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... |
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If there is early or obvious evidence that a pt will be transfered to another facility, time consuming tests including ___ should NOT be performed
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CT
aka if the pt is unstable, only consider FAST or DPL |
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Most gunshot wounds to the abdomen are managed by?
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exploratory laparotomy
the incidence of significant intraperitoneal injury approaches 98% when peritoneal penetration is present (SNAP!) |
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Remember a negative FAST does not exclude the possiblity of significant inraabdominal injury producing small volumes of fluid
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so dont completely rely on them when negative
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AN early noraml srum amylase lvl does not exclude major pancreatic trauma.
flip card |
Conversely, the amylase lvl can be elevated from nonpancreatic sources
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Cocomitant hollow viscus injury occurs in less than __% of pts initially thought ot have isolated solid organ injury
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5%
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At what level of the pelvis is a sheet/pelvic binder applied in order to sufficiently stabilize an unstable pelvis?
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Level of the greater trochanters
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Give the 3 most common forms of pelvic fracutes
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1: Closed fracture (lateral compression): 60-70%
2. Open book ( anterior posterior compression): 15-20% 3. Vertical shear: 5-15% |
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Since significant resources are required to care for pts with severe pelvic fractures, what should be considered early?
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transfer to trauma center
JPS ONE, what what!? |
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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
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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 |
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SUMMARY
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 |
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SUMMARY
hemodynamically abnormal pts with multiple blunt injuries should be rapidly assessed for intrabadominal bleeding or contamination form the GI tract by performing? |
DPL or FAST
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SUMMARY
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
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1. T/F obtaining a CT scan should not delay pt transfer to trauma center that is capable of immediate and definitive neurosurgical intervention
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True
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2. What is the classic sign of uncal herniation?
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a. Ipsilateral pupillar dilation associated with contralteral hemiparesis
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3. What are 3 efforts that can be made to enhance cerebral perfusion
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a. Reduce elevated ICP
b. Maintain normal intravascular volume c. Maintaining a normal MAP d. Resotre normal oxygenation and normocapnia |
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4. GCS score of what is the generally accepted definition of coma or severe brain injury
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a. 8 or less
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5. When there is a right/left and upper/lower asymmetry, GCS should be scored how?
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a. Using the BEST motor response
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when should a pt with a contusion undergo repeat CT scanning?
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within 24 hours
evaluate for changes in the pattern of injury |
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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
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a CT
but it should never delay transfer (it says this like 10 times) |
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what should be performed early in comatose pts?
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endotracheal intubation
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T/F
Hypotension is usually a result of a brain injury itself |
FALSE
only in terminal stages |
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What must be ruled out before doing Dolls' Eyes testing?
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c-spine injury
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make sure to do a GCS and pupillary exam prior to doing what?
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giving sedation or paralyzation
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what size midline shift (mass effect) is often indicative of the need of surgery to evacuate the clot/contusion
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5mm or greater
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at what GCS is a neurosurgery evaluation required?
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12 and below
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What effect do anticonvulsants have on brain recovery?
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may inhibit it
avoid them unless you have to |
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what GCS is brain death?
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3
other things: nonreactive pupils absent brainstem reflexes no spontaneous ventilatory effor |
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Approximately 10% of pts with a cervical spine fracture have a second noncontiguous _______?
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vertebral column fracture
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When can evaluation of the spine and exclusion of spinal injury be safely deffered?
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if the spine is protected
espeically in the presence of systemic instability |
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what is the function of the corticospinal tract?
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controls motor power on the same side of the body
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what is the function of the spinothalamic tract
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transmits pain and temp from the opposite side of the body
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what is the function of the dorsal column
*** |
carreis proprioception, vibration, and light tough from same side of body
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give the spinal nerve segment for the following
middle finger: nipple: umbilicus: perianal region: |
middle finger: C7
nipple: T4 umbilicus: T10 perianal region: S4-5 |
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when is neurogenic shock rare? (what level)
TEST**** |
below the lvl of T6
note: this results in the loss of vasomotor tone and in sympathetic innervation to the heart IT DOES NOT EFFECT PARASYMPATHETIC |
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pt gets in accident
presents with hypotension and bradycardia why? ** |
neurogenic shock
loss of vasomotor tone and sympathetic innervation to heart |
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what does Spinal shock refer to?
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flaccidity (loss of muscle tone) and loss of reflexes seen after spinal cord injury
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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 |
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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 |
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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 |
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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 |
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what is the big difference btw anterior cord and brown-sequard syndrome?
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in anterior cord, the dorsal column is spared
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what leads to death in shaken baby syndrome related to the spinal cord
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atlanto-occipital dislocation
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posterior elements of C2 aka the pars interarticularis fracture = ?
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hangmans fracture
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anterior loading with flexion produces what kind of thoracic spine fracture?
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anterior wedge compression
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vertical axial compression produces what kind of thoracic spine fracture?
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burst injury
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transverse fractures though the vertebral body produces what kind of thoracic spine fracture?
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Chance fractures
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patients with throacolumbar fractures are particular vulnerable to what kind of movement?
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rotational movement
so be careful when log rolling |
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after how long of staying on a backboard is a pt at high risk for pressure ulcer?
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2 hours
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c spine injuries above what level can result in partial or total loss of respiratory function?
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C6
remember C3,4,5 keep the diaphragm alive |
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remember the thing about splints and why they help
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long bone fractures may cause significant bleeding into the thigh
splinting helps to reduce the available volume to bleed into |
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what should be used in the presnese of ongoing hemorrhage that is uncontrolled by direct pressure (on a limb)
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tourniquet
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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
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TRUE
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T/F Traction should still be applied in femur fracture when there is a concomitant ipsilateral lower leg fracture
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FALSE
avoid it |
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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?
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Intubation
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 |
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what represents 1% of a patients body surface?
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their hand
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does the following describe 1st degree, partial thickness, or full thickness burn?
erythema, pain, absence of blisters |
first degree
sunburn |
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does the following describe 1st degree, partial thickness, or full thickness burn?
red or mottled appearance with associated swelling and blister formation |
partial thickness
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does the following describe 1st degree, partial thickness, or full thickness burn?
dark and leathery, painless and dry, |
full thickness
DOES NOT BLANCH |
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T/F
there is NO indicatoin for prophylactic antibiotics in early post burn period |
TRUE
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When should an escharotomy be done
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when you have compartment syndrome following a burn
circumferential burn |
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give the rule of 9s for an adult
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9 for each arm total
9 for each side of each leg 18 for chest 9 for whole head 1 for the penis/vag |
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what type of burn may be associated with extensive occult myonecrosis?
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electrical
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how should an oral airway in a child be placed?
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DO NOT insert it backwards then turn 180
it can cause trauma with hemorrhage into soft tissues just put it straight in |
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most likely cause of sudden deteroiration in the intubated ped patient?
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transfer from one bed to another
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DOPE is a mnemonic for deterioration in kids with ET tubes...what is it
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Dislodgement
Obstruction (clot, secretions) Pneumothorax Equipment failure |
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in abscense of adequate ventilation and perfusion, attempting to correct an acidosis with sodium bicarb will result in what?
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further hypercarbia
worsened acidosis |
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failure to improve hemodynamic abnormalities with first bolus of fluid raises suspicion of what?
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continuing hemorrhage
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hwat is the bolus dosage for kiddos?
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20mL/kg of isotonic fluid
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why are kids more susceptible to tension PTX? (the most common immediately life threatening injury in kids)
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mobility of mediastinal structures
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should an ED doc do a DPL on a kid?
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no only the surgeon
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discrepant history, delayed presentation, frequent prior injuries, perineal injuries in kids are all signs of
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abuse
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65 and older are more likely to have what kind of injuries
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FATAL
remember even simple falls can kill old folk |
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if you are intubating an old person with dentures what should you do?
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leave them in place if they are intact and well fitting
only get rid of them if broken |
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remember that in old folk that "normal" BP and HR do not necessarily indicate normovolemia
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early monitoring is needed
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when an elderly pt is on diruetics, what electrolyte imbalance must be considered?
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Serum K deficit
be careful giving crystalloid |
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hypothermia not attributable to shock or exposure should alert the physician to what in old people?
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occult dz
think sepsis, endocrine, or pharmacologic |
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remember pts on B-blockers or CCBs may have issues
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i dont know, im running out of the will to care
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what is the best inital tx for the fetus?
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optimal resuscitation of mom
note, look after baby before the secondary survey of mom |
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if mom has abrupt decrease maternal intravolume loss, what can you expect of her vital signs? what does this mean for baby?
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mom will likely look fine on VS
baby will have decreased O2 |
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a PaCO of ___ to ____ mm Hg may indicate impending resp failure during pregnancy
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35-40
this is normal... so look out, may show impeding resp failure |
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How should the uterus be displaced? why?
** |
manually to the LEFT SIDE to relieve pressure on the IVC
do this in a hypotensive preggo |
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fetal ocodynamometer should be used beyond how many weeks gestation
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20-24
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T/F
fetus may be in jeopardy even with apparently minor maternal injury |
TRUE
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T/F
All pregnant Rh-negative moms should get Rh immunoglobulin therapy unless the injury is remote from the uterus (like an isolated distal extremity injury) |
TRUE
this was a practice Q |
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as pregnancy increases in time, the internal viscera are relatively protected from penetrating injury
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but the uterus becomes more exposed
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