Term
• Sharp objects
• Low energy
• Straight edges
• Little contamination
• Heals with a good result, typically |
|
Definition
|
|
Term
• Crush the skin against underlying bone
• High energy forces
• Stellate, ragged, contused or irregular edges
• Look for underlying injury
• May be contaminated |
|
Definition
|
|
Term
• Flap-type lacerations
• Surrounding devitalized tissue
• Much more susceptible to infection than shear forces
• Large amount of force
• Tearing of the microvasculature
• Extra care to ensure proper healing |
|
Definition
|
|
Term
• Excoriationofthesuperficiallayers of skin
• Doesnotusuallyrequirerepair
• Mostoftencontaminated
• Usuallyhemostasishasoccurredto some extent at time of evaluation |
|
Definition
|
|
Term
• A part or structure that is forcibly torn or pulled away
• Large scar formation
• High likelihood for infection
• Often occurs on the digits
• Repair unlikely |
|
Definition
|
|
Term
• Hole or wound made by sharp object
• Frequently plantar surface of the foot or palmar surface of the hand
• High likelihood for infection
• Difficult to irrigate
• Do not suture!!! |
|
Definition
|
|
Term
• Can involve both characteristics of lacerations and puncture wounds, sometimes even avulsions
• Highly contaminated with bacteria
• Must consider source of the bite
• These should not be sutured unless it is done “loosely” only |
|
Definition
|
|
Term
• Separation of superficial layer of skin from deeper layers often circumferential
• Usually caused by machinery
• Require surgery and ortho consult |
|
Definition
|
|
Term
• Sometimescalledthelagphasebecausewound strength does not begin to return immediately.
• Completedwithinthreedays,exceptinthepresence of infection or other causes of wound chronicity
• Mononuclearleukocytesaccumulateandare transformed into macrophages
• Mastcellsdegranulate,releasinghistamineandother mediators of vasodilation and cellular migration.
• Neutrophilsandmacrophagesphagocytosedead tissue, foreign material, & bacteria
• Physiologicdebridementoccurs
• Physiologicpreventionofinfection |
|
Definition
|
|
Term
• Basal cell proliferation and epithelial migration occurring in the fibrin bridgework inside a clot
• Proliferation continues until individual cells are surrounded by cells of similar type
• Process is impeded by eschar formation and surface debris, including hair |
|
Definition
|
|
Term
• Consists of fibroblast proliferation, accumulation of ground substance, and collagen production
• Fibroblasts are usually present in the wound within 24 hours, and predominate by the tenth postoperative day
• Fibroblasts produce contractile proteins. These contractile cells, which are designated myofibroblasts, are present in the wound by the fifth day and have characteristics of smooth muscle cells with the ability to contract
• Fibroblasts also synthesize collagen, the primary structural protein of the body.
• The developing collagen matrix stimulates angiogenesis (bringing blood vessels back)
• Brings the surrounding “pink” color to healing wounds |
|
Definition
|
|
Term
• Collagen cross-linking
• Collagen remodeling
• Wound contraction
• Repigmentation
• Wound dehiscence is most likely to occur during this critical time |
|
Definition
|
|
Term
• Contraction of the skin changes the appearance of the skin and accounts for the initial eversion of wound edges
• Remodeling is an individual process...no two people heal alike!
• It is impossible to predict exactly what the scar will ultimately look like...Don’t give false hopes
• If patients have a history of keloids or hypertrophic scars they will most likely have the same outcome...be honest with your patient and give realistic expectations |
|
Definition
| Contraction & Remodeling of Skin |
|
|
Term
• Time
• Mechanism of injury
• Location
• Over 24 hours increases risk |
|
Definition
| Things to consider for Infection |
|
|
Term
• Position
• Hemostasis
• Removeallobjectsfrom the wound area, i.e. clothing, jewelry, large debris, etc.
• Physicalexamandhistory must happen simultaneously! |
|
Definition
|
|
Term
• Mechanism
• When did it occur
• Handedness
• Pain, paresthesia, function
• Where is the wound on the body
• Intentional, unintentional, or occupational
• Tetanus status
• Medical history/medications/toxic habits
• Allergies (analgesics, anesthetics, antibiotics, or latex)
• Occupation |
|
Definition
| Important Questions to Ask |
|
|
Term
• Areaofthe body/function/NV status
• Couldtherebeother underlying injury
• Jointcapsule/tendon/nerve involvement
• Doesthehistorymatchthe exam
• Usethemeasuringtapeto document wound length...DON’T GUESS!
• Documentthedepth according to tissue layer
• Is the wound contaminated with radiolucent or radiopaque material
• Do you need consultation
• What type of wound is it
• DOCUMENT HAND OF DOMINANCE FOR UPPER EXTREMITY INJURIES! |
|
Definition
|
|
Term
• Make your patient comfortable and anesthetize the wound and keep them in a reclined position!
• “Dilution is the Solution to Pollution”
• Possible debridement
• Create a sterile/clean environment
• Wound closure
• Tetanus likely or unlikely
• Discharge and follow up instructions |
|
Definition
|
|
Term
• Local injection inhibits depolarization of the nerve membrane by blocking the influx of sodium ions and preventing propagation of the action potential
• Nerve membranes are mostly lipid with some protein increased lipid solubility =faster onset of action, increased protein binding =slower onset of action with longer endurance |
|
Definition
|
|
Term
• Toxic effects include confusion, seizures, coma, myocardial depression and dysrhythmias
• Allergies are rare due to a preservative agent |
|
Definition
|
|
Term
• Fingers • Toes
• Nose
• Penis
• Pinna |
|
Definition
|
|
Term
• When using lidocaine with epi the patient will feel an intense “burning”/”stinging”, this can be minimized by buffering with sodium bicarbonate to raise the pH, this will also decrease the onset of action (between 1:5 and 1:10)
• Topical application only lasts approximately 5 minutes and is not beneficial in wound care |
|
Definition
|
|
Term
• Dependent on the area of the wound
• Local injection causes increased anatomical deformity but is the most common method and does not require a high level of skill
• Regional/Digital blocks require a solid knowledge of anatomy, require a skilled practitioner, require a cooperative patient and risk of compartment syndrome, however does not distort the anatomy, allows for greater area to be anesthetized with fewer injections |
|
Definition
| Which Anesthesia Method to Use? |
|
|
Term
| • Infiltrating directly into the site or by infiltrating around the peripheral nerves supplying the site |
|
Definition
|
|
Term
• Technique that infiltrates local anesthetic agents adjacent to peripheral nerves (‘nerve blocks’)
• Typically used for complicated lacerations, fractures and dislocations |
|
Definition
|
|
Term
• Less anesthesia needed
• Tissues not distorted
• No epinephrine
• Always be careful of nerve injury or toxicity
• Always aspirate
• 27 gauge or smaller
• 1ml local
• Wait five minutes then other side |
|
Definition
|
|
Term
• Highpressureirrigationwithwater/saline decreases the rate of infection substantially! Use a irrigation splash guard
• Guidelinesof60ml/cmofwoundlength should be used, min of 200mls
• DONOTSOAKWOUNDS!Bacteria counts can be increased
• Providone,hydrogenperoxide, chlorhexidine are tissue and fibroblast toxic and should be avoided inside the wound!
• Consideranesthesiabeforeirrigation |
|
Definition
|
|
Term
• Inspect for FB
• If you suspect, X-ray
• Remove hair that can act as FB, clipping 1-2mm above the skin
• Do not shave
• Do not remove hair from eyebrows
• FB like glass will >2mm will be seen on X- ray, others might need CT or MRI or US |
|
Definition
| Foreign Body and Hair Removal |
|
|
Term
• Is the tissue compromised or devitalized
• Is the wound contaminated
• Debridement can decreased rate of infection and improve cosmesis by allowing straighter edges to be repaired
• If you debride substantially do not remove more tissue than you need to cover the wound, the wound must be irrigated after large debridement |
|
Definition
|
|
Term
• Full sterile technique not shown to reduce infection after repair
• Clean, non-sterile gloves and attention to cleanliness may be used to improve efficiency and cost savings |
|
Definition
|
|
Term
• Primary closure
– Non absorbable/absorbable sutures, staples, Dermabond/wound adhesive/steri strips
• Delayed primary closure or tertiary closure
– Wound cleansing then closure if no infection after 4-5 days left open under a moist dressing
• Secondary intention
– Wound is cleansed and allowed to heal without repair |
|
Definition
| Repair of Lacerations/Methods for Wound Closure |
|
|
Term
• IntheEDsettingthewindowofopportunityclosesat8- 12 hours on the extremities and 24 hours on the face, the best outcomes are within 4 hours of the injury
• Sutures:typeandsizeisdecidedonareainjured:6-0for the face, 5-0 or 4-0 for the extremities not under high tension
• ScalpistheONLYacceptableplacetousestaplesinthe ED setting
• Absorbablesuturesshouldonlybeusedonmucous membranes and for intradermal/subcutaneous suturing
• Dermabond or wound adhesive should NOT be used over joints or on hands, feet or moist areas
• Sterile tape, of little use in the ED, can assist with areas under high tension, always apply perpendicular to the wound!
• DO NOT combine multiple methods of repair on one wound!
• Key to good results are clean wounds with well everted edges
• May or may not require antibiotics |
|
Definition
|
|
Term
• Not used frequently in the ED because of poor follow up, usually closed in the OR
• Wound is cleaned well and left open with a moist packed dressing for 4-5 days, if no infection is noted the wound is closed by one of the primary closure methods for improved cosmesis |
|
Definition
|
|
Term
• Used for wounds that present after the window of opportunity has closed
• Used when wounds are heavily contaminated with bacteria or debris that is unable to be removed
• Leaves a much larger scar
• This method is used to decrease
infection by closing bacteria or other contaminates inside the wound |
|
Definition
|
|
Term
• Absorbable and Non-absorbable
• Monofilament synthetic sutures ie: nylon or polypropylene –lowest rates of infection-most commonly used in ED
• Rapidly absorbing sutures (Vicryl) can be used to close superficial skin layers or mucus membranes |
|
Definition
|
|
Term
• Sized according to diameter
• 6-0 smaller and good for face/cosmetic
• 5-0 for hand and finger
• 4-0 for lacerations on the trunk and proximal extremities
• 3-0 for very thick skin found on scalp and sole |
|
Definition
|
|
Term
• Simple interrupted percutaneous Sutures
• Continuous “Running” Percutaneous Sutures
• Deep Dermal Sutures
• Vertical Mattress Sutures
• Horizontal Mattress Sutures
• Delayed Closure |
|
Definition
|
|
Term
• Do not clip eyebrows or shave them!
• If debridement is necessary, debride at an angle that is parallel to that of the hair follicles, to prevent alopecia
• Scalp- Consider sutures that are different color
• Scalp sutures 7-14 days
• Face 5 days
• Nose -Inspect for septal hematoma-bluish septum
• Lip- Vermillion border in layers
• Ear- 5 days approximate as best- 6-0
• Cheeks and Face-remember the facial nerve |
|
Definition
| Lacerations to the Face and Scalp |
|
|
Term
• Occupation, handedness, evaluate sensory and motor nerves, tendons, FB, fractures, bacterial contamination
• X-ray if needed
• Check for suicide lacerations
• Review anatomy of compartments, tendons, motor and sensory nerves
• Extensor tendons may be repaired with experience!
• Always refer to hand specialist
• Flexor tendon lacerations-refer
• Finger and finger-tip-suspect digital nerve injury
• Distal fingertip amputations with skin or pulp loss best treated conservatively. May require grafting if large
• Subungual hematomas may use nail drill, scalpel or 18 gauge needle
• Nail bed associated with distal phalanx fractures in 50% of cases
• May need to remove the nail
• Remove all jewelry and rings |
|
Definition
Injuries to the Arm, Hand,
Fingertip and Nail |
|
|
Term
• Evaluatesensoryandmotornerves,tendons,FB, fractures, bacterial contamination
• Avoiddeepsuturesindiabeticsandpatientswith stasis because of the risk of infection is higher
• Reviewanatomyofcompartments,tendons,and nerves
• ROM
• Knee
– With joint penetration into capsule or laceration of the patellar and quadriceps tendons; x-ray may show air in the joint |
|
Definition
| Lacerations of the Leg and Foot |
|
|
Term
• Knee
– Joint involvement
• Ankle- remember your PD skills- Thompson test
• Foot- examine for FB, crutches, walking boot
• Always splint the affected lower extremity if possible |
|
Definition
|
|
Term
• Byinstilling20mLofasterile colored solution (such as methylene blue) into the joint, the provider can look for leakage of fluid out of the laceration, which would indicate intra- articular involvement.
• Ifnodyeleaksthroughthe wound, the provider can be comfortable closing the wound in the emergency department without further intervention
• Notaguarantee |
|
Definition
|
|
Term
• Wounds most often can be cleaned without anesthetizing the wound
• Most are very superficial and will heal with relatively little complication even though they are usually contaminated
• Antibiotic ointment may help reduce the risk of infection |
|
Definition
|
|
Term
• Brisk bleeding is the usual difficulty
• If wound is on the digit a digital block will assist effective cleansing of the wound
• Avoid scrubbing as this can devitalize the already damaged tissue
• Application of Surgicel, Ethicon, or similar material will assist in hemostasis and should not be removed until it falls off on it’s own
• Antibiotics are recommended
• If bone is involved ortho/surgery should be consulted |
|
Definition
|
|
Term
• Imaging studies
• Metallic needles-small incision if splinter felt
• Wood splinter and organic spines
• Fish hooks
– http://www.youtube.com/watch?v=06T9c5YMLzA
• Post-irrigate, closed primarily if risk of infection slight
• Obtain post-procedure x-ray
• If near tendon or joint-splint extremity if unable to remove and refer to surgical specialist |
|
Definition
| Soft Tissue Foreign Bodies |
|
|
Term
• Heavily contaminated with bacteria, irrigate well
• Rarely closed with primary closure
• If human bites are suspected must cover for Eikenella and Staph, consider Hep B & C, unlikely HIV
• Animal bites must be reported to DOH, consider rabies vaccine, in addition to the normal mouth flora you must cover for Pasteurella
• All of these MUST get antibiotics |
|
Definition
| Puncture or Bite Wound Care |
|
|
Term
• Unless the tissue is still attached proximally will require consultation with surgery or ortho and careful follow up
• Most times skin is reattached in the OR
• ED role is keeping the patient comfortable with local or regional anesthesia, analgesia and assessing for other injury |
|
Definition
|
|
Term
• Incubation is 1 day to several months
• Have they been vaccinated previously?
• Is the wound contaminated with soil the most common agent containing tetanus
• How old are they? Younger than 10 years or older than: Tdap
• In 2018, the US Advisory Committee on Immunization Practices (ACIP): Adults who have never received Tdap also are recommended to receive a booster dose of Tdap. Women are recommended to receive a dose of Tdap during each pregnancy, which should be administered from 27 through 36 weeks' gestation, regardless of previous receipt of Tdap. After receipt of Tdap, adolescents and adults are recommended to receive a booster tetanus and diphtheria toxoids (Td) vaccine every 10 years to assure ongoing protection against tetanus and diphtheria. |
|
Definition
|
|
Term
• Human bites
• Dog or cat bites
• Intraoral lacerations
• Open fractures
• Wounds with exposed joints or tendons • Wounds in areas with lymphedema
• Vascular compromise
• Immunocompromised
• 3-5 day course for non-bite injuries
• 5-7 day course for bite wounds |
|
Definition
|
|
Term
• Woundsshouldbeexaminedin24hoursforsignsof infection; this does not have to be done in the ED if the patient is reliable they can do it themselves with good instruction
• Contaminatedwoundsshouldbefollowedupin48-72 hours
• Woundsontheextremitiesshouldbeelevatedand rested to decrease excess swelling, they should have a sterile non adherent dressing placed
• Facialwoundsshouldhaveantibioticointmentlightly applied to keep the area “greased up” and supple
• DONOTtakethesutures/staplesoutbeforetheyare ready and replace it with Dermabond!! |
|
Definition
| Proper Wound Care Instructions |
|
|
Term
• Most wounds should be covered with an antibiotic ointment and a nonadhesive dressing immediately after laceration repair. Limited evidence from one trial suggests that antibiotic ointments such as topical bacitracin zinc or combination ointment containing neomycin sulfate, bacitracin zinc,
and polymyxin B sulfate significantly reduce the rates of wound infection when compared to a petroleum ointment control
• A nonadherent sterile gauze (Xeroform)
• Instruct on wet to dry dressings |
|
Definition
|
|
Term
• Give your patient clear instructions of what to expect and how to take care of the wound
• Clarify if they need to continue to wear a splint you have placed for wounds over a joint
• Avoid macerated wounds by keeping the bandage dry
• Give your patient clear instructions on what the signs of infection are...do not write... “return if condition worsens” or “if you see infection” |
|
Definition
|
|
Term
• Sutures or stapled wounds may be cleansed as early as 12 hours after closure without increasing infection
• Soap and water
• Examine for infection
• Tissue adhesives-may shower but do not immerse or apply topical antibiotics
• May leave open to air after 24 hours |
|
Definition
|
|
Term
• Drains are placed in wounds for removal of interstitial fluids or blood
• To keep tract open for drainage of pus
• Prevent abscess
• Ribbon gauze-packing in abscess cavity
• Change packing daily
• Pain-analgesics may be needed although narcotic analgesia is rarely necessary after the first 48hours. |
|
Definition
|
|
Term
• Necrotizing fasciitis: flesh eating, fascia, sub-Q tissues, crepitus, ‘dish-water’ fluid leaking, fever, inflammation, tachy
• Pressure ulcers/Decubitus ulcers: area of skin that breaks down when something keeps rubbing or pressing against the skin.
• Venous stasis ulcers: irregular, shallow, and located over bony prominences
• Ischemic ulcers (arterial ulcers)-punched out appearance, painful, pale, pulses gone, shiny, hair loss, distal ends of limbs
• Delayed Radiation soft tissue injury/Chronic radiation damage: is called "osteoradionecrosis" when the bone is damaged and "soft tissue radionecrosis" if it is muscle, skin or internal organs which have been damaged by the radiation |
|
Definition
|
|
Term
• Eyelids – Three days
• Neck – Three to four days
• Face – Five days
• Scalp–7to14days
• Trunk and upper extremities – Seven days • Lower extremities – 8 to 10 days |
|
Definition
|
|
Term
• Traumatic injuries can range from minor isolated wounds to complex injuries involving multiple organ systems.
• Trauma is a leading cause of mortality globally
• All trauma patients require a systematic approach to management to maximize outcomes and reduce the risk of undiscovered injuries. (cookbook medicine) |
|
Definition
|
|
Term
• The "golden hour" concept, which emphasized the increased risk of death and the need for rapid intervention during the first hour of care following major trauma, was described in early trauma studies and has been promulgated in textbooks and instructional courses
• Favors-obstructed airway, tension pneumothorax, severe hemorrhage |
|
Definition
|
|
Term
• 24-hour in-house coverage by general surgeons, and prompt availability of care in specialties such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, pediatric and critical care.
• Referral resource for communities in nearby regions.
• Provides leadership in prevention, public education to surrounding communities.
• Provides continuing education of the trauma team members.
• Incorporates a comprehensive quality assessment program.
• Operates an organized teaching and research effort to help direct new innovations in trauma care.
• Program for substance abuse screening and patient intervention.
• Meets minimum requirement for annual volume of severely injured patients. |
|
Definition
|
|
Term
basic physical concepts that dictate how injuries occur and affect the human body.
• Acceleration
• Deceleration
injury resulting from a collision between a body part and another object or body part while both are in motion
• Coup
occurs under the site of impact with an object
• Contre-coup
occurs on the side opposite the area that was impacted |
|
Definition
|
|
Term
• The tissue expands and then returns to its previous position
• The energy causes compression of the tissues which remains expanded |
|
Definition
|
|
Term
• 1st: A body at rest will remain at rest and a body in motion will remain in motion unless acted on by an outside force.
• 2nd: The second law of motion states that if an unbalanced force acts on a body, that body will experience acceleration ( or deceleration), that is, a change of speed. |
|
Definition
|
|
Term
Pre-Crash
• Alcohol
• Drugs (illicit and prescribed/side effects)
• Acute medical problems (CVA, MI, arrhythmia, dozing off – OSA)
• Chronic medical problems (longer reaction time due to physical disability, poor vision or old age)
• http://www.youtube.com/w atch?v=GLuZTVd2Vu0
Crash
• Collision of objects
• Amount of energy
• Direction of energy
Post Crash
• Starts after the energy is exchanged
• The trauma has already occurred |
|
Definition
| Pre-crash/Crash/Post-crash |
|
|
Term
• Forward motion stops abruptly
• The speed determines the amount of damage
• The impact absorbs all the speed of the car
– Down And Under – Up And Over |
|
Definition
|
|
Term
• The lower body is the leading portion
• Commonly injured body parts:
– KNEE (DISLOCATES, POPLITEAL ARTERY INJURY)
– PELVIS (FRACTURES)
– HIP JOINT (DISLOCATES POSTERIORLY)
• Look for a knee imprint on the dashboard |
|
Definition
|
|
Term
• The head is the leading portion of the body
• Compression injury to the chest and abdomen as they strike the steering wheel
• Spider webbing of the window shield
• Head strikes into the window shield |
|
Definition
|
|
Term
• The impact is converted to acceleration
• The velocity is the difference between the speeds of the two cars
• The position of the headrest is important
• Can also have a head on component if strikes another stationary object or the brakes are engaged. |
|
Definition
|
|
Term
• The car is propelled in the direction of the impact
• Spine fractures are more common
• Can collide with other unrestrained passengers
• Injury is caused by the movement of the car and encroachment of the car into the cavity (Door forced inward into body) |
|
Definition
|
|
Term
Rotational Rollover
• THE RESULT OF A CORNER IMPACT
• COMBINATION OF LATERAL AND HEAD ON IMPACT
• THE CAR SPINS OUT
• ALMOST IMPOSSIBLE TO PREDICT THE INJURIES
• SEVERE INJURIES
• IMPACT AT MULTIPLE ANGLES
• OPEN WINDOWS/ CONVERTIBLE CAN LEAD TO MORE INJURY |
|
Definition
|
|
Term
• Shear is the change in speed
• Thorax: Aorta
• Abdomen:
– Diaphragm
– Solid Organs
– Aortic Insufficiency/Aortic dissection
• Compression occurs when the organs become trapped
• Neck: C-Spine Fractures • Thorax: Paper Bag Effect • Abdomen: Liver Tears |
|
Definition
|
|
Term
• HEADON
– The bike propels the rider over the handle bars
• ANGULARIMPACT
– The lower extremities are crushed as the rider is struck on the side
• EJECTIONIMPACT
– The rider is thrown like a missile and has a high risk of serious injury
• “LAYINGDOWNTHE BIKE” (or how to fall on a motorcycle)
– Lays over, lets go and allows the bike to move away to avoid impact – but injury can/will still occur. |
|
Definition
|
|
Term
• The helmet is the most important
• Without the helmet the head injuries increase by 300%
• Other gear includes boots and leather clothing
• Should look at the helmet to determine possible head injuries |
|
Definition
|
|
Term
• The initial impact
– ADULTS: THE LOWER BODY – CHILDREN: THE CHEST
• Adults: The torso hits the hood of the car
• The impact when they hit the ground
– CHILDREN CAN BE DRAGGED FOR SOME TIME AS THE ARE NOT EASILY THROWN CLEAR OF THE CAR |
|
Definition
| Phases of Pedestrian Injury |
|
|
Term
• Importanttoestimate the height of the fall
• Evaluatethesurface landed on by the victim
• Determinethebody part which made the first impact
• AlwaysXRAYBL HANDS/WRISTS FEET/ANKLES |
|
Definition
|
|
Term
• Can injure up to 70% of persons in the vicinity
• Primary injury – projectile
• Secondary injuries – Internal: shock wave
• Tertiary injuries
– Outside wall falling on passersby |
|
Definition
|
|
Term
• Rapid assessment • Triage
• Resuscitation
• Diagnosis
• Therapeutic Intervention |
|
Definition
|
|
Term
• First peak
– Within minutes of injury
– Due to major neurological or vascular injury
– Medical treatment can rarely improve outcome
• Second peak
– Occurs during the 'golden hour'
– Due to intracranial hematoma, major thoracic or abdominal injury
– Primary focus of intervention for the Advanced Trauma Life Support (ATLS) methodology
• Third peak
– Occurs after days or weeks
– Due to sepsis and multiple organ failure |
|
Definition
| Tri-modal Distribution of Trauma |
|
|
Term
• Primary survey and resuscitation
– A = Airway and cervical spine
– B = Breathing
– C = Circulation and hemorrhage control
– D = Dysfunction of the central nervous system – E = Exposure
• Secondary survey • Definitive treatment |
|
Definition
|
|
Term
• Theprimarysurveyincludes5components,which
should always be followed in strict order.
• A.AirwayMaintenancewithCervicalSpineProtection
• B.BreathingandVentilation
• C.CirculationandHemorrhageControl
• D.Disability/NeurologicalStatus
• E.Exposure/EnvironmentalControl
• Afterthe5maincomponentsofthePrimarySurvey,
continue with F,G,H:
• F.FoleyCatheter
• G.GastricTube
• H.Hertz-TraumaUltrasound |
|
Definition
|
|
Term
• Clear the oropharynx of blood, mucus and foreign bodies.
• Lift the angle of the jaw or the chin to prevent the tongue from falling back and obstructing the airway. (Don't overextend the neck; the patient might have a spinal injury!).
• Choose the correct length oropharyngeal tube. The distance between the angle of the mouth and the earlobe is an easy way to choose the right size tube.
• Apply cricoid pressure during intubation to prevent aspiration. Keep applying the pressure until the cuff of the tube has been inflated. Make sure that the tube is in the correct place by checking for CO2 return, listening for bilateral breath sounds and obtaining a chest x- ray.
• If ET intubation is impossible (e.g. in severe facial trauma), the next step is a cricothyroidotomy. In emergencies there is no place for tracheostomy |
|
Definition
|
|
Term
• High index of suspicion
• Avoid rough manipulation of head and neck
• Use hard C-collars to immobilize the neck
• Immobilize the whole body on a long spinal board
• Obtain proper radiological evaluation after patient stabilized |
|
Definition
|
|
Term
• Inspect for symmetrical chest movements
• Auscultate for breath sounds bilaterally
• Palpate the trachea for deviation
• Palpate the chest wall for fractures and emphysema
– Look for flail chest-intubate
– Open sucking/blowing wound in the chest wall-chest tube
– Tension Pneumothorax-needle decompression 2-3 IC/MC-
– 4-5 IC MA line-chest tube placement |
|
Definition
|
|
Term
• Assesslevelofconsciousness,BP, HR, skin color, skin temperature, and evidence of bleeding
• Controlanyexternalbleedingby direct pressure
• Inpenetratinginjuriestotheneck, where venous injuries are suspected, put the patient in Trendelenberg (head down) to prevent air embolism
• Ifthereisshock,inserttwolarge intravenous lines and start fluid resuscitation. |
|
Definition
| Circulation and Hemorrhage Control |
|
|
Term
• 1. HYPOVOLEMIC SHOCK-due to post- traumatic hypotension and could be due to external or internal blood loss
– Resolution-Fluid challenge
– If we know the patient needs surgery then don’t hesitate
– BLOOD
• 2. CARDIOGENIC SHOCK
– Suspect in trauma patients that have shock in the absence of blood loss.
– BP is low and the neck and peripheral veins are distended
– The following conditions may be associated with cardiogenic shock: cardiac tamponade, myocardial contusion, tension PTX, air embolism, MI, cardiac arrest
• 3. Neurogenic Shock
– Result of loss of vascular tone following cervical cord or upper thoracic spinal cord injury |
|
Definition
| Three Groups That Cause Shock! |
|
|
Term
• Rh negative: no need for typing or cross matching-LIFE THREATENING blood LOSS only
• Typing (Type and Screen) but no cross matching (“Type Specific Blood”) Ready in about 10 minutes
• Fully Typed and Cross Matched-Ready in about 30 minutes
– In severe hypovolemia use Level 1 rapid infusion blood warmers |
|
Definition
| Blood- Quick Trauma Review |
|
|
Term
|
Definition
| higher number = alert. best eye response, best verbal response, best motor response |
|
|
Term
• Undress the patient completely (TRAUMA SHEARS)
• Keep patient warm with blankets and warm IVF |
|
Definition
|
|
Term
• Protect and secure the airway • Ventilate and oxygenate
• Stop the bleeding!!!!
• Crystalloid/Blood Resuscitation • Protect from hypothermia |
|
Definition
|
|
Term
•non level 1 trauma centers
• Use time wisely
• Do not delay transfer for diagnostic tests |
|
Definition
|
|
Term
• Started after the primary survey is complete • ABCDE’s are performed
• Vital functions are returning to normal
• Mechanism of Injury – Illicit full story |
|
Definition
|
|
Term
| • The purpose is to diagnose any occult and minor injuries |
|
Definition
|
|
Term
| • The primary goal of treatment for patients with suspected TBI is to prevent secondary brain injury. |
|
Definition
|
|
Term
• Rigid, non-expansile skull filled with brain, CSF, and blood
• Cerebral blood flow (CBF) usually auto-regulated
• Auto-regulatory compensation disrupted by brain injury
• Mass effect of intracranial hemorrhage |
|
Definition
|
|
Term
| Exponential increase in intracranial pressure (ICP) associated with a small increase in the volume of the mass results in increased pressures in the rigid skull and reduced cerebral blood flow |
|
Definition
|
|
Term
10 mm Hg = Normal >20 mm Hg = Abnormal >40 mm Hg = Severe
• Sustained increased ICP leads to decreased brain function and poor outcome
• Hypotension and low saturation adversely affect outcome |
|
Definition
| Intracranial Pressure (ICP) |
|
|
Term
• Laceration of the scalp may be associated with significant bleeding. Control with deep sutures and compression dressing.
• Never send a patient to the radiology suite before suturing a bleeding scalp wound!
• Scalp infections may spread intracranially via the emissary veins |
|
Definition
|
|
Term
• Skull fractures are classified according to:
– Shape
– Displacement
– Site Integrity of the Overlying Skin
• Examples: Linear, Stellate, Comminuted, Depressed, Compound, Basilar Fractures
– A fracture may be diagnosed by digital exploration, radiographically or clinically |
|
Definition
|
|
Term
Vault- any of the 8 bones
• Depressed or nondepressed • Open / closed
Basilar
• With or without CSF leak
• With or without cranial nerve palsy |
|
Definition
| Skull Injuries by Morphology |
|
|
Term
• Diagnosis often clinical
– CSF leaking from the nose or ear
– Periorbital Ecchymosis (Raccoon Eyes)
– Ecchymosis behind the ear (Battle’s Sign) |
|
Definition
|
|
Term
Focal
• Epidural (extradural) • Subdural
• Intracerebral
Diffuse
• Concussion
• Multiple Contusions
• Hypoxic/Ischemic Injury |
|
Definition
| Brain Injuries: By Morphology |
|
|
Term
• Concussion: No gross pathology. Transient LOC. CT Scan is normal
• Contusion: Bruising of the brain surface underneath a fracture or at the under-surface of the frontal and temporal lobes, due to shearing forces- Seen on CT scan
• Laceration: Tearing of the brain substance- Seen on CT Scan
• Brain Edema: localized in the glial cells, myelin sheaths and intercellular spaces. May cause increased ICP –May not be seen initially on CT scan. |
|
Definition
|
|
Term
• Associatedwithskullfracture
• Classic: middle meningeal artery tear
• Lenticular/biconvex
• Lucidinterval
• Canberapidlyfatal
• Earlyevacuationessential
• Mayhavechronicsubdural- appears many days after injury.
• Commoninelderly. |
|
Definition
|
|
Term
• Venous tear / brain laceration
• Covers cerebral surface
• Morbidity / mortality due to underlying brain injury
• Rapid surgical evacuation recommended, especially if > 5 mm shift of midline |
|
Definition
|
|
Term
• Usually beneath a cortical contusion
• Coup / contre coup injuries
• Most common: frontal / temporal lobes
• CT changes usually progressive
• Most conscious patients: no operation |
|
Definition
|
|
Term
| Coup injury occurs where the brain is impacted, whereas contracoup injury occurs where the brain bounces off the skull on the opposite side of the impact |
|
Definition
|
|
Term
| resultant from shearing of white matter. Usually due to severe deceleration |
|
Definition
|
|
Term
| Herniation of the temporal lobe through the tentorium and compression of the brain stem |
|
Definition
|
|
Term
• By Severity of Injury Based on GCS Score – Mild
– Moderate – Severe |
|
Definition
| Classification of Head Injury |
|
|
Term
• GCSscore=13–15
• History
• Exclude systemic injuries
• Neurologic exam
• Radiographic investigation as indicated
• Alcohol / drug screens as indicated
– Observe or discharge based on findings |
|
Definition
|
|
Term
• GCSscore=9–12
• Initial evaluation same as for mild injury
• CT scan for all
• Admit and observe
• Frequent neurologic exams
• Repeat CT scan
• Deterioration: Manage as severe head injury |
|
Definition
|
|
Term
• GCSscore=3–8
• Evaluate and resuscitate
• Intubate for airway protection
• Neurologic exam prior to intubation • Focused neurologic exam
• Frequent reevaluation
• Identify associated injuries |
|
Definition
|
|
Term
• GCS score still < 15 two hours after injury • Neurologic deficit
• Open skull fracture
• Sign of basal skull fracture
• Vomiting (> 2 episodes) • Extremes of age
• Retrograde amnesia
• Severe headache |
|
Definition
|
|
Term
• ABCDE
• Minimize secondary brain injury
• Administer oxygen
• Maintain adequate ventilation
• Maintain blood pressure(systolic > 90 mm Hg) |
|
Definition
|
|
Term
• All patients with skull fractures, history of loss of consciousness, seizures, significant headache, amnesia, depressed level of consciousness, and focal deficits should be admitted.
• If in doubt, e.g. when dealing with infants or drunken patients, admit |
|
Definition
|
|
Term
• Closed, uncomplicated fractures: Symptomatic management, observation for 2-3 days; no need for antibiotics
• Basilar fractures: Single dose antibiotic prophylaxis. Do not pack the nose or ears to stop CSF leaking because of danger of meningitis. Put the patient in a semi-sitting position. If the CSF leak persists for more than 10 days, consider surgical intervention
• Depressed fractures: If it is a compound fracture, elevation may decrease the incidence of sepsis.
• Routine elevation is not recommended for closed depressed fractures.
• Elevation does not improve the neurological outcome or risk of epilepsy |
|
Definition
|
|
Term
• Seizure prophylaxis in all patients with intracranial bleeding
• Phenytoin loading dose 10-15 mg/Kg over 30-60 minutes, followed by 5 mg/Kg per day or Levetiracetam (Keppra) 500 mg twice a day for 7 days]. Early seizures (within 7 days) do not warrant long-term prophylaxis.
• Prolonged anticonvulsant prophylaxis does not prevent late epilepsy |
|
Definition
|
|
Term
• Controlled ventilation
• Goal: PaCO2 at 35 mm Hg • Intravenous fluids
• Euvolemia
• Isotonic
• Consult with neurosurgeon
• Mannitol
– Use only with signs of tentorial herniation – Avoid in patients with hypovolemia
– Dose 1.0 gram / kg IV bolus
• Hypertonic saline • Anticonvulsants
• Sedation
• Paralytics |
|
Definition
|
|
Term
• Penetrating Trauma
• ABCs
• X-ray / CT scan
• Early neurosurgical consult
• Prophylactic antibiotics
• Do not remove penetrating object or probe the wound. |
|
Definition
|
|
Term
• A knife stuck in the skull: Do NOT remove. This should be done in the OR by a neurosurgeon, in some cases after an angiogram has been obtained
• ABCDE’s
• X-ray/CT scan
• Early neurosurgical consult
• Prophylactic antibiotics |
|
Definition
|
|
Term
• Intracranial Mass Lesion
• Can be life-threatening if expanding rapidly
• Immediate neurosurgical consult
• Hyperventilation / medical therapy
• Damage control craniotomy: transfer to neurosurgeon (rural / austere areas) |
|
Definition
|
|
Term
• GCS score = 3
• Nonreactive pupils
• Absent brainstem reflexes (e.g., oculocephalic, corneal, and Doll’s eyes, and no gag reflex)
• No spontaneous ventilatory effort on formal apnea testing |
|
Definition
|
|
Term
• Organ procurement organization referral for all patients with head injury and GCS < 5
• Consider organ donation for all patients with brain death
• At each hospital you will have an OPO- call them early |
|
Definition
|
|
Term
• Zone 1- between the clavicle and the cricoid cartilage
• Zone 2- between the cricoid and the angle of the mandible
• Zone 3- between the angle of the mandible and the base of the skull |
|
Definition
|
|
Term
• “Hard” Signs
– Severe hypovolemic shock
– Active bleeding
– An expanding or pulsatile hematoma
– An absent or diminished peripheral pulse
– Bubbling of air through the wound or dyspnea
• “Soft” Signs
– Pain on Swallowing
– Small hematemesis
– Hoarseness
– Minor Hemoptysis
– Subcutaneous Emphysema in the absence of pneumothorax
• The presence of an isolated nerve injury is not an indication for an emergency operation
• If there are no hard signs of significant injury and the investigations are normal – manage non-operatively
• 15-20% of penetrating injuries to the neck require operation |
|
Definition
|
|
Term
• Airway-watch for expanding hematoma – May need fiberoptic scope for intubation – Surgical team may need to crich
• Bleeding-apply compression over wound – May need to place in Trendelenburg position – If bleeding may insert foley catheter
• IV lines-always insert on the opposite from proximal venous injury
• Local Examination-check active bleeding, blood in sputum, air bubbling, hoarseness, SubQ emphysema, Exclude injury to spinal cord and CN 7,9, 10,11, and 12 and to brachial plexus and to sympathetic chain (Horner’s syndrome)
• Central Nervous System-Carotid Injuries
– Often associated with brain ischemia and neurologic signs
– Be aware of shocked or intoxicated patients • Don’t forget to look for other injuries
• Neck wounds are distracting!!
• Chest and Neck X-rays
– Hemopneumothorax
– SubQ Emphysema
– Widened upper mediastinum
• CT scan with stable patients
– Can help select patients who might benefit from angio or esophageal studies
• Color Flow Doppler-some limitations but overall a noninvasive, sensitive and specific and cheap test
• Angiography-good for stable patients
• Gastrograffin swallow-for suspected esophageal injuries
• Esophagraphy-for suspected esophageal injuries
• Laryngo-tracheoscopy-for suspected larynx and trachea• |
|
Definition
| Initial Assessment and Management of Neck Injuries |
|
|
Term
• Seatbelts
• Direct Blunt Trauma • Hangings
• Overextension
• Over flexion injuries
• Clinical Evaluation
– Neurological deficits might be due to associated head trauma or vascular injuries |
|
Definition
|
|
Term
• Dyspnea
• Subcutaneous Emphysema • Hemoptysis
• Hoarseness |
|
Definition
|
|
Term
Signs
Petechiae Swelling Plethora Cerebral Edema
Treatment
Airway control Oxygen |
|
Definition
| Strangulation/Traumatic Asphyxia |
|
|
Term
• Hematoma
• Unexplained Neurological Signs • OftenAsymptomatic |
|
Definition
|
|
Term
• CT scan
– Laryngotracheal or spinal injuries
• CT angio
– Vascular evaluation of the carotid and vertebral arteries
• Laryngoscopy
– Laryngotracheal injuries
• IfsuspectedCTangio!
• Lookforseatbeltmarks, hematomas, C-spine or laryngotracheal injuries |
|
Definition
|
|
Term
• Identify and initiate treatment during the primary survey of injuries that affect the airway.
• Airway obstruction
• Tension or open pneumothorax
• Flail chest and pulmonary contusion
• Massive hemothorax
• Cardiac tamponade
• Identify and initiate treatment during the secondary survey of the potentially life-threatening injuries.
• Describe the significance and treatment of subcutaneous emphysema, thoracic crush injuries, and sternal, rib, and clavicular fractures.
• Significant cause of mortality
• Blunt: < 10% require operation
• Penetrating: 15-30% require operation
• Majority: Require simple procedures
• Most life-threatening injuries are identified during the primary survey |
|
Definition
|
|
Term
• Laryngeotracheal injury / Airway obstruction • Tension pneumothorax
• Open pneumothorax
• Flail chest and pulmonary contusion
• Massive hemothorax • Cardiac tamponade |
|
Definition
|
|
Term
• Tachypnea
• Respiratorydistress
• Hypoxia
• Trachealdeviation
• Abnormalbreath sounds
• Percussion abnormalities
• Chestwalldeformity- Flail Chest |
|
Definition
|
|
Term
• Airway Obstruction – Rare
– Hoarseness
– SubQ emphysema
– Manage in the primary survey
• Intubate cautiously • Tracheostomy |
|
Definition
|
|
Term
• Dramaticpresentation
• PanickyPatient
• Dyspnea,cyanosis,tachypnea
• Shock,distendedneckveins
• Tracheashiftedtooppositeside
• Absentbreathsounds
• Hyperressonanceonaffectedside
• DiagnosisisCLINICAL
– Needle- anterior 3rd or 4th intercostal space, mid- clavicular line or at the 5th intercostal space mid- axillary line
– Chest tube-mid-axillary line |
|
Definition
|
|
Term
• Ineffective ventilation
• 3-sided cover, over defect
• Chest tube
• Definitive operation |
|
Definition
|
|
Term
• Intubate as indicated
• Oxygen-CPAP
• Re-expand lung
• Judicious fluids
• Analgesia- Avoid over sedation |
|
Definition
| Flail Chest and Pulmonary Contusion |
|
|
Term
• No breath sounds and percussion dullness
• Chest decompression
• Flat neck veins
• Shock
• > 1500 mL blood loss
• Volume restoration
• Auto transfusion
• Operative intervention
• Always look for lung/vessel laceration |
|
Definition
|
|
Term
• C-XRAY
• Ifminimalmayobserve
• Chesttubeplacement
• Physiotherapy
• Autotransfusion
• Prophylacticsingledoseantibiotic
• >1000-1500urgentthoracotomy
• Residualhemothoraxafterchest tube may need thrombolytic therapy
• Mayplaceadditionalpigtail catheters |
|
Definition
|
|
Term
• Shock
• Distended neck veins
• Muffled heart sounds
• Pulseless electrical activity
• FAST
• Operation |
|
Definition
|
|
Term
• Patients with penetrating thoracic injury arriving with PEA
• When a surgeon with appropriate skills is present
• Resuscitative thoracotomy is not indicated in blunt trauma with PEA |
|
Definition
| When to Consider Thoracotomy |
|
|
Term
• Pulmonary Contusion
• Simple pneumothorax
• Smaller hemothorax
• Perforationofthe tracheobronchial tree
• Traumatic diaphragmatic rupture
• RibFractures
• Containedruptureof the aorta
• Bluntcardiacinjury
• Traumaticaortic disruption
• Bluntesophageal rupture |
|
Definition
Secondary Survey
Potentially life-threatening Chest Injuries |
|
|
Term
• Oftenmissed
• Penetratingorblunttrauma
• Persistentpneumothoraxorpersistentairleak
• Bronchoscopy
• Treatment
– Airway and ventilation
– Tube thoracostomy – Operation
• Suspectiflungdoesnotinflateafterachesttube is placed |
|
Definition
| Tracheobronchial Tree Injury |
|
|
Term
• Pain aggravated by coughing or breathing
• May give oral analgesics or Lidocaine patches
• May consider giving epidural
• Look out for flail chest especially in the elderly
• Fractures of the first 3 ribs may injure the subclavian vessels or major bronchi
• In the elderly admit to SICU |
|
Definition
|
|
Term
• Ribs1-3
– Severe force, high mortality risk with associated injuries
• Ribs4-9
– Pulmonary Contusion, Flail chest, PTX
• Ribs10-12
– Suspect intra-abdominal injury
• Sternum
– Suspect cardiac injury
• Scapula
– Suspect multiple rib fractures, Cardiac, PTX |
|
Definition
| Sternum, Scapula, and Rib Fractures |
|
|
Term
• May vary from asymptomatic or symptomatic cardiac contusion to full cardiac rupture
• Causes: direct blunt trauma over the precordium, rapid deceleration accidents
• Diagnosis: high index of suspicion, cardiac failure, cardiac arrhythmia, unexplained hypotension
– Fast can diagnose tamponade
– EKG: Signs of myocardial ischemia, arrhythmias, or may be normal.
• Troponin measurements on admission and 6-8 hours later.
• Echocardiogram (the best diagnostic modality) if ECG or
• Troponins are abnormal.
• Routine ECG and Troponins should be performed in all
patients with a suspicious mechanism of injury.
• Normal EKG and Troponins on admission reliably exclude any significant cardiac contusion.
• Observation of asymptomatic patients with EKG and Troponin levels monitoring.
• Inotropes in cardiogenic shock.
• Anti-arrhythmics in arrhythmias.
• Bed rest, serial ECG and Troponin levels, until they return to normal. |
|
Definition
|
|
Term
• Usually resultant from rapid deceleration in high speed accidents
• Falls from heights
• Must have a high index of suspicion
• Hypertension in the arms, hypotension in the legs
• Possible hoarseness from compression of the recurrent laryngeal nerve
• CXRAY-wide mediastinum, often left hemothorax
• Deviation of the trachea
• CT-may be investigation of choice-able to
differentiate between hematoma and rupture
• Aortic Arch Angio- if CT non-diagnostic
• TEE- patients in SICU who can’t be moved |
|
Definition
| Traumatic Aortic Disruption |
|
|
Term
• Resuscitationasnecessary
• Keeplowsystolicpressure (about 90mmHg)
• UseBetablockers
• Surgicalrepair
• EndovascularStent/Graft
• Non-operative management for minor aortic injuries or in elderly patients |
|
Definition
| Traumatic Aortic Disruption |
|
|
Term
• Hemothorax (discussed) • Heart
• Diaphragm
• Lungs
• Esophagus |
|
Definition
|
|
Term
• Restless patient
• Shock, tachycardia, weak peripheral pulses
• Signs of cardiac tamponade: Beck’s triad (shock, distended neck veins, distant cardiac sounds) present 90%. Pulsus paradoxus only 10% preent
• CXRAY- wide mediastinum
• FAST- blood noted
• EKG- may show low voltage QRS, elevated ST segments and inverted Twaves
• Pericardiocentesis: used rarely now
• Sub-xiphoid window
• Transdiaphragmatic pericardial window-
• If patient stable and truly suspect, get ECHO
• If patient unstable and arresting, ED thoracotomy- mortality >90% |
|
Definition
| Penetrating Trauma To the Heart |
|
|
Term
• Mostcommon-leftsided
• Blunt-large7-10cmlong
• Penetrating-small
• Brokenribsmaycause
• Decelerationinjuries
• Almostalwaysassociated with other intra-abdominal injuries
• Operation |
|
Definition
|
|
Term
• Have a high index of suspicion for every penetrating injury in the left lower chest (between nipple and costal margin).
• Injuries to the right diaphragm rarely have any clinical significance, except for anterior injuries.
• In left diaphragmatic injuries, the positive intra-abdominal pressure might cause migration of abdominal viscera into the chest and formation of diaphragmatic hernia
• Often asymptomatic
• Blood loss in long tears
• Abdominal visceral obstruction or perforation may occur
• A diaphragmatic hernia may occur minutes to years after injury. Stomach, colon, omentum are most common
• CXRAY-elevatedlefthemi-diaphragm
• Laparoscopy-standardinvestigationforasymptomatic patients with penetrating injuries below nipple line and above the costal margin on the left side
• Thoracoscopy-rarely used initially. May use if residual hemothorax requiring evacuation is necessary
• Ifstomachissuspectedinthechest,insertanNGTand take a CXRAY
• Contrastmealandfollowthruandcontrastenemafor suspected diaphragmatic hernias
• Surgicalrepair
• Pitfall-insertingchesttubeintobowel |
|
Definition
| Penetrating Trauma To the Diaphragm |
|
|
Term
• Uncommonanddifficulttodiagnose – Mechanism is severe epigastric blow
– Unexplained pain
– Unexplained shock
– Radiographs demonstrate mediastinal air • Signsandsymptoms
– Mediastinal air
– Unexplained shock
– Unexplained left hemothorax / effusion
• Investigations – Contrast
– Endoscopy |
|
Definition
|
|
Term
• Highindexofsuspicioninposteriorstabwoundsnear spine and bullet injuries involving the posterior mediastinum.
• Mediastinalemphysemaissuspiciousradiologicalsign
• FortransmediastinalGSW,amulti-sliceCTscanmay show bullet tract
• Water-solubleGastrografinswallowshouldbe peformed
• Anegativestudyshouldbefollowedbythinbarium
• Esophagoscopymostusefulinpatientsnotawake enough to cooperate |
|
Definition
| Penetrating Esophageal Injuries |
|
|
Term
• Intra-abdominal injuries may occur by four mechanisms:
– 1. Crushing of an organ against the spine, pelvis or the abdominal wall.
– 2. Deceleration forces.
– 3. Sudden increase of the intraluminal pressure and bursting of a hollow viscus.
– 4. Injury by broken lower ribs.
• Clinical exam is key
– Peritonitis
– Referred pain to left shoulder (Kehr’s sign) – likely splenic injury. Right shoulder –liver injury
– Seat-belt marks 20%
• Investigations
– FAST
– Abdominal CT scan-most valuable to note free fluid, spinal, pelvic fractures. Also will note hollow viscus injury signs (free air, unexplained free intraperitoneal fluid, bowel wall thickening, mesenteric stranding)
– Microscopic hematuria
– Pregnancy
– Serum amylase-to exclude pancreatic trauma (70% cases elevated)
– DPA or DPL (rarely done) |
|
Definition
|
|
Term
• Indications: Blunt or sometimes penetrating multitrauma with unexplained hypotension, where the FAST exam is not diagnostic.
• Technique
– 1. The bladder is catheterized.
– 2. Under local anesthesia, a 0.5 cm incision is made just below the umbilicus.
– 3. The needle is inserted into the peritoneal cavity and a guide- wire is placed through the needle aiming towards the pelvis. The needle is removed and the plastic catheter is fed into the peritoneal cavity over the guide-wire. Aspirate with a syringe. If blood is aspirated, the procedure is considered positive and it is terminated. If no gross blood is aspirated the reason for hypotension is not intraperitoneal bleeding and the procedure is terminated |
|
Definition
|
|
Term
High Velocity
• Extensive tissue damage
• Almost always require laparotomy
Low Velocity
• Civilian violence (stab wounds, most handguns)
• Three schools of thought
– Routine exploration
– Operation on every case with proven peritoneal penetration with local wound exploration or sonograms
– Selective non-operative management-operate only if peritonitis or severe bleeding; not used in spinal cord injury patients or unconscious patient
• Investigations
– CXRAY/Abdominal xrays (can locate bullet)
– UA
– Diagnostic laparoscopy
– CT scan
– Sigmoidoscopy for pelvic GSW with suspected rectal injuries
• Management
– Preoperative antibiotics
– 24 hour prophylaxis if post-op
– IVF
– NGT
– Vitals
– Serial Hb and WBC q6-12 – No routine narcotics
– Watch for signs of peritonitis |
|
Definition
| Penetrating Abdominal Injuries |
|
|
Term
• Signs of hypovolemia, Kehr’s sign
• CXRAY may show possible rib fractures, elevated hemidiaphragm, enlarged splenic outline
• FAST may show free fluid
• DPApositive
• Elevate WBC
• CT scan -blush
-The "blush sign" is an active pooling of contrast material within or around the spleen seen during intravenous enhanced computed tomography (CT) scan. Adult treatment algorithms often include the "blush sign" as an indication for embolization or surgical intervention
• Treatment
– Non-op ~90% children and 60% adults
– Serial CT investigations in Grade 3 or worse
– Post-splenectomy patients at risk for pneumococcus, meningococcus, hemophilus- GIVE pneumoccoccal vaccine
– Complications post-splenectomy: increase in Platelet count, thrombosis, DVT, subdiaphragmatic collections |
|
Definition
|
|
Term
• Pain radiating to right shoulder, hypovolemia, rib fractures
• FAST-hepatorenal space free fluid
• CXRAY –possible fractured right lower ribs
• DPA
• CT scan-most valuable
• Treat-non-op if stable
• Angio for embolization
• Possible need for OR
• Complications: hemobilia (pain, jaundice, hematemesis, anemia); abscess formation, bilomas, biliary fistulas, liver parenchyma necrosis |
|
Definition
|
|
Term
• Clinical Presentation
– 1.Acontusionorpenetratingwoundover
the loin.
– 2.Painintheloin.
– 3.Grossormicroscopichematuria.
– 4.Bruitormurmurduetotraumatic aneurysm or arteriovenous fistula.
• Investigations – CTscan
– Angiogram
• Treatment
– Non-op,watchingforbruitsor
hypertension
– Surgery-peritonitis
– Earlydiagnosis4-6hourofrenalartery stenosis, endovascular stent |
|
Definition
|
|
Term
• Often associated with pelvic fractures or blunt abdominal trauma with a full bladder. Rupture may occur intraperitoneallyor extraperitoneally.
• Clinical Presentation
– 1.Suprapubicpain.
– 2.Hematuria.
– 3.Inabilitytopassurine.
– 4.Abdominaldistension.
– 5.Urineextravasationinthescrotum.
• Specific Investigations – Serumurea
– CystogramorCTcystogram
• Treatment
– IntraperitonealrupturesrepairSURGICALLY
– Smallextraperitonealmaybemanagednon-opwithtransurethralcatheter drainage for 10 days~ |
|
Definition
|
|
Term
• Almost exclusively in males, usually associated with pelvic fractures, and occasionally with falls resulting in straddle injuries
• Clinical Presentation
– 1.Bloodattheurethralmeatus.
– 2.Inabilitytopassurine.
– 3.High“Floating”prostateonrectal examination.
– 4.Urineextravasationinthescrotum.
• Investigations – Urethrogram
• Treatment
– Avoidtransurethralcatheterizationunless
experienced person
– Suprapubicortransurethralcatheterization for two weeks
– Endoscopicalignmentandcatheterization shortly after |
|
Definition
|
|
Term
• May be due to blunt or penetrating
• Often associated with duodenal injuries
• Clinical Presentation
– 1. History of abdominal trauma.
– 2. Epigastric pain, often very mild.
– 3. Acute pancreatitis.
– 4. Sometimes-late presentation with pancreatitis or a pseudocyst.
– 5. Obvious peritonitis.
• Investigations
– Amylase
– CT scan, may need to repeat in 6-10 hours
– MRCP
– ERCP
• Treatment
– Most non-op
– Watch for pseudocyst formation
– Injuries with major ductal leaks require surgery |
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Definition
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Term
• Usuallyduetopenetrating,butmaybeduetoblunt
• ClinicalPresentation
– Signs of Acute Abdomen
• Investigations
– CT scan may show bowel wall thickening, free air
– WBC may be elevated
– Diagnosis made intraoperatively
• Treatment
– Start preop antibiotics
– Surgical repair: primary repair with or without proximal colostomy, colonic resection with primary anastomosis or colostomy |
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Definition
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Term
• Usuallyduetopenetratingtrauma.Less frequently associated with pelvic fractures or foreign bodies.
• ClinicalPresentation
– Extraperitoneal perforations may give minimal abdominal symptoms. On rectal examination, the perforation might be felt. Blood on glove.
• Investigations
– 1. Sigmoidoscopy
– 2. Gastrografin enema
• Treatment
– Early repair with or without colostomy. |
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Definition
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Term
• Severe bleeding in the pelvic fracture is common.
• Bladder and urethral injuries are common. • Investigations
– 1. Always do a rectal examination!
– 2. Look for signs of bladder or urethral injuries
– 3. Urinalysis for hematuria.
– 4. Cystogram (or CT cystogram) or urethrogram as indicated. – 5. CT scan of the abdomen and pelvis
• Management
– Pelvic binder
– External pelvic fixation
– Angiography and embolization
– Consider laparotomy with ligation of both internal iliac arteries and pelvic packing
– DO CT CYSTOGRAM to evaluate bladder injury! |
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Definition
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Term
• 90% due to blunt trauma
• Fall from greater than 15%
• Delayed diagnosis especially with head injury or intoxication |
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Definition
| spinal injury mechanism of injury |
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Term
• Palpatespinefor tenderness, step-offs, and swelling
• Examineforparalysis or weakness
• Examinesensationto pinprick and reflexes
• Describecordinjury using myotomes and dermatomes |
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Definition
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Term
• No reflexes or voluntary activity distal to the level of injury. This appears immediately after injury and is transient. Once some reflex activity has returned and there is no distal sensation or voluntary motor control, the cord lesion is considered as complete and without any significant chances of functional recovery.
• The sacral reflexes (anal and bulbocavernosus reflexes) are the first to recover from spinal shock, usually within 24 hours |
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Definition
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Term
| Hypotension due to loss of sympathetic tone following cervical or upper thoracic spine injuries. In high cervical cord injuries the hypotension is associated with bradycardia |
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Definition
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Term
• 1. Anterior cord syndrome: Loss of power, loss of pain/temperature sensation, and preservation of proprioception.
• 2. Posterior cord syndrome: Loss of proprioception, preservation of power and pain/ temperature sensation.
• 3. Brown-Sequard syndrome:(usually after penetrating wounds): ipsilateral spastic paralysis and loss of proprioception below the level of the injury, and contralateral loss of pain and temperature sensation below the level of the lesion
• 4. Central cord syndrome: Involves the cervical spinal cord usually in elderly patients. Due to hyperflexion or hyperextension injury. Weakness or paralysis of all four extremities, more severe in upper extremities |
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Definition
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Term
• 1. Fractures of the atlas: The most common type is the extension-compression fracture of the posterior arch. It is a stable fracture. Treatment with hard collar.
• 2. Jefferson’s fracture: Vertical compression and bursting of the lateral masses of the atlas by the condyles of the occiput. It is an unstable fracture.
• 3. Fracture of odontoid process. Instability and non-union are common, depending on the level of the fracture. Operative fusion may be necessary in fractures near the base of the dens..
• 4. Hangman’s fracture: Hyperextension injury with fracture and dislocation of C2-C3. Traction for about six weeks.
• 5. Dislocation of C7-T1: Often operative reduction is necessary |
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Definition
| Specific Fractures of the C-spine |
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Term
• ChanceFractures(seatbelt injury) T12-L2
• Consistsofacompression injury to the anterior portion of the vertebral body and a transverse fracture through the posterior elements of the vertebra and the posterior portion of the vertebral body.
• Itiscausedbyviolentforward flexion, causing distraction injury to the posterior elements |
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Definition
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Term
• Burst Fractures
- fallfromaheight,landingonone'sfeet, is typical of this fracture
- burstfractureinvolvesonlycompressive failure of vertebral body both anteriorly & posteriorly, w/ failure of both anterior and middle columns
- axialloadingappliedtointravertebral disc results in increased nuclear pressure and hoop stresses in the annulus;
- thisresultsinahighshearstressonthe vertebral end plate at inner border of the annulus, away from center of disc;
- alargecentralposterior-superior fragment occurs as a result of these forces |
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Definition
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Term
• CT/MRI/Plainfilms
• Correcthypotension
• Highdosesteroidswithin8hours
• Watchforrespiratoryfailureinquadriplegia
• Reduceandimmobilizeanyexistingdislocation • Watchforparalyticileus
• Drainbladder-watchforhypertension
• Preventpressuresores
• DVTprophylaxis(cavalfilter)
• Spasticitymayoccur-PT,Baclofen,Dantrolene |
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Definition
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