Term
Chest Trauma:
1. __% of deaths from blunt trauma are due solely to chest injuries
2. _/_ of deaths occur after reaching hospital
3. SErious pathological consequences?
4. increases mortality rate by ___%, pneumo by __%, hemothorax by ___%, pulmonary contusion by ___%, flail chest by ___%
5. 3 examples of blunt injuries?
6. __ is the most common sign of blunt thoracic trauma
7. Fx of ___, ___, or ___ suggests massive force of injry |
|
Definition
1. 25%
2. 2/3
3. hypoxia, hypovolemia, cardiac contusions
4. 27%, 38%, 42%, 56%, 69%
5. direct blow, deceleration injury, compression injury
6. rib fx
7. scapula, sternum, first rib |
|
|
Term
air in the pleural cavity caused by blunt or penetrating injury that disrupts the parietal or visceral pleura
unilateral signs: decreased movement and breath sounds, resonant to percussion
confirm by CXR
when do you treat it?
when NOT to treat? |
|
Definition
pneumo
tx: large, any pt on pos pressure ventilation, sx pts
tx with chest tube
DON'T treat: asymptomatic ptsw/ small penumos |
|
|
Term
| How do you treat a pneumo w/o surgery? |
|
Definition
| high flow O2 for 24 hours to help lung expand |
|
|
Term
air enters pleural space and cannot escape
sx: CP, dyspnea, resp distress, tracheal deviation, absence of breath sounds, distended neck veins, hypotension
tx? |
|
Definition
tension pneumo
tx: needle, NOT chest tube
14 gauge needle, midclavicular line above 2nd ICS superior to rib to avoid VAN |
|
|
Term
air in pericardium
usually a sign of a big pneumo
tx? |
|
Definition
pneumopericardium
tx pneumo. if it doesn't get better, needs pericardial window or pericardiocentesis |
|
|
Term
caused by blunt or penetrating trauma, generally from chest wall injury
requires rapid decompression and fluid rescusitation
clinically: hypovolemia, absence of breath sounds, dullness to percussion
CXR may be confused with collapsed lung
tx? |
|
Definition
hemothorax
tx: chest tube w/ larger tube than with pneumo |
|
|
Term
| when does a hemothorax need to go to surgery? |
|
Definition
| immediate return of 1500 ml of blood or 250 ml/hr for 4 hours |
|
|
Term
most common thoracic injury in trauma
- more than half of thoracic injuries from non-penetrating trauma
- 10% of all pts admitted after blunt chest trauma have one or more
- not life threatening in themselves but can be an external marker of more severe visceral injury - injure liver or spleen |
|
Definition
|
|
Term
Rib Fx:
1. ribs __-__ are most commonly injured
2. avg blood loss per fx rib is __-__ ml
3. what makes rib fx's severe?
4. mortality doubles with __ or more ribs
5. fx of lower left ribs can lead to __ injury
6. fx of lower right ribs can lead to __ injury
7. fx of post lower ribs can lead to __ injury
8. fx of upper ribs, scapula, or clavicle can lead to ___ injry |
|
Definition
1. 5-9
2. 100-150 ml
3.pain causes resp splinting = atelectasis and pneumonia, more likely to nee thoaractomy and laparotomy, increased risk of hepatic and splenic injury
4. 3 or more
5. spleen
6. liver
7. renal
8. vascular |
|
|
Term
2 fx sites on three consecutive ribs which creates a mobile fragment that moves paradoxically with respiration and hinders the creation of expected ipsilateral negative inspiratory force
main significants is that it indicates the presence of an underlying pulmonary contusion
dx: wall motion abnormality, Chest CT, 3D recon of chest wall
tx? |
|
Definition
flailed chest
tx: splinting, external fixation, mechanical ventilation, plating |
|
|
Term
1. What is a pulmonary contusion?
2. Why is it so significant?
3. sx?
4. tx? |
|
Definition
1. bruised lung
2. enoguh force to go through bones to bruise lung - acute trauma to lung. injury to alveolar-capillary walls, intra-alveolar hemorrhage, interstitial edema, increased tissue wt, airway and arterial resistance, decreased compliance, decreased surfactant content, decreased blood flow
3. sx: dyspnea, tachypnea, hemoptysis, cyanosis, hypotension
4. Tx: O2 (maintain PaO2 >60 mmHg), vigorous chest physiotherapy, rapid volume replacement, liberal colloid use, place PA catheter when large or rapid volume replacement is needed
controversial tx: proning, nitric oxide, steroids, abx |
|
|
Term
| combination of pulmonary contusion + flail chest has a mortality of __% due to ARDS- pt needs to go to ICU immediately |
|
Definition
|
|
Term
| hemorrhage + decreased lung compliance + airway inflammation + atelectasis + ARDS = ? |
|
Definition
|
|
Term
| indications for an ER thoracotomy |
|
Definition
Pts who come into ER alive and then code
No blunt trauma
Not on pts who are dead when they come in
done on penetrating trauma |
|
|
Term
| How do you differentiate between hemothorax and pulmonary contusion? |
|
Definition
| contusion will have breath soudns |
|
|
Term
caused by a direct impact that causes a tear in the middle meningeal artery
80% over temporal/occipital area
Sx: AMS, lucid interval, deterioration
classic: knocked out, wake up, unconscious again
CT: football shaped area of opacity
tx? |
|
Definition
epidural hematoma
tx: surgery to evacuate
|
|
|
Term
Common in elderly and alcoholics due to tear of tethered bridging veins
Often seen in deceleration injuries
May be acute with s/s w/in 24 hours, subacute w/in 24hours - 2 weeks, or chronic >2 weeks
poor prognosis if AMS at time of presentaiton
CT: bleed follows contour of skull |
|
Definition
|
|
Term
Most common bleed in the brain
Global headache and photophobia with N/V
good prognosis
vasospasm leading to cerebral ischemia is common
outcome related to amount of blood
tx? |
|
Definition
subarachnoid hemorrhage
tx: O2 and maintain BP
one episode of hypoxia increases mortality 10 fold |
|
|
Term
Rules for repairing lip lacerations
1. Local anesthesia distorts anatomy, so use a ___ block
2. ___ must be aligned
3. use ___ suture
4. if >__% of lip is lost, refer
5. Beware of toddlers with ___ |
|
Definition
1. sub-mental
2. vermilion border - most important
3. absorbable
4. 25%
5. electrical peri-oral burns |
|
|
Term
| where do you begin suturing on a nose laceration |
|
Definition
| one stitch and edge then go from top down |
|
|
Term
Rules for repairing ear lacerations:
1. use a ___ block
2. close ___ first
3. Use ___ bc then cartilage has terrible blood supply
4. splint with molded wet cotton and compressive dressing
5. check frequently for ____ |
|
Definition
1. peri-chondral
2. cartilage
3. broad spectrum abx
4. ---
5. perichondral hematoma |
|
|
Term
Facial laceration rules:
1. Wounds <__ hrs can be closed but beware of contamination
2. Use ___ as anesthetic
3. remove ____
4. close in ___ |
|
Definition
1. 24 hrs
2. lidocaine w/ epi
3. tatoos
4. layers |
|
|
Term
| 95% of neck injuries are where in the neck? |
|
Definition
zone 2: between angle of mandible and cricoid cartilage
All of these injuries go to OR immediately |
|
|
Term
| Zones of the neck and what is included in each |
|
Definition
Zone 1: clavicles to cricoid - great vessels, aortic arch, trachea, esophagus, lung apices, c-spine, spinal cord, cervical nerve roots, thyroid
Zone 2: cricoid to angle of mandible - carotid and vertebral arteries, jugulars, pharynx, larynx, trachea, esophagus, c-spine, spinal cord, vagus nerve
Zone 3: angle of mandible to mastoid process - salivary and parotid glands, esophagus, trachea, c-spine, carotids, jugulars, CN IX-XII |
|
|
Term
| If a neck injury penetrates the ___, it needs to go to the OR |
|
Definition
|
|
Term
Flow chart for penetrating neck injuries:
1. hemorrhagic shock, expanding hematoma, or evolving stroke in zone 1 or 3?
2. hemorrhagic shock, expanding hematoma, or evolving stroke in zone 2?
3. NO hemorrhagic shock, expanding hematoma, or evolving stroke in any zone |
|
Definition
1. get emergency angiography available. if not, immediate operation
2. immediate operation
3. get Lateral neck and CXR. If normal --> critical care for observation. If abnormal --> further testing |
|
|
Term
Blunt neck trauma:
1. If AMS, intoxication, distracting injury, tenderness over c-spine, or neuro deficit... ?
2. If abnormal voice, stridor, subcu air, resp signs or sxs, blood in airway .... ?
3. If carotid bruit, unexplained neuro deficit, Horner's synrome, basilar skull fx through carotid canal, severe flexion or extension fx, massive facial injuries or significant hematoma ... ?
4. Pian on swallowing? |
|
Definition
1. C-spine films
2. laryngoscopy, CT larynx, bronchoscopy
3. angiography, color-flow doppler, helical CT angiogram
4. contrast study of esophagus, esophagoscopy |
|
|
Term
| What do you do if a pt has a carotid bruit after trauma? |
|
Definition
| CT angiogram or carotid US |
|
|
Term
Trauma Pearls:
1. Airway management: early ___ is best, even in mildly symptomatic
2. ___ is the best method to control bleeding
3. Neuro deficits not explained by head CT are the hallmark of ____ injury in blunt neck trauma
4. 3 lines to look at on C-spine xr
5. Need to see ___ vertebrae for an adequate c-spine film |
|
Definition
1. intubation
2. direct pressure (NOT clamping)
3. vascular injury
4. anterior bodies, posterior bodies, spinolaminar
5. 8 - 7 C's + T1 |
|
|
Term
| Nexus rules for c-spine clearanc (5) |
|
Definition
1. A&O, no intox
2. no midline c-spine tenderness
3. no distracting injury
4. normal neuro
5. MOI is not suspect |
|
|
Term
| Indications for c-spine xrays |
|
Definition
neck pain and/or midline c-spine tenderness
AMS
intoxication/drugs
focal neuro deficits
distracting injuries
|
|
|
Term
Spinal cord syndromes:
most common of incomplete spinal cord lesions. neck is subjected to forced hyperextension. ligamentum flavum buckles into cord, resulting in a concussion or contusion. Affects central gray matter and most central portions of pyramidal and spinothalamic tracts. variable quadriparesis with some sensory sparing
Hallmark: greater neuro deficit in upper extremities than the lower extremities |
|
Definition
|
|
Term
Spinal cord syndrome:
results from cervical flexion injuries causing cord contusion
protrusion of a bony fragment or herniated disc into spinal cord
results in paralysis and hypalgesia below level of lesion
hallmarks: preservation of posterior column function (fine touch and proprioception) and laceration or thrombosis of anterior spinal artery |
|
Definition
|
|
Term
spinal cord syndrome:
hemisection of spinal cord from a penetraing lesion or after lateral mass fx of c-spine
Hallmarks: ipsilateral motor paralysis and contralateral sensory loss distal to lesion |
|
Definition
|
|
Term
spinal cord syndrome:
severe injury below level of L2
characterized by perineal or bilateral leg pain, bowel/bladder dysfunction, perianal anesthesia (saddle anesthesia) and diminished rectal sphincter tone and lower extremity weakness |
|
Definition
|
|
Term
Spinal cord pearls:
1. always get at least __ xray views
2. data does not support the use of ___ |
|
Definition
|
|
Term
| kid who can't move his legs but everything looks normal on MRI |
|
Definition
| SCIWORA: spinal cord injury w/o radiography abnormality |
|
|
Term
| most important responsibility once the hospital receieves a call that an emergency is coming in? |
|
Definition
|
|
Term
1. The first VS change in shock is ____
2. transient drop in BP with sudden blood loss implies ____
3. |
|
Definition
narrowed pulse pressure
tamponade |
|
|
Term
|
Definition
1. airway - MOST importnat
2. breathing
3. circulation- pulse/bp
4. disability - physical, neurologic
5. expose: strip, flip, touch, smell
how do you assess all these things at once? ask them a question. if they can answer, they're ok |
|
|
Term
| What vitals to get in trauma |
|
Definition
MOM VITALS
M: monitor
O: O2
M: Mast trousers (pelvic fx)
V: Vital signs
I: IVs - 2 large boar
T: tetanus, tubes
A: Abx
L: Labs
S: Studies |
|
|
Term
| IF a pt needs blood and you're not sure what type they are, what do you give them? |
|
Definition
O+ for males
O- for females |
|
|
Term
| what does it mean if a trauma pt has a negative base deficit? |
|
Definition
they are being under resuscitated
|
|
|
Term
Quick US to assess for free fluid in abdomen
should be assumed to be blood in trauma pt |
|
Definition
|
|
Term
Drugs for trauma pts:
1. for everyone
2. for open fx
3. for soft tissue wounds
4. for abd injuries
5. for agitation
6. for pain managment
7. for sedation |
|
Definition
1. tetanus
2. gentamycin
2. ancef
3. unasyn or flagyl
4. haldol or zyprexa
5. fentanyl
6. benzos |
|
|
Term
|
Definition
|
|
Term
| When do pts with a pneumo need a chest tube? |
|
Definition
|
|
Term
| components of the secondary survey |
|
Definition
after pt is stable...
auscultate, palpate, and percuss everywhere
continually reassess primary survey
decide if more imaging or OR |
|
|
Term
| most common cause of morbidity and mortaility in trauma |
|
Definition
abd trauma
young pts can sequester 60% of total blood volume in abd w/o s/s |
|
|
Term
MVA, unrestrained driver, ejected from vehicle, intubated in field
PE: diminished breath sounds on left, open tib/fib fx, scalp lacerations, unconscious
HR 140, BP 105/90, RR 35
What now? |
|
Definition
CXR: pneumo + rib fx
do chest tube
staple scalp lacs
give fluids 2 L
Wrap leg
If stable --> CT
if unstable --> FAST exam, if pos --> OR |
|
|
Term
27 y/o male w/ gunshot wound to chest. No exit wound. Hypotensive
What now? |
|
Definition
A: fine
B: diminished breath sounds on right --> Pneumo
--> Chest tube
C: fine
get CXR to look for bullet.
Not seen = in abd --> GO TO OR ASAP |
|
|
Term
| any penetrating chest wound can be the abdomen if it entered from the ___ ICS or down |
|
Definition
|
|
Term
GSW are most likely to injure the ____
SWs are most likely to injure the ____ |
|
Definition
|
|
Term
| indications for laparotomy in penetrating abd trauma |
|
Definition
hemodynamic abnormalities
GSW
signs of peritonitis or fascial penetration |
|
|
Term
Blunt abd trauma:
___ account for 75% of blunt abd trauma
Most common organ injured?
seat belt sign is indicative of ___ injury
bloody gastric aspirate after MVA?
direct epigastric blow + persistently increasing amylase? |
|
Definition
mvas
spleen
small bowel
duodenal/jejunal injury
pancreatic injury |
|
|
Term
| most common injury from seat belts? |
|
Definition
|
|
Term
Abdominal trauma:
1. Monitor VS every __-__ min
2. Good story, shock, abd tenderness -- ?
3. No bowel sounds is 30% accurate for ____
4. Indications for NG tube?
5. labs for abd trauma?
6. ___ is most important film to get
7. only get abd film if ? |
|
Definition
1. 3-5
2. OR
3. ileus
4. relieve acut gastric dilation, decompression before DPL, reduce risk of aspiration
5.Hct, metabolic acidosis, tox/alcohol screens, UA w/ hcg, type and cross
6. CXR
7. missile trajectory |
|
|
Term
FAST exam:
1. can ID as little as __cc blood
2. scan what 4 areas? |
|
Definition
1. 100cc
2. pericardial sac, hepatorenal fossa, splenorenal fossa, pelvis |
|
|
Term
| ___ is a non-hypovolemic source of bleeding in trauma pts |
|
Definition
|
|
Term
procedure in abd trauma that should be done by surgeon making decision
blind, intra-umbilical approach
good for unstable, multi-traumas
great for bowel injuries
positive tap is 10cc free blood or lavage w/ 100,000 RBCs in aspirate
rarely done anymore |
|
Definition
|
|
Term
| what kind of fluids do adult and kid trauma pts need? |
|
Definition
adults: 1-2L
Kids: 20 ml/kg |
|
|
Term
|
Definition
Oh My, I Almost Lost The Darn Vital Signs
O: O2/airway
M: Monitor
I: IVs
A: ABGs, Abx
L: Labs
T: Tubes/tetanus
D: Drugs
V: Vitals every 3-5 min
S: Studies |
|
|
Term
most common solid organ injury w/ blunt trauma
can sequester entire blood volume in abd due to this
tx? |
|
Definition
splenic injury
tx: observation, splenic artery embolization, splenectomy
vaccinations: N. meningitidis, S. pneumo, H flu |
|
|
Term
| Factors associated with a GI bleed that have a high morbidity rate |
|
Definition
hemodynamic instability
repeated hematemesis or hematochezia
age > 60 y/o
coexistant organ disease |
|
|
Term
upper GI bleeds:
1. originate proximal to ____
2. normally present wtih ____
3. most common cause?
4. Erosive ggastritis and esophagitis most commonly caused by ___, ____, and ____
5. esophageal varices from ___ - high mortality
6. longitudinal tear in mucosa in the cardioesophageal region from repetitive retching - followed by bright red hemateemsis |
|
Definition
1. ligament of treitz
2. hematemesis
3. PUD
4. EtOH, salicylates, NSAIDs
5. portal hypertension
6. mallory-weiss tears |
|
|
Term
Lower GI bleeds:
1. originate distal to ____
2. usually characterized by ____
3. Most common cause?
4. painless, massive bleeding?
5. usually of the right colon, thought to be more common in pts with HTN and aortic stenosis
6. what about melena? |
|
Definition
1. ligament of treitz
2. hematochezia
3. upper GI bleed. Most common cause of true LGI bleed is hemorrhoids
4. diverticulosis
5. angiodysplasia (AVM)
6. melena - most likely UGI that's been in GI tract for >14 hrs |
|
|
Term
GI bleed hx:
1. epigastric or RUQ gnawing or burning that gets better w/ food?
2. weight loss + changes in bowel patterns
3. hematemesis after vomiting
4. epigastric or RUQ gnawing/burning that gets worse w/ food?
5. Black stools? |
|
Definition
1. PUD
2. cancer
3. mallory-weis
4. cholecystitis
5. iron |
|
|
Term
|
Definition
1. vitals - hypotension? tachy?
2. skin - cold, clammy, jaundice, palmer erythema, spinder angiomata
3. ENT - nose bleed? hemoptysis?
4. ABD - tenderness, masses, ascites, organomegaly
5. rectal
6. mental status
Labs: Type and cross, H&H, chemistry w/ glucose, BUN, Cr, coagulation - PT/PTT/INR, LFTs, EKG, NG tube suction |
|
|
Term
| pt with low Hgb but normal HR... what should you rule out before saying they're ok? |
|
Definition
|
|
Term
| Tests/imaging for GI bleed |
|
Definition
1. XR - usually not helpful
2. angiography - may help ID site of bleed and offer therapy such as embolism. Need 0.5-2.0 cc/min bleed to work
3. Bleeding scan (Technetium labeled RBC scan) - more sensitive than angiography, can localize bleeding at rate of 0.1cc/min
4. Endoscopy - most accurate |
|
|
Term
Flow chart for GI bleed:
1. If hemodynamically unstable?
2. If hemodynamically stable? |
|
Definition
If unstable:
1. IV fluids, blood, vasopressors
2. upper endoscopy
- if Pos --> treat
- If neg --> colonoscopy, RBC scan, angiography
IF stable:
1. NG tube
- if pos for coffee grounds or fresh blood or if no hx of hematochezia-- upper endoscopy
- if neg + hx of hematochezia - colonoscopy |
|
|
Term
Pancreatitis:
1. 90% of cases are from ___ or ___
2. __ is most common cause in teens
3. ___ is most common cause in kids
4. sx?
5. ecchymosis on flanks
6. ecchymosis around umbilicus
7. Dx?
8. ALT >80 suggests?
9 XR may show?
10. ___ is best radiographic study
11. Tx? |
|
Definition
1. cholelithiasis or etoh abuse
2. mumps
3. trauma
4. sx: midepigastric or LUQ boring pain that radiates to back, flank, chest, lower abd. intense. variable. increased in supine position. decreased with flexion of trunk and knees. N/V, weakness, sweating, anxiety, low grade fever, tachy, jaundice, pallor, UQ tenderness, +/- gaurding/rebound, absent bowel sounds, evidence of pleural effusion
5. turner's
6. cullen's
7. lipase and amylase will be elevated, leukocytosis (10-30K), proteinuria, granular casts, glycosuria, hyperglycemia, increased bilirubin
8. cholelithiasis
9. XR: calcification (chronic dz), sentinel loop of dilated bowel, pleural effusion
10. CT
11. Tx: supportive - NPO, rest, IVF. analgesia if needed. abx in severe disease only, NG suction if sentinel loop, drain abscesses and remove gallstones |
|
|
Term
|
Definition
predictor of outcomes for pancreatitis
3+ is considered severe disease
8+ indicates significant mortality
On admission:
1. Age >55
2. WBC >16K
3. Glucose > 200
4. LDH >350
5. AST > 250
W/IN 48 Hours:
1. HCT < by 10%
2. BUN > by 5 or more
3. Ca <8
4. PO2 <60
5. Base deficit >4
6. Fluid sequestration >6 |
|
|
Term
| general tx principle for pancreatitis? |
|
Definition
| rest the pancreas - fluids, rest, npo |
|
|
Term
| PE, Labs, and tx for gastroenteritis |
|
Definition
1. good hx - have they been to another country? been on abx? have HIV?
2. PE: GI, Neuro (botulism), VS, signs of dehydration
3. Labs: stool culture, c diff if on recent abx, fecal leukocyte, CBC, O&P,
4. tx: IVF, avoid spicy foods, oral rehydration, anti-diarrheals (lomotil, loperamide, kaopectate, bismuth), anti-emetics (compazine, phenergan, zofran) |
|
|
Term
| occurs when a player returns to play after a mild head injury before the brain has fully healed and incurs a second injury |
|
Definition
second impact syndrome
has exponential effects -- not additive
|
|
|
Term
| treat concussions with ___, not ___ |
|
Definition
| acetaminophen, not narcotics |
|
|
Term
| Charcot's triad in cholangitis |
|
Definition
| jaundice, fever, upper abd pain |
|
|
