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Flashcards in trauma Deck (127):

4 phases of initial assessment

primary survey, resuscitation, secondary surgery, and definitive care


ABCDE of primary survery

airway,breathing, circulation, disability (neuro: GCS), exposure (head to toe exam)


ways to open airway

chin lift, jaw thrust, oral airway, nasal airway, endotracheal tube, cricothyroidotomy


tx tension pneumothorax

vent the high intrapleural pressure w a catheter place in the 2nd rib space at midclavicular line or w a chest tube placed through an incision between the ribs


mc cause shock in trauma pt

hypovolemia from hemorrhage


survey to quickly determine the degree of neurologic disability

glasgow coma scale


glasgow coma scale

Eye opening: spontaneous (4), speech (3), pain (2), none (1)

motor response: obeys commands (6), localizes pain (5), withdraws to pain (4), decorticate posture/abdn flexion (3), decerebrate posture/abn extension (2), none/flaccid (1)

verbal response: oriented (5), confused (4), inappropriate words (3), incomp sounds (2), none (1)

best=15, worst=3


secondary survey

identify and tx additional injuries not uncovered during primary; PE, med hx, allergies, last meal, tetanus immunization status, meds; ng tube, urine cath, ekg, pulse ox


what is indicated if pt has gastric distension

can be from injury or from bag mask ventilation; need to decompress so place NG tube; orogastric route if pt is intubated, basilar skull fracture, extensive facial fractures


mc cause of trauma related mortality and leading cause of long term disability

head injury


cushing reflex

inc in systemic bp asoc w bradycardia and a slowed respiratory rate; caused by inc intracranial pressure


htn, bradycardia and a slow respiratory rate after severe traumatic brain injury indicates

cushing reflex


best initial eval of head injury

non contrast head ct


epidural hematoma

middle meningeal artery is lacerated, often by a fracture of the overlying bone. Blood collects between the bone and the dura mater. The dura is normally tightly adhered to the skull and as a result the collecting hematoma progressively separates the dura from the skull creating a lens-shaped or convex hematoma that can be seen on CT scan


s/sx epidural hematoma

brief loss of consciousness at time of injury followed by normal mental status that progressively deteriorates over time as hematoma expands


subdural hematoma

blood collects between the dura mater and the brain. In this injury, the hematoma follows the contour of the inner cranium and requires surgical drainage if of sufficient size. Typically, subdural hematomas appear concave or crescent shaped on CT scan


what osmotic diuretic effectively reduces brain swelling and lowers ICP



mc site for cervical fracture or subluxation

c5 level


s/sx of tension pneumo

affected side if hyper resonant w diminished or absent breath sounds; trachea shifted to opposite side; hypotension; jugular venous distension


open pneumo

occurs w penetrating thoracic trauma when chest wall wound remains patent; allows lung to collapse completely and creates a sucking chest wound


tx open pneumo

place dressing over chest wound and secure it to the skin; creates a one way valve that allows egress of accumulated pleural gas during exhalation but prevents inflow from the atmosphere during inhalation; then a chest tube thoracostomy


cardiac tamponade

compression of the heart from accumulation of fluid or blood within the pericardial sac; ventricular filling is restricted; the increased pressure within the pericardial sac is transmitted to each cardiac chamber; results in equalization of the right atrial, right ventricular diastolic, pulmonary artery diastolic, pulmonary capillary wedge, left atrial, left ventricular diastolic, and intra-pericardial pressures.


mc cause of cardiac tamponade

stab wound to sternal region


s/sx cardiac tamponade

muffled heart sounds, jugular venous dissension, hypotension (Beck's triad); Kussmaul's sign (jug ben distension w inspiration) and pulsus paradoxes (drop SBP >10 during inspiration)


dx cardiac tamponade

bedside focused assessment w sonography in traume (FAST) which reveals pericardial effusion


tx cardiac tamponade

volume resuscitation, immediate surgical decompression to release tamponade, rapid underlying cardiac injury

may need to do pericardiocentesis


massive hemothorax

rapid loss of more than 1500 mL of blood into the pleural cavity; class III or greater hemorrhage into the pleural cavity; ongoing thoracic blood loss of >200/hr over 4-6hr


s/sx massive hemothorax

diminished breath sounds and dullness to percussion


tx massive hemothorax

tube thoracotomy for control of hemorrhage; may need blood transfusion


simple pneumothorax

gas enters the pleural space causing collapse of the ipsilater lung; gas from atmosphere in penetrating injury or from injury to lung parenchyma or tracheobronchial tree


s/sx simple pneumo

diminished breath sounds on affected side; hyper resonance to percusion


dx/tx of simple pneumo

cxr and tx by chest tube placement for reexpansion of the lung



blood or clots accumulate within pleural space; from pulmonary parenchyma, great vessels, mediastinal structures, or chest wall


s/sx hemothorax

dec breath sounds and dullness to percussion


dx/tx hemothorax

cxr; placement of large bore (36 french) chest tube to drain the pleural space; post procedure X-ray to confirm evacuation


diagnostic peritoneal lavage

surgical procedure used to identify an intraperitoneal injury; under local anesthesia, a peritoneal catheter is inserted into the peritoneal cavity through a small midline incision; a syringe is attached to the catheter and aspirated; if 10 mL blood is aspirated, the test result is positive; if



evaluates for free fluid in the abdomen or pericardium using US views of the right and left upper quadrants, heart, and pelvis


mc injuries of blunt trauma

spleen or liver


tx hypotensive victim of blunt abd trauma

vol resusc but doesn't respond than rapid transfer to operative room for surgical correction of the cause of bleeding


tx penetrating trauma

if clear evidence of peritoneal traverse or hypotension then prompt exploratory lap since incidence of visceral injury is extremely high; if hemodyn stable then CT for more info lowering the risk of non therapeutic operative exploration


dx penetrating trauma to flank or back

triple contrast CT helps screen stable pts who may not need operative intervention


grades of blunt liver injuries (1 represented by small capsular hematomes or parenchymal lacerations to 6 hepatic avulsion)

1.Hematoma:Subcapsular, nonexpanding, 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma >10 cm or expanding
Laceration:>3 cm parenchymal depth

4.Hematoma:Ruptured intraparenchymal hematoma with active bleeding
Laceration:Parenchymal disruption involving 25%–75% of hepatic lobe or 1–3 segments within a single lobe

5. Laceration:Parenchymal disruption involving >75% of hepatic lobe or >3 segments within a single lobe.
Vascular:Juxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepatic veins

6. vascular: hepatic avulsion


dx of blunt liver injuries



tx of ongoing bleeding liver injuries seen on ct

interventional radiology suite w selective angioembolization of bleeding hepatic arterial branches


tx higher grade liver injuries involving hepatic veins or retrohepatic vena cava

urgent or intervention and damage control because they can result in massive hemorrhage


frequently injured in blunt abd trauma esp deceleration injuries in adults or direct impact inkids



grading of splenic injury 1-5

1.Hematoma:Subcapsular, nonexpanding, 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma >5 cm or expanding
Laceration:>3 cm parenchymal depth or involving trabecular vessels

4.Hematoma:Ruptured intraparenchymal hematoma with active bleeding
Laceration:Laceration Involving segmental or hilar vessels producing major devascularization (>25% of spleen)

5.Laceration:Completely shattered spleen
Vascular: Hilar vascular injury which devascularizes spleen


dx spleen injury



tx spleen injury

low grade= observation and serial monitoring of hemoglobin and hematocrit

recurrent hemorrhage/peritonitis=lap

active bleeding/hypotension upon presentation=or

either total splenectomy or splenorrhaphy


mc cause of postsplenectomy bleeding

unligated short gastric vessel or surgical knot that slips after resuscitation and normalization of blood volume (minimized by greater curvature of stomach systolic pressure of 100)


tx hemodyn stable pt w IV contrast extravasation noted on CT

angioembolization of the bleeding splenic after branches


splenectomy pt should receive what vaccines

pneumococcus and meningococcus


injury of the pancreas from trauma

uncommon because of its location but can become transectioned from being compressed against the vertebral column


tx transection pancreas

operative distal pancreatectomy


dx pancreas injuries

ct and endoscopic retrograde cholangiopancreatography (ERCP)


what does gastric injury frequently coexist with

diaphragmatic injury


tx rupture of the diaphragm

interrupted or running permanent suture to minimize risk of recurrence or further tearing; make sure to avoid phrenic nerve


why are left sided diaphragmatic injuries concerning

risk of dev of diaphragmatic hernia and visceral incarceration; commonly assoc w injuries of the stomach, colon, spleen, and small intestine


tx blunt injury to kidney

rarely require operative intervention unless there is ureteral injury or calyces leak of urine


tx of massive destruction or complex hilar injury of the kidney



tx penetrating injuries of kidney

self limiting unless renal artery or vein is involved


who long should foley catheter drainage be maintained about kidney injury

7-10d or until hematuria resolves


what should be suspected when ct shows hemoperitoneum but no liver or spleen injury

mesenteric tears w hemorrhage from arcade vessels can occur in deceleration injury


tx small bowel and mesentery injury from penetrating trauma from knife or gunshot wound

one layer closure w absorbable or nonabsorbalbe suture; staple repair or resection w anastomosis


tx of injury to colon that caused devascularization

resection w primary reanastomosis


tx injuires to rectum below the peritoneal reflection

fecal diversion to avoid perineal sepsis and allow injury to heal


pt w colonic trauma and other injuries or profound shock may be considered candidates for

temporary diverting colostomy due to inc risk for anastomotic breakdown


lethal triad assoc w trying to repair all abd wounds during initial operation w shock and hypotension

hypothermia, acidosis, and coagulopathy; worsened by prolonged operation


fundamental tenets of damage control surgery for abdomen

control of massive hemorrhage and control of enteric contamination of peritoneal cavity while attempting to minimize hypothermia, acidosis, and coagulopathy


how long is the initial control surgery for abd injuries and when is the second surgery

first one takes 60-90min and the next one occurs in 12-36hr after


aggressive crystalloid volume resuscitation and severe hemorrhagic shock sometimes result in

retroperitoneal and intra abdominal swelling and intra abdominal pressures above 30mmHg


effects of rise of abd pressure from aggressive crystalloid volume resuscitation nd severe hemorrhagic shock

con compromise blood flow to abd viscera, producing ischemia and eventual necrosis if left uncorrected


untx abd compartment syndrome results in

multiple organ dysfunction syndrome (MODS) and is commonly fatal


abdominal compartment syndrome triad

inc airway pressures, dec urine output, and elev abd pressure


tx abd compartment syndrome

opening the abd cavity via lapartomy incision; allows prompt decompression and relieves cephalic pressure on the diaphragm and thoracic cavity; renal perfusion is restored and urinary output inc


mc and most stable mechanism of pelvic fracture

lateral compression mechanism; less likely to lead to ligamentous disruption at the sacroiliac joint


known as the open book pelvic fracture

anterior posterior compression- symphysis pubis is disrupted and iliac wings open leading to variable ant of sacroiliac ligamentous disruption


most unstable pelvic fracture

vertical shear injury; least common; caused by severe upward force that may disrupt the hemipelvis from the spine or create a fracture of the iliac wing; assoc w serious abd, pelvic, or vascular injuries


dx pelvic fractures

xray; ct


signs of urethral injury in men

scrotal hematoma, blood at urethral meatus, and high riding or non palpable prostate gland on rectal exam


3 zones of the neck

1. sternal notch to inferior border of cricoid cartilage

2. cricoid cartilage to angle of mandible

3. distal neck (mandible) to base of skull


tx injury to internal jugular vein

lateral venorrhaphy or patch venoplasty


compartment syndrome

elevation of the pressure within a fascial compartment of the upper or lower extremity; interstitial tissue pressure becomes higher than capillary perfusion pressure, resulting in ischemia to the muscles and nerves within the fascial compartment.


s/sx compartment syndrome

early include pain, paresthesias, and diminished sensation; swollen and tense; late include diminished pulses or capillary refill assoc w irrev ischemia


tx compartment syndrome

prompt operative fasciotomy


A 22-year-old man is in the emergency department after a high-speed motor vehicle collision. He complains of back pain. He is alert and oriented and is breathing normally. His oxygen saturation is normal and hemodynamically stable. There are ecchymoses on the left chest. Chest x-ray shows fractures of the left first and second ribs. The aortic knob is not clearly visible, and the mediastinum measures 10 cm. Further evaluation should include which of the following?

A. Contrast-enhanced chest CT

Β. Repeat chest x-ray

C. Diagnostic thoracoscopy

D. Pericardial window

E. Diagnostic mediastinoscopy

Answer: A

The high-speed deceleration mechanism and chest x-ray findings are highly concerning for blunt aortic injury (BAI), which is most efficiently diagnosed by contrast-enhanced chest CT. Repeat chest x-ray would likely reveal the same findings but would not establish the diagnosis. Thoracoscopy is useful for evaluating the pleural space, lungs, and diaphragm, but not the aorta and great vessels. Pericardial window may be utilized to diagnose hemopericardium in suspected penetrating cardiac trauma, but not aortic injury. Mediastinoscopy is used for evaluating lymph node status in lung cancer staging but has no role in trauma


A 30-year-old man is brought to the emergency department after crashing his motorcycle at high speed into a concrete divider. He sustains severe trauma to the mid face and mandible and is lethargic upon arrival. He has copious amounts of bloody airway secretions and pulse oximetry reveals oxygen saturation levels of 82% to 85%. Two unsuccessful attempts have been made to place an orotracheal tube. The next step should be

A. bag-valve mask ventilation.

B. nasotracheal intubation.

C. resuscitative thoracotomy.

D. surgical cricothyroidotomy.

E. bronchoscopy.

Answer: D

In the primary survey, obtaining a patent airway is of paramount importance The patient in this scenario has an unstable airway and poor systemic oxygenation, making the establishment of a definitive airway an urgent matter. Since orotracheal intubation attempts have failed, the next step is to perform a cricothyroidotomy. Bag-valve mask ventilation is unlikely to be successful in this circumstance and does not provide a definitive airway. Nasotracheal intubation is contraindicated in severe facial trauma as false passage into the cranium may occur. Resuscitative thoracotomy may restore circulation but does not provide an airway. Bronchoscopy may be utilized after establishment of an airway to clear blood or secretions.


A 53-year-old man sustains a severe traumatic brain injury after an assault. His GCS score is 6, and an intracranial pressure monitor is inserted. Vital signs are heart rate—92 beats/minute, blood pressure (BP)—152/88 mm Hg, mean arterial pressure—109 mm Hg, and respiratory rate—16/minute. His intracranial pressure is 32 mm Hg. The patient’s cerebral perfusion pressure is

A. 120 mm Hg.

B. 77 mm Hg.

C. 60 mm Hg.

D. 56 mm Hg.

E. 32 mm Hg.

Answer: B

Cerebral perfusion pressure (CPP) is calculated by subtracting the intracranial pressure (ICP) from the mean arterial pressure (MAP).


A 25-year-old woman is brought to the emergency department after involvement in a low-speed motor vehicle collision. She complains of feeling light-headed and states that she is 33 weeks pregnant. Vital signs are heart rate—90 beats/minute and BP—82/44 mm Hg. Abdominal examination reveals a gravid uterus but no tenderness. Chest x-ray is unremarkable, and FAST reveals no intraperitoneal fluid. A viable intrauterine pregnancy is noted, and fetal heart tones are observed The next step in management should be

A. cesarean section.

B. induction of labor with vaginal delivery.

C. left lateral tilt positioning.

D. diagnostic peritoneal lavage.

E. MRI of the abdomen and pelvis.

Answer: C

In the supine position, the gravid uterus compresses the inferior vena cava (IVC), resulting in decreased venous return to the heart and hypotension. Visibly pregnant trauma patients should be placed in the left lateral tilt position (while maintaining spinal precautions) to displace the gravid uterus from the IVC. Induction of labor and cesarean section would not be indicated in the absence of fetal distress. Diagnostic peritoneal lavage (DPL) is relatively contraindicated in pregnancy, as uterine or fetal injury may occur. MRI is not utilized in the acute evaluation of abdominal trauma.


A 22-year-old man is brought to the emergency department after falling from a 10-foot ladder, landing on his left side He has multiple left-sided rib fractures and a pneumothorax requiring a chest tube. Physical examination of the abdomen is unremarkable He remains hemodynamically stable throughout the primary and secondary surveys and undergoes contrast-enhanced CT scanning of the abdomen and pelvis. CT scan reveals a grade II laceration of the spleen, with no evidence of active contrast extravasation. The next appropriate step in management is

A. exploratory laparotomy with splenectomy.

B. exploratory laparotomy with splenorrhaphy.

C. splenic angioembolization.

D. video-assisted thoracoscopy with evacuation of hemothorax.

E. observation with serial abdominal examinations.

Answer: E

Most low-grade splenic injuries can be managed nonoperatively. The key factor is hemodynamic stability of the patient. In this patient, splenectomy and splenorrhaphy would represent unnecessary surgical options, and interventional techniques such as angioembolization should be reserved for cases of high-grade splenic injury with active extravasation of intravenous contrast. Thoracoscopy is indicated for evacuation of residual hemothorax or diagnosis of penetrating diaphragmatic injury.


trauma deaths first peak

immediate at time of injury; lacerations to brain, brain stem, spinal cord, heart, major arteries


trauma deaths second peak

golden hr where intervention can make a difference; subdural, epidural, hemopneumothorax, rupture of spleen, laceration of liver, multi injuries w sig blood loss


trauma deaths third peak

days to weeks later; sepsis and organ failure


algorithmic approach of advance trauma life support

primary survery, resuscitation phase, secondary survery, definitive tx


jane resuscitation

supplemental oxygen (often intubated); 2 lg bore IVs (18gauge), crystalloid fluid; urinary cath; ng tube; ekg monitor; constantly reassess abc's, monitor urine output


when is AMPLE done

during definitive care

allergies, meds, past illness, last meal, events preceding injury


blood work that should be ordered

cbc, chem 12, pt/ptt/inr, type and screen


imaging right away

cxr, lateral c spine xr, pelvis xr


when should a ct be ordered on a pt w a head hematoma

lg, sig mechanism of injury, alt LOC


tx head hematoma

rice, nsaids

don't attempt any aspiration or evacuation


dx closed skull fracture

ct scan


tx closed skull fracture

admit for observation


tx open skull fracture

admit, neurosurgery consult, seizure prophylaxis, +/- abx


dx and tx depressed skull fracture

pe and ct; admit, neurosurgery consult to OR for debridement, abx


s/sx basilar skull fracture

(fracture of temporal bone along base of skull)

battle sign (ecchymosis along mastoids), raccoon eyes (b/l periorbital ecchymosis); can have csf leak from ears or nose (accucheck/halo test)


tx basilar skull fracture

admit, neurosurgery consult


epidural hematoma

bleeding between dura and skull that is arterial; oval shaped (biconvex); lucid interval (brief period of normalcy after head injury)


subdural hematoma

bleeding between dura and brain venous source; crescent shaped, elderly pt


tx subdural hematoma

neurosurgery for eval, aggressive conservation, seizure prophylaxis


tx epidural hematoma

neurosurgery for immediate evacuation; seizure prophylaxis


canadian head ct rules

pts w minor head trauma:
gcs 13-15
witnesed LOC
amnesia or confusion

if on blood thinners getting scanned

scan if any are met:


who should get seizure prophylaxis

head injury:


ex of seizure prophylaxis

phenytoin (dilantin): inc na efflux/dec na influx; 15-20mg/kg once

fosphenytoin (cerebyx): water soluble prodrug of phenytoin; 10-20mg/kg once; loaded within 30m


tx elevated ICP

mannitol: osmotic agent limiting renal resorption and causes diuresis; 0.25-1g/kg IV Q6 prn; can lead to renal dysfunction


which neck zones are surgical and which are not

2 surgical w ct angio, esophogoscopy and tracheoscopy

1/3 are non surgical


pain in jaw, mal occlusion, step off/malallignment of teeth, truisms, mucosal lacerations

mandible fx


dx mandible fx

pe and ct


tx mandible fx

update tetanus; abx (penicillin or clinda); barton bandage to splint


when should mandible fx get immediate OMFS consult

open fx, complex fx w dislocation, grossly dislocated, airway complication


maxillofacial trauma w tripod fx

zygomaticomaxillary complex;

fx through infraorbital rim, zygomatic/frontal suture, and zygomatic/temporal suture


mc orbital fx

maxilary bone (the floor)


s/sx of orbital fx

pain along orbital rim, +/- periorbital ecchymosis; diplopia w upward gaze (inferior rectus entrapment); enophthalmosis (sign of sig inferior displacement)


imaging orbital fx

non contrast ct


tx orbital fx

update tetanus, pain control, abx (augmenting), don't blow nose, OMFS f/u 7-10d


tx nasal fx

ice packs, pain control, orc decongestants, OMFS f/u 3-5d for early correction


auricular hematoma

cauliflower ear; blunt trauma to eat; bleeding between perichondrium and auricular cartilage


tx auricular hematoma

i/d or aspiration; pack w petroleum gauze and stitch in place; pack behind ear and wrap w ace around head; abx (cephalexin), pain, OMFS in 1 d