Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Important Topics Trauma for MBBS 1st Year Important Topics, MBBS 2nd Year Important Topics, MBBS 3rd Year Important Topics & MBBS Final Year Important Topics.
? Vary from state to state
? States are responsible for designating trauma
centers and regionalization of trauma care
?American Col ege of Surgeons' guidelines
? Level 1 essential components
?24/7 availability of al surgical subspecialties
?Neurosurgery, hemodialysis 24/7
?Injury prevention and education programs
?Trauma research program
? Trauma triage based on physiology, anatomy and
mechanism
2
ATLS: Initial Approach
1? rapid resuscitation 2? diagnostic tests
ultimate triage
? Primary survey: identify and treat life-
threatening injuries
?Airway obstruction
?Tension pneumothorax
?Massive hemorrhage
?Open pneumothorax
?Flail chest
?Cardiac tamponade
3
ATLS: Primary Survey A-B-C-D-E
? Airway, C-spine control
?Intubate: GSC < 8 or uncontrol ed agitation
?RSI with C-spine stabilization is the airway
procedure of choice
?NEXUS criteria: If no midline tenderness, neuro
deficits, distracting injury, AMS or intoxication,
C-spine x-rays are not indicated
?The tongue is the most common cause of airway
obstruction in trauma patients
?Nasotracheal intubation is contraindicated in
maxil ofacial trauma, basilar skul fracture, apnea
4
ATLS: Primary Survey
? Breathing
?Occlusive dressing for sucking chest wound
?Reposition ETT (R bronchus, esophagus)
?Chest tube or needle to relieve tension
pneumothorax
?Hemopneumothorax; if >1,500 mL initial y,
thoracotomy is indicated
5
ATLS: Primary Survey
? Circulation
?Radial pulse = BP > 80
Femoral pulse = BP > 70
Carotid pulse = BP > 60
?Normal blood volume 7% of body weight = 5 L
?Blood loss from femur fracture = 1000 mL
?Blood loss from pelvic fracture = 1500-2000mL
Significant hemorrhage may be clinical y
silent in young, healthy adult
6
ATLS: Initial Approach
? Circulation : Assess for shock
?Blood loss of >15% = cap refil , narrowing of
pulse pressure
>30% = BP final y drops
?Replace blood loss: 3 mL crystal oid = 1 mL blood
?Blood replacement
? Whole blood or PRBCs can be used
? Ful crossmatch preferred (takes 1 hour)
? Type-specific ABO + Rh compatible (10 mins)
? If type-specific unavailable
?Type O neg (universal donor)
?Type O pos can be used in males
7
Shock Classification
? Hemorrhagic shock
? Class I: <15% blood loss = no significant
changes
? Class II: 15-30% blood loss = cap refil ,
heart rate
? Class III: 30-40% blood loss = shock, BP,
altered mental status
? Class IV: >40% blood loss = preterminal
? Consider other forms of shock (neurogenic?)
8
ATLS: Primary Survey
? Disability: abbreviated neurologic exam
?Intoxication should not be considered cause of
AMS until significant head injury is ruled out
?AMS requires early head CT
?Early head CT identifies patients who may
benefit from:
? Relative hyperventilation (pC02 30-35)
? ICP monitor (GCS 3-8 & intracranial lesion)
? Early surgical decompression/craniotomy
9
Glasgow Coma Scale
Eye opening
Spontaneous
4
Eyes open to command
3
Eyes open to pain
2
No reaction
1
Verbal
Oriented
5
response
Confused, disoriented
4
Inappropriate words
3
Unintel igible sounds
2
No verbal response
1
Motor
Obeys commands
6
response
Localized pain
5
Withdraws from pain
4
3 = worst
Flexion posturing to pain
3
15 = best
Extensor posturing to pain
2
No reaction
1
10
ATLS: Primary Survey
? Exposure: "Strip-Flip-Touch and Smel "
?Examination of total body surface
?T- and L-spine, back for tenderness
?Gluteal cleft and perineum for injury
?Prevent hypothermia (warming blankets)
? Secondary survey: Compulsive Head-Toe
?Identify as many injuries as possible
?Set priorities for evaluation and management
?Secondary consultations (OMF, ENT, GYN)
11
Traumatic Arrest: ED Thoracotomy
? Absolute indication
?Penetrating chest trauma + signs of life (pre-
hospital or ED) + cardiac activity in ED
? Liberal indications
?Abdominal trauma and cardiac activity requiring
aortic cross clamping to get to operating room
?Blunt chest trauma with loss of vital signs in ED
12
Pediatric Trauma
? Most common cause of pediatric death >1 year
? Trauma causes 50% of al pediatric deaths
? Evaluation / treatment priorities same as adults
? Pediatric anatomy and physiology contribute to
several key management differences
? Airway anatomy considerations
? Large occiput tends to flex neck
Head injury: The
? Obligate nose breathers <6 months
most common
? Increased tongue size
lethal injury
? Anterior larynx
? Narrow subglottic area
13
Pediatric Trauma
Airway Considerations
? Airway treatment
? Straight blade
? ET size (mm) = (age + 16) / 4
? Depth of insertion = 3 x tube size
? No cricothyroidotomy if <8 years old
? Transtracheal jet ventilation if ET intubation
impossible
? Allows oxygenation
? Poor ventilation
? Temporizing measure
? Consider pediatric LMA or ILMA
14
Pediatric Trauma
Vascular Access
? Peripheral line(s) when able
? Intraosseous line
? Fluid resuscitation
? Blood products and drugs
? Complications (rare)
? Growth plate injury
? Fluid leakage
? Fat emboli
? Osteomyelitis
? Compartment syndrome
? Femoral line: identifiable landmarks
Contraindicated in limb with fracture
15
Pediatric Trauma
Fluid Resuscitation
? Normal blood volume = 8-10% of body weight
? Compared to 7% of 70kg in adults which = 5 L
blood volume
? Initial fluid bolus 20 ml/kg crystal oid
? Hypovolemic shock
? Crystal oid 20 ml/kg bolus (x 2 if poor
response)
? PRBC 10 ml/kg
? Avoid hypothermia: Warm fluids to 40 ?C
? Abdominal injuries are frequently managed
non-operatively (spleen and liver)
16
Pediatric Trauma
? C-spine fractures
Cord injuries are
?Rare
more common than
fractures /
?C1-C4 most common <8 yrs
SCIWORA
?Flexion injury
diagnosed by MRI
? Pulmonary and cardiac contusions: Common,
often delayed
? Fractures of ribs and sternum: Rare, imply
great force
Burns: 2nd most common cause of death <5yrs
(many have inhalation injury)
17
Child Abuse (1)
? Injury inconsistent with history, delay in
treatment, certain injury patterns
? Abuser
? Contusions
?Young age
? Buttocks
?Increased stress
? Genitalia
?Unemployed
?History of abuse
? Neck
?Substance abuse
? Face
? Burns
? Low back
? Contact
? Immersion
? Stocking glove distribution
? Cigarette burns
18
Child Abuse
19
Med-Chal enger ? EM
Child Abuse
20
Med-Chal enger ? EM
Child Abuse (2)
Shaken baby syndrome:
Diffuse cerebral injury with edema
Retinal hemorrhages, poor prognosis
? Suspicious Fractures ? Head injury
?Any <1 year
?Subdural
?Rib (posterior)
?Cerebral
?Skul , spine, sternum
?SAH
?Bilateral, multiple,
various stages of healing ?Shaken baby
?
syndrome
Long bone
?Metaphyseal
Undiagnosed child abuse:
Significant 2 year mortality
21
Suspicious fracture for Child Abuse
22
Med-Chal enger ? EM
Suspicious fracture for Child Abuse
Metaphysial deformity (bucket handle)
due to shearing / rotational forces
Pathognomonic for child abuse
23
Geriatrics Trauma
? MVA is leading cause of unintentional injury
and death <75 years old
? Fal s
?Common cause of unintentional injury and
death >75 years old
?Most occur on a level surface due to wrong
shoes or environmental hazards
?Fractures in elderly patients may be
difficult to see on x-ray
24
Domestic Violence (1)
? Inconsistencies in history
? Many women presenting to the ED have
experienced domestic violence
? Suspicious injuries: Fractures, bruising
? May present as depression or suicide attempt
? Mandatory reporting is state specific, most states do
not require reporting
? Increased risk of lethal outcome
? Firearms involved
? Child abuse
? Public displays of violence
? Sexual assault
? Partner ends relationship
25
Domestic Violence (2)
? Elements common in victims of DV
?Pregnancy (increased incidence)
?Injuries: Head, neck, abdomen, thorax
?Injury and reported mechanism do not
correlate
?Injuries in different stages of healing
?Delay in seeking treatment
?Fingernail scratches, cigarette burns, rope
burns, bites, defensive injuries
?Multiple medical visits, vague complaints
26
Pregnancy and Trauma (1)
? MVA, fal s, assaults (DV again)
? Increased injuries to spleen, retroperitoneum,
uterus (seat belt injuries)
? Uterus rises out of pelvis at 12 weeks
? Penetrating trauma
? Maternal mortality is low
Blunt trauma:
? Fetal mortality is high
?
Leading cause
Signs of fetal demise
of maternal death
? Loss of movement
? Absent heart tones
? Extended extremities
Maternal stabilization is the most important
factor in preventing fetal demise
27
Pregnancy and Trauma (2)
? Uterine rupture
?Uncommon, late 2nd-3rd trimester, previous C-
section, VBAC patients
?Fetal mortality almost 100%, maternal
mortality lower
?Presentation may be non-specific: loss of
uterine contour, palpable fetal parts
?Shock, abdominal pain, fetal demise
28
Pregnancy and Trauma (3)
? Abruptio placentae
?A leading cause of fetal death, leading cause of
maternal death
?Minor fal , airbag deployment, bump into counter
?Vaginal bleeding: If neg = "concealed abruptio"
?Abdominal pain and uterine tetany
?Check Kleihauer-Betke (fetal nucleated RBCs in
maternal circulation) (controversial)
?RhoGAM if Rh negative
?Fetal distress (first tachycardia, then bradycardia)
?DIC is a common complication
29
Pregnancy and Trauma (4)
? External fetal monitoring is indicated for al
blunt trauma patients >20 weeks gestation
? Frequent uterine activity is more predictive of
abruption than ultrasound
?>8 contractions/hr x 4 hrs: Risk for abruption
?3-7 contractions/hr x 4 hrs: Extend monitoring
for 24 hrs
?<3 contractions/hr x 4 hrs: Safe for discharge
? Fetal distress (>23 weeks)
?Tachycardia, bradycardia, and decelerations
?May indicate emergent C-section
30
Head Trauma (1)
? Accounts for half of al trauma deaths
? Males, ages 15-30: MVA, assaults, fal s,
bicycle accidents
Hypotension in head
injury: Look for other
?
causes
Cushing reflex
? Late and unreliable sign of increased ICP
? Hypertension
? Bradycardia
? Scalp lacerations may bleed profusely,
leading to shock in children
? CT is stil the imaging study of choice
31
Head Trauma (2)
? No CT if minor mechanism of injury, no
intoxication, GCS = 15, no skul fracture, non-
focal exam, normal mental status
? Skul X-ray indications: Foreign body, vertex,
linear or depressed skul fractures (very few)
? Cerebral perfusion pressure (CPP) = MAP-ICP
? Increased ICP: CSF pressure > 15 mm Hg
? Autoregulation: Constant blood flow despite
intracranial pressure changes
? Rule out cervical spine fracture when serious
head injury occurs
32
Epidural - Coup
Subdural - Contrecoup
33
Contrecoup Injury with
Acute Intracerebral Hematoma
34
Diffuse Cerebral Edema
35
Med-Chal enger ? EM
Skull Fractures
? Rule out abuse in stel ate, complex fractures
? Linear non-depressed fracture does not
require treatment
? Temporal skul fracture (middle meningeal
artery) associated with epidural hematoma
? Open skul fracture: Antibiotics and neurosurg
? Depressed skul fracture (one bone- table
width): Neurosurgery
? Occipital skul fracture: Rule out SAH,
contrecoup injury, posterior fossa hematoma,
cranial nerve injury
36
Depressed Parietal Skull Fracture
37
Med-Chal enger ? EM
Skull Fracture
38
Basilar Skull Fracture
? Clinical diagnosis ? can cause CSF oto- or
rhinorrhea, bleeding from the ear canal,
ecchymosis of the mastoid area or orbital area,
cranial nerve deficits (V, VI, VII and VIII [hearing
loss, nystagmus, ataxia])
? Most CSF leaks resolve spontaneously within a
week
? Prophylactic antibiotics don't decrease the risk
of meningitis with CSF leaks
? Skull x-rays and CT are often negative
? CT findings: Air-fluid level in sphenoid sinus, air in
the posterior fossa
? Ring test for CSF: Halo of clear fluid beyond
blood-tinged fluid / CSF fluid is glucose-positive 39
Basilar Skull Fracture Findings
(Battle's Sign / Hemotympanum)
40
Epidural Hematoma
? Usual y arterial bleed (middle meningeal
artery) between skul and dura
? Early underlying brain injury may be mild
? Presentation (classic)
?Immediate LOC
?Lucid interval
?Skul fracture
?Dilated ipsilateral pupil in 85% (indicates
impending herniation)
? CT: Biconcave (lens-shaped) bleed
41
Epidural Hematoma
42
Epidural Hematoma
43
Med-Chal enger ? EM
Subdural Hematoma
? Bridging veins between dura and arachnoid
? Elderly, alcoholics at increased risk
? Presentation
Six times more
?
common than
Pupil less reactive
epidurals
? Decreased mental status, LOC
? May have lucid interval (more common in
epidurals)
Higher mortality rate
? Classification
than epidurals
? Acute: <24 hours (white on CT)
? Subacute: 24 hours-2 weeks (isodense on CT)
? Chronic: >2 weeks (dark on CT)
? CT: Crescent-shaped bleed
44
Subdural Hematoma : Contrecoup
45
Subdural Hematoma
Subdural blood is free to spread over the convexity of the brain
while extension of epidurals is restricted by attachments of the
dura to the skull
46
Intracerebral Hemorrhage (1)
? Transtentorial herniation
?Mass effect (hemorrhage, edema) pushes
medial temporal lobe (uncus) through the
tentorial notch
?Compression of CN III causes ipsilateral
fixed, dilated pupil
?Compression of ipsilateral corticospinal tract
causes contralateral hemiplegia
? Sometimes the opposite corticospinal tract
is compressed producing ipsilateral
hemiplegia
?Brainstem compression causes coma
47
Intracerebral Hemorrhage (2)
? Central herniation
?Mass effect causes downward displacement
of entire brainstem
?Earliest sign is CN VI (lateral rectus) palsy
?Bilateral uncal herniation
? Tonsil ar herniation (rare)
?Cerebel ar tonsils herniate through foramen
magnum
?Respiratory arrest and death
48
Increased ICP Treatment
? Intubate if GCS 8
? Hyperventilation is controversial
?Decreased pCO2, increased pH,
decreased ICP, vasoconstriction
?Goal: pCO2 30-35 mm Hg
?Avoid excessive hyperventilation
? Mannitol
?Osmotic diuretic (1 g/kg)
?Controversial in children
? Steroids not beneficial
Cerebral perfusion pressure =
(mean arterial pressure) ? (intracranial pressure)
49
Traumatic Seizures
? Immediate, brief seizure with non-focal exam after
trauma is usual y benign: No therapy needed!
? High risk for seizures when:
? Mass effect or focal examination
? Depressed skul fracture
? Penetrating injury
? GCS < 10
? Anticonvulsant prophylaxis: Phenytoin, levetiracetam
(Keppra)
? Delayed posttraumatic seizures
? Increased incidence with intracranial bleed, depressed
fracture
? Most occur within the first year
? Treatment: Phenytoin, levetiracetam (Keppra)
50
Pediatric Head Trauma
? Poor pressure/volume curve
? More non-surgical lesions
? Diffuse cerebral edema
? Diffuse axonal shear
? Contusions
? Peds concussion syndrome (diffuse
cerebral hyperemia)
? GCS may wax and wane
? Skul is much weaker
51
Pediatric "Minor" Head Trauma (1)
? Children less than 2 (and particularly under 6
months) are considered at increased risk for initial y
serious head injuries
? Skul s are thinner / fracture more easily (60%-70%
parietal area)
? A skul fracture increases the risk by a factor of 4-20
fold
? Scalp hematomas are considered potential markers for
fractures
? Some consider scalp hematomas (particularly large
ones) are important predictors of fracture, especial y in
the temporal and parietal area (90% of fractures have
scalp hematomas)
52
Pediatric "Minor" Head Trauma (2)
? IC injury has been associated with "minor mechanisms"
in infants
? "Growing fractures" = Leptomeningeal cyst that enlarges
over time, associated with a tear of the underlying dura
and initial y have > 4mm fragment separation
? May feel a skul defect or local swel ing, seizures, neuro
deficits
? Median age 18 months / most
require surgical repair
? All fractures are advised to be
re-x-rayed in two months to
evaluate for signs of a growing
fracture
53
Pediatric "Minor" Head Trauma
? Concussion = A transient alteration in mental status after head
trauma [e.g., LOC, amnesia] with a lack of focal neurologic
findings (may not have LOC)
? Patients (adults or children) with a normal CT can stil have
a concussion, MRI may show some subtle abnormalities /
Grade III = LOC = no sports for variable time thereafter
? Post-concussive syndrome = Long-term neuropsychologic
sequelae (insomnia, irritability, inability to concentrate,
headache, dizziness, anxiety, etc)
? "Second impact syndrome" = Irreversible brain injury triggered
by a fairly routine second head impact after a prior concussion
? speculated mechanism = disordered autoregulation
54
Penetrating
Neck
Injuries
Slash, from Guns
and Roses.....
55
Penetrating Neck Injury (1)
? Any wound which violates platysma
? Most injuries occur in Zone l
?Vascular > CNS
?Peripheral nerves > brachial plexus
? Vascular injuries need proximal and distal control
? Death from CNS injury, exsanguination, airway
compromise (intubate early)
? Air embolism is potential y fatal complication
?Machinery murmur
?Trendelenburg + left lateral decubitus position to
prevent bubble migration
56
Penetrating Neck Injury (2)
? Hard signs (significant ? Soft signs (require
injury probably exists)
ful diagnostic
?Hypotension
evaluation)
?Arterial bleeding
?Stridor
?Expanding hematoma
?Hoarseness
?Thril , bruit
?Vocal cord
?Focal deficits
paralysis
?Hemothorax >1,000 mL ?Subcutaneous air
?Bubbling wound
?Facial nerve injury
?Hemoptysis,
hematemesis
57
Penetrating Neck Injury (3)
? Hard signs: Unstable require surgical exploration
?Zone I: Requires thoracic surgical approach
?Zone II: Exploration technical y least difficult
?Zone III: May require disarticulation of mandible
? Stable patients (evaluation)
?Zone I: Angiogram, esophagram, endoscopy,
bronchoscopy
?Zone II: Exploration or angiogram, esophagram,
endoscopy, bronchoscopy
?Zone III: Angiography
58
Stab Wound Neck
59
Blunt Neck Trauma
? Mechanism: Steering wheel, dashboard,
shoulder belt shearing forces, clothesline
injuries
? Laryngotracheal and pharyngoesophageal
injuries can be subtle; require diagnostic
imaging
? Carotid/vertebral artery injury: Pseudoaneurysm
or dissection
?Mechanism: Hyperextension, hyperflexion, direct
blow, intraoral trauma, basilar skul fracture
?Neurologic symptoms may be delayed
? CT with contrast
60
Carotid Artery Dissection
Neck trauma + TIA, stroke, or Horner's syndrome
61
Chest Trauma
? Thoracic trauma causes ? of trauma deaths
? Hypotension + blunt trauma: Pelvic fracture >
intraabdominal injury > intrathoracic injury
? Hypotension + penetrating trauma: Lung >
heart > great vessels
? Open (sucking) chest wound: Occlusive
petrolatum gauze can cause tension
pneumothorax
? Immediate treatment: Remove dressing
? Definitive treatment: Chest tube
? Needle thoracostomy: 2nd intercostal space,
midclavicular line
62
Sucking Chest Wound
Application of occlusive
dressing can cause
tension pneumothorax
63
Chest Trauma
? Open thoracotomy
?Penetrating trauma and loss of vital signs
?Poor outcome for blunt trauma
?Incision at 5th ICS, open pericardium vertical y,
anterior to phrenic nerve
Because of their anterior location, the right
ventricle and right atrium are most commonly
injured in penetrating trauma
64
Rib Fractures
? Clinical diagnosis: Localized pain, tenderness
? May not be seen on X-ray
? Rule out
?Pneumothorax
?Pulmonary contusion
?Vascular injury
? Multiple rib fractures
?Two or more: Increased risk of internal injuries
?Lower ribs: Increased risk of liver, kidney,
spleen injuries
?Admit: Elderly, pre-existing pulmonary disease
?Delayed findings: Pneumothorax, aspiration,
pulmonary contusion
? Treatment: Pain medication, nerve block
65
1st and 2nd Rib Fractures
? Often have associated occult injury
? Great force involved
? Significant mortality
? Rule out
?Myocardial contusion
?Bronchial tear
?Vascular injury (consider angiogram)
? If no evidence of neurovascular compromise
?No increased morbidity, angio not mandatory
Scapular fractures are also
associated with occult chest injury
66
Flail Chest
? Segmental fracture of 3 or more ribs
? Paradoxical chest wal movement
? Decreased ventilation and venous return
? Treatment: Direct pressure, intubation, consider
chest tube
? Main cause of hypoxemia: Pulmonary contusion
Sternal Fracture
? MVA is most common cause (steering wheel,
seat belt)
? Associated with myocardial contusion
? Consider cardiovascular injury
67
Flail Chest
68
Med-Chal enger ? EM
Pulmonary Contusion
? Interstitial edema, capil ary damage, bleeding
? Hemoptysis is common
? Decreased compliance, hypoxemia, atelectasis
? X-ray findings range from patchy alveolar
infiltrates to consolidations; can be delayed up to
6 hours
? Aggressive fluid resuscitation can be harmful
? Treatment: Oxygenation, ventilation, PEEP or
permissive hypercapnia, keep dry
Commonly associated with flail chest
69
Pulmonary Contusion
70
Med-Chal enger ? EM
Tracheobronchial Injury
? Seen with deceleration and shear forces
? Most blunt injury occurs within 2 cm of carina
? Continuous bubbling in chest tube is a sign of
bronchopleural fistula
? High mortality with rupture
? Symptoms / signs
? CXR
? Chest pain
? Pneumothorax
? Dyspnea
? Pneumomediastinum
? Hypoxemia
? Tension pneumothorax
? Hamman's crunch
? Rib fracture
(mediastinal friction rub ? Treatment
w/ heart beat)
? Oxygenation
? Hemoptysis
? Ventilation
? Subcutaneous
? Chest tube
emphysema
71
Hemothorax (1)
? Decreased breath sounds, dul ness to
percussion
? Intercostal artery injury is a common cause
? Upright CXR: Blunting of CPA (200-300 mL)
?Volumes of up to 1000 mL may be missed on
supine CXR
? Beware of right mainstem intubation with
white-out of opposite lung (don't confuse with
hemothorax)
? Often associated with pneumothorax
? Layers out on a supine film (CT)
72
Hemothorax (2)
? Diagnosis: CXR, ultrasound, CT
? Treatment: Thoracentesis, chest tube (36-40F)
? Autotransfusion if capability exists
? Thoracotomy indications
? Unstable
? Initial output >1500 mL
? >100 mL/ hr x 6 hours
? Persistent air leak
73
Hemothorax
(Pneumothorax also present)
74
Med-Chal enger ? EM
Pneumothorax
? Chest pain, dyspnea, subcutaneous emphysema
? CXR: Findings can be delayed; repeat in 4 to 6
hours if symptoms persist
? Treatment: Oxygen, chest tube
? Open pneumothorax
?Air moves in and out of wound
?3-sided petrolatum gauze, one-way valve, chest
tube
?Dressing can create a tension pneumothorax;
remove dressing if patient has increased SOB
Expiratory chest X-ray is the
most helpful diagnostic test
75
Tension Pneumothorax
? Severe dyspnea, decreased breath sounds,
distended neck veins
? Classic findings: Tracheal deviation to
opposite side, hyperresonance, no breath
sounds
? Decreased venous return, hypoxemia,
cardiac arrest
? Treatment: Immediate needle thoracostomy,
chest tube thoracostomy
Do not wait for X-ray
76
77
Tension Pneumothorax
78
Pneumomediastinum
? Subcutaneous emphysema
? Hamman's sign: Crunching sound during systole
? Spontaneous due to increased
intrabronchial pressure
? Mechanical ventilation
? Valsalva with drug abuse
? Restraint of a combative pt
? Sneezing
? Ruptured bleb
? Tension pneumomediastinum
? Decreased cardiac output
? Decompression via neck
dissection
79
Pneumomediastinum
80
Med-Chal enger ? EM
Diaphragm: Traumatic Injuries
? Usual y penetrating trauma to chest or upper
abdomen
? Location: Usual y left posterolateral (right handed
assailant)
? Right side more often missed (masked by liver)
? CXR often abnormal, but not diagnostic
? DPL, CT, ultrasound may not be diagnostic
? Often diagnosed at laparotomy
? Treatment: Surgical repair
? Smal injuries wil continue to enlarge
Diagnosis is often missed or delayed
81
DIAPHRAGM SUMMARY
Blunt Mechanism
Penetrating Mechanism
? L > R
? L > R
? Anterior aspect
? Posteriorly (SW in L flank)
? Large rent (6-10cm)
? Smal tear (2-3 cm)
? Delayed diagnosis (by ? Delayed diagnosis (by
48 hours)
years until herniation)
? L hemothorax
? Normal CXR
? Translocation 50%
? Translocation rare
? CXR abnormal but not ? Late herniation and
diagnostic
strangulation
82
Ruptured Diaphragm
83
Traumatic Ruptured Aorta (TRA) (1)
? Most often, tear at isthmus 2? to deceleration
(victims die immediately at scene)
? Survivors who reach ED usual y have tear at
the ligamentum arteriosum
? Preexisting vascular disease (atherosclerosis)
does not predispose to injury
? Retrosternal pain, dyspnea, stridor, dysphagia
? Harsh diastolic murmur (aortic valve)
? Pulse difference between upper and lower
extremities
84
Traumatic Ruptured Aorta (TRA) (2)
? Widened mediastinum on upright CXR: Most
sensitive and specific X-ray finding associated
with TRA
? Controversial if 1st and 2nd rib fractures are
associated with TRA
? X-ray findings
? Left apical cap
? Blurred aortic knob
? Left hemothorax, trachea deviated to right; NG
tube deviated to right
? Depressed left mainstem bronchus
? Loss of aortic-pulmonary window
85
Traumatic Ruptured Aorta (TRA)
Upper rib
Tracheal deviation
fractures
Wide Mediastinum
86
Traumatic Aortic Transection
87
Cardiac Tamponade
? More common in penetrating trauma
? Beck's triad: Hypotension, JVD, muffled heart
sounds
? Pulsus paradoxus (weaker pulse, lower
systolic pressure with inspiration)
? Electrical alternans: Alternating QRS
direction
? Diagnosis: Ultrasound
? Treatment: Pericardiocentesis, thoracotomy
Cardiac rupture: most die at scene from shock,
hemorrhage or tamponade
88
Myocardial Contusion
? Blunt trauma with deceleration forces
? Chest pain, sternal or rib fracture, dyspnea
? EKG: Slowed conduction, ectopy, ST-T wave
changes, and tachycardia
? Diagnosis: Echocardiogram (wal motion defect),
increased CK-MB (poor sensitivity)
? Significant associated trauma is most predictive
(rarely isolated)
? Most heal without specific treatment
? Complications (rare)
? Effusion - Aneurysm
? Thrombosis - Dysrhythmia
89
Abdominal Trauma (1)
? blunt, penetrating
? Blunt: MVA, direct blow, fal s
? Seatbelt injuries
?3-point (lower rib fx and abdominal injuries)
?Lap belt: frequent cause of abdominal injuries
?Bowel compresses against vertebrae
?Seatbelt sign
?Injuries: Mesenteric laceration, hol ow viscus
tear, ruptured diaphragm, Chance fracture
90
Abdominal Trauma (2)
? Laparotomy indications
? Evisceration, GSW, impalement, gross blood
by NG, rectal or DPL, positive FAST scan if
unstable
Hypotension
? CT as opposed to laparotomy if stable & +
FAST
91
Stab Wound Abdomen
92
Abdominal Trauma
? Stab wounds to the anterior abdomen
?Only some penetrate the peritoneum and only
some of these cause surgical injuries
?Rule of thumb: 1/3 no penetration, 1/3
penetration and no surgery, 1/3 require surgery
?Conservative management is appropriate for
patients without positive findings
Because of diaphragm movement, consider
abdominal injury in trauma between the nipple
and the navel:
- 4th ICS anterior
- 6th ICS posterior, lateral
93
Thoracoabdominal Penetrating Wounds
Nipple to Navel in "No Mans Land"....
Chest and abdominal wounds in this area
94
Abdominal Trauma
? Imaging
?Routine plain abdominal films not indicated
?CT
? Insensitive to hol ow organ injury, pancreas,
and diaphragm
? Sensitive to retroperitoneum, solid organs,
bony structures
? CT or cystourethrogram for gross hematuria
? Ultrasound (FAST scan) possibly during the
Primary Survey A-B-C-D-E-Fast Exam
95
Diagnostic Peritoneal Lavage (DPL)
(1)
? Ultrasound now preferred for most cases
? Positive test
?Aspiration of 10 mL of free-flowing blood (DPA)
?>100,000 RBCs/mL in lavage fluid (BAT)
?10,000 RBCs/mL is threshold for laparotomy in
penetrating trauma
?Bile, feces, urine
? May see false negatives
? Pelvic fractures
? Poor sensitivity for diaphragm injuries
96
Diagnostic Peritoneal Lavage (DPL)
(2)
? Laparotomy decision is based primarily on
hemodynamics, associated injuries, FAST scan
and CT
? In a stable patient without peritonitis, a positive
DPL can be managed conservatively
97
DPL
98
Med-Chal enger ? EM
Abdominal Signs
? Grey Turner's sign: Flank discoloration (late
sign of retroperitoneal hematoma; seen in
hemorrhagic pancreatitis)
? Kehr's sign: Referred left shoulder pain due
to subdiaphragmatic irritation or splenic
rupture
? Cul en's sign: Periumbilical ecchymosis (in
hemorrhagic pancreatitis, ectopic pregnancy)
? Rovsing's sign: RLQ pain with LLQ palpation
(due to peritoneal irritation e.g. acute
appendicitis)
99
Cullen's Sign
100
Med-Chal enger ? EM
Grey-Turner (Flank Ecchymosis)
101
Spleen
Most common organ injured in blunt trauma
? Shock, LUQ pain, Kehr's sign
? Diagnosis: CT
? Treatment
?Consider non-operative management
?Give Pneumococcal and HIB vaccines post-
splenectomy
?Post-splenectomy sepsis has high mortality
Liver
Most common organ injured in penetrating trauma
Capsular hematoma: false-negative DPL
Diagnosis: CT scan
102
Pancreas / Small Intestine
? Pancreas
? Commonly injured in blunt trauma
? Handlebar, steering wheel
? Pain delayed as enzymes leak and cause
irritation
? Serum amylase is often normal
? Diagnosis: CT (DPL may be false negative)
? Smal intestine
? Multiple injuries in penetrating trauma
? Symptoms often delayed
? Associated with lap belt injury and lumbar spine
fractures
103
Stomach / Duodenum / Bowel
? More common in penetrating trauma
(except in children)
? Most duodenal injuries have associated liver
injury
? Abdominal wal ecchymosis from seatbelt:
Consider intraabdominal injury (especial y
hol ow viscus)
? Bike handlebar: Consider associated duodenal
hematoma
? Bowel injuries may be delayed in presentation
If colon injured, usual y transverse
104
Urethral Trauma
General
Anterior
Posterior
?Blood at
?Straddle injury
?Pelvic fracture
meatus
?Fracture penis
?Distended
bladder
?Boggy
?Iatrogenic
?
prostate
Lower
(foreign body)
abdominal
?Perineal
?Hematuria
pain
bruising
?
?
Dysuria
Urethrogram
?Dx: Retrograde
?Blood at meatus
?Rx: Primary
urethrogram
?Scrotal
repair
hematoma
(before Foley) ?Complications: ?Complications:
fistula, stricture
Impotence,
incontinence 105
Extravasation with Anterior Urethral Rupture
106
Med-Chal enger ? EM
Extravasation with Posterior Urethral Rupture
107
Med-Chal enger ? EM
Urethra Trauma: Urethrogram
108
Normal Urethrogram
109
Contrast Extravasation Due to Posterior Urethral Tear
110
Med-Chal enger ? EM
Suprapubic Cystostomy
? Seldinger technique to gain bladder access
? Indications
?Need drainage but Foley cannot be passed
?Urethral stricture (severe)
?Transection of urethra (trauma), GU burns (severe)
? Contraindications
?Empty bladder (wait, use ultrasound)
?Higher risk of bowel injury: History of abdominal
surgery, radiation treatment (no blind placement)
?Any patient who can have a urethral catheter
? Pregnancy is not a contraindication
? Complications: Bowel injury, extravasation,
infection, urethral injury
111
Testicular Trauma
? Most common in blunt or straddle injury
? Presentation
? Edema
? Ecchymosis
? Tenderness
? Hematuria
? Diagnosis: Ultrasound, nuclear scan,
exploration
? Complications: Abscess, hydrocele, infertility
112
Scrotal Hematoma
113
Renal Trauma (1)
? Rapid deceleration, compression, penetrating
trauma
? Associated with lower rib fractures, L1-L2
transverse process fractures
Renal injuries can present without hematuria
? Gross hematuria: IVP, contrast CT
? Renal vascular injury requires angiogram
114
Renal Trauma (2)
? Penetrating injury: IVP or CT
? KUB is used to verify two kidneys
? Renal vascular injury
? Associated with multiple trauma
? May not have hematuria
Must revascularize within 12 hours
? Ureter injury is usual y due to penetrating
trauma IVP or CT urogram
? Bladder injury associated with pelvic fracture,
gross hematuria retrograde urethrogram
? Bladder rupture with intraperitoneal
extravasation surgery
115
Laceration Repair (1)
? Cosmesis and infection prevention tend to be major
objectives
? Laceration infection rate <5%
? Most have low bacterial counts
? Wel below the critical mass needed to cause infection
= 100,000 organisms per gram of issue
? Most lacerations: Young males, head, face and
upper extremities, blunt trauma
? Delayed healing: Diabetes, obesity, malnutrition,
renal failure, advanced age, steroids, chemotherapy,
immunosuppressives
? Increased infection risk: Foreign body, crush injury,
bite
116
Tetanus
? Clostridium tetani (anaerobic Gram positive bacil us)
produces tetanospasmin, a potent neurotoxin
? 60 cases/year in US, elderly predisposed
? Wounds at increased risk
?>24 hrs old, crush injury, devitalized tissue
?Burns, IVDA, early postpartum wounds
?Soil in wounds
? Muscle spasm, rigidity, risus sardonicus,
opisthotonus, fever
? Often occurs after minor wounds or without known
injury
? Neonatal tetanus: 3-10 days after birth, poor
prognosis
? May have unexplained tachycardia
117
Laceration Repair (2)
? Tetanus guidelines
?Clean minor wounds (al wounds except
contaminated wounds, punctures, avulsions,
burns and crush injuries)
? If less than three prior immunizations in the past or
unknown ? give Tdap
? If three prior immunizations ? give Tdap only if prior
immunization more than 10 years previously
?All other wounds
? If less than three prior immunizations or unknown,
Tdap and tetanus immune globulin (TIG)
? If three prior immunizations, give Tdap if last prior
immunization more than 5 years prior
118
Laceration Repair (3)
? Local anesthesia
? "Amides" and "esters"
? Most "reactions" due to the methylparaben preservative
(resembles antigenical y "esters")
? One "i" in generic name: Ester. Two "i"s: Amide
? Esters = Tetracaine / pontocaine
? Lidocaine = Amide (duration without epi = 1-2 hr)
? Maximum safe dose without epi = 4.5mg/kg (7 with)
? Bupivacaine = Amide (duration without epi = 4-8 hr)
? Maximum safe dose without epi = 2mg/kg (3 with)
? Minimize injection pain:
? Buffering with HCO3, 27-30 gauge needle, warmed, slow
injection, inject through wound edges, subcut. injection (not
intradermal), pretreat with topical anesthetics
119
Local Anesthetics
Anesthetic
Formulations
Duration of
Maximum
Action
Dosage
Lidocaine
1% (10 mg/ml)
30-60 min
4.5 mg/kg, max
2% (20 mg/ml)
300 mg
(30ml of 1%; 15 ml
of 2%)
Lidocaine with
1% (10 mg/ml)
120-360 min
7 mg/kg
epinephrine
2% (20mg/ml)
(50 ml of 1%; 25
ml of 2%)
Bupivacaine
0.25% (2.5 mg/ml) 120-240 min
2.5 mg/kg, max
0.5% (5 mg/ml)
175 mg
(70 ml 0.25%; 35
ml 0.5%)
Bupivacaine with
0.25% (2.5 mg/ml) 180-420 min
225 mg
epinephrine
0.5% (5 mg/ml)
(90 ml 0.25%; 45
ml 0.5%)
120 120
Laceration Repair (4)
? Clipping is preferable to shaving (re: infection rate)
? Avoid shaving eyebrows
? Can clean dirty wounds with a sponge and tissue surfactant
(e.g. Shur-Clens)
? Pressure irrigation (decreases bacterial counts)
? Avoid excess pressure and delicate tissues
? Not routinely needed in areas of good vascular supply
? Normal saline or tap water are effective
? Detergents, peroxide and povidone iodine at ful strength is
not advised in wounds (tissue toxic)
? The "golden period" for primary closure varies by wound site,
nature, risk of infection
? Delayed primary closure for contaminated wounds 3-5 days
later when infection risk is decreased is under-utilized
121
Antibiotic Wound Prophylaxis
? Consider in
? High risk sites (hands, feet)
? Puncture wounds, foreign bodies
? Contaminated wounds, bites
? Extensive soft tissue injury
? Through-and-through mouth lacerations
? Open fractures, exposed joints and tendons
? Prosthetic valves (endocarditis prophylaxis)
? Immunocompromised
Puncture through sneakers:
Increased risk of Pseudomonas infection
and osteomyelitis. Treatment: Fluoroquinolones
and debridement
122
Gas Gangrene
? C. perfringens produces exotoxin
? Anaerobic infection in contaminated wounds
? Pain out of proportion to physical findings
? Dusky, brawny, "woody" edema with crepitance
? Low grade fever, tachycardia
? Gram's stain not helpful
? X-ray shows air in tissues
? Treatment: fluids, high dose
penicil in, debridement,
hyperbaric O2
123
Necrotizing Fasciitis
? Anaerobes, group A Strep, Staph aureus
? Risk factors: CRF, diabetes, vascular
disease, alcohol, immunosuppressed
? High mortality.....and low sodium
? Tachycardia, high fever, toxic appearance
? Erythema, edema, very painful, crepitance
? WBCs, Gram's stain, blood cultures, X-ray
? Fluid resuscitation, imipenem-cilastatin
? Surgical debridement
124
Trauma Trivia (1)
? Blood bank transfusion: Decreased clotting
factors, decreased platelets, decreased
temperature (the most common sequelae of
massive transfusion is hypothermia)
? Auto vs. pedestrian
?Adults: Tibial plateau fracture, knee injury
?Pediatrics: Chest and abdominal injury, closed
head (contrecoup) injury
? Pediatric trauma patients in shock
?Loss of >30% of blood volume
?Treatment: 20 mL/kg crystal oid bolus x 2, then
10 mL/kg blood
?Urine output: 1 mL/kg per hour
125
Trauma Trivia (2)
? Human bite: Eikenel a
? Reptile bite: Salmonel a
? Cat bites: Pasteurel a multocida (prophylactic
antibiotics)
? Air embolism
?"Machinery murmur" with neck vascular injury;
tachypnea, tachycardia, hypotension
?Place patient in left lateral decubitus and
Trendelenburg position
? Capil ary refil is not reliable in hypothermia
126
TRAUMA QUESTIONS
127
Which of the following best
characterizes Cushing's reflex?
A. Reliable sign of head injury
B. Hypotension and bradycardia
C. Hypertension and tachycardia
D. An early sign of head injury
E. Hypertension and bradycardia
TR 1
A 15 y/o has a brief generalized seizure
after a head injury from a fall. Which of
the following is true regarding post-
traumatic seizures?
A. The majority occur within the first day
B. A large percentage are delayed
C. Seizures that are immediate, brief and
non-focal require no treatment
D. There is no increased risk of seizures with
penetrating injury
E. Recurrent seizures rarely require
anticonvulsants
TR 2
A 38 y/o male was found unconscious after a
motorcycle accident. Examination reveals a
6mm pupil on the left and a GCS of 6. Which
formula correctly represents the cerebral
physiology important to avoiding secondary
brain injury?
A. ICP = CCP / MAP
B. CPP = MAP - ICP
C. MAP = ICP - CPP
D. CPP = ICP / MAP
E. CPP = ICP / 2 - MAP
TR 3
A patient with a sucking chest wound has an
occlusive petroleum dressing in place.
Enroute to the hospital he develops severe SOB,
what should the on-line medical advice be?
A. 500cc fluid chal enge
B. MAST suit inflation
C. Sand bag application
D. Temporary removal of the occlusive dressing
E. Needle thoracostomy through the wound
TR 4
An 18 y/o sustains a head injury
following an assault. Which statement
regarding skull fractures is true?
A. Basilar skul fractures are best diagnosed
clinical y
B. Linear, non-depressed skul fractures require
phenytoin therapy
C. Plain radiographs are the diagnostic study of
choice
D. "Battle's sign" is an early finding in basilar skul
fractures
E. Hemotympanum is only seen with barotrauma
TR 5
Regarding subdural hematomas,
which statement is true?
A. Subdurals are rarely from contrecoup injuries
B. Subdural hematomas have a lower mortality rate
than epidural hematomas
C. Subdural hematomas are more common than
epidural hematomas
D. Subdurals are lens shaped
E. Subdurals are uncommon in the elderly
TR 6
A 14 y/o boy sustained a brief loss of
consciousness following a bicycle accident. On
examination he opens his eyes when spoken to,
he is oriented x 3 and able to follow
instructions. What is his GCS?
A. 3
B. 7
C. 9
D. 12
E. 14
TR 7
An 18 y/o sustains a large stab wound to the
neck just below the angle of the mandible.
Examination reveals no airway compromise, no
active hemorrhage and stable vital signs. Which
of the following is true regarding this injury?
A. Cranial nerves IX, X and XI are located in this
zone
B. Vascular control (proximal control) of zone 1
is more easily achieved than in zone 2
C. This is a zone 2 injury
D. This is a zone 1 injury
E. This is a zone 3 injury
TR 8
A lethargic one year old is found to
have a midshaft femur fracture.
Which finding is associated with the
worst prognosis?
A. Transverse fracture with a ful bone width
displacement
B. Funduscopic exam with retinal hemorrhages
C. Distal femur involvement
D. A pulse deficit which improves with splinting
E. A large thigh hematoma
TR 9
A patient has an allergy to an amide
anesthetic. Which local anesthetic
would be safe to use?
A. Lidocaine
B. Mepivacaine
C. Tetracaine
D. Bupivacaine
E. LET
TR 10
A 56 y/o presents with abdominal pain status post
MVC. He has a seatbelt sign across the
epigastrium. CT of the abdomen is most sensitive
for which of these injuries?
A. Diaphragmatic rupture
B. Splenic laceration
C. Duodenal hematoma
D. Urethral transection
E. Traumatic hydrocele
TR 11
Which of the following is an
independent risk factor for high
mortality from head trauma?
A. Associated skul fracture
B. The mechanism of injury
C. History of previous head trauma
D. Age > 65 yrs
E. Female gender
TR 12
Which statement is true regarding
renal pedicle avulsion injuries?
A. Early surgical intervention is often needed to
control hemorrhage
B. They are usual y isolated injuries
C. All such injuries result in nephrectomy
D. Up to 20% have associated hematuria
E. Nephrectomy is rarely necessary in patients
with injuries to the main renal artery
TR 13
A 46 y/o gentleman is evaluated following a
MVC. His abdomen reveals diffuse tenderness
with peritoneal signs and a transverse contusion
of the lower abdominal wall. Which injury is
associated with this description?
A. Pulmonary contusion
B. Flail chest
C. Lumbar fractures (Chance fractures)
D. Pneumobilia
E. Liver laceration
TR 14
A 4 y/o is evaluated for a neck injury
following a MVC. Which statement is true
regarding cervical spine fractures in
children?
A. More common than in adults
B. Usual y in the lower cervical segments(C 5-7)
C. Most fractures are from extension injuries
D. C1-4 fractures are the most common in
children < 8 years old
E. Spinal cord injuries with normal radiographs
are less common in children
TR 15
An 18 y/o male sustains a gunshot wound
to the upper abdomen. With regard to
ruling out an injury to the diaphragm,
which of the following is true?
A. DPL is very sensitive for diaphragm injury
B. CXR is the most important initial diagnostic
modality
C. 90% occur on the right side
D. Delayed diagnosis is rare
E. CT visualizes the diaphragm very wel
TR 16
A 24 y/o male involved in an MVC
has a wide mediastinum and obscured
aortic knob on CXR. Which of the
following statements is true regarding this
injury?
A. It is associated with a high pitched, blowing,
diastolic murmur
B. 25% mortality at scene
C. Rarely associated with other injuries
D. A normal mediastinum on CXR rules out this
diagnosis
E. Occurs with blunt and penetrating trauma with
similar frequency
TR 17
A bubbling slash wound to the neck is found to
be associated with a "machinery" murmur. After
placing pressure on the wound, the immediate
response should be:
A. (L) Lateral decubitus, reverse Trendelenburg
B. (R) Lateral decubitus, Trendelenburg
C. (R) Lateral decubitus, reverse Trendelenburg
D. (L) Lateral decubitus, knee chest position
E. (L) Lateral decubitus, Trendelenburg
TR 18
A 30 y/o male patient presents following a
deceleration injury. He has 1st and 2nd rib
fractures, a fractured scapula and a fracture
dislocation of his ankle. What is the most
appropriate next step?
A. Splint the extremity after reduction and plan
for the patient's discharge
B. Order a CT of the chest if V.S. are stable
C. Place a prophylactic chest tube on the
affected side
D. Order an arch aortogram if V.S. are stable
E. Transfer the patient for a TEE
TR 19
A 45 y/o patient presents with chest wall trauma
after falling off of his forklift. The chest
radiograph shows a hemothorax. You
performed a chest tube thoracostomy. Which is
an indication for emergent thoracotomy?
A. Initial chest tube output >500 cc
B. Persistent air leak
C. Chest tube output of 500cc in the first hour
D. Mild tachycardia
E. Chest tube output of 100 cc/hr x 3 hours
TR 20
Trauma Answer Key
1. E
11.B
2. C
12.D
3. B
13.A
4. D
14.C
5. A
15.D
6. C
16.B
7. E
17.A
8. C
18.E
9. B
19.B
10.C
20.B
This post was last modified on 24 July 2021