Download MBBS Important Topics Trauma

Trauma Systems
? Vary from state to state
? States are responsible for designating trauma
centers and regionalization of trauma care
?American Col ege of Surgeons' guidelines

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? Level 1 essential components
?24/7 availability of al surgical subspecialties
?Neurosurgery, hemodialysis 24/7
?Injury prevention and education programs
?Trauma research program

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? Trauma triage based on physiology, anatomy and
mechanism
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ATLS: Initial Approach
1? rapid resuscitation 2? diagnostic tests

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ultimate triage
? Primary survey: identify and treat life-
threatening injuries
?Airway obstruction
?Tension pneumothorax

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?Massive hemorrhage
?Open pneumothorax
?Flail chest
?Cardiac tamponade
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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

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?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

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?Nasotracheal intubation is contraindicated in
maxil ofacial trauma, basilar skul fracture, apnea
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ATLS: Primary Survey
? Breathing

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?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,

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thoracotomy is indicated
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ATLS: Primary Survey
? Circulation
?Radial pulse = BP > 80

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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

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Significant hemorrhage may be clinical y
silent in young, healthy adult
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ATLS: Initial Approach
? Circulation : Assess for shock

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?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

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? 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)

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?Type O pos can be used in males
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Shock Classification
? Hemorrhagic shock
? Class I: <15% blood loss = no significant

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changes
? Class II: 15-30% blood loss = cap refil ,
heart rate
? Class III: 30-40% blood loss = shock, BP,
altered mental status

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? Class IV: >40% blood loss = preterminal
? Consider other forms of shock (neurogenic?)
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ATLS: Primary Survey
? Disability: abbreviated neurologic exam

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?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:

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? Relative hyperventilation (pC02 30-35)
? ICP monitor (GCS 3-8 & intracranial lesion)
? Early surgical decompression/craniotomy
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Glasgow Coma Scale

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Eye opening
Spontaneous
4
Eyes open to command
3

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Eyes open to pain
2
No reaction
1
Verbal

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Oriented
5
response
Confused, disoriented
4

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Inappropriate words
3
Unintel igible sounds
2
No verbal response

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1
Motor
Obeys commands
6
response

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Localized pain
5
Withdraws from pain
4
3 = worst

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Flexion posturing to pain
3
15 = best
Extensor posturing to pain
2

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No reaction
1
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ATLS: Primary Survey
? Exposure: "Strip-Flip-Touch and Smel "

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?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

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?Identify as many injuries as possible
?Set priorities for evaluation and management
?Secondary consultations (OMF, ENT, GYN)
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Traumatic Arrest: ED Thoracotomy

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? Absolute indication
?Penetrating chest trauma + signs of life (pre-
hospital or ED) + cardiac activity in ED
? Liberal indications
?Abdominal trauma and cardiac activity requiring

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aortic cross clamping to get to operating room
?Blunt chest trauma with loss of vital signs in ED
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Pediatric Trauma
? Most common cause of pediatric death >1 year

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? 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

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? Large occiput tends to flex neck
Head injury: The
? Obligate nose breathers <6 months
most common
? Increased tongue size

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lethal injury
? Anterior larynx
? Narrow subglottic area
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Pediatric Trauma

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Airway Considerations
? Airway treatment
? Straight blade
? ET size (mm) = (age + 16) / 4
? Depth of insertion = 3 x tube size

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? No cricothyroidotomy if <8 years old
? Transtracheal jet ventilation if ET intubation
impossible
? Allows oxygenation
? Poor ventilation

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? Temporizing measure
? Consider pediatric LMA or ILMA
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Pediatric Trauma
Vascular Access

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? Peripheral line(s) when able
? Intraosseous line
? Fluid resuscitation
? Blood products and drugs
? Complications (rare)

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? Growth plate injury
? Fluid leakage
? Fat emboli
? Osteomyelitis
? Compartment syndrome

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? Femoral line: identifiable landmarks
Contraindicated in limb with fracture
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Pediatric Trauma
Fluid Resuscitation

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? 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

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? 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

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non-operatively (spleen and liver)
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Pediatric Trauma
? C-spine fractures
Cord injuries are

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?Rare
more common than
fractures /
?C1-C4 most common <8 yrs
SCIWORA

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?Flexion injury
diagnosed by MRI
? Pulmonary and cardiac contusions: Common,
often delayed
? Fractures of ribs and sternum: Rare, imply

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great force
Burns: 2nd most common cause of death <5yrs
(many have inhalation injury)
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Child Abuse (1)

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? Injury inconsistent with history, delay in
treatment, certain injury patterns
? Abuser
? Contusions
?Young age

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? Buttocks
?Increased stress
? Genitalia
?Unemployed
?History of abuse

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? Neck
?Substance abuse
? Face
? Burns
? Low back

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? Contact
? Immersion
? Stocking glove distribution
? Cigarette burns
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Child Abuse
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Med-Chal enger ? EM

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Child Abuse
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Med-Chal enger ? EM

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Child Abuse (2)
Shaken baby syndrome:
Diffuse cerebral injury with edema
Retinal hemorrhages, poor prognosis

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? Suspicious Fractures ? Head injury
?Any <1 year
?Subdural
?Rib (posterior)
?Cerebral

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?Skul , spine, sternum
?SAH
?Bilateral, multiple,
various stages of healing ?Shaken baby
?

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syndrome
Long bone
?Metaphyseal
Undiagnosed child abuse:
Significant 2 year mortality

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Suspicious fracture for Child Abuse
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Med-Chal enger ? EM

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Suspicious fracture for Child Abuse

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Metaphysial deformity (bucket handle)
due to shearing / rotational forces
Pathognomonic for child abuse
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Geriatrics Trauma

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? MVA is leading cause of unintentional injury
and death <75 years old
? Fal s
?Common cause of unintentional injury and
death >75 years old

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?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
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Domestic Violence (1)
? Inconsistencies in history
? Many women presenting to the ED have
experienced domestic violence
? Suspicious injuries: Fractures, bruising

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? 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

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? Child abuse
? Public displays of violence
? Sexual assault
? Partner ends relationship
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Domestic Violence (2)
? Elements common in victims of DV
?Pregnancy (increased incidence)
?Injuries: Head, neck, abdomen, thorax
?Injury and reported mechanism do not

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correlate
?Injuries in different stages of healing
?Delay in seeking treatment
?Fingernail scratches, cigarette burns, rope
burns, bites, defensive injuries

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?Multiple medical visits, vague complaints
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Pregnancy and Trauma (1)
? MVA, fal s, assaults (DV again)
? Increased injuries to spleen, retroperitoneum,

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uterus (seat belt injuries)
? Uterus rises out of pelvis at 12 weeks
? Penetrating trauma
? Maternal mortality is low
Blunt trauma:

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? Fetal mortality is high
?
Leading cause
Signs of fetal demise
of maternal death

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? Loss of movement
? Absent heart tones
? Extended extremities
Maternal stabilization is the most important
factor in preventing fetal demise

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Pregnancy and Trauma (2)
? Uterine rupture
?Uncommon, late 2nd-3rd trimester, previous C-
section, VBAC patients

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?Fetal mortality almost 100%, maternal
mortality lower
?Presentation may be non-specific: loss of
uterine contour, palpable fetal parts
?Shock, abdominal pain, fetal demise

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Pregnancy and Trauma (3)
? Abruptio placentae
?A leading cause of fetal death, leading cause of
maternal death

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?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)

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?RhoGAM if Rh negative
?Fetal distress (first tachycardia, then bradycardia)
?DIC is a common complication
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Pregnancy and Trauma (4)

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? 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

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?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

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?May indicate emergent C-section
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Head Trauma (1)
? Accounts for half of al trauma deaths
? Males, ages 15-30: MVA, assaults, fal s,

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bicycle accidents
Hypotension in head
injury: Look for other
?
causes

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Cushing reflex
? Late and unreliable sign of increased ICP
? Hypertension
? Bradycardia
? Scalp lacerations may bleed profusely,

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leading to shock in children
? CT is stil the imaging study of choice
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Head Trauma (2)
? No CT if minor mechanism of injury, no

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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

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? 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

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Epidural - Coup
Subdural - Contrecoup
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Contrecoup Injury with

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Acute Intracerebral Hematoma
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Diffuse Cerebral Edema
35
Med-Chal enger ? EM

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Skull Fractures
? Rule out abuse in stel ate, complex fractures
? Linear non-depressed fracture does not
require treatment
? Temporal skul fracture (middle meningeal

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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,

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contrecoup injury, posterior fossa hematoma,
cranial nerve injury
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Depressed Parietal Skull Fracture
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Med-Chal enger ? EM

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Skull Fracture
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Basilar Skull Fracture
? Clinical diagnosis ? can cause CSF oto- or

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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

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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

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the posterior fossa
? Ring test for CSF: Halo of clear fluid beyond
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Basilar Skull Fracture Findings
(Battle's Sign / Hemotympanum)
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Epidural Hematoma
? Usual y arterial bleed (middle meningeal

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artery) between skul and dura
? Early underlying brain injury may be mild
? Presentation (classic)
?Immediate LOC
?Lucid interval

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?Skul fracture
?Dilated ipsilateral pupil in 85% (indicates
impending herniation)
? CT: Biconcave (lens-shaped) bleed
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Epidural Hematoma
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Epidural Hematoma
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Med-Chal enger ? EM

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Subdural Hematoma
? Bridging veins between dura and arachnoid
? Elderly, alcoholics at increased risk
? Presentation
Six times more

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?
common than
Pupil less reactive
epidurals
? Decreased mental status, LOC

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? May have lucid interval (more common in
epidurals)
Higher mortality rate
? Classification
than epidurals

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? Acute: <24 hours (white on CT)
? Subacute: 24 hours-2 weeks (isodense on CT)
? Chronic: >2 weeks (dark on CT)
? CT: Crescent-shaped bleed
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Subdural Hematoma : Contrecoup
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Subdural Hematoma
Subdural blood is free to spread over the convexity of the brain

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while extension of epidurals is restricted by attachments of the
dura to the skull
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Intracerebral Hemorrhage (1)
? Transtentorial herniation

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?Mass effect (hemorrhage, edema) pushes
medial temporal lobe (uncus) through the
tentorial notch
?Compression of CN III causes ipsilateral
fixed, dilated pupil

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?Compression of ipsilateral corticospinal tract
causes contralateral hemiplegia
? Sometimes the opposite corticospinal tract
is compressed producing ipsilateral
hemiplegia

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?Brainstem compression causes coma
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Intracerebral Hemorrhage (2)
? Central herniation
?Mass effect causes downward displacement

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of entire brainstem
?Earliest sign is CN VI (lateral rectus) palsy
?Bilateral uncal herniation
? Tonsil ar herniation (rare)
?Cerebel ar tonsils herniate through foramen

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magnum
?Respiratory arrest and death
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Increased ICP Treatment
? Intubate if GCS 8

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? Hyperventilation is controversial
?Decreased pCO2, increased pH,
decreased ICP, vasoconstriction
?Goal: pCO2 30-35 mm Hg
?Avoid excessive hyperventilation

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? Mannitol
?Osmotic diuretic (1 g/kg)
?Controversial in children
? Steroids not beneficial
Cerebral perfusion pressure =

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(mean arterial pressure) ? (intracranial pressure)
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Traumatic Seizures
? Immediate, brief seizure with non-focal exam after
trauma is usual y benign: No therapy needed!

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? High risk for seizures when:
? Mass effect or focal examination
? Depressed skul fracture
? Penetrating injury
? GCS < 10

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? Anticonvulsant prophylaxis: Phenytoin, levetiracetam
(Keppra)
? Delayed posttraumatic seizures
? Increased incidence with intracranial bleed, depressed
fracture

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? Most occur within the first year
? Treatment: Phenytoin, levetiracetam (Keppra)
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Pediatric Head Trauma
? Poor pressure/volume curve

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? More non-surgical lesions
? Diffuse cerebral edema
? Diffuse axonal shear
? Contusions
? Peds concussion syndrome (diffuse

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cerebral hyperemia)
? GCS may wax and wane
? Skul is much weaker
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Pediatric "Minor" Head Trauma (1)

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? 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)

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? 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

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ones) are important predictors of fracture, especial y in
the temporal and parietal area (90% of fractures have
scalp hematomas)
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Pediatric "Minor" Head Trauma (2)

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? 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

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? 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

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re-x-rayed in two months to
evaluate for signs of a growing
fracture
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Pediatric "Minor" Head Trauma

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? 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 /

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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

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by a fairly routine second head impact after a prior concussion
? speculated mechanism = disordered autoregulation
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Penetrating
Neck

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Injuries
Slash, from Guns
and Roses.....
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Penetrating Neck Injury (1)

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? Any wound which violates platysma
? Most injuries occur in Zone l
?Vascular > CNS
?Peripheral nerves > brachial plexus
? Vascular injuries need proximal and distal control

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? Death from CNS injury, exsanguination, airway
compromise (intubate early)
? Air embolism is potential y fatal complication
?Machinery murmur
?Trendelenburg + left lateral decubitus position to

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prevent bubble migration
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Penetrating Neck Injury (2)
? Hard signs (significant ? Soft signs (require
injury probably exists)

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ful diagnostic
?Hypotension
evaluation)
?Arterial bleeding
?Stridor

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?Expanding hematoma
?Hoarseness
?Thril , bruit
?Vocal cord
?Focal deficits

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paralysis
?Hemothorax >1,000 mL ?Subcutaneous air
?Bubbling wound
?Facial nerve injury
?Hemoptysis,

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hematemesis
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Penetrating Neck Injury (3)
? Hard signs: Unstable require surgical exploration
?Zone I: Requires thoracic surgical approach

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?Zone II: Exploration technical y least difficult
?Zone III: May require disarticulation of mandible
? Stable patients (evaluation)
?Zone I: Angiogram, esophagram, endoscopy,
bronchoscopy

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?Zone II: Exploration or angiogram, esophagram,
endoscopy, bronchoscopy
?Zone III: Angiography
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Stab Wound Neck

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Blunt Neck Trauma
? Mechanism: Steering wheel, dashboard,
shoulder belt shearing forces, clothesline
injuries

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? Laryngotracheal and pharyngoesophageal
injuries can be subtle; require diagnostic
imaging
? Carotid/vertebral artery injury: Pseudoaneurysm
or dissection

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?Mechanism: Hyperextension, hyperflexion, direct
blow, intraoral trauma, basilar skul fracture
?Neurologic symptoms may be delayed
? CT with contrast
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Carotid Artery Dissection
Neck trauma + TIA, stroke, or Horner's syndrome
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Chest Trauma
? Thoracic trauma causes ? of trauma deaths
? Hypotension + blunt trauma: Pelvic fracture >
intraabdominal injury > intrathoracic injury
? Hypotension + penetrating trauma: Lung >

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heart > great vessels
? Open (sucking) chest wound: Occlusive
petrolatum gauze can cause tension
pneumothorax
? Immediate treatment: Remove dressing

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? Definitive treatment: Chest tube
? Needle thoracostomy: 2nd intercostal space,
midclavicular line
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Sucking Chest Wound
Application of occlusive
dressing can cause
tension pneumothorax
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Chest Trauma
? Open thoracotomy
?Penetrating trauma and loss of vital signs
?Poor outcome for blunt trauma
?Incision at 5th ICS, open pericardium vertical y,

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anterior to phrenic nerve
Because of their anterior location, the right
ventricle and right atrium are most commonly
injured in penetrating trauma
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Rib Fractures
? Clinical diagnosis: Localized pain, tenderness
? May not be seen on X-ray
? Rule out
?Pneumothorax

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?Pulmonary contusion
?Vascular injury
? Multiple rib fractures
?Two or more: Increased risk of internal injuries
?Lower ribs: Increased risk of liver, kidney,

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spleen injuries
?Admit: Elderly, pre-existing pulmonary disease
?Delayed findings: Pneumothorax, aspiration,
pulmonary contusion
? Treatment: Pain medication, nerve block

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65

---

1st and 2nd Rib Fractures
? Often have associated occult injury
? Great force involved
? Significant mortality

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? Rule out
?Myocardial contusion
?Bronchial tear
?Vascular injury (consider angiogram)
? If no evidence of neurovascular compromise

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?No increased morbidity, angio not mandatory
Scapular fractures are also
associated with occult chest injury
66

---

Flail Chest

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? Segmental fracture of 3 or more ribs
? Paradoxical chest wal movement
? Decreased ventilation and venous return
? Treatment: Direct pressure, intubation, consider
chest tube

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? Main cause of hypoxemia: Pulmonary contusion
Sternal Fracture
? MVA is most common cause (steering wheel,
seat belt)
? Associated with myocardial contusion

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? Consider cardiovascular injury
67

---

Flail Chest
68
Med-Chal enger ? EM

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---

Pulmonary Contusion
? Interstitial edema, capil ary damage, bleeding
? Hemoptysis is common
? Decreased compliance, hypoxemia, atelectasis
? X-ray findings range from patchy alveolar

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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

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Commonly associated with flail chest
69

---

Pulmonary Contusion
70
Med-Chal enger ? EM

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---

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

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? High mortality with rupture
? Symptoms / signs
? CXR
? Chest pain
? Pneumothorax

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? Dyspnea
? Pneumomediastinum
? Hypoxemia
? Tension pneumothorax
? Hamman's crunch

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? Rib fracture
(mediastinal friction rub ? Treatment
w/ heart beat)
? Oxygenation
? Hemoptysis

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? Ventilation
? Subcutaneous
? Chest tube
emphysema
71

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---

Hemothorax (1)
? Decreased breath sounds, dul ness to
percussion
? Intercostal artery injury is a common cause
? Upright CXR: Blunting of CPA (200-300 mL)

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?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)

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? Often associated with pneumothorax
? Layers out on a supine film (CT)
72

---

Hemothorax (2)
? Diagnosis: CXR, ultrasound, CT

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? Treatment: Thoracentesis, chest tube (36-40F)
? Autotransfusion if capability exists
? Thoracotomy indications
? Unstable
? Initial output >1500 mL

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? >100 mL/ hr x 6 hours
? Persistent air leak
73

---

Hemothorax
(Pneumothorax also present)

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74
Med-Chal enger ? EM

---

Pneumothorax
? Chest pain, dyspnea, subcutaneous emphysema
? CXR: Findings can be delayed; repeat in 4 to 6

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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

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tube
?Dressing can create a tension pneumothorax;
remove dressing if patient has increased SOB
Expiratory chest X-ray is the
most helpful diagnostic test

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75

---

Tension Pneumothorax
? Severe dyspnea, decreased breath sounds,
distended neck veins
? Classic findings: Tracheal deviation to

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opposite side, hyperresonance, no breath
sounds
? Decreased venous return, hypoxemia,
cardiac arrest
? Treatment: Immediate needle thoracostomy,

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chest tube thoracostomy
Do not wait for X-ray
76

---

77

---

Tension Pneumothorax

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78

---

Pneumomediastinum
? Subcutaneous emphysema
? Hamman's sign: Crunching sound during systole
? Spontaneous due to increased

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intrabronchial pressure
? Mechanical ventilation
? Valsalva with drug abuse
? Restraint of a combative pt
? Sneezing

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? Ruptured bleb
? Tension pneumomediastinum
? Decreased cardiac output
? Decompression via neck
dissection

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79

---

Pneumomediastinum
80
Med-Chal enger ? EM

---

Diaphragm: Traumatic Injuries

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? 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)

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? 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

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Diagnosis is often missed or delayed
81

---

DIAPHRAGM SUMMARY
Blunt Mechanism
Penetrating Mechanism

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? L > R
? L > R
? Anterior aspect
? Posteriorly (SW in L flank)
? Large rent (6-10cm)

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? Smal tear (2-3 cm)
? Delayed diagnosis (by ? Delayed diagnosis (by
48 hours)
years until herniation)
? L hemothorax

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? Normal CXR
? Translocation 50%
? Translocation rare
? CXR abnormal but not ? Late herniation and
diagnostic

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strangulation
82

---

Ruptured Diaphragm
83

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---

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

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? 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

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extremities
84

---

Traumatic Ruptured Aorta (TRA) (2)
? Widened mediastinum on upright CXR: Most
sensitive and specific X-ray finding associated

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with TRA
? Controversial if 1st and 2nd rib fractures are
associated with TRA
? X-ray findings
? Left apical cap

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? Blurred aortic knob
? Left hemothorax, trachea deviated to right; NG
tube deviated to right
? Depressed left mainstem bronchus
? Loss of aortic-pulmonary window

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85

---

Traumatic Ruptured Aorta (TRA)
Upper rib
Tracheal deviation

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fractures
Wide Mediastinum


86

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---

Traumatic Aortic Transection
87

---

Cardiac Tamponade

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? More common in penetrating trauma
? Beck's triad: Hypotension, JVD, muffled heart
sounds
? Pulsus paradoxus (weaker pulse, lower
systolic pressure with inspiration)

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? Electrical alternans: Alternating QRS
direction
? Diagnosis: Ultrasound
? Treatment: Pericardiocentesis, thoracotomy
Cardiac rupture: most die at scene from shock,

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hemorrhage or tamponade
88

---

Myocardial Contusion
? Blunt trauma with deceleration forces
? Chest pain, sternal or rib fracture, dyspnea

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? 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

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(rarely isolated)
? Most heal without specific treatment
? Complications (rare)
? Effusion - Aneurysm
? Thrombosis - Dysrhythmia

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89

---

Abdominal Trauma (1)
? blunt, penetrating
? Blunt: MVA, direct blow, fal s
? Seatbelt injuries

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?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

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tear, ruptured diaphragm, Chance fracture
90

---

Abdominal Trauma (2)
? Laparotomy indications
? Evisceration, GSW, impalement, gross blood

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by NG, rectal or DPL, positive FAST scan if
unstable
Hypotension
? CT as opposed to laparotomy if stable & +
FAST

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91

---

Stab Wound Abdomen
92

---

Abdominal Trauma
? Stab wounds to the anterior abdomen

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?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

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patients without positive findings
Because of diaphragm movement, consider
abdominal injury in trauma between the nipple
and the navel:
- 4th ICS anterior

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- 6th ICS posterior, lateral
93

---

Thoracoabdominal Penetrating Wounds
Nipple to Navel in "No Mans Land"....

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Chest and abdominal wounds in this area
94

---

Abdominal Trauma
? Imaging
?Routine plain abdominal films not indicated

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?CT
? Insensitive to hol ow organ injury, pancreas,
and diaphragm
? Sensitive to retroperitoneum, solid organs,
bony structures

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? 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)

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(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)

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?10,000 RBCs/mL is threshold for laparotomy in
penetrating trauma
?Bile, feces, urine
? May see false negatives
? Pelvic fractures

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? Poor sensitivity for diaphragm injuries
96

---

Diagnostic Peritoneal Lavage (DPL)
(2)
? Laparotomy decision is based primarily on

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hemodynamics, associated injuries, FAST scan
and CT
? In a stable patient without peritonitis, a positive
DPL can be managed conservatively
97

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---

DPL
98
Med-Chal enger ? EM

---

Abdominal Signs
? Grey Turner's sign: Flank discoloration (late

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sign of retroperitoneal hematoma; seen in
hemorrhagic pancreatitis)
? Kehr's sign: Referred left shoulder pain due
to subdiaphragmatic irritation or splenic
rupture

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? 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)

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99

---

Cullen's Sign
100
Med-Chal enger ? EM

---

Grey-Turner (Flank Ecchymosis)

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101

---

Spleen
Most common organ injured in blunt trauma
? Shock, LUQ pain, Kehr's sign
? Diagnosis: CT

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? Treatment
?Consider non-operative management
?Give Pneumococcal and HIB vaccines post-
splenectomy
?Post-splenectomy sepsis has high mortality

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Liver
Most common organ injured in penetrating trauma
Capsular hematoma: false-negative DPL
Diagnosis: CT scan
102

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---

Pancreas / Small Intestine
? Pancreas
? Commonly injured in blunt trauma
? Handlebar, steering wheel
? Pain delayed as enzymes leak and cause

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irritation
? Serum amylase is often normal
? Diagnosis: CT (DPL may be false negative)
? Smal intestine
? Multiple injuries in penetrating trauma

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? Symptoms often delayed
? Associated with lap belt injury and lumbar spine
fractures
103

---

Stomach / Duodenum / Bowel

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? More common in penetrating trauma
(except in children)
? Most duodenal injuries have associated liver
injury
? Abdominal wal ecchymosis from seatbelt:

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Consider intraabdominal injury (especial y
hol ow viscus)
? Bike handlebar: Consider associated duodenal
hematoma
? Bowel injuries may be delayed in presentation

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If colon injured, usual y transverse
104

---

Urethral Trauma
General
Anterior

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Posterior
?Blood at
?Straddle injury
?Pelvic fracture
meatus

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?Fracture penis
?Distended
bladder
?Boggy
?Iatrogenic

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?
prostate
Lower
(foreign body)
abdominal

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?Perineal
?Hematuria
pain
bruising
?

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?
Dysuria
Urethrogram
?Dx: Retrograde
?Blood at meatus

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?Rx: Primary
urethrogram
?Scrotal
repair
hematoma

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(before Foley) ?Complications: ?Complications:
fistula, stricture
Impotence,
incontinence 105

---

Extravasation with Anterior Urethral Rupture

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106
Med-Chal enger ? EM

---

Extravasation with Posterior Urethral Rupture
107
Med-Chal enger ? EM

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---

Urethra Trauma: Urethrogram
108

---

Normal Urethrogram

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109

---

Contrast Extravasation Due to Posterior Urethral Tear
110
Med-Chal enger ? EM

---

Suprapubic Cystostomy

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? Seldinger technique to gain bladder access
? Indications
?Need drainage but Foley cannot be passed
?Urethral stricture (severe)
?Transection of urethra (trauma), GU burns (severe)

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? 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

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? Pregnancy is not a contraindication
? Complications: Bowel injury, extravasation,
infection, urethral injury
111

---

Testicular Trauma

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? Most common in blunt or straddle injury
? Presentation
? Edema
? Ecchymosis
? Tenderness

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? Hematuria
? Diagnosis: Ultrasound, nuclear scan,
exploration
? Complications: Abscess, hydrocele, infertility
112

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---

Scrotal Hematoma
113

---

Renal Trauma (1)
? Rapid deceleration, compression, penetrating
trauma

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? 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

--- Content provided by‌ FirstRanker.com ---

114

---

Renal Trauma (2)
? Penetrating injury: IVP or CT
? KUB is used to verify two kidneys
? Renal vascular injury

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? 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

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? Bladder injury associated with pelvic fracture,
gross hematuria retrograde urethrogram
? Bladder rupture with intraperitoneal
extravasation surgery
115

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---

Laceration Repair (1)
? Cosmesis and infection prevention tend to be major
objectives
? Laceration infection rate <5%
? Most have low bacterial counts

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? 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,

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renal failure, advanced age, steroids, chemotherapy,
immunosuppressives
? Increased infection risk: Foreign body, crush injury,
bite
116

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---

Tetanus
? Clostridium tetani (anaerobic Gram positive bacil us)
produces tetanospasmin, a potent neurotoxin
? 60 cases/year in US, elderly predisposed
? Wounds at increased risk

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?>24 hrs old, crush injury, devitalized tissue
?Burns, IVDA, early postpartum wounds
?Soil in wounds
? Muscle spasm, rigidity, risus sardonicus,
opisthotonus, fever

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? Often occurs after minor wounds or without known
injury
? Neonatal tetanus: 3-10 days after birth, poor
prognosis
? May have unexplained tachycardia

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117

---

Laceration Repair (2)
? Tetanus guidelines
?Clean minor wounds (al wounds except
contaminated wounds, punctures, avulsions,

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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

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?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

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118

---

Laceration Repair (3)
? Local anesthesia
? "Amides" and "esters"
? Most "reactions" due to the methylparaben preservative

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(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)

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? 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

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intradermal), pretreat with topical anesthetics
119

---

Local Anesthetics
Anesthetic
Formulations

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Duration of
Maximum
Action
Dosage
Lidocaine

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1% (10 mg/ml)
30-60 min
4.5 mg/kg, max
2% (20 mg/ml)
300 mg

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(30ml of 1%; 15 ml
of 2%)
Lidocaine with
1% (10 mg/ml)
120-360 min

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7 mg/kg
epinephrine
2% (20mg/ml)
(50 ml of 1%; 25
ml of 2%)

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Bupivacaine
0.25% (2.5 mg/ml) 120-240 min
2.5 mg/kg, max
0.5% (5 mg/ml)
175 mg

--- Content provided by​ FirstRanker.com ---

(70 ml 0.25%; 35
ml 0.5%)
Bupivacaine with
0.25% (2.5 mg/ml) 180-420 min
225 mg

--- Content provided by FirstRanker.com ---

epinephrine
0.5% (5 mg/ml)
(90 ml 0.25%; 45
ml 0.5%)
120 120

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---

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)

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? 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

--- Content provided by​ FirstRanker.com ---

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

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121

---

Antibiotic Wound Prophylaxis
? Consider in
? High risk sites (hands, feet)
? Puncture wounds, foreign bodies

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? Contaminated wounds, bites
? Extensive soft tissue injury
? Through-and-through mouth lacerations
? Open fractures, exposed joints and tendons
? Prosthetic valves (endocarditis prophylaxis)

--- Content provided by FirstRanker.com ---

? Immunocompromised
Puncture through sneakers:
Increased risk of Pseudomonas infection
and osteomyelitis. Treatment: Fluoroquinolones
and debridement

--- Content provided by FirstRanker.com ---

122

---

Gas Gangrene
? C. perfringens produces exotoxin
? Anaerobic infection in contaminated wounds
? Pain out of proportion to physical findings

--- Content provided by​ FirstRanker.com ---

? 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

--- Content provided by⁠ FirstRanker.com ---

penicil in, debridement,
hyperbaric O2
123

---

Necrotizing Fasciitis

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? Anaerobes, group A Strep, Staph aureus
? Risk factors: CRF, diabetes, vascular
disease, alcohol, immunosuppressed
? High mortality.....and low sodium
? Tachycardia, high fever, toxic appearance

--- Content provided by‍ FirstRanker.com ---

? Erythema, edema, very painful, crepitance
? WBCs, Gram's stain, blood cultures, X-ray
? Fluid resuscitation, imipenem-cilastatin
? Surgical debridement
124

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---

Trauma Trivia (1)
? Blood bank transfusion: Decreased clotting
factors, decreased platelets, decreased
temperature (the most common sequelae of
massive transfusion is hypothermia)

--- Content provided by‌ FirstRanker.com ---

? Auto vs. pedestrian
?Adults: Tibial plateau fracture, knee injury
?Pediatrics: Chest and abdominal injury, closed
head (contrecoup) injury
? Pediatric trauma patients in shock

--- Content provided by‍ FirstRanker.com ---

?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

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---

Trauma Trivia (2)
? Human bite: Eikenel a
? Reptile bite: Salmonel a
? Cat bites: Pasteurel a multocida (prophylactic
antibiotics)

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? Air embolism
?"Machinery murmur" with neck vascular injury;
tachypnea, tachycardia, hypotension
?Place patient in left lateral decubitus and
Trendelenburg position

--- Content provided by FirstRanker.com ---

? Capil ary refil is not reliable in hypothermia
126

---

TRAUMA QUESTIONS
127

---

Which of the following best

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characterizes Cushing's reflex?

A. Reliable sign of head injury
B. Hypotension and bradycardia
C. Hypertension and tachycardia

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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

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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

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non-focal require no treatment
D. There is no increased risk of seizures with
penetrating injury
E. Recurrent seizures rarely require
anticonvulsants

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TR 2

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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

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physiology important to avoiding secondary
brain injury?
A. ICP = CCP / MAP
B. CPP = MAP - ICP
C. MAP = ICP - CPP

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D. CPP = ICP / MAP
E. CPP = ICP / 2 - MAP
TR 3

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A patient with a sucking chest wound has an
occlusive petroleum dressing in place.

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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

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D. Temporary removal of the occlusive dressing
E. Needle thoracostomy through the wound
TR 4

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An 18 y/o sustains a head injury
following an assault. Which statement

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regarding skull fractures is true?
A. Basilar skul fractures are best diagnosed
clinical y
B. Linear, non-depressed skul fractures require
phenytoin therapy

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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

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TR 5

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Regarding subdural hematomas,
which statement is true?
A. Subdurals are rarely from contrecoup injuries
B. Subdural hematomas have a lower mortality rate

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than epidural hematomas
C. Subdural hematomas are more common than
epidural hematomas
D. Subdurals are lens shaped
E. Subdurals are uncommon in the elderly

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TR 6

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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

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instructions. What is his GCS?
A. 3
B. 7
C. 9
D. 12

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E. 14
TR 7

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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

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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

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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

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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

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displacement
B. Funduscopic exam with retinal hemorrhages
C. Distal femur involvement
D. A pulse deficit which improves with splinting
E. A large thigh hematoma

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TR 9

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A patient has an allergy to an amide
anesthetic. Which local anesthetic
would be safe to use?
A. Lidocaine

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B. Mepivacaine
C. Tetracaine
D. Bupivacaine
E. LET
TR 10

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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

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B. Splenic laceration
C. Duodenal hematoma
D. Urethral transection
E. Traumatic hydrocele
TR 11

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Which of the following is an
independent risk factor for high
mortality from head trauma?
A. Associated skul fracture
B. The mechanism of injury

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C. History of previous head trauma
D. Age > 65 yrs
E. Female gender
TR 12

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Which statement is true regarding

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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

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D. Up to 20% have associated hematuria
E. Nephrectomy is rarely necessary in patients
with injuries to the main renal artery
TR 13

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A 46 y/o gentleman is evaluated following a

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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

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B. Flail chest
C. Lumbar fractures (Chance fractures)
D. Pneumobilia
E. Liver laceration
TR 14

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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

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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

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are less common in children
TR 15

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An 18 y/o male sustains a gunshot wound
to the upper abdomen. With regard to
ruling out an injury to the diaphragm,

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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

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D. Delayed diagnosis is rare
E. CT visualizes the diaphragm very wel
TR 16

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A 24 y/o male involved in an MVC
has a wide mediastinum and obscured

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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

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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

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similar frequency
TR 17

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A bubbling slash wound to the neck is found to
be associated with a "machinery" murmur. After
placing pressure on the wound, the immediate

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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

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E. (L) Lateral decubitus, Trendelenburg
TR 18

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A 30 y/o male patient presents following a
deceleration injury. He has 1st and 2nd rib
fractures, a fractured scapula and a fracture

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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

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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

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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?

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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

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TR 20

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Trauma Answer Key
1. E
11.B
2. C

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12.D
3. B
13.A
4. D
14.C

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5. A
15.D
6. C
16.B
7. E

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17.A
8. C
18.E
9. B
19.B

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10.C
20.B

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