Part II: Ch 41 - 69 (Trauma)

-Blood in ear canal (Hemotympanum ) -Rhinorrhea -Otorrhea -Battle's sign (retro auricular hematoma) -Racoon's sign (periorbital ecchymosis) -Cranial nerve deficits: ■ Facial paralysis ■Decreased auditory acuity ■Dizziness ■Tinnitus ■Nystagmus

Tell-tale clinical features of basial skull fracture? (Ch. 41)

Snuffbox tenderness and swelling Limited ROM of wrist and thumb Dorsal wrist pain, distal to radius

Tell-tale physcial signs of scaphoid fractures: (Ch. 51)

>24 weeks or >500g estimated by uterine fundus being ABOVE umbilicus

Threshold of fetal viability? How can you guestimate? (Ch. 37)

2 x ETT size 4 x ETT size

Two ways to choose size of chest tube in kids: (Ch. 38)

Dense specifics - best to look up the shownotes, Ch. 50.

Volar plate injuries... describe management. (Ch. 50)

Grade I: Ancef Grade II-III: add gentamicin or broad spectrum coverage (pip-tazo)

What antibiotics are used to prophylactically treat open fracture wounds? (Ch. 49)

History Admission of IPV Vague or changing history Injuries inconsistent with history Statement that patient is "accident prone" Past history of injuries Physical exam Centrally located injury (ie. trunk, breasts) Bilateral injuries Defensive injuries Patterned injuries Head,face,neck injuries

What are 5 clues on history, and 5 on physical exam of intimate partner violence? (Ch 68)

Female Younger age Exposure to childhood familial violence Physical or mental disability Use of alcohol by either party Lower SES Immigrants

What are 7 risk factors for intimate partner violence? (Ch 69)

*Bennett's*: Intra-articular fracture of the base of the thumb, extending into CMC joint *Rolando's*: Y-shaped 3-part fracture of the base of the thumb Manage both with ED reduction, thumb spica splint and ref. to hand surgeon. VERY UNSTABLE.

What are Bennett's and Rolando's fractures and how are they managed?

Treatment without testing - Ceftriaxone 250mg IM x 1 or cefixime 400mg po - Metronidazole 2g po x 1 - Azithromycin 1g po x1 or doxycyline 100mg po BID x 7 days

What are appropriate treatments for STI prophylaxis in cases of suspected sexual abuse/assault (Ch 67)

- Patient is reluctant to describe or hesitant when questioned about how the injury occured - History of medical, drug or alcohol abuse, especially for sleep - Injuries during pregnancy - Multiple vague complaints - Wounds at various stages of healing - Household members that are angry, rushed, indifferent, controlling or minimizing complaints - Homelessness

What are common red flags to alert you to the possibility of domestic violence? (Ch 68)

1. Rupture/burst (i.e. seatbelt injuries) 2. Crust (i.e. direct blow) 3. Acceleration/deceleration 4. Iatrogenic (i.e. PPV, CPR/Heimlich, tube thoracotomy)

What are four key mechanisms of injury in blunt abdominal trauma? (Ch. 46)

Species - Cat - Human - Primate - Pig - Camel Location of wound - Hand - Joint or superficial tendon - Through and through oral - Below the knee Wound type - Puncture - Extensive tissue damage - Contaminated or devitalized tissue - Old - Sutures High risk patients - Immunosuppressed, HIV positive - Transplant patient, steroid dependant - Diabetes, chemo - Prosthetic valve - Peripheral vascular disease - Elderly - Alcoholic - Cirrhosis - Social and compliance problems

What are risk factors for infection with animal bites?(Ch. 54)

Abnormal fetal HR (not 120-160) Decreased HR variability Late decelerations (fetal hypoxia) Decreased fetal movement

What are signs a fetus is in distress (in traumatic injury of mom)? (Ch. 37)

If both limbs are injured If there is an intimal flap allowing partial flow If there is good collateral flow (Proximal subclavian and iliac) If arteries have NO palpable pulses: If the artery in questions is profunda femoris, profunda brachii, peroneal arteries If the injury is a shotgun wounds. If there is venous injuries! (API will miss them)

What are some cases where the API will be limited or not helpful? (Ch. 48)

No pathognomonic signs, but these give a hint: -Hematemesis / blood in saliva/NGT -Odynophagia / dysphagia -Subcutaneous Emphysema -Dyspnea / hoarseness / stridor / cough -Pain / neck tenderness / resistance to neck movement

What are some clinical signs of pharyngoesophageal injury? (Ch. 44)

Pneumonia DVT / thrombophlebitis PE UTI Atrophy Stress ulcers GI bleed

What are some complications of immobilization post-fracture especially in the elderly? (Ch. 49)

Solid organ hematoma or rupture Bowel perforation Mesenteric shearing / avulsion Diaphragmatic herniation

What are some expected seatbelt-related injuries? (Ch. 46)

- Implausible history of injury mechanism - Inconsistent history between patient and caregiver of injury - Delay between injury and presentation to care - Unexplained injuries - Referred to as "accident prone" - Past history of frequent injuries - Noncompliance with medications, appointments or physician directions - Caregiver not able to give details about medical care - Caregiver answers the question regarding patient - Patient or caregiver reluctant to answer questions - Strained patient-caregiver interaction - Poor living conditions according to paramedics or others

What are some indications from a medical history that there may be elder abuse? (Ch 69)

**high incidence of peritoneal violation and viscus damage -almost absolute need for operative exploration

What are some mainstays of managing abdominal gunshot wounds? (Ch. 46)

-selective non-operative management (lap or not) -is peritoneum violated or not? -is diaphragm involved? -"implement in situ"

What are some mainstays of managing abdominal stab wounds? (Ch. 46)

-is patient hemodynamically unstable? (occult bleeding!) -if unstable: laparotomy (+/-FAST u/s) -if stable: FAST/CT, OR vs watchful waiting

What are some mainstays of managing blunt abdominal trauma? (Ch. 46)

1. Orotracheal RSI - consider an awake look first -- C/I if massive facial trauma or laryngotracheal injury 2. Nasotracheal Intubation - only in breathing pts --C/I if suspected midface/basilar skull/laryngeal #s 3. Surgical Intervential Airway --C/I if large neck hematoma or laryngeal injury or <10yo 4. Awake fibre optic

What are some major considerations when managing the airway in penetrating neck trauma? (Ch. 44)

- Dehydration - Evidence that the patient has been lying in urine or stool - Clothing inappropriate for climate, dirty or worn out - Poor hygeine - Untreated injuries and medical problems - Poor oral hygeine - Skin breakdown - Elongated toenails

What are some physical signs of neglect? (Ch 69)

-standard trauma/resus room protocol : MOVIE -10-20ml/kg of crystalloid IV bolus repeated up to 3x then: ○ PRBCs: 10 ml/kg ○ FFP: 25 ml/kg ○ Platelets: 10 ml/kg

What are some potential fluid therapies for hemorrhagic shock in kids and their doses? (Ch. 38)

Caregiver risk factors - Alcohol or drug abuse - Mental illness - Financial stress - Stress as a result of caring for the elder - Stress related to outside factors - Financial dependance on elder - Unrealistic expectations regarding caregiver responsibility - Lack of caregiving skills - Long duration as caregiver Elder Risk factors - Physical or functional impairment - Financial dependance on caregiver - Cognitive impairment or dementia - Social isolation - Low social support - History of family violence - Previous traumatic event exposure - Aggressive behaviour - Female - Advanced age - Incontinence - Frequent falls Environmental and family factors - Shared living - Overcrowded living - Lack of family and community support - Socially isolated Risk factors for institutional abuse - Poor working conditions - Inadequate training, experience Low wages Low staff to patient ratio

What are ten risk factors for elder abuse? (Ch 69)

*Prevention*: education, public law enforcement *Acute Care*: trauma systems, EMS, guidelines for care *Rehabilitation*: physio, OT, mental health

What are the 3 key aspects to injury control? (Ch. 40)

1. *Central cord syndrome* (hyperextenion) weakness in arms > legs often no fracture but have preexisting stinal stenosis painful hyperesthesias usually stable, but need early mobilization 2. *Cervical distraction and extension injuries* from forehead/face trauma 3. *Odontoid fractues*

What are the 3 most common C-spine injuries in the elderly? (Ch. 39)

I-II: Hyperemia and conjunctival eccymosis; some conjunctival haziness III-IV: Deeper penetration causing mydriasis, iris discoloration and cataract formation

What are the 4 categories of ocular chemical injuries(Ch. 64)

High risk vertebral signs and symptoms 1) Any cervical spine fracture 2) Unexplained neurological deficit incongruous with imaging 3) Basilar cranial fracture into carotid canal 4) Le Fort II or III fracture 5) Cervical haematoma 6) Horner syndrome 7) Cervical bruit 8) Ischaemic stroke 9) Head injury with Glasgow Coma Scale score<6 10) Hanging with anoxic injury

What are the Denver Criteria? (Ch. 43)

A. Cullen's sign B. Grey-Turner sign (think: 'turn' pt to the side to see 'Turner' sign) Both represent retroperitoneal bleed >12hrs old

What are the Grey-Turner and Cullen's signs? (Ch. 46)

Dorsally - Extensor pollicis longus Volarly - Extensor pollicis brevis and abductor pollicis longus Proximally - radial styloid Distally - approximate apex of the triangle (where Ext. Pol. Longus and Ext. Pol. Brevis/Abd. Pol. Longus meet) Floor - radial artery, scaphoid, trapezium

What are the anatomical borders of the "snuff box"? (Ch. 50)

Some Lovers Try Positions That They Can't Handle. (Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate)

What are the bones of the wrist? (Ch. 51)

- Multiple superficial incisions located on the anterior trunk, arms and face - Multiple superficial stab wounds located on the anterior trunk, arms and face - Parallel incisions, in close proximity to each other, on non dominant side of body - Sparing of sensitive body areas - Linear or curved incisions toward the hand inflicting the wound - Intact clothing covering the wound - Evidence of prior wounds

What are the characteristics of self inflicted knife wounds? (Ch 65)

Presentation: --diplopia with up-wards gaze (from inf rectus entrapment) --exophthalmos (from retrobulbar hematoma) --parasthesias/anaesthesia of medial cheek (stretched V2) On CT: --visible orbital floor fracture --orbital contents spilling into maxillary sinus

What are the clinical presentations and radiographic findings of an ORBITAL BLOWOUT fracture? (Ch. 42)

Management initially is cleaning with soap, water, and tetanus. Patients with symptoms should have lab work including: CBC, lytes, BUN, Creatinine, coags, UA, and ECG. Treatment include Diazepam for muscle spasms, parenteral analgesics for pain and admission for monitoring. Antivenin Lyovac - a horse serum derivative - In high risk scenarios only

What are the expected management goals for a black widow spider bite?(Ch. 55)

Grade 0: No evidence of envenomation, but suspected bite. No pain, less then one inch of surrounding edema. No systemic or lab changes Grade I (minimal). There is minimal envenomation, and snakebite is suspected. A fang wound is usually present. Pain is moderate or throbbing and localized to the fang wound,surrounded by 1 to 5 inches of edema and erythema. No evidence of systemic involvement. No laboratory changes occur. Grade II (moderate). There is moderate envenomation, more severe and widely distributed pain, edema spreading toward the trunk, and petechiae and ecchymoses limited to the area of edema. Nausea, vomiting, and a mild elevation in temperature are usually present. Grade III (severe). The envenomation is severe. The case may initially resemble a grade I or II envenomation, but the course is rapidly progressive. Within 12 hours, edema spreads up the extremity and may involve part of the trunk.Petechiae and ecchymoses may be generalized. Systemic manifestations may include tachycardia and hypotension.Laboratory abnormalities may include an elevated white blood cell count, creatinine, phosphokinase, prothrombin time,and partial thromboplastin time, as well as elevated fibrin degradation products and D-dimer. Decreased platelets and fibrinogen are common. Hematuria, myoglobinuria,increased bleeding time, and renal or hepatic abnormalities may also occur. Grade IV (very severe). The envenomation is very severe and is seen most frequently after the bite of a large rattlesnake. It is characterized by sudden pain, rapidly progressive swelling that may reach and involve the trunk within a few hours, ecchymoses, bleb formation, and necrosis. Systemic manifestations, often commencing within 15 minutes of the bite, usually include weakness, nausea, vomiting, vertigo, metallic taste in mouth, and numbness or tingling of the lips or face. Muscle fasciculations, painful muscular cramping, pallor, sweating, cold and clammy skin, rapid and weak pulse, incontinence, convulsions, and coma may also be observed. An intravenous bite may result in cardiopulmonary arrest soon after the bite.

What are the grades of pit viper envenomation(Ch. 55)

H - hematoma (expanding) A - arterial bleeding (pulsatile) R - bRuit or thRill D - Don't feel Distal pulse

What are the hard signs of peripheral vascular injury? (Ch. 48)

Circumferential chest or neck burns with: - Increased airway pressures Hypoxemia - Difficulty with ventilation Circumferential extremity burn with: - Decreased doppler signal distally - Pulse oximetry of less than 90% distally in the limb (one study) - Pain, loss of sensation, delayed cap refill (early signs)

What are the indications for an escharotomy(Ch. 63)

- Sharp/clear lines of demarcation(Dipping or immersion burns) - Irregular borders(Splash burns) - Round or oval shapes(Hot liquid or cigarettes)

What are the injury patters in thermal force injuries? (Ch 65)

- Name and address - Date and palce of birth - Social security number - ABO blood type and R factor - Type of injury - Date and time of treatment - Date and time of death - A description of distinguishing physical characteristics

What are the law enforcement exemptions to the HIPPA act? (Ch 65)

Lidocaine without epi: 3-5mg/kg (max 35 ml 1% in 70kg), with epi: 5-7 (max 49 ml 1% in 70 kg). Bupivicaine 2.5mg/kg without (25ml of 0.5% in 70kg) 3mg/kg with (max 42ml 0.5% in 70kg).

What are the maximum doses of two of the most commonly used local anaesthetics (lidocaine and Bupivicaine) (Ch 59):

- Upper extremities(41%) - Lower extremities(26%) - Head and neck(17%)

What are the most common affected parts of the body in burn injuries?(Ch. 63)

Liver >> Spleen >> Kidney *Also remember hollow viscus perforation

What are the most common intra-abdominal injuries in children? (Ch. 46)

Tibia, forearm, thigh, hands/feet

What are the most common sites of compartment syndrome? (Ch. 49)

Intubation - RSI unless suspicion of airway obstruction - If airway obstruction, awake intubation Mechanical ventilation - Avoid barotrauma - limit plateau pressure to 35 mmH2O - PEEP can be helpful Minimize Fi02, maintain Sp02 of >92% - Low tidal volume ventilation Adjuncts - Bronchodilators can be helpful in wheezing patients - Chest physiotherapy and airway suctioning for scretion management - Dont forget about concomitant CO and cyanide intoxication

What are the primary considerations in mechanical ventilation of burn patients?(Ch 63)

1. Upper airway obstruction 2. Inability to handle secretions 3. Hypoxemia despite 100% O2 4. Patient obtundation 5. Muscle fatigue suggested by high or low resp rate 6. Hypoventilation(PC)2>50, ph <7.2)

What are the six indications for intubating a burn patient?(Ch. 63)

Physical abuse Sexual abuse Emotional/ psychological abuse Neglect - Most common! Abandonment Financial or material exploitation

What are the six types of elder abuse? What is the most common? (Ch 69)

pallor/distal cyanosis soft pulses in comparison to other side superficial vein congestions poor temperature

What are the soft signs of peripheral vascular injury? (Ch. 48)

Dull crampy pain in the bite, with spread to the rest of the body over the next hour. The abdomen may become board like with minimal tenderness. Pregnant women may go into premature labor. Other symptoms include dizziness, restlessness, ptosis, N/V, pruritus, dyspnea, and well... just about anything! ECG may indicate dig toxicity like changes

What are the symptoms of a black widow spider bite? What might an ECG show?(Ch. 55)

The toxin causes local tissue damage and hemolysis, and system symptoms are primarily allergic. Pain usually develops over 3-4 hours with a white area of casocronstiction suorrounding a blebb. This bleb eventually undergoes necrosis, and may resemble a MRSA infection. System symptoms include hemolytic complications (thrombocytopenia, shock, jaundice, renal failure, hemorrhage) and pulmonary even, eventually culminating in DIC.

What are the symptoms of a brown recluse spider bite?(Ch. 55)

Ulnar nerve: finger abduction, MCP flexion (starfish hand sign) Median nerve: thumb opposition to index and little finger (A-OK sign) Radial nerve: wrist extension, thumb abduction (hitch-hiker thumb sign)

What are the three nerves of the hand and their associated motor functions? (Ch. 50)

1. Permanent cavity 2. Temporary cavity

What are the two types of cavities caused by bullet wounds? (Ch 65)

1. Irreversible coagulation and necrosis, formed immediately 2. Ischemia with impaired microcirculation 3. Transient hyperemia

What are the zones of burns?(Pathophysiology)(Ch. 63)

Woman with injuries to head face or neck (MC injury type) Female patient who has attempted suicide (90% of hospitalized suicide attempts in women report current severe IPV)

What are two concerning presentations for intimate partner violence? (Ch 68)

1. Confidentiality 2. Informed consent and autonomy

What are two ethical considerations in intimate partner violence (Ch 68)

1. Perthes disease AVN of the femoral head (more common in boys) 2. Slipped capital femoral epiphysis (SCFE) Peaks at 13.5 yrs (more common in boys!)

What are two rare hip conditions predominantly affecting young (2-14 year-old) males (Ch 56)?

Stalking and harassment Estrangement Access to firearms by perpetrator History of forced sex Physical abuse during pregnancy

What characteristics of intimate partner violence increase the risk of death(5) (Ch 68)

- Dry lime: Turns into strong alkali when exposed to water= bad - Elemental metal/ reactive metal compounds - Phenol: Use PEG instead!

What chemicals should you NOT irrigate with water?(Ch. 64)

Head Trauma: Traumatic axonal injury, Retinal hemorrhages(Dot, blot, shear and flame hemorrhages Skeletal injuries(Can have no scalp hematome or skull fractures!!) Abdominal injuries: Pancreatitis, liver and spleen lacerations, duodenal hematomas, viscus perforations

What cluster of injuries is seen in shaken baby syndrome?(Ch 66)

AVN The more proximal the scaphoid fracture the greater the risk of AVN

What condition can complicate scaphoid fractures that go undetected? (Ch. 51)

1. Not applicable in subacute and chronic injuries 2. Not validated in kids < 5-years-old. 3. Does NOT apply to hind or fore foot injuries. 4. Not reliable in patients with: Intoxication Distracting injuries Gross swelling that prevents palpation of bony tenderness Peripheral nerve damage

What conditions make the Ottawa Ankle Rule not valid? (Ch 58)

Rashes: Phytophotodermatitis, dermal melanocytosis, bullous impetigo(Looks like burn) Trauma: Unintentional burns, accidental fractures, Osteogenesis imperfecta Deficiencies: Rickets of prematurity, scurvy Infections: Congenitial syphilis/ rubella, encephalitis/meningitis/post hypoxis edema

What conditions may mimic child abuse(Rash, trauma, Infections, deficiencies) (Ch 66)

- Much less common(About 8%) - Increased risk amongst: Gay and bisexual men, veterans, inmates, MH treatment centers - Increase non genital trauma

What differences should be considered with male victims of sexual assault? (Ch 67)

Functioning RAS (in brainstem) and cerebral cortices.

What does one need to have consciousness? (Ch. 41)

Anterior talofibular ligament (ATFL)

What does the anterior drawer (of the ankle) test for? (Ch 58)

Anterior talofibular ligament (ATFL) and the Calcaneofibular ligament (CFL)

What does the inversion stress-test (also known as the talar tilt) test for? (Ch 58)

Has been shown to increase severity

What effect does mental illness have on sexual assault (Ch 67)

*Zone VI*- ER repair is reasonable as tendons do not retract significantly due to the synechia. *Zone V*- should be discussed with a hand surgeon - possible in ED but often complicated. R/O human bite. *Zone I/II*- only repair in ED if partial and no extensor lag *Zone I-IV*- otherwise need meticulous repair by hand surgeon.

What extensor zones of the hand are reasonable for ER repair? (Ch. 50)

More - Concomitant non genital trauma - Penile penetration - Sexual inexperience of victim - Post menopausal victim - Anal contact - Stranger assault - Sexual dysfunction in the perpetrator - Foreign objects - SAV use of alcohol - SAV is a college graduate Less - Increased time from assault to hospital presentation - menstrual bleeding at time of assault

What factors make genital injury in sexual assault more likely to be observed? Less likely? (Ch 67)

1) fracture over a vascular channel 2) a depressed fracture 3) a diastatic fracture-- one that crosses through/along suture lines. Leptomeningeal cysts (growing fractures) may develop (>2mm of separation) 4) fracture extending over the area of the medial meningeal artery (risk of epidural bleed) 5) rhinorrhea, otorrhea

What features of skull fractures in kids are associated with BAD outcomes? (Ch. 38)

Amox-Clav 875mg PO BID For penicillin allergies: TMP-SMX Moxifloxacin

What first line antibiotic is a good choice for cat and dog bites?(Ch. 54)

Femur, pelvis, tib-fib

What fractures can relate to significant blood loss if not recognized early? (Ch. 49)

X-ray (15% DON'T SHOW FRACTURE immediately after injury)... get scaphoid views CT scan 93% sensitive for occult fracture in acute setting. MRI 100% sensitive

What imaging do you do for scaphoid fracture w/u? (Ch. 51)

Atlantoaxial instability leading to subluxation or dislocation

What increased risk of cervical injury do Down's Syndrome and Rheumatoid arthritis patients both have? (Ch. 43)

1. Type of sexual assault 2. Sexual dysfunction history in suspect 3. Use of foreign body 4. Victim assistance with insertion of penis 5. History of victims sexual experience 6. Gravity/ parity 7. Mental health history 8. Substance use 9. Method of controlling the victim 10. Multiple assailants

What information can be useful in determining location and likelihood of injury in sexual assault (Ch 67)

Produced as heart swings in *massive pericardial effusion* - QRS axis changes from swing to swing

What is "electric alternans"? (Ch. 45)

Screening test for central slip injury (injury to the central tendon over the PIP - causing bouttoniere deformity) https://www.youtube.com/watch?v=G9HY0qXWUvE

What is Elson's test? (Ch. 50)

Vitreal extrusion or Positive fluorescein flowing with Aqueous Humor As Rosen's puts it: "identification of rivulets of fluorescein tracking from the puncture (i.e., positive Seidel test result)" = GLOBE RUPTURE

What is Seidel's sign? (Ch 60)

Interposition of soft tissues between bone and adductor aponeurosis preventing it from ever reattaching and healing Diagnosed with MRI or U/S

What is Stener's lesion? (Ch. 50)

A triad of injuries seen in pediatric ped-struck traumas: -femur injury -intra-abdominal or intrathoracic injury -head injury

What is Waddell's triad? (Ch. 46)

Loss of PICA circulation to the brain PICA supplied by vertebral artery. Results in ischemia to lateral medulla = swallowing difficulty, or dysphagia, slurred speech, ataxia, facial pain, vertigo, nystagmus, Horner's syndrome, diplopia, ataxia

What is Wallenburg's syndrome? (Ch. 43)

Inflammed bursitis tissue - usually arising from overuse or trauma to joint. Supportive care.

What is a bursitis? (Ch. 49)

Matching swelling and erythema on both volar and dorsal aspects of the hand suggesting *deep space hand infection*

What is a collar-button abscess? (Ch. 50)

Complicated minor traumatic brain injury, most commonly from collision sports. Leads to short-lived distortion of axons with neurotransmitters in an elevated/hypermetabolic state for WEEKS post-injury. This can cause secondary damage if not allowed to heal.

What is a concussion? (Ch. 41)

Tx: urgent ref. to hand surgeon

What is a jersey finger? Tx? (Ch. 50)

Luxation = loosening of or displacement of the tooth in the socket, without avulsion Management = repositioning + splint and dental referral

What is a luxed tooth? How are these managed? (Ch. 42)

Mallet finger: rupture of DIP extensor tendon (avulsion or direct tendon injury) Tx: maintain DIP in complete, uninterrupted extension for 6-8 weeks

What is a mallet finger? Tx? (Ch. 50)

Some residual flow through the vascular injury is preserved

What is a non-occlusive vascular trauma? (Ch. 48)

Fetal demise RARE with <10 rads (equivalent to 2 CT abdos) chest Xray = 5 milli-rads pelvis Xray = 200-2000 milli-rads (0.2-2 rads) CT head = 50 milli-rads CT abdomend = 3 rads CT pelvis = 3-9 rads**

What is a safe radiation dose in pregnancy? (Ch. 37)

A fracture of the distal humerus, proximal to the epicondyles

What is a supracondylar fracture in a child? (Ch. 52)

Fracture through the ridge of bone that forms the sockets for the teeth (the dental alveoli) Requires maxillofacial surgeon

What is an alveolar ridge fracture? (Ch. 42)

Total loss of perfusion distal to injury site

What is an occlusive vascular trauma? (Ch. 48)

Pain syndrome that develops after a noxious event and extends beyond a single peripheral nerve and is disproportionate to the inciting event

What is complex regional pain syndrome (CRPS)? (Ch. 49)

Since it is sandwiched between superficial and deep fascial layers, it's violation suggests deeper structures could also be damaged.

What is it important to know if the platysma muscle is damaged in neck trauma? (Ch. 44)

Clinical syndrome characterised by temporary loss of neurologic function and autonomic tone below lesion. Lasts 24 hours to 2 weeks, and is heralded by the return of the bulbocavernosus reflex.

What is spinal shock? (Ch. 43)

Type I - stable with coracoclavicular ligament intact Type II torn coracoclavicular ligament - often displaced Type III - involve articular surface

What is the Allman Classification for clavicle fractures? (Ch. 53)

Used to diagnose abnormal high/low riding patella (Bonus: Lateral knee x-ray with knee 30 deg. Flexed Patellar tendon length / patellar bone length Normal ratio 0.8 - 1.2 (0.74 - 1.5 in other sources) Patella Baja = < 0.8 Patella Alta = >1.2)

What is the Insall-Salvati Ratio used for (Ch 57): *Bonus points for knowing the measurement and ratio.

% TBSA is allocated as: 18% for front of trunk (9% torso, 9% abdomen) 18% for back of trunk (9% upper back, 9% lower back) 18% for an entire lower extremity 9% for the entire head 9% for each upper extremity 1% for the perineal area

What is the Rule of 9s?(Ch. 63)

Type I - not confined to one nerve distribution Type II - demonstrable peripheral nerve injury exists

What is the difference between type I and type II CRPS? (Ch. 49)

Based on mechanism of injury of pelvic fractures: Answer: APC, LC, VS, CM (Details: Anterior-Posterior Compression (APC) APC I: symphysis < 2.5cm (stable) APC II: symphysis > 2.5cm, SI disruption (partially stable) APC III: symphysis > 2.5cm, SI shearing (completely unstable) Lateral Compression (LC) LC I: ipsilateral sacral crush injury (stable) LC II: ipsilateral sacral crush injury, disruption of posterior SI ligaments, possibly iliac wing fracture (partially unstable) LC III: internal rotation of ipsilateral hemipelvis with external rotation of contraleral hemipelvis ('windswept pelvis') Vertical Shear (VS) Vertical displacement of sympysis and SI joints ALWAYS UNSTABLE Combined Mechanism (CM) ALWAYS UNSTABLE)

What is the four categories of pelvic fractures according to the Young-Burgess classification (Ch 55):

-often full thickness (saliva = poor impedence to current) -eschar separation after ~2wks --> labial artery hemorrhage -poor cosmetic outcomes

What is the importance of peri-oral electrical burns? (Ch. 42)

Average of 500ml

What is the minimal volume of intraperitoneal blood detectable on bedside U/S? (Ch. 46)

Pulmonary contusions (30-70% of cases)

What is the most common significant injury in blunt chest trauma? (Ch. 45)

Anterior lower leg compartment

What is the most common site of compartment syndrome? (Ch. 49)

two-point discrimination

What is the most sensitive physial exam for assessing fracture-related nerve injury? (Ch. 49)

Idiopathic Lower Back Pain (note: the cause of back pain remains unknown in 85% of patients after initial investigation).

What is the preferred term for lower back pain with no red flags on Hx or physical exam? (Ch 54)

25%

What is the prevalence of mental illness in sexual assault patients? (Ch 67)

ULTRASOUND (~97% acurate for detecting intrabdominal injuries in blunt trauma)

What is the primary screening investigation modality for major abdominal injury in pregnant patients? (Ch. 37)

1. JVD 2. Absent breath sounds unilaterally 3. Tachycardia

What is the tension pneumothorax clinical TRIAD? (Ch. 45)

- Copius water irrigation - Submerge eyes in running tap water In the ER - Continued tap water irrigation until morgan lens set up - Repeated application of tetracaine/ alcaine local anesthesitc

What is the treatment for ocular chemical injury?(Ch. 64)

Rare problem due to marked massive influx of blood to the head and neck due to sudden thoracic compression, causing retrograde blood flow from the right heart backwards into the SVC

What is traumatic asphyxia? (Ch. 45)

1. Remove victim from snake - bring snake with you if possible or take good pictures 2. Rapid transportation 3. Remove clothing or jewlery around the bite 4. Slow the spread of venom, calm the patient down, avoid movement of effected area(splint!), no alcohol! 5. Consider the monash method or immobilization and compression technique. Can use snuggly fitted band immediately after bite(<30 minutes) 6. Ice applied to the bite wound(Comfort) 7. Document the evolution of wound and limb edema Hospital ASAP!!!! Dont: Incise bitewounds, suck them, drink whiskey, clam juice, split chickens or electrocute them

What is your initial care for a snake bite out of hospital?(Ch. 55)

vitals, IV, normal saline running in, CBC, UA, Creatinine, BUN, CK, Fibrin, INR/PTT, Electrolytes, ECG, type and screen***; consider hepatic studies as well. Minimal constitutes observation for up 6-8 hours. Moderate envenomation requires 4 FabAV (4-6 for pit viper) over 60 min, and monitor for progression to severe. Severe requires 4 FabAV (8-12 for pit viper) over 60 minutes then a maintenance of 2 vials every 3 hours or 4-6 if progressing to very severe. Pit viper envenomation may require initial doses of up to 18 vials, with maintenance up to 10 vials every 6 hours. Dont forget about tetanus and gram negative antibiotice(High risk wounds and patients)

What is your intial care in hospital for snake bites?(Ch. 55)

Treatment is primarily supportive, but dapsone (an antibiotic known better for leprosy and PJP Pneumonia) 50-200mg/d can be consider for prevention of local effects if used within 48 hours. Analgesic are universally recommended. Signs of systemic envenomation require admission for observation. Antivenom is available in South America, but not commonly in North America.

What is your management for a brown recluse spider bite?(Ch. 55)

1. Posterior neural arch # UNSTABLE 2. Hangman's # UNSTABLE 3. Extension Teardrop UNSTABLE

What kind of cervical spinal injuries can you get from EXTENSION mechanisms? And are they stable/unstable? (Ch. 43)

Rotary atlanto-axial dislocation - UNSTABLE Unilateral facet dislocation - STABLE

What kind of cervical spinal injuries can you get from FLEXION/ROTATION forces? And are they stable/unstable? (Ch. 43)

Primarily odontoid fractures (Type I - III)

What kind of cervical spinal injuries can you get from SHEAR (A/P) forces? And are they stable/unstable? (Ch. 43)

1. Burst # STABLE -may impinge on ant. cord 2. Jefferson # UNSTABLE**

What kind of cervical spinal injuries can you get from VERTICAL COMPRESSION forces? And are they stable/unstable? (Ch. 43)

1. Atlanto-occipital or atlantoaxial joint dislocation (+/-odontoid #) UNSTABLE 2. Simple wedge injury STABLE provided post. column intact 3. Flexion Teardrop UNSTABLE - involveds ant/post. ligament disruption 4. Clay-Shoveler's # STABLE 5. Spinal sublux potentially UNSTABLE -depends on lig. 6. Bilateral facet dislocation UNSTABLE

What kind of cervical spinal injuries can you get from a FLEXION mechanism? And are they stable/unstable? (Ch. 43)

1. Victim consent 2. Evidence gathering(Chain of custody, powder free gloves!)

What precautions should be taken prior to engaging in a potential sexual abuse case? (Ch 67)

- Have you been hit, kicked, punched or otherwise hurt by someone within the past year? If yes, by whom? - Do you feel safe in your current relationship - Is there a partner from a previous relationship who is making you feel unsafe now?

What questions would you ask in a partner violence screen? (Ch 68)

- Have you ever been emotionally or physically abused by your partner or someone important to you? - Have you been hit, kicked, punched or otherwise hurt by someone within the past year? If yes, by whom? - Within the last year has anyone forced you to have sexual activities, if yes who? - Are you afraid of your partner or anyone mentioned above?

What questions would you ask in an abuse assessment screen? (Ch 68)

- Stalking and harassment - Estrangement (physical or legal separation) within a family unit - Access to firearms - History of forced sex - History of violence during pregnancy

What risk factors make domestic violence more common?(Ch 68)

0: Soot, seared skin, triangular tears 0-6: Soot, abrasion collar <48: Tattooing, abrasion collar Distant or ind: Abrasion collar

What signs do you see for the various ranges of fire of a bullet?(0, 0-6 inch, <48 inch, distant or indeterminate) (Ch 65)

Femoral head Talus Scaphoid Lunate Capitate

What sites are at highest risk of developing AVN post-fracture? (Ch. 49)

Dogs & Cats possum, rat, Lion, rabbit, pig, wolf, Monkey, Cougar

What species are known to cause infection with pasteurella multocida?(Ch. 54)

*Impingement on spinal cord* by foreign bodies, herniated disks, bony fracture fragments, or epidural hematomas

What spinal cord injuries warrant immediate surgical intervention? (Ch. 43)

-Involvement of deep structures (e.g. tarsal plate) -Avulsion or loss of tissue -Involvement of lid margin -Violation of any lacrimal apparatus (check by instilling fluoroscein in eye and assessing for uptake in the wound)

When should a specialist repair an eyelid lac? (Ch. 42)

1. Cat bites - all. (Staphylococcus, streptococcus and Pasturella multocida). Amox clav (875mg x 7d) 2. Dog bites - controversial. Guidelines say limit to hand, very dirty, older patients, deep puncture and immunocompromised. Amox clav x7d 3. Fight bites - human bites or assumed to the hand. First thoroughly look for tendon or joint damage. Streptococcus, staphylococcus, eikenella corrodens and bacteroides. Amox Clav , plastic surgery consultant opinion 4. Puncture wound of foot - no data supporting but should be considered especially in puncture through subber show (pseudomonas). Ciproflox for pseudomonas, keflex for staph/strep. ?MRSA Septra or Doxy 5. Delayed primary closure in high risk patient 6. Open fractures 7. High velocity missile wounds

When should antibiotic prophylaxis for a wound be considered (Ch 59):

Hard criteria for antivenin include: seizures, resp failure, uncontrolled HTN, pregnancy, and lack of response to prior therapies. Also consider if young, elderly or pregnant Dose is one vial in 50ml NS over 15 minutes. Allergic reactions are common.

When would you give black widow spider anti venom to a patient who has been bitten? What is the dose?(Ch. 55)

HIV PEP in high risk encounters only - Unknown assailant - Drug paraphenalia at scene

When would you give someone HIV PEP in sexual assaults (Ch 67)

Extra-pleural injury (from tracheobronchial tree) -air in anterior neck/supraclavicular Intra-pleural injury (break in the visceral/parietal pleura) -air in chest wall (over site of injury) Boerhaave's Syndrome -air in anterior neck/supraclavicular

Where can subcutaneous air be coming from? (Ch. 45)

Subclavian artery due to *air embolisms* going to brain

Which upper extremety artery injury is potentially most lethal? (Ch. 48)

Brachial and femoral arteries

Which vessel is most commonly injured in upper and lower extremety trauma? (Ch. 48)

penetrating injuries (esp near neurovasc bundle) animal bites fractures crush injuries/dislocations

Wounds at high-risk for vascular trauma based on mechanism? (Ch. 48)

1. Physiologic 2. Anatomic 3. Mechanistic 4. Logistical

4 main categories of indications for Trauma Team Activation: (Ch. 36)

L4-S1 (Know where these dermatomes run!)

95% of lumbar disk herniations occur at: (Ch 54)

-amputation proximal to elbow or knee -2 or more long bone #s -flail chest -tension pneumo or hemothorax -suspected spinal injury with deficit -suspected penetrating injury -unstable pelvis

ANATOMIC indications for trauma team activation: (Ch. 36)

Highly controversial - talk to your surgeon

Are steroid indicated for C-spinal injuries? (Ch. 43)

Yes.

Are tetanus shots safe for mom in prenancy? (Ch. 37)

Thoracotomy in... Blunt trauma with: 1. Signs of life on arrival to the ED (any 1 of): ● blood pressure ● pulse ● cardiac rhythm ● respiratory effort ● U/S ECHO showing cardiac activity or tamponade 2. Less than 10 mins of paramedic-based CPR ● can consider doing thoracotomy **Consider intubating, giving IV fluids, and needling both chests or bilateral finger thoracostomy

BLUNT chest trauma... Crack the chest or not? That is the question. How do you decide? (Ch. 36)

Ulnar nerve.: volar tip of little finger Median nerve: volar tip of index finger Radial nerve: dorsal first web space (between thumb and index finger)

Best places for sensory testing of hand nerves: (Ch. 50)

1. Wide mediastinum in 50-92% 2. obscured aortic knob 3. loss of PA window 4. Displaced NG tube 5. widened paratracheal stripe 6. depressed left main bronchus 7. left pleural effusion 8. left apical cap 9. left tracheal deviation

CXR findings for blunt aortic injury: (Ch. 45)

Yes. No harm to fetus shown with shocks up to 300J.

Can you safely electircally cardiovert a pregnant woman? (Ch. 37)

For all alert (GCS=15) and stable trauma patients where cervical spinal injury is a concern, the following can be applied:

Canadian C-Spine Rule: (Ch. 43)

Remember: this is for whether or not to image someone with a MINOR head injury (GCS 13-15) after witnessed LOC, amnesia, or confusion.

Canadian CT Head Rule: (Ch. 41)

Dense specifics - best to look up the shownotes, Ch. 50.

Carpal-metacarpal & MCP dislocation... describe management. (Ch. 50)

1. Sulcal effacement 2. Loss of gray-white differentiation 3. Ventricular compression

Cerebral edema on CT? 3 key points in identifying cerebral edema on CT: (Ch. 41)

Zone I: proximal ⅔ of the nail bed is preserved, no bony involvement Zone II: exposed bone Zone III: entire nailbed is lost

Classification for finger-tip amputations: (Ch. 50)

Beck's Triad: 1. JVD 2. Muffled heart sounds 3. hypotension

Clinical TRIAD for cardiac tamponade: (Ch. 45)

Presentation: Anterior chest pain - point tenderness (impact mechanism), swelling, bruising, deformity/step visible Management: analgesia, CT (to r/o mediastinal injury), d/c if otherwise well, surgery if severely displaced.

Clinical presentation and management of a sternal #: (Ch. 45)

1. **Fetal distress** 2. Painful, vaginal bleeding 3. abdominal cramping 4. uterine tenderness, contractions 5. Maternal shock

Clinical presentation of placental abruption (it is a clinical diagnosis): (Ch. 37)

-Rotator cuff of the shoulder -Achilles tendon -Radial aspect of the wrist (de Quervain's tenosynovitis), -Insertion of the hand extensors on the lateral humeral epicondyle (tennis elbow). -Patellar tendon -Biceps femoris, semitendinosus, and semimembranosus (hamstring syndrome); -Posterior tibial tendon (shin splint syndrome) -Iliotibial band -Common wrist extensors (medial epicondylitis) (little league pitchers and golfers)

Common Sites for Tendinitis: (Ch. 49)

-Seizures -CNS infection - meningitis, brain abscesses, osteomyelitis -DIC -Cardiac dysfunction

Complications arising after traumatic head injury? (Ch. 41)

1. premature labour 2. stillbirth (exponential rise in fetal mortality) 3. maternal coagulopathy (DIC)

Complications of placental abruption: (Ch. 37)

-no signs of life on scene and in the ED -CPR (despite signs of life initially) > 10 mins -system or department reasons

Contraindications to do thoracotomy in ED: (Ch. 36)

orbital tripod fracture = fracture of the zygoma, maxilla, and lateral orbital wall, creating a mobile bony segment that is often depressed, causing facial asymmetry Management: surgical and ophtho consultation

Decribe an orbital tripod fracture and its management: (Ch. 42)

3 or more ribs, fractured at 2 points leading to PARADOXICAL chest wall motion **one of the MOST SERIOUS chest wall injuries (8-36% mortality)**

Define "flail chest": (Ch. 45)

Judicial hanging: -usually distracts the head from the rest of the body due to the high fall, causing a fracture through the pedicles of C2 (hangman's), complete cord transection, and vascular disruption

Define "judicial hanging" and expected injury pattern: (Ch. 44)

Non-judicial hangings: -usually lead to venous stasis and congested blood flow → loss of consciousness and body relaxation When the person is limp the ligature / force can tighten further leading to complete arterial occlusion and brain death Vagal pressures on the carotid body may also produce fatal dysrhythmias ***Vascular occlusion leads to death, rather than airway occlusion in most cases!***

Define "nonjudicial hanging" and expected injury pattern: (Ch. 44)

Loss of vasomotor tone and lack of reflex tachycardia from disruption of autonomic ganglia. Only consider if: --Flaccid and areflexic --Reflex tachycardia and peripheral vasoconstriction absent --Exclusion of hemorrhage, tamponade, and tension pneumothorax

Define neurogenic shock (hypotension): (Ch. 43)

1. Medial epicondyle avulsion # (wrist flexors) 2. Compression # of the subchondral bone of radial head 3. and/or the capitellum (lateral condyle)

Describe 3 injuries common in little-leaguers elbow (Ch. 52)

1. Anterior cord syndrome --loss of pain/temp, preserved dorsal columns 2. Central cord syndrome --loss of motor function (legs relatively spared) 3. Brown-sequard lesion --ipsilateral dorsal column and motor loss, contralateral pain/temp loss

Describe 3 types of incomplete cord lesions: (Ch. 43)

1. 80-90% = Posteriorly - internally, flexed, adducted hip (knee rests on the opposite thigh) MVC (dashboard forces on the flexed abducted hip) 2. 10--15% = Anteriorly - externally rotated, abducted, slightly flexed hip (leg appears longer) Forceful extension, abduction, and external rotation of the femoral head MVC's or hyperextension during a fall May also be: Obturator dislocation - towards the obturator foramen Pubic dislocation - towards the pubis 3. 2-4% = central dislocation Femoral head is pushed through a decimated acetabulum 4. Luxatio erecta femoris

Describe 4 types of hip dislocation (Ch 56):

1. right-angle probe 2. ballooned catheter (Swanz is my favorite) 3. suction catheter (small) 4. alligator forceps / bayonet forceps 5. Irrigation

Describe 5 techniques for removal of FB from ear (Ch 60)

-Infection of the pulp of any digit, made worse due to the fibrous septa of the pulp. -S. aureus or gram negs Tx: I+D with a deep lateral incision posterior to digital artery and nerve ■Ulnar side of index, middle, ring fingers ■Radial side of thumb and little finger

Describe Felon and its Tx: (Ch. 50)

-Infection or abscess of lateral nail fold -Staph/strep Tx: If fluctuant or discharge, lift lateral nail fold with scalpel and drain + Abx. Risk of osteomyelitis.

Describe Paronychia and its Tx: (Ch. 50)

Glossy black color and bright red marking on the abdomen - either and hour glass or two red spots. These species frequently take cover in protected placed such as rocks, woodpiles, stables and... outhouses

Describe a black widow spider and where you might find one. (Ch. 55)

Assess the A-B-C-D-Es *A*dequacy of film - all 7 cervicl vert. + top of T1 *A*lignment - ant vert, ant spinal, post spinal, spin proc line *B*ones - vert. bodies, facets, spinouc processes *C*artilage - intervertebral space narrowing/widening *D*ens - dens itself, predental space *E*xtraaxial soft tissue - 6/2 rule (6mm at C2, 22mm at C6), distance btw spin proc's

Describe an approach to reading C-Spine X-rays: (Ch. 43)

-Transport to trauma centre -Basic wound compression and occlusion (to prevent air embolus) -If neurologic deficits → should prompt consideration for cervical collar

Describe basic approach to STABLE pts with acute neck trauma: (Ch. 44)

1. Airway - RSI; r/o hemo/pneumothorax if injury in zone 1 2. Vascular concerns - occlusive pressure and trendelenburg lowers risk of air embolus 3. Cervical spine immobilization if indicated 4. Thoracotomy if cardiac arrest - think venous air embolism 5. NG tube? - not usually if still awake 6. CT head/neck for virtually everyone 7. Consult surgery/ICU **If platysma injury --> admission

Describe basic approach to UNSTABLE pts with acute neck trauma: (Ch. 44)

ABC!!!! Analgesia Tetanus Leave blisters intact, debride ruptured blisters Dressings for partial-thickness burns Clearly infected, purulent wounds should be managed in an 'open' manner Topical antimicrobials (e.g. neomycin, mupirocin, silver sulfadiazine) Nonadherent dressing Daily dressing exchange and gentle cleansing with water and soap The second method for burn management is with occlusive dressings - Support a moist wound-healing environment - Less pain as dressings are not exchanged daily - Most appropriate for superficial partial-thickness burns with no signs of infection Dressing such as Mepilex or a nano-crystaline silver-containing occlusive dressing should be applied and left in place for approximately 1 week ***Avoid silver sulfadiazine if transferring patient to a burn center as it can alter the appearance of the burn

Describe basic burn dressing management. (Ch. 63)

First degree(Superficial): Limited to epidermis. Painful, erythematous, dry surfeace Second Degree(Superficial) - Papillary dermis - Painful, erythematous, blisters, blanches with pressure, moist surface Second Degree(Deep) - Reticular dermis - Painful, white or mild erythema, hemorrhagic blisters, minimal blanching, dry or moist surface Third degree - Full thickness - entire dermis - Stiff, white or tan color, dry, leathery and insensate Fourth degree - Involves muscle or bone - Stiff, charred skin

Describe depth classifications for burn injuries(Ch. 63)

HSV infection of the distal finger (Pain, pruritis, swelling of finger followed by clear vesicles) *Avoid* I+D - can result in viral dissemination and it can be hard to tell this apart from a felon or paronychia: careful history of risk factors is needed Can consider oral acyclovir, especially in recurrent infections or patients who are immunocompromised

Describe herpetic whitlow and Tx: (Ch. 50)

1. sedation and analgesia to relax mastication muscles 2. place thumbs in buccal sulcus bilaterally, and provide downward traction on the mandible while rotating the chin upwards and backwards

Describe how you would reduce a jaw? (Ch. 42)

Partner violence screen (Box 68-2) Have you been hit, kicked, punched or otherwise hurt by someone wthinin the past year? If yes, by whome? Do you feel safe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now?

Describe on tool for partner violence screening (Ch 68)

Pit midway between eyes and nostrils Elliptical pupil Tail structure of single rows of subcaudal plates, triangle head

Describe phenotypic characteristics of Pit-Vipers(aka rattle snakes)(Ch. 55)

Source: Fertilizer, some methamphetamine production Tx: irrigation of eyes, skin with water Secure airway if necessary with large bore tube

Describe potential sources of Anhydrous ammonia and how to manage an exposure(Ch. 64)

Sources: Glass etching, microelectronic production, rust remover, aluminum cleaner, cement and brick cleaner Management - Irrigation for 15-30 minutes - Blister removal - Local calcium gluconate gel - Calcium gluconate IV/Intraarterial or subq - Calcium gluconate infusion in hospital

Describe potential sources of Hydroflouric acid and how to manage exposure(Ch. 64)

Anterior triangle: -Contains neurovascular and aerodigestive tract structures Posterior triangle: -Fewer vital structures

Describe the "trangles" approach to neck anatomy: (Ch. 44)

Ellis I -enamel only, can have outpatient follow-up Ellis II -enamel and dentin visible (yellow substance of tooth), can have outpatient follow-up but can benefit from covering/protection of dentin Ellis III -enamel, dentin, and pulp visible (small red line or dot), need early referral to dentist or endodontist

Describe the Ellis classification for dental fractures: (Ch. 42)

Type I - traumatic tear (5%) Usually young patient with microtrauma in overhead sports Type II - Tears with dislocation Typicall anterior, assoiciated with future instability Type III - impingement tears (90%)

Describe the NEER classification for rotator cuff injuries (Ch. 53).

Courtesy of: http://www.mdcalc.com/nexus-chest-decision-instrument-blunt-chest-trauma/

Describe the Nexus CT chest rule" (Ch. 45)

(Easy mnemonic: Don't WAIT: 1 of 5 criteria: W Inability to bear weight (4 steps) both immediately and in ED A Age greater than or equal to 55 I Inability to Flex Knee to 90 degrees T Tenderness isolated to patella or head of fibula

Describe the Ottawa Knee Rule (Ch 57):

The straight leg raise: Sensitive for sciatica (91%) but poor specificity (26%) Method: Supine patient with legs extended. Symptomatic leg is passively raised (knee straight) Presence of radiating back pain past the knee in between 30-70 degrees suggests a L5-S1 radiculopathy If the leg elevation produces isolated low back pain without radiation it is negative

Describe the Straight-leg raise (SLR) and what it tests for (Ch 54):

Distinguishing features include a violin shaped darker area on the cephalothorax and three pairs of eyes instead of four Found in protected areas such as woodpiles and rocks. More common is south- central US, but report as far as the canadian border.

Describe the appearance of a brown recluse spider and where you might find them(Ch. 55)

Access -> stabilize -> control hemorrhage -> resuscitate with blood -> definitive treatment Ensure excellent IV or central access above the pelvis Consider early activation of massive transfusion protocol Typical to require 10 - 20 units of prbcs in first 24 hours Bind/stabilize pelvis with sheet or pelvis binder Consider requesting orthopedic external fixation of pelvis

Describe the approach and management of hemodynamically unstable pelvic fracture (Ch 55):

*Gustilo Classification*: I = clean wound, < 1cm, "bone-poked through" II = wound 1-10 cm length, no contamination/crush III = >10 cm laceration, with extensive soft tissue damage/contamination/crush (farm wound) III.A = soft tissue stripped III.B = periosteal stripping and bone damage III.C = severe vascular injury

Describe the classification system for open fractures: (Ch. 49)

- Slap marks with digits delineated - Looped or flat contusions(Belts or cords) - Circular contusions(Fingertip pressure) - Parallel contusions with central clearing from linear objects(Bat) - Contusions from shoe heels and soles - Semicircular contusions and abrasions from bite marks - Lacerations

Describe the commonly inflicted injury patterns in blunt force trauma, and what might cause these injuries (Ch 65)

First responder uses a scene survey approach Attempt to determine which substance(s) may be involved Don appropriate PPE (personal protective equipment) Safely remove the victim from the hostile environment ALL the victim's clothing should be removed and placed in plastic bags Dry agents should be brushed off; Wet agents should be sprayed off copiously Priority: eyes, mucous membranes, skin, hair Clean until a normal skin pH

Describe the decontamination of an individual who is exposed to a chemical agent(Ch. 64)

Acidic - Protein denaturation and coagulative necrosis - The necrosis forms an eschar which limits the depth of acid penetration - Free hydrogen ions are easily neutralized on the skin by copius water irrigation Alkali - Saponification and liquefactive necrosis of body fat - Produces soluble protein complexes which permit the passage of hydroxyl ions deep into the tissue - No eschar --> penetrates deeper into the tissue

Describe the difference between Alkali and Acid injuries(Ch. 64)

Tendonitis: inflammatory condition characterized by pain at tendinous insertions into bone, occurring in the setting of overuse Tendonosis: contentious name that describes more chronic conditions: eg. degenerative changes, chronic tendinopathy, partial rupture

Describe the difference between tendonitis and tendonosis: (Ch. 49)

-Measure tissue compartment pressure (serial) -When tissue pressure is within 30mmHg of MAP, -consider fasciotomy (STAT or within 12hrs) -Don't elevate limb -Manage rhabdo, hyperKa, lactic acidosis

Describe the management of compartment syndrome? (Ch. 49)

1) Non-pharmacologic -HOB @30deg -head midline -hyperventilate for temporary fix -avoid hyperthermia -keep euvolemic -craniotomy/burr holes if necessary 2) Pharmacologic -Mannitol (0.5 g/kg IV) -rapid osmotic diuresis -Hypertonic saline (0.1-1 mL/kg of 3% saline) -Pentobarbital/phenobarbital-lowers cerebral metabolism -Neuromuscular blockade -Sedation -Treat seizures aggressively

Describe the management of elevated ICP in kids: (Ch. 38)

-W/U with X-ray of chest and neck - r/o pneumomediastinum -Combo endoscope with contrast swallow - 100% sensitive -CT scan with contrast -Abx/NPO/NGT if not contraindicated

Describe the management of suspected pharyngoesophageal trauma" (Ch. 44)

-Can occur from blunt/penetrating/iatrogenic mechanisms -Problem vessels: carotid > subclav > vert a. > int/ext jug vein -Direct occlusive pressure over site -Trendelenburg -Left lat decubitus (so air rises to R atrium) -aspiration of air bubble from R atrium via U/S guided or direct (thoracotomy)

Describe the management of venous air embolism: (Ch. 44)

Cellular toxin - Inhibits oxidative phosphorylation - Cellular hypoxia and death - Leads to profound lactic acidosis, elevated mixed venous O2 saturation, shortened QT interval, normal pulse oximeter Antidote - Amyl nitrite: pearls are broken open and breathed for 30 seconds on 30 sec. Off - Sodium nitrite: 300 mg IV dose over 5 minutes - Sodium thiosulfate: 12.5 g IV dose Hydroxocobalamin 5g diluted in 200ml of 5% dextrose IV over 30 min

Describe the pathophysiology of cyanide poisoning and the antidote(Ch. 64)

1. Patient sedation / analgesia 2. Removal with single digit and abdo pressure 3. Anoscopy / Vaginal Speculum w/ Ring Forceps 4. Advancement of foley catheter past object with gas insufflation to "Break Vacuum" effect 5. Vacuum device 6. Surgery

Describe the stepwise management of a Rectal FB (Ch 60):

1. Mechanical debridement and vigorous irrigation 2. Valacyclovir 1g orally qh x 14 days or acyclovir 800mg po Q 5 times daily x 14 days(Highly virulent herpes simiae) 3. Amox-clav

Describe treatment of monkey bites(Ch. 54)

*Choking*: something inside your mouth/pharynx/trachea blocking air flow *Hanging*: various terms (i/e complete/incomplete ; typical/atypical) based on whether or not the victim's feet were totally suspended and the location of the knot *Strangulation*: may be either manual or ligature due to hands or a device compressing the neck independent from the weight of the patient

Difference between choking, hanging, and strangulation: (Ch. 44)

*Pulmonary Contusion*: Often unilateral, appears within minutes to 6hrs post-injury, lasts 24-48hrs *ARDS*: Diffuse and bilateral, slow onset, appears within 24-72hrs

Differentiate between pulmonary contusion and ARDS: (Ch. 45)

*Myocardial concussion*: "agitation of heart" result of direct blow to anterior chest. Result in non-perfusing rhythm, can be fatal (asystole or VF). *Contusion*: direct injury to cardiac muscle cells; hemorrhage and edema can lead to immediate ventricular dysfunction or delayed pericarditis / scar formation and possible spontaneous rupture. *Rupture*: acute traumatic perforation of atria or ventricles and their surrounding structures (intra-atrial or ventricular septum, chordae, valves, coronary arteries).

Differentiate myocardial concussion, contusion, and rupture: (Ch. 45)

-Watch for deterioration in first 48hrs! Serial neuro checks -Admit for close observation, even if CT head normal

ED management of *moderate TBI* (GCS 9-13): (Ch. 41)

*Airwary* (etomidate?) *Hypotension* (shock etiology? Keep SBP >90 mmHg) *Hyperventilate* (Goal PaCO2 in acute setting=30-35 mmHg) *Osmotic agents* (controversial) - mannitol/hypertonic saline *Cool the patient?* (weak evidence, maybe helps brain) *Steroids?* NO EVIDENCE *Seizure prophylaxis* - if indicated...benzos/barbituates *Antibiotic prophylaxis* - if open or depressed skull #

ED management of *severe TBI* (GCS <8 or intracranial contusion/hemorrhage on CT): (Ch. 41)

-reassurance -F/U if worsening sx

ED management of mild TBI (GCS 14-15, a clinical diagnosis): (Ch. 41)

FCR, FCU, PL

Fast Facts for Hands: What are the 3 wrist flexors? (Ch. 50)

Extensor pollicis longus

Fast Facts for Hands: What extends and hyper-extends the thumb? (Ch. 50)

Supportive care 20% mortality rate No therapy shown to benefit

Fat embolism syndrome after long bone fracture. What can be done? (Ch. 49)

Saddle anaesthesia Lower extremity weakness (bilateral) loss of anal sphincter tone incontinence of stool/retention of urine

Features of Cauda Equina? (Ch. 43)

1. Orbital (blowout most common, beware retrobulbar hematoma) 2. Midface fracture (Le Fort fractures, tripod fracture) 3. Mandibular fracture 4. Dental/alveolar --Ellis system for dental fractures --Alveolar ridge fracture 5. TMJ fractures

Five types of facial fractures: (Ch. 42)

1. C1-C3 # 2. Any vertebral body fracture 3. Transverse foramen fracture 4. Facet sub/dislocation 5. Ligamentous injury

For what C-spine injuries is CT-A indicated to rule out vascular injury? (Ch. 43)

1) pendulous urethra 2) bulbous urethra 3) membranous urethra 4) prostatic urethra

Four main parts of male urethra: (Ch. 47)

Elbow, ankle, foot, knee

Fracture blisters. Common sites of eruption? (Ch. 49)

Dense specifics - best to look up the shownotes, Ch. 50.

Gamekeeper's / Skiier's thumb... describe management. (Ch. 50)

Prepare your team, assign roles Listen to story, vitals en route, vitals now *Primary Survey* (w/ appropriate interventions) -Airway - patent? FBs? ventilating? (intubate?) -Breathing - WOB? trachea midline? chest sounds? subcut air? (chest tube?) -Circulation - deadly bleeding? monitor? IV? abdo pain? (fluids, blood, TXA, thoracotomy?) -Disability - GCS, pupils, power movement x4 (collar?) -Expose patient/Environmental (logroll, tx hypothermia?) *Secondary Survey* -head to toe assessment, log roll if not done yet, FAST -AMPLE hx, tetanus? *Investigations* -CT panscan vs CT focused, X-ray of focal injuries/pain (chest, limbs, pelvis). -trauma labs (include lactate, INR, fibrinogen, G&S, BHCG) *Drugs* -pain, nausea, pressor support, abx, fluids, steroids? *Disposition* -admit, transfer, discharge?

General approach to multi-trauma patients: (Ch. 36)

ATLS approach: Airway Breathing Circulation: control deadly bleeding Disability (GCS/Pupils/Gross Motor) Exposure ----- Secondary survey ; AMPLE hx ; Investigate ------ TIPS: Prepare your team! Control deadly bleeding - TQs, bind pelvis, scalp lacs, Decompress the chest Bind the pelvis

General approach to the multi-trauma patient? (Ch. 36)

Dense specifics - best to look up the shownotes, Ch. 50.

Grade III DIP/PIP ligament disruption + dislocation... describe management for each. (Ch. 50)

Bubbling of any neck wound Massive subcutaneous Air Bony crepitus Clothesline mechanism of injury

Hard signs of laryngeotracheal injury: (Ch. 44)

1. MCV 2. pedestrian struck by motor vehicle 3. shock-wave injury (bomb blast) 4. Ballistics or missle injury 5. CHILDREN (especially if NO rib fracture!!)

High risk populations for pulmonary contusions? (Ch. 45)

Good history and clinical suspicion BP/pulse palpation comparison between sides Examine for expanding hematomas and bruits ABI/API Hand-held Doppler Duplex Ultrasound CT with contrast enhancement

How are vascular injuries diagnosed in the ED? (Ch. 48)

Pseudosubluxation of the c-Spine at C2-3 is common in kids *Swischuk line*: spinolaminar line of C1-3, If the line crosses C2's anterior cortical margin by less than 2 mm, (and no cervical soft tissue swelling and no fracture is seen) the image demonstrates pseudosubluxation. If not... true sublux

How do you determine between true subluxation and pseudosubluxation at C2-3 in kids? (Ch. 38)

-tooth placed in saline or ToothSaver solution -rinse but DO NOT wipe (may damage tennuous ligaments) -reimplant tooth with firm pressure -secure tooth with splint -referral to dentist -66% viability if tooth replaced in <1hr

How do you manage an avulsed tooth? (Ch. 42)

1. Splint and elevate affected hand 2. Analgesia 3. Tetanus prophylaxis 4. Broad-spectrum antiobiotics 5. Avoid digital blocks (risk of iatrogenic compartment syndrome) 6. Emergent hand surgeon consult

How do you manage high pressure injection injuries to hand? (Ch. 50)

*API*: comparison of systolic BP (measured ideally with doppler) in the injured vs. uninjured limb. Think of the injured limb as the "top priority" so its value is the numerator (on "top") divided by the uninjured. Ratio <0.9 suggests badness.

How do you measure an arterial-pressure index (API)? (Ch. 48)

-warm saline compress -topical nitrates -IV nitrates -CCBs -alpha blockers -prostaglandins

How do you reverse arterial spasms in context of vascular trauma? (Ch. 48)

FDS - hold finger in extension at the MCP, patient should be able to flex PIP FDP - hold finger in extension at the PIP, patient should be able to flex DIP

How do you test for function of flexor digitorum superficialis and profundus? (Ch. 50)

Key: mother is main priority from the start Primary Survey: ABCT+UFO -Airway: secure and airway early, RSI -Breathing: Give O2! Goal PaCO2 30mmHg -Circulation: HR and BP not good predictors, uterine bleed? Avoid vasopressors! -Tilt the mom! -Uterus above umbilicus - fetus likely viable (>24wks) -FO-fetal tones Secondary Survery: -Detailed maternal /OB hx - weeks pregnant, GTPAL, vaginal bleeding? discharge? contractions? fetal movement? -Pelvic exam - signs of ferning? cervical dilation? GBS status? RH status? Bimanual exam for pelvic bone protrusion. -Fetal evaluation: FHR, movement

How does primary and secondary survey change in prenant trauma patients? (Ch. 37)

If abdominal contents herniating through, consider intubation for PPV to counteract lung parenchyma compression, and contact thoracics.

How is a diaphragmatic injury managed? (Ch. 45)

Most concern when > 12 weeks into pregnancy. ● Do Kleihauer-betke test for transplacental bleeding -Quantifies the amount of fetal-maternal hemorrhage (>5 mL) -8-30% incidence after trauma ●all Rh neg. mothers with any abd. trauma should receive RhIG within 72 hrs of the incident at a 300 mcg dose (protects against 30 ml of blood)** --Regardless of a negative KHB test!

How is feto-maternal hemorrhage diagnosed and managed? (Ch. 37)

Lund-Browder chart

How is the rule of 9s modified in pediatrics?(Ch. 63)

Limbs kept just above freezing to minimize metabolic demands can tolerate up to 24 hrs of ischemia!

How long does a cooled limb with occlusive vascular injury have until irreversible ischemia sets in? (Ch. 48)

-6hrs until at least 10% have complete muscle and nerve damage -12hrs until 90% have irreversible damage

How long does a warm (not actively cooled) limb with occlusive vascular injury have until irreversible ischemia sets in? (Ch. 48)

*PO2* - inverse - if oxygen content decreases, vasodilation and CBF increases *PCO2* - direct - if CO2 content decreases , vasoconstriction and CBF decreases *MAP* - direct - if systemic BP increases, CBF goes up *ICP* - inverse - if ICP increases, CBF declines.

In a healthy brain, describe how PO2, PCO2, MAP, and ICP all relate to the amount of blood getting to brain tissue (CBF): (Ch. 41)

1. Hypotension (SBP <90 mmHg) 2. Hypoxia (PaO2 <60 mmHg) 3. Anemia 4. Hyperthermia (>38.5 deg) 5. Hypercarbia 6. Coagulopathy 7. Seizures

In head injuries, what are the secondary systemic insults we want to desperately avoid to prevent further neurologic damage? (Ch. 41)

1. hx of urethral trauma (straddle injury) 2. scrotal or penile hematoma 3. blood at urinary meatus 4. high risk of pelvic fracture

In what 4 situations should you do a retrograde urethrogram (RUG) before foley insertion? (Ch. 47)

1. Severe head injury (GCS <9) 2. Moderate head injury (GCS 9-12) who cannot be monitored with serial neurological exam

Indications for ICP monitoring (2 of them)? (Ch. 41)

-Bite wounds -Evidence of devascularization -Damage through the buccal mucosa -Involvement of cartilage of ear or nose -Highly contaminated wounds

Indications for antibiotics in patient with facial trauma: (Ch. 42)

-Must start within 4 min of maternal cardiac arrest -Present fetal heart tones -Greater than 24 wks gestation

Indications for post-mortem C-Section: (Ch. 37)

1. Involvement of motor branch of nerve 2. Digital nerve injuries proximal to DIP 3. Clean single nerve lacerations

Indications for repair of nerve injuries in hands: (Ch. 50)

Mom should receive Rhogam (RhIG) within 72 hrs of incident at a 300mcg dose.

Key consideration for RH negative moms following any abdominal trauma: (Ch. 37)

-They are rare -Higher cord injuries are more common than lower cord -SCIWORA (Spinal Cord Injury without Radiography Abnormality) -found in 25-50% of spinal injuries

Key considerations with spinal injury in pediatric trauma: (Ch. 38)

1. X-ray is part of the physical exam for hands. 2. Shaft fractures cannot tolerate any rotation. 3. Fractures of the head or bases are complicated! Consult.

Key points for management of phalangeal and metacarpal fractures: (Ch. 50)

-whenever the emergency physician needs more help or resources

LOGISTICAL indications for trauma team activation: (Ch. 36)

Absolute CI: -Need for laparotomy Relative CI: -Prior abdominal sx or infections -Coagulopathy -Obesity -2nd or 3rd trimester of pregnancy

List 1 absolute contraindication and 4 relative contraindications to DPL: (Ch. 46)

1. Referred pain - lumbar/spine/knee Diskitis Lumbar disk herniation Knee pathology 2. Hip bone pathology AVN of the femoral head Perthes disease / SCFE Occult fracture Bone tumour Osteoarthritis Transient synovitis / septic joint / osteomyelitis 3. Hip soft tissue pathology Bursitis Iliopsoas abscess DVT Arterial insufficiency 4. Abdominal pathology Inguinal hernia Retroperitoneal pathology PID Nephrolithiasis 5. GU pathology UTI Testicular torsion External genitalia abnormalities 6. Sports med stuff Sports hernia FAI Labral injury Osteitis pubis

List 10 common causes of hip pain without an obvious fracture (Ch 56):

1. higher fulcrum C2-3 (higher c spine injuries) 2. larger head size- greater flexion and extension injuries 3. smaller neck muscle mass 4. increase interspinous lig. flexibility 5. flatter facet joints 6. incomplete ossification at multiple bony sites 7. anterior surfaces of the vertebral bodies are more wedge shaped 8. Epiphytes of spinous processes tips mimic fractures 9. Narrow preodontoid space 10. Pseudosubluxation of C2-3 seen on 40% of kids 8-12 yrs 11. Pre-vertebral space varies with respiration *whew*

List 11 anatomical differences that distinguish peds spines from adult ones: (Ch. 38)

Urologic More common in men, anterior pelvic fractures Check for blood at the meatus Retrograde urethrogram to check for urethral injury Don't forget bladder can be injured as well. Neurologic Worse with worsening instability (Tile A < B < C) Worse with more medial vertical sacral fractures (Denis I < II < III) Cauda equina possible Gynecologic Can have open pelvic fracture into vagina Look for blood at introitus Careful manual examination Gastrointestinal Open pelvic fracture into GI tract High risk of infection Careful digital internal examination

List 3 categories of complications of pelvic fractures (Ch 55):

Bites Generally from cephalopods such as octopi. The octopus has a pair of modified salivary glands that secrete venom from its beak. The blue ringed octopus in particular has reported fatalities from its venomous neuromuscular inhibitor and vasodilator. Treatment is fully supportive, as no anti-venin exists Nematocysts NEmatocysts are, in essence, spring-loaded' venom glands that passively discharge on mechanical or chemical stimulation. They are found in animals known as cnidaria, which include jelly fish, man-of-war, hydraods, box jellyfish, nettles and anemones. They are unique in that they can function even when the animal is dead or limb has been severed. The Toxin is primarily antigenic, and allergic reactions are common. Severity is related to number of nematocysts, species, and the patient's auto pharmacologic response. Death is usually from cardiopulmonary collapse, although death from drowning is more common. Management includes removal from water, treatment of allergic reaction, removing nematocysts, and pouring ideally hot vinegar over affected area. Immersion in fresh water may increase nematocyst firing and is not recommended. Stings Sea animal that sting include sea urchins, cone shells, stingrays, sea snakes, stone fish and many others. Irrespective of which creature causes the sting, although some are worse than others, namely the cone shell and stingray, care is supportive, inducing removing sting apparatus, tetanus, antibiotics (cipro is a good choice) and good cardiopulmonary care.

List 3 classes of venomous marine injuries, and describe key principles of management for each?(Ch. 55)

1. Brachial artery injury 2. Compartment syndrome 3. Loss of the normal carrying angle. 4. Injury to nerves 5. Stiffness

List 3 complications of supracondylar fractures (Ch. 52)

1. Perianal sensation intact 2. Rectal motor function 3. Great toe flexor activity

List 3 features of sacral sparing: (Ch. 43)

1. Hyperventilate 2. Diuretics or osmotic agents 3. CSF drainage

List 3 general ways to decrease ICP: (Ch. 41)

-proximal medial tibia -proximal humerus -anterior distal femur

List 3 ideal IO sites in kids: (Ch. 38)

1. Allis Technique 2. Stimson's Technique 3. Whistler Method 4. Rochester Method 5. Traction counter-traction Method 6. And many others (See: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821229/ for an exceptional list of 12 different techniques with figures)

List 3 reduction techniques for posterior dislocations (Ch 56):

1. Transection 2. Thrombosis 3. Reversible arterial spasm (esp in kids)

List 3 types of occlusive vascular trauma? (Ch. 48)

1. True anteroposterior or '45-degree lateral' 2. Transscapular lateral or 'Y-view' 3. Axillary lateral views

List 3 views of the shoulder (Ch. 53)

1. Force more widely distributed through a child's more fragile frame = more injuries to bone, viscera, spinal cord 2. Kids have larger BSA = lose heat faster 3. Higher metabolism = greater proportional demand for fluids, lytes, O2, and glucose 4. Capacity to maintain BP despite 30-40% blood loss -SERIAL vitals and basically no role for inotropy

List 4 anatomic/physiologic differences between kids and adults in relation to trauma management: (Ch. 38)

1. Compartment syndrome (highest risk at 24-48 hrs) 2. Infection - shallow easily exposed bone (look for subtle open #!) 3. Nerve injury - "foot off the brake, to the right, and on the gas" 4. DVT, pseudoaneurysm 5. Fat embolism 6. Delayed healing - average union times is 20-30 weeks 7. Malrotation 8. CRPS

List 4 complications of tibial shaft fractures (Ch 57):

Attentive listening Conveyance of compassion and concern Nonjudgmental Respect patient's right to autonomy in decision making BONUS: Educational material around ED Note: Gender of DR does not appear to be factor in disclosure.

List 4 features of physician behaviours that encourage disclosure of intimate partner violence (Ch 68)

1. *Increased compartment contents*: Bleeding, reperfusion after ischemia, trauma, exercise, burns, DVT 2. *Decreased compartment volume*: closure of fascia, excessive traction of # 3. *External pressure*: Casts, air splints, dressings, Lying on a limb 4. *Miscellaneous*: Muscle hypertrophy, popliteal cysts, leaky cannulae, interstitial infusions/pressure infusions

List 4 general mechanisms that causes compartment syndrome: (Ch. 49)

- Endoscopy -Contrast filled balloon catheter and fluoroscopy -Bougienage (pushing object into stomach) -Expectant Management

List 4 removal techniques of esophageal FB (Ch 60)

Alcoholic liver disease Fungating or surgical asplenia Lung disease Corticosteroid use

List 4 risk factors for overwhelming sepsis from a dog bite(Ch. 54)

*Kanavel's Signs:* 1. Tenderness along course of the flexor tendon 2. Symmetrical swelling of the finger (sausage finger or fusiform swelling) 3. Pain on passive extension 4. Semi-flexed posture of the finger

List 4 signs of flexor tenosynovitis: (Ch. 50)

1. Intimal flap/dissection 2. Compartment syndrome 3. AV fistula 4. Pseudoaneurysm* (tear in adventitia) *true aneurysm involves all 3 layers of vessel

List 4 types of non-occlusive vascular trauma? (Ch. 48)

1. Supine hypotensive syndrome (of pregnancy) 2. Physiologic alterations: incr blood vol. may mask shock, incr cardiac output by 40% --> incr bleeding, less venous return --> incr. blooding from leg wounds) 3. Pulmonary considerations: decr. FRC, incr O2 consumption, incrased ventilation leads to hypoCO2, difficult BVM --> so be quick to tube 4. GI considerations: reduced sphincter tone leads to incr. apiration risk, incr acid production --> early decompression

List 4 unique considerations in the management of pregnant trauma patient: (Ch. 37)

1. Uncal herniation 2. Central transtentorial herniation 3. Upward transtentorial herniation 4. Downward cerebellar-tonsillar herniation 5. Cingulate-subfalcine herniation

List 5 brain herniation syndromes: (Ch. 41)

Flame burn prevention - Secure matches and lighters where they are inaccessible to children - Safety device around fireplace - Create home escape plan and practice with family - Check that smoke detectors are functional Scald prevention - Use splash guards on stove - Use thermometer on bathwater - Lower hot water heater maximum temperature to 49-54 C

List 5 burn prevention strategies. (Ch. 63)

Colubridae - Boomslang and bird snake Elapidae: Cobras, kraits, mambas and coral snakes Viperidae: True vipers Crotalidae: Pit vipers(Rattle snakes, copper heads, water moccasins, pygmy rattlesnakes) Atractaspididae: Mole vipers

List 5 classes of venomous snakes(Ch. 55)

1. scalp lacerations 2. extremity fractures 3. urethral injuries 4. posterior injuries 5. Injuries in axilla, groin, or buttocks

List 5 commonly missed traumatic injuries: (Ch. 36)

1. Long bone fracture in a preambulatory infant 2. Metaphyseal fractures 3. Rib fractures 4. Scapula fractures 5. Spinous Process fractures(Skull, multiple, wide >3cm, growing, involving more then one cranial bone, occipital)

List 5 high risk fractures for child abuse (Ch 66)

Age < 18, > 50 yrs. Hx of malignancy (of any type!) or B-symptoms (weight loss, fevers, night sweats) Hx of fever, IVDU, immunocompromised Recent trauma Progressive neurologic deficits or cauda equina syndrome Duration > 4-6 weeks

List 5 indications for an Xray in lower back pain (Ch 54):

1. Delayed Thrombosis (e.g post operative anastomoses or shunt placement) 2. Intermittent claudication 3. Chronic pain (nerve compression / ischemia) 4. Edema (venous compression / elevated compartment pressure) 5. Aneurysm / Pseudoaneurysm formation

List 5 late complications of vascular injuries: (Ch. 48)

-cognitive impariment -vision/hearing loss -impaired thirst mechanism - dehydration - orthostatic drops -reduced respiratory reserve -cardiac disease - poor CO, arrythmias -arthritis/osteophytes - poor mobility -loss of fine motor skills -decreased balance -drugs/polypharmacy

List 5 or more risk factors for FALLS in the elderly: (Ch. 39)

1. Long bone fracture 2. Open-book pelvis fracture 3. Neurovascular compromise (AVN, compartment syndrome, vascular injury, etc) 4. Open fractures 5. Fractures involving joints

List 5 orthopedic emergencies (ORTHO consult!): (Ch. 49)

Aerobic bugs: Staphylococcus aureus, alpha- hemolytic and beta-hemolytic streptococci, Klebsiella, Bacillus subtilis, Pseudomonas, Enterobacteriaceae, and Capnocytophaga canimorsus Anaerobic bugs: Bacteroides, Fusobacterium, Peptostreptococcus, Porphyromonas, and Prevotella species

List 5 pathogens responsible for infection from a dog bite(Ch. 54)

No history of suspicion of IPV Prior history but no current exposure(Add history of PIv to medical record) Recent or current abuse but no injuries and no elements of danger on assessment (Add IPV to problem list and give educational materials) Current abuse with injuries on findings on danger assessment(Complete history, involve third parties as required (police, social services, IPV advocate)) Suspicion but denies IPV (Consider involving SS or IPV advocate and give educational materials)

List 5 patient types of intimate partner violence exposure and corresponding appropriate interventions (Ch 68)

1. MS 2. Encephalitis 3. Tumours 4. Lateral Medullary syndrome (Wallenburg's) 5. Thyroid mass or removal (iatrogenic) 6. Trauma to base of neck 7. Pancoast tumour 8. Thoracic aneurysm 9. Sympathectomy

List 6 causes of Horner's Syndrome: (Ch. 43)

1) Flank/pelvic/genital pain (esp with pelvis #) 2) Urinary retention 3) Penile or scrotal ecchymosis 4) Gross hematuria 5) Blood at urethral meatus 6) High-riding prostate (ever seen it? nope)

List 6 clinical signs that would point to genitourinary trauma: (Ch. 47)

Below 45kg 1. Gonorrhea: Ceftriaxone 125mg IM, Cefixime 8mg/kg *One dose 2. Chlymadia: Erythromycin base 50mg/kg/day QID x 14 days 3. Trichomoniasis: Metronidazole 15mg/kg/day PO divided TID x 7 days 4. Syphilis: Benzathine penicillin 50,000 units/kg IM One dose max 2.4 million units 5. HSV: Acyclovir 80mg/kg/day divided tid x 7-10 days 6. Heptatitis B HBIG 0.06mL/kg IM, vaccine 7. HIV: Contact local infectious disease Above 45kg 1. Gonorrhea: Ceftriaxone 250mg IM, or cefixime 400mg po *One dose 2. Chlamydia: If older then 8: Azithromycin 1g po once or doxycycline 100mg po bid x 7 days 3. Bacterial vaginosis: metronidazole 500mg po bid, metronidazole 0.75% 5g intravaginally daily x 5 days or clindamycin cream 2% 5g intravaginally qhs x 7 days 4. Trichomoniasis: Metronidazole 2g po * one dose 5. Syphilis: Benzathine penicillin 2.4 million units *one dose 6. HSV: Acyclovir 400mg po tid x 7-10 days, valacyclovir 1g po bid x 7-10 days 7. Hepatitis b: Same as above 8. HIV: Same as above

List 6 diseases that may require prophylaxis in child sexual abuse and the drugs with dosage that you would use above and below 45kg? (Ch 66)

1. hemodynamic instability despite aggressive resuscitation free fluid on FAST and instability 2. massive bleeding (intraperitoneal) 3. pneumoperitoneum / intraperitoneal bladder rupture / grade V renovascular injury 4. gunshot wound 5. evisceration 6. peritonitis

List 6 indications for laparotomy in peds trauma: (Ch. 38)

1. Depressed skull # 2. paralyzed/intubated pt. 3. Any seizure at any time (or hx of same) 4. PENETRATING brain injury 5. Any brain bleed (epidural, SDH, ICH) 6. Severe head injury: GCS <8

List 6 indications for starting seizure prophylaxis in traumatic head injury patients: (Ch. 41)

1. Patello-femoral pain syndrome 2. Iliotibial band syndrome 3. Peripatellar Tendinitis 4. Plica syndrome (redundant folds of synovium) 5. Popliteus tendinitis 6. Bursitis

List 6 overuse syndromes of the knee and lower leg (Ch 57):

Hoarse voice Dysphagia or odynophagia Difficulty breathing LOC Incontinence Confusion Chronic concussive symptoms (from "shaken adult syndrome")

List 6 physical exam findings of strangulation (Ch 68)

1. Deep, burning, unrelenting, difficult to localize pain 2. Increasing need for analgesics 3. Pain on passive stretching of muscle 4. Pain with active flexion of muscle 5. Hypoesthesias or paresthesias in the distribution of nerves crossing the compartment 6. Tenderness / tenseness of the compartment *NOTE: the 5 P's (pulseless, pallor, poikilothermic, etc) relate to acute disruption of arterial flow and are NOT reliable indicators of compartment syndrome

List 6 physical findings in compartment syndrome: (Ch. 49)

Note: Most due to running: Risk factors: new footwear, change in running surface, overuse/overtraining, female athlete triad/relative energy deficit syndrome, steroid use, vitamin / mineral deficiency, cavus feet

List 6 predisposing conditions for stress fractures (Ch 58)

In infants: 1) full fontanel 2) split sutures 3) altered state of consciousness 4) paradoxical irritability 5) persistent emesis 6) setting sun sign

List 6 signs of elevated ICP in infants (0-1 yrs): (Ch. 38)

1. Hypoxia 2. Hypoglycemia 3. Hypotension 4. Post-seizure 5. Post-intoxicating drugs 6. Brain/brainstem compression from mass effect 7. Bleed

List 7 causes of altered LOC in the trauma patient: (Ch. 41)

1. Witnesses or self reported history of ingestion (eg coin / food / toys / bones / batteries / wood / glass) 2. Atypical chest pain / neck pain 3. FB sensation 4. odynophagia / dysphagia 5. drooling 6. retching / vomiting 7. Anorexia, 8. wheezing

List 7 symptoms of Esophageal FB (Ch 60):

Aortic dissection Pneumonia Myocardial infarction PE Ruptured esophagus Pancreatitis Thoracic disc herniation Usually not diagnosed until 20 months after the first clinical presentation! Tumour / hematoma with nerve impingement Disk infection Pyelonephritis

List 8 Ddx for Thoracic Back Pain (Ch 54):

1. Injury > 8-12 hours old 2. Locations with poor blood supply ( Leg and thigh > arms > feet > chest > back > face > scalp) 3. Contaminated wound 4. Blunt mechanism 5. SubQ sutures 6. Repair material (sutures > staples > tape) 7. Anaesthesia with epi (really?) 8. High-velocity Missile injuries

List 8 risk factors for a wound infection (Ch 59):

"Jumping Off Awnings Nearly Warrants Frank Spinal Trauma" 1. Jefferson 2. Odontoid 3. Atlantoaxial dislocation 4. Neural arch (posterior) 5. Wedge 6. Facet dislocation (large/bilateral) 7. Subluxation 8. Teardrop

List 8 unstable cervical neck fractures: (Ch. 43)

In children: 1) headache 2) stiff neck 3) photophobia 4) altered mental status 5) persistent emesis 6) cranial nerve involvement 7) papilledema 8) hypertension, bradycardia, hypoventilation 9) decorticate and decerebrate posturing

List 9 signs of elevated ICP in children: (Ch. 38)

- Soot in and around nose/mouth - Charring - Mucosal inflammation or necrosis - Edema

List Indicators of upper airway burns(Ch. 63)

Parkland formula: RL 4cc/kg/%TBSA burned - Half of the fluids in first 8 hours, remainder in next 16. Over next 24 hours 20-60% of patient plasma volume, titrating to maintain urine outpt at 0.5-1cc/kg/hr(1 in kids) Galveston formula - Preferred for peds - RL at 5000 cc/m2 TBSA burned + 2000 cc/M2 BSA - Half fluid in first 8, remainder in next 16

List and describe 2 formulas for fluid rescucitation(Ch. 63)

1. Stimson / hanging weight 2. Traction-contertraction 3. Snowbird 4. External rotation method of leidelmeyer 5. Milch 6. Scapular manipulation 7. (Bonus): Hippocratic method

List at least 3 of 7 techniques for reduction of an anterior shoulder dislocation (Ch. 53):

Avulsion of L5 transverse process Avulsion of ischial spine Avulsion of lower lateral lip of the sacrum Displacement at the site of a pubic ramus fracture Asymmetry or lack of definition of bony cortex at the superior aspect of the sacral foramina

List at least 3 of the 5 radiographic cues to posterior arch fractures (Ch 55):

Atraumatic: Chronic corticosteroid use Chronic ETOH abuse Sickle cell anemia Dysbarism Chronic pancreatitis HIV Traumatic: Post-hip dislocation 5% if reduced in 6 hrs, 50% if reduced in 12 hrs Post-femoral neck fracture Athlete with an energy deficit or overtraining

List at least 5 causes of AVN (traumatic and atraumatic) (Ch. 56):

"HARD SIGNS" -very high likelihood of vascular injury

List at least 6 hard and 6 soft signs of penetrating neck trauma: (Ch. 44)

Large burns (> 20% TBSA burned in adults, > 10% TBSA burned in children or elderly) Deep burns (> 5% full-thickness) High-voltage burns Burns over sensitive areas (e.g. face, ears, joints, perineum, hands, feet) Escharotomy required

List criteria for transfer to burn unit.(Ch. 63)

1. Fracture (particularly with trauma or trauma hx). 2. Cauda Equina Syndrome (sudden compression of multiple lumbar or sacral nerve roots, note urinary retention 99.99% specific to rule-out) 3. Spinal infection (Spinal epidural abscess or osteomyelitis of the vertebral bodies - usually Staph. Aureus) 4. Malignancy

List four red-flag diagnosis associated with lower back pain (Ch 54):

-Button battery -Magnet -Sharp Object -Displaced esophageal stent -Duration is place > 24 hours

List indications for removal of esophageal FBs (Ch 60):

- Wheezing - Crepitations - Hypoxemia - Abnormalities on CXR - VQ mismatch, decreased lung compliance, microatelectasis --> ARDS

List indicators of lower airway burns(Ch. 63)

Eye: free air Ears: erosion / infection of the mastoids Nose: chronic erosive sinositis Neck: prevertebral swelling or soft tissue emphysema (cervical spondydisktis) Lungs: - Pulmonary Gas trapping (flat & fixed diaphragm on insp vs exp, shift of mediastinum away from affected side during exp) Narrowing of subglottic space Atelectasis Bronchiectasis and bronchial stenosis (late)

List indirect signs of a foreign body on Xray: (Ch 60)

Pancreas** Diaphragm Small bowel Mesentery

List intra-abdominal sites of injury that may be missed on CT: (Ch. 46)

*Lap belt use:* -small bowel injury/hematoma -pancreatitis -chance fractures *Bike handlebar injuries:* -duodenal hematoma -pancreatic transection/trauma *Sports related:* -spleen, kidney, intestinal tract

List pediatric-specific cardiovascular and abdominal injury patterns associated with classic mechanisms of trauma: (Ch. 38)

1. Clear missile path through abdomen - (in/out wounds) 2. Bowels/organs visualized on Local Wound Exploration 3. "End" of the wound tract not visualized on LWE 4. X-ray showing retained foreign body or free air 5. Laparoscopy showing diaphragm injury 6. CT showing peritoneal violation

List six ways to determine if peritoneum has been violated in penetrating trauma: (Ch. 46)

*Acute*: hemorrhage, vascular/nerve injury, compartment syndrome, fat embolism, #blisters, *Delayed*: AVN, osteomyelitis, CRPS, immobilization illnesses

List some acute and delayed complications of fractures: (Ch. 49)

*S*-Skin *C*-Connective Tissue *A*-Aponeurosis *L*-Loose Connective Tissue *P*-Periosteum Caput succedaneum: -hematoma, freely mobile and crosses suture lines Cephalohematoma -blood UNDER periosteum = does NOT cross suture lines -scalp bleeding can be profuse and lead to shock in infants Cerebral contusions -clearly seen on CT as a brain parenchymal injury -neuro features with altered MS

List the 5 layers of the scalp and describe 3 types of extra cranial bleeding in pediatrics: (Ch. 38)

Breast Kidney Lung Thyroid Prostate

List the 5 most common cancers metastatic to bone (Ch 56):

1. Coagulation (immediate) 2. Inflammation (immediate - 48 hours) 3. Collagen metabolism (>48 hours, peaks 7d, greatest mass 3wks) 4. Wound contraction 5. Epithelialization (48 hours - days) Epithelial Cell migrate across wound, soon resembling uninjured skin

List the 5 stages of wound healing (Ch 59):

Chemical-resistant clothing with a hood Boots Eyewear Two layers of gloves Respiratory mask

List the PPE for first responders or caregivers in chemical exposure injury(Ch. 64)

-Damage to Ear canal -Otitis Externa -TM Perforation -Expansion of vegetable / porous material with irrigation Critical Complications: -Eustachian tube dysfunction -para-pharyngeal abscess -mastoiditis with progression to fatal brain abscess and meningitis.

List the complications of an ear foreign body (Ch 60)

1. Laterally = biceps femoris tendon 2. Medial = semimembranosus and semitendinosus tendons 3. Superiorly = above muscle bellies 4. Inferiorly = two heads of the gastrocnemius muscles Interiorly = popliteal artery + vein, peroneal and tibial nerves

List the components of the popliteal fossa (Ch 57):

Borderline or dysphoric individual Antisocial of generally violent individual Non violent outside home with no psychopathology. Often evidence of passive dependency or OCPD

List the three typologies of intimate partner violence perpetrators (Ch 68)

-ejection from vehicle -ped-struck >30km/hr -high speed MVC or roll-over -fall > 20ft or 6m -severe deceleration injury -bicycle or motorcycle crash -2nd or 3rd degree burns >10% BSA -inhalation burns *special considerations: >60, <16 years, pregnancy

MECHANISTIC indications for trauma team activation: (Ch. 36)

-Headache -Nausea -Sensory hypersensitivity (photophobia, phonophobia) -Memory/concentration problems -Sleep changes -Mood changes, irritability

Main Sxs of Post-Concussive Syndrome? (Ch. 41)

Expectantly until 32 weeks after which OB may elect to C/S

Management of placental abruption: (Ch. 37)

straddle injuries falls gunshots amputations self-instrumentation

Mechanisms of anterior urethral injuries: (Ch. 47)

Pelvic fracture involving ischiopubic rami

Mechanisms of posterior urethral injuries: (Ch. 47)

1. repair with 5-0 or 6-0 absorbable suture once remaining nail has been removed 2. replace nail and secure it with tape or suture into nailbed to splint open 3. Tetanus prophylaxis 4. New nail will grow back 70-160 days later

Nailbed laceration management: (Ch. 50)

-pneumothorax -hemothorax -pulmonary contusion -post-traumatic pneumonia or neuroma -delayed hemorrhage (rebleeding intercostal artery) -liver/spleen injury

Name some potential complications of rib #s: (Ch. 45)

Any stable trauma patient with at least one of the following MUST have imaging of C-spine: "PAID Now" Posterior midline tenderness Altered mental status Intoxication Distracting injury Neurological deficits **notice no consideration of mechanism in Nexus

Nexus Rule for C-Spine: (Ch. 43)

Indications for thoracotomy in penetrating trauma:

PENETRATING chest trauma... Crack the chest or not? That is the question... how do you decide? (Ch. 36)

-Systolic BP <90 -RR <10 or >30 -GCS <12 or focal neurological signs

PHYSIOLOGIC indications for trauma team activation: (Ch. 36)

Color pattern: Red and yellow are adjacent. If red touches black, not venemous. Of note: In brazil this does not apply! only NA

Phenotypic characteristics of coral snakes(Ch. 55)

"Ligamentous injury resulting from an abnormal motion of a joint" 1st degree -minor tearing of ligamentous fibers w/ mild hemorrhage and swelling. 2nd degree -partial tear of ligament with moderate hemorrhage / swelling 3rd degree -complete tearing of ligament

Please define *Sprain*: (Ch. 49)

"injury to musculotendinous unit resulting from violent contraction or excessive forcible stretch" 1st degree -minor tearing of muscle and/or tendon fibers w/ mild hemorrhage and swelling. 2nd degree -partial tear of muscle and/or tendon fibers with moderate hemorrhage / swelling 3rd degree -complete tearing of muscle and/or tendon fibers with possible avulsion fracture

Please define *Strain*: (Ch. 49)

Ensure high quality CPR is underway! chlorhex splash midline vertical incision from epigastrium to symphysis pubis vertical incision of the uterus deliver fetus clamp and cut cord Should be less than 3 minutes

Post-mortem C-section procedure: (Ch. 37)

- Consider local prevalence - Gonorrhea: 6-18% - Chlymadia: 4-17% - Syphilis 0.5-3% - HIV <1% - Pregnancy 2-4%, but increased in women aged 19-26 midcycle

Risks of STIs after sexual assault (Ch 67)

1. ALTE(BRUE now) 2. Seizure 3. Intestinal injuries 4. Pancreatitis 5. Liver/ spleen injury 6. Underlying coagulopathy(Familial, acquired or leukemia) 7. Osteogenesis imperfecta

Six differential diagnoses for physical abuse (Ch 66)

1. Accidental trauma(Straddle injury) 2. Dermal melanocytosis(formerly mongolian spot) 3. Lichen sclerosus 4. Impetigo 5. Urethral prolapse 6. Anal fissures 7. Infectious causes(STI, shigella, Group a beta hemolytic strep, candida, pinworm, chigger) 8. Vaginal foreign bodies 9. Priaprism

Six differential diagnoses for sexual abuse (Ch 66)

Dysphonia / aphonia / dyspnea / stridor / hemoptysis / subcutaneous emphysema / laryngeal crepitus / loss of anatomic landmarks / pain with tongue movement hoarseness / tenderness over larynx

Soft signs of laryngeotracheal injury: (Ch. 44)

1. Traumatic brain injury - contusion, bleed, skull # 2. Thoracic trauma - rib/sternal #, pneumothorax (in COPD) 3. Upper extremity - distal radius > humeral head > elbow 4. Lower extremity - akle #, hip/pelvic #, tibia plateau #

Some specific disorders you need to watch for when dealing with elderly patient trauma: (Ch. 39)

*Vitals:* normal vitals should NOT be reassuring *Airway:* often difficult airway (dentures, stiff neck, obese) faster apneic desat, higher risk of hypotension less RSI meds needed (try to avoid succ) *Breathing:* low FRV, consider high flow Quick to tire with WOB *Circulation:* blunted stress response, less CO reserve previous HTN may mask hypotention as normotension, Pt on anticoagulation? *Disability:* elderly at incr risk of spine # (C, T, L, S) or SCIWORA, watch out for TBI (CT every head) *Exposure:* increased risk of hypothermia (thin skin, less fat/muscle,impaired thermoregulation), remove from backboards ASAP, tetanus UTD?

Specific considerations for elderly trauma patients: (Ch. 39)

1. X-ray to ensure no fracture 2. relieve subungal pressure with trephination 3. distal phalanx # with sub. hem. should be tx like open # with prophylactic antibiotics

Subungal hematoma management: (Ch. 50)