Trauma Surgery

4840: In addition to clinical evaluation, what diagnostic tool is recommended to rule out C-spine injury in major trauma patients?

In addition to clinical evaluation, routine CT is recommended to rule out C-spine injury in the major trauma patient. MRI remains the gold standard to exclude C-spine injury, but it picks up subtle injuries that are clinically insignificant, it is expensive, requires patient transport, and can't be performed immediately.

4566: A patient with severe traumatic injuries is suspected of also having ischemic brain damage. Which fluid would be the least appropriate for fluid resuscitation?

In instances of possible ischemic brain damage, solutions containing dextrose should be avoided as they could exacerbate the ischemia. The only exception to this rule is if hypoglycemia is documented.

4849: A patient with a blunt aortic injury from a motor vehicle accident exhibits increased pulmonary vascularity and a normal heart size on chest xray. What injury-induced pathologies would most likely produce this?

Increased pulmonary vascularity and a normal heart size on chest xray in a patient with blunt chest trauma could be indicative of a ventral septal defect caused by a ventricular septal defect.

4855: If hyperkalemia is detected intraoperatively, which agents may facilitate the treatment of elevated potassium?

If an elevation of K+ is discovered, treatment with regular insulin, 10U IV, with 50 percent Dextrose, 50mL, and sodium bicarbonate, 8.4 percent, 50 mL is recommended.

1547: What are the three stages of shock?

1. Compensated shock or nonprogressive shock 2. Progressive shock 3. Irreversible shock

4850: At what compartment pressure is fasciotomy of an affected extremity indicated?

A compartment pressure exceeding 30 cm H20 of the affected extremity is an indication for immediate fasciotomy. Compartment pressure is measured by inserting a needle and fluid-filled extension tube connected to a transducer into the various compartments of the affected extremity.

4851: During the first phase of the injury of a major trauma patient, a core body temperature below 35 degrees Celsius is often associated with what pathologies?

A core body temperature below 35 degrees Celsius is often associated with acidosis, hypotension, and coagulopathy during the early phase of injury for the major trauma patient.

4578: A patient who has suffered major trauma exhibits changes in his phonation during the interview. You know that this may indicate an increased risk for:

A patient that exhibits changes in phonation may be suffering from damage to the trachea and vocal structures. The mechanism of injury may place the patient at risk for neurological damage during airway instrumentation, resulting in the need for a difficult airway plan to avoid damage to the cervical spine. Changes in voice may also indicate recurrent laryngeal nerve damage which can increase the risk of aspiration.

4843: According to the Advanced Trauma Life Support Classification of Hemorrhagic Shock, Class III hemorrhagic shock criteria includes (select two)

ATLS Classification of Class III Hemorrhagic Shock includes the following parameters: (Blood loss 1500-2000 mL; Pulse rate >120 per min; blood pressure decreased; pulse pressure decreased; respiratory rate 30-40 per min; UOP 5-15 mL per hour; mental status: anxious and confused.

4844: According to the Advanced Trauma Life Support Classification of Hemorrhagic Shock, what are the characteristics of Class III hemorrhagic shock?

ATLS Classification of Class III Hemorrhagic Shock includes the following parameters: (Blood loss 1500-2000 mL; Pulse rate >120 per min; blood pressure decreased; pulse pressure decreased; respiratory rate 30-40 per min; UOP 5-15 mL per hour; mental status: anxious and confused.

4852: What is the recommended dose of fresh frozen plasma for severely traumatized, bleeding, and coagulopathic patients?

Although additional FFP may be required, the recommended dose of thawed FFP to be administered immediately after the arrival of severely traumatized, hemorrhaging, coagulopathic individual is 10-15 mL/kg.

4839: Is succinylcholine safe for use in the initial management of a patient with spinal cord injury?

Because the new nicotinic receptors surrounding the neuromuscular junction have not yet had a chance to develop, succinylcholine is safe during the first 24 hours following injury. After that, there is a risk for dangerous hyperkalemia with the administration of succinylcholine.

4832: What is the recommended cerebral perfusion pressure for traumatic brain injury patients?

Cerebral perfusion pressure should be maintained above 60 mmHg without risking increased hemorrhage from excessive pressure.

4848: What is the initial treatment for commotio cordis?

Commotio cordis is presented by the appearance of ventricular tachycardia or cardiac arrest following a sudden blow to the chest in young people. The immediate treatments including CPR for cardiac arrest and defibrillation for ventricular tachycardia.

4847: The primary cerebral perfusion pressure goal for brain trauma patient is (mm Hg):

Current therapeutic recommendations advise maintaining the CPP at levels between 50- 70 mm Hg.

4845: What secondary events have the highest associated mortality rate in patients with head injury?

Hypotension and hypoxia are the most significant events contributing to the mortality of a head-injured patient.

What is the most common cause of hypotension in the trauma patient?

Hypovolemia. The most common causes of hypovolemia are due to disruption from major vessels of the pelvis, chest and the abdomen.

2693: What is a common complication seen following long-bone fractures?

Hypoxic respiratory failure. This results from microembolization of marrow fat into the venous circulation.

4846: What are the most important parameters to normalize in patients with brain injury?

Interventions aimed at normalizing the ICP, CPP, and oxygen delivery to the patient have the greatest therapeutic significance in patients with brain injury.

4835: What other injuries must be assumed in a patient with traumatic brain injury (TBI)?

It must be assumed that a patient with traumatic brain injury also has a cervical spine injury. Forty percent of patients with TBI will also have another associated life-threatening injury.

3436: What induction agent is contraindicated in a trauma patient with a possible head injury?

Ketamine increases ICP and should not be used in this patient population.

524: How is laryngoscopy performed in all trauma patients that have confirmed or suspected c-spine injuries?

Laryngoscopy should be performed with the head in a neutral position with in-line stabilization applied.

4570: An awake, but intoxicated patient suffered a mid-facial fracture as a result of a head-on motor vehicle accident. What intubation technique would be contraindicated after induction of this patient?

Nasal intubation is contraindicated in this case because of the history of a mid-face fracture. It is also contraindicated in patients with basilar skull fractures.

3572: Is nitrous oxide safe to use in acute trauma case patients?

Nitrous oxide should be avoided in the acute trauma patient. Nitrous oxide diffuses into closed spaces making it contraindicated in patients with bowel injury, pneumothorax, and patients with closed-head injuries. These conditions are difficult to rule out in the acute setting and should be avoided.

4558: A trauma patient presents with a possible cribriform plate injury. Is a nasal intubation an acceptible technique for securing the airway?

No. The endotracheal tube can enter the brain vault during intubation, therefore nasal intubation is contraindicated.

4853: In the trauma patient, platelet transfusion is recommended when the platelet count falls below:

Platelet transfusion is recommended when the platelet count fall less than 50,000. Those with head injury and massive hemorrhaging may need administration of platelets at higher levels (75-100,000 per microliter).

4834: You are performing sedation for a patient undergoing an awake craniotomy. The patient experiences a seizure intraoperatively. What would be the most appropriate immediate treatment?

Propofol 20 mg IV or the application of cold saline to the surface of the brain are appropriated immediate treatments for intraoperative seizures during an awake craniotomy.

4838: How is the spinal cord perfusion pressure (SCPP) determined?

SCPP is calculated by the difference in MAP-CSF pressure (also referred to as spinal subarachnoid space pressure).

4842: What is the formula for shock index (SI)?

Shock index (SI) is obtained by dividing the heart rate (HR) by the systolic blood pressure (SBP). There is some evidence that it may be a better indicator of mortality than individual vital signs.

4540: A trauma patient presents with distended neck veins, unilateral decreased breath sounds, hypotension despite vigorous fluid resuscitation, subcutaneous emphysema of the chest, diminished chest-wall motion, and hyperresonance to percussion of one hemithorax. What is the most probable diagnosis?

Tension pneumothorax. A tension pneumothorax is a life threatening condition that creates a one-way valve of air flow into the pleural cavity. Intrapleural pressure is increased with every breath as more air is trapped within this space. Positive-pressure ventilation increases the size of a pneumothorax

4836: What are the components assessed in a Glasgow Coma Scale?

The Glasgow Coma Scale (GCS) evaluates the best verbal response, eye response, and motor response with a minimum score of 3 and a maximum score of 15. A GCS score less than 9 indicates severe brain injury.

4837: Which aspect of care should take precedence in the initial management of the patient with potential spinal trauma?

The first management of the spine trauma patient is the emphasis on the airway, breathing, and circulation. ETT intubation may be particularly challenging in the patient with spinal cord injury, especially if the lesion is on the cervical spine.

1919: What factors comprise what is known as the lethal triad of hemorrhage in the trauma patient?

The lethal triad that produces a vicious cycle of hemorrhage in the trauma patient is hypothermia, acidosis, and dilutional coagulopathy.

4841: What is the most common cause of traumatic hypotension and shock?

The most common reason of traumatic hypotension and shock is hemorrhage. It is secondary to head injury for the most common cause of mortality after trauma.

2818: What are the primary interventions you should implement for a trauma patient with intracranial hypertension?

The primary interventions to improve cerebral perfusion pressure (CPP) in a trauma patient with intracranial hypertension are to maintain a mean arterial pressure of at least 70-75 mmHg to ensure a CPP of at least 60 mmHg and promote oxygenation and adequate glucose levels without hyperglycemia. Measures to reduce intracranial pressure may include reverse Trendelenburg position, short-acting sedatives such as propofol, midazolam or fentanyl, CSF drainage via a ventriculostomy, and neuromuscular blockade.

5167: What is the recommended minimum platelet count for a patient having a non-emergent neurosurgical procedure?

The recommended minimum platelet count for a patient having a non-emergent neurosurgical procedure is 100,000/mm3.

4830: What is the intraoperative target glucose range for adults undergoing neurosurgical procedures?

Tight glycemic control between 80 and 110 mg/dL was used in the past, but increases the risk for hypoglycemia. A target blood glucose level of 90 to 180 mg/dL is appropriate for patients undergoing neurosurgical patients.

4854: What conditions are required to justify the use of recombinant Factor VIIa?

Use of the recombinant Factor VIIa when conditions are the following: acidosis has been corrected to at least a pH of 7.25, hypothermia has been corrected to a temperature of at least 33 degrees Celsius, and platelet and fibrinogen levels are adequate.