Trauma chapter 3

treatment of flail chest

(flail chest is 2 or more rib fractures in 3 consecutive ribs) Early CPAP can prevent need for intubation as lung mechanics are disrupted and pt will tire out

Indication for thoracotamy in penetrating trauma

(much better outcomes compared to blunt trauma) Prehospital/hospital signs of life Echo evidence of cardiac activity with cardiac tamponade Unresponsive hypotension (BP < 70 mm Hg) despite resuscitation with penetrating chest wound

decorticate posturing

Abnormal flexion of the upper extremities with extension of lower extremities. Indicates damage to corticospinal tract above brainstem

positive DPL

Aspiration of 10 mL blood >100,000 RBCs/mm 3 (or 10,000 with penetrating trauma) WBCs > 500 mm 3 Aspiration of GI contents Amylase > 20 IU/L Alkaline phosphatase ≥ 3 IU/L

Managing TBI

BP>90 systolic Elevate head of bed to 30° reverse anticoagulation If evidence of herniation -hyperventilation w/ CO2 of 30-35 -mannitol 1gm/kg -hypertonic saline 1ml/kg consider seizure prophylaxis avoid fever, hypoxemia

goal pressures (MAP/ICP/CPP) in TBI

CPP > 60 MAP > 80 ICP <15

diagnosis of traumatic aortic injury ie findings on chest xray and further testing

CXR can show a variety of abnormalities, but 10% are normal. Widened mediastinum to > 8 cm on supine AP film ( Figure 3.16 ) and loss of distinct aortic knob are the most reliable signs. CT with contrast is a good test for stable patients. Transesophageal echocardiogram can be performed at the bedside in unstable patients. CXR Findings Suggesting Aortic Injury= Widened mediastinum, Loss of distinct aortic knob, Esophageal or tracheal deviation to right, Widened right paraspinous interface, Widened right paratracheal stripe, Loss of clear space between aortic knob and left pulmonary horizontal artery, Depression of left main stem bronchus 40° below horizontal, Left hemothorax

exceptions to chemical exposures that should be treated with water irrigation

Dry powder (lime) from cement: Brush away before hydration. Sodium metals from agricultural exposure: Use oil, not water. Phenol (carbolic acid) from industry and medicine: Use polyethylene glycol 300 and industrial methylated spirits in 2:1 mixture or more simply, use isopropyl alcohol or glycerol.

decerebrate posturing

Extension/adduction and internal rotation of arms and legs with flexion of wrist, fingers, feet (plantar), and toes. Indicates injury to brainstem.

when to intubate

GCS< 8 loss of airway reflex with intoxication severe facial/airway trauma airway burns with concern for swelling

Physiologic and laboratory changes in pregnant patients

HR incrased 10-15 BP decreases in first and second trimester diaphram rises 4 cm and FRC decreases Baseline hematocrit is decreased to 32%-34%. Baseline P CO 2 is decreased to 30 mm Hg. Baseline serum bicarbonate is decreased to 21 mEq/L.

findings/evaluation in pelvic fracture

Look for Perineal or pelvic edema/ecchymosis/laceration/deformity. Hematoma above inguinal ligament or over scrotum ( Destot sign ). Perform rectal, perineal, and vaginal examinations for lacerations indicating an open pelvic fracture. Palpate prostate for superior or posterior displacement suggesting intraperitoneal or urologic injury. Abnormal prostate position or blood at the urethral meatus requires urethrogram prior to Foley placement to assess for urethral injury.

lines on lateral c-spine xray

On a lateral C-spine x-ray, 3 imaginary lines are identified ( Figure 3.5 ). Disruption to any line suggests injury ( Tables 3.10 and 3.11 ). Anterior contour line: Formed by anterior margin of vertebral body Posterior contour line: Formed by posterior margin of vertebral body Spinolaminar line: Connects the bases of the spinous processes and extends to the posterior aspect of the foramen magnum Swelling of the prevertebral soft tissue suggests injury; a measurement > 7 mm at C2 or > 21 mm at C6 is abnormal

diagnosis and treatment of urethral injury

RUG (retrograde urethrogram)- should be done prior to foley placement partial lacerations= catheter placed by urologist full lacerations= require surgical repair contusion to urethra heals w/o intervention

Goals in thoracotomy

Relieve tamponade (pericardotomy) Control active bleeding from cardiac or pulmonary injuries Compress descending aorta to maximize coronary/cerebral perfusion Perform open cardiac massage

most commonly injured organs for stab vs GSW

Stab wound: Liver first, then small bowel (both have large surface areas) GSW: Small bowel, then colon, then liver

hard signs of arterial injury

hard signs= immediate surgery Pulsatile bleeding Audible bruit/palpable thrill Rapidly expanding hematoma Obvious arterial occlusion Decreased temperature

types of shock in trauma

hemorrhagic neurogenic obstructive (tamponade/tension physiology) cardiogenic (direct cardiac injury) dissociative (CN/CO)

common locations for spinal fractures

where spine is changing in mobility ie cervicalthoracic, thoracolumbar. Less likely to have thoracic fracture as its less mobile but when injured cord injuries more likely

possible treatment of circumferential burns

with concern for compartment syndrome or in the case of the chest with respiratory distress perform escharotomy

treatment of pelvic fractures

with instability/open book fracture treat with pelvic binder/sheet wrapping it around the GREATER TROCHANTER with hemorrhage IR for emoblization vs surgical packing along with fixation of fracture For patients without other operative injuries, angiography can help control bleeding through arterial embolization, although the bleeding is often venous . Indications for embolization include: Persistent hypovolemia/hypotension after treatment of other sources of bleeding Four units packed red blood cells (PRBC)/24 hours or six units PRBC/48 hours Large pelvic hematoma on CT displaced pelvic ring= operative repair

avulsion pelvic fractures (age group, cause, treatment)

young contraction of muscles against unfused apophysis conservative treatment

oculocephalic response

(pontine gaze centers): Conjugate deviation of eyes in direction opposite to passive head rotation (once C-spine cleared) indicates intact brainstem function in a comatose patient (positive "doll's eyes" response).

placental abruption becomes a concern at how many weeks gestation

16 weeks

burn classification

1st degree; superficial: only epidermis, looks like sunburn 2nd degree; superficial and deep partial thickness extends to dermis causing blistering. Superficial partial is blanching, hair follicles remain and healing with minimal scarring occurs in 2-3 weeks deep partial is non blanching, red to pale white, can have 2 point discimination loss, can require 3-8 weeks for healing with scarring and contractures. These require skin grafting third degree; full thickness: subcutaneous structures causing nerve damage, white, leathery and/or charred tissue requiring skin grafting

most common solid organ injured in blunt trauma

1st= spleen 2nd=liver renal less common pancreas rare *positive fast w/ blunt abd injury most likely 2/2 to spleen injury

how many ribs fractures should prompt admission

3 or more

open pneumothoraxic/sucking chest wound treatment

3 sided bandage (4 sided could cause tension) followed by chest tube (not through the wound)

time of viability of amputated appendage

6-8 arms warm 12-24 cold digits do better than limbs

location of most traumatic aortic injuries

90% of blunt aortic injuries occur at the isthmus of the aorta, between the left subclavian artery and ligamentum arteriosum.

signs of urethral injury

Blood at the urethra meatus and an inability to void are common symptoms. In females, urethral injury is often associated with vaginal bleeding. Anterior urethral injury: "Butterfly" perineal hematoma. Posterior urethral injury: Perineal hematoma and high-riding prostate

hollow viscous injury treatment

Bowel perforations should undergo laparotomy, while contusions can be observed. A period of observation is appropriate for those with negative CT imaging but concerning mechanism for injury.

evaluation of suspected arterial injury

CT with contrast vs duplex scan with posterior knee dislocation, if ABI WNL, can simply follow with serial ABIs

pulmonary contusion; diagnosis, complications, treatment

CXR can diagnose but can be delayed, normally will appear within 6 hours of injury but often does not capture the extent of injury (better on CT) can cause shunting of blood to unaffected lung causes edema to lung may require intubation and patients can develop ARDS can see hemoptysis in up to 50% of patients

anterior cord syndrome

Caused by flexion or extension with vascular or bony fragment injury of the anterior spinal artery. S YMPTOMS /E XAMINATION Paralysis and loss of pain and temperature sensation but preserved position, crude touch, and vibration sensation poor prognosis

determinants of injury from ballistics

Degree of crush or laceration which is determined by bullet mass, deformation, and yaw Amount of temporary cavitation (pressure wave) which is determined by bullet velocity (short barrel has less velocity), tissue elasticity (brain and solid organs less elastic while muscle very elastic)

brown-sequard syndrome

Hemisection of the cord, usually associated with penetrating trauma. It has the best prognosis for full recovery of all the incomplete spinal cord syndromes. Ipsilateral loss of motor, proprioception, and vibratory sensation with contralateral loss of pain and temperature sensation.

hip dislocation types with associated mechanisms

Hip dislocations may be anterior (due to an anterior and a medial force applied to the abducted leg), central (direct impact through acetabulum) or posterior (posterior force through a flexed knee). Posterior dislocations are the most common (80%-90%).

treatment of ballastics/bullets in body

If bullet is not found in its expected location, further workup is warranted. In general embolized bullets must be removed. A bullet lodged within the spinal canal may migrate and cause further damage. Consult Neurosurgery. Removal should be considered. Lead poisoning is not usually a concern since bullets typically become encapsulated in fibrous tissue. However, bullets resting in synovial fluid (intraarticular, disk space and bursa) may dissolve and release lead into the body. Bullets must be removed from joints to prevent mechanical and lead damage to joints and lead poisoning.

indication for thoracotomy after chest tube placement

Initial chest tube output of > 1500 mL (> 20 mL/kg) or persistent output of > 200 mL/h (> 3 mL/kg/h) indicates massive hemothorax and need for thoracotomy along with persistent hypotension

blunt hollow viscous injuries (ie stomach and intestines) signs/symptoms and associated injury

Injury is suggested on physical examination by abdominal wall contusion (seat belt sign) and abdominal tenderness. Unlike solid organ injuries, which present with signs of blood loss, hollow viscus injuries tend to cause delayed peritoneal signs from developing full-thickness. Consider with chance fracture of spine

oculovestibular response

Instillation of 30-mL cold saline into the ear; horizontal nystagmus with fast component away from tested ear indicates intact brainstem function.

diagnosis and treatment of esophageal injuries

Plain film chest x-ray (CXR) and neck films may show pneumomediastinum or retropharyngeal air. Sensitivity of endoscopy or esophagography alone is poor; together these tests have improved sensitivity. TREATMENT Broad-spectrum antibiotics with anaerobic coverage. Nothing by mouth; do not place NGT blindly. Surgical repair is required for full-thickness injuries.

Contraindications to thoracotamy

Prehospital CPR > 15 minutes for penetrating and 10 minutes for blunt without response Asystole as presenting rhythm and no echo evidence for cardiac tamponade Significant head trauma

evaluation and treatment of pregnant patients s/p trauma

Stable patients can have fast and serial exam to avoid CT Vaginal bleeding or uterine TTP suggest abruption or rarely uterine rupture vaginal discharge should prompt speculum exam to eval for rupture of membranes continuous fetal monitoring if beyond 24 weeks (viable fetus) Tube thoracostomy above 4th intercostal space DPL above fundus C section only if after 24 weeks with rupture, abruption, premature labor with malpresentation, fetal distress perimortem c-section after 4 minutes of CPR without ROSC

compartment of arms and legs and most commonly involved in compartment syndrome

Two arm compartments: Anterior, posterior Two forearm compartments: Dorsal, volar Four hand compartments: Thenar, hypothenar, central, interossei Three gluteal compartments: Gluteus maximus, gluteus medius and minimus, and tensor fascia latae Three thigh compartments: Anterior, medial, posterior Four leg compartments: Anterior, lateral, superficial posterior, deep posterior Four foot compartments: Medial, lateral, central, interosseous compartment syndrome most commonly seen in anterior compartment of leg

sources alkali burns and treatment

alkali cause liquofactive necrosis and are worse than acidic burns Common alkalis ("lyes") include drain and toilet cleaners, detergents, cement, and paint removers. Treat with copious irrigation.

common causes of uretheral injury; anterior vs posterior

anterior= straddle injuries posterior= pelvic fracture more common in men

cervical vessel injury treatment

anticoagulation and surgery with neuro deficit

sources of pneumomediastinum

any part of the airway from larynx, trachea, bronchi and also pharynx/esophagus (major air containing structure)

topical ointment for burn victim

bacitracin to face (silvadene causes scarring) silvadene to body

testicular trauma, evaluation and treatment

can see dislocation, hematoma, laceration, fracture, contusion absent testis is consistent with dislocation US can help with assessment surgery for laceration, dislocation, disruption. Other injuries can be managed conservatively

Indications for surgery after blunt abd trauma

Abdominal injury (free fluid by FAST or DPL) Positive FAST or DPL with hypotension Evisceration of abdominal wall contents Peritonitis Free air under diaphragm on imaging or aspiration of GI contents on DPL Injuries to diaphragm, aorta, or kidney injury with urine leaking outside of Gerota fascia Persistent blood from NGT, rectum or vagina

symptom of diaphragmatic rupture

Abdominal pain radiating to the ipsilateral shoulder (Kehr sign), worse when supine. Absent breath sounds or positive bowel sounds in the chest. Tension viscerothorax occurs when herniated abdominal contents in chest cause mediastinal shift and compression of the adjacent lung, similar to a tension pneumothorax leading to respiratory distress. Visceral obstruction (obstructive phase) can develop, at which time the patient will have signs of bowel obstruction or strangulation.

treatment of pericardial tamponade

Administer fluids to maximize cardiac output. For the patient who is not in extremis, start with ultrasound-guided pericardiocentesis. Removal of only 5-10 mL of blood can dramatically improve hemodynamics. ED thoracotomy should be performed for patients who have hypotension (BP < 70 mm Hg) unresponsive to resuscitation with ultrasound evidence of cardiac tamponade.

legal considerations with bullet wounds; things to avoid

DO NOT Cut through bullet holes on clothing Cut through bullet holes on skin unless medically necessary Handle bullets/fragments with metal instruments so as not to disturb/cause markings Describe wounds as entrance or exit

causes of cervical vessel injury

Direct impact to neck from seatbelt, clothesline, strangulation etc, causing compression of carotid. Hyperextension with lateral rotation → stretching of carotid across C-spine transverse process; most common. Intraoral trauma causing damage to internal carotid at angle of jaw Basilar skull fractures causing laceration of the carotid in region of carotid canal Hyperextension and/or lateral rotation of neck causing stretching of vertebral artery in region of the more mobile first and second vertebrae

treatment of diaphragmatic rupture

Emergent nasogastric decompression is the first step in treatment and should be performed promptly in the ED. Definitive treatment is surgical repair.

5 components of evaluating burn victims

Evaluation of airway and breathing (can cause airway swelling, burns rarely extend beyond vocal cords) Consideration of possible carbon monoxide and cyanide exposure (see Chapter 6 , Toxicology) Estimation of involved total body surface area (TBSA) Determination of depth of burned skin ( Table 3.16 ) Evaluation for involvement of critical parts and for circumferential burns **majority of deaths are due to smoke inhalation**

signs of tracheal injury 2/2 blunt trauma to neck

Findings include dysphonia, stridor, tenderness, subcutaneous (SQ) emphysema, and loss of anatomic landmarks. Best evaluated by awake laryngoscopy. Prep neck prior to attempting intubation. Beware of intubating false lumen created from injury.

4 categories of spinal injuries and most common

Flexion fractures (eg, wedge, flexion teardrop, odontoid, clay shoveler's) Vertical compression fractures (eg, burst, Jefferson) Flexion-rotation (eg, unilateral facet) Extension (eg, Hangman's) C5 fracture most common fracture , C5-6 subluxation most common subluxation

diagnosis of hollow viscous injury

Free air under diaphragm On CT- mesenteric air, discontinuity of bowel wall, extraluminal enteric contrast, free intraabdominal fluid, extravasated IV contrast, bowel wall thickening, and mesenteric hematoma. Maintain a high index of suspicion in patients that have a seat belt sign with abdominal tenderness and a negative CT. Surgical exploration is definitive for the diagnosis, but diagnostic peritoneal lavage (DPL) can also be used to identify perforation (see DPL later in the chapter). Focused assessment with sonography for trauma (FAST) examination is not sensitive for hollow viscus injury.

unstable c-spine fracture

In additional to JBOAHT wedge >50% loss burst if fragments enter canal

treatment of solid organ injury

In hemodynamically stable patients, liver and splenic injuries can often be treated expectantly rather than surgically. Hemodynamically unstable patients with a positive FAST examination should undergo an emergent laparotomy. Surgery is often required for splenic injuries grade III or higher. High-grade liver injuries have a higher likelihood of requiring surgical intervention; however, these can be managed nonoperatively as long as the patient is hemodynamically stable. interventional radiology is taking on increasingly large role using emoblization to delay or prevent surgery KEY FACT Management of solid organ injury is based on hemodynamic status and transfusion requirements rather than injury grade.

Indications for surgery after penetrating abd trauma

Injury with hypotension Peritonitis Evisceration of abdominal contents through wound Positive FAST or DPL with hypotension Any GSW to the abdomen that is believed to have entered the peritoneum based on projectile trajectory Local wound exploration that reveals violation of abdominal wall Foreign body in abdomen Suspected diaphragmatic injury Blood from NGT, rectum or vagina

signs/findings with pericardial tamponade

JVD/hypotension/muffled hearts sounds electrical alternans effusion on US often now enlarged cardiac silhouette on CXR as the pericardium has not had time to stretch

causes of lung opacification after trauma

Massive hemothorax, Diaphragmatic rupture with herniation, Lung collapse, Pulmonary contusion

symptoms/signs of neck vessel injury

Most patients will complain of pain in region of injury but the vast majority of patients have no neurologic signs or symptoms at the time of initial presentation. Maintaining a high-index of suspicion based on presenting mechanism/injuries is critical. Hard signs include expanding hematoma, bruits, active bleeding, transient ischemic attach (TIA)/stroke, airway compromise. Horner syndrome: Ptosis, miosis, anhidrosis from disruption of periarterial sympathetic plexus of the carotid.

estimating amount of body burned and fluid resuscitation

Nine for each upper extremity 18 for each lower extremity 18 each for front and back of torso Nine for the head One for perineum Alternatively, the % burn may be estimated using the patient's palm and fingers = 1% TBSA. Estimation of burn depth may be difficult on initial evaluation. For this reason, burns should be reevaluated in 24 hours to determine true depth and extent of tissue damage. parkland formula 4ml (3 in children) X %burned X weight in kg= 24 hour fluid requirement. Give half over first 8 hours and adjust according to UOP of .5 to 1ml/hr parkland formula only for partial and full thickness burns

diagnosis of diaphragmatic rupture

None of the imaging modalities is sensitive for diaphragm injury with minimal or no herniation. The gold standard is laparoscopy or thoracoscopy. Initial CXR may show diaphragmatic elevation, basilar atelectasis, blurring of left hemidiaphragm, or bowel gas pattern in the hemithorax. CXR often misinterpreted as hemothorax. CXR showing coiling of a nasogastric tube in the chest is diagnostic ( Figure 3.17 ). CT, MRI, and contrast studies aid in the diagnosis. Look for associated injuries, most commonly liver, lung, spleen, rib, or bowel injury.

Diagnosis and treatment of penetrating abdominal injuries

Penetrating trauma with peritonitis requires immediate surgery. Stab wounds to the abdomen may be evaluated using local wound exploration . Digital probing or injection of contrast is not recommended. Triple contrast CT scans (CT with PO, IV, and rectal contrast) can be used to evaluate a penetrating abdominal injury, especially if direct exploration is not possible or is inconclusive. PO contrast helps identify small bowel injuries, while rectal contrast helps delineate colonic injuries. An extended PO contrast preparation is not required. Observation with serial examinations without imaging is an acceptable method of evaluating penetrating abdominal trauma patients with a low clinical suspicion for significant injury

Indications for thoracotamy in blunt trauma

Prehospital/hospital signs of life with loss for LESS than 10 minutes Unresponsive hypotension (blood pressure [BP] < 70 cc output upon insertion) mm Hg) despite resuscitation with echo evidence of cardiac tamponade Rapid exsanguination from a chest tube (> 1500 cc output upon insertion)

signs/symptoms of traumatic aortic injury

Retrosternal or interscapular pain, dysphagia, shortness of breath, hypotension Stridor or hoarseness in the absence of laryngeal injury Harsh murmur over precordium or space between the scapula Signs of superior vena cava syndrome Compare BP in upper versus lower extremities: Relative upper extremity hypertension indicates " pseudocoarctation syndrome " from a periaortic hematoma KEY FACT Symptoms of descending aortic injury include paraplegia (vertebral artery deficits), mesenteric and LE ischemia, and anuria.

Traumatic kidney injury; S/S, interpretation of UA, diagnosis and tx

Significant trauma required to injury the well protected kidneys, injuries graded from I-V, with one being subcapsular hematoma and V being avulsion S/S: flank pain, bruising, hematuria KEY FACT Isolated microscopic hematuria does not mandate further imaging. Exceptions include: Rapid deceleration injuries where renal pedicles can be damaged Hematuria in a patient with even transient hypotension Hematuria following penetrating trauma to the flank Diagnosis: CT or IV pyelogram. If no contrast going to kidney or angio or venogram should occur with suspicion for pedicle injury T REATMENT Depends on the degree of injury. Injuries with lacerations of > 1 cm depth into renal cortex (Grade III) or those with vascular injury (Grades IV and V) typically require intervention (IR or OR, depending on stability of patient).

spinal shock

Spinal shock is a transient depression of all spinal cord function below the level of a partial or complete injury. Reflex function below the level of injury spontaneously returns (typically within 24-48 hours), at which time the degree of cord injury can be fully determined. KEY FACT Spinal shock can make an incomplete injury appear complete. S YMPTOMS /E XAMINATION Flaccid paralysis, including bowel and bladder, priapism. Bulbocavernosus reflex (anal sphincter contraction in response to squeezing penile glans or pulling on the Foley) returns first. Presence of this reflex early after injury is associated with better long-term outcomes.

central cord syndrome

The most common incomplete spinal cord lesion. It is caused by a hyperextension injury on a congenitally narrow canal or preexisting cervical spondylosis (older patients), resulting in buckling of the ligamentum flavum and compression of the central cord. S YMPTOMS /E XAMINATION Numbness and/or weakness greater in the arms than the legs (patients may have complete quadriplegia); bowel and bladder control remain in all but the most severe cases. Findings can be subtle at presentation; maintain high index of suspicion and obtain MRI early. Although function usually returns, most patients do not regain fine motor control in upper extremities.

treatment of traumatic aortic injury

Use β-blockade to control blood pressure (keep SBP < 120 mm Hg and replace fluids carefully to prevent worsening tear/rupture). Instruct patient not to Valsalva. Operative repair is almost always necessary, but there is no clear consensus as to the optimal timing (immediate or delayed) or method (open vs intravascular). KEY FACT Half of all patients with traumatic aortic injury who reach the hospital and survive for 1 hour die within 24 hours, and 75% die within 7 days.

Consider additional injuries to ? with 1st and 2nd rib fractures

brachial plexus and great vessels

pneumothorax treatment

can treat with oxygen if <20% with repeat chest xray for observation but should consider chest tube if pt requiring intubation 36 french for large pneumo if long doesn't reinflate consider lung paranchyma or bronchial tear likely assuming equipment working correctly which will require surgical intervention if tension pneumo suspected (hypotensive/ shifted mediastinum trachea/respiratory comprimise/distended neck veins) then immediete needle decompression with angiocath at 2nd interocostal space/midclavicular

classes of hemorrhage

class 1 <15% or <750ml: narrowed pulse pressure class 2 15-30% <1500ml: HR 100-120, RR 20-30 class 3 <40% or <2000ml: BP reduced, HR >120, RR >30, confused class 4 >40% or >2000ml: HR >140, RR > 45, lethargic

diagnosis/treatment of compartment syndrome

clinical diagnosis, however compartment pressures greater than 30 concerning along with a less than 30 degree difference between IM pressures and diastolic pressure treatment includes fasciotomy however use caution with snake bites as this often leads to worse outcomes

treatment of neck injury/work up of neck injury

consider early intubation with expanding hematoma close with intact platysma Zone 1 and III- CTA (zone 1 also endoscopy/laryngoscopy_ Zone II- hard signs=surgery, no hard signs=CTA

causes of compartment syndrome

constriction ie cast or circumferential burn swelling within compartment ie Hemorrhage, Fractures (tibia, forearm, supracondylar), Crush injury, Drug or medication injections, Ischemic and/or reperfusion injury

treatment of vascular injuries, BP targets

direct pressure tourniquet but no longer than 120 minutes and do not clamp or tie off vessels target BP of 90 systolic (controversial) major arterial injuries must be repaired within 6 hours minor arterial injuries (pseudoaneursym, intact distal circulation, <5mm intimal flap, no active hemorrhage) can be observed major venous injury usually require repair

when to worry for airway swelling

fire in enclosed space singed facial and nasal hairs carbonaceous sputum soot in nose or mouth direct visualization airway showing soot, scarring or edema of airway is gold standard

Treatment of penile fractures and amputations

fracture: surgery for hematoma evacuation and repair of tunica albugenia Amputations must be reattached within 8-12 hours. The amputated penis should be wrapped in saline-soaked gauze, placed in a sterile bag and then placed on ice. Cooling prolongs viability. Skin lacerations can be repaired with 4-0 absorbable suture. Skin avulsions usually require grafting.

treatment of basilar skull fracture

generally no specific treatment necessary, can discharge in absence of neuro deficits and with simple linear fracture. No consensus on ppx abx.

signs of basilar skull fracture

hemotympanum vertigo/hearing difficulty 7th nerve palsy battles signs racoon eyes

glass etching common chemical exposure and treatment

hydrofloric acid, may not begin experiencing symptoms for hours, treat with calcium gluconate

hard signs of neck injury

include airway compromise, air bubbling from wound, shock, severe active bleeding, expanding or pulsatile hematoma, neurologic deficit, hematemesis, and massive SQ emphysema.

sternal fracture; diagnosis and further testing

lateral chest xray. Should prompt CT chest to look for intrathoraic injuries. Should get screening EKG and troponin to look for blunt cardiac injury (however it does not predict blunt cardiac injury). Does NOT warrant admission for cardiac monitoring

CXR findings with pneumothorax

loss of lung marking, SQ emphysema, low lateral diaphram/deep sulcus sign lateral decupitus most sensistive xray ultrasound more sensitive than xray

blood type for transfusion without blood type

males O+ females of childbearing age O-

pain out of proportion to exam

mesenteric ischemia necrotizing fascitis compartment syndrome

Admit even with negative CT head after head trauma?

moderate (GCS 9-13) and severe (GCS <8) TBI antiocaugulated with concern for delayed bleed

How to test for blunt myocardial injury

normal EKG and trop can effectively r/o blunt injury, should f/u with echo if abnormal

ureteral injuries; causes and symptoms, diagnosis and tratment

normally penetrating trauma or iatrogenic from surgery hematuria (rare with complete tears) flank pain diagnosis: CT or IV pyelogram treatment: surgical vs IR intervention for surgical repair or stenting

high pressure injection injuries

often grease or pain, often innocuous appearing injection wound, often will have pain tracking up arm can track up extremity along fascial planes causes inflammation and necrosis without treatment amputation rate as high as 48% surgical emergency requiring exploration do not perform digital block as this can cause pathologic increase in compartment pressures

types of traumatic bladder injuries, along with signs and symptoms

often seen with pelvic fractures symptoms: Abdominal pain and tenderness Gross or microscopic hematuria Inability to void Peritonitis (if intraperitoneal rupture) KEY FACT Degree of hematuria does not always correlate with the degree of injury. Bladder contusions: Hematoma causing bladder to change shape and shift superiorly Extraperitoneal bladder rupture: Tearing and rupture at bladder neck from shearing forces of anterior pelvic fracture; no communication to peritoneum Intraperitoneal bladder rupture: Rupture of distended bladder at its dome, leading to leakage of urine into peritoneum

neurogenic shock

patient warm and vasodilated rather than cold and clammy A distributive shock state that results from the loss of sympathetic outflow in a cervical or thoracic spinal cord injury, leading to loss of peripheral vascular resistance and unopposed vagal tone. Hypotensive with relative bradycardia. Treat with fluids and pressors.

How to use FAST exam

positive fast w/ unstable vitals= surgery positive fast w/ stable vitals= CT scan and surgery consult negative fast w/ stable vitals= consider serial FASTS negative fast w/ unstable vitals= consider DPL

compartment syndrome signs and symptoms

pressures >30 cause nerve ischemia, 2 point discimination first to go. Loss of pulse late findings tense compartments parasthesias and sensation deficits pain with passive stretch paresis pain out of proportion to exam pulse deficits (late findings)

Diagnosis and treatment of bladder injuries

retrograde cystogram (400ml contrast and clamp catheter) surgery for intraperitoneal catheter decompression for 10-14 days for extraperitoneal

most common parts of heart injured in blunt contusion

right ventricle, aortic valve can also see coronary artery laceration and thrombosis 90% of pts with wall rupture die on seen can present with chest pain, tachycardia, arrhythmia ** over half of pts with blunt injury will develop effusion around 2 weeks later**

treatment of amputated appendage

rinse (not scrub) in saline, place in saline soaked gauze in bag on ice no re-implantation with crush injury, prolonged ischemia, toes other than great toe

hip dislocation complications

sciatic nerve injury avascular necrosis of femoral head (should reduce asap to restore blood flow)

Young-Burgess classification of major pelvic fractures with associated fractures

seperates by vectors of force ie AP, lateral, vertical lateral most common: Tbone accidents transverse ring fracture, sacral compression fracture, iliac wing fracture. AP second most common: straight on collision SI and pubic symphysis disruption Vertical shear least common: fall from height, symphysis displaced vertically, **most likely to cause major bleeding will often see associated retroperitoneal hematoma from venous bleeding

soft signs of arterial injury

soft signs= further investigation History of arterial bleeding Proximity to major artery Diminished distal pulse Peripheral nerve injury (next to vasculature) Small nonpulsatile hematoma Abnormal flow velocity on Doppler Arterial pressure index of < 0.9 (also known as ankle-brachial index)

major thoracolumber fractures (unstable)

wedge compression fracture chance fracture (lap belt injury-horizontal fracture through body and posterior compartments) burst fracture flexion-distraction fracture (compression of anterior elements with distraction of posterior elements) translation fracture (shifting one or more bodies)

zones of finger with regard to amputation and treatment

zone I: bone and nail not involved; treat with dressing, healing by secondary intention following 3 all treated by hand specialist zone II: exposed bone zone III: entire nail bed zone IV: near DIP