Term
| What is the important anatomical landmark for assessing abdominal trauma? |
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Definition
| Nipple line (especially for bullet/penetrating wounds) |
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Term
| Which findings would indicate an exploratory laparotomy in a case of blunt trauma? |
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Definition
Signs of internal bleeding (occur @ 25-30% blood loss)
- Shock
- Fast thready pulse, drop in BP, low CVP
- Cold, pale anxious patient
- Low urinary output
- R/O other possible sights of bleeding
- Neck --> deformities
- Pericardial sac --> tamponade (distended neck)
- Pleural effusion --> CXR
- Femur / pelvis --> CXR and physical exam
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Term
| What is the best modality for diagnosiing intraabdominal bleed? What determines need for surgery? |
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Definition
CT scan (presence of blood, origin of blood, particularly liver or spleen), assuming pt is "hemodynamically stable." If not ,diagnostic peritoneal lavage (DPL) or US.
Response to fluid indicates need for surgery |
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Term
| What is the most common source of significant intraabdominal bleeding? |
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Definition
Splenic rupture (note: liver bleed is more common, but fewer significant cases). Lower left rib fractures.
If removal is indicated, postoperative immunization against encapsulated bacteria (Pneumo, HiB, meningococcus) |
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Term
| What are some of the intraoperative complications that can occur during abdominal surgery for multiple trauma? |
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Definition
- Coagulopathy
- Due to multiple transfusions
- Treat empirically with platelet packs and fresh frozen plasma
- Hypothermia and acidosis
- Terminate laparotomy
- Packing of bleeding surfaces and temporary closure with towel clips
- Resume when stable
- Abdominal compartment syndrome
- Large amount of fluid and blood given
- Tissue swollan and wound cannot be closed
- Temporary ccover is placed (absorable mesh or nonabsorable plastic)
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Term
| What is the appropriate course of action to take against pelvic hematoma? |
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Definition
| Leave alone, unless expanding |
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Term
| What are important initial steps to take with pelvic fractures? |
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Definition
- Rule out associated injuries
- Rectal exam and proctoscopy
- Bladder
- Pelvic exam
- Retrograde urethrogram
- Rule out other sites of bleeding
- R/O abdominal bleeding with DPL or abdominal sonogram
- Replace blood; arteriographic embolization
- Avoid surgery (access and loss of tamponade effect are issues)
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Term
A 14-year-old boy is hit over the right side of the head with a baseball bat. He loses consciousness for a few minutes, but recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated.
What is it?
How is it diagnosed?
Treatment? |
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Definition
-
Acute epidural hematoma (probably right side)
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CT scan
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Emergency surgical decompression (craniotomy). Good prognosis if treated, fatal within hours if it is not.
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Term
A 32-year-old male is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride and arrives at the E.R. in deep coma, with a fixed, dilated right pupil.
What is it?
Diagnosis?
Treatment?
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Definition
What is it? – Could be acute epidural hematoma, but acute subdural is better bet.
Diagnosis? – CT scan. Also need to check cervical spine!
Treatment? – Emergency craniotomy, poor prognosis because of brain injury.
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Term
A 77-year-old man becomes “senile” over a period of three or four weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began.
What is it?
How is diagnosis made?
Treatment
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Definition
- Chronic subdural hematoma (venous bleeding, size 7 brain in size 8 skull)
- CT scan.
- Surgical decompression (craniotomy). Spectacular improvement expected.
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Term
A car hits a pedestrian. He arrives in the ER in coma. He has…(raccoon eyes… or clear fluid dripping from the nose…or clear fluid dripping from the ear…or ecchymosis behind the ear)…
What is it?
How is it diagnosed?
Implications for therapy
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Definition
- Base of the skull fracture.
- CT scan. Needs cervical spine X-Rays.
- Implications for therapy: needs neurosurgical consult, needs antibiotics
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Term
| A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma, with fixed dilated pupils. He has multiple other injuries (extremities, etc). His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What is the reason for the low BP and high pulse rate? |
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Definition
| Extracranial blood loss (no room in the head to bleed enough to induce shock) |
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Term
A 22-year-old gang member arrives in the E.R. with
multiple gun shot wounds to the chest and abdomen. He
is diaphoretic, pale, cold, shivering, anxious, asking for a
blanket and a drink of water. His blood pressure is 60
over 40. His pulse rate is 150, barely perceptible.
What is it? |
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Definition
- Hypovolemic likely,
- Need to rule out pericardial tamponade/tension pneumothorax
- Both would yield distended neck veins
- Pneumo would include distress, tracheal deviation and absent breath sounds, resonance to percussion
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Term
A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation.
What is it?
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Definition
- Pericardial tamponade
- No X-rays needed (clinical diagnosis), go for pericardial window for confirmation, followed by thoracotomy/ex lap
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Term
25-year-old man is stabbed in the right chest. He is moderately short of breath, has stale vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion.
What is it?
How do we find out?
Treatment?
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Definition
- Sounds more like hemothorax.
- Chest X-Ray
- treatment is chest tube on the right, at the base of the pleural cavity.
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Term
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A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood, drains another 20 cc in the next hour
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Definition
| The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterwards. |
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Term
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales.
What is it?
How should it be managed? |
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Definition
- What is it? – Classical physical diagnosis finding of paradoxical breathing, leading to classical diagnosis of flail chest. She is at high risk for other injuries.
- Management: Rule out other injuries (aortic rupture, abdominal injuries) The real problem is flail chest is the underlying pulmonary-contusion, for which the treatment is controversial, including fluid restriction, diuretics, use of colloid rather than crystalloid fluids when needed, and respiratory support. The probable wrong alternatives will revolve around various ways of mechanically stabilizing the part of the chest wall that moves the wrong way…because that used to be what was believed in the past.
- Further management: if other injuries require that she go to the OR, prophylactic bilateral chest tubes because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic.
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Term
| A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white out” on X-Rays and she is in respiratory distress. |
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Definition
- What is it? – Pulmonary contusion. It does not always show up right away, may become evident one or two days after the trauma.
- Management: Fluid restriction (using colloid), diuretics, respiratory support. The later is key, with intubation, mechanical ventilation and PEEP if needed.
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Term
A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar’s Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the Er. he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum.
What is it?
How is the diagnosis made?
Treatment? |
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Definition
- Actually a real case. Classical for traumatic rupture of the aorta: King size trauma, fracture of a hard-to-break bone (it could first rib, scapula or sternum) and the tell-tale hint of widened mediastinum
- Arteriogram (aortogram).
- Emergency surgical repair.
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Term
| A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck. What is it? What additional findings would you expect? What is the appropriate management? |
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Definition
- Traumatic rupture of the trachea or major bronchus.
- Chest X-ray would confirm presence of air in the tissues.
- Fiberoptic bronchoscopy confirms the diagnosis and degree of injury. Used to secure airway, allowing for surgical repair.
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Term
| What is the appropriate management for pelvic fracture with ongoing significant bleeding |
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Definition
- Diagnosis with negative DPL, abdominal sono or CT
- External fixation, arteriographic embolization (does not work for venous bleeding)
- Surgery is no ideal solution (inacessible, pelvic hematoma have tamponade effect)
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Term
| What are some of the sequelae to crushing injuries? |
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Definition
- Hyperkalemia, myoglobinemia, myoglobinuria, renal failure -- treat with fluid administration, osmotic diuretics and alkalinization of urine
- Also worry about compartment syndrome -- treat with fasciotomy
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Term
| What are the components of Goldman's index of cardiac risk? Which is the strongest predictor of poor mortality? |
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Definition
- Jugular venous distenstion (CHF), MI within 6 months, premature ventricular contractions, rhythm other than sinus
- Jugular venous distension; treat with ACE inhibitor, ß blockers, digitalis and diuretics
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Term
| How is severe nutrional depletion defined? How long does it take "optimize" such patients for surgery? |
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Definition
- Loss of 20% of body weight over a couple of months, serum albumin below 3, anergy to skin antigens, serum transferring level of less than 200 mg/dl
- 7-10 days of nutritional support
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Term
| Which factors are suggestive of successful ventilator weaning? |
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Definition
- PaO2 of 70 mm Hg or more with an FiO2 of 0.35 or less
- An alveolar arterial gradient of <350 mm Hg
- A PaO2-to-FiO2 ratio of >200
- A PaCO2 of over 30 mm Hg and <55 mm Hg
- A VC of more than 10–15 mL/kg
- A maximum negative inspiratory force of more than -25 cm H2O
- A minute ventilation of <10 L/min
- A tidal volume of over 5 mL/kg
- A respiratory rate of <30 breaths/min
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