TRAUMA PART 2
3 Question Warm-Up
1 W h a t heart disease fits each o f the following descriptions?
ST segment elevation in leads corresponding to the perfusion of multiple arteries
Hypotension + distant heart sounds + distended neck veins
Cardiac cath shows equal pressures in all heart chambers
Chest pain that lessens when the patient leans forward
2. W h a t is the next step in the evaluation o f a pulsatile abdominal mass and bruit?
3. W h a t is the treatment for ventricular fibrillation?
Neck Trauma
4. W hat are the different zones of the neck and structures contained in each zone?
Zone Landmarks Structures Contained
I Clavicle —> cricoid cartilage
Great vessels, aortic arch, trachea, esophagus, lung apices, cervical spine, spinal cord and cervical nerve roots
II Cricoid cartilage —» angle of the mandible
Carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, cervical spine and spinal cord
III Angle of the mandible —> base of the skull
Salivary and parotid glands, esophagus, trachea, cervical spine, carotid arteries, jugular veins, major cranial nerves
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Chest Traum a
5. W hat C X R findings might indicate a ruptured thoracic aorta?
loss of aortic knob, pleural cap, deviation of the trachea and esophagus to the right, and depression of the left main stem bronchus
6. W hat are the signs of tension pneumothorax? W hat is the treatment?
° Signs: absent breath sounds and hyperresonance to percussion (hollow sound) on the affected side, distended neck veins, hypotension
° Treatment:
- Immediate_____________________________
If delay in chest tube placement,_____________________________ on the affected side (2nd or 3rd 1C space at midclavicular line or 5th 1C space at midaxillary line) 7. W hat is a flail chest, and what is the classic presentation?
° Flail chest is a free-floating portion of the chest wall that moves paradoxically to the rest of the chest wall (inward motion with inspiration) and results from 3 or more sequential rib fractures
° Patients may have muscle splinting due to pain which may conceal the paradoxical motion of the chest wall
° Mechanism of injury is usually direct impact of the steering wheel or crush injury 8. W hat is the treatm ent for a flail chest?
° Oxygen supplementation
° Close monitoring for early signs of respiratory compromise
° Placing an object (e.g., sandbag) to the affected region to stabilize the segment is no longer done due to the consequence of restricting chest expansion
BiPAP by mask or endotracheal intubation with mechanical ventilation
- (otherwise the patient may become hypoxic from limiting breathing due to pain)
TRAUMA PART2 Abdominal Trauma
9. W hat are the initial steps in the management of an abdominal stab wound presenting to the ER?
° Airway, Breathing, Circulation
If hypotensive —>■_________________________________________
® Abdominal exam
Signs of peritonitis (peritoneal irritation) — * ____________________________________
Explore th e stab wound under local anesth< -.ia
» If wound penetrates anterior fascia—> O perate
» If no penetration or unable to assess, admit for serial 24-hour exams —> surgical exploration if peritonitis, hemodynamic instability develop, Or positive on additional testing (listed below)
° NG tube - to decompress stomach and rule out blood in the stomach
° Urinary catheter
Additional possible testing in the stable patient not already needing surgical exploration:
° Diagnostic Peritoneal Lavage (DPL) if indicated
° Upright CXR - to identify hemo- or pneumothorax and/or intraperitoneal air
° Diagnostic ultrasound — to identify hemoperitoneum
° Abdominal C T with contrast
° Diagnostic laparoscopy
10. W hat are the next steps in the management of blunt abdominal traum a in a patient with stable vital signs?
° Airway, Breathing, Circulation (Primary Survey then Secondary Survey)
° Establish IV access at two sites with large bore IVs
° NG tube and Foley O
° Stat H&.H +/- Blood type and cross
11. W hat are the next steps in the management of a patient with blunt abdominal traum a and unstable vital signs?
° Primary and secondary survey
° Assess for and manage pelvic fracture
° FAST (Focused Assessment with Sonography for Trauma)
If blood in pelvis ' ________________ _____________________
If no blood in pelvis —»■ possible retroperitoneal hemorrhage — >___________________
If FAST inconclusive > _______________
° If no blood in pelvis and angiography is normal, then +/- admission
+ observation
12. W hat is the treatm ent for a retroperitoneal hematoma?
° I f penetrating injury or exsanguination into abdomen (bloody peritoneal aspirate)
° If blunt trauma without blood in the abdomen —>
Follow_______________
If hemodynamically unstable or falling H&H —> ________________________________
Genitourinary and Pelvic Traum a
13. W hat is the immediate treatm ent for a patient with a pelvic fracture?
° Primary and secondary survey including a thorough neurovascular examination
° IV F luid+ /-blood
Ultrasound (FAST) to assess for fluid in the pelvis —> if no fluid in pelvis and patient is hemodynamically unstable —» _____________________________________ to detect bleeding missed by FAST
If blood detected —» _____________________________________
If hemodynamic instability but no blood detected —> consider retroperitoneal hemorrhage —> _____________________________________
° _______________________ until the external fixator is placed (a bedsheet twisted and tied tighdy around the pelvis can be used if nothing else is available)
Assess for bladder and urethral injury with retrograde cystourethrogram
- If extraperitoneal bladder rupture —^ _____________________________________
- If intraperitoneal bladder rupture —>■______________________________________
End o f Session Quiz
14. W h a t is the next step in the evaluation o f the following patients?
Pelvic fracture + DPL shows blood in the pelvis
Pelvic fracture + DPL shows urine in the pelvis
Pelvic fracture + DPL shows nothing + hemodynamic instability
Blunt abdominal trauma + unstable vital signs + FAST shows fluid in pelvis
Blunt abdominal trauma + unstable vital signs + FAST shows no fluid in pelvis
Blunt abdominal trauma + unstable vital signs + FAST inconclusive Blunt abdominal trauma + stable vital signs
Abdominal stab wound + hypotensive or signs of peritonitis
15. W h a t additional studies can be performed in the case o f a stable patient w ith an abdominal stab wound that penetrated the peritoneum?