Transcript Trauma Board Review

Trauma Board Review
Part I
Dr. Grumpy
Disclosure
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Drug rep dinners
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Linezolid
Ertapenem
Keppra
Levofloxacin
STC
Blunt Trauma
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High speed head-on MVC. 2 cars. 3
passengers in each car. Front passenger of
car #1 pronounced on scene. The rest are
coming to your trauma center.
Patient #1
A.
B.
C.
D.
E.
Driver of car #1. 23yoM. Moaning and
sonorous respirations; will not open his
eyes to pain but withdraws to pain. GCS?
4
5
6
7
8
GCS
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Eyes
Verbal
Motor
You notice severe midface fractures. You want
to intubate patient with RSI. You know that:
A. Thiopental can raise both systemic and
intracerebral blood pressure.
B. Etomidate is contraindicated.
C. Ketamine reduces intracerebral pressure, but
may cause severe laryngospasm.
D. Pretreatment with lidocaine is not indicated.
E. Succinylcholine should be avoided unless a
defasciculating dose of a nondepolarizing
agent has first been given.
Trauma Intubation
Lidocaine effectively attenuates the cough reflex,
hypertensive response, and increased ICP associated
with intubation.
Thiopental may also be effective but should not be
used in hypotensive patients (consider it to be a less
severe form of propofol)
If succinylcholine is used, premedication with a
subparalytic dose of a nondepolarizing agent should be
considered if time permits, since fasciculations
produced by succinylcholine may increase ICP
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Blunts ICP and cough response, no evidence for clinical
difference
Etomidate has beneficial effects on ICP by reducing
cerebral blood flow and metabolism.
Ketamine should be avoided because it increases ICP
(although studies have bore out no outcome
difference)
Quick word on Etomidate
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Don’t
Don’t
Don’t
Don’t
use
use
use
use
it
it
it
it
Contraindications to nasotracheal
intubation in a trauma patient include
A.
B.
C.
D.
E.
Apnea
Cervical spine fracture
Depressed mental status
Hypotension
Pneumothorax
Nasotracheal intubation
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Must be breathing spontaneously
Contraindications
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Apnea, basilar skull fractures (or suspicion)
Just don’t do it
Astutely, you suspect head trauma. The
most common CT scan abnormality
found after severe closed head injury is:
A. cerebral contusion
B. epidural hematoma
C. intracerebral hemorrhage
D. subdural hematoma
E. traumatic subarachnoid hemorrhage
Head Trauma
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50% (#1) of trauma deaths
Cushing’s (late and unreliable) – htn,
bradycardia, apnea
Head Trauma
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Urgent head CT is indicated if:
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headache
vomiting
drug or alcohol intoxication
short-term memory deficits
posttraumatic seizure
coagulopathy
physical evidence of trauma above the clavicle
older than 60 years
GCS <14 or <15 s/p 2 hours
Amnesia before impact >30min
Witnessed LOC > 15min
Object recall < 3/3
Signs of basilar skull fx
Epidural hemorrhage
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Arterial bleed (middle
meningeal artery)
between skull and dura
“Coup”
Underlying brain injury
usually not severe
Presentation
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LOC then lucid interval
Dilated ipsilateral pupil
(lateralize if high) and
contralateral hemiparesis –
late findings
CT: biconcave or
lenticular
Subdural Hemorrahge
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Bridging veins between dura and
ararchnoid
“Contracoup”
Presentation
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Decreased mental status and LOC
May have lucid period also?!?!
6x more common than epidural
Higher mortality rate than epidurals
CT scan: sickle shaped
Subarachnoid hemorrhage
Blood within the CSF, caused by
disruption of subarachnoid vessels
 Most common CT finding in
mod/severe TBI
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Herniation
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Transtentorial
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Uncus → tentorial
notch
CN III, brainstem
symptoms
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Ipsilateral pupil fixed
and dilated
Respiratory depression
Tonsillar (Central)
(rare)
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Cerebellar tonsil →
foramen magnum
Small bilateral pupils,
posturing, bradycardia,
Head Injury Tidbits
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Isolated linear nondepressed skull fx: no
treatment
Basilar skull fx: temporal bone,
hemotympanum, CSF otorrhea/rhinorrhea,
periorbital ecchymosis, retriauricular
ecchymosis
Diffuse axonal injury is the most common brain
injury resulting in coma.
Bullet to brainstem/basal ganglia  zero
survival
Increased ICP
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Abnormal > 15, treat > 20
CPP = MAP – ICP, keep it >60
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Avoid Sat < 90% or PaO2 < 60
PCO2 30-35 (too low  excessive vasoconstriction)
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Hyperventilation only as temporary salvage
Mannitol (0.25-1g/kg)
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Systolic > 90 and goal = 120
MAP >85
ICP <20
Use pressors if needed keep CPP < 70
“Restrict mannitol use prior to ICP monitoring to patients with signs of
transtentorial herniation or progressive neurological deterioration not
attributable to extracranial causes.”
Dilutes blood and decreases viscosity  increased blood flow 
reactive vasoconstriction and decrease ICP
Replace loss of fluids
Contraindicated when hypotensive
Hypertonic
Pt is intubated. BP 78/48, HR 122, R 16, T
37.5. Neck veins flat. Most likely cause of
hypotension?
A.
B.
C.
D.
E.
Cardiac tamponade
Cardiogenic shock
Hypovolemia
Spinal Shock
Tension PTX
Blunt Traumatic Shock
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Hemorrhagic shock until proven otherwise.
Spinal Shock – bradycardic, hypotension
Cardiogenic shock/tamponade
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FAST
Distended neck veins
Tension PTX
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Distended neck veins, tracheal deviation,
tachypnea, decrease BS on side of PTX
After resuscitation, vitals stabilize. CT
reveals traumatic rupture of aorta. Which
finding is most indicative of this entity on
the patient’s initial CXR?
A.
B.
C.
D.
E.
Deviation of esophagus 1-2cm to the right
1st and 2nd rib fractures
L clavicle fx
Pulmonary contusion
Upward displacement of the L mainstem
bronchus 40o
Thoracic Aortic Disruption
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Rapid deceleration injuries.
Most common cause of death in blunt trauma,
80% die at scene, 10-20% die w/in 1st hour.
Signs & sx: include chest pain, back pain,
dyspnea, intrascapular murmur, and extremity
pain caused by ischemia.
CXR: widen mediastinum (8 cm) most common.
Nl in 2–7% of patients with aortic injury.
Aortogram gold standard, but now CT
False positives with mediastinal hematoma
Tx: BP management and surgical repair.
Aortic Rupture X-ray
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Widened mediastinum
Obscured aortic knob
Opacification of the aorticpulmonary window/apical
capping
Widened paratracheal
stripe
Displacement of the
esophagus/NG tube to the
right
Inferior displacement of
the left mainstem
bronchus.
Traumatic Aortic Transection
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80-90% tear at isthmus from deceleration
and instant death
Survivors to ED – tear at ligamentum
arteriosum
Retrosternal pain, dyspnea, stridor,
dysphagia
Harsh systolic murmur
Pulse difference between upper and lower
extremities
May have delayed presentation
Ruptured Diaphragm
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Left > Right, as liver
protects the right side
Location: 80-90% left
posterolateral
CXR abnormal in 60%,
but often not diagnostic
50% diagnosed at
laparotomy
Treatment: surgical repair
Often missed or delayed
Tracheobronchial Injury
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Seen with deceleration/shear forces
Most blunt injury occurs within 2cm of
carina
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This is where it is teathered
Mortality with rupture=30%
Continuous bubbling in chest tube is a
sign of a bronchopleural fistula
Tracheobronchial Injury
Signs/symptoms
Chest pain
Dyspnea
Hypoxemia
Hamman’s crunch
Hemoptysis
Subcutaneous
emphysema
CXR:
Pneumothorax
Pneumomediastinum
Tension pneumo
Rib fracture
Treatment
Oxygenation
Ventilation
Chest tube
Patient #2
50yoM, driver of 2nd car, has bruising over his sternum.
Hit chest against steering wheel. VS unremarkable.
Asymptomatic except for anterior chest wall tenderness
at site of bruising. CXR and sternal view reveal sternal
fx. EKG is nl. Which of the following is the MOST
appropriate management plan for this pt?
A.
B.
C.
D.
Admit for 24 hr telemetry monitoring
Perform 2 sets of CE and TPN tests, and dc if neg.
Perform echocardiogram in the ED, and dc if neg.
After a repeat EKG in 6 hrs, dc the pt with pain
medication, without any further testing.
Blunt Myocardial Injury (aka
Myocardial Contusion)
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Clinical features: pt in MVA > 35 MPH c/o chest
pain
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CXR greatest value for finding assoc injuries:
pulmonary contusion, rib fx
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Sternal rub or rib fracture, dyspnea, tachycardia
(70%), S3 gallop, rales, elevated CVP
Sternal fx no longer considered important.
Initial EKG predictive of subsequent clinically
significant EKG events – recommend initial EKG
followed by repeat EKG in 4-6 hrs.
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PVCs, 1st degree av block, RBBB (RV closest to
anterior chest wall), T wave flattening or elevation, 
QT
Myocardial contusion
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Dx: echo (but not as screening), increased CE
(poor sensitivity)
Most heal without specific treatment
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Complications: effusion, infarction, dysrhythmia,
aneurysm, thrombosis, vasospasms
Monitor for 12h  d/c (not life-threatening)
If young, ekg and 1 or 2 CE (normal)  d/c
Abnormal  telemetry
Unstable  echo
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If decreased CO  dobutamine or IABP
Patient #3
A.
B.
C.
D.
E.
Complains of tinnitus
and headache. Normal
neuro exam. What is
the injury?
Frontal bone fracture
Parietal contusion
Subarachnoid
hemorrhage
Subdural hemorrhage
Temporal bone fracture
Basilar Skull Fx
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Most common fracture involves the petrous portion of
the temporal bone, the external auditory canal, and the
tympanic membrane
Fractures  dural tear  communication between
subarachnoid space, paranasal sinuses, and middle ear
Compress and entrap cranial nerves passing through
basal foramina
CSF otorrhea or rhinorrhea, mastoid ecchymosis (Battle
sign), periorbital ecchymoses (raccoon eyes),
hemotympanum, vertigo, tinnitus, decreased hearing,
and 7th nerve palsy.
Ring test-halo on sheet-target lesion
Basilar Skull Fracture
Need thin
temporal bone
cuts
Battle’s Sign
Can take 12 hours to show up
HEMOTYMPANUM
Skull fractures
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Abuse=stellate, complex fractures
Linear non-depressed does not require
treatment
Temporal skull fracture=middle
menigeal=epidural hematoma
Open or depressed skull fracture (one
bone table width)→antibiotics +
neurosurgery
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At risk for post-traumatic seizures
Occipital skull fracture: SAH, contrecoup
injury, posterior fossa hematoma, cranial
On exam, your abdominal findings are c/w lap
belt injury. Compared to other patients with
blunt abdominal trauma, this patient is at
increased risk for injury to which of the
following organs?
A. Intestine
B. Kidney
C. Liver
D. Pancreas
E. Spleen
ANSWER: A
A. intestine. When lap belt bruises are present,
there is a higher incidence of intestinal injury.
Although seat belt sign is seen in only 1/3 of
cases, its presence is highly correlated with
injury. Diaphragmatic injury can been seen
secondary to compressive forces.
B. kidney
C. liver
D. pancreas
E. spleen
Abdominal Trauma
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Lap belt injury: hollow viscous rupture,
mesenteric tear, lumbar fracture, bladder
injury or rupture (chest seatbelt sign ok)
Laparotomy indications: evisceration,
GSW, impalement, gross blood by NG,
rectal, DPL
Abdominal Trauma Imaging
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CT scan increasingly important in trauma
management
 Insensitive to hollow organ injury,
pancreas, diaphragm
 Sensitive to retroperitoneum, solid
organs, bony structures
Role of FAST
Easy to Image
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Liver
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Most common in penetrating (large)
Spleen
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Most common in blunt
Hard to Image
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Pancreas
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Small intestine
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Blunt > penetrating
Handle bars, steering wheel, think peds
Nonspecific pain due to delayed diagnosis
DPL may be falsely negative and amylase usually
normal
Multiple in penetrating
Often delayed symptoms
Associated with lap belt injury and lumbar spine fx
(chance)
Colon
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Usually transverse (pinned by spine and gas)
DPL/DPA
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Relative contraindications: obesity, pregnancy, previous
abdominal surgery, pelvic fracture
False negative
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False positive: pelvic fracture
Positive lavage:
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Pancreas
Bowel
Retroperitoneum
Splenic hematoma
10ml gross blood
Blunt > 100,000 RBC/ml
Penetrating > 10,000 RBC/ml (this number a moving target)
WBC > 500/ml
Bile, feces, urine
Increased amylase
Too sensitive! Grade I-II liver and spleen lacs
Abdominal Signs
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Grey Turner’s sign: flank
discoloration, a late sign of
retroperitoneal hematoma; can
be seen with hemorrhagic
pancreatitis
Kehr’s sign: referred left
shoulder pain due to
subdiaphragmatic
irriatation/splenic rupture
Cullen’s sign: periumbilical
ecchymosis due to
retroperitoneal bleeding; can
also be see with hemorrhagic
pancreatitis, ectopic pregnancy
Seat Belt Sign
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Low-lying transverse abdominal ecchymosis has
a strong association with hollow viscus injury
and mesenteric tears .
Hollow viscus injury often does not produce any
pain or tenderness until 6-8 hours following the
traumatic event.
At minimum, patients with lap-belt contusions
should undergo serial abdominal examinations.
Findings of abdominal tenderness should prompt
diagnostic study (e.g., abdominal CT and/or
DPL) or laparotomy.
Still on Patient #4. Blood is noted at the
urethral meatus, and there is perineal
ecchymosis. Which of the following is the
next management step?
A.
B.
C.
D.
E.
Insertion of a coude catheter
IV pyelogram
Pelvic CT scan
Retrograde urethrogram
Urinalysis with sample obtained by
suprapubic route.
GU trauma
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Signs of GU trauma somewhere – hematuria
Urethral injury
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Signs
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Dx
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Tx
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Perineal ecchymosis
Unable to urinate
Blood at meatus
High-riding/absent prostate
Blood in scrotum/scrotal hematoma
Obvious penile trauma
Pelvic fracture
Retrograde urethrogram
Do not blindly put foley (unless you’re really skilled) – partial tear into
complete disruption
Foley over wire. Foley in for 2 weeks.
Suprapubic catheter placement and surgical repair.
Posterior urethral injury from blunt trauma
Normal urethrogram
Urethral tear
What is the most commonly injured
organ of the genitourinary tract?
A.
B.
C.
D.
Urethra
Kidney
Bladder
Ureter
Renal Trauma
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Most commonly injured organ of the GU system
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Rapid deceleration, compression, penetrating trauma
Associated with lower rib, L1-2 transverse process
fractures
25% of vascular injuries have no hematuria (no kidney
perfusion)
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Contusions (92%), followed by lacerations, renal pedicle injuries,
and renal ruptures or shattered kidneys; 1-2% vascular
Diagnosed by CT
Must revascularize < 12 hours
IVP indication: gross hematuria
Penetrating injury (15%)→IVP and/or CT
Most renal injuries are managed conservatively
Rest of GU trauma
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Bladder – 2nd most commonly injured
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Assoc with blunt trauma and pelvic fx
Dx
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Ureter – rarest
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Retrograde cystogram s/p foley or retrograde cystoscopy
Antegrade cystocopy (IV contrast, renal excretion fill bladder)
– incomplete and spurious findings
90% penetrating trauma  IVP
Testicular trauma
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Most common straddle injury
Presentation – edema, ecchymosis, tenderness,
hematuria
Diagnosis – u/s, nuclear scan, exploration
Complications: abscess, hydrocele, infertility
Patient #4
76yoF. Respiratory distress on arrival and has
paradoxical movement of R chest during labored
respirations. 138/76, 118, 28, 88% RA. BS
auscultated on both sides of chest. Which of the
following is correct?
A. Can be treated with supplemental oxygen and
admission to stepdown unit.
B. Injury mandates early ventilatory support.
C. Most likely cause of hypoxia is splinting from
pain
D. R chest wall moves outward with inspiration and
inward with expiration.
E. Tx involves analgesia and adhesive tap or rib
ANSWER: B
A. Can be treated with supplemental oxygen
and admission to stepdown unit. High
potential for deterioration. Early ventilatory
support and ICU.
B. Injury mandates early ventilatory support.
C. Most likely cause of hypoxia is splinting from
pain. Pulmonary contusion.
D. R chest wall moves outward with inspiration
and inward with expiration. Inward with
inspiration and outward with expiration.
E. Tx involves analgesia and adhesive tap or
rib belt to stabilize chest. Inhibit expansion
of chest and aggravate atelectasis,
worsening gas exchange.
Flail Chest
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Segmental fracture of 3
or more ribs
Paradoxical chest wall
movement
Decreased ventilation and
venous return
Tx
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Intubation, consider chest
tube
Main cause of
hypoxemia=pulmonary
contusion
Flail Chest
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Initially compensate for reduce TV by
hyperventilate, when fatigue or underlying
pulmonary injury develops  respiratory failure.
Tx
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Supplemental oxygen
Pain control – allows pt to fully expand lungs and
improve ventilation
Early intubation considered
External chest wall support reduce VC  worsen
respiratory function
Indications for early vent support: shock, three
or more associated injuries, severe head injury,
comorbid pulmonary disease, fracture of eight or
more ribs, or age greater than 65 years
Pulmonary Contusion
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Interstitial edema,
capillary damage,
bleeding
Dec compliance,
hypoxemia, atelectasis
CXR: opacification (often
delayed 6-12 hours), CT
better
Tx: oxygen, ventilation,
PEEP vs. permissive
hypercapnea, keep dry if
possible
A.
B.
C.
D.
E.
This patient also has a clavicle fracture. Which
of the following statements regarding clavicle
fractures is correct?
80% involve the distal third of the clavicle
Closed reduction alleviates pain and allows for
improved recovery
Frequently require surgical intervention to
achieve alignment
Most common location is the middle third of the
clavicle
Most common mechanism of injury is forced
abduction of the shoulder
Clavicle Fx
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5% proximal 3rd
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80% middle 3rd
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Usually direct force to lateral aspect of shoulder
15% distal 3rd
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Usually direct blow to anterior chest
More like complications/other injuries (vasculature)
Subclavian
Usually direct blow to top of shoulder
Treatment
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Most do not need surgery
Sling
Figure-of-eight brace for displaced fxs
Surgery indications
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Fracture penetrate skin
Nerve/vessel injuries
Rib Fractures
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Look for ptx, pulmonary
contusion, vascular injury
Multiple rib fractures
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Lower ribs:  risk of liver, renal,
spleen injury
Admit: elderly, pre-existing
pulmonary disease
Treatment
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pain control (meds and nerve
block)
Bad fractures
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1st & 2nd Ribs Fxs
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40% have associated occult injury
Great force involved
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Rule out
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Well protected, more sturdy rings
Myocardial contusion
Bronchial tear
Vascular injury (consider angio)
Scapula Fx
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Associated with occult chest injury
Patient #5 is a 22yoF, 28wks pregnant. She
denies abdominal pain, contractions, and
vaginal bleeding. Her PE is unremarkable other
than a small contusion to her right flank.
Which of the following is the appropriate
management?
A. D/c home with precautions and 24-hr follow
up.
B. External tocodynamics monitoring for 4 hrs
C. US followed by external tocodynamics
monitoring for 24 hrs
D. US with discharge home if negative
Patient #5
23yoF. 28wks pregnant. 110/78, 105, and 25.
Which of the following statements regarding
her vital signs is correct?
A.
B.
C.
D.
E.
Cardiac output is increased in pregnancy, which
means that she can tolerate larger blood losses than
a nonpregnant trauma patient can
Elevation of the diaphragm and reduced functional
residual capacity are causing the elevated
respiratory rate
Heart rate increases in the second trimester, which
means that the tachycardia is caused by pregnancy,
not hypovolemia
Hypotension might not develop until 35% of her
blood volume is lost due to relative hypervolemia of
pregnancy
Systolic and diastolic blood pressure decrease in the
second trimester, which means that the blood
Pregnancy Trauma
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CO inc 40% by 10wks, HR inc 10-15 beats/min;
SVR dec, widened pulse pressure, low blood
pressure
If hypotensive, roll or move uterus off IVC
Blood volume inc 50% by 28wks; can lose up to
35% without vital signs change (but fetus in
trouble)
MV inc 40%, normal PCO2 is 30
High diaphragm  dec functional residual
capacity
Chest tube 1-2 ribs higher
Pregnancy in Trauma
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Pt is at risk for Placental Abruption although her
trauma appears minor.
Major prospective study showed that minimal of
4 hrs of external tocodynamic monitoring was
able to predict immediate adverse pregnancy
outcome:
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< 3 contractions her hour – discharge
3-7 C/H: monitor 24 hours
> 8 contractions: higher risk of placental abruption,
none occurred in patients < 8 C/H
US is not sensitive to exclude placental
abruption.
Traumatic Placental Abruption

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Leading cause of fetal loss aside from maternal death is
traumatic placental abruption is #1 cause of fetal loss
aside from material death. (This is what we have to
work-up and why we’re consulting ob/gyn.)
Shearing and deceleration forces separate placenta from
uterine wall
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Lack of external signs of abdominal trauma means nothing
Placental position does not affect incidence
Disrupts gas exchange between fetus and mother  hypoxia 
fetal distress.
In blunt trauma, 50-70% fetal loss result from placental
abuption.
Signs
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Vag bleeding (<40%), abd pain/cramping, amniotic fluid
leakage, uterine tetany(???)
Fetal distress – cardiotocographic monitoring (>20wk gestation)
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U/S < 50% accurate
Placental substances cause coagulopathy (DIC from high
levels of ATP III)
Kleihauer-Betke test
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Test for fetomaternal hemorrhage (FMH) (ie,
transplacental bleeding of fetal blood into the normally
separate maternal circulation)
Complications
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Rh sensitization of the mother
Fetal anemia/distress/death from exsanguination.
Acid elution test on maternal blood to determine ratio of
fetal:maternal circulation
Regardless of result, must get rhogam if mother is RhUsed to identify Rh- women at risk of massive FMH 
needs more rhogam
Lecithin-to-sphingomyelin ratio: fetal lung maturity
Fetal fibronectin test: predicts premature delivery
Blunt Abd Trauma

Stable


Abdominal CT
DPL/DPA




Unstable


Resuscitate
Go to OR if


Does not define extent or location of injury
No retroperitoneal
1-2% complication rate
Positive FAST/DPA or Peritonitis
Arresting


Resuscitative Thoracotomy
R Chest Tube
Take a breath

Meant for me…not you.
Penetrating Trauma
The bat-phone rings. A fight has broken
out 5 blocks away from Elmhurst. Multiple
patients coming in.
32yoM. Stab in L side of neck with pocket
knife. Injury is inferior to angle of mandible,
superior to cricoid cartilage, posterior of
sternocleidomastoid. Penetrates platysma. No
bleeding, no evidence of tracheal deviation or
JVD. PE: no carotid bruits, no stridor, no SQ
emphysema, strong carotid pulses b/l, nl neuro
exam. Other than pain to wound area, pt is
asymptomatic. 128/82, 86, 16, 99% on RA.
Correct statement?
A. Can d/c after neg local wound exploration.
B. Must get esophagram and esophagoscopy
C. Must get laryngoscopy and bronchoscopy
D. Must get local wound exploration in the ED
E. Observation alone is appropriate.
The platsyma
For STABLE patient only
Zone III
-above mandible
-Angiograph
-May need
esophogram/endoscopy/bronchoscopy
Zone II
-between cricoid and mandible
-go to OR or…
-Esophagography/esophagoscopy and CT
angiography
Zone I
-below cricoid,
-Angio, esophogram/endoscopy, bronchoscopy
Penetrating Neck Injury
Hard Signs (with
instability  OR)
B/P ED
Arterial Bleeding
Expand hematoma
Diminished carotid
pulse
Thrill / bruit
Focal deficits
Hemothorax > 1L
Bubbling wounds
Soft Signs
Stridor
Hoarseness
Vocal
cord paralysis
Subcut. Air
CN VII injury
Tracheal deviation
Nonexpanding
hematoma
Unexplained brady
(w/o CNS injury)
Penetrating Neck Injury


Any wound which violates platysma
Injuries-most occur in Zone II




Vascular > CNS
Peripheral nerve > brachial plexus
Vascular injuries require proximal and
distal control
Death=CNS, exsanguination, airway
compromise (intubate early)
Blunt Neck trauma




Rare due to protection of head, shoulders and
chest
Mechanism: steering wheel, dashboard, shoulder
belt shearing forces, clothes line injuries
Laryngotracheal and pharyngoesophageal
injuries can be subtle require diagnostic imaging
Carotid artery injury: pseudoaneurysm or
dissection


Mechanism: hyperextension, hyperflexion, direct
blow, intra-oral trauma, basilar skull fracture
Neurologic symptoms may be delayed
Strangulation / Blunt Neck Injuries

Soft-tissue neck x-rays



CT of neck structures
Neck MRI



Soft tissue
Carotid arteries from aortic arch to circle of Willis, making it
particularly applicable in the setting of blunt cervical injuries
where the level of injury is unknown
Carotid doppler U/S



Look for SubQ emphysema (fractured larynx), hyoid bone fx, or
tracheal deviation because of edema or hematoma.
Angiography remains the gold standard for diagnosing blunt
carotid artery injury
Helical CT scans efficacy unvalidated
Laryngosocopy - vocal cord and tracheal evaluation

Particularly with dyspnea, dysphonia/hoarseness, odynophagia
Carotid Artery Dissection
Neck trauma + TIA/Stroke/Horner’s
Also has GSW through R leg. Which of
the following findings on PE suggest the
presence of an arterial injury requiring
expeditious angiography or surgical
intervention?
A.
B.
C.
D.
Diminished distal pulses
Injury to an anatomically related nerve
Unexplained hypotension
Proximity of the injury to major
vascular structures
Arterial Injury: Penetrating
Extremity Trauma
Hard Signs
Soft Signs
Absent/diminished
Small
pulses
Obvious arterial bleed
Large expanding or
pulsatile hematoma
Audible bruit
Palpable thrill
Distal ischemia
stable hematoma
Injury to anatomically
related nerve
Unexplained
hypotension
h/o hemorrhage
Prox of injury to major
vascular structure
Complex fracture
Arterial Injury: Penetrating
Extremity Trauma



Hard signs: expeditious angiography and/or
surgical intervention
Soft signs: inpatient admission for observation
and repeat exams
No hard or soft: Observe in ED 3-12 hrs,
discharge home with close fu.




No signs of arterial bleed
No bone or nerve injury
No developing compartment syndrome
Minimal soft tissue defect
Ankle-Brachial Index
1.0 vs. 0.9
Upon ripping his clothes off, you find
a single stab wound to L flank. VS
are BP 110/80, HR 90. Which of the
following is the most appropriate
next step in management of the flank
stab wound?
A. DPL
B. Wound exploration with a cotton
swab.
C. CT with IV contrast.
D. CT with oral, rectal, and IV
contrast.

ANSWER: D
A. DPL. In a pt who is hemodynamically stable
after penetrating flank trauma, DPL would be
helpful for intraperitoneal injury but does not
sample the retroperitoneal injury (kidney).
B. Wound exploration with a cotton swab. Difficult
and limited, esp with deeper wounds that
extends to muscle layer.
C. CT with IV contrast.
D. CT with oral, rectal, and IV contrast. Triple
contrast should be used to identify rectal and
sigmoid injury. Oral contrast may not extend
down to these areas. Accuracy of CT for flank
stab wounds approaches 98%.
Flank or Back Wound



Associated with to retroperitoneal injuries such
as the colon, kidney, ureters and major vascular
structures
Colon is the injury most often missed. If colon
injury is suspected, serial physical examination is
extended to 72 hours, watching for fever or a
rise in WBC
An alternative is to perform a triple-contrast CT
scan. Where the wound track extends up to the
colon, or there is evidence of abnormal bowel
wall thickening, laparotomy is indicated.
A.
B.
C.
D.
E.
Another patient rolls in – an anterior
abdominal wall stab wound. What is the
likelihood he will need surgery due to
this wound?
10%
30%
50%
70%
90%
Anterior Abdominal Stab Wounds


1/3 don’t penetrate peritoneum, 1/3
penetrate but don’t require laparotomy,
1/3 require laparotomy.
Local wound exploration followed by



Discharge home if no violation anterior fascia
Admission for observation/serial PE/DPL if
superficial muscle fascia violated.
Indications for exploration: progressive
abdominal tenderness, increasing
leukocytosis, fever, abdominal distension, etc.
If the stab wound was in the LUQ, which of
the following is the BEST method for
diagnosing a diaphragmatic injury?
A.
B.
C.
D.
Computed tomography.
Diagnostic peritoneal lavage.
Upper gastrointestinal series.
Laparoscopy.
Diaphragmatic Injuries


Majority caused by penetrating trauma.
Occur predominately on L side b/c liver protects
right side. Most likely sight of injury posteriolateral portion of L diaphragm
Laparoscopy. CT misses a lot of penetrating
injuries.
DPL may be used but must use low cut-off (5000
RBCs/ml) as diaphragm bleeds little.
NG tube/Upper GI series good for blunt, but not
penetrating diaphragmatic injuries
Delays in diagnosis lead to increased morbidity
and mortality.
A.
B.
C.
D.
E.
His CXR comes back with this.
You realized you missed an axillary
injury and pt. has
pneumo/hemothorax. Which of
the following is true?
Once the blood has been drained
from the chest, clamp the
thoracostomy tube while the
patient undergoes further
evaluation
Perform needle aspiration of the
hemothorax if the volume is less
than 300 cc
Perform needle decompression
prior to tube thoracostomy
Place a 28 Fr thoracostomy tube
directed anteriorly in the right
anterior axillary line
Place a 36 Fr thoracostomy tube
directed posteriorly in the right
anterior axillary line
Pneumothorax

Open pneumothorax



Open >2/3 diam. of trachea (air moves in and
out of wound
3 sided petroleum gauze, one way valve,
chest tube
Dressing can create a tension PTX; remove
dressing if patient has increased SOB
Expiratory chest x-ray is the most
helpful diagnostic maneuver
Tension Pneumothorax




Severe dyspnea, ↓ breath sounds,
distended neck veins
Classic=tracheal deviation to opposite
side, hyperresonance, no breath sounds
Decreased venous return, hypoxemia,
arrest
Treatment: immediate needle
thoracostomy, chest tube
Pneumomediastium



Subcutaneous emphysema
Hamman’s sign: crunching during systole (not a rub)
Spontaneous due to increased intrabronhcial
pressure







Mechanical ventilation
Valsalva
Sneezing
Emesis
Ruptured bleb
Drug use
Tension pneumomediastinum


Decreased cardiac output
Decompression via neck dissection
Cardiac Tamponade





Beck’s triad: hypotension, JVD, muffled heart
tones
Pulsus paradoxicus: weaker pulse (lower BP)
than usual with inspiration
Electrical alternans: alternating QRS on EKG
Diagnosis: Echo
Treatment: pericardiocentesis, thoracotomy

If you crack the chest, you MUST skin the heart
Chest tubes

Position – 5th interspace, anterior axillary
line





No needle
Prevent over-intrusion
Slide along chest wall
For blood – large-bore tube (36-40 Fr),
direct posteriorly
For pure air – 28 Fr, directed anteriorly
Which of the following is an indication
for emergency department cesarean
delivery after maternal trauma?
A. Absence of fetal heart tones
B. Fundal height at 19 cm
C. GSW to uterus with vaginal bleeding
D. Maternal death after 5 minutes of
profound shock and a 26-week fetus.
E. Solitary GSW to head with stable vitals
signs of the mother.
Answer D

Indications for Perimortem C-section:





Fetus viable – cardiac activity on US
Gestational age > 23 weeks
Survival from postmortem cesarean
delivery unlikely 15 mins after maternal
death.
No specific duration of death beyond
which C section is contraindicated.
GSW to uterus or solitary GSW to head
with stable VS are not indication for
emergency ED C section.
What are the 4 accepted
indications for ED thoracotomy?

Penetrating thoracic injury



Traumatic arrest with previously witnessed
cardiac activity (pre-hospital or in-hospital)
Unresponsive hypotension (BP < 70mmHg)
Blunt thoracic injury


Unresponsive hypotension (BP < 70mmHg)
Rapid exsanguination from chest tube
(>1500ml)
What are the 4 uses for ED
Thoracotomy?




Relief of tamponade
Control hemorrhage from intrathoracic
source
Cross clamping of pulmonary hilum after
suspected air embolism
Cross clamp aorta with open heart
massage