Transcript Slide 1

Trauma Board Review
Part II
Dr. Grumpy
Disclosure
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Drug rep dinners
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Linezolid
Ertapenem
Keppra
Levofloxacin
Cardene
STC
Topics
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C-spine trauma
Pediatric trauma
Pelvic trauma
6yoM. Rear-seated passenger in a moderatespeed MV crash. “legs were numb” immediately
following, but symptoms resolved in 30 min.
Normal exam. Normal radiographs. Correct
statement
A.
B.
C.
D.
Needs urgent MRI.
Discharge with close f/u as long as his exam
remains normal during a 4-hr observation.
Flexion-extension radiographs should be
performed to rule out any ligamentous injury.
CT scan of the C-spine should be performed
to assess for surrounding soft tissue swelling.
Spinal Cord Injuries
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Central Cord Syndrome
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Hyperextension injury
Upper ext weaker than lower ext
Brown Sequard Syndrome
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Penetrating – hemisection of spinal cord
Loss of ipsilateral motor, position, vibration
Contralateral loss of pain and temp below
level of injury
Spinal Cord Injuries
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Anterior Cord Syndrome
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Flexion of cervical spine
Bilateral paralysis of arms and legs equally
Due to arterial occlusion, disruption blood
flow to spinal cord
Cauda Equina
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Distal sacral roots - peripheral nerve injury
Variable motor/sensory loss in LE, sciatica,
bowel/bladder dysfunction, saddle anesthesia
Spinal Cord Injuries
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Spinal Shock (misnomer)
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Partial or complete injury
Areflexia, loss of sensation, flaccid paralysis
below level of lesion
Flaccid bladder and loss of rectal tone
16 yo football player c/o neck pain s/o
“speared” another player with helmet.
Paramedics immobilized his neck on
scene. Neurologically intact. Which
cervical spine injury is most likely?
A.
B.
C.
D.
E.
Bilateral facet dislocation
Hangman fracture
Jefferson fracture
Odontoid fracture
Teardrop fracture
C-Spine Fxs
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Jefferson fx (unstable)
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Axial loading force
C1 burst fx
Hangman fx (unstable)
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Hyperextension (hanging)
Located in pedicles of C2, with C2
displacing anteriorly on C3
Head on MVC
Associated with prevertebral
swelling and cause respiratory
obstruction
C-Spine Fxs
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Odontoid fx
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Type I – tip superiorly. Ligaments intact
and stable fx
Type II – junction of odontoid and body
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Most common
Type III – superior portion of C2 at base
of odontoid
Teardrop fx (unstable)
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Extreme flexion
Complete disruption of all ligamentous
structures at the level of injury
Unstable
Flexion Injuries
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Simple wedge fx
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Clay shoveler’s fx
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Avulsion of spinous process of lower vertebrae 
stable
Atlantooccipital and atlantoaxial dislocation w/ fx
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Associated with post ligament disruption
High instability and mortality
Bilateral facet dislocation w/ fx
Extension Injuries
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Ant arch of atlas avulsion fx – unstable
Post arch of atlas fx
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Compression. Look for other fxs.
Extension teardrop fx
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Most common at C2. Unstable
Atlanto-occipital Joint Injury
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Severe flexion/extension
Disruption of all ligaments between
occiput and atlas.
Death usually immediately from stretching
of brainstem
Cervical traction absolutely contraindicated
Atlanto-occipital Joint Injury
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Very difficult to
diagnose (CT 84%
sens)
Basion-dens distance
> 12mm
Posterior dens axial
line > 12mm
posterior or > 4mm
anterior to basion
Power Calculation
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BC/AD < 1 normal
Atlanto-axial Joint Injury
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Disruption of transverse ligament
Extremely unstable
Which is classified as low probability of
C-spine injury?
A.
B.
C.
D.
E.
21yoM, no neck tenderness, intoxicated
after MVC
24yo, no neck tenderness and LLE
weakness, pedestrian struck by motor
vehicle
32yoF, no neck tenderness, through-andthrough lip laceration after MVC
48yoM, no neck tenderness and R shoulder
dislocation s/p falling from scaffolding
82yoF, no neck tenderness and a L femoral
neck fx s/p fall
Nexus
No midline tenderness
No pain with neck movement
No distracting injury
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Long Bone Fracture (Most common DPI)
Visceral Injury Necessitating surgical consultation
Large laceration, degloving injury, or crush injury
Large Burns
Any injury producing acute functional impairment
No Neurodeficit
No Alcohol or Drugs
No Altered Mental Status
CCR
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Dangerous
mechanism
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Fall from > 3ft or 5
stairs
Axial load to head
MVC >100km/hr
Collision with
motorized
recreational vehicle
Bicycle collision
Pediatric Head Trauma
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Can bleed enough intracranially for
hypotension
Vomiting, seizures, LOC are all poor in
sensitivity and specificity
Scalp hematoma is indication
A.
B.
C.
D.
E.
2yo s/p struck by car after running out
into the street. Most likely thoracic
injury?
Aortic dissection
Commotio cordis
Esophageal rupture
Pulmonary contusion
Rib fractures
Pediatric Chest Trauma
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Compliant chest walls and ribs relatively
resistant to fracture  forces transmitted to
internal structures
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Pulmonary contusions
Commotio cordis
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Relatively mild blow to the chest (boards usually
pitched baseball)  ventricular fibrillation
No structural damage to the heart
Death usually instantaneous, and successful
resuscitation is uncommon.
8 yoM s/p hit a car door while riding bike. Crying and
c/o abdominal pain. Vital signs age appropriate,
abrasion across his epigastrium, and diffuse
tenderness w/o rebound or guarding. Amylase 220. UA
2-5 RBCs PHF. Which of the following is correct?
A.
B.
C.
D.
Despite a nl abd CT, the child could have pancreatic
injury and should be admitted for observation.
An IV pyelogram should be performed for
evaluation of hematuria.
The bowel is the most commonly injured organ
following this mechanism.
Duodenal hematoma is unlikely if a repeat exam
reveals no abdominal tenderness.
Pediatric Abdominal Trauma
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Pancreatic trauma often missed on CT and
presents later
Spleen > liver >> bowel
Duodenal hematoma needs observation
Traumatic Pancreatitis
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Clinical: mild epigastric tenderness, resolve in
early stages of injury, then increased severity
w/I 6 hrs when pancreatic enzymes begin
irritating the peritoneum, which may become
superinfected and produce retroperitoneal
abscess.
CT scan can’t exclude blunt pancreatic,
diaphragmatic, or bowel injury.
Serum amylase is normal in up to 37% of pts
with pancreatic injury
Rapid deceleration or severe crush injury
Pediatric Vascular Access
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IO
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Medial tibia (unless fx)
Fluid resuscitation, blood, medications
Complications (rare)
 Growth plate injury
 Compartment syndrome
 Fluid leakage
 Fat emboli
 Osteomyelitis
Child Abuse
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Injury inconsistent with history, delay in
treatment
Abuser
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Young age
Increased stress
Unemployed
History of Abuse
Substance abuse
Boyfriend
Child Abuse
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Burns
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Contact
Immersion
Stocking glove
Cigarette
Child Abuse
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Contusions
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Buttocks
Genitalia
Neck
Face
Low back
Child Abuse
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Shaken Baby Syndrome: diffuse cerebral injury
with edema, retinal hemorrhages, poor
prognosis
Suspicious fractures
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Any < 1 years
Rib (posterior)
Skull, spine, sternum
Bilateral/multiple various stages of healing
Long bone
Metaphyseal
Child Abuse
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Head injury
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Subdural
Cerebral
SAH
Shaken baby syndrome
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A.
B.
C.
D.
25yoM s/p hit by car. You are assigned
the task of checking the pelvis.
Push down on the greater trochanters
Push down on the iliac crest
Squeeze together on the iliac crest
Squeeze and rock the greater
trochanters
A.
B.
C.
D.
E.
Pt. has unstable pelvis and binder is
applied. Persistently hypotensive s/p 2
units of blood. FAST, DPA, CXR all
negative. Next action?
ED thoracotomy
Repeat FAST/DPA
OR Laparotomy
Angiography
Pack
A.
B.
C.
D.
Angio ready in 15 minutes. Well
resuscitated. Intubated. Surgical
medical student wants to put in foley so
he can check it off on his list. You…
Make the senior surgeon assist
Get a coude catheter
Insist on urology resident for insertion
Rudely stop the medical student
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
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Which of the following statements
regarding lightning injuries is correct?
A. Aggressive fluid loading is indicated.
B. Fetal death is common in pregnant
victims.
C. Lower extremity paralysis is rare.
D. Rhabdomyolysis is a frequent
complication.
E. Tympanic membranes usually are
normal.
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ANSWER: B
A. Aggressive fluid loading is indicated. Overly
aggressive fluid admin may worsen cerebral
edema.
B. Fetal death is common in pregnant victims.
(50% fetal mortality rate).
C. Lower extremity paralysis is rare. 2/3 p/w LE
paralysis and 1/3 with UE paralysis.
D. Rhabdomyolysis is a frequent complication.
Rhabdomyolysis occurs in only 6% of pts.
E. Tympanic membranes usually are normal.
More than 50% of lightening injury victims
have perforated TMs.
Lightning
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Electrical and most lightning burns have an
entrance and exit point
Death usually secondary to cardiac arrest,
lightening causes massive countershock and
produces asystole.
Burns are superficial, deep muscle damage rare.
Cataracts are common and may occur
immediately or develop up to 2 yrs after
incident.
Secondary injuries: ruptured TMs, spinal
fractures at multiple levels, bilateral scapular
fractures, internal organ injuries, long-bone
fractures, intracranial bleeding, seizures, cardiac
arrhythmias, and cardiac arrest.
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Which does not need burn unit?
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4yo, 10% BSA superficial partial-thickness burns to
arms after pulling a pan of boiling water off a stove
12yo 26% BSA superficial partial-thickness burns to
chest and arms from setting a blanket on fire
38yo 3% BSA full-thickness burn to his hand from a
mechanical injury
42yo, DM, 5% BSA superficial partial-thickness burns
to her feet from scalding bathtub water
75yo, 5% BSA superficial partial-thickness burn to
back from a heating pad
Burn Unit Criteria
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Major
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Moderate
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Partial-thickness burns > 25% BSA in 10-50yo
Partial-thickness burns >20% BSA in <10yo or >50yo
Full-thickness >10% BSA
Burns in hand, face, feet, perineum, cross major joints or
circumferential burns
Burns with inhalation injury, fxs/other trauma, electrical burns
Burns in infants, elderly or poor-risk
Partial-thickness 15-25% BSA in 10-60yo
Partial-thickness 10-20% <10yo or >50yo
Full-thickness < 10% BSA
Minor
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Partial-thickenes < 15% BSA 10-50yo
Partial-thickness < 10% BSA <10yo or >50yo
Full-thickness <2% BSA
Burn Percentage