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Glasgow Coma Scale Correct ans - Chance fracture Correct ans-Transverse fracture through vertebra. In children usually associated with enterc disruption. Seen in motor vehicle accidents involving only lap belt. May be associated with retroperitoneal and Abdominal visceral injuries. Anterior hip dislocation Correct ans - Flexed, abducted, externally rotated. Burst fracture Correct ans - Associated with vertebral-axial compression injuries Posterior hip dislocation Correct ans - Flexed, aDDucted, internally rotated Anterior shoulder dislocation Correct ans - Squared off appearance Posterior shoulder dislocation Correct ans - Lock in internal rotation. Ankle dislocation Correct ans - Most are Externally rotated, with a prominent medial malleolus. FULL thickness (3rd degree) burn Correct ans - Dark or white and leathery. Translucent white as well. Painless and generally "dry" Does not blanch with pressure. Very little swelling of burned tissue. Principle Life saving measures for patients with burn injuries include Correct ans - -Establishing airway control -Stopping the burning. process -Intravenous access Factors that increase the risk for upper AIRWAY OBSTRUCTION in burns include: Correct ans - - Burns to the head and face -Burn size and depth -Burns inside the mouth Partial thickness burn Correct ans - Red remodeled appearance with associated swelling and blister formation. May have weeping or wet appearance and is painfully hypersensitive even to air current. Signs and symptoms and history that suggest INHALATION INJURY include: Correct ans - These patients should be intubated. Inhalation injury is an indication for transfer to a burn center. Rule of nines - adult Correct ans - The palm represents 1% of the body total surface area.
Symptoms of carbon monoxide poisoning and respective levels Correct ans - PaO2 does not reliably predict carbon monoxide poisoning because a CO partial pressure of only 1 mmm Hg results in a hemoglobin CO level of 40% or greater. Carbon monoxide has how many times greater affinity for hemoglobin than oxygen Correct ans - 240 times. It displaces the oxyhemoglobin desaturated curve to the LEFT. Two criteria required for the diagnosis of smoke inhalation injury Correct ans - -Exposure to a combustible agent -Signs of exposure to smoke in the lower airway, below the vocal cords, by bronchoscopy. Performing this action will help reduce neck and chest wall edema in patients with burn and inhalation injury. Correct ans - Elevation of the head and chest by 30 degrees. IV fluid administration formula for burn victims Correct ans - Indicated in burns involving over 20% of the body surface area. *(2-4 mL/kg of LR/NS) (weight in kg) (% area of burn); give 1/2 of this volume in first 8 hours. Remainder in over 16 hours. Large caliber, at least 15 gauge intravenous line should be introduced. Pitfalls for IV fluid requirements for burn victims. Correct ans - These patients require greater fluid requirements: ~immolation injury ~pediatric burn victims ~concomitant blunt or crush injuries. Basic rules regarding IV fluids administration in burn victims Correct ans - IV fluid Rate should not be based on the time of actual injury. In very small children, less than 10 kilograms, it may be necessary to add glucose to the IV fluids to avoid hypoglycemia. Any adjustment in IV fluid rate should be based on urine output. In an adult, urine output above 0.5 ml/ kilogram should result in reduction of IV fluid rate. Initial treatment of frostbite/ cold injuries Correct ans - Place injured part in circulating water and a constant 40 degrees centigrade until pink color and perfusion return, usually within 20 to 30 minutes. Antibiotics are not indicated empirically unless infection develops later. Persisted ACIDEMIA in burn victims may reflect... Correct ans - Cyanide poisoning. (Cyanide is a naturally occurring toxin that may be inhaled in a confined space fire). Hypothermia Severe hypothermia Correct ans - Core temperature of 36 degrees centigrade Temperature below 32 degrees centigrade
15 gauge Packed red blood cell volume transfusion for a child Correct ans - 10 mL/ kilogram Pediatric verbal score Correct ans - Impacted fractures Correct ans - Demonstrate no false motion of the humorous when the shoulder is rotated gently from a flexed elbow. Nonimpacted Fractures Correct ans - Generally experience pain on movement of the arm. Generally require hospitalization for orthopedic consultation and often operation Fundal height in pregnancy Correct ans - The amniotic fluid may cause amniotic fluid EMBOLISM and DIC following trauma if the fluid gains access to maternal intravascular space. Physiologic changes in pregnancy Correct ans - 1.Physiologic changes in pregnancysmall increase in rent till volume resulting in a decrease in hematocrit. 2.Elevation and WBC as high as 25,000. 3.Mild elevation in clotting factors. Bleeding and clotting times are unchanged, however. 4. Arterial pH 7.40-7.
5. PaCO2: 25-30mmHg
6. Bicarbonate space 17-
(Compensatory metabolic Acidosis). A resting PaCO2 of 35 to 40 mm in the setting of pregnancy Correct ans - may represent impending respiratory failure. Normal PaCO2 for a pregnant woman is between 25 to 30 mmHg Kleinhauer-Betke test Correct ans - Maternal blood smear test which allows detection of fetal RBCs in the maternal circulation, indicates fetomaternal hemorrhage. Indication for Rh immunoglobulin therapy. Drugs to avoid in hypovolemia, head injured and intoxicated patients. Correct ans - Benzodiazepines, fentanyl propofol, ketamine Initial Assessment components of seriously injured patient Correct ans
Primary survey Correct ans - 1. Airway maintenance with cervical spine protection 2. Breathing and ventilation 3. Circulation & hemorrhage control
4. Disability: neurological status
5. Environment/Exposure: completely undress the patient but prevent hypothermia
Assume a CERVICAL SPINE injury in patients with BLUNT multisystem trauma, especially those with an altered level of consciousness's or a blunt injury about the clavicles. Correct ans -
IV fluid warming temperature in shock Correct ans - 37 to 40°C Associated with aberrant conduction, premature beats, bradycardia. Correct ans - hypoxemia, hypothermia hypokalemia. AMPLE history. Correct ans - Allergies Medications Past illness/Pregnancy, Last meal Environment/events related to injury Frontal impact automobile collision: Bent steering wheel, Knee imprint dashboard Bulls eye fracture windshield Correct ans - Cervical spine fracture Anterior flail chest Myocardial contusion Pneumothorax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation of hip and/or knee Side impact automobile collision Correct ans - Contralateral next sprain Cervical spine fracture Lateral flail chest Pneumothorax Traumatic aortic disruption Diaphragmatic rupture Fractured spleen/liver and/or Fracture of kidney, pelvis or acetabulum Rear impact automobile collision Correct ans - Cervical spine injury Soft tissue neck injury Ejection from automobile Correct ans - Ejection from the vehicle precludes meaningful prediction of injury patterns. Patient at greater risk from virtually all injury mechanisms. Motor vehicle impact with pedestrian. Correct ans - Head injury Traumatic aortic disruption
Tachycardia in a school age to puberty Correct ans - Greater than 120 beats per minute Tachycardia in an adult Correct ans - Greater than 100 beats per minute. Significance of narrowed pulse pressure Correct ans - Significant blood loss and involvement of compensatory mechanisms. What percent of body weight in kilograms represents the circulating blood volume of an adult (in liters). Correct ans - 7%. Example, a 70 kilogram man's total circulating volume is 70 × 7% which equals 4900 ml. Class hemorrhage and hemodynamic effects. Correct ans - Sepsis Hypovolemic shock Correct ans - Both are characterized by tachycardia, narrow pulse pressure, cutaneous vasoconstriction, decreased systolic blood pressure, impaired urinary output. Normal blood volume percentage Correct ans - 7% of body weight. e.g. a 70 kilogram male has a circulating blood volume of 4.9 liters. Normal percentage blood volume for a child Correct ans - 8 to 9% of body weight. Blood loss associated with a fractured tibia or humerus Correct ans - 750 milliliters of blood Blood loss associated with a femur fracture Correct ans - Up to 1500 milliliters of blood Blood loss associated with pelvic fractures Correct ans - 2 liters or more. Initial warmed IV fluid bolus for shock. Correct ans - 1- 2 liters normal saline or LR for adults, and 20 ml/kilogram for pediatric patients. Normal urinary output for adult Correct ans - 0.5 milliliters per kilogram per hour Normal urinary output for children greater than 1 year of age Correct ans - 1 milliliter per kilogram per hour Normal urine output for child less than 1 year of age Correct ans - 2 milliliters per kilogram per hour Responses to initial fluid resuscitation in shock Correct ans - What needs to happen when there is failure to respond to crystalloid and blood administration in the emergency room in the setting of a motor vehicle accident or trauma resulting in shock. Correct ans
- Depends, but some intervention such as operation or angioembolization to control exsanguinate hemorrhage Three other causes of failure to respond to IV fluids that are not HEMORRHAGIC in origin. Correct ans - =Tension pneumothorax, =Bunt cardiac injury, =Pericardial tamponade
Type-specific blood Correct ans - Indicated in the setting of TRANSIENT responders. Blood to be transfused for minimal or no response trauma patients after crystalloid fluid resuscitation. Correct ans - Typed only packed red blood cells. Rh neg (O negative) preferred for females of childbearing age. Definition of massive transfusion of pack RBC: Correct ans - Greater than 10 units attack with blood cells in the first 24 hours of admission. Preferred temperature of packed red blood cells or peritoneal or thoracic cavity crystalloid solutions for hypothermia Correct ans - 39 degrees centigrade Most common cause of poor response to IV fluids in the setting of shock. Correct ans - Undiagnosed source of bleeding. Central venous pressure Correct ans - Reflects right heart function. May not represent left heart function in patients with primary myocardial dysfunction or abnormal pulmonary circulation. Conditions to consider if a patient does not respond to fluid therapy Correct ans - Unrecognized fluid loss, Ventilatory problems Tension pneumothorax Cardiac tamponade Hypoadrenalism Neurogenic shock Massive hemothorax findings on physical exam Correct ans - Tracheal deviation FLAT neck veins (due to heavy blood loss) Percussion dullness Absent breath sounds Distended neck veins are seen in what two conditions Correct ans - Cardiac tamponade Tension pneumothorax Conditions to consider in transient responders in the setting of shock. Correct ans - 1. Hemorrhagic: Bleeding within the abdomen, pelvis, retroperitoneum, extremity fracture, or obvious external bleeding.
- Nonhemorrhagic: Tension pneumothorax or cardiac tamponade NONresponder to IV fluids. Diagnostic consideration Correct ans - Blunt cardiac injury. Intraosseous needle size. Correct ans - 18 gauge spinal needle with stylet.
Less than 1500 milliliters of fluid evacuated but continued blood loss of 200 milliliters per hour for 2 to 4 hours Beck's triad in cardiac tamponade Correct ans - Venous pressure elevation, decline in arterial pressure, muffled heart tones. Kussmal's sign Correct ans - Paradoxical RISE in central venous pressure with inspiration. Seen in cardiac tamponade. Resuscitative thoracotomy Correct ans - Patients with PENETRATING injuries to the chest, pulseless, but with myocardial electrical activity may be candidates. Patients with BLUNT injuries to the chest, arrive pulseless but with myocardial electrical activity are NOT candidates. SIMPLE hemothorax Correct ans - Less than 1500 milliliters of blood. Most common cause is laceration of an intercostal vessel or internal mammary artery or lung laceration due to penetrating or blunt trauma. Typical presentation of tracheobronchial tree injury Correct ans - Hemoptysis, subcutaneous emphysema, tension pneumothorax; incomplete expansion of the lung after placement of a chest tube also suggests tracheobronchial tree injury. Confirmed by bronchoscopy. Treatment of tracheobronchial tree injury Correct ans - Surgical. Most common findings in blunt cardiac injury Correct ans - Multiple PVCs, unexplained sinus tachycardia, atrial fibrillation, bundle branch block, ST segment changes. Ligamentum arteriosum Correct ans - Site of incomplete laceration in traumatic aortic disruption Radiologic signs on chest x-ray in traumatic aortic rupture that indicate the likelihood of major vascular injury Correct ans - Widened mediastinum Obliteration of aortic knob. Deviation of trachea to the RIGHT Depression of left main stem bronchus Obliteration of space between the pulmonary artery and the aorta. Deviation of esophagus to the right Widened paratracheal stripe Presence of a plural or apical cap. Left hemothorax Fractures of first or second rib or scapula
Traumatic diaphragmatic injury on the left. What action should you pursue Correct ans - Insert a nasal gastric tube. If it appears in chest wall cavity on chest film the need for special contrast studies is eliminated. Suspect blunt esophageal rupture when you see the following Correct ans - Left pneumothorax or hemothorax without a rib fracture History of a severe blow to the LOWER sternum or epigastrium. Pain or shock out of proportion to the apparent injury. Particulate matter in the chest tube after blood begins to clear. Presence of mediastinal air. Treatment of blunt esophageal rupture Correct ans - Wide drainage of the pleural space and mediastinum, with direct repair of the injury through thoracotomy. Causes of subcutaneous emphysema Correct ans - Blast injury. Airway injury. Lung injury. The emphysema itself is generally not treated but underlying causes need to be addressed and treated. Fractures involving ribs 1 through 3, sternum, scapula and clavicle can be associated with Correct ans - Great vessel trauma or airway obstruction. Pneumothorax. Pulmonary contusion. Middle rib fracture, 4 through 9, can be associated with Correct ans - Pneumothorax hemothorax pulmonary contusion. Fracture involving ribs 10 through 12 can be associated with Correct ans - Hepatosplenic trauma Mediastinal widening Correct ans - Great vessel injury Sternal fracture Thoracic spine injury. Mediastinal air Correct ans - Esophageal disruption Tracheal injury Pneumoperitoneum. Air fluid level in the chest Correct ans - Hemopneumothorax or diaphragmatic rupture. Disrupted diaphragm Correct ans - Indicates adominal visceral injury X-ray findings in diaphragmatic ruptured Correct ans - Elevation, irregularity or obliteration of diaphragm. Mass like density above the diaphragm. Air or contrast containing stomach or bowel above diaphragm. Pleural effusion. Fracture of the scapula Correct ans - Great vessel injury, airway injury, pulmonary contusion. Sternal fractures are associated with Correct ans - Myocardial contusion Great vessel injury Pericardiocentesis needle, size Correct ans - 15 - 18 gauge, 15 centimeters length. Current of energy pattern that occurs in pericardiocentesis Correct ans
Direct blows to the back or flank resulting in hematomas or ecchymosis. Correct ans - Gross hematuria and microscopic hematuria with an episode of indicate they are at risk for NONRENAL abdominal injuries. Order a CT scan with IV contrast. Anterior urethral injuries or distuptions Correct ans - Usually present in patient with anterior pelvic fractures from a straddle injury. Usually an isolated finding only. Posterior urethral injury Correct ans - Usually associated with multisystem injuries and pelvic fractures. Blunt injury to the intestines is associated with linear ecchymosis on the abdominal wall or a chance fracture Correct ans - Classic sign of uncal herniation Correct ans - Ipsilateral dilated pupil with contralateral hemiparesis. What is the normal intracranial pressure in the resting state. Correct ans - Normal 5 to 15 mm Hg Physical signs of a basilar skull fracture Correct ans - Raccoons eyes Otorrhea Battle's sign CSF leakage from nose Definition of MINOR traumatic brain injury GCS in 13 and 15 Correct ans - History of disorientation, and amnesia, or transient loss of consciousness in a patient who is conscious and talking. CT scan indicated in the setting of minor traumatic brain injury (GCS 13-15) when the following are seen: Correct ans - *GCS of less than 15 two hours after injury *Suspected open or depressed skull fracture *Any signs of basilar skull fracture *Vomiting more than 2 episodes *Age more than 65 years *Loss of consciousness more than five minutes *More than 30 minutes amnesia before impact *Dangerous mechanism of trauma Management of moderate brain injury GCS 9-12 Correct ans - CT scan of the head in all cases Admission to intensive care unit for frequent neurologic checks repeat CT scan.
(10 to 20% of these patients deteriorate and lapse into coma) Management of patients with severe brain injury GCS 3-8 Correct ans - *CT Scan and admit to neurosurgical ICU *Therapeutic agents if needed including mannitol, hypertonic saline, moderate hyperventilation: PaO2 of ~35mmHg. *Repeat CT scanning as needed. *Intubation. A midline shift of 5 millimeters or greater on CT scan of the brain Correct ans - Indicate the need for surgery to evacuate the blood clot or contusion causing the shift Indication for the use of Mannitol (1gm/kg) Correct ans - Acute neurologic deterioration such as development of a dilated pupil, loss of consciousness, or hemiparesis in a severe head trauma patient. Patient must be euvolemic. Three main factors linked to a high incidence of late epilepsy in post traumatic patients Correct ans
- Seizures occurring within the first week Intracranial hematoma Depressed skull fracture. Diagnosis of brain death criteria Correct ans - *GCS score of 3 *Nonreactive pupils *Absent brainstem reflexes (Doll's eyes, corneal, gag reflexes) *No spontaneous ventilatory effort on formal apnea testing NEUROGENIC shock is rare in spinal cord injuries below this level. Correct ans - T6. Injury to this cervical spine level results in paralysis of the diaphragm Correct ans - C3 thru C segments. Injury to the lower cervical upper thoracic spine results in paralysis of what muscles? Correct ans - The intercostal muscles Definition of neurological level when discussing spinal cord injuries. Correct ans - The segment of spinal cord that has normal sensory and motor function on both sides of the body. Central cord syndrome Correct ans - commonly in hyperextension injuries in elderly with cervical spondylosis. Weakness in UE > LE, possibly loss of local pain/temperature. The motor fibers of the cervical segments are topographically arranged toward the center of the cord. Arms and hands are there for more severely affected. Anterior cord syndrome Correct ans - Paraplegia and dissociated sensory loss with a loss of pain and temperature sensation. Dorsal column function is preserved. Poorest prognosis of the incomplete injuries. Brown-Sèquard syndrome Correct ans - ipsilateral motor paralysis and loss of touch/vibration and contralateral loss of pain and temperature.
If on plain films of the cervical spine, no abnormality is identified, but the patient has evidence of a neurological deficit, order the following: Correct ans - MRI scan to identify any spinal cord contusions,disruptions and paraspinal ligamentous and soft tissue injury. AP films of the spine Correct ans - Detect distance between the pedicles Unstable fractures commonly cause widening of the inter pedicular distance. Lateral x-rays of the spine Correct ans - The Delta P in suspected compartment syndrome Correct ans - Equals the diastolic pressure minus the compartment pressure. If 30 or less the suggest patient has a compartment syndrome. compartment syndrome, however, is a clinical diagnosis. Clavicle fracture Scapular fracture Fracture / dislocation shoulder blade... Can be associated with..... Correct ans - Major thoracic injury, especially pulmonary contusion and rib fractures. Displaced thoracic spine fracture can be associated with Correct ans - Thoracic aortic rupture Spine fractures can be associated with Correct ans - Intraabdominal injury Femur fracture can be associated with Correct ans - Femoral neck fractures posterior hip dislocation Fracture / dislocation of the elbow can be associated with Correct ans - Brachial artery injury Median, mode, and radial nerve injury. Posterior knee dislocation can be associated with Correct ans - Femoral fracture Posterior hip dislocation Need this location or displaced tibial plateau fracture can be associated with Correct ans - Popliteal artery and nerve injuries. Calcaneal fracture can be associated with Correct ans - Spine injury or fracture, fracture dislocation of the hind foot, to be a plateau fracture. Open fractures can be associated with Correct ans - 70% incidence of associated non skeletal injury. Any deformed or dislocated joints should be splinted and x-rayed before testing for stability. Correct ans - Assess the neurovascular status of any extremity before applying a splint
Do not force realign a deformed extremity with a normal pulse. Correct ans - Alternatively, place extremity in a splint if normally aligned. If malaligned, the extremity needs to be realigned and then splinted. Characteristics of pediatric trauma Correct ans - Motor vehicle associated injuries are the most common cause of death in children of all ages. Most serious pediatric trauma is blunt trauma that a bowl of the brain. As a result apnea, hypoventilation and hypoxia after five times more often. Multisystem injury is the rule and should be presumed. Internal organ damage is often noted without overlying bony fractures. Use of atropine for drug assisted intubation. Correct ans - Should be reserved for infants only. Crycothyroidomy in infants and small children Correct ans - Is rarely indicated Up to 30% diminution in circulating blood volume may be required to manifest a decrease in the child systolic blood pressure. Correct ans - Hypotension in a child represents a state of decompensated shock and indicates severe blood loss of greater than 45% of circulating blood volume. Vital functions for pediatric population Correct ans - Characteristics of chest trauma in children. Correct ans - Mediastinal structures are mobile.; pneumomrdiastinum is rare abdominal tension pneumothorax is most common life threatening injury. Chest tube placement is required but thoracotomy is generally not needed in children. Rib fractures are rare. The present, indicates significant energy impact. Typical characteristics of paediatric abdominal trauma. Correct ans - Most pediatric internal injuries occurred as a result of blunt trauma. The presence of shoulder or lap belt marks increases likelihood of intraabdominal injuries. FAST should not be relied upon as the sole diagnostic tool in pediatric abdominal trauma. If a small amount of interim nominal through it is found and the child is hemodynamically normal a CT scan should be obtained. Most pediatric patients have self in a minute intra-abdominal injuries and no hemodynamic abnormalities. Diagnostic peritoneal lavage volume in pediatric patients Correct ans - 10 milliliters per kilogram. A DPL or FAST exam that is positive for blood alone does not mandate laparotomy in a child who was hemodynamically normal, or who stabilizes rapidly with fluid resuscitation. Laparotomy is indicated if child's hemodynamic condition cannot be normalized Characteristics of pediatric head trauma. Correct ans - Subarachnoid space is relatively small and offers less protection to the brain because there is less buoyancy. parenchymal damaged structurally is more common.
Hypothermia not attributable to shock or exposure should alert the physician to the possibility of what diseases? Correct ans - Substance, endocrine diseases such as hypothyroidism original insufficiency, or pharmacologic causes. Most common locations of fractures in the elderly Correct ans - Normal vitals for peds Correct ans -
