Trauma Assessment and Management, Exams of Nursing

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TCRN EXAM STUDY GUIDE

Most common mechanism of injury - answer- Falls Forms of energy - answer- -mechanical -gravitational -thermal -chemical Types of trauma - answer- -blunt -penetrating -burn -other Blunt trauma - answer- accounts most injuries sustained frontal impact -aortic & cardiac injury, rib fxs, liver & spleen -dash board posterior hip fx/dislocation, femur, knee injury lateral impact -head/facial, c spine, clavicle, pelvic, liver/spleen rear end -low velocity, neck hyperextension/hyperflexn rollover -DAI ejection -risk of death 4x greater pedestrian vs car -tib/fib fx, truncal, head injury bicycle -head and abdominal injury from handlebar falls -4 stories 50% will die -calcaneous, pelvis, spine, arm fx Penetrating Trauma - answer- lower incidence higher mortality GSW Stab: low velocity higher direct damage to organs Burn: thermal or inhalation Other: Hanging, strangulation , suffocation, drowning Waddell's Triad - answer- -femoral shaft fx -intrathoracic and abdominal injury -contralateral head injury Newton's three laws of motion - answer- 1. object at rest will stay at rest, object in motion will stay in motion

2. Force: F=ma applying force produces acceleration (think seatbelt sign)
3. Action & Rxn: Every action there is an equal and opposite reaction ABCDE "do your job" Primary Survey - answer- Airway obstruction is major cause of preventable trauma deaths Hemorrhage is the most common cause of mortality in trauma Airway-get definitive airway Circulation-IV access and IVF Disability-assess LOC GCS scale Exposure-get your pt naked! temperature control -hypothermia=acidosis, coagulopathy, low O Hemorrhage Control-STOP THE BLEED replace volume loss, use tourniquet-note tourniquet time -<6yo IO access preferred over central line MTP -1:1:1 pRBC:plasma:platelet -pt receiving >10 units pRBC w/in 24 hrs admit Herniation - answer- Abnormal protrusion of brain tissue through opening where increased ICP is
4. uncal
5. central (transtentorial)
6. cingulate
7. transcalvarial infratentorial
8. upward cerebellar
9. tonsillar Secondary Brain Injury - answer- Prevent secondary injury esp. hypoxia & hypotension Pre hospital: oxygenation, prevent aspiration, field stabilization and triage of GCS Concussions - answer- An immediate disruption of brain activity that is temporary Early GCS, PERRL, VS HA, vertigo, tinnitus, balance, sleep disturbance, and mood change can go on for months educate pt of s/s Recc liberal use of head CT esp in anticoag pts Spinal Column and Cord Injuries - answer- Blunt mechanism -deceleration MVC falls -hypo/hyperflexion -axial load vertical compression Violence Penetrating trauma -missile injury (bullet, knife) -stabbing -impalement

Vertebral anatomy - answer- 33 total vertebrae 7 cervical C1 majority parasympathetic exit C2 axis 12 thoracic 5 lumbar 5 sacral (fused) 5 coccyx (fused) Dermatomes - answer- Cord Syndromes - answer- Incomplete injury Anterior Brown-Sequard Conus Medullaris Cauda equine Anterior Cord Injury - answer- motor function BELOW injury Brown-Sequard - answer- Hemisection of cord from penetrating injury Loss of motor on side of injury Loss of sensation on opposite side Conus Medullaris - answer- S4-5 exit at L May be a fx at L Cauda Equina - answer- Lumbar sacral nerve root w/ or w/o fx Complete Cord Injuries - answer- Quadriplegia/tetraplegia Paraplegia Quadriplegia/tetraplegia - answer- Below level of C1-T Paraplegia - answer- Below level of injury below T ABCDE Spinal Injuries - answer- A-airway! Assume injury C1-C4 definitive airway Below C4 may need airway B-RR effort paradoxical movement? C-fluids, neurogenic shock, poiklothermic D-Diagnosis Helical CT better MRI best peds; determine loss sensation pain, temp, pressure, vibration, proprioception, reflexes, bowel/bladder fxn Exposure associated injuries fxs etc. ASIA type A - answer- Complete no sensory/motor in sacral roots S4-5A. Complete no sensory/motor in sacral roots S4-

American Spinal Injury Association Impairment Scale - answer- A. Complete no sensory/motor in sacral roots S4- B. Sensory Incomplete-sensory preserved below the neurological level includes sacral segments AND no fxn preserved more than 3 levels below on either side of body C. Motor Incomplete-some sacral sparing less than 1/2 muscle groups motor strength

= D. Motor incomplete-preservation below injury. At least 50% muscle groups motor strength >= E. Normal motor and sensory intact ASIA type B - answer- Sensory Incomplete-sensory preserved below the neurological level includes sacral segments AND no fxn preserved more than 3 levels below on either side of body ASIA type C - answer- Motor Incomplete-some sacral sparing less than 1/2 muscle groups motor strength >= ASIA type D - answer- Motor incomplete-preservation below injury. At least 50% muscle groups motor strength >= ASIA type E - answer- Normal motor and sensory intact Most likely vertebrae to get injured - answer- C5-6 because it is the greatest point of flexion C2 Dens fx - answer- Hypertension injury more frequent in geriatric population Compression fx - answer- Axial load Degree of compression affects stability Thoracic & lumbar spine Chance fx - answer- Usually L1-2 teardrop fx May result in paraplegia and SMALL BOWEL INJURY from lap belt compression of lumbar spine Burst fx - answer- Fracturing in outward pattern may impinge cord can have compression & cord compression SCIWORA - answer- spinal cord injury without radiographic abnormality most common in peds population dislocation w/ spontaneous relocation cord injury evident imaging negative Post Traumatic Syringomyelia - answer- may need decompression and laminectomy or shunting

Autonomic Dysreflexia - answer- HTN, bradycardia, pallor, flushing Uncontrolled massive sympathetic reflex to noxious stimuli below level of lesion Cranial Nerves - answer- Facial structures - answer- Upper-intracranial injuries common -Frontal -Frontal sinuses -Upper nasal Middle-may cause loss of smell & communicate w/ orbit -Nasal -Lefort -Orbital Lower-can result in malocclusion or inability to open mouth completely & maybe abnormal facial expression -Maxilla -Mandible LeFort I - answer- Transverse fx b/w maxillary & orbital floor May include maxillary sinuses Lower maxilla and teeth and mobile/floating Nose & midface stable Assess for: Trismus Malocclusion Mandible fx Lefort II - answer- Incl. central maxilla, nasal area, ethmoid bones Tripod shape Grasping front teeth and palate causes movement to nose & upper lip w/o movement to orbital complex Signs: Caved in appearance Subcongunctival hemorrhage epistaxis CSF present, rhinorrhea=open skull fx Intubate this pt! Lefort III - answer- Complete craniofacial dysjunction Often assoc w/massive soft tissue ocular inuries TBI skull injuries, cribiform plate fx & dural tears Assess by gently rocking maxilla moves entire face Anticipate massive facial edema **Anticipate early intubation for airway protection!

Facial Trauma Assessment & Intervention - answer- A-airway! look for concomitant intracranial, thoracic, abdominal injuries & give O Secondary exam done @ head of bed! Assess symmetry & movement CNVII Paresthesia along 3 branches cranial nerve V CN V & C11 test corneal reflex in unconscious pt CN II & III pupil assessment Extracocular movemnents CN III, IV, VI PALPATE your pt. Crepitus?! Batlles sign? CSF leak? smell? CN 1 Eyes on different planes? orbital floor fx Intraocular pressure - answer- Normal is 10-22 mmHg Hyphema - answer- Blood in the anterior chamber Risk of re-bleed in 3-5 days Best rest/limit activity HOB elevated cycloplegic agents like atropine Eye patch Optic Nerve or Globe Rupture - answer- Requires urgent intervention Ophtho consults Tripod Fracture - answer- Separation of all 2 major attachments of zygoma from the face Oribit-o-zygomatic - answer- Presents w/ trismus, diploplia, numbness upper lip, lower eyelid, bilateral sinus area Diploplia may be associated w/ ocular proptosis or enopthalmos Naso-Ethmoidal-Orbital - answer- Associated w/ pain w/ eye movement Associated w/ lacrimal disruption Blowout fx - answer- due to compression and buckling of the orbital floor enopthalmos anesthesia diplopia infraorbital step-off deformity subcutaneous emphysema periorbital swelling proptosis PEARLS :) - answer- 60% pt suffering severe facial trauma have multisystem trauma 20-30% have concurrent TBI Zygoma is 2cd most fx facial bone

Blindness occurs 0.5-3% cases Neck Trauma MOI - answer- Blunt acct for 5% all injuries that occur from rapid deceleration Penetrating trauma most lethal injuries missile (Bullet, knife), stabbing, impalement, bites GSW-more destruction likely need OR intervention velocity can migrate in weird ways lwo velocity less significant injuries DO NOT label entrance/exit wounds Zone I Neck Trauma - answer- clavicle & sternal notch to cricoid cartilage Likely to go to OR Subclavian Vessels Brachiocephalic veins Common carotid arteries Jugular veins aortic arch esophagus lung apices C spine cranial nerves Zone II Neck Trauma - answer- Mid portion of neck-cricoid caritilage to angle of the mandible. Most carotid injuries occur here. Injuries may be managed by observation- usu not surgical depended on criticality Carotid & vertebral arteries Jugular veins Pharynx Larynx Trachea Esophagus C Spine/Cord Zone III Neck Trauma - answer- Angle of mandible to base of skull-difficult to assess hidden injury yet exploration can increase mortality or result in cranial nerve injury. Angiography will delineate site of injury. Embolization is a valuable modality Salivary & parotid glands Hypopharynx Vertebral bodies carotid arteries Jugular veins Cranial nerves IX-XII Denver Screening Criteria & EAST Guidelines - answer-

Neck assessment - answer- ABCs PALPATE your pt remove C collar look! ?anticoagulants/ETOH MOI blunt vs penetrating trauma Weapon related type, blade, length? Platysma: if penetrated may need surgical exploration, but new diagnostics (angiography, esophagoscopy, laryngoscopy) deem new standard esp in stable pt Baseline exam for mental status Denver Screening Criteria Hard Signs for neck trauma-emergent intervention - answer- Airway obstruction Pulsatile bleeding Expanding hematoma Unresponsive extensive SQ emphysema-this is why you palpate! Soft Signs for neck trauma-key info needs more dx - answer- voice changes wide mediastinum hemoptysis hematemesis dysphonia/dysphagia drooling bloody sputum bruit, thrill, Horners pain neck when turning Thinking of placing a nasal airway?! - answer- Nope! Not w/ facial fractures! When to do CXR - answer- Mandated in Zone 1 Hemothorax Pneumothorax Widened mediastinum Mediastinal emphysema Foreign bodies Benefits of CT - answer- It's the most accepted Helical scanning is the best CT Angiogram - answer- Vessels reconstruction may see subtle variances in vessel wall Excellent study for laryngeal & tracheal injuries Studies indicate as reliable as anteriography Bronchoscopy - answer- 100% accurate Thoracic Trauma Assessment - answer- 85% trauma patients need chest tube, obs, and pain management

Late deaths from thoracic blunt trauma causes - answer- missed multi organ system failure SIRS respiratory complications infections Reasons you die 3 hours post thoracic injury - answer- airway obstruction cardiac tamponade aortic disruption continued hemorrhage Six life threatening injuries - answer- 1. Laryngeotracheal injury/airway obstruction

2. Tension pneumothorax
3. Open pTX
4. Flail chest and pulmonary contusion
5. Massive hemothorax >1500 mL in pleural space, distended neck veins
6. Cardiac tamponade BECKS TRIAD, + FAST, PEA Beck's triad - answer- hypotension, JVD, muffled heart sounds Pathophysiologic Consequences of 6 life threatening chest injuries (must manage in primary survey) - answer- Hypoxia Hypoventilation Acidosis: respiratory/metabolic Inadequate tissue perfusion Common Findings in patient with chest trauma - answer- hypotension hypoxia tachycardia SOB tachypnea pleuritic CP diminished breath sounds subcutaneous emphysema Tension Pneumothorax - answer- Air accumulates w/in pleural space on inspiration but can't escape on expiration & creates one way valve When intrathoracic pressure exceeds CVP pressure, atria & vena cava compress which creates obstruction of blood flow to right heart Decrease in preload (venous return) & compromise cardiac output S/S Tension Pneumothorax - answer- CP, restlessness, severe agitation, dyspnea, tachycardia, hypotension, JVD, deviated trachea, breath sounds absent over affected side

Cardiac Tamponade - answer- Distended neck veins Decreased arterial BP Muffled heart sounds Management of Tension Pneumothorax - answer- 12-14 G catheter placed in 2-3rd intercostal space mid-clavicular line -releasing pressure won't relinflate lung -need chest tube 4-5th ICS midaxillary line Consideration if pt does not improve w/ tx for PTX - answer- tracheobroncial tree injury Open PTX aka "sucking chest wound" - answer- large defects of chest wall that stay open can lead to open PTX Visible bubbling/frothing blood as result penetrating trauma If open >2/3rd the diameter of trachea air follows path least resistance through chest wall w/ each inspiration leading to profound hypoventilation & hypoxia Management of open PTX - answer- 3 sided bandage Chest tube Intubation Definitive operation-urgent thoracotomy to evacuate blood clot & treat associated intrathoracic injury Irrigate, debride, close if possible Large defects may require flap closure Massive Hemothorax - answer- Intercostal & internal mammary vessels most injured Accumulation of >1500mL in pleural space & associated w/ s/s shock and hypoperfusion/respiratory distress Each hemothroax can hold up to 3L blood Class III or IV hemorrhage 36-40 F chest tube for easy drainage/prevent clotting Monitor chest tube output consider autotransfusion to reduce coagulopathy and inflammatory response to injury Assessment/Dx of Massive Hemothorax - answer- neck veins flat 2/2 hypovolemia or distended d/t intrathoracic blood hilar or great vessel disruption will present in severe shock NO breath sounds Percussion dullness Hemorrhagic shock >= 1500mL blood loss Management of Massive Hemothorax - answer- volume restoration & chest decompression autotransfusion operative intervention

<1500mL but still bleed may need chest tube 200ml/hr for 2-4 hours Persistent need for blood products=need for chest tube Penetrating anterior chest wounds medial to nipple line & posterior wounds medial to scapula should alert team to possible need for throacotomy d/t potential damage to great vessels, hilar structure, and heart w/ associated potential tamponade Flail chest and pulmonary contusion - answer- usually from high energy direct impact associated w/ multiple rib fractures blunt force produces underlying pulmonary contusions M&M r/t lung parenchymal injury rather than chest wall injury HIGH risk for PTX and HTX Flail chest signs and symptoms - answer- 2-3 rib fx in 2 places creating unstable segments Sternal flail chest separation of sternum from adjacent broken ribs or costochondral joints Often associated w/ pulmonary contusion Potential injury underlying organs Diagnosis can be clinical and seen on CXR palpation of abnormal respiratory motion and crepitation of ribs or cartilage fx can aid in dx accessory muscle use paradoxical movement may not be initially apparent in awake pt w/ muscle spasms, shallow respirations, splinting 2/2 pain or in pt who is on PPV usu seen w/in first 24 hours if not initially as pt ties hypoxemia pain hypoventilation labored breathing Flail chest - answer- Flail chest management - answer- Initial tx: adequate ventilation humidified O fluid/blood product resuscitation Definitive tx: ensure adequate oxygenation administer fluids judiciously provide analgesics to improve ventilation Signs of shock/distress intubate immediately! re-expand lungs provide analgesics need a thoracotomy? may need to fixate ribs w/ wires or plates to improve wall stability

Pulmonary contusion - answer- Most common mechanism is MVC Develops over time Usu associated w/ flail chest/rib fx In kiddos may be isolated w/o rib fx Bruising lung tissue and diffuse hemorrhage w/ interstitial and alveolar edema more interstitial intra-alveolar fluid increases which causes impaired gas exchange Pulmonary contusion symptoms - answer- hypoxemia & respiratory compromise bloody sputum and secretions CXR: patchy infiltrates Pulmonary contusion treatment mild - answer- Aggressive tx initially to avoid complications Mild: -oxygen -Sat monitoring -pulmonary toilet and analgesia -adequate ventilation -humidified O -fluid/blood product resuscitation -analgesics Pulmonary contusion tx moderate - answer- May require intubation w/ PEEP If not responding to conventional ventilation may need pressure control, PRV, PRVC, jet ventilation, analgesic support immediately intubate for s/s/ shock/distress Re-expand lungs Pulmonary toilet/hygiene Cardiac Tamponade - answer- Usually from penetrating injuries can be blunt Pericardial sac contains 20-30mL of serous fluid Clinical Signs of Cardiac Tamponade - answer- Hypotension & stay despite fluid resuscitation b/c of excessive right ventricle filling that causes interventricular septum to shift to the left=no CO Dyspnea Sense of impending doom=ischemia d/t pressure causing decreased coronary blood flow=acidosis Narrow pulse pressure low systolic high diastolic BECKS TRIAD: distended neck veins from elevated pulse pressure decreased arterial BP muffled hearts sounds Diagnosis of Cardiac Tamponade - answer- FAST

Echocardiogram Pericardial window Management of Cardiac Tamponade - answer- Airway! Need for intubation? Volume resuscitation Cardiac injury suspected=do pericardial window Extremis or hyptotensive? Do left thoracotomy Stable pt w/ para sternal penetrating wound pericardial window more appropriate through subxiphoid process + window do a median sternotomy Pericardiocentesis - answer- Done as a temporizing measure until pericardiotomy performed supine w/ HOB elevated 45 degrees 16-18 G needle w/ 60mL syringe Insert needle to side of xiphoid Popping sensation felt when pericardium entered Withdrawl of even small amount can be life saving Repeat as frequently as needed SBP >90mmHg Latrogenic injury to CAD, myocardium risk w/ procedure Traumatic Aortic Disruption - answer- common cause sudden death for MVC @ scene Survival depends on incomplete laceration near ligamentum arteriosum or hematoma @ site High index suspicion May not have specific symptoms Delay in recognition result in early hospital rupture 81% assoc injuries in pt w/ blunt aortic injuries Traumatic Aortic Disruption Assessment - answer- Some pt don't complain, be aware! Intrascapular pain New onset murmur, upper extremity HTN, bilateral femoral pulse deficit CXR widened mediastinum >8cm concerning supine >6cm upright film Ct scan best screening Traumatic Aortic Disruption Groups - answer- Aortic injuries 2 main groups -full thickness tear: hemodynamically unstable -contained injury: watch hemodynamically unstable d/t lac of another organ Pre-op management traumatic aortic disruption - answer- pt who cannot be operated on immediately include: pt who need transfer severe pulmonary or head injuries hemodynamically unstable damage to control pressures pt w/ coagulopathy, hypothermia, acidosis medical co-morbidities

severe sepsis or burns SBP <120mmHg REDUCE RISK OF RUPTURE control BP! short acting anti-hypertensive Operative repair Aortic injury indicated for - answer- hemodynamic instability large volume hemorrhage from chest tubes contrast extravasation from CT rapidly expanding mediastinal hematoma penetrating aortic injury Rib Fractures - answer- Most commonly inured component of thoracic cage Rib 1-3 fx severe force, high mortality w/ assoc injuries 1st rib fx most complicated -watch for scapula, humerus, clavlicle fx -watch for heat, neck, spine, great vessel injury Ribs 4-9 pulmonary contusion and PTX -anterioposterior compression of thoracic cage ribs bow out w/ fx in midshaft -force applies ribs forces end bones into thorax Ribs 10-12 suspect intra-abdominal injury Atelectasis and pneumonia secondary injuries Diagnosis & Management Rib Fx - answer- Localized pain, tenderness on palpation CXR Visible deformity CT scan of chest Management: pain control! taping, rib belts, external splints are a NO NO intercostal block, epidural anesthesia, systemic analgesia surgical fixation plating severe cases i.e. flail chest deformity or >3 rib fxs Sternal, Scapular, Clavicular Fxs - answer- Diagnosis CT CXR Mangment pain control or operative repair Pneumothorax - answer- Collection air in pleural space, visceral pleura, parietal pleura After blunt or penetrating trauma CXR but CT is gold standard Decreased breath sounds are not always helpful indicator esp if pt hyperventilating pain/shock Hemothorax - answer- Blood accumulates in pleural cavity d/t laceration of lung/intercostal vessels, internal mammary artery laceration thoracic spine fx/dislocation Tracheobronchial Tree Injury - answer- Injury b/w cricoid and lobar bronch

Rare, but potentially life threatening Tracheobronchial tree assessment - answer- HIGH suspicion if lung does properly inflate after chest tube insertion or persistent air leak in chest tube MOST telling sign is emphysema, impt touch pt!!! Pneumomediatinum can result DEFINITIVE dx made via DIRECT bronchoscopy CT only 90% sensitive ET tubes can obscure injury watch out Traumatic Diaphragmatic Injury - answer- Usually from high speed MVC or severe blow to abdomen like penetrating trauma let sided more common watch for other injuries left hemidiaphragm injury more common than right if it is suspect liver injury Right sided hemidiaphragm is less common, but more severe Traumatic Diaphragmatic Injury Assessment - answer- Suggestive findings: -abnormal position of nasogastric tube -ipsilateral hemidiaphragm elevation -abdominal visceral herniation into chest Initial CXR usu normal esp in of PPV Any injury b/w 3rd and 5th cervical vertebrae may affect breathing d/t phrenic nerve/diaphragm Diaphragm primarily innervated by phrenic nerve formed from cranial nerve C3, C4, C Peristaltic sounds in chest Delayed rupture-unexplained CP or tachypnea CXR MOST IMPT DX STUDY will see hemidiaphragm bowel pattern in the chest gastric tube curls in chest HTX WATCH s/s masked by other injuries penetrating trauma small tear then as abd pressure rises becomes bigger=herniation/strangulation intestine If dx not made in first 4 hours can be missed for months or years Traumatic Diaphragmatic Injury Treatment & DX - answer- Exploratory laparotomy Dx laparoscopy in penetrating trauma Operative repair necessary b/c visceral herniation can occur even in small defects DX: Primary survey CXR FAST CT chest for hemodynamically stable pts

Esophageal Injuries Incidence/MOI - answer- Penetrating trauma more common for injury Esophageal injuries are often associated w/ sever concomitant injuries that may mask findings, delaying dx until mediastinitis or empyema develop Esophageal perforation SURGICAL EMERGENCY Perforation @ 3 points: -Crico-pharyngeus muscle -Borcho-aortic constriction -Entry into diaphragm Esophageal Assessment/Symptoms - answer- fluid losses may cause respiratory compromise perforation=pain @ site injury or radiation of pain to neck, shoulders, chest, throughout abdomen tear in abdominal portion of esophagus shows as peritoneal irritation from gastric contents-dyspnea & pleuritic pain CXR shows: pneumomediastinum, pleural effusion, mediastinal contour changes, gas bubble in NG tube or esophagus Dx made by endoscopy or esophagography or CT Esophageal Tear Management - answer- Evaluation difficult b/c happens w/ other injuries Primary repair is the gold standard of care GOAL minimize bacterial contamination and enzyme erosion, gastric decompression, abx coverage, drain wound, sx repair Watch For: peritoneal irritation respiratory compromise mediastinitis fistula formation b/w esophagus and portion of respiratory tract Complications after esophageal tear repair - answer- peritonitis mediastinitis intra abdominal abscess esophageal stricture reoccurance of esophageal fistula Blunt cardiac injury - answer- Occur from mild myocardial contusion to frank cardiac chamber rupture Results 2/2 compression, deceleration, blast or direct force to chest Critical injury resulting in hemodynamic stability rare B Blunt cardiac injury assessment - answer- +/- chest pain tenderness & pain over chest wall --> tamponade

ECG: most commone tachy arrhythmias & conduction disturbance i.e. first degree heart block & BBB Six life threatening injuries - answer- Tension PTX PTX Open PTX Flail chest Pulmonary contusion Massive HTX Cardiac tamponade Abdominal Trauma Incidence and MOI - answer- 3rd cause of death-hemorrhage-after 48 hrs it is d/t sepsis and complications accompanied by other injuries that lead to higher M&M Mechanism: Blunt trauma most common injury think acceleration/deceleration MVC 75% Blunt force compresses anteriorly and compresses abdominal viscera against posterior rib cage or verterbral column=crush injuries shearing d/t sudden deceleration=lacerations to both hollow & solid organs stretch injuries cause intimal vessel tears causing organ infarction Seatbelt Sign - answer- Indicates intra-abdominal injury in 1/3rd of pts Classic seatbelt injuries are: abdominal wall disruptions, hollow viscous injuries, flexion-distraction fx of lumbar vertebrae aka chance fx Penetrating injuries Impalement higher mortality Missile injury harder to assess b/c bullets travel Hemorrhage and hollow viscous injuries can lead to chemical and bacterial peritonitis Initial & Ongoing Assessment - answer- *Unrecognized trauma is frequent and preventable cause death FAST indicated BUT remember DOES NOT detect diaphragmatic, intestine, or pancreatic injuries If AUS performed too early can miss injury also do serial FASTS on pt w/ significant MOI Tertiary survey is essential at 24-48 hour mark after injury Methodical exam important so don't miss injury Get pt to CT if stable Role of diagnostic laparoscopy - answer- screening or diagnostic tool invasive procedure w/ some limitations used t detect/exclude certain findings may reduce rate of negative laparotomies

can be used to detect/exclude findings of hemoperitoneum, organ injury, intestinal spillage, peritoneal penetration *most useful in evaluation of possible diaphragmatic injuries esp penetrating thoracoabdominal injuries on the left side Ductal injuries? - answer- Endoscopic retrograde cholangiopancreatography aka ECRP may complement CT to r/o ductal injury STABLE trauma pt most accurate test in pt w/ hyperamylasemia or post pancreatic surgery pt Liverinjury - answer- Most commonly injured organ MVC most common cause Liver Assessment - answer- suspect in any pt w/ blunt injury to right side s/s assoc w/ pain to area & shock like symptoms if severe penetrating trauma produce range of inquiries FAST initially used to r/o free fluid CT scan preferred modality choice if stable would really like helical CT Inquiries graded from I to VI Liver Management - answer- Non-operative management if stable *presence of hemoperitoneum does not mandate exploratory lap in stable pt Angioembolization -IF CT shows ARTERIAL BLUSH or CONTRAST POOLING may need angioembolization this may be enough to stabilize pt -packing may be required if bleeding persists and pt is not stable enough for OR watch out for abdominal compartment syndrome Damage control laparotomy if pt hemodynamically unstable and can't wait for OR Reasons pt return to ED after liver injury/repair - answer- Hemobilia RUQ pain, jaundice, days-weeks post injury Abscess intrahepatic or biloma Biliary fistula usually resolve w/o sx if output is >300mL/day Arterial-portal venous fistula may need more embolization Sepsis Liver failure Spleen injuries MOI/Assessment - answer- One of most commonly injured organs d/t rib fx Suspect liver w/ any blunt injury to left side esp left lower rib fx May have referred pain to left shoulder caused by blood irritation to phrenic nerve=Kehr's sign Spleen Diagnostics - answer- CT scan preferred Injuries graded I to VI Helical CTs more sensitive for OR vs non OR

Active extravasation of contrast indicates ongoing bleeding & need for urgent intervention Classic triad no always present, but is: left hemidiaphragm elevation, LLL atelectasis, pleural effusion *ASA Splenic Injury Scale Grade I - answer- subcapsular hematoma (<10% of surface area) capsular laceration (<1cm depth) Splenic Injury Grade II - answer- subscapular hematoma (10-15% surface area) intraparenchymal hematoma (<5cm diameter) laceration 1-3cm depth Splenic injury Grade III - answer- Subscapular hematoma >50% surface area/expanding Intraparencymal hematoma >5cm/expanding Laceration >3cm in depth or involving trabecular vessels ruptured subcapsular or parenchymal hematoma Splenic Injury Grade IV - answer- Lacerationn involving segmental or hilar vessels w/ major devascularisation (>25% spleen) Splenic Injury Grade V - answer- Shattered spleen HIlar vascular injury w/ splenic devascularization Non-Operative Splenic Management - answer- need to go to ICU for frequent assessments serial abdominal exams serial H&H and INR repeat abd CT 48-72 hrs post injury grade I-II Grade III-IV angioembolization may be utilized for selected pts in these two categories Operative Splenic Intervention - answer- splenorrhaphy & partial splenectomy splenectomy for unstable pts & those w/ high grade injuries unstable pts w/ multiple abdominal organ injuries may require damage control laparotomy w/ aggressive fluid resuscitation MTP Post Op Splenic Complications - answer- bleeding thrombocytosis gastric distention pancreatitis infection OPSI (post splenectomy sepsis) more common kids 1-5 years post sx flu like symptoms, shock/sepsis, DIC 50% mortality

vaccinations, education, medical bracelet Continuum of Care Splenic Injury - answer- Give pneumococcal H. influenza and meningococcal vaccines Recommend all 3 vaccines given in 14 days post splenectomy or just prior to dc when f/up might not happen Pancreas Incidence/MOI - answer- Uncommon injury Rupture often tears ductal system & allows pancreatic juices blunt injury forces against vertebral column & ruptures it

90% pancreatic injuries have another abd injury Dx intraoperatively or on CT scan *Injury may not be evident for 24-72 hours Most commonly caused by penetrating trauma early deaths 2/2 hemorrhage. Late death=infxn Pancreatic Assessment - answer- Peritoneal symptoms can appear later *Umbilical/flank ecchymosis CT scan is exam of choice Initial complaints are vague w/in 6-24hrs after injury c/o midepigatric or back pain Associated w/ chance fx L2 seatbelt fx b/c pancreas sits @ L Pancreas Management - answer- Options depend on site/severity Exploratory laparotomy w/ primary repair injury goal is to control hemorrhage Late death=sepsis, ARDS, multiple organ failure Complications=pancreatic fistulas, pseduocyst formation (esp kids), pancreatic abscess, recurrent hemorrhage, pancreatitis Small intestine MOI - answer- direct blows/crush MVC=shearing force Spinal cord injury may occur w/ bowel trauma & can mask s/s Blunt injury more common w/ high speed MVC Small Intestine Assessment - answer- + seatbelt sign should raise the index of suspicion for sm bowel injury watch for peritonitis trend serum lactate serial FAST exams Small intestine management - answer- bleeding controlled prior exploration multiple defects=bowel resection complete transection/multiple injuries tx operatively w/ bowel resection & primary anastomosis abx should be continues and are given peroperatively to reduce incidence post-op infxn after contaminaton

Duodenum Incidence/MOI - answer- Majority caused by penetrating trauma Blunt duodenum injuries usu result d/t compression injuries Mortality variable & occurs w/ multi organ injury Injury usu dx intraoperatively One of most commonly missed injuries during ex lap Again, might not show 24-72 hours Chance fx, vertebral column fx watch for duodenal injury b/c lies retroperitoneally Dx >24hrs post injury increased mortality & complications occur 64% duodenal injuries Duodenum Assessment - answer- Peritoneal s/s may not be there right away Initial complaint vague show up 6-24hr post injury CT scan findings show hemorrhage, free air, oral contrast leak, intramural hematoma Found intraoperatively Duodenum Management - answer- Options depend severity injury Primary repair/resection w/ anastomosis Pancreatic duodenectomy Control hemorrhage Non-operative management reqs close obs for serial exams Jejunum & Ileum Incidence/MOI - answer- Jejunum lies in umbilical region Ileum lies in hypogastric & pelvic region Seat belts will crush b/w vertebrae & solid object Ugh again watch over 6-24 hours Stomach Incidence/MOI - answer- More common in children Stomach strong wall not usu torn by blunt trauma unless severe Commonly include adjacent organs Stomach Assessment - answer- s/s variable non specific Severe epigastric or abd pain, tenderness & signs peritonitis: fever, abd pain, diarrhea Bloody output from gastric tube Free air on radiograph or CT scan Inflammatory response is d/t chemical irritation Stomach Management - answer- Gastric decompression Sx intervention If contamination peritoneal irrigation etc. Watch post op complications Large Intestine - answer- Complication d/t fecal contamination Transverse colon is most often injured in penetrating trauma Blunt trauma injures colon @ immobile segments think of splenic flexure, rectosigmoid junction, most common contusions Mortality affected associated injuries

Large intestine management/complications - answer- early recognition of contamination watch post op complications hemorrhage control antibiotics rectal injuries - answer- majority rectal injuries are associated w/ penetrating trauma may occur w/ blunt trauma w/ sever pelvic fx foreign bodies=rectal perforation in some cases usually require operative intervention Retroperitoneal injuries percentage - answer- 70-80% retroperitoneal hemorrhage d/t blunt trauma involving pelvic fx Abdominal arterial vascular injuries - answer- Arterial injuries The retroperitoneal space can hold up to 4L blood esp w/ concurrent pelvic or spine trauma Initial c/o s/s are vague like abd pain, back pain, hypoactive bowel sounds, tender abdominal mass CT is best Angioembolization depending on vessel wounds contaminated? autogenous graft Abdominal venous injury - answer- low pressure & capable of tamponade emergent operative repair if unstable pt dx tests for stable pt i.e CT suspect uncontrolled bleed if not re: shock mgmt. Tx Abdominal vascular injuries - answer- Aggressive fluid resuscitation Pressure & pack Operative repair to include ligation & grafting PRN Complications vessel stenosis thrombotic/embolitic event dehiscence @ suture line infection bleeding abdominal compartment syndrome GU trauma incidence/MOI - answer- 60-80% GU injuries have associated injuries -pelvic fx -lower rib fx -L spine transverse process fx -AKI -renal artery/vein injuries d/t shearing force Urethral trauma more common in males Renal trauma more common kids than adults

Geriatric pts who already have renal problems are @ higher risk MOI blunt mechanism most common compression forces to abdomino-pelvic regions result in an intraperitoneal bladder injury traffic related mechanism majority GU in kids penetrating injury d/t direct hit & high energy weapon Genitourinary physical assessment - answer- bruising, ecchymosis, bleeding on abdomen, flank, pelvic, & perineal areas abdomen flat/distended external trauma signs Grey's Turner sign -echhymosis over posterior aspect of 11th rib or 12th rib or the flank may indicate renal trauma/retroperitoneal injury percuss abdomen UROLOGY consult BEFORE Foley catheter Butterfly pattern=classic sign for urethral, pelvis, retroperitoneal injury Diffuse perineal bruising can be sign pubic rami/symphysis diastases fx Boggly, palpable prostate or displaced=urethral injury GU Diagnostic Imaging - answer- CT scan provides the most precise ID of GU injury CT scan gold standard for evaluating injury in kidneys Urethrogram all patients prior to Foley insertion CT scan & cystogram/urethrogram together to dx urethral or bladder injury Pt must be hemodynamically stable Pt must have renal fxn to tolerate scan Urethrogram should be performed in all pts w/ suspected urethral injury or stricture PRIOR to Foley insertion. Indicated when there is the presence of blood at the urethral meatus after blunt/penetrating trauma Penil fx w/ gross hematuria & floating prostate indication for RUG Renal Trauma - answer- Blunt mechanism is biggest cause Suspect fx in 10th-12th rib acceleration/deceleration injury shearing of renal artery/vein Grading Renal Injuries - answer- Grade I & II are majority of injuries, usu non-operative & serial exams/observation Grade III, IV, V major renal injuries where renal fxn is threatened by nephron damage or accumulation of free urine & blood in collecting ducts Grade III can be watched non-operatively Grade IV or V may require sx intervention if there is a large perineal hematoma, urine extravasation, or large areas of parenchymal damage

Rhabdomylosis - answer- Rhabdomyolysis/myoglobinuria caused by muscle damage that can occur w/ burn injuries, orthopedic injuries associated w/ soft tissue damage, crush injuries, & in pts who were immobile for prolonged period of time Rhabdomylosis Monitoring - answer- Watch color of urine Administer sodium bicarb to facilitate excretion of these substances Mannitol used to facilitate diuresis Myoglobin can precipitate renal tubules can result in renal failure. Dialysis can be used in pts w/ elevated K+ or in AKI KEY POINTS: increased myoglobin d/t injured muscle

4 hours ischemia can cause irreversible injury 6 hours necrosis tubules occur Hematuria - answer- Hematuria is NOT present in pts w/ all renal injury Degree hematuria present is in NO WAY r/t degree injury Hematuria does correlate w/ likelihood of another intra-abdominal injury Urine dipstick & UA poor indicators GU injury Dx by abdominal CT scan or IVP (IV pyelogram) Renal Trauma Complications - answer- Sepsis from infections, abscesses, UTI, polynephritis Urinomas: Grade III & IV associated w/ urinomas usually caused by extravasation of urine during injury percutaneous drainage essential to prevent further injury to collecting ducts Renal atrophy, uretheral stricture & obstructive hydronephrosis & loss of renal fxn are all complications that can occur. They are rare but can occur up to 4 weeks after injury Oliguric phase - answer- urinary output <20mL/hr labs abnormal lasts 10-20 days Non-oliguric phase - answer- Urinary output remains normal to high labs abnormal lasts 805 days Acute renal failure in trauma patients - answer- Usually dx by observing rise in BUN and plasma creatinine and decrease in UO ARF is classified as oliguric when UO is <400mL/24 hours. Anuria is defined as UO of <100mL/24 hours May be need for temporary dialysis No nephrotoxic drugs Ureter Injuries - answer- Relatively uncommon but needs to be considered in penetrating abdominal, flank, lumbar, and chest injuries. 80% ureter injuries are from GSW May be missed w/ IVP & on laparotomy b/c retroperitoneum location

If loss of kidney fxn occurs in unilateral injury, pt may remain asymptomatic if contralateral kidney maintains fxn transient increase in serum CREAT & BUN w/o decreased UO ureter transection reqs sx repair & ureterostomy to divert urine flow, wound irrigation, competent drainage & prophylactic antibiotics, internal stenting Bladder Injuries - answer- Hematuria; Common with pelvic injuries; Retrograde cystogram may help define injury; CT with cystogram; Surgery for rupture more common blunt trauma rather than penetrating MOST COMMON bladder injury is extraperitoneal bladder injury 95% bladder injuries are extraperitoneal and are from laceration of bone after pelvic fx S/S Bladder Injury - answer- blood @ meatus &/or scrotum lower abdominal injury pelvic fx suprapubic pain inability to void despite urge to urinate hematuria redness & tenderness in the perineal/lower abdominal/pelvic area abdominal wall muscle ridgitidy, spasm, distention, or involuntary guarding dysuria displacement prostate mortality low, but usu die from hemorrhage & sepsis Urethral Injuries - answer- More common in males than females Urethral trauma in females almost always associated w/ pelvic fx In males prostatic posterior urethral injuries usually caused by pelvic fx as well complete rupture of urethra more common in kids Posterior uretheral injuries most often associated w/ pelvic fx Anterior urethral injuries associated w/ GSW/penetrating, industrial/self-inflicted wounds, straddle S/S urethral injury - answer- NO URINARY CATHETHERS UNTIL urethrogram urge to urinate, but can't suprapubic pain hematuria (microscopic) blood @ external meatus Perineal bruising aka butterfly pattern bruising scrotal hematoma boggy prostate (males) ABD rigidity, spasm, involuntary guarding Urethral MOI Anterior Injuries - answer- straddle injury crushing of urethra against symphysis pubis GSW stab wound