Trauma II Board Review - PowerPoint PPT Presentation

Loading...

PPT – Trauma II Board Review PowerPoint presentation | free to download - id: 69107e-ZjNjM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Trauma II Board Review

Description:

Traumatic Placental Abruption In blunt trauma, ... Fractures of the 1st and 2nd ribs are highly suggestive of aortic injury. Not associated with increased risk. C. – PowerPoint PPT presentation

Number of Views:76
Avg rating:3.0/5.0
Slides: 49
Provided by: clint
Learn more at: http://sinaiem.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Trauma II Board Review


1
Trauma II Board Review
  • Tiffany Truong, MD, MPH
  • Mount Sinai School of Medicine
  • December 5, 2007

2
  • A 50 yo M presents after a MVA with bruising over
    his sternum. He states that he hit his chest
    against the steering wheel. His VS are
    unremarkable, and he is asymptomatic except for
    anterior chest wall tenderness at the site of
    bruising. The init CXR and sternal view reveal a
    sternal fx but are otherwise nl. There are no
    other assoc injuries. EKG is nl. Which of the
    following is the MOST appropriate management plan
    for this pt?
  • A. Admit for 24 hr telemetry monitoring.
  • B. Perform 2 sets of CE and TPN tests, and dc if
    neg.
  • C. Perform echocardiogram in the ED, and dc if
    neg.
  • D. After a repeat EKG in 6 hrs, dc the pt with
    pain medication, without any further testing.

3
  • ANSWER D
  • A. Admit for 24 hr telemetry monitoring. An
    isolated sternal fx is no longer considered an
    indicator of significant blunt myocardial injury
    and does not mandate a work up for BMI.
  • B. Perform 2 sets of CE and TPN tests, and dc if
    neg. CK lacks specificity. Tpn may be elevated in
    pts with BMI, but their elevation doesnt predict
    clinically significant complications, and they
    should not be used as screening tests in the ED.
  • C. Perform echocardiogram in the ED, and dc if
    neg. Echo is not useful as a screening test for
    detecting clinically significant BMI.
  • D. After a repeat EKG in 6 hrs, dc the pt with
    pain medication, without any further testing.

4
Blunt Myocardial Injury (aka Myocardial Contusion)
  • Clinical features pt in MVA gt 35 MPH c/o chest
    pain
  • Significant BMI unlikely, 3 develop
    dysrythymia, 70 have tachycardia out of
    proportion to blood loss, conduction defect
  • CXR greatest value for finding assoc injuries
    pulmonary contusion, rib fx. Sternal fx no longer
    considered impt.
  • Initial EKG predictive of subsequent clinically
    significant EKG events recommend initial EKG
    followed by repeat EKG in 4-6 hrs.
  • Common ekg abnormalities are PVCs, 1st degree av
    block, RBBB (Right ventricle is closest to
    anterior chest wall)

5
  • A 35 yo M presents with a single stab wound to R
    lateral chest. He has no other injuries. His VS
    are blood pressure 150/80 and HR 100. His breath
    sounds are clear and equal b/l. Which of the
    following is the BEST management plan for this
    patient?
  • A. Obtain a CXR, and discharge pt if negative.
  • B. Obtain a CXR on presentation, and perform a
    second one in 6 hrs. Discharge pt if both are
    neg.
  • C. Obtain a CXR on presentation, and perform a
    second one in 12 hrs. Discharge pt if both are
    neg.
  • D. Discharge home, and instruct the pt to return
    if he develops shortness of breath.

6
  • ANSWER B
  • A. Obtain a CXR, and discharge pt if negative. A
    PTX may be delayed after a stab wound, 12 of pts
    will require chest tube for delayed hemothorax or
    pneumothorax.
  • B. Obtain a CXR on presentation, and perform a
    second one in 6 hrs. Discharge pt if both are
    neg.
  • C. Obtain a CXR on presentation, and perform a
    second one in 12 hrs. Discharge pt if both are
    neg. Most of PTX will be evident on CXR performed
    at 6 hours.
  • D. Discharge home, and instruct the pt to return
    if he develops shortness of breath.

7
  • Which of the following statements regarding
    blunt thoracic aortic rupture is correct?
  • A. External evidence of chest trauma is often
    lacking.
  • B. Fractures of the 1st and 2nd ribs are highly
    suggestive of aortic injury.
  • C. Most common symptom is dysphagia.
  • D. Most tears occur at the ascending aorta.
  • E. Obscuration of the aortic knob is the most
    sensitive sign on CXR.

8
  • ANSWER A
  • A. External evidence of chest trauma is often
    lacking. Fewer than 50 have external signs of
    trauma.
  • B. Fractures of the 1st and 2nd ribs are highly
    suggestive of aortic injury. Not associated with
    increased risk.
  • C. Most common symptom is dysphagia. Most common
    sx interscapular or retrosternal pain, absent in
    up to ¾ of pts.
  • D. Most tears occur at the ascending aorta.
    Descending aorta.
  • E. Obscuration of the aortic knob is the most
    sensitive sign on CXR. Widening of mediastinum.

9
Thoracic Aortic Disruption
  • 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
    27 of patients with aortic injury.
  • Angiography gold standard, but now CT.
  • Tx BP management and surgical repair.

10
  • 76 yo F unrestrained driver in MVA p/w
    respiratory distress on arrival and has
    paradoxical movement of her R chest during
    labored respirations. BP 138/76, HR 118, RR 28,
    O2sat 88 RA. BS auscultated on both sides of
    chest. ABG on high flow O2 pH 7.37, Po2 78, HCO3
    28. 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 fr
    pain
  • D. R chest wall moves outward with inspiration
    and inward with expiration.
  • E. Tx involves analgesia and adhesive tap or rib
    belt to stabilize chest.

11
  • 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.

12
Flail Chest
  • Segmental fractures in 2 or more locations on the
    same rib
  • Paradoxical inward movement of the chest wall
    during inspiration and outward movement during
    expiration
  • Significant blunt trauma (MVA, fall from height)
  • Initially compensate for reduce TV by
    hyperventilate, when fatigue or underlying
    pulmonary injury develops -gt respiratory failure.
  • Tx Supplemental oxygen is the first-line
    treatment. Pain control with analgesia to allow
    pt to fully expand lungs and improve ventilation.
    Early intubation considered.
  • External chest wall support reduce VC, worsen
    respiratory function, no indicated.
  • 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

13
  • Which of the following is the BEST method for
    diagnosing a diaphragmatic injury in a patient
    with a stab wound to the left upper quadrant?
  • A. Computed tomography.
  • B. Diagnostic peritoneal lavage.
  • C. Upper gastrointestinal series.
  • D. Laparoscopy.

14
  • ANSWER D
  • A. CT. CT may miss small diaphragmatic injuries
    from penetrating trauma.
  • B. DPL. The threshold RBC count for a positive
    lavage should be lowered since diaphagmatic
    injury does not result in as much bleeding as
    with solid organ injury.
  • C. Upper GI series. Upper GI series may
    demonstrate displacement of viscera into chest
    after blunt diaphragmatic injury, but this does
    not occur acutely after penetrating trauma due to
    the small size of the hole.
  • D. Laparoscopy. With penetrating trauma, the
    diagnosis of diaphragmatic injury is difficult
    and may only be made with laparotomy or
    laparoscopy.

15
Diaphragmatic Injuries
  • Majority caused by penetrating trauma.
  • Occur predominately on L side b/c liver protects
    right side. Most likely sight of injury
    posterio-lateral portion of L diaphragm
  • Often difficult to visualize on initial chest
    x-ray (nasogastric tube may enhance diagnosis).
    Abdominal viscera or NG tube seen in thoracic
    cavity
  • CT scan or laparoscopy more sensitive, although
    diaphragmatic ruptures can be missed even on
    initial CT.
  • Delays in diagnosis lead to increased morbidity
    and mortality.

16
  • A 27 yo M p/w 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?
  • A. DPL
  • B. Wound exploration with a cotton swab.
  • C. CT with IV contrast.
  • D. CT with oral, rectal, and IV contrast.

17
  • 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.

18
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.

19
  • An 8 yo M hit a car door while riding his bike.
    Upon presentation, he is crying and c/o abdominal
    pain. His PE reveals age-appropriate vital signs,
    an abrasion across his epigastrium, and diffuse
    tenderness w/o rebound or guarding. Labs are
    notable for amylase 220 Iu. UA reveals 2-5 RBCs
    per HPF. Which of the following is correct?
  • A. Despite a nl abd CT, the child could have
    pancreatic injury and should be admitted for
    observation.
  • B. An IV pyelogram should be performed for
    evaluation of hematuria.
  • C. The bowel is the most commonly injured organ
    following this mechanism.
  • D. Duodenal hematoma is unlikely if a repeat exam
    reveals no abdominal tenderness.

20
  • ANSWER A
  • A. Despite a nl abd CT, the child could have
    pancreatic injury and should be admitted for
    observation.
  • B. An IV pyelogram should be performed for
    evaluation of hematuria. In pts with nl VS and
    microscopic hematuria, no further wu is indicated
    as long as pt is asymptomatic.
  • C. The bowel is the most commonly injured organ
    following this mechanism. Spleen, followed by
    liver, are most commonly injured organs, with
    bowel injury occuring lt 5 of pts with blunt abd
    trauma.
  • D. Duodenal hematoma is unlikely if a repeat exam
    reveals no abdominal tenderness. Duodenal
    hematomas can be missed by both PE and CT. A
    contrast-CT can aid in diagnosis, but if this
    injury is suspected based on mechanism of injury,
    the child should be admitted for further eval and
    observation.

21
Traumatic Pancreatitis
  • 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 cant 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

22
  • A 52 yo back seat passenger presents after being
    involved in a high speed MVA. Inspection of the
    abdomen reveals the findings 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

23
  • 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

24
Seat Belt Sign
  • 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.

25
  • Which of the following statements regarding
    lightening 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.

26
  • 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.

27
Lightening
  • 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.

28
  • In approximately what percentage of patients is
    laparotomy required for an anterior abdominal
    wall stab wound?
  • A. 10.
  • B. 30.
  • C. 50.
  • D. 70.
  • E. 90

29
  • ANSWER B
  • A. 10.
  • B. 30.
  • C. 50.
  • D. 70.
  • E. 90

30
Anterior Abdominal Stab Wounds
  • 2/3 pts have peritoneal violation, of these ½
    (30 of those injured) will require laparatomy.
  • General rule of thumb 1/3 dont penetrate
    peritoneum, 1/3 penetrate but dont 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.

31
  • 75 yo F slips and falls in her bathtub and
    injures her L hip. She is helped out of the
    bathrub by her daughter but is unable to ambulate
    secondary to pain. In the ED, initial hip and
    pelvis xrays are neg. The pt continues to have
    pain in her L leg when she attempts to ambulate.
    What is the next most appropriate management?
  • A. Admit to a rehab facility for physical therapy
  • B. Order inlet and outlet views of the pelvis
  • C. Order MRI of the left hip
  • D. Order nuclear bone scan
  • E. Prescribe narcotic pain meds and a walker and
    arrange for outpatient orthopedic evaluation.

32
  • ANSWER C
  • A. Admit to a rehab facility for physical
    therapy. Underlying occult fx would be worsen
    with early mobilization.
  • B. Order inlet and outlet views of the pelvis.
    Unlikely to diag occult fem neck fx.
  • C. Order MRI of the left hip
  • D. Order nuclear bone scan. Useful but more
    sensitive after 72 hours.
  • E. Prescribe narcotic pain meds and a walker and
    arrange for outpatient orthopedic evaluation.
    Underlying occult fx would be worsen with early
    mobilization.

33
Occult Femoral Neck Fracture
  • Suspect in elderly pt when hip pain prevents
    ambulation but plain films dont reveal a
    fracture.
  • MRI within 24 hours on injury often reveals a fx
    that was imperceptible at time of injury.
  • Senile osteoporosis leading cause of femoral neck
    fx with minor trauma.

34
  • Which of the following statements regarding
    blunt traumatic placental abruption is correct?
  • A. In pregnant women with blunt trauma, less than
    40 of fetal losses result from placental
    abruption.
  • B. More than ½ of women with placental abruption
    can present with no vaginal bleeding.
  • C. Position of the placenta affects the incidence
    of traumatic placental abruption.
  • D. Ultrasonography is the best method for
    identifying placental abruption.
  • E. Women with traumatic placental abruption are
    less likely to have coagulopathy than are those
    w/o traumatic placental abruption.

35
  • ANSWER
  • A. In pregnant women with blunt trauma, less than
    40 of fetal losses result from placental
    abruption. Leading cause of fetal loss aside from
    maternal death in TPA.
  • B. More than ½ of women with placental abruption
    can present with no vaginal bleeding.
  • C. Position of the placenta affects the incidence
    of traumatic placental abruption. Does not
    affect.
  • D. Ultrasonography is the best method for
    identifying placental abruption. Fetal distress
    most sensitive for TPA, measured by
    cardiotocographic monitoring.
  • E. Women with traumatic placental abruption are
    less likely to have coagulopathy than are those
    w/o traumatic placental abruption. Women w/ TPA
    54 x more likely to have DIC.

36
Traumatic Placental Abruption
  • In blunt trauma, shearing and deceleration forces
    separate placenta from uterine wall.
  • Disrupts gas exchange b/ fetus and mother -gt
    hypoxia -gt fetal distress.
  • In blunt trauma, 50-70 fetal loss result fr
    placental abuption.
  • Classic vaginal bleeding, abd pain, amniotic
    fluid leaking, fetal distress 63 women may not
    have vaginal bleeding.
  • Diag Cardiotoco monitoring.

37
  • A 20 yo F presents for evaluation of a sprained
    ankle. She sustained the injury while running,
    despite pain, she was able to talk for a short
    distance and is able to walk 4 steps in the ED.
    Radiographs are not indicated if the exam also
    reveals absence of bony tenderness
  • A. About the anterior talotibial joint
  • B. Along the posterior edge of the distal 3cm and
    the tips of both malloeli and tibial plafond.
  • C. Along the posterior edge of the distal 6 cm
    and of the tips of both malleoli
  • D. Over the deltoid and anterior talofibular
    ligaments
  • E. Over the distal tibia laterally prox fibula.

38
  • ANSWER C
  • A. About the anterior talotibial joint
  • B. Along the posterior edge of the distal 3cm and
    the tips of both malloeli and and tibial plafond.
  • C. Along the posterior edge of the distal 6 cm
    and of the tips of both malleoli
  • D. Over the deltoid and anterior talofibular
    ligaments
  • E. Over the distal tibia laterally prox fibula.

39
Ottowa Ankle Rules
  • Ankle radiographs are required if either of the
    following is present
  • Patient is unable to bear weight and walk 4 steps
    immediately after the injury and at the time of
    evaluation.
  • Or there is tenderness along the posterior edge
    of the distal 6 cm of the tips of either
    malleolus.
  • If patient does not meet either of these
    criteria, radiographs are not necessary.
  • Rules does not apply to subacute/chronic injuries
    or patients with multiple injuries, intoxication,
    or altered sensation, neurologic injuries, or
    head injuries.

40
  • Which of the following is the most common
    mechanism of injury associated with isolated
    blunt pancreatic injury in children?
  • A. Direct blow to the abdomen from a pitched
    baseball.
  • B. Fall from a 2nd-story window onto a hard
    surface
  • C. Handlebar injury during neighborhood bicycle
    accident
  • D. Lap-belt injury during a high-speed motor
    vehicle crash
  • E. Straddle injury from a fall onto a rigid
    horizontal pole.

41
  • ANSWER C
  • A. Direct blow to the abdomen from a pitched
    baseball. Commotio cordis.
  • B. Fall from a 2nd-story window onto a hard
    surface. Other solid organs more likely from wide
    distribution of forces.
  • C. Handlebar injury during neighborhood bicycle
    accident
  • D. Lap-belt injury during a high-speed motor
    vehicle crash. Bowel injury and lumbar spine
    injury.
  • E. Straddle injury from a fall onto a rigid
    horizontal pole. Genitourinary injuries.

42
Commotio Cordis
  • Sudden cardiac death or near sudden cardiac death
    after blunt, low-impact chest wall trauma in the
    absence of structural cardiac abnormality
  • Ventricular fibrillation is the most commonly
    reported arrhythmia induced
  • Young male athletes aged 518 years
  • Blows to the chest from baseballs, softballs,
    hockey pucks, and other objects.
  • Death is usually instantaneous, and successful
    resuscitation is uncommon.

43
  • A 62 yo M presents after being struck in the
    head with a piece of lumbar 2 hours earlier. His
    wife says that he was dazed immediately after
    the accident but did not lose conciousness. He
    says he has a headache. GCS 15. PE is normal
    except for 3 cm scalp hematoma. The next
    appropriate next step in management is
  • A. Admit to ED observation unit for serial
    neurologic exam.
  • B. Discharge with head injury instructions.
  • C. Obtain a noncontrast CT head and neurosurgery
    consult.
  • D. Obtain a noncontrast CT head and if negative,
    discharge.
  • E. Obtain skull x-rays to screen for more severe
    intracranial injury.

44
  • ANSWER D
  • A. Admit to ED observation unit for serial
    neurologic exam.
  • B. Discharge with head injury instructions.
  • C. Obtain a noncontrast CT head and neurosurgery
    consult.
  • D. Obtain a noncontrast CT head and if negative,
    discharge.
  • E. Obtain skull x-rays to screen for more severe
    intracranial injury.

45
ACEP Clinical Policy for mild TBI
  • Definition At least one met
  • 1) Any of loss of consciousness (LOC) of less
    than 30 minutes and GCS score of 13 to 15 after
    this period of LOC
  • (2) any loss of memory of the event immediately
    before or after the accident, with posttraumatic
    amnesia of less than 24 hours
  • (3) any alteration in mental state at the time
    of the accident (eg, feeling dazed, disoriented,
    or confused).
  • Is there role for plain film skull xrays in
    assessment of acute mild TBI in the ED?
  • No, the literature does not support the use of
    skull xrays in the ED. (level B recommendation)

46
ACEP Clinical Policy for mild TBI
  • Which patients with acute MTBI should have a
    noncontrast head CT scan in the ED?
  • A head CT scan is not indicated in those
    patients with MTBI unless one of the following is
    present headache, vomiting, age greater than 60
    years, drug or alcohol intoxication, deficits in
    short-term memory, physical evidence of trauma
    above the clavicle, or seizure. (level A)

47
ACEP Clinical Policy for mild TBI
  • Can a patient with mild TBI be safely discharge
    from the ED if the head CT shows no acute
    injury?
  • Pt can be discharged under the following
    conditions (level C)
  • Pt presents at least 6 hrs after injury
  • Clinical exam is normal
  • Head CT shows no acute abnormality
  • Pt under supervision of a responsible 3rd
    party can be discharged sooner than 6 hrs

48
  • The End!
About PowerShow.com