Trauma Board ReviewTrauma Board ReviewPart IPart I

Tiffany Truong, MD, MPHTiffany Truong, MD, MPH

October 3, 2007October 3, 2007

A 94-year-old woman is sent from a local A 94-year-old woman is sent from a local nursing home after falling from her wheelchair. nursing home after falling from her wheelchair. Her transfer note asks you to “rule-out Her transfer note asks you to “rule-out subdural.” You know that:subdural.” You know that:

A.A. Blood collects in the subdural space more Blood collects in the subdural space more quickly than in an epidural hematoma.quickly than in an epidural hematoma.

B.B. Infants and toddlers rarely develop subdural Infants and toddlers rarely develop subdural hematomas.hematomas.

C.C. Most subdural hematomas are due to Most subdural hematomas are due to penetrating head injury.penetrating head injury.

D.D. The risk of developing a subdural hematoma The risk of developing a subdural hematoma decreases with age.decreases with age.

E.E. The usual mechanism is a sudden The usual mechanism is a sudden acceleration-deceleration of brain acceleration-deceleration of brain parenchyma and tearing of bridging veins.parenchyma and tearing of bridging veins.

Answer EAnswer ESubdural hematomas (SDH)Subdural hematomas (SDH) are caused are caused by sudden acceleration- deceleration of by sudden acceleration- deceleration of brain parenchyma with subsequent tearing brain parenchyma with subsequent tearing of the bridging veins. Brains with of the bridging veins. Brains with extensive atrophy, such as the elderly and extensive atrophy, such as the elderly and alcoholics, are more susceptible. Children alcoholics, are more susceptible. Children under the age of two are also at increased under the age of two are also at increased risk. Blood tends to collect more slowly risk. Blood tends to collect more slowly than epidural hematomas because of its than epidural hematomas because of its venous origin. venous origin.

Subdural HematomaSubdural Hematoma

Bridging veins between dura and ararchnoidBridging veins between dura and ararchnoidPresentationPresentation

Decreased mental status and LOCDecreased mental status and LOC May have lucid periodMay have lucid period

ClassificationClassification Acute <24 hours (hyperdense=white on CT)Acute <24 hours (hyperdense=white on CT) Subacute = 24 hours – 2 weeks (isodense)Subacute = 24 hours – 2 weeks (isodense) Chronic > 2 weeksChronic > 2 weeks

Six times more common than epiduralSix times more common than epiduralHigher mortality rate than epiduralsHigher mortality rate than epiduralsElderly, alcoholics are at increased riskElderly, alcoholics are at increased riskCT scan: crescent-shaped lesionCT scan: crescent-shaped lesion

Subdural HematomaSubdural Hematoma

Epidural hematomaEpidural hematoma

Usually arterial bleed (middle meningeal artery) Usually arterial bleed (middle meningeal artery) between skull and durabetween skull and dura

““Coup”Coup”

Underlying brain injury usually not severeUnderlying brain injury usually not severe

PresentationPresentation LOC -> then Lucid intervalLOC -> then Lucid interval Skull fracture lac MMASkull fracture lac MMA Dilated ipsilateral pupil and contralateral hemiparesis Dilated ipsilateral pupil and contralateral hemiparesis

– late findings– late findings

CT: biconcave or lenticularCT: biconcave or lenticular

Epidural hematomaEpidural hematoma

The most common CT scan abnormality The most common CT scan abnormality found after severe closed head injury is:found after severe closed head injury is:

A.A. cerebral contusion.cerebral contusion.

B.B. epidural hematoma.epidural hematoma.

C.C. intracerebral hemorrhage.intracerebral hemorrhage.

D.D. subdural hematoma.subdural hematoma.

E.E. traumatic subarachnoid hemorrhage.traumatic subarachnoid hemorrhage.

Answer EAnswer E

Traumatic subarachnoid Traumatic subarachnoid hemorrhagehemorrhage – – Blood within the CSF, caused by Blood within the CSF, caused by

disruption of subarachnoid vessels. disruption of subarachnoid vessels. Most common CT finding in mod/severe Most common CT finding in mod/severe

TBITBI Associated with a worse prognosis in Associated with a worse prognosis in

these patients. these patients.

You have just received by ambulance a You have just received by ambulance a comatose19-year-old college student with comatose19-year-old college student with severe midface fractures following a collision severe midface fractures following a collision with a lamppost. Medics were unsuccessful in with a lamppost. Medics were unsuccessful in field intubation, so you prepare to do rapid field intubation, so you prepare to do rapid sequence intubation, knowing that:sequence intubation, knowing that:

A.A. Thiopental can raise both systemic and Thiopental can raise both systemic and intracerebral blood pressure.intracerebral blood pressure.

B.B. Etomidate is contraindicated.Etomidate is contraindicated.C.C. Ketamine reduces intracerebral pressure, Ketamine reduces intracerebral pressure,

but may cause severe laryngospasm.but may cause severe laryngospasm.D.D. Pretreatment with lidocaine is not indicated.Pretreatment with lidocaine is not indicated.E.E. Succinylcholine should be avoided unless a Succinylcholine should be avoided unless a

defasciculating dose of a nondepolarizing defasciculating dose of a nondepolarizing agent has first been given.agent has first been given.

Answer EAnswer E

Lidocaine effectively attenuates the cough reflex, Lidocaine effectively attenuates the cough reflex, hypertensive response, and increased ICP associated hypertensive response, and increased ICP associated with intubation. with intubation. Thiopental may also be effective but should not be Thiopental may also be effective but should not be used in hypotensive patients. used in hypotensive patients. If succinylcholine is used, premedication with a If succinylcholine is used, premedication with a subparalytic dose of a nondepolarizing agent should subparalytic dose of a nondepolarizing agent should be considered if time permits, since fasciculations be considered if time permits, since fasciculations produced by succinylcholine may increase ICP. produced by succinylcholine may increase ICP. Etomidate has beneficial effects on ICP by reducing Etomidate has beneficial effects on ICP by reducing cerebral blood flow and metabolism. cerebral blood flow and metabolism. Ketamine should be avoided because it increases ICP. Ketamine should be avoided because it increases ICP.

A 19-year-old man was assaulted and robbed A 19-year-old man was assaulted and robbed outside the baseball stadium after “bat day.” He outside the baseball stadium after “bat day.” He has an obvious mid-face fracture and unstable has an obvious mid-face fracture and unstable mandible. His left eye is mildly proptotic with mandible. His left eye is mildly proptotic with severe conjunctival swelling and a subconjunctival severe conjunctival swelling and a subconjunctival hemorrhage. Visual acuity is limited to counting hemorrhage. Visual acuity is limited to counting fingers. His pupil is fixed and mid-point. You must fingers. His pupil is fixed and mid-point. You must now:now:

A.A. arrange for stat consult with ophthalmologist.arrange for stat consult with ophthalmologist.B.B. avoid sedation and analgesia, so as not to avoid sedation and analgesia, so as not to

mask intracranial injuries.mask intracranial injuries.C.C. obtain intraocular pressures.obtain intraocular pressures.D.D. apply a firm occlusive eye patch and arrange apply a firm occlusive eye patch and arrange

outpatient follow-up.outpatient follow-up.E.E. perform emergent lateral canthotomy.perform emergent lateral canthotomy.

Answer EAnswer E

If a patient with orbital emphysema complains of If a patient with orbital emphysema complains of a sudden decrease in visual acuity in the a sudden decrease in visual acuity in the traumatized eye, air may have built up under traumatized eye, air may have built up under pressure in the orbit, causing cessation of blood pressure in the orbit, causing cessation of blood flow in the central retinal artery. Immediate flow in the central retinal artery. Immediate release of this pressure is necessary if the release of this pressure is necessary if the patient’s vision in that eye is to be saved. patient’s vision in that eye is to be saved. Performing a lateral canthotomy with cantholysis Performing a lateral canthotomy with cantholysis or an intraorbital needle aspiration of the trapped or an intraorbital needle aspiration of the trapped air may release the pressure. Accumulation of air may release the pressure. Accumulation of blood in the retro-orbital space may similarly blood in the retro-orbital space may similarly threaten vision and is treated by lateral threaten vision and is treated by lateral canthotomy.canthotomy.

Head Injury PearlsHead Injury Pearls

Cushing reflex: in response to rapid incr in Cushing reflex: in response to rapid incr in ICP, hypertension + brady ICP, hypertension + brady Isolated linear nondepressed skull fx: no Isolated linear nondepressed skull fx: no treatmenttreatmentBasilar skull fx: temporal bone, Basilar skull fx: temporal bone, hemotympanum, CSF otorrhea/rhinorrhea, hemotympanum, CSF otorrhea/rhinorrhea, periorbital ecchymosis, retriauricular periorbital ecchymosis, retriauricular ecchymosisecchymosisDiffuse axonal injury is the most common brain Diffuse axonal injury is the most common brain injury resulting in coma.injury resulting in coma.TBI: mild (GCS>14), mod (9-13), severe (<8)TBI: mild (GCS>14), mod (9-13), severe (<8)

A 6 yo male was the rear-seated passenger in a A 6 yo male was the rear-seated passenger in a moderate-speed MV crash. He reported that his “legs moderate-speed MV crash. He reported that his “legs were numb” immediately following the collision, but were numb” immediately following the collision, but within 30 min these symptoms resolved. His exam was within 30 min these symptoms resolved. His exam was entirely normal, and his plain radiographs were normal. entirely normal, and his plain radiographs were normal. Which of the following is correct:Which of the following is correct:

A.A. Regardless of his normal exam and radiographs, he Regardless of his normal exam and radiographs, he requires urgent MRI.requires urgent MRI.

B.B. He can safely be discharged with close fu as long as He can safely be discharged with close fu as long as his exam remains normal during a 4-hr observation. his exam remains normal during a 4-hr observation.

C.C. Flexion-extension radiographs should be performed Flexion-extension radiographs should be performed to rule out any ligamentous injury.to rule out any ligamentous injury.

D.D. CT scan of the C-spine should be performed to CT scan of the C-spine should be performed to assess for surrounding soft tissue swelling.assess for surrounding soft tissue swelling.

Answer AAnswer ASpinal cord injury without radiographic Spinal cord injury without radiographic abnormality (SCIWORA)abnormality (SCIWORA) can present in can present in children with even minor trauma. Increased children with even minor trauma. Increased flexion of the spine and spinal column in flexion of the spine and spinal column in pediatric pts can permit spinal cord injury without pediatric pts can permit spinal cord injury without fx or dislocation. fx or dislocation. MRI should be performed and neurosurg should MRI should be performed and neurosurg should be consulted for any pediatric pt with neuro be consulted for any pediatric pt with neuro complaints following trauma, even if complaints complaints following trauma, even if complaints are transient. are transient. Admission for observation is generally Admission for observation is generally mandated. Flex-ext radiographs and CT do not mandated. Flex-ext radiographs and CT do not exclude diagnosis of SCIWORA.exclude diagnosis of SCIWORA.

A 60-yo alcoholic female was BIBEMS with c/o A 60-yo alcoholic female was BIBEMS with c/o weakness. The patient’s friends found her weakness. The patient’s friends found her “passed out” at the bottom of the the stairs this “passed out” at the bottom of the the stairs this morning. They put her in bed, but she still c/o morning. They put her in bed, but she still c/o weakness. On PE, she has 4+ reflexes weakness. On PE, she has 4+ reflexes throughout, 3/5 UE strength b/l, 4/5 LE muscle throughout, 3/5 UE strength b/l, 4/5 LE muscle strength. What is her most likely diagnosis:strength. What is her most likely diagnosis:

A.A. Subdural hematomaSubdural hematoma

B.B. Anterior cord syndromeAnterior cord syndrome

C.C. Central cord syndromeCentral cord syndrome

D.D. Cauda equinaCauda equina

Answer CAnswer CCentral Cord SyndromeCentral Cord Syndrome Fall with hyperextension injuryFall with hyperextension injury Weaker in upper extremities compared to Weaker in upper extremities compared to

lower extremitieslower extremities

Brown Sequard syndrome Brown Sequard syndrome Hemisection of spinal cord, due to penetrating Hemisection of spinal cord, due to penetrating

traumatrauma Loss of ipsilateral motor, position, vibrationLoss of ipsilateral motor, position, vibration Contralateral loss of pain and temp below Contralateral loss of pain and temp below

level of injurylevel of injury

Spinal Cord Injuries (cont)Spinal Cord Injuries (cont)

Anterior Cord SyndromeAnterior Cord Syndrome Flexion of cervical spineFlexion of cervical spine Bilateral paralysis of arms and legs equallyBilateral paralysis of arms and legs equally Due to arterial occlusion, disruption blood flow Due to arterial occlusion, disruption blood flow

to spinal cordto spinal cord

Cauda EquinaCauda Equina Distal sacral roots- peripheral nerve injuryDistal sacral roots- peripheral nerve injury Variable motor/sensory loss in LE, sciatica, Variable motor/sensory loss in LE, sciatica,

bowel/bladder dysfunction, saddle anesthesiabowel/bladder dysfunction, saddle anesthesia

Spinal Cord Injuries (cont)Spinal Cord Injuries (cont)

Spinal ShockSpinal Shock Partial or complete injuryPartial or complete injury Areflexia, loss of sensation, flaccid paralysis Areflexia, loss of sensation, flaccid paralysis

below level of lesionbelow level of lesion Flaccid bladder and loss of rectal toneFlaccid bladder and loss of rectal tone Bradycardia and hypotensionBradycardia and hypotension

A 16-month-old child is brought to the A 16-month-old child is brought to the emergency department immobilized in cervical emergency department immobilized in cervical spine precautions. The child was an spine precautions. The child was an unrestrained passenger in a moderate-speed unrestrained passenger in a moderate-speed rapid-deceleration motor vehicle collision. You rapid-deceleration motor vehicle collision. You are concerned about possible neck injury, are concerned about possible neck injury, keeping in mind that:keeping in mind that:

A.A. Pseudosubluxation of C3 on C4 is common in Pseudosubluxation of C3 on C4 is common in children. children.

B.B. The small neck muscles make fractures more The small neck muscles make fractures more common than ligamentous injury. common than ligamentous injury.

C.C. The predental space should not exceed 4 to 5 mm The predental space should not exceed 4 to 5 mm in children younger than 10. in children younger than 10.

D.D. Anatomic features of the cervical spine approach Anatomic features of the cervical spine approach adult patterns at around 12 years of age.adult patterns at around 12 years of age.

E.E. If the child was ambulatory at the scene, spinal If the child was ambulatory at the scene, spinal precautions are unnecessaryprecautions are unnecessary

Answer CAnswer CPseudosubluxation of C2 on C3 - occurs in Pseudosubluxation of C2 on C3 - occurs in approximately 40% of children up to adolescence. approximately 40% of children up to adolescence. Anatomic features of the cervical spine approach adult Anatomic features of the cervical spine approach adult patterns between the ages of 8 and 10 years. patterns between the ages of 8 and 10 years. On a lateral cervical spine view the distance between the On a lateral cervical spine view the distance between the anterior aspect of the odontoid process and the posterior anterior aspect of the odontoid process and the posterior aspect of the anterior ring of C1, the so-called predental aspect of the anterior ring of C1, the so-called predental space, should not exceed 5 mm in a child. space, should not exceed 5 mm in a child. Compared to adults, the child has relatively Compared to adults, the child has relatively underdeveloped neck musculature and a head that is underdeveloped neck musculature and a head that is disproportionately large and heavy compared to the disproportionately large and heavy compared to the body, leading to fewer fractures and more ligamentous body, leading to fewer fractures and more ligamentous injuries. injuries.

A 16 yo high school football player is A 16 yo high school football player is brought in by ambulance after brought in by ambulance after experiencing beck pain when he experiencing beck pain when he “speared” another player with his helmet. “speared” another player with his helmet. Paramedics had immobilized his neck on Paramedics had immobilized his neck on scene. He is neurologically intact. Which scene. He is neurologically intact. Which cervical spine injury is most likely?cervical spine injury is most likely?

A.A. Bilateral facet dislocation Bilateral facet dislocation B.B. Hangman fracture Hangman fracture C.C. Jefferson fracture Jefferson fracture D.D. Odontoid fractureOdontoid fractureE.E. Teardrop fractureTeardrop fracture

Answer CAnswer CJefferson fx – Jefferson fx – axial loading forcesaxial loading forces Burst fx of C1Burst fx of C1 UnnstableUnnstable

Hangman fxHangman fx Hyperextension, knot of noose placed anteriorlyHyperextension, knot of noose placed anteriorly Located in pedicles of C2, with C2 displacing Located in pedicles of C2, with C2 displacing

anteriorly on C3anteriorly on C3 UnstableUnstable Today most common – head on MVAToday most common – head on MVA Associated with prevertebral swelling and cause Associated with prevertebral swelling and cause

respiratory obstructionrespiratory obstruction

Cervical Spine Fractures (cont)Cervical Spine Fractures (cont)

Odontoid fx – most common is type IIOdontoid fx – most common is type II

Teardrop fx Teardrop fx Extreme flexionExtreme flexion Complete disruption of all ligamentous Complete disruption of all ligamentous

structures at the level of injurystructures at the level of injury UnstableUnstable

32 yo man p/w stabbed in the L side of his neck with a 32 yo man p/w stabbed in the L side of his neck with a pocket knife. Injury if inferior to angle of mandible, pocket knife. Injury if inferior to angle of mandible, superior to cricoid cartilage, post of superior to cricoid cartilage, post of sternocleidomastroid. Depth of wound unclear, but sternocleidomastroid. Depth of wound unclear, but penetrates platysma. There is no bleeding from wound penetrates platysma. There is no bleeding from wound and no evidence of tracheal deviation or JVD. PE: no and no evidence of tracheal deviation or JVD. PE: no carotid bruits, no stridor, no SQ emphysema, strong carotid bruits, no stridor, no SQ emphysema, strong carotid pulses b/l, nl neuro exam. Other than pain to carotid pulses b/l, nl neuro exam. Other than pain to wound area, pt is asymptomatic. VS: BP 128/82, HR wound area, pt is asymptomatic. VS: BP 128/82, HR 86, R 16, O2sat 99% RA. Which of the following about 86, R 16, O2sat 99% RA. Which of the following about the pt is correct?the pt is correct?

A.A. Can be discharged home after neg local wound Can be discharged home after neg local wound exploration.exploration.

B.B. Injury mandates an esophagram and Injury mandates an esophagram and esophagoscopyesophagoscopy

C.C. Injury mandates laryngoscopy and bronchoscopyInjury mandates laryngoscopy and bronchoscopyD.D. Injury mandates local wound exploration in the EDInjury mandates local wound exploration in the EDE.E. Observation alone is appropriate.Observation alone is appropriate.

Answer BAnswer B

Penetrating Neck InjuryPenetrating Neck Injury

Any wound which violates platysmaAny wound which violates platysmaInjuries-most occur in Zone IIInjuries-most occur in Zone II Vascular > CNSVascular > CNS Peripheral nerve > brachial plexusPeripheral nerve > brachial plexus

Vascular injuries require proximal and Vascular injuries require proximal and distal controldistal controlDeath=CNS, exsanguination, airway Death=CNS, exsanguination, airway compromise (intubate early)compromise (intubate early)

Penetrating Neck InjuryPenetrating Neck InjuryHard SignsHard Signs

B/P EDB/P ED

Arterial BleedingArterial Bleeding

Expand hematomaExpand hematoma

Dimished carotid pulseDimished carotid pulse

Thrill / bruitThrill / bruit

Focal deficitsFocal deficits

Hemothorax > 1LHemothorax > 1L

Bubbling woundsBubbling wounds

Hemoptysis/Hemoptysis/hematemsishematemsis

Soft SignsSoft Signs

StridorStridor

HoarsenessHoarseness

Vocal cord paralysisVocal cord paralysis

Subcut. AirSubcut. Air

CN VII injuryCN VII injury

Tracheal deviationTracheal deviation

Nonexpanding Nonexpanding hematomahematoma

Unexplained brady Unexplained brady (w/o CNS injury)(w/o CNS injury)

Penetrating Neck InjuryPenetrating Neck Injury

Hard signs + unstable -> surgical exploration in Hard signs + unstable -> surgical exploration in OROR

Stable patientsStable patients Zone I: angiogram, esophagram/endoscopy, Zone I: angiogram, esophagram/endoscopy,

bronchoscopybronchoscopy Zone III: angiographyZone III: angiography Zone II: exploration or triple study (angio + Zone II: exploration or triple study (angio +

esophgram + bronchoscopy)esophgram + bronchoscopy)

Blunt Neck traumaBlunt Neck trauma

Rare due to protection of head, shoulders and Rare due to protection of head, shoulders and chestchestMechanism: steering wheel, dashboard, shoulder Mechanism: steering wheel, dashboard, shoulder belt shearing forces, clothes line injuriesbelt shearing forces, clothes line injuriesLaryngotracheal and pharyngoesophageal Laryngotracheal and pharyngoesophageal injuries can be subtle require diagnostic imaginginjuries can be subtle require diagnostic imagingCarotid artery injury: pseudoaneurysm or Carotid artery injury: pseudoaneurysm or dissectiondissection Mechanism: hyperextension, hyperflexion, direct blow, Mechanism: hyperextension, hyperflexion, direct blow,

intra-oral trauma, basilar skull fractureintra-oral trauma, basilar skull fracture Neurologic symptoms may be delayedNeurologic symptoms may be delayed

What is the most commonly injured What is the most commonly injured organ of the genitourinary tract?organ of the genitourinary tract?

A.A. UrethraUrethra

B.B. KidneyKidney

C.C. BladderBladder

D.D. UreterUreter

Answer BAnswer BKidney - the most commonly injured organ Kidney - the most commonly injured organ of the GU systemof the GU system Contusions (92%), followed by lacerations, Contusions (92%), followed by lacerations,

renal pedicle injuries, and renal ruptures or renal pedicle injuries, and renal ruptures or shattered kidneys.shattered kidneys.

Bladder – 2Bladder – 2ndnd most commonly injured most commonly injured Assoc with blunt trauma and pelvic fx.Assoc with blunt trauma and pelvic fx.

Urethral injuries – freqly in men, assoc Urethral injuries – freqly in men, assoc with pelvic fxwith pelvic fxUreter – rarestUreter – rarest most likely caused by penetrating trauma most likely caused by penetrating trauma

A 23-yo man was the unrestrained driver in a A 23-yo man was the unrestrained driver in a MVA. On PE, blood is noted at the urethral MVA. On PE, blood is noted at the urethral meatus, and there is perineal ecchymosis. meatus, and there is perineal ecchymosis. Which of the following is the next management Which of the following is the next management step?step?

A.A. Insertion of a coude catheterInsertion of a coude catheter

B.B. IV pyelogramIV pyelogram

C.C. Pelvic CT scanPelvic CT scan

D.D. Retrograde urethrogramRetrograde urethrogram

E.E. Urinalysis with sample obtained by Urinalysis with sample obtained by suprapubic route.suprapubic route.

Answer DAnswer DUrethral injury: suspected if Urethral injury: suspected if Blood at the urethral meatusBlood at the urethral meatus Perineal ecchymosisPerineal ecchymosis Blood in the scrotumBlood in the scrotum High-riding or nonpalpable prostateHigh-riding or nonpalpable prostate Pelvic fracturePelvic fracture

Transurethral cath contraindicatedTransurethral cath contraindicatedEvaluated by retrograde urethogram Evaluated by retrograde urethogram Only if urethral integrity compromised should Only if urethral integrity compromised should placement of suprapubic cath be consideredplacement of suprapubic cath be consideredIV pyelogram – eval kidney and ureter injuriesIV pyelogram – eval kidney and ureter injuries

A 25 yo man arrives in the ED reporting A 25 yo man arrives in the ED reporting a GSW to the R arm approx 15 min PTA. a GSW to the R arm approx 15 min PTA. Which of the following findings on PE Which of the following findings on PE suggest the presence of an arterial injury suggest the presence of an arterial injury requiring expeditious angiography or requiring expeditious angiography or surgical intervention?surgical intervention?

A.A. Diminished distal pulsesDiminished distal pulsesB.B. Injury to an anatomically related nerveInjury to an anatomically related nerveC.C. Unexplained hypotensionUnexplained hypotensionD.D. Proximity of the injury to major Proximity of the injury to major

vascular structuresvascular structures

Answer AAnswer A

Arterial Injury: Penetrating Arterial Injury: Penetrating Extremity TraumaExtremity Trauma

Hard SignsHard Signs

Absent/diminished Absent/diminished pulsespulses

Obvious arterial bleedObvious arterial bleed

Large expanding or Large expanding or pulsatile hematomapulsatile hematoma

Audible bruitAudible bruit

Palpable thrillPalpable thrill

Distal ischemiaDistal ischemia

Soft SignsSoft Signs

Small stable Small stable hematomahematoma

Injury to anatomically Injury to anatomically related nerverelated nerve

Unexplained Unexplained hypotensionhypotension

h/o hemorrhageh/o hemorrhage

Prox of injury to major Prox of injury to major vascular structurevascular structure

Complex fractureComplex fracture

Arterial Injury: Penetrating Arterial Injury: Penetrating Extremity TraumaExtremity Trauma

Hard signs: expeditious angiography and/or Hard signs: expeditious angiography and/or surgical interventionsurgical interventionSoft signs: inpatient admission for observation Soft signs: inpatient admission for observation and repeat examsand repeat examsNo hard or soft: Observe in ED 3-12 hrs, No hard or soft: Observe in ED 3-12 hrs, discharge home with close fu.discharge home with close fu. No signs of arterial bleedNo signs of arterial bleed No bone or nerve injuryNo bone or nerve injury No developing compartment syndromeNo developing compartment syndrome Minimal soft tissue defectMinimal soft tissue defect

A 22 yo woman who is 28 weeks pregnant A 22 yo woman who is 28 weeks pregnant presents after falling down 3 stairs and landing presents after falling down 3 stairs and landing on her right side. She denies abdominal pain, on her right side. She denies abdominal pain, contractions, and vaginal bleeding. Her PE is contractions, and vaginal bleeding. Her PE is unremarkable other than a small contusion to unremarkable other than a small contusion to her right flank. Which of the following is the her right flank. Which of the following is the appropriate management?appropriate management?

A.A. Discharge home with approp precautions Discharge home with approp precautions and 24-hr follow up.and 24-hr follow up.

B.B. External tocodynamics monitoring for 4 hrsExternal tocodynamics monitoring for 4 hrsC.C. US followed by external tocodynamics US followed by external tocodynamics

monitoring for 24 hrsmonitoring for 24 hrsD.D. US with discharge home if negativeUS with discharge home if negative

Answer BAnswer BPt is at risk for Placental Abruption although her Pt is at risk for Placental Abruption although her trauma appears minor.trauma appears minor.Major prospective study showed that minimal of Major prospective study showed that minimal of 4 hrs of external tocodynamic monitoring was 4 hrs of external tocodynamic monitoring was able to predict immediate adverse pregnancy able to predict immediate adverse pregnancy outcome:outcome: < 3 contractions her hour – discharge< 3 contractions her hour – discharge 3-7 C/H: monitor 24 hours3-7 C/H: monitor 24 hours > 8 contractions: higher risk of placental abruption, > 8 contractions: higher risk of placental abruption,

none occurred in patients < 8 C/Hnone occurred in patients < 8 C/H

US is not sensative to exclude placental US is not sensative to exclude placental abruption.abruption.

Which of the following is an indication for Which of the following is an indication for emergency department cesarean emergency department cesarean delivery after maternal trauma?delivery after maternal trauma?

A. Absence of fetal heart tonesA. Absence of fetal heart tones

B. Fundal height at 19 cmB. Fundal height at 19 cm

C. GSW to uterus with vaginal bleedingC. GSW to uterus with vaginal bleeding

D. Maternal death after 5 minutes of D. Maternal death after 5 minutes of profound shock and a 26-week fetus.profound shock and a 26-week fetus.

E. Solitary GSW to head with stable E. Solitary GSW to head with stable vitals signs of the mother.vitals signs of the mother.

Answer DAnswer DIndications for Perimortem C-section:Indications for Perimortem C-section: Fetus viable – cardiac activity on USFetus viable – cardiac activity on US Gestational age > 23 weeksGestational age > 23 weeks

Survival from postmortem cesarean Survival from postmortem cesarean delivery unlikely 15 mins after maternal delivery unlikely 15 mins after maternal death.death.No specific duration of death beyond No specific duration of death beyond which C section is contraindicated.which C section is contraindicated.GSW to uterus or solitary GSW to head GSW to uterus or solitary GSW to head with stable VS are not indication for with stable VS are not indication for emergency ED C section.emergency ED C section.

A 19 yo man is BIBEMS. He was the A 19 yo man is BIBEMS. He was the unrestrained driver in a single-car crash and unrestrained driver in a single-car crash and was ejected from the vehicle after it hit a tree. was ejected from the vehicle after it hit a tree. He is amnestic to the event, and there is odor He is amnestic to the event, and there is odor of alcohol on his breath. His main complaints of alcohol on his breath. His main complaints are chest and abdominal pain. VS: BP 78/48, are chest and abdominal pain. VS: BP 78/48, HR 122, R 16, T 37.5. Neck veins are flat. HR 122, R 16, T 37.5. Neck veins are flat. What is the most likely cause of his What is the most likely cause of his hypotension?hypotension?

A.A. Cardiac tamponadeCardiac tamponadeB.B. Cardiogenic shockCardiogenic shockC.C. HypovolemiaHypovolemiaD.D. Spinal ShockSpinal ShockE.E. Tension PTXTension PTX

Answer CAnswer CHemorrhagic shock presumed in any Hemorrhagic shock presumed in any hypotensive trauma pt until proven otherwise.hypotensive trauma pt until proven otherwise.Spinal Shock – bradycardic, hypotensionSpinal Shock – bradycardic, hypotensionCardiogenic shock (presumed 2 myocardial Cardiogenic shock (presumed 2 myocardial contusion) – distended neck veins contusion) – distended neck veins Hypotension due to decrease venous return Hypotension due to decrease venous return Tension PTX - distended neck veins, tracheal Tension PTX - distended neck veins, tracheal

deviation, tachypnea, decrease BS on side of PTXdeviation, tachypnea, decrease BS on side of PTX Cardiac tamponade - distended neck veins unless pt Cardiac tamponade - distended neck veins unless pt

has profound hypovolemiahas profound hypovolemia

Will SmithWill Smith

Mrs. Vladimir Ilyich Lenin AKA Mrs. Vladimir Ilyich Lenin AKA Nadezhda Krupskaya Nadezhda Krupskaya