46yoM. Rear-seated passenger in a moderate-speed MV crash 6yoM. Rear-seated passenger in a moderate-speed MV crash. “legs were numb” immediately following, but symptoms resolved in 30 min. Normal exam. Normal radiographs. Correct statementNeeds urgent MRI.Discharge with close f/u as long as his exam remains normal during a 4-hr observation.Flexion-extension radiographs should be performed to rule out any ligamentous injury.CT scan of the C-spine should be performed to assess for surrounding soft tissue swelling.
5Spinal Cord Injuries Central Cord Syndrome Brown Sequard Syndrome Hyperextension injuryUpper ext weaker than lower extBrown Sequard SyndromePenetrating – hemisection of spinal cordLoss of ipsilateral motor, position, vibrationContralateral loss of pain and temp below level of injury
6Spinal Cord Injuries Anterior Cord Syndrome Cauda Equina Flexion of cervical spineBilateral paralysis of arms and legs equallyDue to arterial occlusion, disruption blood flow to spinal cordCauda EquinaDistal sacral roots - peripheral nerve injuryVariable motor/sensory loss in LE, sciatica, bowel/bladder dysfunction, saddle anesthesia
7Spinal Cord Injuries Spinal Shock (misnomer) Partial or complete injuryAreflexia, loss of sensation, flaccid paralysis below level of lesionFlaccid bladder and loss of rectal tone
816 yo football player c/o neck pain s/o “speared” another player with helmet. Paramedics immobilized his neck on scene. Neurologically intact. Which cervical spine injury is most likely?Bilateral facet dislocationHangman fractureJefferson fractureOdontoid fractureTeardrop fracture
9C-Spine Fxs Jefferson fx (unstable) Hangman fx (unstable) Axial loading forceC1 burst fxHangman fx (unstable)Hyperextension (hanging)Located in pedicles of C2, with C2 displacing anteriorly on C3Head on MVCAssociated with prevertebral swelling and cause respiratory obstruction
10C-Spine Fxs Odontoid fx Teardrop fx (unstable) Type I – tip superiorly. Ligaments intact and stable fxType II – junction of odontoid and bodyMost commonType III – superior portion of C2 at base of odontoidTeardrop fx (unstable)Extreme flexionComplete disruption of all ligamentous structures at the level of injuryUnstable
11Flexion Injuries Simple wedge fx Clay shoveler’s fx Associated with post ligament disruptionClay shoveler’s fxAvulsion of spinous process of lower vertebrae stableAtlantooccipital and atlantoaxial dislocation w/ fxHigh instability and mortalityBilateral facet dislocation w/ fx
12Extension Injuries Ant arch of atlas avulsion fx – unstable Post arch of atlas fxCompression. Look for other fxs.Extension teardrop fxMost common at C2. Unstable
13Atlanto-occipital Joint Injury Severe flexion/extensionDisruption of all ligaments between occiput and atlas.Death usually immediately from stretching of brainstemCervical traction absolutely contraindicated
14Atlanto-occipital Joint Injury Very difficult to diagnose (CT 84% sens)Basion-dens distance > 12mmPosterior dens axial line > 12mm posterior or > 4mm anterior to basion
16Atlanto-axial Joint Injury Disruption of transverse ligamentExtremely unstable
17Which is classified as low probability of C-spine injury? 21yoM, no neck tenderness, intoxicated after MVC24yo, no neck tenderness and LLE weakness, pedestrian struck by motor vehicle32yoF, no neck tenderness, through-and-through lip laceration after MVC48yoM, no neck tenderness and R shoulder dislocation s/p falling from scaffolding82yoF, no neck tenderness and a L femoral neck fx s/p fall
18Nexus No midline tenderness No pain with neck movement No distracting injuryLong Bone Fracture (Most common DPI)Visceral Injury Necessitating surgical consultationLarge laceration, degloving injury, or crush injuryLarge BurnsAny injury producing acute functional impairmentNo NeurodeficitNo Alcohol or DrugsNo Altered Mental Status
19CCR Dangerous mechanism Fall from > 3ft or 5 stairs Axial load to headMVC >100km/hrCollision with motorized recreational vehicleBicycle collision
20Pediatric Head Trauma Can bleed enough intracranially for hypotension Vomiting, seizures, LOC are all poor in sensitivity and specificityScalp hematoma is indication
212yo s/p struck by car after running out into the street 2yo s/p struck by car after running out into the street. Most likely thoracic injury?Aortic dissectionCommotio cordisEsophageal rupturePulmonary contusionRib fractures
22Pediatric Chest Trauma Compliant chest walls and ribs relatively resistant to fracture forces transmitted to internal structuresPulmonary contusionsCommotio cordisRelatively mild blow to the chest (boards usually pitched baseball) ventricular fibrillationNo structural damage to the heartDeath usually instantaneous, and successful resuscitation is uncommon.
238 yoM s/p hit a car door while riding bike 8 yoM s/p hit a car door while riding bike. Crying and c/o abdominal pain. Vital signs age appropriate, abrasion across his epigastrium, and diffuse tenderness w/o rebound or guarding. Amylase 220. UA 2-5 RBCs PHF. Which of the following is correct?Despite a nl abd CT, the child could have pancreatic injury and should be admitted for observation.An IV pyelogram should be performed for evaluation of hematuria.The bowel is the most commonly injured organ following this mechanism.Duodenal hematoma is unlikely if a repeat exam reveals no abdominal tenderness.
24Pediatric Abdominal Trauma Pancreatic trauma often missed on CT and presents laterSpleen > liver >> bowelDuodenal hematoma needs observation
25Traumatic 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 can’t exclude blunt pancreatic, diaphragmatic, or bowel injury.Serum amylase is normal in up to 37% of pts with pancreatic injuryRapid deceleration or severe crush injury
3225yoM s/p hit by car. You are assigned the task of checking the pelvis. Push down on the greater trochantersPush down on the iliac crestSqueeze together on the iliac crestSqueeze and rock the greater trochanters
37Pt. has unstable pelvis and binder is applied Pt. has unstable pelvis and binder is applied. Persistently hypotensive s/p 2 units of blood. FAST, DPA, CXR all negative. Next action?ED thoracotomyRepeat FAST/DPAOR LaparotomyAngiographyPack
38Angio ready in 15 minutes. Well resuscitated. Intubated Angio ready in 15 minutes. Well resuscitated. Intubated. Surgical medical student wants to put in foley so he can check it off on his list. You…Make the senior surgeon assistGet a coude catheterInsist on urology resident for insertionRudely stop the medical student
39GU trauma Signs of GU trauma somewhere – hematuria Urethral injury Perineal ecchymosisUnable to urinateBlood at meatusHigh-riding/absent prostateBlood in scrotum/scrotal hematomaObvious penile traumaPelvic fractureDxRetrograde urethrogramDo not blindly put foley (unless you’re really skilled) – partial tear into complete disruptionTxFoley over wire. Foley in for 2 weeks.Suprapubic catheter placement and surgical repair.Posterior urethral injury from blunt trauma
42Which of the following statements regarding lightning injuries is correct? A. Aggressive fluid loading is indicated.B. Fetal death is common in pregnant victims.C. Lower extremity paralysis is rare.D. Rhabdomyolysis is a frequent complication.E. Tympanic membranes usually are normal.
43ANSWER: BA. 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.
44LightningElectrical and most lightning burns have an entrance and exit pointDeath 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.
45Which does not need burn unit? 4yo, 10% BSA superficial partial-thickness burns to arms after pulling a pan of boiling water off a stove12yo 26% BSA superficial partial-thickness burns to chest and arms from setting a blanket on fire38yo 3% BSA full-thickness burn to his hand from a mechanical injury42yo, DM, 5% BSA superficial partial-thickness burns to her feet from scalding bathtub water75yo, 5% BSA superficial partial-thickness burn to back from a heating pad
46Burn Unit Criteria Major Moderate Minor Partial-thickness burns > 25% BSA in 10-50yoPartial-thickness burns >20% BSA in <10yo or >50yoFull-thickness >10% BSABurns in hand, face, feet, perineum, cross major joints or circumferential burnsBurns with inhalation injury, fxs/other trauma, electrical burnsBurns in infants, elderly or poor-riskModeratePartial-thickness 15-25% BSA in 10-60yoPartial-thickness 10-20% <10yo or >50yoFull-thickness < 10% BSAMinorPartial-thickenes < 15% BSA 10-50yoPartial-thickness < 10% BSA <10yo or >50yoFull-thickness <2% BSA