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Trauma Board Review Part II Dr. Grumpy. Disclosure Drug rep dinners Drug rep dinners Linezolid Linezolid Ertapenem Ertapenem Keppra Keppra Levofloxacin.

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Presentation on theme: "Trauma Board Review Part II Dr. Grumpy. Disclosure Drug rep dinners Drug rep dinners Linezolid Linezolid Ertapenem Ertapenem Keppra Keppra Levofloxacin."— Presentation transcript:

1 Trauma Board Review Part II Dr. Grumpy

2 Disclosure Drug rep dinners Drug rep dinners Linezolid Linezolid Ertapenem Ertapenem Keppra Keppra Levofloxacin Levofloxacin Cardene Cardene STC STC

3 Topics C-spine trauma C-spine trauma Pediatric trauma Pediatric trauma Pelvic trauma Pelvic trauma

4 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 statement A. Needs urgent MRI. B. Discharge with close f/u as long as his exam remains normal during a 4-hr observation. C. Flexion-extension radiographs should be performed to rule out any ligamentous injury. D. CT scan of the C-spine should be performed to assess for surrounding soft tissue swelling.

5 Spinal Cord Injuries Central Cord Syndrome Central Cord Syndrome Hyperextension injury Hyperextension injury Upper ext weaker than lower ext Upper ext weaker than lower ext Brown Sequard Syndrome Brown Sequard Syndrome Penetrating – hemisection of spinal cord Penetrating – hemisection of spinal cord Loss of ipsilateral motor, position, vibration Loss of ipsilateral motor, position, vibration Contralateral loss of pain and temp below level of injury Contralateral loss of pain and temp below level of injury

6 Spinal Cord Injuries Anterior Cord Syndrome Anterior Cord Syndrome Flexion of cervical spine Flexion of cervical spine Bilateral paralysis of arms and legs equally Bilateral paralysis of arms and legs equally Due to arterial occlusion, disruption blood flow to spinal cord Due to arterial occlusion, disruption blood flow to spinal cord Cauda Equina Cauda Equina Distal sacral roots - peripheral nerve injury Distal sacral roots - peripheral nerve injury Variable motor/sensory loss in LE, sciatica, bowel/bladder dysfunction, saddle anesthesia Variable motor/sensory loss in LE, sciatica, bowel/bladder dysfunction, saddle anesthesia

7 Spinal Cord Injuries Spinal Shock (misnomer) Spinal Shock (misnomer) Partial or complete injury Partial or complete injury Areflexia, loss of sensation, flaccid paralysis below level of lesion Areflexia, loss of sensation, flaccid paralysis below level of lesion Flaccid bladder and loss of rectal tone Flaccid bladder and loss of rectal tone

8 16 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? A. Bilateral facet dislocation B. Hangman fracture C. Jefferson fracture D. Odontoid fracture E. Teardrop fracture

9 C-Spine Fxs Jefferson fx (unstable) Jefferson fx (unstable) Axial loading force Axial loading force C1 burst fx C1 burst fx Hangman fx (unstable) Hangman fx (unstable) Hyperextension (hanging) Hyperextension (hanging) Located in pedicles of C2, with C2 displacing anteriorly on C3 Located in pedicles of C2, with C2 displacing anteriorly on C3 Head on MVC Head on MVC Associated with prevertebral swelling and cause respiratory obstruction Associated with prevertebral swelling and cause respiratory obstruction

10 C-Spine Fxs Odontoid fx Odontoid fx Type I – tip superiorly. Ligaments intact and stable fx Type I – tip superiorly. Ligaments intact and stable fx Type II – junction of odontoid and body Type II – junction of odontoid and body Most common Most common Type III – superior portion of C2 at base of odontoid Type III – superior portion of C2 at base of odontoid Teardrop fx (unstable) Teardrop fx (unstable) Extreme flexion Extreme flexion Complete disruption of all ligamentous structures at the level of injury Complete disruption of all ligamentous structures at the level of injury Unstable Unstable

11 Flexion Injuries Simple wedge fx Simple wedge fx Associated with post ligament disruption Associated with post ligament disruption Clay shoveler’s fx Clay shoveler’s fx Avulsion of spinous process of lower vertebrae  stable Avulsion of spinous process of lower vertebrae  stable Atlantooccipital and atlantoaxial dislocation w/ fx Atlantooccipital and atlantoaxial dislocation w/ fx High instability and mortality High instability and mortality Bilateral facet dislocation w/ fx Bilateral facet dislocation w/ fx

12 Extension Injuries Ant arch of atlas avulsion fx – unstable Ant arch of atlas avulsion fx – unstable Post arch of atlas fx Post arch of atlas fx Compression. Look for other fxs. Compression. Look for other fxs. Extension teardrop fx Extension teardrop fx Most common at C2. Unstable Most common at C2. Unstable

13 Atlanto-occipital Joint Injury Severe flexion/extension Severe flexion/extension Disruption of all ligaments between occiput and atlas. Disruption of all ligaments between occiput and atlas. Death usually immediately from stretching of brainstem Death usually immediately from stretching of brainstem Cervical traction absolutely contraindicated Cervical traction absolutely contraindicated

14 Atlanto-occipital Joint Injury Very difficult to diagnose (CT 84% sens) Very difficult to diagnose (CT 84% sens) Basion-dens distance > 12mm Basion-dens distance > 12mm Posterior dens axial line > 12mm posterior or > 4mm anterior to basion Posterior dens axial line > 12mm posterior or > 4mm anterior to basion

15 Power Calculation BC/AD < 1 normal BC/AD < 1 normal

16 Atlanto-axial Joint Injury Disruption of transverse ligament Disruption of transverse ligament Extremely unstable Extremely unstable

17 Which is classified as low probability of C-spine injury? A. 21yoM, no neck tenderness, intoxicated after MVC B. 24yo, no neck tenderness and LLE weakness, pedestrian struck by motor vehicle C. 32yoF, no neck tenderness, through-and- through lip laceration after MVC D. 48yoM, no neck tenderness and R shoulder dislocation s/p falling from scaffolding E. 82yoF, no neck tenderness and a L femoral neck fx s/p fall

18 Nexus No midline tenderness No midline tenderness No pain with neck movement No pain with neck movement No distracting injury No distracting injury Long Bone Fracture (Most common DPI) Long Bone Fracture (Most common DPI) Visceral Injury Necessitating surgical consultation Visceral Injury Necessitating surgical consultation Large laceration, degloving injury, or crush injury Large laceration, degloving injury, or crush injury Large Burns Large Burns Any injury producing acute functional impairment Any injury producing acute functional impairment No Neurodeficit No Neurodeficit No Alcohol or Drugs No Alcohol or Drugs No Altered Mental Status No Altered Mental Status

19 CCR Dangerous mechanism Dangerous mechanism Fall from > 3ft or 5 stairs Fall from > 3ft or 5 stairs Axial load to head Axial load to head MVC >100km/hr MVC >100km/hr Collision with motorized recreational vehicle Collision with motorized recreational vehicle Bicycle collision Bicycle collision

20 Pediatric Head Trauma Can bleed enough intracranially for hypotension Can bleed enough intracranially for hypotension Vomiting, seizures, LOC are all poor in sensitivity and specificity Vomiting, seizures, LOC are all poor in sensitivity and specificity Scalp hematoma is indication Scalp hematoma is indication

21 2yo s/p struck by car after running out into the street. Most likely thoracic injury? A. Aortic dissection B. Commotio cordis C. Esophageal rupture D. Pulmonary contusion E. Rib fractures

22 Pediatric Chest Trauma Compliant chest walls and ribs relatively resistant to fracture  forces transmitted to internal structures Compliant chest walls and ribs relatively resistant to fracture  forces transmitted to internal structures Pulmonary contusions Pulmonary contusions Commotio cordis Commotio cordis Relatively mild blow to the chest (boards usually pitched baseball)  ventricular fibrillation Relatively mild blow to the chest (boards usually pitched baseball)  ventricular fibrillation No structural damage to the heart No structural damage to the heart Death usually instantaneous, and successful resuscitation is uncommon. Death usually instantaneous, and successful resuscitation is uncommon.

23 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? 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.

24 Pediatric Abdominal Trauma Pancreatic trauma often missed on CT and presents later Pancreatic trauma often missed on CT and presents later Spleen > liver >> bowel Spleen > liver >> bowel Duodenal hematoma needs observation Duodenal hematoma needs observation

25 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. 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. CT scan can’t exclude blunt pancreatic, diaphragmatic, or bowel injury. Serum amylase is normal in up to 37% of pts with pancreatic injury Serum amylase is normal in up to 37% of pts with pancreatic injury Rapid deceleration or severe crush injury Rapid deceleration or severe crush injury

26 Pediatric Vascular Access IO IO Medial tibia (unless fx) Medial tibia (unless fx) Fluid resuscitation, blood, medications Fluid resuscitation, blood, medications Complications (rare) Complications (rare) Growth plate injury Growth plate injury Compartment syndrome Compartment syndrome Fluid leakage Fluid leakage Fat emboli Fat emboli Osteomyelitis Osteomyelitis

27 Child Abuse Injury inconsistent with history, delay in treatment Injury inconsistent with history, delay in treatment Abuser Abuser Young age Young age Increased stress Increased stress Unemployed Unemployed History of Abuse History of Abuse Substance abuse Substance abuse Boyfriend Boyfriend

28 Child Abuse Burns Burns Contact Contact Immersion Immersion Stocking glove Stocking glove Cigarette Cigarette

29 Child Abuse Contusions Contusions Buttocks Buttocks Genitalia Genitalia Neck Neck Face Face Low back Low back

30 Child Abuse Shaken Baby Syndrome: diffuse cerebral injury with edema, retinal hemorrhages, poor prognosis Shaken Baby Syndrome: diffuse cerebral injury with edema, retinal hemorrhages, poor prognosis Suspicious fractures Suspicious fractures Any < 1 years Any < 1 years Rib (posterior) Rib (posterior) Skull, spine, sternum Skull, spine, sternum Bilateral/multiple various stages of healing Bilateral/multiple various stages of healing Long bone Long bone Metaphyseal Metaphyseal

31 Child Abuse Head injury Head injury Subdural Subdural Cerebral Cerebral SAH SAH Shaken baby syndrome Shaken baby syndrome

32 25yoM s/p hit by car. You are assigned the task of checking the pelvis. 25yoM s/p hit by car. You are assigned the task of checking the pelvis. A. Push down on the greater trochanters B. Push down on the iliac crest C. Squeeze together on the iliac crest D. Squeeze and rock the greater trochanters

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37 Pt. has unstable pelvis and binder is applied. Persistently hypotensive s/p 2 units of blood. FAST, DPA, CXR all negative. Next action? A. ED thoracotomy B. Repeat FAST/DPA C. OR Laparotomy D. Angiography E. Pack

38 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… A. Make the senior surgeon assist B. Get a coude catheter C. Insist on urology resident for insertion D. Rudely stop the medical student

39 GU trauma Signs of GU trauma somewhere – hematuria Signs of GU trauma somewhere – hematuria Urethral injury Urethral injury Signs Signs Perineal ecchymosis Perineal ecchymosis Unable to urinate Unable to urinate Blood at meatus Blood at meatus High-riding/absent prostate High-riding/absent prostate Blood in scrotum/scrotal hematoma Blood in scrotum/scrotal hematoma Obvious penile trauma Obvious penile trauma Pelvic fracture Pelvic fracture Dx Dx Retrograde urethrogram Retrograde urethrogram Do not blindly put foley (unless you’re really skilled) – partial tear into complete disruption Do not blindly put foley (unless you’re really skilled) – partial tear into complete disruption Tx Tx Foley over wire. Foley in for 2 weeks. Foley over wire. Foley in for 2 weeks. Suprapubic catheter placement and surgical repair. Suprapubic catheter placement and surgical repair. Posterior urethral injury from blunt trauma Posterior urethral injury from blunt trauma

40 Normal urethrogram

41 Urethral tear

42 Which of the following statements regarding lightning injuries is correct? Which 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.

43 ANSWER: B 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.

44 Lightning Electrical and most lightning burns have an entrance and exit point Electrical and most lightning burns have an entrance and exit point Death usually secondary to cardiac arrest, lightening causes massive countershock and produces asystole. Death usually secondary to cardiac arrest, lightening causes massive countershock and produces asystole. Burns are superficial, deep muscle damage rare. Burns are superficial, deep muscle damage rare. Cataracts are common and may occur immediately or develop up to 2 yrs after incident. 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. 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.

45 Which does not need burn unit? Which does not need burn unit? 4yo, 10% BSA superficial partial-thickness burns to arms after pulling a pan of boiling water off a stove 4yo, 10% BSA superficial partial-thickness burns to arms after pulling a pan of boiling water off a stove 12yo 26% BSA superficial partial-thickness burns to chest and arms from setting a blanket on fire 12yo 26% BSA superficial partial-thickness burns to chest and arms from setting a blanket on fire 38yo 3% BSA full-thickness burn to his hand from a mechanical injury 38yo 3% BSA full-thickness burn to his hand from a mechanical injury 42yo, DM, 5% BSA superficial partial-thickness burns to her feet from scalding bathtub water 42yo, DM, 5% BSA superficial partial-thickness burns to her feet from scalding bathtub water 75yo, 5% BSA superficial partial-thickness burn to back from a heating pad 75yo, 5% BSA superficial partial-thickness burn to back from a heating pad

46 Burn Unit Criteria Major Major Partial-thickness burns > 25% BSA in 10-50yo Partial-thickness burns > 25% BSA in 10-50yo Partial-thickness burns >20% BSA in 50yo Partial-thickness burns >20% BSA in 50yo Full-thickness >10% BSA Full-thickness >10% BSA Burns in hand, face, feet, perineum, cross major joints or circumferential burns Burns in hand, face, feet, perineum, cross major joints or circumferential burns Burns with inhalation injury, fxs/other trauma, electrical burns Burns with inhalation injury, fxs/other trauma, electrical burns Burns in infants, elderly or poor-risk Burns in infants, elderly or poor-risk Moderate Moderate Partial-thickness 15-25% BSA in 10-60yo Partial-thickness 15-25% BSA in 10-60yo Partial-thickness 10-20% 50yo Partial-thickness 10-20% 50yo Full-thickness < 10% BSA Full-thickness < 10% BSA Minor Minor Partial-thickenes < 15% BSA 10-50yo Partial-thickenes < 15% BSA 10-50yo Partial-thickness 50yo Partial-thickness 50yo Full-thickness <2% BSA Full-thickness <2% BSA

47 Burn Percentage


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