1˚ ABC
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Airway
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Airway is safe if pt can:
conscious and speaking in a normal tone of voice.
AW is endangered if:
if expanding hematoma or emphysema in the neck.
Intubate when:
· GCS 8 or low
· Breathing is gurgling / abnormal
· Inhalation injury
If there is cervical spinal injury, handle AW 1˚, it’s more important.
· USE ENDOTRACHEAL INRUBATION (FROM MOUTH TO TRACHEA)
· If laryngospasm, severe maxillofacial injuries, an impacted foreign body that cannot be dislodged –> Cricothyroidomy.
· Use a fiberoptic bronchoscope if subcutaneous emphysema in the neck → MUST: it is a sign of major traumatic disruption of the tracheobronchial tree.
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Breathing
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Hearing breath sounds on both sides of the chest and having satisfactory pulse oximetry establishes that breathing is okay.
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Circulation
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· Insert large bore IV
· Check if pt is in shock or not.
· Manage Shock
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Disability
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· GCS
· Pupil
· Neurological Sx
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Exposure
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Expose the pt
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Rx from head to toe:
Head
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Any loss of consciousness
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CT
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Concussion
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Contusion
|
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No focal finding
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Rarely focal
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No lucid interval
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No lucid interval
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Normal CT
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Ecchymoses
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No specific treatment;
observe at home for lucid interval or new focal findings
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No specific treatment; observe in hospital
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Subdural hematoma
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Epidural hematoma
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+/– focal findings
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+/– focal findings
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+/– lucid interval
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+/– lucid interval
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Venous, crescent
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Arterial, biconvex or lens-shaped hematoma
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Drain large ones
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Drain large ones
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LARGE ONES ARE?
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· Compression of ventricles or sulci
· Herniation with abnormal breathing and unilateral dilation of the pupil
· Worsening mental status or focal findings
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If midline structures are deviated
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craniotomy will help, but prognosis is bad.
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If there is no deviation
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therapy is centered on preventing further damage from subsequent increased ICP.
1. Elevate head
2. Hyperventilate (<pco2 35)
a. Hyperventilation is recommended when there are signs of herniation, and the goal is a PCO 2 of 35.
3. Mannitol
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How to ⤵️ O2 demand?
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Sedation and hypothermia have been used to decrease brain activity and oxygen demand. Hypothermia is currently suggested as a better option to reduce oxygen demand.
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Evaluation of head trauma in children age 2-18 👧:
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Clinical scenario
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Recommendation
|
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Any of the following:
· Focal neurologic findings
· Skull fracture, especially signs of basilar skull fracture
· Seizure
· Persistent altered mental status (e.g., agitation, lethargy, slow response)
· Prolonged loss of consciousness
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Head CT without contrast
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GCS = 15 with any of the following:
· Vomiting
· Headache
· Questionable or brief loss of consciousness
· Injury caused by high-risk mechanism of injury
· Severe mechanism of injury
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Clinical preference:
Observation for 4-6 hours
OR
Head CT without contrast
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Minor head trauma (GCS = 15 with non-severe mechanism and no vomiting, headache, loss of consciousness, or signs of fracture)
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No head CT
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NECK TRAUMA
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Penetrating trauma
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expanding hematoma / Unstable VS / or clear signs of esophageal or tracheal injury (coughing or spitting up blood) → Surgical exploration.
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Gun shot:
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· if upper areas –> arteriographic diagnosis and management
· If base of neck –> arteriographic + enema (visualize esophagus) for diagnosis and management
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Stab wounds to the upper and middle zones
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Asx pts can be safely observed.
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PT w/ Severe blunt trauma to the neck,
|
the integrity of the cervical spine has to be ascertained.
|
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If there are neurologic deficits / or pain on palpation of cervical spine
|
Order CT.
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Spine Trauma
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General management
|
Prehospital:
· Spinal immobilization (e.g., backboard, rigid cervical collar, lateral head support)
· Careful helmet removal (e.g., motorcycle helmet)
· Airway oxygenation
Emergency department:
· Orotracheal intubation preferred UNLESS significant facial trauma present
· Rapid-sequence intubation added for unconscious patients who are breathing but need ventilatory support
· In-line cervical stabilization suggested UNLESS it interferes with intubation
· CT of entire cervical spine
· Monitoring for neurogenic shock from spinal cord injury
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1˚ No pelvic / urethral injury
|
Bladder Cath
|
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2˚ Imaging
|
MRI is preferred over CT.
|
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Compression / Neurological sx
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IV STEROIDS –> CT
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Complete cut of SC
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Nothing below lesion (no sensory nor motor)
|
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Brown sequard (hemisection)
|
· You lose 3 tracts
· STT: contralateral loss
· note: loss starts 2 levels below
· DC: ipsilateral loss
· CS: ipsilateral loss
 |
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Anterior cord
|
You lose motor + STT. Burst injury.
So:
· Motor below injury is gone
· STT: contralateral loss
|
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Central cord
|
· elderly with forced hyperextension of the neck
· paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
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CHEST
|
Rib Fx
|
· Rib fracture can be deadly in the elderly,
· because of progression of pain → hypoventilation → atelectasis → pneumonia.
· Tx: pain control.
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|
Features
|
Dx
|
Tx
|
|
|
Aortic injury
|
· Blunt trauma
· Anxious pt
· HTN / PAIN
· CXR:
· Mediastinal deviation
· Mediastinal widening
|
CT
|
Anti-HTN
Surgery
|
|
Diaphragmatic
Rupture
|
Presents w/ either:
· Resp distress
· S/S of SBO
· Abd pain referred to shoulder
|
CXR: bowel in chest
|
Surgery
|
|
Esophageal
Rupture
|
· Mediastinal widening
· Chest pain
· crepitus & ⊕ Hamman sign
· Pleural effusion: green
|
Esophagogram: air leak from esophagus
|
· NPO
· IVF
· ABx
· Surgery 🚨
|
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Bronchial
Rupture
|
· PTX that doesn’t resolve w/ chest tube
· Pneumomediastinum
· Subcutaneous emphysema
|
CXR
|
Surgery
|
|
Myocardial
Rupture
|
Death
|
–
|
–
|
|
Myocardial
Contusion
|
Can presents as it pleases:
· As MI
· Arrhythmia
· Wall injury
· Temponade
· HF
· Most common association: sternal fx
|
Urgent
Echo +ECG changes
Troponin high
|
· Tx based on Sx
· If CHF: diuretics
|
|
PTX
|
Clear
|
Clear
|
Chest tube
|
|
PTX
|
Hemothorax
|
|
· here not tension pneumothorax,
· same finidings
· Dx: clx –> CXR
· Tx: tube
|
· same pathophysiology, but w/ blood, and it goes down, not up.
· Dullness on percussion
· Dx: CXR
· Tx:
· Chest tube
· YOU MUST DDx b/w lung bleeding vs. Vessel bleeding.
· Lung bleeding stops on its own,
· Vessels do not
· How to ddx?
· amount of blood, if >1500, go to OR. (thoracostomy)
|
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Sucking Chest wound
|
Flail chest
|
|
جرح يدخل الهواء جوا بس مايطلعه برى.
lead to tension pneumothorax
Tx: cclusive dressing that allows air out (taped on 3 sides) but not in
|
كذا عظم صدر انكسر، ويصير يتحرك عكس اتجاه التنفّس، إذا سوى شهيق (تدخل)، وإذا زفير (تطلع)
issue is risk of pulmonary contusion.
Tx: Binders
|
Flail chest:
|
Pathophysiology
|
≥3 contiguous ribs fractured in ≥2 locations → flail chest segment
|
|
Findings
|
· Paradoxical chest wall motion with respiration
· Chest pain, tachypnea, rapid shallow breaths
· CXR: rib fractures +/- contusion/hemothorax
|
|
Management
|
· Pain control, supplemental oxygen
· PPV (+/- chest tube) IF respiratory failure
|
Pulmonary contusion:
|
||||||
|
· can appear up to 48 hours later
· Dx: CXR (whitining of lungs)
· Tx:
· do not add fluid!
· Diuretics.
|
Esophageal perforation:
|
?
|
· Instrumentation (endoscopy)
· Trauma
· Boerhaave syndrome/ Esophagitis
|
|
Clx
|
· Chest, back and/or epigastric pain
· Systematic signs such as fever
· Crepitus, Hamman sign (crunching sound auscultation)
· Pleural effusion with atypical (e.g. green) fluid
|
|
Dx
|
· CXR/CT: widened mediastinum, pneumomediastinum, PTX
· CT: esophageal wall thickening, mediastinal fluid collection
· Esophagography with water soluble contrast: leak from perforation
|
|
Tx
|
· NPO, IV Abx and PPI
· Emergency surgical consultation 🚨
|
|
Aortic dissection
|
· ينشخل الأورطة
· w/ deceleration injury
· CT Angio
· Surgery or pt die.
|
Abdomen
§ In patients who have blunt abdominal trauma, resuscitation must coincide with physical examination and diagnostic testing aimed at determining the presence or absence of hemoperitoneum and organ injury. Abdominal wall ecchymosis, abdominal distention, and decreased abdominal sounds may be clues to intra-abdominal injury.
§ FAST US provides an easy and rapid way to assess intra- abdominal injuries and presence of peritoneal fluid. Unstable patients should undergo a FAST examination as part of the initial assessment. Evidence of free fluid on the FAST examination is an indication to avoid diagnostic imaging and go immediately to the ORto correct the source of bleeding. CT scan is the test of choice for patients who have blunt abdominal trauma who meet criterion for evaluation (stable).
§ Most abdominal gunshot wounds require immediate exploratory laparotomy.
§ CT scan is done in cases of blunt trauma to diagnose intra-abdominal bleeding and to identify intra-abdominal injuries if the patient is stable enough to go to the CT scanner.
§ If there is concern for internal bleeding in an unstable patient (hypotension and/or tachycardia), investigate further with an FAST scan or diagnostic peritoneal lavage.
Abdominal trauma:
GENERAL RULES:
If the patient is
1- Peritoneal → OR (exploratory laparotomy)
2- GIT is out → OR (exploratory laparotomy)
3- hemodynamically unstable-FAST⊖→ high susceptibility of internal bleeding → OR(exploratory laparotomy)
Gun shot → OR
Stab wound → follow the rule –⊖→digital exam of the area
Blunt → follow the rule –check for hidden bleeding –FAST
i. ⊕ → OR
ii.⊖→ CT?
→ OR?
→ watch and wait (w/w)
Complications of OR
1- coagulopathy – PLT + FFP
2- coagulopathy + hypothermia + lactic acidosis → STOP OR 🛑
3- prolonged laparotomy – Day 2 post-op –risk of compartment syndrome
Management of blunt abdominal trauma in hemodynamically unstable patients:
Focused assessment with sonography for trauma – FAST- examination
IF THE EXAMINATION
1- positive → laparotomy
2- inconclusive → DPL
IF ⊕ → laparotomy
IF ⊖→ signs of extra-abdominal hemorrhage (e.g. pelvic/ long bone fracture)?
YES? → stabilize (e.g. angiography, splint)
NO? → stabilize, then CT of the abdomen
3- negative → signs of extra-abdominal hemorrhage (e.g. pelvic/ long bone fracture)?
YES? → stabilize (e.g. angiography, splint)
NO? → stabilize, then CT of the abdomen
Pelvis
· Pelvic hematomas are typically left alone if they are not expanding.
· Check for other injuries (rectum, bladder, vagina, urethra “men”)
UROGENITAL
|
Bloody meatus
|
Retrograde
|
Compartment syndrome:
(early pain + paresthesia → S/M Sx)
Common:
· Pain out of proportion to injury
· Pain ⤴️ on passive stretch
· Rapidly increasing and tense swelling
· Paresthesia (early)
Uncommon:
· ⤵️ sensation
· Motor weakness (hours)
· Paralysis (late)
· ⤵️ distal pulses (uncommon)
Vascular
Extremity vascular trauma:
|
Clx
|
Hard signs
· Observed bleeding
· Presence of bruit/thrill over injury
· Expanding hematoma
· Signs of distal ischemia
Soft signs Δ
· Diminished pulses
· Bony injury
· Neurologic 🆎
|
|
Tx
|
If (hard) signs or HD unstable
· Surgical exploration
Otherwise
· CT scan or conventional angiography
· Duplex Doppler ultrasonography
|
BURN
|
Burns
|
|||||||||||||||||
|
Features
|
· Burn.
· Associated stuff: CO / Cyanide poisoning
|
||||||||||||||||
|
S/S
|
|
||||||||||||||||
|
Dx
|
· Clx
 |
||||||||||||||||
|
Tx
|
· ABC
· Remove all clothing
· if inhalational injury is suspected, best next step: immediate intubation
· Best dx test → Bronchoscopy
· if chemical burn, best next step: irrigation
· if burn eschar encircles chest, best next step: escharotomy to relieve constriction
· Fluid:
· 4*kg*BSA
· Lenger lactate
· 1st 8 h: 1st half
· Tetanous ppx: all patients with > 10% BSA burn or burn worse than superficial thickness need Td
· Stress ulcer ppx: Antaacid
|
||||||||||||||||
|
Comp
|
· Severe burns are often complicated by wound infections and sepsis.
· They also can present later (years later) w/ SqCC of skin.
|
Fast HY Review 