Trauma Board Review Part II

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Trauma Board ReviewPart II

• Dr. Grumpy

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Disclosure

• Drug rep dinners
• Linezolid
• Ertapenem
• Keppra
• Levofloxacin
• Cardene
• STC

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Topics

• C-spine trauma
• Pediatric trauma
• Pelvic trauma

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• 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
• Needs 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.

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Spinal Cord Injuries

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

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Spinal Cord Injuries

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

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Spinal Cord Injuries

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

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• 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?
• Bilateral facet dislocation
• Hangman fracture
• Jefferson fracture
• Odontoid fracture
• Teardrop fracture

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C-Spine Fxs

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

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C-Spine Fxs

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

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Flexion Injuries

• Simple wedge fx
• Associated with post ligament disruption
• Clay shovelers fx
• Avulsion of spinous process of lower vertebrae ?
  stable
• Atlantooccipital and atlantoaxial dislocation w/
  fx
• High instability and mortality
• Bilateral facet dislocation w/ fx

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Extension Injuries

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

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Atlanto-occipital Joint Injury

• Severe flexion/extension
• Disruption of all ligaments between occiput and
  atlas.
• Death usually immediately from stretching of
  brainstem
• Cervical traction absolutely contraindicated

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Atlanto-occipital Joint Injury

• Very difficult to diagnose (CT 84 sens)
• Basion-dens distance gt 12mm
• Posterior dens axial line gt 12mm posterior or gt
  4mm anterior to basion

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Power Calculation

• BC/AD lt 1 normal

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Atlanto-axial Joint Injury

• Disruption of transverse ligament
• Extremely unstable

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

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Nexus

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

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CCR

• Dangerous mechanism
• Fall from gt 3ft or 5 stairs
• Axial load to head
• MVC gt100km/hr
• Collision with motorized recreational vehicle
• Bicycle collision

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Pediatric Head Trauma

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

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

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Pediatric Chest Trauma

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

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• 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.

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Pediatric Abdominal Trauma

• Pancreatic trauma often missed on CT and presents
  later
• Spleen gt liver gtgt bowel
• Duodenal hematoma needs observation

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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

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Pediatric Vascular Access

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

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Child Abuse

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

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Child Abuse

• Burns
• Contact
• Immersion
• Stocking glove
• Cigarette

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Child Abuse

• Contusions
• Buttocks
• Genitalia
• Neck
• Face
• Low back

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Child Abuse

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

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Child Abuse

• Head injury
• Subdural
• Cerebral
• SAH
• Shaken baby syndrome

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

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

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• 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 assist
• Get a coude catheter
• Insist on urology resident for insertion
• Rudely stop the medical student

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GU trauma

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

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Normal urethrogram
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Urethral tear
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• 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.

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• 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.

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Lightning

• 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.

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• 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
• 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
• 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

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Burn Unit Criteria

• Major
• Partial-thickness burns gt 25 BSA in 10-50yo
• Partial-thickness burns gt20 BSA in lt10yo or
  gt50yo
• Full-thickness gt10 BSA
• Burns in hand, face, feet, perineum, cross major
  joints or circumferential burns
• Burns with inhalation injury, fxs/other trauma,
  electrical burns
• Burns in infants, elderly or poor-risk
• Moderate
• Partial-thickness 15-25 BSA in 10-60yo
• Partial-thickness 10-20 lt10yo or gt50yo
• Full-thickness lt 10 BSA
• Minor
• Partial-thickenes lt 15 BSA 10-50yo
• Partial-thickness lt 10 BSA lt10yo or gt50yo
• Full-thickness lt2 BSA

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Burn Percentage