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Head Trauma:
- Epidural hematoma, good prognosis if emergent craniotomy w/in first few
hours, fatal otherwise.
o Sx = trauma, initial LOC, lucid interval, gradual coma, fixed dilated
pupil on IL side, CL hemiparesis
- Subdural hematoma may present similarly to epidural, but have more severe
trauma mechanism
o Check CT scan, head + spine b/c of severity of injury. Needs emergent
craniotomy if midline shift but poor prognosis, otherwise medical
MGMT of ICP
- Chronic subdural have trauma several weeks prior, gradual decline of MS,
elderly b/c of increased space and tension on bridging veins
o Tx is surgical decompression w/ craniotomy good improvement post
- Basilar skull fx = rhinorrhea, otorhhea, battles sign, raccoon sign
o CT scan of head and C-spine, neurosurgery, abx
Shock:
- Neuro bleeding cannot cause shock
- Abd GSW and shock try to do ex lap immediately for control of bleeding +
concurrent IVF and blood administration
- Someone w/ GSW to abd + chest + shock could be hypovolemic b/c of
blood loss in GSW but also tamponade or tension PTX given chest injury, look
for CVP (high in last + resp findings of PTX)
- Tamponade is clinical dx if shock + distended neck veins w/out resp
signs/tracheal deviation do pericardial window, no imaging. If + do
thoracotomy.
o If location of wound really suggests tamponade may do thoractomy
right away
- No CXR for tension PTX do needle decompression then CT
- CP + distended neck veins + shock w/out trauma suggests cardiogenic shock
- no fluid resuscitation
- Vasomotor shock = anaphylaxis or spinal anesthesia/transection get low
CVP but warm and flushed patient
o Tx w/ vasoconstrictors, fluids OK too
Chest Trauma:
- Simple traumatic PTX if HDS can get CXR before CT placement
- For HTX, if HDS and not a massive amount of blood (1500 initiall, 600ml in 6
hours) then dont need surgery, just CT, low pressure lung parenchymal bleed
will stop on its own
o If large amount of initial blood or a lot in the preceeding hours then
could be arterial bleed from IC vessels do thoracotomy to ligate.
- Hemo-pneumothorax: dull to percussion at base, hyperresonat at apex, airfluid level on CXR
o Tx is CT, sx only if large amount of blood
- Tension PTX no CXR CT right away (needle decompression first), later CXR
to r/out widened mediastinum.
- Flail chest suggests high risk for other injuries
o MGMT is for pulm contusion fluid restriction, diuretics, colloid rather
than crystalloid fluids, resp support (intubation, PEEP)
Pulm contusion may show up later (day 2), see white on out
imaging + resp deterioration
o If other injuries mean they require OR/resp/intubation should place b/l
CT due to high risk of developing tension PTX during PP breathing
- Sternal fracture means high risk for myocardial contustion or aortic rupture
o Contustion: EKG, enzymes
o Aorta: CTA, TEE
- Diaphragmatic rupture get decreased breath sounds on one side but no
tympanic changes, would see bowel in chest
o Always on left
o Treatment is surgical repair from the abdomen
- Aortic rupture: hidden injury, may initially be stable as hematoma is forming,
be suspicious if have fx of hard-to-break bone like 1 st rib, sternum, or scapula
o See widened mediastinum on CXR
o Dx is arteriogram
o Tx is surgery
- Traumatic rupture of the trachea of major bronchus subQ air, CXR shows air
in tissues, confirm dx and level of injury w/ bronchoscopy, then surgical repair
Abdominal Trauma:
- Patient w/ HDIS but no scalp lac, normal CXR, normal pelvis think blood in
belly
o Shock is loss of 25-30%, approx 1.5 L, would see in neck, CXR, pelvis,
or long bones if fx
o If suspect abd bleeding and stable CT
o If suspect abd bleeding and unstable FAST or peritoneal lavage
o CT w/ ruptured spleen if stable serial exam and CT, if unstable exlap
- All abd GSW go to surgery for exlap, even if stable
o Prep for surgery bladder catheter, big bore venous line, broad
spectrum abx
o Belly begins at nipple but chest does not end at nipple
So if patient with GSW below nipple line needs w/u for
penetrating chest wound (CXR, CT) + exlap
- Most bleeding in abd comes from liver, most clinically significant bleeding site
comes from the spleen
o Think if lower rib fx on left + shocky VS
o Diagnostics: if stable/responds to fluids then CT, may follow w/ serial
CT/exams
o if still unstable then FAST/lavage
If + FAST/lavage then exlap
Always try to save spleen before removing
If remove, need vaccinations
- Unstable + peritoneal signs = exlap
o Peritoneal signs can be from blood (VS) or hollow viscera contents
Urologic Trauma
- Hallmark is blood in urine gross hematuria in setting of trauma needs to be
worked up
o Microhematuria only needs w/u in peds b/c could be congenital
(incidental, not due to trauma)
NG suction first 1-2 days then intense nutritional support (high cal,
high N2)
o If no regeneration in 2-3 weeks then graft
Early excision and grafting if 3rd degree and localized (under 20%)
o
Adults:
o Metastatic: lytic is breast, blastic is prostate
Path fx may be presentation
o MM get punched out lytic lesions + bence jones in urine + Ig in blood
o Soft tissue sarcomas are firm + fixed to surrounding structures
Mets to lung but not lmph nodes
General Adult Orthopedics
- Need two views 90 from one antoher + one join above and below
- Anterior dislocation of shoulder most common hold arm close to body but
located outwards
- Posterior shoulder dislocations from sz w/ massive contractions hold arm
close to body and IR, need axiallary or scapular XRAY views to detect
- Colles fracture: old lady, FOOSH, dinner fork, dorsally distplaced and
angulated distal radius fractures
- Monteggia/nightstick fracture is from blow to ulnar get diaphyseal fracture
of the proximal ulna
- Galeazzi fx is mirror of monteggia but of the raidus
- Metacrapl neck fx (4/5th) from closed fist hitting wall tx depends on degree
of angulation/displacement mild do closed reduction w/ ulnar gutter
- Hip fracture leg is shortned and ER
- Femoral neck fx need replacement of femoral head to prevent avascular
necrosis
- Intertrochanteric fx less tenuous blood supply open reduction + internal
fixation
- Femoral shaft fx need intramedullary rod fixation high risk for clot b/c of
immobilization
- Collateral ligament injuries from sideways blow to knee valgus stress hurts
medial, varus stress hurts lateral
- ACL more common than PCL do anterior drawer or Lachmans
- Meniscal tears do MRI get pop/click
- May get ACL, MCL, and MM together
- Tibial stress fractures xrays may be normal, do cast and repeat xray in 2
weeks
- Leg fx of tibia/fibula concern for compartment syndrome
- Rupture of achilles tendon do equinis position casting or sx
- Back pain
o Lumbar disk herniation L4/L5 or L5/S1 vague aching pain then
sudden neurogenic pain worse when coughing, sneezing, defecating,
+ straight leg raising tx is bed rest pain injections sx if neuro
deficits
o Cauda equine bladder retention, flaccid rectal spinchter, perineal
saddle anesthesias needs emergent decompression
o Ankylosing spondylitis young men, chornic back pain and morning
stiffiness wrose w/ rest, better w/ activity bamboo spine HLA-b27
o Metastatic malignancy progressive BP worse at night and unrelieved
by rest or positional changes + weight loss lytic women blastic men
- Leg Ulcers:
o DM ulcers: pressure points (heel, tips of toes, metatarsal head) , get
b/c of neuropathy, fail to heal b/c of microvascular dz
Felon is abscess at pulp of finger tip fever throbbing can lead to tissue
necrosis so needs drainage
- Gamekeepers thumb is injury of ulnar collateral ligament from forced
hyperextension of the thumb casting
- Jersey finger grab jersey get when flexed finger is forcefully extended splinting
- Mallet finger extended finger is forefully flexed splinting
- Traumatically amputated digits surgically reattached
Pre-Op Assessment:
- EF less than 35% - 75-85% periop MI risk
- Goldmans index: JVD, recent MI, PVCs, other than sinus, emergency sx, >70,
aortic stenosis, poor medical conditions, surgery w/in the chest or abdomen
- JVD indicating CHF is worst, followed by recent MI
- Smokng compromised ventilation measure FEV1 cessation for 8 weeks
and IS therapy prior to surgery
- Hepatic: high bili, low albumin, high PT, ascites, and encephalopathy
- Severe nutritional depletion : loss of 20% of body weight, serum albumin
below 3, anergy to skin antigens, serum transferrin level less than 200 2-5
days of TPN helpful
- Diabetic risk is absolute CI to sx
Post-Op Complications:
- Fever:
o High fever immediately post op think malignant hyperthermia (also w/
metabolic acidosis and hyperCa do dantrolene and O2) or bacteremia
(like if instrumentation in the urinary tract, do blood culures x 3 abx)
o Usual 101-103 range:
Atelectasis POD 1
PNA POD3
UTI POD3
Deep thrombophlebitis POD 5
Wound infection POD7
Deep abscess POD 10-15
- Chest Pain:
o MI: during 2/2 hypotension, 2-3 days post op, much higher mortality
risk than non post op MI cant use tPA but do angioplasty + stenting
o PE: POD 7 hypoxemia, hypocapneia, resp alkalosis CTA, JVD, heparin
+ IVC filter if repeats
Prevent by preventing DVT TEDS on all those w/ LE fx + AC if
>40, pelvic or leg fx, venous injury, femoral venous catheter,
prolonged anticipated immobilization
o Other pulm: aspiration (why NPO, lavage w/ bronchoscopy,
bronchodilators and resp support)
o IO Tension PTX difficult to ventilate can decompress through the
diaphragm or anterior chest
- Disorientation/Coma:
o Hypoxia is first thing to suspect check abg and give supplemental O2,
may be 2/2 sepsis
o ARDS b/l pulm infiltrates w/out evidenve of CHF tx w/ carefell PEEP
o Delirum tremens give IV 5% ethanol in 5% dextrose or benzos