Page 193 - TNFlipTest

Toronto Notes 2019 Traumatology
Airway Injuries
• alwaysmaintainahighindexofsuspicion • larynx
■ history: strangulation, direct blow, blunt trauma, any penetrating injury involving platysma ■ triad: hoarseness, subcutaneous emphysema, palpable fracture
■ other symptoms: hemoptysis, dyspnea, dysphonia
■ investigations: CXR, CT scan, arteriography (if penetrating)
■ management
◆ airway: manage early because of edema
◆ C-spine may also be injured, consider mechanism of injury ◆ surgical: tracheotomy vs. repair
• trachea/bronchus
■ frequently missed
■ history: deceleration, penetration, increased intra-thoracic pressure, complaints of dyspnea,
hemoptysis
■ examination: subcutaneous air, Hamman’s sign (crunching sound synchronous with heart beat)
■ CXR: mediastinal air, persistent pneumothorax or persistent air leak after chest tube inserted for
pneumothorax
■ management
◆ surgical repair if >1/3 circumference
Abdominal Trauma
• twomechanisms
■ blunt: usually causes solid organ injury (spleen = most common, liver = 2nd)
■ penetrating: usually causes hollow organ injury or liver injury (most common)
BLUNT TRAUMA
• resultsintwotypesofhemorrhage:intra-abdominalandretroperitoneal • adopthighclinicalsuspicionofbleedinginmulti-systemtrauma
History
• mechanismofinjury,SAMPLEhistory
Physical Exam
• oftenunreliableinmulti-systemtrauma,widespectrumofpresentations ■ slow blood loss not immediately apparent
■ tachycardia, tachypnea, oliguria, febrile, hypotension
■ other injuries may mask symptoms
■ serial examinations are required
• abdomen
■ inspect: contusions, abrasions, seat-belt sign, distention
■ auscultate: bruits, bowel sounds
■ palpate: tenderness, rebound tenderness, rigidity, guarding
■ DRE: rectal tone, blood, bone fragments, prostate location
■ placement of NG, Foley catheter should be considered part of the abdominal exam
• othersystemstoassess:cardiovascular,respiratory(possibilityofdiaphragmrupture),genitourinary, pelvis, back/neurological
Investigations
• labs:CBC,electrolytes,coagulation,crossandtype,glucose,Cr,CK,lipase,amylase,liverenzymes, ABG, blood EtOH, β-hCG, U/A, toxicology screen
Emergency Medicine ER13
If Penetrating Neck Trauma Present, DON’T:
• Clamp structures (can damage nerves) • Probe
• Insert NG tube (leads to bleeding)
• Remove weapon/impaled object
Zone III
Zone II
Zone I
Zone III: Superior aspect of neck
Zone II: Midportion of neck (cricoid to
the angle of mandible) Zone I: Base of neck (thoracic inlet
to cricoid cartilage)
Figure 6. Zones of the neck in trauma
Seatbelt Injuries May Cause
• Retroperitoneal duodenal trauma • Intraperitoneal bowel transection • Mesenteric injury
• L-spine injury
Indications for Foley and NG Tube in Abdominal Trauma
Foley catheter: unconscious or patient with multiple injuries who cannot void spontaneously or is unconscious
NG tube: used to decompress the stomach and proximal small bowel. Contraindicated if suspected facial or basal skull fractures
Table 9. Imaging in Abdominal Trauma
Imaging
X-Ray
CT Scan
Diagnostic Peritoneal Lavage (rarely used)
Ultrasound: FAST
Strengths
Chest (looking for free air under diaphragm, diaphragmatic hernia, air-fluid levels), pelvis, cervical, thoracic, lumbar spines
Most specific test
Most sensitive test
Tests for intra-peritoneal bleed
Identifies presence/absence of free fluid in peritoneal cavity
RAPID exam: less than 5 min
Can also examine pericardium and pleural cavities
Limitations
Soft tissue not well visualized
Radiation exposure 20x more than x-ray Cannot use if hemodynamic instability
Cannot test for retroperitoneal bleed or diaphragmatic rupture
Cannot distinguish lethal from trivial bleed Results can take up to 1 h
NOT used to identify specific organ injuries If patient has ascites, FAST will be falsely positive
Criteria for Positive Lavage
• >10 cc gross blood
• Bile, bacteria, foreign material • RBC count >100,000 x 106/L • WBC >500 x 106/L,
• Amylase >175 IU
© Adrian Yen 2006