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TRAUMAEMRAM ITE REVIEW COURSE

Kristen Palomba, MD

Beaumont Health System – Troy

Disclosure

• I have no actual or potential conflicts of interest in relation

to this program/presentation.

Overview

What this lecture is:

• Rapid review of frequently tested content

• Highlighting pearls and buzz words

• Broken down systematically

• Sporadically placed questions

What this is lecture not:

• An exhaustive presentation of all things trauma

• Comprehensive

Initial Trauma

• ATLS – know it backward and forward

• ABCDE → if clinical status worsens or changes, restart at airway• Airway

• GCS <8, severe facial burns or airway trauma → intubation

• Breathing

• Identify and treat life threats: tension PTX, open PTX, flail chest, massive hemothorax

• Circulation

• Classes of hemorrhage

• 1:1:1 transfusion ratio, +/- TXA

• Disability

• GCS – memorize it

• Exposure

QUESTION

• During which of the classes of hemorrhage does the

patient become hypotensive?

• Class I

• Class II

• Class III

• Class IV

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ANSWER

• During which of the classes of hemorrhage does the

patient become hypotensive?

• Class I

• Class II

• Class III

• Class IV

Classes of Hemorrhage

QUESTION

• Which of the following is NOT part of Cushing Reflex?

• Bradycardia

• Hypertension

• Irregular respirations

• Altered mental status

ANSWER

• Which of the following is NOT part of Cushing Reflex?

• Bradycardia

• Hypertension

• Irregular respirations

• Altered mental status

Head Trauma

• Basilar Skull Fracture

• Temporal CT

• Hemotympanum

• Raccoons eyes and Battle sign → 1-3 days AFTER injury

• CSF otorrhea or rhinorrhea

• Target lesion (double target sign, halo sign) on filter paper w/ ring of

CSF around blood

QUESTION

• Which of the following is NOT associated with a subdural

hematoma?

• Alcoholics and elderly patients

• Lucid interval after LOC

• Crescent shaped hematoma

• Bridging veins

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ANSWER

• Which of the following is NOT associated with a subdural

hematoma?

• Alcoholics and elderly patients

• Lucid interval after LOC

• Crescent shaped hematoma

• Bridging veins

Head Trauma

• Intracranial Hematomas

• Epidural

• Middle meningeal artery, lucid interval after LOC, biconvex or lens

shaped hematoma

• Subdural

• Alcoholics or elderly, bridging veins, crescent shaped hematoma

• Traumatic Subarachnoid

• Any age, + meningeal signs, acceleration-deceleration mechanism,

blood in basilar cisterns, ventricles, hemispheric sulci, fissures

• Intracerebral hematoma

• Severe blunt or penetrating trauma, shaken baby

QUESTION

• What are the anatomical landmarks that designate the

neck “zones”?

ANSWER

• What are the anatomical landmarks that designate the

neck “zones”?

• Cricoid cartilage, angle of the mandible

Neck Trauma

• Penetrating

• Zone I: CTA, esophageal

and tracheal evaluation

• Zone II: surgery if hard signs,

otherwise as per zone I

• Zone III: CTA

• Platysma violation → surgical c/s

Neck Trauma

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Neck Trauma

• Blunt

• Laryngotracheal injury

• Subcutaneous emphysema, stridor, dysphonia

• Cerebrovascular injury: carotid or vertebral artery injuries

• +/- neuro Sx, “hard signs”, Horner syndrome (ptosis, miosis,

anhidrosis)

• Pharyngoesophageal injury

• RARE

QUESTION

• Which of the following is considered a stable cervical spinal

fracture?

• Odontoid type II fracture

• Clay shoveler’s fracture

• Jefferson’s fracture

• Teardrop fracture

ANSWER

• Which of the following is considered a stable cervical spinal

fracture?

• Odontoid type II fracture

• Clay shoveler’s fracture

• Jefferson’s fracture

• Teardrop fracture

Spinal Injuries

• Cervical Spinal Fractures

• STABLE

• Wedge fractures (<50% vertebral body height)

• Transverse process fractures

• Clay shoveler’s fracture

• spinous process avulsion

• MC at C7

• flexion against contracted posterior muscles

Spinal Injuries

• Cervical Spinal Fractures

• UNSTABLE

• Jefferson Bit Off A Hangman’s Thumb

Type Mechanism Notes

Jefferson axial load with

vertical compression

C1 burst fx

Bilateral facet dislocation flexion anterior displacement

>50%

Odontoid type II/III flexion II – neck, III - body

Atlantoaxial or atlantooccipital flexion or extension C1/C2 dislocation

Hangman’s hyperextension bilateral C2 pedicle fx

Teardrop flexion > extension teardrop = anteroinferior

portion of vertebral body

QUESTION

• Hyperflexion injury to C spine with negative CT scan, but

persistent neuro symptoms (paralysis, loss of pain & temp

below level of lesion). Diagnosis? Prognosis?

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ANSWER

• Hyperflexion injury to C spine with negative CT scan, but

persistent neuro symptoms (paralysis, loss of pain & temp

below level of lesion). Diagnosis? Prognosis?

• Anterior cord syndrome, POOR

Spinal Injuries

• Incomplete Cord Lesions

Syndrome Mechanism Clinical Prognosis

Anterior cord flexion or

vascular

Loss of motor, pain &

temperature below lesion,

intact proprioception &

vibratory sensation

POOR

Central cord forced

hyperextension

Sensory & motor deficits, upper

> lower extremities

AVERAGE/FAIR

Brown-Séquard penetrating Ipsilateral loss of motor,

vibratory sensation and

proprioception, contralateral

loss of pain & temperature

sensation

GOOD

QUESTION

• How do you diagnose a tension pneumothorax?

ANSWER

• How do you diagnose a tension pneumothorax?

• CLINICALLY!

• JVD

• Hypotension/tachycardia

• Tracheal deviation

• Decreased BS

Chest Trauma

• Pneumothoraces

• Simple

• CXR: deep sulcus sign, absent lung markings (check periphery)

• US: loss of lung sliding (higher sensitivity than CXR)

• <12-25%, stable pt: 100% O2 NRB, repeat CXR

• IF INTUBATING → THORACOSTOMY

• Tension

• Mediastinal shift, obstruction of venous return, decrease CO

• JVD, tracheal deviation, hypotension

• CLINICAL DIAGNOSIS → needle decompression, then thoracostomy

Chest Trauma

• Pneumothoraces

• Open

• Large open wound, sucking chest wound

• Three-sided dressing + thoracostomy

• If you completely occlude wound → tension PTX

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Chest Trauma

• Hemothorax

• CXR blunting of costophrenic angle: >250 mL

• Massive hemothorax → mediastinal shift away from hemothorax

• Large-bore chest tube (36-40 Fr)

• Thoracotomy Indications

• Initial chest tube output > 1500 mL (> 20 mL/kg)

• Persistent output > 200 mL/hr (> 3 mL/kg/hr)

• Persistent hypotension despite thoracostomy output

Chest Trauma

• Sternal Fracture

• Restrained > unrestrained passengers

• Lateral CXR, +/- CT

• Eval for dysrhythmias

• ECG and troponin normal → low likelihood of blunt myocardial

injury

QUESTION

• Becks triad, pulsus paradoxus, and electrical alternans

are all associated with what condition?

Answer

• Becks triad, pulsus paradoxus, and electrical alternans

are all associated with what condition?

• Cardiac tamponade

Chest Trauma

• Cardiac Tamponade

• Becks triad: hypotension, JVD, muffled heart sounds

• Pulsus paradoxus: reduction in SBP > 10 mmHg on inspiration

• Electrical alternans: QRS amplitude changes beat to beat

Chest Trauma

• Traumatic Aortic Injury

• High-speed deceleration

• MC occur at aortic isthmus

• Most reliable CXR signs: widened mediastinum (>8 cm), loss of

aortic knob

• Beta blockade, permissive hypotension

• High mortality

• Blunt Diaphragmatic Injury

• Rare, often missed

• Left >>> right

• +/- abdominal contents herniate into thorax

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QUESTION

• Biking accident with associated handlebar injury in a 5yo

male presenting with upper abdominal pain is concerning

for what type of injury?

ANSWER

• Biking accident with associated handlebar injury in a 5yo

male presenting with upper abdominal pain is concerning

for what type of injury?

• Hollow viscous injury (eg duodenum/jejunum), pancreatic

injuries

Abdominal Trauma

• Blunt Hollow Viscous Injury

• Seat belt, steering wheel or handle bar

• Stomach, intestines (duodenum/jejunum), pancreas, Chance fx of

lumbar spine (+ lap belt)

• Delayed peritoneal signs

• Imaging often NEGATIVE

Abdominal Trauma

• Blunt Solid Organ Injury

• MC injured organ = spleen, then liver

• eFAST→ hepatorenal (Morison’s pouch) space

• Even MORE sensitive = caudal edge of the liver

• Penetrating Injury

• MC injured organs based on mechanism

• Stab wounds = liver, then small bowel

• GSW = small bowel, then colon, then liver

QUESTION

• 32yo F at 25w gestation based on LMP presents following

minor MVC. No external signs of trauma. Abdominal exam

benign. Next steps?

• Discharge home

• Observe for 6 hours

• CT A/P

• Continuous fetal monitoring

ANSWER

• 32yo F at 25w gestation based on LMP presents following

minor MVC. No external signs of trauma. Abdominal exam

benign. Next steps?

• Discharge home

• Observe for 6 hours

• CT A/P

• Continuous fetal monitoring

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Trauma in Pregnancy

• Mechanism: MVC, intimate partner violence

• Beware baseline VS and lab value changes in pregnancy

• Minor trauma, >24 weeks gestation = continuous fetal

monitoring to eval for placental abruption

• Kleihauer-Betke test

• >20 weeks gestation

• Evaluates fetomaternal hemorrhage

• Guides RhoGAM

Trauma in Pregnancy

• Fetal viability: 24 week gestation

• Dome of uterus above umbilicus

• Resuscitate the mother first - ALWAYS

• If no ROSC by 4 minutes → perimortem C-section

• Tube thoracostomy

• ABOVE 4th intercostal space

• ANTERIOR axillary line

Pelvic Fractures

• Types

• Acetabular

• Bimodal (young: high energy, elderly: low energy)

• Avulsion

• Adolescents, occur at tendon attachments, rapid/strong muscle

contractions

• Major Ring Fractures

• Pelvis instability

• Evaluate perineum

• Destot sign: hematoma above inguinal ligament or scrotum

• Retroperitoneal bleeding common

• Grey Turner sign (flank ecchymosis)

• Cullen sign (bruising around umbilicus)

QUESTION

• At what anatomical landmark is a pelvic binder placed?

ANSWER

• At what anatomical landmark is a pelvic binder placed?

• Greater trochanter

Pelvic Fractures

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Pelvic Fractures

• Major Ring Fractures

① Lateral Compression

• Most common type

• T-bone MVC, pt struck on side

② Anteroposterior Compression

• e.g. open book

• Second most common

• Head on MVC

③ Vertical Sheer

• Least common, highest incident of severe hemorrhage

• Fall/jump from height

Pelvic Fractures

• Management Pearls

• IV/IO access ABOVE the pelvis

• Pelvic instability → binder application at greater trochanter

• Abnormal prostate position or blood at urethral meatus →

urethrogram prior to Foley placement

• Angioembolization > OR:

• No other operative injuries identified

• Large pelvic hematoma or active IV extravasation on CT

• OR > Angioembolization:

• Concurrent injuries which require emergent operative stabilization

QUESTION

• Traumatic hip dislocation – MC anterior or posterior?

ANSWER

• Traumatic hip dislocation – MC anterior or posterior?

• Posterior

Traumatic Hip Dislocation

• Posterior

• 80-90%

• MVC, knee on the dashboard

• +/- acetabular fractures

• Shortened, internally rotated, adducted

• Reduce ASAP

• Complications

• Sciatic nerve injury

• Prolonged dislocation → AVN femoral head

QUESTION

• Which of the following is most commonly associated with

a POSTERIOR urethral injury?

• Saddle injury

• Pelvic fracture

• Butterfly perineal hematoma

• Female sex

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ANSWER

• Which of the following is most commonly associated with

a POSTERIOR urethral injury?

• Saddle injury

• Pelvic fracture

• Butterfly perineal hematoma

• Female sex

Genitourinary Trauma

• Urethral Injuries

• MC in MALES

• Sx: blood at meatus, inability to void, dysuria/hematuria

① Anterior: saddle injury (MC), instrumentation, direct trauma

• A “butterfly” perineal hematoma

② Posterior: pelvic fracture

• High-riding prostate

• Retrograde urethrogram

Genitourinary Trauma

• Bladder Injuries

① Extraperitoneal bladder rupture

• Occurs at bladder neck 2/2 sheering forces

• No communication with peritoneum

• Tx: Foley decompression 10-14d

② Intraperitoneal bladder rupture

• Distended bladder ruptures at its dome

• Urine leaks into peritoneum → peritonitis

• Tx: Surgery

• Dx: retrograde cystogram

Genitourinary Trauma

• Penile Trauma

• Fracture – rupture of corpus cavernosum

• Blunt trauma to erect penis, + “cracking” sound w/ severe pain

QUESTION

• What is considered to be a normal compartment

pressure?

• 0-10 mmHg

• 5-15 mmHg

• 20-30 mmHg

• 30-40 mmHg

ANSWER

• What is considered to be a normal compartment

pressure?

• 0-10 mmHg

• 5-15 mmHg

• 20-30 mmHg

• 30-40 mmHg

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Soft Tissue Trauma

• Compartment Syndrome

• Mechanism: casts or burns (external constriction), hemorrhage,

fractures, crush injuries, reperfusion injuries

• Normal compartment pressure: 0-10 mmHg

• 20 mmHg: capillary flow affected → observe, repeat measurements

• > 30-40 mmHg: muscle and nerve ischemia → consider fasciotomy

• PEARLS

• MC affected compartment: anterior compartment of the leg

• First affected structure: nerves (loss of two point discrimination)

• Late finding: loss of pulse

• Primarily a clinical diagnosis

• Avoid fasciotomy following snake bites

Soft Tissue Trauma

• Compartment Syndrome

• FIVE Ps

• Pain out of proportion

• Pain with passive stretch of muscle

• Paresthesia, decreased sensation

• Paralysis

• Perfusion (distal pulses, capillary refill)

QUESTION

• What is the feared complication of a knee dislocation?

ANSWER

• What is the feared complication of a knee dislocation?

• Popliteal artery injury

Soft Tissue Trauma

• Peripheral Vascular Injuries

• Check for HARD signs of arterial injury → warrants immediate

surgery

• Pulsatile bleeding, thrill or bruit, rapidly expanding hematoma, arterial

occlusion

• No hard signs → duplex, arteriography

• ABI: normal > 0.9

Soft Tissue Trauma

• Amputation/Replantation

• Transportation of appendage

① Wrap in saline-soaked gauze

• Do NOT use antiseptics or scrub the appendage

② Put in closed plastic bag

③ THEN place on ice

• NEVER DIRECTLY PLACE ON ICE

• High Pressure Injection Injuries

• Often grease or paint, innocuous exam

• Surgical emergency → exploration and debridement

• Do NOT digital block

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Burns

• Thermal Burns

• Evaluate airway

• Know WHEN to intubate → inhalation injury, resp distress or AMS,

facial or perioral burns

• Carbon monoxide, cyanide exposures

• Burn depth

① Superficial: red, painful

② Superficial partial thickness: red, blistering, painful, blanching

③ Deep partial thickness: red to pale white-yellow, blistering, no

blanching

④ Full-thickness: dry, insensate, charred white/black, leathery

• Circumferential burns → eval for escharotomy

QUESTION

• What is the Parkland Formula?

ANSWER

• Parkland Formula

• 4 mL x %burn x weight (kg) = fluid requirement

(mL) over first 24 hours• Half of fluid over first 8 hours

• Second half of fluid over remaining 16 hours

• Do NOT include superficial burns in TBSA

Burns

• TBSA

• Rule of Nines

Burns

• Who do I transfer to a burn center?

• TBSA > 10%

• Burns involving face, hand, feet, genitalia, perineum or MAJOR

joints

• ANY full thickness burn of ANY age group

• Electrical or chemical burns

• Inhalation injuries

Burns

• Chemical Burns

• Acids → coagulative necrosis

• Alkalis → liquefactive necrosis

• WORSE PROGNOSIS

• Deep burns

• Treatment PEARLS

• 1st step is ALWAYS to remove offending agent

• Ophthalmologic irrigation until pH = 7.0 (neutral)

• Primary treatment for almost all chemical exposures EXCEPT metals,

dry powder lime and phenol = copious water irrigation

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References

• https://doctorlib.info/surgery/principles-surgery/5.html

• https://rebelem.com/penetrating-neck-injuries/

• https://smhs.gwu.edu/urgentmatters/news/keep-it-simple-acute-gcs-score-binary-decision

• https://www.slideshare.net/manbachan/csf-for-upload

• https://www.nejm.org/doi/full/10.1056/nejmicm1408805

• https://westjem.com/articles/diaphragmatic-rupture-secondary-to-blunt-thoracic-trauma.html

• https://www.aliem.com/management-major-pelvic-trauma/

• https://www.physio-pedia.com/Pelvic_Fractures

• https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=hw262650&lang=en-ca

References

• https://emedicine.medscape.com/article/1277360-

overview

• Blok, B., Cheung, D., & Platts-Mills, T. (2016). First Aid for

the Emergency Medicine Boards Third Edition (3rd ed.).

McGraw-Hill Education / Medical.

• Tintinalli, J., Ma, J. O., Yealy, D., Meckler, G., Stapczynski,

J., Cline, D., & Thomas, S. (2019). Tintinalli’s Emergency

Medicine: A Comprehensive Study Guide, 9th Edition (9th

ed.). McGraw-Hill Education / Medical.

• https://wikem.org/

• Rosh Review

References

• Life in the Fastlane (https://litfl.com/)

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