Trauma Notes

Whenever the patient’s status changes in a trauma, start over with primary survey.
Thoracic aortic rupture – rare, but a common cause of death from blunt MVC trauma.  Many die before arrival at the hospital.
– two stages of injury:  injury to intima and media, followed by adventitia rupture second to years later
– causes a diastolic murmur
– X-ray findings:  mediastinal widening, L apical pleural cap, blurring or enlargement of aortic knob, tracheal deviation to R (usually bleeding on the L pushing things to the R)
Four grades:
Grade 1:  intimal tear
Grade 2:  intramural hematoma
Grade 3:  pseudoaneurysm
Grade 4:  aortic rupture
Medical management:
– permissive hypotension – keep SBP near 100, HR < 100/min
– IV esmolol is ideal first-line agent
– CCB can be used as second-line agent
– IV nitroglycerin or nitroprusside can be used
Endovascular v Open Repair:
– open: may need systemic anticoagulation, risk of spinal ischemia due to aortic cross-clamping; 17% complication rate
– endovascular: stents are designed more for older patients with aneurysms; 13-14% complication rate
Basically, if they survive to the ED, you can stay calm and address their trauma.
Ionizing radiation:  X-rays, gamma rays, etc.
Tobacco becomes radioactive via absorbing radium through soil – radon decays to polonium, which can give heavy smoker the radiation exposure equivalent to 100 CXR/year!
CXR = 10 millirems, vs a body CT (low end) is 1000 millirems.  Head CTs can be 4000-6000 millirems.
Pregnancy:  recommended radiation not to exceed 50 mrem/mo – one CXR is about 10 mrem.
Effects of exposure vary according to dose and radiosensitivity of the tissues:  rapidly replicating cells (GI, marrow, gonads) are more sensitive to radiation damage.
Acute radiation syndrome:  0-48 h – vomiting, abdominal pain, diarrhea (time of onset of vomiting is prognostically important); 1-60 days, multiple organ involvement, sepsis, death.  If exposure >5-12 Gy, can cause death of GI crypt stem cells, which means no regeneration, which means death.  There are also CNS and pulmonary syndromes.
Radiation skin ulcers:  early telangiectasias, followed by skin and SQ fat atrophy, followed by tissue loss.  Late malignant transformation.
Cataracts can occur with as little as 0.2 Gy, and may be delayed by 5+ years – wear eye protection!
Who to call for help:  Poison Control, Radiation Safety Office (or Security after hours).
An acute surgical emergency, must be recognized early!
Can lead to flexion contractures, rhabdomyelitis, sepsis, etc.
Volkman’s Ischemic Contracture – flexed elbow, forearm pronation, wrist flexion, MP extension.
What’s a compartment:  an enclosed anatomic space usually bounded by relatively inflexible fascial planes, and with individual neurovascular supply.
Etiologies:  circumferential burns, arterial injury, snake envenomations, spider bites, intrauterine cord strangulation of a fetal limb, revascularization, prolonged immobilization.
Most common:  after long bone fractures, most commonly the tibial diaphysis fracture (1-10% of these).
Compartments:  forearm volar compartment most at risk with radial fractures; hand has 10 small compartments; 3 gluteal compartments; proximal lower extremity (thigh) – less at risk for compartment syndrome that lower leg;  lower leg:  anterior > deep posterior compartment.  Foot compartments – most often seen in the pediatric population.
Sxs:  intense pain, out of proportion to the exam.  The five Ps:  pain, parasthesias, pallor, paralysis, pulselessness (don’t wait to get to pulselessness!).  So, it’s possible to have compartment syndrome in a normal-looking limb with preserved pulses!
Exam:  swelling, tenseness, “wood-like” feeling.
Measuring intracompartmental pressures:  Stryker handheld intracompartmental pressure monitor, needle manometer, Wick catheter.  Should always take several readings to ensure accurate results.
Pressure 30+ is bad – needs immediate surgical treatment
Pressure 20+ should probably be urgently addressed
Pressure 10-15 – frequent re-checks
Pressure < 10 – okay (if no symptoms or signs)
– from lecture by Drs Eric Frankel and Saba Rivzi, 2016

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