How to determine ASC Class of Hemorrhagic Shock
I: Normal vitals (<15% loss, 750cc), II: Tachy, but normal BP with ↓ PP (15-30% loss, 750-1.5L), III:
Hypotension (30-40% loss, 1.5-2L), IV: AMS-confused/lethargic (>40%, >2L)
Compare subfalcine, uncal and tonsillar herniation
Subfalcine: most common, frontal lobe under falx, ssx abnormal gait; Uncal: temporal lobe under
cerebellar tentorium, ssx CN3 palsy (blown pupil, down and out), ipsilateral hemiparesis, coma;
Tonsillar: rare, brainstem herniation, coma and death
Injuries CT can commonly miss
Diaphragmatic injury, pancreas injury, basilar skull fracture, hollow viscus injuries
Classification of LeFort Fractures
Midface fx resulting in detachment of maxilla from skull all the fractures involve pterygoid plate; Dx:
CT; I: palate mobile (fx below nose); II: palate + nose mobile (inferior orbits); III: entire face is mobile
(zygoma bone), ± CSF rhinorrhea. IV: a III that involves the frontal bone
Dx and Tx of Mandibular Fractures
SSx: malocclusion, trismus, lower lip paresthesias; BODY = most common; Dx: CT or panorex; Rx:
manage non-condylar fx as open fx with empiric PCN/Clinda, ENT/OMFS consult
Dx and Tx of Orbital Fractures
SSx: Diplopia, proptosis, limited EOM, ↓ visual acuity; check for infraorbital paresthesia, inhibited
upward gaze, diplopia, globe injury; Dx: CT orbit; Rx: consult ophtho/ENT, decongestants, abx
(Augmentin) for sinus involvement
Which facial bone fx has the lowest rate of infection?
Zygomatic.
Dx and Tx of Nasal Septal Hematomas
Dx: dark red mass/hematoma associated with nasal fx/trauma; Rx: MUST incise & pack (NO needle) to
prevent saddle nose deformity/pressure necrosis
, Classification of Neck Zones
I: sternum/clavicles to cricoid cartilage; II: cricoid to angle of mandible, (most common site of injury);
III: angle of mandible to base of skull
Management of Penetrating Neck Injury
Intubate early, straight to OR if unstable vitals or HARD signs of vascular injury ("HARD BRUIT":
Hypotension (shock), Arterial bleeding, Rapidly expanding hematoma, Deficit [pulse/neuro],
Bruit/thirll), airway obstruction; Soft signs: CT angio, possible scope/exploration if stable
Possible complications of blunt neck injury
Pseudoaneurysm, carotid artery dissection, tracheal injury; Dx: CT angio, if unstable, intubate/ENT
consult; blunt neck trauma + neuro findings = carotid artery dissection until proven otherwise
Dx and Tx of Traumatic Aortic Dissection
Most die in field; Consider when- high speed deceleration, chest pain/back pain, new murmur, pulse
deficits BUT exam often unremarkable; Dx: stable- CXR (1/3 normal, look for mediastinal widening,
obscured aortic knob, L apical pleural cap, R tracheal deviation, ↓ L bronchus/↑ R bronchus, loss of
AP window, R displaced NGT), VERY stable- get CTA; Rx: if (+) dispo to OR on beta blocker for BP
control; aortic isthmus = most common location
Dx and Tx of Flail Chest
≥3 adjacent rib fractures at 2 different points; leads to paradoxical chest motion with respirations;
Association: pulmonary contusion; Rx: ealy intubation, ± chest tube
Appropriate imaging to eval for sternal fracture
Must get lateral CXR; consider CT if high suspicion and XR (-)
Identify high risk rib fractures
1-2: associated with vascular and broncheal injuries; 9-11: associated with liver and spleen
lacerations; 4-9: most common location; multiple ribs: associated with underlying lung contusion
Indications for OR Thoracostomy with Hemothorax
Unstable vitals, initial chest tube output >1.5L (20cc/kg) OR >200/hr over 3-4hr (3cc/kg), persistent
bleeding >7cc/kg/he, persistent air leak
Management of Traumatic Pneumothorax
Small: O2, repeat CXR; Large: chest tube; *Pearl: if intubating with ptx, do chest tube first to prevent
tension ptx*
Indications for ED Thoracotomy
Penetrating traumatic cardiac arrest: field arrest with intial vitals, ED arrest, SBP <50 after IVF; Blunt
trauma: ED arrest; Other: suspected air embolism
General approach to traumatic abdominal injury
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