Surgery Marrow Pg 437-446 (Trauma)
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Surgery Marrow Pg 437-446 (Trauma)

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Questions and Answers

What Glasgow Outcome Score indicates a good recovery?

  • 2
  • 1
  • 5 (correct)
  • 4

    • Brain death can be declared if there is a possibility for recovery of brain function.

    False

    List two criteria used to certify brain death.

    GCS of 3, nonreactive pupils

    The absence of __________ is one of the criteria for declaring brain death.

    <p>spontaneous ventilatory effort</p> Signup and view all the answers

    Match the following Glasgow Outcome Scores with their descriptions:

    <p>1 = Death 2 = Persistent vegetative state 3 = Severe disability 4 = Moderate disability 5 = Good recovery</p> Signup and view all the answers

    What is the primary indication for performing a CT scan in adults within 1 hour after a head injury?

    <p>Any GCS &lt; 13</p> Signup and view all the answers

    Children with a Glasgow Coma Scale (GCS) of less than 15 two hours post-injury do not require CT imaging.

    <p>False</p> Signup and view all the answers

    What does GCS stand for?

    <p>Glasgow Coma Scale</p> Signup and view all the answers

    In adults, a GCS of _____ or less is an indication to involve a neurosurgeon.

    <p>8</p> Signup and view all the answers

    Match the following indicators with their corresponding time for CT scan in adults:

    <p>GCS &lt; 13 = Within 1 hour Age &gt; 65 years = Within 8 hours Focal neurological deficit = Within 1 hour Retrograde amnesia &gt; 30 minutes = Within 8 hours</p> Signup and view all the answers

    What is a common clinical finding in an elderly patient with chronic subdural hemorrhage post trivial injury?

    <p>Altered sensorium</p> Signup and view all the answers

    The Kernohan notch phenomenon can result in left-sided hemiparesis due to right-sided brain compression.

    <p>True</p> Signup and view all the answers

    What investigation is primarily used to diagnose subdural hemorrhage?

    <p>CT scan</p> Signup and view all the answers

    The most common cause of subarachnoid hemorrhage (SAH) is __________.

    <p>trauma</p> Signup and view all the answers

    Match the following criteria with their respective indications for craniotomy/burr hole:

    <blockquote> <p>1 cm thickness = Indication for craniotomy/burr hole 20 mmHg ICP = Indication for craniotomy/burr hole 5 mm midline shift = Indication for craniotomy/burr hole 2 points drop in GCS = Indication for craniotomy/burr hole</p> </blockquote> Signup and view all the answers

    Which method is considered the best for calculating burn percentage?

    <p>Lund &amp; Browder chart</p> Signup and view all the answers

    1st-degree burns heal without scarring in 2-3 weeks.

    <p>False</p> Signup and view all the answers

    What color and tenderness describe a first-degree burn?

    <p>Red, tender, and blanching</p> Signup and view all the answers

    The zone of burn characterized by irreversible damage is called the ______.

    <p>Coagulation/necrosis</p> Signup and view all the answers

    Match the degrees of burns with their description:

    <p>1st Degree = Red, tender, heals in 3-5 days Superficial = Epidermis and papillary dermis involved Deep = Hypertrophic scars and requires dressing 2nd Degree = Similar to 1st degree, +/- blanching</p> Signup and view all the answers

    What is a characteristic of deep burns?

    <p>Can lead to hypertrophic scars and keloids</p> Signup and view all the answers

    The stasis zone is characterized by well-managed tissue that promotes healing.

    <p>False</p> Signup and view all the answers

    What is the healing time for superficial burns?

    <p>2-3 weeks</p> Signup and view all the answers

    Which of the following parameters should be maintained in head injury patients? (Select all that apply)

    <p>ICP &lt; 20 mmHg</p> Signup and view all the answers

    Steroids are recommended for managing raised intracranial pressure in all cases of head injury.

    <p>False</p> Signup and view all the answers

    What is the recommended minimum mean arterial pressure (MAP) for head injury patients?

    <p>80 mmHg</p> Signup and view all the answers

    In patients with mild head injury, verbal and written head injury advice is part of the discharge criteria, alongside a GCS of _____ and no focal deficits.

    <p>15/15</p> Signup and view all the answers

    What is the primary mechanism of a concussion?

    <p>Contact sports</p> Signup and view all the answers

    Match the following interventions with their purpose in trauma management:

    <p>Mannitol = Reduce ICP Hyperventilation = Control carbon dioxide levels Slight head elevation = Facilitate venous drainage Phenytoin = Prevent early posttraumatic seizures</p> Signup and view all the answers

    Diffuse Axonal Injury (DAI) is the mildest type of brain injury.

    <p>False</p> Signup and view all the answers

    What GCS score range indicates a moderate brain injury?

    <p>9-13</p> Signup and view all the answers

    A rise in __________ can lead to secondary brain injury.

    <p>intracranial pressure</p> Signup and view all the answers

    Match the following types of brain injuries with their characteristics:

    <p>Concussion = Mildest type of primary brain injury Diffuse Axonal Injury = Most severe type of brain injury Secondary Injury = Injury due to rise in intracranial pressure Primary Injury = Injury due to impact</p> Signup and view all the answers

    Which condition is characterized by a lucid interval following a head injury?

    <p>EDH</p> Signup and view all the answers

    Chronic subdural hematoma typically affects elderly patients after trivial injuries.

    <p>True</p> Signup and view all the answers

    What is the formula for calculating Cerebral Perfusion Pressure (CPP)?

    <p>CPP = Mean Arterial Pressure - Intracranial Pressure</p> Signup and view all the answers

    In the context of head trauma, a ______________ injury is associated with coma and no signs of recovery.

    <p>Diffuse axonal</p> Signup and view all the answers

    Match the following features with their corresponding conditions:

    <p>EDH = Lucid interval Chronic SDH = Normal for a few weeks, then altered sensorium Diffuse axonal injury = Coma; No signs of recovery</p> Signup and view all the answers

    Which of the following are signs of airway burns?

    <p>Carbonaceous deposits in sputum</p> Signup and view all the answers

    Eschar around the chest does not affect chest expansion.

    <p>False</p> Signup and view all the answers

    What is the immediate required management for airway burns?

    <p>Prophylactic intubation</p> Signup and view all the answers

    Inhalation of smoke can lead to __________ due to airway obstruction.

    <p>hypoxia</p> Signup and view all the answers

    Match the phases of bronchopneumonia with their causative organisms:

    <p>Early = S. aureus Late = Gram-negative bacteria</p> Signup and view all the answers

    What is the main fluid resuscitation formula used for burns?

    <p>Parkland formula</p> Signup and view all the answers

    Crystalloids should be administered after 24 hours of burn injury.

    <p>False</p> Signup and view all the answers

    What is the target urine output for infants and young children after a burn injury?

    <p>1 mL/kg/hr</p> Signup and view all the answers

    The amount of fluid required in 24 hours is calculated using the formula 4 x Body weight (kg) x % TBSA of burns, excluding __________ burns.

    <p>primary</p> Signup and view all the answers

    Match the following categories of burns with their corresponding adjusted fluid rates:

    <p>Flame or scald (Adults and older children) = 3 mL LR x kg x % TBSA Electrical injury (All ages) = 4 mL LR x kg x % TBSA until urine clears Flame or scald (Children) = 3 mL LR x kg x % TBSA Flame or scald (Infants and young children) = 3 mL LR x kg x % TBSA</p> Signup and view all the answers

    What is the most common type of bleed following head trauma?

    <p>Contusion (Intra Parenchymal Bleed)</p> Signup and view all the answers

    A lucid interval is a definitive diagnostic feature of Extradural Hemorrhage.

    <p>False</p> Signup and view all the answers

    What imaging technique is considered the initial choice for diagnosing intracranial hemorrhages?

    <p>NCCT</p> Signup and view all the answers

    The middle meningeal artery is responsible for bleeding in __________ hemorrhage.

    <p>Extradural</p> Signup and view all the answers

    Match the following characteristics with their corresponding type of hemorrhage:

    <p>Contusion = Most common type of bleed after trauma Extradural Hemorrhage = Biconvex/lens-shaped appearance on NCCT Lucid Interval = Temporary period of consciousness Management = Control of intracranial tension</p> Signup and view all the answers

    Study Notes

    Glasgow Outcome Score (Prognostic Score)

    • Death is rated 1
    • Persistent vegetative state is rated 2
    • Severe disability is rated 3
    • Moderate disability is rated 4
    • Good recovery is rated 5

    Brain Death

    • Brain death requires certification by experts
    • Brain death can be declared if there is no possibility of brain function recovery
    • There are 5 criteria:
      • Glasgow Coma Scale (GCS) of 3
      • Nonreactive pupils
      • Absence of brainstem reflexes
      • No spontaneous ventilation
      • Absence of confounding factors like drug intoxication or hypothermia
    • Additional studies like EEG and cerebral angiography may be used

    Burns

    • 1% of Total Body Surface Area (TBSA) is equivalent to the size of the palm
    • Wallace’s Rule of 9 is used for percentage calculation
    • Lund & Browder chart is the gold standard for calculating burn percentage
    • There are 3 zones of burns:
      • Coagulation/necrosis: Tissue damage is irreversible
      • Stasis: Unclear in text
      • Hyperemia: If poorly managed, results in necrosis; If well managed results in hyperemia
    • There are 3 burn degrees:
      • 1st Degree: Involves epidermis only, heals without scarring.
        • Examples include sunburn
      • Superficial: Involves epidermis and papillary dermis.
        • Red and tender, may have some blanching
      • Deep: Involves epidermis and entire dermis:
        • Can lead to hypertrophic scarring and keloids
        • Requires wound dressing

    NICE Guidelines: For Head Injury

    • Cervical spine injury should be ruled out in all patients
    • GCS is monitored:
      • Every 30 minutes in the first 2 hours
      • Every 1 hour for the next 4 hours
      • Every 2 hours after 6 hours
    • CT scan criteria for adults:
      • Within 1 hour:
        • GCS less than 13 at any point
        • GCS less than 15 at 2 hours
        • Focal neurological deficit
        • Suspected open, depressed or basal skull fracture
        • More than one episode of vomiting
        • Post-traumatic seizure
        • Loss of consciousness
      • Within 8 hours:
        • Over 65 years old
        • Retrograde amnesia greater than 30 minutes
    • CT scan criteria for children:
      • Suspicion of non-accidental injury (NAI)
      • First seizure
      • GCS less than 14 or less than 15 in under-ones
      • GCS less than 15 at 2 hours post injury
    • Neurological surgeon involvement criteria:
      • GCS ≤8
      • Fall in GCS score after admission
      • Unexplained confusion longer than 4 hours
      • Loss of consciousness, seizure, or more than 1 episode of vomiting
      • Focal neurological signs

    Trauma

    • Kernohan Notch Phenomenon:
      • Occurs when there is a left temporal lobe epidural hematoma (EDH)
      • Increased intracranial tension
      • Temporal lobe/uncal herniation
      • Compression of the Kernohan notch on the right side
      • Compresses the right corticospinal tract
      • Leads to left-sided hemiparesis
      • Can be falsely localized as a right-sided bleed
    • Chronic Subdural Hemorrhage (SDH)
      • Types based on duration: Acute - less than 21 days
      • Mechanism of Chronic SDH: Trivial injury
      • Caused by bleeding in bridging veins
      • Clinical findings: Elderly patient with trivial injury, normal for a few days/weeks then altered sensorium
      • Investigations: CT scan
        • Concavo convex or crescenteric hemorrhage
        • Blood between dura and arachnoid
        • No restriction by suture lines
        • Increased extent of brain injury
      • Indications for Craniotomy/Burr Hole:
        • Clot thickness greater than 1 cm
        • Midline shift greater than 5 mm
        • 2 or more point drop in GCS score
        • OR
        • ICP greater than 20 mmHg
        • Fixed dilated pupil
    • Traumatic Subarachnoid Hemorrhage (SAH)
      • Most common cause of a SAH is trauma
      • Management is typically conservative

    Trauma Management

    • Management of raised ICT in trauma:
      • Adeqaute oxygen
      • Adequate perfusion: Systolic blood pressure greater than 100 mmHg
      • Avoid dextrose solutions as hyperglycemia can worsen cerebral edema
      • Give 1/V Mannitol
      • Hyperventilation in moderate amounts
      • Slight head elevation
      • Steroids do not play a role in management
    • Key parameters to maintain in head injury patients:
      • Paco₂: 4.5-5.0 kPa
      • CPP greater than 60 mmHg
      • PaO₂: Greater than 11 kPa
      • MAP: 80-90 mmHg
      • [Na⁺]: Greater than 140 mmol/L
      • [K⁺]: greater than 4 mmol/L
      • ICP less than 20 mmHg
    • Prophylactic use of phenytoin or valproate:
      • Not recommended for late post-traumatic seizures (PTS)
      • Used for early PTS

    Discharge Criteria for Mild Head Injury

    • GCS score of 15/15 without focal deficits
    • Normal CT brain if indicated
    • Patient is not under the influence of drugs or alcohol
    • Patient is accompanied by a responsible adult
    • Verbal and written head injury advice
    • Seek medical attention if:
      • Persistent or worsening headache despite analgesia
      • Persistent vomiting
      • Drowsiness
      • Visual disturbances
      • Limb weakness or numbness

    Brain Injury

    • Types of Brain Injury:
      • Primary injury: Injury due to impact
      • Secondary injury: Injury due to a rise in intracranial pressure (ICT)
    • Severity and GCS score:
      • Minor: GCS 15/15, no loss of consciousness (LOC)
      • Mild: GCS 14/15, LOC (+)
      • Moderate: GCS 9 - 13
      • Severe: GCS ≤ 8
    • Concussion:
      • Severity: Mildest type of primary brain injury
      • Mechanism: Contact sports
      • Colorado Classification (subdivided into grades)
        • Grade 1: Confusion
        • Grade 2: Amnesia
        • Grade 3: LOC
      • Possible complications:
        • Multiple Concussions
        • Chronic Traumatic Encephalopathy
    • Diffuse Axonal Injury (DAI):
      • Severity: Most severe type
      • Mechanism: High velocity injury, shearing force between gray and white matter
        • Symptoms:
          • Coma
          • No improvement in GCS score
      • Imaging Findings:
        • NCCT: Normal
        • MRI: Shows punctate hemorrhages of gray and white matter junction
      • Management:
        • Avoid contact sports
        • Hypotension should raise suspicion of other areas of bleeding (thorax, pelvis, abdomen, long bones)
    • DAI can also indicate spinal injury (neurogenic bladder) or late stage brain herniation

    Head Trauma

    • Summary table of EDH, Chronic SDH and Diffuse Axonal injury:
      EDH Chronic SDH Diffuse axonal injury
      History Usually young patient, High velocity impact Usually elderly patient, Trivial injury High velocity impact
      Features Lucid interval Normal for a few weeks, then altered sensorium Coma; No signs of recovery
      CT Bi convex hemorrhage Concavo convex
    • Secondary Brain Injury:
      • Mechanism: Rise in ICT
      • Image describes normal state (normal ICP) and decompensated state (increased ICP)
    • Clinical Features:
      • Increased MAP:
        • Increased systolic blood pressure
        • Decreased heart rate
        • Altered respiration
      • Cushing’s Reflex:
        • Site: Acid producing areas of stomach
        • Type: Stress ulcers
    • Intracranial volume-pressure Curves:
      • Cerebral Perfusion Pressure (CPP) is required to perfuse brain parenchyma
        • CPP = mean arterial pressure - Intracranial pressure
        • Normal= 260 mmHg
      • Graph shows intracranial pressure plotted against volume of mass

    CIRCULATION

    • Pathophysiology of Burns:
      • Burns lead to release of inflammatory mediators
      • Vasodilation
      • With 10% TBSA, increased evaporation occurs, vascular leak leads to edema within the 1st 24-48 hours
      • Localized immune response
      • Generalized immune response: Dehydration occurs as albumin is lost to the extravascular space
      • 3rd space fluid loss
    • Fluid resuscitation:
      • Colloids are used after 24 hours and are calculated using Muir & Barclay formula
      • Crystalloids are used mainly with Ringer lactate and are calculated using the Parkland formula
        • 4 x Body weight (kg) x % TBSA of burns (excluding 1º burns) = Amount of fluid required in 24 hrs.
        • 1/2 amount over 8 hrs, 1/2 amount over 16 hrs
    • Modified Parkland/Brooke formula:
      • 2 x Body weight (kg) x %TBSA
    • Burn resuscitation fluid rate and target urine outputs:
      Category of burn Age and weight Adjusted fluid rates Urine output
      Flame or scald Adults and older children (≥ 14 years) 3 mL LR x kg x % TBSA 0.5 mL/kg/hr
      Children (< 14 years) 3 mL LR x kg x % TBSA 30-50 mL/hr
      Infants and young children (≤ 30 kg) 3 mL LR x kg x % TBSA 1 mL/kg/hr
      Electrical injury All ages 4 mL LR x kg x % TBSA until urine clears 1-1.5 mL/kg/hr until urine clears
    • Maintenance fluids in children:
      1. 100 mL/kg for first 10 kg
      2. 50 mL/kg for next 10 kg
      3. 20 mL/kg for every kg after 20 kg.
    • Galveston formula: Used for crystalloid solutions, also used in children

    THERMAL INJURIES

    • Burns Unit Emergency Management:
      • Referral criteria:
        • Burns involving face, hands, genitalia
        • Chemical burns
        • Electrical burns
        • Inhalation injury
        • Partial thickness burns over 10% TBSA (Total Body Surface Area)
        • Full thickness (3rd degree) burns
    • AIRWAY:
      • Signs of airway burns:
        • Singed nasal hair
        • Hoarseness of voice
        • Carbonaceous deposits in sputum
      • Airway burns require prophylactic intubation
        • Due to rapid airway collapse
      • Stages:
        • Acute pulmonary insufficiency: Hypoxia
        • Acute Respiratory Distress Syndrome-like picture (24-48 hrs) : Bilateral lung infiltrates, hypoxia
      • Management:
        • Intubation
        • Bronchodilators
    • ACLS guidelines for management of burns:
      • Airway
      • Breathing
      • Circulation
      • Disability
      • Exposure
    • Determine cause of burns and extent of area burned
    • Stages of Bronchopneumonia:
      Phase Duration Causative Organism
      Early 1-3 days S.aureus
      Late > 3 days Gram-negative bacteria
    • Causes of hypoxia:
      • Inhalation of smoke
      • Airway collapse
      • CO poisoning:
        • CO increases affinity to hemoglobin, decreasing oxygen transportation
    • Eschar around the chest:
      • Restricts chest expansion
      • Requires escharotomy

    Intracranial Hemorrhages

    • Contusion (Intra Parenchymal Bleed)
      • Mechanism: Most common type of bleed following head trauma
      • Location: Temporal lobe (more common than frontal lobe)
      • Imaging: Non-contrast CT (NCCT)
      • Management: Conservative management, control ICT
    • Extradural Hemorrhage (EDH)
      • Incidence: Common in young patients
      • Mechanism: High velocity impact injuries
      • Etiology: Bleeding from the middle meningeal artery (MMA)
      • Lucid Interval: A temporary period of lucidity that is followed by decreased consciousness (this isn't a diagnostic feature)
      • Imaging: NCCT
      • Appearance: Biconvex/lens-shaped hemorrhage, restricted between the skull and dura, crossing cranial sutures
      • Management:
        • Surgical: Craniotomy, Burr hole
        • Site: Location near the pterion
        • Indications for surgery:
          • Clot size greater than 30 cc
          • Midline shift greater than 0.75 cm
          • Clot thickness greater than 1.5 cm
      • Choosing the site for surgery:
        • NCCT: The site of the bleed on the NCCT is considered
        • If NCCT is unavailable: Check the pupil dilation - Affected side corresponds to the bleeding side
      • Important Considerations:
        • Normal phenomenon: Left EDH → Right-sided hemiparesis

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    Test your knowledge on the Glasgow Outcome Score and its implications in recovery assessment. This quiz also covers brain death criteria, CT scan indications, and the Glasgow Coma Scale's relevance in neurology. Challenge yourself with matching statements and answering critical questions relevant to patient assessment in emergency medicine.

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