Dr. Ali’s Uworld Notes For Step 2 CK Surgery Trauma Hemorrhagic Shock - Hemorrhagic shock may be divided into four classes based on the amount of blood loss. Patients with class I hemorrhage have lost less than 15% of their intravascular volume (or less than 750 cc) and are generally alert. The blood pressure is normal and the major organs are satisfactorily perfused as evidenced by a normal urine output. The patient compensates for blood loss through a sympathetic response that induces mild tachycardia and peripheral vascular constriction. Capillary refill is maintained (< 2 seconds). Patients with a class II hemorrhage have lost between 15 and 30% of their blood volume (or 750-1500 cc) and are generally more anxious and agitated. Pulse rate will be more than 1 DO/min. While the mean arterial blood pressure remains normal, the pulse pressure is narrowed and the blood pressure starts to trend downward. Urine output is slightly decreased and the skin is cool and moist. Capillary refill may be delayed. All of these manifestations can be attributed to further increases in sympathetic discharge and shunting of blood from less critical vascular beds such as the skin, leading to skin vasoconstriction. Patients with class Ill hemorrhage have lost 30-40% of their blood volume (or 1500-2000 cc) and can no longer maintain their blood pressure at normal levels despite further increases in heart rate and peripheral vascular constriction. These patients will begin to have a decreased level of consciousness and a further decrease in urine output due to poor cerebral and renal perfusion, respectively. Class IV hemorrhage is defined as a blood loss of more than 40% of the blood volume (or > 2000 cc). The patient appears lethargic, tachypneic and has markedly decreased urine output. At this point, circulatory failure and death are imminent without therapeutic intervention. When hemorrhage occurs, tachycardia and peripheral vascular constriction are the first physiological changes. These responses act to maintain the blood pressure within normal limits until severe blood loss has occurred. Tetanus Immunization - All patients with traumatic wounds should be assessed for the need of tetanus prophylaxis. Tetanus immune globulin (TIG) provides passive, temporary, and immediate immunity. Tetanus-diphtheria toxoid (Td) provides active, prolonged, and delayed immunity. Wounds at high risk for vegetative Clostridium fefani growth are those that provide an anaerobic environment for growth, such as puncture wounds, projectile wounds, wounds containing foreign bodies, sites of active infection by other organisms, and wounds containing necrotic tissue. Tetanus immune globulin (TIG) provides passive, temporary and immediate immunity. Tetanus-diphtheria toxoid (Td) provides active, prolonged and delayed immunity. Wounds at high risk for vegetative Clostridium teeani growth are those that provide an anaerobic environment for growth, such as puncture wounds, Projectile wounds, wounds containing foreign bodies, sites of active infection by other organisms and wounds containing necrotic tissue. A Td booster should be administered to individuals with more severe or dirty wounds (e.g .. puncture wounds and wounds contaminated with dirt. feces. or saliva) who received their latest dose more than 5 years ago and those with clean minor wounds who received their latest dose more than 10 years ago. A TIG injection should be administered to individuals who have received less than three doses of tetanus vaccine and those with a more severe or dirty wounds who have an unknown immunization status. Glasgow Coma Scale - All trauma patients should be first assessed using the GCS, which estimates the severity of the patient's neurologic injury for triage. The GCS can also give some prognostic information when used in conjunction with the patient's age and presence of concomitant adverse clinical findings, such as hypoxia, cardiovascular compromise, increased intracranial pressure, and radiographic evidence of a midline shift of the brain. Calculation of GCS score is shown below. The GCS is used to predict the prognosis of coma and other medical conditions, such as bacterial meningitis, traumatic brain injury, and subarachnoid hemorrhage. However, the GCS is not used to diagnose coma in a patient. Findings used to diagnose coma include impaired brainstem activity (e.g., disruption of the papillary light, extraocular, and corneal reflexes), motor dysfunction (e.g., decorticate or decerebrate posturing), and impaired level of consciousness, Blunt Head Trauma – These patients presents after blunt head trauma (look for scalp lacerations, skull depression). In such patients, look for signs/symptoms worrisome for transtentorial (uncal) herniation secondary to an epidural hematoma. Epidural hematomas result from rupture of the middle meningeal artery, and this higher arterial pressure can rapidly expand the hematoma and compress the temporal lobe. The fluid resuscitation in such patient likely increased the rate at which the epidural hematoma expanded. The presence of hypertension, bradycardia, and respiratory depression (Cushing's reflex) indicates elevated intracranial pressure. The uncus is the innermost part of the temporal lobe and herniates through the tentorium to cause pressure on the ipsilateral oculomotor nerve, ipsilateral posterior cerebral artery, and contralateral cerebral peduncle against the edge of the tentorium. Patients typically present with the focal neurologic signs shown in the table above. Abducens nerve (i.e., CN VI) injury from uncal herniation usually occurs later in the clinical presentation, with a symptom of inability to abduct the eye. Most head injuries are mild and will not progress to more serious clinical scenarios. Minor head trauma is defined as a head injury that is associated with a Glasgow coma scale (GCS) score of 15, normal mental status on examination, no abnormal neurologic or funduscopic examination findings and no physical evidence of skull fracture. These patients can be discharged with no further imaging or studies if a reliable individual can monitor them for 24 hours following the injury. Mild traumatic brain injury (TBI) is defined as a head injury that is associated with a GCS score of 13-15 and brief loss of consciousness, vomiting, headache or disorientation. Patients with moderate TBI have a GCS score of 9-12, and those with severe TBI have a GCS score of less than 8. Patients with severe TBI, evidence of intracranial injury, focal neurologic signs, seizure, prolonged loss of consciousness, and evident skull fracture on examination should have a CT scan of the brain and be observed in the hospital with frequent neurologic examinations. Patients with mild-to-moderate TBI who have vomiting,headache, or brief loss of consciousness should also have a CT scan of the head. If the CT scan is normal, these patients can be discharged with a reliable caretaker and printed instructions (with a list of symptoms) that describe when they should return to the hospital. Patients with mild-to-moderate TBI who do not have any of the above symptoms do not need neuroimaging and can be observed for 4-6 hours in the emergency department, with neuroimaging reserved for those who worsen. Diffuse axonal injury is the most significant cause of morbidity in patients with traumatic brain injuries. It is frequently due to traumatic deceleration injury and results in vegetative state. Sudden acceleration-deceleration impact produces rotational forces that affect the brain areas where the density difference is the maximum, thus most of the diffuse axonal injury occur at gray white matter junction. Clinical features of patients with diffuse axonal injury are out of proportion with the CT scan findings. Patient loses consciousness instantaneously and later develops persistent vegetative state. CT scan characteristically shows numerous minute punctate hemorrhages with blurring of grey white interface. However, MRI is more sensitive than CT scan for diagnosing diffuse axonal injury. Intracranial pressure is a function of volume and compliance and determined by pressure in the brain parenchyma, CSF and blood. Brain parenchyma is fairly constant unless there is a mass lesion, and CSF is also fairly constant unless there is a ventricular obstruction. Cerebral blood flow (CBF) determines the volume of blood and increases with hypercapnia, increased metabolic demand and hypoxia through cerebral vasodilation. The brain autoregulates CBF and cerebral perfusion pressure to maintain a relatively constant flow, but this becomes dysfunctional in certain pathologic conditions (e.g .. trauma and stroke). Increased CBF from more cerebral vasodilation and elevated blood pressure raises the ICP. The interventions for lowering ICP are summarized below. Short-term hyperventilation lowers the ICP by lowering the vascular C02 concentration in the brain (i.e .. C02 washout), leading to cerebral vasoconstriction. However, this should be closely monitored because extreme hyperventilation can decrease CBF too much and lead to marked iatrogenic brain ischemia. Traumatic Amputation - All patients suffering traumatic amputations should be treated as candidates for reimplantation while in the field. As such, their amputated limb or digit should be wrapped in sterile gauze, moistened with sterile saline and placed in a plastic bag. The bag should be then placed on ice and transported with the patient to the nearest emergency department. The amputated part should not be allowed to freeze. Packaging of the amputated part in this manner prolongs the viability of the part for up to 24 hours. Younger patients suffering sharp amputations with no crush injury or avulsion are the best candidates for amputation reimplantation. Cervical Spine Injury - The first step in evaluating this patient in the field is to stabilize the cervical spine and spinal column with a backboard, a rigid cervical collar, and lateral head supports until a spinal injury is excluded. The next step is to assess the airway because unstable lesions above the C3 level can cause immediate paralysis and lower lesions can damage the phrenic nerve. Cervical spine injuries can be associated with oral maxillofacial trauma, hemorrhage in the retropharyngeal space, and significant airway and neck edema. Traumatic Lower Spinal Cord injury – It is most commonly caused by motor vehicle accidents. The trauma causes a primary injury to the spinal cord through mechanical compression, contusion, or shear injury. A secondary injury follows (within minutes to hours) and causes spinal cord edema that eventually leads to central hemorrhagic necrosis. All trauma patients with suspected spinal injuries should first be hemodynamically stabilized and have a secure airway (possibly requiring intubation). The neck should be immobilized until spinal injury has been ruled out. Orotracheal intubation with rapid sequence intubation (RSI) is the preferred route to manage unstable and apneic patients to protect the airway and provide oxygenation. Four people are involved in RSI; one manually stabilizes the patient, one induces the patient with anesthesia, one applies cricoid pressure to prevent passive regurgitation until endotracheal tube placement is confirmed and one places the endotracheal tube. Manual stabilization requires firmly holding either side of the patient's head with the neck midline and on a firm surface, without applying traction. This prevents any flexion or rotation of the neck during intubation. Patients should then have a urinary catheter placed to assess for urinary retention and prevent possible bladder injury from acute distention. Imaging, such as CT scans and x-rays, mightthen be required to diagnose the injury and evaluate the extent of spinal cord damage. The use of high-dose intravenous steroids (e.g., methylprednisolone) is somewhat controversial, with conflicting evidence on benefit in spinal cord injury patients. Surgical decompression is indicated in patients who need acute spine stabilization. Needle cricothyroidotomy is an excellent field procedure to establish an airway in children. It is not suitable in adults due to the risk of carbon dioxide retention, especially in patients with head injury in whom hyperventilation might be required to prevent or treat intracranial hypertension. Tracheostomy is no longer a first option to establish an airway because of its complications. Surgical cricothyroidotomy is preferred over surgical tracheostomy but should be converted to formal tracheostomy in 5-7 days if prolonged airway control is needed. Prolonged use of cricothyroidotomy has a high incidence of tracheal stenosis. CO Poisoning - CO (produced by incomplete combustion of carbon- containing compounds) is a tasteless, colorless and odorless gas whose poisoning should be considered in all patients who are exposed to smoke in a closed space. Carbon monoxide has over 200 times higher affinity for hemoglobin than oxygen and impairs the delivery of oxygen to tissue by shifting the hemoglobin-oxygen dissociation curve to the left. Symptoms and signs of mild to moderate CO toxicity include headache, nausea, dyspnea, malaise, altered mentation, and dizziness. Severe CO poisoning can present with seizure, coma, syncope, heart failure, or arrhythmias. Bright cherry lips can be a sign of CO poisoning on exam but is not specific. The diagnosis is confirmed clinically and by documenting an elevated carboxyhemoglobin level (> 3% in nonsmokers and > 15% in smokers). A pulse oximetry is unreliable and may appear normal since it cannot differentiate carboxyhemoglobin from oxyhemoglobin (as in this patient). The treatment of carbon monoxide poisoning is administration of 100% oxygen via nonrebreather facemask to competitively remove the binding of CO to hemoglobin and decrease the half life of CO from nearly 5 hours on room air to 1-2 hours. The patient should then be monitored for at least four hours and hospitalized if not improved. Hyperbaric oxygen can be used in severe cases not responsive to facemask-administered oxygen. Sharp Abdominal Trauma - All hemodynamically unstable patients with sharp penetrating abdominal trauma and gunshot wounds that are believed to have entered the peritoneum must be treated with emergent exploratory laparotomy in order to prevent the development of sepsis resulting from hollow organ perforation and to prevent exsanguinating hemorrhage. Blunt Abdominal Trauma – The most reliable symptoms of BAT in stable patients are abdominal pain, tenderness, and peritoneal signs. lntraabdominal injury should be suspected in patients with abdominal wall ecchymosis, abdominal distention and hypoactive bowel sounds. The first step is fluid resuscitation. If the patient is not responding to IV fluids (sustained low BP after IV fluids) continuous bleeding should be suspected. The next step is to determine if a patient needs exploratory laparotomy. All patients with BAT should first be assessed for intraperitoneal free fluid or hemorrhage. A convenient and effective test is bedside ultrasonography to detect free intraperitoneal fluid in the hepatorenal space, splenorenal recess, and inferior portion of the intraperitoneal cavity. When combined with evaluation of the pericardium, this is known as the focused assessment with sonography for trauma (FAST) examination.