8 - Trauma 2026

Securing the airway

Except in patients with hypovolemic shock

What is the first priority in the primary survey?

Securing the circulation

In the primary survey, what is the first priority in patients with hypovolemic shock?

Jaw thrust (Esmarch) maneuver

Chin lift

What manual airway maneuvers can be used to elevate the tongue out of the hypopharynx?

Tongue

What is the most common cause of airway obstruction in an unconscious patient?

Cricothyroidotomy

What is the first airway control maneuver in cases of craniofacial trauma?

Orotracheal intubation

Which option for endotracheal intubation is the most preferred as it allows large-diameter tubes and is applicable in apnea?

Tracheostomy

Which surgical airway is applicable in cases of laryngeal fracture?

Basilar skull fracture

CSF rhinorrhea, raccoon eyes, Battle sign are signs of?

Basilar skull fracture (CSF rhinorrhea, raccoon eyes, Battle sign)

Nasotracheal intubation may be inserted without a laryngoscope. However, it is contraindicated in patients with suspected ___ fracture

Tracheostomy

Between cricothyroidotomy and tracheostomy, which option is preferred in patients under 11 years of age?

Cricoid cartilage

Hence, cricothyroidotomy is contraindicated

What is the narrowest portion of the airway in pediatric patients?

Glottis

What is the narrowest portion of the airway in adult patients?

Tension pneumothorax

Complete occlusion of the chest wall in a sucking chest wound may convert an open pneumothorax into a ___

3-sided occlusion dressing

Forms a one-way valve

The initial treatment of open pneumothrax (sucking chest wound) is with temporary occlusion of the wound with what kind of dressing?

Hypotension

The diagnosis of tension pneumothorax is defined by the presence of ___ in addition to other classic signs of pneumothorax, such as tracheal deviation away from affected side, decreased breath sounds, and subcutaneous emphysema

Immediate needle thoracostomy at 5th ICS AAL (adult) or 2nd ICS MCL (child)

What is the management of tension pneumothorax in the field?

Adult: 5th ICS AAL

Child: 2nd ICS MCL

What is the landmark or site of insertion for needle decompression for pneumothorax?

Closed tube thoracostomy (CTT) at 4th or 5th ICS AAL

What is the preferred management of tension pneumothorax in the ER setting?

Open pneumothorax (sucking chest wound)

This type of pneumothorax involves full thickness loss of the chest wall, leading to free communication between the pleural space and the atmosphere

Fracture of 3 or more contiguous ribs in at least 2 locations

What is the definition of flail chest?

Associated pulmonary contusion

What is the main source of pulmonary dysfunction in patients with flail chest?

Intubation and mechanical ventilation

Flail chest is managed with presumptive __ and __

Blunt injury: > 1500 mL

Operative intervention for hemothorax is indicated in blunt injury if there is drainage of > ___ mL

Penetrating injury: > 1000 mL

Operative intervention for hemothorax is indicated in penetrating injury if there is drainage of > ___ mL

> 200 mL/hr for 3 hours

Operative intervention for hemothorax is indicated if there is ongoing drainage of more than ___ mL for 3 consecutive hours in non-coagulopathic patients

>60 mmHg

A palpable carotid pulse indicates an SBP of at least?

>70 mmHg

A palpable femoral pulse indicates an SBP of at least?

>80 mmHg

A palpable radial pulse indicates an SBP of at least?

20 mL/kg IV bolus of plain LR

What is the initial fluid resuscitation in the management of shock secondary to trauma?

5 liters

The average man has how many liters of blood?

Medial malleolus (1 cm superior and anterior)

What is the landmark used to perform a saphenous vein cutdown?

Class II

Tachycardia begins presenting at what class of hemorrhagic shock?

Class II

Pulse pressure begins to decrease at what class of hemorrhagic shock?

1500-2000 mL

Class III hemorrhagic shock is defined by blood loss of at least how many mL?

>2000 mL

Class IV hemorrhagic shock is defined by blood loss of at least how many mL?

Class III

Hypotension and significant tachycardia >120 bpm occurs at what class of hemorrhagic shock?

Class III

Hypotension and decreased urine output occurs at what class of hemorrhagic shock?

Class III

Blood transfusion is indicated at what class of hemorrhagic shock?

Class IV

Marked confusion and lethargy are seen in what class of hemorrhagic shock?

>1500 mL

Or at least >25% of patient’s blood volume in the pleural space

Massive hemothorax is defined as > ___ mL of blood

Operative intervention for hemothorax

Caked hemothorax despite insertion of two CTTs is an indication for?

< 100 mL

At least how many mL of pericardial blood is enough to cause cardiac tamponade?

Hypotension

Muffled heart sounds

Dilated neck veins

What are the components of Beck's triad?

15-20 mL

In cardiac tamponade, removal of at least __ mL of blood is enough to stabilize the patient's status and will allow transport to the OR for definitive management

Trendelenburg position

In the management air emboli, the patient is placed in this position to trap the air in the left ventricle

100 to 200 mL

Fracture-related blood loss is an important potential source of bleeding. Each rib contributes ___ mL of blood loss

>2000 mL

Fracture-related blood loss is an important potential source of bleeding. Fracture of the pelvis may lead to ___ mL of blood loss

2D echocardiography

The diagnosis of cardiac tamponade is best achieved using?

Air embolism

When air enters the bloodstream following blunt or penetrating injuries, this can cause shock, cardiac arrest, or even death. This condition is called:

Spinal injury

Trauma patient presents with priapism and loss of anal sphincter tone and bulbocavernosus reflex. Consideration?

Battle sign

This sign refers to ecchymosis behind the ear and is a sign of basal skull fracture

CSF leak

Rhinorrhea, otorrhea, and postnasal drip in the setting of traumatic head injury are possible signs of?

Raccoon eyes

This sign refers to periorbital ecchymosis and is a sign of basal skull fracture

Halo sign

This sign of CSF leak occurs when dried blood is surrounded by a clear ring of dried CSF

β2 transferrin

The gold standard to diagnose CSF leak is when the fluid tests positive for this marker:

GCS 9 (E2 V2 M5)

GCS-P 8 (P-1)

Trauma patient arrives at ER after MVA. There is eye opening to pain, incomprehensible verbal output, and localizes to pain. Pupils are anisocoric. What is the GCS and GCS-P score?

GCS = E + DVS + M

Where DVS is derived verbal response and computed as M x 0.5 + E x 0.4

How do you compute GCS if the patient is intubated or unable to verbalize?

< 20 mmHg

Cerebral perfusion pressure (CPP) at 50-70 mmHg is desirable

In head trauma, ICP should be maintained at ___ mmHg

Yes, they reduce the incidence of early seizures, defined as occurring during the first 7 days after head injury

In patients with severe head injury, is there benefit to prophylactic antiepileptic drug use?

GCS < 15

According to the Canadian CT Head Rule, immediate CT Head is indicated for GCS score ___

Observation for 6 hours

For patients with suspected TBI, consider __ if the only criterion present for CT is intoxication (alcohol, drugs)

>30 mL

Surgery is indicated for epidural hematoma regardless of GCS score if volume is > ___ mL

Respiratory suppression

Hypertension

Bradycardia

Intracranial hypertension causes Cushing's reflex, which manifests as:

Temporal (from rupture of middle meningeal)

What is the most common location of epidural hematoma?

Epidural

Patients with ___ hematoma classically display a "lucid" interval followed by sudden deterioration

>10 mm (> 1 cm) thickness

> 5 mm midline shift (MLS)

Surgery is indicated for acute subdural hematoma regardless of GCS score if the hematoma is more than __ mm thick or midline shift is more than __ mm

Epidural hematoma

Lentiform and hyperdense hematoma limited by suture lines

Acute subdural hematoma

Crescentric and hyperdense hematoma not limited by suture lines; follows convexity of the brain

Chronic subdural hematoma

Crescentic and hypodense hematoma, typically associated with significant mass effect

Chronic subdural hematoma

Patient presents 4-8 weeks after minor head bump, now with depressed sensorium, dysphasia, and focal neurologic deficits. The patient is a known alcoholic. Likely impression?

Chronic subdural hematoma

Patient with history of head trauma 4 weeks prior to consult presents with decrease in sensorium. Burr hole craniotomy was done revealing "motor oil" like fluid. Diagnosis?

Subarachnoid hemorrhage

The most common finding in fatal head trauma is traumatic ___ ___

Vertebral artery

Traumatic subarachnoid hemorrhage most commonly results from rupture of what vessel?

Diffuse axonal injury

A 25/M is brought to the ER following high-speed MVA and was found unconscious. Initial CT scan of the brain shows minimal findings despite depressed sensorium. MRI demonstrates multiple tiny hemorrhages at the grey-white matter junction, corpus callosum, and brainstem. Most likely diagnosis?

Severe angular acceleration-deceleration forces

As seen in high-speed motor vehicular accidents

Diffuse axonal injury is caused by widespread shearing axons most commonly caused by what type of forces?

Kothari formula

The __ formula can be used to estimate the volume of an intracranial hematoma

S100B, GFAP

These two markers can be used to rule out intracranial lesions, particularly in mild traumatic brain injury (TBI). Positive results indicate need for cranial CT.

GCS < 8

Severe TBI is defined as GCS:

GCS 9-12

Moderate TBI is defined as GCS:

GCS ≥ 13

Mild TBI is defined as GCS:

ASIA A

No motor or sensory function is preserved below the level of spinal injury, extending to sacral segments S4-S5.

What is the ASIA grade?

ASIA B

Only sensory function is preserved below the neurologic level, but there is no motor function extending to S4-S5

What is the ASIA grade?

ASIA C

Sensory and motor function is preserved below the neurologic level, with most key muscles have MMT < 3/5

What is the ASIA grade?

ASIA D

Sensory and motor function is preserved below the neurologic level, which most key muscles with MMT >3/5

What is the ASIA grade?

ASIA E

E for Excellent

Motor and sensory function is normal in which ASIA grade?

Spine MRI

The diagnostic modality of choice for incomplete spinal cord syndromes is:

Central cord syndrome

This spinal cord syndrome presents with bilateral paresis but the upper extremities are more involved than the lower extremities

Posterior cord syndrome

This spinal cord syndrome presents with ipsilateral loss of proprioception and vibration, and loss of touch sensation below the level of the lesion

Brown-Sequard syndrome

This spinal cord syndrome presents with ipsilateral loss of proprioception and vibration and contralateral loss of pain and temperature sensation one or two levels below the lesion

Ipsilateral loss of proprioception, vibration, and tactile discrimination;

Contralateral loss of pain and temperature sensation

In Brown-Sequard syndrome, there is ipsilateral loss of ___, and contralateral loss of ___ one or two levels below the lesion

Brown-Sequard syndrome

This spinal cord syndrome results from hemisection of the spinal cord, typically seen in penetrating trauma or in spinal cord compression

Cauda Equina Syndrome

This spinal cord syndrome occurs in injuries below the L1 level and results in flaccidity, areflexia, and impairment of bowel & bladder function

WBC > 500

A 56-year-old man was stabbed in the right lower quadrant of his abdomen. He complains of pain at the wound site. His vital signs are normal and the findings from his abdominal examination are normal. Local wound exploration reveals penetration of the anterior fascia and DPL reveals 7000 RBCs/mm3 and 750 WBC/mm3.

What is the indication for EL in this patient?

RBC > 100,000/mL

RBC > ___ /mL in an anterior abdominal stab wound on DPL is an indication to perform operative exploration

RBC > 10,000/mL

RBC > ___ /mL in a thoraco-abdominal stab wound on DPL is an indication for operative exploration

WBC > 500/mL

WBC > ____/mL on DPL is an indication for operative exploration

Amylase > 19 IU/L

Amylase > ___ IU/L on DPL is an indication for operative exploration

Alkaline phosphatase > 2 IU/L

Alkaline phosphatase > ___ IU/L on DPL is an indication for operative exploration

Bilirubin > 0.01 mg/dL

Bilirubin > ___ mg/dL on DPL is an indication for operative exploration

Diagnostic laparoscopy or thoracoscopy

DPL that reveals RBC between 10,000 to 100,000/mL is an indication to perform what procedure?