Trauma

Concussion

Mild TBI with GCS $\ge 13$; may involve brief LOC, amnesia, vertigo, confusion, or delayed responses.

Coup/Contrecoup Injury

Brain hits back and forth in skull.

Post-Concussion Symptoms

Vertigo, amnesia, delayed speech, disorientation, emotional lability, incoordination.

Post-Traumatic Seizures

Occur in <5\% within the first week after head injury.

Head CT Indications (Canadian Rules)

LOC with head strike, GCS <15 after 2h, skull/basilar fracture signs, $\ge 2$ vomiting, $\ge 65$yo, amnesia $\ge 30$min, dangerous mechanism, neuro deficit, seizure, anticoagulant use.

Head CT Indications (New Orleans Rule)

GCS 15 + headache, vomiting, age >60 , ETOH/drug use, anterograde amnesia, visible trauma above clavicle.

Head Injury Admission Criteria

GCS <15 , abnormal CT, seizures, bleeding diathesis, or anticoagulant use.

Concussion treatment

Brain rest.

Head Injury Discharge Precautions

Return if confusion, worsening HA, vision change, weakness, vomiting, or seizure.

Cerebral Contusion

Focal brain bleeding; monitor and admit for observation.

Epidural Hematoma

Arterial bleed (middle meningeal artery) between skull and dura; lucid interval $\to$ rapid decline from brain herniation; needs evacuation of hematoma.

Anasacoria

Unequal pupils.

Normal ICP

<20 mmHg.

Steroids help with trauma?

No.

Epidural Hematoma Prognosis

Worse with large volume, midline shift, GCS <8 .

Subdural Hematoma

Venous bleed from bridging veins between dura and arachnoid; often from falls or ETOH.

Subdural Hematoma Symptoms

LOC $\pm$ lucid interval, HA, N/V, ataxia, pupil defects.

Subdural Hematoma Treatment

Surgery or observation based on severity.

Subarachnoid Injury

Bleeding into subarachnoid space; risk of vasospasm and seizures due to brain parenchyma irritation.

Secondary Brain Injury symptoms (Intracranial)

Hemorrhage, ischemia, edema, $\uparrow$ICP, vasospasm, infection.

Secondary Brain Injury symptoms (Systemic)

Hypoxia, hyper/hypocapnia, hyperglycemia, hypotension, fever, hyponatremia.

Cerebral Blood Flow Formula

CBF $=$ CPP $-$ ICP; CPP $=$ MAP $-$ ICP.

Monroe-Kellie Hypothesis

Skull is fixed space; $\uparrow$volume in one component $\uparrow$ICP.

Increased ICP Symptoms

HA, diplopia (CN VI palsy), papilledema, bradycardia, HTN, $\downarrow$LOC.

Cushing’s Triad

Bradycardia, hypertension, irregular respirations (brainstem compression).

ICP Management

Keep ICP <20 mmHg; elevate HOB $30^{\circ}$, drain CSF, mannitol, brief hyperventilation.

Fever in Brain Injury

Common; search for infection (sinusitis, UTI, PNA); cooling and antipyretics limited benefit.

Tension Pneumothorax

Clinical diagnosis: absent breath sounds, JVD, tracheal deviation, hypotension.

Tension Pneumo Chest Tube

24–28F tube, 4–5th ICS midaxillary; relieves air accumulation.

Hemothorax

Blood in pleural space; 24–28F tube at 4–5th ICS midaxillary; massive >1500 mL.

Thoracotomy Indication

Drain >20 mL/kg initially or $1500/3$hrs.

Chest Tube Removal (Pneumo)

No air leak, full expansion.

Chest Tube Removal (Hemo)

<100 mL/day output, full expansion.

Traumatic Aortic Dissection

Deceleration injury tearing aortic isthmus; fatal in $80\%$ prehospital.

Aortic Dissection Signs

Chest/back pain, L supraclavicular hematoma, widened mediastinum.

Aortic Injury CXR

Wide mediastinum ( >8 cm supine), apical cap, L bronchus displacement.

Aortic Injury Management

BP control (SBP <100 ), esmolol, CTA confirmation, endovascular repair preferred.

Cardiac Tamponade

Blood in pericardial sac; $150$ mL can be fatal.

Beck’s Triad

Hypotension, JVD, muffled heart sounds.

Tamponade Signs

Tachycardia, pulsus paradoxus systolic blood pressure drops significantly during inspiration), enlarged silhouette, effusion on echo.

Tamponade Treatment

IV fluids (support preload/filling), pericardiocentesis, thoracotomy.

Primary Survey (ABCDE)

Airway, Breathing, Circulation, Disability, Exposure.

Life-Threatening Thoracic Injuries

Tension/open pneumo, massive hemothorax, tamponade, flail chest, obstruction.

Flail Chest

Paradoxical chest wall motion due to multiple broken ribs; may need fixation.

Rib Fracture Pain Control

Multimodal (NSAIDs, acetaminophen, oxycodone, methocarbamol, nerve block).

Rib fracture treatment

Symptomatic treatment only.

PIC Score

Monitors pain, incentive spirometry, cough quality.

Rib Fixation Indications

Flail chest, severe pain, failed weaning, deformity.

Intubation Indications

RR >30 or <9 , SpO₂ <90\% , PaO₂/FiO₂ <280 , pulmonary contusion, age/poor reserve.

Ventilation Strategy

Tidal volume 6–8 mL/kg, plateau <30 , use PEEP, prone/ECMO for refractory hypoxemia.

Trauma Coagulopathy (TIC)

Triad: acidosis, hypothermia, coagulopathy.

Massive bleeding Management

Whole blood or 1:1:1 transfusion, minimize crystalloids, warm fluids, early TXA, LMWH prophylaxis.

TXA in Trauma

Antifibrinolytic; give within 3 hours; not a procoagulant.

Blunt Cardiac Injury (BCI) def and complications

Myocardial trauma from MVCs; causes arrhythmia, troponin $\uparrow$, hypotension.

BCI Screening

ECG + troponin; normal results exclude BCI ($100\%$ NPV).

BCI Management

Telemetry $\ge 24$h if abnormal; ICU if unstable or arrhythmic.

BCI Dysrhythmias

Sinus tachy, PVCs, AFib; treat per ACLS, correct electrolytes.

Commotio Cordis

Sudden VF in young athlete; R-on-T impact; no structural injury.

Myocardial Rupture

$80\%$ fatal; requires immediate thoracotomy and pericardiotomy.

Valvular Injury (Trauma)

Aortic (AR/shock), Mitral (papillary rupture), Tricuspid (RHF); surgical repair.

Coronary Artery Injury

LAD most common; causes traumatic STEMI; PCI or bypass.

Blunt Aortic Injury (BTAI)

Deceleration tear at ligamentum arteriosum.

Blunt Aortic Injury Imaging

US, CTA $=$ gold standard ($100\%$ sens, $99.7\%$ spec).

Blunt Aortic Injury Treatment

Esmolol, SBP <120 , TEVAR preferred; open repair if arch small.

FAST Exam (EFAST)

Bedside US for pericardial, hepatorenal, splenorenal, pelvic, and pleural fluid.

FAST Sensitivity

42–100%.

Abdominal Trauma Workup

Low threshold for CT; serial exams; labs (HCG, T&S).

Renal/GU Trauma Mechanism

Usually blunt (MVCs, falls, straddle).

Renal/GU Injury Signs

Hematuria, blood at meatus/introitus $=$ urethral injury.

Retrograde Urethrogram

Consider if blood at meatus.

GU Imaging

CT angio may miss urethral injury; US for testicular trauma.

Junctional Hemorrhage

Bleeding at neck, axilla, groin, buttocks, or perineum—difficult to compress.

Junctional Tourniquets

Abdominal aortic, combat ready clamp, SAM, junctional emergency tool.

Abdominal Aortic Tourniquet

Inflates to $80$ lbs pressure; effective in small trials.

SAM Junctional Tourniquet

Fast application ( <30 s); approved for axillary and pelvic bleeding.

Elderly Trauma Patients

Higher morbidity due to comorbidities, meds, poor compensation.

Elderly Resuscitation Risks

Sensitive to fluid overload and under-resuscitation; fragile bones.

Crystalloid Risks

Dilutional coagulopathy, hyperchloremic acidosis, edema, hypothermia.

Effective Fluid Strategy

Permissive hypotension, hemorrhage control, avoid hypothermia, balanced transfusion.

TXA Uses

Trauma, postpartum hemorrhage, epistaxis, ICH; poor in GI bleed or angioedema.

Most deadly type of pelvic fracture

Open book.

Cerebral contusion

epidural hematoma 

subdural hematoma

Subarachnoid hemorrhage

tension pnemothorax

Aortic dissection 

Aortic disection

cardiac tamponade

Cardiac tamponade EKG. Alternating QRS amplitude/voltage

open book pelvic fracture