234 Section II / General Surgery
What is a normal human	GCS 15
GCS?
What is the GCS score for a	GCS 3
dead man?
What is the GCS score for a	GCS 8
patient in a “coma”?
How does scoring differ if	Verbal evaluation is omitted and replaced
the patient is intubated?	with a “T”; thus, the highest score for an
	intubated patient is 11 T

EXPOSURE AND ENVIRONMENT

What are the goals in	Complete disrobing to allow a thorough
obtaining adequate	visual inspection and digital palpation of
exposure?	the patient during the secondary survey
What is the “environment”	Keep a warm Environment (i.e., keep the
of the E in ABCDEs?	patient warm; a hypothermic patient can
	become coagulopathic)

SECONDARY SURVEY

What principle is followed in completing the secondary survey?

Why look in the ears?

Complete physical exam, including all orifices: ears, nose, mouth, vagina, rectum

Hemotympanum is a sign of basilar skull fracture; otorrhea is a sign of basilar skull fracture

Examination of what part of the trauma patient’s body is often forgotten?

What are typical signs of basilar skull fracture?

What diagnosis in the anterior chamber must not be missed on the eye exam?

Patient’s back (logroll the patient and examine!)

Raccoon eyes, Battle’s sign, clear otorrhea or rhinorrhea, hemotympanum

Traumatic hyphema blood in the anterior chamber of the eye

What potentially destructive lesion must not be missed on the nasal exam?

What is the best indication of a mandibular fracture?

What signs of thoracic trauma are often found on the neck exam?

Chapter 38 / Trauma 235

Nasal septal hematoma: Hematoma must be evacuated; if not, it can result in pressure necrosis of the septum!

Dental malocclusion: Tell the patient to “bite down” and ask, “Does that feel normal to you?”

Crepitus or subcutaneous emphysema from tracheobronchial disruption/PTX; tracheal deviation from tension pneumothorax; jugular venous distention from cardiac tamponade; carotid bruit heard with seatbelt neck injury resulting in carotid artery injury

What is the best physical exam for broken ribs or sternum?

What physical signs are diagnostic for thoracic great vessel injury?

Lateral and anterior-posterior compression of the thorax to elicit pain/instability

None: Diagnosis of great vessel injury requires a high index of suspicion based on the mechanism of injury, associated injuries, and CXR/radiographic findings (e.g., widened mediastinum)

What is the best way to	CT angiogram
diagnose or rule out aortic
injury?

What must be considered in every penetrating injury of the thorax at or below the level of the nipple?

What is the significance of subcutaneous air?

What is the physical exam technique for examining the thoracic and lumbar spine?

What conditions must exist to pronounce an abdominal physical exam negative?

Concomitant injury to the abdomen: Remember, the diaphragm extends to the level of the nipples in the male on full expiration

Indicates PTX, until proven otherwise

Logrolling the patient to allow complete visualization of the back and palpation of the spine to elicit pain over fractures, step off (spine deformity)

Alert patient without any evidence of head/spinal cord injury or drug/EtOH intoxication (even then, the abdominal exam is not 100% accurate)

236 Section II / General Surgery

What physical signs may indicate intra-abdominal injury?

What is the seatbelt sign?

Tenderness; guarding; peritoneal signs; progressive distention (always use a gastric tube for decompression of air); seatbelt sign

Ecchymosis on lower abdomen from wearing a seatbelt ( 10% of patients with this sign have a small bowel perforation!)

What must be documented Sphincter tone (as an indication of spinal from the rectal exam? cord function); presence of blood (as an

indication of colon or rectal injury); prostate position (as an indication of urethral injury)

What is the best physical exam technique to test for pelvic fractures?

What is the “halo” sign?

What physical signs indicate possible urethral injury, thus contraindicating placement of a Foley catheter?

What must be documented from the extremity exam?

Lateral compression of the iliac crests and greater trochanters and anteriorposterior compression of the symphysis pubis to elicit pain/instability

Cerebrospinal fluid from nose/ear will form a clear “halo” around the blood on a cloth

High-riding ballotable prostate on rectal exam; presence of blood at the meatus; scrotal or perineal ecchymosis

Any fractures or joint injuries; any open wounds; motor and sensory exam, particularly distal to any fractures; distal pulses; peripheral perfusion

What complication after prolonged ischemia to the lower extremity must be treated immediately?

What is the treatment for this condition?

What injuries must be suspected in a trauma patient with a progressive decline in mental status?

Compartment syndrome

Fasciotomy (four compartments below the knee)

Epidural hematoma, subdural hematoma, brain swelling with rising intracranial pressure

But hypoxia/hypotension must be ruled out!

		Chapter 38 / Trauma 237
TRAUMA STUDIES
What are the classic blunt	1.	AP (anterior-to-posterior) chest film
trauma ER x-rays?	2.	AP pelvis film
What are the common	Blood for complete blood count,
trauma labs?	chemistries, amylase, liver function tests,
	lactic acid, coagulation studies, and type
	and crossmatch; urine for urinalysis

Will the hematocrit be low after an acute massive hemorrhage?

No (no time to equilibrate)

How can a C-spine be evaluated?

What patients can have their C-spines cleared by a physical exam?

How do you rule out a C-spine bony fracture?

What do you do if no bony C-spine fracture is apparent on CT scan and you cannot obtain an MRI in a COMATOSE patient?

1.Clinically by physical exam

2.Radiographically

No neck pain on palpation with full range of motion (FROM) with no neurologic injury (GCS 15), no EtOH/drugs, no distracting injury, no pain meds

With a CT scan of the C-spine

This is controversial; the easiest answer is to leave the patient in a cervical collar

Which x-rays are used for	MRI, lateral flexion and extension
evaluation of cervical spine	C-spine films
LIGAMENTOUS injury?
What findings on chest film	Widened mediastinum (most common
are suggestive of thoracic	finding), apical pleural capping, loss
aortic injury?	of aortic contour/KNOB/AP window,
	depression of left main stem bronchus,
	nasogastric tube/tracheal deviation,
	pleural fluid, elevation of right mainstem
	bronchus, clinical suspicion, high-speed
	mechanism

238 Section II / General Surgery
What study is used to rule	Spiral CT scan of mediastinum looking
out thoracic aortic injury?	for mediastinal hematoma with CTA
	Thoracic arch aortogram (gold standard)
What is the most common	Just distal to the take-off of the left
site of thoracic aortic	subclavian artery
traumatic tear?
What studies are available to	FAST, CT scan, DPL
evaluate for intra-abdominal
injury?

What is a FAST exam?

What does the FAST exam look for?

What does DPL stand for?

What diagnostic test is the test of choice for evaluation of the unstable patient with blunt abdominal trauma?

Ultrasound: Focused Assessment with Sonography for Trauma FAST

Blood in the peritoneal cavity looking at Morison’s pouch, bladder, spleen, and pericardial sac

Diagnostic Peritoneal Lavage

FAST

What is the indication for abdominal CT scan in blunt trauma?

What is the indication for DPL or FAST in blunt trauma?

Normal vital signs with abdominal pain/tenderness/mechanism

Unstable vital signs (hypotension)

How is a DPL performed?

Place a catheter below the umbilicus (in patients without a pelvic fracture) into the peritoneal cavity

Aspirate for blood and if 10 cc are aspirated, infuse 1 L of saline or LR

Drain the fluid (by gravity) and analyze

What is a “grossly positive”	10 cc blood aspirated
DPL?

Where should the DPL catheter be placed in a patient with a pelvic fracture?

Chapter 38 / Trauma 239

Above the umbilicus

Common error: If you go below the umbilicus, you may get into a pelvic hematoma tracking between the fascia layers and thus obtain a false-positive DPL

What constitutes a positive Prior to starting a peritoneal lavage, the peritoneal tap? DPL catheter should be aspirated; if

10 mL of blood or any enteric contents are aspirated, then this constitutes a positive tap and requires laparotomy

What are the indicators of a positive peritoneal lavage in blunt trauma?

What must be in place before a DPL is performed?

What injuries does CT scan miss?

What injuries does DPL miss?

What study is used to evaluate the urethra in cases of possible disruption due to blunt trauma?

Classic:

Inability to read newsprint through lavaged fluid

RBC 100,000/mm3

WBC 500/mm3 (Note: mm3, not mm2)

Lavage fluid (LR/NS) drained from chest tube, Foley, NG tube

Less common:

Bile present

Bacteria present

Feces present

Vegetable matter present

Elevated amylase level

NG tube and Foley catheter (to remove the stomach and bladder from the line of fire!)

Small bowel injuries and diaphragm injuries

Retroperitoneal injuries

Retrograde urethrogram (RUG)