– for through and through bullet wounds below the elbow and knee with nerve injury – you can do delayed exploration of the nerve.
– Nerve injuries above the elbow and knee should be explored
– be quick to apply the pelvic x-fix to anyone with pelvic trauma who is hemodynamically unstable.
– for the trauma patient with massive transfusion – their JVP may be elevated, and they may get diffuse pulmonary infiltrates from the edema and resulting hypoxemia. Interestingly though, their PCO2 may be NORMAL.
– a child who sustains a thoracolumbar fracture with paralysis will most certainly develop a severe and increasingly rigid curve that will necessitate fusion as it approaches 60 degrees. “In patients with paraplegia who are skeletally immature, the effect of gravity on the growth plates of the spine and the failure of the torso musculature to support the spine in a normal manner results in progressive kyphoscoliosis”.
– for blood transfusions: do NOT fuck up the A and B compatibilities. A patient who is AB can get from anyone (the “universal receiver”. A patient who is O must not get A or B but can give to anyone “the universal donor”. The “positive or negative” refers to rH compatibility and is only an issue in women of childbearing age. Hence, an O negative male should receive O negative blood if available; if not, then O positive is fine.
– Dextran is a glucose polymer and is a useful synthetic colloid used for volume expansion in shock situations. Dextran molecules distribute initially in the intravascular compartment, but quickly equilibrate to the extracellular space too. Dextran has two properties of an ideal plasma volume expander – a relatively long dwell time, and ultimate biodegradability. In shock, dextran can improve hemodynamics and increase survival rates. Dextran infusion increases the intravascular volume by an amount equal to or greater than the volume infused. A 500 cc bolus of Dextran 40 produces an intravascular volume expansion of 750 cc at 1 hour and 1050 at 2 hours. This volume expansion may last up to 8 hours in hypovolemic patients.
– a femur fracture can bleed up to 1500 cc – representing class II shock (750-1500) or even class III shock (1500-2000)
– a patient who has a brief LOC, then recovers, then later becomes obtunded and has an enlarged pupil probably has a epidural hematoma. This is typical of epidurals – a brief LOC followed by an interval of lucidity, then a secondary depression of consciousness and the development of hemiparesis on the opposite side. A dilated and fixed pupil on the same side as the impact area is the hallmark of this injury.
– the most common complication of closed treatment of tibial shaft fractures is VARUS.
Remember the x-ray signs of arch injury:
– wide mediastinum (8.0 – 8.5 cm at T4)
– deviation of trachea to right
– deviation of NG tube to right
– deviation of left mainstem bronchus down 40 degrees
– obliteration of aortic knob
– 1st and 2nd rib fractures
– apical cap
– widened paratracheal stripe
– The grade III compound tibia with vascular injury and tibial nerve injury should probably get an amputation, especially if ischemia time is long.
– don’t be fooled on the trauma questions in which there is an obvious MSK injury – always start with the ABC’s
– in the child, the systolic BP is typically 80 plus twice the age in years. (eg. An 8 year old should have a systolic of at least 96) and the diastolic should be two/thirds of systolic.
– hemodynamic instability can occur with a femur fracture in a child
– for the MESS, you double the ischemia score if the time is > 6 hours. You do not double the entire score (a composite between ischemia, hypotension, age, and soft tissue injury.
– DIC is a contraindication to ORIF (also, hypothermia, hypoxia, persistent hypotension, and ICP greater than 20)
– watch out for delayed hypotension in a patient who develops left shoulder tip pain (but has a negative cardiopulmonary workup) – look at their SPLEEN!
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