1he exam cons|sts of s|ng|e best answer quesnons on|y.

1h|s type of quesnon uses a panent-based case scenar|o,

p|cture, or graph that assesses the h|gher order cogn|nve
ab|||nes requ|red for c||n|ca| dec|s|on-mak|ng fo||owed by
a quesnon and ||st of poss|b|e opnons. ou must choose
the one answer that |s beuer than the others, note that
other opnons may be parna||y correct. Iam|||ar|z|ng
yourse|f w|th the quesnon format |n advance may he|p
you work more eecnve|y.
8urns & 1rauma
8en de8o|sb|anc, MD, IAC, ICC, ICCM
LSU nea|th Sc|ences Center
New Cr|eans, LA

D|sc|osures
No potenna| con|cts of |nterest to d|sc|ose.

Cb[ecnves
1) kecogn|ze r|sk factors for trauma
coagu|opathy and se|ect best transfus|on
management strateg|es.
2) Idennfy common trauma syndromes: CNS,
thorac|c, abdom|na|, pe|v|c
3) D|erennate comp||canons of therma| vs
e|ectr|ca| burns

32 y]o b|cyc||st was h|t by a car. In the
LD, h|s GCS |s 12, 8 90]30, 130,
SpC2 9S, ngb 14 g]d|. ne has a
femur fracture, pe|v|c fracture, ||ver
|aceranon, & pu|monary contus|on.
Wh|ch of the fo||ow|ng resusc|tanon
u|ds |s best for th|s panent?
a. Norma| sa||ne on|y
b. Norma| sa||ne a|ternanng w|th a|bum|n |n a 2:1 rano
c. k8C, II, |ate|ets 1:1:1 rano p|us tranexam|c ac|d
d. k8C p|us Iactor VII concentrate
e. Lactated r|ngers
Case
4
th
Lead|ng Cause of Death Age <4S
red|ctors of Death:
Age
GCS
In[ury Sever|ty Score
Duranon of shock
nypotherm|a
Ac|dos|s
Coagu|opathy
80 of Lar|y Deaths Due to Uncontro||ed nemorrhage
20 of Uncontro||ed nemorrhage Due to Coagu|opathy
Causes of Coagu|opathy
D||unona|
Consumpnve
nypotherm|a
Ac|dos|s
nypoca|cem|a
Anem|a

kecs:
1x 1:1:1 |asma:k8C:|ate|ets
Iactor VIIa sn|| controvers|a|
1ranexam|c ac|d
I 1rauma 2007,63:80S-13
0
10
20
30
40
S0
60
70
1:8 1:3 1:1
Morta||ty vs kano of |asma:k8C
CkASn-2
>20,000 adu|t
trauma pts
274 hosp|ta|s
40 countr|es
0
2
4
6
8
10
12
14
16
18
1ranexam|c ac|d |acebo
*
*
Lancet 376:23-32, 2010

Damage Contro| kesusc|tanon & Surgery
Iocus:
Contro| hemorrhage (b|ood products over crysta||o|d,
correct hypotherm|a, perm|ss|ve hypotens|on)
Decontam|nate
De|ay dehn|nve repa|r unn| stab|e
28 y]o woman was stabbed |n the |eh par|eta| cortex. Aher
c|ot evacuanon she |s adm|ued to the ICU w|th a GCS of 6.
Wh|ch of the fo||ow|ng has been shown to |mprove her
neuro|og|c prognos|s?
a. 1|ght g|ycem|c contro|
b. rophy|acnc
hypervenn|anon
c. 1herapeunc hypertens|on
d. nyperton|c sa||ne
resusc|tanon
e. 1reatment of fever
Case
ICU Care of 18I
Iocus on prevennon of 2
o
bra|n |n[ury
due to hypotens|on, hypoxem|a,
hypercarb|a, fever, hyperg|ycem|a,
ac|dos|s, a|ka|os|s, sz
Caveats:
Intens|ve |nsu||n therapy not
super|or to usua| care
nypervenn|anon paCC2<30
|ncreases r|sk of death &
d|sab|||ty
1herapeunc hypotherm|a
unproven
7 day ann-ep||epncs prevent sz
LDn
90 sku|| fx
MMA tear |n
2]3
rds

SDn
C|der pts on
anncoags
Chen b||at
SAn
Lar|y - reb|eed
M|d - vasospasm
Late - hydroceph
DAI
Wh|te mauer
|n[ury
90 vegetanve

Common kad|ograph|c Man|festanons of 18I
nern|anon
1. revennon
1reat causes of 2
o
bra|n |n[ury, e.g.
shock, hypoxem|a, Sz, etc
2. kecogn|non
k|sk stranfy by |ocanon of |n[ury
(subfa|c|ne, centra|, unca|, tons||ar)
Any change |n 8, nk, kk LCC
New cran|a| nerve pa|sy, postur|ng,
extrem|ty weakness, nucha| r|g|d|ty
3. 1reatment
Ma|nta|n C, oxygenate, contro| Sz,
treat fever
1emporary hypervenn|anon
Csmonc d|ures|s
G|ucocornco|ds for tumor
CSI dra|nage
Surg|ca| decompress|on
A 22 y]o panent was stabbed under the r|ght n|pp|e. In
the LD wh|ch of the fo||ow|ng |s an |nd|canon for
emergent thoracotomy?
a. Gurg||ng chest wound
b. er|card|a| eus|on
c. S00cc b|ood on chest tube
p|acement
d. A|r |eak aher chest tube
p|acement
e. S cm |ntrapu|monary
hematoma on C1
Case
A8Cs
nemodynam|ca||y
stab|e
U]S, Ckk, C1, LkG,
tube thoracostomy
Stab|e
Cbserve
ers|stent a|r |eak,
>1S00cc b|ood |n|na||y
or >300cc]hr x 3
Ck
nemodynam|ca||y
unstab|e
Leh antero|atera|
thoracotomy
1horac|c 1rauma A|gor|thm
A 17 y]o man who was stabbed |n |eh
ax|||a w|th |ce p|ck has a chest tube
p|aced for a pneumothorax. kepeat
Ckk performed 1 hr |ater shows a
pers|stent pneumothorax but no a|r
|eak. What |s the prob|em?
a. In[ury to a |arge bronchus
b. Lsophagea| |n[ury
c. kupture of a |arge subp|eura|
b|eb
d. M|sp|aced chest tube
e. |acement of too sma|| of a chest
tube
Case
1ubes for a|r anter|or, tubes for b|ood poster|or,
tubes for pus |nto the pus, avo|d the ma[or hssure.
Chest 1984,8S,81-83
u|monary Contus|on
Can be assoc|ated
w|th pu|monary
|aceranon,
|ntrapu|monary
hematoma,
pneumatocoe|s
1x- suppornve
a|n contro|
I|u|d restr|cnon?
Venn|atory support
prn
I|a|| Chest
Iree oanng chest wa||
segment
Lung |n[ury |s the rate
||m|nng factor
Venn|atory support on|y
prn
a|n contro| - ep|dura| or
|ntercosta| b|ock
kare|y requ|res operanve
hxanon
1racheobronch|a|
In[ur|es
8|unt (3S) enetranng (6S)
80 18
21 21
61 0
! Ma[or|ty penetranng
! Suspect w|th
pneumomed|asnnum or
pers|stent a|r |eak
! Most w|th|n 2cm of car|na
! r|mary repa|r |f |arge or
pers|stent |eak
4S y]o motor cyc||st struck br|dge
support at h|gh speed & susta|ned
the |n[ury shown. Wh|ch of the
fo||ow|ng |s the most accurate
statement regard|ng h|s |n[ury?
a. Morta||ty rate |s ~10
b. Most beg|n at the ||gamentum
c. Surg|ca| repa|r |s usua||y
reserved for those who fa||
med|ca| management
d. Chen assoc|ated w|th cauda
equ|na syndrome
e. D|agnos|s requ|res LGD
Case
8|unt Aornc 1rauma
90 dead at scene
Suspect w|th 1
st
r|b Ix, w|de
med|asnnum, b|unted knob,
ap|ca| cap, dev|ated trachea]
NG, depressed L ma|nstem
Aortography, C1
Most at ||gamentum
reoperanve 8 contro|
arap|eg|a (emergent
|umbar dra|n)
emed|c|ne.medscape.com]
arnc|e]416939-overv|ew
Lsophagea| In[ur|es
Most are penetranng
Cerv|ca| > thorac|c >
abdom|na|
neumomed|asnnum,
p|eura| eus|on w|th h|gh
amy|ase
I|ex|b|e]r|g|d scope,
gastrogramn swa||ow
r|mary repa|r usua||y
poss|b|e
Med|asnn|ns- cons|der
exc|us|on
a. Anox|c bra|n |n[ury
b. aradox|ca| venous thromboembo||sm
c. Coca|ne-assoc|ated |schem|c stroke
d. System|c a|r embo||sm
e. Unrecogn|zed ep|dura| hematoma
19 y]o skateboarder fe|| from a br|dge onto
an |ron fence susta|n|ng a h|p fx and
penetranng L ant chest wound. U-tox + for
coca|ne. Lmergent L anter|or thoracotomy
revea|s |aceranon of ant wa|| of L ventr|c|e.
Cn awaken|ng |n ICU, he has L hem|p|eg|a.
1he most ||ke|y exp|ananon for th|s
comp||canon |s:

Case
Card|ac In[ury
Cons|der Dx w|th mechan|sm of
|n[ury
Dx: echo, LkG - SV1, S1-1 changes,
tropon|n I, CkM8, card|ac MkI
1x:
Contus|on - observanon
er|card|a| eus|on - Ck
Spec|a| c|rcumstances, e.g. |ate
tr|cusp|d chordae rupture
e|v|c In[ury
Comp||canons:
ma[or retroper|tonea|
b|ood |oss
ILS, V1L
1x:
Immob|||ze
kep|ace u|ds
Ana|ges|a
Search for |nterna| |n[ury

a. ne shou|d be adm|ued to the ICU for q 4 hr VS & n]n.
b. ne shou|d have a stat non-contrasted C1 scan of the abdomen.
c. ne shou|d have an emergent exp|oratory |aparotomy.
d. Late comp||canons |nc|ude chron|c pancreanns.
e. Intervennona| rad|o|ogy |s most usefu| |n the hrst 48 hours.
SS y]o roofer fe|| ~10 h on to
concrete s|ab susta|n|ng mu|np|e k
|ower r|b fx. 8 130]80, 88, n]n
10]30. IAS1 exam |s shown at
r|ght. ne has no hematur|a. Wh|ch
of the fo||ow|ng statements about
h|s cond|non |s most accurate?

Case
D|agnosncs for 8|unt Abdom|na| 1rauma
IAS1 exam
Detects b|ood
Accuracy s|m||ar to DL &
C1
C1 scan* requ|red for:
Non-op management of
so||d organ |n[ur|es
Lqu|voca| s|gns
Mu|np|e or neuro |n[ury
*Must be hemodynam|ca||y
stab|e
L|ver]Sp|een In[ur|es
Suspect w|th |ps||atera| |ower
r|b fx
kequ|rements for non-
operanve management:
nemodynam|c stab|||ty
1ransfus|on of s2 un|ts
No other need for surgery
8ed rest, connnuous VS,
n&n q 4 hours
kepeat abdomen g|rth
Ik support for |ate
hemorrhage
Sp|en|c Artery
seudoaneurysm
Case
a. Intubanon & I|C2 1.0
b. Measure carboxyhemog|ob|n
c. nead C1
d. Aggress|ve u|d resusc|tanon
e. 1ox|co|ogy screen
60 y]o woman who was trapped |n house hre arr|ves to
LD w|th 2
o
fac|a| burns, resp|ratory d|stress & cough
producnve of carbonaceous sputum. GCS 10, 8
100]60, 130, SpC2 94. 1he most appropr|ate next
step wou|d be:
8urn In|na| Approach
r|mary survey for A8Cs of
A1LS
A|rway, CC, cyan|de
Gu|ded u|d resusc|tanon
Mon|tor|ng of organ
funcnon
1op|ca| agents
kN escharotom|es
Caveats of e|ectr|ca| |n[ury
Inha|anon In[ur|es
C|ass|hcanon
anox|c (|ow I|C2)
cytotox|c (CC]cyan|de)
smoke |nha|anon
therma| |n[ury (rare)
C|ues to Dx:
carbonaceous sputum,
nasopharyngea| soot, fac|a|
burns
dyspnea, wheez|ng,
hoarseness, str|dor
a|tered mentanon
Ind|canons for Intubanon
Inab|||ty to protect
a|rway
kesp|ratory d|stress
noarseness]str|dor
3
o
fac|a| burns
CCngb >20 w|th
neuro|og|c sx
Large resusc|tanon
Lund-8rowder ku|e Cf N|nes
nead 9
Lach arm 9
Ant trunk 18
ost trunk 18
Lach |eg 18
Gen|ta||a 1
a|m 1
a. Use of co||o|d avo|ds
extravascu|ar u|d |oss.
b. Use of standard formu|ae
avo|ds under]
overresusc|tanon.
c. Use of co|d sa||ne can reduce
hypermetabo||sm
d. S||ght overresusc|tanon
|mproves wound hea||ng.
e. IVs may be p|aced through
burned nssue
4S y]o 80 kg man was s|phon|ng gaso||ne wh||e ho|d|ng burn|ng
c|gareue. ne susta|ned 2
nd
& 3
rd
degree burns of both |egs &
poster|or trunk. Wh|ch of the fo||ow|ng statements about h|s |n|na|
IV u|d resusc|tanon |s most accurate?
Case
I|u|d kesusc|tanon
ark|and formu|a]8rooke formu|a
4m|]2mm Lk]kg] 2
nd
]3
rd
degree
burn
x over |n|na| 8 hrs
x over fo||ow|ng 16 hrs
86 overresusc|tated
IV access may be through burn but
not d|sta| to c|rcumferenna| burns
8oth under- & over-resusc|tanon
detr|menta| to wound.
Determ|n|ng adequacy of
resusc|tanon cha||eng|ng
ICU Care
U]C 0.S-1.S m|]kg]hr
Mu|np|e organ dysfuncnon common
rophy|acnc system|c annb|oncs not
|nd|cated.
1op|ca| annb|oncs decrease |nc|dence of
|nvas|ve |nfecnons.
Avo|d hypotherm|a
Search for assoc|ated |n[ur|es (fx, 18I,
cornea|, etc).
1etanus toxo|d
8urn Wound Infecnons
2 -7 d: G+
>7 d: |nvas|ve G- (esp "#$%&'(')*#) + fung|
40 Cand|da - add|nona| sk|n |oss
,-. /#0$12344%# deep |nvas|ve |nfecnon,
h|gh morta||ty
Mafen|de acetate:
a|nfu|, exce||ent penetranon, metabo||c
ac|dos|s (CA |nh|b|tor), no known res|stance
S||ver su|fad|az|ne:
Sooth|ng, poor penetranon, su|fa a||ergy,
trans|ent neutropen|a, res|stant
"#$%&'(')*# stra|ns, |nh|b|ts ep|the||a|
hea||ng
Lscharotomy
Inc|s|on to re||eve
compartment pressures
Ind|canons:
c|rcumferenna| 3
o
decreased pu|se s|gna| by
Dopp|er
|ncreased musc|e
compartment pressure
(e.g. ACS)
|ncreased aw |n |n|na| 8hr
a. She may be safe|y d|scharged to
home now
b. 1here |s a s|gn|hcant r|sk of |ate
rhabdo and AkI
c. She |s at s|gn|hcant r|sk of recurrent
VI
d. Deep v|scera| |n[ury |s common w|th
th|s type of e|ectrocunon
e. She shou|d have 24 hr LLG
mon|tor|ng to ru|e out non-
convu|s|ve status ep||epncus.
A 23 y]o woman dropped a b|ow dryer |nto the tub wh||e bath|ng. She
remembers fee||ng her musc|es tense up before |oos|ng consc|ousness. Aher
hear|ng a moan her roommate ca||ed LMS. When LMS arr|ved, pt |s a|ert. In
the LD, VS, 12 |ead LkG, Ck & tropon|n, and exam are WNL. She has no
neuro|og|c sx. Wh|ch of the fo||ow|ng statements |s true?
Case
L|ectr|ca| In[ury
Low vo|tage - < 1,000 vo|ts.
occas|ona| |mmed|ate VI but
||u|e nssue or card|ac damage.
May be treated as outpanent.
n|gh vo|tage - > 1,000 vo|ts.
card|ac |n[ury common,
pers|stent arrhythm|as.
musc|e necros|s w|th
compartment syndrome
rena| dysfuncnon 2
o
to
rhabdomyo|ys|s
damage to CNS & per|phera|
nerves
In|na| Assessment of L|ectr|ca| In[ury
A8Cs
ku|e of N|nes not usefu|
1e|emetry
2
o
survey focused on neuro|og|ca| |n[ury
& compartment syndromes
Contact po|nts:
hands may requ|re |mmed|ate
carpa| tunne| re|ease
trunk ohen w|th |nterna| |n[ur|es
(1k, organ |acs, perf of |ntesnnes,
etc.)
khabdomyo|ys|s
Lxtrem|ty Compartment Syndrome
Ser|a| exams |nh|gh r|sk e|ectr|ca|
|n[ury - hours-days to deve|op
pa|n > numbness > weakness > |oss of
pu|se
Iac|otomy |f pressure >30 mmng