DIP Episode 221 - The Floridly HY Trauma Podcast (for Step 2CK, Step 3, Surgery, EMED Shelf Exams)

Welcome. My name is Devine, I'm a resident. This is episode 221 of the Divine Intervention Podcast. And I'm going to call this podcast the trauma podcast. It's basically a podcast for people that are taking the surgery shelf or the emergency medicine shelf. I'm trying to make the short and sweet so let's just get right into it. So what did they give you a question about a patient? And they tell you that this patient was in a motor vehicle accident. And then this patient is having like a lot of a shortness of breath and they tell you that on physical exam you notice a subcutaneous infezima and then so like you know like a crunchy appearance of the person's skin. And then they tell you that oh this person they they get a chest x-ray or they get a chest CT and they see dark linear lines outlining the tracheal bronchial tree. If you see that what do you want to think about an exam? I would really hope you're thinking about some kind of rupture of the broncus or rupture of the trachea. This thing has a very classic presentation on mbim exams and it's actually pretty easy to recognize. So essentially it'll be a present that would be like a motor vehicle accident right and then they'll tell you that the present has subcutaneous infezima. So I know somebody will be saying oh but divine. Could this also be a subcutaneous infezima? You're right. It could also be a subcutaneous infezima. But the thing is your friends on the mbim exam.

And so the juu rupture they will typically give it in a present that has been a retching very powerfully or they will give it in a present that recently got some kind of operating doscopy right. So that's something you want to keep at the back of your mind. So if you don't see that history you see more of like a trauma incident you want to think more about like injury to the to the bronchial of the trachea right. So what are some classic things you see in a test question? They'll tell you that oh the person has like a rice crispy sensation of the skin right or they may tell you that oh you see linear dark lines outlining the trachea bronchial tree. That's essentially the mbim describing no more media sign on to you on a test right. So if you see that right you want to think about trachea bronchial injury. And other way the occasionally test this on exams is they'll tell you about a person that has like you know you think that they have like let's say you're like oh decrease red sounds on all that crap right boy like man I've placed the chest tube like hours ago this person does not appear to be getting better or they tell you that oh you see a persistent ear leak even in the presence of a chest tube if you see that you absolutely want to think about injury to the trachea or bronchial. They've probably ruptured or something right and again like I said the classic image and finding is a new moment just in them.

For the most part I mean you tend to these people have to go to surgery pretty much right so for you to be able to fix fix their problem and the thing is the question again they may write it to look a lot like a new motor axe question but just some features of a new motor axe won't be there right like everything will be in the middle so you'll have any kind of like media stench shift you won't have any like JVD and stuff like that if you see those things I really want you to consider like ruptured like a traumatic ruptured or the broncus or traumatic ruptured or the trachea and that those circumstances.

Now what if they give you a question about a patient and they tell you that oh this patient was in a high-speed motor vehicle collision and this patient is you know kind of completely not some chest pain and you know they tell you that this patient gets fluids right so they may tell you that oh when the patient came into the hospital patient didn't have crackles nothing well then you give the patient fluids and then oh everything gets really bad from there right so and then they begin to give you like all these hemodine like cardiac numbers right so they give you like a pulmonary capillary which pressure that's elevated they tell you that oh they are crackles on the scotation of the lungs or oh they tell you that the cardiac index is decreased right basically they may have like a mild elevation in their in their troponins believe it or not right but the big thing will be the temporal because you they may try to fully on an MBME into picking an MI right but if you see a person that has a mildly not super elevated troponing mildly elevated troponing in the setting of like recent like motor vehicle trauma you absolutely absolutely absolutely want to think about something called a myocardial contusion right myocardial contusion on an MBME exam and the thing is when you see a myocardial contusion again they will have almost like a cardiogenic shock like a picture right so you may give those people fluids and by giving them fluids their their their status begins to worsen right you know they become more hypoxic you begin to hear crackles in the lungs the CVP the central venous pressure which is a surrogate for ready-trial pressure goes up the PCWP the pulmonary capillary which pressure which is a surrogate for left-trial pressure goes up right if you see all those things you absolutely want to think about a myocardial contusion on an MBME exam it typically won't go into det

ails of managing it or whatever that's about where they stop on these tests right and then what if they give you a question about a patient similar issue you know high-speed motor vehicle collision but now this person is completely not shortness of breath and then they may give you like all these ABG labs right and you notice that oh this person oxygen tension in the blood like PEO2 is low right so P little AO2 is low and they may give you like you know that PCO2 is mildly innovative or it may actually be decreased so that number is a little less reliable and then they tell you that oh on on chest x3 they see like they see what is this thing called they see all these infiltrates like these are in testicially infiltrate so you can see like a long that is almost like white whenever you see those kinds of things think about a pulmonary contusion okay so they won't have many cardiac maladies going on on the test you'll have a you'll have mostly pulmonary things right so like they'll have hypoxia they'll have like white out long right like a passionately one thought long is not like terrible terrible terrible ARDS style white out long if you see those kinds of things you absolutely want to think about a pulmonary contusion on an MBME exam right and then what if they give you a question about a patient and they tell you that oh this patient was in again high speed motor vehicle collision and then this patient they tell you that this patient has like very severe like pain with like very you know very severe pain with whenever they take a deep breath and they show you some lapse and again you see signs of hypoxia you see this person is building up CO2 so the apesio 2 is high so in this case the apesio 2 is almost always high on a test right and then they tell you that all that you can feel like some crepidus on palpation of the chest right and then they tell you that oh when th

e person inhales you notice that the ribs move inward with inspiration and outward with expiration whenever you see stuff like that you want to think about the person that's potentially fractured your ribs right and if you want to get a little more specific there those people have something known as flu chest okay those people have something known as flu chest basically be fractured multiple ribs right and when you fracture multiple ribs you begin to have like paradoxical chest wall motion because usually your ribs should move outward with inspiration and inward with expiration whenever you see paradoxical movement of the ribs right where presence ribs move inward with inspiration you see that ends kind of match or outward right or externally with expiration let me see if I can match it up there and you absolutely want to think about flu chest on your exam right those are classic findings and really you may see divine all these chest injuries you are talking about like how do you do that what's your initial diagnostic step just get a chest x-ray for the most part and you should be fine right so the thing is there are some entry cases that your friends at the mbmi love to test with these things right so the thing is for the most part when people fracture their ribs they'll be fine right but they're dealing with a lot of pain and you need to make sure that they are ventilating appropriately right because one thing that they may say on an mbmi exam they may say which of the following best represents the most likely complication like the most likely short-term complication of this person's problem right on that the circumstances of the mbmi you absolutely want to think something more along the lines of like other like this is right because the thing is when a person has like a rib fract like rib fractures of flu chest because it hurts a ton to breathe right they will not

be taking very good breaths in right and if you're not taking good breaths in then their lungs are more prone to collapse so they can get a like this is and the thing is again if you're not moving air really well the moving sections of the longer really well then bacteria can begin to have a filled day in those in that region of lung right and essentially the person can get a pneumonia with that right so those are things you absolutely want to keep at the back of your mind for exams and remember that they can give you even give you a question about a person that has a rib fracture and in detail that all this person you know is like super high-poxy complete of shortness of breath and in detail you that on the quotation of the chest you see you hear you in a literally decreased breath sounds if you see that you absolutely want to think about a new mothorax on the those circumstances that's also one of the complications of having like a rib fracture right and the thing is typically when people have rib fractures one unique answer you may want to see on an mbmi is typically for those people if you can do some kind of nerve block right if you can do like some kind of chest to owner block like a thoracic nerve block typically those people tend to do pretty well because essentially you will just help them breathe and then over time they will just recover right so that's one thing that's beginning to be done more commonly in hospitals to be honest to be honest with you and then what if they give you a question about a patient and they tell you that oh this patient you know was in was in a you know high-speed motor vehicle collision and then they tell you that oh on imaging of the on imaging of the chest like a chest x-ray you notice that this person has like a wide-in media stine right a wide-in media stine if you see that it's kind of a that's kind of bad news right there ri

ght so this person has essentially ruptured the great vessel right the other essentially right and again you'll almost kind of present like a newtic dissection picture you say like wide-in media stine on well you'll see the temporal association with recent trauma if you see that you absolutely want to think about some kind of traumatic aortic rupture right and the thing is money hunt of these patients is pretty easy for the most part they are gonna go to surgery right but the thing is if you are hemodynamically unstable you perform a TE model transphoracic trans esophageal echocardiogram you know a TE and then you will them over to surgery right but if they are hemodynamically stable right you can do like a CT scan right you can do like CT like a CT scan of the chest or you can do like a CT angiogram of the chest right you will see the origin of traumatic rupture and then those people are you go ahead and well them to surgery I mean the other crop tray is like bad news right because the thing is if you're the other ruptures where's the blood supply to you what you're gonna come from and it's not usually those people don't don't don't do very well I mean the vast majority of them die of a combrianded right and the thing is in general when a person has an aortic rupture the thing that usually causes the transaction is usually the ligamentum material so you just kind of just like this through like a clean slice through the other and then it's entirely transacted and it's usually like the beginnings of the descending the other that people tend to get those kinds of squibbles so you definitely again want to make sure you know that stuff for purposes of your exam right and then if they give you a question about a patient that you know had like some kind of I don't know like neck trauma or something like that right and then they tell you that this person is having like sharp

ness or breath and that you notice that you can hear breath sounds on one side of the chest but you cannot hear breath sounds on the other side of the chest and then they make sure you like a big like a chest x-ray and you may see like one hemi die from that is vastly elevated compared to the other if you see that what you want to think about on an exam I'll really hope you're thinking that this person has injured the front ear right so remember on in the exam I mean you probably remember this from like studying for another me for step one this whole business with like C345 keeps the diaphragm alive right so if for whatever reason you have like cervical injury or neck injury and then you transsects the front ear the diaphragm on that side will be paralyzed and it's actually the paralyzed diaphragm that will be elevated right the paralyzed diaphragm will elevate right so if you see like a unilaterally elevated diaphragm in a person with sharpness or breath with a normal AA gradient you absolutely want to think about you absolutely want to think about like a frenic nerve like injury on that those are circumstances and you know typically for those people you need to go ahead and into beat them and then you kind of go from there but the thing is going from there that's beyond the scope of many of these MBM exams if you're resident I can go over that stuff with you but not for purposes of a of a med student so I'm going to go ahead and and skip that and again key thing to keep in mind because we can make this very easily a respiratory physiology question the person will have hypoxia but you'll have a normal EE gradient remember your EE gradient will typically be normal in the setting of hypoxia if you have a non-pominary cause of the hypoxia right so if for example you have like an extra-pominary problem right that will cause a normal EE gradient compared that with somethi

ng like ARDS right ARDS remember it's a very common complication of like drowning right or being like in a house fire right so those people right their lungs are wet with fluid right they have like a non-cardogenic pominary dimmer with a pominary capillary which pressure being less than 18 right whenever you see that you know ARDS increase vascular permeability those people because their lungs actually have a problem those people will be hypoxemic but that hypoxemia will be accompanied by an increased EE gradient that's a very high-yield thing to keep at the back of your mind for exams and then one of the thing you may see on a test right is they be giving you a question about a person that has like a common question that pops up on these MBA muses if a person is an abdominal trauma who goes to for x-lapimility this one is actually pretty easy to answer essentially if you have any kind of penetrating injury to the abdomen right so let's say stab wound, gonshot wound those people are getting exploratory laparadomy like instantly right another common one you miss your own a test is if a person has like free air under the diaphragm right for person has free air under the diaphragm that's bad news right those people that means they've peppered it some part of the abdomen they have like some kind of perforated viscous right so if they have a perforated viscous again those people don't pass code you don't collect 200 if you can't steal by the way I really love monopoly and you go ahead and wield those people over to surgery right and then another classic one you may see on tests is if a person has signs of peritomitis right so let's see the tell you that they have like a rigid abdomen they have rebound they have guardian and if anything you see that you know you go ahead and wield those people to surgery right those people you don't get any kind of diagnostic testing you j

ust go ahead and proceed straight straight to the operating room right and the thing is in general so that's the penetrating trauma algorithm for the abdomen and that's pretty much all you need to do there the thing is if a person has blunt trauma to the abdomen right the first question you need to ask yourself is is this patient he more dynamically stable or he more dynamically unstable I'll say that again if a person has blunt abdominal trauma you need to ask yourself are they he more dynamically stable or he more dynamically unstable if the patient is he more dynamically stable then your next step in diagnosis on the exam is to just go ahead and you know get those people like a CT scan of the abdomen right with contrast you get a CT scan of the abdomen with contrast you'll see whatever badness is going on and then you manage as needed right but if the patient is he more dynamically unstable your first step in diagnosis on an MBA exam is to proceed to obtaining a fast scan a fast scan is essentially an ultrasound of some recesses in the abdomen I'll encourage you to watch watch a video on this you know some recesses in the abdomen you're trying to look for blood obviously if you see blood then X-lap is your next best step in in in our management and the thing is your friends at the MBA me sometimes they may not write exploratory laprodomy they may write exploratory ciliotomy exploratory ciliotomy is essentially the same thing as it's just a five dollar word for exploratory laprodomy essentially the thing that happens is instead of saying laprodomy right because think about it what is the main artery that supplies many of the four got organs that tend to be involved in abdominal injury it's the cilia corduille right so it would make sense that we call that an exploratory ciliotomy on an MBA me exam so that's something you absolutely want to keep at the back of your m

ind for tests right so like I said blood was thrown into the abdomen face the agnostic step fast scan right if the fast scan does not show you what if it's negative right your next step will be a DPL a diagnostic periodontial avaish right if the diagnostic periodontial avaish is negative then the next thing you go to is to perform a CT scan of the abdomen right so again let me read it out from beginning to end fast scan first that's number one number two so if fast scan is negative you proceed to a diagnostic periodontial avaish if that's if the DPL is negative then you proceed to you proceed to to a CT scan of the abdomen I mean that algorithm doesn't really make sense to me it will make sense to just get the CT scan and that you can get in like you know like 30 seconds but you know that's the MBA me they're the ones that determine your grades so you got to go with what with what dimension right so that's how your money is planned for stroma to the abdomen and obviously if any of those things are ever positive and your next step in management is going to be exploratory laparotomy right that's something you absolutely want to keep at the back of your mind for tests and then what if they give you a question about a patient and they tell you that oh this patient you know it's like a boy and this boy was you know riding his bicycle and then and then he's being complete of like sodium onset severe abdominal pain and then they give you like a lipase and an amylase that's super elevated what are you thinking about on that of circumstances well I hope you're thinking about traumatic pancreatitis right traumatic pancreatitis for those you generally don't need to make any kind of imaging diagnosis although routinely people try to get like some kind of imaging of the abdomen just to make sure that this child did not rupture some kind of vessel right but remember it like your cl

assic you probably remember this studying for step one handle boundaries they are very commonly implicated in people that end up getting like pancreatitis right so especially in kids kids are the ones you want to look out for on exams right so you see that you know you think about pancreatitis the lipos will be elevated you'll have the classic symptoms if you have like the classic symptoms you don't really need to do any kind of imaging those people you essentially make them NPO you give them pain control right and you give them IV fluids right and that's it and remember that pancreatitis there are some things that are very bad prognostic indicators right so let's say for example your BUN raises by a lot right or I'll encourage you to look up the Rancens criteria I'm kind of speeding through this year because I got to going like five minutes but I want to make sure I cover all like all the chest and abdomen trauma in this one podcast so basically you know NPO IV fluids pain control right but again like I said if your calcium is really low that's bad in pancreatitis that's a bad prognostic sign if your white count is really high or if your hematocrygid drops by a lot or if your BUN raises by a lot or if your LDH raises by a lot those are all bad prognostic indicators but a common one on NBM is the calcium if your calcium is really low in pancreatitis you need to maybe you know kind of keep your eyes peeled on that patient they may not do very well in the hospital unfortunately right and then another question you may see on a test that involves in worst kids is let me give you a question about a kid again maybe in the motor vehicle accident and this kid has been complaining of abdominal pain and then they give you a hemoglobin that is low right and the patient you know clips clutching his abdomen blah blah blah blah blah he more dynamically unstable hypotensive hemoglob

in low if you see that you want to think about a doodonal hematoma okay or doodonal rupture as the as the child's complaint essentially as the diagnosis basically that child has impacted the gastro-doodonal artery right so those people your next step in management on an NBM exam is to go ahead and get like angiography with embolization right so that they don't bleed out and die GDA bleeds are very deadly they have I mean like I have like real world experience GDA bleeds are super super super deadly right so it's just one of those things you don't you don't really mess around with and one thing that they may give you on an NBM exam is they may give you a question about a patient right and they tell you that oh this patient was in trauma and this patient is having like right shoulder pain if you see that you know the person's spleen has ruptured essentially right that's something that's known as care sign right K E H R right care sign essentially thing that has happened is because the spleen has ruptured it's irritating the diaphragm right so the the phrenic nerve is like getting some like weird signals right and because the phrenic nerve I mean like some fibers from C345 actually supply the oppressed mainly I mean think about like you know like a brachial plexus C5-2-1 right then those people get like referred shoulder pain I mean in general if a person has like a blunt force trauma to the abdomen the liver and the spleen are usually like the big big big implicated big big things that tend to be implicated as a e-drop under those circumstances and then under high yield thing I think I wonder this cost is like like GI bleeds right GI bleeds you know essentially these things are very simple but people get them wrong all the time on exams I don't know why I mean honestly I really don't know but the thing is if a person has a GI bleed your first step in management is one i

n yeah in management right you place to pay for livis right two large varieties you give fluids plus or minus blood first that's always what you do first they will put eGD as an answer but it will be wrong if you've not started giving fluids you need to give fluids plus or minus blood before you proceed right and then after you do that right the next thing you do essentially is you go ahead and I'm doing eGD first right you do an eGD first you do oprenedoscopy and they suffer go gastrodoinoscopy if that's negative then your next step is to do a colonoscopy right if the colonoscopy is negative thing you know you start doing like the exotic stuff like you can do like angiography you can do like a tabred blood cell scan and all that fun stuff but that's essentially how you manage GI bleeds and you know people that have GI bleeds you need to give them IV proton pump inhibitors right you know to kind of help them there you need to give them uh can give them like IV IV octuotide as well right so that you don't get like peptic ulcer disease right they don't get like an ulcer in that in those settings so I think those are kind of like the big things I'm gonna talk about here um I'm just trying to think is they know the high uffin I've not re-mentioned uh you know I think I've kind of talked about all the I think I've talked about many of the big things yeah many of like the you know like chest abdominal wall stuff and the GI bleeds stuff so this podcast I promise you I promise you if you're taking your surgery shelf or your e-match shelf or step 2ck you will very likely get like 10 like on the shelf maybe like five to seven questions right on step 2ck you probably get like 10 to 15 questions right from just this one like 23-ish mini podcast so I'll strongly encourage you to pay attention to this um sorry I can't really talk about a life lesson today I kind of need to go but a

gain as I do at the end of every podcast I'll talk to you in for many exams step one 2ck 2c and step three pre-clean comets call exams 30-ish off exams if you're a medicine or a repeat resident I'll tell you for the interesting exam and the board exams for those I tell you for all the pre-med like m-cut subjects and I do these booster courses for step one 2ck and step three um they're 20 hours each again it's like the most knows the highest of the high yields I've done this with tons of people and all the people I've done it with they found a bit to be like super super helpful for the tests um so if that's something you're interested in uh just reach out to neither through the website or send me an email at divine intervention podcasts with an s at bn.gmail.com and please subscribe to the youtube channel subscribe to the podcast it's on apple podcast Spotify and um and uh was the sort of thing called google play and you can also subscribe to my Word Press website so thank you for listening god bless you I'll see you in the next podcast thank you

Unilaterally elevated diaphragm (due to phrenic nerve injury).

FAST exam (Focused Assessment with Sonography for Trauma).

Perforated viscus/viscera.

IV fluids plus or minus blood products $\rightarrow$ EGD $\rightarrow$ Colonoscopy (if negative).

Atelectasis and subsequent pneumonia/lung collapse.

Traumatic aortic rupture.

Subcutaneous emphysema (crepitus) and/or persistent air leak despite chest tube placement.

CT scan of the abdomen with contrast $\rightarrow$ If negative, proceed to DPL $\rightarrow$ If DPL negative, then CT scan (Note: The algorithm prioritizes imaging).

Low serum calcium ($\text{Ca}^{2+}$) and high BUN/LDH.

Spleen rupture irritates the diaphragm, causing referred pain to the shoulder via the phrenic nerve (C3-C5).

ARDS causes a high $\text{PaO}_2/\text{FiO}_2$ gradient (indicating V/Q mismatch), whereas non-pneumonic causes usually have a normal gradient.

The aorta, typically at the level of the ligamentum arteriosum.

Subcutaneous emphysema (crepitus) and/or persistent air leak despite chest tube placement.

CT scan of the abdomen with contrast $\rightarrow$ If negative, proceed to DPL $\rightarrow$ If DPL negative, then CT scan (Note: The algorithm prioritizes imaging).

Low serum calcium ($\text{Ca}^{2+}$) and high BUN/LDH.

Spleen rupture irritates the diaphragm, causing referred pain to the shoulder via the phrenic nerve (C3-C5).

ARDS causes a high $\text{PaO}_2/\text{FiO}_2$ gradient (indicating V/Q mismatch), whereas non-pneumonic causes usually have a normal gradient.

The aorta, typically at the level of the ligamentum arteriosum.