Trauma Surgery Flashcards
Traumatic Brain Injury
Path: Any trauma that causes change in neurologic function without bleeding which results with edema and increased ICP. Can be mild or severe
Symptoms: GCS < 8 or dilated pupils, rapid deterioration. Cushings reflex (High BP with low HR) suggests about to herniate
Diagnosis: Noncontrast CT to rule out bleed. May see gyri pushed against skull or midline shift but no bleeding. ICP monitor in the ICU
Management: May need craniectomy. Goal is to prevent herniation by decreasing ICP. Intubate if GCS < 8. Elevate the head of the bed. Sedate and paralyze. Hyperventilate. Hypertonic saline/mannitol. May need seizure ppx and BP control but debated. Avoid hypotonic fluids
Complications: Herniation
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Concussion / Mild TBI
Path: Blunt or deceleration trauma that causes LOC with amnesia and normal CT
Symptoms: LOC
Diagnosis: Noncontrast CT head
Management: Can discharge if normal and no neuro deficits and not on anticoagulation. Avoid hypotonic fluids
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Cerebral Contusions
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Management: Avoid hypotonic fluids
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Basilar skull fractures
Symptoms: CSF from nose or ears
Diagnosis: Battle sign, Racoon eyes, CT max/fac, CTA looking for blunt cerebrovascular injury
Management: Some need surgery. No ppx antibiotics. Avoid hypotonic fluids
Complications: CSF can get infected
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Diffuse Axonal Injury
Path: Deceleration or rotational injury resulting in shearing of axons
Symptoms: Unconscious
Diagnosis: Noncontrast CT shows nothing initially. CT head will eventually show focal hemorrhages but usually don’t realize this diagnosis until day 4 when patient not waking up at which point you will be getting an MRI
Management: GCS < 8. Avoid secondary injury. Poor prognosis
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Penetrating head trauma
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Brain dead
Penetrating neck trauma
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Diagnosis: Passes through platysma clinically. Vascular/aerodigestive compromise = unstable. (hematoma, neuroloc deficits, hemodynamic instability, pulsatile bleeding, subq emphysema or bubbling of wound, blood in mouth). CT angio neck to further evaluate stable. If still nothing found then bronchoscopy, esophaghoscopy, or gastrograffin swallow
Management: Operate unstable or stable with findings. Zone 1 requires subluxation of mandible, craniectomy, or endovascular. Zone 2 requires open exploration. Zone 3 requires thoracotomy or endovascular (zone 1 is angle of mandible up, zone 3 is cricoid cartilage down, zone 2 is the middle)
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Blunt cerebrovascular injury
Path: Deceleration which shears blood vessels. Usually interior carotids and vertebrals
Symptoms: Stroke like symptoms or asymptomatic following MVC
Diagnosis: CTA, endovascular angiogram if treatment is planned
Management: Severe grade 5/transection requires surgery. Grade 4 traumatic occlusion gets heparin and reimaging and maybe endovascular stent. Grade 3 pseudoaneurysm gets heparin and reimaging and maybe endovascular stent. Grade 2 Large intimal flap gets heparin and reimaging. Grade 1 Small Intimal Flap gets heparin and reimaging. Eventually switch from heparin to aspirin. All this is to reduce risk of stroke which occurs after. May need endovascular angiogram if not clear from CTA
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Blunt trauma subaxial C spine, thoracolumbar spinal fx
Path: Spine divided into 3 columns. Behind nucleus pulposis vertebral body is middle. Spinal cord and behind is posterior.
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Diagnosis: Nexus criteria or canadian CT neck criteria suggests when to get CT. CT will show fractures. MRI shows ligament injury looking specifically at posterior longitudinal and ligamentum flavum. Spinal involvement of 1 column is stable. 2 columns if middle involved is unstable. 3 columns is unstable
Management: Unstable = ORIF. Stable = External fixation. C spine correctio. Compression with edema gets glucocorticoids
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Craniocervical C spine fx
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Diagnosis: CT scan of C spine showing step off. MRI is best. C1 broken in 2 places is unstable. C2 ring broken in 2 places is unstable. Proximal dens is unstable. Alar ligament and cruciform ligament tear is unstable
Management: Unstable = ORIF. Stable = External fixation
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Spinal Cord Injury
Path: Occurs from blunt/penetrating trauma, impingement, bleeding compressing
Symptoms: Depend on level of lesion. Complete resection results in motor (Corticospinal tract), sensation (dorsal column), and temp/pain loss (spinothalamic tract). Brown sequard (hemisection) results in ipsilateral motor/sensation loss and contralateral pain/temp. Middle cord hematoma knocks out pain/temp bilaterally. Anterior cord knocks out bilateral motor and pain/temp. Cauda equina causes saddle anesthesia and incontinence
Diagnosis: CTA. MRI always if you see fx as it is better at diagnosing and shows ligaments
Management: Steroids within 8 hours if edema. No steroids for penetrating trauma because there is no edema. Neurosurgery within 24 hours
Complications: Spinal shock or stunning (reflexes turn off) where bladder turns off and will need cath
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