Flashcards in 15 Trauma Deck (379):
when do deaths from trauma occur?
1st, 2nd, 3rd peaks. 0-30 min, 30min to 4hr, days to weeks
what are the causes of deaths during 1st peak?
1st: lacs of heart, aorta, brain, brainstem, spinal cord; cannot save these pts, death is too quick
what are the causes of deaths during 2nd peak?
head injury (#1), hemorrhage (#2), saved w rapid assessment (golden hour)
what are the causes of deaths during 3rd peak?
deaths due to multisystem organ failure and sepsis
what percentage of all traumas are 2/2 blunt injury?
what organ is the most commonly injured from blunt trauma?
liver. sometimes spleen
for falls, what are the biggest predictors of survival?
age and body orientation
how many stories is LD50 for falls?
what is most commonly injured in penetrating injury?
small bowel. some say liver
what is the most commonc ause of death in first hour?
at what blood volume does BP start to drop?
30% of total blood volume is lost
what do you start resuscitation with? then what?
2L LR, then switch to blood
what is the mcc of death after reaching the ER alive?
what is the mcc of death in long term after trauma?
what is the mcc of upper airway obstruction? what do you do to treat?
tongue. perform jaw thrust
what injuries do seat belts cause?
small bowel perforations, lumbar spine fx, sternal fxs
what is the best site for cutdown for venous access?
when do you use DPL?
hypotensive pts w blunt trauma
what is a positive DPL?
>10 cc of blood
what do you do if DPL is positive?
where do you do DPL if pelvic fx present?
where does DPL fall short?
retroperitoneal bleeds, contained hematomas
where is FAST performed?
perihepatic fossa, perisplenic fossa, pelvis, pericardium
what are the limitations of FAST?
operator dependent, obesity obstructs view, may not detect free fluid <50-80 ml, retroperitoneal bleed, hollow viscous injury
what do you do if FAST is positive?
what do you do if a hypotensive pt has neg FAST scan?
find source of bleeding (pelvis, fx, chest, or extremity)
what test is required for blunt trauma pts?
what are the indications for CT in blunt trauma pts?
abd pain, need for general anesthesia, closed head inj, intoxicants on board, paraplegia, distracting inj, hematuria
what does CT miss in trauma?
hollow viscus inj, diaphragm inj
which trauma pts get laparotomies?
peritonitis, evisceration, positive DPL, uncontrolled visceral hemorrhage, free air, diaphragm inj, intraperitoneal bladder inj, contrast extravasation from hollow viscus, specific renal, panc, and biliary tract injuries
what is the algorithm for diagnosis of blunt trauma?
do penetrating injuries need laparotomies?
what do you do if a pt has possible penetrating abd injury?
local exploration and observation if fascia not violated.
what is the algorithm for diagnosis of low velocity penetrating abd trauma?
when does abd compartment syndrome occur?
after massive fluid resuscitation, trauma, or abd surgery
what test do you get to find out if pt has compartment syndrome?
bladder scan: pressure >25-30
with compartment syndrome, why does pt get dec cardiac output?
what are good indicators of low cardiac output after abd compartment syndrome?
visceral and renal malperfusion (dec urine output)
what do you see on imaging with abd compartment syndrome?
upward displacement of diaphragm, affects ventilation
what is treatment for abd compartment syndrome?
what does a pneumatic antishock garment do? when do you use it?
releases compartments one at a time after reaching ER. controversial. use in pts with SBP <50 and no thoracic injury
when do you do ED thoracotomy for blunt trauma?
only if pressure/pulse lost in ER
when do you do ED thoracotomy for penetrating trauma?
use only if pressure/pulse lost on way to ER or in ER
what are the steps in thoracotomy?
open pericardium anterior to phrenic nerve, cross clamp aorta, watch for esophagus
is the esophagus anterior or posterior to aorta?
when do catecholamines peak after trauma?
24-48 hrs after inj
what else increases after trauma?
ADH, ACTH, glucagon (flight or flight response)
who cannot receive Rh-pos blood?
females who are prepubescent or of childbearing age. everyone else can get Rh-pos or Rh-neg blood
is giving only type-specific blood ok?
can be administered safely, but there may be effects for abs to HLA minor antigens in the donated blood.
at what gcs do you do what?
<= 8 icp monitor
what are the indications for head ct?
• suspected skull penetration by foreign body
• discharge of CSF, blood, or both from nose
• hemotympanum or discharge of blood or CSF from ear
• head inj w alcohol or drug intox
• altered state of consciousness at time of exam
• focal neurologic si/sx
• any situation precluding proper surveillance
• head inj plus additional trauma
• protracted unconsciousness
laceration of the middle meningeal artery is the cause of what kind of hematoma?
what kind of shape is epidural hematoma on head ct?
what are si/sx of epidural hematoma?
LOC -> lucid interval -> sudden deterioration (vomiting, restlessness, LOC)
when do you operate for an epidural hematoma?
significant neurologic degernation or significant mass effect (shift >5mm)
what is mcc of subdural hematoma?
tearing of venous plexus (bridging veins) that cross between dura and arachnoid
what is finding on head ct for subdural hematoma?
when do you operate for SDH?
degeration of mass effect >1cm
who gets chronic SDH?
elderly after minor fall
where are intracerebral hematomas located?
frontal or temporal
can intracerebral hematomas cause mass effect?
yes, can require operation
what kind of injury is coup, contrecoup?
what do you need to do for a traumatic intraventricular hemorrhage?
ventriculostomy if causing hydrocephalus
what is the best imaging modality for diffuse axonal injury?
MRI > CT
what is treatment for DAI?
supportive, may need craniectomy if ICP elevated, very poor prognosis
how do you calculate cerebral perfusion pressure?
CPP = MAP - ICP
what are signs of elevated ICP on imaging?
dec ventricular size, loss of sulci, loss of cisterns
when do you place an ICP monitor?
GCS <=8, suspected inc ICP, or pt with moderate to severe head inj and inability to follow clinical exam (intubated)
what is normal ICP? at what ICP requires treatment?
normal is 10. >20 needs treatment
what should CPP be?
how do you increase CPP?
• sedation and paralysis
• raise HOB
• relative hyperventilation (but do not overhyperventilate) -> can cause too much cerebral ischemia from too much vasoconstriction
what should Na and serum Osms be?
Na: 140-150, Osm 295-310
what can you give to draw cluid out of brain to maintain Na and serum Osms?
what is the dosage of mannitol?
load 1g/kg, give 0.25 mg/kg q4h after that
what does mannitol do?
draws fluid out of brain
what do you consider if mannitol or hypertonic saline dont work?
how do you reduce ICP?
ventriculostomy to keep ICP <20
when do you do a craniotomy decompression? what else can you do?
if unable to get ICP down medically. can also do Burr hole
what can be given to prevent seizures? who gets it?
fosphenytoin or keppra. give to mod to severe head injury pts
when does ICP peak?
48-72 hours after injury
what is the anatomical cause of dilated pupil?
temporal pressure on same side (CNIII, oculomotor, compression)
what are the si/sx of basal skull fx?
racoon eyes, battle's sign, hemotympanum and csf rhinorrhea/otorrhea
what does raccoon eyes tell you?
anterior fossa fracture
what does battle's sign tell you?
middle fossa fracture; can injure facial nerve (CN VII)
what is the most common site of facial nerve injury?
what nerve do temporal skull fractures injure?
CN VII and VIII (vestibulocochlear nerve)
temporal skull fractures are associated with what kind of other injury?
lateral skull or orbital blows
do most skull fxs require surgical treatment?
normal is 10. >20 needs treatment
when do you operate for skull fx?
if significant depression (>1cm)
persistent CSF leak not responding to conservative therapy
what do you do about csf leaks?
manage expectantly, can use lumbar CSF drainage if present. if persistent, operate
what is the cause of coagulopathy with traumatic brain injury?
release of tissue factor
what is a c1 fx called?
c1 burst is called jefferson fracture
what causes c1 burst?
what is treatment for c1 burst?
what is the cause of c2 hangman's fracture?
distraction and extension
what is the treatment for c2 fx?
traction and halo
what are the types of c2 odontoid fxs?
type I: above base, stable
type II: at base, unstable
type III: extends into vertebral body
what do you do about type I, II, III c2 fxs?
type I: nothing
type II: fusion or halo
type III: fusion or halo
what is associated w a facet injury or dislocation?
cord injury can be caused by facet injury.
associated with hyperextension and rotation with ligamentous disruption
what is an "unstable" spine?
if more than 1 column is disrupted
what are the columns of the thoracolumbar spine?
what makes the anterior thoracolumbar spine?
anterior longitudinal ligament and anterior 1/2 of the vertebral body
what makes the middle thoracolumbar spine?
posterior 1/2 of the vertebral body and posterior longitudinal ligament
what makes the posterior thoracolumbar spine?
facet joints, lamina, spinous processes, interspinous ligament
what kinds of injuries affect the thoracolumbar spine?
what is a compression fracture? what is it also called? is it a stable fx?
wedge fracture. anterior column only. stable
what is a burst fracture? is it stable?
unstable (>1column), need a spinal fusion
what injuries do you find with upright fall?
calcaneus, lumbar, wrist/forearm fx
what do you need to get if pt has neurologic deficits without bony injury?
MRI to check ligamentous inj
when do you need to emergently decompress a spine surgically?
1. fx or dislocation not reducible with distraction
2. open fracture
3. soft tissue or bony compression of the cord
4. progressive neurologic dysfunction
what is the what is the most common cause of facial nerve injury?
fracture of temporal bone
for facial lacerations, what do you try to do when suturing/repairing?
preserve skin, not trim edges
what are the Le Fort fractures?
I: maxillary fracture straight across (-)
II: lateral to nasal bone, underneath eyes, diagonal towards maxilla ( / \ )
III: lateral orbital walls (- -)
what are the treatments for le fort I?
reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires
what are the treatments for le fort II?
same as le fort I
what are the treatments for le fort III?
suspension wiring to stable frontal bone; may need ex fix
illustrate the le fort fractures.
how often do nasoethmoidal orbital fractures have a CSF leak?
what is the treatment for nasoethmoidal orbital fractures?
-conservative therapy for 2 weeks
-try epidural catheter to dec CSF pressure to help it close CSF leak
-may need surgical closure of dura to stop leak
what are the different types of nosebleeds?
how do you treat nosebleeds?
posterior: difficult. try balloon tamponade. may need angioembolization of internal maxillary artery or ethmoid artery
who needs repair after an orbital blowout fx? what do you do?
impaired upward gaze or diplopia with upward vision. restore orbital floor with bone fragments or bone grafts
how do you diagnose mandibular injury?
fine cut facial CT scan with reconstruction
what is the #1 indicator of mandibular injury?
how do you repair mandibular injury?
IMF (metal arch bars to upper and lower dental arches, 6-8 weeks) or ORIF
what is a tripod fracture and how do you treat?
zygomatic bone fracture. ORIF for cosmesis
what are pts w maxillofacial fractures at high risk for?
cervical spine injuries
what do you do for an asymptomatic blunt neck trauma?
what do you do for an asymptomatic penetrating neck trauma in zone I?
angiography, bronchoscopy, esophagoscopy, and barium swallow. pericardial window may be indicated. may need median sternotomy to reach these lesions
what do you do for an asymptomatic penetrating neck trauma in zone II?
need neck exploration in OR
what do you do for an asymptomatic penetrating neck trauma in zone III?
angiography and laryngoscopy. may need jaw subluxation/digastric and sternocleidomastoid muscle release/mastoid sinus resection to reach vascular injuries here
where are zone I, II, III?
I: clavicle to cricoid
II: cricoid to angle of mandible
III: angle of mandible to base of skull
what is the important implication of zone I injury?
greater potential for intrathoracic great vessel injury
what do you do for symptomatic blunt or penetrating neck trauma?
neck exploration if:
shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit
what is the most difficult neck injury to find?
how do you find an esophageal injury?
esophagoscopy and esophagram together
how often do esophagoscopy and esophagogram together find esophageal injuries?
what do you do about a contained esophageal injury?
what do you do about a small noncontained esophageal injury?
if small and minimal contamination, primary closure
what do you do about an extensive injury or contaminated esophageal injury?
depends on where it is.
neck: just place drains (will heal)
chest: chest tubes to drain injury and place spit fistula in neck (will eventually need esophagectomy)
how often do esophageal and hypopharyngeal repairs leak? what do you need to do for these repairs?
leak 20%. always place a drain
what is the approach to esophageal injuries to the neck?
what is the approach to esophageal injuries to the upper 2/3 of thoracic esophagus?
what is the approach to esophageal injuries to the lower 1/3 of thoracic esophagus?
does the esophagus lie on the right or left? how does it course?
left to right to left
what do you do about laryngeal fxs and tracheal injuries?
airway emergency. secure airway emergently in ER w cricothyroidotomy usually. primarily repair using strap muscle for airway support. tracheostomy to allow edema to subside, and to check for stricture (convert cricothyroidotomy to tracheostomy)
what are the symptoms of laryngeal fx and tracheal injuries?
crepitus, stridor, resp compromise
what do you do for thyroid gland injuries?
control bleeding, drain. (not thyroidectomy)
what do you do for a recurrent laryngeal nerve injury?
try to repair or can reimplant in cricoarytenoid muscle
what are the sx of recurrent laryngeal nerve injury?
what do you do for a shotgun injury to neck?
angiogram and neck CT; esophagus/trachea evaluation
what do you do for a vertebral arteyr bleed?
embolize or ligate. no sequelae in most pts
how often does ligation of common carotid bleed cause stroke?
when do you have to do a thoracotomy for chest trauma?
if chest tube
>1500 cc after initial insertion
>250 cc/h x3 h
bleeding with instability
why do you need to drain all the blood in the chest after chest trauma? how soon?
<48 hrs to prevent fibrothorax, pulm entrapment, infected hemothorax
what do you do for an unresolved hemothorax, and what is considered an unresolved hemothorax?
unresolved after 2 well placed chest tubes. then do a thorascopic drain
when is a sucking chest wound significant?
if the wound is 2/3 the diameter of the trachea
what do you do for a significant sucking chest wound?
dressing with tape on 3 sides. prevents development of tension PTX while allowing lung to expand w inspiration
may have worse oxygenation. one of the few indications for clamping chest tube
when might you clamp a chest tube?
pt with tracheobronchial injury
which side are bronchus injuries more common?
how would you intubate if a pt has tracheobronchial injury?
how do you diagnose tracheobronchial injury?
when do you treat tracheobronchial injury?
if large air leak and resp compromise
or after 2 weeks of persistent air leak
when do you do a right thoracotomy? a left thoracotomy?
right thoracotomy for right mainstem, trachea, and proximal left mainstem injuries (avoids the aorta)
left thoracotomy for distal left mainstem injuries
which side of the diaphragm is more often injured? what is the cause of most diaphragm injuries?
left. cause is blunt trauma
what do you see on cxr in diaphragm injury?
air-fluid level in chest from stomach herniation through hole
do you need any other imaging for diaphragm injury other than cxr?
what approach would you take to repair diaphragm injury?
transabdominal approach if 1 week (need to take down adhesions in the chest)
do you need mesh to repair diaphragm injury?
may need mesh.
what are signs of aortic transection?
widened mediastinum, 1st or 2nd rib fxs, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemithorax, trachea deviation to right
where is the tear/injury located in an aortic transection?
ligamentum arteriosum (just distal to subclavian takeoff). other areas are near aortic valve and where aorta traverses the diaphragm
how do you work up aortic injury?
CT angiogram of chest. cxr is normal in 5% of pts. get CT angio if significant mechanism
what is the operative approach to repairing aorta?
left thoracotomy and repair with partial left heart bypass or place a covered stent endograft (distal transections only)
what do you have to consider in aortic transection?
treat other life threatening injuries first
when do you use median sternotomy?
injuries to ascending aorta, innominate artery, prox right subclavian artery, innominate vein, prox left common carotid
when do you use left thoracotomy?
injuries to left subclavian artery, descending aorta
what approach do you take for injury tot he distal right subclavian artery?
midclavicular incision, resection of medial clavicle
what are the most common causes of death in a pt with myocardial contusion?
v-tach and v-fib
when is the risk for death highest in pts with myocardial contusion?
first 24 hours
what is the most common arrhythmia overall in pts with myocardial contusion?
how long do you have to monitor pts with myocardial contusion?
what is flail chest?
>= 2 consecutive ribs broken at >= 2 sites, resulting in paradoxical motion
what does flail chest imply?
underlying pulmonary contusion
what does cxr look like immediately after aspiration?
how do you work up a penetrating chest injury?
start w cxr if pt is stable (place chest tube for PTX or hemothorax)
what are borders of the "box"?
clavicles, xiphoid process, nipples
what do you do if there's a penetrating box injury?
pericardial window, bronchoscopy, esophagoscopy, barium swallow
what do you do if there's a chest wound outside the box without PTX or HTX
chest tube if pt requires intubation. otherwise follow serial CXR
what do you do if you find blood in pericardial window?
median sternotomy to fix injury to heart or great vessels. place pericardial drain
what do you do for penetrating injuries anterior-medial to midaxillary line and below nipples?
laparotomy or laparoscopy. may need evaluation for penetrating box injury depending on exact location
what can replace a pericardial window for box injuries?
what are traumatic causes of cardiogenic shock?
2. cardiac contusion
3. tension ptx
what are si/sx of tension ptx?
hypotension, inc airway pressure, dec breath sounds, bulging neck veins, tracheal shift. can see bulging diaphragm during laparotomy.
how does tension ptx cause cardiac compromise?
dec venous return (IVC, SVC compression)
what are pts with sternal fractures at high risk for?
what are pts with 1st and 2nd rib fx at high risk for?
can pelvic fractures be a major source of blood loss?
what do you do if a pt has a pelvic fx, is hemodynamically unstable, neg DPL/FAST, neg CXR, no other signs of blood loss or reasons for shock, what do you do?
stabilize pelvis w C-clamp, ex fix, or sheet, and go to angio for embolization
what are pelvic trauma pts at high risk for?
genitourinary and abd injuries
what are the types of pelvic fractures?
type I, II, III
which types of pelvic fxs are unstable?
I and II
what is mortality of type I, II, and III pelvic fx?
what is blood loss amount in type I, II, III pelvic fxs?
which type of pelvic fx is an "open book"
of anterior and posterior pelvic fxs, which is more likely to have venous and which is most likely to have arterial bleeding?
what might you need to do if a pt has open pelvic fx with rectal tears and perineal lacs?
is it ok to delay a pelvic fx repair?
yes, until other associated injuries are repaired
how do you approach a penetrating injury pelvic hematoma?
open. some suggest angiography
how do you approach a blunt injury pelvic hematoma
leave. if expanding or pt is unstable, stabilize pelvic fx, pack pelvis if in OR, and go to angiography for embolization
when do you remove pelvic packing after a pt is stable if the packs were placed intraop for a blunt injury pelvic hematom?
what is the usual cause of duodenal trauma?
blunt trauma (crush or deceleration)
which part of the duodenum is most commonly injured?
2nd portion (descending portion, near ampulla of vater)
also tears near ligament of treitz
how often is surgery required for duodenal trauma? what do you do?
80%, can be treated w debridement and primary closure. can do segmental resection with primary end to end closure.
where can you NOT do segmental resection with primary end to end closure?
2nd portion of the duodenum
what is mortality in duodenal trauma pts? what causes mortality?
25% b/c associated w shock.
what is the major source of morbidity in duodenal trauma pts?
where are hematomas found in duodenal trauma pts? what size is considered significant? what do you do for it?
>= 2cm considered significant.
usually hematomas in third portion of duodenum overlying spine in blunt injury.
how do you approach duodenal injury with hematoma?
need to open for both blunt and penetrating injuries
what is a complication of a paraduodenal hematoma that was missed on CT or found on repeat CT? when can it present?
SBO 12-72 hr after injury
what will UGI study show with paraduodenal hematomas?
stacked coins or coiled spring appearance. make sure no extravasation.
what is treatment of paraduodenal hematoma? how effective is it?
conservative (NGT and TPN).
cures 90% over 2-3 weeks (hematoma reabsorbed)
what do you do intraop if duodenal injury is suspected?
1. kocher maneuver and open lesser sac through omentum.
2. check for hematoma, bile, succus, and fat necrosis.
3. if found, need formal inspection of entire duodenum (also check for pancreatic inj)
how do you diagnose a suspected duodenal injury?
abd CT w contrast initially (bowel thickening, hematoma, free air, contrast leak, or retroperitoneal fluid/air)
UGI contrast study is the best
what do you do if abd ct in suspected duodenal injury is negative or nondiagnostic?
repeat CT in 8-12h
what is treatment for duodenal injury?
1. primary repair or anastomosis.
2. may need to divert w pyloric exclusion and gastrojejunostomy to allow healing.
3. place distal feeding jejunostomy and poss proximal draining jejunostomy tube that threads back to duodenal injury site
what do you do if the duodenal injury is in the 2nd portion of duodenum?
can't do primary repair.
1. place jejunal serosal patch over hole, may need whipple in future
2. need pyloric exclusion and gastrojejunostomy
3. consider feeding and draining jejunostomies; leave drains
when do you do trauma whipples?
rare if ever indicated (very high mortality)
when do you remove drains in pt with duodenal trauma?
when pt tolerating diet without inc in drainage
what happens to fistulas over time? what is the treatment for fistulas?
fistulas often close w time
treatment is bowel rest, TPN, octreotide, conservative management for 4-6weeks
illustrate the jejunal serosal patch.
illustrate the gastrojejunostomy and pyloric exclusion for complex duodenal injury
what is the most common organ injured with penetrating injury?
small bowel (some texts say liver)
what is an occult small bowel injury?
abd CT scan showing intra-abdominal fluid not associated w solid organ injury, bowel wall thickening, or a mesenteric hematoma
what is management for occult small bowel injury?
need close observation
possible repeat abd CT after 8-12h to make sure finding is not getting worse
what do you have to make sure in pts with occult small bowel injury?
tolerate a diet before d/c
in which direction do you repair small bowel?
transverse. avoids stricture
when do you resect and reanastomose small bowel lacerations?
if laceration >50% of bowel circumference or results in lumen diameter <1/3 normal
what do you do about multiple close lacerations in small bowel?
resect that segment
what do you do about mesenteric hematomas?
open if expanding or large (>2cm)
which kind of injury is colon trauma associated with: blunt or penetrating?
how do you manage colon injuries?
transverse/right: perform primary repair/anastomosis
left: perform primary repair/anastomosis; place diverting ileostomy if pt is in shock or there is gross contamination
what do you do for paracolonic hematomas if blunt? if penetrating?
both blunt and penetrating need to be opened
what kind of injury is rectal trauma most associated with? blunt or penetrating?
classify the different typeso f rectal traumas.
high rectal and low rectal
high rectal: extraperitoneal and intraperitoneal
what do you do for high rectal extraperitoneal trauma?
generally not repaired b/c of inaccessibility.
serial debridement; consider diverting ileostomy
what do you do for high rectal intraperitoneal trauma?
repair defect, presacral drainage, consider diverting ileostomy.
place diverting ileostomy with shock, gross contamination, or extensive injury
what do you do for low rectal injuries?
if <5cm, can probably be repaired transanally
which organ is most commonly injured with blunt abd trauma?
liver. some texts say spleen
do you do lobectomies for liver trauma?
can you ligate the common hepatic artery?
yes. collaterals through gastroduodenal artery
what is the pringle maneuver?
clamping of portal triad.
where can still bleed after pringle maneuver?
what is the portal triad?
1. branches of the portal vein
2. hepatic artery
3. biliary ducts
what do you do for severe penetrating liver injuries?
damage control peri-hepatic packing
what do you do if pt with severe liver injury becomes unstable while in OR doing damage control peri-hepatic packing? what injury can do this?
go to ICU and get pt resuscitated and stabilized. retro-hepatic IVC injury can cause this
when do you use an atriocaval shunt? what does it do?
for retrohepatic IVC injury
allows for control while performing repair
how do you repair CBD injury?
may need intraop cholangiogram to define injury
-if injury is 50% or complex injury, choledochojejunostomy
-if 10% of duct anastomoses leak, place drain intraop
what do you do about portal vein injuries?
need to repair
may need distal pancreatectomy to get to injury in the portal vein
what is the mortality rate of portal vein ligation?
what can you use to stop bleeding and prevent bile leaks after liver lac?
do you leave a drain in with liver injuries?
when do you have to go to the OR for blunt liver injury?
-if pt becomes unstable despite aggressive resuscitation, including 4U pRBCs (HR>120, SBP 4U pRBCs to keep hct >25
-active blush on abd CT
if the liver injury is posterior, what do you do? anterior?
how long should you be bed rest if doing conservative management of blunt liver injury?
when is spleen trauma fully healed?
after 6 weeks
when is postsplenectomy sepsis greatest risk?
within 2 years of splenectomy
what can increase chances of splenic salvage?
what is considered failure of conservative management of splenic injury?
-if pt becomes unstable despite aggressive resuscitation, including 4U pRBCs (HR>120, SBP 4U pRBCs to keep hct >25
-active blush on abd CT
how long should you be bed rest if doing conservative management of splenic injury?
what is the threshold for splenectomy in children?
much higher. hardly any children get splenectomy
what do pts get after trauma splenectmy?
what percent does penetrating injury account for in all pancreatic injuries?
what can blunt injury cause in pancreatic trauma?
pancreatic duct fx, usu perpendicular to the duct
what are signs of pancreatic injury on either CT or in the OR?
peripancreatic fat necrosis or edema
what can be done for pancreatic contusion?
leave if stable. place drains if in OR
how much of the distal pancreas can you take for a distal pancreatic duct injury?
up to 80% of the gland
what do you do for a pancreatic head duct injury that is not reparable?
place drains initially
eventually delayed whipple or possible ERCP w stent
how do you decide whipple vs distal pancreatectomy?
based on duct injury in relation to the SMV
what can you do to help evaluate the pancreas in the operating room?
do you place drains for pancreatic injury?
what do you need to do for a pt with pancreatic hematoma if it's blunt? penetrating?
open in both cases
what can tell you that you missed a pancreatic injury?
rising amylase or persistent amylase
are CT scans good at diagnosing pancreatic injuries?
what are the delayed CT signs of pancreatic injury?
fluid, edema, necrosis
what is the best modality for finding pancreatic duct injuries?
ERCP and may be able to treat with temporary stent
is the orthopedic or vascular repair done first?
vascular repair (or vascular shunt) done before
what are major signs of vascular injury? what do you need to do?
active hemorrhage, pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill.
go to OR for exploration (may need angio in OR to define injury)
what are the moderate/soft signs of vascular injury? what do you need to do?
h/o hemorrhage, deficit of anatomically related nerve, large stable/nonpulsatile hematoma, ABI<0.9. need to go to angio
what do you need to use to repair a vascuar segment >2cm?
contralateral saphenous vein graft.
which veins need repair when injured?
vena cava, femoral, popliteal, brachiocephalic, subclavian, axillary
what do you do if a pt has transected single artery in the calf, otherwise healthy?
what do you do over site of vascular anastomosis?
cover site with viable tissue and muscle
if pt has ischemia, what do you do? why?
consider fasciotomy if >4-6h (prevents compartment syndrome)
what are findings of compartment syndrome?
compartment pressures >20mmhg or if clinical exam suggests elevated pressures
-pain, paresthesia, anesthesia, paralysis, poikilothermia, pulselessness (late)
what injuries are susceptible to compartment syndrome of the extremities?
-supracondylar humeral fx
-injuries that cause disruption and then restoration of blood flow after 4-6hrs
what is treatment for compartment syndrome?
where do you approach the lower extremity for fasciotomy?
when do you do primary repair of IVC? when can you not do primary repair and what do you do instead?
if residual stenosis <50% diameter of IVC. otherwise place saphenous vein or synthetic patch
how do you control bleeding of IVC?
proximal and distal pressure, NOT clamps. it can tear
how do you repair posterior wall injury of the IVC?
through anterior wall (need to cut through anterior IVC to get to posterior IVC injury
can femur fractures be a source of major blood loss? how much blood can be lost from a femur fx?
yes. >2L of blood
list the orthopedic emergencies
-pelvic fx in unstable pts
-spine inj with deficit
-dislocations or fx with vascular compromise
what do femoral neck fractures put pts at risk for?
what do you do if a pt has a long bone fx or dislocation w loss of pulse (or weak pulse)?
immediate reduction of fx or dislocation and reassess pulse
if pulse doesn't return after reduction of fx, what do you do?
go to OR for vascular bypass or repair (may need angio in OR)
if pulse is weak after reduction of fx, what do you do?
what do you do for knee dislocation?
angiogram, unless pulse is absent. if absent, go to OR (may need angio in OR)
what can get fractured with upright falls?
calcaneus, lumbar, distal forearm (radius/ulnar) fractures
injury to what causes axillary nerve injury?
anterior and posterior shoulder dislocation, proximal humerus fx
injury to what causes radial nerve injury?
midshaft humerus fx (or spinal humerus fx)
injury to what causes brachial artery injury?
distal (supracondylar) humerus fx, elbow dislocation
injury to what causes median nerve injury?
distal radius fx
injury to what causes femoral artery injury?
anterior hip dislocation
injury to what causes sciatic nerve injury?
posterior hip dislocation
injury to what causes popliteal artery injury?
distal (supracondylar) femur fx, posterior knee dislocation
injury to what causes common peroneal nerve injury?
fibula neck fx
injury to what causes epidural hematoma?
temporal or parietal bone fx
injury to what causes cervical spine fx?
injury to what causes cardiac contusion?
injury to what causes aortic transection?
first or second rib fx, scapula fx
injury to what causes pulmonary contusion?
injury to what causes spleen lac?
rib fxs (left, 8-12)
injury to what causes liver lac?
rib fxs (right 8-12)
injury to what causes bladder rupture or urethral transection?
what is the best indicator of renal trauma?
what imaging do renal trauma pts get?
abdominal CT scan
what other imaging can be useful?
IVP if going to OR without abd scan. identifies presence of functional contralateral kidney, which could affect intraop decision making
what is different between right and left renal veins?
left renal vein can be ligated near IVC. it has adrenal and gonadal vein collaterals
right renal vein doesn't ahve these collaterals
what are the structures of the renal hilum from anterior to posterior?
vein, artery, pelvis (VAP)
what percent of renal injuries are treated nonoperatively?
do all urine extravasation injuries require operation?
no not all
what are the indications for operation in a renal trauma pt?
acutely: ongoing hemorrhage w instability
after acute phase: major collecting system disruption, non-resolving urine extravasation, severe hematuria
when you explore renal area, what structure do you try to get control of?
vascular hilum first
do you place drains intraop?
yes, esp if the collecting system is injured
what can oyu use to check for leak?
methylene blue dye
what do you do for blunt injury with hematoma to the kidney?
leave unless preop CT /IVP shows no function to sigificant urine extravasation.
what do you do for a penetrating renal injury with hematoma?
open unless preop CT/IVP shows good function without statistical urine extravasastion
what do you do for a trauma to flank and IVP shows no uptake in a stable pt?
angiogram. can stent if flap present.
how often is hematuria associated with pelvic fx?
what are si/sx of ureteral injury?
meatal blood, sacral or scrotal hematoma
how do you diagnose ureteral injury?
what is the diagnosis and treatment for extraperitoneal bladder rupture?
cystogram shows starbursts Tx foley 7-14d
what is the treatment for intraperitoneal bladder rupture? who does it happen in?
happens in kids. cystogram shows leak. Tx: operation and repair of defect, followed by foley
what are the best tests to diagnose ureteral trauma?
IVP and retrograde urethrogam (RUG). hematuria is unreliable
what do you do for large (>2cm) upper 1/3 or middle 1/3 ureter injuries?
if upper 1/3 and middle 1/3 ureter (pelvic brim) is injured, poss cant reach bladder:
- temporize with percutaneous nephrostomy (tie off both ends of the ureter)
- or ileal interposition or trans-ureteroureterostomy later
what do you do for lower 1/3 ureter injuries that can't be repaired with anastomosis?
reimplant in the bladder; may need bladder hitch procedure
what do you do if small ureteral segment is missing (<2cm)?
upper and middle 1/3 injuries: mobilize ends of ureter and perform primary repair over stent
lower 1/3 injury: re-implant into bladder (easier than primary repair
can you evaluate ureters with one shot intravenous pyelogram?
what contrast do you use for ureters to check for leaks?
IV indigo carmine or IV methylene blue
where is the blood supply located in upper 2/3 ureter located? how about in the lower 1/3 of the ureter?
medial in upper 2/3
lateral in lower 1/3
do you need drain for ureteral injuries?
what are signs of urethral trauma?
best: hematuria or blood at meatus
others: free-floating prostate, usu a/w pelvic fxs
do you place a foley in pts with poss urethral trauma?
what is the best test to identify urethral trauma?
what portion of the uretrha is at highest risk for transection?
what is the treatment for significant tears of the urethra?
suprapubic cystostomy and repair in 2-3 months.
what is prevented if urethral trauma is repaired early?
reduced rate of high stricture and impotence
what is treatment for small partial tears of the urethra?
bridging urethral catheter across tear are and repair in 2-3 month
what do you need to repair for penis trauma?
repair tunica and buck's fascia
what do you do if pt has testicular trauma?
ge tultrasound to see if tunica albuginea is violated, then repair if necessary
in children, what are the best indicators of hypovolemic shock?
HR, RR, mental status, clinical exam. BP is the last thing to go after blood loss
what are children at higher risk for in trauma?
hypothermia (inc BSA compared with weight)
head injury risk inc
what are normal VS in children?
what is the most important thing to do when treating a pregnant woman in trauma?
save the mother
what is scary about pregnant trauma?
pregnant pts can have up to 1/3 total blood volume loss without signs
what do you do for trauma during pregnancy that is different?
estimate pregnancy based on fundal height (20cm = 20wk = umbilicus. place on fetal monitor
-try to avoid CT with early pregnancy, but get if life threatening
-check for vaginal d/c - blood, amnion; check for effacement, dilation, fetal station
what can you measure to determine whether fetus is mature?
lecithin:sphingomyelin (LS) ratio >2:1
phosphatidylcholine in amniotic fluid
what is fetal death rate with 50% or more abruption of the placenta?
what are signs of abruption of placenta?
uterine tenderness, contractions, fetal HR <120, kleihauer-betke test (test for fetal blood in the maternal circulation)
what can cause placental abruption? what is most common?
shock (most common) or mechanical forces
where is uterine rupture most likely to occur?
what do you do if uterine rupture occurs during delivery of a child?
uterus will clamp down after delivery eventually
what are indications for C-section during exlap for trauma?
-persistent maternal shock or severe injuries and pregnancy near term (>34weeks)
-pregnancy a threat to the mother's life (hemorrhage, DIC)
-mechanical limitation to life-threatening vessel injury
-risk of fetal distress exceeds risk of immature
-direct intra-uterine trauma
what is your assessment of the pregnant uterus during ex lap?
in which traumatic situations do you leave a drain?
pancreatic, liver, biliary system, urinary, duodenal injuries
what are sx of snakebites?
shock, bradycardia, arrhythmias
what is treatment for snakebite?
stabilize, anti-venom, tetanus shot
what is the management of hematomas in penetrating and blunt trauma?