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PGY 4 > Trauma > Flashcards

Trauma Flashcards

1
Q

Where is a zone 3 neck injury? How to obtain distal control?

A

Above angle of mandible, distal control hard to obtain - fogarty balloon can be tried.

(NB this diagram is labelled wrong! Zone 1 and 3 should be switched)

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2
Q

Where is a zone 2 neck injury? How to obtain proximal control?

A

Between cricoid and angle of mandible. Proximal and distal control in neck.

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3
Q

Where is a zone 1 neck injury? How to obtain proximal control?

A

Below cricoid. Proximal control in the chest.

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4
Q

What zone neck injury is the most commonly injured?

A

Zone 2

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5
Q

What are 7 hard signs of vascular injury?

A
  1. shock
  2. refractory hypotension
  3. pulsatile bleeding
  4. bruit
  5. enlarging hematoma
  6. loss of pulse
  7. evolving neurologic deficit
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6
Q

What are 5 soft signs of vascular injury?

A
  1. Proximity to major vessel
  2. History of bleeding at scene of injury
  3. Unequal blood pressure
  4. Stable hematoma
  5. Nerve injury
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7
Q

What are 2 hard signs of a tracheobronchial injury?

A
  1. Respiratory distress
  2. Air bubbling from wound
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8
Q

What are 4 soft signs of cervical neck injury?

A
  1. painful swallowing
  2. subcu emphysema
  3. hematemesis
  4. CN injury or brachial plexus injury
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9
Q

What investigations should you order for patients with hard signs of vascular or tracheobronchial neck injury?

A

Immediately to OR. X-rays in trauma bay to determine track of injury and r/o occult hemothorax/pneumothorax

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10
Q

What investigations should you order for patients with a penetrating neck injury that are hemodynamically stable and no hard signs of vascular/airway injury?

A

CTA

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11
Q

Which neck zone injuries are more suitable for endovascular repair? which are more suitable for open?

A

Endo - 1 and 3

Open - 2

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12
Q

In trauma situations what is the risk of dying from internal carotid artery ligation?

A

45% (?!)

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13
Q

What are 3 basic mechanisms of blunt cerobrovascular injury?

A

1- extreme hypertension and rotation

2- direct blow to vessel

3 - laceration from adjacent bone fracture

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14
Q

What is the most common mechanism causing blunt carotid injury?

A

hyperextension of carotid over lateral articular process of C1-3 in high speed motor vehicle crashes

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15
Q

What are 5 symptoms of carotid cavernous fistula?

A

1-orbital pain

2-proptosis

3-seizure

4-cerebral swelling

5-hyperemia

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16
Q

What are 3 scoring systems to screen for blunt cerebrovascular injury?

A

1-Denver

2-Memphis

3-Modified

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17
Q

What signs/symptoms are included in the denver criteria for blunt cerebrovascular injury?

A

1-arterial hemorrhage or expanding hematoma

2-neuro deficit

3-cervical bruit

4-stroke on follow up CT head

5-neuroexam inconsistent with CT head

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18
Q

What risk factors are included in the denver criteria for blunt cerebrovascular injury?

A

1- le fort 2 or 3

2-basilar skull fracture involving carotid canal

3-diffuse axonal injury with GCS <6

4-cervical spine fracture

5-near hanging with anoxic brain injury

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19
Q

What angiographic findings are associated with a grade 5 blunt cerebrovascular injury

A

vessel transection

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20
Q

What angiographic findings are associated with a grade 4 blunt cerebrovascular injury

A

vessel occlusion

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21
Q

What angiographic findings are associated with a grade 3blunt cerebrovascular injury

A

pseudoaneurysm

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22
Q

What angiographic findings are associated with a grade 2 blunt cerebrovascular injury

A

dissection or IMH > 25% of lumen

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23
Q

What angiographic findings are associated with a grade 1 blunt cerebrovascular injury

A

luminal irregularity/dissection, IMH < 25% narrowing

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24
Q

what is the risk of death with a grade 1 blunt cerebrovascular injury?

A

11

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25
Q

what is the risk of death with a grade 2 blunt cerebrovascular injury?

A

11

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26
Q

what is the risk of death with a grade 3 blunt cerebrovascular injury?

A

11

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27
Q

what is the risk of death with a grade 4 blunt cerebrovascular injury?

A

22

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28
Q

what is the risk of death with a grade 5 blunt cerebrovascular injury?

A

100

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29
Q

what is the risk of stroke with a grade 5 blunt cerebrovascular injury?

A

100

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30
Q

what is the risk of stroke with a grade 4 blunt cerebrovascular injury?

A

44

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31
Q

what is the risk of stroke with a grade 3 blunt cerebrovascular injury?

A

33

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32
Q

what is the risk of stroke with a grade 2 blunt cerebrovascular injury?

A

11

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33
Q

what is the risk of stroke with a grade 1 blunt cerebrovascular injury?

A

3%

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34
Q

how do you treat most blunt cerebrovascular injuries?

A

anticoagulation, or if cannot tolerate - antiplatelet. either for 3 months. Serial imaging at 1 week and 3 months.

35
Q

what are indications to repair blunt cerebrovascular injuries?

A

1-evolving dissections

2- worsening neuro deficit on anticoagulation

3-pseudoaneurysms that persist or enlarge despite anticoagulation

36
Q

What is the stroke risk of blunt vertebral artery injuries?

A

20% irrespective of grade of injury (vs. carotid where stroke risk is goes up with higher grades of injury)

37
Q

What is the natural history and complictions of traumatic transection?

A
38
Q

What is the natural history and complictions of traumatic thrombosis

A
39
Q

What is the natural history and complictions of traumatic pseudoaneurysms

A
40
Q

What is the natural history and complictions of intimal dissetions or thrombosis > 25%

A
41
Q

What is the natural history and complictions of intimal dissetions or thrombosis < 25%

A
42
Q

What is the natural history and complictions of traumatic AV fistula

A
43
Q

What is the natural history and complictions of contusion

A
44
Q

What is the natural history and complictions of laceration

A
45
Q

Name 6 categories of arterial injury

A

Penetrating or Iatrogenic:

  1. Laceration
  2. Contusion
  3. AV fistula

Blunt:

  1. Intimal dissection
  2. Pseudoaneurysm
  3. Thrombosis
  4. AVF
  5. Transection
46
Q

Name 5 critical concepts for interventions in patient with noncompressible truncal hemorrhage

A
  1. Minimize delay to OR
  2. Permissive hypotension
  3. Balanced resuscitation with early plasma
  4. Procoagulant adjuncts like transexamic acid
  5. Damage control surgery and intravascular shunts when indicated.
47
Q

Which major vessels are in Zone 4 of the retroperitoneum?

A

Retrohepatic IVC, hepatic veins

48
Q

Which major vessels are in Zone 3 of the retroperitoneum?

A

Iliac arteries and veins

49
Q

Which major vessels and organs are in Zone 2 of the retroperitoneum?

A

Organ: Kidneys

Vessels: renal vessels

50
Q

Which major vessels are in Zone 1 of the retroperitoneum?

A

Supramesocolic: Suprarenal aorta, celiac axis, SMA, renal arteries, IVC, SMV

Inframesocolic: Infrarenal aorta and IVC

51
Q

Name 3 mechanisms by which blunt abdominal trauma may cause vascular injuries

A
  1. Rapid deceleration (high speed MVC, fall from height) - avulsion/intimal tear and subsequent thrombosis
  2. Direct AP crush from seat belt or direct blow
  3. Direct laceration of major vessel by a bone fragment.
52
Q

What are the 6 most commonly injured abdominal vessels, in order of most to least frequent

A
  1. IVC
  2. Aorta
  3. Iliac arteries
  4. Iliac veins
  5. SMV
  6. SMA
53
Q

What are 3 indications for an immediate laparotomy in a patient with a penetrating abdominal injury?

A
  1. Hemodynamic instability
  2. Peritonitis
  3. Unevaluable patient
54
Q

What are 3 indications for immediate laporotomy in a patient with blunt abdominal trauma?

A
  1. Peritonitis
  2. Hemodynamic instability
  3. Positive abdominal FAST
  4. Unstable patients with negative FAST but positive diagnostic peritoneal aspirate.
55
Q

Should an abdominal hematoma associated with a penetrating trauma be explored?

A

Yes - except if in zone 4

56
Q

When should retroperitoneal hematomas due to blunt trauma be explored (4 situations)?

A
  1. Zone 1
  2. Zone 2/3 only if hematoma is expanding, pulsatile or leaking
  3. Paraduodenal hematomas
  4. Hematomas at the root of the mesentery in presence of ischemic bowel
57
Q

Whichof the following trauma patients should have exploration of their hematomas?

Blunt zone 3 hematoma?

Penetrating zone 2 hematoma?

Blunt peri-duodenal hematoma?

A

Blunt zone 3 hematoma? No

Penetrating zone 2 hematoma? Yes

Blunt peri-duodenal hematoma? Yes

58
Q

How do you expose the supramesocolic aorta in the context of abdominal trauma?

A

Medial rotation of the viscera in the left upper abdomen: left colon, splenic flexure, spleen, tail of the pancreas, stomach, left kidney rotated to the right.

59
Q

How do you expose the IVC for suspected supramesocolic injuries?

A

Medial rotation of right colon and hepatic flexure, kocher mobilization of duodenum and head of pancreas.

60
Q

How to expose inframesocolic zone 1?

A

Like a regular infrarenal aortic exposure - transverse colon cephalad, small bowel to right, incise peritoneum over aorta/IVC.

61
Q

How do you explore Zone 2 hematoma or bleeding?

A

Right side: mobilization and medial rotation of right colon, duodenum, head of pancreas

Left side: Mobilization of left colon

62
Q

In damage control surgery, how do you manage:

1) Complex venous injuries
2) Arterial injuries
3) Retroperitoneal bleeding
4) Parenchymal bleeding

A

1) Complex venous injuries: Ligate
2) Arterial injuries: Shunt
3) Retroperitoneal bleeding: Tight gauze packing
4) Parenchymal bleeding: Tight gauze packing

63
Q

What is the definition of abdominal compartment syndrome?

A

Elevated intra-abdominal pressure > 20 mm Hg and end-organ dysfunction

64
Q

What intraabdominal pressure constitutes “intraabdominal hypertension”

A

> 12 mm Hg

65
Q

Name 4 signs/symptoms of abdominal compartment syndrome

A
  1. Tense abdomen
  2. Tachycardia +/- hypotension
  3. Resp dysfunction, high peak inspiratory and plateau pressures
  4. Oliguria
66
Q

Name 6 risk factors for abdominal compartment syndrome

A
  1. Massive transfusions
  2. Prolonged hypotension
  3. Hypothermia
  4. Aortic cross clamping
  5. Damage control procedures
  6. Closure of abdominal wall
67
Q

Where is a “Zone 4” SMA injury? What happens if you ligate the SMA here?

A

Segmental intestinal branches.

Ligation in zones 3 and 4 may result in localized ischemia of the small bowel requiring segmental resection.

68
Q

Where is a “Zone 3” SMA injury? What happens if you ligate the SMA here?

A

Distal to the middle colic artery

Ligation in zones 3 and 4 may result in localized ischemia of the small bowel requiring segmental resection.

69
Q

Where is a “Zone 2” SMA injury? What happens if you ligate the SMA here?

A

Between inferior pancreaticoduodenal artery and middle colic

Ligation in zones 1 and 2 result in severe ischemia of small bowel and right colon.

70
Q

Where is a “Zone 1” SMA injury? What happens if you ligate the SMA here?

A

Between aortic origin and inferior pancreaticoduodenal artery.

Ligation in zones 1 and 2 result in severe ischemia of small bowel and right colon.

71
Q

What are your options for repairing an IVC injury?

A
  1. Lateral venorrhaphy
  2. Patch
  3. Interposition graft
  4. Ligate (only infrarenal!! cannot ligate suprarenal because patient will be in renal failure)
  5. Temporizing shunt
72
Q

Name 10 arterial disorders associated with occupational or recreational activities

A

Manual Labour

  1. Hand arm vibration syndrome
  2. Hypothenar hammer syndrome

Exposure

  1. Acro-osteolysis
  2. Electrical burns
  3. Extreme thermal injuries

Athletic

  1. Chronic hand ischemia
  2. Quadrilateral space syndrome
  3. Humeral head compression of axillary artery
  4. Thoracic outlet syndrome.
73
Q

What is a Stage 4 Hand arm vibration syndrome?

A
74
Q

What is a Stage 3 Hand arm vibration syndrome?

A
75
Q

What is a Stage 2 Hand arm vibration syndrome?

A
76
Q

What is a Stage 1 Hand arm vibration syndrome?

A
77
Q

What is a Stage 0 Hand arm vibration syndrome? 0T? 0N?

A
78
Q

What causes hypothenar hammer syndrome?

A

The ulner artery and never travel in a tunnel (Guyon canal) that is bound by pisiform and hamate bones. In this region, the ulnar artery is very superficial and only covered by skin/subcu tissue/palmaris brevis.

When palm used as a hammer it compresses the ulnar artery against the hamate bone which acts as the hammer.

79
Q

Which occupational trauma condition causes vascular damage from repetitive trauma and an underlying vessel abnormality like fibromuscular dysplasia?

A

Hypothenar hammer syndrome

80
Q

What are 3 key signs/symptoms that differentiate hypothenar hammer syndrome from other conditions presenting with Raynaud’s?

A
  1. Male smokers with repetitive hand trauma history
  2. Asymmetrical - dominant hand
  3. Sparing of thumb
81
Q

Which condition is associated with ischemic hand symptoms with resorption of the distal phalangeal tufts, similar to scleroderma?

A

Occupational acro-osteolysis

82
Q

Which vessel and nerve pass through the quadrilateral space?

A

Posterior humeral circumflex artery

Axillary nerve

83
Q

What are the borders of the quadrilateral space?

A

Superior: teres minor

Lateral: humaral shaft

Inferior: teres major

Medial: long head of triceps

PGY 4 (25 decks)

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