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Flashcards in Chapter 15: Trauma Deck (346):
1

First peak for trauma deaths (0-30 minutes)

Deaths due to lacerations of heart, aorta, brain, brainstem, or spinal cord; cannot really save these patients; death is too quick.

2

Second peak for trauma deaths (30 minutes-4 hours)

Deaths due to head injury (#1) and hemorrhage (#2); these patients can be saved with rapid assessment (golden hour)

3

Third peak for trauma deaths (Days to weeks)

Deaths due to multi system organ failure and sepsis

4

80% of all trauma

Blunt injury

5

Most commonly injured organ in blunt trauma

Liver

6

Falls: biggest predictors of survival

Age and body orientation.
LD50 is 4 stories

7

MC'ly injured organ in penetrating injury

Small bowel

8

MCC death in 1st hour

Hemorrhage

9

When is blood pressure affected in hemorrhage?

30% of total blood volume lost

10

How do you resuscitate hemorrhage?

2L Lactated Ringers, then switch to blood

11

MCC death after reaching the ER alive

Head injury

12

MCC upper airway obstruction -> perform jaw thrust

Tongue

13

Injuries: seat belts

Small bowel perforations, lumbar spine fractures, sternal fractures

14

Best site for cutdown for venous access

Saphenous vein at ankle

15

- Used in hypotensive patients with blunt trauma
- Need laparotomy if DPL is positive

DPL

16

Criteria: positive DPL

> 10 cc blood, > 100,000 RBCs/cc, food particles, bile, bacteria, > 500 WBC/cc

17

What does a DPL miss?

Retroperitoneal bleeds, contained hematoma

18

DPL for pelvic fracture

Needs to be supra umbilical

19

What does FAST stand for?

Focused abdominal sonography for trauma

20

Where does FAST scan check?

Perihepatic fossa
Perisplenic fossa
Pelvis
Pericardium

21

Disadvantages of FAST scan

- Examiner dependent
- Obesity can obstruct view
- May not detect free fluid

22

What does FAST scan miss?

Retroperitoneal bleeding, hollow viscous injury

23

Hypotensive patients: negative FAST scan, negative DPL. What to do?

Find the source of bleeding (pelvic fracture, chest, extremity)

24

When do you need a CT scan following blunt trauma?

- Abdominal pain
- Need for general anesthesia
- Closed head injury
- Intoxicants on board
- Paraplegia
- Distracting injury
- Hematuria

25

What can a CT scan miss?

hollow viscous injury, diaphragm injury

26

When do you need laparotomy?

Peritonitis. Evisceration. Positive DPL. Uncontrolled visceral hemorrhage. Free air. Diaphragm injury. Intraperitoneal bladder injury. Contrast extravasation from hollow viscus. Specific renal, pancreas, and biliary tract injuries.

27

Tx: penetrating abdominal injury (eg, GSW)

Generally need laparotomy

28

Tx: possible penetrating abdominal injuries (knife or low-velocity injuries)

Local exploration and observation if fascia not violated

29

- Occurs after massive fluid resuscitation, trauma, or abdominal surgery
- IVC compression is the final common pathway for decreased cardiac output.
- Upward displacement of diaphragm affects ventilation

Abdominal compartment syndrome

30

Bladder pressure suggesting abdominal compartment syndrome

> 25-30

31

Tx: abdominal compartment syndrome

Decompressive laparotomy

32

Low cardiac output in abdominal compartment syndrome causes..

Visceral and renal malperfusion

33

- Controversial
- Use in patients with SBP

Pneumatic antishock garment

34

ER thoractomy: blunt trauma

Use only if pressure / pulse lost in ER

35

ER: thoracotomy: penetrating trauma

Use only if pressure / pulse lost on way to ER or in ER

36

Location for emergency department thoracotomy

Fourth and fifth intercostal space using the anterolateral approach

37

Abdominal injury: emergent thoracotomy

Clamp descending thoracic aorta:
- Blood pressure increase to > 70mmHg -> laparotomy
- Blood pressure

38

Cardiac injury: emergent thoracotomy

Open pericardium longitudinally anterior to phrenic nerve, cross clamp the aorta, watch for the esophagus (anterior to the aorta)

39

Peak 24-48 hours after injury

Catecholamines, ADH, ACTH, and glucagon

40

- Contains no A or B antigens
- Males can receive Rh-positive blood
- Females who are prepubescent or of childbearing age should receive Rh-negative blood

Type O Blood (universal donor)

41

Can be administered relatively safely, but there may be effects from antibodies to HLA minor antigens in the donated blood

Type-specific blood (nonscreened, non-cross matched)

42

Tx - GCS score:

43

Indications for head CT

- Suspected skull penetration by a foreign body
- Discharge of CSF, blood, or both from the nose
- Hemotympanum or discharge of blood or CSF from ear
- Head injury with alcohol or drug intoxication
- AMS, protracted unconsciousness
- Focal neurologic s/s

44

Most commonly due to arterial bleeding from the middle meningeal artery

Epidural hematoma

45

Epidural hematoma: head CT

Shows lenticular (lens-shaped) deformity

46

Patients often have LOC -> then lucid interval -> then sudden deterioration (vomiting, restlessness, LOC)

Epidural hematoma

47

When do you operate for epidural hematoma?

Significant neurologic degeneration or significant mass effect (shift > 5mm)

48

Mostly commonly from tearing of venous plexus (bridging veins) that cross between the dura and arachnoid

Subdural hematoma

49

Subdural hematoma: head CT

Crescent-shaped deformity

50

When do you operate for subdural hematoma?

Significant neurologic degeneration or mass effect (> 1 cm)

51

Where are common location for intracerebral hematoma?

- Usually frontal or temporal
- Can cause significant mass effect requiring operation

52

Can be croup or contrecoup

Cerebral contusions

53

Tx: traumatic intraventricular hemorrhage causing hydrocephalus

Ventriculostomy

54

Shows up better on MRI than CT scan
- Tx: supportive, may need craniectomy if ICP elevated
- Very poor prognosis

Diffuse axonal injury

55

Equation: Cerebral perfusion pressure

CPP = MAP - ICP

56

Signs of elevated ICP

Decreased ventricular size, loss of sulci, loss of cisterns

57

Indications for ICP monitors

- GCS

58

Supportive treatment for elevated ICP

- Sedation and paralysis
- Raise head of bed
- Relative hyperventilation
- Na 140-150, serum Osm 295-310
- Mannitol, Barbiturate coma
- Ventriculostomy w CSF drainage, craniotomy decompression
- Fosphenytoin / Keppra

59

What is relative hyperventilation for elevated ICP?

CO2 30-35. Do not want to over-hyperventilate and cause cerebral ischemia from too much vasoconstriction.

60

Dose mannitol for elevated ICP

Load 1 g/kg. Give 0.25 mg/kg q4h after that.

61

When do you consider barbiturate coma for elevated ICP?

If noninvasive supportive treatment is failing.

62

When do you consider craniotomy decompression for elevated ICP?

If not able to get ICP down medically (can also perform Burr hole)

63

Can be given prophylactically to prevent seizures with moderate to severe head injury

Fosphenytoin or Keppra

64

When does peak ICP occur after head injury?

Occurs 48-72 hours after injury.

65

What is normal ICP?

10.

66

When do you treat elevated ICP? Goal CPP?

Treat ICP > 20.
Goal CPP > 60.

67

Dx: dilated pupil with elevated ICP.

Temporal pressure on the same side (CN 3, oculomotor, compression)

68

Physical signs: basal skull fracture

- Raccoon eyes (peri-orbital ecchymosis): anterior fossa fracture
- Battle's sign (mastoid ecchymosis) : middle fossa fracture, can injury facial nerve.
- Hemotympanum and CSF rhinorrhea / otorrhea

69

Acute vs delayed facial nerve injury with basal skull fractures

- Acute: exploration and repair.
- Delayed: likely secondary to edema and exploration not needed.

70

What nerves are at risk with temporal skull fractures?

Can injure CN 7 and 8 (vestibulococlear nerve)

71

MC site of facial nerve injury

Geniculate ganglion

72

MC'ly associated with lateral skull or orbital blows

Temporal skull fractures

73

Most skull fractures _____ surgical treatment.

Most skull fractures do not require surgical treatment.

74

Indications for operation of skull fractures.

Significant depression (>1cm). Contaminated. Persistent CSF leak not responding to conservative therapy.

75

Tx: CSF leaks after skull fracture.

Treat expectantly, can use lumbar CSF drainage if persistent.

76

What causes coagulopathy with traumatic brain injury?

Release of tissue factor.

77

Caused by axial loading.
- Tx: rigid collar.

C-1 burst (Jefferson fracture).

78

Caused by distraction and extension.
- Tx: traction and halo.

C-2 Hangman's fracture.

79

Classification: C-2 odontoid fracture.

Type 1: Above base, stable
Type 2: at base, unstable (will need fusion or halo)
Type 3: Extends into vertebral body (will need fusion or halo)

80

- Can cause cord injury
- Usually associated with hyperextension and rotation with ligamentous disruption.

Facet fractures or dislocations.

81

Three columns of the thoracolumbar spine.

- Anterior: anterior longitudinal ligament and anterior 1/2 of vertebral body.
- Middle: posterior 1/2 of vertebral body and posterior longitudinal ligament.
- Posterior: facet joints, lamina, spinous processes, interspinous ligament.

82

When is thoracolumbar spine considered unstable?

If more than 1 column is disrupted.

83

Thoracolumbar: fractures usually involve the anterior column only and are considered stable.

Compression (wedge) fractures

84

Thoracolumbar: fractures considered unstable (>1 column) and require spinal fusion

Burst fractures

85

Upright fall: at risk for injury

Calcaneus, lumbar, and wrist/forearm fractures.

86

When do you need MRI in spinal trauma?

Neurologic deficits without bony injury to check for ligamentous injury.

87

Indications for emergent surgical spine decompression

- Fracture or dislocation not reducible with distraction
- Open fractures
- Soft tissue or bony compression of the cord
- Progressive neurologic dysfunction

88

MCC facial nerve injury

Temporal bone fracture

89

Goal with facial lacerations

Try to preserve skin and not trim edges with facial lacerations

90

LeFort Type 1?
Tx?

Maxillary fracture straight across (-)
- Tx: reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires.

91

LeFort Type 2?
Tx?

Lateral to nasal bone, underneath eyes, diagonal toward maxilla (/ \)
- Tx: reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires.

92

LeFort Type 3?
Tx?

Lateral orbital walls (- -)
Tx: suspension wiring to stable frontal bone, may need external fixation.

93

- 70% have CSF leak
- Conservative therapy for up to 2 weeks.
- Can try epidural catheter to decrease CSF pressure and help it close CSF leak
- May need surgical closure of dura to stop leak

Nasoethmoidal orbital fractures

94

Nosebleeds - anterior: Tx?

Packing

95

Nosebleeds - posterior: Tx?

Can be hard to deal with; try balloon tamponade first.
- May need angioembolization of internal maxillary artery or ethmoidal artery.

96

Tx: orbital blowout fractures

Patients with impaired upward gaze or diplopia with upward vision need repair; perform restoration of orbital floor with bone fragments or bone graft

97

#1 indication of mandibular injury

Malocclusion

98

Dx / Tx: mandibular injury

- Dx: fine-cut facial CT scans with reconstruction to assess injury
- Tx: Most repaired with IMF (metal arch bars to upper and lower dental arches, 6-8 weeks) or ORIF

99

Tx: tripod fracture (zygomatic bone)

ORIF for cosmesis

100

What do you need to look for with maxillofacial fractures?

Cervical spine injuries

101

What to do: asymptomatic blunt neck trauma

Neck CT scan

102

What to do: asymptomatic penetrating neck trauma

Controversial

103

Neck zone 1: penetrating injury

Zone: clavicle to cricoid cartilage
- Need angiography, bronchoscopy, esophagoscopy and barium swallow. Pericardial window may be indicated.
- May need median sternotomy to reach these lesions.

104

Neck zone 2: penetrating injury

Zone: cricoid to angle of mandible.
- Need neck exploration in OR.

105

Neck zone 3: penetrating injury

Zone: angle of mandible to base of skull.
- Need angiography and laryngoscopy.
- May need jaw subluzation / digastric and SCM release / mastoid sinus resection to reach vascular injuries in this location.

106

Important implication of a zone one injury

Greater potential for intrathoracic great vessel injury

107

Tx: symptomatic blunt of penetrating neck trauma

All need neck exploration. (Shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit)

108

Hardest neck injury to find

Esophageal injury

109

Best combined modality to identify esophageal injury

Esophagoscopy and esophagogram. (Find essentially 95% of injuries when using both methods).

110

Tx: contained esophageal injury

Observation

111

Tx: non contained esophageal injury
- Small / minimal contamination
- Extensive / contamination

- Small / minimal contamination: primary closure
- Extensive / contamination: Neck (place drains - will heal). Chest (Chest tube to drain injury and place spit fistula in neck - will eventually need esophagectomy)

112

What do you always drain esophageal and hypo pharyngeal repairs?

20% leak rate

113

Approach to esophageal injuries:
- Neck
- Upper 2/3 thoracic esophagus
- Lower 2/3 thoracic esophagus

- Neck: left side
- Upper 2/3 thoracic esophagus: right thoracotomy
- Lower 1/3 thoracic esophagus: left thoracotomy

114

These injuries are airway emergencies

Laryngeal fracture and tracheal injuries.

115

Symptoms: laryngeal fracture / tracheal injury

Crepitus, stridor, respiratory compromise

116

Tx: laryngeal fracture and tracheal injury

Tx: primary repair, can use strap muscle for airway support; tracheostomy necessary for most to allow edema to subside and to check for stricture (need to convert cricothyroidotomy to tracheostomy)

117

Tx: thyroid gland injury

Control bleeding and drain (not thyroidectomy)

118

Tx: recurrent laryngeal nerve injury

Can try to repair or can reimplant in cricoarytenoid muscle (sx - hoarseness)

119

Tx: shotgun injuries to neck

Need angiogram and neck CT; esophagus / trachea evaluation

120

Tx: vertebral artery bleeds

Can embolize or ligate without sequela in majority

121

Ligation will cause stroke in 20%

Common carotid bleeds

122

Chest trauma: chest tube output relative indications for thoracotomy in OR

- > 1,500 cc after initial insertion
- > 250 cc/h for 3 hours
- > 2,500 cc/24h
- Bleeding with instability

123

Why do you need to completely drain hemothorax in

To prevent fibrothorax, pulmonary entrapment, infected hemothorax

124

Tx: unresolved hemothorax after 2 well-placed chest tubes

Thoracoscopic drainage

125

What is considered a significant sucking chest wound (open pneumothorax)?

Needs to be at least 2/3 the diameter of the trachea to be significant

126

Tx: sucking chest wound (open pneumothorax)?

Cover wound with dressing that has tape on three sides -> prevents development of tension pneumothorax while allowing the lung to expand with inspiration.

127

- Pt may have worse oxygenation after chest tube placement.
- One of very few indications in which clamping the chest tube may be indicated.
- May need to mainstem intubate patient on unaffected side.

Tracheobronchial injury

128

Bronchus injuries are more common on the ___

Right.

129

Dx / Tx: tracheobronchial injury

Dx: Bronchoscopy
Tx: repair if large air leak and respiratory compromise or after 2 weeks of persistent air leak

130

Trachebronchial injury: indications for right thoracotomy

Right mainstem, trachea, and proximal left mainstem injuries (avoids the aorta)

131

Tracheobronchial injury: indications for left thoracotomy

Distal left mainstem injuries

132

Diaphragmatic injuries: mechanism and location

Injuries are most likely to be found on left and to result from blunt trauma

133

CXR: air-fluid level in chest from stomach herniation through hole (diagnosis can be made essentially with CXR)

Diaphragmatic injuries

134

Tx: diaphragmatic injury

Chest approach if > 1 week (need to take down adhesions in the chest)
- May need mesh.

135

Widened mediastinum. 1st or 2nd rib fractures. Apical capping. Loss of aortopulmonary window. Loss of aortic contour. Left hemothorax. Trachea deviation to right.

S/S: aortic transection.

136

Where is the tear of aortic transection located?

Usually at the ligamentum arteriosum (just distal to subclavian takeoff). Other areas include near the aortic valve and where the aorta traverses the diaphragm.

137

Can you trust a chest XR when ruling out aortic transection?

CXR normal in 5% of patients with aortic tears. Need aortic evaluation in pts with significant mechanism (head on car crash > 45mph, fall > 15ft)

138

Dx: aortic transection

CT angiogram of chest

139

Operative approach: aortic transection

Left thoracotomy and repair with partial left heart bypass or place a covered stent endograft (distal transections only)

140

What is extremely important when approaching a patient with aortic transection?

You need to treat life-threatening injuries first: patient with positive DPL or other life-threatening injury needs to have that addressed before the aortic transection.

141

Approach for specific injuries: ascending aorta, innominate artery, proximal right subclavian artery, innominate vein, proximal left common carotid

Median sternotomy

142

Approach for specific injuries: left subclavian artery, descending aorta

Left thoracotomy

143

Approach for specific injuries: midclavicular incision, resection of medial clavicle

Distal right subclavian artery

144

MCC death myocardial contusion

V-tach and V-fib
- Risk highest in first 24 hours

145

MC arrhythmia overall in patients with myocardial contusion

Supra-ventricular tachycardia

146

Why monitor a myocardial contusion for 24-48 hours?

Arrhythmia is the most common cause of death with the highest risk in the first 24 hours.

147

Definition: flail chest.

> 2 consecutive ribs broken at > 2 sites. Results in paradoxical motion.

148

Biggest pulmonary impairment in flail chest

Underlying pulmonary contusion.

149

May not produce CXR findings immediately

Aspiration

150

Workup: penetrating chest injury

Start with a CXR if the patient is stable (place chest tube for pneumothorax or hemothorax)

151

Borders of penetrating "box" injuries in chest trauma

Clavicles, xiphoid process, nipples

152

Workup: penetrating "box" injuries

Need pericardial window, bronchoscopy, esophagoscopy, barium swallow

153

Tx: penetrating chest wound outside "box" without pneumo or hemothorax

Need chest tube if patient requires intubation. Otherwise follow patient's serial CXRs.

154

What if you find blood in the pericardial window?

Need median sternotomy to fix possible injury to heart or great vessels; place pericardial drain.

155

Workup: penetrating injuries anterior-medial to midaxillary line and below nipples.

- Need laparotomy or laparoscopy.
- May also need evaluation for penetrating "box" injury depending on the exact location.

156

Traumatic causes of cariogenic shock

Cardiac tamponade
Cardiac contusion
Tension pneumothorax

157

One way valve effect causes air entry and pressure build up

Tension pneumothorax

158

Hypotension, increased airway pressures, decreased breath sounds, bulging neck veins, tracheal shift. Can see bulging diaphragm during laparotomy.
- Tx: chest tube

Tension pneumothorax

159

What causes cardiac compromise in tension pneumothorax?

Decreased venous return (IVC, SVC compression)

160

High risk injury in sternal fractures

Cardiac contusion

161

1st and 2nd rib fractures are high risk for?

Aortic transection

162

What is pulmonary tractotomy?

Dividing the pulmonary parenchyma between adjacent staple lines permits rapid access to injured vessels or bronchi along the tract of penetrating injury.

163

Significance of pelvic fractures

Can be a major source of blood loss

164

If hemodynamically unstable with pelvic fracture and negative DPL, negative CXR and no other signs of blood loss or reasons for shock..what do you do?

Stabilize pelvis (C-clamp, external fixator or sheet) and go to angio for embolization.

165

What injuries are associated with pelvic trauma?

High risk for genitourinary and abdominal injuries

166

Type 1 pelvic fracture: unstable (crush)
- Mortality
- Blood loss
- Complications

- Mortality: 20-30%
- Blood loss: > 10 units
- Complications: 60-75%

167

Type II Pelvic Fracture (Unstable)
- Mortality
- Blood loss
- Complications

- Mortality: 8-12%
- Blood loss: 2-10 units
- Complications: 30-50%

168

Type III Pelvic Fracture (Stable)
- Mortality
- Blood loss
- Complications

- Mortality:

169

Pelvic fractures: more likely to have venous bleeding

Anterior pelvic fractures

170

Pelvic fractures: more likely to have arterial bleeding

Posterior pelvic fractures

171

When would you need a colostomy in the setting of pelvic fractures?

May need colostomy for open pelvic fractures with rectal tears and perineal lacerations

172

When do you delay pelvic fracture repair?

Until other associated injuries are repaired

173

Tx: intra-op penetrating injury pelvic hematomas

Open (some suggest going to angiography for these)

174

Tx: intra-op blunt injury pelvic hematomas

Leave, if expanding or patient unstable -> stabilize pelvic fracture, pack pelvis if in OR, and go to angiography for embolization; if packs are placed intra-op, remove after 24-48 hours when patient is stable.

175

Usual cause of duodenal trauma

Usually from blunt trauma (crush or deceleration injury)

176

MC area of duodenal injury

2nd portion of duodenum (descending portion, near ampulla of Vater)

177

What ligament is associated with duodenal injury?

Tears near ligament of Treitz

178

Most likely treatment of duodenal trauma

80% of injuries requiring surgery can be treated with debridement and primary closure

179

Duodenal trauma: segmental resection with primary end-to-end closure is possible with all segments of the duodenum EXCEPT?

Second portion of the duodenum

180

Why is there a 25% mortality rate in patients with duodenal trauma?

Associated shock

181

Major source of morbidity in duodenal trauma

Fistulas

182

Tx: intra-op paraduodenal hematoma

>/ 2 cm considered significant
- Usually in third portion of duodenum overlying spine in blunt injury
- Need to open for both blunt and penetrating injuries

183

- Can present with high SBO 12-72 hours after injury
- UGI study will show "stacked coins" or "coiled spring" appearance (make sure there is no extravasation of contrast)
- Tx?

Dx: paraduodenal hematomas on CT scan (or missed on initial CT scan)

Tx: Conservative (NGT and TPN) -> cures 90% over 2-3 weeks (hematoma is reabsorbed)

184

Surgical approach: duodenal trauma

Perform Kocher maneuver and open lesser sac through the omentum; check for hematoma, bile, success, and fat necrosis -> if found, need formal inspection of the entire duodenum (also need to check for pancreatic injury)

185

Diagnosing suspected duodenal injury

Abdominal CT with contrast initially. UGI contrast study best. CT scan may show bowel wall thickening, hematoma, free air, contrast leak, or retroperitoneal fluid/air.

186

Duodenal trauma: if CT scan is worrisome for injury but non diagnostic..

Can repeat the CT in 8-12 hours to see if the finding is getting worse.

187

Surgical treatment: duodenal trauma

Try to get primary repair or anastomosis; may need to divert with pyloric exclusion and gastrojejunostomy to allow healing. Place a distal feeding jejunostomy and possibly a proximal draining jejunostomy tube that threads back to duodenal injury site. Place drains.

188

Duodenal injury: if in 2nd portion of duodenum and can't get primary repair.

- Place jejunal serosal patch over hole; may need Whipple in future.
- Need pyloric exclusion and gastrojejunostomy.
- Consider feeding and draining jejunostomies; leave drains.

189

Is trauma Whipple ever indicated?

RARELY. Very high mortality.

190

When do you remove drains in duodenal trauma?

Remove drains when patient tolerating diet without an increase in drainage.

191

Treatment: fistulas secondary to duodenal trauma.

Often close with time.
- Tx: bowel rest, TPN, octreotide, conservative management for 4-6 weeks.

192

Most common organ injured with penetrating injury (some texts say liver)

Small bowel

193

These injuries can be hard to diagnose early if associated with blunt trauma

Small bowel trauma

194

Abdominal CT scan suggesting occult small bowel injury

Intra-abdominal fluid not associated with a solid organ injury, bowel wall thickening, or a mesenteric hematoma

195

Imaging Management: occult small bowel trauma

Need close observation and possibly repeat abdominal CT after 8-12 hours or so to make sure finding is not getting worse.

196

What do you need to make sure of before discharging a patient with non conclusive small bowel injury?

Need to make sure patients with non conclusive findings can tolerate a diet before discharge.

197

What avoids stricture in small bowel trauma repair?

Repair lacerations transversely.

198

Small bowel: large lacerations that are > 50% of the bowel circumference or results in lumen diameter

Perform resection and anastomosis

199

Surgery small bowel: multiple close lacerations

Just resect that segment

200

Surgery small bowel mesenteric hematomas

Open if expanding or large (> 2 cm)

201

Colon trauma: most associated with what type of injury?

Most associated with penetrating injury

202

Colon trauma surgery: right and transverse colon injuries

Perform primary repair / anastomosis

203

Colon trauma surgery: left colon

Perform primary repair / anastomosis; place diverting ileostomy if patient is in shock or there is gross contamination

204

Colon trauma surgery: paracolonic hematomas

Both blunt and penetrating need to be opened

205

Rectal trauma: most associated with what type of injury?

Penetrating injury

206

High rectal trauma: extarperitoneal repair

Generally not repaired because of inaccessibility.
- Tx: serial debridement; consider diverting ileostomy.
- Place diverting ileostomy with shock, gross contamination, or extensive injury.

207

High rectal trauma: intraperitoneal repair

Tx: repair defect, presacral drainage, consider diverting ileostomy.
- Place diverting ileostomy with shock, gross contamination, or extensive injury.

208

Low rectal trauma repair

(

209

Most common organ injury with blunt abdominal trauma (some texts say spleen)

Liver

210

Is lobectomy necessary in liver trauma?

Rarely.

211

Common hepatic artery injury repair

Can be ligated with collateral through gastroduodenal artery

212

Pringle maneuver?

Clamping portal triad. Does not stop bleeding from hepatic veins.

213

Damage control peri-hepatic packing

Can pack severe penetrating liver injuries if patient becomes unstable in the OR and the injury is not easily fixed (e.g., retro-hepatic IVC injury). Go to the ICU and get the patient resuscitated and stabilized. Live to fight another day.

214

For retrohepatic IVC injury, allows for control while performing repair

Atriocaval shunt

215

Management: portal triad hematomas

Need to be explored

216

Mgmt: Common bile duct injury:
- 50% circumference or complex injury?

- 50% / complex: go with choledochojejunostomy

May need intraoperative cholangiogram to define injury.

217

How many common bile duct injury anastomoses leak?

10% of duct anastomoses leak -> place drains intra-op.

218

Surgical management: portal vein injury

Need to repair.
- May need to transect through the pancreas to get the to the injury in the portal vein.
- Will need to perform distal pancreatectomy with that maneuver.
- Ligation of portal vein associated with 50% mortality.

219

Mortality: ligation of portal vein

50% mortality.

220

Can be placed in liver laceration to help with bleeding and prevent bile leaks

Omental graft

221

Do you use drains with liver injury?

Yes, leave drains.

222

When is conservative management of blunt liver injuries considered to have failed?

Has failed if patient becomes unstable despite aggressive resuscitation, including 4 units of PRBCs (HR 4 u PRBCs to keep Hct > 25. Go to OR.

223

Surgical management: liver trauma - active blush on abdominal CT or pseudoaneurysm

Indication for OR
- Posterior: may be better off going to angiogram (when in doubt -> OR)
- Anterior: go to OR

224

Liver trauma: conservative management requires how much time of bed rest?

5 days

225

Spleen fully heals after..

6 weeks

226

Greatest risk postsplenectomy sepsis

Within 2 years of splenectomy

227

What is splenic salvage associated with?

Increased transfusions

228

When is conservative management of blunt splenic injury considered to have failed?

If patient becomes unstable despite aggressive resuscitation, including 2 u of PRBCs (HR > 120 or SBP 2 u PRBCs to keep Hct > 25. Go to OR.

229

Conservative management requires how many days of bed rest with splenic trauma

5 days bed rest

230

Threshold for splenectomy in children

Is much higher; hardly any children undergo splenectomy

231

Accounts for 80% of all pancreatic injuries

Penetrating injury

232

How can blunt injury affect the pancreas?

Can result in pancreatic duct fractures, usually perpendicular to the duct.

233

Usually indicative of pancreatic injury

Edema or necrosis of peripancreatic fat

234

Tx: pancreatic contusion

Leave if stable, place drains if in OR

235

Tx: distal pancreatic duct injury

Distal pancreatectomy, can take up to 80% of the gland

236

Tx: pancreatic head duct injury that is not repairable

Place drains initially; delayed Whipple or possible ERCP with stent may eventually be necessary

237

Pancreatic trauma: whipple vs distal pancreatectomy

Based on duct injury in relation to the SMV (superior mesenteric vein)

238

Helps evaluate the pancreas operatively

Kocher maneuver

239

Do you use drains with pancreatic injury?

Yes, leave drains with pancreatic injury.

240

Tx: pancreatic hematoma

Both penetrating and blunt need to be opened.

241

Persistent or rising amylase

May indicate missed pancreatic injury

242

Are CT scans reliable for diagnosis of pancreatic injury?

CT scans poor at diagnosing pancreatic injuries initially. Delayed signs - fluid, edema, necrosis.

243

Test: good at finding duct injuries in pancreatic trauma

ERCP good at finding duct injuries and may be able to treat with temporary stent

244

Vascular trauma: vascular or orthopedic repair first?

Vascular repair (or vascular shunt) performed before orthopedic repair.

245

Major signs of vascular injury

Active hemorrhage, pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill -> go to OR for exploration (may need angio in the OR to define injury)

246

Moderate / soft signs of vascular injury

History of hemorrhage, deficit of anatomically related nerve, large stable / nonpulsatile hematoma, ABI go to angio.

247

When do you need a saphenous vein graft?

If segment > 2 cm is missing. Use vein from the contralateral leg when fixing lower extremity arterial injuries.

248

Vein injuries that need repair

Vena cava, femoral, popliteal, brachiocephalic, subclavian, and axillary

249

Tx: transection of single artery in the calf in an otherwise healthy patient

Ligate

250

How do you cover site of anastomosis in vascular trauma?

Cover site of anastomosis with viable tissue and muscle.

251

When do you consider fasciotomy in vascular trauma?

Consider fasciotomy if ischemia > 4-6 hours (prevents compartment syndrome)

252

When do you consider compartment syndrome?

Consider if compartment pressures are > 20 mmHg or if clinical exam suggests elevated pressures

253

Late signs of compartment syndrome

Pain -> paresthesia -> anesthesia -> paralysis -> poikilothermia -> pulselessness (late finding)

254

When does compartment syndrome most likely occur?

After supracondylar fractures, tibial fractures, crush injuries or other injuries that result in a disruption and then restoration of blood flow after 4-6 hours.
- Tx: fasciotomy

255

Repair of IVC trauma

Primary repair if residual stenosis is

256

How do you control IVC bleeding?

Bleeding of IVC best controlled with proximal and distal pressure, not clamps -> can tear it.

257

How do you repair the posterior wall of the IVC?

Repair posterior wall injury through the anterior wall (may need to cut through the anterior IVC to get to posterior IVC injuries).

258

How much blood can the femur lose?

> 2L blood

259

What are considered orthopedic emergencies?

- Pelvic fractures in unstable patients
- Spine injury with deficit
- Open fractures
- Dislocations or fractures with vascular compromise
- Compartment syndrome

260

Ortho trauma: high risk for avascular necrosis

Femoral neck fractures

261

Tx: long bone fracture or dislocations with loss of pulse (or weak pulse)

Tx: immediate reduction of fracture or dislocation and reassessment of pulse

262

What if pulse does not return after reduction of long bone fracture?

Go to OR for vascular bypass or repair (may need angiography in OR to define injury)

263

What if a weak pulse returns after reduction of long bone fracture?

Angiography

264

Management: knee dislocations

All knee dislocations need to go to angiogram, unless pulse is absent, in which case you would just go to OR (may need angio in OR to define injury)

265

What are upright falls associated with?

Calcaneus, lumbar, and distal forearm (radius / ulnar) fractures

266

Associated injury: anterior shoulder dislocation

Axillary nerve

267

Associated injury: Posterior shoulder dislocation

Axillary nerve

268

Associated injury: proximal humerus fracture

Axillary nerve

269

Associated injury: mid shaft humerus fracture (or spiral humerus fracture)

Radial nerve

270

Associated injury: distal (supracondylar) humerus fracture

Brachial artery

271

Associated injury: elbow dislocation

Brachial artery

272

Associated injury: Distal radius fracture

Median nerve

273

Associated injury: anterior hip dislocation

Femoral artery

274

Associated injury: posterior hip dislocation

Sciatic nerve

275

Associated injury: Distal (supracondylar) femur fracture

Popliteal artery

276

Associated injury: posterior knee dislocation

Popliteal artery

277

Associated injury: fibula neck fracture

Common perennial nerve

278

Associated injury: temporal or parietal bone fracture

Epidural hematoma

279

Associated injury: maxillofacial fracture

Cervical spine fracture

280

Associated injury: sternal fracture

Cardiac contusion

281

Associated injury: first or second rib fracture

Aortic transection

282

Associated injury: Scapula fracture

pulmonary contusion, aortic transection

283

Associated injury: Rib fractures (left, 8-12)

Spleen laceration

284

Associated injury: rib fractures (right, 8-12)

Liver laceration

285

Associated injury: pelvic fracture

Bladder rupture, urethral transection

286

Best indicator of renal trauma

hematuria
- all patients with hematuria need an abdominal CT scan

287

When is IVP useful in renal trauma?

If going immediately to OR without a CT scan -> will identify presence of functional contralateral kidney, which could affect intraoperative decision making.

288

Where can you ligate the left renal vein?

Near the IVC: has adrenal and gonadal vein collaterals. (Right renal vein does not have these collaterals).

289

Anterior -> posterior renal hilum structures

Vein, artery, pelvis (VAP)

290

How is most renal trauma managed?

95% of injuries are treated non operatively.
- Not all urine extravasation injuries require operation.

291

Renal trauma: indications for operation

- Acutely: ongoing hemorrhage with instability.
- After acute phase: major collecting system disruption, non-resolving urine extravasation, severe hematuria.

292

First thing to do with exploration in renal trauma

With exploration, try to get control of the vascular hilum first

293

When do you place drains in renal trauma?

Place drains intra-op, especially if collecting system is injured.

294

Renal trauma: methods to check for leak

Methylene blue dye can be used at the end of the case to check for a leak

295

What to do: when at exploration for another blunt injury or penetrating trauma..
- Blunt renal injury with hematoma
- Penetrating renal injury with hematoma

- Blunt: leave unless pre-op CT/IVP shows no function or significant urine extravasation

- Penetrating: open unless pre-op CT/IVP shows good function without significant urine extravasation.

296

Tx: Trauma to flank and IVP shows no uptake in stable patient

Tx: angiogram, can stent if flap present

297

Best indicator of bladder trauma

Hematuria

298

Associated injury in bladder trauma

> 95% associated with pelvic fractures

299

S/S: bladder trauma

Meatal blood, sacral or scrotal hematoma

300

Dx: bladder trauma

Cystogram

301

Cystogram shows starbursts
- Tx: Foley 7-14 days

Extraperitoneal bladder rupture

302

More likely in kids, cystogram shows leak
- Tx: operation and repair of defect, followed by Foley drainage

Intraperitoneal bladder rupture

303

Best tests for ureteral trauma

IVP and retrograde urethrogram (RUG) best tests -> hematuria unreliable.

304

If large ureteral segment is missing (> 2 cm) and cannot perform reanastomosis..
- Upper 1/3 injuries and middle 1/3 injuries that won't reach bladder (above pelvic brim)
- Lower 1/3 injuries

- Upper / Middle: temporize with percutaneous nephrostomy (tie off both ends of the ureter); can go with ill interposition or trans-ureteroureterostomy later
- Lower: reimplant in the bladder; may need bladder hitch procedure

305

If small ureteral segment is missing (

- Upper / middle: mobilize ends of ureter and perform primary repair over stent
- Lower: re-implant in the bladder (easier anastomosis than primary repair)

306

Indications for one-shot IVP for evaluation of ureter

None. One-shot IVP does not evaluate the ureters sufficiently

307

How do you check for leaks with ureteral trauma?

IV indigo carmine or IV methylene blue can be used to check for leaks.

308

Blood supply: ureteral trauma

Medial in the upper 2/3 of the ureter and lateral in the lower 1/3 of the ureter

309

Drains for ureteral trauma?

Leave drains for all ureteral injuries

310

Best signs of urethral trauma

Hematuria or blood at meatus are the best signs; free-floating prostate gland; usually a/w pelvic fractures

311

Foley for urethral trauma?

No foley if this injury is suspected.

312

Best test for urethral trauma

Retrograde urethrogram

313

Urethral: portion at risk for transection

Membranous portion at risk for transection

314

Tx: significant urethral tears

Tx: Suprapubic cystostomy and repair in 2-3 months (safest method - high stricture and impotence rate if repaired early)

315

Tx: small, partial urethral tears

Tx: may get away with bridging urethral catheter across tear area and repair in 2-3 months

316

Tx: genital trauma

Can get fracture in erectile bodies from vigorous sex.
- Need to repair the tunica and Buck's fascia

317

Management: testicular trauma

Get ultrasound to see if tunica albuginea is violated, then repair if necessary

318

Is blood pressure a good indicator of blood loss in children?

Nope, blood pressure is the last thing to go

319

Pediatrics: best indication of shock

Heart rate, respiratory rate, mental status, and clinical exam

320

Patient population: increased risk of hypothermia and head injury

Pediatric trauma
- Increased BSA compared with weight

321

Vitals: infant (

- Pulse: 160
- SBP: 80
- RR: 40

322

Vitals: preschool (

- Pulse: 140
- SBP: 90
- RR: 30

323

Vitals: adolescent (> 10 year)
- Pulse, SBP, RR

- Pulse: 120
- SBP: 100
- RR: 20

324

How much blood loss can a pregnant patient have without signs?

Up to a 1/3 total blood volume loss

325

What do you look for in trauma during pregnancy?

Check for vaginal discharge - blood, amnion. Check for effacement, dilation, fetal station

326

Fetal maturity: lecithin : sphingomyelin (LS) ratio

> 2:1, positive phosphatidylcholine in amniotic fluid

327

> 50% results in almost 100% fetal death rate.

Placental abruption
- > 50% of all traumatic placental abruptions result in fetal demise

328

S/S: pregnant with uterine tenderness, contractions, fetal HR

Placental abruption

329

MC mechanism of placental abruption in trauma

Shock or mechanical forces

330

Test for fetal blood in the maternal circulation -> sign of placental abruption

Kleihauer-Betke test

331

Where is uterine rupture more likely to occur?

Posterior fundus

332

Management: uterine rupture

If occurs after delivery of child, aggressive resuscitation even in the face of shock leads to the best outcome. The uterus will eventually clamp down after delivery; just have to aggressively resuscitate.

333

Indications for C-section during exploratory laparotomy for trauma

- Persistent maternal shock or severe injuries and pregnancy near term (> 34 weeks)
- Pregnancy a threat to the mother's life (hemorrhage, DIC)
- Mechanical limitation to life-threatening vessel injury
- Risk of fetal distress exceeds risks of immaturity
- Direct intra-uterine trauma

334

Management of hematoma:
Pelvic: penetrating / blunt

Pelvic:
- Penetrating: Open
- Blunt: Leave

335

Management of hematoma:
Paraduodenal: penetrating / blunt

Paraduodenal:
- Penetrating: Open
- Blunt: Open

336

Management of hematoma:
Portal triad: penetrating / blunt

Portal triad:
- Penetrating: Open
- Blunt: Open

337

Management of hematoma:
Retrohepatic: penetrating / blunt

Retrohepatic:
- Penetrating: Leave if stable
- Blunt: Leave

338

Management of hematoma:
Midline supramesocolic: penetrating / blunt

Midline supramesocolic:
- Penetrating: Open
- Blunt: Open

339

Management of hematoma:
Midline inframesocolic: penetrating / blunt

Midline inframesocolic:
- Penetrating: Open
- Blunt: Open

340

Management of hematoma:
Pericolonic: penetrating / blunt

Pericolonic:
- Penetrating: Open
- Blunt: Open

341

Management of hematoma:
Perirenal: penetrating / blunt

Perirenal:
- Penetrating: Open
- Blunt: Leave

342

Zones of the peritoneum
- Zone 1 / Associated injury

Zone 1: central retroperitoneum
- Pancreaticoduodenal injuries or major abdominal vascular injury (usually open hematoma in these areas)

343

Zones of the peritoneum
- Zone 2 / Associated injury

Zone 2: flank or perinephric area
- Injuries to the genitourinary tract or to the colon (i.e. with penetrating trauma; usually open hematomas in these areas)

344

Zones of the peritoneum:
- Zone 3 / Associated injury

Zone 3: Pelvis
- Pelvic fractures (usually leave these hematomas alone)

345

Injuries that you leave drains with

Pancreatic, liver, biliary system, urinary and duodenal injuries

346

Shock, bradycardia and arrhythmias can result.
- Tx: stabilize patient, anti-venin, tetanus shot

Snakebites (symptoms depend on species)