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Chapter 23 Flashcards

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1
Q

How is a TBI classified?

A

By the specific parenchymal lesion as well as the pt’s neurological function

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2
Q

What is the clinical classification of a TBI based on?

A

GCS < 8 indicates severe injury
GCS 8-12 indicates moderate injury
GCS >12 indicates mild injury

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3
Q

In the GCS, what is the most important predictor of neurologic severity and recovery?

A

Motor score

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4
Q

How can a TBI be categorized anatomically?

A

Based on CT scan findings

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5
Q

Postconcussive sx

A

HA
Inattention
Short-term memory loss
Mood swings

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6
Q

Parenchymal TBI lesions

A

Include cerebral contusions and intraparenchymal hematomas

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7
Q

Cerebral contusion

A

Essentially a “brain bruise” with localized intracerebral hemorrhage and edema adjacent to an area of impact
Can enlarge and coalesce into intraparenchymal hematomas

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8
Q

Extra-axial hematomas

A

Usually characterized by their relationship to the dural lining and include epidural, subdural, and subarachnoid lesions

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9
Q

Epidural hematomas

A

Most often seen after a direct lateral impact to the temporal region resulting in a skull fx and laceration of the middle meningeal artery

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10
Q

Presentation of epidural hematomas

A

Experience a brief loss of consciousness and a subsequent lucid interval in which they may appear normal, sleepy, or even intoxicated.
After a short interval, they lose consciousness again as the lesion expands and produces cerebral compression

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11
Q

PE of epidural hematomas

A

Ipsilateral pupillary dilation occurs as the result of direct compression of the third cranial nerve and reflects impending uncal herniation

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12
Q

Tx of epidural hematomas

A

Immediate surgical intervention is indicated in any pt with an AMS, a hematoma volume >30 mL, or evidence of midline shift on CT scan

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13
Q

Subdural hematomas

A

Accumulate between the dura and the brain itself

The shearing or tearing of dural bridging veins is the most common underlying cause of hemorrhage

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14
Q

Subarachnoid hemorrhage

A

Often represents a shearing mechanism with local vascular disruption
Typically do not cause mass effect

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15
Q

Diffuse axonal injury (DAI)

A

An axonal shearing injury caused by rapid deceleration, often with little or no evidence of intracerebral trauma on CT scan

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16
Q

Zone I of the neck

A 
Extends from the clavicles to the cricoid cartilage
Includes:
Thoracic outlet
Subclavian vessels
Lung apices
Thoracic duct
Spinal cord
Esophagus
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17
Q

Zone II of the neck

A 
Includes all structures between the cricoid and the angle of mandible
Including:
Carotid and vertebral arteries
Jugular veins
Trachea
Esophagus
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18
Q

Zone III of the neck

A

The area between the angle of the mandible and the skull base and contains the distal internal carotid artery

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19
Q

Tx of tension pneumo

A

Immediate decompression, which may be accomplished by inserting a 12-or 14-gauge intravenous catheter into the second or third intercostal space in the midclavicular line
Must always be followed immediately by definitive tube thoracostomy

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20
Q

Tx of massive hemothorax

A

Airway control
Large-bore IV access
volume infusion
Large chest tube (36 or 40 French) should be placed expeditiously and ideally should be attached to a collecting system with an auto-transfusion reservoir

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21
Q

When is a thoracotomy indicated for massive hemothorax?

A

> 1500 mL blood loss
Ongoing bleeding of >200 mL/h for >4 hrs
Failure of a hemothorax to drain despite at least two functioning and well-positioned chest tubes
If pt remains hemodynamically unstable despite initial resuscitation attempts

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22
Q

Pericardial tamponade tx in extremis

A

An emergent left anterolateral thoracotomy can also be performed to relieve tamponade in the ER or the trauma bay

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23
Q

Pericardial tamponade tx in the unstable pt

A

Urgent sternotomy or thoracotomy should be performed in the OR

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24
Q

Pericardial tamponade tx in stable pts with pericardial fluid evident on FAST

A

Should undergo a diagnostic subxiphoid pericardial window in the OR to confirm the dx

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25
Tx for open pneumothorax
Temporarily occlude the chest wall with the gloved hand and close with an occlusive dressing taped on three sides to act as a flutter valve Pts with large chest wounds should subsequently undergo formal operative thoracotomy to evacuate blood clot, debride devitalized tissue and close the chest wall defect
26
Tx of chest wall injury
Initial care should occur in the ICU with monitoring to detect clinical deterioration, progressive hypoxia, or hypercapnia Adequate analgesia is paramount for all pts with chest wall trauma in order to facilitate aggressive pulmonary toilet and early immobilization
27
Tx of lung injury
Pain control Pulmonary toilet Supplemental oxygen Occasionally mechanical ventilatory support
28
Tx of diaphragm injury
A transabdominal surgical approach should be used in cases of acute rupture to make sure that there are no other intra-abdominal injuries Laparoscopic repair of the injury may be possible in selected cases Chronic herniation should be approached via thoracotomy
29
Tx of blunt cardiac injury
Dobutamine or epinephrine may be useful in overcoming the impaired contractility experienced after blunt cardiac injury
30
Tx of traumatic aortic injury
Continuous infusion of short-acting beta blocker In the multiply injured pt, management may be complicated by competing interests Cardiothoracic surgeon should be consulted for possible repair via open thoracotomy or endovascular stent graft.
31
When does a traumatic rupture of the aorta occur?
Occurs after rapid deceleration injury, such as a fall from a significant height or high-speed motor vehicle crash
32
What occurs in 85% of pts with traumatic rupture of the aorta?
Aortic laceration is located just distal to the ligamentum arteriosum, past the left subclavian artery
33
What are physical findings that increase suspicion of traumatic rupture of the aorta?
Asymmetry of upper extremity blood pressures Chest wall contusion Intrascapular pain Intrascapular murmur
34
Radiographic signs suggesting traumatic rupture of the aorta
``` Widened mediastinum (>8 cm) Obliteration of the aortic knob Deviation of the trachea to the right Presence of an apical pleural cap Depression of the left mainstem bronchus Obliteration of the aortopulmonary window Deviation of the esophagus to the right ```
35
Notable PE findings for blunt abdominal trauma
``` Abdominal distention Abdominal guarding Rebound tenderness Hypotension Abdominal wall ecchymoses ```
36
What diagnostic studies should be done for blunt abdominal trauma pts who are hemodynamically unstable or who have considerable ongoing fluid requirements?
Should undergo immediate cavitary triage with CXR, pelvis X-ray and either FAST or DPL Immediate surgery is indicated in if the FAST is positive or the DPL is grossly bloody
37
What should be done in blunt abdominal trauma pts who remain hemodynamically stable and in whom abdominal injury is suspected?
Get a contrast-enhanced abdominal-pelvic CT scan | Alternatively, serial FAST exams in conjunction with a UA and serial abdominal exams over 24 hrs
38
Most pts with a penetrating injury to the abdomen will require a _______
Laparotomy
39
Stab wounds of the abdomen
Plain film of the abdomen should be performed to confirm the absence of a retained foreign body
40
Gunshot wounds of the abdomen
A chest, abdominal and pelvic X-ray should be performed in order to identify retained bullets and determine the trajectory
41
Anterior penetrating abdominal wound diagnostics
Local wound exploration using sterile technique and local anesthesia If the anterior fascia is violated, an open laparotomy or diagnostic laparoscopy should be performed If peritoneal violation is seen on laparoscopy, an open exploratory laparotomy is indicated
42
What is the most commonly injured organ in blunt injury?
The liver
43
What should raise suspicion for hepatic injury?
Pts with a hx of RUQ, right lower chest, or flank trauma
44
Exam of hepatic injury
RUQ pain or right shoulder pain secondary to diaphragmatic irritation
45
Tx of hepatic injuries
Most isolated hepatic injuries can be managed nonoperatively regardless of injury grade provided the pt is hemodynamically stable The presence of hepatic contrast extravasation on initial CT scan suggests active hemorrhage and warrants angiography and possible embolization
46
What should be done if signs of peritoneal irritation develop with hepatic injury?
Laparotomy is required to explore for hollow visceral injury
47
Tx of massive hemoperitoneum from hepatic hemorrhage
The liver should be compressed manually until the anesthesia team can match blood losses with transfusion of red cells, plasma, and platelets The use of autotransfusion and cell-saving devices is highly recommended
48
Tx of severe liver trauma
Occluding the portal triad at eh hepatoduodenal ligament manually or with a Rumel tourniquet (Pringle maneuver) If that doesn't work, the liver should be firmly packed supra- and infrahepatically without dividing the hepatic suspensory ligaments If that doesn't work, total hepatic vascular isolation with control of both the suprahepatic and infrahepatic venae cavae may be necessary Sternotomy or thoracotomy may be required
49
Physiologic derangements of hepatic trauma
Coagulopathy Hypothermia Metabolic acidosis
50
Tx of physiologic derangements of hepatic trauma
Hemorrhage should be promptly controlled and the laparotomy abbreviated in favor of subsequent abdominal angioembolization and a second laparotomy when the pt is physiologically more stable
51
What should prompt a concern for splenic trauma?
Hx of trauma to the LUQ, flank, or left chest wall
52
Pt complaints in splenic injuries
Pain in the LUQ Left shoulder pain Left chest wall discomfort Abdominal tenderness
53
Dx of splenic injuries
Contrast-enhanced CT scan
54
Hemodynamically stable splenic pt
Nonoperative management
55
Tx of isolated low-grade splenic injuries without a blush sign on CT
Bed rest Serial abdominal examination Close monitoring of vital signs Serial hemoglobin evaluation
56
What should be considered for all pts with severe splenic injuries (>grade III) and in those with a contrast blush, moderate hemoperitoneum, or evidence of ongoing bleeding?
Angioembolization
57
What is the safest splenectomy approach?
Via midline laparotomy
58
What can seat belt sign indicate?
Should alert the physician to possible intestinal and mesenteric injury caused by abrupt deceleration
59
What does the presence of an anterior lumbar compression fracture (Chance fx) suggest?
Extreme hyperflexion and injuries to the duodenum, proximal jejunum, and pancreas should be suspected
60
What are CT signs suggestive of hollow viscus injury?
Bowel wall thickening Free intra-abdominal fluid (in the absence of solid organ injury) Mesenteric stranding Extraluminal air
61
Who should undergo urgent operative exploration in a hollow viscus injury?
``` Pts with: Fever Changes in vital signs Worsening PE findings New leukocytosi ```
62
Tx for all victims of penetrating injury to the anterior abdomen with facial violation
Exploratory laparotomy
63
When is a colonic resection with colostomy indicated?
The presence of shock Heavy contamination Destructive injury
64
Management of intraperitoneal rectal injuries
Managed as if they were colonic injuries
65
Management of extraperitoneal rectal injuries
Diversion Distal washout Presacral drainage

Surgery (30 decks)

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