Trauma

Question 1

Cricothyroidotomy

Answer 1

simple and safe
Should not be performed in children younger than 12 years old bec of risk of damage to cricoid cartilage and the subseequent risk of SUBGLOTTIC STENOSIS
Dis: inability to place a tube >6mm

Question 2

In trauma patients, the differential diagnosis of cardiogenic shock consists of:

Answer 2

1. Tension pneumothorax (m/c)
2. Pericardial tamponade
3. Myocardial contusion or infarction
4. Air embolism

Question 3

With acute tamponade, as little as _____________ of blood within the pericardial sac can produce life-threatening hymodynamic compromise

Answer 3

100mL

Question 4

A trauma patient arrives following a stab wound to the left chest with SBP 85mmHg, which improves slightly with IV fluid res. CXR clear lung fields. What’s the most appropriate next step?

Answer 4

FAST exam, one of its view is the pericardium, for us to check for pericardial tamponade

Question 5

During the circulation section of the primary survey, 4 life-threatening injuries must be identified promptly

Answer 5

1. Massive hemothorax
2. Cardiac tamponade
3. Massive hemoperitoneum
4. Mechanically unstable pelvic fractures with bleeding

Question 6

Primary repair of the trachea should be carried out with

Answer 6

Absorbable monofillament suture

Question 7

Primary repair of the esophagus should be carried out with

Answer 7

Absorbable monofilament suture

Question 8

Most common sites of injury in terms of heart

Answer 8

Penetrating - right ventricle

Blunt - right atrium

Question 9

When to do emergency department thoracotomy (EDT) in tamponade, and how?

Answer 9

SBP < 60mmHg

Best accomplished using left anterolateral thoracotomy, with the incision started to the right of the sternum

Question 10

Current indications for emergency department thoracotomy in a salvagable postinjury cardia arrest

Answer 10

Patients sustaining witnessed penetrating trauma with <15mins of prehospital CPR
Patients sustaining witnessed BLUNT trauma with <10 mins of prehospital CPR
Patients sustaining witnessed PENETRATING trauma to the NECK or EXTREMITIES with <=5 mins of prehospital CPR

Question 11

Current indications for emergency department thoracotomy in a patient with persistent severe postinjury hypotension (<=60mmHg)

Answer 11

Cardiac tamponade
Hemorrhage (intrathoracic, intraabdominal, extremity, cervical)
Air embolism

Question 12

Contraindications to emergency department thoracotomy

Answer 12

Penetrating trauma: CPR > 15 mins and no signs of life (pupillary response, respiratory effort, motor activity)
Blunt trauma: CPR >10 mins and no signs of life or asystole without assoc’d tamponade

Question 13

Survival in resuscitative thoracotomy (RT)

Answer 13

RT is associated with the highest survival rate afer isolated cardiac injury; 35% of patients presenting in shock and 20% without vital signs are salvage after isolated penetrating injury to the HEART. For all penetrating wounds, survival rate is 15%

Question 14

Head injury classification

Answer 14

13-15: mild head injury
9-12: moderate injury
8 and below: severe

Question 15

GCS: eye opening

Answer 15

4: spontaneous
3: to voice
2: to pain
1: none

Question 16

GCS verbal

Answer 16

5: oriented
4: confused (converses, but confused, disoriented)
3: inappropiate words (intelligible, no sustained sentences)
2: incomprehensible
1: none

Question 17

GCS motor

Answer 17

6: obeys commands
5: localizes pain
4: withdraws
3: abnormal flexion
2: abnormal extension
1: none

Question 18

Neck injuries

Answer 18

<15% penetrating injuries require neck exploration, a majority can be managed conservatively
Asymptomtaic patients are typically observed for 6-12 hours
The one caveat is asymptomatic patients with a transcervical gunshot wound; CTA to deterine the track of the bullet

Question 19

Appropriate surgical management of a through-and-through gunshot wound to the lung with minimal bleeding and some air leak

Answer 19

Pulmonary tractotomy with a stapler and oversewing of vessels or bronchi
No effort is made to close the defect

Question 20

Positive DPL for abdominal trauma

Answer 20

RBC> 100,000/mL 
WBC >500/mL
Amylase >19IU/L
ALP > 2 IU/L
Bilirubin > 0.01 mg/dL

Question 21

Positive DPL on thoracoabdominal stab wounds

Answer 21

RBC> 10,000/mL 
WBC >500/mL
Amylase >19IU/L
ALP > 2 IU/L
Bilirubin > 0.01 mg/dL

Question 22

Remarks on pelvic bleeding

Answer 22

In the unstable patient, celiotomy is manadatoryy
Most severe pelvic hemorrhage is venous in origin
If the hematoma ha ruptured into the peritoneal cavity, pelvic packing offers the best hope of control

Question 23

A-A index in vascular injuries of the extremities

Answer 23

If the pressures within 10% of each other, no further evaluation is performed.
If >10%, CTA or arteriography is indicated

Question 24

Hard signs of peripheral arterial injury

Answer 24

Pulsatile hemorrhage
Absent pulses
Acute ischemia
(Operation mandatory)

Question 25

Soft signs of peripheral arterial injury

Answer 25

``` Proximity to vasculature Significant hematoma Associated nerve injury A-A index of <0.9 Thrill or bruit 📌 *furter evaluation indicted ```

Question 26

Blunt carotid injuries

Answer 26

~50% of patients have a delayed diagnosis Mechanism of injury: facial contact resulting in hypertension and rotation Diagnostics: CTA Tx: heparin, ff’d by warfarin for 3 months

Question 27

ACOT

Answer 27

“Acute Coagulopathy of Trauma” - activated protein C is a key element - fibrinolysis is an important component of the ACOT - present in only 5% of injured patient requiring hospitalization - but 20% in those requiring massive transfusion

Question 28

Triggers for massive transfusion protocol

Answer 28

Uncontrolled hemorrhage - SBP <90mmHg despite 3.5 L crystalloid (50mL/kg) - estimated blood loss (EBL) 150mL/min - pH <7.1; temp<34C; IS S> 25

Question 29

The most aprropriate treatment for a duodenal hematoma that occurs from blund trauma is

Answer 29

Observation In children, managed nonoperatively with nasogastric suction and parenteral nutrition for 7-14 days “No reason to believe that hematomas in adults should be treated differently from those of chldren” *new approach is laparoscopic evacuation if the obstruction persists >7 days

Question 30

Damage control surgery

Answer 30

Goal: to control surgical bleeding and limit GI spillage (by rapid repair of partial small bowel injuries with whipstitch, and complete transection with a GIA stapling device) The bowel is covered with a *fenestrated subfascial sterile drape* and *two Jakson-Pratt drains* are placed along the fascial edges; this is then covered using an *Ioban drape*

Question 31

Therapy for increased ICP in a patient with closed head injury is instituted when the icp is >

Answer 31

20mmHg | *although an ICP of 10mmHg is the ULN

Question 32

A shift of _____ typically is considered an indicatiotn for evacuation

Answer 32

>5mm | But this is not an absolute rule

Question 33

Targets in treatment of head trauma

Answer 33

SBP >100mmHg | CPP >50 mmHg

Question 34

How to prevent aortic rupture?

Answer 34

Selective B1 antagonist, esmolol, should be instituted in the trauma bay, with a target SBP <100mmHg and HR <100bpm

Question 35

Indications for operative mgt (e.g. thoracotomy) of thoracic injuries

Answer 35

1. Initial tube thoracostomy drainage of >1,000mL (penetrating) or >1,500mL (blunt) 2. Ongoing tube thoracostomy drainage of >200mL/ for 3 consecutive hours 3. Caked hemothorax despite placement of 2 chest tubes 4. Selected descending torn aortas 5. Great vessel injury 6. Pericardial tamponade 7. Cardiac herniation 8. Massive air leak from the chest tube with inadequate ventilation 9. Tracheal or main stem bronchial injury diagnosed by endoscopy or imaging 10. Open pneumothorax 11. Esophageal perforation 12. Air embolism

Question 36

Hepatic injury

Answer 36

>grade II injuries: admit to SICU Stable, transfusion of 4 u of RBC in 6 hours orr 6 u of RBC in 24 hours —> indication for ANGIOGRAPHY Unstable —> OPERATIVE MGT *delayed rebleeding occur within 48 hours of injury

Question 37

Intra-abdominal pressure >25mmHg. What’s the immediate step?

Answer 37

Open the incision to decompress the abdomen

Question 38

Traumatic spleen injury

Answer 38

Delayed hemorrhage or rupture of spleen can occur up to WEEKS after injury An immediate postsplenectomy increase in platelets and WBCs is normal HOWEVER, byond postop day 5, a wbc >15,000 and plt/wbc ratio of <20 are astrongly assoc’d with SEPSIS

Question 39

Complications after splenectomy

Answer 39

``` Subdiaphargmatic abscess, pancreatic tail injury Gastric perforation (during short gastric artery ligation) ```

Question 40

OPSI

Answer 40

Overwhelming PostSplenectomy Infection 4.4% in <16 y/o 0.9% in adults Greatest in the first 2 years after splenectomy In the setting of elective splenectomy, patients should be vaccinated 2 WEEKS PRIOR TO SURGERY If emergent splenectomy, consideration should be given to delay administration for 2 weeks to avoid transient immunosuppression after surgery *vaccination has lead to OPSI incidence of <1%

Question 41

Responsible for >50% of OPSI

Answer 41

S pneumoniae

Question 42

Other things regarding asplenic patients

Answer 42

Annual influenza vaccine is associated with 54% reduced risk of death

Question 43

Transection of the main pancreatic duct at the middle of the pancreatic body. Next step?

Answer 43

Distal pancreatectomy with splenic preservation ^preferred especially if physiologically compromised Alt: R-en-Y pancreaticojejunostomy or pancreaticogastrostomy (preserves both spleen and distal transected end of pancreas

Question 44

Other remarks on pacreatic trauma

Answer 44

Pancreati contusions: nonoperative or closed suction drainage Proximal pancreatic injuries (defined as those that lie to the right of superior mesenteric vessles): closed suciton draiange

Question 45

Thos most appropriate treatment for a gunshot wound to the hepatic flexure of the colon that cannot be repaired primarily is

Answer 45

Resection of the right colon with ileocolostomy (Kasi proximal to the middle colic artery) *”ileocolostomy heals more reliable than colocolostomy” **if distal to middle colic artery, then an end colostomy is created and the distal colon oversewn and left within the abdomen

Question 46

Remarks on traumatic genitourinary injuries

Answer 46

Succes of renal artery repiar after blunt trauma is slim, but can be attempted if injury occurred within 5 hours or patient does not have any reserve renal function Evaluation: methylene blue or indigo carmine can help Extraperitoneal ruptures: nonop with bladder decompressoin for 2 weeks Intraperitoneal ruptures: closed primarily

Question 47

At what pressure is operative decompression of a compartment mandatory?

Answer 47

45mmHg | *patient pressures between 30 and 45 mmHg should be carefully evaluated and closely watched

Question 48

Trauma in geriatric patients

Answer 48

Mortality in patients with severe head injury more than doubles after the age of 55y/o 25% of patients with a normal GCS of 15 had intracranial bleeding, with assoc’d mortality of 50% Admission GCS is a POOR predictor of outcome 50% of patients >65y/o sustained rib fracutres from a fall of <6ft, compared with only 1% of patients younger than 65 y/o. Concurrent pulmonary contusion is noted in up to 35% of patients. Pneumonia complicates the injuries in 10-30% of patients with rib fractures.