Trauma Flashcards
(141 cards)
1
Q
MCC of death
A
MCC of death for trauma patients in 1st hour: hemorrhagic shock
MCC of death for trauma patients reaching hospital: TBI
2
Q
Best measure of resuscitation
A
Lactate (<2.5) is the best measure of resuscitation in trauma patients, not UOP
3
Q
DPL
A
DPL make the incision above umbilicus: positive with: > 100,000 RBC, 10 cc of blood, or > 500 WBC
4
Q
Penetrating abdominal injury:
A
-Unstable or high velocity GSW OR
-Stable (knife) evaluate with Local wound exploration vs CT vs diagnostic laparoscopy vs serial abdominal exams
5
Q
Penetrating flank wounds
A
-Unstable go to OR for LAPAROTOMY
-Stable: CT abd
6
Q
Injury below nipples
A
laparotomy
7
Q
ED thoracotomy
A
SBP <60 or loss of pulse
8
Q
Tranaxemic Acid TXA
A
-Reduces all-cause mortality if given to traumatic hemorrhagic and shock if used <3 hours from injury
-CRASH-3 trial showed reduced mortality in patients given TXA with TBI!!!
-Indications: Traumatic hemorrhagic shock with SBP <75 or LYS >3 %
-Only give if injury was < 3 hours ago
-Give 1 g IV over 10 minutes, followed by 1 gram every 8 hours
9
Q
Classes of hemorrhagic shock
A
-“End organ hypoperfusion”
-Hemorrhage classes:
-Class I= 0-15% blood loss; no physiologic signs
-Class II= 15-30% blood loss; tachycardia, narrowed pulse pressure
-Class III= 30-40% blood loss; hypotension
-Class IV= >40% blood loss
-Earliest sign of shock: tachycardia & narrowed pulse pressure (Class II)
10
Q
REBOA
A
Zone I – left subclavian to celiac artery (Abdominal injuries)
Zone II – Celiac artery to lowest renal artery (never use here)
Zone III – Lowest renal artery to aortic bifurcation (Pelvic Injuries)
Do not place REBOA for penetrating chest injuries. These need an ED thoracotomy
Reboa is only used for injuries below the diaphragm
Only deploy REBOA in Zone I or III
11
Q
Concussion and sports related LOC
A
They will need testing of vision, oculomotor, balance etc
GCS cannot be used to rule out a concussive event
Most who present with concussion or LOC DO NOT require imaging of brain
Frequent awakening is no longer recommended
Any person who has sustained a concussion has a 2-5 time higher likelihood to get another one
12
Q
GCS
A
(MVC…MVE…654)
Motor:
6: follows commands
5: localizes pain (purposeful movement toward stimuli)
4: withdraws from pain
3: flexion with pain (decorticate)
2: extension with pain (decerebrate)
1: no response
Verbal:
5: oriented
4: confused
3: inappropriate words
2: incomprehensible sounds
1: no response
Eye opening:
4: spontaneous opening
3: opens to command
2: opens to pain
1: no response
TBI mild (13-15), moderate (9-12) and severe (8 or less)
GCS 8 or less: intubation (and ICP monitoring if head injury)
Most important prognostic indicator= motor score
13
Q
TBI
A
Mild TBI: GCS 13-15, moderate TBI: GCS 9-12, major TBI: GCS < 8
Mild traumatic brain injury definition
- GCS 13-15
- LOC is < 30 minutes
If has a mild TBI, GCS 13-15 with no other signs: observe for 4 hours in ED then DC
Obtain a CT for all MODERATE AND SEVERE = GCS < 12.
Only obtain CT for MILD TBI GCS 13-15 if one of below:
- Depressed skull fracture
- Any sign of Basilar skull fracture: Racoon eyes, hemotympanum, Battle sign, CSF leak,
- 2 or more episodes of vomiting
- Age > 65
- Amnesia > 30 minutes
- Neuro deficit, seizure
- AC use
- Dangerous mechanism: auto-ped, ejected from vehicle, fall > 3 feet
Fosphenytoin or Keppra for 1 week given prophylactically to prevent seizures with moderate to severe head injury
-Bilateral pinpoint pupils: Pontine hemorrhage
14
Q
Subdural hematomas
A
Tearing of venous plexus (bridging veins) that cross between the dura and arachnoid
Crescent-shaped; crosses suture lines
Chronic subdural hematoma: elderly after minor fall, severe alcoholic; mental status deteriorates over days to weeks as hematoma forms
Decompressive craniectomy is ONLY indicated if there is a midline shift with MASS (hematoma) present that can be evacuated.
Not indicated if only has intracranial HTN.
Surgical indications: SDH > 10 mm thick or midline shift > 5 mm, change in GCS of 2 points or more, signs and symptoms of increased ICP
15
Q
DVT px 72 hours after stable brain bleed
A
LMWH has decreased mortality and rates of VTE when compared to heparin
Coagulopathy with traumatic brain injury: due to release of tissue thromboplastin
16
Q
Epidural hematoma
A
Arterial bleeding from middle meningeal artery
Lenticular (lens-shaped); contained by suture lines
LOC -> then lucid interval (awake) -> then sudden deterioration (vomiting, restlessness, LOC)
Craniotomy for significant neurological deterioration or shift > 5 mm
17
Q
Intracerebral hematoma
A
Intraparenchymal hemorrhage
Frontal or temporal
Most common brain injury in trauma; occurs with blunt trauma
18
Q
Diffuse axonal injury
A
MRI: blurring of gray-white matter; multiple small punctate hemorrhages
-Blunt injury with shear forces
-Non-contrast head CT characteristically normal
-More severe lesions in corpus callosum and brainstem
Tx: supportive; very poor prognosis
19
Q
CPP
A
Cerebral perfusion pressure = MAP-ICP
CPP= surrogate for cerebral blood flow; main regulator= PaCO2
-In TBI, autoregulation is lost; CPP sensitive to changes in MAP
Normal ICP= 10; ICP > 20 needs treatment
TBI= CPP between 60 and 70
Want CPP > 60
- > 70 risk of ARDS & brain edema
- < 50 risk of ischemia
*Give volume and pressers to improve MAP. Want systolic > 100.
*Sedation & paralysis decrease brain activity and oxygen demand
*Raise head of bead: lowers ICP
Brain tissue oxygen partial pressure (PbtO2): predictor of cerebral ischemia and hypoxia; PbTO2 > 20
Avoid PaCO2<30
-Relative hyperventilation for modest cerebral vasoconstriction; do not want to hyperventilate and cause cerebral ischemia
-avoid hypotension and hypoxia to avoid secondary brain injury
ICP monitoring for TBI in a patient who DOES NOT have CT brain findings or traumatic injury is indicated in:
- Age > 40
- Motor posturing
- Systolic blood pressure <90
ICP monitoring indicated for all with mass effect on CT and GCS < 8
CSF drainage is indicated for TBI with GCS < 6
External ventricular drain= ventriculostomy – inserted into lateral ventricles= Able to drain CSF if needed to decrease ICP
-Bolt monitor: Placed intraparenchymal.
Steroids increase mortality
Avoid albumin – associated with increased mortality
20
Q
Supportive treatment for elevated ICP
A
Want ICP < 20
Peak ICP (max brain swelling) occurs 48-72 hours after injury
-Sedation/paralysis
-Raise head of bead
-Relative hyperventilation (short term): CO2 30-35 for modest cerebral vasoconstriction
-Na 140-150, serum OSm 295-310
-Mannitol: draws fluid from brain
-Hypertonic saline preferred in trauma due to hypotension that can result from mannitol
-Remove C collar- improves cerebral perfusion
-Barbiturate comma if above not working
-Ventriculostomy with CSF drainage
-Craniostomy decompression/ also can do burr hole
21
Q
Uncal herniation
A
Temporal lobe herniation
Cardinal sign: LOC, ipsilateral blown/dilated pupil + contralateral hemiplegia (due to compression of oculomotor CN III and corticospinal tract)
Earliest sign is anisorcia (one pupil is different than the other); can have unilateral dilated pupil without severe impairment of LOC; and overtime impaired EOM (down-and-out)
Initially present with sx of increased intracranial pressure: headache, n/v, AMS
Cushing’s triad: HTN, bradycardia, irregular respirations
-Late finding, indicates impending herniation
-Initial tx: Elevate HOB, ventilate to pC02 35, Mannitol &/or Hypertonic Saline, Sedate & Paralyze
22
Q
CN VII injury
A
Facial nerve, main function: Motor innervation to muscles of facial expression
MC site for CN VII traumatic injury: temporal skull fracture (at the geniculate ganglion)
Cranial nerve VII injury
- If motor defect and lateral to canthus (corner) of eye: needs surgical repair of nerve in <72 hours
- Injury medial to this will recover
- Approximate epineural layers
23
Q
Nexus criteria for traumatic Cervical spine injuries
A
Do not need imaging if: Alert, no neurological deficit, not intoxicated or altered, no midline C spine TTP, no distracting injury
Burst fracture -> spinal fusion
C2: Odontoid fracture
-Type I Odontoid fracture: Tip of the dens (odontoid process)/ above base: Stable, non op. Hard collar
-Type II Odontoid fracture: Base of the dens, Unstable. Tx: halo vest vs surgery
-Type III Odontoid fracture: Extending into vertebral body. Rarely need surgery. Stable, hard collar
C1 burst: Jefferson fracture: caused by axial loading; tx= rigid collar
C2 Hangman: caused by extension: traction halo
Clinical clearance of C spine: must have no other injuries, GCS 15, not intoxicated, no neck tenderness, no neurological deficits
24
Q
Le fort
A
Type I – straight across on the maxilla
Type II – lateral to nasal bone, underneath eye
Type III – Across orbit
Type I and II Le Forte = Stabilization and intramaxillary fixation (IMF) MMF
Type III - Suspension wire to stabilize frontal bone and possible external fixation
25
Vascular injuries grading system
26
Blunt cerebrovascular injury
1st step for grade I-IV is to start heparin drip. No bolus. Low dose. PTT 40-50
- This is the treatment for the vast majority of all patients
Need follow up CTA for Grade I-III, on day 7. If resolved: DC AC. If not, then DC on aspirin only.
Operative repair generally not feasible because of location of injury, MC distal internal carotid artery
Stenting – Generally not used for Grade I or II. only used for symptomatic patients (dissections) or enlarging or symptomatic pseudoaneurysm, or grade V lesions that are not accessible
Surgey – rarely ever indicated, usually only for grade V
Occlusion: just AC
Carotid dissection Grade I or II – treated with AC unless symptomatic
- #1 heparin or Plavix.
- Symptomatic (neuro sx): endovascular covered stent
Carotid disruption (presents with carotid thrombosis)
- Complete occlusion: OR
- If anterograde flow present: Endovascular/open repair
Vertebral artery dissection: treated the same as carotid
27
Penetrating neck injuries
- If it did not penetrate the platysma: No need for imaging or OR
- If there are any HARD signs of vascular injury (also, air bubbling) or hemodynamic instability: OR
- Hard signs:
*Expanding/pulsatile Hematoma
*Signs of limb ischemia/ comportment syndrome= pulseless, pallor, paresthesia,
pain, paralysis, poikilothermia
* Bruit/Thrill
* Absent Doppler Signals
* Arterial Pressure Index, API,
(<0.9)
- Soft Signs = hoarseness, odynophagia, non-expanding hematoma CTA neck
- CTA neck is the INITIAL diagnostic test of choice if not going to the OR (no hard signs of vascular injury)
- Once CTA neck is done, THEN you can selectively work up other injuries if there is a concern.
- Air bubbling: Bronch
- Odynophagia or CT evidence of esophageal injury: esophogram and EGD
28
Penetrating neck wounds divided in two locations:
1. Posterior neck triangle:
- Bounded by posterior SCM, clavicle and trapezius
2. Anterior neck triangle:
- Zone I: clavicle to cricoid cartilage; can injure, apex of lung, trachea, esophagus, brachiocephalic or subclavian vessels, nerves; median sternotomy
- Zone II: cricoid to angle of mandible; carotid, vertebral, jugular, esophagus, trachea; lateral neck incision
- Zone III: angle of mandible to base of skull; internal/external carotid, jugular, cranial nerve, hypoglossal nerve; ; lateral neck incision
Anyone with penetrating neck injury that has any of the following need OR:
- HARD signs of vascular injury
- Tracheal injury (Subcutaneous air, bubbling, coughing blood)
- Neurologic deficit
29
Esophageal trauma
Esophagoscopy + esophogram – finds 95% of injuries
If contained: treat conservatively/observe
Non-contained (ALL NEED SURGERY):
- If small and minimal contamination: primary closure
- If extensive with severe contamination (unable to repair) or hemodynamically unstable:
- Neck – just wash and place drains; will heal on its own
- Chest – Place chest tubes, cervical esophagostomy, staple distal esophagus, will eventually need esophagectomy
30
Thoracotomy/ VATS
Indications for thoracotomy: > 1.5L after initial insertion; > 200/cc for 4 hours; > 2.5L/24 hours; bleeding w instability
Need to drain all blood in < 48 hours to prevent fibrothorax, pulmonary entrapment, infected hemothorax, empyema
Retained hemothorax = residual hemothorax AFTER thoracostomy tube already placed, only if > 25% -> Tx: = VATS drainage is best.
Should be EARLY, by day 3
- Don’t place a second thoracostomy tube
- Don’t use fibrinolytics
Persistent air leak by POD 3: Need to do VATS at this point
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Open pneumothorax
Sucking chest wound
Open pneumothorax – large chest wall defect leads to direct communication of pleura to environment.
If wound is great than 2/3 diameter trachea: during inspiration, air will go into wound instead of airway
-needs immediate 3 sided occlusive dressing followed by chest tube
32
Rib fractures
- epidural shown to decrease ventilator days, fewer pulmonary complications, and shortened ICU and hospital length of stay, especially when used in older patients
- Contraindication to epidural = increased intracranial pressure
- Only indication for surgical fixation really is flail chest or failed medical management
- Surgical fixation with flail chest: reduces PNA, decrease ICU LOS, ventilation duration, decreased need for tracheostomy.
- Surgical rib fixation does NOT decrease mortality
Flail chest: 3 or more consecutive ribs broken at 2 or more sites= paradoxical motion; underlying pulmonary contusion= biggest impairment
-Normally chest wall moves outward during inspiration, reducing intrathoracic pressure and drawing air into lungs
-In flail chest: detached segment of ribs drawn inward by negative pressure during inspiration and outward during expiration
33
Tracheobronchial injuries
Worsening oxygenation after chest tube placement.
Persistent large PTX after 1st chest tube: place a second anteriorly-> if doesn’t respond will need bronchoscopy to check for tracheobronchial injury or mucus plug
Sx:
* Subcutaneous emphysema
* Hemoptysis
* Pneumomediastinum
* Large continuous air leak throughout respiratory cycle
* Persistent PTX
MC right main stem
Dx: bronchoscopy
May need to mainstem intubate patient on unaffected side
Indications for surgical repair:
1. Respiratory compromise
2. Unable to get lung up
3. 3 days of persistent air leak
4. Injuries > 1/3 the size of the tracheal or bronchial lumen
Cervical incision - for tracheal injuries above the clavicle
Median sternotomy – if Injury is from clavicle to 2-3 cm proximal to carina
Right posterolateral thoracotomy 4th-5th ICS– for right mainstem, trachea, proximal left main stem
Left posterolateral thoracotomy 5th ICS- For distal left mainstem
34
Activated clotting time ACT
Want ACT150-200 sec for routine AC
Want ACT >480 for cardiopulmonary bypass
35
Blunt traumatic aortic injury
Aortic transection
Proximal descending aorta, where relatively mobile aortic arch can move against fixed descending aorta (ligamentum arteriosum)= greatest risk from shearing forces of sudden deceleration
-PE: HoTN, UE HTN, unequal blood pressures, external evidence of chest trauma, thoracic outlet hematoma, fractured sternum, fractured thoracic spine, left flail chest
-CXR low sensitivity: concerning for BAI
1) Widened mediastinum (8cm)
2) Depression of mainstem bronchus
3) Deviation of NG tube to the right
4) Apical Cap
5) Disruption of calcium ring (broken halo)
-CT angiography of the chest= diagnostic study of choice
-Severity of aortic injury:
-Type I (intimal tear)
-Type II (intramural hematoma)
-Type III (pseudoaneurysm)
Type IV (rupture)
MC location of tear is at ligamentum arteriosum (proximal descending thoracic aorta; just distal to left subclavian take off)
-Most blunt aortic injuries surviving to hospital are partial- transections, and should be managed with blood pressure control until definitive repair.
Maintain blood pressure between 100 and 120 mmg (esmolol; with or without nitroprusside)
Treat other life threatening injuries first
For intervention stent is > than open repair. But if doing open: left posterolateral thoracotomy while on left heart bypass, with interposition graft
* Grade I: intimal flap/tear < 1 cm. Tx: Beta blockers. Impulse control HR <100, BP < 120 systolic
* Grade II: Intimal flap/tear > 1 cm or Intramural hematoma. Tx: Beta blockers. Impulse control HR <100, BP < 120 systolic. Repeat CTA in 7 days.
* Grade III: pseudoaneurysm. Tx: endovascular stent
* Grade IV: rupture/transection. Tx: endovascular stent
-Post endovascular repair of BAI develops left hand ischemia: carotid to subclavian bypass (subclavian covered routinely during endovascular repair of BAI)
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Approach for specific injuries
Best with left posterolateral thoracotomy: left ventricle, left subclavian artery, descending aorta, left pulmonary artery, left lung, left hilum, left internal mammary artery, and distal esophagus are best approached through a left thoracotomy
However, Anterior approach is preferred if the patient is being taken in emergent situation.
Median sternotomy
- Heart, pericardium,
- Brachiocephalic artery and vein
- Proximal right subclavian, proximal left and right common carotid,
- ascending aorta,
- SVC, IVC,
- main pulm artery
- Poor choice for lung or esophagus
Proximal left subclavian: (need trap door incision, divide left 2nd intercostal space and elevate 1st and 2nd rib)
- Needs left anterolateral thoracotomy at the third intercostal space, supraclavicular incision, and partial sternotomy
- Distal control through supraclavicular approach
Left anterolateral = ED thoracotomy
A right anterior thoracotomy is relatively rarely used in trauma.
Right posterolateral thoracotomy is performed in a lateral position.
- Right lung including hilum, diaphragm, trachea, right bronchus, proximal left bronchus, mid-esophagus
Left posterolateral thoracotomy is performed in a lateral position
- Left lung and hilum, aortic arch, descending thoracic aorta, diaphragm, distal thoracic esophagus
Distal right subclavian artery – Mid clavicular incision, resection of medial clavicle
Lung injury bleeding: perform pulmonary tractotomy with stapler
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Pelvic fracture bleeding
Anterior pelvic fracture: venous bleed
Posterior pelvic fracture: arterial bleed
38
Diaphragm injury
Diaphragm injury: repair with non-absorbable suture, usually no mesh needed
polyester or polypropylene
39
Resuscitative thoracotomy indications (ED thoracotomy)
Penetrating trauma:
-CPR was started within 15 minutes of penetrating thoracic injury
-CPR was started within 5 minutes of a penetrating extra-thoracic injury (e.g. abdominal trauma)
-Patient had signs of life and pulse or pressure was lost (SBP < 60) on way to ED or in ED
Blunt trauma:
-Only if pressure or pulse lost in ED (CPR started within 5 minutes)
40
Cardiac tamponade
Cardiac tamponade – causes cariogenic shock
-Decreased ventricular filling due to fluid in the pericardial sac around the heart
Beck's triad: JVD, hypotension, muffled heart sounds
Echo: impaired diastolic filling of right atrium (1st sign)
FAST – best to dx in trauma bay
-If US positive and patient is hemodynamically normal: pericardial window to confirm diagnosis, if positive= median sternotomy
- If US positive and unstable: no need for further diagnosis. No need for pericardial window or any imaging -> Median sternotomy
- Rarely will you ever choose pericardiocentesis to temporize, unless the facility does not have the capabilities to perform median sternotomy
Any patient with a penetrating injury to chest and pericardial fluid on US mandates operative intervention, will need a pericardial window or median sternotomy
Can present in post cardiac surgery patient as sudden decrease chest tube output followed by hypotension and elevated wedge/CVP or as PEA
-Coding: open sternum in ICU
-If still as BP and HR: return to OR for reentry
41
Morel-Lavallée
Morel-Lavallée – closed degloving injury, when skin and subq separate from fascia.
The space fills with serous/bloody fluid
Will see internal debris in the collection on imaging = fat globules
If small= compression
Large, failed medical management, skin necrosis= percutaneous aspiration then compression (very important)
42
Duodenal trauma
-MC blunt
-Usually, CT with oral contrast is best for diagnosis: free INTRAperitoneal air or contrast leak
-MC location for tears – 2nd
-MC location for hematoma – 3rd
Retroperitoneal air or leak: non-op, abx, NPO, NGT
Do Kocher maneuver and open lesser sac through the omentum for: RUQ bile staining, succus drainage, fat necrosis, paraduodenal hematoma (found intra op)
Duodenal hematomas on CT scan are managed non-op, NGT, TPN, NPO for up to 14 days! If more -> OR
-UGI study shows "stacked coins" or "coiled spring"
Usually for duodenal injuries, the initial operation is just damage control, and definitive surgery will follow
Most of them 80%--> primary repair
If laceration is through and through (ant and post): needs resection
If Grade II, < 50% circumference for all:
- #1 choice is transverse primary repair
- If tension free repair is not possible (reduces lumen <50%) do duodenoduodenostomy
- If you can’t do above bc of tension then: Roux-en-y duodenojejunostomy over the injury
If grade III > 50% circumference 1st, 3rd, 4th duo OR 2nd portion 50-75%:
- #1 choice is transverse primary repair, often cannot do this here
- If tension free repair is not possible do duodenoduodenostomy
- If you can’t do above bc of tension then: Roux-en-y duodenojejunostomy over the injury or close the duodenum laceration and do it proximal to injury
- If injury is in the 1st or proximal 2nd portion of duodenum can do antrectomy (include lacerated bowel) staple distal to injury so ampulla is in distal end and do gastrojejunostomy
If Grade IV but ampulla or CBD not involved, only >75% D2 treat like grade III
If grade IV D2 >75% and involving ampulla or CBD
- Initial operation is almost always damage control, save the patient’s life
- Complex reconstruction vs whipple
- Avoid pyloric exclusion if possible
- jejunal serosal patch, pyloric exclusion (oversew pylorus through gastrostomy), gastroJ, feeding tube
Grade V
- Initial operation is almost always damage control, save the patient’s life
Triple tube decompression with duodenostomy tubes no longer supported
Destructive injuries to the duodenopancreatic complex often require pancreaticoduodenectomy.
- For the First operation just place drains
- Never do whipple on first trauma operation
Lateral tube duodenostomy may be helpful in patients who leak after a duodenal repair breaks down but should not be used at the initial surgery
Pyloric exclusion and gastrojejunostomy – typically used in duodenal repairs with pancreatic injury. Pancreatic injury may cause breakdown of the duodenal repair (the sutures may dissolve from the pancreatic fluid). The diversion of the gastric contents permits adequate drainage of the area without development of a lateral duodenal fistula that is unlikely to heal.
43
Small bowel trauma
MC organ injured in penetrating trauma
>50% laceration or lumen <50% needs resection
Injury grading = small bowel = colon = rectum = all the same
Blunt hollow viscus injury – easily missed bowel injury.
CT scan findings may show free fluid, mesenteric stranding or hematoma, bowel wall thickening
You have 2 choices. Either exploratory laparotomy or observe
Intra-op mesenteric hematomas: open if expanding or large (> 2 cm)
44
Colon Trauma
MC penetrating
Destructive colon injury is defined as = >50% laceration or colon devascularization = need segmental resection
Right and transverse colon treated like small bowel. Primary repair unless destructive, then you would resect. Don’t need diversion
Left colon- Primary repair without diversion for all non-destructive injury
If left colectomy (sigmoid too) indicated, diverting ileostomy or Hartmann’s indicated only if for:
- Unstable (defined as SBP <90), at any point in time EVEN IF IT WAS PRE-OP, transient, or now resolved.
- Peritonitis (SEVERE gross/fecal contamination)
NEVER DO PRIMARY REPAIR or anastomosis IF HEMODYNAMICALLY UNSTABLE/SHOCK: keep in discontinuity and come back later
Intra-op paracolonic hematoma: open both blunt and penetrating
45
Rectal trauma
Upper rectum = Intraperitoneal = treated like colon injuries
- if non-destructive: primary repair without diversion
- If performing LAR for destructive injury (greater than 50% circumference or devascularization) diverting LOOP colostomy indicated if any below
o Unstable (defined as SBP <90), at any point in time EVEN IF IT WAS PRE-OP, transient, or now resolved.
o Peritonitis (Severe gross/fecal contamination)
o Significant comorbidities
- If destructive and in shock place end colostomy (Hartmann’s= avoids left sided anastomosis in a sick patient and diverts stool)
For all extraperitoneal
- High (proximal 1/3): If LAR needed= diverting colostomy
- Middle: end colostomy only (not APR) area will heal after 6-8 weeks
- Low: if repair not fesible: end colostomy only (not APR)
- Never do presacral drainage
- Never do distal rectal wash out
46
Splenic injury
-If unstable BP <90: OR
-Transient responder: IR embolization
-Active contrast or pseudoaneurysm in stable patient: IR embolization
CI to splenic salvage: head injury, unstable
-Fluid collection late after splenectomy = pancreatic injury (high in amylase) PC drainage only
-Nonoperative management: bed rest for 5 days
-Unusual to have to remove spleen in children
-Postsplenecotmy sepsis greatest risk w/n 2 years of splenectomy
-Vaccines: pneumococcus, menigocoffus, H. influenzae; 2 weeks after splenectomy
47
Liver injury
MC organ injury with blunt abdominal trauma
-Common hepatic artery can be ligated proximal to the GDA; will be retrograde flow from the GDA into the proper
-Pringle maneuver: clamping portal triad does not stop bleeding from hepatic veins or retro-hepatic IVC
-Common bile duct injury (Kocher maneuver and direct out portal triad): < 50% of circumference repair over stent; >50% circumference choledochojejunostomy
-Portal vein injury: may need to transect through pancreas to get to injury= distal pancreatectomy; ligating portal vein associated with 50% mortality
Leave drains with liver injuries
Omental graft
-Damage control peri-hepatic packing:
If bleeding from hepatic veins (retro-hepatic IVC) and can’t stop it: take down triangular, falciform, and right coronary ligament and perform kocher for direct packing of IVC
Active contrast or pseudoaneurysm in stable or transient responder: angioembolization
Fluid collection later after liver injury: PC drainage
48
Pancreatic trauma
MC penetrating
80% treated with just drains; primary concern is figuring out if duct is involved
-If main duct disrupted left of SM vessels (Grade III): distal pancreatectomy
If main duct disrupted to right of SM vessels (Grade IV), without major pancreatic head disruption AND without duodenum injury is best managed DISTAL PANCREATECTOMY!!! +/- pancreatiojejunostomy
If major pancreatic head injury (Grade V) or severe pancreatic head and duodenal injury: initially place drains, will need delayed whipple
If there is bleeding behind pancreas and can’t get to it: transect neck of pancreas, requires distal pancreatectomy
If there is concern for ductal injury: Need ERCP or MRCP
Always place drains inra-op, and can remove when amylase level is less than serum
If treated non-op and find peripancreatic fluid collection, may have duct injury, Do ERCP instead to diagnose duct injury and temporize with stent
Need Cattell to evaluate head, need Mattox to see tail
49
Mattox vs Kocher vs Cattel-Braasch vs Pringle
Mattox: Left-Sided Medial Visceral Rotation; Mobilize Descending Colon at White Line of Toldt; visualize: entire abdominal aorta, proximal celiac axis, and SMA
Kocher: Incise Posterolateral Peritoneal Attachments of Duodenum; place Hand Behind Duodenum/Pancreatic Head and Retract Medially; visualize: suprarenal IVC
Cattel-Braasch Maneuver: Right-Sided Medial Visceral Rotation; extended Kocher
Pringle Maneuver: compression of portal triad; stops hepatic inflow but does not stop backflow from hepatic vein bleed
50
Popliteal access
Above the knee popliteal access: posterolateral Sartorius
Below the knee popliteal access: posterolateral gastrocnemius (medial head)
51
Leg compartments:
Anterior - anterior tibial artery, deep peroneal nerve (dorsiflexion, sensation between first two toes)
Lateral: superficial peroneal nerve (eversion, lateral foot sensation)
Deep posterior: Posterior tibial artery, peroneal artery, tibial nerve (plantar flexion)
Superficial posterior: sural nerve
52
Compartment syndrome
Compartment pressure > 30 mmHg suggests compartment syndrome
Pain with passive motion -> paresthesia -> poikilothermia -> pallor -> paralysis -> pulselessness (late finding)
Lateral incision 4-5 cm lateral to tibia and in between fibula: opens anterior and lateral compartments
Medial incision 2-3 cm medial to tibia: opens both posterior compartments.
- Need to make sure to take soleus off of tibia to open deep posterior compartment
- Incise gastrocnemius for superficial posterior compartment
Superficial peroneal nerve MC nerve injured in fasciotomy at the lateral fasciotomy site (decreased eversion)
53
Gustilo classification for open fractures
Type I and Type II: ancef
Type III: Ancef + gentamicin or ceftriaxone monotherapy
Farm injury: automatically Type IIIA injury, need to add flagyl here= ancef + gent + flagyl or ceftriaxone + flagyl
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Primary Amputation
Primary Amputation (= no attempt for limb salvage) for mangled extremity can be performed in only one situation:
- Hemodynamically unstable with multiple injuries is only indication
Do not attempt limb salvage in this situation for mangled extremity -> straight to amputation.
Gustilo fracture pattern, loss of sensation, number of vessels injured, nerve injured, or any scoring system: Should not alter decision making for primary amputation. Studies show that this does not matter.
55
IVC Repair
Primary repair if <50%. Otherwise need saphenous vein or synthetic patch
56
Ureter injury
MCC penetrating
Best diagnosed with CT with DELAYED phase or multiple shot IVP (intravenous pyelogram), retrograde urethrogram
Hematuria not a reliable indicator
Blood supply medially upper 2/3, laterally lower 1/3
Any injury with electrocautery needs debridement prior to repair
If GSW blast injury causes ureter injury: all of these need to be debrided to healthy tissue first
If partial transection <50%, or hematoma/contusion: just place stent
If >50% transection or complete transection but has < 2 cm devascularization: Debride, spatulate, then primary repair over stent.
- For all upper and middle
If complete transection and < 2 cm: primary repair unless it is in lower 1/3 then reimplant bladder (ureteroneocystostomy)
If complete transection > 2 cm and can’t do primary repair:
- Upper and middle 1/3 (above pelvic brim/proximal to iliac vessels):
o If not able to repair in the acute setting (unstable and doing damage control) then needs staged repair. ligate both ends of ureter then percutaneous nephrostomy tubes. Will ultimately need transureteroureterostomy or ileal conduit
o if stable can do transureterouretorostomy
- Lower 1/3 (below pelvic brim/distal to iliac vessels):
o Re-implant into bladder if it is within 2 cm of the bladder. If > than 2 cm do primary repair
o If can’t reach: using psoas hitch: mobilize bladder and suture bladder to iliopsoas fascia above the iliac vessels
o If still can’t reach with psoas hitch then do Boari flap: anchor base of flap to psoas. Take 4 cm wide flap from bladder and tunnel ureter through flap
Iatrogenic injury during LAR, APR, gynecologic/sarcoma surgery: By definition they are lower 1/3: ureterocystostomy
Missed injury:
- If found < 7 days from injury: Go to OR
- If any abscess, urinoma, fistula or > 7 days: Nephrostomy tube and try to place stent
Leave drains for all ureteral injuries
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Renal trauma
MCC blunt; often lower rib fractures
Hematuria best indicator of renal trauma but may not have hematuria
Indications for OR: ongoing renal hemorrhage in unstable patient and Grade V
Surgery is mandated for vascular, renal pedicle or shattered injury. Grade V
Pseudoaneurysm and active contrast extravasation: treat with angio interventions (stent, embolize)
Non-op: cortical, collection system disruption, urine extravasation
Grade I-IV: If blunt, all of these are managed non-op in stable patient
Most Urine extravasation is managed by observation. If persistent or sepsis: nephrostomy tube
In the OR:
- If blunt, hemodynamically stable, with no previous imaging, found a non-expanding hematoma in zone II around kidney: do not explore
- If penetrating without pre-op imaging, peri-nephric hematoma ALL mandate exploration
-Intra-op expanding or bleeding hematoma: open
Left renal vein: can be ligated near IVC; has adrenal and gonadal vein collaterals
Right renal vein does not have these collaterals
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Bladder trauma
-MCC blunt; > 95% pelvic fractures
-Hematuria best indicator; mental blood, sacral or scrotal hematoma
-Dx: cystogram; include post-void films
Extra-peritoneal rupture: cystogram shows starbursts; tx= foley 7-14 days
Intra-peritoneal rupture: cystogram shows leak; more likely in kids; tx= repair drainage followed by foley drainage
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Urethral trauma
MCC blunt; pelvic fractures
hematuria or blood at meatus
Also: high-riding prostrate, scrotal/peritoneal hematoma
No foley if suspected
Retrograde urethrogram
Significant tears: suprapubic cystotomy and repair in 2-3 months; high stricture and impotence if repair early
Small tears: may be able to bridge urethral catheter across tear and repair in 2-3 months
60
Orthopedic trauma
-Femur fracture: can have > 2L blood loss
-Femoral neck fracture & hip dislocation: high risk for avascular necrosis
-Long bone fracture or dislocation with weak/loss of pulse: CT angio/vascular bypass/repair
-All knee dislocations: formal angiogram
-Upright fall: calcaneus, lumbar, distal forearm fx
61
Vascular shunt (damage control)
-Do not require anticoagulation
-Should return to the OR ASAP. <6 hours decreases complications
62
Retroperitoneal hematoma Zone 1
Zone 1 Central (medial to psoas)
-Potential for injuries: pancreas, duodenum, aorta, IVC.
-Explore all blunt and penetrating
-Divided into two areas:
*Supramesocolic Zone 1: Supra-renal aorta, celiac, renal vessels, proximal SMA
-Proximal aortic control: at abdominal diaphragmatic hiatus (Need left thoracotomy if hematoma is at the level of diaphragm) then
-Mattox maneuver (left medial visceral rotation) for exposure (mobilize left colon, left kidney, spleen, and tail of the pancreas toward the midline)
*Inframesocolic Zone 1: Infra-renal aorta, infra-hepatic IVC
-Proximal aortic control (If needed) – infra-renal aorta, just below the left renal vein
-(same exposure as AAA) at the base of transverse mesocolon. TV colon up, SB to the right
-Proximal IVC control (if needed) – just below renal veins,
-Cattell maneuver for exposure
63
Retroperitoneal hematoma Zone 2
Zone 2 Flank (lateral to psoas)
-Potential for injury: kidney, ureter, or colon
-Explore for penetrating, leave for blunt (except expanding/pulsatile perirenal or colon hematoma)
-Need Mattox/Cattel for exposure
-Aortic control is at diaphragmatic hiatus
-IVC control after Cattell
-Retrohepatic hematoma – LEAVE ALL blunt and penetrating. Unless ruptured, expanding, or pulsatile
-Mattox maneuver: spleen, pancreas, and left colon. Good for aortic, left renal, left ureter, and left iliac vessel exposure
-Cattell maneuver: duodenum and right colon. Good for Suprarenal infrahepatic IVC, right renal, and right iliac vessel exposure
64
Retroperitoneal hematoma Zone 3
Zone 3 Pelvis
-Penetrating – generally explore, although IR embolization may be indicated
oVascular control at aortic bifurcation and junction of iliac veins with IVC
-Pelvic fractures (Blunt) – leave hematomas alone, pelvic stabilization and IR embolization
65
What you can/ can't ligate
Distal IVC and iliac vein has difficult exposure due to right iliac artery, sometimes have to ligate this to expose, then primary repair it
Can ligate infra-renal IVC (spares kidneys) but not supra-renal IVC, will need fasciotomy
SMV, left renal vein close to IVC, can be ligated if unstable, prefer to repair
Can ligate radial or ulnar artery, anterior tibial/posterior tibial arteries (one must be present)
Can ligate subclavian artery!!
Never ligate and always try to repair these arteries: innominate, brachial, superior mesenteric, proper hepatic, iliac, femoral, and popliteal arteries and the aorta
66
Button battery ingestion
Emergent evaluation and X-ray for all below:
- < 12 years old
- Button battery > 1.2 cm or unknown size
If > 12 years old, only a SINGLE battery ingested: no need for X-ray. OK to DC with outpatient follow up
Battery in the esophagus: emergent endoscopy and removal
Battery in stomach
- All symptomatic patients need endoscopic removal of button battery
- If asymptomatic, but < 5 years old or battery > 20 mm: endoscopic removal
- Rest of asymptomatic: follow up X-ray in 24-48 hours
If battery is past the stomach: observation
67
Pregnant trauma patients
Pregnant patients can lose 30% blood volume without change in vitals. So, if pregnant patient comes in tachy, with normal rest of vitals, likely in shock
All pregnant women should have supplemental oxygen in trauma bay.
-Physiologic changes in pregnancy:
-Increase in circulating blood volume with physiological dilution/anemia
-Increased respirations, decreased tidal volume results in respiratory alkalosis
-Place patient left side down to take pressure off IVC
-Abdominal trauma in pregnant patient
-Concern for placental abruption and maternal-fetal hemorrhage
-RhoGAM if mother Rh- if concern for maternal- fetal hemorrhage
-Kleihauer Betke Test: looks for fetal blood cells in maternal circulation
-Fetal monitoring: viable pregnancies; Generally 24+ weeks gestation
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Admission criteria/referral to burn
Admission criteria/referral to burn
-Partial thickness = 2nd degree > 10%
-Burn to hands, face, feet, genital, perineum, skin over major joint
-Full thickness = 3rd degree burn in any age
-Electrical/lightening and chemical burn
-Inhalation injury
-Child abuse
69
1st degree burn
superficial – sunburn, blanches (epidermis only)
70
2nd degree burn
2nd superficial partial thickness – Involves superficial dermis, but not reticular dermis
-BLANCHES, pink and moist!! painful, blisters, hair follicles present
-Does not need skin graft
2nd deep partial thickness – into deep dermis, involves reticular dermis
-DOES NOT BLANCH, NOT PAINFUL . Pink and WHITE but more dry, still has SOME sensation, lose hair follicles.
-Needs skin grafting
71
3rd degree burn
3rd Full thickness- all the way through the dermis, (sub-dermal)
- White leathery, waxy, No sensation at all, eschar, subQ exposed
- Needs graft
72
4th degree burn
muscle, fascia bone, fat,
73
Burn resuscitation
Parkland resuscitation: No longer recommended by American Burn association.
Use brooke formula
Only for burns >20% TBSA and > 2nd degree
Modified Brooke formula = 2 ml/kg/TBSA for burns > 15% TBSA 2nd degree or higher
- First ½ given 1st 8 hours, then next half given over latter 16 hours
- Should use lactated ringer
- Titrate to goal UOP .5-1 cc/kg/hour
- Prevents over resuscitation
For children:
- ALSO need to add D5 AND maintenance in addition to resuscitative fluid above in 1st 24 hours
Adult: Head 9, arms 9 each, chest/abd 18, back 18, legs 18 each, perineum 1
Child: head 18, legs 14 each, back 18, chest/abd 18, arms 9 each
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Escharotomy
- Only considered for circumferential third degree burns
- When performed can help avoid compartment syndrome
- Sometimes may need to combine with fasciotomy if concerned about compartment syndrome
- Skin is usually insensate (full thickness burns), can be done without anesthesia
- For hands: in between metatarsals. Don’t do finger fasciotomy
- Extremities: medial and lateral aspect
- Elbow, watch medial epicondyle for ulnar nerve
- Snuff box – watch for superficial radial nerve
- Fibula: watch for common peroneal artery
- Medial ankle: great saphenous
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Inhalation injury
If there is hoarseness, stridor, > 40% TBSA burn, drooling -> intubate
Not all patients with inhalation injury need intubation!
If there are signs of inhalation injury (face/neck burn, singed nasal hair, soot in nares) -> next step is laryngoscopy/bronchoscopy
In bronch if you see vocal cord edema, ulcers, blisters-> Intubate
All patients get 100% FIO2 X 6 hours
O2 saturations will be misleading -> Always get ABG, and carboxyhemoglobin levels!! Use this to determine if need to intubate
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First week after burn
Enteral Feed in 24-48 hours
Excise burn wounds within 24 hours only AFTER proper resuscitation.
Superficial (1st degree), superficial partial thickness (2nd):Xeroform bacitracin. Don’t need antibiotics
Anything deeper: silver sulfadiazine (needs abx)
Need skin graft for 2nd deep partial thickness and greater
Wounds to face/palms/soles/genitals defer grafting 1st week: topical abx X 1 week
Autograft contraindicated if wound is positive for B hemolytic strep OR bacteria>105
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STSG
- Takes epidermis and small part of dermis
- donor site re-epithelizes from #1 hair follicles, and skin edges
- Takes 3 weeks to heal, can use donor site again after that
- More likely to survive 2/2 to better imbibition
- Less primary contracture, more secondary contracture
- Worse cosmetic result. Vs full thickness
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Full thickness SG
- Takes epidermis and dermis
- More primary contracture (more dermis), less secondary contracture
- Face, hands, feet
- Donor site must be closed primarily
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Skin grafting
Series of events after skin grafting: Day 1-3 imbibition, Day 3-4 inosculation (direct connection of vessels to graft), Day 5 neovascularization and angiogenesis
Poorly vascularized areas, unlikely to support skin grafting:
- Tendon
- Bone without periosteum
- XRT areas
Areas that will support skin graft – omentum, bowel wall, bone with periosteum
Hands/fingers: splint in extension before grafting, then keep in extension X 7 days after grafting
Genitals: topical abx X 1 week, then STSG
80
Bacitracin
Good gram positive coverage; good for shallow facial burns; nephrotoxicity
81
Silvadene (silver sulfadiazine)
- Can cause *neutropenia* and thrombocytopenia.
- Don’t use if has sulfa allergy.
- Painless application
- Limited eschar penetration.
- Not effective against pseudomonas but is for candida
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Silver nitrate
- Causes electrolyte imbalances (*hyponatremia*, hypochloremia, hypocalcemia, hypokalemia).
- Can cause *methemoglobinemia*. CI in G6PD deficiency.
- Limited eschar penetration.
- Not very effective against pseudomonas.
- Painful application
- Can be used in sulfa allergy
83
Sulfamylon (mafenide sodium)
-*Painful* application
-Causes hyperchloremic *metabolic acidosis* due to carbonic anhydrase inhibitor.
-Has good eschar penetration. Good for burns over cartilage.
-Active against Pseudomonas and enterococcus
## Footnote
mafenide acetate
84
Mupirocin
Good for MRSA
85
High voltage electrical injury
-can lead to compartment syndrome
-DO NOT NEED ESCHAROTOMY -> NEED FASCIOTOMY
86
Hydrofluoric acid burn
– Absorbed fluoride ion binds Ca -> hypocalcemia -> life threatening arrythmias
Tx: intra-arterial calcium gluconate
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Snake bite
Tetanus shot (penetrating injuries require tetanus shot)
Only give anti-venom if patient has signs of envenomation = systemic signs, tachycardia, diaphoresis, increased swelling
Never make an incision or suck out the site
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Abdominal compartment syndrome
Normal pressure 5-7
Grade I 12-15 – non-op. Minimize IVF, sedate, NGT to suction, hold enteral feeds, aspiration of ascites
Grade II 16-20 – non-op Minimize IVF, sedate, NGT to suction, hold enteral feeds, aspiration of ascites
Grade III 21-25 – if organ dysfunction needs decompressive laparotomy
Grade IV > 25 – needs decompressive laparotomy
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Black widow spider
N/v; muscle cramps
Tx= IV calcium gluconate, muscle relaxants
90
Brown recluse spider
skin ulcer with necrotic center and surrounding erythema
Tx: dapsone, possible skin grafting but wait at least one week
91
Freezing injuries
Frostnip - brief exposure to freezing cold. Forms crystals on the surface of the skin. Intense painful vasoconstriction, progress to numbness and pallor. Pulses can be decreased Tx: rewarm, no long-term issues
When freezing is below the skin = frostbite
- First degree Superficial frostbite- numbness and edema, no blisters no necrosis, forms a firm yellow plaque. Spontaneously Heals 1-2 weeks
- Second degree partial thickness. Milky white/clear blisters. 2-4 weeks to heal
- Third degree – Full thickness skin loss, through dermis. hemorrhagic blisters. Dead skin, eschar. Can result in limb or tissue loss
- Intra arterial TpA can be used for severe injuries, if <24 hours
- Fourth degree to bone, Black or mummified appearance
- Intra arterial TpA can be used for severe injuries, if <24 hours
Reperfusion leads to further injury. TpA prevents this
Tx for all
- 1st step for all rapid moist rewarming with 37-39C water bath
- tPa given after rewarming, for severe, especially to those are don’t improve with rewarming or with no doppler signals
DRAIN milky and clear blister. DO NOT touch hemorrhagic blisters
Give tetanus shot
Avoid early debridement/amputation because it takes days to weeks for injury to demarcate
Tissue reperfusion in frost bite can cause compartment syndrome
92
Cricothyroidotomy
-Can't intubate, can't ventilate: cricothyroidotomy
93
Subarachnoid Hemorrhage
-Worst headache of life, spontaneous
94
Reversal agents for coagulopathy
-Coumadin: PCC for rapid reversal; FFP, Vit K
-Pradaxa (Dabigatran): Dialysis or Praxbind (idarucizumab)
-Apixaban/Rivaroxaban: PCC gives partial reversal
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Spinal cord injury syndromes
-Central cord syndrome: upper extremity weakness (cape and gloves); elderly pt w spinal stenosis
-Brown Sequard (hemi-section): ipsilateral motor deficit, contralateral pain/temperature deficit below level of injury; penetrating (stab) injury
-Anterior cord syndrome: motor deficit below level of injury; results from vascular injury to anterior spinal artery
-Spinal Cord Injury Without Radiographic Abnormality (SCIWORA): seen in pediatric population
-No steroids for spinal injury
-2 of 3 columns disrupted = unstable and requires operative fixation
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Neurogenic vs spinal shock
-Neurogenic shock: affects hemodynamics. Hypotensive, Bradycardic
-Spinal Shock:
-Sensory/Motor affects
-No effect on hemodynamics
-Absent bulbocavernosus, cremasteric reflex
-Some functions may return with spinal shock
-Intact reflexes indicate deficits are likely permanent.
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Neck Trauma
-Zones of the neck
-Zone 1: clavicles to cricoid cartilage
-Zone 2: cricoid cartilage to angle of the mandible
-Zone 3: Angle of mandible to skull base
-Penetrating neck injury + hypotensive= OR
-Penetrating neck injury with hard sign of vascular injury= OR
-Penetrating neck injury and patient stable without hard sign of vascular injury= CT neck including CT angiogram
-If concerned for esophageal injury: add esophagram or EGD
98
-Esophageal injury
-Extend myotomy to see mucosal injury extent, repair in 2 layers, buttress, drain
-Can’t locate injury during neck exploration= widely drain
99
Blunt cerebrovascular injury (BCVI)
Consider screening imaging (CTA) for:
-Severe cervical hyperextension/rotation or hyperflexion mechanism
-Hanging mechanism
-Neurological examination not explained by brain imaging
-Diffuse axonal injury
-Skull base fractures involving the foramen lacerum
-Horner’s syndrome
-LeFort II or III facial fractures
-Cervical spine fracture, particularly C1-C3
-Epistaxis from suspected arterial source after trauma
-Blunt head trauma with GCS < 8
-Cervical bruit, hematoma
-An isolated cervical seat belt sign without other risk factors and normal physical examination should not be used as the sole criteria to stratify patients for screening
-Distal internal carotid= MC site for BCVI
-Antiplatelet therapy for most BCVI
-Endovascular intervention for pseudoaneurysm of AV fistula
100
Sternal fracture
-Concern for blunt cardiac injury -> EKG
-Sinus tach and PVCs MC abnormalities
-Tropinin as screening tool for BCVI controversial
-Hemodynamic instability or persistent new arrhythmia= Echocardiogram
101
TEG
-TEG/ROTEM can guide resuscitation
-Time: how long it takes to start clot
-If prolonged= give FFP
-Angle: how fast they are forming a strong clot
-If low= give cryoprecipitate
-Amplitude: size of clot
-If low= platelets
-LY30: measure lysis
-If high= give TXA
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Blunt Abdominal Trauma
-FAST: looking for free fluid (blood, succus, urine) in abdomen or pericardium
-MC injuries following blunt abdominal trauma= solid organ injury
-Hollow viscus or pancreas= MC missed injury
-Abdominal seat belt sign: concern for bowel or pancreatic injury
-Solid organ injury & hemodynamically unstable -> OR
-Solid organ injury & hemodynamically stable -> non-operative management= ICU monitoring, trend labs, supportive care
-OR for ongoing transfusion requirement or becomes unstable
-CT scan w free fluid & no solid organ injury= hollow viscus injury until proven otherwise
-Hemodynamically stable with blush on CT (Spleen, liver, kidney)= angioembolization
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Abdominal stab wounds
-Hemodynamically unstable, evisceration, peritoneal signs= OR
-Anterior stab wounds:
-Look for violation of anterior rectus sheath.
-If negative: discharge patient
-If violation of anterior sheath:
-Serial exams if hemodynamically stable +/- CT
-If hemodynamically stable: CT vs laparoscopic exploration looking
for violation of posterior fascia/peritoneum (controversial)
104
Flank stab wounds
-Concern for retroperitoneal structures
-Triple contrast CT scan: Oral, Rectal, IV
105
-Thoracoabdominal stab wound
-concerned for diaphragm injury, even if stable + negative imaging
-Frequently missed on CT; best evaluated with laparoscopy
106
Bowel injury:
-Non-Destructive= <50% + no vascular compromise
-Tx: 1ary repair
-Destructive= >50% circumference bowel wall involvement or devascularized
-Tx= resection & anastomosis
-Damage control setting with destructive bowel injury:
-Staple off bowel, leave in discontinuity (no anastomosis), temporary abdominal closure, take to ICU for resuscitation
107
Penetrating Colon Injury
-Tx: 1ary repair for non-destructive injury; resection & anastomosis for destructive injury.
-Left-sided injury no longer mandates diversion.
108
Bucket Handle Injury
-Typically from blunt injury
-Mesentery of bowel torn from bowel but bowel intact
-Tx= resection
109
Pancreatic Injury
-Involvement of pancreatic duct, location (Head, Body, or Tail), duodenal injury ?
-Distal injury w no ductal injury: Leave drains
-Distal injury w duct injury: distal pancreatectomy with splenectomy
-Spleen sparing in hemodynamically stable children
-Laceration to head of pancreas w or w/o ductal injury: drainage only
110
Retroperitoneal Hematoma
-Zone 1: Central (aorta, vena cava)
-Zone 2: Lateral (renal)
-Zone 3: Pelvis (Iliac)
-Penetrating injury= explore all 3
-Blunt Injury:
-Zone 1: explore
-Zone 2: explore only expanding/pulsatile hematoma
-Zone 3: Generally don’t explore (pack and angiography)
111
Pelvic Fracture
-Concern for injury to: rectum, bladder, vagina, urethra
-Open book pelvic fracture w HoTN: pelvic binder 1st step
-Angiography in stable patient
-OR for preperitoneal packing in unstable patient
112
Triad of death
Hypothermia, Coagulopathy, Acidosis
113
Abdominal Compartment Syndrome
-1st signs: increased peak pressures on vent, decreased UOP, confirm with bladder pressure
-Absolute P >20= concerning for ACS
-Tx= decompressive laparotomy
-Be cautious about decompressive laparotomy in burn patients following massive resuscitation; associated w high mortality
-In burn patients, drain placement to drain ascites for ACS is preferred
114
Damage Control Resuscitation
-Avoid crystalloid if possible. Key is permissive hypotension.
-Balanced blood product resuscitation of platelets, PRBC, FFP in a 1:1:1 ratio
-Bleeding trauma patient requiring massive blood product resuscitation
-Give TXA: 1g within 3 hours of injury with subsequent 1g given over 8 hours; decreases fibrinolysis
115
Bladder Injury
-Frequently associated with pelvic fractures
-Will always have hematuria (renal injury may not have hematuria)
-Intraperitoneal injury: operative repair
-Extraperitoneal injury: foley drainage
116
Ureteral Injury
-Mid ureteral injury: spatulate ends, primary anastomosis over double J stent with fine absorbable suture
-Distal Ureteral Injury: re-implant into bladder. if doesn’t reach= Psoas Hitch
117
Urethra Injury
-PE: blood at meatus, scrotal/perineal hematoma, high riding prostate
-Dx: retrograde urethrogram
118
Extremity Trauma
-Hard signs of vascular injury: pulsatile bleeding, expanding hematoma, absent pulses,
bruit/thrill
-Soft signs: non-expanding hematoma, decreased pulses (ABI <0.9), proximity to neurovascular structures
-Soft signs of injury -> CT angiogram
-Extremity arterial trauma: repair with reversed saphenous
-Extremity venous injury: 1ary repair if possible or ligate
-Popliteal artery and vein: fasciotomy after repair
119
Pediatric trauma patients:
-Airway: narrow, short, more anterior than adults
-Intubate with cuffed tubed; uncuffed tube in infants only
-ET tube size: size of patient’s pinky nail bed width; age/4 + 4 = ET tube size
-Bradycardia common with direct laryngoscopy: have atropine ready
- 20cc/kg bolus for crystalloid; 10cc/kg bolus for blood products
120
-Bubbles seen in Coronary vessels during resuscitative thoracotomy?
-Air embolism, typically from pulmonary injury
121
-MVC with lumbar chance fracture and seat belt sign?
-Hollow viscus injury, maybe pancreatic injury
122
-Kid with handle bar blow to abdomen?
-Duodenal hematoma
123
-Left thoracoabdominal stab injury with negative imaging and normal exam?
-Laparoscopy looking for diaphragm injury
124
-Posterior knee dislocation?
-Popliteal artery injury
125
-Patient found down, oliguric, Cr 3.5?
-Rhabdomyolysis
126
-10cc of bright red blood from tracheostomy site
-Tracheoinnominate fistula with sentinel bleed
127
-Severe TBI patient with Na 155 and 5L UOP?
-Diabetes insipidus; tx= DDAVP
128
-Trauma patient paralyzed from head down with no cremasteric reflex?
-Spinal shock
129
-Stab wound to abdomen, benign exam, eviscerated omentum?
-Laparotomy
130
-Liver bleeding unchanged after Pringle maneuver?
-Hepatic Vein or retrohepatic vena cava injury
131
-Chest x-ray with apical cap?
-Blunt thoracic aortic injury
132
-Major arterial bleeding posterior in neck exploration?
-Vertebral artery injury
133
-Stab wound to flank?
-Kidney or colon injury, need triple contrast CT
134
-Trauma patient with elevated LY30 on TEG?
-Give TXA
135
-Gateway structure to carotid bifurcation
common facial vein
136
-Gateway structure for great vessels during median sternotomy:
innominate Vein
137
Hematemesis 2 weeks after MVC with Grade IV liver laceration:
Haemobilia; tx= angioembolization
138
-Open pelvic fracture with complex perineal wound:
Diverting colostomy
139
-GSW to pelvis w rectal wall hematoma seen on rigid proctoscopy:
Diverting colostomy
140
Denver Criteria
141
Denver Grading System
