Trauma Flashcards

Question

What objectives can you achieve with a resuscitative thoracotomy?

Answer 1

- Cardiac tamponade decompression - Control intra-thoracic bleeding - Control air embolism or bronchopleural fistula - Permit open cardiac massage - Allow temporary descending aorta occlusion to limit abdominal haemorrhage

Answer 2

- Indication ○ Penetrating trauma <15 CPR ○ Blunt trauma <10 minutes of CPR ○ Penetrating neck or extremities with <5 minutes CPR ○ CPR with signs of life - Against Inverse of above

Answer 3

○ Unrepairable cardiac or great vessel damage occurred ○ Massive head injuries identified (probably shouldn't start if identified prior) - No ROSC after 15 minutes of surgical procedure

Answer 4

- Based on pelvic ring stability. - Type A - Complete stable ring with intact posterior arch. ○ A1 - iliac wing ○ A2 - pubic ramus ○ A3 - transverse fracture of the sacrum - Type B ○ Rotational instability (vertically stable) ○ B1 § Externally rotated unilateral. i.e. open book. ○ B2 § Internally rotated unilateral § Associated with bladder injury and shock. ○ B3 § Bilateral rotation. - Type C ○ Vertically unstable ○ C1 - unilateral disruption of posterior arch. ○ C2 - unilateral disruption of posterior arch with contralateral posterior arch incomplete disruption. - C3 - bilateral complete posterior arch disruption with spinopelvic dissociation.

Answer 5

- Push, pack, pringle, then total vascular isolation. - Push ○ Restore the anatomy of the liver - Packing ○ Dry, folded packs with radio-opaque marker ○ Remove within 1-3 days (can cause infection) ○ Complications § Reduced CO if too tight and compressing IVC. § Respiratory deterioration if diaphragmatic movement restricted too much - Pringle ○ Diagnostic - hepatic artery/portal vein versus hepatic vein/caval bleeding. ○ Timing § 1 hour max § Less ischaemia with 10 minutes on 5 minutes off. ○ Sometimes need to finger fracture to get access to deeper bleeders within the parenchyma. ○ Can staple off or ligasure bleeding segments along anatomical planes. ○ Anatomical lobectomy has high mortality § Situations where anatomical lobectomy is needed □ Left lateral segment extensive injury - can't pack. □ Non-viable liver segment post-packing. □ Almost free segment. □ Devitalised liver at pack removal. - If ongoing bleeding despite Pringle's being applied ○ Means there is an injury to either a hepatic vein or retrohepatic IVC - very difficult injury to control with high mortality even in experienced hands ○ I would placed additional packs anteriorly to see if this can achieve haemostasis and allow transfer. ○ If this does not § Try and ascertain what side of the liver blood is coming from - consider mobilising right of left lobe to tie of corresponding hepatic vein. ○ If concern that injury is to retrohepatic IVC § Consider total hepatic exclusion Clamp inferior IVC above right kidney and suprahepatic IVC - repair IVC.

Answer 6

○ Procedure § Mobilise the hepatic flexure and ascending colon via dividing the line of Toldt § Then mobilise the SB mesentery from caecum/RLQ to ligament of Treitz and reflect right colon to LUQ § Then Kocherise the Duodenum ○ Provides exposure to § Entire duodenum - particularly D3 and D4 □ Accessing D3 with SM vessels there □ Need to be retracted upwards § Pancreas - Head, neck and proximal body § Access to IVC and renal vessels Right kidney

Answer 7

§ Open Pars flaccida § The oesophagus is retracted to the left § The peritoneum overlying the left crus is incised and the muscle fibers are split to expose the aorta. § The adventitia around the aorta is exposed and then the aorta is clamped with a Satinsky clamp. ****Often in reality it will be difficult to get a clamp on so you can use an "aortic compressor" and compress while you wait for help*****

Answer 8

Right or left medial visceral rotation

Answer 9

Right medial visceral rotation with a Kochers maneuvre

Answer 10

Right medial visceral rotation with a Kochers maneuvre and then clamp the infrahepatic IVC Mobilise the coronary ligaments superiorly and then clamp the suprahepatic IVC Mobilise the right lobe of the liver to identify injury - suture with 4/0 Prolene

Answer 11

Select an appropriate shunt - the shunt length should be 3x the length of the defect. - the diameter of the tube should be 2/3 the diameter of the injured vessel. - should be an ETT, NG, chest drain - Place silk sutures around each third (i.e. 1/3 along and 2/3 along)

Answer 12

- Can be divided to non-destructive or destructive injuries ○ Non-destructive - <50% of the circumference of the bowel without any devascularisation - primary repair ○ Destructive - >50% of the circumference or with devascularisation - segmental resection - Colostomy as definitive procedure rather that anastomosis dependent on patient factors at time of re-look/definitive surgery. - Stomas should be placed laterally and at the level of the umbilicus and away from wounds.

Answer 13

1. Subcapsular haematoma < 10% SA Laceration < 1cm depth 2. Subcapsular haematoma 10-50% SA Laceration 1-3cm depth. Intraparenchymal haematoma <10cm. 3. Subcapsular haematoma > 50% SA Laceration > 3cm depth Intraparenchymal haematoma > 10cm Active bleeding contained in parenchyma or vascular injury (AV fistula/pseudoaneurysm) 4. Parenchymal disruption 25-75% of a lobe. Active bleeding into the peritoneal cavity. 5. Parenchymal disruption > 75% Juxtahepatic venous injury - retrohepatic IVC and central hepatic veins.

Answer 14

Reduced CO if too tight and compressing IVC. Respiratory deterioration if diaphragmatic movement restricted too much.

Answer 15

1. Subcapsular haematoma <10% SA Laceration < 1cm in depth. 2. Subcapsular haematoma 10-50% SA Laceration 1-3cm. Intraparenchymal haematoma < 5cm. 3. Subcapsular haematoma > 50% SA Laceration > 3cm. Intraparenchymal haematoma > 5cm. 4. Any injury + splenic vascular injury with contained blush in capsule. Parenchymal laceration with segmental/hilar involvement and >25% of spleen devascularised. 5. Shattered spleen Any injury + splenic vascular injury with blush into peritoneal cavity.

Answer 16

- Haemodynamically stable. - CT performed to classify the injury severity. - No other injuries which require surgery - Transfusion requirement is < 2 packed red cells. - Has to be in a facility which trauma laparotomy can be performed

Answer 17

Therapeutic - ongoing bleeding - dropping Hb - tachycardia - Blush on CTA - Pseudoaneurysm Prophylactic embolisation - Grade 4 or 5 injury - Reduces liklihood of these patients failing non-operative management.

Answer 18

- Insufficient opsonization filter function - Delayed and impaired production of immunoglobulins. - Lack of splenic macrophages. - Reduced number of memory B cells - usually produce IgM to promote clearance of encapsulated bacteria.

Answer 19

NOM - For grade 1 and 2 found on imaging at time of surgery - Consideration to ERCP and stenting Operative - Grade 3/distal injuries with duct transection - distal pancreatectomy +/- splenectomy (as reduces operative time) - Grade 4/5 - pyloric exclusion with gastrojejunostomy.

Answer 20

Chance fracture of L1/2

Answer 21

Bile staining of the tissues. Retroperitoneal haematoma Periduodenal haematoma. Periduodenal air bubbles

Answer 22

1. Haematoma involving single portion of duodenum Partial thickness laceration, no perforation. 2. Haematoma involving more than one portion Disruption <50% of circumference. 3. Disruption of 50-75% of circumference of D2 Disruption of 50-100% of circumference of D1, D3, D4 4. Disruption of >75% of D2 Disruption involving ampulla or distal bile duct. 5. Massive disruption of duodenopancreatic complex. Devascularisation of the duodenum.

Answer 23

Proximity to ampulla Injury charactersitics i.e. simple versus complex. Circumference Associated injuries - pancreas, biliary tree.

Answer 24

- Simple suture closure of simple wounds - Closure of longitudinal duodenotomy transversely if length <50% of circumference. - Primary anastomosis of complete transection - Diversion (gastrojejunostomy + pyloric exclusion, Bilroth II) - Consider cholangiogram if close to the ampulla/bile duct.

Answer 25

1. Subcapsular haematoma Parenchymal contusion No laceration 2. Laceration <1cm with no urine extravasation Peri-renal haematoma confined to Gerotas fascia. 3. Laceration >1cm with no urine extravasation Any injury with renal vascular injury or active bleeding confined to Gerota's fascia. 4. Parenchymal laceration into collecting system with urine extravasation. Renal pelvis laceration and/or complete uretero-pelvis disruption. Segmental renal vessel injury. Active bleeding beyond Gerotas fascia. Segmental infarction secondary to vessel thrombosis. 5. Shattered kidney. Devitalised kidney. Hilar vessel injury.

Answer 26

Haematoma displaces renal tissue Closed retroperitoneal space to tamponade it. Kidney is rich in tissue factor - thus stimulates the extrinsic coagulation cascade aiding in haemostasis

Answer 27

High creatinine High urea Low sodium - peritoneum re-absorbs urine (which is usually low in sodium) resulting in a dilution hyponatraemia

Answer 28

Bladder neck injury Presense of bony fragments in bladder wall. Infected urine Associated female genital tract injury.

Answer 29

Grade 1 - contusion/haematoma. Partial thickness laceration Grade 2 - full thickness laceration < 50% circumference. Grade 3 - full thickness laceration >50% circumference. Grade 4 - segmental loss/devascularisation < 2cm. Grade 5 - segmental loss/devascularisation > 2cm.

Answer 30

Proximal injury - Stent - Repair primarily Distal bronchial injury - Will often resolve with a chest drain alone - If persistent - or impaired ventilation - Posterolateral thoracotomy and repair with monofilament suture OR segmental lobar resection. If they don't settle with multiple drains - need to perform bronchoscopy to confirm proximal injury then operate.

Answer 31

1. Contusion 2. Laceration < 2cm. 3. Laceration 2-10cm. 4. Laceration >10cm with < 25cm2 tissue loss 5. Laceration > 10cm with > 25cm2 tissue loss

Answer 32

3 or more contiguous ribs all fractured in 2 spots creating a floating segment which loses mechanical continuity and thus move paradoxically.

Answer 33

Early - Respiratory failure - either impending or diagnosed. - Severe deformity of chest wall. - Failure to wean off ventilator. Late - Mal or non-union of the ribs (i.e. painful clicking)

Answer 34

- Reduced need for intubation. - Easier to wean ventilator. - More likely to wean ventilator. - Reduced mortality, chest morbidity (pneumonia), LOS.

Answer 35

- A flail chest is 3 or more contiguous ribs broken in 2 or more places creating a segment of chest which moves independently and movers paradoxically with breathing. - When the patient breaths in the flail segment gets sucked in, damaging the lung parenchyma worsening the chest injury. This also results in ineffective ventilation.

Answer 36

Depends on the pressure differential If from bronchus to vein - will get air embolism. If from vein to bronchus - will get massive haemoptysis.

Answer 37

- Focal/lateralizing neurology - Sudden CV collapse - air embolism to coronaries. - Frothy blood sample - Neurology in the absence of a head injury and the presence of a chest injury. - Fundoscopy - air in retinal vessels.

Answer 38

Spinal shock - occur due to inflammation of the cord causing vasoconstriction - results in flaccid paralysis, loss of sensation and reflexes, as well as autonomic instability. - is temporary - can occur at any level Neurogenic shock. - occurs in high spinal cord injuries due to disruption of the sympathetic outflow - results in hypotension and bradycardia. - generally don't get flaccid paralysis and loss of sensation.

Answer 39

Loss of consciousness Amnesia. Imaging. GCS

Answer 40

LOC and post traumatic amnesia > 24 hours with GCS 8 or less

Answer 41

MAP - ICP Normal is 60-70mmHg

Answer 42

Primary insult. Mechanical injury leads to excessive glutamine release which results in cellular influx of calcium ATPase pump failure occurs which drives cellular oedema. - The blood-brain barrier is disrupted which drives cerebral oedema - CPP will drop if the MAP is not elevated. - This can result in cerebral ischaemia. Lactic acid levels increase from anaerobic metabolism.

Answer 43

To counter the increased ICP as CPP = MAP - ICP

Answer 44

Neurologically deteriorating patient Sizebale intracranial haematoma. Nearest surgical unit > 2 hours away.

Answer 45

GCS 8 or less with epidural haematoma causing midline shift.

Answer 46

Frontal - 10cm above the pupli and in the mid-pupillary line Parietal - 5cm superior to the ear Temporal - 3cm superior to the posterior zygomatic arch.

Answer 47

Primary - Due to direct pressure or Barotrauma from the shockwave of the blast - At risk organs are gas filled - Lung, bowel, tympanic membrane, ocular injuries, concussion. Secondary - Caused by projectiles and debris propelled by the explosion - fragmentation injury - Results in penetrating trauma, lacerations, fractures. Tertiary - Displacement injury - caused by displacement of the body from the blast wind - Results in blunt trauma and fractures - Can also cause acceleration/deceleration injuries, soft tissue destruction. Quaternary - Due to injuries from event during trauma - Burns, inhalation of toxic gas or smoke, exacerbation of pre-existing injuries. Quinary - Injury caused by exposure to toxins from blast - Ionizing radiation, radiation sickness etc.

Answer 48

Blast lung injury results in tissue disruption at the capillary-alveolar interface. Causes - pulmonary oedema, parenchymal damage and air embolism. Clinical diagnosis based on hypoxia, respiratory distress, and bilateral lung infiltrates on Chest Xray. Supportive management - ICU, mechanical ventialtion, low pressure ventilation to avoid barotrauma, chest physio, nebulisers.

Answer 49

Myoglobin is released into the plasma from crushed muscle which overhelms the haptoglobin pick up rate. Results in - Nephrotoxity and AKI

Answer 50

Aggressive fluid resus - 2ml/kg/hour May need dialysis May need fasciotomies

Answer 51

Vascular - Rapidly expanding, pulsatile, or largesu haematoma - Refractory shock. - Palpable thrill or bruit. - Shock unresponsive to IV fluid resuscitation. - Absent or diminished radial pulse. - Neurological deficit consistent with cerebral ischaemia. Hard signs of aero-digestive injury - air bubbling from the wound. - massive haemoptysis. - respiratory distress

Answer 52

1. Sternal notch to lower border of cricoid cartilage 2. Cricoid cartilage to angle of the mandible. 3. Angle of the mandible to base of the skull.

Answer 53

Median sternotomy If you are having difficultly accessing the left proximal subclavian you can perform an infra-clavicular extension.

Answer 54

Incision along medial border of SCM with lateral mobilisation of the SCM. The common facial vein is the landmark used to identify the carotid bifurcation - this should be ligated - omohyoid should be divided.

Answer 55

Incision along medial border of SCM which is lateralised. Three structures need to be divided - middle thyroid vein. - inferior thyroidal artery - omohyoid.

Answer 56

1. Intimal transection with <25% of luminal narrowing. 2. Dissection or intramural haematoma with >25% of luminal narrowing or visible intimal flap 3. Pseudoaneurysm or a haemodynamically insignificant AV fistula. 4. Complete vessel occlusion. 5. Vessel transection or a haemodynamically significant fistula.

Answer 57

Arterial haemorrhage from neck and nose or mouth. Expanding neck haematoma. Cervical bruit. Focal neurological deficit. Horners syndrome. Stroke seen on imaging.

Answer 58

- 2 exam findings ○ No posterior midline tenderness ○ No abnormal neurological findings. - 3 reasons which would make findings invalid. ○ No painful distracting injury. ○ Normal level of alertness. - No evidence of intoxication.

Answer 59

A - Visually trace 4 lines (anterior, posterior, spinolaminar, and posterior spinous space) - Look for widening between vertebra B - Overt fractures or lucency - Disruption of C1 C - Widened of narrowed disc spaces. S - Widened pre-vertebral space - can be a sign of blood or oedema associated with a fracture. - C2 space should measure <7mm - C6 space should measure < 22mm.

Answer 60

1. Left subclavian to coeliac 2. Coeliac to renal vessels - NO GO ZONE 3. Renal vessels to bifurcation

Answer 61

- S - secretions are minimal - O - oxygenation is good - A - alert - A - airway is not injured or compromised. - P - pressure or parameters are satisfactory - Tidal volume etc.

Answer 62

Jackson's Burn Wound Mode 3 zones Coagulation - Protein coagulation and cell death - Irreversible necrosis Stasis - Viable but at risk due to impaired perfusion and inflammation - Can be saved with good aggressive and early resuscitation Hyperaemia - Outermost zone with minimal injury - Viable tissue with expected full recovery

Answer 63

- Entry and exit burn - Clots to blood vessels and damage to nerves - Damage to muscles - causing rhabdomyolysis and compartment syndrome - Muscle spasm causing dislocations and compression fractures. - Cardiac rhythm problems

Answer 64

o Mechanism * Alkalis cause liquefactive necrosis * Hydroxide ions saponify cell membrane lipids and denature proteins. * Resulting in deep tissue penetration and ongoing damage. o Tissue effects * Liquefaction allows the agents to spread rapidly through tissue planes * Can continue causing damage long after contact unless neutralised or removed. o Clinical course * Damage is often underestimated initially due to the limited surface signs * Tissues may appear pale and slippery before progressive necrosis occurs. * Examples - oven cleaners, drain cleaners, industrial agents

Answer 65

o Mechanism * Cause coagulation necrosis * Hydrogen ions denature proteins, leading to eschar formation. * The eschar limits deep penetration of the acid. o Tissue effects. * Injury tends to be more superficial compared to alkalis * Coagulation of proteins forms a thick eschar that impedes further spread. o Clinical course * Burn is usually well demarcated and painful. * May evolve over hours depending on concentration and contact duration.

Answer 66

* Inhalation injury can be very morbid - associated with burns in an enclosed space o Facial burns o Singed hair o Airway oedema/stridor. o Carbonaceous sputum/oral deposits. o Carboxyhaemoglobin > 10% o Hoarse voice. Burns in an enclosed space can result in carbon monoxide poisoning * Can have a normal sats as CO has displaced oxygen * Should measure carboxyhemoglobin.

Answer 67

4 x TBSA burn x kg - give first half over 8 hours and next half over next 16 hours. - titrate to a urine output of 1ml/kg/hour (or 2ml/kg/hour for children)

Answer 68

- >10% TBSA adult - >5% TBSA child - Special areas - face, hands, feet, perineum, major joints. - Circumferential limbs/chest. - Inhalation injury - Electrical/chemical burns. - Extremes of age. - Burns with complex co-morbidities

Answer 69

Killian’s triangle is between oblique fibers of the thyropharyngeus, and horizontal fibers of the cricopharyngeus muscle (both of which make up the inferior constrictor) Discordinated relaxation between the pharyngeus muscles and cricopharyngeus results in a pulsion diverticulum.

Trauma Flashcards

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