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The most commonly accepted definition of massive transfusion is

more than 10 units in a 24 hour period.

This approximates one total blood volume exchange.


Indications of massive transfusion include

multiple (usually >3) units of uncrossmatched blood given with anticipated ongoing need,


a severely injured patients in extremis with no response to 2 units of blood.


massive transfusion protocol would include

repeatedly sending pRBCs, FFP and platelets every 20 minutes until the team requests it be stopped.

Ratios are kept as close to 1:1:1 as possible.


after 2 packs of massive transfusion, one should consider additionally requesting

cryoprecipitate (fibrinogen, factor 8, VWF)




labs followed in massive transfusion and what are rough endpoints

CBC, PT/PTT, fibrinogen, ABG, calcium and BMP should be serially checked. There are no specific guidelines on when to discontinue massive transfusion. In general, control of bleeding with a Hb >8, INR 100,000 are appropriate goals.


Some of the major indications for damage control are:

Core temperature 95 F or 35 C SBP 14 mmol/L
INR or PTT > 50% normal Blood Loss > 4L Blood transfusion >10 units Fluid replacement >10L Persistent non-surgical bleeding


physiologic capture

describes there resussutation to be acheieved before attempting definitive repaire of inuries differed in damage control

has take place.


what injuries are managed even when doing damage control

Complex injuries to the duodenum may be treated with debridement and primary repair or pyloric exclusion.

Pancreatic injuries are treated with drainage alone or with resection and drainage.

CBD injuries are primarily repaired if less than 50% circumfrence.

Gallbladder is resected


Goals of resuscitation with damage control

basically a normal preop patient!!

temperature to 37 C (98.6 F)

Packed red blood cells, fresh frozen plasma and platelets should be administered in a 1:1:1 ratio for maximum benefit.

Goals of resuscitation should be:

PT < 15 or INR < 1.2
(using FFP, vitamin K, calcium)

Fibrinogen >100 mg/dL

(using cryoprecipitate or fibrinogen concentrate)

-remember cryo has fibrinogen, VWF, 8-

Platelets >100,000/mm^3 using packed platelets

NO pulse goal


function of fibrinogen and normal level

Fibrinogen is broken down to fibrin by the enzyme thrombin to form clots. ( if you're fibrinogen level is low then you're using it all up trying to make clots)

greater than 100


epidural hematoma

blood in the space between the skull and dura.

traumatic arterial injury.

lucid interval

biconvex (lenticular) mass that does not cross cranial suture lines


Acute subdural hematomas

tearing of bridging veins.

Blood between the arachnoid and dura mater and appears as a bright colored crescent-shaped mass which may cross suture lines but not the midline secondary to the presence of the falx


tracheoinnominate fistula

90% mortality associated with and an initial bleed in or around the tracheostomy tube may be the only indication of subsequent occurrence.

The first step should be overinflation of the tracheostomy / endotracheal tube cuff (choice A) for attempted tamponade.

If unsuccessful, digital compression of the artery against the sternum should be the next step

Pressure should be maintained on the artery during transport to the operating room.

An oral endotracheal tube should be inserted after successful arterial compression.

Diagnosis may require bronchoscopy and wound exploration if found early

Primary repair
should not be attempted due to high risk for failure and associated


Those that develop and biloma tx algorrhthm

usually treatable with percutaneous drainage alone

less than 300 mL/day will usually close spontaneously.

more than 300 mL drains daily, the injury should be localized with fistulogram, ERCP, radionucleotide scan or transhepatic cholangiogram.

Sphincterotomy may help close biliary leaks.

Major ductal injuries may be stented or require operative repair.

Persistence of drainage more than 50 mL/day beyond 2 weeks indicates development of a biliary fistula. These often resolve without further intervention. (CAREFUL just because turns into "fistula" and has been 2 wk - does not mean you do anything but watch it resolve with drainage!)


If the Pringle maneuver is effective, hepatic artery ligation may be considered. what are potential complicaitons

increase the risk for hepatic abscess



(CAREFUL, increase risk of hepatic necrosis is listed as a not fully correct answer compared to above)


Injuries to the bladder (choice D) following blunt trauma most commonly what type, associated with what injuries and are managed how

extraperitoneal and associated with pelvic fractures. Extraperitoneal injuries can be managed non-operatively with foley catheter drainage.


Urethral injuries should be suspected if

inability to void,
high riding prostate,
blood at the urethral meatus,
palpable bladder
butterfly perineal hematoma.

pubic symphysis fractures,

Pubic diastasis and inferior pubic rami fractures are termed "straddle fracture" and correlate highly with urethral injuries.

associated bladder injury
pelvic hematomas.


Diagnosis of urethral injuries is made by

retrograde urethrogram.


immunologic function after embolization

Multiple studies have demonstrated preserved immunologic function after embolization.


Indications embolization for splenic injury

active extravasation,
traumatic pseudoaneurysm,
grade III injury with large hemoperitoneum
grade IV injuries.


Nonoperative management of blunt splenic injury is successful in what percent of peds patients versus adults

what time period are failures seen by percent

90% of pediatric patients

60-80% of adults.

The majority of failures (61%) occur within the first 24 hours,

90% within the first 72 hours.

Failure is most commonly associated with grade of injury, with grade V having a 75% failure rate.

Grade IV liver injuries have a 33% chance of failure.


Flank stab wounds are located where

those between the anterior and posterior axillary lines and between the tip of the scapular and the iliac crest.


The recommended modality of evaluation Flank stab wounds

hemodynamically stable patient

CT with triple contrast.

oral, IV and rectal contrast.

When performed this way, the sensitivity for injury is 89% and specificity 98%.

Rectal contrast is given to improve detection of colonic injuries, which is a partially retroperitoneal organ.

In the hemodynamically unstable patient, or those with peritoneal signs, evisceration or findings on other diagnostic modalities (free air on CXR, positive FAST),

laparotomy is


The Eastern Association for the Surgery of Trauma (EAST) practice management guidelines have tried to delineate the appropriate evaluation for BCI

Recommendations are as follows:

1.) An admission ECG and another at 8 hours should be performed in any patient suspected of having BCI (choice A.) 2.)

If the admission ECG results are normal then pursuit of the diagnosis can be terminated.

However, if they are abnormal then the patient should be admitted for cardiac monitoring for 24-48 hours

3.) If the patient is hemodynamically UNstable then an imaging study such as an echocardiogram should be obtained

4.) The presence of a sternal fracture does NOT predict the presence of BCI and thus does not mandate continuous monitoring in the face of a normal ECG

5.) Neither CPK-MB nor troponin T are useful in predicting which patients will have BCI

Echocardiogram is not mandated unless the patient is hemodynamically unstable.


evaluation of Zone I neck injuries

Zone I is located from the clavicle to the cricoid.

may involve lung apex, trachea, brachiocephalic or subclavian artery and veins, nerve roots and esophagus.

Those patients that are hemodynamically unstable require operative intervention, regardless of zone.

Other indications for operative intervention include hard signs of vascular injury (bruit, thrill, expanding or pulsatile hematoma) or tracheal injury (subcutaneous air or bubbling from the wound).

A chest x-ray is performed to evaluate for hemo or pneumothorax, retropharyngeal air or apical capping.

If nonoperative intervention is chosen, evaluation for vascular, esophageal and tracheal injuries should take place.

This can include four vessel angiography, CTA, or even color flow Doppler.

Additionally, esophagography with barium or esophagoscopy should be performed.

Laryngotracheaobronchoscopy may also be done at the same time.


Zone II and III are located

Zone II is located from the cricoid to the angle of the mandible. Injury in this location may involve the carotid or vertebral arteries, the jugular veins, esophagus or trachea.

Zone III is located from the angle of the mandible to the skull base. Injury to this zone may result in external or internal carotid injury, jugular injury, cranial nerve injury or hypopharyngeal injury.


Penetrating injuries to the neck are divided into two triangles:

the anterior and
posterior triangle.


The posterior triangle is bound by

the sternocleidomastoid

the trapezius posteriorly

he clavicle inferiorly.


The anterior
triangle is bound by

anterior to the anterior border of the sternocleidomastoid

divided into three zones:


Zone I neck

clavicle to the cricoid.

lung apex,



subclavian artery and veins,

nerve roots



Zone II neck

cricoid to the angle of the mandible.



VERTEBRAL arteries,

the jugular veins,

esophagus or trachea.


Zone III neck

angle of the mandible to the skull base. I

external or internal carotid injury,

jugular injury,

cranial nerve injury


hypopharyngeal injury.


Work up of penetrating neck injury

In the absence of immediate operative indications, the primary and secondary surveys are continued.

A chest x- ray to evaluate hemo or pneumothorax, retropharyngeal air or apical capping.

If nonoperative intervention is chosen, evaluation for vascular, esophageal and tracheal injuries should take place.

four vessel angiography,
color flow Doppler

and laryngotracheaobronchoscopy.

Some older texts still advocate for operative exploration of all Zone II injuries, however, this is seldom the case in modern practice.


Peds Total blood volume may be estimated as



The earliest indicator of shock in a child

What is the hemodynamic phys is a kid


As stroke volume is relatively FIXED in children,

cardiac output is maintained by increasing heart rate.

This is unreliable, however, as a greater than 25% blood loss may be required to produce tachycardia.


Hypotension in pediatrics may be defined as

<70 + 2 x age in years.


what percent of blood vol is lost to produce tachy in kid

a greater than 45% blood loss!


Absolute indications for surgical exploration with renal injuries include:

renal pedicle avulsion

expanding, uncontained retroperitoneal hematoma.

Patients with these injuries often present with severe shock states.

Renal pedicle avulsion and shattered kidney may not be amendable to operative repair and may require life saving nephrectomy.


relative indication for surgical exploration with renal injuries include:

A large amount of devitalized renal parenchyma

Intervention includes early debridement due to high rates of abscess and infected urinoma development.


management of Urinary extravasation from kindey

Urinary extravasation does not mandate surgical repair.

Most lacerations to fornices and minor calyces stop spontaneously.

Non-operative management in the setting of urinary extravasation requires serial CT scanning.


Brown recluse spider bites

can initially be managed with cold compresses and elevation to decrease the spread of the venom (though elevation may spread problem prox...)

Frank areas of necrosis will need debrided,

no anti-venom currently exists - Dapsone has been used OFF-LABEL label with some success, but is NOT approved in the use of PEDS


Pelvic fractures more likely to have associated bladder injuries.

pubic diastasis


obturator ring fractures are


Imaging for bladder injuries

CT cystography is now the standard in most trauma centers.

Sensitivity and specificity are 95% and 100%, respectively.

This is performed by back-filling the bladder with 350 mL of contrast.



Spontaneous – 4 To Voice – 3 To Pain – 2 None – 1

Obeys verbal commands – 6 Localizes to pain – 5 Withdraws from pain – 4 Decorticate posturing – 3 Decerebrate posturing – 2 None – 1

Oriented – 5 Disoriented/confused – 4 Inappropriate words – 3 Incomprehensible sounds – 2 None – 1


what part of the liver has increased risk of non op failure in trauma

left lobe injuries as they are less contained than right lobe


True Brown-Sequard syndrome

injury to one half of the spinal cord.

ipsilateral loss of motor control


contralateral loss of pain and temperature sensation.

Posterior column and spinothalamic loss occur on opposite sides of the body in this syndrome secondary to spinothalamic decussation near the level of the lesion (below the injury).

This injury may occur due to penetrating trauma, disc herniation, vasculitis and radiation exposure.


If any of these signs are present, the patient should be immediately intubated then operatively explored with tracheal injury

large amount of crepitus,
stridor, horseness,
tracheal deviation.

Sigs of vascular or esophageal injuries:
pulsatile bleeding,
expanding hematoma,


If a tracheal injury is identified, it is repaired by

using a single layer of interrupted absorbable suture.

A tissue buttress using strap muscles or sternocleidomastoid should then be performed.


The chest should also be auscultated where to most clearly check for peripheral ventilation.



Chest radiograph is a component of what part of the the trauma algorrhythm



Indications for immediate action when discovered on circulation exam in trauma

Weak or lack of carotid pulse indicated

SBP < 60 mmHg


loss of cardiac function and immediate action should be taken.


algorrhythm in order for trauma work up

PRIMARY survey:

A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) and F (Fast).

Each must be addressed prior to proceeding to the next.


BREATHING: A suspected pneumothorax should be decompressed at this stage.

(CAREFUL Chest radiograph is a component of the SECONDARY survey)

Circulation Weak or lack of carotid pulse indicated a SBP < 60 mmHg or loss of cardiac function and immediate action should be taken. Additional monitoring at this stage includes pulse oxymetry to confirm peripheral perfusion and oxygenation.

Disability stands for a neurologic assessment. A GCS is performed, pupils examined and brief neurologic exam (wiggle fingers and toes).

Exposure stands for a complete visual examination of all patient surfaces. The patient is completely undressed and a log roll is performed. Palpation for crepitus, fractures and fluid collections
is performed.

The patient is still in the primary survey under exposure.

rewarming is performed with warmed Iv fluid or forced air ventilation.

FAST stands for the Focused Assessment with Sonography for Trauma. A brief conograph for the identification of fluid is performed. The exams begins with visualizing the pericardium to look for hemopericardium. The right upper quadrant looking at Morrison's pouch and the right subphrenic space is then examined. This is followed by the left upper quadrant looking at the splenorenal space and left
subphrenic spaces.

Finally, the pelvis is examined approximately 4cm above the pubic symphysis.

Rewarming needs to be begun prior to imaging.


posterior hip dislocation reduced with

longitudinal traction followed by gentle abduction and external rotation


Displacement of the femoral head or acetabulum may injure the

sciatic, femoral, or obturator nerve.


Supracondylar humerus fracture associated injury

- Brachial artery injury (may lead to Volkmann's ischemic contracture)


Distal radius fracture associated injury

- Median nerve compression


Anterior dislocation of shoulder associated injury

- Axillary nerve injury


Posterior dislocation of hip associated injury

- Sciatic nerve (peroneal division)


gold standard for diagnosis of bladder rupture

CT cystography


Intraperitoneal bladder ruptures will be identified as contrast extravasation how

outlines of loops of small bowel.


Extraperitoneal bladder ruptures will result in contrast where

space of Retzius,
lateral coloc areas,
groin and thigh.


Indications for operative management of bladder injury include

intraperitoneal rupture,
bladder neck injury

concomitant rectal injury
major vaginal injury
open pelvic fractures or those with fragments, or
foreign body within the bladder.


Bladder lacerations are repaired how

AFTER inspecting the urethral oriphesous

in two layers using absorbable suture.

The first layer should include the mucosa and muscularis,


the second layer should include the muscularis and serosa.

Closed suction drains are then placed.

The bladder is drained for 10 to 14 days with either a Foley or suprapubic cystostomy.

Repeat cystography is performed prior to removal to ensure healing.


UOP goal for adult vs child with burn

An output of 0.5 – 1 cc/kg/hr in adults

kid: 1 - 1.5


Hyperventilation Treatment of severe head injury

Hyperventilation is no longer recommended,

short term used in the setting of active herniation.


Cerebral perfusion pressure should be kept at

50-70 mmHg.


Seizure prophylaxis is also recommended for what duration

the first 7 days with phenytoin.


Physiologic stress will cause the release of what stress hormones

from the pituitary- adrenal axis
including corticotropin-releasing hormone (CRH)
adrenocorticotropic hormone (ACTH)
increase the levels of norepinephrine and epinephrine

Growth hormone (GH)
anti-diuretic hormone (ADH)
released from the pituitary in response to stress,

Bottom Line: CRH, ACTH, ADH, and growth hormone are all released in response to physiologic stress.


Burn center referral guidelines:

FULL thickness burn!
inhalational burns

>10% TBSA PARTIAL thickness burns

Burns to the:
face, hands, feet, genitalia, perineum and joints

Burns in patients with significant co-morbidities

Patients with advanced rehabilitation needs Burns in children

Answer E: Frostbite injuries do not mandate burn center transfer.


Zone I is located
Injuries to this zone may involve

from the clavicle to the cricoid.

lung apex,
subclavian artery and veins,
nerve roots


Zone II is located
Injury in this location may involve

from the cricoid to the angle of the mandible.

vertebral arteries,
the jugular veins,


Zone III is located
Injury to this zone may result in

from the angle of the mandible to the skull base.

external carotid
internal carotid injury,
jugular injury (also at risk in zone II)
cranial nerve injury


hard signs of penetrating neck injury that need to go to the OR

pulsatile hematoma

tracheal injury
subcutaneous air
bubbling from the wound


The clinical presentation of an anterior hip dislocation is

characterized by abduction and EXTERNAL rotation
(opposite of posterior hip dislocation)

Anterior dislocation of the hip, although less common, is more frequently associated with FRACTURE of the femoral head or indentation deformation

Caution must be taken to evaluate for a femoral head injury.


Almost all pure hip dislocations reduce with what difficulty

quite easily under general anesthesia and muscle relaxation.


injury pattern with high incidence of avascular necrosis and hip arthritis

ANTERIOR hip dislocations are associated with

Large femoral head fractures


those associated with acetabular or femoral neck fractures have a


indications of failure of liver injury with non- operative management

higher grade injuries (IV or V)

are left lobe are less contained than right lobe injuries

involve major vessels.


Split liver in trauma

(transection between the right and left lobes of the liver) may frequently be managed non-operatively.


describe non op management of liver injury

no evidence that supports frequent hemoglobin monitoring, bed rest or reimaging.

Many will repeat a CT in 8 weeks after the injury in order to document healing.

Other indications for imaging are suspicion of complications from liver injury, including: biloma, bilious ascites or hemoperitoneum.

Bilious drainage may necessitate ERCP and sphincterotomy.


electrocardiac abnormalities due to cardiac contusions

Sinus tachycardia - most common
with premature atrial contractions
premature ventricular contractions also very prevalent.

right bundle branch block
ST changes may occur.


When blunt cardiac injury is suspected what is work up

admission EKG as screening test.

if significant EKG abnormalities are present:

ECHO may be performed to assess motion and valve competency.

Once a blunt cardiac injury is identified:

patient is monitored on telemetry.

If hemodynamic changes or ECHO abnormalities are also present:

ICU monitoring is recommended.


Brain death relies primarily on

clinical examination.

Brainstem reflexes:

all indicate some level of neurologic activity and preclude the declaration of brain death:

oculovestibular (cold calorics)
oculocephalic (doll's eyes)
pupillary reactions

An apnea test prerequisites:
core temperature of 36.5 Celcius or 97 degrees Farenheit,
systolic blood pressure greater than 90 diabetes insipidus corrected to a positive fluid balance,
PCO2 must be normal (35-45 mmHg).

preoxygenated with 100% O2 for 30 minutes. A pulse oximeter is connected, and the patient is disconnected from the ventilator.

looks closely for respiratory movements.

PO2, PCO2, and pH are
measured after ten minutes and then the patient is reconnected to the ventilator.

If respiratory movements are absent and arterial PCO2 is 60 mmHg, the apnea test
result is positive.

Ancillary tests such as electroencephalography (EEG) or cerebral blood flow analysis may also be employed as an adjunct to clinical findings.

Most institutions require at least two examiners with an appropriate period of observation between ranging from 6 to 24 hours.

Spinal reflexes may still be present.

Spinal reflexes, such as limb withdrawal, are not an indication of brain function and, therefore, do not rule out brain death.


Odontoid fractures Type I

upper portion of the dens obliquely oriented

While these are painful they are relatively stable and rarely are associated with a neurologic deficit or threat.

Treatment is usually nonoperative.


Odontoid fractures Type II

extend into the base of the dens (NOT body)


may be associated with NEURO findings,
especially with posterior displacement.

These patients may also have AIRWAY compromise due to the upper airway swelling.

associated with a relatively high rate of nonunion,
especially in those over age 50.

Treatment may consist of rigid cervical collar or halo-vest. Some may have posterior displacement and impinge upon the spinal cord.

These may require surgical intervention.
odontoid screw,
posterior fixation
C1-C2 construct.


Odontoid fractures Type III

extend into the C2 vertebral BODY (CAREFUL, this is not the base of the dense)

Overall, these tend to have a better healing rate than


according to ATLS guidelines what is the secondary survey

to identify any missed injuries and guide future care. Evaluation has

4 main components:
1. History
2. head to toe physical examination,
3. additional procedures
4. specialized imaging


according to ATLS guidelines what is the secondary survey history

The mnemonic AMPLE is recommended by the ATLS.

A- allergies
M- medications currently used
P- past illnesses and Pregnancy
L- Last meal
E- Events leading up to the injury and Environment


tracheal-innominate fistula can be caused by

(1) placing the tracheostomy BELOW the THIRID RING where the inferior concave surface of the cannula may erode the artery,
(4) over hyperextending the neck during the procedure,
(2) an aberrant course of the innominate artery such that it crosses the trachea at an abnormally high level,
(3) use of an excessively long or curved tube,

(5) prolonged pressure on the tracheal wall by an inflated
(6) tracheal infection.
Answer B: This can prevent displacement of the tube post-operatively.


Bjork flap for tracheostomy greatly reduces the incidence of

accidental decannulation

makes reinsertion of the tracheotomy tube easier if inadvertent decannulation occurs.


Blunt trauma is responsible for what percent of diaphragmatic injuries. what side is most common


left (liver protects right)


The accuracy of CT for dx of blunt diaphragmatic injuries

63% sensitivity and 100% specificity.

Injuries without herniation are usually missed on CT, however, these are more common in penetrating injuries.

If neither of these methods is diagnostic, exploration is recommended.

exploratory laparoscopy be used when there are no other operative indications.

Diagnostic thoracoscopy, while effective, would require lateral decubitus positioning and single lung ventilation and is not preferred.


surgical airway may be required. In those 12 ages or older

cricothyroidotomy is the procedure of choice in this scenario.

It is superior to jet insufflation as requires less specialized equipment and protects against aspiration.


surgical airway may be required. In those 12 ages or younger

cricothyroidotomy is contraindicated as the cricothyroid membrane is very delicate in this age group.

Needle techniques such as jet ventilation (also called translaryngeal catheter or needle cric) may be used as a quick method for improving oxygenation, however it provides no protection against aspiration.


To perform an open cricothyrotomy steps

cricothyoid membrane is identified immediately caudad to the thyroid cartilage.

Over this area a longitudinal skin incision is made, approximately 3 cm long.

(A transverse skin incision may be used in a thin patient with clear landmarks, however, a longitudinal incision has the benefit of easy extension if needed)

Next, the tissues above the cricothyroid membrane are bluntly dissected by use of finger or skin retractor. This must be done by palpation.

TRANSVERSE incision is made in the cricothyroid membrane,

dilated with the blunt handle of the scalpel. It is important to preserve the cricoid cartilage by spreading transversely, NOT longitudinally.

A number 5 or 6 tracheostomy tube or ET tube is inserted into the trachea and the cuff is inflated.


best serologic indication of the effect of hepatic disease

Prothrombin time

Although hospital serology panels labeled as “liver function tests” (LFTs) generally contain ALT AST and alkaline phosphatase these are not tests of true function and not always specific to the liver.

They are, nonetheless, valuable in assessing hepatic disease as they are leaked into the circulation with hepatocellular necrosis.

(ALBUMIN - may be second - choice- also made in the liver but confounded by nutrition..)


which is most liver specific - AST or ALT

ALT = L is for LIVER!
is liver specific but still has never been shown to be of any prognostic value.

is found in a variety of other ogans including the heart, muscle, and kidney.