Flashcards in TRAUMA Deck (91):
Zone one –Great vessels requires exploration if the blunt trauma?
Zone two –lateral retroperitoneum
Zone three –pelvis
Any zone requires expiration if penetrating trauma
Any zone requires exploration if expanding hematoma
This is a curvilinear incision that is made intermedia condyle obliquely across Cuba Fosse Milford is a form before aspect of the mobile wad coming centrally distal third of the Farm curvilinear me back or to be Radio distal form and across the carpal tunnel
Volar superficial fashion is released
Deep fascia released just raial to FCR exposing FPL and PQ
Dorsal forearm fashion release longitudinal incision older dorsal aspect mobile wad
Superficial fashion is released longitudinally
Dissection is carried down to the abductor pollicis longus and supinator to release deep compartment overlying these structures
Two important details to remember with splenectomy
Leave a dream because of risk of concomitant pancreatic detail injury
fall from hight abd distension, pelvic fracture, bone fragments on rectal exam.
Used a sheet for the pelvis, went to angio appro- priately.
Then went to OR for rectal injury, I did a proximal diversion with loop
What vessel will you tell the IR colleagues to embolize with pelvic fracture
small branches off internal iliac arteries.
after prevail in postrenal causes of Gary I have been evaluated what should you look for for renal causes
Gentamicin nephrotoxic medication!
Supra pubic catheter placement
2 fingerbreadths above the pubic symphysis in the midline;
avoid placing the catheter in natural skin creases.
Fill a 10-mL Luer-Lok syringe with 5 mL of 1% lidocaine and 5 mL of 0.25% bupivacaine.
Attach the syringe to a 22-gauge, 7.75-cm spinal needle.
Raise a skin wheal at the marked site, and infiltrate the anesthetic into the subcutaneous tissue and rectus abdominis muscle fascia,
aiming the needle at a 10-20° angle toward the pelvis.
Advance the needle in this direction, while aspirating the syringe; urine should be easily aspirated when the bladder is entered.
advance a guide wire through the needle into the bladder.
While holding the wire securely (this is now the route of access to the bladder), carefully remove the needle over the wire, leaving the wire in place.
Directly posterior to the wire, use a scalpel with a No. 11 blade to make a stab incision through the skin and subcutaneous tissue.
Pass the Peel-Away Sheath and the indwelling fascial dilator together over the wire and into the bladder.
Remove the guide wire and the fascial dilator, leaving only the Peel-Away Sheath inside the bladder.
Pass a Foley catheter (of appropriate size) through the indwelling intravesical sheath and into the bladder. Aspirate urine to confirm proper placement.
Inflate the Foley balloon with 10 mL of sterile water, using a Luer-Lok syringe.
Gently withdraw the Peel-Away Sheath from the bladder and anterior abdominal wall; using each side of the Peel-Away Sheath, split the sheath into 2 parts, leaving the catheter in place. Connect the indwelling suprapubic Foley catheter to a drainage bag.
secure the catheter to the skin of the anterior abdominal wall.
posterior approach to popliteal a /v
retract semiMeninosis retreact Medially
discect out tibial nerve protected
popliteal artery most posterior
popliteal vein most anterior
hard signs of neck penetrating injury
“Hard” signs mandating immediate operative exploration without the need for additional diagnostic workup include
expanding or pulsatile hematoma,
loss of pulse,
significant subcutaneous emphysema,
air leaking through the neck wound.
clavicle to crycoid
crycoid to angle mandible
angle mandible to base of skull
Work up for penetrating injury violating the platysma in a stable patient without hard signs
operating room table with arms tucked, neck extended, and head rotated to the contralateral side
A vertical neck incision along the anterior border of the SCM muscle is routinely utilized
dissection is carried through skin, subcutaneous tissue, and platysma,
posterolateral retraction of the SCM provides exposure to all vital structures.
the vascular structures are typically explored first by opening the carotid sheath.
Division of the middle thyroid and facial veins will facilitate complete visualization the carotid artery, which lies deep and medial to the internal jugular vein.
Attention is then turned to the aerodigestive tract with care taken not to injure the recurrent laryngeal nerve, which lies in the tracheoesophageal groove.
Mobilization of the esophagus is accomplished
dissecting in the posterior areolar plane and then encircling the esophagus with a Penrose drain to facilitate rotation and circumferential inspection.
The larynx and trachea should be visualized and palpated for signs of injury.
This may require mobilization of the thyroid and/ or division of strap muscles.
Intraoperative esophagoscopy and bronchoscopy are often utilized to supplement direct open examination and minimize the incidence of missed injuries.
rule of nines
entire head / face = 9
(neck alone 1%)
entire upper extremity = 9
entire lower extremity = 18
anterior trunk ( chest and abdomen) = 18
posterior trunk ( upper and lower back) = 18
start with burns over 10% (or 20% clinical scenarios)
must add maintenance (+glucose):
4, 2, 1
1-10 kg: 4 mL/kilogram
10-20 kg: 40 mL / h + 2 mL /kg/hr
>20 kg: 20 mL / h + 1 mL / kg / hr
Greater than 60% fatal
first 1/2 of parkland over first 8 hr
the rest over the next 16 hours
A general rule for burn excision
has been to limit the operative time to
Skin grafts thickness
very thin more likely to take on the wound
mount of contracture of the graft will be greater
due to the small amount of dermal tissue
Donor sites taken thicker will have more dermis and will contract less; therefore, these types of thicker grafts are more desirable in areas of high mobility, such as the hands, antecubital fossa, neck, and face.
Donor sites are typically taken at
0.010 to 0.012 inch thick,
"ten onethousandth of an inch"
and for areas needing thicker grafts the thickness is commonly 0.018 inch.
As a general rule, donor sites taken at 0.010 inch take about 10 to 14 days to heal.
A skin graft that is applied in a sheet fashion will commonly contract about 30%, and a graft that is meshed 1.5: 1 will commonly retain the original size of the donor site. Faces and necks are universally grafted with thick sheet grafts or full-thickness grafts. Hands are commonly grafted with either sheet or nonexpanded 1: 1 split-thickness grafts. Expanded mesh grafts are used to a variable degree based
Past medical illness/pregnancy
Events such as environment related to the injury
What is the primary survey
B breathing and ventilation
C circulation with hemorrhage control
D disability (narrow exam)
E exposure/environment control (warm pt)
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.
Bladder injury work up
CT cystography is now the standard in most trauma centers.
This is performed by back-filling the bladder with 350 mL of contrast.
Sensitivity and specificity are 95% and 100%, respectively.
"pain and temp are fancy they cross twice"
motor is simple
True injury to one half of the spinal cord.
ipsilateral loss of motor control
contralateral loss of pain and temperature sensation.
This injury may occur due to penetrating trauma, disc herniation, vasculitis and radiation exposure.
algorrhythm in order for trauma work up
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
Cerebral perfusion pressure should be kept at
Seizure prophylaxis is also recommended for what duration
the first 7 days with phenytoin.
Burn center referral guidelines:
FULL thickness burn!
>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.
describe non op management of liver injury
hemoglobin monitoring, bed rest or reimaging.
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:
Bilious drainage may necessitate ERCP and sphincterotomy.
(no evidence that supports frequent)
Brain death relies primarily
Not dead yet if ANY ONE is present..
oculovestibular (cold calorics)
oculocephalic (doll's eyes)
An apnea test prerequisites:
diabetes insipidus corrected to a positive fluid balance
Off of seditives
core temperature of 36.5 C
SBP greater than 90
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.
look 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
arterial PCO2 is 60 mmHg, the apnea test
result is positive.
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.
according to ATLS guidelines what is the secondary survey
to identify any missed injuries
1. History (AMPLE)
2. head to toe physical examination,
3. additional procedures
4. specialized imaging
Hypotension in pediatrics may be defined as
when is appropriate to use interosseous infusion
less than 6
but also used as last resort and adults now
management of anal rectal injury with sphincter involvement
ELECTIVE overlapping sphincteroplasty after associated soft tissue injury as healed and sphincter is fibrosed
management of Combined rectal and genital urinary injury
Primary repair of both
Interposition of viable tissue between repairs
DIVERSION of fecal and urinary streams
motor, propio, vibration are primal feelings - same side - simple
sensation pain and temp:
fancy fine contra latera and 2 verts down
1-4% and vital injury
right or left half of spinal cord was transected
below level of lesion
Central cord syndrome seen in patients with
classic cervical spondylosis
Sensory loss below level lesion
Can be preserved:
Anterior cord syndrome
Anterior ALS fancy perserved
AAA spinal cord ischemia - lumbar drain
hyperesthesia and hypoesthesia at level
Posterior cord syndrome
p is for p
below level of injury
The conus medullaris syndrome Injury of
saddle = cone
sacral cord and lumbar nerve roots
Reflex bladder and bowel
Variable lower extremity weakness
Cauda equina syndrome
saddle = cauda EQUINE
Similar to conus medullaris syndrome
But ASYMMETRIC lower extremity weakness
Chest x-ray findings suggesting ascending thoracic aortic tear
Abnormal aortic contour
New gastric tube shift
Left apical cap
Left or right paraspinal stripe thickening
Depressed left mainstem bronchus
The obliteration of aortic pulmonary window
Left pulmonary hilar hematoma
Patient with refractory cardiogenic shock after blunt cardiac injury what is treatment
aortic balloon pump
Howe is a grade 1 duodenal hematoma managed
Involves a single portion of duodenum
Fusiform mass resolves over 2-4 weeks success 90%
if he does not resolve and 3-4 weeks
in the case that hematoma cannot be evacuated during the operation any time:
screen for H. pylori ( antibiotic eradication if positive)
Significant other injuries
Positive DPL blunt trauma 4 reliable past need 250 milliliters of return
10 mL gross blood
100,000 cc RBC Blunt
5000-10,000 cc RBC penetrating
Any vegetable or fecal matter
aggressive management to control her ICP
Usual and ICP increases more than 20-25 mm mercury
decreased pCO2 not lowered and 30-35
3% (or 7%) saline Titrated serum sodium-155-160
Ventriculostomy required ventricular space
Barbiturate coma lower cerebral metabolism and ICP
Decompressive craniotomy controversial to lower ICP may be more effective in children when performed early
Cerebral perfusion pressure map minus ICP
Normal 80 mmHg
what concomitant injury to the lower extremity absolute contraindication in attempt to salvage
Defect associated with tibial nerve transection
superficial and deep posterior compartments
Anesthesia plantar surface of foot
Defect with loss of deep peroneal nerve
Numbness first web space
First compartment to be effective in compartment syndrome of the lower extremity
With deficit Anterior compartment
DEEP peroneal nerve (even though anterior compartment)
Numbness first web space
Compartment most commonly inadequately decompressed in compartment syndrome of lower leg
With is nerve and deficit
what is exposure
The posterior compartment
tibial nerve-devastating consequences
Access requires detaching soleus muscle from tibia
Management injury pancreatic duct to the right of superior mesenteric vessels with pancreatic head intact
Drainage and subsequent pancreatic enteric anastomosis
Guidelines for the Management of Severe Brain Injury indicates ICP monitoring of all patients with
postresuscitation GCS score equal to or less than 8
have any CT evidence of intracranial pathology
have a NORMAL CT scan but two or three of the following:
(a) age greater than 40 years;
(b) any history of hypotension;
(c) abnormal motor posturing.
ICP monitoring should also be considered in any patient with a GCS of 12 or less who cannot be closely monitored clinically or whose CT scan demonstrates evidence of intracranial hypertension (i.e., mass lesion, obscured or absent basal cisterns, or midline shift).
During celiotomy for trauma, the following are indications for cesarean section:
maternal shock - uncontrollable
threat to life from exsanguination (injury or disseminated intravascular coagulation),
risk of fetal distress exceeding risk of prematurity,
unstable thoracolumbar spinal injury.
indications for angio / w/u with posterior Dislocation of the knee
In the past, it was recommended that all patients with a dislocated knee undergo an angiogram for popliteal artery evaluation.
Studies have now shown that for patients that are alert and able to give a
reliable exam and no diminished pulse or ABI >0.9(- 1.0)
observation for 12-24 hours is all that is needed.
Imaging is necessary when:
there are signs of diminished or absent pulses or with an ABI that is
replace SMA injury in contaminated trauma field with what is best conduit
with INTERNAL iliac
management of zone one injury
Diaphragm to sacrum
Renal hilum lateral
Proximal renal vessels
Both penetrating and blood injuries with hematoma should be explored surgically
Zone 2 retroperitoneal injury
Blunt injuries and hematoma did not need to be explored
Unless associated colon injury, urinoma, expanding hematoma
Stone to penetrating injuries with hematoma are explored
Zone 3 retroperitoneal injury
inferior central -
Stable non-expanding hematomas nonoperative
Hematomas from penetrating injury may need exploration
2 - mild systemic disease
3-severe systemic disease
4-severe systemic disease that is consistent with threat to life (unstable angina)
5-morbnd patient does not expected to survive without intervention
lack of any adjustment and intubation difficulty
Intraoperative choices to administer and bleeding hemophilia A in order of preference
factor 8 and fibrinogen
Increase myocardial oxygen consumption
Increased intracranial pressure
most common cause of bleeding from pelvic fracture and zone 3 hematoma
sacroiliac joint associated arterial bleeding
Usually branch of the internal iliac artery
went blood work findings are seen with complete asplenia
Howell-Jolly bodies - no more spleen to filter is out
Workup and treatment for suspected hemobilia
first endoscopy - Rules out other sources
angioma and embolectomy definitive
most minor hemobilia is managed conservatively
shock from blunt trauma differential diagnosis
This patient presents with shock from blunt Hemorrhage
Extremity/ long bone
Spinal cord injury
MI / arrhythmia
type and screen,
complete blood count,
what may IR embolize if you bring them a bleeding pelvs
internal pudendal artery
Intraoperative control of pelvic bleeding
Ligation of the hypogastric arteries is one technique to control pelvic arterial bleeding, (but may be complicated by difficult exposure and distorted anatomy in the face of an extensive retroperitoneal hematoma)
Venous pelvic bleeding usually arises from cancellous bone or the sacral venous plexus,
(difficult or impossible to control with ligation)
This type of pelvic bleeding is best controlled by tamponade.
tightly packing the pelvis via an intraperitoneal approach in combination with temporary abdominal closure.
Postoperatively, the patient may need to be managed with angiography and embolization if there is continued hemorrhage.
describe the perfect intubation language
After rapid sequence induction of anesthesia direct laryngoscopy is performed with in-line cervical stabilization and cricoid pressure
after removing the anterior portion of the cervical spine collar.
Mallampati scoring system, which is a description of how much of the oropharynx can be visualized. A Class III (no visualization of the uvula but the soft palate can be seen) or Class IV (even the soft palate cannot be visualized) Mallampati score alerts to the likelihood of both difficult mask ventilation and intubation with direct laryngoscopy. Alternative airway devices and airway expert consultation should be obtained immediately.
managing an unsuccessful intubation.
initial intubation attempt is unsuccessful, the pulse-ox reading should be noted while optimizing intubation conditions for subsequent attempts.
If the saturation is already dropping below 90%, further intubation attempts should not be attempted!
Oxygenation and ventilation with bag mask should be attempted immediately, while calling for a surgical airway kit and preparing for surgical airway.
A surgical airway is not the next step, but parallel preparations should be made.
If the bag-mask ventilation is successful, the patient is “re” preoxygenated before subsequent attempts at intubation utilizing alternate airway techniques by an airway expert familiar with alternate devices.
If bag-mask ventilation is unsuccessful, a laryngeal mask airway (LMA) should be placed.
If LMA placement is successful and ventilation through the LMA is adequate, an airway expert may then consider trans-LMA intubating techniques.
If LMA placement is UNsuccessful, or inadequate at providing effective oxygenation, a surgical airway should be promptly established
Of critical importance is the immediate call for help from experienced providers if the initial attempt at intubation is unsuccessful.
We recommend against the use of advanced alternative airway devices (video laryngoscope, intubating supraglottic airways, fiberoptic intubations, etc.) by inexperienced providers.
Just as an anesthesiologist is unlikely to safely perform an appendectomy (even after observing the procedure hundreds of times), it is unlikely that a surgical team member will be successful in using advanced, alternative airway devices in a critical situation. The strong focus should
Melker cricothyrotomy kit
18 ga crycoid membr (air return)
advance dilator deflated airway cath assemble over wire
remove dilator / wire
pediatric tube sizes
Tips to Remember:
Children 1 year or older (uncuffed):
age/4 + 4
Use uncuffed tubes in children under 7 years.
Pediatric NG tube or Foley size =
ET tube size x 2.
ET tube length (in cm) at the teeth =
ET tube size x 3.
Pediatric chest tube size =
ET tube size x 4.
management of bile leak after liver lac from trauma
ERCP to document the level of the leak and rule out extrahepatic ductal injury either from the trauma or my pringle,
I expect it to be in the parenchyma.
I would have them do a sphincterotomy and stent placement to overcome the 10mmHg pressure gradient across the sphincter which allows most, and by most I mean 95+% of bile leaks to resolve.
I warm him with a rapid rewarmer after placing cordis...
What do you watch for when releasing the superficial and deep components of the Posterior compartment
Blunt trauma to the carotid
grade 1-4 get anticoagulation
low grade - anticoagulate - reck scan 7 days and stop anticoag if lesion is gone
grade 3 - embolize
grade 5 (transection) - repair
if hint of flow fix it
every one gets explored if penetrating even if just a little ditzle
if there is no flow done.
Active extrav of spleen
if stable go to IR
this is complete emoliztion of splenic artery
blunt trauma with kidney that does not light up
just leave it alone
don't even have IR squirt them even if they are already in there
penetrating chest trauma
FIRST make sure not one of the immeidate probs:
Massive liver lac stepS
pingle (gastrohepatic ligament)
thrombin / surgicel ...
pack omentum in there and compression
Proximal and distal control for right subclavian artery penetrating trauma
Proximal control is median sternotomy
Distal controls axillary artery
And for a coffee can where approach
Proximal and distal control for left subclavian artery penetrating trauma
ant lat thoracotomy proximal control
Distal control second intercostal space versus supraclavicular
Where are concerning fetal heart Tone findings
Rapid a acceleration
Accepted Indications for ed thoracotomy
Penetrating thoracic injury:
Traumatic arrest with previously witnessed cardiac activity
(prehospital or in-hospital)
Unresponsive hypotension (BP 1,500 mL)
Penetrating thoracic injury:
Traumatic arrest WITHOUT previously witnessed cardiac activity
Penetrating NONTHORACIC injury:
Traumatic arrest with previously witnessed cardiac activity (prehospital or in-hospital)
Blunt THORACIC injuries:
Traumatic arrest with previously witnessed cardiac activity (prehospital or in-hospital)
ED thoracotomy steps
4th intercostal incision
take down inferior pulmonary ligament.
open the parietal pleural and place a vascular clamp across the aorta
If a nasogastric tube (NGT) is present, the NGT can be used to identify the esophagus.
If cardiac tamponade or a cardiac injury is suspected,
open the pericardium, pinch the left lateral aspect with your finger or clamp
anterior to the phrenic nerve and open widely parallel to the nerve sliding scissors along the pericardium.
Pediatric bikes versus auto handlebar the Abdomen
Amylase and lipase
CT recons for chance fracture!
One no movement
Basic bivent settings
Hi peeps 30
low peep 5
2:1 inspiration expiration
What buttress should you use for tracheoesophageal injury