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A ORAL BOARDS 2016 > TRAUMA > Flashcards

Flashcards in TRAUMA Deck (91):
1

Retroperitoneal zones

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

2

Forearm fasciotomy

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

3

Two important details to remember with splenectomy

Leave a dream because of risk of concomitant pancreatic detail injury

Immunize:
Pneumovax
Meningococcus
H flu

4

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

5

What vessel will you tell the IR colleagues to embolize with pelvic fracture

small branches off internal iliac arteries.


6

after prevail in postrenal causes of Gary I have been evaluated what should you look for for renal causes

Gentamicin nephrotoxic medication!

7

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.

Cath-Secure

8

posterior approach to popliteal a /v

curvilinear incision
watch
small saph
sural n
open fascia
retract semiMeninosis retreact Medially
discect out tibial nerve protected
popliteal artery most posterior
popliteal vein most anterior

9

hard signs of neck penetrating injury

“Hard” signs mandating immediate operative exploration without the need for additional diagnostic workup include

shock/ hypotension,
active hemorrhage,
expanding or pulsatile hematoma,
bruit,
loss of pulse,
neurologic deficit,
significant subcutaneous emphysema,
respiratory distress,
air leaking through the neck wound.

10

neck zones

clavicle to crycoid
crycoid to angle mandible
angle mandible to base of skull

11

Work up for penetrating injury violating the platysma in a stable patient without hard signs

CTA
Barium swallow
esophagoscopy
Laryngoscopy bronchoscopy

12

neck exploration

neck exploration

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.

13

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

14

parkland

start with burns over 10% (or 20% clinical scenarios)

Parkland and..
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
40-60%
Greater than 60% fatal

first 1/2 of parkland over first 8 hr
the rest over the next 16 hours

15

A general rule for burn excision

has been to limit the operative time to

16

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

17

trauma history

AMPLE

Allergies
Medications
Past medical illness/pregnancy
Last meal
Events such as environment related to the injury

18

What is the primary survey

A airway
B breathing and ventilation
C circulation with hemorrhage control
D disability (narrow exam)
E exposure/environment control (warm pt)

19

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.

20

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.



21

GCS


Eye:
none
pain
voice
spont


Verbal:
none
Incomprehensible
Inappropriate
Disoriented/confused
Oriented

Motor:
none
Decerebrate
Decorticate
Withdraws
Localizes
follows

22

Brown-Sequard syndrome

"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

and

contralateral loss of pain and temperature sensation.

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

23

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.

Airway

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

24

Cerebral perfusion pressure should be kept at


60

50-70 mmHg.


25

Seizure prophylaxis is also recommended for what duration

the first 7 days with phenytoin.

26

Burn center referral guidelines:


ANY
FULL thickness burn!
electrical
chemical
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.

27

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:

biloma,
bilious ascites
hemoperitoneum

Bilious drainage may necessitate ERCP and sphincterotomy.

(no evidence that supports frequent)

28

Brain death relies primarily

Brainstem reflexes:
Not dead yet if ANY ONE is present..

gag
cough
oculovestibular (cold calorics)
oculocephalic (doll's eyes)
Pupils reactive

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
and
arterial PCO2 is 60 mmHg, the apnea test
result is positive.

Ancillary tests
electroencephalography (EEG)
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.

29


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


30

Hypotension in pediatrics may be defined as



31

when is appropriate to use interosseous infusion


less than 6

but also used as last resort and adults now

32

management of anal rectal injury with sphincter involvement

initial debridement


ELECTIVE overlapping sphincteroplasty after associated soft tissue injury as healed and sphincter is fibrosed

33

management of Combined rectal and genital urinary injury

Primary repair of both

Interposition of viable tissue between repairs

DIVERSION of fecal and urinary streams

34

Brown-Sequard syndrome

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

Loss:
IPSILATERAL
motor
proprioception
vibration?

preserved:
CONTRALATERAL
Pain
Temperature

35

Central cord syndrome seen in patients with

classic cervical spondylosis

Hyperextension


Loss:
UPPER extremity
Motor
bladder

Variable:
Sensory loss below level lesion

Can be preserved:
LOWER extremity

36

Anterior cord syndrome

Anterior ALS fancy perserved

AAA spinal cord ischemia - lumbar drain

poor prognosis

Loss:
COMPLETE paralysis
hyperesthesia and hypoesthesia at level

preserved:
Touch
proprioception
Vibration


37

Posterior cord syndrome

p is for p

LEAST common


Loss Selective:
proprioception
Vibration

below level of injury


38

The conus medullaris syndrome Injury of

saddle = cone

conus
or
sacral cord and lumbar nerve roots

Loss
Sensation-Seidel anesthesia

Reflex bladder and bowel

Variable lower extremity weakness


39


Cauda equina syndrome

saddle = cauda EQUINE


Similar to conus medullaris syndrome

But ASYMMETRIC lower extremity weakness

40

Chest x-ray findings suggesting ascending thoracic aortic tear


wide mediastinum
Abnormal aortic contour
Tracheal shift
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

41

Patient with refractory cardiogenic shock after blunt cardiac injury what is treatment


aortic balloon pump

42

Howe is a grade 1 duodenal hematoma managed


Involves a single portion of duodenum

observed
NG. suction
TPN
Fusiform mass resolves over 2-4 weeks success 90%

if he does not resolve and 3-4 weeks
or
in the case that hematoma cannot be evacuated during the operation any time:

Antecolic gastrojejunostomy
screen for H. pylori ( antibiotic eradication if positive)

Requires no:
hypotension
Peritonitis
Significant other injuries

43

Positive DPL


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
500 WBC
any bile
Any amylase
Any vegetable or fecal matter

44


aggressive management to control her ICP

Usual and ICP increases more than 20-25 mm mercury

decreased pCO2 not lowered and 30-35

Mannitol

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

45

what concomitant injury to the lower extremity absolute contraindication in attempt to salvage


tibial nerve

46

Defect associated with tibial nerve transection


paralysis of
superficial and deep posterior compartments

Anesthesia plantar surface of foot

47

Defect with loss of deep peroneal nerve

anterior compartment

Footdrop

Numbness first web space

48

First compartment to be effective in compartment syndrome of the lower extremity



Blood nerves

With deficit Anterior compartment

DEEP peroneal nerve (even though anterior compartment)

Numbness first web space

49


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


50

Management injury pancreatic duct to the right of superior mesenteric vessels with pancreatic head intact


Drainage and subsequent pancreatic enteric anastomosis

51


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
or
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).

52


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.

53

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

54

replace SMA injury in contaminated trauma field with what is best conduit


with INTERNAL iliac

55

Zone I
management of zone one injury

Central-

Diaphragm to sacrum

Renal hilum lateral
contained
colon
Aorta
Vena cava
Portal vein
Proximal renal vessels
Anchors
Duodenum

Both penetrating and blood injuries with hematoma should be explored surgically

56

Zone 2 retroperitoneal injury

lateral

Renal hilum
Kidneys
Adrenals
Superior ureters

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

57

Zone 3 retroperitoneal injury

inferior central -

pelvis
Iliac vessels
Rectum
Distal sigmoid
Distal ureters

Stable non-expanding hematomas nonoperative

Hematomas from penetrating injury may need exploration

58

ASA classification


one-normal healthy
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
6-brain-dead

lack of any adjustment and intubation difficulty

59

Intraoperative choices to administer and bleeding hemophilia A in order of preference


cryoprecipitate:
factor 8 and fibrinogen

60

contraindications ketamine


myocardial disease
brain lesion
(Downs ok)

Increase myocardial oxygen consumption

Increased intracranial pressure

61

most common cause of bleeding from pelvic fracture and zone 3 hematoma


sacroiliac joint associated arterial bleeding

Usually branch of the internal iliac artery

62

went blood work findings are seen with complete asplenia


Howell-Jolly bodies - no more spleen to filter is out

63

Workup and treatment for suspected hemobilia


first endoscopy - Rules out other sources

angioma and embolectomy definitive

most minor hemobilia is managed conservatively

64

shock from blunt trauma differential diagnosis

This patient presents with shock from blunt Hemorrhage
Thorax
Abdomen
Pelvis
Retroperitoneum
Extremity/ long bone
External
Tension pneumothorax
Cardiac tamponade
Spinal cord injury
MI / arrhythmia

65

trauma labs

type and screen,
complete blood count,
electrolytes,
coagulation studies,
blood gas,
lactate,
base deficit

B HCG
urine tox

66

what may IR embolize if you bring them a bleeding pelvs

internal pudendal artery

sacral artery

67

Intraoperative control of pelvic bleeding

Arterial:
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.

68

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.

69

Mallampati scoring

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.

70

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

71

Melker cricothyrotomy kit

prep
vert incision
18 ga crycoid membr (air return)
wire
remove needle
advance dilator deflated airway cath assemble over wire
remove dilator / wire
inflate balloon
captnography

72

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.

73

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.

74

aggressive rewarm

I warm him with a rapid rewarmer after placing cordis...

NG lavage.

Warm IVF,

bare hugger,

heat lamps

75

What do you watch for when releasing the superficial and deep components of the Posterior compartment

Saphenous vein
And
Saphenous nerve

76

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

unless g

77

penetrating carotid

if hint of flow fix it

every one gets explored if penetrating even if just a little ditzle

if there is no flow done.

78

Active extrav of spleen

if stable go to IR
this is complete emoliztion of splenic artery

79

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

80

penetrating chest trauma

FIRST make sure not one of the immeidate probs:
ptx
tempanod
great vessles

Fast
upright pCXR

81

Massive liver lac stepS

pack
pingle (gastrohepatic ligament)
thrombin / surgicel ...
pack omentum in there and compression

82

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

83

Proximal and distal control for left subclavian artery penetrating trauma

ant lat thoracotomy proximal control

Distal control second intercostal space versus supraclavicular

84

Where are concerning fetal heart Tone findings

Deceleration

Rapid a acceleration

85

Accepted Indications for ed thoracotomy

ACCEPTED INDICATIONS:

Penetrating thoracic injury:

Traumatic arrest with previously witnessed cardiac activity
(prehospital or in-hospital)

Unresponsive hypotension (BP 1,500 mL)

***********************************************
RELATIVE Indications:

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)

86

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.

87

Pediatric bikes versus auto handlebar the Abdomen

Amylase and lipase
CT recons for chance fracture!
Duodenal hematoma

88

GCS

Motor
One no movement
To decerebrate
Three decorticate
For withdraw
Localized
Follow commands

Verbal
None
Incoherent
Incomprehensible
Disoriented
Oriented/Appropriate

eye
None
To pain
To voice
Spontaneous

89

Basic bivent settings

A PRV
Hi peeps 30
low peep 5
Release?
2:1 inspiration expiration

90

What buttress should you use for tracheoesophageal injury

omohyoid

91

Control of the IVC bleeding in liver trauma


Take down triangular ligaments
Take take down coronary ligaments

(Inferior IVC deep to portal vein)

Infrahepatic IVC:
This is at the right lobe
Might need to mobilize:
Might need to perform Koker

Super hepatic IVC:
You need to be in the chest!
You can divide the diaphragm from the belly!
Get it right angles Statinski clamp around it