TRAUMA

Question 1

Retroperitoneal zones

Answer 1

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

Question 2

Forearm fasciotomy

Answer 2

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

Question 3

Two important details to remember with splenectomy

Answer 3

Leave a dream because of risk of concomitant pancreatic detail injury

Immunize:
Pneumovax
Meningococcus
H flu

Question 4

fall from hight abd distension, pelvic fracture, bone fragments on rectal exam.

Answer 4

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

Question 5

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

Answer 5

small branches off internal iliac arteries.

Question 6

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

Answer 6

Gentamicin nephrotoxic medication!

Question 7

Supra pubic catheter placement

Answer 7

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

Question 8

posterior approach to popliteal a /v

Answer 8

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

Question 9

hard signs of neck penetrating injury

Answer 9

“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.

Question 10

neck zones

Answer 10

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

Question 11

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

Answer 11

CTA
Barium swallow
esophagoscopy
Laryngoscopy bronchoscopy

Question 12

neck exploration

Answer 12

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.

Question 13

rule of nines

Answer 13

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

Question 14

parkland

Answer 14

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

Question 15

A general rule for burn excision

Answer 15

has been to limit the operative time to

Question 16

Skin grafts thickness

Answer 16

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

Question 17

trauma history

Answer 17

AMPLE

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

Question 18

What is the primary survey

Answer 18

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

Question 19

management of Urinary extravasation from kindey

Answer 19

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.

Question 20

Bladder injury work up

Answer 20

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.

Question 21

GCS

Answer 21

Eye:
none
pain
voice
spont 

Verbal:
none
Incomprehensible
Inappropriate
Disoriented/confused
Oriented

Motor:
none
Decerebrate
Decorticate
Withdraws
Localizes
follows

Question 22

Brown-Sequard syndrome

Answer 22

“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.

Question 23

algorrhythm in order for trauma work up

Answer 23

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

Question 24

Cerebral perfusion pressure should be kept at

Answer 24

60

50-70 mmHg.

Question 25

Seizure prophylaxis is also recommended for what duration

Answer 25

the first 7 days with phenytoin.

Question 26

Burn center referral guidelines:

Answer 26

``` 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.

Question 27

describe non op management of liver injury

Answer 27

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)

Question 28

Brain death relies primarily

Answer 28

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.

Question 29

according to ATLS guidelines what is the secondary survey

Answer 29

to identify any missed injuries 1. History (AMPLE) 2. head to toe physical examination, 3. additional procedures 4. specialized imaging

Question 30

Hypotension in pediatrics may be defined as

Question 31

when is appropriate to use interosseous infusion

Answer 31

less than 6 but also used as last resort and adults now

Question 32

management of anal rectal injury with sphincter involvement

Answer 32

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

Question 33

management of Combined rectal and genital urinary injury

Answer 33

Primary repair of both Interposition of viable tissue between repairs DIVERSION of fecal and urinary streams

Question 34

Brown-Sequard syndrome

Answer 34

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

Question 35

Central cord syndrome seen in patients with

Answer 35

classic cervical spondylosis Hyperextension Loss: UPPER extremity Motor bladder Variable: Sensory loss below level lesion Can be preserved: LOWER extremity

Question 36

Anterior cord syndrome

Answer 36

Anterior ALS fancy perserved AAA spinal cord ischemia - lumbar drain poor prognosis Loss: COMPLETE paralysis hyperesthesia and hypoesthesia at level preserved: Touch proprioception Vibration

Question 37

Posterior cord syndrome

Answer 37

p is for p LEAST common Loss Selective: proprioception Vibration below level of injury

Question 38

The conus medullaris syndrome Injury of

Answer 38

saddle = cone conus or sacral cord and lumbar nerve roots Loss Sensation-Seidel anesthesia Reflex bladder and bowel Variable lower extremity weakness

Question 39

Cauda equina syndrome

Answer 39

saddle = cauda EQUINE Similar to conus medullaris syndrome But ASYMMETRIC lower extremity weakness

Question 40

Chest x-ray findings suggesting ascending thoracic aortic tear

Answer 40

``` 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 ```

Question 41

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

Answer 41

aortic balloon pump

Question 42

Howe is a grade 1 duodenal hematoma managed

Answer 42

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

Question 43

Positive DPL

Answer 43

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 ```

Question 44

aggressive management to control her ICP

Answer 44

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

Question 45

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

Answer 45

tibial nerve

Question 46

Defect associated with tibial nerve transection

Answer 46

paralysis of superficial and deep posterior compartments Anesthesia plantar surface of foot

Question 47

Defect with loss of deep peroneal nerve

Answer 47

anterior compartment Footdrop Numbness first web space

Question 48

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

Answer 48

Blood nerves With deficit Anterior compartment DEEP peroneal nerve (even though anterior compartment) Numbness first web space

Question 49

Compartment most commonly inadequately decompressed in compartment syndrome of lower leg With is nerve and deficit what is exposure

Answer 49

The posterior compartment tibial nerve-devastating consequences Access requires detaching soleus muscle from tibia

Question 50

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

Answer 50

Drainage and subsequent pancreatic enteric anastomosis

Question 51

Guidelines for the Management of Severe Brain Injury indicates ICP monitoring of all patients with

Answer 51

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).

Question 52

During celiotomy for trauma, the following are indications for cesarean section:

Answer 52

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.

Question 53

indications for angio / w/u with posterior Dislocation of the knee

Answer 53

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

Question 54

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

Answer 54

with INTERNAL iliac

Question 55

Zone I | management of zone one injury

Answer 55

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

Question 56

Zone 2 retroperitoneal injury

Answer 56

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

Question 57

Zone 3 retroperitoneal injury

Answer 57

inferior central - ``` pelvis Iliac vessels Rectum Distal sigmoid Distal ureters ``` Stable non-expanding hematomas nonoperative Hematomas from penetrating injury may need exploration

Question 58

ASA classification

Answer 58

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

Question 59

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

Answer 59

cryoprecipitate: | factor 8 and fibrinogen

Question 60

contraindications ketamine

Answer 60

myocardial disease brain lesion (Downs ok) Increase myocardial oxygen consumption Increased intracranial pressure

Question 61

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

Answer 61

sacroiliac joint associated arterial bleeding Usually branch of the internal iliac artery

Question 62

went blood work findings are seen with complete asplenia

Answer 62

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

Question 63

Workup and treatment for suspected hemobilia

Answer 63

first endoscopy - Rules out other sources angioma and embolectomy definitive most minor hemobilia is managed conservatively

Question 64

shock from blunt trauma differential diagnosis

Answer 64

``` 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 ```

Question 65

trauma labs

Answer 65

``` type and screen, complete blood count, electrolytes, coagulation studies, blood gas, lactate, base deficit ``` B HCG urine tox

Question 66

what may IR embolize if you bring them a bleeding pelvs

Answer 66

internal pudendal artery sacral artery

Question 67

Intraoperative control of pelvic bleeding

Answer 67

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.

Question 68

describe the perfect intubation language

Answer 68

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.

Question 69

Mallampati scoring

Answer 69

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.

Question 70

managing an unsuccessful intubation.

Answer 70

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

Question 71

Melker cricothyrotomy kit

Answer 71

``` 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 ```

Question 72

pediatric tube sizes

Answer 72

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.

Question 73

management of bile leak after liver lac from trauma

Answer 73

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.

Question 74

aggressive rewarm

Answer 74

I warm him with a rapid rewarmer after placing cordis... NG lavage. Warm IVF, bare hugger, heat lamps

Question 75

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

Answer 75

Saphenous vein And Saphenous nerve

Question 76

Blunt trauma to the carotid

Answer 76

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

Question 77

penetrating carotid

Answer 77

if hint of flow fix it every one gets explored if penetrating even if just a little ditzle if there is no flow done.

Question 78

Active extrav of spleen

Answer 78

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

Question 79

blunt trauma with kidney that does not light up

Answer 79

just leave it alone don't even have IR squirt them even if they are already in there

Question 80

penetrating chest trauma

Answer 80

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

Question 81

Massive liver lac stepS

Answer 81

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

Question 82

Proximal and distal control for right subclavian artery penetrating trauma

Answer 82

Proximal control is median sternotomy Distal controls axillary artery And for a coffee can where approach

Question 83

Proximal and distal control for left subclavian artery penetrating trauma

Answer 83

ant lat thoracotomy proximal control Distal control second intercostal space versus supraclavicular

Question 84

Where are concerning fetal heart Tone findings

Answer 84

Deceleration Rapid a acceleration

Question 85

Accepted Indications for ed thoracotomy

Answer 85

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)

Question 86

ED thoracotomy steps

Answer 86

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.

Question 87

Pediatric bikes versus auto handlebar the Abdomen

Answer 87

Amylase and lipase CT recons for chance fracture! Duodenal hematoma

Question 88

GCS

Answer 88

``` 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 ```

Question 89

Basic bivent settings

Answer 89

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

Question 90

What buttress should you use for tracheoesophageal injury

Answer 90

omohyoid

Question 91

Control of the IVC bleeding in liver trauma

Answer 91

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