TRAUMA

Question 1

burr hole

Answer 1

Patient with reduced GCS ( 8

• No Imaging*
• Neurosurgical intervention available in a reasonable time frame.

The hand held drill (which can be a Hudson-Brace or air powered drill) should have a specific perforator (e.g. a 14 mm perforator clutch drill bit (26-1221, Codman, Johnson and Johnson, Chicago, USA),

Confirm position of haematoma on CT scan and be able to view images while performing procedure (Figure ​(Figure2).2).

Mark the patients shoulder that corresponds to the side of the haematoma.

Haematomas most commonly occur in the temporal region. Frontal, parietal, and rarely posterior fossa haematomas also occur.

Count down the number of slices to calculate how many centimetres below the vertex the burr hole should be.

(1, temporal (above zygoma), 2 frontal (over the coronal suture, approx 10 cm behind and in the mid-pupillary line) and 3 parietal (over the parietal eminence)

Shave

Mark a 3 cm incision.

chlorhexidine

Make an incision straight down to bone. Bleeding (e.g. from the superficial temporal artery) can be controlled with direct pressure while continuing the procedure.

Push the periosteum off the bone with knife/swab

insert self-retaining retractor

Push down firmly with drill and start drilling keeping drill perpendicular to the skull. Ensure an assistant is holding the head still and ideally apply saline wash as you drill.

Keep going - do NOT stop (as this will disengage the clutch mechanism which can be difficult to re-engage manually)

Drill until the drill bit stops spinning. Remove drill.

Use blunt hook to remove remaining bone fragments.

Extradural blood should now escape.

*If the blood is subdural, very carefully open the dura using a sharp hook to tent the dura up, and a new sharp knife to incise the dura in a cruciate manner. Subdural blood is likely to be more clotted and difficult to extrude than extradural. Manual removal of clot (e.g. with forceps or very careful suction) could be considered, but may damage brain and is unlikely to remove sufficient haematoma. If no blood is found either extra or sub-durally, stop, check side, and check location of hole. DO NOT DELAY TRANSFER.

If fresh blood is continuing to ooze from the wound, do NOT try to tamponade. Leaving the self-retainer in place may stop the bleeding. Try to diathermy skin edges; if not available, apply direct pressure to wound edges during transfer.

Question 2

spleen preservation

Answer 2

: I would do everything I could to salvage the spleen in this 14 year old boy. I would compress it and do splenorrhaphy, wrapping the spleen with a vicryl mesh.

Question 3

neck exploration

Answer 3

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

dissection through skin, subcutaneous tissue, and platysma,

posterolateral retraction of the SCM

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
care taken not to injure the recurrent laryngeal nerve, which lies in the tracheoesophageal groove.

Mobilization of the esophagus with 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
to supplement direct open examination and minimize the incidence of missed injuries.

Question 4

Bladder lacerations are repaired how

Answer 4

AFTER inspecting the urethral oriphesous

2-0 Chromic

first layer mucosa and muscularis,

and

the second layer muscularis and serosa.

Closed suction drains are then placed.

10 to 14 days with either a Foley or suprapubic cystostomy.

Repeat cystography is performed prior to removal to ensure healing

Question 5

To perform an open cricothyrotomy steps

Answer 5

First,
cricothyoid membrane is identified immediately caudad to the thyroid cartilage.

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

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 normal size ET tube is inserted into the trachea and the cuff is inflated.

Question 6

tracheoinnominate fistula management

Answer 6

first step should overinflation of the tracheostomy / endotracheal tube cuff for attempted tamponade.

If unsuccessful,

digital compression of the artery against the sternum

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

insert oral endotracheal tube after successful arterial compression.

Diagnosis may require bronchoscopy and wound exploration if found early

NO Primary repair due to high risk for failure and associated mortality.

Question 7

biloma tx algorrhthm

Answer 7

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!)

Question 8

management of Urinary extravasation from kindey

Answer 8

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 9

Damage control moves if ureters transected

Answer 9

bring up to skin

temporary cutaneous ureterostomy over a
single-J ureteral stent
or
pediatric feeding tube

No extra time should be spent mobilizing ureter to bring it to the skin rather tie should be placed around the ureter and stent should be brought out through the skin

Last resort:
Ureter ligated proximal to injury followed by percutaneous nephrostomy when patient becomes stable (this is not intraoperative nephrostomy-time too time consuming)

Question 10

Diagnosis of ureteral injury

Answer 10

gold standard:
CT urography with delayed cuts ( no longer intravenous urography)

Not reliable:
Microscopic/gross hematuria
Intravenous urography and-NO

too time-consuming:
retrograde pyelography

Question 11

named vessels that may be ligated in trauma

Answer 11

INFRA- renal IVC

superior mesenteric VEIN - Repair is preferred

radial artery
Ulnar artery the

may ligate one out of 3 palpable vessels in the lower extremity

Subclavian artery ligation well-tolerated due to collaterals of shoulder

Question 12

Name the vessels that cannot be ligated in trauma

Answer 12

superior vena
(cava-superior vena cava syndrome)

RIGHT Renal veins
(Left renal vein close to IVC is well-tolerated as drainage can occur from adrenal, gonadal, iliolumbar veins)

SUPRA-renal IVC

Portal vein
if ligated must compensate for dramatic transient edema and bowel

Carotid artery
(this is relative since can rely on contralateral)
(may ligate external carotid)

Innominate artery

Brachial artery

Superior mesenteric artery

Proper hepatic artery

Iliac artery 
(may ligate the internal iliac hypogastric)

Femoral artery
(may ligate profunda proably)

Popliteal artery

Aorta

Question 13

exposure for innominate artery injury

Answer 13

median sternotomy

Question 14

Exposure for left subclavian artery injury

Answer 14

left anterior lateral thoracotomy

Question 15

list the preferred algorithm for access an 11-month-old, patient

Answer 15

antecubital fossa
Percutaneous saphenous vein
Intraoseus cannulation
Proximal tibia
Followed by a reattempt at peripheral access went resuscitation through IO
if bilateral tibial injury distal femur just above femoral condyle
Saphenous cutdown recommended age 1-6

alternatives:
Younger than 6 Percutaneous femoral vein - blood associated with thrombosis and kids

Question 16

major vessels are accessed with median sternotomy

Answer 16

innominate
Proximal RIGHT subclavian
Proximal RIGHT common carotid
Proximal LEFT common carotid

Question 17

Exposure for proximal vertebral artery

Answer 17

takeoff of this vessel is from subclavian artery

Access easy from the supraclavicular incision-

division anterior scalene

divide clavicle head of sternocleidomastoid

Protect phrenic nerve there overlies SMA

protect thoracic duct LEFT

Question 18

exposure of midportion vertebral artery

Answer 18

travels through bony foramen adjacent to vertebral body - basically screwed

Question 19

exposure of proximal left subclavian artery

Answer 19

challenging

Arises from aortic arch posteriorly

BEST anterior lateral thoracotomy third intercostal space with distal control via a supraclavicular approach

Occasionally, and medial head of clavicle resected as well as partial median sternotomy trapdoor thoracotomy

(NOT approachable from just a median sternotomy)

Question 20

Cattell maneuver

Answer 20

“Cattle- slow moving blood” IVC
From the right
rotation of cecum and ascending colon to the left
to expose right-sided pancreatic head an IVC

Incised peritoneal reflection, white line of Toldt,

pancreatic surgeons are like cattle

medial visceral rotation of the right-sided organs to bring them into the midline.

It can be regarded as an extension of a Kocher’s manoeuvre;

where as a Kocher’s lifts the duodenum off the retroperitoneum, i

dissection is then continued down the right-sided white line of Toldt

and then across the small bowel mesenteric root

Question 21

Kocker maneuver

Answer 21

cephalad mobilization and medial rotation of the duodenum-

exposes suprarenal IVC below liver
!cannot get to celiac access!

Question 22

Mattox maneuver

Answer 22

Mattox maneuver

Left-sided medial visceral rotation (Mattox maneuver)

exposes the entire length of the abdominal aorta and its branches (except the right renal artery).

incising the lateral peritoneal attachment of the sigmoid and LEFT colon.

The plane of dissection is developed bluntly in front of the left common iliac vessels and behind the kidney,

Question 23

distal IVC and iliac vein bifurcation exposure in dying patient

Answer 23

cut through right common iliac artery

Repair of his artery primarily before closing

Question 24

Exposure of massive bleeding junction of SMA, splenic vein, portal vein in dying pateint

Answer 24

dividing neck of pancreas!

Question 25

Why is cricothyroidotomy contraindicated the patient's under the age of 8-12

Answer 25

risk of subglottic stenosis Do tracheostomy instead

Question 26

when he is emergent tracheostomy indicated instead of cricothyroidotomy

Answer 26

patient under the age of 8-12 (can jet vent through cricoid membrane until you get them up there) Laryngeal tracheal separation Laryngeal fracture truly emergent tracheostomy requires sternal saw on back up

Question 27

indicated emergency department thoracotomy

Answer 27

Clearly indicated: PENETRATING thoracic injury with signs of live and patient not responding to fluids then loss of vital signs in the emergency department within 10 minutes of arrival Possibly indicated: PENETRATING abdominal trauma with at least one field sign of life and less than 15 minutes of CPR BLUNT trauma initial field signs of life and loss of signs of life within 5 minutes of arrival to emergency department CONTRAINDICATED: No field signs of life penetrating and blunt trauma Blunt trauma with greater than 5 minutes prehospital CPR Penetrating trauma with greater than 15 minutes of CPR

Question 28

If broncho- venous air embolism what is you the move you make

Answer 28

clamp pulmonary hilum

Question 29

Treatment of bronchial venous fistula from acute trauma

Answer 29

Air embolism as an into the left ventricle impedes diastolic filling Trendelenburg-trapped air and to apex the ventricle Emergency thoracotomy (NOT median sternotomy) -cross-clamp pulmonary hilum on site of injury Aspirate air from the apex of left ventricle and aortic root with 18-gauge needle Vigorous massage for sparing through coronary arteries (endotracheal epinephrine keep air from brain) Once there removed, keep patient in Trendelenburg with pulmonary hilum clamped until pulmonary venous injury is controlled

Question 30

why is primary repair of carotid artery injury controversial the patient has neurologic deficit

Answer 30

may convert ischemic stroke into hemorrhagic stroke Cameron recommends repair in this setting with controlled intracerebral pressure

Question 31

diagnostic peritoneal lavage

Answer 31

anterior abdominal stab wound positive: 10 mL frank blood Gastric contents ``` Microcytic: Greater than 100,000 RBC wbc greater than 500 Amylase crit of 19 Alkaline phosphatase greater than 2 Bilirubin greater than 0.01 ``` Thoracoabdominal stab wound: Rbc greater than 10,000 the rest of the same the

Question 32

Duodenal hematoma if have to operate, what is the approach

Answer 32

Exploratory laparotomy if: Contrast extravasation or free air indicating free perforation Evacuation hematoma partial thickness incision duodenal wall followed by closure equal success but fewer complications in the bypass? (gastro-J)

Question 33

treatment of a thrombosed penetrating trauma injury to the carotid

Answer 33

repair with neurologic deficit provided backbleeding from the internal carotid While harvesting vein temporary shunt should be placed graft is - saphenous preferred providing patient is stabilized

Question 34

Duodenal Exposure

Answer 34

Exposure of the duodenal loop and pancreatic head is achieved using a combination of the Kocher and the Cattell-Braasch maneuvers: The surgeon may also elect to divide the ligament of Treitz to further expose the fourth portion of the duodenum and the duodenojejunal junction. ``` divide retroperitoneal attachments of the hepatic flexure of the colon gastrocolic ligament gain access to the lateral aspect of the second portion of the duodenum. ``` A Kocher maneuver is performed by incising the peritoneum laterally to the duodenal C-loop then mobilizing the duodenum and the pancreatic head medially. This will allow visualization of the majority of the first, second, and a portion of the third section of the duodenum. The Cattell-Braasch maneuver is a full right to medial visceral rotation including the right colon and small bowel. white line of Toldt is incised lateral to the right colon right colon and cecum are mobilized medially. protect the right ureter in the process. the base of the bowel mesentery, is also mobilized from the right lower quadrant to the ligament of Treitz. This exercise will further expose the third and the fourth portions of the duodenum with additional mobilization provided by division of the ligament of Treitz itself. Once the full medial visceral rotation is performed, the surgeon also has access to all of the right-sided retroperitoneal organs and vascular structures including the IVC, right renal complex, the superior mesenteric blood vessels.

Question 35

Assessment of how to Repair duodenum

Answer 35

assess whether the duodenal papilla is involved If uncertainty exists, a cholecystectomy and an on-table cholangiogram can be performed to assess the common bile duct. Passing a balloon catheter (“ biliary Fogarty”) or a similar small catheter through the cystic duct stump following cholecystectomy and feeding it distally can prove to be a simple maneuver to identify the relationship of the ampulla to the area of injury.

Question 36

types of duodenal repair

Answer 36

Most simple duodenal injuries are closed primarily Complex duodenal injuries > 50% of the duodenal circumference or more than a simple perforation) will require selection of a more complex repair double-layer closure technique in a transverse fashion to avoid narrowing the bowel lumen. Suture lines may be buttressed with an omental flap or a serosal flap by oversewing with a loop/ limb of jejunum. more extensive lacerations which cannot be closed primarily,: create a Roux limb of jejunum and use it to repair the luminal defect by constructing a duodenojejunostomy in a side-toside fashion. Pyloric exclusion can offer protection of a fresh suture line and temporarily redirect gastric outflow To create pyloric exclusion: distal longitudinal gastrostomy is made on the anterior surface of the stomach. The pyloric ring is grasped with an Allis clamp, pulled into the stomach and oversewn with a running 2-0 or 3-0 Prolene suture. Another option is to staple the pylorus shut with a thoracoabdominal (TA) stapler. A draining loop gastrojejunostomy is then fashioned. More complex repairs such as duodenal diverticularization (biliary and pancreatic diversion from the affected duodenum): have become less favored with the more frequent use of a pyloric exclusion approach. Decompression of a duodenal repair with an antegrade or a retrograde duodenostomy tube can reduce the rate of fistula formation. Most simple lacerations of the duodenum can be repaired primarily, and decompression and pyloric exclusion are often not necessary. feed with NJ tube g-tube j-tube

Question 37

One shot IVP:

Answer 37

inject 2mg/kg contrast IV, plain film 10 min later

Question 38

MATTOX PROCEDURE gives you access to what injuries

Answer 38

gain access to: aorta— celiac axis to bifurcation the left kidney, left adrenal gland, left ureter,

Question 39

Mattox | TECHNICAL STEPS

Answer 39

Take down splenorenal ligament and splenophrenic peritoneal reflection and extend down to L paracolic gutter to the level of the distal sigmoid colon ``` A plane of dissection is then bluntly developed between the: spleen, pancreas, colonic mesentery anterior to Gerota’s fascia ``` Bring to the right: left colon, spleen, tail of the pancreas Watch spleen and kidney with this one.

Question 40

If active hemorrhage from supramesocolic aortic area

Answer 40

don’t need to do Mattox, can do following o Packing and aortic compression o Divide lesser omentum o Retract stomach and esophagus to L o Separate the muscle fibers of the crura from the supraceliac aorta o Apply clamp on aorta

Question 41

Temp abdominal closure for damage control

Answer 41

if skin can come together towel clips, placed 1cm apart, or running suture with 2-0 or thicker nylon Bogota Bag: 3-L urology irrigation bag: opened on three sides sutured to skin (preserve fascial integrity for later) Vac-Packing: “pie-crust” holes with non-adherent dressing (like Owen’s gauze or plastic drape) tucked under fascial edges; moist surgical sponges placed over dressing; two large close-suctioned drains place over sponges large adherent plastic drape over entire apparatus; drains immediately connected to continuous wall suction; once granulation tissue forms, can swith to VAC appliance VICRYL mesh closure: sutured to fascia if not planning on returning to OR (ie, non-laparotomy situation) after first OR, or can be used at second OR if fascia still doesn’t come together and some sort of closure required

Question 42

Sub xiphoid pair cardio window

Answer 42

A short vertical incision (about 5-8 cm long) is made over the xiphoid, extending onto the midline of the abdomen The linea alba is incised, the xiphoid is often completely removed. retrosternal space is entered by means of finger dissection. With upward retraction, the diaphragmatic aspect of the pericardium is visualized. he pericardium is grasped with Allis clamp and incised opening in the pericardium is enlarged by sharply incising the pericardium. A sucker is inserted into the pericardial space and the fluid aspirated. Often, this sucker or a finger is used for further dissection of any adhesions. Finally, through a separate stab wound, a tube is inserted into the pericardial space and connected; the incision is closed in layers.[3]

Question 43

left anterior descending coronary artery, and a | laceration to the right ventricle as well next to the artery.

Answer 43

Pass machine: Likely this will need to be ligated and possibly put in aortic balloon pump. If its distal enough it may not have any symptoms. Osler: At this stage, I would like to have the cardiac surgeons around. Ventricular laceration repaired 3-0 Prolene with wide pledgets. The left anterior decending artery many times has to be ligated, if it is directly injured and then bypassed distally. I will most likely use a vein graft. For that, I would prefer that a cardiac surgeon be around. The LAD supplies blood to the anterior heart septum (muscle partition that separates the Left Ventricle (LV) Right Ventricle (RV) - what you just repaired.