Trauma: abdominal Flashcards
(190 cards)
1
Q
What should be considered in any penetrating wound below the nipples?
A
Penetrating abdominal trauma
The diaphragm reaches the 4th intercostal space on full expiration or tips of scapulae posteriorly.
2
Q
What is the most common injury pattern for stab wounds?
A
- Liver (40%)
- Small bowel (30%)
- Diaphragm (20%)
- Colon (15%)
These percentages indicate the frequency of injuries to these organs from stab wounds.
3
Q
What is the most common injury pattern for gunshot wounds?
A
- Small bowel (50%)
- Colon (40%)
- Liver (30%)
- Vascular (25%)
These percentages reflect the injury distribution from gunshot wounds.
4
Q
What is the incidence of significant intra-abdominal injuries associated with penetrating gluteal injuries?
A
50%
This statistic emphasizes the risk of intra-abdominal injuries in gluteal trauma.
5
Q
What is a recommended examination for clinical assessment of penetrating abdominal trauma?
A
Digital rectal (PR) exam and neurological checks
These assessments help identify potential injuries and neurological deficits.
6
Q
When is CT especially useful in the context of penetrating abdominal trauma?
A
For posterior/flank ± RUQ stab wounds
CT is not recommended for anterior stab wounds due to high risk of false negatives.
7
Q
What indicates laparotomy if found on CT?
A
Fluid with no solid organ injury
This suggests the possibility of small bowel injury.
8
Q
What is the management for penetrating abdominal stab wounds?
A
- Local exploration of wound (LA)
- Clean & suture if superficial to deep fascia
- Laparoscopy if through deep fascia
- Laparotomy if peritoneal breech
These steps outline the surgical management approach.
9
Q
What can laparoscopy miss in penetrating abdominal injuries?
A
Up to 25% of hollow viscus injuries
This statistic highlights the limitations of laparoscopy in detecting certain injuries.
10
Q
What is a relative contraindication for local wound exploration?
A
Obesity
Local wound exploration may be difficult in obese patients.
11
Q
What is a contraindication for local wound exploration?
A
Multiple stab wounds
The presence of multiple stab wounds increases the risk of undetected injuries.
12
Q
What is mandated for gunshot wounds?
A
Laparotomy
This is necessary due to the high risk of significant internal injuries.
13
Q
What happens to major visceral injuries in shotgun wounds beyond the 7-foot range?
A
They decrease
This indicates that the severity of injury may lessen with distance.
14
Q
What is the percentage of small bowel injury found at laparotomy in blunt abdominal trauma according to Ng’s retrospective study?
A
36%
Ng (Canada) J Trauma 2003; 54:204
15
Q
What is the recommendation for laparotomy if more than a trace of fluid is found in blunt abdominal trauma?
A
Laparotomy is recommended unless only a trace of fluid is found.
Ng’s study indicated that 28% of patients who underwent non-operative management failed within 24hrs.
16
Q
What are the indications for laparotomy in blunt trauma?
A
- Unstable patient & +ve FAST
- Peritonitis
- Diaphragmatic rupture
- Failure of non-operative management
Ongoing significant GI bleeding is seen with gross PR or NGT blood or imaging.
17
Q
What are the indications for laparotomy in penetrating trauma (stable & GSW)?
A
- Unstable patient - haemodynamically non-responder
- Peritonitis
- Evisceration
- Ongoing significant GI bleeding
Gross haematemesis or PR bleeding indicates significant GI bleeding.
18
Q
What percentage of abdominal stab wounds breach the peritoneum?
A
50-70%
Only about half of those that breach require open surgical intervention.
19
Q
What is the role of local wound exploration in penetrating trauma?
A
- If fascia has been breached → laparotomy
- If fascia no breach → safe for discharge
This is part of the management options for penetrating trauma.
20
Q
What is the recommended management if fascia is breached in penetrating trauma?
A
Laparotomy or laparoscopy
If fascia is not breached, observation for 12-24 hours is recommended due to the risk of missed GI injuries.
21
Q
What is the role of laparoscopy in penetrating trauma?
A
May be used to rule out diaphragmatic injury
Not recommended for blunt trauma.
22
Q
What is the concordance rate for laparoscopy in identifying injuries?
A
83% for retroperitoneal injuries
Up to 25% of identified injuries may be managed with laparoscopic intervention.
23
Q
What are the advantages of laparoscopy over laparotomy?
A
- <1% complication rate
- Less morbidity associated with negative laparotomy
- Less ileus
- Less painful recovery
- Faster return to activities
- Cosmetically pleasing
Laparotomy has approximately a 5% complication rate including wound infections and dehiscence.
24
Q
A
25
What percentage of blunt trauma cases result in diaphragmatic rupture?
1-9%
## Footnote
This indicates that diaphragmatic injuries are often overlooked in blunt trauma situations.
26
In patients with mid torso penetrating trauma, what percentage sustain diaphragmatic injury?
6%
## Footnote
This statistic highlights the association between penetrating trauma and diaphragmatic injuries.
27
Which hemidiaphragm is more commonly injured and why?
Left hemidiaphragm; the right side is protected by the liver
## Footnote
This anatomical difference contributes to the prevalence of left-sided injuries.
28
What are some potential presentations of diaphragmatic injury?
* Herniation of abdominal organs
* Impaired ventilation and venous return
* Respiratory distress
* Obstruction/incarceration
* Gastric distension/volvulus
## Footnote
These presentations can complicate the clinical picture and require careful evaluation.
29
Why is the diagnosis of diaphragmatic injury considered difficult?
CXR and CT may miss the injury
## Footnote
Imaging methods often fail to provide clear results for diaphragmatic injuries.
30
What imaging technique is probably the best test for diagnosing diaphragmatic injury at a later date?
MRI
## Footnote
MRI provides better visualization of soft tissues compared to other imaging modalities.
31
What surgical approach is usually taken for repairing diaphragmatic injuries?
Abdominal approach via laparotomy
## Footnote
Laparotomy allows for direct access to the diaphragm for repair.
32
What type of suture is recommended for repairing diaphragmatic injuries?
Continuous 0 nylon
## Footnote
The suturing technique can vary, but the material is crucial for effective repair.
33
What is a potential complication if diaphragmatic injuries are not repaired?
Will enlarge over time due to negative pressure of the thorax
## Footnote
This can lead to progressive complications as abdominal contents are pulled into the thoracic cavity.
34
What is a rare requirement during the repair of diaphragmatic injuries?
Occasionally require mesh
## Footnote
Mesh may be needed in specific cases to support the repair.
35
What role does laparoscopy play in the management of diaphragmatic injury?
Helpful in stable patients, but requires an experienced surgeon
## Footnote
Laparoscopy can facilitate diagnosis and repair but is dependent on the surgeon's skill.
36
How is the anterior surface of the stomach inspected?
By pulling caudally and lifting the stomach up
## Footnote
This technique ensures a clear view of the anterior surface.
37
How is the posterior surface of the stomach examined?
By entering the lesser sac via the greater omentum
## Footnote
The greater omentum provides access to the lesser sac for posterior examination.
38
What should be done with all injuries to the stomach?
All injuries should be repaired
## Footnote
This is crucial to prevent complications and promote healing.
39
How are small injuries to the stomach repaired?
By oversweing with 3-0 PDS in 2 layers
## Footnote
This method provides adequate closure for small injuries.
40
What is the approach for larger injuries to the stomach?
Non-anatomic resection with definitive repair deferred until re-look
## Footnote
This approach allows for better assessment and management of larger injuries.
41
What type of injuries most commonly affect the stomach's surfaces?
Most penetrating injuries affect both anterior and posterior surfaces
## Footnote
Understanding this can guide surgical intervention strategies.
42
What is the grading for a haematoma of a single portion of the duodenum?
Grade I: Haematoma of single portion of duo, partial thickness lac
## Footnote
This grading system is useful for research purposes.
43
What does Grade II indicate in duodenal injuries?
Haematoma >1 portion of duo, lac <50% circumference
## Footnote
This grade shows a more extensive injury compared to Grade I.
44
Describe Grade III duodenal injuries.
Lac 50-75% D2, Lac 50-100% D1, D3, D4
## Footnote
This indicates significant damage to the duodenum.
45
What characterizes a Grade IV duodenal injury?
Lac >75% D2, involving ampulla or CBD
## Footnote
This level of injury often requires more complex management.
46
What defines a Grade V duodenal injury?
Massive disruption of duodenopancreatic complex or devascularisation of duo
## Footnote
This is the most severe type of injury.
47
What anatomical relationship is important in duodenal injury management?
Anatomical relationship of ampulla of Vater
## Footnote
This relationship can impact surgical decisions.
48
What is the best investigation method for duodenal injuries?
CT with oral contrast is best test
## Footnote
High index of suspicion is necessary as injuries are often missed on CT scanning.
49
What is the ultimate diagnostic test if there is high suspicion of duodenal injury?
Exploratory laparotomy
## Footnote
This is used when radiological signs are equivocal.
50
What happens to mortality rates if surgery is performed more than 24 hours after injury?
Mortality rises from 11% to 40%
## Footnote
Timeliness of surgery is critical in managing duodenal injuries.
51
What is Kocherisation?
A surgical maneuver important for viewing 3rd and 4th parts of duodenum
## Footnote
This technique helps in accessing the duodenum during surgery.
52
What is the management controversy regarding intramural haematoma?
Either open serosa to evacuate clot or explore duodenum to exclude perforation
## Footnote
Both options carry risks, including converting partial thickness injury to full thickness.
53
How are the majority of duodenal lacerations managed?
With simple procedures
## Footnote
Most lacerations do not require extensive surgical intervention.
54
What defines 'high risk' duodenal injuries?
Injuries involving >75% of wall, injury to D1 or D2, >24h post injury, associated CBD injury
## Footnote
These factors increase the risk of complications.
55
What is the primary closure technique used for perforations?
Close transversely if length of perforation <50% circumference
## Footnote
This technique is suitable for smaller perforations.
56
What should be considered if primary wound closure would cause stricture?
Consider pedicled mucosal graft or serosal patch
## Footnote
Clinical studies in this area are lacking.
57
What procedure is performed if end-to-end anastomosis is not possible?
Antrectomy with closure of duodenal stump and Billroth II gastrojejunostomy
## Footnote
This is a more complex surgical option for extensive injuries.
58
What is duodenal diversion?
Diversion of gastric contents to protect repair in high-risk injuries
## Footnote
This can help in managing complex duodenal injuries.
59
What is the purpose of pyloric exclusion?
To divert enteric contents away from duodenum
## Footnote
This technique is widely reported for managing severe combined pancreaticoduodenal injuries.
60
When is pancreaticoduodenectomy (Whipple Procedure) indicated?
Reserved for massive destruction and devascularisation of duodenum
## Footnote
It often requires extensive post-operative support.
61
What is the management guideline for Grade I and II duodenal injuries?
Primary repair and drainage
## Footnote
These grades typically have a better prognosis.
62
What is the management approach for Grade III duodenal injuries?
Repair/resection of duodenum as indicated, pyloric exclusion, gastrojejunostomy and closure
## Footnote
This approach addresses the more severe nature of these injuries.
63
What characterizes the management of Grade IV and V injuries?
Pancreaticoduodenectomy
## Footnote
These injuries are associated with higher morbidity.
64
What is the first step in managing an unstable patient with duodenal injury?
Control haemorrhage
## Footnote
Immediate control of bleeding is critical in unstable patients.
65
What should be done if there are injuries to the CBD and pancreatic duct?
Ligate
## Footnote
Ligation is necessary to prevent further complications.
66
How should GI perforations be managed?
Rapid closure of GI perforations (staple off duodenal ends)
## Footnote
Quick closure minimizes the risk of infection and further complications.
67
What is the recommended approach for drainage in managing duodenal injuries?
Triple drain - Lots of drains
## Footnote
Multiple drains are used to manage different aspects of the injury.
68
What type of tube should be placed in the stomach?
NGT
## Footnote
Nasogastric tube (NGT) is essential for gastric decompression.
69
What is the preferred drainage method for bile?
T-tube/PTC or
## Footnote
T-tube or percutaneous transhepatic cholangiography (PTC) are used for bile drainage.
70
What type of drain is recommended for the pancreas?
Intra-abdominal drain
## Footnote
This helps manage pancreatic secretions and prevent complications.
71
What should not be forgotten for feeding in these patients?
NJ for feeding
## Footnote
A nasojejunal (NJ) tube is important for nutritional support.
72
What is one method used in the management of duodenal injury?
Packing
## Footnote
Packing can be used to control bleeding and stabilize the patient.
73
What type of resuscitation is required in the ICU for these patients?
ICU resuscitation
## Footnote
Intensive care unit resuscitation is crucial for stabilizing unstable patients.
74
When should a relook procedure be performed?
24h
## Footnote
A relook is necessary to assess the surgical site and ensure no complications.
75
What is the prognosis after duodenal exclusion?
Duodenal fistula 5%
## Footnote
A low percentage of patients may develop a duodenal fistula post-surgery.
76
What percentage of patients have a patent pylorus at 4 weeks?
95%
## Footnote
Most patients maintain pyloric function after duodenal exclusion.
77
What is a potential complication in 10% of patients?
Marginal ulceration
## Footnote
Marginal ulceration can occur after duodenal surgery.
78
What is the fundamental question in small bowel management?
Definitive repair vs damage control
## Footnote
This question guides the approach to treating injuries in the small bowel.
79
What is the approach if damage control is indicated?
Resect damaged gut and leave bowel stapled in discontinuity
## Footnote
This method is used to manage the immediate consequences of bowel damage.
80
How should bowel be examined during surgery?
Examine with 2 people and examine both sides
## Footnote
This ensures a thorough assessment of the bowel condition.
81
What are the two methods of definitive repair for small bowel injuries?
Primary closure with 3/0 PDS or resection and anastomosis
## Footnote
These methods are used based on the extent of the injury.
82
What tool can be used to quickly close multiple small wounds?
35W skin stapler
## Footnote
This tool allows for efficient closure in cases of multiple small injuries.
83
What test can be performed with multiple small wounds, such as gunshot wounds?
Pass bowel through bowl of water for air leak test
## Footnote
This test helps identify leaks in the bowel.
84
What is the fundamental question regarding large bowel injuries?
Definitive repair vs damage control
85
What type of injuries are classified as non-destructive?
Simple injuries
86
What should be done for non-destructive injuries?
Minimal debridement and primary repair
87
What characterizes destructive injuries?
Complex injuries
88
In an unstable patient, how should small wounds be managed?
Closed with 3-0 PDS and can be re-inspected at re-look
89
How should large wounds be managed in unstable patients?
Stapled off as per small bowel
90
What percentage of patients can undergo delayed anastomosis?
Up to 75%
91
Is early reversal of stoma safe in selected patients?
Yes
92
What should be done for destructive injuries without serious comorbidity?
Debride and primary anastomosis
93
What is the recommended action for destructive injuries with co-existent serious injury?
Faecal diversion if >6 units of transfusion required
94
How is the rectum classified anatomically in terms of injury?
Intraperitoneal upper 1/3 and extraperitoneal lower 2/3
95
What is a challenge in diagnosing rectal injuries?
Can be difficult to diagnose or easily missed
96
In what types of injuries should rectal injury be considered?
Any penetrating injury to lower abdomen, hips, thighs
97
What type of injury can occur during a major pelvic fracture?
Rectal injury
98
What is the management for intraperitoneal rectal injuries?
Consider primary repair
99
What should be done for extraperitoneal injuries that can be mobilised?
Consider primary repair
100
When should a diverting colostomy be considered?
If extensive injury
101
What is the common management practice in military settings for rectal injuries?
Almost all patients receive colostomy
102
103
What is a grade one:
- liver haematoma
- capsular tear
Subcapsular <10% surface area
Capsular tear <1cm parenchymal depth
104
What is a grade two:
- liver haematoma
- capsular tear
Subcapsular 10-50% surface area, intraparenchymal <10cm in diameter
Capsular tear 1-3cm depth, <10cm length
105
What is a grade three:
- liver haematoma
- liver laceration
- vascular injury
Subcapsular > 50% SA, intraparenchymal >10cm diameter or >3cm depth
Parenchymal disruption 25-75% hepatic lobe or 1-3 segments
Active bleed within parenchyma
106
What is a grade four:
- liver laceration
- vascular injury
Parenchymal disruption >75% hepatic lobe or >3 segments within 1 lobe
Active bleed into peritoneum
107
What is a grade 5 liver vascular injury
Juxtahepatic venous injuries – eg retrohepatic IVC, central major hepatic veins
108
What is a grade six liver vascular injury?
Hepatic avulsion (removed in 2018 classification)
109
What percentage of blunt injuries are classified as grade I-III?
85%
## Footnote
Blunt injuries grade IV-V account for 15-20% and often arrive unstable.
110
What are the two main types of injuries mentioned?
Penetrating and blunt
## Footnote
These injuries can have different patterns and management approaches.
111
What causes liver tears during deceleration injuries?
Tears on peritoneal attachments resulting in linear lacerations
## Footnote
Deceleration injuries create specific patterns of liver trauma.
112
What is the management approach for grade IV and V injuries?
70% require operative intervention
## Footnote
Management depends on grade, patient physiology, and context.
113
What percentage of adults with blunt trauma can be managed non-operatively?
50-80%
## Footnote
Non-operative management is highly successful.
114
What is the success rate of non-operative management for blunt trauma?
95%
## Footnote
Only 5% of those suitable for non-operative management will fail and require operation.
115
List the criteria for non-operative management.
* No immediate indication for laparotomy
* Haemodynamic stability
* Absence of peritoneal signs
* CT scan delineating extent of injury
* Lack of associated injuries requiring management
* No evidence of ongoing bleeding
* Experienced radiologist
* Limited transfusion requirement
* Ability to monitor patients in ICU
* Facility for immediate surgery
## Footnote
These criteria ensure safe non-operative management.
116
What indicates the need for an angiogram in liver trauma?
* Expanding intra-hepatic haematoma
* Extravasation of contrast on CT
* All patients who have packing once stable in ICU
## Footnote
Angiograms help identify arterial injuries.
117
What is the primary goal in the operative management of liver trauma?
Restore normal anatomy with compression
## Footnote
This is followed by maintaining it with packing.
118
What are indications for operative intervention in liver trauma?
* Cardiovascular compromise
* Peritoneal signs
* Ongoing transfusion requirement
* Large subcapsular haematoma
## Footnote
These factors necessitate surgical intervention.
119
What does the 'Packing' technique involve?
Holding liver in normal anatomy and packing across injury
## Footnote
Avoid excessive packing to prevent vena cava compression.
120
What is the purpose of the Pringle maneuver?
Controls bleeding by compressing the hepatic pedicle
## Footnote
It helps differentiate between arterial and venous injuries.
121
What is the recommended timing for re-evaluation after packing?
Aim for re-look at 48 hours
## Footnote
No longer than 72 hours due to the risk of infection.
122
What is the purpose of hepatic isolation?
Pringle + clamping of suprarenal and suprahepatic IVC
## Footnote
Results can be disappointing in trauma patients.
123
What can sudden onset of bleeding during liver mobilization indicate?
Retrohepatic IVC injury
## Footnote
This requires immediate attention and possibly packing.
124
What is the role of Penrose tubing in liver trauma management?
Used to tourniquet left lobe
## Footnote
This technique helps control bleeding in specific injuries.
125
True or False: Majority of liver trauma cases can be managed without mobilization.
True
## Footnote
Mobilization is not universally recommended for inexperienced personnel.
126
What are the "p's" of managing liver trauma?
- Press (into normal anatomy)
- Pack
- Pringle (If this controls bleeding, suggests arterial injury (requires further procedures). If fails suggests hepatic venous/retrohepatic IVC injury )
- Pray
127
What organ is most commonly injured in blunt trauma?
Spleen
## Footnote
Isolated injuries account for 30% of cases
128
What percentage of splenectomies are due to iatrogenic damage?
20%
## Footnote
Iatrogenic damage refers to injuries caused by medical intervention
129
What type of trauma is associated with 30-60% of splenic injuries?
Blunt trauma
## Footnote
Often accompanied by intra-abdominal injury
130
What is a delayed rupture of the spleen usually caused by?
Rupture of subcapsular haematoma
## Footnote
Typically occurs 3-6 days post injury but can be as late as 4 weeks
131
What usually causes spontaneous rupture of the spleen?
Trivial injury
## Footnote
Often occurs in a diseased spleen due to conditions like EBV, malaria, or haematological disorders
132
What is the risk associated with the spleen in sudden deceleration?
Particular risk of injury
## Footnote
The spleen is relatively protected under the ribcage
133
What is the primary aetiology of splenic injuries?
Trauma
## Footnote
Includes both blunt and penetrating trauma
134
Fill in the blank: The spleen is relatively protected under the _______.
ribcage
135
136
What is a grade one splenic injury:
- haematoma
- laceration
Subcapsular <10% surface area
Capsular tear <1cm parenchymal depth
137
What is a grade two splenic injury:
- haematoma
- laceration
Subcapsular 10-50% surface area, intraparenchymal <5cm
Capsular tear 1-3cm depth that doesn’t involve trabecular vessel
138
What is a grade three splenic injury:
- haematoma
- laceration
Subcapsular >50%, ruptured haematoma, intraparenchymal haematoma >5cm
>3cm depth or involving trabecular vessels
139
What is a grade four splenic injury:
- laceration
- vascular
Involving segmental or hilar vessels producing devascularisation >25% of spleen
Active bleed within splenic capsule
140
What is a grade five splenic injury:
- laceration
- vascular
Completely shattered spleen
Hilar vascular injury with devascularised spleen, active bleeding into peritoneum
141
What is the failure rate for non-operative management of grade 3-5 splenic injuries?
Approximately 15 to 5%
## Footnote
Refers to the likelihood of needing surgical intervention after initial non-operative management
142
What are the indications for non-operative management of splenic injuries?
Haemodynamically stable patient without peritoneal signs and no other injuries
## Footnote
This indicates that the patient does not show signs of internal bleeding or other injuries that require immediate surgical attention
143
What monitoring is required during non-operative management of splenic injuries?
CT scan, close monitoring (HDU/ICU), daily Hb
## Footnote
These measures help assess the patient's condition and detect any complications early
144
What activities should be avoided for 3 months after non-operative management of splenic injuries?
Contact sports
## Footnote
This is to minimize the risk of re-injury to the spleen
145
What is the role of angiography in the management of splenic injuries?
Consider in all patients > Grade III, presence of contrast blush, moderate haemoperitoneum, splenic pseudoaneurysm, evidence of ongoing bleeding
## Footnote
Angiography can help identify bleeding sources and guide treatment
146
What are the indications for surgical intervention in splenic injuries?
Haemodynamic instability, risk of concurrent abdominal hollow organ injury, ongoing bleeding, replacement of >50% blood volume, age >55 (relative indication)
## Footnote
These factors indicate a higher risk of complications and the need for surgical management
147
What is the procedure for accessing the spleen during surgery?
Stand on patient's right, pull spleen upwards and medial, divide lienorenal and lienocolic ligaments, pull spleen down, divide leinophrenic ligament, divide short gastric vessels
## Footnote
This approach allows for safe access to the spleen while minimizing damage to surrounding structures
148
When should the spleen be preserved during surgery?
If the spleen is not bleeding, surface bleeding managed with manual compression, packing, diathermy, argon beam, fibrin adhesives with collagen fleece
## Footnote
Preservation can help maintain immune function and prevent complications
149
What is the management for minor splenic lacerations?
Attempt suturing with 3-0 PDS with Teflon pledgets, fibrin adhesive and collagen fleece
## Footnote
These methods aim to repair the spleen while avoiding splenectomy when possible
150
What is mesh splenorrhaphy?
Using vicryl mesh (mesh bag) to repair splenic tears
## Footnote
This technique helps to reinforce the splenic tissue and promote healing
151
What is the post-operative risk of delayed bleeding after non-operative management?
Low – 1-8%
## Footnote
This indicates that while there is a risk, it is relatively low compared to other complications
152
What infections are patients at risk for after splenic surgery?
Encapsulated organism infections (pneumococcus, meningococcus, H. influenzae)
## Footnote
These infections can be severe in patients who have had their spleen removed or damaged
153
What prophylactic measures are sometimes given post-operatively?
Prophylactic antibiotics for 1 year (penicillin or amoxicillin), continued in patients with immunocompromise or history of encapsulated organism infection
## Footnote
This is to prevent infections that the spleen would normally help protect against
154
What is a grade one pancreatic injury?
- haematoma
- laceration
Minor contusion without duct injury
Superficial laceration without duct injury
155
What is a grade two pancreatic injury?
- haematoma
- laceration
Major contusion without duct injury
Major laceration without duct injury
156
What is a grade three pancreatic injury?
- laceration
Distal transection or parenchymal injury with duct involvement
157
What is a grade four pancreatic injury?
- laceration
Proximal transection or injury involving ampulla
158
What is a grade five pancreatic injury?
- laceration
Massive disruption of pancreatic head
159
Is clinical evaluation reliable in cases of severe pancreatic injury?
No, clinical evaluation is unreliable even with severe injury.
## Footnote
Clinical evaluation does not provide accurate assessments for pancreatic trauma.
160
What is the positive predictive value of amylase and lipase in pancreatic injury?
10%.
## Footnote
The negative predictive value is 95%, indicating a low correlation with pancreatic injury in trauma.
161
What imaging technique has a sensitivity and specificity of up to 80% for pancreatic injury?
CT scan.
## Footnote
CT may miss or underestimate the severity of the injury initially.
162
What is MRCP used for in the context of pancreatic injury?
To assess for complications in the non-acute phase.
## Footnote
MRCP is not used during acute injury but can provide valuable information later.
163
What is the mainstay of treatment for pancreatic injury?
Operative management.
## Footnote
Non-operative management may be suitable for blunt grade I and II injuries.
164
What is a common complication of pancreatic injury management?
Missed diagnosis.
## Footnote
Accurate diagnosis is critical to prevent complications.
165
What manoeuvre is used to explore the pancreas during surgery?
Kocher manoeuvre.
## Footnote
This manoeuvre helps assess the posterior aspect of the pancreas.
166
What is the safest management for injuries to the tail and body of the pancreas?
Resection.
## Footnote
This approach minimizes complications associated with extensive injuries.
167
What characterizes grade I and II pancreatic injuries?
No duct injury.
## Footnote
These grades comprise the majority of pancreatic injuries.
168
How should bleeding vessels be managed during pancreatic surgery?
Ligation of individual vessels.
## Footnote
Using large haemostatic sutures can cause necrosis.
169
What is the treatment for grade III pancreatic injuries?
Distal pancreatectomy and splenectomy.
## Footnote
Damage to the duct lateral to the SMV necessitates this approach.
170
What is the fistula rate associated with grade III pancreatic injuries?
14%.
## Footnote
This indicates a significant risk of complications following surgery.
171
What is the recommended approach for grade IV pancreatic injuries?
Wide drainage.
## Footnote
Diversion may also be indicated in certain cases.
172
What is the primary concern in managing grade V pancreatic injuries?
Devitalisation of pancreatic head.
## Footnote
Damage control is crucial in the first instance.
173
What are the indications for a Whipple procedure?
Massive disruption of pancreaticoduodenal complex, devascularisation of duodenum, extensive injury to D2.
## Footnote
This is a major surgical procedure with significant risks.
174
What is the mortality rate associated with Whipple procedures?
Can approach 50%.
## Footnote
Mortality varies based on patient condition and injury severity.
175
What is the post-operative mortality rate for pancreatic surgery?
19%.
## Footnote
Early deaths are often due to associated intra-abdominal injuries.
176
What is the complication rate for pancreatic surgeries?
40%.
## Footnote
This rate increases with the severity of the injury.
177
What is the management approach for pancreatic fistulas?
Conservative management for 6-8 weeks, Roux-en-Y for definitive management.
## Footnote
The output of the fistula influences management strategies.
178
What is the incidence of pancreatitis following pancreatic surgery?
<5%.
## Footnote
Hemorrhagic pancreatitis is rare but can be fatal.
179
What is the common issue with pseudocyst management?
Usually inadequate drainage.
## Footnote
Most can be drained percutaneously.
180
What endocrine/exocrine function is preserved after pancreatic surgery?
Usually preserved as long as 10-20% of gland remains.
## Footnote
This highlights the importance of preserving pancreatic tissue during surgery.
181
What are the three zones for classifying retroperitoneal injury?
Central zone (Zone 1): Aorta and IVC
Lateral zones (zone 2): Renal vessels and hilum
Pelvis (zone 3): Pelvic haematoma
182
What factors influence the decision to explore a retroperitoneal injury?
Location (zone), mechanism (blunt vs penetrating), presence of vascular injury signs.
183
What should be done if there is evidence of an expanding haematoma in Zone 1?
Always explore for duodenal, pancreas, or major vascular injuries.
184
How should blunt trauma in Zone 2 be managed?
Observe; renal injuries usually managed non-operatively or with embolization.
185
When should penetrating trauma in Zone 2 be explored?
Only if there is rapidly expanding/pulsatile haematoma.
186
What are the risks associated with penetrating injuries in Zone 2?
Risk of damage to IVC, colon, or ureter.
187
How should Zone 3 injuries be managed?
Manage as per pelvic trauma; CT angio may show blush.
188
What is the initial management approach for Zone 3 injuries when possible?
Angiography +/- embolization.
189
What should be done if there is a rapidly expanding haematoma in Zone 3?
May need surgical exploration.
190
What is a useful damage control technique for Zone 3 injuries?
Extraperitoneal packing.
