Vivas Flashcards
(3 cards)
Trauma laparotomy
Drape clavicle to knee
Large incision
Evacuate clot
Eviscerate small bowel
Examine for any major bleeding
Haemostatic packing
Under left diaphragm
Left paracolic gutter
Pelvis
Right paracolic gutter
Subhepatic space
Above and lateral to liver
Remove packs one at a time, starting at area least likely to be bleeding
Apply pressure, compress organ that is bleeding
Allow anaesthetist to ‘catch up’
Perform definitive packing and haemorrhage control
Packs should provide sufficient pressure to tamponade venous bleeding but preserve arterial flow
Copious washout
Replace small intestine
Perform temporary abdominal closure if required
Trauma thoracotomy
Procedure
airway doctor advances ET tube into R main bronchus
long L thoracotomy incision (5th space) initially Costochondral junction (1-2cm from edge of sternum) to mid-axillary line ±extended across sternum if required
use Finochietto retractor (with handles/bar pointing downward, to allow access to RHS if required)
displace lung medially – ask anaesthetist to collapse lung
surface markings: 3 fingerbreadths below the nipple → 2 fingerbreadths below the tip of the scapula → midpoint between med border of scapula & the vertebral column (≈ edge of erector spinae muscles)
INJURIES
Go chest wall lungs heart & great vessels
Examine chest wall for intercostal or internal thoracic bleeding
Pericardial tamponade: identify phrenic nerve, open pericardium anterior to phrenic nerve in craniocaudal fashion (can make a small nick & tear – less likely to damage nerve), evacuate clot, plug hole in heart (finger, IDC, suture, skin stapler)
Close cardiac defect with 3/0 or 4/0 Prolene (on SH needle) – Teflon pledgets/ horizontal mattress suture
Tears close to coronary arteries must be sutured with vertical mattress suture so don’t oversew artery
Satinsky clamp to bleeding atria
Not essential to close pericardium on completion of procedure
Lung laceration: aortic/Satinsky clamp across area of bleeding (hilum if necessary); tell the airway doc so that ventilation can be adjusted, control bleeding lung
attempt at repair x2 if no success → stapled pneumonectomy
tractotomy with suture ligation of blood and air leaks is an option
Hypovolemic asystole: clamp descending aorta just above diaphragm
Incise pleura ant & post to aorta, separate from oesophagus, clamp just the aorta at the level of the diaphragm – no more than 30 minutes
Reduces exsanguination & increases flow to coronaries
internal cardiac massage: use the flat of your hands, one in front one behind (as using your fingertips can penetrate the heart); use internal paddles if defibrillation is required
±aspirate RA for air
When to stop:
injuries are irreparable (eg blunt cardiac rupture)
volume replacement not achieved within 15mins of thoracotomy (ie heart remains empty)
heart is not in a self-sustaining rhythm after 30mins
Operating room thoracotomy
Indications (typically following penetrating trauma)
massive hemothorax (>1500ML blood drained immediately from chest tube)
on-going bleeding (>200mL/hour for 2-4hrs, on-going transfusion requirement)
cardiac tamponade, confirmed by echo, pericardiocentesis or subxiphoid window
sig undrained hemothorax following chest drain insertion warrants thoracoscopy or thoracotomy to evaluate
specific injury requiring surgical intervention (eg tracheobronchial, oesophageal)
persistent air leak
Retained FB
Procedure:
(NB useful to place an NG (to aid in palpation of the oesophagus, cf flat aorta))
pt supine, L thoracotomy ±can “clam shell” across to RHS
to cut across sternum: use heavy scissors or Leibsche knife (pronounced “Lipshi”; looks like a chisel, that you “hammer” to cause it to cut) and be aware of internal mammary a’s (tie them off)
alternative: median sternotomy (using Leibsche knife or circular saw)
use Finochietto retractor (with handles/bar pointing downward, to allow access to RHS if required)
the supradiaphragmatic aorta can be cross-clamped (after first dividing & clearing the mediastinal pleura that covers it; the inferior pulmonary ligament may also have to be divided to gain access)
