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ABSITE > 15 Trauma > Flashcards

15 Trauma Flashcards

1
Q

when do deaths from trauma occur?

A

1st, 2nd, 3rd peaks. 0-30 min, 30min to 4hr, days to weeks

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2
Q

what are the causes of deaths during 1st peak?

A

1st: lacs of heart, aorta, brain, brainstem, spinal cord; cannot save these pts, death is too quick

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3
Q

what are the causes of deaths during 2nd peak?

A

head injury (#1), hemorrhage (#2), saved w rapid assessment (golden hour)

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4
Q

what are the causes of deaths during 3rd peak?

A

deaths due to multisystem organ failure and sepsis

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5
Q

what percentage of all traumas are 2/2 blunt injury?

A

80%.

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6
Q

what organ is the most commonly injured from blunt trauma?

A

liver. sometimes spleen

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7
Q

for falls, what are the biggest predictors of survival?

A

age and body orientation

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8
Q

how many stories is LD50 for falls?

A

4 stories

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9
Q

what is most commonly injured in penetrating injury?

A

small bowel. some say liver

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10
Q

what is the most commonc ause of death in first hour?

A

hemorrhage

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11
Q

at what blood volume does BP start to drop?

A

30% of total blood volume is lost

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12
Q

what do you start resuscitation with? then what?

A

2L LR, then switch to blood

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13
Q

what is the mcc of death after reaching the ER alive?

A

head inj

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14
Q

what is the mcc of death in long term after trauma?

A

infection

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15
Q

what is the mcc of upper airway obstruction? what do you do to treat?

A

tongue. perform jaw thrust

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16
Q

what injuries do seat belts cause?

A

small bowel perforations, lumbar spine fx, sternal fxs

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17
Q

what is the best site for cutdown for venous access?

A

saphenous vein

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18
Q

when do you use DPL?

A

hypotensive pts w blunt trauma

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19
Q

what is a positive DPL?

A 
>10 cc of blood
>100,000 RBC/cc
food particles
bile
bacteria
>500 wbc/cc
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20
Q

what do you do if DPL is positive?

A

laparotomy

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21
Q

where do you do DPL if pelvic fx present?

A

supraumbilical

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22
Q

where does DPL fall short?

A

retroperitoneal bleeds, contained hematomas

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23
Q

where is FAST performed?

A

perihepatic fossa, perisplenic fossa, pelvis, pericardium

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24
Q

what are the limitations of FAST?

A

operator dependent, obesity obstructs view, may not detect free fluid <50-80 ml, retroperitoneal bleed, hollow viscous injury

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25
Q

what do you do if FAST is positive?

A

OR

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26
Q

what do you do if a hypotensive pt has neg FAST scan?

A

find source of bleeding (pelvis, fx, chest, or extremity)

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27
Q

what test is required for blunt trauma pts?

A

CT

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28
Q

what are the indications for CT in blunt trauma pts?

A

abd pain, need for general anesthesia, closed head inj, intoxicants on board, paraplegia, distracting inj, hematuria

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29
Q

what does CT miss in trauma?

A

hollow viscus inj, diaphragm inj

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30
Q

which trauma pts get laparotomies?

A

peritonitis, evisceration, positive DPL, uncontrolled visceral hemorrhage, free air, diaphragm inj, intraperitoneal bladder inj, contrast extravasation from hollow viscus, specific renal, panc, and biliary tract injuries

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31
Q

what is the algorithm for diagnosis of blunt trauma?

A

http://cl.ly/image/1e1t3q3r462f

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32
Q

do penetrating injuries need laparotomies?

A

generally

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33
Q

what do you do if a pt has possible penetrating abd injury?

A

local exploration and observation if fascia not violated.

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34
Q

what is the algorithm for diagnosis of low velocity penetrating abd trauma?

A

http://cl.ly/image/0N021n3q071r

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35
Q

when does abd compartment syndrome occur?

A

after massive fluid resuscitation, trauma, or abd surgery

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36
Q

what test do you get to find out if pt has compartment syndrome?

A

bladder scan: pressure >25-30

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37
Q

with compartment syndrome, why does pt get dec cardiac output?

A

IVC compression

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38
Q

what are good indicators of low cardiac output after abd compartment syndrome?

A

visceral and renal malperfusion (dec urine output)

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39
Q

what do you see on imaging with abd compartment syndrome?

A

upward displacement of diaphragm, affects ventilation

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40
Q

what is treatment for abd compartment syndrome?

A

decompressive laparotomy

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41
Q

what does a pneumatic antishock garment do? when do you use it?

A

releases compartments one at a time after reaching ER. controversial. use in pts with SBP <50 and no thoracic injury

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42
Q

when do you do ED thoracotomy for blunt trauma?

A

only if pressure/pulse lost in ER

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43
Q

when do you do ED thoracotomy for penetrating trauma?

A

use only if pressure/pulse lost on way to ER or in ER

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44
Q

what are the steps in thoracotomy?

A

open pericardium anterior to phrenic nerve, cross clamp aorta, watch for esophagus

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45
Q

is the esophagus anterior or posterior to aorta?

A

anterior

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46
Q

when do catecholamines peak after trauma?

A

24-48 hrs after inj

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47
Q

what else increases after trauma?

A

ADH, ACTH, glucagon (flight or flight response)

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48
Q

who cannot receive Rh-pos blood?

A

females who are prepubescent or of childbearing age. everyone else can get Rh-pos or Rh-neg blood

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49
Q

is giving only type-specific blood ok?

A

can be administered safely, but there may be effects for abs to HLA minor antigens in the donated blood.

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50
Q

at what gcs do you do what?

A

<= 8 icp monitor

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51
Q

what are the indications for head ct?

A
  • suspected skull penetration by foreign body
  • discharge of CSF, blood, or both from nose
  • hemotympanum or discharge of blood or CSF from ear
  • head inj w alcohol or drug intox
  • altered state of consciousness at time of exam
  • focal neurologic si/sx
  • any situation precluding proper surveillance
  • head inj plus additional trauma
  • protracted unconsciousness
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52
Q

laceration of the middle meningeal artery is the cause of what kind of hematoma?

A

epidural hematoma

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53
Q

what kind of shape is epidural hematoma on head ct?

A

lenticular (lens)

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54
Q

what are si/sx of epidural hematoma?

A

LOC -> lucid interval -> sudden deterioration (vomiting, restlessness, LOC)

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55
Q

when do you operate for an epidural hematoma?

A

significant neurologic degernation or significant mass effect (shift >5mm)

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56
Q

what is mcc of subdural hematoma?

A

tearing of venous plexus (bridging veins) that cross between dura and arachnoid

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57
Q

what is finding on head ct for subdural hematoma?

A

crescent-shaped deformity

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58
Q

when do you operate for SDH?

A

degeration of mass effect >1cm

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59
Q

who gets chronic SDH?

A

elderly after minor fall

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60
Q

where are intracerebral hematomas located?

A

frontal or temporal

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61
Q

can intracerebral hematomas cause mass effect?

A

yes, can require operation

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62
Q

what kind of injury is coup, contrecoup?

A

cerebral contusion

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63
Q

what do you need to do for a traumatic intraventricular hemorrhage?

A

ventriculostomy if causing hydrocephalus

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64
Q

what is the best imaging modality for diffuse axonal injury?

A

MRI > CT

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65
Q

what is treatment for DAI?

A

supportive, may need craniectomy if ICP elevated, very poor prognosis

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66
Q

how do you calculate cerebral perfusion pressure?

A

CPP = MAP - ICP

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67
Q

what are signs of elevated ICP on imaging?

A

dec ventricular size, loss of sulci, loss of cisterns

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68
Q

when do you place an ICP monitor?

A

GCS <=8, suspected inc ICP, or pt with moderate to severe head inj and inability to follow clinical exam (intubated)

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69
Q

what is normal ICP? at what ICP requires treatment?

A

normal is 10. >20 needs treatment

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70
Q

what should CPP be?

A

> 60

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71
Q

how do you increase CPP?

A
  • sedation and paralysis
  • raise HOB
  • relative hyperventilation (but do not overhyperventilate) -> can cause too much cerebral ischemia from too much vasoconstriction
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72
Q

what should Na and serum Osms be?

A

Na: 140-150, Osm 295-310

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73
Q

what can you give to draw cluid out of brain to maintain Na and serum Osms?

A

hypertonic saline

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74
Q

what is the dosage of mannitol?

A

load 1g/kg, give 0.25 mg/kg q4h after that

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75
Q

what does mannitol do?

A

draws fluid out of brain

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76
Q

what do you consider if mannitol or hypertonic saline dont work?

A

barbiturate coma

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77
Q

how do you reduce ICP?

A

ventriculostomy to keep ICP <20

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78
Q

when do you do a craniotomy decompression? what else can you do?

A

if unable to get ICP down medically. can also do Burr hole

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79
Q

what can be given to prevent seizures? who gets it?

A

fosphenytoin or keppra. give to mod to severe head injury pts

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80
Q

when does ICP peak?

A

48-72 hours after injury

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81
Q

what is the anatomical cause of dilated pupil?

A

temporal pressure on same side (CNIII, oculomotor, compression)

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82
Q

what are the si/sx of basal skull fx?

A

racoon eyes, battle’s sign, hemotympanum and csf rhinorrhea/otorrhea

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83
Q

what does raccoon eyes tell you?

A

anterior fossa fracture

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84
Q

what does battle’s sign tell you?

A

middle fossa fracture; can injure facial nerve (CN VII)

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85
Q

what is the most common site of facial nerve injury?

A

geniculate ganglion

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86
Q

what nerve do temporal skull fractures injure?

A

CN VII and VIII (vestibulocochlear nerve)

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87
Q

temporal skull fractures are associated with what kind of other injury?

A

lateral skull or orbital blows

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88
Q

do most skull fxs require surgical treatment?

A

normal is 10. >20 needs treatment

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89
Q

when do you operate for skull fx?

A

if significant depression (>1cm)
contaminated
persistent CSF leak not responding to conservative therapy

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90
Q

what do you do about csf leaks?

A

manage expectantly, can use lumbar CSF drainage if present. if persistent, operate

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91
Q

what is the cause of coagulopathy with traumatic brain injury?

A

release of tissue factor

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92
Q

what is a c1 fx called?

A

c1 burst is called jefferson fracture

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93
Q

what causes c1 burst?

A

axial loading

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94
Q

what is treatment for c1 burst?

A

rigid collar

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95
Q

what is the cause of c2 hangman’s fracture?

A

distraction and extension

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96
Q

what is the treatment for c2 fx?

A

traction and halo

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97
Q

what are the types of c2 odontoid fxs?

A

type I: above base, stable
type II: at base, unstable
type III: extends into vertebral body

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98
Q

what do you do about type I, II, III c2 fxs?

A

type I: nothing
type II: fusion or halo
type III: fusion or halo

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99
Q

what is associated w a facet injury or dislocation?

A

cord injury can be caused by facet injury.

associated with hyperextension and rotation with ligamentous disruption

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100
Q

what is an “unstable” spine?

A

if more than 1 column is disrupted

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101
Q

what are the columns of the thoracolumbar spine?

A

anterior
middle
posterior

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102
Q

what makes the anterior thoracolumbar spine?

A

anterior longitudinal ligament and anterior 1/2 of the vertebral body

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103
Q

what makes the middle thoracolumbar spine?

A

posterior 1/2 of the vertebral body and posterior longitudinal ligament

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104
Q

what makes the posterior thoracolumbar spine?

A

facet joints, lamina, spinous processes, interspinous ligament

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105
Q

what kinds of injuries affect the thoracolumbar spine?

A

compression fracture

burst fracture

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106
Q

what is a compression fracture? what is it also called? is it a stable fx?

A

wedge fracture. anterior column only. stable

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107
Q

what is a burst fracture? is it stable?

A

unstable (>1column), need a spinal fusion

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108
Q

what injuries do you find with upright fall?

A

calcaneus, lumbar, wrist/forearm fx

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109
Q

what do you need to get if pt has neurologic deficits without bony injury?

A

MRI to check ligamentous inj

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110
Q

when do you need to emergently decompress a spine surgically?

A
  1. fx or dislocation not reducible with distraction
  2. open fracture
  3. soft tissue or bony compression of the cord
  4. progressive neurologic dysfunction
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111
Q

what is the what is the most common cause of facial nerve injury?

A

fracture of temporal bone

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112
Q

for facial lacerations, what do you try to do when suturing/repairing?

A

preserve skin, not trim edges

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113
Q

what are the Le Fort fractures?

A

I: maxillary fracture straight across (-)
II: lateral to nasal bone, underneath eyes, diagonal towards maxilla ( / \ )
III: lateral orbital walls (- -)

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114
Q

what are the treatments for le fort I?

A

reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires

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115
Q

what are the treatments for le fort II?

A

same as le fort I

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116
Q

what are the treatments for le fort III?

A

suspension wiring to stable frontal bone; may need ex fix

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117
Q

illustrate the le fort fractures.

A

http://cl.ly/image/1V2o2U0o2o3z

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118
Q

how often do nasoethmoidal orbital fractures have a CSF leak?

A

70%

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119
Q

what is the treatment for nasoethmoidal orbital fractures?

A
  • conservative therapy for 2 weeks
  • try epidural catheter to dec CSF pressure to help it close CSF leak
  • may need surgical closure of dura to stop leak
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120
Q

what are the different types of nosebleeds?

A

anterior, posterior

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121
Q

how do you treat nosebleeds?

A

anterior: packing
posterior: difficult. try balloon tamponade. may need angioembolization of internal maxillary artery or ethmoid artery

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122
Q

who needs repair after an orbital blowout fx? what do you do?

A

impaired upward gaze or diplopia with upward vision. restore orbital floor with bone fragments or bone grafts

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123
Q

how do you diagnose mandibular injury?

A

fine cut facial CT scan with reconstruction

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124
Q

what is the #1 indicator of mandibular injury?

A

malocclusion

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125
Q

how do you repair mandibular injury?

A

IMF (metal arch bars to upper and lower dental arches, 6-8 weeks) or ORIF

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126
Q

what is a tripod fracture and how do you treat?

A

zygomatic bone fracture. ORIF for cosmesis

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127
Q

what are pts w maxillofacial fractures at high risk for?

A

cervical spine injuries

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128
Q

what do you do for an asymptomatic blunt neck trauma?

A

neck CT

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129
Q

what do you do for an asymptomatic penetrating neck trauma in zone I?

A

angiography, bronchoscopy, esophagoscopy, and barium swallow. pericardial window may be indicated. may need median sternotomy to reach these lesions

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130
Q

what do you do for an asymptomatic penetrating neck trauma in zone II?

A

need neck exploration in OR

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131
Q

what do you do for an asymptomatic penetrating neck trauma in zone III?

A

angiography and laryngoscopy. may need jaw subluxation/digastric and sternocleidomastoid muscle release/mastoid sinus resection to reach vascular injuries here

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132
Q

where are zone I, II, III?

A

I: clavicle to cricoid
II: cricoid to angle of mandible
III: angle of mandible to base of skull

http://cl.ly/image/2G2X1Y451J3H

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133
Q

what is the important implication of zone I injury?

A

greater potential for intrathoracic great vessel injury

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134
Q

what do you do for symptomatic blunt or penetrating neck trauma?

A

neck exploration if:
shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit

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135
Q

what is the most difficult neck injury to find?

A

esophageal injury

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136
Q

how do you find an esophageal injury?

A

esophagoscopy and esophagram together

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137
Q

how often do esophagoscopy and esophagogram together find esophageal injuries?

A

95%

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138
Q

what do you do about a contained esophageal injury?

A

observe

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139
Q

what do you do about a small noncontained esophageal injury?

A

if small and minimal contamination, primary closure

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140
Q

what do you do about an extensive injury or contaminated esophageal injury?

A

depends on where it is.

neck: just place drains (will heal)
chest: chest tubes to drain injury and place spit fistula in neck (will eventually need esophagectomy)

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141
Q

how often do esophageal and hypopharyngeal repairs leak? what do you need to do for these repairs?

A

leak 20%. always place a drain

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142
Q

what is the approach to esophageal injuries to the neck?

A

left side

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143
Q

what is the approach to esophageal injuries to the upper 2/3 of thoracic esophagus?

A

right thoracotomy

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144
Q

what is the approach to esophageal injuries to the lower 1/3 of thoracic esophagus?

A

left thoracotomy

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145
Q

does the esophagus lie on the right or left? how does it course?

A

left to right to left

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146
Q

what do you do about laryngeal fxs and tracheal injuries?

A

airway emergency. secure airway emergently in ER w cricothyroidotomy usually. primarily repair using strap muscle for airway support. tracheostomy to allow edema to subside, and to check for stricture (convert cricothyroidotomy to tracheostomy)

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147
Q

what are the symptoms of laryngeal fx and tracheal injuries?

A

crepitus, stridor, resp compromise

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148
Q

what do you do for thyroid gland injuries?

A

control bleeding, drain. (not thyroidectomy)

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149
Q

what do you do for a recurrent laryngeal nerve injury?

A

try to repair or can reimplant in cricoarytenoid muscle

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150
Q

what are the sx of recurrent laryngeal nerve injury?

A

hoarseness

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151
Q

what do you do for a shotgun injury to neck?

A

angiogram and neck CT; esophagus/trachea evaluation

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152
Q

what do you do for a vertebral arteyr bleed?

A

embolize or ligate. no sequelae in most pts

153
Q

how often does ligation of common carotid bleed cause stroke?

A

20%

154
Q

when do you have to do a thoracotomy for chest trauma?

A 
if chest tube
>1500 cc after initial insertion
>250 cc/h x3 h
>2500 cc/24h
bleeding with instability
155
Q

why do you need to drain all the blood in the chest after chest trauma? how soon?

A

<48 hrs to prevent fibrothorax, pulm entrapment, infected hemothorax

156
Q

what do you do for an unresolved hemothorax, and what is considered an unresolved hemothorax?

A

unresolved after 2 well placed chest tubes. then do a thorascopic drain

157
Q

when is a sucking chest wound significant?

A

if the wound is 2/3 the diameter of the trachea

158
Q

what do you do for a significant sucking chest wound?

A

dressing with tape on 3 sides. prevents development of tension PTX while allowing lung to expand w inspiration

may have worse oxygenation. one of the few indications for clamping chest tube

159
Q

when might you clamp a chest tube?

A

pt with tracheobronchial injury

160
Q

which side are bronchus injuries more common?

A

right

161
Q

how would you intubate if a pt has tracheobronchial injury?

A

mainstem intubate

162
Q

how do you diagnose tracheobronchial injury?

A

bronchoscopy

163
Q

when do you treat tracheobronchial injury?

A

if large air leak and resp compromise

or after 2 weeks of persistent air leak

164
Q

when do you do a right thoracotomy? a left thoracotomy?

A

right thoracotomy for right mainstem, trachea, and proximal left mainstem injuries (avoids the aorta)

left thoracotomy for distal left mainstem injuries

165
Q

which side of the diaphragm is more often injured? what is the cause of most diaphragm injuries?

A

left. cause is blunt trauma

166
Q

what do you see on cxr in diaphragm injury?

A

air-fluid level in chest from stomach herniation through hole

167
Q

do you need any other imaging for diaphragm injury other than cxr?

A

no

168
Q

what approach would you take to repair diaphragm injury?

A

transabdominal approach if 1 week (need to take down adhesions in the chest)

169
Q

do you need mesh to repair diaphragm injury?

A

may need mesh.

170
Q

what are signs of aortic transection?

A

widened mediastinum, 1st or 2nd rib fxs, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemithorax, trachea deviation to right

171
Q

where is the tear/injury located in an aortic transection?

A

ligamentum arteriosum (just distal to subclavian takeoff). other areas are near aortic valve and where aorta traverses the diaphragm

172
Q

how do you work up aortic injury?

A

CT angiogram of chest. cxr is normal in 5% of pts. get CT angio if significant mechanism

173
Q

what is the operative approach to repairing aorta?

A

left thoracotomy and repair with partial left heart bypass or place a covered stent endograft (distal transections only)

174
Q

what do you have to consider in aortic transection?

A

treat other life threatening injuries first

175
Q

when do you use median sternotomy?

A

injuries to ascending aorta, innominate artery, prox right subclavian artery, innominate vein, prox left common carotid

176
Q

when do you use left thoracotomy?

A

injuries to left subclavian artery, descending aorta

177
Q

what approach do you take for injury tot he distal right subclavian artery?

A

midclavicular incision, resection of medial clavicle

178
Q

what are the most common causes of death in a pt with myocardial contusion?

A

v-tach and v-fib

179
Q

when is the risk for death highest in pts with myocardial contusion?

A

first 24 hours

180
Q

what is the most common arrhythmia overall in pts with myocardial contusion?

A

SVT

181
Q

how long do you have to monitor pts with myocardial contusion?

A

24-48h

182
Q

what is flail chest?

A

> = 2 consecutive ribs broken at >= 2 sites, resulting in paradoxical motion

183
Q

what does flail chest imply?

A

underlying pulmonary contusion

184
Q

what does cxr look like immediately after aspiration?

A

normal

185
Q

how do you work up a penetrating chest injury?

A

start w cxr if pt is stable (place chest tube for PTX or hemothorax)

186
Q

what are borders of the “box”?

A

clavicles, xiphoid process, nipples

187
Q

what do you do if there’s a penetrating box injury?

A

pericardial window, bronchoscopy, esophagoscopy, barium swallow

188
Q

what do you do if there’s a chest wound outside the box without PTX or HTX

A

chest tube if pt requires intubation. otherwise follow serial CXR

189
Q

what do you do if you find blood in pericardial window?

A

median sternotomy to fix injury to heart or great vessels. place pericardial drain

190
Q

what do you do for penetrating injuries anterior-medial to midaxillary line and below nipples?

A

laparotomy or laparoscopy. may need evaluation for penetrating box injury depending on exact location

191
Q

what can replace a pericardial window for box injuries?

A

FAST scan

192
Q

what are traumatic causes of cardiogenic shock?

A
  1. tamponade
  2. cardiac contusion
  3. tension ptx
193
Q

what are si/sx of tension ptx?

A

hypotension, inc airway pressure, dec breath sounds, bulging neck veins, tracheal shift. can see bulging diaphragm during laparotomy.

194
Q

how does tension ptx cause cardiac compromise?

A

dec venous return (IVC, SVC compression)

195
Q

what are pts with sternal fractures at high risk for?

A

cardiac contusion

196
Q

what are pts with 1st and 2nd rib fx at high risk for?

A

aortic transection

197
Q

can pelvic fractures be a major source of blood loss?

A

yes

198
Q

what do you do if a pt has a pelvic fx, is hemodynamically unstable, neg DPL/FAST, neg CXR, no other signs of blood loss or reasons for shock, what do you do?

A

stabilize pelvis w C-clamp, ex fix, or sheet, and go to angio for embolization

199
Q

what are pelvic trauma pts at high risk for?

A

genitourinary and abd injuries

200
Q

what are the types of pelvic fractures?

A

type I, II, III

http://cl.ly/image/1e0M380J123f

201
Q

which types of pelvic fxs are unstable?

A

I and II

202
Q

what is mortality of type I, II, and III pelvic fx?

A

I: 20-30%
II: 8-12%
III: <5%

203
Q

what is blood loss amount in type I, II, III pelvic fxs?

A

I: >10units
II: 2-10u
III: 1-4u

204
Q

which type of pelvic fx is an “open book”

A

type II.

205
Q

of anterior and posterior pelvic fxs, which is more likely to have venous and which is most likely to have arterial bleeding?

A

anterior: venous
posterior: arterial

206
Q

what might you need to do if a pt has open pelvic fx with rectal tears and perineal lacs?

A

colostomy

207
Q

is it ok to delay a pelvic fx repair?

A

yes, until other associated injuries are repaired

208
Q

how do you approach a penetrating injury pelvic hematoma?

A

open. some suggest angiography

209
Q

how do you approach a blunt injury pelvic hematoma

A

leave. if expanding or pt is unstable, stabilize pelvic fx, pack pelvis if in OR, and go to angiography for embolization

210
Q

when do you remove pelvic packing after a pt is stable if the packs were placed intraop for a blunt injury pelvic hematom?

A

24-48h postop

211
Q

what is the usual cause of duodenal trauma?

A

blunt trauma (crush or deceleration)

212
Q

which part of the duodenum is most commonly injured?

A 
2nd portion (descending portion, near ampulla of vater)
also tears near ligament of treitz
213
Q

how often is surgery required for duodenal trauma? what do you do?

A

80%, can be treated w debridement and primary closure. can do segmental resection with primary end to end closure.

214
Q

where can you NOT do segmental resection with primary end to end closure?

A

2nd portion of the duodenum

215
Q

what is mortality in duodenal trauma pts? what causes mortality?

A

25% b/c associated w shock.

216
Q

what is the major source of morbidity in duodenal trauma pts?

A

fistulas

217
Q

where are hematomas found in duodenal trauma pts? what size is considered significant? what do you do for it?

A

> = 2cm considered significant.

usually hematomas in third portion of duodenum overlying spine in blunt injury.

218
Q

how do you approach duodenal injury with hematoma?

A

need to open for both blunt and penetrating injuries

219
Q

what is a complication of a paraduodenal hematoma that was missed on CT or found on repeat CT? when can it present?

A

SBO 12-72 hr after injury

220
Q

what will UGI study show with paraduodenal hematomas?

A

stacked coins or coiled spring appearance. make sure no extravasation.

221
Q

what is treatment of paraduodenal hematoma? how effective is it?

A

conservative (NGT and TPN).

cures 90% over 2-3 weeks (hematoma reabsorbed)

222
Q

what do you do intraop if duodenal injury is suspected?

A
  1. kocher maneuver and open lesser sac through omentum.
  2. check for hematoma, bile, succus, and fat necrosis.
  3. if found, need formal inspection of entire duodenum (also check for pancreatic inj)
223
Q

how do you diagnose a suspected duodenal injury?

A

abd CT w contrast initially (bowel thickening, hematoma, free air, contrast leak, or retroperitoneal fluid/air)
UGI contrast study is the best

224
Q

what do you do if abd ct in suspected duodenal injury is negative or nondiagnostic?

A

repeat CT in 8-12h

225
Q

what is treatment for duodenal injury?

A
  1. primary repair or anastomosis.
  2. may need to divert w pyloric exclusion and gastrojejunostomy to allow healing.
  3. place distal feeding jejunostomy and poss proximal draining jejunostomy tube that threads back to duodenal injury site
226
Q

what do you do if the duodenal injury is in the 2nd portion of duodenum?

A

can’t do primary repair.

  1. place jejunal serosal patch over hole, may need whipple in future
  2. need pyloric exclusion and gastrojejunostomy
  3. consider feeding and draining jejunostomies; leave drains
227
Q

when do you do trauma whipples?

A

rare if ever indicated (very high mortality)

228
Q

when do you remove drains in pt with duodenal trauma?

A

when pt tolerating diet without inc in drainage

229
Q

what happens to fistulas over time? what is the treatment for fistulas?

A

fistulas often close w time

treatment is bowel rest, TPN, octreotide, conservative management for 4-6weeks

230
Q

illustrate the jejunal serosal patch.

A

http://cl.ly/image/1e0M380J123f

231
Q

illustrate the gastrojejunostomy and pyloric exclusion for complex duodenal injury

A

http://cl.ly/image/1E1M1j0F210A

232
Q

what is the most common organ injured with penetrating injury?

A

small bowel (some texts say liver)

233
Q

what is an occult small bowel injury?

A

abd CT scan showing intra-abdominal fluid not associated w solid organ injury, bowel wall thickening, or a mesenteric hematoma

234
Q

what is management for occult small bowel injury?

A

need close observation

possible repeat abd CT after 8-12h to make sure finding is not getting worse

235
Q

what do you have to make sure in pts with occult small bowel injury?

A

tolerate a diet before d/c

236
Q

in which direction do you repair small bowel?

A

transverse. avoids stricture

237
Q

when do you resect and reanastomose small bowel lacerations?

A

if laceration >50% of bowel circumference or results in lumen diameter <1/3 normal

238
Q

what do you do about multiple close lacerations in small bowel?

A

resect that segment

239
Q

what do you do about mesenteric hematomas?

A

open if expanding or large (>2cm)

240
Q

which kind of injury is colon trauma associated with: blunt or penetrating?

A

penetrating

241
Q

how do you manage colon injuries?

A

transverse/right: perform primary repair/anastomosis

left: perform primary repair/anastomosis; place diverting ileostomy if pt is in shock or there is gross contamination

242
Q

what do you do for paracolonic hematomas if blunt? if penetrating?

A

both blunt and penetrating need to be opened

243
Q

what kind of injury is rectal trauma most associated with? blunt or penetrating?

A

penetrating

244
Q

classify the different typeso f rectal traumas.

A

high rectal and low rectal

high rectal: extraperitoneal and intraperitoneal

245
Q

what do you do for high rectal extraperitoneal trauma?

A

generally not repaired b/c of inaccessibility.

serial debridement; consider diverting ileostomy

246
Q

what do you do for high rectal intraperitoneal trauma?

A

repair defect, presacral drainage, consider diverting ileostomy.
place diverting ileostomy with shock, gross contamination, or extensive injury

247
Q

what do you do for low rectal injuries?

A

if <5cm, can probably be repaired transanally

248
Q

which organ is most commonly injured with blunt abd trauma?

A

liver. some texts say spleen

249
Q

do you do lobectomies for liver trauma?

A

rarely necessary

250
Q

can you ligate the common hepatic artery?

A

yes. collaterals through gastroduodenal artery

251
Q

what is the pringle maneuver?

A

clamping of portal triad.

http://cl.ly/image/0w1g090W1F0U

252
Q

where can still bleed after pringle maneuver?

A

hepatic veins

253
Q

what is the portal triad?

A
  1. branches of the portal vein
  2. hepatic artery
  3. biliary ducts
254
Q

what do you do for severe penetrating liver injuries?

A

damage control peri-hepatic packing

255
Q

what do you do if pt with severe liver injury becomes unstable while in OR doing damage control peri-hepatic packing? what injury can do this?

A

go to ICU and get pt resuscitated and stabilized. retro-hepatic IVC injury can cause this

256
Q

when do you use an atriocaval shunt? what does it do?

A

for retrohepatic IVC injury

allows for control while performing repair

257
Q

how do you repair CBD injury?

A

may need intraop cholangiogram to define injury

  • if injury is 50% or complex injury, choledochojejunostomy
  • if 10% of duct anastomoses leak, place drain intraop
258
Q

what do you do about portal vein injuries?

A

need to repair

may need distal pancreatectomy to get to injury in the portal vein

259
Q

what is the mortality rate of portal vein ligation?

A

50%

260
Q

what can you use to stop bleeding and prevent bile leaks after liver lac?

A

omental graft

261
Q

do you leave a drain in with liver injuries?

A

yes

262
Q

when do you have to go to the OR for blunt liver injury?

A
  • if pt becomes unstable despite aggressive resuscitation, including 4U pRBCs (HR>120, SBP 4U pRBCs to keep hct >25
  • active blush on abd CT
  • pseudoaneurysm
263
Q

if the liver injury is posterior, what do you do? anterior?

A

posterior: angiogram
anterior: OR

264
Q

how long should you be bed rest if doing conservative management of blunt liver injury?

A

5 days

265
Q

when is spleen trauma fully healed?

A

after 6 weeks

266
Q

when is postsplenectomy sepsis greatest risk?

A

within 2 years of splenectomy

267
Q

what can increase chances of splenic salvage?

A

increased transfusions

268
Q

what is considered failure of conservative management of splenic injury?

A
  • if pt becomes unstable despite aggressive resuscitation, including 4U pRBCs (HR>120, SBP 4U pRBCs to keep hct >25
  • active blush on abd CT
  • pseudoaneurysm
269
Q

how long should you be bed rest if doing conservative management of splenic injury?

A

5 days

270
Q

what is the threshold for splenectomy in children?

A

much higher. hardly any children get splenectomy

271
Q

what do pts get after trauma splenectmy?

A

immunizations

272
Q

what percent does penetrating injury account for in all pancreatic injuries?

A

80%

273
Q

what can blunt injury cause in pancreatic trauma?

A

pancreatic duct fx, usu perpendicular to the duct

274
Q

what are signs of pancreatic injury on either CT or in the OR?

A

peripancreatic fat necrosis or edema

275
Q

what can be done for pancreatic contusion?

A

leave if stable. place drains if in OR

276
Q

how much of the distal pancreas can you take for a distal pancreatic duct injury?

A

up to 80% of the gland

277
Q

what do you do for a pancreatic head duct injury that is not reparable?

A

place drains initially

eventually delayed whipple or possible ERCP w stent

278
Q

how do you decide whipple vs distal pancreatectomy?

A

based on duct injury in relation to the SMV

279
Q

what can you do to help evaluate the pancreas in the operating room?

A

kocher maneuver

280
Q

do you place drains for pancreatic injury?

A

yes

281
Q

what do you need to do for a pt with pancreatic hematoma if it’s blunt? penetrating?

A

open in both cases

282
Q

what can tell you that you missed a pancreatic injury?

A

rising amylase or persistent amylase

283
Q

are CT scans good at diagnosing pancreatic injuries?

A

not initially

284
Q

what are the delayed CT signs of pancreatic injury?

A

fluid, edema, necrosis

285
Q

what is the best modality for finding pancreatic duct injuries?

A

ERCP and may be able to treat with temporary stent

286
Q

is the orthopedic or vascular repair done first?

A

vascular repair (or vascular shunt) done before

287
Q

what are major signs of vascular injury? what do you need to do?

A

active hemorrhage, pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill.
go to OR for exploration (may need angio in OR to define injury)

288
Q

what are the moderate/soft signs of vascular injury? what do you need to do?

A

h/o hemorrhage, deficit of anatomically related nerve, large stable/nonpulsatile hematoma, ABI<0.9. need to go to angio

289
Q

what do you need to use to repair a vascuar segment >2cm?

A

contralateral saphenous vein graft.

290
Q

which veins need repair when injured?

A

vena cava, femoral, popliteal, brachiocephalic, subclavian, axillary

291
Q

what do you do if a pt has transected single artery in the calf, otherwise healthy?

A

ligate

292
Q

what do you do over site of vascular anastomosis?

A

cover site with viable tissue and muscle

293
Q

if pt has ischemia, what do you do? why?

A

consider fasciotomy if >4-6h (prevents compartment syndrome)

294
Q

what are findings of compartment syndrome?

A

compartment pressures >20mmhg or if clinical exam suggests elevated pressures
-pain, paresthesia, anesthesia, paralysis, poikilothermia, pulselessness (late)

295
Q

what injuries are susceptible to compartment syndrome of the extremities?

A
  • supracondylar humeral fx
  • tibial fx
  • crush injuries
  • injuries that cause disruption and then restoration of blood flow after 4-6hrs
296
Q

what is treatment for compartment syndrome?

A

fasciotomy

297
Q

where do you approach the lower extremity for fasciotomy?

A

http://cl.ly/image/0M113e1T2r0c

298
Q

when do you do primary repair of IVC? when can you not do primary repair and what do you do instead?

A

if residual stenosis <50% diameter of IVC. otherwise place saphenous vein or synthetic patch

299
Q

how do you control bleeding of IVC?

A

proximal and distal pressure, NOT clamps. it can tear

300
Q

how do you repair posterior wall injury of the IVC?

A

through anterior wall (need to cut through anterior IVC to get to posterior IVC injury

301
Q

can femur fractures be a source of major blood loss? how much blood can be lost from a femur fx?

A

yes. >2L of blood

302
Q

list the orthopedic emergencies

A
  • pelvic fx in unstable pts
  • spine inj with deficit
  • open fx
  • dislocations or fx with vascular compromise
  • compartment syndrome
303
Q

what do femoral neck fractures put pts at risk for?

A

avascular necrosis

304
Q

what do you do if a pt has a long bone fx or dislocation w loss of pulse (or weak pulse)?

A

immediate reduction of fx or dislocation and reassess pulse

305
Q

if pulse doesn’t return after reduction of fx, what do you do?

A

go to OR for vascular bypass or repair (may need angio in OR)

306
Q

if pulse is weak after reduction of fx, what do you do?

A

angiography

307
Q

what do you do for knee dislocation?

A

angiogram, unless pulse is absent. if absent, go to OR (may need angio in OR)

308
Q

what can get fractured with upright falls?

A

calcaneus, lumbar, distal forearm (radius/ulnar) fractures

309
Q

injury to what causes axillary nerve injury?

A

anterior and posterior shoulder dislocation, proximal humerus fx

310
Q

injury to what causes radial nerve injury?

A

midshaft humerus fx (or spinal humerus fx)

311
Q

injury to what causes brachial artery injury?

A

distal (supracondylar) humerus fx, elbow dislocation

312
Q

injury to what causes median nerve injury?

A

distal radius fx

313
Q

injury to what causes femoral artery injury?

A

anterior hip dislocation

314
Q

injury to what causes sciatic nerve injury?

A

posterior hip dislocation

315
Q

injury to what causes popliteal artery injury?

A

distal (supracondylar) femur fx, posterior knee dislocation

316
Q

injury to what causes common peroneal nerve injury?

A

fibula neck fx

317
Q

injury to what causes epidural hematoma?

A

temporal or parietal bone fx

318
Q

injury to what causes cervical spine fx?

A

maxillofacial fx

319
Q

injury to what causes cardiac contusion?

A

sternal fx

320
Q

injury to what causes aortic transection?

A

first or second rib fx, scapula fx

321
Q

injury to what causes pulmonary contusion?

A

scapula fx

322
Q

injury to what causes spleen lac?

A

rib fxs (left, 8-12)

323
Q

injury to what causes liver lac?

A

rib fxs (right 8-12)

324
Q

injury to what causes bladder rupture or urethral transection?

A

pelvic fx

325
Q

what is the best indicator of renal trauma?

A

hematuria

326
Q

what imaging do renal trauma pts get?

A

abdominal CT scan

327
Q

what other imaging can be useful?

A

IVP if going to OR without abd scan. identifies presence of functional contralateral kidney, which could affect intraop decision making

328
Q

what is different between right and left renal veins?

A

left renal vein can be ligated near IVC. it has adrenal and gonadal vein collaterals

right renal vein doesn’t ahve these collaterals

329
Q

what are the structures of the renal hilum from anterior to posterior?

A

vein, artery, pelvis (VAP)

330
Q

what percent of renal injuries are treated nonoperatively?

A

95%.

331
Q

do all urine extravasation injuries require operation?

A

no not all

332
Q

what are the indications for operation in a renal trauma pt?

A

acutely: ongoing hemorrhage w instability

after acute phase: major collecting system disruption, non-resolving urine extravasation, severe hematuria

333
Q

when you explore renal area, what structure do you try to get control of?

A

vascular hilum first

334
Q

do you place drains intraop?

A

yes, esp if the collecting system is injured

335
Q

what can oyu use to check for leak?

A

methylene blue dye

336
Q

what do you do for blunt injury with hematoma to the kidney?

A

leave unless preop CT /IVP shows no function to sigificant urine extravasation.

337
Q

what do you do for a penetrating renal injury with hematoma?

A

open unless preop CT/IVP shows good function without statistical urine extravasastion

338
Q

what do you do for a trauma to flank and IVP shows no uptake in a stable pt?

A

angiogram. can stent if flap present.

339
Q

how often is hematuria associated with pelvic fx?

A

> 95%

340
Q

what are si/sx of ureteral injury?

A

meatal blood, sacral or scrotal hematoma

341
Q

how do you diagnose ureteral injury?

A

cystogram

342
Q

what is the diagnosis and treatment for extraperitoneal bladder rupture?

A

cystogram shows starbursts Tx foley 7-14d

343
Q

what is the treatment for intraperitoneal bladder rupture? who does it happen in?

A

happens in kids. cystogram shows leak. Tx: operation and repair of defect, followed by foley

344
Q

what are the best tests to diagnose ureteral trauma?

A

IVP and retrograde urethrogam (RUG). hematuria is unreliable

345
Q

what do you do for large (>2cm) upper 1/3 or middle 1/3 ureter injuries?

A

if upper 1/3 and middle 1/3 ureter (pelvic brim) is injured, poss cant reach bladder:

  • temporize with percutaneous nephrostomy (tie off both ends of the ureter)
  • or ileal interposition or trans-ureteroureterostomy later
346
Q

what do you do for lower 1/3 ureter injuries that can’t be repaired with anastomosis?

A

reimplant in the bladder; may need bladder hitch procedure

347
Q

what do you do if small ureteral segment is missing (<2cm)?

A

upper and middle 1/3 injuries: mobilize ends of ureter and perform primary repair over stent
lower 1/3 injury: re-implant into bladder (easier than primary repair

348
Q

can you evaluate ureters with one shot intravenous pyelogram?

A

no

349
Q

what contrast do you use for ureters to check for leaks?

A

IV indigo carmine or IV methylene blue

350
Q

where is the blood supply located in upper 2/3 ureter located? how about in the lower 1/3 of the ureter?

A

medial in upper 2/3

lateral in lower 1/3

351
Q

do you need drain for ureteral injuries?

A

yes

352
Q

what are signs of urethral trauma?

A

best: hematuria or blood at meatus
others: free-floating prostate, usu a/w pelvic fxs

353
Q

do you place a foley in pts with poss urethral trauma?

A

no

354
Q

what is the best test to identify urethral trauma?

A

RUG

355
Q

what portion of the uretrha is at highest risk for transection?

A

membranous portion

356
Q

what is the treatment for significant tears of the urethra?

A

suprapubic cystostomy and repair in 2-3 months.

357
Q

what is prevented if urethral trauma is repaired early?

A

reduced rate of high stricture and impotence

358
Q

what is treatment for small partial tears of the urethra?

A

bridging urethral catheter across tear are and repair in 2-3 month

359
Q

what do you need to repair for penis trauma?

A

repair tunica and buck’s fascia

360
Q

what do you do if pt has testicular trauma?

A

ge tultrasound to see if tunica albuginea is violated, then repair if necessary

361
Q

in children, what are the best indicators of hypovolemic shock?

A

HR, RR, mental status, clinical exam. BP is the last thing to go after blood loss

362
Q

what are children at higher risk for in trauma?

A

hypothermia (inc BSA compared with weight)

head injury risk inc

363
Q

what are normal VS in children?

A

https://www.dropbox.com/s/p9zxbu5tm2ka3x2/Screenshot%202013-11-07%2000.08.57.jpg

364
Q

what is the most important thing to do when treating a pregnant woman in trauma?

A

save the mother

365
Q

what is scary about pregnant trauma?

A

pregnant pts can have up to 1/3 total blood volume loss without signs

366
Q

what do you do for trauma during pregnancy that is different?

A

estimate pregnancy based on fundal height (20cm = 20wk = umbilicus. place on fetal monitor

  • try to avoid CT with early pregnancy, but get if life threatening
  • check for vaginal d/c - blood, amnion; check for effacement, dilation, fetal station
367
Q

what can you measure to determine whether fetus is mature?

A

lecithin:sphingomyelin (LS) ratio >2:1

phosphatidylcholine in amniotic fluid

368
Q

what is fetal death rate with 50% or more abruption of the placenta?

A

100%

369
Q

what are signs of abruption of placenta?

A

uterine tenderness, contractions, fetal HR <120, kleihauer-betke test (test for fetal blood in the maternal circulation)

370
Q

what can cause placental abruption? what is most common?

A

shock (most common) or mechanical forces

371
Q

where is uterine rupture most likely to occur?

A

posterior fundus

372
Q

what do you do if uterine rupture occurs during delivery of a child?

A

aggressive resuscitation

uterus will clamp down after delivery eventually

373
Q

what are indications for C-section during exlap for trauma?

A
  • persistent maternal shock or severe injuries and pregnancy near term (>34weeks)
  • pregnancy a threat to the mother’s life (hemorrhage, DIC)
  • mechanical limitation to life-threatening vessel injury
  • risk of fetal distress exceeds risk of immature
  • direct intra-uterine trauma
374
Q

what is your assessment of the pregnant uterus during ex lap?

A

https://www.dropbox.com/s/sntmd5e32o24dhe/Screenshot%202013-11-07%2000.22.56.jpg

375
Q

in which traumatic situations do you leave a drain?

A

pancreatic, liver, biliary system, urinary, duodenal injuries

376
Q

what are sx of snakebites?

A

shock, bradycardia, arrhythmias

377
Q

what is treatment for snakebite?

A

stabilize, anti-venom, tetanus shot

378
Q

what is the management of hematomas in penetrating and blunt trauma?

A

https://www.dropbox.com/s/hb4ptwansva0dml/Screenshot%202013-11-07%2000.25.17.jpg

379
Q

what are the zones of the peritoneum, where are they located, and what are the associated injuries?

A

https://www.dropbox.com/s/ysgu7jho1aijzt4/Screenshot%202013-11-07%2000.25.24.jpg

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