15 Trauma Flashcards
1st peak for trauma deaths
0-30 minutes
Due to lacerations of heart, aorta, brain, brainstem or spinal cord
Cannot really save these patients - they die too quickly
2nd peak for trauma deaths
30 min - 4 hours
Death due to head injury (#1) and hemorrhage (#2)
These patients can be saved with rapid assessment
‘golden hour’
3rd peak for trauma deaths
Days to weeks
Death due to MODS and sepsis
Most common solid organ damaged in blunt trauma?
Liver
Spleen
What is the biggest predictors of survival in a fall?
Age and body orientation
LD50 is 4 stories
Most common organ damaged in penetrating trauma?
Small bowel
Liver
What is the most common cause of death in the first hour?
Hemorrhage
How much blood can you lose without effecting BP?
30%
Treatment of hemorrhage?
2L LR then switch to blood
What is the most common cause of death after reaching the ER alive?
Head injury
Most common cause of death in trauma patients over the long term?
Infection
Most common cause of upper airway obstruction?
Tongue
Perform jaw-thrust
What injuries are associated with seat belts?
Small bowel perforations
Lumbar spine fractures
Sternal fractures
What is the best site for cutdown for venous access?
Saphenous vein
Diagnostic peritoneal lavage
Hypotensive patients with blunt injuries
Need laparotomy if positive
What indicates a DPL is positive?
>10cc blood >100,000 RBCs/cc Food particles Bile Bacteria >500 WBC/cc
What does DPL miss?
Retroperitoneal bleeds
Contained hematomas
Focused abdominal sonography for trauma
Perihepatic fossa, perisplenic fossa, pelvis and pericardium
If positive - take to OR
FAST misses?
Free fluid <50-80cc
Retroperitoneal bleeding
Hollow viscus injury
In hypotensive patient with negative FAST scan?
Find source of bleeding
Pelvic fracture, chest or extremity
Indications for CT scan following blunt trauma?
ABdominal pain, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria
Negative DPL
CT scan misses in trauma?
Hollow viscous injury
Diaphragm injury
Indications for laparotomy in trauma?
Peritonitis Eviseration Positive DPL Uncontrolled visceral hemorrhage Free air Diaphragm injury Intraperitoneal bladder injury Contrast extravasation from hollow viscus Specific renal, pancreas and biliary tract injury
Treatment for penetrating abdominal injury?
Laparotomy
Exception - knife or low velocity injuries: local exploration and obs if fascia no violated
Abdominal compartment syndrome
Bladder pressure > 25-30
IVC compression is the final common pathway for decreased CO
Low CO causes visceral and renal malperfusion (decreased urine output)
Upward displacement of diaphragm affect ventilation
Causes of abdominal compartment syndrome?
Massive fluid resuscitation
Trauma
Abdominal surgery
Treatment for abdominal compartment syndrome?
Decompressive laparotomy
Pneumatic antishock garment
Controversial use for pt with SBP<50 and no thoracic injury
Remove one compartment at a time upon arriving at ED
Indications for ED thoracotomy
Blunt trauma - only if pressure/pulses lost in ED
Penetrating trauma - If pressure/pulses lost enroute or within the ED
Performing an ED thoracotomy?
Through fourth and fifth intercostal spaces
Open pericardium anterior to the phrenic nerve
Cross-clamp the aorta (watch anteriorly to the esophagus)
If the thoracotomy is performed for abdominal injury?
Clamp the descending thoracic aorta.
IF BP improves to >70 - transport to OR for laparotomy
If BP does NOT improve - further treatment is futile
If the thoracotomy is performed for a cardiac injury?
Open the pericadrium longitudinally and anterior to the phrenic nerve. The heart can be rotated out of the pericardium for repair.
When do catecholamines peak after injury?
What other hormones increase?
24-48hrs
ADH, ACTH, glucagon
Glasgow Coma Scale
Motor (6)
Verbal (5)
Eye opening (4)
<14 - head CT
<10 - intubation
< 8 - ICP monitor
Scores for motor rating of GCS?
6 - follows commands 5 - localizes pain 4 - withdraws from pain 3 - flexion with pain (decorticate) 2 - extension with pain (decerebrate) 1 - no response
Scores for verbal ratings of GCS?
5 - Oriented 4 - Confused 3 - Inappropriate words 2 - Incomprehensible sounds 1 - no response
Scores for eye opening ratings of GCS?
4 - Spontaneous opening
3 - Opens to command
2 - Opens to pain
1 - No response
Indications for head CT in trauma?
Suspected skull penetration by a foreign body
Discharge of CSF, blood or both from nose
Hemotympanum or discharge of blood/CSF from ear
Head injury with intoxication
Altered state of consciousness at time of exam
Focal neurologic signs or symptoms
Any situation precluding proper surveillance
Head injury plus additional trauma
Protracted unconsciousness
Indications for surgical intervention in epidural hematoma?
Significant neurologic degeneration
Significant mass effect (shift > 5mm)
Indications for surgical intervention in subdural hematoma?
Significant neurologic degeneration
Significant mass effect (>1cm)
Indications for ventriculostomy in traumatic IVH?
Hydrocephalus
Indications for craniectomy with diffuse axonal injury?
Elevated ICP
Cerebral perfusion pressure
CPP = MAP - ICP
Signs of elevated ICP?
Decreased ventricular size
Loss of sulci
Loss of cisterns
Indications for ICP monitors
GCS < 8
Suspected increased ICP
Patients with moderate to severe head injury and inability to follow clinical exam
Normal ICP? Needs treatment? Goal CPP?
Normal ICP 10, >20 needs treatment
Goal CPP is >60
Treatment for ICP?
Sedation and paralysis Raid head of bed Relative hyperventilation Hypertonic saline (keep Na 140-150, sOsm 295-310) Mannitol Barbiturate coma Ventriculostomy w/ CSF drainage Craniotomy decompression Fosphenytoin or Keppra (prophylaxtic)
How does relative hyperventilation effect ICP?
CO2 causes modest cerebral vasoconstriction
Goal CO2 30-35
Avoid over-hyperventilation and cause cerebral ischemia from too much vasoconstriction
Raccoon eyes
Peri-orbital ecchymosis
Anterior fossa fracture
Battle’s sign
Mastoid ecchymosis Middle fossa fracture Can injury facial nerve (CN VII) If deficit presents: - Acute: exploration and repair - Delayed: secondary to edema, no exploration
Temporal skull fracture
Can injure CN VII/VIII
Most common site of facial nerve injury?
Geniculate ganglion
Most common cause of temporal skull fractures?
Lateral skull or orbital blow
Indications for operation in skull fracture?
Significantly depressed (>1cm)
Contaminated
Persistent CSF leak
Cause of coagulopathy with traumatic brain injury?
Release of tissue factor
Jefferson fracture
C-1 burst
Caused by axial loading
Tx: Rigid collar
Hangman’s fracture
C-2
Distraction and extension
Tx: traction and halo
Odontoid fracture
C-2
Type I - above base, stable
Type II - at base, unstable (Requires fusion or halo)
Type III - extends into vertebral body (fusion or halo)
Facet fractures or dislocations
Can cause cord injury
Associated with hyperextension and oration with ligamentous disruption
Three columns of the thoracolumbar spine?
Anterior - anterior longitudinal ligament and anterior 1/2 of the vertebral body
Middle - posterior 1/2 of the vertebral body and posterior longitudinal ligament
Posterior - facet joints, lamina, spinous processes, interspinous ligament
More than one column = unstable
Compression fractures
Anterior column only
Stable
Burst fractures
Unstable (involve more than one column)
Require fusion
At risk for fracture in upright fall?
Calcaneus
Lumbar
Wrist/forearm
Indications for emergent surgical spine decompression?
Fracture or dislocation not reducible with distraction
Open fractures
Soft tissue or bony compression of the cord
Progressive neurologic dysfunction
Most common cause of facial nerve injury?
Temporal bone fracture
Le Fort Classification - Type I
Maxillary fracture straight across ( — )
Tx: Reduction, stabilization, intramaxillary fixation +/- circuzygomatic and orbital rim suspension wires
Le Fort Classification - Type II
Lateral to nasal bone, underneath eyes, diagonal toward maxilla ( / \ )
Tx: Reduction, stabilization, intramaxillary fixation +/- circuzygomatic and orbital rim suspension wires
Le Fort Classification - Type III
Lateral orbital walls ( – – )
Tx: Suspension wiring to stable frontal bone; may need external fixation
Nasoethmoidal orbital fractures
70% have a CSF leak
Conservative therapy for up to 2 weeks
Can use epidural catheter to decrease CSF pressure and help close leak
May need surgical closure of dura to stop leak
Anterior nose bleed - treatment?
Packing
Posterior nose bleed?
Balloon tamponade
Angioembolization
Arteries - internal maxillary artery or ethmoidal artery
Orbital blowout fracture
Indications for repair:
Impaired upward gaze or diplopia with upward vision
Perform restoration fo orbital floor with bone fragments or bone graft
Mandibular injury
Malocclusion
Diagnosis - fine-cut facial CT with reconstruction
Most repaired with IMP for 6-8 weeks or open reduction and internal fixation (ORIF)
Tripod fracture
Zygomatic bone
ORIF for cosmesis
What must you have a high suspicion for with maxillofacial fractures?
Cervical spine issues
Work up for asymptomatic blunt trauma to the neck?
Neck CT scan
Work up for asymptomatic penetrating trauma?
Based on neck zone
Penetrating trauma - Zone I
Clavicle to cricoid cartilage
Workup: angiography, bronchoscopy, esophagoscopy and barium swallow
Tx: pericardial window, median sternotomy
(Potential for damage to great vessels)
Penetrating trauma - Zone II
Cricoid to angle of mandible
Workup: Neck exploration in OR
Penetrating trauma - Zone III
Angle of mandible to the base of skull
Workup: angiography, laryngoscopy
Tx: Jaw subluxation, digastric and SCM muscle release, mastoid sinus resection to reach vascular injuries to this location
Symptomatic neck trauma? Indications? Treatment?
Shock, bleeding, expanding hematoma, losing/lost airway, subQ air, stridor, dysphagia, hemoptysis, neurological deficit
Neck exploration
Work up of esophageal injuries?
Esophagoscopy and esophagogram
Treatment of contained esophageal injuries?
Observation
Treatment of non-contained esophageal injuries?
Small, with minimal contamination - primary closure
Extensive or contaminated:
- Neck - place drains
- Chest - chest tube and place split fistula in neck (eventually will need esophagectomy)
Approach to esophageal injuries?
Neck - left side
Upper 2/3 of thoracic esophagus - right thoracotomy
Lower 1/3 of thoracic esophagus - left thoracotomy
Laryngeal fracture and tracheal injuries?
Airway emergency
Sx: Crepitus, stridor, respiratory compromise
Emergent Tx: secure airway (cricothyroidotomy)
Tx: Primary repair (strap muscles); convert to trachyeostomy (allows for edema to subside)
Thyroid gland injuries
Control bleeding and drain
NOT thyroidecomy
Recurrent laryngeal nerve injury
Can repair or reimplant in cricoarythenoid muscle
Sx: hoarseness
Shotgun injury to neck
Requires angiogram and next CT
Evaluate the esophagus and trachea
Vertebral artery bleeds
Embolize or ligate
Common carotid bleed
Ligation causes stroke in 20%
Indications for OR after chest tube placement?
> 1500cc after initial insertion
250cc/h for 3 hrs
2500cc/24hrs
Bleeding with instability
Treatment for unresolved hemothorax after 2 well-placed chest tubes?
Thoracoscopic drainage
Sucking chest wound (open pneumothorax)
Needs to be at least 2/3 diameter of the trachea to be significant
Cover wound with valve dressing
Tracheobronchial injury
Worse oxygenation after CT placement - clamp the chest tube
Bronchus injuries are more common on the right
ED tx: mainstem intubate on unaffected side
DX: bronchoscopy
Tx:
- Immediately if large air leak and respiratory compromise
- After 2 weeks of persistent air leak
Indication for right thoracotomy in tracheobronchial injury?
Right mainstem, trachea, and proximal mainstem injuries (avoids the aorta)
Indication for left thoracotomy in tracheobronchial injury?
Distal left mainstem injury
Diaphragmatic injuries
Most commonly on the left and secondary to blunt injuries
Dx: CXR (air-fluid level in chest)
TX:
- If less than 1 week - transabdominal approach
- If greater than 1 week (chest approach)
May need mesh
Signs of aortic transection on CXR?
Widened mediastinum 1st or 2nd rib fractures Apical capping Loss of aortopulmonary window Loss of aortic contour Left hemothorax Trachea deviation to right
Locations for aortic transection?
Ligamentum arteriosum (distal to subclavian tackeoff)
Near aortic valve
Diaphragmatic hiatus
Diagnosis of aortic transection?
CT angiogram of chest
Operative approach to repair of aortic transection?
Left thoracotomy with repair with partial left heart bypass
OR
Covered stent endograft (distal transection only)
Indication for median sternotomy?
Injuries to ascending aorta, innominate artery, proximal right subclavian artery, innominate vein, proximal left common carotid
Indication for left thoracotomy?
Injuries to left subclavian artery, descending aorta
Access for distal right subclavian artery?
Midclavicular inscision resection of medial clavicle
Most common cause of death after myocardial contusion?
V-tach and V-fib
Highest risk in first 24hrs
Flail chest
2 consecutive ribs broken at > 2 sites
Paradoxical motion
Risk for pulmonary contusion
Penetrating chest injury - first step
If stable - CXR
Penetrating ‘box’ injuries?
borders are clavicle, xiphoid process and nipples Requires: - Pericardial window (FAST scan) - Bronchoscopy - Esophagoscopy - Barium swallow
Penetrating ‘non-box’ injuries without pneumothorax or hemothorax?
Needs chest tube if patient requires intubation
Otherwise, serial CXR
Pericardial window
If you find blood - median sternotomy (to fix possible injury to heart or great vessels)
Place pericardial drain
Penetrating injuries anterior-medial to midaxillary line and below nipples
Laparotomy
Plus work up for penetrating ‘box’ injuries
Traumatic causes of cardiogenic shock?
Cardiac tamponade
Cardiac contusion
Tension pneumothorax
Tension pneumothorax
Sx: hypotension, increased airway pressure, decrease breath sounds, bulging neck veins, tracheal shift
Can see bulging diaphragm during laparotomy
Cardiac compromise seconary to decreased venous return (IVC, SVC compression)
Tx: Chest tube
Hemodynamically unstable with pelvic fracture and negative DPL, negative CXR, and no other signs of blood loss or reasons for shock
Stabilize pelvis (C-clamp, external fixator, sheet) Go to angio for embolization
Type I pelvic fracture
Ubstable (crush)
Fracture in multiple facets
Type II pelvic fracture
Unstable
Book fracture - one rami and sacroiliac join
Type III pelvic fracture
Stable
Through a rami
Bleeding in anterior pelvic fractures
Venous
Bleeding in posterior pelvic fractures
Arterial
Intra-op penetrating injury pelvic hematomas
Open (possibly angiography)
Intra-op blunt injury pelvic hematomas
Leave
If expanding or patient unstable - stablize pelvic fracture, pack paelvis if inOR
Go to angiography for embolization
Most common cause of duodenal trauma
Blunt trauma
Crush or deceleration injury
Most common area of duodenal injury?
2nd portion of the duodenum
Which segment of the duodenum cannot be repaired with primary end-to-end closure
Second portion of the duodenum
Intra-op paraduodenal hematomas
> 2cm are considered significant
Most common in 3rd portion of the duodenum overlying the spine
Need to open both blunt and penetrating injuries
Paraduodenal hematoma on CT scan
Can present as SBO 12-72hrs after injury
UGI: ‘stacked coins’ or ‘coiled sping’
Tx: NGT and TPN (90% resolve over 2-3 weeks)
If at laparotomy and duodenal injury is suspected?
Perform kocher maneuver and open lesser sac through the omentum
Check for hematoma, bile, succus and fat necrosis
If found - need to inspect entire duodenum and check for pancreatic injury
Diagnosing suspected duodenal injury
Abdominal CT with contrast
- Bowel wall thickening, hematoma, free air, contrast leak or retroperitoneal fluid/air
UGI contrast study*
Treatment of duodenal injury
Try to get primary repair or anastomosis
May need to divert with pyloric exclusion and gastrojejunostomy
Place a distal feeding jejunostomy and possble draining jejunostomy tube that threads to the duodenum
Place drains
Treatment of 2nd portion of duodenum and cannot get a primary repair
Place jejunal serosal patch Pyloric exclusion and gastrojejunostomy Consider feeding and draining jenuostomy Leave drains Will eventually need a whipple
When do you remove drains after duodenal injury?
When patient can tolerate PO feeding without increased in drain output
Treatment of fistulas
Bowel rest
TPN
Octreotide
Conservative management for 4-6 weeks
Most common organ injured in penetrating injury?
Small bowel (liver)
Occult small bowel injuries
Abdominal CT - intra-abdominal fluid not associated with solid organ injury, bowel wall thickening, mesenteric hematoma suggestive of inury
Repeat CT in 24hrs
Need to be tolerating a diet before they can be discharged home
Criteria for resection and reanastomosis after small bowel injury?
Defect >50% bowel circumference
Results in lumen diameter <1/3 normal
When do you open a mesenteric hematoma?
Expanding
Large (>2cm)
Most common cause for colon trauma?
Penetrating
Repair of right and transverse colon injuries?
Primary repair
Anastamosis
Repair of left colon injuries?
Primary repair/anastamosis
AND
Diverting ileostomy is patient is in shock or there is gross contamination
Paracolonic hematomas
Both blunt and penetrating hematomas need to be opened
Repair of an extraperitoneal rectal hematoma
Serial debridement
Consider diverting ileostomy
Repair of intraperitoneal rectal hematoma
Repair defect, prescral drainage
Consider diverting ileostomy
Indications for diverting ileostomy?
Shock
Gross contamination
Extensive injury
Most common organ injured in blunt trauma?
Liver (spleen)
When common hepatic artery is ligated, where do collaterals run through?
Gastroduodenal artery
Pringle maneuver
Clamp the portal triad - using non-crushing vascular clamps
Does NOT stop bleeding from hepatic veins
Limited to 15-20 minute intervals
Atriocaval shunt
For retrohepatic IVC injury
Allows for control while performing repair
Portal triad hematomas
Need to be explored
Repair of common bile duct injuries?
<50% circumference - repair over stent
>50% circumference or complex injury - choledochoejunostomy
May need intra-op cholangiogram to define injury
10% will leak - place a drain
Portal vein injury
Need to repair
Can transect pancreas to get to the injury in the portal vein
Perform distal pancreatectomy
Ligation of portal vein has 50% mortality
Omental graft
Can be placed in liver lacerations to help with bleeding and prevent bile leaks
Patient has failed conservative management of blunt liver injury if:
Unstable despite aggressive resuscitation 4uPRBCs (HR >120, SBP <90) OR >4uPRBCs to keep Hct >25 Go to OR
Indications to go to OR with blunt liver injury
Failure of conservative management
Active blush on abdominal CT
Pseudoaneurysm
Posterior injuries may respond to angiogram
How long does it take for spleen trauma to heal?
6 weeks
Greatest risk of post-splenectomy sepsis?
Within 2 years of splenectomy
Failure of conservative management for blunt splenic injuries?
Unstable despite aggressive management
- 2 uPRBCs with HR >120 or SBP <90
- Requiring 2uPRBC to keep Hct >25
Indications for OR in blunt splenic injuries?
Failure of conservative management
Active blush
Pseudoaneurysm
Indications of pancreatic trauma
Edema
Necrosis of peripancreatic fat
Treatment of pancreatic contusion
Leave if stable
If in OR - drain
Treatment of distal pancreatic duct injury?
Distal pancreatectomy
Can take up to 80%
Pancreatic head duct injury that is not repairable?
Place drains
Delayed whipple or ERCP with stent eventually
How do you decide between whipple and distal pancreatectomy?
Duct injury in relation to the SMV
Pancreatic hematoma
Both penetrating and blunt injuries need to be explored
Signs of a missed pancreatic injury?
Persistent or rising amylase
Major signs of vascular injury
Active hemorrhage Pulse deficit Expanding or pulsatile hematoma Distal ischemia Bruit Thrill
All require OR for exploration (possible intra-op angio)
Moderate/soft signs of vascular injury
History of hemorrhage
Deficits of anatomically related nerve
Large stale/nonpulsatile hematoma
ABI < 0.9
Go for angio
When do you need a saphenous vein graft?
When deficit is greater than 2cm
Take from opposite leg
Venous injuries that require repair?
Vena cava Femoral Popliteal Brachiocephalic Subclavian Axillary
Treatment for transection of single artery in the calf of an otherwise health patient
Ligate
When do you perform a fasciotomy?
> 4-6 hours ischemia
Compartment syndrome
Pressures >20mmHg or clinical exam
Pain > paresthesia > anesthesia > paralysis > poikilothermia > pulselessness
Most common causes of compartment syndrome?
Supracondylar humeral fractures
Tibial fractures
Crush injuries
How much blood can you lose from a femur fracture?
> 2L
Orthopedic emergencies?
Pelvic fractures in unstable patient Spine injury with deficit Open fractures Dislocations or fractures with vascular compromise Compartment syndrome
Complication of femoral neck fracture
Avascular necrosis of femoral head
Long bone fracture or dislocation with loss of pulse (or weak pulse)
Immediate reduction of fracture for dislocation and reassessment of pulse
- Pulse does not return - OR (vascular bypass/repair, intra-op angio)
- Pulse returns, but weak - angiogram
(Exception - knee dislocations go to angio even if full pulse returns)
Fractures associated with upright falls?
Calcaneus
Lumbar
Distal forearm
Anterior shoulder dislocation
Axillary nerve
Posterior shoulder dislcoation
Axillary nerve
Proximal humerus fracture
Axillary nerve
Midshaft humerus fracture (or spiral humerus fracture)
Radial nerve
Distal (supracondylar) humerus fracture
Brachial artery
Elbow dislocation
Brachial artery
Distal radius fracture
Median nerve
Anterior hip dislocation
Femoral artery
Posterior hip dislocation
Sciatic nerve
Distal (supracondylar) femur fracture
Popliteal artery
Posterior knee dislocation
Popliteal artery
Fibular neck fracture
Common peroneal nerve
Temporal or parietal bone fracture
Epidural hematoma
Maxillofacial fracture
Cervical spinal fracture
Sternal fracture
Cardiac contusion
First or second rib fracture
Aortic transection
Scapula fracture
Pulmonary contusion
Aortic transection
Rib fractures - left, 8-12
Spleen laceration
Rib fractures - right, 8-12
Liver laceration
Pelvic freacture
Bladder rupture
Urethral transection
Best indicator of renal trauma?
Hematuria
Requires abdominal CT
Benefit of Intravenous pyelogram before going to OR with kidney trauma?
Can identify presence of functional contralateral kidney
Left renal vein
Can be ligated near the IVC
Has adrenal and gonadal vein collaterals
(NOT seen in the right renal vein)
Renal hilum structures (anterior to posterior)
Vein, artery, pelvis (VAP)
Indications for operative intervention in kidney trauma?
Acutely - ongoing hemorrhage with instability After acute phase: - Major collecting system disruption - Non-resolving urine extravasation - Severe hematuria
How do you assess for leak after repair for kidney trauma?
Methylene blue dye to check for leak
When found at exploration for another injury - blunt renal injury with hematoma
Leave unless pre-op CT/IVP shows no function or significant urine extravasation
When found at exploration for another injury - penetrating renal injury with hematoma
Open unless pre-op CT/IVP shows good function without significant urine extravasation
Trauma to flank and IVP shows no uptake in stable patient
Angiogram
Stent if flap present
Best indicator for bladder trauma?
Hematuria
Signs and symptoms of bladder trauma
Meatal blood
Sacral or scrotal hematoma
Diagnosis for bladder trauma
Cystogram
Extraperitoneal bladder rupture
Cystogram shows starburts
Tx: Foley 7-14 days
Intraperitoneal bladder rupture
Cystogram shows leak
Tx: Operation and repair of defect, followed by foley drainage
Best test for identifying ureteral injury?
NOT hematuria (unreliable) IVP and retrograde urethrogram
Large ureteral segment is missing and cannot perform reanastomosis
> 2 cm
Upper 1/3 and middle 1/3 (above pelvic brim) - don’t reach bladder
- Temporaize with percutaneous nephrostomy (tie off both ends of the ureter)
- Ileal interposition or trans-ureteroureterostomy
Lower 1/3 - reimplant in Bladder
Small ureteral segment is missing
<2cm
Upper and middle 1/3 - mobolize ends of ureter and perform primary repair over stent
Lower 1/3 - re-implant in the bladder
Blood supply to the ureters
Medial in upper 2/3rds
Lateral in lower 1/3rd
Signs of uretheral injury
Hematuria*
Blood at meatus*
Free-floating prostate gland
(Associated with pelvic fracture)
Best test for uretheral injury
REtrograde uretherogram
Area of the urethra that is at greatest risk for transection?
Membranous portion
Treatment of significant urethral injury
Suprapubic cystostomy
Repair in 2-3 months
(High stricture and impotence rate if repaired early)
Treatment of small, partial urethral tears
Bridging urethral catheter across tear
Repair in 2-3 months
Genital trauma
Can get fracture in erectile bodies from vigorous sex
Need to repair the tunica and Buck’s fascia
Testicular trauma
Get US to see if tunica alburginea is violated
Repair if needed
Best indicators of shock in children
Heart rate, respiratory rate, mental status and clinical exam
BP is NOT reliable - last to go
Indications for C-section during exploratory laparotomy for trauma
Persistent maternal shock or severe injuries and pregnancy near term (>34 weeks)
Pregnancy a threat to mother’s life (hemorrhage, DIC)
Mechanical limitation to life-threatening vessel injury
Risk of fetal distress exceeds risk of immaturity
Direct intra-uterine trauma
Uterine rupture
If after fetal delivery - aggressive resuscitation
Uterus will eventually clamp down
Placental abruption
Most likely to occur in the posterior fundus
>50% of placental - 100% fetal demise
Signs - uterine tenderness, contractions, fetal HR <120
Can be caused by shock or mechanical forces
Kleihauer-Betke test
Test for fetal blood in the maternal circulation
Signs of placental abruption
Pelvic hematoma
Open penetrating
Leave blunt
Paraduodenal hematoma
Open penetrating
Open blunt
Portal triad
Open penetrating
Open blunt
Retrohepatic
Leave penetrating
Leave blunt
Midline supramesocolic
Open penetrating
Open blunt
Midline inframesocolic
Open penetrating
Open blunt
Pericolonic
Open penetrating
Open blunt
Perirenal
Open penetrating
Leave blunt
Zone I of the peritoneum
Central retroperitoneum
Pancreaticouodenal injury or major abdominal vascular injury
OPEN hematomas in these areas
Zone II of the peritoneum
Flank or perinephric area
Injuries to the gentiurinary tract or to the colon
OPEN hematomas in these areas
Zone III of the peritoneum
Pelvis
Pelvic fractures
LEAVE hematomas in these areas
When should you always leave a drain?
Pancreatic, liver, biliary system, urinary and duodenal injuries
Snake bites
Sx: Shock, bradycardia, arrythmias
Tx: Stabilize patients, anti-venim, tetanus shot
