15: Trauma Flashcards

Question

FAST scan is often falsely negative in patients with which three findings?

Answer 1

1. \<50-80 mL of free fluid 2. Retroperitoneal bleeding 3. Hollow viscus injury [Need laparotomy if FAST scan is positive. In hypotensive patients with a negative FAST or negative DPL, the source of bleeding (pelvic fracture, chest, extremity) must be found.]

Answer 2

Left thoracotomy and repair with partial left heart bypass or place a covered stent endograft (for distal transections only) [Important to treat other life-threatening injuries 1st. For example a patient with a positive FAST needs to have that addressed before the aortic transection.] [UpToDate: Open surgical repair of the thoracic aorta is performed under general anesthesia using a double lumen tube. One-lung ventilation allows collapse of the left lung and facilitates access to the aorta. It is important to note that patients with severe associated right chest or lung injuries may not tolerate one-lung ventilation. Delayed repair or endovascular repair may be warranted. The extent of the thoracotomy incision is based upon the location of the pathology. As examples, in blunt aortic injury, the aortic disruption usually occurs at the aortic isthmus, and thus, a fourth intercostal space thoracotomy incision should be performed. More extensive involvement may require sternotomy or thoracoabdominal exposure. Once the chest is entered, the site of pathology is identified and any bleeding should be controlled with direct pressure while an aortic clamp is placed just distal to the left subclavian artery. If the aortic disruption is in close proximity to the left subclavian artery, the clamp will need to be placed between the left common carotid artery and the left subclavian artery. In some cases, such as a small traumatic tear, the aorta can be repaired primarily; however, most patients require the placement of an interposition graft (eg, Dacron).]

Answer 3

* Small/partial tears: May be able to place a bridging urethral catheter across the tear area and repair in 2-3 months * Significant tears: Suprapubic cystostomy tube and repair in 2-3 months [High stricture and impotence rate if a significant urethral injury is repaired early.] [UpToDate: Optimal definitive management of urethral injuries depends on several factors, including: location (anterior or posterior), severity (partial or complete), and the preference and expertise of the consulting urologist. Options vary from placement of a Foley catheter to facilitate healing by secondary intention (for some partial anterior urethral injuries) to early endoscopic realignment or delayed urethroplasty (for posterior urethral injuries). Often, placement of a suprapubic cystostomy tube will be required to promote decompression of the bladder and divert urine from the healing urethral injury or anastomosis. Regardless of the approach, the ultimate goal is the maintenance of urinary continence and sexual function.]

Answer 4

1. Retroperitoneal bleed 2. Contained hematoma

Answer 5

* Zone I: Clavicle to cricoid cartilage * Zone II: Cricoid to angle of mandible * Zone III: Angle of mandible to base of skull

Answer 6

1. 1st and 2nd rib fractures 2. Cardiac contusion

Answer 7

* Extraperitoneal bladder rupture: Foley for 7-14 days (cystogram shows starbursts) * Intraperitoneal bladder rupture: Operation and repair of defect followed by foley drainage (Cystogram shows leak)

Answer 8

Saphenous vein at the ankle

Answer 9

Left renal veincan be ligated near the IVC because it has adrenal and gonadal vein collaterals [The right renal vein does not have these collaterals. With exploration, try to get control of the vascular hilum before addressing an injury to the collecting duct system. Drains should be placed intraoperatively, especially if there is an injury to the collecting duct system. 95% of traumatic renal injuries are treated nonoperatively.]

Answer 10

Basal skull fracture (anterior fossa fracture) [Can also have hemotympanum and CSF rhinorrhea/otorrhea with basal skull fractures. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (\>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.] [UpToDate: "Raccoon eyes" is a common term for periorbital ecchymosis, which suggests a basilar skull fracture or anterior or middle fossa facial trauma. Like Battle sign, raccoon eyes are typically NOT present during the examination immediately following the injury but appear one to three days later.]

Answer 11

* Small laceration: Repair laceration transversely (avoids stricture) * Large laceration (\>50% of circumference): Resection and reanastomosis * Multiple small laceration in close proximity: Resection and reanastomosis * Mesenteric hematoma: Open it if expanding or if large (\>2 cm) [UpToDate: **Low grade injuries (grade I, II, or III) of the stomach, small bowel, colon, and rectum can usually be repaired primarily, whereas higher grade injuries are generally not amenable to primary repair, and will require resection.** Grade I – Partial-thickness lacerations should be repaired primarily in one or two layers. Intramural hematomas encountered intraoperatively are typically opened, evacuated, and the bowel wall inspected and repaired. Grade II – The edges of small, full-thickness lacerations should be debrided to fresh margins and repaired as in grade I injuries. **Small bowel defects should be closed transversely** (aligned with mesenteric/antimesenteric axis) to avoid narrowing the lumen or compromising bowel vascularity. Grade III – Many larger lacerations of the small bowel, colon, and rectum can also be repaired with debridement and primary closure. Grade IV and V – Extensive injury or devascularized segments of small or large bowel require resection and anastomosis as appropriate. Such injuries to the stomach and/or duodenum often require complex repair or reconstruction depending upon the location and extent of injury as well as the patient’s overall clinical status.]

Answer 12

* \>1,500 cc after initial insertion * \>250 cc/h for 3 hours * \>2,500 cc in 24 hour period * Bleeding with hemodynamic instability [Need to drain all blood in \<48 hours to prevent fibrothorax, pulmonary entrapment, and infected hemothorax. Unresolved hemothorax after 2 well-placed chest tubes requires thoracoscopic drainage.]

Answer 13

* Clamp chest tube (one of the rare times when this is indicated) * May need mainstem intubation on unaffected side * Must be repaired if large air leak and respiratory compromise or after 2 weeks of persistent air leak [Bronchus injuries are more common on the right. Diagnosis with bronchoscopy.]

Answer 14

C1 burst fracture caused by axial loading [Treatment is a rigid collar.] [UpToDate: The Jefferson fracture of C1 is highly unstable and occurs when a vertical compression force is transmitted through the occipital condyles to the lateral masses of the atlas. This force drives the lateral masses outward, resulting in fractures of the anterior and posterior arches of the C1, with or without disruption of the transverse ligament. Disruption of the transverse ligament determines instability. Prevertebral hemorrhage combined with disruption of the transverse ligament may cause an increase in the predental space between C1 and the odontoid (dens) seen on the lateral radiograph. A predental space greater than 3 mm in adults or 5 mm in children is abnormal. In the anterior-posterior (AP) projection (open-mouth or odontoid view), the masses of C1 lie lateral to the outer margins of the articular pillars of C2. The Jefferson fracture may be difficult to recognize on plain radiograph if there is minimal displacement. The transverse ligament is presumed to be disrupted if the interval between the atlas and the dens is increased on a lateral radiograph, or the lateral masses of the atlas extend laterally beyond those of the axis on the odontoid radiograph. In such instances, clinicians should obtain a computed tomography (CT) scan of the cervical spine.]

Answer 15

Within first 2 years of splenectomy [UpToDate: The highest risk of sepsis **occurs during the first few years following splenectomy** but has been documented as late as 20 years after splenectomy. In a population-based cohort study, the risk of infection requiring hospital contact was highest during the 90 days following splenectomy, occurring in 10% of individuals who had undergone splenectomy compared with 0.6% in the general population (adjusted odds ratio 18.1, 95% CI 14.8 to 22.1). In comparison, hazard of infection was 4.6-fold higher from 91 to 365 days following splenectomy and 2.5-fold higher \>365 days following splenectomy compared with the general population. The fraction of bacteremic episodes due to pneumococci in splenectomized patients, most of whom were adults with a high burden of comorbid conditions, was surprisingly low (\<5%); the frequency of fulminant sepsis complicating bacteremia due to nonencapsulated pathogens was not reported. Similar risks of postsplenectomy infection were noted in a review of 288 patients who had undergone splenectomy: one-third of first infections occurred within the first year of surgery and just over half within two years. One-third of all pneumococcal infections occurred at least five years after splenectomy. Among survivors of an initial episode of severe sepsis in another series, the risk of subsequent severe infection was increased more than sixfold, and the risk of a third episode among survivors of two severe infections was further increased more than twofold. Patients who undergo posttraumatic splenectomy are thought to retain variable degrees of splenic function postoperatively and may have a reduced risk of subsequent sepsis. However, experimental studies suggest that regenerated splenic tissue is histologically and functionally abnormal, thus offering limited protection against sepsis. Splenic angioembolization is often utilized in the management of patients with moderate splenic injury to avoid splenectomy. Patients who have undergone this procedure may subsequently demonstrate Howell-Jolly bodies on peripheral blood smears, a sign of splenic hypofunction indicating an increased risk of asplenic sepsis.]

Answer 16

* Abdominal pain * Need for general anesthesia * Closed head injury * Intoxicants on board * Paraplegia * Distracting injury * Hematuria [Patients requiring a DPL that turned out negative will need an abdominal CT scan.]

Answer 17

Inferior vena cava compression [Low cardiac output causes visceral and renal malperfusion (decreased urine output). Upward displacement of diaphragm affects ventilation. Treatment is decompressive laparotomy.]

Answer 18

1/3 of total blood volume [Check for vaginal discharge in a pregnant trauma patient to assess for blood, amniotic fluid. Also check for effacement, dilation, fetal station.]

Answer 19

* CN VII (facial nerve) * CN VIII (vestibulocochlear nerve) [Temporal skull fractures are most commonly associated with lateral skull or orbital blows. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (\>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]

Answer 20

* Trachea: Right thoracotomy * Proximal left mainstem bronchus injury: Right thoracotomy * Distal left mainstem bronchus injury: Left thoracotomy * Proximal right mainstem bronchus injury: Right thoracotomy * Distal right mainstem bronchus injury: Right thoracotomy [A right thoracotomy approach is preferred for most cases because it avoids the aorta.]

Answer 21

* Normal ICP is 10 * ICP \>20 requires treatment * Want CPP \>60

Answer 22

When the injury results in ischemia for \> 4-6 hours [Compartment syndrome should be considered if compartment pressures exceed 20 mmHg or if clinical exam suggests elevated pressures.] [UpToDate: **Prophylactic fasciotomy should be performed in all high-risk extremities which can include patients with significant crush injury, and those patients with an ischemic time greater than 6 hours, which includes prehospital and operative time**. In the lower extremity, the standard approach is a two-incision four compartment release through medial and lateral lower leg incisions. Thigh compartment syndrome is rare but is similarly managed by opening the anterior and posterior fascia of the thigh. In the upper extremity, forearm compartment syndrome is decompressed through a single volar incision. Following decompression, the extremity wound is initially dressed with moist sterile gauze. As the swelling in the extremity decreases, the wound edges can be gradually reapproximated. In some cases, the skin edges can eventually be closed, but many of these wounds require skin grafting. Complications related to the need for fasciotomy, including rhabdomyolysis and wound-related issues, are discussed in detail elsewhere.]

Answer 23

_Classification_ * Type I: Maxillary fracture straight across * Type II: Lateral to nasal bone, underneath eyes, diagonal toward maxilla * Type III: Lateral orbital walls _Treatment_ * Type I: Reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires * Type II: Same as type I * Type III: Suspension wiring to stable frontal bone, may need external fixation

Answer 24

* Thyroid gland injury: Control bleeding and drain (not thyroidectomy) * Recurrent laryngeal nerve injury: Can try to repair or can reimplant in cricoarytenoid muscle * Vertebral artery bleed: Can embolize or ligate without sequela in majority of patients * Common carotid artery bleed: Ligation will cause a stroke in 20% of patients

Answer 25

Basal skull fracture (middle fossa fracture) [Injury to facial nerve may occur with a middle fossa fracture. If facial nerve is injured, patient will need exploration and repair. Can also have hemotympanum and CSF rhinorrhea/otorrhea with basal skull fractures. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (\>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.] [UpToDate: Retroauricular or mastoid ecchymosis (ie, Battle sign) typically appears one to three days after the fracture is sustained.]

Answer 26

24-48 hours after injury [ADH, ACTH, and glucagon also increase after trauma (part of fight or flight response).]

Answer 27

Ligamentum arteriosum (Just distal to subclavian takeoff) [Other common areas include near the aortic valve and where the aorta traverses the diaphragm. Diagnosis with CT angiogram of the chest. Chest xray is normal in 5% of patients with aortic tears.] [UpToDate: Most blunt injuries of the thoracic aorta occur at the aortic isthmus just distal to the left subclavian artery. Other locations include the transverse arch, proximal ascending aorta, and descending aorta just proximal to the diaphragm. A number of theories are used to explain the mechanism of thoracic aortic injury at the isthmus. It is likely that most injuries probably involve a combination of forces. * The isthmus is thought to be a transition zone between the more mobile ascending aorta and arch and the relatively fixed descending thoracic aorta which allows for stretching with rapid deceleration. * The isthmus may be intrinsically weaker than the remainder of the aorta as evidenced by a series of tensile strength tests conducted on aortic samples. * Blunt aortic injury may be the result of a “water hammer” effect in which compression of the abdomen due to a sudden impact occludes the aorta, leading to rupture of the proximal, intrinsically weak isthmus or other susceptible portion of the aorta. This proposed mechanism may explain the association between blunt aortic injury and diaphragmatic rupture. * The “osseous pinch,” theory purports that the aorta is trapped between the anterior bony structures (manubrium, first rib, medial clavicles, and sternum) and the vertebral column leading to focal rupture. Regardless of the force mechanism leading to tissue disruption, it appears that the time course of aortic rupture occurs as two distinct phases separated by an interval of time. Rupture of the intimal and medial layers occurs first, followed by an interval of unpredictable duration, and then rupture of the adventitia. The duration of time between intima/medial injury and adventitial rupture may be from seconds to several years. In an in-vitro study of porcine aortic injury, an intimal-medial tear occurred before complete disruption of the entire vessel in 93% of specimens. Partial aortic disruption occurred at a mean mechanical stress that was 74% of the stress needed for complete rupture. These findings suggest that a sufficient residual strength exists in the aortic wall following the initial injury to allow timely diagnosis and treatment.]

Answer 28

CCP = MAP - ICP

Answer 29

* Anterior shoulder dislocation: Axillary _nerve_ * Posterior shoulder dislocation: Axillary **artery** * Proximal humerus fracture: Axillary _nerve_ * Midshaft humerus fracture: Radial _nerve_ * Distal (Supracondylar) humerus fracture: Brachial **artery** * Elbow dislocation: Brachial **artery** * Distal radius fracture: Median _nerve_

Answer 30

30% [Resuscitate with 2L of crystalloid, then blood.]

Answer 31

* Type I: Above the base (Stable) * Type II: At the base (Unstable and will need fusion or halo) * Type III: Extends into the vertebral body (Unstable and will need fusion or halo) [UpToDate: Forceful flexion or extension of the head in an anterior-posterior orientation (ie, sagittal plane), as might occur with a forward fall onto the forehead, may result in a fracture of the odontoid process, also called the dens. Fractures can occur above the transverse ligaments (type I) or, most commonly, at the base of the odontoid process where it attaches to C2 (type II). Type I fractures are stable. Although spinal cord injury is uncommon, type II odontoid fractures are unstable and complicated by nonunion in over 50% of patients treated with halo vest immobilization. Slight angulation of the force may result in extension of the fracture through the upper portion of the body of C2 (type III). Type III fractures are mechanically unstable, since they allow the odontoid and the occiput to move as a unit. Odontoid fractures are best seen on the AP odontoid radiograph (ie, open-mouth view) and cause prevertebral soft tissue swelling on lateral radiographs. Caution is necessary when interpreting the open mouth view as a radiographic line created by the space between the two front incisors may be confused for a dens fracture.]

Answer 32

Epidural hematoma [Arterial bleeding from middle meningeal artery. Surgery for significant neurologic degeneration or significant mass effect (shift \>5 mm). In subdural hematomas, surgery is indicated for significant neurologic degeneration or mass effect (shift \>1 cm).]

Answer 33

* Peritonitis * Evisceration * Positive DPL or FAST * Uncontrolled visceral hemorrhage * Free air * Diaphragm injury * Intraperitoneal bladder injury * Contrast extravasation from a hollow viscus * Specific renal, pancreatic, and biliary tract injuries

Answer 34

Vein, artery, renal pelvis (VAP)

Answer 35

1. Pain 2. Paresthesia 3. Anesthesia 4. Paralysis 5. Poikilothermia 6. Pulselessness

Answer 36

Conservative management (bed rest for 5 days) [Indications for surgical treatment are hemodynamic instability despite resuscitation, active blush on CT, and pseudoaneurysm. The threshold for splenectomy in children is much higher. Hardly any children undergo splenectomy. Need splenectomy immunizations if splenectomy performed.] [UpToDate: Splenic injury is graded (I through V) depending upon the extent and depth of splenic hematoma and/or laceration identified on CT scan or intraoperatively. Splenic injury grading is one factor used to stratify patient management. Other factors include associated injuries and medical comorbidities. Per ATLS protocol, hemodynamically unstable patients with a positive FAST exam or diagnostic peritoneal lavage or aspirate (DPL/DPA) require operative surgical exploration to determine the source of life-threatening hemorrhage that may be due to splenic injury. For hemodynamically stable patients with low grade (I to III) injuries, we suggest nonoperative management over definitive surgical intervention (Grade 2C). Wide variation exists in the clinical application of nonoperative strategies but, in general, patients are admitted to a monitored care setting, either an intensive care or step-down unit, depending upon the capabilities of the unit, grade of splenic injury, nature and severity of other injuries, and clinical status. **We initially place the patient on bed rest, though no clear benefit exists for this practice**. In agreement with an expert panel, we obtain serial hemoglobin levels every six hours in the first 24 hours. Patients are not given a diet (ie, nil per os [NPO]) for at least the first 24 hours. When the hemoglobin level is stable and operative intervention unlikely, the patient may eat. Observation may involve splenic embolization depending upon resources. Failure of nonoperative management indicates a need for angiographic embolization, if not initially used, or surgical exploration. For hemodynamically stable patients with active contrast extravasation or contrast blush on CT scan, we suggest initial splenic embolization over observation (Grade 2C). Splenic embolization requires specialized imaging facilities and a suitably experienced interventionalist. Failure of embolization indicates the need for surgery. For patients who develop hemodynamic instability during the course of nonoperative management, we suggest surgical exploration over splenic embolization (Grade 2C).]

Answer 37

* 5 points: Oriented * 4 points: Confused * 3 points: Inappropriate words * 2 points: Incomprehensible sounds * 1 point: No response [For GCS score \<14 patient needs a head CT. For GCS score \<10 Patient requires intubation. For GCS score \<8 Patient needs ICP monitor.]

Answer 38

Release of tissue factor [UpToDate: Approximately one-third of patients with severe TBI develop a coagulopathy, which is associated with an increased risk of hemorrhage enlargement, poor neurologic outcomes and death. While the coagulopathy may result from existing patient medications such as warfarin or antiplatelet agents, acute TBI is also thought to produce a coagulopathy through the systemic release of tissue factor and brain phospholipids into the circulation leading to inappropriate intravascular coagulation and a consumptive coagulopathy.]

Answer 39

* \>10cc blood * \>100,000 RBCs/cc * Food particles * Bile * Bacteria * \>500 WBC/cc [Need laparotomy if DPL is positive. DPL needs to be supraumbilical if pelvic fracture is present.]

Answer 40

* Contained: Observation * Not contained: Small injuries can be closed primarily. Extensive injuries or injuries with contamination require drainage [UpToDate: Primary repair of esophageal injuries can be performed whenever there is an ability to get a closure of healthy tissue without tension. The esophagus should be debrided to healthy tissue and repaired. Most low grade (I through III) traumatic esophageal perforations can be repaired primarily, or repaired over a drain. If primary repair is not possible because of contamination or hemodynamic instability, but there is only a small amount of tissue loss, an effective strategy is to repair the esophagus around a large T-tube, but this is rarely needed with the availability of esophageal stents. This creates a controlled esophageal-cutaneous fistula, which may close spontaneously after edema resolves and the T-tube is removed. Alternatively, an esophageal stent could be used to cover the defect. The esophagus should be debrided to healthy tissue and the mucosal defect should be completely exposed, even if this requires enlarging the muscular defect. Failure to close the mucosa will most assuredly result in failure of the repair. Intraoperative endoscopy can be helpful for identifying the extent of the defect. The mucosal defect should be closed first, followed by a second layer closure of the muscularis layer. There are no studies comparing the techniques. Some recommend absorbable suture with knots on the outside to avoid granuloma formation, but this has not been subjected to rigorous evaluation. Larger defects or those involving significant devascularization (IV, V) require more challenging surgical management. Typically in the traumatic circumstance, esophagectomy with reconstruction is not indicated due to the length and technical nature of the procedure as well as the patient's hemodynamic status. Rather, esophageal diversion may be required. This includes creation of an end cervical esophagostomy and division of the esophagus at the gastroesophageal junction to exclude the site of injury. If the patient is hemodynamically stable, removal of the thoracic esophagus should be performed. In the unstable patient, the thoracic esophagus may be left in situ with removal later once the patient is stable. While in the abdomen, a gastrostomy is recommended but should be placed strategically so as to not damage the subsequent formation of a gastric tube for reconstruction of the gastrointestinal tract. Feeding jejunostomy is also recommended, although only in stable patients. Delayed esophageal reconstruction is planned months later. In one review, the types and frequencies of repairs of 346 penetrating traumatic injuries included: * Primary repair: 82% * Drainage alone: 11% * Resection and diversion: 4% * Resection and anastomosis: 3% * Drainage as an adjunct procedure: 62%]

Answer 41

* \<1 week from injury: Transabdominal approach * \>1 week from injury: Thoracic approach [Thoracic approach is needed after 1 week because there may be adhesions in the chest that will need to be taken down. A repair with mesh may be required.]

Answer 42

80% of injuries requiring surgery can be treated with debridement and primary closure [Segmental resection with primary end-to-end closure is possible for all segments except the second portion of the duodenum.] [UpToDate: The majority of duodenal lacerations can be managed by simple procedures such as debridement and primary repair, or resection and re-anastomosis. More complex procedures are rare, but are associated with a high risk of postoperative complications including suture line failure and anastomotic leak or small bowel fistula formation. Mortality is also increased, but is often related to associated injuries and not strictly a consequence of complications related to duodenal repair. Low grade – Partial thickness injuries (Grade I) are repaired by suturing the serosa in a Lembert fashion. Full thickness duodenal lacerations (Grade II) are debrided and the duodenum is repaired with a tension-free primary closure in one or two layers. Longitudinal injuries should be closed transversely, if possible, to minimize the potential for luminal narrowing. If the injury is judged to be too extensive for primary repair (eg, \>3 cm) after debridement, the injured segment should be resected and the duodenal ends brought together with a primary end-to-end duodeno-duodenostomy. Injuries to the 2nd portion of the duodenum may not be amenable to this approach if the common bile duct or ampulla is injured, or if resection would require removal of these structures. Intermediate grade – As with low-grade injuries, many intermediate (Grade III) injuries can also be treated with debridement and primary closure or resection and primary anastomosis. High grade – Injuries involving the ampulla (Grade IV, V) increase the complexity of duodenal repair. For limited injuries to the ampulla, management options include stenting or sphincteroplasty. Avulsion of the ampulla can occur and has been successfully managed with common bile duct reimplantation using choledochoduodenostomy. Extensive periampullary injuries, such as intraduodenal bile duct injury, intrapancreatic bile duct injury, or Grade V injury often require staged pancreaticoduodenectomy.]

Answer 43

Local exploration and observation if fascia not violated [Penetrating abdominal injuries generally need a laparotomy.]

Answer 44

* Blunt (80% of all trauma): Liver (Some texts say spleen) * Penetrating: Small bowel (Some texts say liver)

Answer 45

Clamping the portal triad [Does not stop bleeding from hepatic veins.]

Answer 46

* Clavicles, xiphoid process, nipples * Consider pericardial window, bronchoscopy, esophagoscopy, barium swallow [UpToDate: Generally, a knife or other sharp object produces injury along its entry track and may damage any intrathoracic organ in its path. Although knowledge of the size and shape, as well as the angle and direction of the entrance, of the wounding instrument provides some guidance about potential injuries, the extent of internal injury from a seemingly small external wound can easily be underestimated. Of particular importance are penetrating wounds to “the box” because of the high risk of injury to the heart and other mediastinal structures. **The box is defined superiorly by the clavicles and sternal notch, laterally by the nipple line, and inferiorly by the costal margins.** Gunshot wounds and other higher velocity implements or debris have a less predictable pattern of injury. The trajectory of a missile may not follow a straight course. In addition, tissues can sustain damage not only from the direct path of the bullet, known as the permanent cavity, but also from the shock waves caused by the bullet, known as the temporary cavity. Temporary cavity wounds are caused by high velocity missiles.]

Answer 47

48-72 hours after injury [Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (\>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]

Answer 48

C2 fracture caused by distraction and extension [Treatment is traction and halo.] [UpToDate: Traumatic spondylolysis of C2 (so-called "hangman's fracture") is an unstable injury that occurs when the cervicocranium (the skull, atlas, and axis functioning as a unit) is thrown into extreme hyperextension as a result of abrupt deceleration (ie, forced extension of an already extended neck). Bilateral pedicle fractures of the axis may occur with or without dislocation in this circumstance. Although this lesion is unstable, spinal cord damage is often minimal because the AP diameter of the neural canal is greatest at C2, and bilateral pedicle fractures permit spinal canal decompression.]

Answer 49

* Pyloric exclusion * Gastrojejunostomy * Feeding and/or draining jejunostomies * Leave drains (remove when tolerating diet without increased drainage) * Jejunal serosal patch over hole [UpToDate: Several adjunctive procedures have been used in conjunction with duodenal repair with a primary aim of decreasing the likelihood of leak following repair. There is no consensus on when these procedures are indicated and none of these techniques have demonstrated a clear benefit. Under most circumstances, these adjunctive techniques are not needed. Pyloric exclusion, duodenal decompression and duodenal diverticularization are described briefly below. Given a lack of data, we prefer pyloric exclusion because it is more easily performed in the face of severe traumatic injuries. Pyloric exclusion — Pyloric exclusion refers to a procedure in which the pylorus is closed for the purpose of excluding gastric secretions from the duodenal repair. Pyloric exclusion is used selectively as an adjunctive procedure to manage intermediate or high grade duodenal or combined injuries. Following duodenal repair, the pylorus is sutured closed through a longitudinal antral gastrotomy using partial-thickness absorbable or nonabsorbable sutures placed proximally into the pylorus or alternatively using a noncutting linear stapler applied transversely just distal to the pylorus. Once the pylorus has been closed, a loop gastrojejunostomy is performed. The pylorus will reopen spontaneously in the majority of patients within three to six weeks, even when nonabsorbable sutures or staples are used. In a small retrospective review of 29 patients with penetrating duodenal injuries, no significant differences in clinical outcomes were seen in patients who underwent pyloric exclusion compared with those who underwent primary repair alone. Although pyloric exclusion is a relatively straightforward procedure to perform, it is associated with a high incidence of marginal ulceration along the gastrojejunostomy. Duodenal decompression — Following repair, the duodenum can be decompressed in an antegrade (duodenostomy) or a retrograde (jejunostomy) fashion. The rationale for duodenal decompression is to decrease the pressure and volume of secretions in the duodenum, thereby protecting the duodenal repair. In studies that have evaluated tube enterostomy, a serosal patch or mucosal graft taken from the jejunum or stomach has often been used to reinforce the duodenal repair. There are no randomized trials evaluating the use of duodenal decompression in patients following duodenal injury and the outcomes of retrospective reviews are mixed. Given the lack of consistent results as illustrated in the following studies, and the risk of other complications such as duodenal fistula, we prefer not to use duodenal decompression following duodenal repair. * One retrospective review of 276 patients with duodenal injuries repaired by primary closure compared 237 patients treated with tube decompression (mostly retrograde tube jejunostomy) and 57 who were not decompressed. Significantly more duodenal fistulas developed in patients who were not decompressed compared with those who were (11 of 57 versus 0 of 237). * However, in another review of 247 patients, the incidence of duodenal fistula was the same whether or not duodenal decompression was performed. An increased incidence of complications was found in another study in patients with duodenal injury requiring repair and treated with duodenal decompression. Duodenal diverticulization — Duodenal diverticulization refers to suture closure of the duodenal injury, antrectomy with end-to-side gastrojejunostomy, and tube duodenostomy. It is a complex, time-consuming procedure that is generally unnecessary.]

Answer 50

The contralateral saphenous vein [A primary repair may be possible if \< 2cm segment missing from injured vessel. Vein graft will usually be necessary if \> 2cm is missing. Cover site of anastomosis with viable tissue and muscle.] [UpToDate: For hemodynamically stable patients, the timing of the management of extremity injury when vascular injury is present depends upon the degree and duration of ischemia. Patients with hard signs of vascular injury should be taken immediately to the operating room for evaluation and management. Patients with clinical signs of arterial injury, including an injured extremity index (IEI) \<0.9, should be evaluated using computed tomographic (CT) angiography or conventional arteriography depending upon institutional resources. In the presence of bony instability, arterial revascularization is fraught with difficulties. Under these circumstances, arterial shunting, if needed, and fracture stabilization followed by definitive vascular repair once the bones have been stabilized may be the most appropriate sequence of care. In stabilized patients following initial shunt placement for damage control, or patients with few other injuries, we suggest the following approach at the index operation for definitive vascular reconstruction: * The patient should be systemically anticoagulated if there are no known contraindications (eg, intracranial bleeding). * Regional anticoagulation should be used with heparinized saline (1 to 10 Units heparin per mL 0.9% normal saline) injected in the proximal and distal arterial segments. * Once the injured vessel (artery or vein) has been identified, the devitalized vessel wall should be debrided back to healthy tissue. * Thrombus should be removed from the proximal and distal artery using a Fogarty embolectomy catheter. * Whenever possible, the vessel (artery or vein) should be brought together (primary end-to-end anastomosis). However, more typically, reconstruction with an interposition or bypass graft is needed due to an intervening defect. * **The interposition graft should ideally be reversed autologous saphenous vein taken from an uninjured leg**. **If both lower extremities are injured, the saphenous vein from the least injured extremity can be used, or arm vein can be considered**. Prosthetic graft material (eg, polytetrafluoroethylene [PTFE]) is an option for the extremities, if no autologous conduit is available. In a small retrospective review of combat vascular injuries reconstructed with PTFE compared with matched injuries reconstructed with autologous vein, PTFE had good long-term patency and freedom from infection in axillosubclavian region, but long-term outcomes for brachial, common femoral, and superficial femoral reconstruction were sub-optimal. * At the conclusion of the reconstruction, we confirm the adequacy of arterial repair using Doppler, repeat injured extremity index (IEI), ankle-brachial index (ABI), or completion arteriogram depending upon available time and resources. * Whenever possible, we repair proximal venous injuries, particularly if the adjacent paired vein is also injured. Venous ligation is appropriate for distal veins and proximal injuries associated with other life-threatening injuries. Extremity injury causing vascular injury is often associated with soft tissue injury that disrupts collateral venous flow, and although the patency rates of venous reconstruction are lower than arterial reconstruction, vein repair provides outflow and limits extremity swelling in the short term. Preserving venous outflow also decreases the likelihood of early arterial graft failure, especially with injuries to the popliteal vessels, which may ultimately decrease the incidence of secondary amputation as compared with venous ligation.]

Answer 51

* Proximal 1/3 ureter: Medial * Middle 1/3 ureter: Medial * Distal 1/3 ureter: Lateral

Answer 52

Lecithin:Sphingomyelin (LS) ratio [LS ratio \> 2:1 is suggestive of lung maturity. The presence of phosphatidylglycerol and phosphatidylcholine in the amniotic fluid is also suggestive of lung maturity.] [UpToDate: The lecithin/sphingomyelin (L/S) ratio for assessment of fetal lung maturity was first introduced by Gluck and colleagues in 1971. It is based upon the observation that there is outward flow of lung secretions from the lungs into the amniotic fluid. This process changes the phospholipid composition of amniotic fluid, thereby enabling indirect assessment of fetal lung maturity through evaluation of this fluid. The concentrations of lecithin and sphingomyelin in amniotic fluid are approximately equal until 32 to 33 weeks of gestation, at which time the concentration of lecithin begins to increase significantly while the sphingomyelin concentration remains about the same. The measurement of sphingomyelin serves as a constant comparison for control of the relative increases in lecithin because the volume of amniotic fluid cannot be accurately measured clinically. Determining the lecithin/sphingomyelin ratio involves thin-layer chromatography after organic solvent extraction. It is a technically difficult test to perform and interpret; care at each step of sample handling is critical for consistent results. The sample should be kept on ice or refrigerated if transport to a laboratory is required (most laboratories cannot perform this test). Improper storage conditions can change the lecithin/sphingomyelin ratio since amniotic fluid contains enzymes that can be affected by temperature. The amniotic fluid sample must be well mixed before testing. It takes several hours to perform the test and may take 24 hours when both transport and testing time are considered, which is another disadvantage of this method. Individual laboratories should calculate a threshold value for predicting lung maturity by correlating their test results with clinical outcome as the variation within and between laboratories can be considerable. Empirically, **the risk of respiratory distress is exceedingly low when the lecithin/sphingomyelin ratio is greater than 2.0.** Phosphatidylglycerol (PG) is a minor constituent of surfactant. It begins to increase appreciably in amniotic fluid after 35 weeks, several weeks after the rise in lecithin. Because PG enhances the spread of phospholipids on the alveoli, its presence indicates an advanced state of fetal lung development and function. PG testing can be performed by thin-layer chromatography, so it can be determined alone or in conjunction with testing for the lecithin/sphingomyelin ratio. It may be reported qualitatively as positive or negative, where positive represents an exceedingly low risk of respiratory distress, or quantitatively, where a thin-layer chromatography value \>2% is associated with a minimal rate of respiratory distress. Because thin-layer chromatography is a complicated and time-consuming technique, a rapid, semiquantitative immunologic slide agglutination test (AmnioStat-FLM) and several enzymatic assays were developed and have been validated as acceptable alternative techniques. The slide agglutination test is the most common method for testing for PG; however, it appears to be less sensitive for detecting fetal lung maturity than thin-layer chromatography. An advantage of testing for PG is that blood or meconium usually does not affect test results. A disadvantage is that the absence of PG, especially before 36 weeks of gestation, is less predictive of the occurrence of respiratory distress than immature results from other tests.]

Answer 53

* Primary repair (can use strap muscle for airway support) * Tracheostomy is necessary for most to allow edema to subside and to check for stricture [Patient was likely stabilized initially with a cricothyroidotomy. This will need to be converted to a tracheostomy after repair.]

Answer 54

_\>_2 consecutive ribs fractured at _\>_2 sites [Results in paradoxical chest motion. Underlying pulmonary contusions are the biggest reason for pulmonary impairment.]

Answer 55

* Sedation and paralysis * Raise head of bed * Relative hyperventilation (modest cerebral vasoconstriction at CO₂ 30-35) * Hypertonic saline (draws fluid out of brain) but keep Na 140-150 * Mannitol (draws fluid out of brain) * Keppra or Fosphenytoin (prophylaxis against seizure) [Induction of a barbiturate coma if above measures do not work. If supportive measures do not work then ventriculostomy with drainage of CSF or craniotomy decompression may be required. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (\>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]

Answer 56

Head MRI (Shows up better on MRI than CT scan) [Treatment is supportive. May need craniectomy if elevated intracranial pressure. Poor prognosis.]

Answer 57

* Urethra: Retrograde urethrogram * Bladder: Cystogram * Ureter: Intravenous pyelogram or retrograde urethrogram * Kidney: CT scan [UpToDate: Bladder injury can be evaluated with a cystogram if cystoscopy cannot be performed; however, a cystogram can detect a laceration or large foreign body, but not more subtle findings (eg, a transmural suture or attenuation of the bladder mucosa). When ureteral injury is suspected, ultrasonography can be helpful as an initial test to assess for hydronephrosis or to exclude a retroperitoneal collection. We follow this with computed tomography with renal contrast or cystoscopy with retrograde intravenous pyelography, depending on test availability. Once a diagnosis of ureteral injury is suspected or confirmed, a retrograde pyelogram can give more information regarding the precise location of the injury. Depending upon the skills and experience of the urologist, ureteral double-J stenting during the retrograde pyelogram as a first-line treatment may manage the injury and avoid the need for more invasive surgery, especially in cases of ureteric obstruction in the postoperative period without large lacerations. If a retroperitoneal, pelvic, or abdominal urinoma is suspected, ultrasonography is the initial imaging study of choice. Further clarification of the location of a fluid collection can be evaluated with computed tomography or magnetic resonance imaging.]

Answer 58

* Temporal or parietal bone fracture: Middle meningeal artery injury (Epidural hematoma) * Maxillofacial fracture: Cervical spine fracture * Sternal fracture: Cardiac contusion * First or second rib fracture: Aortic transection * Scapula fracture: Pulmonary contusion, aortic transection * Left rib fractures 8-12: Spleen laceration * Right rib fractures 8-12: Liver laceration * Pelvic fracture: Bladder rupture, urethral transection

Answer 59

Conservative management (NGT and TPN) [Often causes obstruction. Conservative management cures 90% over 2-3 weeks (hematoma is reabsorbed). If duodenal injury is suspected at the time of laparotomy, perform a Kocher maneuver and open the lesser sac through the omentum (check for hematoma, bile, succus, and fat necrosis).] [UpToDate: Nonoperative management of duodenal and pancreatic injury is safe for patients with blunt Grade I or Grade II injuries of the duodenum (duodenal hematoma) or pancreas (contusion, superficial laceration). Nonoperative management has not been reported for penetrating mechanisms. Patients found to have ductal injury using computed tomography or cholangiopancreatography are not candidates for nonoperative management. Nonoperative management consists of gastrointestinal decompression and nutritional support, as indicated. For patients with symptoms of proximal bowel obstruction due to duodenal hematoma, a nasogastric tube is placed for decompression and parenteral nutrition initiated. After five to seven days, imaging should be repeated to evaluate patency of the duodenum. If the obstruction has resolved, an oral diet can be initiated. However, if the obstruction persists after 10 to 14 days, exploratory laparotomy is indicated. Careful follow-up is essential to monitor for complications that indicate the need for surgical exploration. A retrospective multicenter study evaluated the outcomes of 230 patients with blunt pancreatic and/or duodenal injury. Of the 97 patients managed nonoperatively, 10 patients (6 pancreatic, 3 duodenal) failed nonoperative management and required surgery.]

Answer 60

* 70% have CSF leak * Treatment is conservative therapy for 2 weeks [Can try epidural catheter to decrease CSF pressure and help close CSF leak. May need surgical closure of dura if leak does not stop.]

Answer 61

1. Hollow viscus injury 2. Diaphragm injury

Answer 62

1. Stable pancreatic hematoma: **Conservative management** (place drains if discovered in OR) 2. Distal pancreatic duct injury: **Distal pancreatectomy** (can take 80-90% of the mass of the pancreas without causing diabetes) 3. Irreparable pancreatic head injury: **Place drains initially**. Delayed Whipple or ERCP with stent placement may eventually be necessary. [Drains should be placed if a pancreatic injury is noted in the OR. ERCP is good at finding duct injuries and may be able to treat with temporary stent.] [UpToDate: Most pancreatic injuries are low grade (Grade I or Grade II) and most can be managed nonoperatively. When injury to the pancreas is identified during abdominal exploration, the integrity of the main pancreatic duct should be evaluated, and the location of the injury (proximal versus distal) ascertained. Generally accepted principles of operative management of pancreatic injuries include control of bleeding, wide drainage to control potential pancreatic fistula, avoiding pancreaticoenteric anastomoses, and limiting the extent of procedures in the setting of damage control surgery. **Perhaps the only consensus among trauma surgeons is that wide closed-suction drainage should be performed**. When drains are placed, we prefer to use closed-suction drains rather than sump drainage, which has been associated with a greater incidence of septic pancreatic complications. Drains should be placed transversely, adjacent to the gland. When treating pancreatic injuries, a minimum of two drains should be placed, one superior to the pancreas and one inferior to the pancreas. * Grade I injuries are minor contusions associated with small hematomas, minor capsular injury, and traumatic pancreatitis. **When minor contusions are identified in the operating room, no specific intervention is needed (not even drainage).** * Grade II injuries are pancreatic lacerations that do not involve the main pancreatic duct. Bleeding from the parenchyma is often apparent. **Grade II injuries are treated with limited debridement and closed-suction drainage.** Several procedures including suture repair of the capsule, omental plug, bipolar cautery, and tissue sealant have been advocated to decrease pancreatic fistula formation from minor pancreatic ducts injury, but there is no evidence to support these methods. * Higher grade injuries (grades III, IV, V) include pancreatic ductal injuries and these injuries are often associated with duodenal injury. Multiple other traumatic injuries are often associated, necessitating a damage-control approach. **The management of pancreatic ductal injuries depends upon whether the main pancreatic duct is injured to the right or left of the superior mesenteric vein.** Pancreatic transection or parenchymal injury to the **left of the superior mesenteric vein is managed with distal pancreatectomy**. Distal pancreatic resection can be accomplished without sacrificing the spleen, or significantly prolonging operative time and should be considered in hemodynamically stable patients with isolated pancreatic injury. To salvage the spleen, the splenic artery branches and venous tributaries draining the posterior surface of the pancreas are isolated and ligated, working from distal to proximal, followed by division of the pancreas. **Management of pancreatic duct injury to the right of the superior mesenteric vessels depends upon the presence and extent of pancreatic tissue devitalization and concomitant duodenal injury. Options include debridement and wide suction drainage, extended distal pancreatectomy with division of the pancreas to the right of the superior mesenteric vessels, and pancreaticoduodenectomy.** Due to the high incidence of endocrine insufficiency and diabetes with removal of \>90% of the pancreas, some authors have advocated Roux-en-Y distal pancreaticojejunostomy (with oversewing of the proximal segment) for proximal duct transections (ie, central pancreatectomy). Central pancreatectomy has an advantage over distal or subtotal pancreatectomy in preserving the tail of the pancreas and its endocrine and exocrine function, as well as the spleen. However, the risk of anastomotic leak and morbidity are significant and some argue that a more conservative approach should be used. In a review of 134 patients with blunt pancreatic duct injury, 34 patients with proximal injuries (not Grade V) were treated with closed suction drainage alone. Complication rates were no different compared with more aggressive approaches. Favorable results have also been reported for proximal duct injury due to gunshot wounds using debridement, suture repair, and closed suction drainage. These considerations and the complexity of the procedure make central pancreatectomy unsuitable for many patients, particularly multiply-injured patients. The technical aspects of central pancreatectomy are discussed elsewhere. **Main pancreatic duct injuries with extensive injury to the pancreatic head can also be managed using anterior Roux-en-Y pancreaticojejunostomy for internal drainage provided there is sufficient parenchyma that is preserved. However, this procedure has been associated with a high incidence of pancreatic leak and abscess formation.**]

Answer 63

* Persistent maternal shock or severe injuries and pregnancy near term (\>34 weeks) * Pregnancy a threat to the mother's life (hemorrhage, DIC) * Mechanical limitation to life-threatening vessel injury * Risk of fetal distress exceeds risk of immaturity * Direct intra-uterine trauma [UpToDate: Emergency cesarean delivery is performed in an attempt to: * Save the fetus in the setting of imminent maternal death or an abnormal fetal heart rate tracing. Cesarean delivery for fetal indications is generally avoided before fetal viability. However, deciding upon a threshold of viability is challenging, as it remains uncertain which extremely preterm infants, particularly those born at 23 and 24 weeks of gestation, have a reasonable chance of survival without severe deficits. * Save the mother if cardiopulmonary resuscitation has not been effective within four minutes. Cesarean delivery is also performed to provide adequate surgical exposure for management of maternal injuries during laparotomy and when a displaced pelvic fracture precludes vaginal delivery. In pregnant burn patients, delivery is recommended if the pregnancy has reached the third trimester and total body burn surface area is \>50%. The route of delivery is based on standard obstetric considerations. Fetal death is not an indication for cesarean delivery, except in some cases of abruptio placenta resulting in maternal coagulopathy and hemodynamic instability.]

Answer 64

Bladder pressure \> 25-30 [Occurs after massive fluid resuscitation, trauma, or abdominal surgery.]

Answer 65

20 weeks [Fundal height can be estimated by gestational week. 20 weeks gestation = 20cm fundal height = umbilicus.]

Answer 66

* Colon injury: Primary repair/anastomosis * Extraperitoneal rectal injury: Diverting loop ileostomy (generally not repaired because of inaccessibility) * Intraperitoneal rectal injury: Primary repair, presacral drainage, consider diverting ileostomy [Place diverting ileostomy with shock, gross contamination, or extensive injury.] [UpToDate: For most patients with colon or intraperitoneal rectal injuries, we suggest primary repair, or resection and re-anastomosis (as appropriate), but without a diverting colostomy (Grade 2C). For most patients with extraperitoneal rectal injuries, proximal diverting colostomy alone is sufficient.]

Answer 67

* Proximal 1/3 with large (\> 2cm) missing segment: **Temporize with percutaneous nephrostomy, ileal interposition or trans-ureteroureterostomy later** * Middle 1/3 with large (\> 2cm) missing segment: **Temporize with percutaneous nephrostomy, ileal interposition or trans-ureteroureterostomy later** * Distal 1/3 with large (\> 2cm) missing segment: **Reimplant in bladder (may need bladder hitch procedure)** * Proximal 1/3 with small (\< 2cm) missing segment: **Mobilize ends of ureter and perform primary repair over stent** * Middle 1/3 with small (\< 2cm) missing segment: **Mobilize ends of ureter and perform primary repair over stent** * Distal 1/3 with small (\< 2cm) missing segment: **Reimplant in bladder (easier anastomosis than primary repair)** [Leave drains for all ureteral injuries.]

Answer 68

* **Damage control with peri-hepatic packing** (can pack severe penetrating injuries if patient becomes unstable in the OR and the injury is not easily fixed such as with a retrohepatic IVC injury. Patient can be packed and returned to ICU to get the patient resuscitated and stabilized. Live to fight another day) * **Atriocaval shunt** for retrohepatic IVC injury (allows for control while performing repair) * **Ligation of common hepatic artery** can be done without causing ischemia because of gastroduodenal collaterals * **Leave drains** [Ligation of portal vein associated with 50% mortality.] [UpToDate: Nonoperative management is the treatment of choice for hemodynamically stable patients with hepatic injury, regardless of injury grade, and consists of observation and supportive care with the adjunctive use of arteriography and hepatic embolization. Retrospective reviews of the National Trauma Data Bank and other observational studies have found that more than 80 percent of patients with blunt hepatic injury can be treated nonoperatively with success rates (defined as no need for operative intervention for the hepatic injury) in \>90% of patients. A review of the National Trauma Data Bank identified 35,510 hepatic injuries over a 10-year period from 1994 to 2003. Of these, 91% of adults were successfully managed nonoperatively. Over the study period, the percentage of patients with liver injury managed nonoperatively rose from 75% to 82%, but the overall mortality associated with liver trauma remained unchanged at about 15%. The steady improvement in rates of successful nonoperative management that has occurred in the United States since the mid-1990s appears to be associated with greater overall survival, reduced resource consumption, and lower health care expenditures for patients with liver injuries. Greater utilization of damage control resuscitation strategies over this time period appears to be one factor leading to these higher successful nonoperative management rates. Successful nonoperative management requires appropriate patient selection and the availability of resources including availability of intensive care unit beds, blood bank support, immediate operating room availability, and surgeons and interventional angiographers experienced in managing hepatic injury. Patients who are hemodynamically stable but demonstrate extravasation from the liver on computed tomography (CT) of the abdomen have higher failure rates with nonoperative management, and these patients should undergo arteriography and possible liver embolization followed by continued observation and serial hemoglobin determination. Exploratory laparotomy for trauma consists of initial control of hemorrhage by four-quadrant abdominal packing, followed by systematic inspection of all intraabdominal organs, and exploration of the retroperitoneum, if indicated. Active bleeding is managed prior to addressing gastrointestinal injury. Control of hemorrhage from liver injury is performed initially using manual compression, portal clamping and perihepatic packing. If packing is successful at controlling bleeding, the packs can be left in place as part of a damage control strategy or an attempt at removal made. Definitive measures to control bleeding from the liver include the use of topical hemostatic agents, coagulation techniques, ligation of intraparenchymal vessels, and direct liver suturing. Low-grade injuries generally respond to conservative techniques for hemostasis. Higher grade injuries may require hepatic artery ligation to control bleeding or debridement (resectional debridement, anatomic resection) of the liver to remove devitalized tissue. Juxtahepatic injuries (grade V) may require hepatic shunting techniques to identify and repair hepatic vein or inferior vena cava injuries; however, mortality associated with shunting remains high. Patients with devastating injuries (including avulsion) may require hepatectomy and liver transplant.]

Answer 69

2nd portion of duodenum [Usually results from blunt trauma (IE crush or deceleration injury). Can also get tears at ligament of treitz.]