15 Trauma Flashcards
1
Q
1st peak for trauma deaths
A
0-30 minutes
Due to lacerations of heart, aorta, brain, brainstem or spinal cord
Cannot really save these patients - they die too quickly
2
Q
2nd peak for trauma deaths
A
30 min - 4 hours
Death due to head injury (#1) and hemorrhage (#2)
These patients can be saved with rapid assessment
‘golden hour’
3
Q
3rd peak for trauma deaths
A
Days to weeks
Death due to MODS and sepsis
4
Q
Most common solid organ damaged in blunt trauma?
A
Liver
Spleen
5
Q
What is the biggest predictors of survival in a fall?
A
Age and body orientation
LD50 is 4 stories
6
Q
Most common organ damaged in penetrating trauma?
A
Small bowel
Liver
7
Q
What is the most common cause of death in the first hour?
A
Hemorrhage
8
Q
How much blood can you lose without effecting BP?
A
30%
9
Q
Treatment of hemorrhage?
A
2L LR then switch to blood
10
Q
What is the most common cause of death after reaching the ER alive?
A
Head injury
11
Q
Most common cause of death in trauma patients over the long term?
A
Infection
12
Q
Most common cause of upper airway obstruction?
A
Tongue
Perform jaw-thrust
13
Q
What injuries are associated with seat belts?
A
Small bowel perforations
Lumbar spine fractures
Sternal fractures
14
Q
What is the best site for cutdown for venous access?
A
Saphenous vein
15
Q
Diagnostic peritoneal lavage
A
Hypotensive patients with blunt injuries
Need laparotomy if positive
16
Q
What indicates a DPL is positive?
A
>10cc blood >100,000 RBCs/cc Food particles Bile Bacteria >500 WBC/cc
17
Q
What does DPL miss?
A
Retroperitoneal bleeds
Contained hematomas
18
Q
Focused abdominal sonography for trauma
A
Perihepatic fossa, perisplenic fossa, pelvis and pericardium
If positive - take to OR
19
Q
FAST misses?
A
Free fluid <50-80cc
Retroperitoneal bleeding
Hollow viscus injury
20
Q
In hypotensive patient with negative FAST scan?
A
Find source of bleeding
Pelvic fracture, chest or extremity
21
Q
Indications for CT scan following blunt trauma?
A
ABdominal pain, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria
Negative DPL
22
Q
CT scan misses in trauma?
A
Hollow viscous injury
Diaphragm injury
23
Q
Indications for laparotomy in trauma?
A
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
24
Q
Treatment for penetrating abdominal injury?
A
Laparotomy
Exception - knife or low velocity injuries: local exploration and obs if fascia no violated
25
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
26
Causes of abdominal compartment syndrome?
Massive fluid resuscitation
Trauma
Abdominal surgery
27
Treatment for abdominal compartment syndrome?
Decompressive laparotomy
28
Pneumatic antishock garment
Controversial use for pt with SBP<50 and no thoracic injury
| Remove one compartment at a time upon arriving at ED
29
Indications for ED thoracotomy
Blunt trauma - only if pressure/pulses lost in ED
| Penetrating trauma - If pressure/pulses lost enroute or within the ED
30
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)
31
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
32
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.
33
When do catecholamines peak after injury?
| What other hormones increase?
24-48hrs
| ADH, ACTH, glucagon
34
Glasgow Coma Scale
Motor (6)
Verbal (5)
Eye opening (4)
<14 - head CT
<10 - intubation
< 8 - ICP monitor
35
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
```
36
Scores for verbal ratings of GCS?
```
5 - Oriented
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds
1 - no response
```
37
Scores for eye opening ratings of GCS?
4 - Spontaneous opening
3 - Opens to command
2 - Opens to pain
1 - No response
38
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
39
Indications for surgical intervention in epidural hematoma?
Significant neurologic degeneration
| Significant mass effect (shift > 5mm)
40
Indications for surgical intervention in subdural hematoma?
Significant neurologic degeneration
| Significant mass effect (>1cm)
41
Indications for ventriculostomy in traumatic IVH?
Hydrocephalus
42
Indications for craniectomy with diffuse axonal injury?
Elevated ICP
43
Cerebral perfusion pressure
CPP = MAP - ICP
44
Signs of elevated ICP?
Decreased ventricular size
Loss of sulci
Loss of cisterns
45
Indications for ICP monitors
GCS < 8
Suspected increased ICP
Patients with moderate to severe head injury and inability to follow clinical exam
46
Normal ICP? Needs treatment? Goal CPP?
Normal ICP 10, >20 needs treatment
| Goal CPP is >60
47
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)
```
48
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
49
Raccoon eyes
Peri-orbital ecchymosis
| Anterior fossa fracture
50
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
```
51
Temporal skull fracture
Can injure CN VII/VIII
52
Most common site of facial nerve injury?
Geniculate ganglion
53
Most common cause of temporal skull fractures?
Lateral skull or orbital blow
54
Indications for operation in skull fracture?
Significantly depressed (>1cm)
Contaminated
Persistent CSF leak
55
Cause of coagulopathy with traumatic brain injury?
Release of tissue factor
56
Jefferson fracture
C-1 burst
Caused by axial loading
Tx: Rigid collar
57
Hangman's fracture
C-2
Distraction and extension
Tx: traction and halo
58
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)
59
Facet fractures or dislocations
Can cause cord injury
| Associated with hyperextension and oration with ligamentous disruption
60
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
61
Compression fractures
Anterior column only
| Stable
62
Burst fractures
Unstable (involve more than one column)
| Require fusion
63
At risk for fracture in upright fall?
Calcaneus
Lumbar
Wrist/forearm
64
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
65
Most common cause of facial nerve injury?
Temporal bone fracture
66
Le Fort Classification - Type I
Maxillary fracture straight across ( --- )
| Tx: Reduction, stabilization, intramaxillary fixation +/- circuzygomatic and orbital rim suspension wires
67
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
68
Le Fort Classification - Type III
Lateral orbital walls ( -- -- )
| Tx: Suspension wiring to stable frontal bone; may need external fixation
69
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
70
Anterior nose bleed - treatment?
Packing
71
Posterior nose bleed?
Balloon tamponade
Angioembolization
Arteries - internal maxillary artery or ethmoidal artery
72
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
73
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)
74
Tripod fracture
Zygomatic bone
| ORIF for cosmesis
75
What must you have a high suspicion for with maxillofacial fractures?
Cervical spine issues
76
Work up for asymptomatic blunt trauma to the neck?
Neck CT scan
77
Work up for asymptomatic penetrating trauma?
Based on neck zone
78
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)
79
Penetrating trauma - Zone II
Cricoid to angle of mandible
| Workup: Neck exploration in OR
80
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
81
Symptomatic neck trauma? Indications? Treatment?
Shock, bleeding, expanding hematoma, losing/lost airway, subQ air, stridor, dysphagia, hemoptysis, neurological deficit
Neck exploration
82
Work up of esophageal injuries?
Esophagoscopy and esophagogram
83
Treatment of contained esophageal injuries?
Observation
84
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)
85
Approach to esophageal injuries?
Neck - left side
Upper 2/3 of thoracic esophagus - right thoracotomy
Lower 1/3 of thoracic esophagus - left thoracotomy
86
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)
87
Thyroid gland injuries
Control bleeding and drain
| NOT thyroidecomy
88
Recurrent laryngeal nerve injury
Can repair or reimplant in cricoarythenoid muscle
| Sx: hoarseness
89
Shotgun injury to neck
Requires angiogram and next CT
| Evaluate the esophagus and trachea
90
Vertebral artery bleeds
Embolize or ligate
91
Common carotid bleed
Ligation causes stroke in 20%
92
Indications for OR after chest tube placement?
>1500cc after initial insertion
>250cc/h for 3 hrs
>2500cc/24hrs
Bleeding with instability
93
Treatment for unresolved hemothorax after 2 well-placed chest tubes?
Thoracoscopic drainage
94
Sucking chest wound (open pneumothorax)
Needs to be at least 2/3 diameter of the trachea to be significant
Cover wound with valve dressing
95
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
96
Indication for right thoracotomy in tracheobronchial injury?
Right mainstem, trachea, and proximal mainstem injuries (avoids the aorta)
97
Indication for left thoracotomy in tracheobronchial injury?
Distal left mainstem injury
98
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
99
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
```
100
Locations for aortic transection?
Ligamentum arteriosum (distal to subclavian tackeoff)
Near aortic valve
Diaphragmatic hiatus
101
Diagnosis of aortic transection?
CT angiogram of chest
102
Operative approach to repair of aortic transection?
Left thoracotomy with repair with partial left heart bypass
OR
Covered stent endograft (distal transection only)
103
Indication for median sternotomy?
Injuries to ascending aorta, innominate artery, proximal right subclavian artery, innominate vein, proximal left common carotid
104
Indication for left thoracotomy?
Injuries to left subclavian artery, descending aorta
105
Access for distal right subclavian artery?
Midclavicular inscision resection of medial clavicle
106
Most common cause of death after myocardial contusion?
V-tach and V-fib
| Highest risk in first 24hrs
107
Flail chest
2 consecutive ribs broken at > 2 sites
Paradoxical motion
Risk for pulmonary contusion
108
Penetrating chest injury - first step
If stable - CXR
109
Penetrating 'box' injuries?
```
borders are clavicle, xiphoid process and nipples
Requires:
- Pericardial window (FAST scan)
- Bronchoscopy
- Esophagoscopy
- Barium swallow
```
110
Penetrating 'non-box' injuries without pneumothorax or hemothorax?
Needs chest tube if patient requires intubation
| Otherwise, serial CXR
111
Pericardial window
If you find blood - median sternotomy (to fix possible injury to heart or great vessels)
Place pericardial drain
112
Penetrating injuries anterior-medial to midaxillary line and below nipples
Laparotomy
| Plus work up for penetrating 'box' injuries
113
Traumatic causes of cardiogenic shock?
Cardiac tamponade
Cardiac contusion
Tension pneumothorax
114
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
115
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
```
116
Type I pelvic fracture
Ubstable (crush)
| Fracture in multiple facets
117
Type II pelvic fracture
Unstable
| Book fracture - one rami and sacroiliac join
118
Type III pelvic fracture
Stable
| Through a rami
119
Bleeding in anterior pelvic fractures
Venous
120
Bleeding in posterior pelvic fractures
Arterial
121
Intra-op penetrating injury pelvic hematomas
Open (possibly angiography)
122
Intra-op blunt injury pelvic hematomas
Leave
If expanding or patient unstable - stablize pelvic fracture, pack paelvis if inOR
Go to angiography for embolization
123
Most common cause of duodenal trauma
Blunt trauma
| Crush or deceleration injury
124
Most common area of duodenal injury?
2nd portion of the duodenum
125
Which segment of the duodenum cannot be repaired with primary end-to-end closure
Second portion of the duodenum
126
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
127
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)
128
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
129
Diagnosing suspected duodenal injury
Abdominal CT with contrast
- Bowel wall thickening, hematoma, free air, contrast leak or retroperitoneal fluid/air
UGI contrast study*
130
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
131
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
```
132
When do you remove drains after duodenal injury?
When patient can tolerate PO feeding without increased in drain output
133
Treatment of fistulas
Bowel rest
TPN
Octreotide
Conservative management for 4-6 weeks
134
Most common organ injured in penetrating injury?
Small bowel (liver)
135
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
136
Criteria for resection and reanastomosis after small bowel injury?
Defect >50% bowel circumference
| Results in lumen diameter <1/3 normal
137
When do you open a mesenteric hematoma?
Expanding
| Large (>2cm)
138
Most common cause for colon trauma?
Penetrating
139
Repair of right and transverse colon injuries?
Primary repair
| Anastamosis
140
Repair of left colon injuries?
Primary repair/anastamosis
AND
Diverting ileostomy is patient is in shock or there is gross contamination
141
Paracolonic hematomas
Both blunt and penetrating hematomas need to be opened
142
Repair of an extraperitoneal rectal hematoma
Serial debridement
| Consider diverting ileostomy
143
Repair of intraperitoneal rectal hematoma
Repair defect, prescral drainage
| Consider diverting ileostomy
144
Indications for diverting ileostomy?
Shock
Gross contamination
Extensive injury
145
Most common organ injured in blunt trauma?
Liver (spleen)
146
When common hepatic artery is ligated, where do collaterals run through?
Gastroduodenal artery
147
Pringle maneuver
Clamp the portal triad - using non-crushing vascular clamps
Does NOT stop bleeding from hepatic veins
Limited to 15-20 minute intervals
148
Atriocaval shunt
For retrohepatic IVC injury
| Allows for control while performing repair
149
Portal triad hematomas
Need to be explored
150
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
151
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
152
Omental graft
Can be placed in liver lacerations to help with bleeding and prevent bile leaks
153
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
```
154
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
155
How long does it take for spleen trauma to heal?
6 weeks
156
Greatest risk of post-splenectomy sepsis?
Within 2 years of splenectomy
157
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
158
Indications for OR in blunt splenic injuries?
Failure of conservative management
Active blush
Pseudoaneurysm
159
Indications of pancreatic trauma
Edema
| Necrosis of peripancreatic fat
160
Treatment of pancreatic contusion
Leave if stable
| If in OR - drain
161
Treatment of distal pancreatic duct injury?
Distal pancreatectomy
| Can take up to 80%
162
Pancreatic head duct injury that is not repairable?
Place drains
| Delayed whipple or ERCP with stent eventually
163
How do you decide between whipple and distal pancreatectomy?
Duct injury in relation to the SMV
164
Pancreatic hematoma
Both penetrating and blunt injuries need to be explored
165
Signs of a missed pancreatic injury?
Persistent or rising amylase
166
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)
167
Moderate/soft signs of vascular injury
History of hemorrhage
Deficits of anatomically related nerve
Large stale/nonpulsatile hematoma
ABI < 0.9
Go for angio
168
When do you need a saphenous vein graft?
When deficit is greater than 2cm
Take from opposite leg
169
Venous injuries that require repair?
```
Vena cava
Femoral
Popliteal
Brachiocephalic
Subclavian
Axillary
```
170
Treatment for transection of single artery in the calf of an otherwise health patient
Ligate
171
When do you perform a fasciotomy?
>4-6 hours ischemia
172
Compartment syndrome
Pressures >20mmHg or clinical exam
| Pain > paresthesia > anesthesia > paralysis > poikilothermia > pulselessness
173
Most common causes of compartment syndrome?
Supracondylar humeral fractures
Tibial fractures
Crush injuries
174
How much blood can you lose from a femur fracture?
> 2L
175
Orthopedic emergencies?
```
Pelvic fractures in unstable patient
Spine injury with deficit
Open fractures
Dislocations or fractures with vascular compromise
Compartment syndrome
```
176
Complication of femoral neck fracture
Avascular necrosis of femoral head
177
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)
178
Fractures associated with upright falls?
Calcaneus
Lumbar
Distal forearm
179
Anterior shoulder dislocation
Axillary nerve
180
Posterior shoulder dislcoation
Axillary nerve
181
Proximal humerus fracture
Axillary nerve
182
Midshaft humerus fracture (or spiral humerus fracture)
Radial nerve
183
Distal (supracondylar) humerus fracture
Brachial artery
184
Elbow dislocation
Brachial artery
185
Distal radius fracture
Median nerve
186
Anterior hip dislocation
Femoral artery
187
Posterior hip dislocation
Sciatic nerve
188
Distal (supracondylar) femur fracture
Popliteal artery
189
Posterior knee dislocation
Popliteal artery
190
Fibular neck fracture
Common peroneal nerve
191
Temporal or parietal bone fracture
Epidural hematoma
192
Maxillofacial fracture
Cervical spinal fracture
193
Sternal fracture
Cardiac contusion
194
First or second rib fracture
Aortic transection
195
Scapula fracture
Pulmonary contusion
| Aortic transection
196
Rib fractures - left, 8-12
Spleen laceration
197
Rib fractures - right, 8-12
Liver laceration
198
Pelvic freacture
Bladder rupture
| Urethral transection
199
Best indicator of renal trauma?
Hematuria
| Requires abdominal CT
200
Benefit of Intravenous pyelogram before going to OR with kidney trauma?
Can identify presence of functional contralateral kidney
201
Left renal vein
Can be ligated near the IVC
Has adrenal and gonadal vein collaterals
(NOT seen in the right renal vein)
202
Renal hilum structures (anterior to posterior)
Vein, artery, pelvis (VAP)
203
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
```
204
How do you assess for leak after repair for kidney trauma?
Methylene blue dye to check for leak
205
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
206
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
207
Trauma to flank and IVP shows no uptake in stable patient
Angiogram
| Stent if flap present
208
Best indicator for bladder trauma?
Hematuria
209
Signs and symptoms of bladder trauma
Meatal blood
| Sacral or scrotal hematoma
210
Diagnosis for bladder trauma
Cystogram
211
Extraperitoneal bladder rupture
Cystogram shows starburts
| Tx: Foley 7-14 days
212
Intraperitoneal bladder rupture
Cystogram shows leak
| Tx: Operation and repair of defect, followed by foley drainage
213
Best test for identifying ureteral injury?
```
NOT hematuria (unreliable)
IVP and retrograde urethrogram
```
214
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
215
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
216
Blood supply to the ureters
Medial in upper 2/3rds
| Lateral in lower 1/3rd
217
Signs of uretheral injury
Hematuria*
Blood at meatus*
Free-floating prostate gland
(Associated with pelvic fracture)
218
Best test for uretheral injury
REtrograde uretherogram
219
Area of the urethra that is at greatest risk for transection?
Membranous portion
220
Treatment of significant urethral injury
Suprapubic cystostomy
Repair in 2-3 months
(High stricture and impotence rate if repaired early)
221
Treatment of small, partial urethral tears
Bridging urethral catheter across tear
| Repair in 2-3 months
222
Genital trauma
Can get fracture in erectile bodies from vigorous sex
| Need to repair the tunica and Buck's fascia
223
Testicular trauma
Get US to see if tunica alburginea is violated
| Repair if needed
224
Best indicators of shock in children
Heart rate, respiratory rate, mental status and clinical exam
BP is NOT reliable - last to go
225
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
226
Uterine rupture
If after fetal delivery - aggressive resuscitation
| Uterus will eventually clamp down
227
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
228
Kleihauer-Betke test
Test for fetal blood in the maternal circulation
| Signs of placental abruption
229
Pelvic hematoma
Open penetrating
| Leave blunt
230
Paraduodenal hematoma
Open penetrating
| Open blunt
231
Portal triad
Open penetrating
| Open blunt
232
Retrohepatic
Leave penetrating
| Leave blunt
233
Midline supramesocolic
Open penetrating
| Open blunt
234
Midline inframesocolic
Open penetrating
| Open blunt
235
Pericolonic
Open penetrating
| Open blunt
236
Perirenal
Open penetrating
| Leave blunt
237
Zone I of the peritoneum
Central retroperitoneum
Pancreaticouodenal injury or major abdominal vascular injury
OPEN hematomas in these areas
238
Zone II of the peritoneum
Flank or perinephric area
Injuries to the gentiurinary tract or to the colon
OPEN hematomas in these areas
239
Zone III of the peritoneum
Pelvis
Pelvic fractures
LEAVE hematomas in these areas
240
When should you always leave a drain?
Pancreatic, liver, biliary system, urinary and duodenal injuries
241
Snake bites
Sx: Shock, bradycardia, arrythmias
Tx: Stabilize patients, anti-venim, tetanus shot
