16 - ATLS & management of acute trauma Flashcards
1
Q
Primary survey should be repeated every time there is a __ in the patient’s status.
A
change
2
Q
What are the stage of ATLS?
A
Airway + C spine Breathing Circulation Disability / neurological condition Exposure & environmental control
3
Q
The basic fundamentals of ATLS determine that:
- patients in the most acute __ should be treated first
- Diagnosis should not __ treatment
- detailed __ is not crucial to assess and treat
A
risk
delay
history
4
Q
If the patients can produce __ response= AW is protected.
A
verbal
5
Q
What are the main indications to manage AW?
A
GCS < 8 + cannot speak airflow obstruction laud breathing facial trauma/burn spreading neck hematoma
6
Q
GCS (3-15) =
eye movement -
verbal response -
motor response -
A
1-4
1-5
1-6
7
Q
GCS eye movement: 1- 2- 3- 4-
A
1- none
2- to pain
3- to voice
4- spontaneous
8
Q
GCS verbal response: 1- 2- 3- 4- 5-
A
1- none 2- incomprehensible 3- inappropriate 4- confused 5- oriented
9
Q
GCS motor response: 1- 2- 3- 4- 5- 6-
A
1- none 2- extension 3- flexion 4- withdraws to pain 5- localized pain 6- obeys commands
10
Q
If GCS < _ or 2 points lower than the previous rotation= mental status __.
A
decrease
11
Q
A patient with an airway problem should be __.
A
intubated
12
Q
When the patient is being prepared to be intubated, pre __ should be performed with: 3
A
oxygenation
ambo
mask
airway
13
Q
Sellick maneuver = __
A
cricoid pressure to prevent aspiration
14
Q
If we want to get a better view of the glottis give fast acting muscle relaxants such as: 2. Consider also hypotonic/sedative drugs such as: 3
A
succinylcholine rocuronium (esmeron) midazolam ketamine etomidate
15
Q
What are the ways to know if the intubation is well placed in the trachea? 3
A
chest auscultation
CXr
ETCO2
16
Q
What are the indications for surgical airway?
A
glottis edema laryngeal pathology 2 failed intubation attempts severe oropharyngeal bleeding voice cord injury
17
Q
What is preferred surgical airway in the trauma room?
A
cricothyroidotomy (coniotomy)
18
Q
Tracheostomy is recommended when there is a __ injury and the anatomy of the __ membrane is abnormal.
A
larynx
cricothyroid
19
Q
We can remove the __ part of the orthopedic cervical collar to gain access.
A
anterior
20
Q
Rigid long spine boards is good to mobilize the patient, but should be __ ASAP to avoid fast evolving __.
A
removed
pressure ulcers
21
Q
Use the - technique to move the patient (keeping one axis).
A
log-roll
22
Q
How do we assess the breathing in ATLS?
A
observing chest movement (symmetric? contusions?)
auscultations in the apex and axilla
saturation
tracheal deviation
subcutaneous emphysema
Jugular vein distention (tension pneumothorax/tamponade)
23
Q
Name 5 “breathing killers” of ATLS which requires an immediate attention:
A
tension pneumothorax massive hemothorax flail chest + lung contusion open pneumothorax cardiac contusion
24
Q
In tension pneumothorax air goes __ but cannot get back __.
A
out
in
25
What are the clinical signs of tension pneumothorax? 5
```
tachycardia
tachypnea
tracheal deviation
hypotension
unilateral decreased breathing sound
Jugular vein distention
```
26
What is the treatment for tension pneumothorax?
thoracic decompression with needle application in the midclavicular line, 2nd rib (first intracoastal space after the clavicula)
27
What is the trauma room treatment for tension pneumothorax?
intracoastal trocar + CXr
28
Massive hemothorax is caused by __/__ blood vessels damage leading to > _ L in first drainage / flow > __ cc/hour.
lung/intracoastal
1.5
100
29
In massive hemothorax, __ may be necessary. The bleeding may spread to the: 5
```
thoracotomy
lung
abdomen
pelvis
retroperitoneum
thighs
```
30
Flail chest= abnormal movement of parts of the chest wall due to > _ broken ribs in > _ places each. That causes __ breathing.
3
2
paradoxical
31
How to you treat flail chst?
aggressive ventilation with high PEEP
32
What is the treatment for open pneumothorax?
bandaging the hole with partial closure of the wound + chest trocar
33
What can cardiac contusion cause? 4
tamponade
VF
papillary muscle rapture
large vessels rapture
34
In cardiac contusion remember to always perform __. In case of pathology / __ signs -> __ admission.
ECG
tamponade
ICU
35
When managing a patient with a problems in the breathing part of ATLS, always give ___, sometime add also __ and then perform __.
oxygen
chest trocar
CXr
36
What is the most common cause for shock in trauma?
bleeding
37
When examining the circulation part of ATLS- check:4
pulse
BP
temperature
capillary feeling
38
What are the main shock signs in a trauma patient? 6
```
agitation / confusion
tachycardia/tachypnea
diaphoresis
cold periphery/reduced pulse
oliguria
hypotension
```
39
```
What is 1st degree hemorrhagic shock?
blood loss-
pulse-
systolic BP-
pulse pressure-
RR-
urine production-
mental status-
```
```
blood loss- <750 ml (15%)
pulse- <100
systolic BP- normal
pulse pressure- normal
RR- 14-20
urine production- >30
mental status- anxious
```
40
```
What is 2nd degree hemorrhagic shock?
blood loss-
pulse-
systolic BP-
pulse pressure-
RR-
urine production-
mental status-
```
```
blood loss- 750-1500 ml (15-30%)
pulse- 100-120
systolic BP- normal
pulse pressure- decreased
RR- 20-30
urine production- 20-30
mental status- very anxious
```
41
```
What is 3rd degree hemorrhagic shock?
blood loss-
pulse-
systolic BP-
pulse pressure-
RR-
urine production-
mental status-
```
```
blood loss- 1500-2000 ml (30-40%)
pulse- 120-140
systolic BP- decreased
pulse pressure- decreased
RR- 30-40
urine production- 5-15
mental status- anxious/confused
```
42
```
What is 4th degree hemorrhagic shock?
blood loss-
pulse-
systolic BP-
pulse pressure-
RR-
urine production-
mental status-
```
```
blood loss- >2000 (40%)
pulse- >140
systolic BP- decreased
pulse pressure- decreased
RR- >40
urine production- negligible
mental status- confused/lethargic
```
43
```
What is the primary treatment for each the shock degrees according to ATLS?
1st-
2nd-
3rd-
4th-
```
1st- crystalloid
2nd- crystalloid
3rd- crystalloid + blood
4th- crystalloid + blood
44
What are the 6 steps in managing a patient with ATLS circulation problem?
```
open 2 lines
rehydration
blood transfusion
look for bleeding source
resuscitative thoracotomy
```
45
When opening lines in a trauma patient include the following tests: 6
```
blood type
chemistry
coagulation
ABG
hemoglobin
beta hCG
```
46
Rehydration of a trauma patient consists of: 3
1-2 l bolus of crystalloid (ringer lactate/NS), warmed IV
47
In case rehydration does not elicit a response- give __ transfusion. Do not strive for normal __ (it may increase the __).
blood
BP
bleeding
48
Blood transfusion should be administrated only if __ is non responsive or level __ shock.
rehydration
| III
49
What are the main areas in which life threatening bleeding may occur in a trauma patient?
external- direct pressure
chest- CXr + trocar (consider thoracotomy)
abdominal- FAST (if unstable- laparotomy)
retroperitoneum (hip fractures)- hip Xr
multiple fractures in long bones
50
What is the Beck's triad? What does it suggest?
hypotension
distanced heart sounds
increased JVP
tamponade
51
What are the FAST points? 4
hepatorenal
splenorenal
pelvic (Douglas pouch)
pericardium
52
Resuscitative thoracotomy is performed in the __ room for patients with lost __, in cases of __ trauma.
trauma
life signs (pulse disappeared)
penetrating
53
What are the 4 goals of resuscitative thoracotomy?
open pericardium to release potential tamponade
direct heart massage
cross clamp on the descending aorta
control chest bleeding
54
Blunt trauma patients showing lost signs of life have _% survival rates. Do not perform __.
1
| resuscitative thoracotomy
55
REBOA= __
resuscitative endovascular balloon of the aorta
56
REBOA is useful for uncontrolled __ bleeding (__ rapture). It allows blood supply to the __ and __ + slowing the bleeding in the __ and __.
```
abdominal
aneurism
brain
chest
abdomen
pelvis
```
57
GCS helps us divide head injuries into different severities:
severe- <= __
moderate- _-_
mild- _-_
<=8
9-12
13-15
58
All trauma patients, beside __ rapture, should get a urine catheter.
urethra
59
In case of urethra rapture retrograde __/__ + contrast is required before inserting __.
cystography
CT
urine catheter
60
What are the C/I for urine catheter in a trauma patient?
meatus bleeding
peritoneum/scrotum hematoma
high riding prostate
significant pelvic fracture
61
__ tube should be placed in every trauma patient due to stomach distension caused by the trauma (acute __). It also helps with reducing __ and assessing __.
nasogastric
gastric dilatation
aspiration
UGIB
62
In case of suspected skull fracture, insert the nasogastric tube through the __.
mouth
63
Name 4 signs suggesting skull injury:
racoon eyes
CSF leakage from ears/nose
Battle's sign (mastoid ecchymosis)
hemotympanum
64
In trauma, hope for urine production > __ ml/h/kg and pH around __.
0. 5-1
| 7. 4
65
Penetrating trauma requires __ + imaging of the __.
CXr
| area
66
Blunt trauma requires __ + __:
CT for assessing __ in stable patients.
FAST in __ patient
CXr
pelvic Xr
C spine
unstable
67
If FAST is unavailable, diagnostic __ can be performed. When > __ ml of blood- abdominal bleeding requiring emergency __.
peritoneal lavage
10
laparotomy
68
Full history should be taken in __ survey.
secondary
69
Which cases require chest trocar? 6
```
tension pneumothorax
hemothorax
open pneumothorax
flail chest
pleural effusion
empyema
```
70
Where should you insert chest trocar? After placing it, perform __ to make sure it is in place.
4-5 intracoastal space midaxillary line (nipple line)
| CXr
71
When should we remove the chest trocar?
> _ hours without __ released
< _ ml of __ drained
> 24 hours with no air release
| < 100 ml of fluid
72
What are the 3 indications for OR thoracotomy?
* > __ ml of blood when inserting the trocar, or > __ ml/hr for _ straight hours.
* Massive __
* __/__ content in the trocar.
```
> 1500
300
3
air leak (uncontrolled pneumothorax)
esophageal/stomach
```
73
What is the indication for emergency thoracotomy?
| Immediate need for __ in patients with __ trauma witness lost __ of life.
aortic clamp
penetrating
signs
74
What are the three approaches for surgical thoracotomy?
posterolateral thoracotomy
left thoracotomy
median sternotomy
75
What is the deadly triad?
hypothermia
coagulopathy
metabolic acidosis
76
When performing damage control, first exploration should include:
1. fast __ control
2. look for __ organ damage
3. __ closure of the chest/abdomen
4. leave __
bleeding
hollow
temporary
trocars
77
In order to control the bleeding, use intra __/__ __.
Remove them one at a time and __/__ bleeding vessels (IVC/suprarenal/SVC/SMV/popliteal vein). Bleeding spleen- __, bleeding liver- __.
```
abdominal/thoracic
packing
ligate/clamp
splenectomy
packing
```
78
In trauma damage control, hollow organs should be __ or __. No __ + place __.
primary repaired
resected
anastomosis
trocar
79
Aggressive resuscitation with massive transfusion should include 1:1:1:1 replacement of:
packed red blood cells
plasma
platelets
cryoprecipitate
80
What is the most common etiology of traumatic brain injuries?
falling from great height
81
What are the 5 types of brain injuries?
```
epidural hematomas (lens)
subdural hematomas (crescent)
subarachnoid bleeding (
parenchymal contusions of brain tissue
diffuse axonal injury (DAI)
```
82
Epidural hematomas have a __ like shape. It does not cross the __. The main etiology is __ fracture, leading to __ arterial bleeding.
lens
sutures
lateral
middle meningeal
83
What is the clinical manifestation of epidural hematomas?
1. loss of __ ->
2. __ interval (the __ increases)
3. big hematoma causing significant __
conciseness
lucid
hematoma
neurological deuteriation
84
What is the treatment for epidural hematoma?
decompression
85
Subdural hematoma is __ shaped, and crosses the __. It usually causes __ damage to the proximal brain tissue.
crescent
sutures
severe
86
In subdural hematoma, the clinical manifestation is determined by the __ damage rather than the __ itself, which can increase the __.
axonal
hematoma
ICP
87
Subarachnoid bleeding is indicative for spread __ from the brain __. The bleeding in itself is __.
bleeding
parenchyma
benign
88
Parenchymal contusions of brain tissue is caused by direct energy transfer to the adjacent __. Look for __ injury.
tissue
| contralateral
89
The main reason for morbidity in parenchymal contusion is due to __ brain injury caused by ___.
secondary
| edema
90
DAI is secondary to severe __ forces causing shearing effect. Imaging does not capture the damage well, showing: __ hemorrhage and loss of border between __ and __ matter.
rotational
punctate (small)
white
grey
91
We should suspect DAI when the imaging test is __ while the neurological status is __.
normal
| decreased
92
What are the component of primary care of TBI (traumatic brain injury)? 3
airway control
bleeding control and resuscitation (BP>90
reverse effect of antiplatelet/anticoagulation
93
What is the Cushing triad for increased ICP?
hypertension
bradycardia
irregular breathing
94
What are the steps of initial assessment of TBI? 3
- GCS
- pupil reaction
- imaging (CT w/o contrast)
95
What are the additional treatment methods for TBI? 2
surgical decompression
| reducing ICP
96
What are the indications for surgical decompression? 3
epidural/subdural hematoma with mass effect
compression fractures
increased refractory ICP
97
How do you calculate CPP (cerebral perfusion pressure)?
Mean arterial pressure - ICP
98
What are the ways to decrease ICP? 6
head elevation to 30 degrees
ventriculostomy
moderate hyperventilation (PCO2 30-35 mmHg)
sedation and pain control
hyperosmolar treatment (mannitol/hypertonic saline)
barbiturate induced coma
99
__ is not part of treating acute head injury.
steroids
100
What are the main etiologies of spinal cord injury? what is the mortality rate? 2
vehicle accident
gunshot injuries
13-17%
101
What are the first steps in initial treatment for spinal cord injuries? 4
spinal fixation with collar and back board
ventilation if necessary
neurogenic shock treatment (vasopressors-dopamine/epinephrine)
102
What are the manifestations of neurogenic shock? 5
```
decreased CO and SVR
hypotension + bradycardia
warm periphery
paralysis/reduced sphincteric tonus
no response to rehydration
```
103
Steroids should be given to patients with spinal cord injury only if it __ and with low risk for __.
isolated
| infection
104
Neck injuries are __, but lead to the highest __ rate (__%) than any other area of the body.
uncommon
mortality
20
105
Blunt trauma neck injury may cause compression with __/__ fracture leading to __/__ infection if left untreated.
pharynx/larynx
| neck/mediastinum
106
Blunt trauma neck injury can also damage the __ & __ arteries. Usually due to __ or severe __-__ mechanism.
Carotid
vertebral
seatbelt
flexion-extension
107
BCVI=__. The morbidity is usually related to __ secondary to __ caused by vascular injury.
blunt cerebrovascular injuries
stroke
thromboembolism
108
Penetrating neck injuries can be classified into 3 according to their anatomical location:
Zone I: __.
Zone II: __.
Zone III: __.
thoracic inlet-crocoid (large vessels, trachea, pharynx)
cricoid- mandibular angle (jugular veins, carotid & vertebral arteries, GI tracts, URT)
mandibular angle- skull base
109
```
The first step in treating penetrating neck injury is to secure __:
1-__
2-__
3-__
4-__
```
```
airway
immediate intubation
surgical airway (tracheostomy)
bleeding control
surgical exploration
```
110
We must perform immediate intubation in penetrating neck trauma when we find expending cervical __ or when we suspect eminent __ damage.
hematoma
| airway
111
What are the indications of surgical exploration of a penetrating neck injury? 6
```
unstable patient
expending hematoma
active bleeding
air bubbling
neurological disorder
hematemesis
```
112
Patients with penetrating neck injury in zone __ who are __ but __(active bleeding/respiratory disorder), should go through __.
II
stable
symptomatic
surgical exploration
113
Unstable patients with penetrating neck injury should be taken directly to __. Stable patients- __ room.
surgery
| trauma
114
What are the 4 steps of initial assessment of patients with penetrating neck injury?
physical examination (which zone?)
imaging
identifying BCVI
clinical assessment of the trachea and esophagus
115
Imaging of patients with penetrating neck injury:
CTA-__
angiography-__
doppler US-__
CTA- assessing vessels and injury route
angiography- gunshot wounds, BCVI
doppler US- carotid & vertebral arteries
116
Which signs will make you suspect BCVI? 5
```
expanding neck hematoma
arterial bleeding from the neck/mouth/nose
focal neurological deficiency
hematoma in patients > 50
stroke seen in CT/MRI
```
117
What are the indications for immediate surgery in patients with penetrating neck injury? 4
unstable
active bleeding
expanding neck hematoma
significant injury to trachea/esophagus
118
טכניקות ניתוחיות ב 87
טכניקות ניתוחיות ב 87
119
When should we suspect a mediastinal penetrating injury which require assessing bleeding/perforation? 4
injury with the following borders:
superior- sternal notch,
inferior- rib cage
lateral- nipple
120
If the clinical presentation matches that of a tamponade, but FAST is inconclusive, perform __ surgery in __ pericardial window approach.
diagnostic
| subxiphoid
121
Subxiphoid pericardial window approach allows reaching the __, checking the presence of __. If found, extend to __.
pericardium
blood
midline sternotomy
122
Perform CXr in __ chest injury at the end of __ survey. If __/__- insert chest trocar
every
primary
pneumothorax/hemothorax
123
What is the GS imaging for chest injury?
CTA
124
In case of suspected tracheal/bronchi injury, perform __ imaging.
bronchoscopy
125
In case of suspected esophageal injury, perform __ imaging + __.
esophagoscopy
| contrast
126
What is the main complication of broken ribs? What is the best way to prevent it? 2
pneumonia
| pain management
127
What is the best way to manage pain7 in chest wall and pleural space injuries? (remember to include respiratory physiotherapy)
mild-
moderate-
severe-
NSAID
opioid
epidural catheter
128
Cardiac injuries occur in _% of penetrating chest trauma, causing _% mortality.
8. 7%
| 72. 9%
129
Cardiac injuries usually present with __ bleeding and __.
pericardium
| tamponade
130
In patients with cardiac injuries and severe __/__ perform __ in the __ room.
hypotension/loss of life signs
thoracotomy
trauma
131
In suspected contusion to the heart perform __. If normal/minimal changes- monitor for __ hours. In case of arrhythmia- monitor for _-_ hours and treat accordingly. In case of heart failure- __.
ECG
12
24-48
ECO
132
Thoracic aorta injury is rare, but has high mortality rate- __% in blunt, __% in penetrating.
37%
| 88%
133
Which Xr signs suggest aorta injury 4
mediastinal expansion
apical capping
aortic knob loss
left main bronchus deviation
134
The immediate treatment for thoracic aorta injury includes: 5
```
hemodynamic stabilization
treating other life threatning injuries
beta blocker
endovascular repair
left thoracotomy surgical repair
```
135
How do you diagnose esophageal injury? 3
```
upper gastrointestinal series (UGI)- a radiographic Xr
+
contrast
+
esophagoscopy
```
136
What is the treatment for esophageal injury? 3
diagnose and treat ASAP
- upper/middle injury- right poster lateral thoracotomy along rib #5
- lower injury- left thoracotomy along rib #7
137
In case of esophageal injury + mediastinitis- no __, instead- __ with a __/__ or if necessary- __.
primary repair
drainage
gastrostomy/jejunotomy
esophagectomy
138
Diaphragmatic injury usually occur on the __ side. Diagnosis is usually made in the __. Treatment involves ___ followed by __ repair.
left
OR
exploratory laparotomy
primary
139
What is the main source of morbidity and mortality in injuries to the abdomen?
bleeding and perforation leading to sepsis
140
Which patients with blunt abdominal trauma should go through- immediate ___ in the __? 2
exploratory laparotomy
OR
unstable + positive FAST/DPL>10 ml)
peritonitis signs during primary survey
141
What is the management of other blunt abdominal trauma?
CT + IV contrast
142
In which cases of abdominal trauma with free __ fluid should __ laparotomy be performed? 4
```
peritoneal
exploratory
large fluid volume
seatbelt sign
vital signs disorder
DPL > 500 WBC/mm, increased amylase/bilirubin/GI content
```
143
In abdominal gunshot wounds __ usually required.
surgery
144
In abdominal stabbing wound __ not usually required.
surgery
145
In which cases urgent surgery is necessary for patients with abdominal stabbing wound? 3
hemodynamic instability
peritonitis
extravasation
146
In case of posterior abdominal penetrating wounds CT with __ contrast (__/__/__) is necessary.
triple
| IV/drinking/enema
147
Which abdominal injuries require immediate exploratory laparotomy? 2
anterior abdomen gunshot
| unstable/peritonitis/extravasation stab wound
148
In case of positive splenic injury + positive FAST->__. In other cases->___.
directly to the OR (usually if unstable->splenectomy)
| CT
149
Angiography and embolization are only for __ patients with contrast __ in CT.
stable
| extravasation
150
# Define level I AAST spleen injury scale:
* __ - subcapsular, < __% surface area
| * __- capsular tear < _ cm parenchymal depth
hematoma
10
laceration
1
151
Define level II AAST spleen injury scale:
* __ - subcapsular, _-_% surface area
intraparenchymal,
```
hematoma
10-50
5
laceration
1-3
```
152
Define level III AAST spleen injury scale:
* __ - subcapsular, > __% surface area or __.
intraparenchymal hematoma >=_ cm in diameter
* __- capsular tear >_ cm parenchymal depth
```
hematoma
50%
expanding
5
laceration
3
```
153
Define level IV AAST spleen injury scale:
| * __ - involving segmental/hilar vessels producing major ___ (>__% of spleen).
laceration
devascularization
25
154
# Define level V AAST spleen injury scale:
* __ - completely __ spleen
| * __- hilar vascular injury __ spleen
hematoma
shattered
devascularized
155
Blunt spleen injury conservative treatment consists of __ in the __. Notice that patients> __ are in higher risk for conservative treatment failure.
monitoring
ICU
55
156
Which blunt spleen injury should receive conservative treatment?
stable
no active bleeding
no need for blood products
grade I-III
157
Blunt splenic injury patients in grade _ or _ have _ and _ respective chances for conservative treatment failure.
IV
V
33
75
158
Surgical treatment- __ is for splenic blunt injury patients who are __ or suffer from __ bleeding.
splenectomy
unstable
active
159
In case of penetrating splenic injury, the decision if __ is necessary will depend on if __ bleeding is present.
splenectomy
| active
160
Which organ is most likely to get damaged in penetrating injury to the abdomen?
liver
161
In case of hepatic injuries, if FAST is positive- __, if not __.
OR
| CT
162
Classify the AAST hepatic injury grade I:
| I- Hematoma: subcapsular,
10
| 1
163
Classify the AAST hepatic injury grade II:
- Hematoma- subcapsular _-_% of surface area, the intraparenchymal hematoma < __ cm
- Laceration- capsular rapture, _-_ cm into the parenchyma and < _ cm in length.
10-50%
10
1-3
10
164
Classify the AAST hepatic injury grade III:
- Hematoma- subcapsular > _% of surface area
intra parenchymal > _ cm / __
- Laceration- rapture >_ cm.
50%
10
expanding
3
165
Classify the AAST hepatic injury grade V:
-Laceration involving >_ of the liver lobe / _ segments in one lobe.
Vascular- __/__ injury.
25-75%
3
IVC/hepatic vein
166
Classify the AAST hepatic injury grade VI:
| - hepatic __.
avulsion (tearing away of a body part)
167
Classify the AAST hepatic injury grade VI:
| - hepatic __.
avulsion (tearing away of a body part)
168
What is the best success predictor for conservative treatment in hepatic injury? Which patients should be treated conservatively?
hemodynamic stability
| stable W/O active bleeding
169
Which hepatic injury patients should be treated with embolization?
stable + active bleeding
170
Which hepatic injury patients should be treated with urgent surgery?
unstable + active bleeding
171
In IVC injury, the preferred treatment is __ and __
conservative
| packing
172
Name 4 possible complications in hepatic injury:
bile leakage
hepatic abscess
hemobilia
biloma
173
Hepatic injury damage control consists of:
bleeding control with __ and temporary abdominal __. In case of diffuse bleeding __ the abdomen until stable and consider__ of the bleeding arteries.
packing
closure
close
embolization
174
How do you diagnose gastric injury?
physical (peritonitis/penetrating wound)
| CT (less effective)
175
How do you treat gastric injury?
surgery (stiches/stapler)
| total/partial gastrectomy (Billroth I/II) in severe cases
176
How do you diagnose pancreatic injury? 3
3D CT
lab (increased amylase 3 post injury)
ERCP/MRCP
177
Describe 4 CT findings suggesting pancreatic injury:
decreased pancreatic perfusion
liquid surrounding the pancreas
hematoma
unclear structures around the pancreas (cloudiness)
178
Most cases of pancreatic injury will require __ treatment.
surgical
179
Body/tail pancreatic injuries are of the duct to the left of the __.
They should be treated by ___.
superior mesenteric vessels
duct
distal pancreatectomy
180
Head pancreatic injury should be treated by ___ in limited injuries or __ when more extensive.
drainage
| Whipple
181
In pancreatic injury, leave __ to prevent retroperitoneal organs exposed to pancreatic __.
trocars
| enzymes
182
What are the indications for external drainage in pancreatic injury?
does not involve the duct
hematoma/contusion
capsular laceration, w/o parenchymal penetration
183
Colon injuries should be assessed with: __ or __ only in __ patients.
PR
proctosigmoidoscopy
stable
184
What are the C/I for post injury primary colon anastomosis?
unstable/shock
peritonitis
severe comorbidity
other severe injuries
185
Colon injury <= 50% should be treated with __ closure with _ layers of stiches.
primary
| 2
186
What is the diameter of the following GI tracts?
small bowel-
colon
cecum-
3 cm
6 cm
9 cm
187
Colon injury > 50% should be treated with __ and immediate __. If unstable- __.
resection
primary anastomosis
colostomy
188
Colon injuries proximal to the middle colic artery should be treated with: __ + __.
right hemicolectomy
| ileocolostomy
189
Colon injuries distal to the middle colic artery should be treated with: __ + __.
segmental resection
| colo-colostomy
190
Rectum injury should be treated with surgery: 2.
| If > 50 % of the diameter- __ + __.
loop/end colostomy
presacral drainage
resection + end colostomy
191
In case of infra renal hematoma or right kidney contusion repair the blood vessels by __ and __ control.
proximal
| distal
192
What is the treatment for stable patients with blunt abdominal great vessels trauma and no active bleeding?
endovascular repair
193
When treating retroperitoneal hematoma the treatment is decided by the anatomical region:
zone I - __
zone II - __
zone III -__
zone I - surgery and exploration (aorta/IVC)
zone II - conservative/exploration if it expands (kidney)
zone III -conservative/exploration in massive active bleeding (pelvis)
194
How do you diagnose genitourinary blunt trauma injuries? 4
gross hematuria
physical examination (displaced prostate...)
CT + contrast
CT cystography
195
Most kidney injuries are __. Usually requires __ surgical involvement. If severe __.
blunt
minimal
nephrectomy
196
What is the treatment for ureter trauma? 3
if stable- primary repair
nephrectomy
endoscopic stent + ureter diversion
197
Although most bladder injuries are caused by __ trauma, __ trauma should be treated with __.
blunt
penetrating
surgery
198
In case of bladder injury with intraperitoneal leakage-__ repair of the bladder's __ + __. Follow up with __ to confirm recovery.
primary
borders
Foley catheter (supra pubic exit)
199
In case of bladder injury with extraperitoneal leakage-__ the bladder with urine catheter, followed by __ to confirm recovery.
decompress
| CT cystography
200
What are the indication for CT + contrast in kidney trauma?
stable + BP>90
hematuria (micro/macro)
renal injury suspicion
201
In which cases of kidney injury should IVP (Intravenous Pyelogram) be performed? 2
unstable
| going to surgery
202
```
What are the grades of kidney injury?
I-__
II-__
III-__
IV-__
V-__
```
I-subcapsular hematoma
II-hematoma + laceration<1 cm
III-hematoma + laceration>1cm
IV-laceration into collecting system and/or renal vein/artery injury and/or arterial clot from endothelial injury
V-kidney shattered and/or avulsion of helium
203
Hemodynamic stable patient with kidney injury should be treated according to the CT result:
I-III-__
IV-__
V-__
no surgery
conservative, if unstable/vascular injury- surgery
exploratory surgery-reconstruction/resection
204
Hemodynamic unstable patient with kidney injury should be sent to __ and treated according to the __ results.
surgery
| IVP
205
What are the indications for surgical exploration in an unstable kidney injury? 5
expanding hematoma
contentious renal bleeding contrast extravasation
non viable renal parenchyma
arterial injury
206
What are the indication for angiography and embolization in an unstable kidney injury? 4
continuous extravasation of contrast (blush)
perirenal ring hematoma > 25 mm
medial hematoma
conservative treatment with > 2 blood packs
207
In case of positive FAST for pelvic injury- __, if negative __, if the patient is responsive-__, if not- __ with __.
```
surgery
rehydration
CT
angiography
embolization
```
208
What are the steps for pelvic injury treatment?
sheet fixation-better for venous bleeding
angiography + embolization (arterial bleeding)
packing surgery (active bleeding + unstable)
orthopedic surgery (after stabilization)
209
What are the hard signs for vascular injuries requiring emergency surgery?
```
pulsatile bleeding
expanding hematoma
thrill palpation / bruit sound
ischemic limb
penetrating trauma with arterial/venous injury
```
210
What are the soft signs for vascular injuries requiring imaging (CTA/angiography)? 5
Hx of moderate bleeding
proximal dislocation and/or penetrating injury
reduced pulse
peripheral nerve deficiency near a main vessel
wounds proximal to the limb
211
Which arteries should not be ligated? 4
```
SMA
brachial
superficial femoral
external iliac
popliteal
```
212
In vascular injuries damage control for patients with vascular instability the treatment is mostly: 2
ligation
| intraluminal shunts
213
The _ nerve is injured in 60% of arterial limb injuries . Treatment is __ and __, followed by arterial __ or graft from the __ vein
```
median
surgery
thrombectomy
anastomosis
saphenous vein
```
214
Lower limbs injury should be repaired with __ graft using the __ vein from the __ leg.
interposition
saphenous
contralateral
215
What are the indications for acute limb amputation?
* severe crushing car accident
* unrecoverable limb
* extensive soft tissue lost
severe scapulothoracic dislocation with neurological deficiencies
* extensive fractures/vascular damage
* MESS>7
