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Surgery > abdomen and thoracic trauma > Flashcards

abdomen and thoracic trauma Flashcards

1
Q

blunt injury

A

-MC injured in blunt abdominal trauma
-2nd MC injured in blunt abdominal trauma
-we are most worried about solid organs for blunt trauma
-ribs cant protect you from this

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2
Q

A 21 year old male sustains a single gunshot wound to the abdomen. There is an entrance wound 5 cm lateral to the umbilicus on the right side. BP is 80/40, P 130/min, R: 22, T: 99. What is the stepwise management of this patient?

A

-monitor
-supplemental O2
-2 large bores IV access`
-trauma panel sent- CBC, BMP, coagulation studies, tox screen, cross match

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3
Q

A 33 yo male is brought into the ED after been extricated from a head on collision with a van. His Glascow is 11. BP: 80/60, P: 134, R: 18/min. Please discuss the stepwise management of this patient up until definitive care can be rendered.

A

-potential for bleed from abdomen but also hypotension
-head injury may be significant
-worry about brain injury with hypotension -> ischemia
-hypocarbia -> vasodilation -> ICP
-scan the brain

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4
Q

approach to trauma pt

A

-Initial survey - blood or spillage of bowel contents
-Blood vs peritoneal contamination
-Primary goal is to evaluate the need for emergent surgery
-No abdominal problem takes precedence over primary survey responsibilities

-its all about the 1st hr
-trauma is the leading cause of death in the 1st 4 decades of life in developed countries
-rule of rights
-diagnosis is not important
-ABCDE = same for adult/peds/pregnant
-primary survey should be repeated often
-primary and resuscitation should happen at the same time

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5
Q

abdominal eval

A

-unconscious pt
-development of peritoneal signs
-tender abdomen or unconscious pt
-assume significant injury
-hypotensive!! pt or those who will undergo non-abdominal surgery-> FAST
-pelvis- free blood around bladder or uterus
-heart- pericardial effusion
-spleen- blood under diaphragm - morrisons pouch
-lung sliding- hemo/pneumo thorax
-stable -> CT

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6
Q

dx

A

-FAST
-CT scan
-organ specific dx is foolish - dont know about injury type -> just want to know where
-GSW vs stab wounds
-GSW all need to be explored
-stab wounds depend if peritoneal cavity was penetrated

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7
Q
A

morrisons pouch
-anechoic - blood

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8
Q

stablization

A

-ABCs
-NGT
-oral GT if head trauma- worry about cribriform plate
-foley catheter
-thoracoabdominal wounds- combined abdominal and thoracic wounds

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9
Q

hepatic injury

A

-Blunt or penetrating trauma
-Biliary tract injury is harder to dx
-Look for overlying rib fractures
-CT scan -> Approach to repair
-DPL- dx peritoneal lavage- bile

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10
Q

classification of hepatic injury

A

-Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking
-Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick
-Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter
-Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization
-Grade 5 - Global destruction or devascularization of the liver
-Grade 6 - Hepatic avulsion

-devascularization, evulsion -> OR for embolization
-porta hepatis - exsanguination
-IR is always your friend

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11
Q

spleen

A

-2nd most injured solid viscera
-hypotension from hemorrhage is MC presenting sign
-8,9,10 left sided rib fractures
-Trendelenburg position -> khers sign
-FAST vs CT scan
-splenorrhaphy (dont do) vs splenectomy
-splenectomy is now recommended

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12
Q
A

-calcifications
-splenic artery aneurysms

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13
Q

radiographic splenic triad

A

-elevated hemidiaphragm
-left lower lobe atelectasis
-pleural effusion - not really often

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14
Q
A

-spleen that has been shattered
-transection through the spleen
-surgery
-subcapsular contained hematoma
-splenectomy

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15
Q

Grading Splenic Injuries

A

-Grade I
-Subcapsular non-expanding < 10%
-Non-bleeding noncapsular tear < 1cm

-Grade II
-Subcapsular, non-expanding, 10-50% surface area; intra-parenchymal non-expanding < 2 cm in diameter
-Capsular tear, active bleeding, 1-3 cm parenchymal depth that does not involve a trabecular vessel

Grade III
Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding, intra-parenchymal hematoma > 2 cm or expanding
> 3 cm parenchymal depth or involving trabecular vessels

Grade IV
Ruptured intra-parenchymal hematoma with active bleeding
Laceration involving segmental or hilar vessels producing major devascularization (> 25% of spleen)

Grade V
Laceration: Completely shattered spleen
Vascular: Hilar vascular injury that devascularizes spleen

-shattered spleen -> surgery
-3-4 surgery

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16
Q

kidney injury

A

-Proximity of injury
-Hematuria of any type must be investigated
-Flank pain
-Fractures of 11th - 12th ribs
-Don’t look for flank discoloration - no grey turners sign like in pancreas
-CT with contrast
-Contused vs lacerated kidney
-trauma surgery- nephrectomy
-urologist called in- heminephrectomy or repair

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17
Q

bowel injuries

A

-free air
-penetrating vs blunt
-symptoms depend upon location of injury
-retroperitoneal air
-incorrect use of seatbelt
-tears
-duodenum - fixation at pyloric sphincter
-ileocecal valve

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18
Q

pancreatic injuries

A

-overlies vertebral bodies
-rapid deceleration -> transection
-delayed presentation
-retroperitoneal injury
-lipase levels
-ERCP with cannulation of pancreatic duct with dye

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19
Q

order of intervention

A

-primary survey- airway (c-spine stabilization), breathing, circulation
-resuscitation
-secondary survey
-diagnostic evaluation
-definitive care

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20
Q

airway

A

-listen to the voice
-protect the c-spine
-nasotracheal
-orotrachael
-cricothyroidotomy- not under age 12
-operative intervention

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21
Q

breathing

A

-tension pneumothorax
-open pneumothorax
-flail chest

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22
Q

shock

A

-hypovolemic
-neurogenic (spinal shock)
-septic
-cardiogenic
-FES
-PE

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23
Q

shock classification

A

-Class 1- 750cc
-class 2- 750-1500cc
-class 3- 1500-2000cc
-class 4- >2000cc

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24
Q

a transient response to resuscitation in an acute trauma is most likely due to

A

Pulmonary embolism
Myocardial infarction
Continued hemorrhage
Dehydration

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25
Q

circulation

A

-60mmHg - Carotid
-70mmHg - Femoral
-80mmHg - Radial
-Control
-IV access
-Hypotension is not an early sign of hypovolemia

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26
Q

fluids

A

-ringers lactate
-isotonic crystalloid
-role of collodis - O+ or O- for women of childbearing age
-monitoring response
-urine output- .5cc/kg/h(adult), 1cc/kg/h(child), 2cc/kg/h(infant)

27
Q

fluid response categories

A

-responders
-transient responders
-non-responders

28
Q

nonresponders

A

-nonsurvivable injuries
-tension pneumothorax
-pericardial tamponade
-myocardial contusion or infarction
-air embolism
-emergency bay thoracotomy

29
Q

myocardial contusion

A

-1/3 of significant blunt chest trauma
-ventricular dysrhythmias
-atrial fibrillation
-sinus bradycardia
-bundle branch blocks
-NOT transient sinus tachycardia

30
Q

transient responders

A

-ACTIVE HEMORRHAGE

31
Q

Pt with myocardial contusions should be?

A

-Discharged if with a normal EKG
-Admitted to the hospital for observation
-Discharged after normal enzymes
-24 hours telemetry admission

32
Q

secondary survey

A

-identification of occult injuries
-digit in every orifice, tube in every opening
-look everywhere!!!!!
-at site hx
-time of transport
-selective radiography

33
Q

energy transfer rules

A

-20 miles/hour
-20 feet/distance
-20 minutes trapped
-Low velocity GSW <2000ft/s
-High velocity GSW >2000ft/s
-Shotgun wounds > or < 7 meters

34
Q

penetrating injuries

A

-stab
-gunshot
-shotgun

35
Q

head

A

-GCS < 14 get CT scan
-Epidural, subdural, diffuse axonal injury
-Subdurals have a worse prognosis
-Penetrating - plain films
-Entry wounds can be hidden

36
Q

what is MC injured structure in blunt chest trauma

A

Heart
Lung
Ribs
Diaphragm

37
Q

thoracic trauma

A

-Chest trauma is often sudden and dramatic
-Accounts for 25% of all trauma deaths
-2/3 of deaths occur after reaching hospital
-Serious pathological consequences: -hypoxia, hypovolemia, myocardial failure

38
Q

mechanism of injury: penetrating injuries

A

-stab wounds etc.
-Primarily peripheral lung
-Hemothorax
-Pneumothorax
-Cardiac, great vessel or esophageal injury

39
Q

blunt injuries

A

-Either: -direct blow (e.g. rib fracture)
-deceleration injury or
-compression injury
-Rib fracture is the most common sign of blunt thoracic trauma
-Fracture of scapula, sternum, or first rib suggests massive force of injury

40
Q

chest wall injuries

A

-rib fractures
-flail chest
-open pneumothorax

41
Q

rib fractures

A

-MC thoracic injury
-Localised pain, tenderness, crepitus
-CXR to exclude other injuries
-Analgesia..avoid taping
-Underestimation of effect
-Upper ribs, clavicle or scapula fracture: suspect vascular injury

42
Q

A 23-year-old man is brought to the ED after having fallen onto a construction barrier from a height of 15 feet. In the ED he has right chest ecchymosis, marked tenderness and paradoxical respirations are noted. The most likely diagnosis is?

A

Flail chest
Pnemothorax
Pulmonary contusion
Hemothorax
Cardiac tamponade

43
Q

in flail chest the most likely assoc injury is

A

Hemothorax
Pneumothorax
Cardiac tamponade
Pulmonary contusion

44
Q

flail chest

A

-multiple rib fractures produce a mobile fragment which moves paradoxically with respiration
-significant force required
-usually dx clinically
-rx- ABC
-analgesia

45
Q
A

flail chest

46
Q
A

flail chest

47
Q

open pneumothorax

A

-Defect in chest wall provides a direct communication between the pleural space and the environment
-Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax
-“Sucking chest wound”
-Rx: ABCs…closure of wound…chest drain

48
Q
A
49
Q

what is your dx based on the previous slide

A

Cardiomegaly
Cardiac tamponade
Pnemothorax
Hemothorax
Ruptured diaphragm

50
Q

lung injury

A

-Pulmonary contusion
-Pneumothorax
-Hemothorax
-Parenchymal injury
-Trachea and bronchial injuries
-Pneumomediastinum

51
Q

pneumothorax

A

-Air in the pleural cavity
-Blunt or penetrating injury that disrupts the parietal or visceral pleura
-Unilateral signs: movement and breath sounds, resonant to percussion
-Confirmed by CXR
-Rx: chest drain

52
Q
A

pneumothorax

53
Q

A 45-year-old male is in the ICU on a ventilator when he suddenly develops desaturation, increasing airway pressures, and difficulty ventilating with an Ambu bag off of the ventilator. Exam reveals absent breath sounds on the left with shift of the trachea to the right and hypotension. The next most appropriate step in his management would be?

A

Chest tube insertion on the right
Pericardiocentesis
Needle decompression of the left thorax
Increase PEEP and tidal volume

54
Q

tension pneumothorax

A

-Air enters pleural space and cannot escape
-P/C: chest pain, dyspnoea
-Dx: - respiratory distress -tracheal deviation (away)
-absence of breath sounds
-distended neck veins
-hypotension

-Surgical emergency
-Rx: emergency decompression before CXR
-Either large bore cannula in 2nd ICS, MCL or insert chest tube
-CXR to confirm site of insertion

55
Q

hemothorax

A

-Blunt or penetrating trauma
-Requires rapid decompression and fluid resuscitation
-May require surgical intervention
-Clinically: hypovolemia absence of breath sounds dullness to percussion
-CXR may be confused with collapse

56
Q

heart, aorta, and diaphragm

A

-Blunt cardiac injury
-contusion
-ventricular, septal or valvular rupture

-Cardiac tamponade
-Ruptured thoracic aorta
-Diaphragmatic rupture

57
Q

cardiac tamponade

A

-Blood in the pericardial sac
-Most frequently penetrating injuries
-Shock, increase JVP, PEA, pulsus paradoxus

-Classically, Beck’s triad: -distended neck veins -
-muffled heart sounds
-hypotension

-Rx: Volume resuscitation Pericardiocentesis

58
Q
A

cardiac tamponade

59
Q

aortic rupture

A

-Usually blunt trauma involving deceleration forces
-~90% die within minutes
-MC site near ligamentum arteriosum
-Dx: clinical suspicion, CXR, aortography, contrast CT or TOE
-Rx: surgical…poor prognosis

60
Q
A

aortic rupture

61
Q

iatrogenic trauma

A

-NG tubes:
-coiling -
-endobronchial placement -
-pneumothorax

-Chest tubes:
-subcutaneous
-intraparenchymal
-intrafissural

-Central lines:
-neck
-coronary sinus -
-pneumothorax

62
Q
A

line in jugular vein

63
Q
A

misplaced NG tube

64
Q

thoracic trauma summary

A

-Common
-Serious
-Primary goal is to provide oxygen to vital organs
-Remember -Airway -
-Breathing -Circulation
-Be alert to change in clinical condition

Surgery (21 decks)

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