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A1-G Surg Note Trauma > Blunt Abdominal Trauma > Flashcards

Blunt Abdominal Trauma Flashcards

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1
Q

DPL remains an excellent tool for ?

A

for further workup of occult bowel injury or
when FAST is not available or has questionable findings.

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2
Q

Positive DPL

A

10 mL gross blood
Bacteria
> 100,000 red blood cell/ mm3
Bile
> 500 white blood cell/ mm3
Food particles
> 75 IU/ L amylase

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3
Q

index of suspicion for Bowel injury

A

predicated on mechanism of injury and physical exam findings

abdominal wall ecchymosis,
tattooing
seat belt sign

CT > extravasation of oral contrast or pneumoperitoneum, bowel wall thickening, stranding of the mesentery, or free fluid in the absence of solid organ injury.

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4
Q

Resuscitation edema may cause a hazy appearance around the head of the pancreas and duodenal c-loop

A

repeat CT scan with oral contrast and the injection of 300 to 500 mL bolus of air down the nasogastric tube to make pneumoperitoneum obvious.

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5
Q

Blunt Bowel Injury ct findings

A

Direct findings > extravasation of oral contrast and free air

Indirect findings > mesenteric hematoma or contrast blush, bowel wall edema, unexplained free fluid, “fat streaking,” and bowel loops that do not opacify with intravenous contrast.

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6
Q

a vascular blush in the leaves of the mesentery

A

indicative of active hemorrhage until proven otherwise

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7
Q

Free fluid in the absence of solid organ injury

A

further evaluated with DPL or diagnostic peritoneal aspiration (DPA)

if the abdominal exam is unreliable

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8
Q

nondestructive wounds Small bowel

A

Grade 1 and 2 , managed with debridement and primary-suture enterorrhaphy

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9
Q

Destructive wounds

A

Grade 3 to 4 , resection of an entire segment of the bowel

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10
Q

relative contraindication to definitive repair

A

An interval from injury to repair greater than 12 hours if there is widespread (greater than one quadrant) fecal contamination.

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11
Q

AIDS and cirrhosis

A

these patients may be better off with the establishment of an ostomy.

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12
Q

How can larger wounds contributing to ongoing soiling be temporarily controlled?

A

controlled with a “whip stitch” (quick running suture) or Babcock clamps

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13
Q

What should be done after identifying mesenteric injuries?

A

Active bleeding should be controlled appropriately

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14
Q

In mesenteric injuries encroaching on the root of the mesentery, what specific area should attention be directed to?

A

The location of the superior mesenteric artery

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15
Q

What should be done with mesenteric hematomas?

A

Mesenteric hematomas should be explored with ligation of injured vessels, and mesenteric defects should be closed by careful reapproximation of the peritoneal edges

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16
Q

How should mesenteric defects be closed to avoid compromising vasculature?

A

By carefully reapproximating the peritoneal edges without compromising associated vasculature

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17
Q

What should be noted in relation to any mesenteric injury?

A

Bowel viability.

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18
Q

How can clusters of grade I and II injuries be managed?

A

They may be resected or individually repaired

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19
Q

How should small, superficial grade I bowel injuries be managed?

A

They can be left alone without intervention

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20
Q

How should deeper, longer grade I bowel injuries be closed?

A

They can be closed with a simple running suture or interrupted Lembert sutures

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21
Q

What is the appropriate management for grade II bowel wounds?

A

They should be debrided back to healthy, viable bowel and closed transversely to prevent narrowing of the lumen.

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22
Q

What type of closure is generally sufficient for repair of small bowel wounds?

A

A single-layer running or interrupted closure is generally sufficient.

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23
Q

When might a two-layer closure be preferential for bowel repair?

A

When there is significant bowel wall edema, peritonitis, or soiling

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24
Q

How is a two-layer closure typically performed?

A

A running inner layer and an interrupted Lembert outer layer are used

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25
How should grade I colon wounds be managed?
Grade I colon wounds may be managed with single-layer closure
26
What is the recommended closure method for grade II colon wounds?
Grade II colon wounds should be closed in two layers for added protection
27
What is Kehr's sign?
Referred pain to the left shoulder on deep inspiration in the presence of a splenic hematoma
28
What factors increase the risk of failure in nonoperative management of splenic injuries?
Higher AAST splenic injury grade, age greater than 55 years, moderate to large hemoperitoneum, subcapsular hematoma, and portal hypertension.
29
Why do patients with a splenic subcapsular hematoma or a history of portal hypertension require special consideration in splenic injury management?
These patients are at increased risk for delayed rupture 6 to 8 days following injury, often after hospital discharge
30
Why is splenic embolization not very effective for treating a splenic subcapsular hematoma?
It usually necessitates coiling of the main splenic artery, which can lead to significant pain and abscess formation
31
What must be carefully weighed when considering laparotomy in patients with Child-Pugh B or C cirrhosis?
The general risks of laparotomy must be weighed against the risk of worsening coagulopathy in these patients.
32
When might splenic artery embolization be dictated in patients with portal hypertension or cirrhosis?
It may be required when balancing the risks of laparotomy with the potential for worsening coagulopathy
33
How quickly do lower-grade (I, II) splenic injuries tend to heal?
Lower-grade injuries tend to heal more quickly, and almost all are healed by 5 to 6 weeks.
34
What percentage of blunt splenic injuries may not show complete healing?
Approximately 20% of blunt splenic injuries may not show complete healing
35
What is the risk associated with splenic injuries that do not heal completely?
They may be at risk for pseudocyst formation.
36
When should a CT scan be repeated for grade I and II splenic injuries?
CT scan should be repeated in 6 weeks for grades I and II injuries
37
When should a CT scan be repeated for grades III to V splenic injuries?
CT scan should be repeated in 10 to 12 weeks for grades III to V injuries
38
When can patients with splenic injuries return to normal activity?
After a follow-up CT scan shows complete healing, typically after 6 weeks for grades I and II, and 10 to 12 weeks for grades III to V injuries
39
What type of patients may be candidates for splenic preservation during laparotomy?
Hemodynamically stable patients with small to moderate amounts of parenchymal hemorrhage.
40
What factors influence the decision to resect a portion of the spleen during surgery?
Resection may be necessary if the parenchymal injury extends into the hilum or if arterial bleeding is present within the splenic laceration
41
How is parenchymal resection performed?
The parenchyma is divided with cautery, and the associated hilar vessels are taken with clamps and ties.
42
What technique is used to reinforce the remaining splenic tissue after partial resection?
A tongue of omentum is sutured into the laceration or onto the raw surface of the remaining spleen.
43
What percentage of the spleen is required to preserve adequate phagocytic and immunologic function?
Approximately 50% of the spleen is required
44
What is the reported incidence of overwhelming post-splenectomy infection (OPSI) in adult patients undergoing splenectomy for all causes?
The incidence is 0.9%, with a mortality of 0.8%
45
What is the recommended prophylactic penicillin V regimen for children after splenectomy?
125 mg twice daily until 3 years of age, then 250 mg twice daily until 5 years of age
46
Where do most blunt liver lacerations occur?
They tend to occur along segmental fissures
47
Why are vascular and biliary duct structures less likely to be damaged in blunt liver trauma?
These structures are moderately shear resistant
48
How are most grade I and II liver injuries managed during surgery?
They usually require simple suture repair.
49
What is the management approach for grades III, IV, and V liver injuries?
An organized approach, including manual compression, direct ligation, or clipping of lacerated vessels
50
How long can a noncrushing or vascular clamp safely be applied to the porta hepatis during the Pringle maneuver?
It can be safely left in place for approximately 45 minutes, though the exact threshold for hemodynamically unstable patients is unknown.
51
What technique is used by the operating surgeon to separate liver parenchyma during hepatotomy?
The surgeon uses fingertips or the handle of a scalpel to separate the liver parenchyma, while severed vessels are ligated.
52
What tools are used for vessel ligation during hepatotomy?
A multiple loaded clip applier or nonabsorbable suture ligation is used to control vessels as they are encountered
53
Why is knowledge of liver anatomy essential during hepatotomy?
To avoid injuring critical structures such as the confluence of the left and middle hepatic veins, and to prevent damaging the inferior vena cava and the hepatic veins near the caudate lobe
54
What does persistent hepatic bleeding despite the Pringle maneuver indicate?
It may indicate that the source of the bleeding has not been adequately identified or the patient is experiencing coagulopathic bleeding.
55
What surgical technique should be in a surgeon’s armamentarium when dealing with penetrating hepatic injuries?
The ability to perform a tractotomy of a missile wound.
56
What material was described by Bluett et al. for tamponade of a bleeding missile tract in the liver?
A tamponade device using multiple Penrose drains dragged through the liver tract
57
What is the preferred method to control bleeding from a missile wound in the liver?
Opening the liver and directly suturing or clipping the bleeding site, if possible
58
What is resectional debridement in the context of liver injury?
It involves completing the injury to remove nonviable hepatic tissue and facilitating vascular control, often using the finger-fracture technique
59
What is a useful homeostatic agent for persistent oozing from the raw surface of the liver after injury?
A viable omental patch sutured to the liver bed, as described by Stone and Lamb.
60
What device is used to address bleeding from raw liver surfaces by forming an eschar?
The argon beam coagulator, which ionizes energy and reaches temperatures up to 110°C
61
What alternative to surgical repair of the liver can be used to control bleeding and close parenchymal defects?
A mesh wrap, which provides compression and aids in the restoration of liver architecture
62
When should perihepatic packing be considered in liver injury management?
When a patient has severe injuries, hypothermia, coagulopathy, acidosis, or requires a 10-unit blood transfusion.
63
What is the purpose of silo-like closures with sterile towels and plastic drapes?
To minimize fluid loss and maintain abdominal pressure.
64
What condition should be monitored for after liver packing?
Intraabdominal compartment syndrome
65
What is a significant complication of liver packing?
An increased incidence of sepsis
66
What is an additional benefit of liver packing in critically ill patients?
It allows transport to the angiography suite for angioembolization or transfer to another center for definitive liver injury treatment.
67
What is the anatomical location of the juxtahepatic vena cava?
It is located within the bare area of the liver, extending for approximately 7 cm, bordered by the phrenic veins cephalad (above) and the right adrenal vein caudad (below)
68
How are juxtahepatic injuries classified?
They are classified as type A (intraparenchymal hepatic venous wounds) and type B (extraparenchymal venous wounds)
69
Which additional injuries are more commonly associated with type A juxtahepatic injuries?
Injuries to the portal vein and its tributaries are more common with type A wounds
70
What are the three operative approaches in the management of juxtahepatic venous injuries?
1) Direct repair of the venous wounds, (2) Surgical resection, and (3) Pressure application (containment/tamponade measures)
71
What is the paramount principle in establishing vascular isolation during surgery for juxtahepatic venous injuries?
Obtaining proximal and distal control of all vessels to totally isolate the liver.
72
What does the Heaney maneuver advocate in addressing juxtahepatic venous injuries?
more expedient approach to achieve vascular isolation during surgery Pringle + Suprahepatic and infrahepatic IVC
73
What is an alternative method for achieving vascular isolation in retrohepatic wounds?
venovenous bypass, which involves cannulation of the femoral vein and axillary vein, connected with heparin-coated tubing and assisted by a centrifugal pump
74
What is required for a venovenous bypass during surgery?
Both suprahepatic and intrahepatic clamps are necessary.
75
Why has tamponade with containment followed by angiography and possible embolization become a viable option for managing juxtahepatic venous injuries?
Due to the inherent and overwhelming risks of surgical management for these complex injuries.
76
What is the “nonshunting approach” described by Pachter et al. for managing juxtahepatic venous injuries?
It consists of four components: Manual compression and aggressive fluid resuscitation Prolonged portal triad occlusion (mean time 46 minutes) Rapid and extensive finger fracture through normal hepatic parenchyma to the injury site Wide mobilization of hepatic attachments with medial rotation of the liver for access to the retrohepatic cava and hepatic vein.
77
What is the reported mortality rate for patients subjected to ligation of the portal vein?
The mortality rate is as high as 90%
78
When is repair of the portal vein preferable to ligation?
Repair is preferable when the injury is less than 25% circumferential, as it is associated with increased survivability.
79
What procedure has been advocated after portal vein ligation to check for bowel viability?
A second-look laparotomy to assess bowel viability
80
How are partial circumferential bile duct injuries typically treated?
They can be treated by primary repair
81
What is the recommended treatment for complex or complete bile duct disruption?
These injuries are best managed by biliary-enteric anastomosis.
82
Why is end-to-end anastomosis not recommended for bile duct injuries?
It has an excessive stenosis rate.
83
What approach can be used in an unstable patient with a bile duct injury before full biliary reconstruction?
Stenting and external drainage can be used, with biliary reconstruction performed later.
84
What diagnostic test is best for investigating bile duct injuries during surgery?
An intraoperative cholangiogram is best for diagnosing bile duct injuries
85
What is the management option for a missed bile duct injury that results in a biloma?
An endoscopic retrograde cholangiopancreatogram (ERCP) with stenting may be used for both diagnosis and treatment
86
When should laparoscopy be considered in trauma patients?
without an indication for trauma laparotomy but where there is concern for unidentified bowel, mesenteric, or diaphragmatic injury.

A1-G Surg Note Trauma (26 decks)

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