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06 - absite > Chapter 15: Trauma > Flashcards

Chapter 15: Trauma Flashcards

1
Q

First peak for trauma deaths (0-30 minutes)

A

Deaths due to lacerations of heart, aorta, brain, brainstem, or spinal cord; cannot really save these patients; death is too quick.

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2
Q

Second peak for trauma deaths (30 minutes-4 hours)

A

Deaths due to head injury (#1) and hemorrhage (#2); these patients can be saved with rapid assessment (golden hour)

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3
Q

Third peak for trauma deaths (Days to weeks)

A

Deaths due to multi system organ failure and sepsis

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4
Q

80% of all trauma

A

Blunt injury

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5
Q

Most commonly injured organ in blunt trauma

A

Liver

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6
Q

Falls: biggest predictors of survival

A

Age and body orientation.

LD50 is 4 stories

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7
Q

MC’ly injured organ in penetrating injury

A

Small bowel

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8
Q

MCC death in 1st hour

A

Hemorrhage

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9
Q

When is blood pressure affected in hemorrhage?

A

30% of total blood volume lost

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10
Q

How do you resuscitate hemorrhage?

A

2L Lactated Ringers, then switch to blood

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11
Q

MCC death after reaching the ER alive

A

Head injury

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12
Q

MCC upper airway obstruction -> perform jaw thrust

A

Tongue

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13
Q

Injuries: seat belts

A

Small bowel perforations, lumbar spine fractures, sternal fractures

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14
Q

Best site for cutdown for venous access

A

Saphenous vein at ankle

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15
Q
  • Used in hypotensive patients with blunt trauma

- Need laparotomy if DPL is positive

A

DPL

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16
Q

Criteria: positive DPL

A

> 10 cc blood, > 100,000 RBCs/cc, food particles, bile, bacteria, > 500 WBC/cc

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17
Q

What does a DPL miss?

A

Retroperitoneal bleeds, contained hematoma

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18
Q

DPL for pelvic fracture

A

Needs to be supra umbilical

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19
Q

What does FAST stand for?

A

Focused abdominal sonography for trauma

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20
Q

Where does FAST scan check?

A

Perihepatic fossa
Perisplenic fossa
Pelvis
Pericardium

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21
Q

Disadvantages of FAST scan

A
  • Examiner dependent
  • Obesity can obstruct view
  • May not detect free fluid
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22
Q

What does FAST scan miss?

A

Retroperitoneal bleeding, hollow viscous injury

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23
Q

Hypotensive patients: negative FAST scan, negative DPL. What to do?

A

Find the source of bleeding (pelvic fracture, chest, extremity)

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24
Q

When do you need a CT scan following blunt trauma?

A
  • Abdominal pain
  • Need for general anesthesia
  • Closed head injury
  • Intoxicants on board
  • Paraplegia
  • Distracting injury
  • Hematuria
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25
Q

What can a CT scan miss?

A

hollow viscous injury, diaphragm injury

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26
Q

When do you need laparotomy?

A

Peritonitis. Evisceration. Positive DPL. Uncontrolled visceral hemorrhage. Free air. Diaphragm injury. Intraperitoneal bladder injury. Contrast extravasation from hollow viscus. Specific renal, pancreas, and biliary tract injuries.

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27
Q

Tx: penetrating abdominal injury (eg, GSW)

A

Generally need laparotomy

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28
Q

Tx: possible penetrating abdominal injuries (knife or low-velocity injuries)

A

Local exploration and observation if fascia not violated

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29
Q
  • Occurs after massive fluid resuscitation, trauma, or abdominal surgery
  • IVC compression is the final common pathway for decreased cardiac output.
  • Upward displacement of diaphragm affects ventilation
A

Abdominal compartment syndrome

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30
Q

Bladder pressure suggesting abdominal compartment syndrome

A

> 25-30

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31
Q

Tx: abdominal compartment syndrome

A

Decompressive laparotomy

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32
Q

Low cardiac output in abdominal compartment syndrome causes..

A

Visceral and renal malperfusion

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33
Q
  • Controversial

- Use in patients with SBP

A

Pneumatic antishock garment

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34
Q

ER thoractomy: blunt trauma

A

Use only if pressure / pulse lost in ER

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35
Q

ER: thoracotomy: penetrating trauma

A

Use only if pressure / pulse lost on way to ER or in ER

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36
Q

Location for emergency department thoracotomy

A

Fourth and fifth intercostal space using the anterolateral approach

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37
Q

Abdominal injury: emergent thoracotomy

A

Clamp descending thoracic aorta:

  • Blood pressure increase to > 70mmHg -> laparotomy
  • Blood pressure
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38
Q

Cardiac injury: emergent thoracotomy

A

Open pericardium longitudinally anterior to phrenic nerve, cross clamp the aorta, watch for the esophagus (anterior to the aorta)

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39
Q

Peak 24-48 hours after injury

A

Catecholamines, ADH, ACTH, and glucagon

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40
Q
  • Contains no A or B antigens
  • Males can receive Rh-positive blood
  • Females who are prepubescent or of childbearing age should receive Rh-negative blood
A

Type O Blood (universal donor)

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41
Q

Can be administered relatively safely, but there may be effects from antibodies to HLA minor antigens in the donated blood

A

Type-specific blood (nonscreened, non-cross matched)

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42
Q

Tx - GCS score:

A
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43
Q

Indications for head CT

A
  • Suspected skull penetration by a foreign body
  • Discharge of CSF, blood, or both from the nose
  • Hemotympanum or discharge of blood or CSF from ear
  • Head injury with alcohol or drug intoxication
  • AMS, protracted unconsciousness
  • Focal neurologic s/s
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44
Q

Most commonly due to arterial bleeding from the middle meningeal artery

A

Epidural hematoma

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45
Q

Epidural hematoma: head CT

A

Shows lenticular (lens-shaped) deformity

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46
Q

Patients often have LOC -> then lucid interval -> then sudden deterioration (vomiting, restlessness, LOC)

A

Epidural hematoma

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47
Q

When do you operate for epidural hematoma?

A

Significant neurologic degeneration or significant mass effect (shift > 5mm)

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48
Q

Mostly commonly from tearing of venous plexus (bridging veins) that cross between the dura and arachnoid

A

Subdural hematoma

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49
Q

Subdural hematoma: head CT

A

Crescent-shaped deformity

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50
Q

When do you operate for subdural hematoma?

A

Significant neurologic degeneration or mass effect (> 1 cm)

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51
Q

Where are common location for intracerebral hematoma?

A
  • Usually frontal or temporal

- Can cause significant mass effect requiring operation

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52
Q

Can be croup or contrecoup

A

Cerebral contusions

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53
Q

Tx: traumatic intraventricular hemorrhage causing hydrocephalus

A

Ventriculostomy

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54
Q

Shows up better on MRI than CT scan

  • Tx: supportive, may need craniectomy if ICP elevated
  • Very poor prognosis
A

Diffuse axonal injury

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55
Q

Equation: Cerebral perfusion pressure

A

CPP = MAP - ICP

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56
Q

Signs of elevated ICP

A

Decreased ventricular size, loss of sulci, loss of cisterns

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57
Q

Indications for ICP monitors

A
  • GCS
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58
Q

Supportive treatment for elevated ICP

A
  • Sedation and paralysis
  • Raise head of bed
  • Relative hyperventilation
  • Na 140-150, serum Osm 295-310
  • Mannitol, Barbiturate coma
  • Ventriculostomy w CSF drainage, craniotomy decompression
  • Fosphenytoin / Keppra
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59
Q

What is relative hyperventilation for elevated ICP?

A

CO2 30-35. Do not want to over-hyperventilate and cause cerebral ischemia from too much vasoconstriction.

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60
Q

Dose mannitol for elevated ICP

A

Load 1 g/kg. Give 0.25 mg/kg q4h after that.

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61
Q

When do you consider barbiturate coma for elevated ICP?

A

If noninvasive supportive treatment is failing.

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62
Q

When do you consider craniotomy decompression for elevated ICP?

A

If not able to get ICP down medically (can also perform Burr hole)

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63
Q

Can be given prophylactically to prevent seizures with moderate to severe head injury

A

Fosphenytoin or Keppra

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64
Q

When does peak ICP occur after head injury?

A

Occurs 48-72 hours after injury.

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65
Q

What is normal ICP?

A

10.

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66
Q

When do you treat elevated ICP? Goal CPP?

A

Treat ICP > 20.

Goal CPP > 60.

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67
Q

Dx: dilated pupil with elevated ICP.

A

Temporal pressure on the same side (CN 3, oculomotor, compression)

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68
Q

Physical signs: basal skull fracture

A
  • Raccoon eyes (peri-orbital ecchymosis): anterior fossa fracture
  • Battle’s sign (mastoid ecchymosis) : middle fossa fracture, can injury facial nerve.
  • Hemotympanum and CSF rhinorrhea / otorrhea
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69
Q

Acute vs delayed facial nerve injury with basal skull fractures

A
  • Acute: exploration and repair.

- Delayed: likely secondary to edema and exploration not needed.

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70
Q

What nerves are at risk with temporal skull fractures?

A

Can injure CN 7 and 8 (vestibulococlear nerve)

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71
Q

MC site of facial nerve injury

A

Geniculate ganglion

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72
Q

MC’ly associated with lateral skull or orbital blows

A

Temporal skull fractures

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73
Q

Most skull fractures _____ surgical treatment.

A

Most skull fractures do not require surgical treatment.

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74
Q

Indications for operation of skull fractures.

A

Significant depression (>1cm). Contaminated. Persistent CSF leak not responding to conservative therapy.

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75
Q

Tx: CSF leaks after skull fracture.

A

Treat expectantly, can use lumbar CSF drainage if persistent.

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76
Q

What causes coagulopathy with traumatic brain injury?

A

Release of tissue factor.

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77
Q

Caused by axial loading.

- Tx: rigid collar.

A

C-1 burst (Jefferson fracture).

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78
Q

Caused by distraction and extension.

- Tx: traction and halo.

A

C-2 Hangman’s fracture.

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79
Q

Classification: C-2 odontoid fracture.

A

Type 1: Above base, stable
Type 2: at base, unstable (will need fusion or halo)
Type 3: Extends into vertebral body (will need fusion or halo)

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80
Q
  • Can cause cord injury

- Usually associated with hyperextension and rotation with ligamentous disruption.

A

Facet fractures or dislocations.

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81
Q

Three columns of the thoracolumbar spine.

A
  • Anterior: anterior longitudinal ligament and anterior 1/2 of vertebral body.
  • Middle: posterior 1/2 of vertebral body and posterior longitudinal ligament.
  • Posterior: facet joints, lamina, spinous processes, interspinous ligament.
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82
Q

When is thoracolumbar spine considered unstable?

A

If more than 1 column is disrupted.

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83
Q

Thoracolumbar: fractures usually involve the anterior column only and are considered stable.

A

Compression (wedge) fractures

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84
Q

Thoracolumbar: fractures considered unstable (>1 column) and require spinal fusion

A

Burst fractures

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85
Q

Upright fall: at risk for injury

A

Calcaneus, lumbar, and wrist/forearm fractures.

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86
Q

When do you need MRI in spinal trauma?

A

Neurologic deficits without bony injury to check for ligamentous injury.

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87
Q

Indications for emergent surgical spine decompression

A
  • Fracture or dislocation not reducible with distraction
  • Open fractures
  • Soft tissue or bony compression of the cord
  • Progressive neurologic dysfunction
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88
Q

MCC facial nerve injury

A

Temporal bone fracture

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89
Q

Goal with facial lacerations

A

Try to preserve skin and not trim edges with facial lacerations

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90
Q

LeFort Type 1?

Tx?

A

Maxillary fracture straight across (-)

- Tx: reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires.

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91
Q

LeFort Type 2?

Tx?

A

Lateral to nasal bone, underneath eyes, diagonal toward maxilla (/ )
- Tx: reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires.

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92
Q

LeFort Type 3?

Tx?

A

Lateral orbital walls (- -)

Tx: suspension wiring to stable frontal bone, may need external fixation.

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93
Q
  • 70% have CSF leak
  • Conservative therapy for up to 2 weeks.
  • Can try epidural catheter to decrease CSF pressure and help it close CSF leak
  • May need surgical closure of dura to stop leak
A

Nasoethmoidal orbital fractures

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94
Q

Nosebleeds - anterior: Tx?

A

Packing

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95
Q

Nosebleeds - posterior: Tx?

A

Can be hard to deal with; try balloon tamponade first.

- May need angioembolization of internal maxillary artery or ethmoidal artery.

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96
Q

Tx: orbital blowout fractures

A

Patients with impaired upward gaze or diplopia with upward vision need repair; perform restoration of orbital floor with bone fragments or bone graft

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97
Q

1 indication of mandibular injury

A

Malocclusion

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98
Q

Dx / Tx: mandibular injury

A
  • Dx: fine-cut facial CT scans with reconstruction to assess injury
  • Tx: Most repaired with IMF (metal arch bars to upper and lower dental arches, 6-8 weeks) or ORIF
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99
Q

Tx: tripod fracture (zygomatic bone)

A

ORIF for cosmesis

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100
Q

What do you need to look for with maxillofacial fractures?

A

Cervical spine injuries

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101
Q

What to do: asymptomatic blunt neck trauma

A

Neck CT scan

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102
Q

What to do: asymptomatic penetrating neck trauma

A

Controversial

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103
Q

Neck zone 1: penetrating injury

A

Zone: clavicle to cricoid cartilage

  • Need angiography, bronchoscopy, esophagoscopy and barium swallow. Pericardial window may be indicated.
  • May need median sternotomy to reach these lesions.
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104
Q

Neck zone 2: penetrating injury

A

Zone: cricoid to angle of mandible.

- Need neck exploration in OR.

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105
Q

Neck zone 3: penetrating injury

A

Zone: angle of mandible to base of skull.

  • Need angiography and laryngoscopy.
  • May need jaw subluzation / digastric and SCM release / mastoid sinus resection to reach vascular injuries in this location.
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106
Q

Important implication of a zone one injury

A

Greater potential for intrathoracic great vessel injury

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107
Q

Tx: symptomatic blunt of penetrating neck trauma

A

All need neck exploration. (Shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit)

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108
Q

Hardest neck injury to find

A

Esophageal injury

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109
Q

Best combined modality to identify esophageal injury

A

Esophagoscopy and esophagogram. (Find essentially 95% of injuries when using both methods).

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110
Q

Tx: contained esophageal injury

A

Observation

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111
Q

Tx: non contained esophageal injury

  • Small / minimal contamination
  • Extensive / contamination
A
  • Small / minimal contamination: primary closure
  • Extensive / contamination: Neck (place drains - will heal). Chest (Chest tube to drain injury and place spit fistula in neck - will eventually need esophagectomy)
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112
Q

What do you always drain esophageal and hypo pharyngeal repairs?

A

20% leak rate

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113
Q

Approach to esophageal injuries:

  • Neck
  • Upper 2/3 thoracic esophagus
  • Lower 2/3 thoracic esophagus
A
  • Neck: left side
  • Upper 2/3 thoracic esophagus: right thoracotomy
  • Lower 1/3 thoracic esophagus: left thoracotomy
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114
Q

These injuries are airway emergencies

A

Laryngeal fracture and tracheal injuries.

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115
Q

Symptoms: laryngeal fracture / tracheal injury

A

Crepitus, stridor, respiratory compromise

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116
Q

Tx: laryngeal fracture and tracheal injury

A

Tx: primary repair, can use strap muscle for airway support; tracheostomy necessary for most to allow edema to subside and to check for stricture (need to convert cricothyroidotomy to tracheostomy)

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117
Q

Tx: thyroid gland injury

A

Control bleeding and drain (not thyroidectomy)

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118
Q

Tx: recurrent laryngeal nerve injury

A

Can try to repair or can reimplant in cricoarytenoid muscle (sx - hoarseness)

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119
Q

Tx: shotgun injuries to neck

A

Need angiogram and neck CT; esophagus / trachea evaluation

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120
Q

Tx: vertebral artery bleeds

A

Can embolize or ligate without sequela in majority

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121
Q

Ligation will cause stroke in 20%

A

Common carotid bleeds

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122
Q

Chest trauma: chest tube output relative indications for thoracotomy in OR

A
  • > 1,500 cc after initial insertion
  • > 250 cc/h for 3 hours
  • > 2,500 cc/24h
  • Bleeding with instability
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123
Q

Why do you need to completely drain hemothorax in

A

To prevent fibrothorax, pulmonary entrapment, infected hemothorax

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124
Q

Tx: unresolved hemothorax after 2 well-placed chest tubes

A

Thoracoscopic drainage

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125
Q

What is considered a significant sucking chest wound (open pneumothorax)?

A

Needs to be at least 2/3 the diameter of the trachea to be significant

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126
Q

Tx: sucking chest wound (open pneumothorax)?

A

Cover wound with dressing that has tape on three sides -> prevents development of tension pneumothorax while allowing the lung to expand with inspiration.

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127
Q
  • Pt may have worse oxygenation after chest tube placement.
  • One of very few indications in which clamping the chest tube may be indicated.
  • May need to mainstem intubate patient on unaffected side.
A

Tracheobronchial injury

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128
Q

Bronchus injuries are more common on the ___

A

Right.

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129
Q

Dx / Tx: tracheobronchial injury

A

Dx: Bronchoscopy
Tx: repair if large air leak and respiratory compromise or after 2 weeks of persistent air leak

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130
Q

Trachebronchial injury: indications for right thoracotomy

A

Right mainstem, trachea, and proximal left mainstem injuries (avoids the aorta)

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131
Q

Tracheobronchial injury: indications for left thoracotomy

A

Distal left mainstem injuries

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132
Q

Diaphragmatic injuries: mechanism and location

A

Injuries are most likely to be found on left and to result from blunt trauma

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133
Q

CXR: air-fluid level in chest from stomach herniation through hole (diagnosis can be made essentially with CXR)

A

Diaphragmatic injuries

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134
Q

Tx: diaphragmatic injury

A

Chest approach if > 1 week (need to take down adhesions in the chest)
- May need mesh.

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135
Q

Widened mediastinum. 1st or 2nd rib fractures. Apical capping. Loss of aortopulmonary window. Loss of aortic contour. Left hemothorax. Trachea deviation to right.

A

S/S: aortic transection.

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136
Q

Where is the tear of aortic transection located?

A

Usually at the ligamentum arteriosum (just distal to subclavian takeoff). Other areas include near the aortic valve and where the aorta traverses the diaphragm.

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137
Q

Can you trust a chest XR when ruling out aortic transection?

A

CXR normal in 5% of patients with aortic tears. Need aortic evaluation in pts with significant mechanism (head on car crash > 45mph, fall > 15ft)

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138
Q

Dx: aortic transection

A

CT angiogram of chest

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139
Q

Operative approach: aortic transection

A

Left thoracotomy and repair with partial left heart bypass or place a covered stent endograft (distal transections only)

140
Q

What is extremely important when approaching a patient with aortic transection?

A

You need to treat life-threatening injuries first: patient with positive DPL or other life-threatening injury needs to have that addressed before the aortic transection.

141
Q

Approach for specific injuries: ascending aorta, innominate artery, proximal right subclavian artery, innominate vein, proximal left common carotid

A

Median sternotomy

142
Q

Approach for specific injuries: left subclavian artery, descending aorta

A

Left thoracotomy

143
Q

Approach for specific injuries: midclavicular incision, resection of medial clavicle

A

Distal right subclavian artery

144
Q

MCC death myocardial contusion

A

V-tach and V-fib

- Risk highest in first 24 hours

145
Q

MC arrhythmia overall in patients with myocardial contusion

A

Supra-ventricular tachycardia

146
Q

Why monitor a myocardial contusion for 24-48 hours?

A

Arrhythmia is the most common cause of death with the highest risk in the first 24 hours.

147
Q

Definition: flail chest.

A

> 2 consecutive ribs broken at > 2 sites. Results in paradoxical motion.

148
Q

Biggest pulmonary impairment in flail chest

A

Underlying pulmonary contusion.

149
Q

May not produce CXR findings immediately

A

Aspiration

150
Q

Workup: penetrating chest injury

A

Start with a CXR if the patient is stable (place chest tube for pneumothorax or hemothorax)

151
Q

Borders of penetrating “box” injuries in chest trauma

A

Clavicles, xiphoid process, nipples

152
Q

Workup: penetrating “box” injuries

A

Need pericardial window, bronchoscopy, esophagoscopy, barium swallow

153
Q

Tx: penetrating chest wound outside “box” without pneumo or hemothorax

A

Need chest tube if patient requires intubation. Otherwise follow patient’s serial CXRs.

154
Q

What if you find blood in the pericardial window?

A

Need median sternotomy to fix possible injury to heart or great vessels; place pericardial drain.

155
Q

Workup: penetrating injuries anterior-medial to midaxillary line and below nipples.

A
  • Need laparotomy or laparoscopy.

- May also need evaluation for penetrating “box” injury depending on the exact location.

156
Q

Traumatic causes of cariogenic shock

A

Cardiac tamponade
Cardiac contusion
Tension pneumothorax

157
Q

One way valve effect causes air entry and pressure build up

A

Tension pneumothorax

158
Q

Hypotension, increased airway pressures, decreased breath sounds, bulging neck veins, tracheal shift. Can see bulging diaphragm during laparotomy.
- Tx: chest tube

A

Tension pneumothorax

159
Q

What causes cardiac compromise in tension pneumothorax?

A

Decreased venous return (IVC, SVC compression)

160
Q

High risk injury in sternal fractures

A

Cardiac contusion

161
Q

1st and 2nd rib fractures are high risk for?

A

Aortic transection

162
Q

What is pulmonary tractotomy?

A

Dividing the pulmonary parenchyma between adjacent staple lines permits rapid access to injured vessels or bronchi along the tract of penetrating injury.

163
Q

Significance of pelvic fractures

A

Can be a major source of blood loss

164
Q

If hemodynamically unstable with pelvic fracture and negative DPL, negative CXR and no other signs of blood loss or reasons for shock..what do you do?

A

Stabilize pelvis (C-clamp, external fixator or sheet) and go to angio for embolization.

165
Q

What injuries are associated with pelvic trauma?

A

High risk for genitourinary and abdominal injuries

166
Q

Type 1 pelvic fracture: unstable (crush)

  • Mortality
  • Blood loss
  • Complications
A
  • Mortality: 20-30%
  • Blood loss: > 10 units
  • Complications: 60-75%
167
Q

Type II Pelvic Fracture (Unstable)

  • Mortality
  • Blood loss
  • Complications
A
  • Mortality: 8-12%
  • Blood loss: 2-10 units
  • Complications: 30-50%
168
Q

Type III Pelvic Fracture (Stable)

  • Mortality
  • Blood loss
  • Complications
A
  • Mortality:
169
Q

Pelvic fractures: more likely to have venous bleeding

A

Anterior pelvic fractures

170
Q

Pelvic fractures: more likely to have arterial bleeding

A

Posterior pelvic fractures

171
Q

When would you need a colostomy in the setting of pelvic fractures?

A

May need colostomy for open pelvic fractures with rectal tears and perineal lacerations

172
Q

When do you delay pelvic fracture repair?

A

Until other associated injuries are repaired

173
Q

Tx: intra-op penetrating injury pelvic hematomas

A

Open (some suggest going to angiography for these)

174
Q

Tx: intra-op blunt injury pelvic hematomas

A

Leave, if expanding or patient unstable -> stabilize pelvic fracture, pack pelvis if in OR, and go to angiography for embolization; if packs are placed intra-op, remove after 24-48 hours when patient is stable.

175
Q

Usual cause of duodenal trauma

A

Usually from blunt trauma (crush or deceleration injury)

176
Q

MC area of duodenal injury

A

2nd portion of duodenum (descending portion, near ampulla of Vater)

177
Q

What ligament is associated with duodenal injury?

A

Tears near ligament of Treitz

178
Q

Most likely treatment of duodenal trauma

A

80% of injuries requiring surgery can be treated with debridement and primary closure

179
Q

Duodenal trauma: segmental resection with primary end-to-end closure is possible with all segments of the duodenum EXCEPT?

A

Second portion of the duodenum

180
Q

Why is there a 25% mortality rate in patients with duodenal trauma?

A

Associated shock

181
Q

Major source of morbidity in duodenal trauma

A

Fistulas

182
Q

Tx: intra-op paraduodenal hematoma

A

> / 2 cm considered significant

  • Usually in third portion of duodenum overlying spine in blunt injury
  • Need to open for both blunt and penetrating injuries
183
Q
  • Can present with high SBO 12-72 hours after injury
  • UGI study will show “stacked coins” or “coiled spring” appearance (make sure there is no extravasation of contrast)
  • Tx?
A

Dx: paraduodenal hematomas on CT scan (or missed on initial CT scan)

Tx: Conservative (NGT and TPN) -> cures 90% over 2-3 weeks (hematoma is reabsorbed)

184
Q

Surgical approach: duodenal trauma

A

Perform Kocher maneuver and open lesser sac through the omentum; check for hematoma, bile, success, and fat necrosis -> if found, need formal inspection of the entire duodenum (also need to check for pancreatic injury)

185
Q

Diagnosing suspected duodenal injury

A

Abdominal CT with contrast initially. UGI contrast study best. CT scan may show bowel wall thickening, hematoma, free air, contrast leak, or retroperitoneal fluid/air.

186
Q

Duodenal trauma: if CT scan is worrisome for injury but non diagnostic..

A

Can repeat the CT in 8-12 hours to see if the finding is getting worse.

187
Q

Surgical treatment: duodenal trauma

A

Try to get primary repair or anastomosis; may need to divert with pyloric exclusion and gastrojejunostomy to allow healing. Place a distal feeding jejunostomy and possibly a proximal draining jejunostomy tube that threads back to duodenal injury site. Place drains.

188
Q

Duodenal injury: if in 2nd portion of duodenum and can’t get primary repair.

A
  • Place jejunal serosal patch over hole; may need Whipple in future.
  • Need pyloric exclusion and gastrojejunostomy.
  • Consider feeding and draining jejunostomies; leave drains.
189
Q

Is trauma Whipple ever indicated?

A

RARELY. Very high mortality.

190
Q

When do you remove drains in duodenal trauma?

A

Remove drains when patient tolerating diet without an increase in drainage.

191
Q

Treatment: fistulas secondary to duodenal trauma.

A

Often close with time.

- Tx: bowel rest, TPN, octreotide, conservative management for 4-6 weeks.

192
Q

Most common organ injured with penetrating injury (some texts say liver)

A

Small bowel

193
Q

These injuries can be hard to diagnose early if associated with blunt trauma

A

Small bowel trauma

194
Q

Abdominal CT scan suggesting occult small bowel injury

A

Intra-abdominal fluid not associated with a solid organ injury, bowel wall thickening, or a mesenteric hematoma

195
Q

Imaging Management: occult small bowel trauma

A

Need close observation and possibly repeat abdominal CT after 8-12 hours or so to make sure finding is not getting worse.

196
Q

What do you need to make sure of before discharging a patient with non conclusive small bowel injury?

A

Need to make sure patients with non conclusive findings can tolerate a diet before discharge.

197
Q

What avoids stricture in small bowel trauma repair?

A

Repair lacerations transversely.

198
Q

Small bowel: large lacerations that are > 50% of the bowel circumference or results in lumen diameter

A

Perform resection and anastomosis

199
Q

Surgery small bowel: multiple close lacerations

A

Just resect that segment

200
Q

Surgery small bowel mesenteric hematomas

A

Open if expanding or large (> 2 cm)

201
Q

Colon trauma: most associated with what type of injury?

A

Most associated with penetrating injury

202
Q

Colon trauma surgery: right and transverse colon injuries

A

Perform primary repair / anastomosis

203
Q

Colon trauma surgery: left colon

A

Perform primary repair / anastomosis; place diverting ileostomy if patient is in shock or there is gross contamination

204
Q

Colon trauma surgery: paracolonic hematomas

A

Both blunt and penetrating need to be opened

205
Q

Rectal trauma: most associated with what type of injury?

A

Penetrating injury

206
Q

High rectal trauma: extarperitoneal repair

A

Generally not repaired because of inaccessibility.

  • Tx: serial debridement; consider diverting ileostomy.
  • Place diverting ileostomy with shock, gross contamination, or extensive injury.
207
Q

High rectal trauma: intraperitoneal repair

A

Tx: repair defect, presacral drainage, consider diverting ileostomy.
- Place diverting ileostomy with shock, gross contamination, or extensive injury.

208
Q

Low rectal trauma repair

A

(

209
Q

Most common organ injury with blunt abdominal trauma (some texts say spleen)

A

Liver

210
Q

Is lobectomy necessary in liver trauma?

A

Rarely.

211
Q

Common hepatic artery injury repair

A

Can be ligated with collateral through gastroduodenal artery

212
Q

Pringle maneuver?

A

Clamping portal triad. Does not stop bleeding from hepatic veins.

213
Q

Damage control peri-hepatic packing

A

Can pack severe penetrating liver injuries if patient becomes unstable in the OR and the injury is not easily fixed (e.g., retro-hepatic IVC injury). Go to the ICU and get the patient resuscitated and stabilized. Live to fight another day.

214
Q

For retrohepatic IVC injury, allows for control while performing repair

A

Atriocaval shunt

215
Q

Management: portal triad hematomas

A

Need to be explored

216
Q

Mgmt: Common bile duct injury:

- 50% circumference or complex injury?

A
  • 50% / complex: go with choledochojejunostomy

May need intraoperative cholangiogram to define injury.

217
Q

How many common bile duct injury anastomoses leak?

A

10% of duct anastomoses leak -> place drains intra-op.

218
Q

Surgical management: portal vein injury

A

Need to repair.

  • May need to transect through the pancreas to get the to the injury in the portal vein.
  • Will need to perform distal pancreatectomy with that maneuver.
  • Ligation of portal vein associated with 50% mortality.
219
Q

Mortality: ligation of portal vein

A

50% mortality.

220
Q

Can be placed in liver laceration to help with bleeding and prevent bile leaks

A

Omental graft

221
Q

Do you use drains with liver injury?

A

Yes, leave drains.

222
Q

When is conservative management of blunt liver injuries considered to have failed?

A

Has failed if patient becomes unstable despite aggressive resuscitation, including 4 units of PRBCs (HR 4 u PRBCs to keep Hct > 25. Go to OR.

223
Q

Surgical management: liver trauma - active blush on abdominal CT or pseudoaneurysm

A

Indication for OR

  • Posterior: may be better off going to angiogram (when in doubt -> OR)
  • Anterior: go to OR
224
Q

Liver trauma: conservative management requires how much time of bed rest?

A

5 days

225
Q

Spleen fully heals after..

A

6 weeks

226
Q

Greatest risk postsplenectomy sepsis

A

Within 2 years of splenectomy

227
Q

What is splenic salvage associated with?

A

Increased transfusions

228
Q

When is conservative management of blunt splenic injury considered to have failed?

A

If patient becomes unstable despite aggressive resuscitation, including 2 u of PRBCs (HR > 120 or SBP 2 u PRBCs to keep Hct > 25. Go to OR.

229
Q

Conservative management requires how many days of bed rest with splenic trauma

A

5 days bed rest

230
Q

Threshold for splenectomy in children

A

Is much higher; hardly any children undergo splenectomy

231
Q

Accounts for 80% of all pancreatic injuries

A

Penetrating injury

232
Q

How can blunt injury affect the pancreas?

A

Can result in pancreatic duct fractures, usually perpendicular to the duct.

233
Q

Usually indicative of pancreatic injury

A

Edema or necrosis of peripancreatic fat

234
Q

Tx: pancreatic contusion

A

Leave if stable, place drains if in OR

235
Q

Tx: distal pancreatic duct injury

A

Distal pancreatectomy, can take up to 80% of the gland

236
Q

Tx: pancreatic head duct injury that is not repairable

A

Place drains initially; delayed Whipple or possible ERCP with stent may eventually be necessary

237
Q

Pancreatic trauma: whipple vs distal pancreatectomy

A

Based on duct injury in relation to the SMV (superior mesenteric vein)

238
Q

Helps evaluate the pancreas operatively

A

Kocher maneuver

239
Q

Do you use drains with pancreatic injury?

A

Yes, leave drains with pancreatic injury.

240
Q

Tx: pancreatic hematoma

A

Both penetrating and blunt need to be opened.

241
Q

Persistent or rising amylase

A

May indicate missed pancreatic injury

242
Q

Are CT scans reliable for diagnosis of pancreatic injury?

A

CT scans poor at diagnosing pancreatic injuries initially. Delayed signs - fluid, edema, necrosis.

243
Q

Test: good at finding duct injuries in pancreatic trauma

A

ERCP good at finding duct injuries and may be able to treat with temporary stent

244
Q

Vascular trauma: vascular or orthopedic repair first?

A

Vascular repair (or vascular shunt) performed before orthopedic repair.

245
Q

Major signs of vascular injury

A

Active hemorrhage, pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill -> go to OR for exploration (may need angio in the OR to define injury)

246
Q

Moderate / soft signs of vascular injury

A

History of hemorrhage, deficit of anatomically related nerve, large stable / nonpulsatile hematoma, ABI go to angio.

247
Q

When do you need a saphenous vein graft?

A

If segment > 2 cm is missing. Use vein from the contralateral leg when fixing lower extremity arterial injuries.

248
Q

Vein injuries that need repair

A

Vena cava, femoral, popliteal, brachiocephalic, subclavian, and axillary

249
Q

Tx: transection of single artery in the calf in an otherwise healthy patient

A

Ligate

250
Q

How do you cover site of anastomosis in vascular trauma?

A

Cover site of anastomosis with viable tissue and muscle.

251
Q

When do you consider fasciotomy in vascular trauma?

A

Consider fasciotomy if ischemia > 4-6 hours (prevents compartment syndrome)

252
Q

When do you consider compartment syndrome?

A

Consider if compartment pressures are > 20 mmHg or if clinical exam suggests elevated pressures

253
Q

Late signs of compartment syndrome

A

Pain -> paresthesia -> anesthesia -> paralysis -> poikilothermia -> pulselessness (late finding)

254
Q

When does compartment syndrome most likely occur?

A

After supracondylar fractures, tibial fractures, crush injuries or other injuries that result in a disruption and then restoration of blood flow after 4-6 hours.
- Tx: fasciotomy

255
Q

Repair of IVC trauma

A

Primary repair if residual stenosis is

256
Q

How do you control IVC bleeding?

A

Bleeding of IVC best controlled with proximal and distal pressure, not clamps -> can tear it.

257
Q

How do you repair the posterior wall of the IVC?

A

Repair posterior wall injury through the anterior wall (may need to cut through the anterior IVC to get to posterior IVC injuries).

258
Q

How much blood can the femur lose?

A

> 2L blood

259
Q

What are considered orthopedic emergencies?

A
  • Pelvic fractures in unstable patients
  • Spine injury with deficit
  • Open fractures
  • Dislocations or fractures with vascular compromise
  • Compartment syndrome
260
Q

Ortho trauma: high risk for avascular necrosis

A

Femoral neck fractures

261
Q

Tx: long bone fracture or dislocations with loss of pulse (or weak pulse)

A

Tx: immediate reduction of fracture or dislocation and reassessment of pulse

262
Q

What if pulse does not return after reduction of long bone fracture?

A

Go to OR for vascular bypass or repair (may need angiography in OR to define injury)

263
Q

What if a weak pulse returns after reduction of long bone fracture?

A

Angiography

264
Q

Management: knee dislocations

A

All knee dislocations need to go to angiogram, unless pulse is absent, in which case you would just go to OR (may need angio in OR to define injury)

265
Q

What are upright falls associated with?

A

Calcaneus, lumbar, and distal forearm (radius / ulnar) fractures

266
Q

Associated injury: anterior shoulder dislocation

A

Axillary nerve

267
Q

Associated injury: Posterior shoulder dislocation

A

Axillary nerve

268
Q

Associated injury: proximal humerus fracture

A

Axillary nerve

269
Q

Associated injury: mid shaft humerus fracture (or spiral humerus fracture)

A

Radial nerve

270
Q

Associated injury: distal (supracondylar) humerus fracture

A

Brachial artery

271
Q

Associated injury: elbow dislocation

A

Brachial artery

272
Q

Associated injury: Distal radius fracture

A

Median nerve

273
Q

Associated injury: anterior hip dislocation

A

Femoral artery

274
Q

Associated injury: posterior hip dislocation

A

Sciatic nerve

275
Q

Associated injury: Distal (supracondylar) femur fracture

A

Popliteal artery

276
Q

Associated injury: posterior knee dislocation

A

Popliteal artery

277
Q

Associated injury: fibula neck fracture

A

Common perennial nerve

278
Q

Associated injury: temporal or parietal bone fracture

A

Epidural hematoma

279
Q

Associated injury: maxillofacial fracture

A

Cervical spine fracture

280
Q

Associated injury: sternal fracture

A

Cardiac contusion

281
Q

Associated injury: first or second rib fracture

A

Aortic transection

282
Q

Associated injury: Scapula fracture

A

pulmonary contusion, aortic transection

283
Q

Associated injury: Rib fractures (left, 8-12)

A

Spleen laceration

284
Q

Associated injury: rib fractures (right, 8-12)

A

Liver laceration

285
Q

Associated injury: pelvic fracture

A

Bladder rupture, urethral transection

286
Q

Best indicator of renal trauma

A

hematuria

- all patients with hematuria need an abdominal CT scan

287
Q

When is IVP useful in renal trauma?

A

If going immediately to OR without a CT scan -> will identify presence of functional contralateral kidney, which could affect intraoperative decision making.

288
Q

Where can you ligate the left renal vein?

A

Near the IVC: has adrenal and gonadal vein collaterals. (Right renal vein does not have these collaterals).

289
Q

Anterior -> posterior renal hilum structures

A

Vein, artery, pelvis (VAP)

290
Q

How is most renal trauma managed?

A

95% of injuries are treated non operatively.

- Not all urine extravasation injuries require operation.

291
Q

Renal trauma: indications for operation

A
  • Acutely: ongoing hemorrhage with instability.

- After acute phase: major collecting system disruption, non-resolving urine extravasation, severe hematuria.

292
Q

First thing to do with exploration in renal trauma

A

With exploration, try to get control of the vascular hilum first

293
Q

When do you place drains in renal trauma?

A

Place drains intra-op, especially if collecting system is injured.

294
Q

Renal trauma: methods to check for leak

A

Methylene blue dye can be used at the end of the case to check for a leak

295
Q

What to do: when at exploration for another blunt injury or penetrating trauma..

  • Blunt renal injury with hematoma
  • Penetrating renal injury with hematoma
A
  • Blunt: leave unless pre-op CT/IVP shows no function or significant urine extravasation
  • Penetrating: open unless pre-op CT/IVP shows good function without significant urine extravasation.
296
Q

Tx: Trauma to flank and IVP shows no uptake in stable patient

A

Tx: angiogram, can stent if flap present

297
Q

Best indicator of bladder trauma

A

Hematuria

298
Q

Associated injury in bladder trauma

A

> 95% associated with pelvic fractures

299
Q

S/S: bladder trauma

A

Meatal blood, sacral or scrotal hematoma

300
Q

Dx: bladder trauma

A

Cystogram

301
Q

Cystogram shows starbursts

- Tx: Foley 7-14 days

A

Extraperitoneal bladder rupture

302
Q

More likely in kids, cystogram shows leak

- Tx: operation and repair of defect, followed by Foley drainage

A

Intraperitoneal bladder rupture

303
Q

Best tests for ureteral trauma

A

IVP and retrograde urethrogram (RUG) best tests -> hematuria unreliable.

304
Q

If large ureteral segment is missing (> 2 cm) and cannot perform reanastomosis..

  • Upper 1/3 injuries and middle 1/3 injuries that won’t reach bladder (above pelvic brim)
  • Lower 1/3 injuries
A
  • Upper / Middle: temporize with percutaneous nephrostomy (tie off both ends of the ureter); can go with ill interposition or trans-ureteroureterostomy later
  • Lower: reimplant in the bladder; may need bladder hitch procedure
305
Q

If small ureteral segment is missing (

A
  • Upper / middle: mobilize ends of ureter and perform primary repair over stent
  • Lower: re-implant in the bladder (easier anastomosis than primary repair)
306
Q

Indications for one-shot IVP for evaluation of ureter

A

None. One-shot IVP does not evaluate the ureters sufficiently

307
Q

How do you check for leaks with ureteral trauma?

A

IV indigo carmine or IV methylene blue can be used to check for leaks.

308
Q

Blood supply: ureteral trauma

A

Medial in the upper 2/3 of the ureter and lateral in the lower 1/3 of the ureter

309
Q

Drains for ureteral trauma?

A

Leave drains for all ureteral injuries

310
Q

Best signs of urethral trauma

A

Hematuria or blood at meatus are the best signs; free-floating prostate gland; usually a/w pelvic fractures

311
Q

Foley for urethral trauma?

A

No foley if this injury is suspected.

312
Q

Best test for urethral trauma

A

Retrograde urethrogram

313
Q

Urethral: portion at risk for transection

A

Membranous portion at risk for transection

314
Q

Tx: significant urethral tears

A

Tx: Suprapubic cystostomy and repair in 2-3 months (safest method - high stricture and impotence rate if repaired early)

315
Q

Tx: small, partial urethral tears

A

Tx: may get away with bridging urethral catheter across tear area and repair in 2-3 months

316
Q

Tx: genital trauma

A

Can get fracture in erectile bodies from vigorous sex.

- Need to repair the tunica and Buck’s fascia

317
Q

Management: testicular trauma

A

Get ultrasound to see if tunica albuginea is violated, then repair if necessary

318
Q

Is blood pressure a good indicator of blood loss in children?

A

Nope, blood pressure is the last thing to go

319
Q

Pediatrics: best indication of shock

A

Heart rate, respiratory rate, mental status, and clinical exam

320
Q

Patient population: increased risk of hypothermia and head injury

A

Pediatric trauma

- Increased BSA compared with weight

321
Q

Vitals: infant (

A
  • Pulse: 160
  • SBP: 80
  • RR: 40
322
Q

Vitals: preschool (

A
  • Pulse: 140
  • SBP: 90
  • RR: 30
323
Q

Vitals: adolescent (> 10 year)

- Pulse, SBP, RR

A
  • Pulse: 120
  • SBP: 100
  • RR: 20
324
Q

How much blood loss can a pregnant patient have without signs?

A

Up to a 1/3 total blood volume loss

325
Q

What do you look for in trauma during pregnancy?

A

Check for vaginal discharge - blood, amnion. Check for effacement, dilation, fetal station

326
Q

Fetal maturity: lecithin : sphingomyelin (LS) ratio

A

> 2:1, positive phosphatidylcholine in amniotic fluid

327
Q

> 50% results in almost 100% fetal death rate.

A

Placental abruption

- > 50% of all traumatic placental abruptions result in fetal demise

328
Q

S/S: pregnant with uterine tenderness, contractions, fetal HR

A

Placental abruption

329
Q

MC mechanism of placental abruption in trauma

A

Shock or mechanical forces

330
Q

Test for fetal blood in the maternal circulation -> sign of placental abruption

A

Kleihauer-Betke test

331
Q

Where is uterine rupture more likely to occur?

A

Posterior fundus

332
Q

Management: uterine rupture

A

If occurs after delivery of child, aggressive resuscitation even in the face of shock leads to the best outcome. The uterus will eventually clamp down after delivery; just have to aggressively resuscitate.

333
Q

Indications for C-section during exploratory laparotomy for trauma

A
  • 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 risks of immaturity
  • Direct intra-uterine trauma
334
Q

Management of hematoma:

Pelvic: penetrating / blunt

A

Pelvic:

  • Penetrating: Open
  • Blunt: Leave
335
Q

Management of hematoma:

Paraduodenal: penetrating / blunt

A

Paraduodenal:

  • Penetrating: Open
  • Blunt: Open
336
Q

Management of hematoma:

Portal triad: penetrating / blunt

A

Portal triad:

  • Penetrating: Open
  • Blunt: Open
337
Q

Management of hematoma:

Retrohepatic: penetrating / blunt

A

Retrohepatic:

  • Penetrating: Leave if stable
  • Blunt: Leave
338
Q

Management of hematoma:

Midline supramesocolic: penetrating / blunt

A

Midline supramesocolic:

  • Penetrating: Open
  • Blunt: Open
339
Q

Management of hematoma:

Midline inframesocolic: penetrating / blunt

A

Midline inframesocolic:

  • Penetrating: Open
  • Blunt: Open
340
Q

Management of hematoma:

Pericolonic: penetrating / blunt

A

Pericolonic:

  • Penetrating: Open
  • Blunt: Open
341
Q

Management of hematoma:

Perirenal: penetrating / blunt

A

Perirenal:

  • Penetrating: Open
  • Blunt: Leave
342
Q

Zones of the peritoneum

- Zone 1 / Associated injury

A

Zone 1: central retroperitoneum

- Pancreaticoduodenal injuries or major abdominal vascular injury (usually open hematoma in these areas)

343
Q

Zones of the peritoneum

- Zone 2 / Associated injury

A

Zone 2: flank or perinephric area
- Injuries to the genitourinary tract or to the colon (i.e. with penetrating trauma; usually open hematomas in these areas)

344
Q

Zones of the peritoneum:

- Zone 3 / Associated injury

A

Zone 3: Pelvis

- Pelvic fractures (usually leave these hematomas alone)

345
Q

Injuries that you leave drains with

A

Pancreatic, liver, biliary system, urinary and duodenal injuries

346
Q

Shock, bradycardia and arrhythmias can result.

- Tx: stabilize patient, anti-venin, tetanus shot

A

Snakebites (symptoms depend on species)

06 - absite (44 decks)

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