Chapter 15: Trauma Flashcards
First peak for trauma deaths (0-30 minutes)
Deaths due to lacerations of heart, aorta, brain, brainstem, or spinal cord; cannot really save these patients; death is too quick.
Second peak for trauma deaths (30 minutes-4 hours)
Deaths due to head injury (#1) and hemorrhage (#2); these patients can be saved with rapid assessment (golden hour)
Third peak for trauma deaths (Days to weeks)
Deaths due to multi system organ failure and sepsis
80% of all trauma
Blunt injury
Most commonly injured organ in blunt trauma
Liver
Falls: biggest predictors of survival
Age and body orientation.
LD50 is 4 stories
MC’ly injured organ in penetrating injury
Small bowel
MCC death in 1st hour
Hemorrhage
When is blood pressure affected in hemorrhage?
30% of total blood volume lost
How do you resuscitate hemorrhage?
2L Lactated Ringers, then switch to blood
MCC death after reaching the ER alive
Head injury
MCC upper airway obstruction -> perform jaw thrust
Tongue
Injuries: seat belts
Small bowel perforations, lumbar spine fractures, sternal fractures
Best site for cutdown for venous access
Saphenous vein at ankle
- Used in hypotensive patients with blunt trauma
- Need laparotomy if DPL is positive
DPL
Criteria: positive DPL
> 10 cc blood, > 100,000 RBCs/cc, food particles, bile, bacteria, > 500 WBC/cc
What does a DPL miss?
Retroperitoneal bleeds, contained hematoma
DPL for pelvic fracture
Needs to be supra umbilical
What does FAST stand for?
Focused abdominal sonography for trauma
Where does FAST scan check?
Perihepatic fossa
Perisplenic fossa
Pelvis
Pericardium
Disadvantages of FAST scan
- Examiner dependent
- Obesity can obstruct view
- May not detect free fluid
What does FAST scan miss?
Retroperitoneal bleeding, hollow viscous injury
Hypotensive patients: negative FAST scan, negative DPL. What to do?
Find the source of bleeding (pelvic fracture, chest, extremity)
When do you need a CT scan following blunt trauma?
- Abdominal pain
- Need for general anesthesia
- Closed head injury
- Intoxicants on board
- Paraplegia
- Distracting injury
- Hematuria
What can a CT scan miss?
hollow viscous injury, diaphragm injury
When do you need laparotomy?
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.
Tx: penetrating abdominal injury (eg, GSW)
Generally need laparotomy
Tx: possible penetrating abdominal injuries (knife or low-velocity injuries)
Local exploration and observation if fascia not violated
- 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
Abdominal compartment syndrome
Bladder pressure suggesting abdominal compartment syndrome
> 25-30
Tx: abdominal compartment syndrome
Decompressive laparotomy
Low cardiac output in abdominal compartment syndrome causes..
Visceral and renal malperfusion
- Controversial
- Use in patients with SBP
Pneumatic antishock garment
ER thoractomy: blunt trauma
Use only if pressure / pulse lost in ER
ER: thoracotomy: penetrating trauma
Use only if pressure / pulse lost on way to ER or in ER
Location for emergency department thoracotomy
Fourth and fifth intercostal space using the anterolateral approach
Abdominal injury: emergent thoracotomy
Clamp descending thoracic aorta:
- Blood pressure increase to > 70mmHg -> laparotomy
- Blood pressure
Cardiac injury: emergent thoracotomy
Open pericardium longitudinally anterior to phrenic nerve, cross clamp the aorta, watch for the esophagus (anterior to the aorta)
Peak 24-48 hours after injury
Catecholamines, ADH, ACTH, and glucagon
- 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
Type O Blood (universal donor)
Can be administered relatively safely, but there may be effects from antibodies to HLA minor antigens in the donated blood
Type-specific blood (nonscreened, non-cross matched)
Tx - GCS score:
Indications for head CT
- 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
Most commonly due to arterial bleeding from the middle meningeal artery
Epidural hematoma
Epidural hematoma: head CT
Shows lenticular (lens-shaped) deformity
Patients often have LOC -> then lucid interval -> then sudden deterioration (vomiting, restlessness, LOC)
Epidural hematoma
When do you operate for epidural hematoma?
Significant neurologic degeneration or significant mass effect (shift > 5mm)
Mostly commonly from tearing of venous plexus (bridging veins) that cross between the dura and arachnoid
Subdural hematoma
Subdural hematoma: head CT
Crescent-shaped deformity
When do you operate for subdural hematoma?
Significant neurologic degeneration or mass effect (> 1 cm)
Where are common location for intracerebral hematoma?
- Usually frontal or temporal
- Can cause significant mass effect requiring operation
Can be croup or contrecoup
Cerebral contusions
Tx: traumatic intraventricular hemorrhage causing hydrocephalus
Ventriculostomy
Shows up better on MRI than CT scan
- Tx: supportive, may need craniectomy if ICP elevated
- Very poor prognosis
Diffuse axonal injury
Equation: Cerebral perfusion pressure
CPP = MAP - ICP
Signs of elevated ICP
Decreased ventricular size, loss of sulci, loss of cisterns
Indications for ICP monitors
- GCS
Supportive treatment for elevated ICP
- 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
What is relative hyperventilation for elevated ICP?
CO2 30-35. Do not want to over-hyperventilate and cause cerebral ischemia from too much vasoconstriction.
Dose mannitol for elevated ICP
Load 1 g/kg. Give 0.25 mg/kg q4h after that.
When do you consider barbiturate coma for elevated ICP?
If noninvasive supportive treatment is failing.
When do you consider craniotomy decompression for elevated ICP?
If not able to get ICP down medically (can also perform Burr hole)
Can be given prophylactically to prevent seizures with moderate to severe head injury
Fosphenytoin or Keppra
When does peak ICP occur after head injury?
Occurs 48-72 hours after injury.
What is normal ICP?
10.
When do you treat elevated ICP? Goal CPP?
Treat ICP > 20.
Goal CPP > 60.
Dx: dilated pupil with elevated ICP.
Temporal pressure on the same side (CN 3, oculomotor, compression)
Physical signs: basal skull fracture
- 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
Acute vs delayed facial nerve injury with basal skull fractures
- Acute: exploration and repair.
- Delayed: likely secondary to edema and exploration not needed.
What nerves are at risk with temporal skull fractures?
Can injure CN 7 and 8 (vestibulococlear nerve)
MC site of facial nerve injury
Geniculate ganglion
MC’ly associated with lateral skull or orbital blows
Temporal skull fractures
Most skull fractures _____ surgical treatment.
Most skull fractures do not require surgical treatment.
Indications for operation of skull fractures.
Significant depression (>1cm). Contaminated. Persistent CSF leak not responding to conservative therapy.
Tx: CSF leaks after skull fracture.
Treat expectantly, can use lumbar CSF drainage if persistent.
What causes coagulopathy with traumatic brain injury?
Release of tissue factor.
Caused by axial loading.
- Tx: rigid collar.
C-1 burst (Jefferson fracture).
Caused by distraction and extension.
- Tx: traction and halo.
C-2 Hangman’s fracture.
Classification: C-2 odontoid fracture.
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)
- Can cause cord injury
- Usually associated with hyperextension and rotation with ligamentous disruption.
Facet fractures or dislocations.
Three columns of the thoracolumbar spine.
- 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.
When is thoracolumbar spine considered unstable?
If more than 1 column is disrupted.
Thoracolumbar: fractures usually involve the anterior column only and are considered stable.
Compression (wedge) fractures
Thoracolumbar: fractures considered unstable (>1 column) and require spinal fusion
Burst fractures
Upright fall: at risk for injury
Calcaneus, lumbar, and wrist/forearm fractures.
When do you need MRI in spinal trauma?
Neurologic deficits without bony injury to check for ligamentous injury.
Indications for emergent surgical spine decompression
- Fracture or dislocation not reducible with distraction
- Open fractures
- Soft tissue or bony compression of the cord
- Progressive neurologic dysfunction
MCC facial nerve injury
Temporal bone fracture
Goal with facial lacerations
Try to preserve skin and not trim edges with facial lacerations
LeFort Type 1?
Tx?
Maxillary fracture straight across (-)
- Tx: reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires.
LeFort Type 2?
Tx?
Lateral to nasal bone, underneath eyes, diagonal toward maxilla (/ )
- Tx: reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires.
LeFort Type 3?
Tx?
Lateral orbital walls (- -)
Tx: suspension wiring to stable frontal bone, may need external fixation.
- 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
Nasoethmoidal orbital fractures
Nosebleeds - anterior: Tx?
Packing
Nosebleeds - posterior: Tx?
Can be hard to deal with; try balloon tamponade first.
- May need angioembolization of internal maxillary artery or ethmoidal artery.
Tx: orbital blowout fractures
Patients with impaired upward gaze or diplopia with upward vision need repair; perform restoration of orbital floor with bone fragments or bone graft
1 indication of mandibular injury
Malocclusion
Dx / Tx: mandibular injury
- 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
Tx: tripod fracture (zygomatic bone)
ORIF for cosmesis
What do you need to look for with maxillofacial fractures?
Cervical spine injuries
What to do: asymptomatic blunt neck trauma
Neck CT scan
What to do: asymptomatic penetrating neck trauma
Controversial
Neck zone 1: penetrating injury
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.
Neck zone 2: penetrating injury
Zone: cricoid to angle of mandible.
- Need neck exploration in OR.
Neck zone 3: penetrating injury
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.
Important implication of a zone one injury
Greater potential for intrathoracic great vessel injury
Tx: symptomatic blunt of penetrating neck trauma
All need neck exploration. (Shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit)
Hardest neck injury to find
Esophageal injury
Best combined modality to identify esophageal injury
Esophagoscopy and esophagogram. (Find essentially 95% of injuries when using both methods).
Tx: contained esophageal injury
Observation
Tx: non contained esophageal injury
- Small / minimal contamination
- Extensive / contamination
- 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)
What do you always drain esophageal and hypo pharyngeal repairs?
20% leak rate
Approach to esophageal injuries:
- Neck
- Upper 2/3 thoracic esophagus
- Lower 2/3 thoracic esophagus
- Neck: left side
- Upper 2/3 thoracic esophagus: right thoracotomy
- Lower 1/3 thoracic esophagus: left thoracotomy
These injuries are airway emergencies
Laryngeal fracture and tracheal injuries.
Symptoms: laryngeal fracture / tracheal injury
Crepitus, stridor, respiratory compromise
Tx: laryngeal fracture and tracheal injury
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)
Tx: thyroid gland injury
Control bleeding and drain (not thyroidectomy)
Tx: recurrent laryngeal nerve injury
Can try to repair or can reimplant in cricoarytenoid muscle (sx - hoarseness)
Tx: shotgun injuries to neck
Need angiogram and neck CT; esophagus / trachea evaluation
Tx: vertebral artery bleeds
Can embolize or ligate without sequela in majority
Ligation will cause stroke in 20%
Common carotid bleeds
Chest trauma: chest tube output relative indications for thoracotomy in OR
- > 1,500 cc after initial insertion
- > 250 cc/h for 3 hours
- > 2,500 cc/24h
- Bleeding with instability
Why do you need to completely drain hemothorax in
To prevent fibrothorax, pulmonary entrapment, infected hemothorax
Tx: unresolved hemothorax after 2 well-placed chest tubes
Thoracoscopic drainage
What is considered a significant sucking chest wound (open pneumothorax)?
Needs to be at least 2/3 the diameter of the trachea to be significant
Tx: sucking chest wound (open pneumothorax)?
Cover wound with dressing that has tape on three sides -> prevents development of tension pneumothorax while allowing the lung to expand with inspiration.
- 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.
Tracheobronchial injury
Bronchus injuries are more common on the ___
Right.
Dx / Tx: tracheobronchial injury
Dx: Bronchoscopy
Tx: repair if large air leak and respiratory compromise or after 2 weeks of persistent air leak
Trachebronchial injury: indications for right thoracotomy
Right mainstem, trachea, and proximal left mainstem injuries (avoids the aorta)
Tracheobronchial injury: indications for left thoracotomy
Distal left mainstem injuries
Diaphragmatic injuries: mechanism and location
Injuries are most likely to be found on left and to result from blunt trauma
CXR: air-fluid level in chest from stomach herniation through hole (diagnosis can be made essentially with CXR)
Diaphragmatic injuries
Tx: diaphragmatic injury
Chest approach if > 1 week (need to take down adhesions in the chest)
- May need mesh.
Widened mediastinum. 1st or 2nd rib fractures. Apical capping. Loss of aortopulmonary window. Loss of aortic contour. Left hemothorax. Trachea deviation to right.
S/S: aortic transection.
Where is the tear of aortic transection located?
Usually at the ligamentum arteriosum (just distal to subclavian takeoff). Other areas include near the aortic valve and where the aorta traverses the diaphragm.
Can you trust a chest XR when ruling out aortic transection?
CXR normal in 5% of patients with aortic tears. Need aortic evaluation in pts with significant mechanism (head on car crash > 45mph, fall > 15ft)
Dx: aortic transection
CT angiogram of chest
Operative approach: aortic transection
Left thoracotomy and repair with partial left heart bypass or place a covered stent endograft (distal transections only)
What is extremely important when approaching a patient with aortic transection?
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.
Approach for specific injuries: ascending aorta, innominate artery, proximal right subclavian artery, innominate vein, proximal left common carotid
Median sternotomy
Approach for specific injuries: left subclavian artery, descending aorta
Left thoracotomy
Approach for specific injuries: midclavicular incision, resection of medial clavicle
Distal right subclavian artery
MCC death myocardial contusion
V-tach and V-fib
- Risk highest in first 24 hours
MC arrhythmia overall in patients with myocardial contusion
Supra-ventricular tachycardia
Why monitor a myocardial contusion for 24-48 hours?
Arrhythmia is the most common cause of death with the highest risk in the first 24 hours.
Definition: flail chest.
> 2 consecutive ribs broken at > 2 sites. Results in paradoxical motion.
Biggest pulmonary impairment in flail chest
Underlying pulmonary contusion.
May not produce CXR findings immediately
Aspiration
Workup: penetrating chest injury
Start with a CXR if the patient is stable (place chest tube for pneumothorax or hemothorax)
Borders of penetrating “box” injuries in chest trauma
Clavicles, xiphoid process, nipples
Workup: penetrating “box” injuries
Need pericardial window, bronchoscopy, esophagoscopy, barium swallow
Tx: penetrating chest wound outside “box” without pneumo or hemothorax
Need chest tube if patient requires intubation. Otherwise follow patient’s serial CXRs.
What if you find blood in the pericardial window?
Need median sternotomy to fix possible injury to heart or great vessels; place pericardial drain.
Workup: penetrating injuries anterior-medial to midaxillary line and below nipples.
- Need laparotomy or laparoscopy.
- May also need evaluation for penetrating “box” injury depending on the exact location.
Traumatic causes of cariogenic shock
Cardiac tamponade
Cardiac contusion
Tension pneumothorax
One way valve effect causes air entry and pressure build up
Tension pneumothorax
Hypotension, increased airway pressures, decreased breath sounds, bulging neck veins, tracheal shift. Can see bulging diaphragm during laparotomy.
- Tx: chest tube
Tension pneumothorax
What causes cardiac compromise in tension pneumothorax?
Decreased venous return (IVC, SVC compression)
High risk injury in sternal fractures
Cardiac contusion
1st and 2nd rib fractures are high risk for?
Aortic transection
What is pulmonary tractotomy?
Dividing the pulmonary parenchyma between adjacent staple lines permits rapid access to injured vessels or bronchi along the tract of penetrating injury.
Significance of pelvic fractures
Can be a major source of blood loss
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?
Stabilize pelvis (C-clamp, external fixator or sheet) and go to angio for embolization.
What injuries are associated with pelvic trauma?
High risk for genitourinary and abdominal injuries
Type 1 pelvic fracture: unstable (crush)
- Mortality
- Blood loss
- Complications
- Mortality: 20-30%
- Blood loss: > 10 units
- Complications: 60-75%
Type II Pelvic Fracture (Unstable)
- Mortality
- Blood loss
- Complications
- Mortality: 8-12%
- Blood loss: 2-10 units
- Complications: 30-50%
Type III Pelvic Fracture (Stable)
- Mortality
- Blood loss
- Complications
- Mortality:
Pelvic fractures: more likely to have venous bleeding
Anterior pelvic fractures
Pelvic fractures: more likely to have arterial bleeding
Posterior pelvic fractures
When would you need a colostomy in the setting of pelvic fractures?
May need colostomy for open pelvic fractures with rectal tears and perineal lacerations
When do you delay pelvic fracture repair?
Until other associated injuries are repaired
Tx: intra-op penetrating injury pelvic hematomas
Open (some suggest going to angiography for these)
Tx: intra-op blunt injury pelvic hematomas
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.
Usual cause of duodenal trauma
Usually from blunt trauma (crush or deceleration injury)
MC area of duodenal injury
2nd portion of duodenum (descending portion, near ampulla of Vater)
What ligament is associated with duodenal injury?
Tears near ligament of Treitz
Most likely treatment of duodenal trauma
80% of injuries requiring surgery can be treated with debridement and primary closure
Duodenal trauma: segmental resection with primary end-to-end closure is possible with all segments of the duodenum EXCEPT?
Second portion of the duodenum
Why is there a 25% mortality rate in patients with duodenal trauma?
Associated shock
Major source of morbidity in duodenal trauma
Fistulas
Tx: intra-op paraduodenal hematoma
> / 2 cm considered significant
- Usually in third portion of duodenum overlying spine in blunt injury
- Need to open for both blunt and penetrating injuries
- 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?
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)
Surgical approach: duodenal trauma
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)
Diagnosing suspected duodenal injury
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.
Duodenal trauma: if CT scan is worrisome for injury but non diagnostic..
Can repeat the CT in 8-12 hours to see if the finding is getting worse.
Surgical treatment: duodenal trauma
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.
Duodenal injury: if in 2nd portion of duodenum and can’t get primary repair.
- Place jejunal serosal patch over hole; may need Whipple in future.
- Need pyloric exclusion and gastrojejunostomy.
- Consider feeding and draining jejunostomies; leave drains.
Is trauma Whipple ever indicated?
RARELY. Very high mortality.
When do you remove drains in duodenal trauma?
Remove drains when patient tolerating diet without an increase in drainage.
Treatment: fistulas secondary to duodenal trauma.
Often close with time.
- Tx: bowel rest, TPN, octreotide, conservative management for 4-6 weeks.
Most common organ injured with penetrating injury (some texts say liver)
Small bowel
These injuries can be hard to diagnose early if associated with blunt trauma
Small bowel trauma
Abdominal CT scan suggesting occult small bowel injury
Intra-abdominal fluid not associated with a solid organ injury, bowel wall thickening, or a mesenteric hematoma
Imaging Management: occult small bowel trauma
Need close observation and possibly repeat abdominal CT after 8-12 hours or so to make sure finding is not getting worse.
What do you need to make sure of before discharging a patient with non conclusive small bowel injury?
Need to make sure patients with non conclusive findings can tolerate a diet before discharge.
What avoids stricture in small bowel trauma repair?
Repair lacerations transversely.
Small bowel: large lacerations that are > 50% of the bowel circumference or results in lumen diameter
Perform resection and anastomosis
Surgery small bowel: multiple close lacerations
Just resect that segment
Surgery small bowel mesenteric hematomas
Open if expanding or large (> 2 cm)
Colon trauma: most associated with what type of injury?
Most associated with penetrating injury
Colon trauma surgery: right and transverse colon injuries
Perform primary repair / anastomosis
Colon trauma surgery: left colon
Perform primary repair / anastomosis; place diverting ileostomy if patient is in shock or there is gross contamination
Colon trauma surgery: paracolonic hematomas
Both blunt and penetrating need to be opened
Rectal trauma: most associated with what type of injury?
Penetrating injury
High rectal trauma: extarperitoneal repair
Generally not repaired because of inaccessibility.
- Tx: serial debridement; consider diverting ileostomy.
- Place diverting ileostomy with shock, gross contamination, or extensive injury.
High rectal trauma: intraperitoneal repair
Tx: repair defect, presacral drainage, consider diverting ileostomy.
- Place diverting ileostomy with shock, gross contamination, or extensive injury.
Low rectal trauma repair
(
Most common organ injury with blunt abdominal trauma (some texts say spleen)
Liver
Is lobectomy necessary in liver trauma?
Rarely.
Common hepatic artery injury repair
Can be ligated with collateral through gastroduodenal artery
Pringle maneuver?
Clamping portal triad. Does not stop bleeding from hepatic veins.
Damage control peri-hepatic packing
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.
For retrohepatic IVC injury, allows for control while performing repair
Atriocaval shunt
Management: portal triad hematomas
Need to be explored
Mgmt: Common bile duct injury:
- 50% circumference or complex injury?
- 50% / complex: go with choledochojejunostomy
May need intraoperative cholangiogram to define injury.
How many common bile duct injury anastomoses leak?
10% of duct anastomoses leak -> place drains intra-op.
Surgical management: portal vein injury
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.
Mortality: ligation of portal vein
50% mortality.
Can be placed in liver laceration to help with bleeding and prevent bile leaks
Omental graft
Do you use drains with liver injury?
Yes, leave drains.
When is conservative management of blunt liver injuries considered to have failed?
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.
Surgical management: liver trauma - active blush on abdominal CT or pseudoaneurysm
Indication for OR
- Posterior: may be better off going to angiogram (when in doubt -> OR)
- Anterior: go to OR
Liver trauma: conservative management requires how much time of bed rest?
5 days
Spleen fully heals after..
6 weeks
Greatest risk postsplenectomy sepsis
Within 2 years of splenectomy
What is splenic salvage associated with?
Increased transfusions
When is conservative management of blunt splenic injury considered to have failed?
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.
Conservative management requires how many days of bed rest with splenic trauma
5 days bed rest
Threshold for splenectomy in children
Is much higher; hardly any children undergo splenectomy
Accounts for 80% of all pancreatic injuries
Penetrating injury
How can blunt injury affect the pancreas?
Can result in pancreatic duct fractures, usually perpendicular to the duct.
Usually indicative of pancreatic injury
Edema or necrosis of peripancreatic fat
Tx: pancreatic contusion
Leave if stable, place drains if in OR
Tx: distal pancreatic duct injury
Distal pancreatectomy, can take up to 80% of the gland
Tx: pancreatic head duct injury that is not repairable
Place drains initially; delayed Whipple or possible ERCP with stent may eventually be necessary
Pancreatic trauma: whipple vs distal pancreatectomy
Based on duct injury in relation to the SMV (superior mesenteric vein)
Helps evaluate the pancreas operatively
Kocher maneuver
Do you use drains with pancreatic injury?
Yes, leave drains with pancreatic injury.
Tx: pancreatic hematoma
Both penetrating and blunt need to be opened.
Persistent or rising amylase
May indicate missed pancreatic injury
Are CT scans reliable for diagnosis of pancreatic injury?
CT scans poor at diagnosing pancreatic injuries initially. Delayed signs - fluid, edema, necrosis.
Test: good at finding duct injuries in pancreatic trauma
ERCP good at finding duct injuries and may be able to treat with temporary stent
Vascular trauma: vascular or orthopedic repair first?
Vascular repair (or vascular shunt) performed before orthopedic repair.
Major signs of vascular injury
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)
Moderate / soft signs of vascular injury
History of hemorrhage, deficit of anatomically related nerve, large stable / nonpulsatile hematoma, ABI go to angio.
When do you need a saphenous vein graft?
If segment > 2 cm is missing. Use vein from the contralateral leg when fixing lower extremity arterial injuries.
Vein injuries that need repair
Vena cava, femoral, popliteal, brachiocephalic, subclavian, and axillary
Tx: transection of single artery in the calf in an otherwise healthy patient
Ligate
How do you cover site of anastomosis in vascular trauma?
Cover site of anastomosis with viable tissue and muscle.
When do you consider fasciotomy in vascular trauma?
Consider fasciotomy if ischemia > 4-6 hours (prevents compartment syndrome)
When do you consider compartment syndrome?
Consider if compartment pressures are > 20 mmHg or if clinical exam suggests elevated pressures
Late signs of compartment syndrome
Pain -> paresthesia -> anesthesia -> paralysis -> poikilothermia -> pulselessness (late finding)
When does compartment syndrome most likely occur?
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
Repair of IVC trauma
Primary repair if residual stenosis is
How do you control IVC bleeding?
Bleeding of IVC best controlled with proximal and distal pressure, not clamps -> can tear it.
How do you repair the posterior wall of the IVC?
Repair posterior wall injury through the anterior wall (may need to cut through the anterior IVC to get to posterior IVC injuries).
How much blood can the femur lose?
> 2L blood
What are considered orthopedic emergencies?
- Pelvic fractures in unstable patients
- Spine injury with deficit
- Open fractures
- Dislocations or fractures with vascular compromise
- Compartment syndrome
Ortho trauma: high risk for avascular necrosis
Femoral neck fractures
Tx: long bone fracture or dislocations with loss of pulse (or weak pulse)
Tx: immediate reduction of fracture or dislocation and reassessment of pulse
What if pulse does not return after reduction of long bone fracture?
Go to OR for vascular bypass or repair (may need angiography in OR to define injury)
What if a weak pulse returns after reduction of long bone fracture?
Angiography
Management: knee dislocations
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)
What are upright falls associated with?
Calcaneus, lumbar, and distal forearm (radius / ulnar) fractures
Associated injury: anterior shoulder dislocation
Axillary nerve
Associated injury: Posterior shoulder dislocation
Axillary nerve
Associated injury: proximal humerus fracture
Axillary nerve
Associated injury: mid shaft humerus fracture (or spiral humerus fracture)
Radial nerve
Associated injury: distal (supracondylar) humerus fracture
Brachial artery
Associated injury: elbow dislocation
Brachial artery
Associated injury: Distal radius fracture
Median nerve
Associated injury: anterior hip dislocation
Femoral artery
Associated injury: posterior hip dislocation
Sciatic nerve
Associated injury: Distal (supracondylar) femur fracture
Popliteal artery
Associated injury: posterior knee dislocation
Popliteal artery
Associated injury: fibula neck fracture
Common perennial nerve
Associated injury: temporal or parietal bone fracture
Epidural hematoma
Associated injury: maxillofacial fracture
Cervical spine fracture
Associated injury: sternal fracture
Cardiac contusion
Associated injury: first or second rib fracture
Aortic transection
Associated injury: Scapula fracture
pulmonary contusion, aortic transection
Associated injury: Rib fractures (left, 8-12)
Spleen laceration
Associated injury: rib fractures (right, 8-12)
Liver laceration
Associated injury: pelvic fracture
Bladder rupture, urethral transection
Best indicator of renal trauma
hematuria
- all patients with hematuria need an abdominal CT scan
When is IVP useful in renal trauma?
If going immediately to OR without a CT scan -> will identify presence of functional contralateral kidney, which could affect intraoperative decision making.
Where can you ligate the left renal vein?
Near the IVC: has adrenal and gonadal vein collaterals. (Right renal vein does not have these collaterals).
Anterior -> posterior renal hilum structures
Vein, artery, pelvis (VAP)
How is most renal trauma managed?
95% of injuries are treated non operatively.
- Not all urine extravasation injuries require operation.
Renal trauma: indications for operation
- Acutely: ongoing hemorrhage with instability.
- After acute phase: major collecting system disruption, non-resolving urine extravasation, severe hematuria.
First thing to do with exploration in renal trauma
With exploration, try to get control of the vascular hilum first
When do you place drains in renal trauma?
Place drains intra-op, especially if collecting system is injured.
Renal trauma: methods to check for leak
Methylene blue dye can be used at the end of the case to check for a leak
What to do: when at exploration for another blunt injury or penetrating trauma..
- Blunt renal injury with hematoma
- Penetrating renal injury with hematoma
- 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.
Tx: Trauma to flank and IVP shows no uptake in stable patient
Tx: angiogram, can stent if flap present
Best indicator of bladder trauma
Hematuria
Associated injury in bladder trauma
> 95% associated with pelvic fractures
S/S: bladder trauma
Meatal blood, sacral or scrotal hematoma
Dx: bladder trauma
Cystogram
Cystogram shows starbursts
- Tx: Foley 7-14 days
Extraperitoneal bladder rupture
More likely in kids, cystogram shows leak
- Tx: operation and repair of defect, followed by Foley drainage
Intraperitoneal bladder rupture
Best tests for ureteral trauma
IVP and retrograde urethrogram (RUG) best tests -> hematuria unreliable.
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
- 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
If small ureteral segment is missing (
- Upper / middle: mobilize ends of ureter and perform primary repair over stent
- Lower: re-implant in the bladder (easier anastomosis than primary repair)
Indications for one-shot IVP for evaluation of ureter
None. One-shot IVP does not evaluate the ureters sufficiently
How do you check for leaks with ureteral trauma?
IV indigo carmine or IV methylene blue can be used to check for leaks.
Blood supply: ureteral trauma
Medial in the upper 2/3 of the ureter and lateral in the lower 1/3 of the ureter
Drains for ureteral trauma?
Leave drains for all ureteral injuries
Best signs of urethral trauma
Hematuria or blood at meatus are the best signs; free-floating prostate gland; usually a/w pelvic fractures
Foley for urethral trauma?
No foley if this injury is suspected.
Best test for urethral trauma
Retrograde urethrogram
Urethral: portion at risk for transection
Membranous portion at risk for transection
Tx: significant urethral tears
Tx: Suprapubic cystostomy and repair in 2-3 months (safest method - high stricture and impotence rate if repaired early)
Tx: small, partial urethral tears
Tx: may get away with bridging urethral catheter across tear area and repair in 2-3 months
Tx: genital trauma
Can get fracture in erectile bodies from vigorous sex.
- Need to repair the tunica and Buck’s fascia
Management: testicular trauma
Get ultrasound to see if tunica albuginea is violated, then repair if necessary
Is blood pressure a good indicator of blood loss in children?
Nope, blood pressure is the last thing to go
Pediatrics: best indication of shock
Heart rate, respiratory rate, mental status, and clinical exam
Patient population: increased risk of hypothermia and head injury
Pediatric trauma
- Increased BSA compared with weight
Vitals: infant (
- Pulse: 160
- SBP: 80
- RR: 40
Vitals: preschool (
- Pulse: 140
- SBP: 90
- RR: 30
Vitals: adolescent (> 10 year)
- Pulse, SBP, RR
- Pulse: 120
- SBP: 100
- RR: 20
How much blood loss can a pregnant patient have without signs?
Up to a 1/3 total blood volume loss
What do you look for in trauma during pregnancy?
Check for vaginal discharge - blood, amnion. Check for effacement, dilation, fetal station
Fetal maturity: lecithin : sphingomyelin (LS) ratio
> 2:1, positive phosphatidylcholine in amniotic fluid
> 50% results in almost 100% fetal death rate.
Placental abruption
- > 50% of all traumatic placental abruptions result in fetal demise
S/S: pregnant with uterine tenderness, contractions, fetal HR
Placental abruption
MC mechanism of placental abruption in trauma
Shock or mechanical forces
Test for fetal blood in the maternal circulation -> sign of placental abruption
Kleihauer-Betke test
Where is uterine rupture more likely to occur?
Posterior fundus
Management: uterine rupture
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.
Indications for C-section during exploratory laparotomy for trauma
- Persistent maternal shock or severe injuries and pregnancy near term (> 34 weeks)
- Pregnancy a threat to 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
Management of hematoma:
Pelvic: penetrating / blunt
Pelvic:
- Penetrating: Open
- Blunt: Leave
Management of hematoma:
Paraduodenal: penetrating / blunt
Paraduodenal:
- Penetrating: Open
- Blunt: Open
Management of hematoma:
Portal triad: penetrating / blunt
Portal triad:
- Penetrating: Open
- Blunt: Open
Management of hematoma:
Retrohepatic: penetrating / blunt
Retrohepatic:
- Penetrating: Leave if stable
- Blunt: Leave
Management of hematoma:
Midline supramesocolic: penetrating / blunt
Midline supramesocolic:
- Penetrating: Open
- Blunt: Open
Management of hematoma:
Midline inframesocolic: penetrating / blunt
Midline inframesocolic:
- Penetrating: Open
- Blunt: Open
Management of hematoma:
Pericolonic: penetrating / blunt
Pericolonic:
- Penetrating: Open
- Blunt: Open
Management of hematoma:
Perirenal: penetrating / blunt
Perirenal:
- Penetrating: Open
- Blunt: Leave
Zones of the peritoneum
- Zone 1 / Associated injury
Zone 1: central retroperitoneum
- Pancreaticoduodenal injuries or major abdominal vascular injury (usually open hematoma in these areas)
Zones of the peritoneum
- Zone 2 / Associated injury
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)
Zones of the peritoneum:
- Zone 3 / Associated injury
Zone 3: Pelvis
- Pelvic fractures (usually leave these hematomas alone)
Injuries that you leave drains with
Pancreatic, liver, biliary system, urinary and duodenal injuries
Shock, bradycardia and arrhythmias can result.
- Tx: stabilize patient, anti-venin, tetanus shot
Snakebites (symptoms depend on species)
