Comprehensive Prep > Chapter 15: Trauma > Flashcards
Chapter 15: Trauma Flashcards
What is the second peak of trauma death? causes
30 minutes- 4 hours. -#1 head injury -#2 hemorrhage -Golden hour, rapid assessment
What is the 3rd peak of trauma death?
days to weaks -multisystem organ failure -sepsis
What is the most commonly injured organ in blunt trauma?
Liver (some say spleen)
What is the LD50 fall height?
4 stories
What is the most commonly injured organ in penetrating trauma?
Small bowel (some say liver)
What is the most common cause of upper airway obstruction and how is it alleviated?
Tongue, jaw thrust (ohhhh yeaaaa)
What site is best for cutdown access?
Saphenous vein
If a pelvic fx is present, where must DPL be performed?
Supraumbilical
Where does a FAST look for blood?
-perihepatic fossa -Pelvis -Pericardium
CT after blunt trauma needed for what?
-Abdominal Pain -Need for General Anasthesia -closed head injury -intoxicants -paraplegia -distracting injury -Hematuria
These patients need a laparotomy after blunt trauma:
-Peritonitis -evisceration -(+) DPL -clinical deterioration -uncrontrolled hemorrhage -free air -diaphragm injury -intraperitoneal bladder injury -specific renal, pancreas, biliary tract injury
Bladder pressures of what indicate abdominal compartment syndrome?
>25-30
What causes decreased urine output in abdominal compartment syndrome?
Compressed renal vein
When do you use a pneumatic antishock garment?
-SBP <50 without thoracic injury -release one compartment at a time after reaching ED
Along with catecholamines, what rises after trauma?
-ADH -ACTH -Glucagon Fight or flight response
Type specific, non-screened, non-crossmatched blood can be given safely with what side effects?
effects from antibodies to minor antigens
Glasgow coma score verbal
5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no response
GCS that gets head CT, Intubation, ICP monitor
<= 8 ICP monitor
Subdural Hematoma caused by damage to what? Head CT shows? when do you operate?
-venous plexus tearing between dura and arachnoid -CT shows crescent deformity -operate for significant mass defect
Cerebral contusions can be one of these 2 types
coup or contracoup
When imaging is best for DAI?
MRI better than CT
What are signs of elevated ICP?
-decreased ventricular size -loss of sulci -loss of cisterns
What is a normal ICP?
-10, >20 needs tx
What is supportive therapy for increased ICP?
-sedation and paralysis -raise head of bed -relative hyperventilation -Na 140-150 -Serum Osm 295-310 -Manitol -Barbituate coma -ventriculostomy with CSF drainage -Phenytoin
What does dilated pupil show?
Temporal pressure on SAME side (CNIII compression)
Battle’s sign shows what?
middle fossa fx -acute need exploration -delayed secondary to edema
What is the most common site of facial nerve injury?
geniculate ganglion
What is a Jefferson cervical fx?
-C1 burst -caused by axial loading -tx rigid collar
What are the 3 types of C2 odontoid fx?
I above base, stable II at base, unstable- need fusion or halo III extend to vertebral body-need fusion/halo
What is the anterior column or thoracolumbar spine?
anterior longitudinal ligament and 1/2 of vertebral body
What is the posterior column of the thoracolumbar spine?
facet joints, lamina, spinous processes, interspinous ligament
What are wedge fractures? stable or unstable?
anterior column only; stable
What structures are at risk after upright fall?
calcaneus lumbar wrist/forearm fractures
What skull fracture is most common cause of facial nerve injury?
temporal bone FX
What is type II Le Fort fx? tx?
-Lateral to nasal bone, underneath eyes, diagonal toward maxilla ( / \ ) -tx with reduction, stabilization, intramaxillary fixation, +/- circumzygomatic and orbital rim suspension wires
What is a type III Le Fort Fx? tx?
Lateral orbital walls ( - - ) -suspension wiring to stable frontal bone; may need external fixation
What is the #1 indicator of mandibular injury?
malocclusion
what are patients with maxillofacial fx at a high risk for?
cervical spine injury
Neck Zone I? penetrating injury gets what?
Clavicle to Cricoid -angiography -bronchoscopy -rigid esophagoscopy -barium swallow -may need pericardial window/sternotomy
Neck Zone III? Penetrating injury gets what?
Angle of mandible to base of skull -Angio -Laryngoscopy -may need jaw subluxation/digastric SCM release/mastoid sinus resection to reach vascular injuries
Contained esophageal injuries treated how?
observation
What percentage of esophageal and hypoesophageal injuries leak?
20%. always drain
What are the sx of laryngeal fx?
crepitus, stridor, respiratory compromise
Tx recurrent laryngeal nerve injury?
repair or reimplant in cricoarytenoid muscle
Tx for vertebral artery injury?
ligate or embolize without sequelae
When to placed, indications for thoracotomy?
>1500 initially >250cc/h for 3 h >2500cc for 24h >instability
unresolved hemothorax after 2 tubes?
thorascopic or open drainage
Tracheobronchial injury can be diagnosed by what?
worse oxygenation after chest tube placement
What kind of intubation may be needed for bronchial injuries?
mainstem to unaffected side
When would you do left thoracotomy for tracheobronchial injury?
-distal left mainstem injuries
When would you do right thoracotomy for tracheobronchial injury?
right mainstem, tracheal, proximal left mainstem -avoid aorta
What side are bronchial injuries more common?
right
How large does a sucking chest wound need to be to be significant?
>2/3 diameter of trachea -cover wound with dressing that has tape on 2 sides
If all blood from hemothorax not drained in _____hours, risk this
48 hours; fibrothorax, pulmonary entrapment, infected hemothorax
Common carotid bleeds?
can tx with ligation - 20% will stroke
What do fucking shot gun injuries to the neck need other than a pine box?
angiogram, neck CT, esophagus/tracheal evaluation.
Tx for thyroid injuries?
control bleeding, drain
How do you approach esophageal injuries?
-Neck- left side -upper 2/3- right thoracotomy -lower 1/3- left thoracotomy
Non-contained injuries to esophagus treated how?
small, <24h old, stable- primary closure -otherwise, spit fistula and drain leak with chest tube
What is the best method to evaluate esophageal injury?
rigid esophagoscopy and esophogram (95% of injuries found)
Neck Zone II? penetrating injury gets what?
Cricoid to angle of the mandible -Exploration in the OR
Asymptomatic blunt neck trauma gets what?
Neck CT
What is a tripod fx? what do you do?
zygomatic bone fx. May need ORIF for cosmesis
What are the 2 types of Nosebleeds? Tx?
-Anterior - Packing -Posterior - balloon tamponade first, may need embolization of internal maxillary a or ethmoidal a
What percentage of nasoethmoidal bone fx have CSF leak?
70%
What is type I Le Fort fx? tx?
-maxillary fx straight across ( - ) -tx with reduction, stabilization, intramaxillary fixation, +/- circumzygomatic and orbital rim suspension wires
What are the indications for emergent surgical spine decompression?
-fx not reducible with distraction -acute anterior spinal syndrome -open fractures -soft tissue or bony compression of the cord -progressive neurological dysfunction
What are burst fractures? stable or unstable?
>1 column and usually require fusion
How many columns of thoracolumbar spine must be disrupted for fx to be considered unstable?
>1
What is the middle column of thoracolumbar spine?
Posterior 1/2 of vertebral body and posterior longitudinal ligament
What can facet fractures or disocations cause? how do they happen?
cord injury associated with hyperextension and rotation with ligamentous disruption
What is a hangman’s fx?
-C2 distraction and extension -traction and halo
when do skull fx need treatment?
8-10 mm or > depression -contaminated -persistent CSF leak
Temporal skull fx can injure what cranial nerves?
VII and VIII
Raccoon eyes indicates what?
anterior fossa fx
When does ICP peak after injury?
48-72 hours
What do you want the CPP to be?
>60
When are ICP monitors needed?
-GCS = 8 -suspected increased ICP and inability to follow clinical exam
how do you calculate cerebral perfusion pressure?
MAP minus ICP
When do traumatic intraventricular hemorrhages need treatment?
ventriculostomy if causing hydrocephalus
Intracerebral hematomas usually where? When do they need operation?
-Usually frontal or temporal -operate for significant mass effect
Epidural Hematoma caused by damage to what? What does head CT show? What is patient presentation? When do you operate?
-Arterial bleed from middle meningeal A -CT shows lens shape lenticular deformity -initial LOC, lucid interval, sudden deterioration -Operate for significant degeneration or mass effect shift >5mm
Glasgow coma score eye opening
4 spontaneous 3 to command 2 to pain 1 no response
Glasgow coma score Motor
6 follows commands 5 localizes pain 4 withdraws from pain 3 flexion with pain 2 extension with pain 1 no response
What blood type is a universal donor? Why? Rh can and cannot go to who?
-O, does not contain A or B antigens -Males can get Rh positive -prepubescent and child bearing age females must get Rh negative
When do catecholamines peak after trauma?
24-48 hours
What is tx for abdominal compartment syndrome?
decompressive laparotomy
What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?
ICV compression
When does abdominal compartment syndrome happen?
-massive fluid resuscitation -trauma -abdominal surgery
What does a CT scan of blunt trauma miss?
-hollow viscous injury -retroperitoneal bleed
What are flaws with FAST?
-Operator Dependent (fuckin Belsky) -Obesity -May not detect fluid <50-80 -Misses retroperitoneal bleed and hollow viscous injury
What does a DPL miss?
Retroperitoneal hematoma Contained hematomas
When is a DPL positive?
>10cc blood >100k RBC’s -food particles, bile, bacteria >500cc WBC
What injuries to seat belts cause?
-small bowel perfs -lumbar spine fxs -Sternal fxs
What is the most common cause of long term death with trauma?
Sepsis
At what point of blood loss is blood pressure effected?
30%
What is the formula for kinetic energy?
1/2 MV^2
What percentage of trauma is blunt?
80%
What is the first peak of trauma death? causes
0-30 minutes. -Heart/aorta -brain/brainstem/spinal cord -cannot save these patients
What side is more likely for a diaphragm injury from blunt trauma?
left
What would you see on CXR from a diaphragm injury
Air fluid level in chest from stomach herniation through hole
What is the approach for repair of diaphragm injury?
transabdominal if 1 weekmay need mesh
Signs of aortic transection?
-widened mediastinum-1st rib fx-apical capping-loss of aortopulmonary window-loss of aortic contour-left hemothorax-trachea deviation to right
Where is aortic tear usually located?
ligamentum arteriosum (just distal to subclavian take off-also aortic take-off-also where aorta crosses diaphragm
What percentage of aortic tears is CXR normal?
5%
What injuries need further aortic examination?
crash >45mph and falls >15ft
What do you use to control BP with aortic injury?
Nipride and esmolol
What is the operative approach for aortic injury?
left thoracotomy with partial left heart bypass**treat other life threatening injuries first
Median sternotomy required for what injuries?
-ascending aorta-innominate artery-proximal R subclavian-innominate vein-proximal left common carotid
Left thoracotomy for what injuries?
left subclaviandescending aorta
Operative approach for distal right subclavian artery injury?
midclavicular incision, 1/2 resection of medial clavicle
most common cause of death in myocardial contusion?
v-tach and v-fib (risk highest in 1st 24h)-SVT most common arrhythmia
Flail chest occurs when?
>= 2 consecutive fractures in >=2 sites-pulmonary contusion biggest impairment
What is the penetrating box (ha) in chest injuries?
borders are clavicles, xiphoid, nips-need pericardial window, bronchoscopy, esphagoscopy, barium swallow
penetrating chest wounds outside the penetrating box get treated how?
-chest tube if intubation required-otherwise follow CXR’s
If you do a pericardial window and find blood, what do you do?
sternotomy, place pericardial drain
Penetrating injuries anterior-medial to midaxillary line and below nipples need what?
laparotomy or laparoscopy
What are the traumatic causes of cardiogenic shock?
-caridac tamponade-cardiac contusion-tension pneumo
Signs of tension pneumo?
-hypotension-increased airway pressure-decreased breath sounds-bulging neck veins-tracheal shift-may see bulging diaphragm during laparotomy-cardiac compromise from decreased venous return
Sternal fractures are at a high risk for what cardiac issue?
cardiac contusion
1st and 2nd rib fx at increased risk of what?
aortic transection
What do you do with hemodynamically unstable pelvic fractures?
neg DPL, neg CXR and no other signs of bleeding—> stabilize pelvis, go to angio
Anterior pelvic fx have what type of bleeding?
venous
Posterior pelvic fx likely to have what type of bleed
arterial
what do do with penetrating injury and pelvic hematoma?
open
what to do with blunt pelvic injury and hematoma?
leave unless expanding and unstable-unstable-> stabilize fx, pack pelvis in OR, angiography embolization
Duodenal trauma ususally from what?
blunt injury from deceleration or crush
Where is most common location for duodenal injury?
descending (2nd) portion near ampula of vater-also at ligament of treitz
What percentage of duodenal injuries can be treated with debridement and primary closure?
70-80%
what parts of the duodenum can be treated with segmental resection with primary end-to end closure?
all but second portion
what is mortality of duodenal injuries? major source of morbidity?
25% (associated shock); fistulas
Where are paraduodenal hematomas common? what to do?
3rd portion overlying spine-open them if in OR
Missed duodenal hematomas present as what? what do they look like on upper GI?
SBO 12-72hrs after injury-stacked coins or coiled spring appearance-conservative sbo tx cures 90% in 2-3wks
If injury suspected to duodenum in OR, what do you do?
Kocher maneuver, open lesser sac-hematoma, bile, petichiae, sucus, fat necrosis require formal inspection of entire duodenum
How do you diagnose suspected duoedenal injury?
abdominal CT, upper GI.-if worrisome repeat in 8-12h
Treatment for found duodenal injury?
primary repair first, if not, divert with pyloric exclusion and gastrojejunostomy. feeding J, proximal draining J that threads to injury. Drains!
Occult small bowel injury diagnosed how?
abdominal CT showing intra-abdominal fluid not associated with a solid organ injury, bowel wall thickening, mesenteric hematoma
What must patients with nonconclusive CT findings of small bowel injury need to tolerate before discharge
a diet
How do you repair small bowel injuries to avoid stricture?
transversely
what size laceration requires resection and reanastamosis of small bowel?
greater than 50% circumference or results on lumen diameter 1/3 normal size
What do you do if there are multiple close laceration of small bowel?
resect that segment
What size mesenteric hematomas require opening?
>2cm or expanding
Colon trauma most associated with what type of trauma?
penetrating
for right and transverse colon injury, what do you do?
primary anastamosis
For left colon injuries, what is safest?
colostomy and hartman’s pouch or mucous fistula
What do you do with paracolonic hematomas?
open
what is the abscess rate after colon injury? fistula rate?
10%; 2% (higher with primary repair)
Rectal injury most often associated with what?
penetrating trauma
extraperitoneal rectal injury treated with what?
presagral drainage and fecal diversion with colostomy. Serial debridement
intrapeitoneal rectal injury treated with what?
repair defect, presacral drainage, fecal diversion with colostomy
Low rectal injuries treated with what?
transanal repair
Can common hepatic be ligated? why?
yes, collaterals through GDA
Can hepatic lobar arteries be ligated?
yes, unless hypotensive
What is the pringle maneuver?
clamp portal triad. Does not stop hepatic vein bleeding
What do you need to do during repair of retrohepatic IVC injury repair?
atriocaval shunt
Severe penetrating liver injury and pt becomes unstable, what to do?
Pack, go to ICU
What to do with portal triad hematomas?
explore
What do you do with common bile duct injury?
50% or complex- choledocojejuonstomy
What percentage of bile duct anastamoses leak?
10%
What do you do with a portal vein injury behind the pancreas?
Transect pancreas to get to vein. Need to do distal pancreatectomy. Ligation of portal vein results in 50% mortality
What can be placed over a liver laceration to prevent bile leak and help with bleeding?
Omental graft
When has conservative management of blunt liver injury failed?
Patient becomes unstable including needing 4+ prbc, HR >120, SBP 4PRBC to keep HCT >25
What to do with active blush on CT or pseudoaneurysm after blunt liver injury?
OR, Posterior may be better managed with angiogram. Anterior, OR
What is activity restriction with blunt liver injury when managing coservatively?
bed rest for 5 days
When has a spleen injury fully healed?
6 weeks
Postsplenectomy sepsis is most common at what age?
1-5 years
Postplenectomy sepsis is greatest risk for how long after operation?
2 years
When has conservative management of splenic injury failed?
Patient becomes unstable including needing 2+ prbc, HR >120, SBP 2PRBC to keep HCT >25
What activity restriction is required for conservative management of spleen injury
bed rest for 5 days
What percentage of pacreatic injury is penetrating?
80%
What can a blunt pancreatic injury result in?
pancreatic duct fx, usually perpendicular to duct
What is indicative sign of pancreatic injury?
edema or necrosis of peripancreatic fat
What do you do with a pancreatic contusion?
leave if stable, place drain
What do you do with a distal pancreatic duct injury?
distal pancreatectomy, can take 80% of gland
What do you do with a pancreatic head injury that is not repareable?
place drains, delayed whipple
What can you do other than resection with pancreatic duct injuries?
ERCP stent
What makes the decision of whipple v distal pancreatectomy?
duct injury in relationship to SMA/SMV. Injuries to the right get drains instead of whipple initially
What to do with a pancreatic hematoma?
both penetrating and blunt need to be opened
What is a sign of a missed pancreatic injury?
rising amylase
Major signs of vascular injury are?
active hemorrhage, pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill. Need to go to OR
What are moderate/soft signs of vascular injury?
history of hemorrhage, deficit of anatomically related nerve, large stable/non-pulsatile hematoma–> go to angio
what size vascular injuries need graft?
greater than 2 cm get saphenous graft
what to do with a transection of a single artery in healthy calf?
ligate
How many hours of ischemia requires fasciotomy?
4
what compartment pressure = compartment syndrome?
>20
What residual stenosis of IVC after repair does not require saphenous or synthetic patch?
50%
IVC injury- clamp above and below?
no, can tear easily, apply pressure above and below?
How do you fix a posterior IVC injury?
through anterior wall of IVC
how much blood can be lost through a femur fx?
>2L
Anterior shoulder dislocation puts what nerve/artery at risk?
axillary nerve
Posterior shoulder dislocation puts what nerve/artery at risk?
Axillary artery
Proximal humerus injury puts what nerve/artery at risk?
Axillary nerve
midshaft humerus injury puts what nerve/artery at risk?
radial nerve
distal humerus puts what nerve/artery at risk?
brachial artery
elbow dislocation puts what nerve/artery at risk?
brachial artery
distal radius injury puts what nerve/artery at risk?
median nerve
anterior hip dislocation puts what nerve/artery at risk?
Femoral artery
posterior hip dislocation puts what nerve/artery at risk?
sciatic nerve
Distal femur injury puts what nerve/artery at risk?
Popliteal artery
Posterior knee dislocation puts what nerve/artery at risk?
popliteal artery
fibula neck injury puts what nerve/artery at risk?
common peroneal nerve
What is the hardest injury to find in blunt or penetrating trauma to the neck and how is it diagnosed?
- Esophageal injury
- Diagnosed with esophagoscopy and esophagram (best combined modality. 95% of injuries identified when this dual modality is used)
What glascow coma scale score is an indication for intracranial pressure monitoring?
GCS < 8
[ICP monitoring also indicated when there is a suspicion of elevated ICP, or when a patient with moderate to severe head injury is unable to follow clinical exam because they are intubated or for some other reason (thus GCS score unable to be determined).]
What laboratory test is used to diagnose placental abruption in a pregnant trauma patient?
Kleihauer-Betke test
[This test is used to detect fetal blood in the maternal circulation. Signs of abruption include uterine tenderness, contractions, fetal HR < 120. Abruption can be caused by shock or mechanical forces. >50% of all traumatic placental abruptions result in fetal demise.]
[UpToDate: The Kleihauer-Betke test is positive in a small proportion of abruptions. There is poor correlation between the results of this test and the presence or absence of abruption with a sensitivity of only 4%.
The immediate cause of the premature placental separation is rupture of maternal vessels in the decidua basalis, where it interfaces with the anchoring villi of the placenta. Rarely, the bleeding originates from the fetal-placental vessels. The accumulating blood splits the decidua, separating a thin layer of decidua with its placental attachment from the uterus. The bleed may be small and self-limited, or may continue to dissect through the placental-decidual interface, leading to complete or near complete placental separation. The detached portion of the placenta is unable to exchange gases and nutrients; when the remaining fetoplacental unit is unable to compensate for this loss of function, the fetus becomes compromised.
The etiology of bleeding at the decidua basalis remains speculative in most cases, despite extensive clinical and epidemiologic research. A small proportion of all abruptions are related to sudden mechanical events, such as blunt abdominal trauma or rapid uterine decompression, which cause shearing of the inelastic placenta due to sudden stretching or contraction of the underlying uterine wall. In motor vehicle crashes, an additional factor is rapid acceleration-deceleration of the uterus, which causes uterine stretch without concomitant placental stretch, leading to a shearing force between the placenta and the uterine wall. Although even minor trauma may be associated with an increased risk of preterm birth, severe maternal trauma is associated with a six-fold increased risk of abruption.
The diagnosis of abruptio placentae is primarily clinical, but findings from imaging, laboratory, and postpartum pathologic studies can be used to support the clinical diagnosis. Women with an acute abruption classically present with the abrupt onset of mild to moderate vaginal bleeding and abdominal and/or back pain, accompanied by uterine contractions. The uterus has increased tone/rigidity and may be tender both during and between contractions. In patients with classic symptoms, fetal heart rate (FHR) abnormalities or intrauterine fetal demise and/or disseminated intravascular coagulation strongly support the clinical diagnosis and indicate extensive placental separation.
Ultrasound examination is useful for identifying a retroplacental hematoma and for excluding other disorders associated with vaginal bleeding and abdominal pain. A retroplacental hematoma is the classic ultrasound finding and strongly supports the clinical diagnosis, but is absent in many patients with abruption.
Postpartum, the absence of characteristic placental findings does not exclude the diagnosis. In a multicenter case-control study, standardized gross and histopathological evaluation of the placenta was only able to confirm a strong clinical diagnosis in 30% of cases (49/162).]
Crepitus, stridor, and/or respiratory compromise in the setting of neck trauma are indicative of what injury?
Laryngeal fracture or tracheal injury
[These are airway emergencies. Need to secure airway emergently in the ER - usually with cricothyroidotomy.]
What kind of dressing should be applied to a sucking chest wound (open pneumothorax)?
Occlusive dressing with tape on 3 sides to prevent development of a tension pneumothorax while allowing the lung to expand with inspiration
[Wound needs to be at least 2/3 the diameter of the trachea to be significant.]
[UpToDate: A “sucking” chest wound exists when air enters the pleural cavity preferentially via an open chest wound, rather than the lungs via the trachea. Placement of an occlusive dressing, taped on three sides, over a sucking chest wound can seal off air entry into the pleural cavity and prevent the expansion of a pneumothorax. Evidence of a tension pneumothorax (eg, severe dyspnea with asymmetric breath sounds and hypotension) requires prehospital decompression with needle thoracostomy.]
What imaging should be obtained immediately in a stable patient with penetrating chest trauma?
Chest Xray
[Place chest tube for pneumothorax or hemothorax.]
[UpToDate: In general, a plain chest radiograph is obtained for all hemodynamically stable patients who present with penetrating chest trauma, whether or not they are experiencing signs or symptoms of intrathoracic injury. For stable patients, many recommend obtaining a posteroanterior (PA) film with the patient upright. With more severely injured patients, this approach is often impractical and possibly dangerous if spinal injuries are suspected. Supine anteroposterior (AP) films are generally obtained in such cases. Retrospective studies suggest that chest radiographs taken during expiration do not increase the sensitivity for detecting pneumothorax.
We recommend that an ultrasound examination of the chest (E-FAST) be performed in all hemodynamically stable patients with penetrating chest trauma. Ultrasound is easily portable, immediately available, and non-invasive. Overall, ultrasound appears to have superior sensitivity and similar specificity to supine AP chest radiography for the identification of pneumothorax in adults. Of note, the size and location of a pneumothorax affects ultrasound’s accuracy (as is the case with plain radiographs); small apical and medial pneumothoraces are more difficult to detect.
When the heart can be clearly visualized (eg, hemothorax does not obscure the image), the sensitivity of the cardiac portion of the FAST examination for identifying hemopericardium after penetrating chest trauma is reported to be as high as 100%, decreasing the need to obtain formal echocardiography. However, if the FAST examination cannot be performed or is inadequate because the heart cannot be well visualized or findings are ambiguous, formal transthoracic echocardiography should be performed if there is any concern for cardiac injury.
Indications for obtaining a chest CT in a hemodynamically stable patient with penetrating thoracic trauma include the following:
- Trajectory of a penetrating object crosses the mediastinum or middle of the chest.
- Symptoms or signs concerning for esophageal or tracheobronchial or vascular injury are present.
- Chest pain, shortness of breath, or other symptoms consistent with injury are present that are not explained adequately by a plain chest radiograph.
These indications are not exhaustive and if there is clinical suspicion for a thoracic injury on other grounds it is reasonable to obtain a CT. CT of the chest demonstrates the greatest sensitivity and specificity for detecting pneumothorax and hemothorax, and most studies of ultrasound and chest radiographs use CT as the gold standard. However, CT exposes the patient to higher levels of radiation and may not be necessary if initial and follow-up plain chest radiographs are normal and there is no clinical suspicion for aortic or other major thoracic injury.
Any patient with a knife or gunshot wound that traverses the mediastinum should be evaluated with a chest CT. Injuries to a number of vital structures, including the heart, great vessels, esophagus, and trachea, can be missed on plain chest radiograph. If CT reveals that the wound track does not traverse the mediastinum or travel close to vital structures, additional diagnostic imaging, such as angiography, echocardiography, and esophagoscopy, may be unnecessary.]
What is the motor component of the th Glasgow coma scale?
- 6 points: Follows commands
- 5 points: Localizes pain
- 4 points: Withdraws from pain
- 3 points: Flexion with pain (decorticate)
- 2 points: Extension with pain (decerebrate)
- 1 point: No response
[For GCS score _<_14 patient needs a head CT. For GCS score _<_10 Patient requires intubation. For GCS score _<_8 Patient needs ICP monitor.]
What is the most commonly injured organ in penetrating trauma?
Small bowel
[Some texts say the liver is most common. Can be hard to diagnose early in blunt trauma.]
What is the major source of morbidity in patients with traumatic duodenal injury?
Fistulas
[Often close with time. Treatment is bowel rest, TPN, octreotide, conservative management for 4-6 weeks.]
[UpToDate: Duodenal injuries are associated with very high complications rates. In a systematic review of 15 case series describing more than 1400 patients with duodenal injuries, complications occurred in 64% of the patients. Complications related to duodenal injury include intraabdominal abscess, posttraumatic pancreatitis, and duodenal fistula, which are discussed below.
Risk factors for complications following duodenal repair include blunt mechanism or high-energy missile injury, injuries involving more than 75% of duodenal circumference, injury of the 1st or 2nd portion of the duodenum, delay in repair greater than 24 hours, and common bile duct injury.
Intraabdominal abscess – The most common complication of duodenal injuries is intraabdominal abscess, which occurs in 11% to 18% of patients. Fluid collections are managed with antibiotics and percutaneous drainage. Reoperation is generally not needed.
Post-traumatic pancreatitis – Post-traumatic pancreatitis complicates duodenal injury in 3% to 15% of patients. Management of post-traumatic pancreatitis is similar to the management of other forms of pancreatitis with bowel rest and nutritional support.
Duodenal fistula – The most life-threatening complication of duodenal injury is duodenal fistula, which occurs in about 7% of patients. Management consists of drainage to control the fistula output, drainage of any associated intraabdominal abscesses, broad spectrum antibiotics, fluid therapy, and nutritional support. In patients who develop a high-output duodenal fistula, re-exploration should be performed, and pyloric exclusion should be considered if not previously performed. Managing patients who have undergone diversion already remains challenging.]
What is the most common cause of death after a myocardial contusion and when is it most at risk of happening?
- Ventricular arrhythmia (V-tach and V-fib)
- Highest risk in first 24 hours
[Supraventricular tacchycardia is the most common overall arrhythmia in these patients. Patients should be placed on cardiac monitoring for 24-48 hours.]
What are 4 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
[UpToDate: Indications for cervical spine surgery include significant cord compression with neurologic deficits, especially those that are progressive, that are not amenable or do not respond to closed reduction, or an unstable vertebral fracture or dislocation. Neurologically intact patients are treated nonoperatively unless there is instability of the vertebral column. Most penetrating injuries require surgical exploration to ensure that there are no foreign bodies imbedded in the tissue, and also to clean the wound to prevent infection.
Defining surgical indications for closed thoracolumbar fractures has been somewhat more challenging, in part because of difficulties defining spinal instability in these lesions. The Denis anatomic-based classification based on a three-column model of spinal stability has somewhat limited clinical utility, as it does not clearly accommodate all fracture types. The Thoracolumbar Injury Severity Score has been proposed as an alternative and uses a scoring system of three variables: the morphology of the injury, the integrity of the posterior ligamentous complex, and the neurologic status of the patient. A total score of less than four indicates a nonoperative injury; more than four, an operative injury; and four, an injury that is operative at the surgeon’s discretion. This algorithm has good intrarater and interrater reliability. The clinical efficacy of the algorithm itself remains to be prospectively evaluated.]
Which one upper extremity and one lower extremity fracture most commonly result in compartment syndrome?
- Upper extremity: Supracondylar humerus fracture
- Lower extremity: Tibial fracture
What is the most common site of facial nerve injury with a temporal skull fracture?
Geniculate ganglion
[Temporal bone fracture is the most common cause of facial nerve injury.]
What is the treatment for a bile duct injury in a trauma patient?
- <50% of circumference: Repair over stent
- >50% of circumference: Choledochojejunostomy
[10% of duct anastomoses leak. Place drains intraop.]
What is the eye opening component of the Glasgow coma scale?
- 4 points: Spontaneous opening
- 3 points: Opens to command
- 2 points: Opens to pain
- 1 point: No response
[For GCS score <14 patient needs a head CT. For GCS score <10 Patient requires intubation. For GCS score <8 Patient needs ICP monitor.]
What is the surgical approach to esophageal injuries?
- Neck: Left side approach
- Upper 2/3 of thoracic esophagus: Right thoracotomy
- Lower 1/3 of thoracic esophagus: Left thoracotomy
[Always drain esophageal and hypopharyngeal repairs - 20% leak rate.]
[UpToDate: The cervical esophagus is generally approached via an incision along the medial border of the left sternocleidomastoid; a right-sided, or if bilateral access is required (eg, coexistent tracheal injury), a transverse incision can be used. However, the chest should also be prepped into the field in case broader exposure is required. Violation of the platysma by a penetrating object predicts deeper injury of vital neck structures 24% to 33% of the time. This includes a 10.8% to 12.6% rate of esophageal injury.
Due to the anatomic confines of the neck, cervical esophageal injuries can often be managed with drainage alone. First and foremost is the identification of associated injuries including the airway, major vessels, and spine. Dissection should begin along the lateral edge of the sternocleidomastoid muscle with judicious use of cautery. The omohyoid muscle is then divided and the lateral aspect of the esophagus is exposed. Care must be taken to avoid injury to the recurrent laryngeal nerve, which includes careful retraction of the deeper structures (a finger on the trachea is best), minimal use of cautery and, if cautery is used, bipolar rather than monopolar cautery. The retroesophageal space should be opened sharply. If an injury is readily identified, it may be closed in two layers without tension. Otherwise, closed-suction drains may be simply placed behind the esophagus and in any potentially contaminated space with subsequent wound closure. The patient should be kept nil per os (NPO) and restudied with barium esophagram in approximately one week based on drain output.
The hemodynamically stable patient in whom the diagnosis has been confirmed by endoscopy should undergo posterolateral thoracotomy. The proximal esophagus (upper and middle third) is approached via right lateral thoracotomy incision (fifth to eighth interspace depending on the suspected site of injury) and the distal esophagus (lower third) via a left thoracotomy (seventh or eighth interspace).
Special considerations in the context of trauma include the following:
- For patients requiring immediate transport to the operating room, without time for radiologic or preoperative endoscopic assessment, endoscopy and bronchoscopy can be performed intraoperatively. Intraoperative endoscopy aids in identifying the site(s) of perforation, and to assess for a leak following repair. Following endoscopy, place a nasogastric tube under direct vision if an injury is identified.
- Primary thoracic esophageal repairs should be buttressed with pleura, pericardium, intercostal muscle, or diaphragm. The stomach should not be pulled up into the chest to buttress a distal esophageal injury, as this tends to create severe gastroesophageal reflux due to the disruption of the gastroesophageal junction.
- Wide chest drainage using closed-suction drains is necessary following repair.]
What do the following look like on CT and which vessel is injuried?
- Epidural hematoma:
- Subdural hematoma:
- Epidural hematoma: Biconcave (lens-shaped) deformity on CT caused by arterial bleeding from the middle meningeal artery
- Subdural hematoma: Crescent-shaped deformity on CT caused by tearing of venous plexus (bridging veins) that cross between the dura and arachnoid
How is asymptomatic penetrating trauma to the neck managed by zone?
- Zone I:
- Zone II:
- Zone III:
- Zone I: Need angiography, bronchoscopy, esophagoscopy, and barium swallow; a pericardial window may be indicated. May need median sternotomy to reach these lesions
- Zone II: Need neck expoloration in OR
- Zone III: Need angiography and laryngoscopy. May need jaw subluxation/digastric and sternocleidomastoid muscle release/mastoid sinus resection to reach vascular injuries in this location
[UpToDate: Mortality in patients with penetrating neck injury (PNI) appears to be highest with Zone I injuries (below the cricoid cartilage).
The management of penetrating neck injuries (PNIs), particularly in stable patients, has remained a source of debate among trauma surgeons for decades. A brief summary of this debate is provided above.
Improvements in diagnostic imaging technology, particularly multidetector helical computed tomography with angiography (MDCT-A), have led many trauma centers to discard anatomic zone-based protocols for the management of PNI in favor of a “no-zone” approach. No-zone algorithms are based on patient stability and the presence of soft versus hard signs of injury, regardless of injury location (ie, the zone of the neck involved), whereas zone-driven approaches are based on the location of the external wound.
MDCT-A has high sensitivity and specificity for laryngotracheal and vascular injuries, and identifies many pharyngoesophageal injuries, thereby eliminating the need for multiple imaging studies to assess each type of injury. In addition, MDCT-A enables clinicians to assess signs of injury situated close to important internal structures (so-called “proximity wounds”) and determine whether these are high or low risk, thereby allowing for better informed decisions concerning the need for observation or surgical exploration.
Studies using MDCT-A in the assessment of PNI patients have shown that important discrepancies frequently exist between the location of the entry wound and the structures injured. As an example, one prospective study found that one in five surface wounds located in Zone II extended across Zone I or Zone III internally. Furthermore, when multiple neck wounds are present in more than one region, zone-driven protocols become unclear. Perhaps most importantly, use of a zone-based approach in stable, symptomatic patients has led to a high rate of negative surgical exploration in Zone II injuries.
The no-zone approach is relatively new and evidence about its effectiveness is limited. One potential problem is the limitations of MDCT-A for detecting pharyngoesophageal injuries, which are potentially life-threatening if missed. Given the controversies about the management of PNI, limited evidence base, and variability in resources and experience, decisions about whether to use a selective, zone-based management approach or a no-zone approach will vary by local expertise and resources and are likely to remain institution-specific for the time being.]
What is the treatment for an anterior and a posterior nose bleed?
Anterior: Packing
Posterior: Attempt balloon tamponade first, may need angioembolization of internal maxillary artery or ethmoidal artery
[UpToDate: Most epistaxis is anterior, occurring in Kiesselbach’s plexus; posterior bleeds can cause significant hemorrhage. Anterior bleeds arise most commonly from trauma; other etiologies for anterior and posterior bleeds include coagulation or platelet disorders, vascular lesions, nasal tumors, and hereditary telangiectasias. Hypertension does not cause, but may prolong, epistaxis.
Posterior epistaxis arises most commonly from the posterolateral branches of the sphenopalatine artery (branch of maxillary artery) but may also arise from the carotid artery.
Posterior nosebleeds can result in significant hemorrhage. The skilled clinician may temporize with nasal packing, but most patients require prompt referral to an emergency department, possible consultation with an otolaryngologist, and sometimes hospital admission.]
Pair the below lower extremity injuries with the commonly associated nerve or artery injury:
- Anterior hip dislocation:
- Posterior hip dislocation:
- Distal (supracondylar) femur fracture:
- Posterior knee dislocation:
- Fibula neck fracture:
- Anterior hip dislocation: Femoral artery
- Posterior hip dislocation: Sciatic nerve
- Distal (supracondylar) femur fracture: Popliteal artery
- Posterior knee dislocation: Popliteal artery
- Fibula neck fracture: Common peroneal nerve
Are pancreatic injuries more common in blunt or penetrating trauma?
Penetrating trauma accounts for 80% of pancreatic injuries
[Blunt injury can result in pancreatic duct fractures, usually perpendicular to the duct. Edema or necrosis of peripancreatic fat is usually indicative of injury.]
[UpToDate: Approximately 75% to 85% of blunt injuries to the duodenum and pancreas are caused by motor vehicle collisions. The mechanism is typically due to crushing of these fixed retroperitoneal organs between the vertebral column and steering wheel or seatbelt. The remainder of blunt duodenal and pancreatic injuries results from falls and assaults. Blunt duodenal and pancreatic injury can also be due to bicycle accidents in which the duodenum and pancreas are crushed between the spinal column and bicycle (or motorcycle) handlebar.
Any implement or missile that enters the abdomen can injure the pancreas or duodenum. Gunshot or shotgun wounds are more likely to result in injury compared with stab wounds because of their high energy. However, depending upon the girth of the victim and force applied, even a short implement that penetrates the upper abdomen can cause duodenal or pancreatic injury.]
What should be done for an unstable patient with a traumatic pelvic fracture who has a negative FAST, negative DPL, and negative CXR?
Stabilize pelvis and go to cath lab for angioembolization?
[Anterior pelvic fractures are more likely to have venous bleeding, whereas posterior pelvic fractures are more likely to have arterial bleeding.]
What are the boundaries of the 3 columns of the thoracolumbar spine?
- Anterior: Anterior longitudinal ligament and anterior half of the vertebral body
- Middle: Posterior half of the vertebral body and posterior longitudinal ligament
- Posterior: Facet joints, lamina, spinous processes, interspinous ligament
[The spine is considered unstable with disruption of more than 1 column. Compression (wedge) fractures usually involve the anterior column only and are considered stable. Burst fractures are considered unstable (>1 column) and require spinal fusion.]
What can be used to assess for urine leak at the end of a surgical exploration for renal injury in a trauma patient?
Methylene blue
[UpToDate: A dye is instilled into the bladder through the bladder catheter; options include 200 to 500 mL of either methylene blue (two to three drops in saline) or sterile infant formula (commonly available in obstetric operating rooms; no dilution required). Intravesical dye is primarily for suspected bladder injury; ureteral injuries distal from the bladder may not be revealed.]
FAST scan is often falsely negative in patients with which three findings?
- <50-80 mL of free fluid
- Retroperitoneal bleeding
- Hollow viscus injury
[Need laparotomy if FAST scan is positive. In hypotensive patients with a negative FAST or negative DPL, the source of bleeding (pelvic fracture, chest, extremity) must be found.]
What is the operative approach to aortic injury after blunt trauma?
Left thoracotomy and repair with partial left heart bypass or place a covered stent endograft (for distal transections only)
[Important to treat other life-threatening injuries 1st. For example a patient with a positive FAST needs to have that addressed before the aortic transection.]
[UpToDate: Open surgical repair of the thoracic aorta is performed under general anesthesia using a double lumen tube. One-lung ventilation allows collapse of the left lung and facilitates access to the aorta. It is important to note that patients with severe associated right chest or lung injuries may not tolerate one-lung ventilation. Delayed repair or endovascular repair may be warranted.
The extent of the thoracotomy incision is based upon the location of the pathology. As examples, in blunt aortic injury, the aortic disruption usually occurs at the aortic isthmus, and thus, a fourth intercostal space thoracotomy incision should be performed. More extensive involvement may require sternotomy or thoracoabdominal exposure.
Once the chest is entered, the site of pathology is identified and any bleeding should be controlled with direct pressure while an aortic clamp is placed just distal to the left subclavian artery. If the aortic disruption is in close proximity to the left subclavian artery, the clamp will need to be placed between the left common carotid artery and the left subclavian artery. In some cases, such as a small traumatic tear, the aorta can be repaired primarily; however, most patients require the placement of an interposition graft (eg, Dacron).]
What is the treatment for a urethral injury in a trauma patient?
- Small/partial tears: May be able to place a bridging urethral catheter across the tear area and repair in 2-3 months
- Significant tears: Suprapubic cystostomy tube and repair in 2-3 months
[High stricture and impotence rate if a significant urethral injury is repaired early.]
[UpToDate: Optimal definitive management of urethral injuries depends on several factors, including: location (anterior or posterior), severity (partial or complete), and the preference and expertise of the consulting urologist. Options vary from placement of a Foley catheter to facilitate healing by secondary intention (for some partial anterior urethral injuries) to early endoscopic realignment or delayed urethroplasty (for posterior urethral injuries). Often, placement of a suprapubic cystostomy tube will be required to promote decompression of the bladder and divert urine from the healing urethral injury or anastomosis. Regardless of the approach, the ultimate goal is the maintenance of urinary continence and sexual function.]
Diagnostic peritoneal lavage (DPL) is often falsely negative in patients with which two findings?
- Retroperitoneal bleed
- Contained hematoma
What are the boundaries of the 3 zones of the neck?
- Zone I: Clavicle to cricoid cartilage
- Zone II: Cricoid to angle of mandible
- Zone III: Angle of mandible to base of skull
- Fractures of which ribs are a high risk for aortic transection?
- What is a sternal fracture a high risk for?
- 1st and 2nd rib fractures
- Cardiac contusion
What is the treatment for the below bladder injuries in a trauma patient?
- Extraperitoneal bladder rupture:
- Intraperitoneal bladder rupture:
- Extraperitoneal bladder rupture: Foley for 7-14 days (cystogram shows starbursts)
- Intraperitoneal bladder rupture: Operation and repair of defect followed by foley drainage (Cystogram shows leak)
Where is the best site for a cutdown for venous access?
Saphenous vein at the ankle
Which renal vein can be ligated in a trauma patient?
Left renal veincan be ligated near the IVC because it has adrenal and gonadal vein collaterals
[The right renal vein does not have these collaterals. With exploration, try to get control of the vascular hilum before addressing an injury to the collecting duct system. Drains should be placed intraoperatively, especially if there is an injury to the collecting duct system. 95% of traumatic renal injuries are treated nonoperatively.]
Raccoon eyes (peri-orbital ecchymosis) is indicative of what injury?
Basal skull fracture (anterior fossa fracture)
[Can also have hemotympanum and CSF rhinorrhea/otorrhea with basal skull fractures. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]
[UpToDate: “Raccoon eyes” is a common term for periorbital ecchymosis, which suggests a basilar skull fracture or anterior or middle fossa facial trauma. Like Battle sign, raccoon eyes are typically NOT present during the examination immediately following the injury but appear one to three days later.]
How are the below small bowel injuries managed in a trauma patient?
- Small laceration:
- Large laceration (>50% of circumference):
- Multiple small laceration in close proximity:
- Mesenteric hematoma:
- Small laceration: Repair laceration transversely (avoids stricture)
- Large laceration (>50% of circumference): Resection and reanastomosis
- Multiple small laceration in close proximity: Resection and reanastomosis
- Mesenteric hematoma: Open it if expanding or if large (>2 cm)
[UpToDate: Low grade injuries (grade I, II, or III) of the stomach, small bowel, colon, and rectum can usually be repaired primarily, whereas higher grade injuries are generally not amenable to primary repair, and will require resection.
Grade I – Partial-thickness lacerations should be repaired primarily in one or two layers. Intramural hematomas encountered intraoperatively are typically opened, evacuated, and the bowel wall inspected and repaired.
Grade II – The edges of small, full-thickness lacerations should be debrided to fresh margins and repaired as in grade I injuries. Small bowel defects should be closed transversely (aligned with mesenteric/antimesenteric axis) to avoid narrowing the lumen or compromising bowel vascularity.
Grade III – Many larger lacerations of the small bowel, colon, and rectum can also be repaired with debridement and primary closure.
Grade IV and V – Extensive injury or devascularized segments of small or large bowel require resection and anastomosis as appropriate. Such injuries to the stomach and/or duodenum often require complex repair or reconstruction depending upon the location and extent of injury as well as the patient’s overall clinical status.]
Following chest tube placement in a trauma patient, what volume output would be a relative indication for a thoracotomy in the OR?
- >1,500 cc after initial insertion
- >250 cc/h for 3 hours
- >2,500 cc in 24 hour period
- Bleeding with hemodynamic instability
[Need to drain all blood in <48 hours to prevent fibrothorax, pulmonary entrapment, and infected hemothorax. Unresolved hemothorax after 2 well-placed chest tubes requires thoracoscopic drainage.]
What is the treatment of a tracheobronchial injury with ongoing air leak detected with chest tube?
- Clamp chest tube (one of the rare times when this is indicated)
- May need mainstem intubation on unaffected side
- Must be repaired if large air leak and respiratory compromise or after 2 weeks of persistent air leak
[Bronchus injuries are more common on the right. Diagnosis with bronchoscopy.]
What is a Jefferson fracture?
C1 burst fracture caused by axial loading
[Treatment is a rigid collar.]
[UpToDate: The Jefferson fracture of C1 is highly unstable and occurs when a vertical compression force is transmitted through the occipital condyles to the lateral masses of the atlas. This force drives the lateral masses outward, resulting in fractures of the anterior and posterior arches of the C1, with or without disruption of the transverse ligament. Disruption of the transverse ligament determines instability.
Prevertebral hemorrhage combined with disruption of the transverse ligament may cause an increase in the predental space between C1 and the odontoid (dens) seen on the lateral radiograph. A predental space greater than 3 mm in adults or 5 mm in children is abnormal. In the anterior-posterior (AP) projection (open-mouth or odontoid view), the masses of C1 lie lateral to the outer margins of the articular pillars of C2. The Jefferson fracture may be difficult to recognize on plain radiograph if there is minimal displacement.
The transverse ligament is presumed to be disrupted if the interval between the atlas and the dens is increased on a lateral radiograph, or the lateral masses of the atlas extend laterally beyond those of the axis on the odontoid radiograph. In such instances, clinicians should obtain a computed tomography (CT) scan of the cervical spine.]
When are patients at greatest risk of postsplenectomy sepsis?
Within first 2 years of splenectomy
[UpToDate: The highest risk of sepsis occurs during the first few years following splenectomy but has been documented as late as 20 years after splenectomy. In a population-based cohort study, the risk of infection requiring hospital contact was highest during the 90 days following splenectomy, occurring in 10% of individuals who had undergone splenectomy compared with 0.6% in the general population (adjusted odds ratio 18.1, 95% CI 14.8 to 22.1). In comparison, hazard of infection was 4.6-fold higher from 91 to 365 days following splenectomy and 2.5-fold higher >365 days following splenectomy compared with the general population. The fraction of bacteremic episodes due to pneumococci in splenectomized patients, most of whom were adults with a high burden of comorbid conditions, was surprisingly low (<5%); the frequency of fulminant sepsis complicating bacteremia due to nonencapsulated pathogens was not reported.
Similar risks of postsplenectomy infection were noted in a review of 288 patients who had undergone splenectomy: one-third of first infections occurred within the first year of surgery and just over half within two years. One-third of all pneumococcal infections occurred at least five years after splenectomy. Among survivors of an initial episode of severe sepsis in another series, the risk of subsequent severe infection was increased more than sixfold, and the risk of a third episode among survivors of two severe infections was further increased more than twofold.
Patients who undergo posttraumatic splenectomy are thought to retain variable degrees of splenic function postoperatively and may have a reduced risk of subsequent sepsis. However, experimental studies suggest that regenerated splenic tissue is histologically and functionally abnormal, thus offering limited protection against sepsis. Splenic angioembolization is often utilized in the management of patients with moderate splenic injury to avoid splenectomy. Patients who have undergone this procedure may subsequently demonstrate Howell-Jolly bodies on peripheral blood smears, a sign of splenic hypofunction indicating an increased risk of asplenic sepsis.]
When is a CT scan indicated following blunt trauma?
- Abdominal pain
- Need for general anesthesia
- Closed head injury
- Intoxicants on board
- Paraplegia
- Distracting injury
- Hematuria
[Patients requiring a DPL that turned out negative will need an abdominal CT scan.]
What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?
Inferior vena cava compression
[Low cardiac output causes visceral and renal malperfusion (decreased urine output). Upward displacement of diaphragm affects ventilation. Treatment is decompressive laparotomy.]
What fraction of total blood volume can a pregnant woman lose without having clinical signs of blood loss?
1/3 of total blood volume
[Check for vaginal discharge in a pregnant trauma patient to assess for blood, amniotic fluid. Also check for effacement, dilation, fetal station.]
Which cranial nerves can be injured with temporal skull fractures?
- CN VII (facial nerve)
- CN VIII (vestibulocochlear nerve)
[Temporal skull fractures are most commonly associated with lateral skull or orbital blows. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]
Which approach is indicated for surgical repair of each of the following?
- Trachea:
- Proximal left mainstem bronchus injury:
- Distal left mainstem bronchus injury:
- Proximal right mainstem bronchus injury:
- Distal right mainstem bronchus injury:
- Trachea: Right thoracotomy
- Proximal left mainstem bronchus injury: Right thoracotomy
- Distal left mainstem bronchus injury: Left thoracotomy
- Proximal right mainstem bronchus injury: Right thoracotomy
- Distal right mainstem bronchus injury: Right thoracotomy
[A right thoracotomy approach is preferred for most cases because it avoids the aorta.]
What is a normal intracranial pressure (ICP), at what pressure is treatment indicated, and what cerebral perfusion pressure (CPP) is desired?
- Normal ICP is 10
- ICP >20 requires treatment
- Want CPP >60
When should a fasciotomy be considered in a trauma patient with a vascular injury?
When the injury results in ischemia for > 4-6 hours
[Compartment syndrome should be considered if compartment pressures exceed 20 mmHg or if clinical exam suggests elevated pressures.]
[UpToDate: Prophylactic fasciotomy should be performed in all high-risk extremities which can include patients with significant crush injury, and those patients with an ischemic time greater than 6 hours, which includes prehospital and operative time.
In the lower extremity, the standard approach is a two-incision four compartment release through medial and lateral lower leg incisions. Thigh compartment syndrome is rare but is similarly managed by opening the anterior and posterior fascia of the thigh.
In the upper extremity, forearm compartment syndrome is decompressed through a single volar incision.
Following decompression, the extremity wound is initially dressed with moist sterile gauze. As the swelling in the extremity decreases, the wound edges can be gradually reapproximated. In some cases, the skin edges can eventually be closed, but many of these wounds require skin grafting. Complications related to the need for fasciotomy, including rhabdomyolysis and wound-related issues, are discussed in detail elsewhere.]
What is the Le Fort classification of facial fractures and what is the treatment for each?
Classification
- Type I: Maxillary fracture straight across
- Type II: Lateral to nasal bone, underneath eyes, diagonal toward maxilla
- Type III: Lateral orbital walls
Treatment
- Type I: Reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires
- Type II: Same as type I
- Type III: Suspension wiring to stable frontal bone, may need external fixation
What is the treatment for each of the below in the setting of neck trauma?
- Thyroid gland injury:
- Recurrent laryngeal nerve injury:
- Vertebral artery bleed:
- Common carotid artery bleed:
- Thyroid gland injury: Control bleeding and drain (not thyroidectomy)
- Recurrent laryngeal nerve injury: Can try to repair or can reimplant in cricoarytenoid muscle
- Vertebral artery bleed: Can embolize or ligate without sequela in majority of patients
- Common carotid artery bleed: Ligation will cause a stroke in 20% of patients
Battle sign (mastoid ecchymosis) is indicative of what injury?
Basal skull fracture (middle fossa fracture)
[Injury to facial nerve may occur with a middle fossa fracture. If facial nerve is injured, patient will need exploration and repair. Can also have hemotympanum and CSF rhinorrhea/otorrhea with basal skull fractures. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]
[UpToDate: Retroauricular or mastoid ecchymosis (ie, Battle sign) typically appears one to three days after the fracture is sustained.]
When do catecholamines peak following trauma?
24-48 hours after injury
[ADH, ACTH, and glucagon also increase after trauma (part of fight or flight response).]
Where is the aorta usually injured in blunt trauma?
Ligamentum arteriosum (Just distal to subclavian takeoff)
[Other common areas include near the aortic valve and where the aorta traverses the diaphragm. Diagnosis with CT angiogram of the chest. Chest xray is normal in 5% of patients with aortic tears.]
[UpToDate: Most blunt injuries of the thoracic aorta occur at the aortic isthmus just distal to the left subclavian artery. Other locations include the transverse arch, proximal ascending aorta, and descending aorta just proximal to the diaphragm.
A number of theories are used to explain the mechanism of thoracic aortic injury at the isthmus. It is likely that most injuries probably involve a combination of forces.
- The isthmus is thought to be a transition zone between the more mobile ascending aorta and arch and the relatively fixed descending thoracic aorta which allows for stretching with rapid deceleration.
- The isthmus may be intrinsically weaker than the remainder of the aorta as evidenced by a series of tensile strength tests conducted on aortic samples.
- Blunt aortic injury may be the result of a “water hammer” effect in which compression of the abdomen due to a sudden impact occludes the aorta, leading to rupture of the proximal, intrinsically weak isthmus or other susceptible portion of the aorta. This proposed mechanism may explain the association between blunt aortic injury and diaphragmatic rupture.
- The “osseous pinch,” theory purports that the aorta is trapped between the anterior bony structures (manubrium, first rib, medial clavicles, and sternum) and the vertebral column leading to focal rupture.
Regardless of the force mechanism leading to tissue disruption, it appears that the time course of aortic rupture occurs as two distinct phases separated by an interval of time. Rupture of the intimal and medial layers occurs first, followed by an interval of unpredictable duration, and then rupture of the adventitia. The duration of time between intima/medial injury and adventitial rupture may be from seconds to several years. In an in-vitro study of porcine aortic injury, an intimal-medial tear occurred before complete disruption of the entire vessel in 93% of specimens. Partial aortic disruption occurred at a mean mechanical stress that was 74% of the stress needed for complete rupture. These findings suggest that a sufficient residual strength exists in the aortic wall following the initial injury to allow timely diagnosis and treatment.]
What is the formula for cerebral perfusion pressure (CCP) using mean arterial pressure (MAP) and intracranial pressure (ICP) as variables?
CCP = MAP - ICP
Pair the below upper extremity injuries with the commonly associated nerve or artery injury:
- Anterior shoulder dislocation:
- Posterior shoulder dislocation:
- Proximal humerus fracture:
- Midshaft humerus fracture:
- Distal (Supracondylar) humerus fracture:
- Elbow dislocation:
- Distal radius fracture:
- Anterior shoulder dislocation: Axillary nerve
- Posterior shoulder dislocation: Axillary artery
- Proximal humerus fracture: Axillary nerve
- Midshaft humerus fracture: Radial nerve
- Distal (Supracondylar) humerus fracture: Brachial artery
- Elbow dislocation: Brachial artery
- Distal radius fracture: Median nerve
Blood pressure is usually normal until what percent of total blood volume is lost?
30%
[Resuscitate with 2L of crystalloid, then blood.]
What are the 3 types of odontoid fracture?
- Type I: Above the base (Stable)
- Type II: At the base (Unstable and will need fusion or halo)
- Type III: Extends into the vertebral body (Unstable and will need fusion or halo)
[UpToDate: Forceful flexion or extension of the head in an anterior-posterior orientation (ie, sagittal plane), as might occur with a forward fall onto the forehead, may result in a fracture of the odontoid process, also called the dens. Fractures can occur above the transverse ligaments (type I) or, most commonly, at the base of the odontoid process where it attaches to C2 (type II). Type I fractures are stable. Although spinal cord injury is uncommon, type II odontoid fractures are unstable and complicated by nonunion in over 50% of patients treated with halo vest immobilization. Slight angulation of the force may result in extension of the fracture through the upper portion of the body of C2 (type III). Type III fractures are mechanically unstable, since they allow the odontoid and the occiput to move as a unit. Odontoid fractures are best seen on the AP odontoid radiograph (ie, open-mouth view) and cause prevertebral soft tissue swelling on lateral radiographs. Caution is necessary when interpreting the open mouth view as a radiographic line created by the space between the two front incisors may be confused for a dens fracture.]
Which type of hematoma (epidural or subdural) is characterized by a loss of conciousness (LOC), followed by a lucid interval, and then sudden deterioration (vomiting, restlessness, LOC)?
Epidural hematoma
[Arterial bleeding from middle meningeal artery. Surgery for significant neurologic degeneration or significant mass effect (shift >5 mm). In subdural hematomas, surgery is indicated for significant neurologic degeneration or mass effect (shift >1 cm).]
What are the indications for a laparotomy in a trauma patient?
- Peritonitis
- Evisceration
- Positive DPL or FAST
- Uncontrolled visceral hemorrhage
- Free air
- Diaphragm injury
- Intraperitoneal bladder injury
- Contrast extravasation from a hollow viscus
- Specific renal, pancreatic, and biliary tract injuries
What are the renal hilum structures from anterior to posterior?
Vein, artery, renal pelvis (VAP)
What is the typical order of the below symptoms in the progression of compartment syndrome?
- Anesthesia
- Pain
- Paralysis
- Paresthesia
- Poikilothermia
- Pulselessness
- Pain
- Paresthesia
- Anesthesia
- Paralysis
- Poikilothermia
- Pulselessness
What is the treatment for a stable trauma patient with a splenic injury?
Conservative management (bed rest for 5 days)
[Indications for surgical treatment are hemodynamic instability despite resuscitation, active blush on CT, and pseudoaneurysm. The threshold for splenectomy in children is much higher. Hardly any children undergo splenectomy. Need splenectomy immunizations if splenectomy performed.]
[UpToDate: Splenic injury is graded (I through V) depending upon the extent and depth of splenic hematoma and/or laceration identified on CT scan or intraoperatively. Splenic injury grading is one factor used to stratify patient management. Other factors include associated injuries and medical comorbidities.
Per ATLS protocol, hemodynamically unstable patients with a positive FAST exam or diagnostic peritoneal lavage or aspirate (DPL/DPA) require operative surgical exploration to determine the source of life-threatening hemorrhage that may be due to splenic injury.
For hemodynamically stable patients with low grade (I to III) injuries, we suggest nonoperative management over definitive surgical intervention (Grade 2C). Wide variation exists in the clinical application of nonoperative strategies but, in general, patients are admitted to a monitored care setting, either an intensive care or step-down unit, depending upon the capabilities of the unit, grade of splenic injury, nature and severity of other injuries, and clinical status. We initially place the patient on bed rest, though no clear benefit exists for this practice. In agreement with an expert panel, we obtain serial hemoglobin levels every six hours in the first 24 hours. Patients are not given a diet (ie, nil per os [NPO]) for at least the first 24 hours. When the hemoglobin level is stable and operative intervention unlikely, the patient may eat.
Observation may involve splenic embolization depending upon resources. Failure of nonoperative management indicates a need for angiographic embolization, if not initially used, or surgical exploration.
For hemodynamically stable patients with active contrast extravasation or contrast blush on CT scan, we suggest initial splenic embolization over observation (Grade 2C). Splenic embolization requires specialized imaging facilities and a suitably experienced interventionalist. Failure of embolization indicates the need for surgery.
For patients who develop hemodynamic instability during the course of nonoperative management, we suggest surgical exploration over splenic embolization (Grade 2C).]
What is the verbal component of the Glasgow coma scale?
- 5 points: Oriented
- 4 points: Confused
- 3 points: Inappropriate words
- 2 points: Incomprehensible sounds
- 1 point: No response
[For GCS score <14 patient needs a head CT. For GCS score <10 Patient requires intubation. For GCS score <8 Patient needs ICP monitor.]
What causes coagulopathy in traumatic brain injury?
Release of tissue factor
[UpToDate: Approximately one-third of patients with severe TBI develop a coagulopathy, which is associated with an increased risk of hemorrhage enlargement, poor neurologic outcomes and death. While the coagulopathy may result from existing patient medications such as warfarin or antiplatelet agents, acute TBI is also thought to produce a coagulopathy through the systemic release of tissue factor and brain phospholipids into the circulation leading to inappropriate intravascular coagulation and a consumptive coagulopathy.]
What findings on diagnostic peritoneal lavage (DPL) meet criteria for a positive exam?
- >10cc blood
- >100,000 RBCs/cc
- Food particles
- Bile
- Bacteria
- >500 WBC/cc
[Need laparotomy if DPL is positive. DPL needs to be supraumbilical if pelvic fracture is present.]
What is the treatment for esophageal injuries?
- Contained: Observation
- Not contained: Small injuries can be closed primarily. Extensive injuries or injuries with contamination require drainage
[UpToDate: Primary repair of esophageal injuries can be performed whenever there is an ability to get a closure of healthy tissue without tension. The esophagus should be debrided to healthy tissue and repaired.
Most low grade (I through III) traumatic esophageal perforations can be repaired primarily, or repaired over a drain. If primary repair is not possible because of contamination or hemodynamic instability, but there is only a small amount of tissue loss, an effective strategy is to repair the esophagus around a large T-tube, but this is rarely needed with the availability of esophageal stents. This creates a controlled esophageal-cutaneous fistula, which may close spontaneously after edema resolves and the T-tube is removed. Alternatively, an esophageal stent could be used to cover the defect.
The esophagus should be debrided to healthy tissue and the mucosal defect should be completely exposed, even if this requires enlarging the muscular defect. Failure to close the mucosa will most assuredly result in failure of the repair. Intraoperative endoscopy can be helpful for identifying the extent of the defect. The mucosal defect should be closed first, followed by a second layer closure of the muscularis layer. There are no studies comparing the techniques. Some recommend absorbable suture with knots on the outside to avoid granuloma formation, but this has not been subjected to rigorous evaluation.
Larger defects or those involving significant devascularization (IV, V) require more challenging surgical management. Typically in the traumatic circumstance, esophagectomy with reconstruction is not indicated due to the length and technical nature of the procedure as well as the patient’s hemodynamic status. Rather, esophageal diversion may be required. This includes creation of an end cervical esophagostomy and division of the esophagus at the gastroesophageal junction to exclude the site of injury. If the patient is hemodynamically stable, removal of the thoracic esophagus should be performed. In the unstable patient, the thoracic esophagus may be left in situ with removal later once the patient is stable. While in the abdomen, a gastrostomy is recommended but should be placed strategically so as to not damage the subsequent formation of a gastric tube for reconstruction of the gastrointestinal tract. Feeding jejunostomy is also recommended, although only in stable patients. Delayed esophageal reconstruction is planned months later.
In one review, the types and frequencies of repairs of 346 penetrating traumatic injuries included:
- Primary repair: 82%
- Drainage alone: 11%
- Resection and diversion: 4%
- Resection and anastomosis: 3%
- Drainage as an adjunct procedure: 62%]
What is the surgical approach to repair of a diaphragm injury at the below times?
- <1 week from injury:
- >1 week from injury:
- <1 week from injury: Transabdominal approach
- >1 week from injury: Thoracic approach
[Thoracic approach is needed after 1 week because there may be adhesions in the chest that will need to be taken down. A repair with mesh may be required.]
What is the treatment of duodenal injury in a trauma patient?
80% of injuries requiring surgery can be treated with debridement and primary closure
[Segmental resection with primary end-to-end closure is possible for all segments except the second portion of the duodenum.]
[UpToDate: The majority of duodenal lacerations can be managed by simple procedures such as debridement and primary repair, or resection and re-anastomosis. More complex procedures are rare, but are associated with a high risk of postoperative complications including suture line failure and anastomotic leak or small bowel fistula formation. Mortality is also increased, but is often related to associated injuries and not strictly a consequence of complications related to duodenal repair.
Low grade – Partial thickness injuries (Grade I) are repaired by suturing the serosa in a Lembert fashion. Full thickness duodenal lacerations (Grade II) are debrided and the duodenum is repaired with a tension-free primary closure in one or two layers. Longitudinal injuries should be closed transversely, if possible, to minimize the potential for luminal narrowing. If the injury is judged to be too extensive for primary repair (eg, >3 cm) after debridement, the injured segment should be resected and the duodenal ends brought together with a primary end-to-end duodeno-duodenostomy. Injuries to the 2nd portion of the duodenum may not be amenable to this approach if the common bile duct or ampulla is injured, or if resection would require removal of these structures.
Intermediate grade – As with low-grade injuries, many intermediate (Grade III) injuries can also be treated with debridement and primary closure or resection and primary anastomosis.
High grade – Injuries involving the ampulla (Grade IV, V) increase the complexity of duodenal repair. For limited injuries to the ampulla, management options include stenting or sphincteroplasty. Avulsion of the ampulla can occur and has been successfully managed with common bile duct reimplantation using choledochoduodenostomy. Extensive periampullary injuries, such as intraduodenal bile duct injury, intrapancreatic bile duct injury, or Grade V injury often require staged pancreaticoduodenectomy.]
How are possible penetrating (knife or low-velocity) injuries managed?
Local exploration and observation if fascia not violated
[Penetrating abdominal injuries generally need a laparotomy.]
Which organs are most commonly injured in blunt and penetrating trauma respectively?
- Blunt (80% of all trauma): Liver (Some texts say spleen)
- Penetrating: Small bowel (Some texts say liver)
What is the Pringle maneuver?
Clamping the portal triad
[Does not stop bleeding from hepatic veins.]
What are the borders of “the box” in the context of a penetrating thoracic injury and what studies/procedures should be considered for a patient with a penetrating box injury?
- Clavicles, xiphoid process, nipples
- Consider pericardial window, bronchoscopy, esophagoscopy, barium swallow
[UpToDate: Generally, a knife or other sharp object produces injury along its entry track and may damage any intrathoracic organ in its path. Although knowledge of the size and shape, as well as the angle and direction of the entrance, of the wounding instrument provides some guidance about potential injuries, the extent of internal injury from a seemingly small external wound can easily be underestimated. Of particular importance are penetrating wounds to “the box” because of the high risk of injury to the heart and other mediastinal structures. The box is defined superiorly by the clavicles and sternal notch, laterally by the nipple line, and inferiorly by the costal margins.
Gunshot wounds and other higher velocity implements or debris have a less predictable pattern of injury. The trajectory of a missile may not follow a straight course. In addition, tissues can sustain damage not only from the direct path of the bullet, known as the permanent cavity, but also from the shock waves caused by the bullet, known as the temporary cavity. Temporary cavity wounds are caused by high velocity missiles.]
When does intracranial pressure peak after injury?
48-72 hours after injury
[Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]
What is a hangman’s fracture?
C2 fracture caused by distraction and extension
[Treatment is traction and halo.]
[UpToDate: Traumatic spondylolysis of C2 (so-called “hangman’s fracture”) is an unstable injury that occurs when the cervicocranium (the skull, atlas, and axis functioning as a unit) is thrown into extreme hyperextension as a result of abrupt deceleration (ie, forced extension of an already extended neck). Bilateral pedicle fractures of the axis may occur with or without dislocation in this circumstance. Although this lesion is unstable, spinal cord damage is often minimal because the AP diameter of the neural canal is greatest at C2, and bilateral pedicle fractures permit spinal canal decompression.]
What adjuncts can one use to protect a repaired duodenal injury in a trauma patient?
- Pyloric exclusion
- Gastrojejunostomy
- Feeding and/or draining jejunostomies
- Leave drains (remove when tolerating diet without increased drainage)
- Jejunal serosal patch over hole
[UpToDate: Several adjunctive procedures have been used in conjunction with duodenal repair with a primary aim of decreasing the likelihood of leak following repair. There is no consensus on when these procedures are indicated and none of these techniques have demonstrated a clear benefit. Under most circumstances, these adjunctive techniques are not needed. Pyloric exclusion, duodenal decompression and duodenal diverticularization are described briefly below. Given a lack of data, we prefer pyloric exclusion because it is more easily performed in the face of severe traumatic injuries.
Pyloric exclusion — Pyloric exclusion refers to a procedure in which the pylorus is closed for the purpose of excluding gastric secretions from the duodenal repair. Pyloric exclusion is used selectively as an adjunctive procedure to manage intermediate or high grade duodenal or combined injuries.
Following duodenal repair, the pylorus is sutured closed through a longitudinal antral gastrotomy using partial-thickness absorbable or nonabsorbable sutures placed proximally into the pylorus or alternatively using a noncutting linear stapler applied transversely just distal to the pylorus. Once the pylorus has been closed, a loop gastrojejunostomy is performed.
The pylorus will reopen spontaneously in the majority of patients within three to six weeks, even when nonabsorbable sutures or staples are used. In a small retrospective review of 29 patients with penetrating duodenal injuries, no significant differences in clinical outcomes were seen in patients who underwent pyloric exclusion compared with those who underwent primary repair alone. Although pyloric exclusion is a relatively straightforward procedure to perform, it is associated with a high incidence of marginal ulceration along the gastrojejunostomy.
Duodenal decompression — Following repair, the duodenum can be decompressed in an antegrade (duodenostomy) or a retrograde (jejunostomy) fashion. The rationale for duodenal decompression is to decrease the pressure and volume of secretions in the duodenum, thereby protecting the duodenal repair. In studies that have evaluated tube enterostomy, a serosal patch or mucosal graft taken from the jejunum or stomach has often been used to reinforce the duodenal repair.
There are no randomized trials evaluating the use of duodenal decompression in patients following duodenal injury and the outcomes of retrospective reviews are mixed. Given the lack of consistent results as illustrated in the following studies, and the risk of other complications such as duodenal fistula, we prefer not to use duodenal decompression following duodenal repair.
- One retrospective review of 276 patients with duodenal injuries repaired by primary closure compared 237 patients treated with tube decompression (mostly retrograde tube jejunostomy) and 57 who were not decompressed. Significantly more duodenal fistulas developed in patients who were not decompressed compared with those who were (11 of 57 versus 0 of 237).
- However, in another review of 247 patients, the incidence of duodenal fistula was the same whether or not duodenal decompression was performed. An increased incidence of complications was found in another study in patients with duodenal injury requiring repair and treated with duodenal decompression.
Duodenal diverticulization — Duodenal diverticulization refers to suture closure of the duodenal injury, antrectomy with end-to-side gastrojejunostomy, and tube duodenostomy. It is a complex, time-consuming procedure that is generally unnecessary.]
What should be used to reconstruct a lower extremity arterial injury in a trauma patient?
The contralateral saphenous vein
[A primary repair may be possible if < 2cm segment missing from injured vessel. Vein graft will usually be necessary if > 2cm is missing. Cover site of anastomosis with viable tissue and muscle.]
[UpToDate: For hemodynamically stable patients, the timing of the management of extremity injury when vascular injury is present depends upon the degree and duration of ischemia. Patients with hard signs of vascular injury should be taken immediately to the operating room for evaluation and management. Patients with clinical signs of arterial injury, including an injured extremity index (IEI) <0.9, should be evaluated using computed tomographic (CT) angiography or conventional arteriography depending upon institutional resources. In the presence of bony instability, arterial revascularization is fraught with difficulties. Under these circumstances, arterial shunting, if needed, and fracture stabilization followed by definitive vascular repair once the bones have been stabilized may be the most appropriate sequence of care.
In stabilized patients following initial shunt placement for damage control, or patients with few other injuries, we suggest the following approach at the index operation for definitive vascular reconstruction:
- The patient should be systemically anticoagulated if there are no known contraindications (eg, intracranial bleeding).
- Regional anticoagulation should be used with heparinized saline (1 to 10 Units heparin per mL 0.9% normal saline) injected in the proximal and distal arterial segments.
- Once the injured vessel (artery or vein) has been identified, the devitalized vessel wall should be debrided back to healthy tissue.
- Thrombus should be removed from the proximal and distal artery using a Fogarty embolectomy catheter.
- Whenever possible, the vessel (artery or vein) should be brought together (primary end-to-end anastomosis). However, more typically, reconstruction with an interposition or bypass graft is needed due to an intervening defect.
- The interposition graft should ideally be reversed autologous saphenous vein taken from an uninjured leg. If both lower extremities are injured, the saphenous vein from the least injured extremity can be used, or arm vein can be considered. Prosthetic graft material (eg, polytetrafluoroethylene [PTFE]) is an option for the extremities, if no autologous conduit is available. In a small retrospective review of combat vascular injuries reconstructed with PTFE compared with matched injuries reconstructed with autologous vein, PTFE had good long-term patency and freedom from infection in axillosubclavian region, but long-term outcomes for brachial, common femoral, and superficial femoral reconstruction were sub-optimal.
- At the conclusion of the reconstruction, we confirm the adequacy of arterial repair using Doppler, repeat injured extremity index (IEI), ankle-brachial index (ABI), or completion arteriogram depending upon available time and resources.
- Whenever possible, we repair proximal venous injuries, particularly if the adjacent paired vein is also injured. Venous ligation is appropriate for distal veins and proximal injuries associated with other life-threatening injuries. Extremity injury causing vascular injury is often associated with soft tissue injury that disrupts collateral venous flow, and although the patency rates of venous reconstruction are lower than arterial reconstruction, vein repair provides outflow and limits extremity swelling in the short term. Preserving venous outflow also decreases the likelihood of early arterial graft failure, especially with injuries to the popliteal vessels, which may ultimately decrease the incidence of secondary amputation as compared with venous ligation.]
Is the blood supply to the ureter medial or lateral at the below points?
- Proximal 1/3 ureter:
- Middle 1/3 ureter:
- Distal 1/3 ureter:
- Proximal 1/3 ureter: Medial
- Middle 1/3 ureter: Medial
- Distal 1/3 ureter: Lateral
What lab value can be used to assess fetal lung maturity in a pregnant trauma patient?
Lecithin:Sphingomyelin (LS) ratio
[LS ratio > 2:1 is suggestive of lung maturity. The presence of phosphatidylglycerol and phosphatidylcholine in the amniotic fluid is also suggestive of lung maturity.]
[UpToDate: The lecithin/sphingomyelin (L/S) ratio for assessment of fetal lung maturity was first introduced by Gluck and colleagues in 1971. It is based upon the observation that there is outward flow of lung secretions from the lungs into the amniotic fluid. This process changes the phospholipid composition of amniotic fluid, thereby enabling indirect assessment of fetal lung maturity through evaluation of this fluid.
The concentrations of lecithin and sphingomyelin in amniotic fluid are approximately equal until 32 to 33 weeks of gestation, at which time the concentration of lecithin begins to increase significantly while the sphingomyelin concentration remains about the same. The measurement of sphingomyelin serves as a constant comparison for control of the relative increases in lecithin because the volume of amniotic fluid cannot be accurately measured clinically.
Determining the lecithin/sphingomyelin ratio involves thin-layer chromatography after organic solvent extraction. It is a technically difficult test to perform and interpret; care at each step of sample handling is critical for consistent results. The sample should be kept on ice or refrigerated if transport to a laboratory is required (most laboratories cannot perform this test). Improper storage conditions can change the lecithin/sphingomyelin ratio since amniotic fluid contains enzymes that can be affected by temperature. The amniotic fluid sample must be well mixed before testing. It takes several hours to perform the test and may take 24 hours when both transport and testing time are considered, which is another disadvantage of this method.
Individual laboratories should calculate a threshold value for predicting lung maturity by correlating their test results with clinical outcome as the variation within and between laboratories can be considerable. Empirically, the risk of respiratory distress is exceedingly low when the lecithin/sphingomyelin ratio is greater than 2.0.
Phosphatidylglycerol (PG) is a minor constituent of surfactant. It begins to increase appreciably in amniotic fluid after 35 weeks, several weeks after the rise in lecithin. Because PG enhances the spread of phospholipids on the alveoli, its presence indicates an advanced state of fetal lung development and function.
PG testing can be performed by thin-layer chromatography, so it can be determined alone or in conjunction with testing for the lecithin/sphingomyelin ratio. It may be reported qualitatively as positive or negative, where positive represents an exceedingly low risk of respiratory distress, or quantitatively, where a thin-layer chromatography value >2% is associated with a minimal rate of respiratory distress.
Because thin-layer chromatography is a complicated and time-consuming technique, a rapid, semiquantitative immunologic slide agglutination test (AmnioStat-FLM) and several enzymatic assays were developed and have been validated as acceptable alternative techniques. The slide agglutination test is the most common method for testing for PG; however, it appears to be less sensitive for detecting fetal lung maturity than thin-layer chromatography.
An advantage of testing for PG is that blood or meconium usually does not affect test results. A disadvantage is that the absence of PG, especially before 36 weeks of gestation, is less predictive of the occurrence of respiratory distress than immature results from other tests.]
What is the surgical treatment for laryngeal fractures or tracheal injuries?
- Primary repair (can use strap muscle for airway support)
- Tracheostomy is necessary for most to allow edema to subside and to check for stricture
[Patient was likely stabilized initially with a cricothyroidotomy. This will need to be converted to a tracheostomy after repair.]
What is required to make the diagnosis of flail chest?
_>_2 consecutive ribs fractured at _>_2 sites
[Results in paradoxical chest motion. Underlying pulmonary contusions are the biggest reason for pulmonary impairment.]
What are the supportive measures that can be used to lower intracranial pressure?
- Sedation and paralysis
- Raise head of bed
- Relative hyperventilation (modest cerebral vasoconstriction at CO2 30-35)
- Hypertonic saline (draws fluid out of brain) but keep Na 140-150
- Mannitol (draws fluid out of brain)
- Keppra or Fosphenytoin (prophylaxis against seizure)
[Induction of a barbiturate coma if above measures do not work. If supportive measures do not work then ventriculostomy with drainage of CSF or craniotomy decompression may be required. Most skull fractures do not require surgical treatment. Surgery is indicated if significantly depressed fracture (>1 cm), contaminated wound, or persistent leak not responding to conservative therapy.]
Diffuse axonal brain injury is best assessed with which test?
Head MRI (Shows up better on MRI than CT scan)
[Treatment is supportive. May need craniectomy if elevated intracranial pressure. Poor prognosis.]
What is the best test to evaluate injuries to the below structures?
- Urethra:
- Bladder:
- Ureter:
- Kidney:
- Urethra: Retrograde urethrogram
- Bladder: Cystogram
- Ureter: Intravenous pyelogram or retrograde urethrogram
- Kidney: CT scan
[UpToDate: Bladder injury can be evaluated with a cystogram if cystoscopy cannot be performed; however, a cystogram can detect a laceration or large foreign body, but not more subtle findings (eg, a transmural suture or attenuation of the bladder mucosa). When ureteral injury is suspected, ultrasonography can be helpful as an initial test to assess for hydronephrosis or to exclude a retroperitoneal collection. We follow this with computed tomography with renal contrast or cystoscopy with retrograde intravenous pyelography, depending on test availability.
Once a diagnosis of ureteral injury is suspected or confirmed, a retrograde pyelogram can give more information regarding the precise location of the injury. Depending upon the skills and experience of the urologist, ureteral double-J stenting during the retrograde pyelogram as a first-line treatment may manage the injury and avoid the need for more invasive surgery, especially in cases of ureteric obstruction in the postoperative period without large lacerations.
If a retroperitoneal, pelvic, or abdominal urinoma is suspected, ultrasonography is the initial imaging study of choice. Further clarification of the location of a fluid collection can be evaluated with computed tomography or magnetic resonance imaging.]
Pair the below injuries with the commonly associated injury:
- Temporal or parietal bone fracture:
- Maxillofacial fracture:
- Sternal fracture:
- First or second rib fracture:
- Scapula fracture:
- Left rib fractures 8-12:
- Right rib fractures 8-12:
- Pelvic fracture:
- Temporal or parietal bone fracture: Middle meningeal artery injury (Epidural hematoma)
- Maxillofacial fracture: Cervical spine fracture
- Sternal fracture: Cardiac contusion
- First or second rib fracture: Aortic transection
- Scapula fracture: Pulmonary contusion, aortic transection
- Left rib fractures 8-12: Spleen laceration
- Right rib fractures 8-12: Liver laceration
- Pelvic fracture: Bladder rupture, urethral transection
What is the treatment for duodenal hematoma in a trauma patient?
Conservative management (NGT and TPN)
[Often causes obstruction. Conservative management cures 90% over 2-3 weeks (hematoma is reabsorbed). If duodenal injury is suspected at the time of laparotomy, perform a Kocher maneuver and open the lesser sac through the omentum (check for hematoma, bile, succus, and fat necrosis).]
[UpToDate: Nonoperative management of duodenal and pancreatic injury is safe for patients with blunt Grade I or Grade II injuries of the duodenum (duodenal hematoma) or pancreas (contusion, superficial laceration). Nonoperative management has not been reported for penetrating mechanisms. Patients found to have ductal injury using computed tomography or cholangiopancreatography are not candidates for nonoperative management.
Nonoperative management consists of gastrointestinal decompression and nutritional support, as indicated. For patients with symptoms of proximal bowel obstruction due to duodenal hematoma, a nasogastric tube is placed for decompression and parenteral nutrition initiated. After five to seven days, imaging should be repeated to evaluate patency of the duodenum. If the obstruction has resolved, an oral diet can be initiated. However, if the obstruction persists after 10 to 14 days, exploratory laparotomy is indicated.
Careful follow-up is essential to monitor for complications that indicate the need for surgical exploration. A retrospective multicenter study evaluated the outcomes of 230 patients with blunt pancreatic and/or duodenal injury. Of the 97 patients managed nonoperatively, 10 patients (6 pancreatic, 3 duodenal) failed nonoperative management and required surgery.]
What percent of nasoethmoidal orbital fractures present with CSF leak and what is the treatment for such fractures?
- 70% have CSF leak
- Treatment is conservative therapy for 2 weeks
[Can try epidural catheter to decrease CSF pressure and help close CSF leak. May need surgical closure of dura if leak does not stop.]
CT scan is often falsely negative in patients with which two findings?
- Hollow viscus injury
- Diaphragm injury
What is the treatment for the below pancreatic injuries in a trauma patient?
- Stable pancreatic hematoma:
- Distal pancreatic duct injury:
- Irreparable pancreatic head injury:
- Stable pancreatic hematoma: Conservative management (place drains if discovered in OR)
- Distal pancreatic duct injury: Distal pancreatectomy (can take 80-90% of the mass of the pancreas without causing diabetes)
- Irreparable pancreatic head injury: Place drains initially. Delayed Whipple or ERCP with stent placement may eventually be necessary.
[Drains should be placed if a pancreatic injury is noted in the OR. ERCP is good at finding duct injuries and may be able to treat with temporary stent.]
[UpToDate: Most pancreatic injuries are low grade (Grade I or Grade II) and most can be managed nonoperatively. When injury to the pancreas is identified during abdominal exploration, the integrity of the main pancreatic duct should be evaluated, and the location of the injury (proximal versus distal) ascertained.
Generally accepted principles of operative management of pancreatic injuries include control of bleeding, wide drainage to control potential pancreatic fistula, avoiding pancreaticoenteric anastomoses, and limiting the extent of procedures in the setting of damage control surgery. Perhaps the only consensus among trauma surgeons is that wide closed-suction drainage should be performed. When drains are placed, we prefer to use closed-suction drains rather than sump drainage, which has been associated with a greater incidence of septic pancreatic complications. Drains should be placed transversely, adjacent to the gland. When treating pancreatic injuries, a minimum of two drains should be placed, one superior to the pancreas and one inferior to the pancreas.
- Grade I injuries are minor contusions associated with small hematomas, minor capsular injury, and traumatic pancreatitis. When minor contusions are identified in the operating room, no specific intervention is needed (not even drainage).
- Grade II injuries are pancreatic lacerations that do not involve the main pancreatic duct. Bleeding from the parenchyma is often apparent. Grade II injuries are treated with limited debridement and closed-suction drainage. Several procedures including suture repair of the capsule, omental plug, bipolar cautery, and tissue sealant have been advocated to decrease pancreatic fistula formation from minor pancreatic ducts injury, but there is no evidence to support these methods.
- Higher grade injuries (grades III, IV, V) include pancreatic ductal injuries and these injuries are often associated with duodenal injury. Multiple other traumatic injuries are often associated, necessitating a damage-control approach.
The management of pancreatic ductal injuries depends upon whether the main pancreatic duct is injured to the right or left of the superior mesenteric vein.
Pancreatic transection or parenchymal injury to the left of the superior mesenteric vein is managed with distal pancreatectomy. Distal pancreatic resection can be accomplished without sacrificing the spleen, or significantly prolonging operative time and should be considered in hemodynamically stable patients with isolated pancreatic injury. To salvage the spleen, the splenic artery branches and venous tributaries draining the posterior surface of the pancreas are isolated and ligated, working from distal to proximal, followed by division of the pancreas.
Management of pancreatic duct injury to the right of the superior mesenteric vessels depends upon the presence and extent of pancreatic tissue devitalization and concomitant duodenal injury. Options include debridement and wide suction drainage, extended distal pancreatectomy with division of the pancreas to the right of the superior mesenteric vessels, and pancreaticoduodenectomy.
Due to the high incidence of endocrine insufficiency and diabetes with removal of >90% of the pancreas, some authors have advocated Roux-en-Y distal pancreaticojejunostomy (with oversewing of the proximal segment) for proximal duct transections (ie, central pancreatectomy). Central pancreatectomy has an advantage over distal or subtotal pancreatectomy in preserving the tail of the pancreas and its endocrine and exocrine function, as well as the spleen. However, the risk of anastomotic leak and morbidity are significant and some argue that a more conservative approach should be used. In a review of 134 patients with blunt pancreatic duct injury, 34 patients with proximal injuries (not Grade V) were treated with closed suction drainage alone. Complication rates were no different compared with more aggressive approaches. Favorable results have also been reported for proximal duct injury due to gunshot wounds using debridement, suture repair, and closed suction drainage. These considerations and the complexity of the procedure make central pancreatectomy unsuitable for many patients, particularly multiply-injured patients. The technical aspects of central pancreatectomy are discussed elsewhere.
Main pancreatic duct injuries with extensive injury to the pancreatic head can also be managed using anterior Roux-en-Y pancreaticojejunostomy for internal drainage provided there is sufficient parenchyma that is preserved. However, this procedure has been associated with a high incidence of pancreatic leak and abscess formation.]
When is cesarean section indicated in a pregnant trauma patient?
- 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 risk of immaturity
- Direct intra-uterine trauma
[UpToDate: Emergency cesarean delivery is performed in an attempt to:
- Save the fetus in the setting of imminent maternal death or an abnormal fetal heart rate tracing. Cesarean delivery for fetal indications is generally avoided before fetal viability. However, deciding upon a threshold of viability is challenging, as it remains uncertain which extremely preterm infants, particularly those born at 23 and 24 weeks of gestation, have a reasonable chance of survival without severe deficits.
- Save the mother if cardiopulmonary resuscitation has not been effective within four minutes.
Cesarean delivery is also performed to provide adequate surgical exposure for management of maternal injuries during laparotomy and when a displaced pelvic fracture precludes vaginal delivery.
In pregnant burn patients, delivery is recommended if the pregnancy has reached the third trimester and total body burn surface area is >50%. The route of delivery is based on standard obstetric considerations.
Fetal death is not an indication for cesarean delivery, except in some cases of abruptio placenta resulting in maternal coagulopathy and hemodynamic instability.]
What bladder pressure is indicative of abdominal compartment syndrome?
Bladder pressure > 25-30
[Occurs after massive fluid resuscitation, trauma, or abdominal surgery.]
At what gestational week does the fundal height reach the umbilicus?
20 weeks
[Fundal height can be estimated by gestational week. 20 weeks gestation = 20cm fundal height = umbilicus.]
What is the treatment for the below bowel injuries in a trauma patient?
- Colon injury:
- Extraperitoneal rectal injury:
- Intraperitoneal rectal injury:
- Colon injury: Primary repair/anastomosis
- Extraperitoneal rectal injury: Diverting loop ileostomy (generally not repaired because of inaccessibility)
- Intraperitoneal rectal injury: Primary repair, presacral drainage, consider diverting ileostomy
[Place diverting ileostomy with shock, gross contamination, or extensive injury.]
[UpToDate: For most patients with colon or intraperitoneal rectal injuries, we suggest primary repair, or resection and re-anastomosis (as appropriate), but without a diverting colostomy (Grade 2C). For most patients with extraperitoneal rectal injuries, proximal diverting colostomy alone is sufficient.]
What is the appropriate surgical management of the below ureteral injuries?
- Proximal 1/3 with large (> 2cm) missing segment:
- Middle 1/3 with large (> 2cm) missing segment:
- Distal 1/3 with large (> 2cm) missing segment:
- Proximal 1/3 with small (< 2cm) missing segment:
- Middle 1/3 with small (< 2cm) missing segment:
- Distal 1/3 with small (< 2cm) missing segment:
- Proximal 1/3 with large (> 2cm) missing segment: Temporize with percutaneous nephrostomy, ileal interposition or trans-ureteroureterostomy later
- Middle 1/3 with large (> 2cm) missing segment: Temporize with percutaneous nephrostomy, ileal interposition or trans-ureteroureterostomy later
- Distal 1/3 with large (> 2cm) missing segment: Reimplant in bladder (may need bladder hitch procedure)
- Proximal 1/3 with small (< 2cm) missing segment: Mobilize ends of ureter and perform primary repair over stent
- Middle 1/3 with small (< 2cm) missing segment: Mobilize ends of ureter and perform primary repair over stent
- Distal 1/3 with small (< 2cm) missing segment: Reimplant in bladder (easier anastomosis than primary repair)
[Leave drains for all ureteral injuries.]
What are the principles of surgical management for liver injury in a trauma patient?
- Damage control with peri-hepatic packing (can pack severe penetrating injuries if patient becomes unstable in the OR and the injury is not easily fixed such as with a retrohepatic IVC injury. Patient can be packed and returned to ICU to get the patient resuscitated and stabilized. Live to fight another day)
- Atriocaval shunt for retrohepatic IVC injury (allows for control while performing repair)
- Ligation of common hepatic artery can be done without causing ischemia because of gastroduodenal collaterals
- Leave drains
[Ligation of portal vein associated with 50% mortality.]
[UpToDate: Nonoperative management is the treatment of choice for hemodynamically stable patients with hepatic injury, regardless of injury grade, and consists of observation and supportive care with the adjunctive use of arteriography and hepatic embolization. Retrospective reviews of the National Trauma Data Bank and other observational studies have found that more than 80 percent of patients with blunt hepatic injury can be treated nonoperatively with success rates (defined as no need for operative intervention for the hepatic injury) in >90% of patients. A review of the National Trauma Data Bank identified 35,510 hepatic injuries over a 10-year period from 1994 to 2003. Of these, 91% of adults were successfully managed nonoperatively. Over the study period, the percentage of patients with liver injury managed nonoperatively rose from 75% to 82%, but the overall mortality associated with liver trauma remained unchanged at about 15%. The steady improvement in rates of successful nonoperative management that has occurred in the United States since the mid-1990s appears to be associated with greater overall survival, reduced resource consumption, and lower health care expenditures for patients with liver injuries. Greater utilization of damage control resuscitation strategies over this time period appears to be one factor leading to these higher successful nonoperative management rates.
Successful nonoperative management requires appropriate patient selection and the availability of resources including availability of intensive care unit beds, blood bank support, immediate operating room availability, and surgeons and interventional angiographers experienced in managing hepatic injury.
Patients who are hemodynamically stable but demonstrate extravasation from the liver on computed tomography (CT) of the abdomen have higher failure rates with nonoperative management, and these patients should undergo arteriography and possible liver embolization followed by continued observation and serial hemoglobin determination.
Exploratory laparotomy for trauma consists of initial control of hemorrhage by four-quadrant abdominal packing, followed by systematic inspection of all intraabdominal organs, and exploration of the retroperitoneum, if indicated. Active bleeding is managed prior to addressing gastrointestinal injury.
Control of hemorrhage from liver injury is performed initially using manual compression, portal clamping and perihepatic packing. If packing is successful at controlling bleeding, the packs can be left in place as part of a damage control strategy or an attempt at removal made. Definitive measures to control bleeding from the liver include the use of topical hemostatic agents, coagulation techniques, ligation of intraparenchymal vessels, and direct liver suturing. Low-grade injuries generally respond to conservative techniques for hemostasis.
Higher grade injuries may require hepatic artery ligation to control bleeding or debridement (resectional debridement, anatomic resection) of the liver to remove devitalized tissue. Juxtahepatic injuries (grade V) may require hepatic shunting techniques to identify and repair hepatic vein or inferior vena cava injuries; however, mortality associated with shunting remains high. Patients with devastating injuries (including avulsion) may require hepatectomy and liver transplant.]
What is the most commonly injured segment of the duodenum in trauma patients?
2nd portion of duodenum
[Usually results from blunt trauma (IE crush or deceleration injury). Can also get tears at ligament of treitz.]
