Chapter 15 - Trauma - Part 2 Flashcards by Julian Burgos

What side is more likely for a diaphragm injury from blunt trauma?

left

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What would you see on CXR from a diaphragm injury

Air fluid level in chest from stomach herniation through hole

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What is the approach for repair of diaphragm injury?

transabdominal if 1 week may need mesh

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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

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Where is aortic tear usually located?

ligamentum arteriosum (just distal to subclavian take-off)
aortic take-off
where aorta crosses diaphragm

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What percentage of aortic tears is CXR normal?

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What blunt trauma mechanisms need further aortic examination?

crash >45mph and falls >15ft
CT chest w/ IV contrast should cover this

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What do you use to control BP with aortic injury?

Nipride and esmolol

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What is the operative approach for aortic injury?

left thoracotomy with partial left heart bypass **treat other life threatening injuries first

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Median sternotomy required for what injuries?

ascending aorta
innominate artery
proximal R subclavian
innominate vein
proximal left common carotid

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Left thoracotomy for what injuries?

left subclavian, descending aorta

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Operative approach for distal right subclavian artery injury?

midclavicular incision, 1/2 resection of medial clavicle

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most common cause of death in myocardial contusion?

arrhythmia: v-tach and v-fib (risk highest in 1st 24h)

SVT most common arrhythmia

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Flail chest occurs when?

>= 2 consecutive fractures in >=2 sites -pulmonary contusion biggest impairment

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What is the penetrating box in chest injuries?

What do you do if there is a penetrating wound to this area?

borders are clavicles, xiphoid, nips

need pericardial window, bronchoscopy, esophagoscopy, barium swallow

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penetrating chest wounds outside the penetrating box get treated how?

-chest tube if intubation required -otherwise follow CXR’s

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If you do a pericardial window and find blood, what do you do?

sternotomy, place pericardial drain

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Penetrating injuries anterior-medial to midaxillary line and below nipples need what?

laparotomy or laparoscopy

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What are the traumatic causes of cardiogenic shock?

-caridac tamponade -cardiac contusion -tension pneumo

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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

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Sternal fractures are at a high risk for what cardiac issue?

cardiac contusion

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1st and 2nd rib fx at increased risk of what?

aortic transection

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What do you do with hemodynamically unstable pelvic fractures?

neg DPL, neg CXR and no other signs of bleeding—> stabilize pelvis, go to angio

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Anterior pelvic fx have what type of bleeding?

venous

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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 duodenal 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 suspected with what imaging findings in the setting of trauma?

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... was considered safest... however primary closure is associated with fewer complications * primary anastomosis can also be done if primary repair can't be done * https://www.ncbi.nlm.nih.gov/pubmed?term=12724824 * this includes high-risk patients * https://www.ncbi.nlm.nih.gov/pubmed?term=11371831

What do you do with paracolonic hematomas found in OR?

open, evacuate, inspect, repair primarily

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?

presacral drainage and fecal diversion with colostomy, then serial debridement... used to be the answer fecal diversion can now be used alone https://www.ncbi.nlm.nih.gov/pubmed?term=9783600

intraperitoneal rectal injury treated with what?

* no longer repair defect, presacral drainage, fecal diversion with colostomy * just repair the defect or resect and anastomose * https://www.ncbi.nlm.nih.gov/pubmed?term=12724824

Low rectal injuries treated with what?

transanal repair

Can common hepatic artery 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 would you consider conservative management of blunt liver injury to have 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

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?

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

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Chapter 15 - Trauma - Part 2 Flashcards

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