Chapter 15 Trauma - Part 2 Flashcards
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 week
may 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 subclavian
descending 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
