Chapter 23 Flashcards
How is a TBI classified?
By the specific parenchymal lesion as well as the pt’s neurological function
What is the clinical classification of a TBI based on?
GCS < 8 indicates severe injury
GCS 8-12 indicates moderate injury
GCS >12 indicates mild injury
In the GCS, what is the most important predictor of neurologic severity and recovery?
Motor score
How can a TBI be categorized anatomically?
Based on CT scan findings
Postconcussive sx
HA
Inattention
Short-term memory loss
Mood swings
Parenchymal TBI lesions
Include cerebral contusions and intraparenchymal hematomas
Cerebral contusion
Essentially a “brain bruise” with localized intracerebral hemorrhage and edema adjacent to an area of impact
Can enlarge and coalesce into intraparenchymal hematomas
Extra-axial hematomas
Usually characterized by their relationship to the dural lining and include epidural, subdural, and subarachnoid lesions
Epidural hematomas
Most often seen after a direct lateral impact to the temporal region resulting in a skull fx and laceration of the middle meningeal artery
Presentation of epidural hematomas
Experience a brief loss of consciousness and a subsequent lucid interval in which they may appear normal, sleepy, or even intoxicated.
After a short interval, they lose consciousness again as the lesion expands and produces cerebral compression
PE of epidural hematomas
Ipsilateral pupillary dilation occurs as the result of direct compression of the third cranial nerve and reflects impending uncal herniation
Tx of epidural hematomas
Immediate surgical intervention is indicated in any pt with an AMS, a hematoma volume >30 mL, or evidence of midline shift on CT scan
Subdural hematomas
Accumulate between the dura and the brain itself
The shearing or tearing of dural bridging veins is the most common underlying cause of hemorrhage
Subarachnoid hemorrhage
Often represents a shearing mechanism with local vascular disruption
Typically do not cause mass effect
Diffuse axonal injury (DAI)
An axonal shearing injury caused by rapid deceleration, often with little or no evidence of intracerebral trauma on CT scan
Zone I of the neck
Extends from the clavicles to the cricoid cartilage Includes: Thoracic outlet Subclavian vessels Lung apices Thoracic duct Spinal cord Esophagus
Zone II of the neck
Includes all structures between the cricoid and the angle of mandible Including: Carotid and vertebral arteries Jugular veins Trachea Esophagus
Zone III of the neck
The area between the angle of the mandible and the skull base and contains the distal internal carotid artery
Tx of tension pneumo
Immediate decompression, which may be accomplished by inserting a 12-or 14-gauge intravenous catheter into the second or third intercostal space in the midclavicular line
Must always be followed immediately by definitive tube thoracostomy
Tx of massive hemothorax
Airway control
Large-bore IV access
volume infusion
Large chest tube (36 or 40 French) should be placed expeditiously and ideally should be attached to a collecting system with an auto-transfusion reservoir
When is a thoracotomy indicated for massive hemothorax?
> 1500 mL blood loss
Ongoing bleeding of >200 mL/h for >4 hrs
Failure of a hemothorax to drain despite at least two functioning and well-positioned chest tubes
If pt remains hemodynamically unstable despite initial resuscitation attempts
Pericardial tamponade tx in extremis
An emergent left anterolateral thoracotomy can also be performed to relieve tamponade in the ER or the trauma bay
Pericardial tamponade tx in the unstable pt
Urgent sternotomy or thoracotomy should be performed in the OR
Pericardial tamponade tx in stable pts with pericardial fluid evident on FAST
Should undergo a diagnostic subxiphoid pericardial window in the OR to confirm the dx
Tx for open pneumothorax
Temporarily occlude the chest wall with the gloved hand and close with an occlusive dressing taped on three sides to act as a flutter valve
Pts with large chest wounds should subsequently undergo formal operative thoracotomy to evacuate blood clot, debride devitalized tissue and close the chest wall defect
Tx of chest wall injury
Initial care should occur in the ICU with monitoring to detect clinical deterioration, progressive hypoxia, or hypercapnia
Adequate analgesia is paramount for all pts with chest wall trauma in order to facilitate aggressive pulmonary toilet and early immobilization
Tx of lung injury
Pain control
Pulmonary toilet
Supplemental oxygen
Occasionally mechanical ventilatory support
Tx of diaphragm injury
A transabdominal surgical approach should be used in cases of acute rupture to make sure that there are no other intra-abdominal injuries
Laparoscopic repair of the injury may be possible in selected cases
Chronic herniation should be approached via thoracotomy
Tx of blunt cardiac injury
Dobutamine or epinephrine may be useful in overcoming the impaired contractility experienced after blunt cardiac injury
Tx of traumatic aortic injury
Continuous infusion of short-acting beta blocker
In the multiply injured pt, management may be complicated by competing interests
Cardiothoracic surgeon should be consulted for possible repair via open thoracotomy or endovascular stent graft.
When does a traumatic rupture of the aorta occur?
Occurs after rapid deceleration injury, such as a fall from a significant height or high-speed motor vehicle crash
What occurs in 85% of pts with traumatic rupture of the aorta?
Aortic laceration is located just distal to the ligamentum arteriosum, past the left subclavian artery
What are physical findings that increase suspicion of traumatic rupture of the aorta?
Asymmetry of upper extremity blood pressures
Chest wall contusion
Intrascapular pain
Intrascapular murmur
Radiographic signs suggesting traumatic rupture of the aorta
Widened mediastinum (>8 cm) Obliteration of the aortic knob Deviation of the trachea to the right Presence of an apical pleural cap Depression of the left mainstem bronchus Obliteration of the aortopulmonary window Deviation of the esophagus to the right
Notable PE findings for blunt abdominal trauma
Abdominal distention Abdominal guarding Rebound tenderness Hypotension Abdominal wall ecchymoses
What diagnostic studies should be done for blunt abdominal trauma pts who are hemodynamically unstable or who have considerable ongoing fluid requirements?
Should undergo immediate cavitary triage with CXR, pelvis X-ray and either FAST or DPL
Immediate surgery is indicated in if the FAST is positive or the DPL is grossly bloody
What should be done in blunt abdominal trauma pts who remain hemodynamically stable and in whom abdominal injury is suspected?
Get a contrast-enhanced abdominal-pelvic CT scan
Alternatively, serial FAST exams in conjunction with a UA and serial abdominal exams over 24 hrs
Most pts with a penetrating injury to the abdomen will require a _______
Laparotomy
Stab wounds of the abdomen
Plain film of the abdomen should be performed to confirm the absence of a retained foreign body
Gunshot wounds of the abdomen
A chest, abdominal and pelvic X-ray should be performed in order to identify retained bullets and determine the trajectory
Anterior penetrating abdominal wound diagnostics
Local wound exploration using sterile technique and local anesthesia
If the anterior fascia is violated, an open laparotomy or diagnostic laparoscopy should be performed
If peritoneal violation is seen on laparoscopy, an open exploratory laparotomy is indicated
What is the most commonly injured organ in blunt injury?
The liver
What should raise suspicion for hepatic injury?
Pts with a hx of RUQ, right lower chest, or flank trauma
Exam of hepatic injury
RUQ pain or right shoulder pain secondary to diaphragmatic irritation
Tx of hepatic injuries
Most isolated hepatic injuries can be managed nonoperatively regardless of injury grade provided the pt is hemodynamically stable
The presence of hepatic contrast extravasation on initial CT scan suggests active hemorrhage and warrants angiography and possible embolization
What should be done if signs of peritoneal irritation develop with hepatic injury?
Laparotomy is required to explore for hollow visceral injury
Tx of massive hemoperitoneum from hepatic hemorrhage
The liver should be compressed manually until the anesthesia team can match blood losses with transfusion of red cells, plasma, and platelets
The use of autotransfusion and cell-saving devices is highly recommended
Tx of severe liver trauma
Occluding the portal triad at eh hepatoduodenal ligament manually or with a Rumel tourniquet (Pringle maneuver)
If that doesn’t work, the liver should be firmly packed supra- and infrahepatically without dividing the hepatic suspensory ligaments
If that doesn’t work, total hepatic vascular isolation with control of both the suprahepatic and infrahepatic venae cavae may be necessary
Sternotomy or thoracotomy may be required
Physiologic derangements of hepatic trauma
Coagulopathy
Hypothermia
Metabolic acidosis
Tx of physiologic derangements of hepatic trauma
Hemorrhage should be promptly controlled and the laparotomy abbreviated in favor of subsequent abdominal angioembolization and a second laparotomy when the pt is physiologically more stable
What should prompt a concern for splenic trauma?
Hx of trauma to the LUQ, flank, or left chest wall
Pt complaints in splenic injuries
Pain in the LUQ
Left shoulder pain
Left chest wall discomfort
Abdominal tenderness
Dx of splenic injuries
Contrast-enhanced CT scan
Hemodynamically stable splenic pt
Nonoperative management
Tx of isolated low-grade splenic injuries without a blush sign on CT
Bed rest
Serial abdominal examination
Close monitoring of vital signs
Serial hemoglobin evaluation
What should be considered for all pts with severe splenic injuries (>grade III) and in those with a contrast blush, moderate hemoperitoneum, or evidence of ongoing bleeding?
Angioembolization
What is the safest splenectomy approach?
Via midline laparotomy
What can seat belt sign indicate?
Should alert the physician to possible intestinal and mesenteric injury caused by abrupt deceleration
What does the presence of an anterior lumbar compression fracture (Chance fx) suggest?
Extreme hyperflexion and injuries to the duodenum, proximal jejunum, and pancreas should be suspected
What are CT signs suggestive of hollow viscus injury?
Bowel wall thickening
Free intra-abdominal fluid (in the absence of solid organ injury)
Mesenteric stranding
Extraluminal air
Who should undergo urgent operative exploration in a hollow viscus injury?
Pts with: Fever Changes in vital signs Worsening PE findings New leukocytosi
Tx for all victims of penetrating injury to the anterior abdomen with facial violation
Exploratory laparotomy
When is a colonic resection with colostomy indicated?
The presence of shock
Heavy contamination
Destructive injury
Management of intraperitoneal rectal injuries
Managed as if they were colonic injuries
Management of extraperitoneal rectal injuries
Diversion
Distal washout
Presacral drainage
