Critical Care Part 1 Flashcards
What are the two mechanisms of abdominal trauma?
Blunt injury
Penetrating injury
In abdominal trauma, what are the five parts of the abomen?
- Abdominal wall: front and back
- Subcostal portion: containing the stomach, liver, spleen and lesser sac
- Pelvic portion: containing the rectum, internal genitalia, and iliac vessels
- Intraperitoneal portion: containing the large and small bowel (situated between the subcostal and pelvic portions)
- Retroperitoneum: containing the kidneys, urinary tract, great vessels, pancreas and the rest of the colon
Which of the abdominal organs are most commonlu injured?
The three most commonly injured abdominal organs are:
liver, spleen and kidneys
How could one investigate abdominal trauma?
(4)
Investigations assessing the abdomen as a whole include:
- Plain radiography
- Ultrasound: assessing free fluid or haematoma around organs (10% risk of false negative)
- Diagnostic peritoneal lavage: 98% sensitive for intra-peritoneal bleeding
- CT scanning: very good for imaging the retroperitoneal structures, less good for imaging hollow viscus such as the bowel
When would you consider a diagnostic peritoneal lavage?
Possible indications are:
- Suspicion of abdominal trauma
- Unexplained hypotension: with the abdomen being the source of the occult haemorrhage
- Equivocal abdominal examination because of head injury and reduced consciousness
- Presence of a wound that has traversed the abdominal wall but there is no indication for a laparotomy e.g. stab wound in a patient that is haemodrynamically stable
What is a contraindication to diagnostic peritoneal lavage?
When there is a clear indication for laparotomy
e. g. peritonism on examination following trauma
e. g. when there is an abdominal gunshot injury
e. g. hypotensive patient with abdominal distension
How is a diagnostic peritoneal lavage performed?
Open method
- Aseptic technique
- Decompression of the abdomen by inserting a NG tube and urinary catheter
- Local anaesthetic is infiltrated around the sub-umbilical area in the midline
- An incision is made (however, in pelvic fractures a supraumbilical incision is made to avoid disrupting a haematoma)
- Dissection is performed down to the peritoneum
- Cannula is inserted under direct vision and directed down into the pelvis
- 1L of warmed normal saline infused, the patient is tilted and gently rolled to distribute
- The bag of saline can be left on the floor to siphon off the sample f luid from the abdomen
What are the positive criteria for diagnostic peritoneal lavage?
- Presence of lavage fluid in the chest drain or urinary catheter
- Frank blood on entering the abdomen
- Presence of bile or faeces
- Red cell count >100,000 /microL
- White cell count >500 /microL
- Amylase >175U/ml
What are the percutaneous ways of accessing thorax?
Percutaneous Access
Needle throacostomy: drain fluid or biopsy
Tube throacostomy: chest drain for drainage of air, fluid and blood
Thorascopic surgery: permits procedure such as lung/ pleural biopsy, lobectomy. pleurodesis, pleuroectomy, sympathectomy, pericardiocentesis, and pericardial window
Thoracotomy approaches
Median sternotomy: from the top of the manubrium at the jugular notch passing longitudinally through the sternum to the xiphisternum
-permits access to the pericardium, great vessels, and both hemo-thoraces
Posterolateral thoracotomy (most common): incisiomn from point midway between medial scapular edge and thoracic spine, following a curve thats runs 2cm below the inferior scapula angle to the mid-point of the axilla
Anterior thoracotomy: incision from the sternal edge, curving laterally along the intercostal space below the nipple to the axilla
-permits access to the lung, pericadium, lymph nodes and aotro-pulmonary window
Posterior thoracotomy: similar line of incision to posterolateral but starts more posteriorly enroaching on the trapezius and erector spinae
-permits access to the lung and great vessels and is sued in some paediatric cardiac procedures
Bilateral anterior sternotomy (clamshell): incision runs from one nipple to the nipple on the other side, dividing the sternum
-permits access to the pericaridum and pleural cavities
Thoracolaparotomy: posterolateral incision that continues anteriroly to cross the costal margin at the junction of the 6th and 7th ribs, the line runs another 5cm into the abdominal wall, extended inferirly as mideline laparotomy
-permits access to posterior mediastinal structures as they continue into the abdomen such as aorta or oesophagus
What is mediastinoscopy?
The incision runs across the neck 2 fingers above the jugular notch
Allows access to the sub-carinal lymph nodes for diagnosis and staging
Describe the median sternotomy approach.
Median sternotomy: from the top of the manubrium at the jugular notch passing longitudinally through the sternum to the xiphisternum
-permits access to the pericardium, great vessels, and both hemo-thoraces
Describe the posterolateral thoracotomy approach
Posterolateral thoracotomy (most common): incisiomn from point midway between medial scapular edge and thoracic spine, following a curve thats runs 2cm below the inferior scapula angle to the mid-point of the axilla
Describe the posterior thoracotomy apprpoach
Posterior thoracotomy: similar line of incision to posterolateral but starts more posteriorly enroaching on the trapezius and erector spinae
-permits access to the lung and great vessels and is sued in some paediatric cardiac procedures
Describe the bilateral anterior sternotomy approach
Bilateral anterior sternotomy (clamshell): incision runs from one nipple to the nipple on the other side, dividing the sternum
-permits access to the pericaridum and pleural cavities
Describe the thoracolaparotomy approach.
Thoracolaparotomy: posterolateral incision that continues anteriroly to cross the costal margin at the junction of the 6th and 7th ribs, the line runs another 5cm into the abdominal wall, extended inferirly as mideline laparotomy
-permits access to posterior mediastinal structures as they continue into the abdomen such as aorta or oesophagus
