Fiser ABSITE CH. 15 Trauma Flashcards
1
Q
1st peak for trauma deaths occur during what time period? Deaths due to lacerations of heart, aorta, brain, brainstem, spinal cord. Cannot really save these patients; death is too quick.
A
0-30 minutes
2
Q
The 2nd peak in trauma deaths occurs in 30 min to 4 hrs. What classification of injury is the first and second most common cause? These are the patients you can save with rapid assessment (golden hour).
A
Head injury (#1) and hemorrhage (#2)
3
Q
The 3rd peak for trauma deaths occurs in days to weeks. Deaths due to what two main reasons?
A
multisystem organ failure and sepsis
4
Q
Blunt trauma accounts for 80% of all trauma; what is the most common injured organ?
A
liver (some texts say spleen)
5
Q
What is the physics formula for kinetic entery?
A
1/2 mv2
6
Q
What is the LD50 of height of fall.
A
4 stories
7
Q
What is the most commonly injured organ in penetrating injury?
A
small bowel (some texts say liver)
8
Q
What is the most common cause of death in the 1st hour of trauma?
A
hemorrhage
9
Q
Blood pressure is usually OK until ___% of total blood volume is lost.
A
30
10
Q
What is the most common cause of death after reaching the ER alive?
A
head injury
11
Q
What is the most common cause of death long term in trauma patients?
A
infection
12
Q
What is the most common cause of upper airway obstruction? and what is the tx?
A
tongue, perform jaw thrust
13
Q
What injuries are associated with seat belts?
A
small bowel perforations, lumbar spine fractures, sternal fractures
14
Q
What is the best site for cutdown for access?
A
saphenous vein
15
Q
General indications for DPL or FAST?
A
hypotensive pt with blunt trauma
16
Q
What is considered a positive DPL?
A
>10cc of blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500 WBC/cc
17
Q
What do you do if DPL is positive?
A
laparotomy
18
Q
What location should DPL performed if pelvic fracture is present?
A
supraumbilical
19
Q
What 2 things can DPL miss?
A
retroperitoneal bleed, contained hematoma
20
Q
What four places are checked for blood in FAST?
A
perihepatic fossa, perisplenic fossa, pelvis, pericardium
21
Q
FAST can be obstructed by obesity and what amount of free fluid may not be detected?
A
Less than 50-80
22
Q
What 2 things does FAST scan miss?
A
retroperitoneal bleeding, hollow viscus injury
23
Q
Need a CT scan following blunt trauma in pts with ___, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria.
A
abdominal injury
24
Q
Pt requiring DPL that turned out to be negative will need what?
A
abdominal CT scan
25
Name 2 injuries that CT scan misses.
hollow viscous injury, diaphragm injury
26
Peritonitis, evisceration, positive DPL, clinical deterioration, uncontrolled hemorrhage, free air, diaphragm injury, intraperitoneal bladder injury, positive contrast studies, specific renal, pancreas, and biliary tract injuries.
Need laparotomy
27
Possible penetrating abdominal injuries (knife or low-velocity injuries) - When would you just do local exploration and observation? What is the purpose of diagnostic laparoscopy?
fascia not violated; to see if fascia is violated
28
Name three situations that can cause abdominal compartment syndrome.
massive fluid resuscitation, trauma or abdominal surgery
29
What is the bladder pressure seen with abdominal compartment syndrome?
\>25-30
30
What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?
IVC compression
31
How does abdominal compartment syndrome lead to decreased urine output?
renal vein compression
32
What is the treatment for abdominal compartment syndrome?
decompressive laparotomy
33
Pneumatic antishock garment is controversial; use in pts with SBP
50, thoracic
34
ER thoracotomy: In what type of trauma is it used only if pressure/pulse lost ER? What type if lost on way to ER or in ER?
Blunt; Penetrating
35
If ER thoracotomy is performed for cardiac injury, the pericardium is opened anterior to what structure?
phrenic nerve
36
In ER thoracotomy, for what type of injury is the aorta cross clamped? and what structure must you watch out for?
abdominal, esophagus
37
After cross clamping the aorta in ER thoractomy, at what BP level is further treatment futile?
if BP fails to reach 70 mmHg
38
When to catecholamines peak after injury?
24-48 hours
39
What is the time it takes for type specific blood? type and screen? type and crossmatch?
Less than 10 minutes 20-30 min 45-60 min
40
Can you give nonscreened, noncrossmatched blood (Type specific)?
can be administered relatively safely but there may be effects from antibodies to minor antigens in the donated blood
41
GCS
42
Pt with head injury and GCS less than or equal to 14 what next? and 10? and 8?
head CT, intubation, ICP monitor
43
What is the most common artery injured with epidural hematoma?
middle meningeal artery
44
Head CT shows lenticular (lens-shaped) deformity?
epidural hematoma
45
Operation of epidural hematoma indicated for significant neurologic degeneration or significan mass effect (shift \> \_\_\_)
5 mm
46
Subdural hematoma is most commonly from tearing of what?
venous plexus (bridging veins) between dura and arachnoid
47
What is the head CT finding with subdural hematoma?
crescent-shaped deformity
48
Chronic subdural hematoma is usually in elderly after minor fall. Need drainage if \> ___ or causing significant symptoms.
1 cm
49
In which 2 lobes are intracerebral hematoma usually found?
frontal, temporal
50
Traumatic intraventricular hemorrhage needs what procedure if causing hydrocephalus?
ventriculostomy
51
Diffuse axonal injury shows up better on MRI or CT?
MRI
52
Tx for diffuse axonal injury is supportive; may need what if ICP elevated?
craniectomy
53
Mean arterial pressure minus intracranial pressure = ? and what is the desired value
Cerebral perfusion pressure \>60
54
What are the following signs of on brain imaging?: decreased ventricular size, loss of sulci, loss of cisterns
elevated ICP
55
ICP monitors are indicated for (2)
1) Suspected increase in ICP 2) GCS 8
56
Normal ICP is \_\_\_; \>\_\_\_ needs treatment
10; 20
57
Name three interventions that are tried first with elevated ICP
1) Sedation and paralysis 2) Raise head of bed 3) Relative hyperventilation
58
When hyperventilating a pt due to increased ICP. What is a target CO2 range? and what is the effect and what can happen if overhyperventilated?
30-35 cerebral vasoconstriction cerebral ischemia from too much vasoconstriction
59
What can be done with fluids to manage elevated ICP?
give hypertonic saline at times to draw fluid out of brain. (keep Na 140-150, serum Osm 295-310)
60
What medication can be given to pts with elevated ICP and what is the MOA?
mannitol, draws fluid from the brain
61
What are three procedural options for elevated ICP if other measures fail?
ventriculostomy w/CSF drainage; craniotomy decompression; Burr hole
62
What medication is given prophylactically to prevent seizures to most pts with traumatic brain injury?
phenytoin
63
Peak ICP levels occur after how long after head injury?
48-72
64
In traumatic brain injury, dilated pupil indicates temporal pressure on same side. Which CN is compressed?
CN III
65
Racoon eyes are a sign of fracture of what part of the basal skull?
anterior fossa
66
Battle's sign indicates fracture of what part of the basal skull? What nerve can be injured?
middle fossa, facial
67
What is difference in tx for acute and delayed Battle's sign?
if acute need exploration, if delayed, likely secondary to edema and exploration not needed
68
Temporal skull fractures can injure what 2 cranial nerves?
CN VII and VIII
69
What is the most common site of facial nerve injury with temporal skull fractures?
geniculate ganglion
70
Most skull fractures do not require surgical treatment. Operate if (3)
1) Significantly depressed by 8-10mm 2) Contaminated 3) CSF leak not responding to conservative therapy
71
What is a Jefferson fracture and what is the tx?
C-1 burst caused by axial loading. Tx: rigid collar
72
C-2 hangman's fracture is caused by distraction and extension. What is the tx?
traction and halo
73
What are the 3 types of C-2 odontoid fractures and what is their tx?
Type I - above base, stable Type II - at base, unstable (will need fusion or halo) Type III - extends into vertebral body (will need fusion or halo)
74
Cervical facet fractures or dislocations can cause injury to the\_\_\_; usually associated with hyperextension and rotation and with disruption of ___ .
cord; ligament/s
75
What are the three columns of the thoracolumbar spine?
1) anterior - anterior longitudinal ligament and anterior 1/2 of the vertebral body 2) middle - posterior 1/2 of the vertebral body and posterior longitudinal ligament 3) posterior - facet joints, lamina, spinous processess, interspinous ligament
76
What is the significance of more than one thoracolumbar spine column disruption.
Considered unstable
77
What is the difference between compression (wedge) fractures and burst fractures of the thoracolumbar spine?
Compression fractures usually involve the anterior column only and are considered stable. Burst fractures are considered unstable and require spinal fusion.
78
Upright fall. Look for fractures of what 3 areas?
calcaneus, lumbar, wrist/forearm
79
Neurologic deficits without bony injury. What injury should you consider and how to dx?
Check for ligamentous injury with MRI
80
The following are indications for what? fracture or dislocation not reducible with distraction; acute anterior spinal syndrome; open fractures; soft tissue or bony compression of the cord; progressive neurological dysfunction
emergent surgical spine decompression
81
Facial nerve injuries need repair. Fracture of what bone is most common cause of facial nerve injury?
temporal bone
82
Try to preserve skin and not trime edges with lacerations in what part of the body
Face
83
Maxillary fracture straight across is called what?
Le Fort type I
84
Maxillary fracture lateral to nasal bone underneath eyes, diagonal. ( / \ ) What is that called?
Le Fort type II
85
Fracture of lateral orbital walls ( - - ) is called what?
Le Fort type III
86
Nasoethmoidal orbital fractures, what percentage have a CSF leak? Try conservative therapy for how long? What can you try to decrease CSF pressure to help it close? May need surgical closure of dura to deal with leak.
70%, 2 weeks, epidural catheter
87
What is the difference in tx for anterior vs posterior nose bleeds?
anterior is just packing; posterior is harder to dea with; try ballon tamponade 1st; may need angioembolization of internal maxillary artery or ethmoidal artery
88
Orbital blowout fractures - pts with impaired upward gaze or diplopia with upward vision need what?
repair with restoration of orbital floor with bone fragments or bone graft
89
What is the number one indicator of mandibular injury?
malocclusion (misaligned teeth)
90
What are two imaging modalities to assess mandibular injury?
panorex film and fine-cut facial CT scan with reconstruction
91
Most mandibular injuries are repaired with (2)
1) IMF (intermaxillary fixation): metal arch bars to upper and lower dental arches, 6-8 weeks 2) ORIF
92
What is the tx for tripod fracture (zygomatic bone)?
ORIF for cosmesis
93
Pts with maxillofacial fractures are at high risk for what other injury?
cervical spine
94
Asymptomatic blunt trauma to the neck. What is the best next step?
neck CT scan
95
What are the delineations between the zones of the neck?
Zone I is clavicle to cricoid cartilage Zone II is cricoid to angle of mandible Zone III is angle of mandible to base of the skull
96
Asymptomatic penetrating trauma to Zone I of the neck. What is the best next step?
Zone I needs angiography, bronchoscopy, rigid esophagoscopy, barium swallow, pericardial window may be indicated. May need sternotomy to reach these lesions
97
Asymptomatic penetrating trauma to Zone II of the neck. What is the best next step?
Exploration in OR.
98
Asymptomatic penetrating trauma to Zone III of the neck. What is the best next step?
Need angio, laryngoscopy. May need jaw subluxation/digastric and sternocleidomastoid muscle release/mastoid sinus resection to reach vascular injuries in this location.
99
What is the important implication of neck Zone I injuries?
greater potential for intrathoracic great vessel injury
100
What is the tx for symptomatic blunt or penetrating trauma to the neck? (shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit)
neck exploration
101
Injury to what structure is the hardest to find in neck trauma?
esophagus
102
What is the best combined modality for diagnosing esophageal injury (find essentially 95% of injuries when using both methods)
rigid esophagoscopy and esophagogram
103
What is the tx for a contained injury to the esophagus?
observation
104
Noncontained esophageal injury - if small, less than 24 hours, without significant contamination, and patient is stable
primary closure, otherwise make spit fistula and drain leak with chest tube
105
What is the surgical approach to repairing esophageal injury in the neck? Upper 2/3 of thoracic esophagus? Lower 1/3 of thoracic esophagus?
left side, right thoracotomy, left thoracotomy
106
Laryngeal fracture and tracheal injuries are airway emergencies. Secure airway in ER. Tx: primary repair, can use ___ for airway support; ___ necessary for most to allow edema to subside and to check for stricture.
strap muscle, tracheostomy
107
Recurrent laryngeal nerve injury - can try to repair or reimplant in ____ (hoarseness)
cricoarytenoid muscle
108
Management for shotgun injury to neck
1) Angiogram 2) Neck CT (esophagus/tracheal evaluation)
109
Can vertebral artery bleeds be ligated or embolized without sequela?
yes
110
What are the relative indications for thoracotomy in the OR based on chest tube output quantity? (there are 3 of them, bleeding with instability is another indication)
\>1,500 cc after initial insertion \>250 cc/h for 3 hours 2,500 cc/24 h
111
Chest trauma and hemothorax - all blood needs to be drained in what timeframe and why?
Less than 48 hrs, to prevent fibrothorax, pulmonary entrapment, infected hemothorax
112
Unresolved hemothorax after 2 well placed chest tubes. What next?
thoracoscopic or open drainage
113
Sucking chest wound needs to be at least 2/3 the diameter of the trachea to be significant. What is the tx and explain the concern with just plugging the hole?
Cover wound with dressing that has tape on three sides. This prevents development of tension pneumothorax while allowing lung to expand with inspiration
114
Patient has worse oxygenation after chest tube placement. What should you think of?
tracheobronchial injury (one of the very few indications in which clamping the chest tube may be indicated)
115
Bronchial injuries are more common on which side?
right
116
How should you intubate a pt with bronchial injury?
may need to mainstem intubate pt on unaffected side
117
How do you diagnose tracheobronchial injury?
bronchoscopy
118
Blunt trauma injuries to the diaphragm are more common on which side?
left
119
How can the diagnosis of diaphragm injury be made?
CXR shows air-fluid level in chest from stomach herniation through hole
120
What are the following signs of? widened mediastinum, 1st rib fractures, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to right
Aortic transection
121
The tear in aortic transection is usually at the ____ (just distal to subclavian takeoff). Other areas include near the aortic valve and where the aorta traverses the diaphragm.
ligamentum arteriosum
122
What percentage of patients with an aortic tear have a normal CXR?
5%
123
Indications for aortic evaluation include head on mva \> ___ mph or fall \>\_\_\_ ft
45, 15
124
Name the two diagnostic modalities for aortic transection.
aortogram or CT angiogram of chest
125
Name two medications used to control BP in pts with aortic transection.
Nipride and esmolol
126
When repairing aortic transection. Which do you treat first other life-threatening injury (ie positive DPL) or the transection?
treat other injury first
127
What are the 2 most common causes of death after myocardial contusion?
v-tach and v-fib
128
What is the timeframe for the highest risk of death with myocardial contusion?
first 24 hours
129
What is the most common arrhythmia overall in patients with myocardial contusion?
SVT
130
What is the biggest pulmonary impairment in pts with flail chest?
the underlying pulmonary contusion
131
Will aspiration produce CXR findings immediately?
not always
132
What defines the "box" in penetrating chest injury?
clavicles, xiphoid process, nipples
133
Name three traumatic causes of cardiogenic shock?
cardiac tamponade, cardiac contusion, tension pneumothorax
134
What exactly causes the cardiac compromise in tension pneumothorax?
decreased venous return
135
Pts with sternal fractures are at high risk for \_\_\_. Pts with 1st and 2nd rib fractures are at high risk for \_\_\_
cardiac contusion, aortic transection
136
Anterior vs Posterior pelvic fractures. Which is more likely to have venous vs arterial bleeding
Anterior - venous. Posterior - arterial
137
Which portion of the duodenum is most commonly injured in trauma?
2nd (descending portion near ampulla of Vater), can also get tears near ligament of treitz
138
Duodenal trauma - segmental resection with primary end-to-end closure possible with all segments except which one?
second portion
139
What is the major source of morbidity with duodenal trauma?
fistulas
140
Paraduodenal hematomas usually occur with trauma to which portion of the duodenum and why?
usually third portion because it is overlying the spine in blunt injury
141
What is the most common organ injured with penetrating injury?
small bowel
142
Abdominal CT scan showing intra-abdominal fluid not associated with a solid organ injury, bowel wall thickening, or a mesenteric hematoma is suggestive of what injury?
occult small bowel injury
143
Initial tx for occult small bowel injury?
close observation and possibly repeat abdominal CT after 8-12 hours to make sure finding is not getting worse.
144
Pt with non occlusive small bowel injury from trauma, what do you need to make sure of before they are discharged?
can tolerate diet
145
How do you repair small lacerations to small bowel? and large (\>50% of circumference or results in lumen diameter 1/3 normal)?
transversely to avoid stricture; perform resection and reanastomosis
146
When do you open a mesenteric hematoma?
if expanding or large (\>2 cm)
147
What is the difference in repair of trauma between right/transverse colon vs left colon?
right and transverse can perform primary reanastomosis; left colon it is safest to preform colostomy and Hartman's pouch or mucus fistula
148
What is approach to repairing low rectal trauma (less than 5 cm)
transanally
149
Does the pringle maneuver stop bleeding from hepatic veins?
no, clamping of portal triad only
150
If possible, clamp time intervals in the pringle maneuver should be limited to what?
15-20 min
151
Do portal triad hematomas need to be explored?
yes
152
What type of graft can be placed in liver laceration to help with bleeding and prevent bile leaks?
omental graft
153
In blunt liver injury or spleen trauma, what are the indications for OR?
1) Active blush on abdominal CT 2) Pseudoaneurysm
154
How long will pt with blunt liver injury or splenic trauma need bed rest with conservative mgmt?
5 days
155
How long does it take for splenic trauma to fully heal?
6 weeks
156
What age range is postsplenectomy sepsis most common? How long after splenectomy is the greatest risk of sepsis?
1st 5 years of life. Within 2 years of splenectomy.
157
Splenic salvage is associated with increased \_\_\_.
transfusions
158
Is the threshold for splenectomy in children higher or lower?
much higher; hardly any children undergo splenectomy
159
Are immunizations after trauma splenectomy necessary?
yes
160
What is more common blunt or penetrating pancreatic trauma?
penetrating (80%)
161
What is necessary in a distal pancreatic duct injury? How much of the gland can you take?
distal pancreatectomy, 80%
162
What test is useful in evaluating a missed pancreatic injury?
rising amylase
163
When there is vascular and orthopedic trauma, which is repaired first?
vascular
164
Major signs of vascular trauma are pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill. Moderate/soft signs are deficit of anatomically related nerve, large stable/nonpulsatile hematoma. What is the difference in tx between the two?
Major signs go to OR for exploration (some say angio 1st) Moderate/soft signs go to angio
165
Name 6 veins that need repair if injured.
vena cava, femoral, popliteal, brachiocephalic, subclavian, and axillary
166
Limb ischemia \> 4 hours, what tx should you consider and why?
fasciotomy to prevent compartment syndrome
167
Consider compartment syndrome with pressures \> __ mmHg
20
168
What are the "Ps" of compartment syndrome?
pain -\> parathesias -\> anathesia -\> paralysis -\> poikilothermia -\> pulselessness (late finding)
169
Compartment syndrome most commonly occurs with what type of injuries?
supracondylar humeral fractures, tibial fractures, crush injuries or other injuries that result in a disruption and then restoration of blood flow
170
How is bleeding of IVC best controlled?
with proximal and distal pressure, not clamps -\> can tear it
171
How much blood loss is possible from a femur fracture?
\>2L
172
Femoral neck fractures are at high risk for \_\_\_
avascular necrosis
173
Long bone fracture or dislocations with loss of pulse (or weak pulse). What next? And if pulse does not return?
immediate reduction and reassessment of pulse Go to OR for vascular bypass or repair (some say angio)
174
Name the concomitant nerve or artery injury associated with anterior shoulder dislocation. and posterior?
axillary nerve axillary artery
175
Name the concomitant nerve or artery injury associated with proximal humerus fracture.
axillary nerve
176
Name the concomitant nerve or artery injury associated with midshaft humerus (or spiral humerus fracture).
radial nerve
177
Name the concomitant nerve or artery injury associated with distal (supracondylar) humerus fracture.
brachial artery
178
Name the concomitant nerve or artery injury associated with elbow dislocation.
brachial artery
179
Name the concomitant nerve or artery injury associated with distal radius fracture.
median nerve
180
Name the concomitant nerve or artery injury associated with anterior hip dislocation? and posterior?
femoral artery; sciatic nerve
181
Name the concomitant nerve or artery injury associated with distal (supracondylar) femur fracture.
popliteal artery
182
Name the concomitant nerve or artery injury associated with posterior knee dislocation.
popliteal artery
183
Name the concomitant nerve or artery injury associated with fibular neck fracture.
common peroneal nerve
184
All knee dislocations need to go to \_\_\_, unless pulse is absent, in which case some would just go to \_\_\_
angio, OR
185
What is the best indicator of renal trauma? And what is the diagnostic study needed with the finding?
Hematuria, CT scan
186
With renal trauma what is the study that is useful if going to the OR without abdominal CT, to identify presence of functional contralateral kidney, which could affect intraoperative decision making?
IVP
187
Why is it possible to ligate the left renal vein near the IVC while this cannot be done on the right?
Left has adrenal and gonadal vein collaterals
188
From anterior to posterior, what are the renal hilum structures?
vein, artery pelvis
189
What percentage of renal trauma is treated nonoperatively?
95%
190
Do all urine extravasation injuries require operation?
no
191
Indications for operation in renal trauma include
1) acute ongoing hemorrhage with instability 2) after acute phase - major collecting system disruption, unresolved urine extravasation, hematuria
192
In operation for renal trauma, with exploration, what do you get control of first?
vascular renal hilum
193
How do you check for a leak at the end of an operation for renal trauma?
methylene blue dye
194
What is the best indicator of bladder trauma?
hematuria
195
\>95% of bladder trauma is associated with what other injury?
pelvic fractures
196
How is the diagnosis of bladder trauma made?
cystogram
197
In what type of bladder rupture does cystogram show starbursts?
extraperitoneal bladder rupture
198
What is the tx for extraperitoneal bladder rupture?
Foley 7-14 days
199
What does the cystogram show in intraperitoneal bladder rupture?
leak (as opposed to starbursts seen with intraperitoneal)
200
What type of bladder rupture is more likely in kids?
intraperitoneal
201
What is the tx of intraperitoneal bladder rupture?
operation and repair of defect, followed by foley drainage
202
Hematuria is unreliable indicator of what type of trauma?
ureteral (best for renal and bladder)
203
What are the two best tests for ureteral trauma?
IVP and retrograde urethrogram (RUG)
204
What direction does the blood supply come from for the ureter?
medially in the upper 2/3, laterally in the lower 1/3
205
Hematuria or blood at meatus best sign; free-floating prostate gland; usually associated with pelvic fractures. What is the injury?
Urethral trauma
206
You suspect urethral injury. Do you insert a foley? What is the best test?
No, urethrogram
207
What are the possible problems with early urethral injury repair as opposed to the recommended 2-3 months?
High stricture and impotence rate if repaired early
208
Testicular trauma - order ___ to see if ___ is violated then repair if necessary.
ultrasound, tunica albuginea
209
\_\_\_ is not a good indicator of blood loss in children - last thing to go.
blood pressure
210
What are the best indicators of shock in children (4)
HR, RR, mental status and clinical exam
211
In an infant less than 1 yr what is a normal pulse, SBP and RR?
160, 80, 40
212
In a preschool age child (1-5 yrs) what is a normal pulse, SBP and RR?
140, 90, 30
213
In an adolescent (\>10 yr) what is a normal pulse, SBP and RR?
120, 100, 20
214
What fraction of total blood volume loss can occur in a pregnant pt without signs?
1-3
215
In trauma during pregnancy estimate age based on \_\_\_
fundal height (20 cm = 20 wk = umbilicus)
216
What is the most common mechanism of placental abruption?
shock
217
What is the Kleihauer-Betke test?
tests for fetal blood in maternal circulation, sign of placental abruption
218
What location is uterine rupture with trauma in pregnancy most likely to occur?
posterior fundus
219
If uterine rupture occurs after delivery of child. What intervention leads to the best outcome?
Aggressive resuscitation even in the face of shock, uterus will eventually clamp down after delivery.
