Fiser.15.Trauma Flashcards
1
Q
When does the “first peak” for trauma deaths occur?
A
0-30 minutes
2
Q
What are the 5 underlying causes for this first peak of trauma deaths?
A
Lacerations of heart, aorta, brain, brainstem, or spinal cord
3
Q
What is the prognosis for first peak of trauma death patients?
A
Cannot be saved
4
Q
When does the “second peak” for trauma deaths occur?
A
30 minutes to 4 hours
5
Q
What are the 2 MCC of deaths in the second peak of trauma deaths?
A
1) head injury and 2) hemorrhage
6
Q
What is the prognosis for second peak patients?
A
Can be saved with rapid assessment, “golden hour”
7
Q
When is the “third peak” for trauma deaths?
A
Days to weeks
8
Q
What is the cause of the third peak of trauma deaths? (2)
A
Multisystem organ failure and sepsis
9
Q
What percent of traumas are blunt?
A
80%
10
Q
Which organ is most commonly injured in blunt abdominal trauma?
A
Liver (some texts say spleen)
11
Q
What is the physics formula for kinetic energy?
A
Kinetic energy = 1/2MV2 where M = mass and V = velocity
12
Q
What are the two biggest predictors for survival from falls?
A
Age and body orientation
13
Q
What is the LD50 height for falls (from which 50% of people die)?
A
4 stories (40 feet)
14
Q
Which organ is most commonly injured with penetrating injury?
A
Small bowel (some texts say liver)
15
Q
What is the MCC of death within 1 hour of trauma?
A
Hemorrhage
16
Q
What percent of blood volume can be lost before blood pressure is affected?
A
30%
17
Q
What fluid should you resuscitate a trauma patient with (to start)?
A
2 liters LR before blood
18
Q
What is the MCC of trauma death after reaching the ER alive?
A
Head injury
19
Q
What is the MCC of long-term trauma death?
A
infection
20
Q
What is the MCC of airway obstruction s/p trauma and how do you manage it?
A
Tongue – manage with jaw thrust
21
Q
What three injuries are a/w seatbelt use / seatbelt sign?
A
Small bowel perforations; lumbar spine fractures; sternal fractures
22
Q
What is the best site for cutdown for venous access?
A
Saphenous vein at the ankle
23
Q
What is the indication for DPL?
A
Hypotensive patients with blunt trauma
24
Q
What 6 findings would make a DPL positive?
A
> 10 cc blood; >100,000 RBC/cc; food particles; bile; bacteria; >500 WBC/cc
25
What do you do if a DPL is positive?
laparotomy
26
What adjustment do you need to make to your DPL technique with pelvic fractures?
Supraumbilical approach
27
Name two findings/pathologies missed by DPLs
Retroperitoneal bleeds; contained hematomas
28
What does FAST stand for in FAST scan?
Focused abdominal sonography for trauma
29
Which four quadrants are examined in the FAST?
Pericardium, perihepatic fossa (Morrison’s pouch), perisplenic fossa, and pelvis
30
Name three limitations of the FAST
Examiner dependent; obesity can obstruct view; may not detect free fluid \< 50-80cc
31
What is indicated with a positive FAST?
Laparotomy indicated
32
Name two pathologies missed by FAST scan
Retroperitoneal bleeding; hollow viscus injury
33
What is the next step in the hypotensive patient with a negative FAST/DPL?
Find the source of bleeding (pelvis, chest, or extremity)
34
What is the next imaging step if a patient has a negative DPL?
Abdominal CT scan
35
Name 7 indications for CT scan s/p blunt trauma
Abdominal pain; Need for general anesthesia; Closed head injury; Intoxicants on board; Paraplegia; Distracting injury; Hematuria
36
What two injuries are missed by CT scan?
Hollow viscus injury; diaphragm injury
37
Name 9 indications for laparotomy s/p any trauma
Peritonitis; Evisceration; Positive DPL; Uncontrolled visceral hemorrhage; Free air; Diaphragm injury; Intraperitoneal bladder injury; Contrast extravasation from hollow viscus; Specific renal / pancreas / biliary injuries
38
What is the management of a BAT patient with positive physical exam findings?
exlap
39
What is the next step in management of a BAT patient who is hemodynamically unstable?
DPL/FAST
40
What is the next step in management of a BAT patient who is hemodynamically unstable & has grossly positive DPL or FAST?
exlap
41
What is the next step in management of a BAT patient who is hemodynamically unstable & has an indeterminate DPL or FAST?
CT scan
42
What are the RBC counts of an indeterminate DPL?
50-100K RBCs/cc
43
What is the next step in management of a BAT patient who is hemodynamically unstable, has an indeterminate DPL or FAST, and has a negative CT scan?
find cause of hemodynamic instability
44
What is the next step in management of a BAT patient who is hemodynamically unstable, has an indeterminate DPL or FAST, and has a positive CT scan?
exlap or find cause of hemodynamic instability
45
What is the next step in management of a BAT patient who is hemodynamically unstable who has a negative FAST or DPL? (2 options)
CT scan or observe Find cause of hemodynamic instability
46
What is the management of a penetrating anterior abdominal trauma patient with positive physical exam?
exlap
47
What is the management of a penetrating anterior abdominal trauma patient with evisceration?
exlap
48
What is the next step in management of a penetrating anterior abdominal trauma patient with no obvious peritonitis or evisceration?
local wound exploration
49
What is the next step in management of a penetrating anterior abdominal trauma patient with no obvious peritonitis or evisceration and no fascial violation on local wound exploration?
observation
50
What is the next step in management of a penetrating anterior abdominal trauma patient with no obvious peritonitis or evisceration and positive or equivocal fascial violation on local wound exploration?
diagnostic laparoscopy
51
What is the next step in management of a penetrating anterior abdominal trauma patient with no obvious peritonitis or evisceration, positive/equivocal fascial violation on local wound exploration, and peritoneal violation on diagnostic laparoscopy?
exlap
52
What is the next step in management of a penetrating anterior abdominal trauma patient with no obvious peritonitis or evisceration, positive/equivocal fascial violation on local wound exploration, and NO peritoneal violation on diagnostic laparoscopy?
discharge from PACU
53
Name three common causes of abdominal compartment syndrome
Massive fluid resuscitation; trauma; abdominal surgery
54
What bladder pressure suggests ACS?
\>25-30
55
What causes reduced cardiac output with ACS?
IVC compression is the final common pathway that causes decreased cardiac output
56
What are the two end-organs affected by reduced cardiac output with ACS?
Visceral and renal malperfusion leads to low UOP
57
How is ventilation affected by ACS?
Increased abdominal pressures causes upward displacement of diaphragm
58
How do you treat ACS?
Decompressive laparotomy
59
When is a pneumatic antishock garment indicated?
Controversial, used in pts with SBP \< 50 without thoracic injuryReleases compartments one at a time after reaching ER
60
When is ED thoracotomy indicated for blunt trauma?
Use only if pressure / pulse is lost in the ER
61
When is ED thoracotomy indicated for penetrating trauma?
only if pressure/pulse is lost on the way to the ER or in the ER
62
between which ribs do you make the incision for ED thoracotomy?
between 4-5th intercostal spaces
63
What step should you perform during an ED thoracotomy with associated abdominal injury?
Clamp descending thoracic aorta
64
What is the SBP threshold you must reach with thoracotomy to transport to the OR?
SBP \> 70, can transport. SBP \< 70, further intervention is futile
65
What additional procedure do you perform for a cardiac injury?
Incise pericardium longitudinally and anterior to the phrenic nerve, rotate heart out of the pericardium for the repair
66
When do catecholamines peak after trauma
Peak 24-48 hours post-trauma
67
Name three hormones that peak after trauma
ADH, ACTH, glucagon
68
Which demographic should receive Rh-negative blood?
Prepubescent and childbearing age females
69
What can a patient react to in non-screened, non-cross-matched blood?
HLA minor antigens
70
What should you do for a patient with GCS ≤14 s/p trauma?
Head CT
71
What should you do for a patient with GCS ≤10 s/p trauma?
intubate
72
What should you do for a patient with GCS ≤8 s/p trauma?
ICP monitor
73
What is a GCS Motor 6?
Follows commands
74
What is a GCS Motor 5?
Localizes pain
75
What is GCS Motor 4?
Withdraws from pain
76
What is a GCS Motor 3?
Flexion with pain (decorticate)
77
What is a GCS Motor 2?
Extension with pain (decerebrate)
78
What is a GCS Motor 1?
No response
79
What is a GCS Verbal 5?
Oriented
80
What is a GCS Verbal 4?
confused
81
What is a GCS Verbal 3?
Inappropriate words
82
What is a GCS verbal 2?
Incomprehensible wtf sounds
83
What is a GCS verbal 1?
No response
84
What is a GCS Eye Opening 4?
Spontaneous opening
85
What is a GCS Eye Opening 3?
Opens to command
86
What is a GCS Eye Opening 2?
Opens to pain
87
What is a GCS Eye Opening 1?
No response
88
What interaction does a foreign body have to have with the head to indicate CT?
Suspected skull penetration by foreign body
89
What ear or nose findings indicate CT
CSF, blood, or both from nose; Hemotympanum or discharge of blood/CSF from ear
90
What neuro symptoms (4) indicate need for head CT?
Altered state of consciousness; Focal neurologic S/Sx; Head injury + EtOH/drug intoxication; Protracted unconsciousness
91
What additional trauma findings outside the head indicate need for head CT?
Any additional trauma findings outside the head
92
What is the MC bleeding source for an epidural hematoma?
Middle meningeal artery
93
What are the S/Sx a/w epidural hematoma
LOC to lucid interval to sudden deterioration with vomiting, restlessness, LOC
94
How does an epidural hematoma show up on head CT?
Lens shaped (lenticular) deformity
95
When is OR indicated for epidural hematoma (2)?
Operate for significant neurologic degeneration or significant mass effect (shift \> 5mm)
96
What is the MC source of bleeding for subdural hematoma
Tearing of venous plexus (bridging veins) crossing between dura and arachnoid
97
What are the head CT findings of a subdural hematoma?
Crescent shaped deformity
98
What are the two indications for OR with SDH?
Significant neurological degeneration or mass effect (\> 1 cm)
99
What is the MCC of chronic SDH?
In the elderly after a minor fall
100
What are the two MC involved lobes in an intracerebral hematoma?
Frontal or temporal
101
When is OR indicated for ICH?
Mass effect
102
Where can cerebral contusions occur?
Can be coup or contrecoup
103
When is OR indicated for traumatic intraventricular hemorrhage?
If causing hydrocephalus
104
What procedure would you perform for traumatic IVH causing hydrocephalus?
Ventriculostomy
105
What imaging should you use for diffuse axonal injury?
MRI over CT scan
106
How do you treat DAI?
Supportive, craniectomy if ICP is elevated
107
What is the prognosis for DAI?
Poor prognosis
108
What is the formula for cerebral perfusion pressure?
CPP = MAP – ICP
109
Name 3 imaging findings concerning for increased ICP
Reduced ventricular size, loss of sulci, loss of cisterns
110
When are ICP monitors indicated (3)?
GCS ≤ 8; suspected increased ICP; patient with moderate-severe head injury and unable to follow commands b/c intubated/sedated
111
What is a normal ICP?
10
112
What is the threshold to treat ICP?
\> 20
113
What is a normal CPP?
\> 60
114
Name two positional interventions to reduce ICP
Sedation and paralysis Raise the head of the bed
115
How should you adjust ventilation to reduce ICP?
Relative hyperventilation to allow modest cerebral vasoconstriction
116
What is your goal CO2 during relative hyperventilation?
30-35
117
Why do you want to avoid over-hyperventilation in an elevated ICP pt?
Overhyperventilation can cause cerebral ischemia 2/2 too much vasoconstriction
118
What is your goal Na level for elevated ICP pts?
140-150
119
What is your goal serum Osm for elevated ICP patients?
295-310
120
What kind of saline do you need to use intermittently and why?
Use hypertonic saline get to goal Osm/Na and to draw fluid out of the brain
121
What is the MOA of mannitol when used for elevated ICP?
Draws fluid from brain
122
What is the loading and maintenance dose for mannitol?
Load 1g/kg, give 0.25mg/kg q4hr after that
123
What to antiepileptic drugs can be administered to head injury patients?
Fosphenytoin or Keppra can be given prophylactically to prevent seizures in moderate to severe head injury
124
What two bedside surgical interventions can be performed to reduce ICP?
Ventriculostomy with CSF drainage Craniotomy decompression
125
When is craniotomy decompression indicated?
When unable to get ICP down medically
126
At what time post-trauma does peak ICP occur?
48-72 hours after injury
127
What nerve and location of injury is indicated by a dilated pupil?
CN III – oculomotor compression, indicated ipsilateral temporal pressure
128
What are Raccoon eyes?
Periorbital ecchymosis
129
What subtype of basilar skull fracture is a/w Raccoon eyes?
Anterior fossa fracture
130
What is Battle’s sign?
Mastoid ecchymosis
131
What is the subtype of basal skull fracture a/w Battle’s sign?
Middle fossa fracture
132
Which cranial nerve can get injured with a middle fossa basal skull fracture?
Facial nerve
133
How do you treat a suspected facial nerve injury if it presents acutely vs delayed?
Acute presentation: needs exploration and repair Delayed presentation: likely 2/2 edema, therefore exploration not needed
134
Name two other ear/nose symptoms a/w basilar skull fractures
CSF drainage from nose/ear or bleeding from nose/ear (hemotympanum)
135
Which two cranial nerves are at risk with a temporal skull fracture?
CN VII (facial) and VIII (vestibulocochlear nerve)
136
What is the MC site of facial nerve injury?
The geniculate ganglion
137
What are the two MC mechanisms of injury leading to a temporal skull fracture?
Lateral skull blow or orbital blow
138
Name three indications for OR s/p skull fracture
Most skull fractures do not require OR OR if significantly depressed (\>1cm); contaminated; or persistent CSF leak not responding to conservative therapy
139
What is the initial treatment for CSF leak
Treat expectantly lumbar CSF drainage if persistent
140
Why does coagulopathy occur with TBI?
Due to release of tissue factor
141
What is the eponym for a C1 burst fracture?
Jefferson fracture
142
What is the cause of a C1 burst fracture?
Caused by axial loading
143
How do you treat a C1 burst fracture?
Rigid collar
144
What is the cause of a C2 hangman’s fracture?
Distraction and extension
145
What is the treatment for a C2 hangman’s fracture?
Traction & halo
146
What is a type 1 C2 odontoid fracture and what is its stability?
Above base, stable
147
What is a type-2 C2 odontoid fracture and what is its stability?
At the base, unstable
148
How do you treat a type 2 C2 odontoid fracture?
Fusion or halo
149
What is a type 3 C2 odontoid fracture and its stabilty?
Extends into vertebral body
150
How do you treat a type 3 C2 odontoid fracture?
Fusion or halo
151
What other structure can be injured by facet fractures and dislocations?
Can cause cord injury
152
What is the MOA of facet fractures and dislocation
Hyperextension and rotation with ligamentous disruption
153
Name the three columns of the thoracolumbar spine
Anterior, middle, and posterior
154
What are the boundaries of the anterior column of the thoracolumbar spine?
Anterior longitudinal ligament and anterior ½ of vertebral body
155
What are the boundaries of the middle column?
Posterior ½ of vertebral body and posterior longitudinal ligament
156
What are the boundaries and contents of the posterior column of the thoracolumbar column?
Facet joints, lamina, spinous processes, interspinous ligament
157
How many columns in the TL spine must be injured before the spine is considered unstable?
\>1 column must be injured
158
Which column is involved with compression/wedge fractures and are they considered stable?
Usually only involves anterior column, therefore considered stable
159
Which column is involved with burst fractures and are they considered stable?
Involve \> 1 column, unstable
160
What treatment is required for burst fractures?
Spinal fusion
161
What is a Chance fracture and what is the MCC?
Usually 2/2 seatbelt injury at T12/L1, compression fx to anterior VB and transverse fx thru posterior VB
162
What three injuries are you at risk for with an upright fall?
Calcaneus, lumbar, and wrist/forearm fractures
163
What is the next step if you have a patient with neuro deficits without bony injury?
MRI to evaluate for ligamentous injury
164
Name four indications for emergent surgical spine decompression
Fracture/dislocation not reducible with distraction Open fractures Soft tissue / bony compression of cord Progressive neurological dysfunction
165
What is the MCC of facial nerve trauma?
Temporal bone fracture
166
How should you handle skin edges with a facial laceration?
Try to preserve skin and not trim edges
167
What is a LeFort type I fracture?
Maxillary fracture straight across
168
What is the treatment for a LeFort type I fracture?
Reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires
169
What is a LeFort type II fracture?
Lateral to nasal bone, underneath eyes, diagonal to maxilla
170
What is the treatment of a LeFort type II fracture?
Reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires
171
What is a LeFort type III fracture?
Lateral orbital walls
172
What is the treatment for LeFort type III fracture?
Suspension wiring to stabilize frontal bone; may need exfix
173
What percent of nasoethmoidal orbital fractures have a CSF leak?
70%
174
What is the treatment of a CSF leak a/w nasoethmoidal orbital fractures(3)?
Conservative therapy for 2 weeks Can try epidural catheter to reduce CSF pressure and help close CSF leak May need surgical closure of dura to stop leak
175
How do you treat an anterior nosebleed?
Packing
176
How do you treat a posterior nosebleed
First line: balloon tamponade
177
How do you treat a persistent posterior nosebleed and which two arteries should be targeted?
Angioembolization of the internal maxillary artery or ethmoidal artery
178
Name two indications for surgery with orbital blowout fractures
Impaired upward gaze or diplopia with upward gaze
179
What is the surgical approach for orbital blowout fractures?
Restoration of orbital floor with bone fragments or bone graft
180
What is the #1 indicator of mandibular injury?
Malocclusion
181
How do you diagnose mandibular injury?
Fine-cut facial CT scans with reconstruction to assess injuries
182
Name two surgical approaches to treat mandibular injury
Most repaired with IMF (intermaxillary fixation): metal arch bars to upper and lower dental arches x 6-8 weeks ORIF also possible
183
What is a tripod fracture and how do you treat it?
Zygomatic bone fracture, treated with ORIF
184
What injury is associated with maxillofacial fractures?
Cervical spine injuries
185
What imaging is indicated for asymptomatic blunt neck trauma?
Neck CT scan
186
What is the treatment for symptomatic blunt or penetrating neck trauma
Neck exploration
187
Name four airway/respiratory symptoms mandating neck exploration
Losing/lost airway; hemoptysis; stridor; subcutaneous air
188
Name three hemodynamic / blood findings mandating neck exploration
Shock; bleeding; expanding hematoma
189
Name 1 GI symptom mandating neck exploration
Dysphagia
190
Name 1 neuro symptom mandating neck exploration
Neurological defect
191
What are the boundaries to zone 1 of the neck?
Clavicle to cricoid cartilage
192
What are the boundaries of zone 2 of the neck?
Cricoid cartilage to angle of mandible
193
What are the boundaries to zone 3 of the neck
Angle of the mandible to base of the skull
194
What are the four imaging/interventions needed to evaluate to zone 1 neck trauma?
Angiography, bronchoscopy, esophagoscopy, and barium swallow
195
What two surgical interventions may be indicated to reach zone 1 neck trauma lesions?
Pericardial window or median sternotomy to reach lesions
196
What is the management of zone II neck trauma?
Neck exploration in OR
197
What is imaging needed to evaluate zone III trauma?
Angiography and laryngoscopy
198
Name two surgical interventions that may be indicated to reach zone III neck trauma lesions
Jaw subluxation / digastric and SCM release Mastoid sinus resection to reach vascular injuries
199
What is the hardest neck injury to find?
Esophageal injury
200
What are the two best modalities to find esophageal injury?
Esophagoscopy and esophagogram
201
What percentage of injuries are found with esophagoscopy and esophagogram?
95% of injuries are found when these two methods are combined
202
How do you treat contained esophageal injuries?
Observation
203
How do you treat noncontained esophageal injuries that are small with minimal contamination?
Primary closure
204
How do you treat noncontained esophageal injuries that are extensive or contaminated in the neck?
Just place drains, will heal on its own
205
How do you treat noncontained esophageal injuries that are extensive or contaminated in the chest?
Chest tubes to drain injury and place spit fistula in neck Will eventually need esophagectomy
206
What is the leak rate for esophageal and hypopharyngeal repairs?
20% leak rate
207
How does this high leak rate affect your surgical treatment for esophageal and hypopharyngeal repairs?
Always leave drains!
208
What side (laterality) should you approach neck esophageal injuries?
Left side
209
What side (laterality) should you approach upper 2/3 of thoracic esophageal injuries?
Right thoracotomy
210
What side (laterality) should you approach lower 1/3 thoracic esophageal injuries?
Left thoracotomy
211
What are the S/Sx a/w laryngeal fractures and tracheal injuries? (4)
Airway emergencies - crepitus, stridor, respiratory compromise
212
How do you emergently manage laryngeal fracture and tracheal injuries?
Secure airway emergently in ER – usu with a cricothyroidotomy
213
What is the surgical management of a laryngeal fracture or tracheal injury?
Primary repair, can use strap muscle for airway support Tracheostomy for most to allow edema to subside and check for stricture Convert cricothyroidotomy to tracheostomy
214
How do you treat thyroid gland injuries?
Control bleeding and drain – do NOT perform thyroidectomy
215
How does a recurrent laryngeal nerve injury present?
Hoarseness
216
How do you treat recurrent laryngeal nerve injury?
Repair or reimplant in cricoarytenoid muscle
217
How do you evaluate shotgun injuries to the neck?
Angiogram, neck CT, evaluate for esophagueal/tracheal injury
218
How do you treat vertebral artery bleeding?
Can embolize or ligate without sequalae in majority of patients
219
What percent of patients will get a stroke if you ligate a bleeding common carotid artery?
20% of patients will have a stroke
220
How many cc of blood upon initial insertion of chest tube indicates need for thoracotomy in OR?
\>1500 cc of blood after initial insertion
221
How many cc of blood per hour over 3 hours after chest tube insertion indicates need for thoracotomy in OR?
\>250cc/hr x 3 hours
222
How many cc of blood over 24 hours after chest tube insertion indicates need for thoracotomy in OR?
\>2500cc over 24 hours
223
What vital sign finding indicates need for OR thoracotomy
Bleeding with instability
224
Why do you need to drain all the thoracic blood in less than 48 hours? (3 reasons)
Prevent fibrothorax; pulmonary entrapment; infected hemothorax
225
How do you treat an unresolved hemothorax after 2 well-placed chest tubes?
Thoracoscopic drainage
226
How large does a sucking chest wound (open PTX) need to be significant?
\> 2/3 diameter of trachea
227
How do you treat a sucking chest wound?
Cover wound with dressing with tape on three sides to prevent development of tension PTX while allowing lung to expand with inspiration
228
What side are bronchus injuries more common?
More common on the right
229
What can happen to O2 sats after chest tube placement in a patient with tracheobronchial injury?
O2 sats may worsen after chest tube placement
230
How do you manage a patient with worsening O2 sats with chest tube placement after tracheobronchial injury
One of the few indications to clamp a chest tube
231
How do you intubate a patient with a trachobronchial injury
Qqf need to mainstem intubate patient on unaffected side
232
How do you diagnose a tracheobronchial injury?
Bronchoscopy
233
When is treatment indicated for a tracheobronchial injury (2)?
If large air leak and respiratory compromise \_OR\_ after two weeks of persistent air leak
234
When is a right thoracotomy indicated when treating a tracheobronchial injury?
Injuries to the right mainstem, trachea, and proximal left mainstem
235
What is the benefit of a right thoracotomy over a left thoracotomy?
Avoids the aorta
236
When is a left thoracotomy indicated in treating a trachobronchial injury?
Distal left mainstem injuries
237
What laterality is more likely for diaphragm trauma?
Left
238
Is diaphgramatic injury more likely to occur 2/2 blunt or penetrating trauma?
Blunt trauma
239
What are the CXR findings a/w diaphragmatic injury?
Air-fluid level in chest from stomach herniation through hole
240
What approach should you use for a \<1 week old diaphgram injury vs \> 1 week old injury and why?
Transabdominal approach if \< 1 week and chest approach if \> 1 week to take down adhesions in chest
241
What type of repair do you use for diaphgram injury repair
Primary repair, may need mesh
242
Name 7 signs of aortic transection
Widened mediastinum; 1st or 2nd rib fracture; apical capping; loss of aortopulmonary window; loss of aortic contour; left hemothorax; tracheal deviation to the right
243
What is the MC location of aortic transection?
Ligamentum arteriosum just distal to the left subclavian takeoff
244
What are two other common locations of aortic transection?
Near aortic valve and where aorta transverses the diaphragm
245
What percent of CXRs are normal in patients with aortic tears?
5% normal
246
Name two mechanisms of injury with significant risk of aortic transection
Head on car crash \> 45 MPH; fall \> 15 feet
247
How do you evaluate for aortic transection
CTA chest
248
What are two operative approaches to treat aortic transection?
Left thoracotomy and repair with partial left heart bypass Covered stent endograft
249
What is the only subtype of aortic transection that can be treated with stent endografts?
Distal transections only
250
What are the MCC of death after myocardial contusion (2)?
Vtach and Vfib
251
What is the MC arrhythmia in pts with myocardial contusion?
SVT
252
What is the management of a pt p/w myocardial contusion?
Monitoring for 24-48 hours
253
Define the number of ribs and locations they need to be broken to create a flail chest
≥2 consecutive ribs broken at ≥ 2 sites
254
What is the pulmonary impairment associated with flail chest
Underlying pulmonary contusion 2/2 paradoxical motion of chest wall
255
What is the problem with getting a CXR after an aspiration event?
Aspiration may not produce immediate CXR findings
256
When is a CXR indicated in a penetrating chest injury?
For evaluation if the patient is stable
257
What are the borders of the cardiac box?
Clavicles, xiphoid process, nipples
258
What is the management of a penetrating injury to the cardiac box?
Pericardial window, bronchoscopy, esophagoscopy, barium swallow
259
What is the next step in management if a pericardial window finds blood?
Need median sternotomy to fix possible injury to heart or great vessels and place pericardial drain for monitoring
260
How do you manage a patient with a penetrating injury outside the cardiac box without PTX or hemothorax? How is this affected by need for intubation
If patient requires intubation, needs a chest tube If no intubation required, follow with serial CXRs
261
How do you manage a patient with penetrating injuries anterior/medial to the mid-axillary line and below the nipples?
Needs laparotomy or laparoscopy May need evaluation for penetrating box injury depending on location
262
What is a non-invasive alternative to pericardial window for cardiac box injuries?
Use the FAST scan with the ultrasound evaluation of the pericardium
263
Name three traumatic causes of cardiogenic shock
Cardiac tamponade; cardiac contusion; tension PTX
264
What is the MOA of tension PTX?
One-way valve effect causes air entry without leaving and pressure builds up
265
What are the S/Sx of tension PTX (5)?
Hypotension; increased airway pressures; decreased breath sounds; bulging neck veins; tracheal shift
266
What is one observation during laparotomy that would make you suspect a tension PTX?
Bulging diaphragm during laparotomy
267
What is the mechanism of cardiac compromise 2/2 tension PTX?
Reduced venous return from IVC/SVC compression
268
What is the tx of a tension PTX
Needle decompression, then chest tube
269
What is the MC associated injury with sternal fractures?
Cardiac contusions
270
What associated injury are patients with first or second-rib fractures at high risk for?
High risk for aortic transection
271
How do you perform a pulmonary tractotomy in penetrating lung trauma?
Divide the pulmonary parenchyma between adjacent staple lines
272
What is the benefit of performing a pulmonary tractotomy for penetrating lung trauma?
Allows rapid direct access to injured vessels or bronchi along the tract of penetrating injury
273
What is the biggest hemodynamic risk a/w pelvic fracture?
Blood loss
274
What is the management of a hemodynamically unstable pelvic fracture patient with a negative DPL, negative CXR, and no other signs of blood loss / reasons for shock?
Stabilize pelvis (C-clamp, exfix, sheet) and go to angio for embolization
275
What are the two types of injuries pelvic fracture patients are at high risk for?
Abdominal and GU injuries
276
What is the most likely source of bleeding with anterior pelvic fractures?
Venous bleeding
277
What is the most likely source of bleeding with posterior pelvic fractures?
Arterial bleeding
278
What is the surgical management of rectal tears and perineal lacerations a/w open pelvic fractures?
May need colostomy.
279
What is the timing of pelvic fracture repair when you have other traumatic injuries?
You may need to delay pelvic fracture repair until associated injuries are repaired
280
Intraop, how do you manage a pelvic hematoma 2/2 penetrating injury?
Open the hematoma, qqf go to angio
281
Intraop, how do you manage a non-expanding pelvic hematoma 2/2 blunt injury in a stable patient?
Leave it alone
282
Intraop, how do you manage an expanding pelvic hematoma 2/2 blunt injury in a stable or unstable patient?
Stabilize pelvic fracture, pack pelvis if in OR, go to angiography for embolization
283
Intraop, how do you manage a nonexpanding pelvic hematoma 2/2 blunt injury in an unstable patient?
Stabilize pelvic fracture, pack pelvis if in OR, go to angiography for embolization
284
If you pack the pelvis, when should you remove them?
24-48 hours later when the patient is stable
285
What are the three classifications of the Young-Burgess Pelvic Fractures?
APC: anterior-posterior compression (common feature is diastasis of pubic symphysis or vertical fracture of pubic rami) LC: lateral compression (common feature is transverse fracture of pubic rami) VS: vertical shear (common feature is vertical fracture of pubic rami)
286
Which Young-Burgess Pelvic Fracture classification is a/w the highest rate of hypovolemic shock? Give rate
Vertical shear a/w highest rate of hypovolemic shock at 63%
287
What is the mortality a/w vertical shear pelvic fractures?
25% mortality
288
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a POSITIVE FAST
exlap with hemorrhage control
289
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement s/p exlap with hemorrhage control who is hemodynamically stable postop?
Ongoing evaluation / support consider exfix
290
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement s/p exlap with hemorrhage control who is hemodynamically UNSTABLE postop?
pelvic angiography with embolization
291
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a NEGATIVE FAST?
evaluate response to IVF resuscitation
292
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a NEGATIVE FAST who is NOT responsive to IVF resuscitation?
pelvic angiography with embolization
293
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a NEGATIVE FAST who IS responsive to IVF resuscitation?
CT abdomen/ pelvis
294
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a NEGATIVE FAST who IS responsive to IVF resuscitation with CT-A/P with pelvic hematoma with active extravasation?
pelvic angiography with embolization
295
What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a NEGATIVE FAST who IS responsive to IVF resuscitation with CT-A/P with NO pelvic hematoma with active extravasation?
pelvic fracture exfix as needed
296
What is the definition of the APC-I classification pelvic fracture? Is it stable or unstable?
Symphysis widening \< 2.5cm, no posterior ring injury, stable
297
What is the treatment for APC-I pelvic fracture?
Nonop, protected WB
298
What is the definition of the APC-II classification pelvic fracture? Is it stable or unstable?
Symphysis widening \> 2.5cm; anterior SI joint diastasis; posterior SI ligaments intact; disruption of sacrospinous and sacrotuberous ligaments, rotationally unstable, vertically stable
299
What is the treatment for APC-II pelvic fracture?
Anterior symphyseal plate or exfix +/- posterior fixation
300
What is the definition of the APC-III classification pelvic fracture? Is it stable or unstable?
Disruption of anterior and posterior SI ligaments (SI dislocation); disruption of sacrospinous and sacrotuberous ligaments, completely unstable
301
What is the treatment for APC-III pelvic fracture?
Anterior symphyseal multihole plate or exfix and posterior stabilization with SI screws +/- plate
302
What is the definition of the LC-I classification pelvic fracture? Is it stable or unstable?
Oblique/transverse ramus fracture and ipsilateral sacral ala compression fracture Posterior compression of SI joint without ligament disruption, stable
303
What is the treatment for an LC-I pelvic fracture?
Nonop. Complete comminuted sacral component: protected WB Simple, incomplete sacral fracture-WBAT
304
What is the definition of the LC-II classification pelvic fracture? Is it stable or unstable?
Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture) Posterior SI ligament rupture, sacral crush injury or iliac wing fracture, rotationally unstable, vertically stable
305
What is the treatment for an LC-II pelvic fracture?
ORIF ilium
306
What is the definition of the LC-III classification pelvic fracture? Is it stable or unstable?
Ipsilateral lateral compression and contralateral APC (open book) (windswept pelvis); Common MOA is rollover or ped vs auto; completely unstable
307
What is the treatment for an LC-III pelvic fracture?
Posterior stabilization with plate or SI screws
308
What is the definition of the VS classification pelvic fracture? Is it stable or unstable?
Posterior and superior directed force, displaced fx of anterior rami and posterior columns, +SI dislocation, completely unstable
309
What is the treatment for a VS pelvic fracture?
Posterior stabilization with plate or SI screws
310
What is the MCC of duodenal trauma
Blunt trauma (crush or deceleration injury)
311
What is the most common area of injury in the duodenum?
2nd portion of duodenum (descending, near ampulla of Vater)
312
What is another common area of duodenal injury s/p trauma
Tears near the ligament of Treitz
313
How can most injuries requiring surgical intervention be treated?
Most can be treated with debridement and primary closure
314
What percent of duodenal injuries requiring surgical intervention can be treated with debridement and primary closure?
80%
315
Which portions of the duodenum can be treated with segmental resection and primary end-to-end anastomosis
All segments except D2
316
What is the rate of mortality in duodenal trauma patients and why?
25% due to shock
317
What is a major source of morbidity a/w duodenal trauma?
Fistulas
318
What is the MC location of paraduodenal hematomas and why?
In D3 due to overlying spine in blunt injury
319
What size paraduodenal hematoma is considered significant?
≥2 cm is considered significant
320
With what size paraduodenal hematoma and what mechanism of injury do you need to open and explore the hematoma?
A significiant hematoma (≥2 cm) and for either blunt or penetrating trauma
321
What S/Sx are a/w paraduodenal hematomas missed on initial CT scan or seen but not explored?
p/w high SBO 12-72 hours after injury
322
What is the appearance of a paraduodenal hematoma on UGI study?
“stacked coins” or “coiled spring” appearance
323
What are you specifically looking to rule out on an UGI study of a paraduodenal hematoma?
Extravasation of contrast
324
How do you treat a paraduodenal hematoma?
Conservative therapy (NGT, TPN)
325
What is the cure rate with conservative therapy of a paraduodenal hematoma, over what time course, and why?
90% over 2-3 weeks because hematoma is reabsorbed
326
What intraoperative maneuvers should you perform when suspecting dudoenal injury during exlap? (2)
Kocher maneuver and open lesser sac through the omentum
327
What four findings are you looking for during the Kocher maneuver and lesser sac exploration with suspected duodenal trauma?
Checking for hematoma, bile, succus, or fat necrosis
328
What is the next step if hematoma, bile, succus, or fat necrosis are found in the lesser sac when exploring for suspected duodenal trauma?
Formal inspection of the entire duodenum and check for pancreatic injury
329
What are two imaging studies if you suspect duodenal injury? Which is better?
CT-abdomen with PO/IV contrast or UGI contrast study. UGI better
330
What findings on CT-abdomen would concern you for duodenal injury (5)?
Bowel wall thickening, hematoma, free air, contrast leak, RP fluid/air
331
What do you do if a CT scan is worrisome for duodenal injury but not diagnostic
Repeat CT scan in 8-12 hours to see if its getting worse
332
What is the optimal surgical treatment for duodenal trauma?
Try to get primary repair or anastomosis
333
What do you do if primary duodenal repair or anastomosis fails?
Diversion with pyloric exclusion and gastrojejunostomy to allow healing
334
What tubes/drains need to be placed for a duodenal repair?
Distal feeding jejunostomy +/- proximal draining jejunostomy tube that threads back to the duodenal injury site Drains in the bed of the repair
335
What is your surgical approach if D2 is injured and you can’t get a primary repair
Place jejunal serosal patch over hole, pyloric exclusion, and gastrojejunosotomy Consider feeding and draining jejunostomies, leave drains
336
What operation may D2 injury patients eventually need?
May eventually need Whipple
337
Why are trauma whipples rarely indicated?
High mortality
338
When can postop drains be removed?
When patient is tolerating a diet without increase in drainage
339
How do you treat duodenal fistulas?
Close with time, tx with bowel rest, TPN, octreotide over 4-6 weeks
340
What is the MC organ injured with penetrating trauma?
Small bowel (some texts say liver)
341
What mechanism of injury makes it difficult to diagnose small bowel trauma?
Difficult to diagnose SB trauma early with blunt trauma
342
What three abdominal CT findings are suggestive of occult SB injury?
Intraabdominal fluid not associated with a solid organ injury Bowel wall thickening Mesenteric hematoma
343
What is your management of a patient with suspected SB trauma?
Close observation, possible repeat abdominal CT after 8-12 hours to see if findings are stable or worsening
344
What do you need to be sure of in patients with nonconclusive findings prior to discharge?
Be sure they can tolerate a diet
345
Directionally, how should small bowel injuries be repaired and why?
Repair transversely to avoid stricture
346
What are the two defining criteria for “large lacerations” of the SB?
\> 50% of bowel circumference or result in lumen diameter \< 1/3 normal
347
What is the management of a large SB laceration?
Resection and reanastomosis
348
How do you manage a SB segment with multiple close lacerations?
Resection
349
What are the criteria of mesenteric hematomas that require exploration? (2)
If large (\> 2cm) or expanding, need to open
350
Is colon trauma a/w blunt or penetrating injury?
Penetrating
351
How do you manage right colon injuries?
Primary repair / anastomosis
352
How do you manage transverse colon injuries?
Primary repair / anastomosis
353
How do you manage left colon injuries?
Primary repair / anastomosis
354
When is a diverting ileostomy indicated in left colon injury? (2)
If patient is in shock or there is gross contamination
355
For which mechanism of injury do paracolonic hematomas need to be opened?
Both blunt and penetrating
356
Is rectal trauma a/w blunt or penetrating injury?
Penetrating injury
357
What is the management of high rectal extraperitoneal injury?
Generally not repaired, treat with serial debridement and consider diverting ileostomy
358
Why don’t you repair high rectal extraperitoneal injury?
Inaccessibility
359
How do you repair high rectal intraperitoneal injury?
Repair defect, presacral drainage, consider diverting ileostomy
360
What are the indications for diverting ileostomy with high rectal injury? (3)
Shock, gross contamination, or extensive injury
361
What is your management of low rectal injuries (\< 5cm)
Repair transanally
362
What is the MC organ injured with blunt abdominal trauma?
Liver, some texts say spleen
363
What operation is rarely indicated with liver trauma?
Lobectomy
364
Why can the common hepatic artery be ligated?
Collaterals through the GDA
365
What is the Pringle maneuver?
Clamping the portal triad
366
Why would the Pringle maneuver fail to stop hepatic bleeding?
Bleeding from the hepatic veins
367
Name two indications for “damage control perihepatic packing”
Severe penetrating injuries when patient becomes unstable in the OR and the injury is not easily fixed (ex: retrohepatic IVC injuries) Go to ICU for resusctiation and stabilization, live to fight another day
368
What is the indication for an atriocaval shunt with liver trauma?
Retrohepatic IVC injury, allows for control while performing repair
369
What is the management of portal triad hematomas?
They need to be explored
370
What is the management of CBD injury \< 50% circumference?
Repair over stent
371
What is the management of CBD injury \> 50% circumference
Choledochojejunostomy
372
What is the management of complex CBD injury?
Choledochojejunostomy
373
What intraoperative procedure may you require to define CBD injury?
May need IOC to define injury
374
Why should you place drains after CBD repair?
In case of a duct anastomotic leak
375
What percent of duct anastomoses leak after CBD repair?
10%
376
Do you need to repair Portal Vein injury?
Needs to be repaired
377
How do you access retropancreatic portal vein?
May need to transect through the pancreas to get to injury in the portal vein
378
What additional procedure is required if you need to transect through the pancreas to repair the portal vein?
Distal pancreatectomy
379
What is the mortality rate a/w portal vein ligation?
50%
380
What are two benefits of using an omental graft with liver lacerations?
Help with bleeding and prevent bile leaks
381
Should you leave drains with liver injuries?
Yes
382
What are two criteria that define failure of conservative management of blunt liver injuries?
Unstable despite aggressive resuscitation (includes 4U PRBC) with HR \> 120 or SBP \< 90 Requires \> 4 units to get Hct \> 25
383
What two vascular findings on CT indicate need for OR?
Active blush or pseudoaneurysm
384
What is the difference in management between anterior or posterior vascular liver injuries?
If posterior, may be better off with angiogram. With anterior, go to OR
385
How much time is needed for bedrest for conservative management of liver trauma?
5 days
386
Define a Grade I Liver hematoma
Subcapsular, \<10% surface area
387
Define a Grade I Liver laceration
capsular tear, \<1cm parenchymal depth
388
Define a Grade II Liver hematoma (subcapsular)
subcapsular, 10-50% surface area
389
Define a Grade II liver laceration
1-3cm parenchymal depth, \<10cm length
390
Define a Grade III liver hematoma (subcapsular)
subcapsular, \> 50% surface area or expanding ruptured subcapsular or expanding
391
Define a Grade III liver laceration
\>3cm parenchymal depth
392
Define a Grade IV liver laceration
parenchymal disruption involving 25-75% of the hepatic lobe or 1-3 Coinaud's segments in a single lobe
393
Define a Grade V liver laceration
parenchymal disruption involving \> 75% of hepatic lobe or \>3 Coinaud's segments within a single lobe
394
Define a Grade V liver vascular injury
juxtahepatic venous injuries (ie retrohepatic vena cava / central major hepatic veins)
395
Define a Grade VI liver vascular injury
hepatic avulsion
396
How many weeks before splenic trauma is fully healed?
6 weeks
397
What is the postop time period during which patients are at highest risk of post-splenectomy sepsis?
Within 2 years of splenectomy
398
What medical intervention is a/w splenic salvage?
Increased transfusions
399
What two vascular CT findings are indications for the OR?
Active blush or pseudoaneurysm
400
How long do you need to be on bedrest with conservative management
5 days
401
How does the management of splenectomy differ in pediatrics?
Threshold for splenectomy is much higher in peds, hardly any children undergo splenectomy
402
What meds need to be given post-splenectomy?
Need immunizations
403
How do multiple injuries affect liver grading s/p trauma?
advance one grade for multiple injuries to the same organ up to grade III
404
Define Grade I splenic hematoma
subcapsular, \<10% surface area
405
Define Grade I splenic laceration
capsular tear, \<1cm parenchymal depth
406
Define a Grade II Liver hematoma (intraparenchymal)
intraparenchymal, \<10cm length
407
Define a Grade III Liver hematoma (intraparenchymal)
ruptured parenchymal hematoma intraparenchymal hematoma \>10cm or expanding
408
Define a Grade II splenic hematoma, subcapsular
10-50% surface area
409
Define a Grade II splenic hematoma, intraparenchymal
\<5cm diameter
410
Define a Grade III splenic hematoma, subcapsular
\>50% surface area or expanding Ruptures subcapsular or parenchymal hematoma
411
Define a Grade III splenic hematoma, intraparenchymal
\>5cm
412
Define a Grade III splenic laceration
\> 3cm parenchymal depth or involving trabecular vessels
413
Define a Grade IV splenic laceration
laceration of segmental or hilar vessels producing major devascularization (\> 25% of spleen)
414
Define a Grade V splenic laceration
completely shattered spleen
415
Define a Grade V splenic vascular injury
hilar vascular injury with devascularized spleen
416
What to you do for multiple injuries to the spleen via trauma when grading?
advance one grade for multiple injuries to the same organ up to grade III
417
What percent of pancreatic trauma is 2/2 penetrating injury?
80% 2/2 penetrating injury
418
What structure in the pancreas is MC damaged with blunt injury?
Pancreatic duct fractures
419
Where are pancreatic duct fractures located after blunt injury?
Perpendicular to the duct
420
What two changes to peripancreatic fat indicates injury?
Necrosis or edema
421
How can you treat a pancreatic contusion? (2)
If pt stable, leave it alone. If pt in OR, leave drains
422
How do you treat a distal pancreatic duct injury?
Distal pancreatectomy
423
How much of the gland can you remove with a distal pancreatectomy?
80%
424
How do you treat an irreperable pancreatic head duct injury?
Start by leaving drains; Delayed whipple or possible ERCP with stent may eventually be needed
425
What anatomic structure provides a landmark to determine whether a whipple vs distal pancreatectomy should be used for a pancreatic duct injury?
Use the duct injury’s relation to the SMV to determine how to treat the injury
426
What is the benefit of the Kocher maneuver intraop?
Helps elevate the pancreas in the OR
427
What precaution should you take intraop with pancreatic injury?
Always leave drains
428
Which mechanism of injury is an indication for opening a pancreatic hematoma?
Both blunt and penetrating trauma are indications for opening a pancreatic hematoma
429
What should you suspect in a patient with persistent or rising amylase?
Missed pancreatic injury
430
Are CT scans good at diagnosing pancreatic injuries initially?
Nope
431
What are the delayed CT findings a/w pancreatic injury?
Fluid, edema, necrosis
432
Why would an ERCP be indicated with a pancreatic duct injury?
Good at localizing the duct injury and may be able to treat with a temporary stent
433
If a patient has concomitant vascular and ortho injuries, which should be repaired first?
First vascular repair, then ortho repair
434
Name six hard signs of vascular injury
Active hemorrhage Pulse deficit Expanding/pulsatile hematoma Distal ischemia Bruit Thrill
435
What is the management of a patient with a hard sign of vascular injury?
To the OR, may need intraop angio to define injury
436
Name the four soft signs of vascular injury
History of hemorrhage Deficit in anatomically-related nerve Large stable/nonpulsatile hematoma ABI \< 0.9
437
How do you treat a patient with a soft sign of vascular injury?
Go to angio
438
How much of the vasculature must be missing to require a GSV graft?
If segment \> 2cm missing
439
Which leg should you harvest GSV from when fixing lower extremity arterial injuries?
Use vein from contralateral leg
440
Name the six veins that, when injured, require repair and not ligation
Vena cava Femoral vein Popliteal vein Brachiocephalic vein Subclavian vein Axillary vein
441
How should you manage the transection of a single artery in a calf in an otherwise healthy patient?
Ligate it
442
What should you do once you’ve created an anastomosis to protect it?
Cover it with viable tissue and muscle
443
How long should a lower extremity be compromised for you to consider fasciotomy after revascularization?
\> 4-6 hours to prevent compartment syndrome
444
What compartment pressure is concerning for compartment syndrome?
Compartment pressure \> 20mm Hg
445
What are the six clinical findings (in order of presentation) concerning for compartment syndrome?
Pain to paresthesia to anesthesia to paralysis to poikilothermia to pulselessness (late)
446
Name the four MC traumatic causes of compartment syndrome?
Supracondylar humerus fractures Tibial fractures Crush injuries Other injuries resulting disruption and restoration of blood flow after 4-6 hours
447
How do you treat compartment syndrome?
Fasciotomy https://www.youtube.com/watch?v=-1NDJkFH1vM
448
\*\*LOWER EXTREMITY COMPARTMENTS\*\*
\*\*LOWER EXTREMITY COMPARTMENTS\*\*
449
\*\*LOWER EXTREMITY COMPARTMENTS\*\*
\*\*LOWER EXTREMITY COMPARTMENTS\*\*
450
\*\*LOWER EXTREMITY COMPARTMENTS\*\*
\*\*LOWER EXTREMITY COMPARTMENTS\*\*
451
When should you perform primary repair of IVC versus patch repair?
If residual stenosis \< 50% of diameter of IVC, can do primary repair, otherwise patch
452
What two materials can you use for IVC patch repair?
Saphenous vein or synthetic patch
453
What is the best way to control IVC bleeding?
Proximal and distal pressure
454
Why should you avoid clamping the IVC?
You can tear it
455
What should your approach to posterior IVC wall injuries be?
Through the anterior wall, you may need to cut anterior wall of IVC to get to posterior wall
456
How much blood could you lose with a femur fracture
\> 2L blood loss with a femur fracture
457
Name five orthopedic emergencies
Pelvic fractures in unstable patients Spine injury with deficit Open fractures Dislocations or fractures with vascular compromise Compartment syndrome
458
What complication are you at risk for with femoral neck fractures?
High risk of avascular necrosis
459
How do you manage a long bone fracture / dislocation with a loss of pulse?
Immediately reduce the fracture / dislocation and reassess the pulse
460
What do you do if the pulse does not return with reduction of fracture?
Go to OR for vascular bypass / repair, may need angio to define the injury
461
What do you do if a pulse is weak after reduction of fracture?
Angio
462
What imaging do all knee dislocations require and what is the exception?
All need angio unless absent distal pulse, then straight to OR
463
What are the three fractures a/w upright falls?
Calcaneus, lumbar, and distal forearm fractures (radial/ulnar)
464
What nerve injury is a/w anterior shoulder dislocation?
Axillary nerve
465
What arterial injury is a/w posterior shoulder dislocation?
Axillary artery
466
What nerve injury is a/w proximal humerus fx?
Axillary nerve
467
What nerve injury is a/w midshaft humerus fx?
Radial nerve
468
What nerve injury is a/w spiral humerus fx?
Radial nerve
469
What arterial injury is a/w distal/supracondylar humerus fx?
Brachial artery
470
What arterial injury is a/w elbow dislocation?
Brachial artery
471
What nerve injury is a/w distal radius fx?
Median nerve
472
What arterial injury is a/w anterior hip dislocation?
Femoral artery
473
What nerve injury is a/w posterior hip dislocation?
Sciatic nerve
474
What arterial injury is a/w distal/supracondylar femur fx?
Popliteal artery
475
What arterial injury is a/w posterior knee dislocation?
Popliteal artery
476
What nerve injury is a/w fibular neck fractures?
Common peroneal nerve
477
What complication is a/w temporal or parietal bone fx?
Epidural hematoma
478
What fracture is a/w maxillofacial fx?
Cervical spine fx
479
What injury is a/w sternal fx?
Cardiac contusion
480
What vascular injury is a/w first/second rib fractures?
Aortic transection
481
What lung injury is a/w scapular fracture?
Lung contusion
482
What vascular injury is a/w scapular fracture?
Aortic transection
483
What injury is a/w left 8-12 rib fractures?
Splenic lac
484
What injury is a/w right 8-12 rib fx?
Liver laceration
485
What two GU injuries are a/w pelvic fx?
Bladder rupture, urethral transection
486
What sign/symptom is the best indicator of renal trauma?
Hematuria
487
What imaging do all trauma patients with hematuria need?
abdominal CT scan
488
Why does an IVP accomplish that precludes the need for a CT scan?
Can be used in patients going directly to the OR, identifies the presence of a functional contralateral kidney
489
Why are you able to ligate the left renal vein but not the right renal vein?
LRV has adrenal and gonadal vein collaterals while RRV does not
490
Where on the LRV should you ligate it?
Ligate it close to the IVC
491
Name the renal hilar structures anterior to posterior
VAP: vein, artery, pelvis
492
What percent of renal trauma injuries are treated nonoperatively
95% are treated nonoperatively
493
Do all urine extravasation injuries require OR?
nope
494
What are acute indications for OR s/p renal trauma?
Ongoing hemorrhage with instability
495
Name three non-acute indications for OR (after the acute phase of care):
Major collecting system disruption, non-resolving urine extravasation, severe hematuria
496
With exploration, which portion of the kidney should you try to get control of first?
Get control of the vascular hilum first
497
When should you place drains intraop?
Always, but especially if the collecting system is injured
498
In the setting of an exlap for another injury, you see a blunt renal injury with hematoma, what do you do?
Leave it alone unless the preop CT/IVP showed no function or significant urine extravasation
499
In the setting of an exlap for another injury, you see a penetrating renal injury with hematoma, what do you do?
Open unless preop CT/IVP showed good function without significant urine extravasation
500
How do you treat flank trauma with IVP showing no uptake in the stable patient?
Angiogram, stent if flap is present
501
How do you perform an IV pyelogram?
Iodinated contrast provided at 2cc/kg, 10 minutes later get an XR
502
Define a Grade I Renal Contusion
microscopic or gross hematuria with normal urologic studies
503
Define a Grade I renal hematoma
subcapsular, non-expanding without parenchymal laceration
504
Define a Grade II renal hematoma
nonexpanding perirenal hematoma confined to renal retroperitoneum
505
Define a Grade II renal laceration
\<1.0cm parenchymal depth of renal cortex with no urinary extravasation
506
Define a Grade III renal laceration
\>1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
507
Define a Grade IV renal laceration
parenchymal laceration extending through renal cortex, medulla, and collecting system
508
Define a Grade IV vascular renal injury
main renal artery or vein injury with contained hemorrhage
509
Define a grade V renal laceration
completely shattered kidney
510
Define a grade V vascular renal injury
avulsion of renal hilum that devascularizes kidney
511
What S/Sx is the best indicator of bladder trauma?
Hematuria is the best indicator of bladder trauma
512
What is the MC injury a/w bladder trauma?
Pelvic fractures
513
What percent of bladder traumas are a/w pelvic fractures?
\> 95%
514
Name 2 more S/Sx of bladder trauma
Blood at the meatus, sacral or scrotal hematoma
515
What does the cystogram show for extraperitoneal bladder rupture?
starbursts
516
What is the treatment for extraperitoneal bladder rupture?
Foley 7-14 days
517
What does the cystogram show for intraperitoneal bladder rupture?
leak
518
What demographic is more likely to have intraperitoneal bladder rupture?
kids
519
What is the treatment for intraperitoneal bladder rupture?
Operation and repair of defect folllowed by Foley drainage
520
Is hematuria a reliable indicator of ureteral trauma?
No
521
What two tests are the best indicators of ureteral trauma?
IVP and retrograde urethrogram (RUG)
522
Where is the blood supply of the upper 2/3 of the ureter (lateral or medial)?
medial
523
Where is the blood supply of the lower 1/3 of the ureter (lateral or medial)?
lateral
524
What is the cutoff to be considered a large ureteral injury that may prevent repair?
\> 2cm
525
How do you treat a large upper 1/3 ureteral injuries that won’t reach the bladder?
Tie off both ends of the ureter, temporize with a percutaneous nephrostomy Treat with ileal interposition or trans-ureteroureterostomy later
526
How do you treat a large middle 1/3 ureteral injuries that won’t reach the bladder?
Tie off both ends of the ureter, temporize with a percutaneous nephrostomy Treat with ileal interposition or trans-ureteroureterostomy later
527
How do you treat a large lower 1/3 ureteral injury?
Reimplant in bladder, may need bladder hitch procedure
528
What length of ureter should be measured to be considered a “small” injury?
\<2cm
529
How do you treat a small upper 1/3 ureteral injury?
Mobilize ends of ureter and perform primary repair over stent
530
How do you treat a small middle 1/3 ureteral injury?
Mobilize ends of ureter and perform a primary repair over a stent
531
How do you treat a small lower 1/3 ureteral injury?
Reimplant into the bladder since this is an easier anastomosis than primary repair
532
What is a “one-shot” IVP?
100cc of 60% iodine followed by plain film 2-5 minutes later identifies presence of both kidneys and evaluates for extravasation
533
What structure is not appropriately evaluated by one-shot IVP?
Ureters are not sufficiently evaluated by one-shot IVP
534
What two IV dyes can be used to check for ureteral leaks?
IV methylene blue or IV indigo carmine
535
When should you leave drains?
Leave drains for all ureteral injuries
536
\*\*URETHRA PHOTO\*\*
\*\*URETHRA PHOTO\*\*
537
What are the two best signs of uretheral trauma?
Hematuria or blood at meatus
538
What injury is often associated with a free-floating prostate
Pelvic fractures
539
Should you place a Foley?
Nah, nope, absolutely not
540
What is the best imaging test for uretheral trauma?
RUG (retrograde urethrogram)
541
Which portion of the urethra is at highest risk for transection?
Membranous portion
542
How do you treat a significant urethral tear?
Suprapubic cystostomy and repair in 2-3 months
543
Why do you wait 2-3 months to repair a significant urethral tear?
High rates of stricture and impotence if repaired early
544
How do you treat small, partial urethral tears?
Bridge urethral catheter across tear and repair in 2-3 months
545
How do you treat erectile body fracture from vigorous sex?
Repair tunica and Buck’s fascia
546
How do you evaluate and treat testicular trauma?
Ultrasound to see if tunica albuginea is violated, if yes then treat
547
Why is blood pressure NOT a good indicator of blood loss in children?
It is the last thing to fall in kids
548
What are the four best indicators of shock in children?
Heart rate, respiratory rate, mental status, and clinical exam
549
Why are children at increased risk of hypothermia in trauma?
Increased body surface area compared to weight
550
Are children at increased risk for head injury?
Yes
551
What age group is an infant?
\<1 year
552
What age group is a preschool child?
\< 5 years
553
What age group is an adolescent?
\> 10 years
554
What is a normal HR, SBP and RR for an infant?
infant \< 1 year HR 160 / SBP 80 / RR 40
555
What is a normal HR, SBP and RR for a preschool child (\<5 years)?
HR 140 / SBP 90 / RR 30
556
What is a normal HR, SBP, and RR for an adolescent (\> 10 years)
HR 120 / SBP 100 / RR 20
557
in a pregnant trauma patient, Do you save mother or baby?
At all costs, save the mother
558
How much blood volume can a pregnant patient lose without evidence of hemorrhagic shock?
Can lose up to 1/3 of total blood volume without signs
559
How can you estimate weeks of pregnancy?
Based on fundal height. Ex: 20cm = 20 weeks
560
What should you use to monitor the fetus?
A fetal monitor
561
What imaging should you avoid except in life-threatening situations?
Try to avoid CT scan, especially in early pregnancy
562
What imaging may have a role?
Ultrasound / FAST scan
563
What should you check on cervical exam? (4)
Check for vaginal discharge (blood / amnion) Check for effacement, dilation, and fetal station
564
What two tests on amniotic fluid can determine fetal maturity?
Lecithin: sphingomyelin ratio \> 2:1 Positive phophatidylcholine
565
What does the lecithin: sphingomyelin ratio indicate
Lecithin: sphingomyelin ratio \> 2:1 is normal (indicates fetal lung maturity and lecithin makes surfactant more active)
566
What is placental abruption?
Separation of the placenta (decidual basalis) from the uterine wall with the pooling of blood from uterine arterial/venous bleeding between the two surfaces
567
How is placental abruption classified?
Partial or complete Apparent (vaginal bleeding) or concealed (pocket of blood)
568
What are potential maternal complications of placental abruption (4)?
Hypovolemic shock, Sheehan syndrome (perinatal pituitary necrosis), renal failure, or DIC (from release of thromboplastin from decidua basalis).
569
What percentage of placental abruption is a/w a 100% fetal death rate?
\> 50% abruption is a/w ~100% death rate
570
Name 3 signs of abruption
Uterine tenderness, contractions, fetal HR \< 120
571
What are the 2 MCC of placental abruption?
Shock (clamping down of blood vessels?) or mechanical forces
572
What does the Kleihauer-Betke test look for?
Looks for fetal blood in maternal circulation and is a sign of placental abruption
573
Where in the uterus is uterine rupture more likely to occur?
Posterior fundus
574
How do you manage uterine rupture AFTER delivery of the child?
Aggressive resuscitation (IVF, blood) even in the face of shock since the uterus will eventually clamp down after delivery --\> leads to best outcomes
575
Name five indications for C-section during trauma exlap?
Persistent maternal shock or severe injuries and pregnancy near term (\> 34 weeks) Pregnancy is a threat to mother’s life (hemorrhage, DIC) Mechanical limitation to life-threatening vessel injury Risk of fetal distress exceeds risk of immaturity Direct intra-uterine trauma
576
What is the intervention s/p pregnant trauma when the fetus is alive, there is evidence of fetal injury, and the fetus is mature enough to survive the extrauterine environment?
perform C-section and address fetal injuries
577
What is the intervention s/p pregnant trauma where the fetus is dead and the surgical exposure on exlap is inadequate to deal with maternal injuries?
evacuate uterus
578
what is the intervention s/p pregnant trauma when the fetus is dead and the surgical exposure on exlap is adequate to deal with maternal injuries with NO uterine injury?
leave uterine contents intact
579
what is the intervention s/p pregnant trauma when the fetus is dead and the surgical exposure on exlap is adequate to deal with maternal injuries WITH uterine injury?
repair uterus
580
What is the blood loss for Class I hemorrhagic shock?
up to 750cc
581
What is the % blood volume lost in Class I hemorrhagic shock?
up to 15%
582
what is the HR in Class I hemorrhagic shock?
\<100
583
What is the blood pressure in class I hemorrhagic shock?
normal
584
what is the pulse pressure in class I hemorrhagic shock?
normal or increased
585
what is the RR in class I hemorrhagic shock?
14-20
586
what is the UOP in class I hemorrhagic shock?
\>30cc/hr
587
what is the mental status in class I hemorrhagic shock?
slightly anxious
588
What is the blood loss for Class II hemorrhagic shock?
750-1500cc
589
What is the % blood volume lost in Class II hemorrhagic shock?
15-30%
590
What is the HR in Class II hemorrhagic shock?
100-120
591
what is the BP in class II hemorrhagic shock?
normal
592
what is the pulse pressure in class II hemorrhagic shock?
decreased
593
what is the RR in class II hemorrhagic shock?
20-30
594
what is the UOP in class II hemorrhagic shock?
20-30cc/hr
595
what is the mental status in class II hemorrhagic shock?
mildly anxious
596
what is the blood loss in class III hemorrhagic shock?
1500-2000cc
597
what is the % blood volume loss in class III hemorrhagic shock?
30-40%
598
what is the HR in class III hemorrhagic shock?
120-140
599
what is the bp in class III hemorrhagic shcok?
decreased
600
what is the pulse pressure in class III hemorrhagic shock?
decreased
601
what is the RR in class III hemorrhagic shock?
30-40
602
what is UOP in class III hemorrhagic shock?
5-15cc/hr
603
what is the mental status in class III hemorrhagic shock?
anxious/confused
604
what is the blood loss in class IV hemorrhagic shock?
\>2000cc
605
what is the % blood volume lost in class IV hemorrhagic shock?
\>40%
606
what is the HR in class IV hemorrhagic shock?
\>140
607
what is the BP in class IV hemorrhagic shock?
decreased
608
what is the pulse pressure in class IV hemorrhagic shock?
decreased
609
what is the respiratory rate in class IV hemorrhagic shock?
\>35
610
what is the UOP in class IV hemorrhagic shock
negligible
611
what is the mental status in class IV hemorrhagic shock?
confused / lethargic
612
how do you manage a pelvic hematoma \>2cm s/p penetrating trauma?
open it
613
how do you manage a pelvic hematoma \>2cm s/p blunt trauma?
leave it alone
614
how do you manage a \>2cm paraduodenal hematoma s/p penetrating trauma?
open it
615
how do you manage a \>2cm paraduodenal hematoma s/p blunt trauma?
open it
616
how do you manage a \>2cm portal triad hematoma s/p penetrating trauma?
open it
617
how do you manage a \>2cm portal triad hematoma s/p blunt trauma?
open
618
how do you manage a \>2cm retrohepatic hematoma s/p penetrating trauma?
leave it alone if stable
619
how do you manage a \>2cm retrohepatic hematoma s/p blunt trauma?
leave it alone
620
how do you manage a \>2cm midline supramesocolic hematoma s/p penetrating trauma?
open it
621
how do you manage a \>2cm midline supramesocolic hematoma s/p blunt trauma?
open it
622
how do you manage a \>2cm midline inframesocolic hematoma s/p penetrating trauma?
open it
623
how do you manage a \>2cm midline inframesocolic hematoma s/p blunt trauma?
open it
624
how do you manage a \>2cm pericolonic hematoma s/p penetrating trauma?
open it
625
how do you manage a \>2cm pericolonic hematoma s/p blunt trauma?
open it
626
how do you manage a \>2cm perirenal hematoma s/p penetrating trauma?
open it unless preop CT/IVP shows NO injury
627
how do you manage a \>2cm perirenal hematoma s/p blunt trauma?
leave it alone unless preop CT/IVP shows injury
628
Where is zone 1 of the retroperitoneum located?
Central retroperitoneum
629
What are the injuries a/w penetrating zone 1 trauma?
Pancreaticoduodenal injury or major abdominal vascular injury
630
How do you approach zone 1 hematomas?
Pancreaticoduodenal injury or major abdominal vascular injury
631
How do you approach zone 1 hematomas?
Usually open them
632
Where is zone 2 located?
Flank or perinephric area
633
What injuries are a/w zone 2 injuries?
Injuries to the GU tract or colon
634
How do you approach zone 2 hematomas?
Usually open them
635
Where is zone 3 located?
Pelvis
636
What are the injuries a/w zone 3 injury?
Pelvic hematomas
637
describe the boundaries of the three zones of the zones of the RP
Zone 1: aortic; Zone 2: perirenal and colonic; Zone 3: pelvic
638
What five injuries should you leave drains for?
Pancreatic, liver, biliary, urinary, duodenal
639
What are the three sx a/w snakebites?
Shock, bradycardia, arrhythmia
640
What is the treatment of snakebites?
Stabilize pt, antivenin, tetanus shot
