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Z.Fiser > Fiser.15.Trauma > Flashcards

Fiser.15.Trauma Flashcards

1
Q

When does the “first peak” for trauma deaths occur?

A

0-30 minutes

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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

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3
Q

What is the prognosis for first peak of trauma death patients?

A

Cannot be saved

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4
Q

When does the “second peak” for trauma deaths occur?

A

30 minutes to 4 hours

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5
Q

What are the 2 MCC of deaths in the second peak of trauma deaths?

A

1) head injury and 2) hemorrhage

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6
Q

What is the prognosis for second peak patients?

A

Can be saved with rapid assessment, “golden hour”

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7
Q

When is the “third peak” for trauma deaths?

A

Days to weeks

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8
Q

What is the cause of the third peak of trauma deaths? (2)

A

Multisystem organ failure and sepsis

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9
Q

What percent of traumas are blunt?

A

80%

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10
Q

Which organ is most commonly injured in blunt abdominal trauma?

A

Liver (some texts say spleen)

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11
Q

What is the physics formula for kinetic energy?

A

Kinetic energy = 1/2MV2 where M = mass and V = velocity

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12
Q

What are the two biggest predictors for survival from falls?

A

Age and body orientation

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13
Q

What is the LD50 height for falls (from which 50% of people die)?

A

4 stories (40 feet)

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14
Q

Which organ is most commonly injured with penetrating injury?

A

Small bowel (some texts say liver)

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15
Q

What is the MCC of death within 1 hour of trauma?

A

Hemorrhage

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16
Q

What percent of blood volume can be lost before blood pressure is affected?

A

30%

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17
Q

What fluid should you resuscitate a trauma patient with (to start)?

A

2 liters LR before blood

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18
Q

What is the MCC of trauma death after reaching the ER alive?

A

Head injury

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19
Q

What is the MCC of long-term trauma death?

A

infection

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20
Q

What is the MCC of airway obstruction s/p trauma and how do you manage it?

A

Tongue – manage with jaw thrust

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21
Q

What three injuries are a/w seatbelt use / seatbelt sign?

A

Small bowel perforations; lumbar spine fractures; sternal fractures

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22
Q

What is the best site for cutdown for venous access?

A

Saphenous vein at the ankle

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23
Q

What is the indication for DPL?

A

Hypotensive patients with blunt trauma

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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

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25
Q

What do you do if a DPL is positive?

A

laparotomy

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26
Q

What adjustment do you need to make to your DPL technique with pelvic fractures?

A

Supraumbilical approach

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27
Q

Name two findings/pathologies missed by DPLs

A

Retroperitoneal bleeds; contained hematomas

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28
Q

What does FAST stand for in FAST scan?

A

Focused abdominal sonography for trauma

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29
Q

Which four quadrants are examined in the FAST?

A

Pericardium, perihepatic fossa (Morrison’s pouch), perisplenic fossa, and pelvis

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30
Q

Name three limitations of the FAST

A

Examiner dependent; obesity can obstruct view; may not detect free fluid < 50-80cc

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31
Q

What is indicated with a positive FAST?

A

Laparotomy indicated

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32
Q

Name two pathologies missed by FAST scan

A

Retroperitoneal bleeding; hollow viscus injury

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33
Q

What is the next step in the hypotensive patient with a negative FAST/DPL?

A

Find the source of bleeding (pelvis, chest, or extremity)

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34
Q

What is the next imaging step if a patient has a negative DPL?

A

Abdominal CT scan

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35
Q

Name 7 indications for CT scan s/p blunt trauma

A

Abdominal pain; Need for general anesthesia; Closed head injury; Intoxicants on board; Paraplegia; Distracting injury; Hematuria

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36
Q

What two injuries are missed by CT scan?

A

Hollow viscus injury; diaphragm injury

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37
Q

Name 9 indications for laparotomy s/p any trauma

A

Peritonitis; Evisceration; Positive DPL; Uncontrolled visceral hemorrhage; Free air; Diaphragm injury; Intraperitoneal bladder injury; Contrast extravasation from hollow viscus; Specific renal / pancreas / biliary injuries

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38
Q

What is the management of a BAT patient with positive physical exam findings?

A

exlap

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39
Q

What is the next step in management of a BAT patient who is hemodynamically unstable?

A

DPL/FAST

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40
Q

What is the next step in management of a BAT patient who is hemodynamically unstable & has grossly positive DPL or FAST?

A

exlap

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41
Q

What is the next step in management of a BAT patient who is hemodynamically unstable & has an indeterminate DPL or FAST?

A

CT scan

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42
Q

What are the RBC counts of an indeterminate DPL?

A

50-100K RBCs/cc

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43
Q

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?

A

find cause of hemodynamic instability

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44
Q

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?

A

exlap or find cause of hemodynamic instability

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45
Q

What is the next step in management of a BAT patient who is hemodynamically unstable who has a negative FAST or DPL? (2 options)

A

CT scan or observe Find cause of hemodynamic instability

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46
Q

What is the management of a penetrating anterior abdominal trauma patient with positive physical exam?

A

exlap

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47
Q

What is the management of a penetrating anterior abdominal trauma patient with evisceration?

A

exlap

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48
Q

What is the next step in management of a penetrating anterior abdominal trauma patient with no obvious peritonitis or evisceration?

A

local wound exploration

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49
Q

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?

A

observation

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50
Q

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?

A

diagnostic laparoscopy

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51
Q

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?

A

exlap

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52
Q

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?

A

discharge from PACU

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53
Q

Name three common causes of abdominal compartment syndrome

A

Massive fluid resuscitation; trauma; abdominal surgery

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54
Q

What bladder pressure suggests ACS?

A

>25-30

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55
Q

What causes reduced cardiac output with ACS?

A

IVC compression is the final common pathway that causes decreased cardiac output

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56
Q

What are the two end-organs affected by reduced cardiac output with ACS?

A

Visceral and renal malperfusion leads to low UOP

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57
Q

How is ventilation affected by ACS?

A

Increased abdominal pressures causes upward displacement of diaphragm

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58
Q

How do you treat ACS?

A

Decompressive laparotomy

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59
Q

When is a pneumatic antishock garment indicated?

A

Controversial, used in pts with SBP < 50 without thoracic injuryReleases compartments one at a time after reaching ER

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60
Q

When is ED thoracotomy indicated for blunt trauma?

A

Use only if pressure / pulse is lost in the ER

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61
Q

When is ED thoracotomy indicated for penetrating trauma?

A

only if pressure/pulse is lost on the way to the ER or in the ER

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62
Q

between which ribs do you make the incision for ED thoracotomy?

A

between 4-5th intercostal spaces

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63
Q

What step should you perform during an ED thoracotomy with associated abdominal injury?

A

Clamp descending thoracic aorta

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64
Q

What is the SBP threshold you must reach with thoracotomy to transport to the OR?

A

SBP > 70, can transport. SBP < 70, further intervention is futile

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65
Q

What additional procedure do you perform for a cardiac injury?

A

Incise pericardium longitudinally and anterior to the phrenic nerve, rotate heart out of the pericardium for the repair

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66
Q

When do catecholamines peak after trauma

A

Peak 24-48 hours post-trauma

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67
Q

Name three hormones that peak after trauma

A

ADH, ACTH, glucagon

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68
Q

Which demographic should receive Rh-negative blood?

A

Prepubescent and childbearing age females

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69
Q

What can a patient react to in non-screened, non-cross-matched blood?

A

HLA minor antigens

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70
Q

What should you do for a patient with GCS ≤14 s/p trauma?

A

Head CT

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71
Q

What should you do for a patient with GCS ≤10 s/p trauma?

A

intubate

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72
Q

What should you do for a patient with GCS ≤8 s/p trauma?

A

ICP monitor

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73
Q

What is a GCS Motor 6?

A

Follows commands

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74
Q

What is a GCS Motor 5?

A

Localizes pain

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75
Q

What is GCS Motor 4?

A

Withdraws from pain

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76
Q

What is a GCS Motor 3?

A

Flexion with pain (decorticate)

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77
Q

What is a GCS Motor 2?

A

Extension with pain (decerebrate)

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78
Q

What is a GCS Motor 1?

A

No response

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79
Q

What is a GCS Verbal 5?

A

Oriented

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80
Q

What is a GCS Verbal 4?

A

confused

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81
Q

What is a GCS Verbal 3?

A

Inappropriate words

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82
Q

What is a GCS verbal 2?

A

Incomprehensible wtf sounds

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83
Q

What is a GCS verbal 1?

A

No response

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84
Q

What is a GCS Eye Opening 4?

A

Spontaneous opening

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85
Q

What is a GCS Eye Opening 3?

A

Opens to command

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86
Q

What is a GCS Eye Opening 2?

A

Opens to pain

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87
Q

What is a GCS Eye Opening 1?

A

No response

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88
Q

What interaction does a foreign body have to have with the head to indicate CT?

A

Suspected skull penetration by foreign body

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89
Q

What ear or nose findings indicate CT

A

CSF, blood, or both from nose; Hemotympanum or discharge of blood/CSF from ear

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90
Q

What neuro symptoms (4) indicate need for head CT?

A

Altered state of consciousness; Focal neurologic S/Sx; Head injury + EtOH/drug intoxication; Protracted unconsciousness

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91
Q

What additional trauma findings outside the head indicate need for head CT?

A

Any additional trauma findings outside the head

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92
Q

What is the MC bleeding source for an epidural hematoma?

A

Middle meningeal artery

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93
Q

What are the S/Sx a/w epidural hematoma

A

LOC to lucid interval to sudden deterioration with vomiting, restlessness, LOC

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94
Q

How does an epidural hematoma show up on head CT?

A

Lens shaped (lenticular) deformity

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95
Q

When is OR indicated for epidural hematoma (2)?

A

Operate for significant neurologic degeneration or significant mass effect (shift > 5mm)

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96
Q

What is the MC source of bleeding for subdural hematoma

A

Tearing of venous plexus (bridging veins) crossing between dura and arachnoid

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97
Q

What are the head CT findings of a subdural hematoma?

A

Crescent shaped deformity

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98
Q

What are the two indications for OR with SDH?

A

Significant neurological degeneration or mass effect (> 1 cm)

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99
Q

What is the MCC of chronic SDH?

A

In the elderly after a minor fall

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100
Q

What are the two MC involved lobes in an intracerebral hematoma?

A

Frontal or temporal

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101
Q

When is OR indicated for ICH?

A

Mass effect

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102
Q

Where can cerebral contusions occur?

A

Can be coup or contrecoup

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103
Q

When is OR indicated for traumatic intraventricular hemorrhage?

A

If causing hydrocephalus

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104
Q

What procedure would you perform for traumatic IVH causing hydrocephalus?

A

Ventriculostomy

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105
Q

What imaging should you use for diffuse axonal injury?

A

MRI over CT scan

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106
Q

How do you treat DAI?

A

Supportive, craniectomy if ICP is elevated

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107
Q

What is the prognosis for DAI?

A

Poor prognosis

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108
Q

What is the formula for cerebral perfusion pressure?

A

CPP = MAP – ICP

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109
Q

Name 3 imaging findings concerning for increased ICP

A

Reduced ventricular size, loss of sulci, loss of cisterns

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110
Q

When are ICP monitors indicated (3)?

A

GCS ≤ 8; suspected increased ICP; patient with moderate-severe head injury and unable to follow commands b/c intubated/sedated

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111
Q

What is a normal ICP?

A

10

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112
Q

What is the threshold to treat ICP?

A

> 20

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113
Q

What is a normal CPP?

A

> 60

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114
Q

Name two positional interventions to reduce ICP

A

Sedation and paralysis Raise the head of the bed

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115
Q

How should you adjust ventilation to reduce ICP?

A

Relative hyperventilation to allow modest cerebral vasoconstriction

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116
Q

What is your goal CO2 during relative hyperventilation?

A

30-35

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117
Q

Why do you want to avoid over-hyperventilation in an elevated ICP pt?

A

Overhyperventilation can cause cerebral ischemia 2/2 too much vasoconstriction

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118
Q

What is your goal Na level for elevated ICP pts?

A

140-150

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119
Q

What is your goal serum Osm for elevated ICP patients?

A

295-310

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120
Q

What kind of saline do you need to use intermittently and why?

A

Use hypertonic saline get to goal Osm/Na and to draw fluid out of the brain

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121
Q

What is the MOA of mannitol when used for elevated ICP?

A

Draws fluid from brain

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122
Q

What is the loading and maintenance dose for mannitol?

A

Load 1g/kg, give 0.25mg/kg q4hr after that

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123
Q

What to antiepileptic drugs can be administered to head injury patients?

A

Fosphenytoin or Keppra can be given prophylactically to prevent seizures in moderate to severe head injury

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124
Q

What two bedside surgical interventions can be performed to reduce ICP?

A

Ventriculostomy with CSF drainage Craniotomy decompression

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125
Q

When is craniotomy decompression indicated?

A

When unable to get ICP down medically

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126
Q

At what time post-trauma does peak ICP occur?

A

48-72 hours after injury

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127
Q

What nerve and location of injury is indicated by a dilated pupil?

A

CN III – oculomotor compression, indicated ipsilateral temporal pressure

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128
Q

What are Raccoon eyes?

A

Periorbital ecchymosis

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129
Q

What subtype of basilar skull fracture is a/w Raccoon eyes?

A

Anterior fossa fracture

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130
Q

What is Battle’s sign?

A

Mastoid ecchymosis

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131
Q

What is the subtype of basal skull fracture a/w Battle’s sign?

A

Middle fossa fracture

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132
Q

Which cranial nerve can get injured with a middle fossa basal skull fracture?

A

Facial nerve

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133
Q

How do you treat a suspected facial nerve injury if it presents acutely vs delayed?

A

Acute presentation: needs exploration and repair Delayed presentation: likely 2/2 edema, therefore exploration not needed

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134
Q

Name two other ear/nose symptoms a/w basilar skull fractures

A

CSF drainage from nose/ear or bleeding from nose/ear (hemotympanum)

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135
Q

Which two cranial nerves are at risk with a temporal skull fracture?

A

CN VII (facial) and VIII (vestibulocochlear nerve)

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136
Q

What is the MC site of facial nerve injury?

A

The geniculate ganglion

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137
Q

What are the two MC mechanisms of injury leading to a temporal skull fracture?

A

Lateral skull blow or orbital blow

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138
Q

Name three indications for OR s/p skull fracture

A

Most skull fractures do not require OR OR if significantly depressed (>1cm); contaminated; or persistent CSF leak not responding to conservative therapy

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139
Q

What is the initial treatment for CSF leak

A

Treat expectantly lumbar CSF drainage if persistent

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140
Q

Why does coagulopathy occur with TBI?

A

Due to release of tissue factor

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141
Q

What is the eponym for a C1 burst fracture?

A

Jefferson fracture

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142
Q

What is the cause of a C1 burst fracture?

A

Caused by axial loading

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143
Q

How do you treat a C1 burst fracture?

A

Rigid collar

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144
Q

What is the cause of a C2 hangman’s fracture?

A

Distraction and extension

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145
Q

What is the treatment for a C2 hangman’s fracture?

A

Traction & halo

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146
Q

What is a type 1 C2 odontoid fracture and what is its stability?

A

Above base, stable

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147
Q

What is a type-2 C2 odontoid fracture and what is its stability?

A

At the base, unstable

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148
Q

How do you treat a type 2 C2 odontoid fracture?

A

Fusion or halo

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149
Q

What is a type 3 C2 odontoid fracture and its stabilty?

A

Extends into vertebral body

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150
Q

How do you treat a type 3 C2 odontoid fracture?

A

Fusion or halo

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151
Q

What other structure can be injured by facet fractures and dislocations?

A

Can cause cord injury

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152
Q

What is the MOA of facet fractures and dislocation

A

Hyperextension and rotation with ligamentous disruption

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153
Q

Name the three columns of the thoracolumbar spine

A

Anterior, middle, and posterior

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154
Q

What are the boundaries of the anterior column of the thoracolumbar spine?

A

Anterior longitudinal ligament and anterior ½ of vertebral body

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155
Q

What are the boundaries of the middle column?

A

Posterior ½ of vertebral body and posterior longitudinal ligament

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156
Q

What are the boundaries and contents of the posterior column of the thoracolumbar column?

A

Facet joints, lamina, spinous processes, interspinous ligament

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157
Q

How many columns in the TL spine must be injured before the spine is considered unstable?

A

>1 column must be injured

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158
Q

Which column is involved with compression/wedge fractures and are they considered stable?

A

Usually only involves anterior column, therefore considered stable

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159
Q

Which column is involved with burst fractures and are they considered stable?

A

Involve > 1 column, unstable

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160
Q

What treatment is required for burst fractures?

A

Spinal fusion

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161
Q

What is a Chance fracture and what is the MCC?

A

Usually 2/2 seatbelt injury at T12/L1, compression fx to anterior VB and transverse fx thru posterior VB

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162
Q

What three injuries are you at risk for with an upright fall?

A

Calcaneus, lumbar, and wrist/forearm fractures

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163
Q

What is the next step if you have a patient with neuro deficits without bony injury?

A

MRI to evaluate for ligamentous injury

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164
Q

Name four indications for emergent surgical spine decompression

A

Fracture/dislocation not reducible with distraction Open fractures Soft tissue / bony compression of cord Progressive neurological dysfunction

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165
Q

What is the MCC of facial nerve trauma?

A

Temporal bone fracture

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166
Q

How should you handle skin edges with a facial laceration?

A

Try to preserve skin and not trim edges

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167
Q

What is a LeFort type I fracture?

A

Maxillary fracture straight across

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168
Q

What is the treatment for a LeFort type I fracture?

A

Reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires

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169
Q

What is a LeFort type II fracture?

A

Lateral to nasal bone, underneath eyes, diagonal to maxilla

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170
Q

What is the treatment of a LeFort type II fracture?

A

Reduction, stabilization, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires

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171
Q

What is a LeFort type III fracture?

A

Lateral orbital walls

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172
Q

What is the treatment for LeFort type III fracture?

A

Suspension wiring to stabilize frontal bone; may need exfix

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173
Q

What percent of nasoethmoidal orbital fractures have a CSF leak?

A

70%

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174
Q

What is the treatment of a CSF leak a/w nasoethmoidal orbital fractures(3)?

A

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

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175
Q

How do you treat an anterior nosebleed?

A

Packing

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176
Q

How do you treat a posterior nosebleed

A

First line: balloon tamponade

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177
Q

How do you treat a persistent posterior nosebleed and which two arteries should be targeted?

A

Angioembolization of the internal maxillary artery or ethmoidal artery

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178
Q

Name two indications for surgery with orbital blowout fractures

A

Impaired upward gaze or diplopia with upward gaze

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179
Q

What is the surgical approach for orbital blowout fractures?

A

Restoration of orbital floor with bone fragments or bone graft

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180
Q

What is the #1 indicator of mandibular injury?

A

Malocclusion

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181
Q

How do you diagnose mandibular injury?

A

Fine-cut facial CT scans with reconstruction to assess injuries

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182
Q

Name two surgical approaches to treat mandibular injury

A

Most repaired with IMF (intermaxillary fixation): metal arch bars to upper and lower dental arches x 6-8 weeks ORIF also possible

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183
Q

What is a tripod fracture and how do you treat it?

A

Zygomatic bone fracture, treated with ORIF

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184
Q

What injury is associated with maxillofacial fractures?

A

Cervical spine injuries

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185
Q

What imaging is indicated for asymptomatic blunt neck trauma?

A

Neck CT scan

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186
Q

What is the treatment for symptomatic blunt or penetrating neck trauma

A

Neck exploration

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187
Q

Name four airway/respiratory symptoms mandating neck exploration

A

Losing/lost airway; hemoptysis; stridor; subcutaneous air

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188
Q

Name three hemodynamic / blood findings mandating neck exploration

A

Shock; bleeding; expanding hematoma

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189
Q

Name 1 GI symptom mandating neck exploration

A

Dysphagia

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190
Q

Name 1 neuro symptom mandating neck exploration

A

Neurological defect

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191
Q

What are the boundaries to zone 1 of the neck?

A

Clavicle to cricoid cartilage

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192
Q

What are the boundaries of zone 2 of the neck?

A

Cricoid cartilage to angle of mandible

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193
Q

What are the boundaries to zone 3 of the neck

A

Angle of the mandible to base of the skull

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194
Q

What are the four imaging/interventions needed to evaluate to zone 1 neck trauma?

A

Angiography, bronchoscopy, esophagoscopy, and barium swallow

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195
Q

What two surgical interventions may be indicated to reach zone 1 neck trauma lesions?

A

Pericardial window or median sternotomy to reach lesions

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196
Q

What is the management of zone II neck trauma?

A

Neck exploration in OR

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197
Q

What is imaging needed to evaluate zone III trauma?

A

Angiography and laryngoscopy

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198
Q

Name two surgical interventions that may be indicated to reach zone III neck trauma lesions

A

Jaw subluxation / digastric and SCM release Mastoid sinus resection to reach vascular injuries

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199
Q

What is the hardest neck injury to find?

A

Esophageal injury

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200
Q

What are the two best modalities to find esophageal injury?

A

Esophagoscopy and esophagogram

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201
Q

What percentage of injuries are found with esophagoscopy and esophagogram?

A

95% of injuries are found when these two methods are combined

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202
Q

How do you treat contained esophageal injuries?

A

Observation

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203
Q

How do you treat noncontained esophageal injuries that are small with minimal contamination?

A

Primary closure

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204
Q

How do you treat noncontained esophageal injuries that are extensive or contaminated in the neck?

A

Just place drains, will heal on its own

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205
Q

How do you treat noncontained esophageal injuries that are extensive or contaminated in the chest?

A

Chest tubes to drain injury and place spit fistula in neck Will eventually need esophagectomy

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206
Q

What is the leak rate for esophageal and hypopharyngeal repairs?

A

20% leak rate

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207
Q

How does this high leak rate affect your surgical treatment for esophageal and hypopharyngeal repairs?

A

Always leave drains!

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208
Q

What side (laterality) should you approach neck esophageal injuries?

A

Left side

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209
Q

What side (laterality) should you approach upper 2/3 of thoracic esophageal injuries?

A

Right thoracotomy

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210
Q

What side (laterality) should you approach lower 1/3 thoracic esophageal injuries?

A

Left thoracotomy

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211
Q

What are the S/Sx a/w laryngeal fractures and tracheal injuries? (4)

A

Airway emergencies - crepitus, stridor, respiratory compromise

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212
Q

How do you emergently manage laryngeal fracture and tracheal injuries?

A

Secure airway emergently in ER – usu with a cricothyroidotomy

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213
Q

What is the surgical management of a laryngeal fracture or tracheal injury?

A

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

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214
Q

How do you treat thyroid gland injuries?

A

Control bleeding and drain – do NOT perform thyroidectomy

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215
Q

How does a recurrent laryngeal nerve injury present?

A

Hoarseness

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216
Q

How do you treat recurrent laryngeal nerve injury?

A

Repair or reimplant in cricoarytenoid muscle

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217
Q

How do you evaluate shotgun injuries to the neck?

A

Angiogram, neck CT, evaluate for esophagueal/tracheal injury

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218
Q

How do you treat vertebral artery bleeding?

A

Can embolize or ligate without sequalae in majority of patients

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219
Q

What percent of patients will get a stroke if you ligate a bleeding common carotid artery?

A

20% of patients will have a stroke

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220
Q

How many cc of blood upon initial insertion of chest tube indicates need for thoracotomy in OR?

A

>1500 cc of blood after initial insertion

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221
Q

How many cc of blood per hour over 3 hours after chest tube insertion indicates need for thoracotomy in OR?

A

>250cc/hr x 3 hours

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222
Q

How many cc of blood over 24 hours after chest tube insertion indicates need for thoracotomy in OR?

A

>2500cc over 24 hours

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223
Q

What vital sign finding indicates need for OR thoracotomy

A

Bleeding with instability

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224
Q

Why do you need to drain all the thoracic blood in less than 48 hours? (3 reasons)

A

Prevent fibrothorax; pulmonary entrapment; infected hemothorax

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225
Q

How do you treat an unresolved hemothorax after 2 well-placed chest tubes?

A

Thoracoscopic drainage

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226
Q

How large does a sucking chest wound (open PTX) need to be significant?

A

> 2/3 diameter of trachea

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227
Q

How do you treat a sucking chest wound?

A

Cover wound with dressing with tape on three sides to prevent development of tension PTX while allowing lung to expand with inspiration

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228
Q

What side are bronchus injuries more common?

A

More common on the right

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229
Q

What can happen to O2 sats after chest tube placement in a patient with tracheobronchial injury?

A

O2 sats may worsen after chest tube placement

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230
Q

How do you manage a patient with worsening O2 sats with chest tube placement after tracheobronchial injury

A

One of the few indications to clamp a chest tube

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231
Q

How do you intubate a patient with a trachobronchial injury

A

Qqf need to mainstem intubate patient on unaffected side

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232
Q

How do you diagnose a tracheobronchial injury?

A

Bronchoscopy

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233
Q

When is treatment indicated for a tracheobronchial injury (2)?

A

If large air leak and respiratory compromise _OR_ after two weeks of persistent air leak

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234
Q

When is a right thoracotomy indicated when treating a tracheobronchial injury?

A

Injuries to the right mainstem, trachea, and proximal left mainstem

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235
Q

What is the benefit of a right thoracotomy over a left thoracotomy?

A

Avoids the aorta

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236
Q

When is a left thoracotomy indicated in treating a trachobronchial injury?

A

Distal left mainstem injuries

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237
Q

What laterality is more likely for diaphragm trauma?

A

Left

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238
Q

Is diaphgramatic injury more likely to occur 2/2 blunt or penetrating trauma?

A

Blunt trauma

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239
Q

What are the CXR findings a/w diaphragmatic injury?

A

Air-fluid level in chest from stomach herniation through hole

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240
Q

What approach should you use for a <1 week old diaphgram injury vs > 1 week old injury and why?

A

Transabdominal approach if < 1 week and chest approach if > 1 week to take down adhesions in chest

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241
Q

What type of repair do you use for diaphgram injury repair

A

Primary repair, may need mesh

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242
Q

Name 7 signs of aortic transection

A

Widened mediastinum; 1st or 2nd rib fracture; apical capping; loss of aortopulmonary window; loss of aortic contour; left hemothorax; tracheal deviation to the right

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243
Q

What is the MC location of aortic transection?

A

Ligamentum arteriosum just distal to the left subclavian takeoff

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244
Q

What are two other common locations of aortic transection?

A

Near aortic valve and where aorta transverses the diaphragm

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245
Q

What percent of CXRs are normal in patients with aortic tears?

A

5% normal

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246
Q

Name two mechanisms of injury with significant risk of aortic transection

A

Head on car crash > 45 MPH; fall > 15 feet

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247
Q

How do you evaluate for aortic transection

A

CTA chest

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248
Q

What are two operative approaches to treat aortic transection?

A

Left thoracotomy and repair with partial left heart bypass Covered stent endograft

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249
Q

What is the only subtype of aortic transection that can be treated with stent endografts?

A

Distal transections only

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250
Q

What are the MCC of death after myocardial contusion (2)?

A

Vtach and Vfib

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251
Q

What is the MC arrhythmia in pts with myocardial contusion?

A

SVT

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252
Q

What is the management of a pt p/w myocardial contusion?

A

Monitoring for 24-48 hours

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253
Q

Define the number of ribs and locations they need to be broken to create a flail chest

A

≥2 consecutive ribs broken at ≥ 2 sites

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254
Q

What is the pulmonary impairment associated with flail chest

A

Underlying pulmonary contusion 2/2 paradoxical motion of chest wall

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255
Q

What is the problem with getting a CXR after an aspiration event?

A

Aspiration may not produce immediate CXR findings

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256
Q

When is a CXR indicated in a penetrating chest injury?

A

For evaluation if the patient is stable

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257
Q

What are the borders of the cardiac box?

A

Clavicles, xiphoid process, nipples

258
Q

What is the management of a penetrating injury to the cardiac box?

A

Pericardial window, bronchoscopy, esophagoscopy, barium swallow

259
Q

What is the next step in management if a pericardial window finds blood?

A

Need median sternotomy to fix possible injury to heart or great vessels and place pericardial drain for monitoring

260
Q

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

A

If patient requires intubation, needs a chest tube If no intubation required, follow with serial CXRs

261
Q

How do you manage a patient with penetrating injuries anterior/medial to the mid-axillary line and below the nipples?

A

Needs laparotomy or laparoscopy May need evaluation for penetrating box injury depending on location

262
Q

What is a non-invasive alternative to pericardial window for cardiac box injuries?

A

Use the FAST scan with the ultrasound evaluation of the pericardium

263
Q

Name three traumatic causes of cardiogenic shock

A

Cardiac tamponade; cardiac contusion; tension PTX

264
Q

What is the MOA of tension PTX?

A

One-way valve effect causes air entry without leaving and pressure builds up

265
Q

What are the S/Sx of tension PTX (5)?

A

Hypotension; increased airway pressures; decreased breath sounds; bulging neck veins; tracheal shift

266
Q

What is one observation during laparotomy that would make you suspect a tension PTX?

A

Bulging diaphragm during laparotomy

267
Q

What is the mechanism of cardiac compromise 2/2 tension PTX?

A

Reduced venous return from IVC/SVC compression

268
Q

What is the tx of a tension PTX

A

Needle decompression, then chest tube

269
Q

What is the MC associated injury with sternal fractures?

A

Cardiac contusions

270
Q

What associated injury are patients with first or second-rib fractures at high risk for?

A

High risk for aortic transection

271
Q

How do you perform a pulmonary tractotomy in penetrating lung trauma?

A

Divide the pulmonary parenchyma between adjacent staple lines

272
Q

What is the benefit of performing a pulmonary tractotomy for penetrating lung trauma?

A

Allows rapid direct access to injured vessels or bronchi along the tract of penetrating injury

273
Q

What is the biggest hemodynamic risk a/w pelvic fracture?

A

Blood loss

274
Q

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?

A

Stabilize pelvis (C-clamp, exfix, sheet) and go to angio for embolization

275
Q

What are the two types of injuries pelvic fracture patients are at high risk for?

A

Abdominal and GU injuries

276
Q

What is the most likely source of bleeding with anterior pelvic fractures?

A

Venous bleeding

277
Q

What is the most likely source of bleeding with posterior pelvic fractures?

A

Arterial bleeding

278
Q

What is the surgical management of rectal tears and perineal lacerations a/w open pelvic fractures?

A

May need colostomy.

279
Q

What is the timing of pelvic fracture repair when you have other traumatic injuries?

A

You may need to delay pelvic fracture repair until associated injuries are repaired

280
Q

Intraop, how do you manage a pelvic hematoma 2/2 penetrating injury?

A

Open the hematoma, qqf go to angio

281
Q

Intraop, how do you manage a non-expanding pelvic hematoma 2/2 blunt injury in a stable patient?

A

Leave it alone

282
Q

Intraop, how do you manage an expanding pelvic hematoma 2/2 blunt injury in a stable or unstable patient?

A

Stabilize pelvic fracture, pack pelvis if in OR, go to angiography for embolization

283
Q

Intraop, how do you manage a nonexpanding pelvic hematoma 2/2 blunt injury in an unstable patient?

A

Stabilize pelvic fracture, pack pelvis if in OR, go to angiography for embolization

284
Q

If you pack the pelvis, when should you remove them?

A

24-48 hours later when the patient is stable

285
Q

What are the three classifications of the Young-Burgess Pelvic Fractures?

A

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
Q

Which Young-Burgess Pelvic Fracture classification is a/w the highest rate of hypovolemic shock? Give rate

A

Vertical shear a/w highest rate of hypovolemic shock at 63%

287
Q

What is the mortality a/w vertical shear pelvic fractures?

A

25% mortality

288
Q

What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a POSITIVE FAST

A

exlap with hemorrhage control

289
Q

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?

A

Ongoing evaluation / support consider exfix

290
Q

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?

A

pelvic angiography with embolization

291
Q

What is the next step for a blunt trauma patient, hemodynamically unstable, fracture on pelvic XR s/p binder placement, with a NEGATIVE FAST?

A

evaluate response to IVF resuscitation

292
Q

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?

A

pelvic angiography with embolization

293
Q

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?

A

CT abdomen/ pelvis

294
Q

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?

A

pelvic angiography with embolization

295
Q

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?

A

pelvic fracture exfix as needed

296
Q

What is the definition of the APC-I classification pelvic fracture? Is it stable or unstable?

A

Symphysis widening < 2.5cm, no posterior ring injury, stable

297
Q

What is the treatment for APC-I pelvic fracture?

A

Nonop, protected WB

298
Q

What is the definition of the APC-II classification pelvic fracture? Is it stable or unstable?

A

Symphysis widening > 2.5cm; anterior SI joint diastasis; posterior SI ligaments intact; disruption of sacrospinous and sacrotuberous ligaments, rotationally unstable, vertically stable

299
Q

What is the treatment for APC-II pelvic fracture?

A

Anterior symphyseal plate or exfix +/- posterior fixation

300
Q

What is the definition of the APC-III classification pelvic fracture? Is it stable or unstable?

A

Disruption of anterior and posterior SI ligaments (SI dislocation); disruption of sacrospinous and sacrotuberous ligaments, completely unstable

301
Q

What is the treatment for APC-III pelvic fracture?

A

Anterior symphyseal multihole plate or exfix and posterior stabilization with SI screws +/- plate

302
Q

What is the definition of the LC-I classification pelvic fracture? Is it stable or unstable?

A

Oblique/transverse ramus fracture and ipsilateral sacral ala compression fracture Posterior compression of SI joint without ligament disruption, stable

303
Q

What is the treatment for an LC-I pelvic fracture?

A

Nonop. Complete comminuted sacral component: protected WB Simple, incomplete sacral fracture-WBAT

304
Q

What is the definition of the LC-II classification pelvic fracture? Is it stable or unstable?

A

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
Q

What is the treatment for an LC-II pelvic fracture?

A

ORIF ilium

306
Q

What is the definition of the LC-III classification pelvic fracture? Is it stable or unstable?

A

Ipsilateral lateral compression and contralateral APC (open book) (windswept pelvis); Common MOA is rollover or ped vs auto; completely unstable

307
Q

What is the treatment for an LC-III pelvic fracture?

A

Posterior stabilization with plate or SI screws

308
Q

What is the definition of the VS classification pelvic fracture? Is it stable or unstable?

A

Posterior and superior directed force, displaced fx of anterior rami and posterior columns, +SI dislocation, completely unstable

309
Q

What is the treatment for a VS pelvic fracture?

A

Posterior stabilization with plate or SI screws

310
Q

What is the MCC of duodenal trauma

A

Blunt trauma (crush or deceleration injury)

311
Q

What is the most common area of injury in the duodenum?

A

2nd portion of duodenum (descending, near ampulla of Vater)

312
Q

What is another common area of duodenal injury s/p trauma

A

Tears near the ligament of Treitz

313
Q

How can most injuries requiring surgical intervention be treated?

A

Most can be treated with debridement and primary closure

314
Q

What percent of duodenal injuries requiring surgical intervention can be treated with debridement and primary closure?

A

80%

315
Q

Which portions of the duodenum can be treated with segmental resection and primary end-to-end anastomosis

A

All segments except D2

316
Q

What is the rate of mortality in duodenal trauma patients and why?

A

25% due to shock

317
Q

What is a major source of morbidity a/w duodenal trauma?

A

Fistulas

318
Q

What is the MC location of paraduodenal hematomas and why?

A

In D3 due to overlying spine in blunt injury

319
Q

What size paraduodenal hematoma is considered significant?

A

≥2 cm is considered significant

320
Q

With what size paraduodenal hematoma and what mechanism of injury do you need to open and explore the hematoma?

A

A significiant hematoma (≥2 cm) and for either blunt or penetrating trauma

321
Q

What S/Sx are a/w paraduodenal hematomas missed on initial CT scan or seen but not explored?

A

p/w high SBO 12-72 hours after injury

322
Q

What is the appearance of a paraduodenal hematoma on UGI study?

A

“stacked coins” or “coiled spring” appearance

323
Q

What are you specifically looking to rule out on an UGI study of a paraduodenal hematoma?

A

Extravasation of contrast

324
Q

How do you treat a paraduodenal hematoma?

A

Conservative therapy (NGT, TPN)

325
Q

What is the cure rate with conservative therapy of a paraduodenal hematoma, over what time course, and why?

A

90% over 2-3 weeks because hematoma is reabsorbed

326
Q

What intraoperative maneuvers should you perform when suspecting dudoenal injury during exlap? (2)

A

Kocher maneuver and open lesser sac through the omentum

327
Q

What four findings are you looking for during the Kocher maneuver and lesser sac exploration with suspected duodenal trauma?

A

Checking for hematoma, bile, succus, or fat necrosis

328
Q

What is the next step if hematoma, bile, succus, or fat necrosis are found in the lesser sac when exploring for suspected duodenal trauma?

A

Formal inspection of the entire duodenum and check for pancreatic injury

329
Q

What are two imaging studies if you suspect duodenal injury? Which is better?

A

CT-abdomen with PO/IV contrast or UGI contrast study. UGI better

330
Q

What findings on CT-abdomen would concern you for duodenal injury (5)?

A

Bowel wall thickening, hematoma, free air, contrast leak, RP fluid/air

331
Q

What do you do if a CT scan is worrisome for duodenal injury but not diagnostic

A

Repeat CT scan in 8-12 hours to see if its getting worse

332
Q

What is the optimal surgical treatment for duodenal trauma?

A

Try to get primary repair or anastomosis

333
Q

What do you do if primary duodenal repair or anastomosis fails?

A

Diversion with pyloric exclusion and gastrojejunostomy to allow healing

334
Q

What tubes/drains need to be placed for a duodenal repair?

A

Distal feeding jejunostomy +/- proximal draining jejunostomy tube that threads back to the duodenal injury site Drains in the bed of the repair

335
Q

What is your surgical approach if D2 is injured and you can’t get a primary repair

A

Place jejunal serosal patch over hole, pyloric exclusion, and gastrojejunosotomy Consider feeding and draining jejunostomies, leave drains

336
Q

What operation may D2 injury patients eventually need?

A

May eventually need Whipple

337
Q

Why are trauma whipples rarely indicated?

A

High mortality

338
Q

When can postop drains be removed?

A

When patient is tolerating a diet without increase in drainage

339
Q

How do you treat duodenal fistulas?

A

Close with time, tx with bowel rest, TPN, octreotide over 4-6 weeks

340
Q

What is the MC organ injured with penetrating trauma?

A

Small bowel (some texts say liver)

341
Q

What mechanism of injury makes it difficult to diagnose small bowel trauma?

A

Difficult to diagnose SB trauma early with blunt trauma

342
Q

What three abdominal CT findings are suggestive of occult SB injury?

A

Intraabdominal fluid not associated with a solid organ injury Bowel wall thickening Mesenteric hematoma

343
Q

What is your management of a patient with suspected SB trauma?

A

Close observation, possible repeat abdominal CT after 8-12 hours to see if findings are stable or worsening

344
Q

What do you need to be sure of in patients with nonconclusive findings prior to discharge?

A

Be sure they can tolerate a diet

345
Q

Directionally, how should small bowel injuries be repaired and why?

A

Repair transversely to avoid stricture

346
Q

What are the two defining criteria for “large lacerations” of the SB?

A

> 50% of bowel circumference or result in lumen diameter < 1/3 normal

347
Q

What is the management of a large SB laceration?

A

Resection and reanastomosis

348
Q

How do you manage a SB segment with multiple close lacerations?

A

Resection

349
Q

What are the criteria of mesenteric hematomas that require exploration? (2)

A

If large (> 2cm) or expanding, need to open

350
Q

Is colon trauma a/w blunt or penetrating injury?

A

Penetrating

351
Q

How do you manage right colon injuries?

A

Primary repair / anastomosis

352
Q

How do you manage transverse colon injuries?

A

Primary repair / anastomosis

353
Q

How do you manage left colon injuries?

A

Primary repair / anastomosis

354
Q

When is a diverting ileostomy indicated in left colon injury? (2)

A

If patient is in shock or there is gross contamination

355
Q

For which mechanism of injury do paracolonic hematomas need to be opened?

A

Both blunt and penetrating

356
Q

Is rectal trauma a/w blunt or penetrating injury?

A

Penetrating injury

357
Q

What is the management of high rectal extraperitoneal injury?

A

Generally not repaired, treat with serial debridement and consider diverting ileostomy

358
Q

Why don’t you repair high rectal extraperitoneal injury?

A

Inaccessibility

359
Q

How do you repair high rectal intraperitoneal injury?

A

Repair defect, presacral drainage, consider diverting ileostomy

360
Q

What are the indications for diverting ileostomy with high rectal injury? (3)

A

Shock, gross contamination, or extensive injury

361
Q

What is your management of low rectal injuries (< 5cm)

A

Repair transanally

362
Q

What is the MC organ injured with blunt abdominal trauma?

A

Liver, some texts say spleen

363
Q

What operation is rarely indicated with liver trauma?

A

Lobectomy

364
Q

Why can the common hepatic artery be ligated?

A

Collaterals through the GDA

365
Q

What is the Pringle maneuver?

A

Clamping the portal triad

366
Q

Why would the Pringle maneuver fail to stop hepatic bleeding?

A

Bleeding from the hepatic veins

367
Q

Name two indications for “damage control perihepatic packing”

A

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
Q

What is the indication for an atriocaval shunt with liver trauma?

A

Retrohepatic IVC injury, allows for control while performing repair

369
Q

What is the management of portal triad hematomas?

A

They need to be explored

370
Q

What is the management of CBD injury < 50% circumference?

A

Repair over stent

371
Q

What is the management of CBD injury > 50% circumference

A

Choledochojejunostomy

372
Q

What is the management of complex CBD injury?

A

Choledochojejunostomy

373
Q

What intraoperative procedure may you require to define CBD injury?

A

May need IOC to define injury

374
Q

Why should you place drains after CBD repair?

A

In case of a duct anastomotic leak

375
Q

What percent of duct anastomoses leak after CBD repair?

A

10%

376
Q

Do you need to repair Portal Vein injury?

A

Needs to be repaired

377
Q

How do you access retropancreatic portal vein?

A

May need to transect through the pancreas to get to injury in the portal vein

378
Q

What additional procedure is required if you need to transect through the pancreas to repair the portal vein?

A

Distal pancreatectomy

379
Q

What is the mortality rate a/w portal vein ligation?

A

50%

380
Q

What are two benefits of using an omental graft with liver lacerations?

A

Help with bleeding and prevent bile leaks

381
Q

Should you leave drains with liver injuries?

A

Yes

382
Q

What are two criteria that define failure of conservative management of blunt liver injuries?

A

Unstable despite aggressive resuscitation (includes 4U PRBC) with HR > 120 or SBP < 90 Requires > 4 units to get Hct > 25

383
Q

What two vascular findings on CT indicate need for OR?

A

Active blush or pseudoaneurysm

384
Q

What is the difference in management between anterior or posterior vascular liver injuries?

A

If posterior, may be better off with angiogram. With anterior, go to OR

385
Q

How much time is needed for bedrest for conservative management of liver trauma?

A

5 days

386
Q

Define a Grade I Liver hematoma

A

Subcapsular, <10% surface area

387
Q

Define a Grade I Liver laceration

A

capsular tear, <1cm parenchymal depth

388
Q

Define a Grade II Liver hematoma (subcapsular)

A

subcapsular, 10-50% surface area

389
Q

Define a Grade II liver laceration

A

1-3cm parenchymal depth, <10cm length

390
Q

Define a Grade III liver hematoma (subcapsular)

A

subcapsular, > 50% surface area or expanding ruptured subcapsular or expanding

391
Q

Define a Grade III liver laceration

A

>3cm parenchymal depth

392
Q

Define a Grade IV liver laceration

A

parenchymal disruption involving 25-75% of the hepatic lobe or 1-3 Coinaud’s segments in a single lobe

393
Q

Define a Grade V liver laceration

A

parenchymal disruption involving > 75% of hepatic lobe or >3 Coinaud’s segments within a single lobe

394
Q

Define a Grade V liver vascular injury

A

juxtahepatic venous injuries (ie retrohepatic vena cava / central major hepatic veins)

395
Q

Define a Grade VI liver vascular injury

A

hepatic avulsion

396
Q

How many weeks before splenic trauma is fully healed?

A

6 weeks

397
Q

What is the postop time period during which patients are at highest risk of post-splenectomy sepsis?

A

Within 2 years of splenectomy

398
Q

What medical intervention is a/w splenic salvage?

A

Increased transfusions

399
Q

What two vascular CT findings are indications for the OR?

A

Active blush or pseudoaneurysm

400
Q

How long do you need to be on bedrest with conservative management

A

5 days

401
Q

How does the management of splenectomy differ in pediatrics?

A

Threshold for splenectomy is much higher in peds, hardly any children undergo splenectomy

402
Q

What meds need to be given post-splenectomy?

A

Need immunizations

403
Q

How do multiple injuries affect liver grading s/p trauma?

A

advance one grade for multiple injuries to the same organ up to grade III

404
Q

Define Grade I splenic hematoma

A

subcapsular, <10% surface area

405
Q

Define Grade I splenic laceration

A

capsular tear, <1cm parenchymal depth

406
Q

Define a Grade II Liver hematoma (intraparenchymal)

A

intraparenchymal, <10cm length

407
Q

Define a Grade III Liver hematoma (intraparenchymal)

A

ruptured parenchymal hematoma intraparenchymal hematoma >10cm or expanding

408
Q

Define a Grade II splenic hematoma, subcapsular

A

10-50% surface area

409
Q

Define a Grade II splenic hematoma, intraparenchymal

A

<5cm diameter

410
Q

Define a Grade III splenic hematoma, subcapsular

A

>50% surface area or expanding Ruptures subcapsular or parenchymal hematoma

411
Q

Define a Grade III splenic hematoma, intraparenchymal

A

>5cm

412
Q

Define a Grade III splenic laceration

A

> 3cm parenchymal depth or involving trabecular vessels

413
Q

Define a Grade IV splenic laceration

A

laceration of segmental or hilar vessels producing major devascularization (> 25% of spleen)

414
Q

Define a Grade V splenic laceration

A

completely shattered spleen

415
Q

Define a Grade V splenic vascular injury

A

hilar vascular injury with devascularized spleen

416
Q

What to you do for multiple injuries to the spleen via trauma when grading?

A

advance one grade for multiple injuries to the same organ up to grade III

417
Q

What percent of pancreatic trauma is 2/2 penetrating injury?

A

80% 2/2 penetrating injury

418
Q

What structure in the pancreas is MC damaged with blunt injury?

A

Pancreatic duct fractures

419
Q

Where are pancreatic duct fractures located after blunt injury?

A

Perpendicular to the duct

420
Q

What two changes to peripancreatic fat indicates injury?

A

Necrosis or edema

421
Q

How can you treat a pancreatic contusion? (2)

A

If pt stable, leave it alone. If pt in OR, leave drains

422
Q

How do you treat a distal pancreatic duct injury?

A

Distal pancreatectomy

423
Q

How much of the gland can you remove with a distal pancreatectomy?

A

80%

424
Q

How do you treat an irreperable pancreatic head duct injury?

A

Start by leaving drains; Delayed whipple or possible ERCP with stent may eventually be needed

425
Q

What anatomic structure provides a landmark to determine whether a whipple vs distal pancreatectomy should be used for a pancreatic duct injury?

A

Use the duct injury’s relation to the SMV to determine how to treat the injury

426
Q

What is the benefit of the Kocher maneuver intraop?

A

Helps elevate the pancreas in the OR

427
Q

What precaution should you take intraop with pancreatic injury?

A

Always leave drains

428
Q

Which mechanism of injury is an indication for opening a pancreatic hematoma?

A

Both blunt and penetrating trauma are indications for opening a pancreatic hematoma

429
Q

What should you suspect in a patient with persistent or rising amylase?

A

Missed pancreatic injury

430
Q

Are CT scans good at diagnosing pancreatic injuries initially?

A

Nope

431
Q

What are the delayed CT findings a/w pancreatic injury?

A

Fluid, edema, necrosis

432
Q

Why would an ERCP be indicated with a pancreatic duct injury?

A

Good at localizing the duct injury and may be able to treat with a temporary stent

433
Q

If a patient has concomitant vascular and ortho injuries, which should be repaired first?

A

First vascular repair, then ortho repair

434
Q

Name six hard signs of vascular injury

A

Active hemorrhage Pulse deficit Expanding/pulsatile hematoma Distal ischemia Bruit Thrill

435
Q

What is the management of a patient with a hard sign of vascular injury?

A

To the OR, may need intraop angio to define injury

436
Q

Name the four soft signs of vascular injury

A

History of hemorrhage Deficit in anatomically-related nerve Large stable/nonpulsatile hematoma ABI < 0.9

437
Q

How do you treat a patient with a soft sign of vascular injury?

A

Go to angio

438
Q

How much of the vasculature must be missing to require a GSV graft?

A

If segment > 2cm missing

439
Q

Which leg should you harvest GSV from when fixing lower extremity arterial injuries?

A

Use vein from contralateral leg

440
Q

Name the six veins that, when injured, require repair and not ligation

A

Vena cava Femoral vein Popliteal vein Brachiocephalic vein Subclavian vein Axillary vein

441
Q

How should you manage the transection of a single artery in a calf in an otherwise healthy patient?

A

Ligate it

442
Q

What should you do once you’ve created an anastomosis to protect it?

A

Cover it with viable tissue and muscle

443
Q

How long should a lower extremity be compromised for you to consider fasciotomy after revascularization?

A

> 4-6 hours to prevent compartment syndrome

444
Q

What compartment pressure is concerning for compartment syndrome?

A

Compartment pressure > 20mm Hg

445
Q

What are the six clinical findings (in order of presentation) concerning for compartment syndrome?

A

Pain to paresthesia to anesthesia to paralysis to poikilothermia to pulselessness (late)

446
Q

Name the four MC traumatic causes of compartment syndrome?

A

Supracondylar humerus fractures Tibial fractures Crush injuries Other injuries resulting disruption and restoration of blood flow after 4-6 hours

447
Q

How do you treat compartment syndrome?

A

Fasciotomy https://www.youtube.com/watch?v=-1NDJkFH1vM

448
Q

**LOWER EXTREMITY COMPARTMENTS**

A

**LOWER EXTREMITY COMPARTMENTS**

449
Q

**LOWER EXTREMITY COMPARTMENTS**

A

**LOWER EXTREMITY COMPARTMENTS**

450
Q

**LOWER EXTREMITY COMPARTMENTS**

A

**LOWER EXTREMITY COMPARTMENTS**

451
Q

When should you perform primary repair of IVC versus patch repair?

A

If residual stenosis < 50% of diameter of IVC, can do primary repair, otherwise patch

452
Q

What two materials can you use for IVC patch repair?

A

Saphenous vein or synthetic patch

453
Q

What is the best way to control IVC bleeding?

A

Proximal and distal pressure

454
Q

Why should you avoid clamping the IVC?

A

You can tear it

455
Q

What should your approach to posterior IVC wall injuries be?

A

Through the anterior wall, you may need to cut anterior wall of IVC to get to posterior wall

456
Q

How much blood could you lose with a femur fracture

A

> 2L blood loss with a femur fracture

457
Q

Name five orthopedic emergencies

A

Pelvic fractures in unstable patients Spine injury with deficit Open fractures Dislocations or fractures with vascular compromise Compartment syndrome

458
Q

What complication are you at risk for with femoral neck fractures?

A

High risk of avascular necrosis

459
Q

How do you manage a long bone fracture / dislocation with a loss of pulse?

A

Immediately reduce the fracture / dislocation and reassess the pulse

460
Q

What do you do if the pulse does not return with reduction of fracture?

A

Go to OR for vascular bypass / repair, may need angio to define the injury

461
Q

What do you do if a pulse is weak after reduction of fracture?

A

Angio

462
Q

What imaging do all knee dislocations require and what is the exception?

A

All need angio unless absent distal pulse, then straight to OR

463
Q

What are the three fractures a/w upright falls?

A

Calcaneus, lumbar, and distal forearm fractures (radial/ulnar)

464
Q

What nerve injury is a/w anterior shoulder dislocation?

A

Axillary nerve

465
Q

What arterial injury is a/w posterior shoulder dislocation?

A

Axillary artery

466
Q

What nerve injury is a/w proximal humerus fx?

A

Axillary nerve

467
Q

What nerve injury is a/w midshaft humerus fx?

A

Radial nerve

468
Q

What nerve injury is a/w spiral humerus fx?

A

Radial nerve

469
Q

What arterial injury is a/w distal/supracondylar humerus fx?

A

Brachial artery

470
Q

What arterial injury is a/w elbow dislocation?

A

Brachial artery

471
Q

What nerve injury is a/w distal radius fx?

A

Median nerve

472
Q

What arterial injury is a/w anterior hip dislocation?

A

Femoral artery

473
Q

What nerve injury is a/w posterior hip dislocation?

A

Sciatic nerve

474
Q

What arterial injury is a/w distal/supracondylar femur fx?

A

Popliteal artery

475
Q

What arterial injury is a/w posterior knee dislocation?

A

Popliteal artery

476
Q

What nerve injury is a/w fibular neck fractures?

A

Common peroneal nerve

477
Q

What complication is a/w temporal or parietal bone fx?

A

Epidural hematoma

478
Q

What fracture is a/w maxillofacial fx?

A

Cervical spine fx

479
Q

What injury is a/w sternal fx?

A

Cardiac contusion

480
Q

What vascular injury is a/w first/second rib fractures?

A

Aortic transection

481
Q

What lung injury is a/w scapular fracture?

A

Lung contusion

482
Q

What vascular injury is a/w scapular fracture?

A

Aortic transection

483
Q

What injury is a/w left 8-12 rib fractures?

A

Splenic lac

484
Q

What injury is a/w right 8-12 rib fx?

A

Liver laceration

485
Q

What two GU injuries are a/w pelvic fx?

A

Bladder rupture, urethral transection

486
Q

What sign/symptom is the best indicator of renal trauma?

A

Hematuria

487
Q

What imaging do all trauma patients with hematuria need?

A

abdominal CT scan

488
Q

Why does an IVP accomplish that precludes the need for a CT scan?

A

Can be used in patients going directly to the OR, identifies the presence of a functional contralateral kidney

489
Q

Why are you able to ligate the left renal vein but not the right renal vein?

A

LRV has adrenal and gonadal vein collaterals while RRV does not

490
Q

Where on the LRV should you ligate it?

A

Ligate it close to the IVC

491
Q

Name the renal hilar structures anterior to posterior

A

VAP: vein, artery, pelvis

492
Q

What percent of renal trauma injuries are treated nonoperatively

A

95% are treated nonoperatively

493
Q

Do all urine extravasation injuries require OR?

A

nope

494
Q

What are acute indications for OR s/p renal trauma?

A

Ongoing hemorrhage with instability

495
Q

Name three non-acute indications for OR (after the acute phase of care):

A

Major collecting system disruption, non-resolving urine extravasation, severe hematuria

496
Q

With exploration, which portion of the kidney should you try to get control of first?

A

Get control of the vascular hilum first

497
Q

When should you place drains intraop?

A

Always, but especially if the collecting system is injured

498
Q

In the setting of an exlap for another injury, you see a blunt renal injury with hematoma, what do you do?

A

Leave it alone unless the preop CT/IVP showed no function or significant urine extravasation

499
Q

In the setting of an exlap for another injury, you see a penetrating renal injury with hematoma, what do you do?

A

Open unless preop CT/IVP showed good function without significant urine extravasation

500
Q

How do you treat flank trauma with IVP showing no uptake in the stable patient?

A

Angiogram, stent if flap is present

501
Q

How do you perform an IV pyelogram?

A

Iodinated contrast provided at 2cc/kg, 10 minutes later get an XR

502
Q

Define a Grade I Renal Contusion

A

microscopic or gross hematuria with normal urologic studies

503
Q

Define a Grade I renal hematoma

A

subcapsular, non-expanding without parenchymal laceration

504
Q

Define a Grade II renal hematoma

A

nonexpanding perirenal hematoma confined to renal retroperitoneum

505
Q

Define a Grade II renal laceration

A

<1.0cm parenchymal depth of renal cortex with no urinary extravasation

506
Q

Define a Grade III renal laceration

A

>1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation

507
Q

Define a Grade IV renal laceration

A

parenchymal laceration extending through renal cortex, medulla, and collecting system

508
Q

Define a Grade IV vascular renal injury

A

main renal artery or vein injury with contained hemorrhage

509
Q

Define a grade V renal laceration

A

completely shattered kidney

510
Q

Define a grade V vascular renal injury

A

avulsion of renal hilum that devascularizes kidney

511
Q

What S/Sx is the best indicator of bladder trauma?

A

Hematuria is the best indicator of bladder trauma

512
Q

What is the MC injury a/w bladder trauma?

A

Pelvic fractures

513
Q

What percent of bladder traumas are a/w pelvic fractures?

A

> 95%

514
Q

Name 2 more S/Sx of bladder trauma

A

Blood at the meatus, sacral or scrotal hematoma

515
Q

What does the cystogram show for extraperitoneal bladder rupture?

A

starbursts

516
Q

What is the treatment for extraperitoneal bladder rupture?

A

Foley 7-14 days

517
Q

What does the cystogram show for intraperitoneal bladder rupture?

A

leak

518
Q

What demographic is more likely to have intraperitoneal bladder rupture?

A

kids

519
Q

What is the treatment for intraperitoneal bladder rupture?

A

Operation and repair of defect folllowed by Foley drainage

520
Q

Is hematuria a reliable indicator of ureteral trauma?

A

No

521
Q

What two tests are the best indicators of ureteral trauma?

A

IVP and retrograde urethrogram (RUG)

522
Q

Where is the blood supply of the upper 2/3 of the ureter (lateral or medial)?

A

medial

523
Q

Where is the blood supply of the lower 1/3 of the ureter (lateral or medial)?

A

lateral

524
Q

What is the cutoff to be considered a large ureteral injury that may prevent repair?

A

> 2cm

525
Q

How do you treat a large upper 1/3 ureteral injuries that won’t reach the bladder?

A

Tie off both ends of the ureter, temporize with a percutaneous nephrostomy Treat with ileal interposition or trans-ureteroureterostomy later

526
Q

How do you treat a large middle 1/3 ureteral injuries that won’t reach the bladder?

A

Tie off both ends of the ureter, temporize with a percutaneous nephrostomy Treat with ileal interposition or trans-ureteroureterostomy later

527
Q

How do you treat a large lower 1/3 ureteral injury?

A

Reimplant in bladder, may need bladder hitch procedure

528
Q

What length of ureter should be measured to be considered a “small” injury?

A

<2cm

529
Q

How do you treat a small upper 1/3 ureteral injury?

A

Mobilize ends of ureter and perform primary repair over stent

530
Q

How do you treat a small middle 1/3 ureteral injury?

A

Mobilize ends of ureter and perform a primary repair over a stent

531
Q

How do you treat a small lower 1/3 ureteral injury?

A

Reimplant into the bladder since this is an easier anastomosis than primary repair

532
Q

What is a “one-shot” IVP?

A

100cc of 60% iodine followed by plain film 2-5 minutes later identifies presence of both kidneys and evaluates for extravasation

533
Q

What structure is not appropriately evaluated by one-shot IVP?

A

Ureters are not sufficiently evaluated by one-shot IVP

534
Q

What two IV dyes can be used to check for ureteral leaks?

A

IV methylene blue or IV indigo carmine

535
Q

When should you leave drains?

A

Leave drains for all ureteral injuries

536
Q

**URETHRA PHOTO**

A

**URETHRA PHOTO**

537
Q

What are the two best signs of uretheral trauma?

A

Hematuria or blood at meatus

538
Q

What injury is often associated with a free-floating prostate

A

Pelvic fractures

539
Q

Should you place a Foley?

A

Nah, nope, absolutely not

540
Q

What is the best imaging test for uretheral trauma?

A

RUG (retrograde urethrogram)

541
Q

Which portion of the urethra is at highest risk for transection?

A

Membranous portion

542
Q

How do you treat a significant urethral tear?

A

Suprapubic cystostomy and repair in 2-3 months

543
Q

Why do you wait 2-3 months to repair a significant urethral tear?

A

High rates of stricture and impotence if repaired early

544
Q

How do you treat small, partial urethral tears?

A

Bridge urethral catheter across tear and repair in 2-3 months

545
Q

How do you treat erectile body fracture from vigorous sex?

A

Repair tunica and Buck’s fascia

546
Q

How do you evaluate and treat testicular trauma?

A

Ultrasound to see if tunica albuginea is violated, if yes then treat

547
Q

Why is blood pressure NOT a good indicator of blood loss in children?

A

It is the last thing to fall in kids

548
Q

What are the four best indicators of shock in children?

A

Heart rate, respiratory rate, mental status, and clinical exam

549
Q

Why are children at increased risk of hypothermia in trauma?

A

Increased body surface area compared to weight

550
Q

Are children at increased risk for head injury?

A

Yes

551
Q

What age group is an infant?

A

<1 year

552
Q

What age group is a preschool child?

A

< 5 years

553
Q

What age group is an adolescent?

A

> 10 years

554
Q

What is a normal HR, SBP and RR for an infant?

A

infant < 1 year HR 160 / SBP 80 / RR 40

555
Q

What is a normal HR, SBP and RR for a preschool child (<5 years)?

A

HR 140 / SBP 90 / RR 30

556
Q

What is a normal HR, SBP, and RR for an adolescent (> 10 years)

A

HR 120 / SBP 100 / RR 20

557
Q

in a pregnant trauma patient, Do you save mother or baby?

A

At all costs, save the mother

558
Q

How much blood volume can a pregnant patient lose without evidence of hemorrhagic shock?

A

Can lose up to 1/3 of total blood volume without signs

559
Q

How can you estimate weeks of pregnancy?

A

Based on fundal height. Ex: 20cm = 20 weeks

560
Q

What should you use to monitor the fetus?

A

A fetal monitor

561
Q

What imaging should you avoid except in life-threatening situations?

A

Try to avoid CT scan, especially in early pregnancy

562
Q

What imaging may have a role?

A

Ultrasound / FAST scan

563
Q

What should you check on cervical exam? (4)

A

Check for vaginal discharge (blood / amnion) Check for effacement, dilation, and fetal station

564
Q

What two tests on amniotic fluid can determine fetal maturity?

A

Lecithin: sphingomyelin ratio > 2:1 Positive phophatidylcholine

565
Q

What does the lecithin: sphingomyelin ratio indicate

A

Lecithin: sphingomyelin ratio > 2:1 is normal (indicates fetal lung maturity and lecithin makes surfactant more active)

566
Q

What is placental abruption?

A

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
Q

How is placental abruption classified?

A

Partial or complete Apparent (vaginal bleeding) or concealed (pocket of blood)

568
Q

What are potential maternal complications of placental abruption (4)?

A

Hypovolemic shock, Sheehan syndrome (perinatal pituitary necrosis), renal failure, or DIC (from release of thromboplastin from decidua basalis).

569
Q

What percentage of placental abruption is a/w a 100% fetal death rate?

A

> 50% abruption is a/w ~100% death rate

570
Q

Name 3 signs of abruption

A

Uterine tenderness, contractions, fetal HR < 120

571
Q

What are the 2 MCC of placental abruption?

A

Shock (clamping down of blood vessels?) or mechanical forces

572
Q

What does the Kleihauer-Betke test look for?

A

Looks for fetal blood in maternal circulation and is a sign of placental abruption

573
Q

Where in the uterus is uterine rupture more likely to occur?

A

Posterior fundus

574
Q

How do you manage uterine rupture AFTER delivery of the child?

A

Aggressive resuscitation (IVF, blood) even in the face of shock since the uterus will eventually clamp down after delivery –> leads to best outcomes

575
Q

Name five indications for C-section during trauma exlap?

A

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
Q

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?

A

perform C-section and address fetal injuries

577
Q

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?

A

evacuate uterus

578
Q

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?

A

leave uterine contents intact

579
Q

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?

A

repair uterus

580
Q

What is the blood loss for Class I hemorrhagic shock?

A

up to 750cc

581
Q

What is the % blood volume lost in Class I hemorrhagic shock?

A

up to 15%

582
Q

what is the HR in Class I hemorrhagic shock?

A

<100

583
Q

What is the blood pressure in class I hemorrhagic shock?

A

normal

584
Q

what is the pulse pressure in class I hemorrhagic shock?

A

normal or increased

585
Q

what is the RR in class I hemorrhagic shock?

A

14-20

586
Q

what is the UOP in class I hemorrhagic shock?

A

>30cc/hr

587
Q

what is the mental status in class I hemorrhagic shock?

A

slightly anxious

588
Q

What is the blood loss for Class II hemorrhagic shock?

A

750-1500cc

589
Q

What is the % blood volume lost in Class II hemorrhagic shock?

A

15-30%

590
Q

What is the HR in Class II hemorrhagic shock?

A

100-120

591
Q

what is the BP in class II hemorrhagic shock?

A

normal

592
Q

what is the pulse pressure in class II hemorrhagic shock?

A

decreased

593
Q

what is the RR in class II hemorrhagic shock?

A

20-30

594
Q

what is the UOP in class II hemorrhagic shock?

A

20-30cc/hr

595
Q

what is the mental status in class II hemorrhagic shock?

A

mildly anxious

596
Q

what is the blood loss in class III hemorrhagic shock?

A

1500-2000cc

597
Q

what is the % blood volume loss in class III hemorrhagic shock?

A

30-40%

598
Q

what is the HR in class III hemorrhagic shock?

A

120-140

599
Q

what is the bp in class III hemorrhagic shcok?

A

decreased

600
Q

what is the pulse pressure in class III hemorrhagic shock?

A

decreased

601
Q

what is the RR in class III hemorrhagic shock?

A

30-40

602
Q

what is UOP in class III hemorrhagic shock?

A

5-15cc/hr

603
Q

what is the mental status in class III hemorrhagic shock?

A

anxious/confused

604
Q

what is the blood loss in class IV hemorrhagic shock?

A

>2000cc

605
Q

what is the % blood volume lost in class IV hemorrhagic shock?

A

>40%

606
Q

what is the HR in class IV hemorrhagic shock?

A

>140

607
Q

what is the BP in class IV hemorrhagic shock?

A

decreased

608
Q

what is the pulse pressure in class IV hemorrhagic shock?

A

decreased

609
Q

what is the respiratory rate in class IV hemorrhagic shock?

A

>35

610
Q

what is the UOP in class IV hemorrhagic shock

A

negligible

611
Q

what is the mental status in class IV hemorrhagic shock?

A

confused / lethargic

612
Q

how do you manage a pelvic hematoma >2cm s/p penetrating trauma?

A

open it

613
Q

how do you manage a pelvic hematoma >2cm s/p blunt trauma?

A

leave it alone

614
Q

how do you manage a >2cm paraduodenal hematoma s/p penetrating trauma?

A

open it

615
Q

how do you manage a >2cm paraduodenal hematoma s/p blunt trauma?

A

open it

616
Q

how do you manage a >2cm portal triad hematoma s/p penetrating trauma?

A

open it

617
Q

how do you manage a >2cm portal triad hematoma s/p blunt trauma?

A

open

618
Q

how do you manage a >2cm retrohepatic hematoma s/p penetrating trauma?

A

leave it alone if stable

619
Q

how do you manage a >2cm retrohepatic hematoma s/p blunt trauma?

A

leave it alone

620
Q

how do you manage a >2cm midline supramesocolic hematoma s/p penetrating trauma?

A

open it

621
Q

how do you manage a >2cm midline supramesocolic hematoma s/p blunt trauma?

A

open it

622
Q

how do you manage a >2cm midline inframesocolic hematoma s/p penetrating trauma?

A

open it

623
Q

how do you manage a >2cm midline inframesocolic hematoma s/p blunt trauma?

A

open it

624
Q

how do you manage a >2cm pericolonic hematoma s/p penetrating trauma?

A

open it

625
Q

how do you manage a >2cm pericolonic hematoma s/p blunt trauma?

A

open it

626
Q

how do you manage a >2cm perirenal hematoma s/p penetrating trauma?

A

open it unless preop CT/IVP shows NO injury

627
Q

how do you manage a >2cm perirenal hematoma s/p blunt trauma?

A

leave it alone unless preop CT/IVP shows injury

628
Q

Where is zone 1 of the retroperitoneum located?

A

Central retroperitoneum

629
Q

What are the injuries a/w penetrating zone 1 trauma?

A

Pancreaticoduodenal injury or major abdominal vascular injury

630
Q

How do you approach zone 1 hematomas?

A

Pancreaticoduodenal injury or major abdominal vascular injury

631
Q

How do you approach zone 1 hematomas?

A

Usually open them

632
Q

Where is zone 2 located?

A

Flank or perinephric area

633
Q

What injuries are a/w zone 2 injuries?

A

Injuries to the GU tract or colon

634
Q

How do you approach zone 2 hematomas?

A

Usually open them

635
Q

Where is zone 3 located?

A

Pelvis

636
Q

What are the injuries a/w zone 3 injury?

A

Pelvic hematomas

637
Q

describe the boundaries of the three zones of the zones of the RP

A

Zone 1: aortic; Zone 2: perirenal and colonic; Zone 3: pelvic

638
Q

What five injuries should you leave drains for?

A

Pancreatic, liver, biliary, urinary, duodenal

639
Q

What are the three sx a/w snakebites?

A

Shock, bradycardia, arrhythmia

640
Q

What is the treatment of snakebites?

A

Stabilize pt, antivenin, tetanus shot

Z.Fiser (22 decks)

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