SESAP - Trauma Flashcards
Pneumomediastinum in blunt trauma
What is the associated risk of esophageal injury?
Only 1%
More commonly had CHEST injury, specifically pneumothorax
What is the Macklin Effect?
Air dissecting along the pulmonary vasculature from injured alveoli from traumatic pneumothorax to cause pneumomediastinum
When to act on a pneumomediastinum?
Depends on location – if patient has air in posterior mediastinum or diffusely in all (ant/sup/post) then swallow, CT and endoscopy to r/o esophageal injury
penetrating chest trauma witnessed in hospital arrest
Left anterolateral resuscitative thoracotomy at 4-5th intercostal space, open pericardium anterior to left phrenic nerve, occlude injury. You can try to repair.
Duodenal injuries approach to management
if isolated -
Grade 1, 2, 3, can be primarily repaired
Grade 4,5 require wide drainage and possible assessment for reconstruction
Grade 1 Duodenal injury
Hematoma - minimal, one segment. Laceration - not through to mucosa
Treatment - monitor. may need a feeding access
Grade 2 Duodenal injury
Hematoma - multiple segments. laceration < 50% circumference
Treatment - primary repair
Grade 3 Duodenal injury
Laceration - 50-75% of D2, up to 100% of injury to D1/D3/D4
Primary repair –> DJ or DD
Grade 4 Duodenal injury
75% with involvement of ampulla or distal CBD
Trauma Whipple
Grade 5 Duodenal injury
total devascularization or massive destruction of duodenum and pancreas
Trauma Whipple
When to use a pyloric exclusion in patients with duodenal injury?
When they have an associated pancreatic injury during your primary repair…protects the repair of the duodenum.
Rectal injury
Workup - evaluate the rectum. Contrast via rectum versus proctoscopy
Rectal injury
what to do ?
what has fallen out of favor?
if it is high (8-10 cm above the dentate line) –> diversion (loop colostomy)
if is lower and closer to the anal opening, then primary repair.
Presacral drainage and rectal washout
Bladder injuries
Work up?
Retrograde urethrogram to assess for intra versus extra peritoneal injury
Bladder injuries
what to do?
Intra-peritoneal injuries = OR
Extra-peritoneal injuries = foley catheter placed for 14 days.
DVT Prophylaxis in TBI/ICB patients
Yes. Chemo-prophylaxis in 24-48 hours - LMWH > UFH. Use mechanical prophylaxis as well.
Spleen Injuries
Grading 1 and 2?
Hematoma/Laceration - subcapsular 10/capsular <1 cm
Hematoma/Laceration - 10-50% hematoma, 1-3 cm in depth
Observe. serial H/H. serial abdominal exam
Spleen Injury
Grade 3
Hematoma > 50%, Laceration > 3 cm
Likely will need Embolization if transiently responsive.
Spleen Injury
Grade 4
Laceration involving segmental/hilar vessels with devitalization of 25% of spleen
Embolization. Close monitoring for possible OR
Spleen Injury
Grade 5
Total destruction with complete devacsularization of spleen.
OR
Pregnancy in Trauma
Principle - Return to euvolemia. Reduce time in shock. (Early splenectomy is better )
Duodenal Blunt injury - hematoma - patient scenario, management
Patient scenario - child on a bike, delayed presentation. Or adult with abdominal blunt force, delayed presentation. Obstructive symptoms. 1-3 weeks to resolve.
Management - non-operative. first - gastric decompression, second - contrast study. then nutrition options - if partial, then NJ tube, if complete, then TPN.
TBI - Management - IMPACT study
Looked at secondary injury and saw direct link between patient outcomes in :
hypoxemia (pa02<60)
hypotension (SBP <90)
REBOA
- What is it?
- What is the best indication for it?
- Resuscitative endovascular balloon occlusion of the aorta.
- extremis FROM hemorrhage in PELVIC or ABDOMINAL source. Not to be used in blunt cardiac injury, penetrating neck/chest trauma –> THORACOTOMY
REBOA
Zones
ZONE 1 - Left subclavian - celiac trunk –> for abdominal hemorrhage
ZONE 2 - celiac trunk to lowest renal –> avoid this if possible
ZONE 3 - below renal –> for pelvic hemorrhage
NEXUS Criteria
- Alert, awake without distracting injuries. No midline tenderness. No neurologic deficits –> clinically clear.
- Cannot cooperate with examination, intoxicated/neuro impaired –>imaging. CT > Sn then XR
Chest Trauma
hemodynamically normal, + cardiac window in FAST in penetrating left chest trauma - what next?
Subxiphoid pericardiotomy –> check for bloody output. If bloody, then go to sternotomy (active bleeding) or consider irrigation and drainage (just bloody)
Pelvic trauma –>
first step to temporize bleeding
- External pelvic binder/compression
2. Options after that include –> IR angioembolization, pre-peritoneal packing.
Pancreatic Trauma
GRADE 1
Minor contusion, superficial laceration. No duct injury.
observe
Pancreatic Trauma
GRADE 2
Major contusion or laceration. no duct injury
Pancreatic Trauma
GRADE 3
Distal transection with duct injury
Pancreatic Trauma
GRADE 4
GRADE 5
Proximal transection with ampulla
Major disruption
Pancreatic Trauma
Management of high grade injuries
Principles -
ductal disruption - operation will help
With proximal ductal disruption, may attempt ERCP if available or to allow for pancreatic psuedocyst to form for later drainage is > operation.
With distal ductal disruption, do a distal pancreatectomy with splenic preservation.
TBI Management
Severe TBI - ICP monitor v. Mannitol
Recommend the use of mannitol before intracranial pressure (ICP) monitoring in patients with signs of transtentorial herniation or progressive neurologic deterioration not attributable to extracranial injury. Thus, waiting to place an ICP monitor is not recommended.
Blast injuries - primary injuries
pathophys - overpressurized wave impacting gas filled structures –> lung (pulm contusions/barotrauma), GI (hemorrhage/perforation), middle ear (TM perforation), concussion, eye glob rupture
Blast injuries - secondary injuries
pathophys - flying debris –> can impact any body part (penetrating injuries)
Blast injuries - tertiary injuries
pathophys - body being through by the blast wind –> any body part (fractures, closed TBI)
Blast injuries - quarterary injuries
anything not 1/2/3 injuries such as crush injuries, burn injuries
Spinal Cord -
Loss of motor function
Loss of pain, temperature below injury
Intact proprioception, vibration
ANTERIOR CORD SYNDROME
anterior spinal artery insufficiency
Spinal Cord -
Loss of proprioception
Intact motor
POSTERIOR CORD SYNDROME
super rare issues with dorsal columns
Spinal Cord -
Brown-Seqard Syndrome
Loss of IPSILATERAL motor function
Loss of IPSILATERAL proprioception
Loss of IPSILATERAL light touch
Loss of CONTRALATERAL pain and temperature sensation
Spinal Cord -
Central Cord syndrome
hyperextension cervical spine in patients with previous cervical spondylosis.
Upper extremity weakness/sensation > lower extremity weakness
Spinal Cord -
T12-L1/L2 injuries
CONUS MEDULLARIS with loss of sensation to the saddle region –> bowel and bladder dysnfunction. no LE weakness.
Pregnancy in trauma
what position?
left lateral decubitus. left side down, right up so that there is no uterine pressure on IVC
Pregnancy in trauma
blood cell changes?
increased RBC mass ~ 30%
Increased Blood volume ~40-50%
relative anemia of pregnancy
Pregnancy in trauma
fundal height and viability
when can you CT?
umbilicus - 20 weeks
1 cm above = 1 week
23 weeks is viability age.
CT is safe outside of 10 weeks. Most dangerous at 5-10 weeks.
Neck Injuries
Zones?
1: sternal notch to cricoid
2: cricoid to angle mandible
3. superior to base of occiput
Zone 1 Neck Injury
- CTA, contrast studies then possible OR or observe.
Zone 2 Neck Injury
- CT Angiogram of neck, contrast esophagram OR flexible esophagoscopy.
Hard signs –> surgical exploration.
Zone 3 Neck Injury
- CTA –> ? neurointerventional versus OR
Hypothermia in trauma
associated mortality
treatment
<35 degrees C independent risk factor for mortality
warming blanket prevent heat loss
rapid transfusers can heat blood to 37 deg (core temp) and transfuse in minutes
correct blood loss
core temperature is not impacted by peritoneal lavage completely nor is it impacted by airway rewarming immediately. Those techniques can be used but not in isolation.
