Surgery SC031: Chopped And Stabbed Wound In Gang Fight: Nerves And Vascular Injury, Classification Of Injuries Flashcards

1
Q

Advanced trauma life support (ATLS)

A
  • Training program for medical providers in the management of acute trauma cases
  • Developed by American College of Surgeon
  • Emphasise the primary management of the injured patient (often with lack of full history)
    —> starting at the point in **time of injury + **continuing throughout
    1. Initial assessment
    2. Life-saving intervention
    3. Re-evaluation
    4. Stabilisation (when needed)
    5. Transfer to a facility in which the patient can receive specialised care, such as a trauma centre

Goals:
- **Systematic and **concise standardised approach to the care of trauma patienst
- Standard care for ***initial assessment + treatment
- ATLS program is to treat the greatest threat to life first
—> lack of definitive diagnosis / detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early

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2
Q

Initial assessment

A

Phase 1:
- Primary survey + Resuscitation

Phase 2:
- Secondary survey

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3
Q

Phase 1: Primary survey + Resuscitation

A

Objective: To **identify + **treat any ***immediately life-threatening condition

Primary survey
1. Airway maintenance + Cervical spine protection
- patent airway, no stridor (obstruction in major airway) —> ask patient to talk (evaluate airway, brain)
- cervical injury presumed —> neck collar

  1. Breathing + Ventilation
    - equal breath sounds
    - frail segment
  2. Circulation, Haemorrhage control
    - BP, Pulse
    - occult / overt bleeding
    - young patients compensate better than elderly patients
  3. Disability
    - e.g. CNS
    - GCS score
  4. Exposure and Environmental control
    - undress patient
    - prevent hypothermia
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4
Q

Airway and Breathing algorithm

A

Need for intubation
—> Manual in-line-stabilisation + Pre-oxygenation + Consider rapid sequence intubation (apply cricoid pressure)

—> Successful tracheal intubation
—> Confirm placement, fix tracheal tube (auscultation, CO2 detector, CXR)

—> Unsuccessful tracheal intubation
—> Valve mask ventilation
—> Repeat intubation (senior laryngoscopist, change blade, optimal position, OELM (optimum external laryngeal manipulation))
—> Successful
—> Confirm placement, fix tracheal tube (auscultation, CO2 detector, CXR)

—> Unsuccessful
—> Cricothyrotomy + place cuffed tracheal tube

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5
Q

Airway mis-management in trauma patients

A
  1. Failure to ***recognise the inadequate aiway in trauma victim
  2. Failure to ***establish a clear airway with / without an airway protection device
  3. Failure to recognise airway device is ***incorrectly placed
  4. ***Displacement of a previously established airway
  5. Failure to recognise the need for ***ventilation
  6. ***Aspiration of gastric contents
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6
Q

Resuscitation

A
  • Occur ***simultaneously with Primary survey (ABCDE)
    1. Oxygenation + Ventilation
  1. Shock management
    - IV lines
    - Warmed IV fluids (cold fluid may make bleeding worse —> ∵ coagulopathy)
  2. Management of life-threatening problems identified in Primary survey
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7
Q

Adjuncts to Primary survey + Resuscitation

A
  1. X-ray
    - CXR
    - Pelvic (e.g. pelvic fracture: stable / unstable (need pelvic binder))
    - C-spine (need to include C7, T1 junction, even if normal —> still keep neck collar on)
    —> easy to obtain, give a lot of information about condition (e.g. pneumothorax) + how ABCDE was performed (e.g. intubation)
  2. Focused assessment with sonography for trauma (FAST scan) / Diagnostic peritoneal lavage (DPL)
    - FAST scan: free fluids in abdomen, liver, pelvis
    - DPL: draw fluid out to see if blood-stained
  3. Orogastric tube (decompress stomach, can use NG tube if confident no head trauma), Urine output (NOT put in catheter if pelvic fracture)
  4. Monitor
    - BP
    - Pulse
    - RR —> Capnography
    - SaO2 —> Pulse oximeter
    - ECG
    - GCS scale
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8
Q

Phase 2: Secondary survey

A

Begins when:
- Primary survey (ABCDE) is **complete + secured
- Resuscitation efforts are well established
- Patient’s vital signs are **
stabilised

  1. Examine the patient from **head to toe + **front to back
    - Log roll with neck collar on
    —> spinal injury may result in motor / sensory loss / incontinence / lax anal tone
    —> spinal shock = **flaccid paralysis, **areflexia, ***autonomic dysfunction (low BP)
  • Head, neck, chest, abdomen, pelvis, perineum, extremities
  1. Assimilate the history (AMPLE)
    - Allergies
    - Medications currently used (e.g. aspirin, anticoagulants —> may exacerbate bleeding, phenytoin (underlying epilepsy))
    - Past illness / pregnancy
    - Last meal
    - Events / Environmental leading to injuries
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9
Q

Spinal shock

A

2 meanings:
1. **Flaccid paralysis + **Areflexia for 1-2 weeks after injury
- Acute damage to spinal cord —> ***Denervation response —> Completely Areflexic + Weak muscle tone
- Return of anal tone / reflex usually signifies end of spinal shock —> Can properly assess motor + sensory function again —> Determine permanent deficits
- Phase 1 (0-1 day): Areflexia (Loss of descending facilitation)
- Phase 2 (1-3 day): Initial reflex return (Denervation supersensitivity)
- Phase 3 (1-4 week): Initial Hyperreflexia (Axon-supported synapse growth)
- Phase 4 (1-12 month): Final Hyperreflexia (Soma-supported synapse growth)

SpC Revision:
- Period of temporary loss of function after injury (hours - days)
- No motor / sensory function: cannot differentiate between complete / incomplete injury
- All reflexes absent
- Spinal shock is over if bulbocavernosus / anal wink reflex has returned (these are lowest local reflexes mediated by spinal cord level)
- Assess for motor / sensory function ONLY after spinal shock is over

(Web:
- loss of muscle tone and spinal reflexes below the level of a severe spinal cord lesion
- this “shock” does not imply a state of circulatory collapse (vs neurogenic shock) but of suppressed spinal reflexes below the level of cord injury
- it takes between days and months for spinal shock to completely resolve —> when it does, the flaccidity that was once seen gradually becomes ***spasticity (UMN lesions))

  1. Neurogenic shock
    - **Sympathetic signal disruption in C1-T1
    —> Sudden of sympathetic tone
    —> **
    Vasodilation, Hypotension, Bradycardia, Warm, Flushed skin
    —> Shock, Hypoperfusion of body
    —> Require resuscitation
    - C5 or below: affect Diaphragmatic breathing (Diaphragm innervated by C3-5)
    - Above C3: ***Respiratory arrest (cannot breathe at all)
    —> Require intubation, mechanical ventilation, cardiopulmonary support
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10
Q

Biomechanics of injury

A

Classification
1. Blunt trauma
- e.g. RTA

  1. Penetrating trauma
    - e.g. knife, gunshot
  2. Burns
    - flame
    - scald
    - chemical
    - electric
    - radiation
  3. Blast injuries
    - e.g. bombs
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11
Q
  1. Blunt trauma
A

Force is ***dissipated over a wide area, minimising energy transfer at one spot

3 types of forces (often in combination):
1. Shearing (2 forces acting in **opposite directions)
- e.g. fall from height (e.g. acceleration-deceleration)
- maximum effects on **
abdominal viscera at the points where organs are tethered (e.g. duodenojejunal junction, liver, spleen, aortic arch around ligamentum arteriosum)

  1. Tension (a force acting ***<90o to surface causing avulsions / flap formation)
    - tissue necrosis
  2. Compression (a force acting ***at 90o to surface causing avulsions / flap formation)
    - contusion / haematoma
    - raised internal pressure may result in rupture of hollow viscus
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12
Q

Potential injuries with fall from height

A
  1. Head injury
  2. Cervical injury
  3. Vertebral wedge fracture
  4. Pelvic fracture
  5. Tracheo-bronchial dislocation
  6. Pneumothorax / Haemothorax
  7. Rupture / Dissection of aorta
  8. Liver / Spleen laceration
  9. Rupture of bowel
  10. Lower limb / ankle / fracture of calcaneum / metatarsals
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13
Q
  1. Penetrating trauma
A

***Kinetic energy (KE = mass / 2x velocity^2) is transferred to tissues surrounding the track of weapon / missile

Depends on:
- Mean presenting area of weapon
- Tendency of weapon to deform / change pathway / fragment
- Density / Characteristics of tissue (e.g. through viscera)
- Impact velocity / damage to neighbouring tissue

3 conseqences:
1. Functional + Mechanical disruption of neighbouring tissues and energy transfer
- solid organs sutain severe damage (e.g. liver)
- lungs, muscles, bones may all be disrupted

  1. A core of covering clothing is carried deep into the wound —> cause contamination
  2. In gutshot wounds
    - exit wound is usually larger than entry wound (∵ temporary cavitation effect extends along wound track)
    - some missile may fragment on contact

Chopped vs Stabbed wounds:
- Cut wounds / Incised (Chopped) wounds: wounds caused by a sharp edged weapon / instrument
- Stabbed wounds: wounds where depth of wound > width of wound
- may be difficult to differentiate, depends on mode of injury
—> both classified as penetrating / sharp injury (X blunt injury)

Location:
1. Chest
2. Neck
3. Abdomen

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14
Q

Documentation

A

Important:
- Classify injuries correctly
- Note the details
—> location
—> size
—> shape
—> direction
—> presence of foreign bodies etc.
- Wound should be photographed / sketched before surgical repair

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15
Q

Penetrating injury to the chest

A
  • Life threatening conditions need to be ruled out
  • **Cardiac + **Lung injuries presumed until proven otherwise
    1. Cardiac tamponade
    2. Open pneumothorax
    3. Massive haemothorax (>0.5L: significant)

Penetrating injury to the chest:
- Big / Small wound is irrelevant to chance of injury to underlying organs
- Bleeding may be excessive / occult
- Open pneumothorax

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16
Q

Pneumothorax, Haemothorax

A
  1. Insert chest tube (5th ICS, MAL)
  2. Give O2
  3. Treat local wound, consult CTS
  4. Urgent thoracotomy for haemostasis if massive bleeding
17
Q

Penetrating injury to the neck

A

Suicide attempt

S/S:
1. Exanguinating external bleeding (but injury may not be deep —> can still be from a major superficial vein e.g. EJV)

  1. Expanding haematoma
    - **ETT intubation protect airway
    - **
    Operative exploration
    —> if unsure of diagnosis / wound deeper than platysma
18
Q

Penetrating injury to the abdomen

A

Surface anatomy:
1. Thoracoabdominal area
2. Anterior abdomen
3. Flank
4. Back
—> Location of stabbed wounds is important

Management:
Stable patient:
1. CT
2. Local wound exploration in operating room
3. Laparoscopy (not common)
4. Laparotomy (more common)

Unstable patient:
1. Immediate laparotomy

Surgical principles:
- Damage control surgery: do what is necessary only (e.g. haemostasis)
—> purpose: make sure patient is stabilised and survived
—> come back 1-2 days later for ***re-look laparotomy

19
Q

Unstable pelvic fracture

A

A lot more veins than arteries in pelvis (e.g. Iliac veins, Sacral veins)
—> Bleed massively
—> Stablise pelvis (Tamponade effect, confine bleeding)

20
Q

Chopped wound of the limbs

A
  1. Skin
  2. Arteries (complete / partial cut)
  3. Veins
  4. Nerves
  5. Muscles, tendons
  6. Bones, joints

Management (Identify + Treat life-threatening injuries ***before limb salvage):
1. Save life
2. Haemostasis + Blood replacement
3. Primary repair (proximal + distal control of arteries first)
4. Limb salvage
5. Rehabilitation
6. Late reconstruction

21
Q

Arteries injuries

A

Partially severed:
- Incomplete contraction, retraction —> ***massive bleeding + formation of pseudoaneurysm

Completely severed (i.e. Divided):
- contraction, retraction by arterial smooth muscles —> less severe bleeding —> do not be fooled by apparent “normal” outlook

Vs Veins injuries:
- Partially / Completely severed —> still massive bleeding

Contracted arteries:
- cannot simply re-anastomose 2 ends together (∵ will be under a lot of tension —> bound to fai) —> need interposition vein graft (from long saphenous vein)

Investigations:
1. Angiogram (on table)
2. Exploration

Blunt trauma —> Shearing injury —> Endothelial damage —> Thrombogenic —> Ischaemia

(Ischaemic leg take 4-6 hours to completely die —> grossly damaged muscles + dead nerves —> even after revascularisation the leg is useless)

22
Q

Vein injuries

A
  • Unless big vein (e.g. IVC)
  • Most veins not need repair —> can simply tie off —> rely on collaterals
  • Patients maybe susceptible to DVT
23
Q

Nerve injuries

A

Structure of nerve:
Axon
—> Endoneurium (around each axon)
—> Fascicle
—> Perineurium (around each fascicle)
—> Nerve
—> Epineurium (around nerve)

Peripheral nerve injury classification:
1. Neuropraxia (class 1)
- minor blunt injury to a nerve may produce **temporary block to conduction of impulses, leaving **axonal system intact, complete functional recovery expected

  1. Axonotmesis (class 2)
    - severe trauma causing **interruption of axonal system —> distal axon dies + myelin sheath disintegrates
    - **
    endoneurium intact
    - eventual good functional outcome, take months
  2. Neurotmesis (class 3)
    - total disruption, laceration, extreme traction of nerve fibre
    - **distal Wallerian disintegration and axonal death with **poor functional outcome
    - axons sprouts to repair at 1mm per day
    - ***surgical repair indicated (e.g. nerve graft)