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Surgery > Torso Trauma > Flashcards

Torso Trauma Flashcards

1
Q

Junctional zones of the torso

A

1- between neck and thorax
2- between thorax and abdomen
3- between abdomen and pelvic structures/groin

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2
Q

Zones of the retroperitoneum and management in case of injury

A

Zone 1- central- always opened
Zone 2- lateral- usually renal injury. Managed conservatively.
Zone 3- pelvic- don’t open. Pack and do angioembolisation

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3
Q

Bleeding sites

A

Bleeding occurs from 5 sites . 1 on the floor and 4 more.

1- external skin
2- thorax 
3- abdomen 
4- pelvis 
5- long bone fracture
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4
Q

Diagnostic modality of choice in thoracic aorta injuries

A

CT

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5
Q

Management of sucking chest wound (open pneumothorax)

A

Covered with plastic . Closed from 3 sides and open from 1. Flutter-type valve. Chest tube placed away from injury with an underwater low pressure (5 cm h20) suction.
Don’t close the wound otherwise it gets converted to tension pneumothorax

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6
Q

6 immediately life threatening injuries of the chest

A 
1- tension pneumothorax 
2- open pneumothorax 
3- cardiac tamponade 
4- massive hemothorax 
5- flail chest 
6- airway obstruction
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7
Q

Airway intubation is done earliest in

A

Impending airway oedema

Neck hematoma

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8
Q

Clinical presentation in tension pneumothorax

A 
Lung is collapsed. 
Decreased air entry.
Hyperresonance. 
Decreased venous entry. 
Distended neck veins. 
Mediastinum and trachea displaced to opposite side.
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9
Q

Rx of tension pneumothorax

A

Immediate decompression by a large bore needle into 2nd intercostal space (midclavicular line)
Later chest tube placed into 5th intercostal space (anterior axillary line)

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10
Q

Investigations in cardiac tamponade

A

Increased heart shadow on chest x ray.

Cardiac ultrasound showing fluid in pericardial sac.

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11
Q

Emergency Rx of pericardial tamponade

A

Needle pericardiocentesis.
Risk of injury to heart.
Done under ecg control.

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12
Q

Correct treatment of pericardial tamponade

A

Operative repair of the heart

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13
Q

Important points in management of open pneumothorax

A

Don’t use small tube. 28FG or larger should be used.
Place in underwater suction.
Sometimes use of 2nd tube is required.

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14
Q

Massive hemothorax

A

Compresses lung
Absent breath sounds
Flat neck veins
Dullness to percussion

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15
Q

Indications for open thoracatomy in hemothorax

A

Drainage of greater than 1500 ml or 200 ml per hour over 3-4 hours

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16
Q

Flail chest

A

Fracture of 3 or more ribs at 2 or more sites

Can cause pulmonary contusion

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17
Q

Management of flail chest

A

Oxygen administration
Adequate pain control
Physio therapy

If severe then mechanical ventilation

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18
Q

Thoracic aortic disruption on erect chest x ray

A

Widened mediastinum

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19
Q

Clinical findings in thoracic aortic disruption

A

Difference in BP in upper and lower limbs.
Widened pulse pressure.
Chest wall contusion.

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20
Q

Management of thoracic aortic disruption

A

Endovascular intraaortic stent
Surgical repair
Excision and grafting with Dacron graft

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21
Q

Tracheobronchial injuries

A

Subcutaneous emphysema with decreased respiratory function.
Bronchoscopy is diagnostic.
Treatment is intubation of the inflated bronchus with operative repair of the damaged bronchus.

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22
Q

Blunt myocardial injury

A

Early ECG changes.
Echocardiography shows heart wall movement changes.
Risk of arrythmias

23
Q

Diaphragmatic injuries

A

any penetrating injury below 5th intercostal space or blunt compressing injury to the abdomen
Herniation of abdominal contents into thorax.
Always repaired via abdominal route.

24
Q

Oesophageal injury

A

Emphysema.
Air in retroesophageal space.
Pleural effusion.

Treatment is surgical repair.

25
Q

Sign of pulmonary contusion

A

Haemoptysis or blood in the endotracheal tube.

Management same as that of flail chest.

26
Q

Indications of emergency thoractomy

A

1- cardiac massage
2- hemothorax from injury to lung or heart
3- hemothorax from injury to any other organ
4- massive air leak

27
Q

Types of thoracotomy

A

Emergency department thoracotomy

Planned emergency thoracotomy

28
Q

EDT not useful if

A

1- CPR done for more than 5 minutes in the absence of endotracheal tube.
2- CPR done for more than 10 minutes in the presence or absence of endotracheal tube
3- blunt injury and no sign of life

29
Q

Clamshell incision

A

Right and left anterolateral thoracotomy incisions if joined

30
Q

Median sternotomy

A

Ascending aorta and arch of aorta.

Carina of trachea

31
Q

Right anterolateral thoracotomy

A 
Oesophagus upper 
Trachea 
SVC 
IVC 
Azygous veins
32
Q

Left anterolateral thoracotomy

A

Oesophagus lower
Thoracic aorta
Origin of the left subclavian artery

33
Q

Abdominal injury investigations

A

Hemodynamically normal : all investigations can be completed

Hemodynamically stable: limited

Hemodynamically unstable: perform operative repair first

34
Q

FAST

A

Focused abdominal sonar for trauma.

Detects greater than 100 ml blood.

Areas 
1- pericardium 
2- liver 
3- spleen 
4- right paracolic gutter
5- left paracolic gutter 
6- peritoneal area of pelvis
35
Q

Diagnostic peritoneal lavage

A

Gastric tube to empty stomach. Urinary catheter to empty bladder
Cannula below the umbilicus.
Aspiration of greater than 10 ml of blood is positive finding.
1000 ml of ringers lactate given to wash.
100,000 rbcs/uL or 500 wbc/uL are indicative of atleast 20 ml blood in peritoneum

36
Q

CT

A

Gold standard.

Especially for retroperitoneal organs

37
Q

Operative management of liver injuries

A 
4 Ps 
1- push 
2- Pringle 
3- plug 
4- pack

Closed suction drainage can be used in hepatic surgery

38
Q

Spleen injury

A

Can be packed
Repaired
Placed in mesh bag
Splenectomy can be done.
Selective angioembolisation can be done.
Platelets and white blood cells rise after splenectomy mimicking sepsis

39
Q

Pancreas

A

Distal pancreas: closed suction drainage. Or distal pancreatectomy if damage to duct.

Promixal pancreas: managed conservatively. Partial pancreatectomy can be done. Whipples procedure (pancreaticoduodenectomy) done rarely

40
Q

Stomach injury

A

Blood in nasogastric tube is diagnostic

41
Q

Small bowel injury

A

Resection
Anastomoses
Haematomas at mesenteric border need to be explored to rule out perforation

42
Q

Rectum injuries

A

In pelvic fractures.
End colostomy with closure of distal end (hartmans procedure)
Or
Loop colostomy

43
Q

Renal injury

A

Managed nonoperatively unless patient is unstable.

Kidney can be angioembolised.

44
Q

Bladder injury

A

Extraperitoneal associated with pelvic fracture and can be managed conservatively.
Intraperitoneal needs surgical repair.

45
Q

Abdominal compartment syndrome

A

Raised intraabdominal pressure.
If there is risk of ACS. Abdomen should be left open post surgery.
Esp in damage control surgery.

46
Q

Effects of raised intraabdominal pressure

A 
Decreased GFR 
Decreased perfusion of organs 
Decreased CO 
Splinting of diaphragm 
Severe rise in intracranial pressure
47
Q

Damage control surgery

A

1- stopping active bleeding

2- preventing contamination

48
Q

Stages of damage control surgery

A 
Stage 1- patient selection 
Stage 2- control of bleeding and prevention of contamination 
Stage 3- resuscitation continued in ICU 
Stage 4- definitive repair 
Stage 5- abdominal closure
49
Q

Vacpac or Opsite Sandwich

A

Temporary closure of abdomen in damage control surgery by 2 layers of plastic and intermediate layer of packing to form a water tight and air tight seal.
Suction is applied to intermediate layer

50
Q

Definitive surgery

A

Done within 24-72 hours.

Abdominal closure by closure of the fascia or only by skin closure

51
Q

Damage control resuscitation

A

Repeated Point of care testing for hemoglobin. Acidosis. PH and lactate. Thromboelastography for clotting. Early delivery of biologically active fluids like colloids. Clotting factors. Whole blood.

52
Q

Indications for damage control surgery

A

Operating time of surgery less than 60 minutes.
Closure of abdomen not possible.
Desire to reassess abdominal contents later on.
Temperature less than 34 degree Celsius
Ph less than 7.2
Lactate greater than 5 mmol/L
PT greater than 16 seconds
PTT greater than 60 seconds
Greater than 10 units of blood transfused.
Systolic Bp below 90 mmHg for greater than an hour.
Complex surgery with trauma to multiple organ systems

53
Q

Non operative management

A

Done in solid organ injury
In children
Who are stable hemodynamically

Surgery (10 decks)

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