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Surgery; Restart, ABSITE (BASIC) > Trauma > Flashcards

Trauma Flashcards

1
Q

Cricothyroidotomy

A

simple and safe
Should not be performed in children younger than 12 years old bec of risk of damage to cricoid cartilage and the subseequent risk of SUBGLOTTIC STENOSIS
Dis: inability to place a tube >6mm

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2
Q

In trauma patients, the differential diagnosis of cardiogenic shock consists of:

A
  1. Tension pneumothorax (m/c)
  2. Pericardial tamponade
  3. Myocardial contusion or infarction
  4. Air embolism
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3
Q

With acute tamponade, as little as _____________ of blood within the pericardial sac can produce life-threatening hymodynamic compromise

A

100mL

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4
Q

A trauma patient arrives following a stab wound to the left chest with SBP 85mmHg, which improves slightly with IV fluid res. CXR clear lung fields. What’s the most appropriate next step?

A

FAST exam, one of its view is the pericardium, for us to check for pericardial tamponade

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5
Q

During the circulation section of the primary survey, 4 life-threatening injuries must be identified promptly

A
  1. Massive hemothorax
  2. Cardiac tamponade
  3. Massive hemoperitoneum
  4. Mechanically unstable pelvic fractures with bleeding
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6
Q

Primary repair of the trachea should be carried out with

A

Absorbable monofillament suture

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7
Q

Primary repair of the esophagus should be carried out with

A

Absorbable monofilament suture

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8
Q

Most common sites of injury in terms of heart

A

Penetrating - right ventricle

Blunt - right atrium

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9
Q

When to do emergency department thoracotomy (EDT) in tamponade, and how?

A

SBP < 60mmHg

Best accomplished using left anterolateral thoracotomy, with the incision started to the right of the sternum

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10
Q

Current indications for emergency department thoracotomy in a salvagable postinjury cardia arrest

A

Patients sustaining witnessed penetrating trauma with <15mins of prehospital CPR
Patients sustaining witnessed BLUNT trauma with <10 mins of prehospital CPR
Patients sustaining witnessed PENETRATING trauma to the NECK or EXTREMITIES with <=5 mins of prehospital CPR

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11
Q

Current indications for emergency department thoracotomy in a patient with persistent severe postinjury hypotension (<=60mmHg)

A

Cardiac tamponade
Hemorrhage (intrathoracic, intraabdominal, extremity, cervical)
Air embolism

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12
Q

Contraindications to emergency department thoracotomy

A

Penetrating trauma: CPR > 15 mins and no signs of life (pupillary response, respiratory effort, motor activity)
Blunt trauma: CPR >10 mins and no signs of life or asystole without assoc’d tamponade

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13
Q

Survival in resuscitative thoracotomy (RT)

A

RT is associated with the highest survival rate afer isolated cardiac injury; 35% of patients presenting in shock and 20% without vital signs are salvage after isolated penetrating injury to the HEART. For all penetrating wounds, survival rate is 15%

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14
Q

Head injury classification

A

13-15: mild head injury
9-12: moderate injury
8 and below: severe

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15
Q

GCS: eye opening

A

4: spontaneous
3: to voice
2: to pain
1: none

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16
Q

GCS verbal

A

5: oriented
4: confused (converses, but confused, disoriented)
3: inappropiate words (intelligible, no sustained sentences)
2: incomprehensible
1: none

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17
Q

GCS motor

A

6: obeys commands
5: localizes pain
4: withdraws
3: abnormal flexion
2: abnormal extension
1: none

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18
Q

Neck injuries

A

<15% penetrating injuries require neck exploration, a majority can be managed conservatively
Asymptomtaic patients are typically observed for 6-12 hours
The one caveat is asymptomatic patients with a transcervical gunshot wound; CTA to deterine the track of the bullet

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19
Q

Appropriate surgical management of a through-and-through gunshot wound to the lung with minimal bleeding and some air leak

A

Pulmonary tractotomy with a stapler and oversewing of vessels or bronchi
No effort is made to close the defect

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20
Q

Positive DPL for abdominal trauma

A 
RBC> 100,000/mL 
WBC >500/mL
Amylase >19IU/L
ALP > 2 IU/L
Bilirubin > 0.01 mg/dL
21
Q

Positive DPL on thoracoabdominal stab wounds

A 
RBC> 10,000/mL 
WBC >500/mL
Amylase >19IU/L
ALP > 2 IU/L
Bilirubin > 0.01 mg/dL
22
Q

Remarks on pelvic bleeding

A

In the unstable patient, celiotomy is manadatoryy
Most severe pelvic hemorrhage is venous in origin
If the hematoma ha ruptured into the peritoneal cavity, pelvic packing offers the best hope of control

23
Q

A-A index in vascular injuries of the extremities

A

If the pressures within 10% of each other, no further evaluation is performed.
If >10%, CTA or arteriography is indicated

24
Q

Hard signs of peripheral arterial injury

A

Pulsatile hemorrhage
Absent pulses
Acute ischemia
(Operation mandatory)

25
Q

Soft signs of peripheral arterial injury

A 
Proximity to vasculature
Significant hematoma
Associated nerve injury
A-A index of <0.9
Thrill or bruit 📌
*furter evaluation indicted
26
Q

Blunt carotid injuries

A

~50% of patients have a delayed diagnosis
Mechanism of injury: facial contact resulting in hypertension and rotation
Diagnostics: CTA
Tx: heparin, ff’d by warfarin for 3 months

27
Q

ACOT

A

“Acute Coagulopathy of Trauma”

  • activated protein C is a key element
  • fibrinolysis is an important component of the ACOT
  • present in only 5% of injured patient requiring hospitalization
  • but 20% in those requiring massive transfusion
28
Q

Triggers for massive transfusion protocol

A

Uncontrolled hemorrhage

  • SBP <90mmHg despite 3.5 L crystalloid (50mL/kg)
  • estimated blood loss (EBL) 150mL/min
  • pH <7.1; temp<34C; IS S> 25
29
Q

The most aprropriate treatment for a duodenal hematoma that occurs from blund trauma is

A

Observation
In children, managed nonoperatively with nasogastric suction and parenteral nutrition for 7-14 days
“No reason to believe that hematomas in adults should be treated differently from those of chldren”
*new approach is laparoscopic evacuation if the obstruction persists >7 days

30
Q

Damage control surgery

A

Goal: to control surgical bleeding and limit GI spillage (by rapid repair of partial small bowel injuries with whipstitch, and complete transection with a GIA stapling device)
The bowel is covered with a fenestrated subfascial sterile drape and two Jakson-Pratt drains are placed along the fascial edges; this is then covered using an Ioban drape

31
Q

Therapy for increased ICP in a patient with closed head injury is instituted when the icp is >

A

20mmHg

*although an ICP of 10mmHg is the ULN

32
Q

A shift of _____ typically is considered an indicatiotn for evacuation

A

> 5mm

But this is not an absolute rule

33
Q

Targets in treatment of head trauma

A

SBP >100mmHg

CPP >50 mmHg

34
Q

How to prevent aortic rupture?

A

Selective B1 antagonist, esmolol, should be instituted in the trauma bay, with a target SBP <100mmHg and HR <100bpm

35
Q

Indications for operative mgt (e.g. thoracotomy) of thoracic injuries

A
  1. Initial tube thoracostomy drainage of >1,000mL (penetrating) or >1,500mL (blunt)
  2. Ongoing tube thoracostomy drainage of >200mL/ for 3 consecutive hours
  3. Caked hemothorax despite placement of 2 chest tubes
  4. Selected descending torn aortas
  5. Great vessel injury
  6. Pericardial tamponade
  7. Cardiac herniation
  8. Massive air leak from the chest tube with inadequate ventilation
  9. Tracheal or main stem bronchial injury diagnosed by endoscopy or imaging
  10. Open pneumothorax
  11. Esophageal perforation
  12. Air embolism
36
Q

Hepatic injury

A

> grade II injuries: admit to SICU
Stable, transfusion of 4 u of RBC in 6 hours orr 6 u of RBC in 24 hours —> indication for ANGIOGRAPHY
Unstable —> OPERATIVE MGT
*delayed rebleeding occur within 48 hours of injury

37
Q

Intra-abdominal pressure >25mmHg. What’s the immediate step?

A

Open the incision to decompress the abdomen

38
Q

Traumatic spleen injury

A

Delayed hemorrhage or rupture of spleen can occur up to WEEKS after injury
An immediate postsplenectomy increase in platelets and WBCs is normal
HOWEVER, byond postop day 5, a wbc >15,000 and plt/wbc ratio of <20 are astrongly assoc’d with SEPSIS

39
Q

Complications after splenectomy

A 
Subdiaphargmatic abscess, pancreatic tail injury
Gastric perforation (during short gastric artery ligation)
40
Q

OPSI

A

Overwhelming PostSplenectomy Infection
4.4% in <16 y/o
0.9% in adults
Greatest in the first 2 years after splenectomy
In the setting of elective splenectomy, patients should be vaccinated 2 WEEKS PRIOR TO SURGERY
If emergent splenectomy, consideration should be given to delay administration for 2 weeks to avoid transient immunosuppression after surgery
*vaccination has lead to OPSI incidence of <1%

41
Q

Responsible for >50% of OPSI

A

S pneumoniae

42
Q

Other things regarding asplenic patients

A

Annual influenza vaccine is associated with 54% reduced risk of death

43
Q

Transection of the main pancreatic duct at the middle of the pancreatic body. Next step?

A

Distal pancreatectomy with splenic preservation
^preferred especially if physiologically compromised
Alt: R-en-Y pancreaticojejunostomy or pancreaticogastrostomy (preserves both spleen and distal transected end of pancreas

44
Q

Other remarks on pacreatic trauma

A

Pancreati contusions: nonoperative or closed suction drainage
Proximal pancreatic injuries (defined as those that lie to the right of superior mesenteric vessles): closed suciton draiange

45
Q

Thos most appropriate treatment for a gunshot wound to the hepatic flexure of the colon that cannot be repaired primarily is

A

Resection of the right colon with ileocolostomy
(Kasi proximal to the middle colic artery)
*”ileocolostomy heals more reliable than colocolostomy”
**if distal to middle colic artery, then an end colostomy is created and the distal colon oversewn and left within the abdomen

46
Q

Remarks on traumatic genitourinary injuries

A

Succes of renal artery repiar after blunt trauma is slim, but can be attempted if injury occurred within 5 hours or patient does not have any reserve renal function
Evaluation: methylene blue or indigo carmine can help
Extraperitoneal ruptures: nonop with bladder decompressoin for 2 weeks
Intraperitoneal ruptures: closed primarily

47
Q

At what pressure is operative decompression of a compartment mandatory?

A

45mmHg

*patient pressures between 30 and 45 mmHg should be carefully evaluated and closely watched

48
Q

Trauma in geriatric patients

A

Mortality in patients with severe head injury more than doubles after the age of 55y/o
25% of patients with a normal GCS of 15 had intracranial bleeding, with assoc’d mortality of 50%
Admission GCS is a POOR predictor of outcome
50% of patients >65y/o sustained rib fracutres from a fall of <6ft, compared with only 1% of patients younger than 65 y/o.
Concurrent pulmonary contusion is noted in up to 35% of patients.
Pneumonia complicates the injuries in 10-30% of patients with rib fractures.

Surgery; Restart, ABSITE (BASIC) (9 decks)

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