Trauma Flashcards
Cricothyroidotomy
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
In trauma patients, the differential diagnosis of cardiogenic shock consists of:
- Tension pneumothorax (m/c)
- Pericardial tamponade
- Myocardial contusion or infarction
- Air embolism
With acute tamponade, as little as _____________ of blood within the pericardial sac can produce life-threatening hymodynamic compromise
100mL
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?
FAST exam, one of its view is the pericardium, for us to check for pericardial tamponade
During the circulation section of the primary survey, 4 life-threatening injuries must be identified promptly
- Massive hemothorax
- Cardiac tamponade
- Massive hemoperitoneum
- Mechanically unstable pelvic fractures with bleeding
Primary repair of the trachea should be carried out with
Absorbable monofillament suture
Primary repair of the esophagus should be carried out with
Absorbable monofilament suture
Most common sites of injury in terms of heart
Penetrating - right ventricle
Blunt - right atrium
When to do emergency department thoracotomy (EDT) in tamponade, and how?
SBP < 60mmHg
Best accomplished using left anterolateral thoracotomy, with the incision started to the right of the sternum
Current indications for emergency department thoracotomy in a salvagable postinjury cardia arrest
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
Current indications for emergency department thoracotomy in a patient with persistent severe postinjury hypotension (<=60mmHg)
Cardiac tamponade
Hemorrhage (intrathoracic, intraabdominal, extremity, cervical)
Air embolism
Contraindications to emergency department thoracotomy
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
Survival in resuscitative thoracotomy (RT)
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%
Head injury classification
13-15: mild head injury
9-12: moderate injury
8 and below: severe
GCS: eye opening
4: spontaneous
3: to voice
2: to pain
1: none
GCS verbal
5: oriented
4: confused (converses, but confused, disoriented)
3: inappropiate words (intelligible, no sustained sentences)
2: incomprehensible
1: none
GCS motor
6: obeys commands
5: localizes pain
4: withdraws
3: abnormal flexion
2: abnormal extension
1: none
Neck injuries
<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
Appropriate surgical management of a through-and-through gunshot wound to the lung with minimal bleeding and some air leak
Pulmonary tractotomy with a stapler and oversewing of vessels or bronchi
No effort is made to close the defect
Positive DPL for abdominal trauma
RBC> 100,000/mL WBC >500/mL Amylase >19IU/L ALP > 2 IU/L Bilirubin > 0.01 mg/dL
Positive DPL on thoracoabdominal stab wounds
RBC> 10,000/mL WBC >500/mL Amylase >19IU/L ALP > 2 IU/L Bilirubin > 0.01 mg/dL
Remarks on pelvic bleeding
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
A-A index in vascular injuries of the extremities
If the pressures within 10% of each other, no further evaluation is performed.
If >10%, CTA or arteriography is indicated
Hard signs of peripheral arterial injury
Pulsatile hemorrhage
Absent pulses
Acute ischemia
(Operation mandatory)
Soft signs of peripheral arterial injury
Proximity to vasculature Significant hematoma Associated nerve injury A-A index of <0.9 Thrill or bruit 📌 *furter evaluation indicted
Blunt carotid injuries
~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
ACOT
“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
Triggers for massive transfusion protocol
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
The most aprropriate treatment for a duodenal hematoma that occurs from blund trauma is
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
Damage control surgery
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
Therapy for increased ICP in a patient with closed head injury is instituted when the icp is >
20mmHg
*although an ICP of 10mmHg is the ULN
A shift of _____ typically is considered an indicatiotn for evacuation
> 5mm
But this is not an absolute rule
Targets in treatment of head trauma
SBP >100mmHg
CPP >50 mmHg
How to prevent aortic rupture?
Selective B1 antagonist, esmolol, should be instituted in the trauma bay, with a target SBP <100mmHg and HR <100bpm
Indications for operative mgt (e.g. thoracotomy) of thoracic injuries
- Initial tube thoracostomy drainage of >1,000mL (penetrating) or >1,500mL (blunt)
- Ongoing tube thoracostomy drainage of >200mL/ for 3 consecutive hours
- Caked hemothorax despite placement of 2 chest tubes
- Selected descending torn aortas
- Great vessel injury
- Pericardial tamponade
- Cardiac herniation
- Massive air leak from the chest tube with inadequate ventilation
- Tracheal or main stem bronchial injury diagnosed by endoscopy or imaging
- Open pneumothorax
- Esophageal perforation
- Air embolism
Hepatic injury
> 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
Intra-abdominal pressure >25mmHg. What’s the immediate step?
Open the incision to decompress the abdomen
Traumatic spleen injury
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
Complications after splenectomy
Subdiaphargmatic abscess, pancreatic tail injury Gastric perforation (during short gastric artery ligation)
OPSI
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%
Responsible for >50% of OPSI
S pneumoniae
Other things regarding asplenic patients
Annual influenza vaccine is associated with 54% reduced risk of death
Transection of the main pancreatic duct at the middle of the pancreatic body. Next step?
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
Other remarks on pacreatic trauma
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
Thos most appropriate treatment for a gunshot wound to the hepatic flexure of the colon that cannot be repaired primarily is
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
Remarks on traumatic genitourinary injuries
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
At what pressure is operative decompression of a compartment mandatory?
45mmHg
*patient pressures between 30 and 45 mmHg should be carefully evaluated and closely watched
Trauma in geriatric patients
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.
