Trauma Flashcards
What are the tenets of trauma laparotomy?
- Rapid entry via adequate incision
- Control of massive haemorrhage by
- Identification of source
- Packing
- Direct control
- Proximal (source) control
- Identification of injuries
- Control of contamination
- Recontruction as physiological state allows
Discuss the evidence for primary repair versus diversion in traumatic colonic injuries
Dogmatic practice post WWII was diversion for all colonic injuries. That practice has since been challengd with increasing use of primary repair for penetrating colon injuries.
The Cochrane metanalysis of 2003 included ~700 patients with penetrating colonic injury; it demonstrated that total complications, total infectious complications, abdominal infections and wound complications all favored primary repair.
What is Damage Control Surgery?
Damage Control Resuscitation and Damage Control Surgery are a deliberate and pre-emptive set of non-traditional resuscitative and surgical manoeuvers used to reverse the pre-terminal effect of exsanguination, massive injury, and shock.
The primary goal is to temporize injuries with abbreviated surgery to allow for correction of physiological abnormalities.
Describe techniques of reducing intra-cranial pressure
- Hyperventilation; lowering PaCO2 by 1mmHg reduces cerebral blood flow by 3 percent. Aim for levels of 26-30mmHg
- Mannitol according to local protocol
- Hypertonic saline according to local protocol
- High-dose Barbiturate or Propofol for refractory cases
- Surgery - Burr Holes or Craniotomy
*High dose steroids do not improve outcome and are associated with increased mortality!
Discuss the classification of burns by depth
- superficial burn
- painful, dry, not blistered
- will fade on own within 7days, no debridement
- not calculated in TBSA
- superficial partial thickness
- entire epidermis down to BM & no more than upper 1/3 dermis
- bc large no of remaining epithelial cells & good blood supply, v small zone of injury or stasis below burn eschar
- rapid re-epithelialisation in 1-2wks
- wet, often blistered, painful ++, red or white, blanches on pressure
- skin still feels elastic & supple, hair remains attached when pulled
- generally heal w/o SSG, usu within 10-14 days, don’t scar
- deep partial thickness
- entire epidermis down to BM & middle third dermis
- depth of wound has signif risk of conversion; zone of stasis much larger than in SPT injury bc of lower blood flow & greater initial injury to remaining epidermal cells
- re-epithelialisation much slower (2-3wks) due to fewer remaining epidermal cells & a lesser blood supply
- more collagen deposition will occur espec if wound not excised & grafted within 3wks
- often a mixture of wet & dry; the drier it is, the deeper
- sensation variable but still present to touch, though often less painful
- skin texture thicker & more rubbery
- red patches don’t blanche - ‘fixed skin staining’ due to capillary stasis
- hairs will come out readily when pulled
- if not excisedtake 4-6wks to heal & scar badly
- function of a re-epithelialised DPT burn is poor due to fragility of epidermis & rigidity of scar-laden dermis
- full thickness
- entire epidermis & at least 2/3 dermis, leaving v few dermis & epidermal cells to regenerate
- spontaneous healing v slow, over 4wks w usually severe scarring/contracture if not grafted & high risk of infection
- thick, dry, insensate, leathery, usu black or yellow
- thormbosis often visible in surface vessels
- hairs burned off
- may need escharotomies/fasciotomies if full-thickness circumferential
- need early excision and grafting
What are the indications for rib-plating?
- Flail chest with resultant respiratory failure requiring mechanical ventilation is the only indication for rib fracture fixation for which a strong evidence base exists.
- In this population, there are
- reduced intubation times and
- reduced tracheostomy requirements.
Describe the theatre set-up for a trauma
- Experienced assisstant and scrub nurse
- Headlight
- Warm theatre
- Bair Huggers
- Two Yankauer suckers
- 20 large packs
- Cell-saver
- Omnitract
- Vascular set and thoracotomy set
- Fogarty, Haemostatic agents, Shunts
Describe the principles of vascular surgery in trauma
- Prepare the patient for wide access
- Proximal control
- Consider adjuncts such as IR for junctional areas
- Distal control
- Temporise injuries in DCS; shunt
- Repair injury with vascular surgeon
- Adjuncts in vascular surgery
- Fasciotomies
- _Tissue coverag_e of vascular repairs
How is neurological disability grossly calculated?
What is a simplicfication of this score?
With good interobserver reliability and ease of use, the admission Glasgow Coma Scale has been linked to prognosis prediction for a number of conditions, including traumatic brain injury, subarachnoid hemorrhage, and bacterial meningitis.
AVPU is a simplification where:
A = 15
V = 12
P = 8
U = 3
What is the Injury Severity Score?
The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale(AIS) score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities (including Pelvis), External).
Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score.
The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity.
Describe the classification of splenic trauma
American Association of Surgical Trauma classifies splenic injury according to degree of subcapsular haematoma, depth of laceration, or size of intraparenchymal haematoma:
Describe the classification of liver trauma
AAST classification is based on degree of subcapsular haematoma, depth of laceration, or size of parenchymal haematoma:
Describe the classification of retroperitoneal trauma
The retroperitoneum is traditionally classified into three zones; a central zone, a (bi)lateral zone, and a pelvic zone
The management algorithm is based on which zone is injured, the mechanism of injury, and whether the haematoma is rapidly expanding.
Zone 1
- Always explored
- Supramesocolic and inframesocolic compartments
Zone 2
- Blunt injury; explore only if haematoma expanding
- Penetrating injury; explore
Zone 3
- Avoid exploration wherever possible; aim for packing and angioembolization
- May require exploration with major vascular injury to lower limb (e.g. no palpable femoral pulse)
Describe the classification of pancreatic trauma
The AAST uses the degree of parenchymal injury as well as the status of the duct to stratify pancreatic trauma:
Describe the classification of duodenal trauma
The AAST classification uses number of haematomas, or the circumferential extent of laceration to stratify duodenal injuries: