Trauma Flashcards
What are the 2 main types of vascular trauma?
Blunt and Penetrating
What lower extrimity trauma mechanism is more lethal?
Blunt injuries experience mortality rates between 2% and 5%, whereas penetrating injuries generally result in fewer deaths.
What lower extremity arterial injury results in greater mortality?
Proximal arteries
What factors and injuries predict amputation?
Blant trauma.
Involvment of fracture.
Arterial injury.
Venous and nerve injuries do not predict amputation!!!
“Hard Signs” of Extremity Arterial Injury?
- Absent distal pulse
- Palpable thrill or audible bruit
- Actively expanding hematoma
- Active pulsatile bleeding
“Soft Signs” of Extremity Arterial Injury?
- Diminished distal pulse
- History of significant hemorrhage
- Neurologic deficit
- Proximity of wound to named vessel
What is the management of patient with lower extremity Hard sign?
Operative exploration and repair.
What is the management of patient with lower extremity Soft sign?
Complete pulse examination and Doppler pressures.
If the index is < 1.0, a further diagnostic and localization
study should be performed.
The proximity of wound to named vessel alone (without the findings above) should not prompt a localization study.
What is the modality of choice to localization of injury in a stable patient with lower extremity soft signs.
CTA initial diagnostic and localization modality of choice with soft signs of extremity arterial injury.
What arterial injuries do not mandate surgical theraphy
injuries that produce no active hemorrhage or distal ischemia:
small (non–flow-limiting) intimal defects and flaps.
small pseudoaneurysms.
small arteriovenous fistulas.
Keep high index of suspicion!!!
When is endovascular treatmnet is most appropriate in extremity trauma?
There is no clear EBM to favore endovascular treatment.
Can be used when the morbidity difference between open and endovascular is greatest:
- Injuries to junctional vessels (such as the subclavian and iliac).
- If the traumatic vascular lesion can be safely traversed with a guide wire.
- Catheter-directed embolization in smaller
vessels, small pseudoaneurysms and arteriovenous fistulas of the crural and deep femoral branch arteries.
What are the 3 option for extremity arterial injury repair?
- End to End anastomosis.
- Debridement of artery with patch angiplasty.
- Interposition graft.
Whan is it acceptable to use prosthetic graft as interposition graft in extremity arterial injury?
Arterial injury to porximal vessel (axillary or CFA) where size match with GSV may be problematic.
Arterial demage control shunts have a very low patency in which atreries?
Forarm
Tibial
What is the patency of venous demage control shunts?
93%
Ligation of major extremity veins will be done if?
patient’s condition will not tolerate the additional operative time.
What physical examination should be preformed before ligation of forarm artery?
Allen test to reveal patent palmar arch.
If both the radial and ulnar arteries are injured. Preferance to repair what artery should be made?
Unlar is most commonly the dominant contributor.
When would you consider fasciotomy after arterial injury?
All patients with restoration of distal perfusion after ischemia. Especially after multiple fractures or arterial injuries is present.
Thigh and upper arm for proximal arterial injury if proximal venous occlusion and outfloe is not restored.
What are the Zones of the RP?
Zone 1 upper midline RP from hiatus to bifurcation and laterally from hilum to hilum. subdivided into supramesocolic and inframesocolic. Axis, SMA/SMV, distal RV, prox RA, sepraceliac IVC, portal vein.
Zone 2 Lateral perinephric area. infrarenal aorta, infrarenal IVC
Zone 3 Pelvic RP from bifurcation inferiorly
What are symptoms of RP hematoma?
non-specific groin/back or lower abdo pain
thigh pain or numbness/weakness from femoral nerve compression
What are findings on exam of RP hematoma?
flank ecchymosis/hematoma-grey-turner
umbilicus hematoma-cullens
lower quad fullness on exam
flexion/external rotation of the hip with extension causing pain (from illipsoas spasm)
pain-paresthesias in antero-medial thigh (lat cutaneous branch fem nerve)
What is the management?
conservative first
bed rest
reverse anticoagulants
What are indications for intervention?
Neuro deficits
hemodynamic instability
ongoing bleeding
severe pain
what are interventions?
endovascular, embolization
open evacuation?
what are surgical approaches for evacuation?
supra-iguinal
groin
what are RF for soon RPB?
HD, anticoagulants, bleeding abnormality
Heparin greater risk then warfarin
what is the incidence of spontaneous vs iatrogenic RPB on anticoagulation?
spon 0.6-6% on anticoagulation
iatro 0.15-0.5 with fem cannulation
higher with bigger calibre
What is the equation for impact kinetic energy?
IKE= 1/2mass x velocity squared
What kind of injuries can occur from a blast injury?
direct blast pressure
penetrating fragments
collision with objects
thermal injury
What are principles of management for non compressible truncal haemorrhage?
minimize delay to OR
permissive hypotension
balancced resuscitation
procoagulant adjuncts (tranexamic acid)
damage control surgery/shunts
Most common injured abdo vessels?
IVC
aorta
SMA
Portal
What are the zones of the carotid? And how do you obtain control of each zone?
Zone I
Below the cricoid cartilage—proximal control obtained in the chest
Zone II
b/w the cricoid cartilage and the angle of the mandible—proximal and distal control obtained in the neck
most commonly injured
zone III
above the angle of the mandible—distal control difficult to obtain
In what time period should you attempt revascularization if neurological defects?
within 24 hours
What is treatment for BCVI?
heparin
can consider warfarin
What is treatment for BCVI?
heparin
can consider warfarin
What is classification of aortic injury?
grade I intimal tear
grade II intramural hematoma
grade III PSA
Grade IV rupture
What are mechanisms of blunt aortic trauma?
stretching
sudden BP elevation
osseous pinching
water-hammer effect
What injuries would you consider initial management of blunt AI in grade I?
cardiac RF
head injury
pulmonary injury
coagulopathy
severe abdo injury
What injuries would you consider initial management of blunt AI in grade I?
cardiac RF
head injury
pulmonary injury
coagulopathy
severe abdo injury
What are the zones of the abdomen?
zone 1 aortic hiatus to sacral promontory
zone 2 L and R kidney, paracolic gutter and renal vessels
Zone 3 pelvic retroperitoneum and iliacs
zone 4 liver
When should RPB be explored?
penetrating unless stable and non-expanding
paraduodenal (rule out duodenal injury)
root of mesentery with ischemic bowel
When to do damage control?
coagulopathic
hypothermic
BE >15 mmol
signif bowel edema
At what pressure is abdo compartment syndrome suspected?
>20mmHg with organ dysfunction
20-30 consider decopression
What are RF for ACS?
Massive blood transfusion
Vascular injury
Prolonged hypotension, aortic cross clamping
Damage control procudreus
Tight closure of abdo wall.
What are the zones of the SMA?
Zone 1
b/w aortic origin and inferior pancreaticoduodenal artery
zone2
b/w inf pancduo and middle colic artery
zone 3
distal to middle colic artery
zone 4
segmental intestinal branches
What zones of the SMA can be ligated with limited ischemia?
3 and 4
What veins does the IVC receive?
lumbar
right gonadal
renal
right adrenal
hepatic
phrenic
What veins does the IVC receive?
lumbar
right gonadal
renal
right adrenal
hepatic
phrenic
What is hepatic vascular isolation clamp order?
clamp infradiaphragmatic aorta, suprahepatic IVC,
infrahepatic IVC above renals
and portal triad
What is the portal vein formed by?
confluence of SMV and splenic vein
What are had signs?
Absent distal pulses
Palpable thrill or audible bruit
Actively expanding hemotoma
Active pulsatile bleeding
What are soft signs?
Diminished pulses
History of significant hemorrhage
Neurologic defecit
Proximity of wound to named vessel
What are soft signs?
Diminished pulses
History of significant hemorrhage
Neurologic defecit
Proximity of wound to named vessel
For bypass in LE injury, was conduit do you use?
Take vein form non injured side to preserve collateral venous drainage as vein injury rate is high
What are features of the MESS score?
type of injury
degree of limb schema
hemodynamic instability
age
What score correlates with primary amp?
>/= 7
What is treatment for frostbite?
Local, intr-arterial CDT,
close observation,
limb rewarming,
wound care
What are the segments of the vertebral artery?
V1 readily accessible
V2 within bony foramen of cervical canal
V3 exit foramen and enter skull
V4 intracranial
What is the grading scale for blunt cerebrovascular injury?
grade I, luminal irreg or disection 25% of lumen
Grade III PSA
Grade IV occlusion
Grade V transection
Who should be screened for BCVI?
GCS
