Trauma Flashcards
MCC of death
MCC of death for trauma patients in 1st hour: hemorrhagic shock
MCC of death for trauma patients reaching hospital: TBI
Best measure of resuscitation
Lactate (<2.5) is the best measure of resuscitation in trauma patients, not UOP
DPL
DPL make the incision above umbilicus: positive with: > 100,000 RBC, 10 cc of blood, or > 500 WBC
Penetrating abdominal injury:
-Unstable or high velocity GSW OR
-Stable (knife) evaluate with Local wound exploration vs CT vs diagnostic laparoscopy vs serial abdominal exams
Penetrating flank wounds
-Unstable go to OR for LAPAROTOMY
-Stable: CT abd
Injury below nipples
laparotomy
ED thoracotomy
SBP <60 or loss of pulse
Tranaxemic Acid TXA
-Reduces all-cause mortality if given to traumatic hemorrhagic and shock if used <3 hours from injury
-CRASH-3 trial showed reduced mortality in patients given TXA with TBI!!!
-Indications: Traumatic hemorrhagic shock with SBP <75 or LYS >3 %
-Only give if injury was < 3 hours ago
-Give 1 g IV over 10 minutes, followed by 1 gram every 8 hours
Classes of hemorrhagic shock
-“End organ hypoperfusion”
-Hemorrhage classes:
-Class I= 0-15% blood loss; no physiologic signs
-Class II= 15-30% blood loss; tachycardia, narrowed pulse pressure
-Class III= 30-40% blood loss; hypotension
-Class IV= >40% blood loss
-Earliest sign of shock: tachycardia & narrowed pulse pressure (Class II)
REBOA
Zone I – left subclavian to celiac artery (Abdominal injuries)
Zone II – Celiac artery to lowest renal artery (never use here)
Zone III – Lowest renal artery to aortic bifurcation (Pelvic Injuries)
Do not place REBOA for penetrating chest injuries. These need an ED thoracotomy
Reboa is only used for injuries below the diaphragm
Only deploy REBOA in Zone I or III
Concussion and sports related LOC
They will need testing of vision, oculomotor, balance etc
GCS cannot be used to rule out a concussive event
Most who present with concussion or LOC DO NOT require imaging of brain
Frequent awakening is no longer recommended
Any person who has sustained a concussion has a 2-5 time higher likelihood to get another one
GCS
(MVC…MVE…654)
Motor:
6: follows commands
5: localizes pain (purposeful movement toward stimuli)
4: withdraws from pain
3: flexion with pain (decorticate)
2: extension with pain (decerebrate)
1: no response
Verbal:
5: oriented
4: confused
3: inappropriate words
2: incomprehensible sounds
1: no response
Eye opening:
4: spontaneous opening
3: opens to command
2: opens to pain
1: no response
TBI mild (13-15), moderate (9-12) and severe (8 or less)
GCS 8 or less: intubation (and ICP monitoring if head injury)
Most important prognostic indicator= motor score
TBI
Mild TBI: GCS 13-15, moderate TBI: GCS 9-12, major TBI: GCS < 8
Mild traumatic brain injury definition
- GCS 13-15
- LOC is < 30 minutes
If has a mild TBI, GCS 13-15 with no other signs: observe for 4 hours in ED then DC
Obtain a CT for all MODERATE AND SEVERE = GCS < 12.
Only obtain CT for MILD TBI GCS 13-15 if one of below:
- Depressed skull fracture
- Any sign of Basilar skull fracture: Racoon eyes, hemotympanum, Battle sign, CSF leak,
- 2 or more episodes of vomiting
- Age > 65
- Amnesia > 30 minutes
- Neuro deficit, seizure
- AC use
- Dangerous mechanism: auto-ped, ejected from vehicle, fall > 3 feet
Fosphenytoin or Keppra for 1 week given prophylactically to prevent seizures with moderate to severe head injury
-Bilateral pinpoint pupils: Pontine hemorrhage
Subdural hematomas
Tearing of venous plexus (bridging veins) that cross between the dura and arachnoid
Crescent-shaped; crosses suture lines
Chronic subdural hematoma: elderly after minor fall, severe alcoholic; mental status deteriorates over days to weeks as hematoma forms
Decompressive craniectomy is ONLY indicated if there is a midline shift with MASS (hematoma) present that can be evacuated.
Not indicated if only has intracranial HTN.
Surgical indications: SDH > 10 mm thick or midline shift > 5 mm, change in GCS of 2 points or more, signs and symptoms of increased ICP
DVT px 72 hours after stable brain bleed
LMWH has decreased mortality and rates of VTE when compared to heparin
Coagulopathy with traumatic brain injury: due to release of tissue thromboplastin
Epidural hematoma
Arterial bleeding from middle meningeal artery
Lenticular (lens-shaped); contained by suture lines
LOC -> then lucid interval (awake) -> then sudden deterioration (vomiting, restlessness, LOC)
Craniotomy for significant neurological deterioration or shift > 5 mm
Intracerebral hematoma
Intraparenchymal hemorrhage
Frontal or temporal
Most common brain injury in trauma; occurs with blunt trauma
Diffuse axonal injury
MRI: blurring of gray-white matter; multiple small punctate hemorrhages
-Blunt injury with shear forces
-Non-contrast head CT characteristically normal
-More severe lesions in corpus callosum and brainstem
Tx: supportive; very poor prognosis
CPP
Cerebral perfusion pressure = MAP-ICP
CPP= surrogate for cerebral blood flow; main regulator= PaCO2
-In TBI, autoregulation is lost; CPP sensitive to changes in MAP
Normal ICP= 10; ICP > 20 needs treatment
TBI= CPP between 60 and 70
Want CPP > 60
- > 70 risk of ARDS & brain edema
- < 50 risk of ischemia
*Give volume and pressers to improve MAP. Want systolic > 100.
*Sedation & paralysis decrease brain activity and oxygen demand
*Raise head of bead: lowers ICP
Brain tissue oxygen partial pressure (PbtO2): predictor of cerebral ischemia and hypoxia; PbTO2 > 20
Avoid PaCO2<30
-Relative hyperventilation for modest cerebral vasoconstriction; do not want to hyperventilate and cause cerebral ischemia
-avoid hypotension and hypoxia to avoid secondary brain injury
ICP monitoring for TBI in a patient who DOES NOT have CT brain findings or traumatic injury is indicated in:
- Age > 40
- Motor posturing
- Systolic blood pressure <90
ICP monitoring indicated for all with mass effect on CT and GCS < 8
CSF drainage is indicated for TBI with GCS < 6
External ventricular drain= ventriculostomy – inserted into lateral ventricles= Able to drain CSF if needed to decrease ICP
-Bolt monitor: Placed intraparenchymal.
Steroids increase mortality
Avoid albumin – associated with increased mortality
Supportive treatment for elevated ICP
Want ICP < 20
Peak ICP (max brain swelling) occurs 48-72 hours after injury
-Sedation/paralysis
-Raise head of bead
-Relative hyperventilation (short term): CO2 30-35 for modest cerebral vasoconstriction
-Na 140-150, serum OSm 295-310
-Mannitol: draws fluid from brain
-Hypertonic saline preferred in trauma due to hypotension that can result from mannitol
-Remove C collar- improves cerebral perfusion
-Barbiturate comma if above not working
-Ventriculostomy with CSF drainage
-Craniostomy decompression/ also can do burr hole
Uncal herniation
Temporal lobe herniation
Cardinal sign: LOC, ipsilateral blown/dilated pupil + contralateral hemiplegia (due to compression of oculomotor CN III and corticospinal tract)
Earliest sign is anisorcia (one pupil is different than the other); can have unilateral dilated pupil without severe impairment of LOC; and overtime impaired EOM (down-and-out)
Initially present with sx of increased intracranial pressure: headache, n/v, AMS
Cushing’s triad: HTN, bradycardia, irregular respirations
-Late finding, indicates impending herniation
-Initial tx: Elevate HOB, ventilate to pC02 35, Mannitol &/or Hypertonic Saline, Sedate & Paralyze
CN VII injury
Facial nerve, main function: Motor innervation to muscles of facial expression
MC site for CN VII traumatic injury: temporal skull fracture (at the geniculate ganglion)
Cranial nerve VII injury
- If motor defect and lateral to canthus (corner) of eye: needs surgical repair of nerve in <72 hours
- Injury medial to this will recover
- Approximate epineural layers
Nexus criteria for traumatic Cervical spine injuries
Do not need imaging if: Alert, no neurological deficit, not intoxicated or altered, no midline C spine TTP, no distracting injury
Burst fracture -> spinal fusion
C2: Odontoid fracture
-Type I Odontoid fracture: Tip of the dens (odontoid process)/ above base: Stable, non op. Hard collar
-Type II Odontoid fracture: Base of the dens, Unstable. Tx: halo vest vs surgery
-Type III Odontoid fracture: Extending into vertebral body. Rarely need surgery. Stable, hard collar
C1 burst: Jefferson fracture: caused by axial loading; tx= rigid collar
C2 Hangman: caused by extension: traction halo
Clinical clearance of C spine: must have no other injuries, GCS 15, not intoxicated, no neck tenderness, no neurological deficits
Le fort
Type I – straight across on the maxilla
Type II – lateral to nasal bone, underneath eye
Type III – Across orbit
Type I and II Le Forte = Stabilization and intramaxillary fixation (IMF) MMF
Type III - Suspension wire to stabilize frontal bone and possible external fixation
Vascular injuries grading system
Blunt cerebrovascular injury
1st step for grade I-IV is to start heparin drip. No bolus. Low dose. PTT 40-50
- This is the treatment for the vast majority of all patients
Need follow up CTA for Grade I-III, on day 7. If resolved: DC AC. If not, then DC on aspirin only.
Operative repair generally not feasible because of location of injury, MC distal internal carotid artery
Stenting – Generally not used for Grade I or II. only used for symptomatic patients (dissections) or enlarging or symptomatic pseudoaneurysm, or grade V lesions that are not accessible
Surgey – rarely ever indicated, usually only for grade V
Occlusion: just AC
Carotid dissection Grade I or II – treated with AC unless symptomatic
- #1 heparin or Plavix.
- Symptomatic (neuro sx): endovascular covered stent
Carotid disruption (presents with carotid thrombosis)
- Complete occlusion: OR
- If anterograde flow present: Endovascular/open repair
Vertebral artery dissection: treated the same as carotid
Penetrating neck injuries
- If it did not penetrate the platysma: No need for imaging or OR
- If there are any HARD signs of vascular injury (also, air bubbling) or hemodynamic instability: OR
- Hard signs:
*Expanding/pulsatile Hematoma
*Signs of limb ischemia/ comportment syndrome= pulseless, pallor, paresthesia,
pain, paralysis, poikilothermia - Bruit/Thrill
- Absent Doppler Signals
- Arterial Pressure Index, API,
(<0.9) - Soft Signs = hoarseness, odynophagia, non-expanding hematoma CTA neck
- CTA neck is the INITIAL diagnostic test of choice if not going to the OR (no hard signs of vascular injury)
- Once CTA neck is done, THEN you can selectively work up other injuries if there is a concern.
- Air bubbling: Bronch
- Odynophagia or CT evidence of esophageal injury: esophogram and EGD
Penetrating neck wounds divided in two locations:
- Posterior neck triangle:
- Bounded by posterior SCM, clavicle and trapezius - Anterior neck triangle:
- Zone I: clavicle to cricoid cartilage; can injure, apex of lung, trachea, esophagus, brachiocephalic or subclavian vessels, nerves; median sternotomy
- Zone II: cricoid to angle of mandible; carotid, vertebral, jugular, esophagus, trachea; lateral neck incision
- Zone III: angle of mandible to base of skull; internal/external carotid, jugular, cranial nerve, hypoglossal nerve; ; lateral neck incision
Anyone with penetrating neck injury that has any of the following need OR:
- HARD signs of vascular injury
- Tracheal injury (Subcutaneous air, bubbling, coughing blood)
- Neurologic deficit
Esophageal trauma
Esophagoscopy + esophogram – finds 95% of injuries
If contained: treat conservatively/observe
Non-contained (ALL NEED SURGERY):
- If small and minimal contamination: primary closure
- If extensive with severe contamination (unable to repair) or hemodynamically unstable:
- Neck – just wash and place drains; will heal on its own
- Chest – Place chest tubes, cervical esophagostomy, staple distal esophagus, will eventually need esophagectomy
Thoracotomy/ VATS
Indications for thoracotomy: > 1.5L after initial insertion; > 200/cc for 4 hours; > 2.5L/24 hours; bleeding w instability
Need to drain all blood in < 48 hours to prevent fibrothorax, pulmonary entrapment, infected hemothorax, empyema
Retained hemothorax = residual hemothorax AFTER thoracostomy tube already placed, only if > 25% -> Tx: = VATS drainage is best.
Should be EARLY, by day 3
- Don’t place a second thoracostomy tube
- Don’t use fibrinolytics
Persistent air leak by POD 3: Need to do VATS at this point
Open pneumothorax
Sucking chest wound
Open pneumothorax – large chest wall defect leads to direct communication of pleura to environment.
If wound is great than 2/3 diameter trachea: during inspiration, air will go into wound instead of airway
-needs immediate 3 sided occlusive dressing followed by chest tube
Rib fractures
- epidural shown to decrease ventilator days, fewer pulmonary complications, and shortened ICU and hospital length of stay, especially when used in older patients
- Contraindication to epidural = increased intracranial pressure
- Only indication for surgical fixation really is flail chest or failed medical management
- Surgical fixation with flail chest: reduces PNA, decrease ICU LOS, ventilation duration, decreased need for tracheostomy.
- Surgical rib fixation does NOT decrease mortality
Flail chest: 3 or more consecutive ribs broken at 2 or more sites= paradoxical motion; underlying pulmonary contusion= biggest impairment
-Normally chest wall moves outward during inspiration, reducing intrathoracic pressure and drawing air into lungs
-In flail chest: detached segment of ribs drawn inward by negative pressure during inspiration and outward during expiration
Tracheobronchial injuries
Worsening oxygenation after chest tube placement.
Persistent large PTX after 1st chest tube: place a second anteriorly-> if doesn’t respond will need bronchoscopy to check for tracheobronchial injury or mucus plug
Sx:
* Subcutaneous emphysema
* Hemoptysis
* Pneumomediastinum
* Large continuous air leak throughout respiratory cycle
* Persistent PTX
MC right main stem
Dx: bronchoscopy
May need to mainstem intubate patient on unaffected side
Indications for surgical repair:
1. Respiratory compromise
2. Unable to get lung up
3. 3 days of persistent air leak
4. Injuries > 1/3 the size of the tracheal or bronchial lumen
Cervical incision - for tracheal injuries above the clavicle
Median sternotomy – if Injury is from clavicle to 2-3 cm proximal to carina
Right posterolateral thoracotomy 4th-5th ICS– for right mainstem, trachea, proximal left main stem
Left posterolateral thoracotomy 5th ICS- For distal left mainstem
Activated clotting time ACT
Want ACT150-200 sec for routine AC
Want ACT >480 for cardiopulmonary bypass
Blunt traumatic aortic injury
Aortic transection
Proximal descending aorta, where relatively mobile aortic arch can move against fixed descending aorta (ligamentum arteriosum)= greatest risk from shearing forces of sudden deceleration
-PE: HoTN, UE HTN, unequal blood pressures, external evidence of chest trauma, thoracic outlet hematoma, fractured sternum, fractured thoracic spine, left flail chest
-CXR low sensitivity: concerning for BAI
1) Widened mediastinum (8cm)
2) Depression of mainstem bronchus
3) Deviation of NG tube to the right
4) Apical Cap
5) Disruption of calcium ring (broken halo)
-CT angiography of the chest= diagnostic study of choice
-Severity of aortic injury:
-Type I (intimal tear)
-Type II (intramural hematoma)
-Type III (pseudoaneurysm)
Type IV (rupture)
MC location of tear is at ligamentum arteriosum (proximal descending thoracic aorta; just distal to left subclavian take off)
-Most blunt aortic injuries surviving to hospital are partial- transections, and should be managed with blood pressure control until definitive repair.
Maintain blood pressure between 100 and 120 mmg (esmolol; with or without nitroprusside)
Treat other life threatening injuries first
For intervention stent is > than open repair. But if doing open: left posterolateral thoracotomy while on left heart bypass, with interposition graft
- Grade I: intimal flap/tear < 1 cm. Tx: Beta blockers. Impulse control HR <100, BP < 120 systolic
- Grade II: Intimal flap/tear > 1 cm or Intramural hematoma. Tx: Beta blockers. Impulse control HR <100, BP < 120 systolic. Repeat CTA in 7 days.
- Grade III: pseudoaneurysm. Tx: endovascular stent
- Grade IV: rupture/transection. Tx: endovascular stent
-Post endovascular repair of BAI develops left hand ischemia: carotid to subclavian bypass (subclavian covered routinely during endovascular repair of BAI)
Approach for specific injuries
Best with left posterolateral thoracotomy: left ventricle, left subclavian artery, descending aorta, left pulmonary artery, left lung, left hilum, left internal mammary artery, and distal esophagus are best approached through a left thoracotomy
However, Anterior approach is preferred if the patient is being taken in emergent situation.
Median sternotomy
- Heart, pericardium,
- Brachiocephalic artery and vein
- Proximal right subclavian, proximal left and right common carotid,
- ascending aorta,
- SVC, IVC,
- main pulm artery
- Poor choice for lung or esophagus
Proximal left subclavian: (need trap door incision, divide left 2nd intercostal space and elevate 1st and 2nd rib)
- Needs left anterolateral thoracotomy at the third intercostal space, supraclavicular incision, and partial sternotomy
- Distal control through supraclavicular approach
Left anterolateral = ED thoracotomy
A right anterior thoracotomy is relatively rarely used in trauma.
Right posterolateral thoracotomy is performed in a lateral position.
- Right lung including hilum, diaphragm, trachea, right bronchus, proximal left bronchus, mid-esophagus
Left posterolateral thoracotomy is performed in a lateral position
- Left lung and hilum, aortic arch, descending thoracic aorta, diaphragm, distal thoracic esophagus
Distal right subclavian artery – Mid clavicular incision, resection of medial clavicle
Lung injury bleeding: perform pulmonary tractotomy with stapler
Pelvic fracture bleeding
Anterior pelvic fracture: venous bleed
Posterior pelvic fracture: arterial bleed
Diaphragm injury
Diaphragm injury: repair with non-absorbable suture, usually no mesh needed
polyester or polypropylene
Resuscitative thoracotomy indications (ED thoracotomy)
Penetrating trauma:
-CPR was started within 15 minutes of penetrating thoracic injury
-CPR was started within 5 minutes of a penetrating extra-thoracic injury (e.g. abdominal trauma)
-Patient had signs of life and pulse or pressure was lost (SBP < 60) on way to ED or in ED
Blunt trauma:
-Only if pressure or pulse lost in ED (CPR started within 5 minutes)
Cardiac tamponade
Cardiac tamponade – causes cariogenic shock
-Decreased ventricular filling due to fluid in the pericardial sac around the heart
Beck’s triad: JVD, hypotension, muffled heart sounds
Echo: impaired diastolic filling of right atrium (1st sign)
FAST – best to dx in trauma bay
-If US positive and patient is hemodynamically normal: pericardial window to confirm diagnosis, if positive= median sternotomy
- If US positive and unstable: no need for further diagnosis. No need for pericardial window or any imaging -> Median sternotomy
- Rarely will you ever choose pericardiocentesis to temporize, unless the facility does not have the capabilities to perform median sternotomy
Any patient with a penetrating injury to chest and pericardial fluid on US mandates operative intervention, will need a pericardial window or median sternotomy
Can present in post cardiac surgery patient as sudden decrease chest tube output followed by hypotension and elevated wedge/CVP or as PEA
-Coding: open sternum in ICU
-If still as BP and HR: return to OR for reentry
Morel-Lavallée
Morel-Lavallée – closed degloving injury, when skin and subq separate from fascia.
The space fills with serous/bloody fluid
Will see internal debris in the collection on imaging = fat globules
If small= compression
Large, failed medical management, skin necrosis= percutaneous aspiration then compression (very important)
Duodenal trauma
-MC blunt
-Usually, CT with oral contrast is best for diagnosis: free INTRAperitoneal air or contrast leak
-MC location for tears – 2nd
-MC location for hematoma – 3rd
Retroperitoneal air or leak: non-op, abx, NPO, NGT
Do Kocher maneuver and open lesser sac through the omentum for: RUQ bile staining, succus drainage, fat necrosis, paraduodenal hematoma (found intra op)
Duodenal hematomas on CT scan are managed non-op, NGT, TPN, NPO for up to 14 days! If more -> OR
-UGI study shows “stacked coins” or “coiled spring”
Usually for duodenal injuries, the initial operation is just damage control, and definitive surgery will follow
Most of them 80%–> primary repair
If laceration is through and through (ant and post): needs resection
If Grade II, < 50% circumference for all:
- #1 choice is transverse primary repair
- If tension free repair is not possible (reduces lumen <50%) do duodenoduodenostomy
- If you can’t do above bc of tension then: Roux-en-y duodenojejunostomy over the injury
If grade III > 50% circumference 1st, 3rd, 4th duo OR 2nd portion 50-75%:
- #1 choice is transverse primary repair, often cannot do this here
- If tension free repair is not possible do duodenoduodenostomy
- If you can’t do above bc of tension then: Roux-en-y duodenojejunostomy over the injury or close the duodenum laceration and do it proximal to injury
- If injury is in the 1st or proximal 2nd portion of duodenum can do antrectomy (include lacerated bowel) staple distal to injury so ampulla is in distal end and do gastrojejunostomy
If Grade IV but ampulla or CBD not involved, only >75% D2 treat like grade III
If grade IV D2 >75% and involving ampulla or CBD
- Initial operation is almost always damage control, save the patient’s life
- Complex reconstruction vs whipple
- Avoid pyloric exclusion if possible
- jejunal serosal patch, pyloric exclusion (oversew pylorus through gastrostomy), gastroJ, feeding tube
Grade V
- Initial operation is almost always damage control, save the patient’s life
Triple tube decompression with duodenostomy tubes no longer supported
Destructive injuries to the duodenopancreatic complex often require pancreaticoduodenectomy.
- For the First operation just place drains
- Never do whipple on first trauma operation
Lateral tube duodenostomy may be helpful in patients who leak after a duodenal repair breaks down but should not be used at the initial surgery
Pyloric exclusion and gastrojejunostomy – typically used in duodenal repairs with pancreatic injury. Pancreatic injury may cause breakdown of the duodenal repair (the sutures may dissolve from the pancreatic fluid). The diversion of the gastric contents permits adequate drainage of the area without development of a lateral duodenal fistula that is unlikely to heal.
Small bowel trauma
MC organ injured in penetrating trauma
>50% laceration or lumen <50% needs resection
Injury grading = small bowel = colon = rectum = all the same
Blunt hollow viscus injury – easily missed bowel injury.
CT scan findings may show free fluid, mesenteric stranding or hematoma, bowel wall thickening
You have 2 choices. Either exploratory laparotomy or observe
Intra-op mesenteric hematomas: open if expanding or large (> 2 cm)
Colon Trauma
MC penetrating
Destructive colon injury is defined as = >50% laceration or colon devascularization = need segmental resection
Right and transverse colon treated like small bowel. Primary repair unless destructive, then you would resect. Don’t need diversion
Left colon- Primary repair without diversion for all non-destructive injury
If left colectomy (sigmoid too) indicated, diverting ileostomy or Hartmann’s indicated only if for:
- Unstable (defined as SBP <90), at any point in time EVEN IF IT WAS PRE-OP, transient, or now resolved.
- Peritonitis (SEVERE gross/fecal contamination)
NEVER DO PRIMARY REPAIR or anastomosis IF HEMODYNAMICALLY UNSTABLE/SHOCK: keep in discontinuity and come back later
Intra-op paracolonic hematoma: open both blunt and penetrating
Rectal trauma
Upper rectum = Intraperitoneal = treated like colon injuries
- if non-destructive: primary repair without diversion
- If performing LAR for destructive injury (greater than 50% circumference or devascularization) diverting LOOP colostomy indicated if any below
o Unstable (defined as SBP <90), at any point in time EVEN IF IT WAS PRE-OP, transient, or now resolved.
o Peritonitis (Severe gross/fecal contamination)
o Significant comorbidities
- If destructive and in shock place end colostomy (Hartmann’s= avoids left sided anastomosis in a sick patient and diverts stool)
For all extraperitoneal
- High (proximal 1/3): If LAR needed= diverting colostomy
- Middle: end colostomy only (not APR) area will heal after 6-8 weeks
- Low: if repair not fesible: end colostomy only (not APR)
- Never do presacral drainage
- Never do distal rectal wash out
Splenic injury
-If unstable BP <90: OR
-Transient responder: IR embolization
-Active contrast or pseudoaneurysm in stable patient: IR embolization
CI to splenic salvage: head injury, unstable
-Fluid collection late after splenectomy = pancreatic injury (high in amylase) PC drainage only
-Nonoperative management: bed rest for 5 days
-Unusual to have to remove spleen in children
-Postsplenecotmy sepsis greatest risk w/n 2 years of splenectomy
-Vaccines: pneumococcus, menigocoffus, H. influenzae; 2 weeks after splenectomy
Liver injury
MC organ injury with blunt abdominal trauma
-Common hepatic artery can be ligated proximal to the GDA; will be retrograde flow from the GDA into the proper
-Pringle maneuver: clamping portal triad does not stop bleeding from hepatic veins or retro-hepatic IVC
-Common bile duct injury (Kocher maneuver and direct out portal triad): < 50% of circumference repair over stent; >50% circumference choledochojejunostomy
-Portal vein injury: may need to transect through pancreas to get to injury= distal pancreatectomy; ligating portal vein associated with 50% mortality
Leave drains with liver injuries
Omental graft
-Damage control peri-hepatic packing:
If bleeding from hepatic veins (retro-hepatic IVC) and can’t stop it: take down triangular, falciform, and right coronary ligament and perform kocher for direct packing of IVC
Active contrast or pseudoaneurysm in stable or transient responder: angioembolization
Fluid collection later after liver injury: PC drainage
Pancreatic trauma
MC penetrating
80% treated with just drains; primary concern is figuring out if duct is involved
-If main duct disrupted left of SM vessels (Grade III): distal pancreatectomy
If main duct disrupted to right of SM vessels (Grade IV), without major pancreatic head disruption AND without duodenum injury is best managed DISTAL PANCREATECTOMY!!! +/- pancreatiojejunostomy
If major pancreatic head injury (Grade V) or severe pancreatic head and duodenal injury: initially place drains, will need delayed whipple
If there is bleeding behind pancreas and can’t get to it: transect neck of pancreas, requires distal pancreatectomy
If there is concern for ductal injury: Need ERCP or MRCP
Always place drains inra-op, and can remove when amylase level is less than serum
If treated non-op and find peripancreatic fluid collection, may have duct injury, Do ERCP instead to diagnose duct injury and temporize with stent
Need Cattell to evaluate head, need Mattox to see tail
Mattox vs Kocher vs Cattel-Braasch vs Pringle
Mattox: Left-Sided Medial Visceral Rotation; Mobilize Descending Colon at White Line of Toldt; visualize: entire abdominal aorta, proximal celiac axis, and SMA
Kocher: Incise Posterolateral Peritoneal Attachments of Duodenum; place Hand Behind Duodenum/Pancreatic Head and Retract Medially; visualize: suprarenal IVC
Cattel-Braasch Maneuver: Right-Sided Medial Visceral Rotation; extended Kocher
Pringle Maneuver: compression of portal triad; stops hepatic inflow but does not stop backflow from hepatic vein bleed
Popliteal access
Above the knee popliteal access: posterolateral Sartorius
Below the knee popliteal access: posterolateral gastrocnemius (medial head)
Leg compartments:
Anterior - anterior tibial artery, deep peroneal nerve (dorsiflexion, sensation between first two toes)
Lateral: superficial peroneal nerve (eversion, lateral foot sensation)
Deep posterior: Posterior tibial artery, peroneal artery, tibial nerve (plantar flexion)
Superficial posterior: sural nerve
Compartment syndrome
Compartment pressure > 30 mmHg suggests compartment syndrome
Pain with passive motion -> paresthesia -> poikilothermia -> pallor -> paralysis -> pulselessness (late finding)
Lateral incision 4-5 cm lateral to tibia and in between fibula: opens anterior and lateral compartments
Medial incision 2-3 cm medial to tibia: opens both posterior compartments.
- Need to make sure to take soleus off of tibia to open deep posterior compartment
- Incise gastrocnemius for superficial posterior compartment
Superficial peroneal nerve MC nerve injured in fasciotomy at the lateral fasciotomy site (decreased eversion)
Gustilo classification for open fractures
Type I and Type II: ancef
Type III: Ancef + gentamicin or ceftriaxone monotherapy
Farm injury: automatically Type IIIA injury, need to add flagyl here= ancef + gent + flagyl or ceftriaxone + flagyl
Primary Amputation
Primary Amputation (= no attempt for limb salvage) for mangled extremity can be performed in only one situation:
- Hemodynamically unstable with multiple injuries is only indication
Do not attempt limb salvage in this situation for mangled extremity -> straight to amputation.
Gustilo fracture pattern, loss of sensation, number of vessels injured, nerve injured, or any scoring system: Should not alter decision making for primary amputation. Studies show that this does not matter.
IVC Repair
Primary repair if <50%. Otherwise need saphenous vein or synthetic patch
Ureter injury
MCC penetrating
Best diagnosed with CT with DELAYED phase or multiple shot IVP (intravenous pyelogram), retrograde urethrogram
Hematuria not a reliable indicator
Blood supply medially upper 2/3, laterally lower 1/3
Any injury with electrocautery needs debridement prior to repair
If GSW blast injury causes ureter injury: all of these need to be debrided to healthy tissue first
If partial transection <50%, or hematoma/contusion: just place stent
If >50% transection or complete transection but has < 2 cm devascularization: Debride, spatulate, then primary repair over stent.
- For all upper and middle
If complete transection and < 2 cm: primary repair unless it is in lower 1/3 then reimplant bladder (ureteroneocystostomy)
If complete transection > 2 cm and can’t do primary repair:
- Upper and middle 1/3 (above pelvic brim/proximal to iliac vessels):
o If not able to repair in the acute setting (unstable and doing damage control) then needs staged repair. ligate both ends of ureter then percutaneous nephrostomy tubes. Will ultimately need transureteroureterostomy or ileal conduit
o if stable can do transureterouretorostomy
- Lower 1/3 (below pelvic brim/distal to iliac vessels):
o Re-implant into bladder if it is within 2 cm of the bladder. If > than 2 cm do primary repair
o If can’t reach: using psoas hitch: mobilize bladder and suture bladder to iliopsoas fascia above the iliac vessels
o If still can’t reach with psoas hitch then do Boari flap: anchor base of flap to psoas. Take 4 cm wide flap from bladder and tunnel ureter through flap
Iatrogenic injury during LAR, APR, gynecologic/sarcoma surgery: By definition they are lower 1/3: ureterocystostomy
Missed injury:
- If found < 7 days from injury: Go to OR
- If any abscess, urinoma, fistula or > 7 days: Nephrostomy tube and try to place stent
Leave drains for all ureteral injuries
Renal trauma
MCC blunt; often lower rib fractures
Hematuria best indicator of renal trauma but may not have hematuria
Indications for OR: ongoing renal hemorrhage in unstable patient and Grade V
Surgery is mandated for vascular, renal pedicle or shattered injury. Grade V
Pseudoaneurysm and active contrast extravasation: treat with angio interventions (stent, embolize)
Non-op: cortical, collection system disruption, urine extravasation
Grade I-IV: If blunt, all of these are managed non-op in stable patient
Most Urine extravasation is managed by observation. If persistent or sepsis: nephrostomy tube
In the OR:
- If blunt, hemodynamically stable, with no previous imaging, found a non-expanding hematoma in zone II around kidney: do not explore
- If penetrating without pre-op imaging, peri-nephric hematoma ALL mandate exploration
-Intra-op expanding or bleeding hematoma: open
Left renal vein: can be ligated near IVC; has adrenal and gonadal vein collaterals
Right renal vein does not have these collaterals
Orthopedic trauma
-Femur fracture: can have > 2L blood loss
-Femoral neck fracture & hip dislocation: high risk for avascular necrosis
-Long bone fracture or dislocation with weak/loss of pulse: CT angio/vascular bypass/repair
-All knee dislocations: formal angiogram
-Upright fall: calcaneus, lumbar, distal forearm fx
Retroperitoneal hematoma Zone 1
Zone 1 Central (medial to psoas)
-Potential for injuries: pancreas, duodenum, aorta, IVC.
-Explore all blunt and penetrating
-Divided into two areas:
*Supramesocolic Zone 1: Supra-renal aorta, celiac, renal vessels, proximal SMA
-Proximal aortic control: at abdominal diaphragmatic hiatus (Need left thoracotomy if hematoma is at the level of diaphragm) then
-Mattox maneuver (left medial visceral rotation) for exposure (mobilize left colon, left kidney, spleen, and tail of the pancreas toward the midline)
*Inframesocolic Zone 1: Infra-renal aorta, infra-hepatic IVC
-Proximal aortic control (If needed) – infra-renal aorta, just below the left renal vein
-(same exposure as AAA) at the base of transverse mesocolon. TV colon up, SB to the right
-Proximal IVC control (if needed) – just below renal veins,
-Cattell maneuver for exposure
Cricothyroidotomy
-Can’t intubate, can’t ventilate: cricothyroidotomy
TEG
-TEG/ROTEM can guide resuscitation
-Time: how long it takes to start clot
-If prolonged= give FFP
-Angle: how fast they are forming a strong clot
-If low= give cryoprecipitate
-Amplitude: size of clot
-If low= platelets
-LY30: measure lysis
-If high= give TXA
Denver Criteria
Denver Grading System
