Trauma 2

Question 0

Patient with fresh spinal cord injury presents with priapism. Other associated findings?

Answer 0

Loss of anal sphincter tone, loss of vasomotor tone, bradycardia, intestinal ileus

Question 1

Patient presents after MVA. Regarding cervical spine, appropriate management if:

1. Awake and alert
2. Comatose
3. Loss of neurologic function below neck
4. Priapism

Answer 1

1. Maintain cervical stabilization, palpate for deformities, Assess for motor/sensory functions, lateral cervical radiographs
2. Cannot clear cervical spine without MRI
3. Continue cervical spine precautions, consult neurosurgery, image, immediate STEROIDS to prevent edema, extreme caution with intubation
4. Recent spinal cord injury

Question 2

Concern and management if patient presents with a stab wound to:

1. Left chest, lateral to the nipple
2. Below nipple on left side
3. Inferior to the clavicle

Answer 2

1. Hemopneumothorax – Chest tube insertion or thoracostomy
2. Injury to the diaphragm – surgical exploration
3. Subclavian arterial/venous injury – angiogram if stable; urgent exploration if unstable

Question 3

Patient presents after MVA. On CXR, mediastinum is wide on portable anteroposterior film – interpretation? Next steps?

Answer 3

Portable CXR is unreliable

1. Get posteroanterior CXR – if still enlarged, consider thoracic aortic transection
2. Establish diagnosis with aortic angiography or CT chest
3. Proceed to OR for repair

Question 4

Most reliable findings on CXR to suggest aortic disruption? Other findings?

Answer 4

Indistinct aortic knob or descending aorta

#Tracheal deviation to the right
#Pleural cap (pleural fluid top of long cupola)
#obliteration of aortic-pulmonary window
#Depression of left mainstem bronchus or elevation of right mainstem bronchus

Question 5

Injuries require further evaluation based solely on the mechanism of injury?

Answer 5

Unprotected trauma (Pedestrians and MVAs, motorcycle/bicycle crashes, assaults)

Question 6

Patient presents after trauma. When is exploration of the abdomen justified?

If not justified, other options?

Answer 6

#Obvious penetrating injuries (gunshot wounds, penetrating lacerations)
#Unstable patients with abdominal distention or severe pain

Diagnostic paratonia lavage (DPL), CT with contrast, abdominal ultrasound (FAST)

Question 7

diagnostic peritoneal lavage?

Advantages? Disadvantages?

Answer 7

1. Empty bladder
2. Small midline incision and peritoneum opened
3. If 10 mL or more gross blood encountered OR 1000 RBCs/mL, positive test
4. If positive test, open exploration indicated

Fast, low-cost, low false-negative

May miss injuries to retroperitoneal structures (duodenum/pancreas)

Question 8

When to use diagnostic peritoneal lavage versus CT scan?

Answer 8

Hemodynamically unstable versus stable patient

Question 9

Appropriate management for trauma patient with:

1. Flat, nontender abdomen with no evidence of injury
2. Complaints of severe diffuse abdominal pain
3. Coma on admission
4. CXR shows stomach in left chest
5. CXR shows free air in abdomen
6. Hypotensive with no obvious cause of blood loss
7. Hypotension and distending abdomen
8. Hypotension and obviously fractured pelvis

Answer 9

1. Imaging only if mechanism of injury that warrants further evaluation
2. Indication for exploration (option of doing CT or FAST first)
3. DPL, CT, FAST
4. Surgery for ruptured diaphragm
5. Surgery for perforated viscous
6. FAST or DPL
7. Surgery for major abdominal injury
8. FAST – if positive, abdominal exclamation first. If negative, deal with pelvic fracture

Question 10

Patient presents after trauma with obvious fracture of pelvis. Develops hypotension - specific management?

Answer 10

1. FAST cash if positive, first do abdominal exploration
2. It’s negative, do pelvic angiogram (If significant bleeding from branch of internal iliac – Control with embolization)
3. Reduce and externally fix fracture

Question 11

Patient presents after MVA. Vitals stable and CT scan performed. CT shows splenic laceration with fluid adjacent to injury. Two guiding principles for management?

Answer 11

Preserve spleen if possible and avoid blood transfusions if not absolutely necessary

Question 12

Patient presents after trauma. Differences management if splenic injury versus liver injury?

Answer 12

Splenic injury:
#Observation if grade III or lower
#Otherwise exploration

Versus

Liver: 
#if stable, observation
#If unstable, exploration necessary regardless of grade

Question 13

Patient presents after trauma. CT scan shows Injury to root of mesentery – suspect?

Answer 13

Significantly large injury forces – suspect tear or rupture of bowel

Question 14

Patient presents after trauma. CT scan shows hematoma located centrally in area of SMA – suggests injury to? Management?

Answer 14

Upper abdominal aorta, major aortic branches, direct injury to pancreas or duodenum

If unstable, urgent exploration

If stable, angiography

Question 15

Patient presents after trauma. CT scan shows partial transection of the pancreas – management if minor? If complex?

Answer 15

Urgent exploration
#If minor, the debride and drain
#If Complex, resection of pancreatic tissue, repair of duodenal injuries with duodenal diverticularization/diversion (divert intestinal fluids away from injury to allow healing)

Question 16

Patient presents after trauma. CT scan shows hematoma of duodenum – diagnosed with? Management?

Answer 16

Upper G.I. series

#observe and NPO until obstruction resolves (usually 5-7 days)
#if hematoma persists after several weeks, exploration

Question 17

Patient presents after trauma. CT scan shows large pelvic hematoma – management? Do not attempt?

Answer 17

Angiography and embolization if continued bleeding/instability

No Surgical exploration –

1) bleeding somewhat tamponaded by intact peritoneum. It’s open, bleeding gets worse.
2. Difficult to visualize area surgically

Question 18

Patient presents after trauma. CT scan shows ruptured diaphragm – management?

Answer 18

Surgical repair with prosthetic mesh

Question 19

Patient presents after trauma. CT scan shows free fluid in peritoneal cavity and no evidence of solid organ injury – suspect? Confirm with?

Answer 19

Blood or intestinal contents – suspect bowel injury

Surgical exploration or serial examinations

Question 20

General management of abdominal trauma with bleeding?

Answer 20

1. Stop bleeding by packing four quadrants
2. Remove each pack, assess area and attempt hemostasis
3. After bleeding controlled, inspect remainder and repair injuries