TRAUMA Flashcards
The most commonly accepted definition of massive transfusion is
more than 10 units in a 24 hour period.
This approximates one total blood volume exchange.
Indications of massive transfusion include
multiple (usually >3) units of uncrossmatched blood given with anticipated ongoing need,
or
a severely injured patients in extremis with no response to 2 units of blood.
massive transfusion protocol would include
repeatedly sending pRBCs, FFP and platelets every 20 minutes until the team requests it be stopped.
Ratios are kept as close to 1:1:1 as possible.
after 2 packs of massive transfusion, one should consider additionally requesting
cryoprecipitate (fibrinogen, factor 8, VWF)
or
fibrinogen
labs followed in massive transfusion and what are rough endpoints
CBC, PT/PTT, fibrinogen, ABG, calcium and BMP should be serially checked. There are no specific guidelines on when to discontinue massive transfusion. In general, control of bleeding with a Hb >8, INR 100,000 are appropriate goals.
Some of the major indications for damage control are:
Core temperature 95 F or 35 C SBP 14 mmol/L
INR or PTT > 50% normal Blood Loss > 4L Blood transfusion >10 units Fluid replacement >10L Persistent non-surgical bleeding
physiologic capture
describes there resussutation to be acheieved before attempting definitive repaire of inuries differed in damage control
has take place.
what injuries are managed even when doing damage control
Complex injuries to the duodenum may be treated with debridement and primary repair or pyloric exclusion.
Pancreatic injuries are treated with drainage alone or with resection and drainage.
CBD injuries are primarily repaired if less than 50% circumfrence.
Gallbladder is resected
Goals of resuscitation with damage control
basically a normal preop patient!!
temperature to 37 C (98.6 F)
Packed red blood cells, fresh frozen plasma and platelets should be administered in a 1:1:1 ratio for maximum benefit.
Goals of resuscitation should be:
PT < 15 or INR < 1.2
(using FFP, vitamin K, calcium)
Fibrinogen >100 mg/dL
(using cryoprecipitate or fibrinogen concentrate)
-remember cryo has fibrinogen, VWF, 8-
Platelets >100,000/mm^3 using packed platelets
NO pulse goal
function of fibrinogen and normal level
Fibrinogen is broken down to fibrin by the enzyme thrombin to form clots. ( if you’re fibrinogen level is low then you’re using it all up trying to make clots)
greater than 100
epidural hematoma
blood in the space between the skull and dura.
traumatic arterial injury.
lucid interval
biconvex (lenticular) mass that does not cross cranial suture lines
Acute subdural hematomas
tearing of bridging veins.
Blood between the arachnoid and dura mater and appears as a bright colored crescent-shaped mass which may cross suture lines but not the midline secondary to the presence of the falx
tracheoinnominate fistula
90% mortality associated with and an initial bleed in or around the tracheostomy tube may be the only indication of subsequent occurrence.
The first step should be overinflation of the tracheostomy / endotracheal tube cuff (choice A) for attempted tamponade.
If unsuccessful, digital compression of the artery against the sternum should be the next step
Pressure should be maintained on the artery during transport to the operating room.
An oral endotracheal tube should be inserted after successful arterial compression.
Diagnosis may require bronchoscopy and wound exploration if found early
Primary repair
should not be attempted due to high risk for failure and associated
mortality.
Those that develop and biloma tx algorrhthm
usually treatable with percutaneous drainage alone
less than 300 mL/day will usually close spontaneously.
more than 300 mL drains daily, the injury should be localized with fistulogram, ERCP, radionucleotide scan or transhepatic cholangiogram.
Sphincterotomy may help close biliary leaks.
Major ductal injuries may be stented or require operative repair.
Persistence of drainage more than 50 mL/day beyond 2 weeks indicates development of a biliary fistula. These often resolve without further intervention. (CAREFUL just because turns into “fistula” and has been 2 wk - does not mean you do anything but watch it resolve with drainage!)
If the Pringle maneuver is effective, hepatic artery ligation may be considered. what are potential complicaitons
increase the risk for hepatic abscess
or
biloma
(CAREFUL, increase risk of hepatic necrosis is listed as a not fully correct answer compared to above)
Injuries to the bladder (choice D) following blunt trauma most commonly what type, associated with what injuries and are managed how
extraperitoneal and associated with pelvic fractures. Extraperitoneal injuries can be managed non-operatively with foley catheter drainage.
Urethral injuries should be suspected if
inability to void, high riding prostate, blood at the urethral meatus, palpable bladder butterfly perineal hematoma.
pubic symphysis fractures,
Pubic diastasis and inferior pubic rami fractures are termed “straddle fracture” and correlate highly with urethral injuries.
associated bladder injury
pelvic hematomas.
Diagnosis of urethral injuries is made by
retrograde urethrogram.
immunologic function after embolization
Multiple studies have demonstrated preserved immunologic function after embolization.
Indications embolization for splenic injury
active extravasation, traumatic pseudoaneurysm, grade III injury with large hemoperitoneum or grade IV injuries.
Nonoperative management of blunt splenic injury is successful in what percent of peds patients versus adults
what time period are failures seen by percent
90% of pediatric patients
60-80% of adults.
The majority of failures (61%) occur within the first 24 hours,
90% within the first 72 hours.
Failure is most commonly associated with grade of injury, with grade V having a 75% failure rate.
Grade IV liver injuries have a 33% chance of failure.
Flank stab wounds are located where
those between the anterior and posterior axillary lines and between the tip of the scapular and the iliac crest.
The recommended modality of evaluation Flank stab wounds
hemodynamically stable patient
CT with triple contrast.
oral, IV and rectal contrast.
When performed this way, the sensitivity for injury is 89% and specificity 98%.
Rectal contrast is given to improve detection of colonic injuries, which is a partially retroperitoneal organ.
In the hemodynamically unstable patient, or those with peritoneal signs, evisceration or findings on other diagnostic modalities (free air on CXR, positive FAST),
laparotomy is
indicated.
The Eastern Association for the Surgery of Trauma (EAST) practice management guidelines have tried to delineate the appropriate evaluation for BCI
Recommendations are as follows:
1.) An admission ECG and another at 8 hours should be performed in any patient suspected of having BCI (choice A.) 2.)
If the admission ECG results are normal then pursuit of the diagnosis can be terminated.
However, if they are abnormal then the patient should be admitted for cardiac monitoring for 24-48 hours
- ) If the patient is hemodynamically UNstable then an imaging study such as an echocardiogram should be obtained
- ) The presence of a sternal fracture does NOT predict the presence of BCI and thus does not mandate continuous monitoring in the face of a normal ECG
- ) Neither CPK-MB nor troponin T are useful in predicting which patients will have BCI
Echocardiogram is not mandated unless the patient is hemodynamically unstable.
evaluation of Zone I neck injuries
Zone I is located from the clavicle to the cricoid.
may involve lung apex, trachea, brachiocephalic or subclavian artery and veins, nerve roots and esophagus.
Those patients that are hemodynamically unstable require operative intervention, regardless of zone.
Other indications for operative intervention include hard signs of vascular injury (bruit, thrill, expanding or pulsatile hematoma) or tracheal injury (subcutaneous air or bubbling from the wound).
A chest x-ray is performed to evaluate for hemo or pneumothorax, retropharyngeal air or apical capping.
If nonoperative intervention is chosen, evaluation for vascular, esophageal and tracheal injuries should take place.
This can include four vessel angiography, CTA, or even color flow Doppler.
Additionally, esophagography with barium or esophagoscopy should be performed.
Laryngotracheaobronchoscopy may also be done at the same time.
Zone II and III are located
Zone II is located from the cricoid to the angle of the mandible. Injury in this location may involve the carotid or vertebral arteries, the jugular veins, esophagus or trachea.
Zone III is located from the angle of the mandible to the skull base. Injury to this zone may result in external or internal carotid injury, jugular injury, cranial nerve injury or hypopharyngeal injury.
Penetrating injuries to the neck are divided into two triangles:
the anterior and
posterior triangle.
The posterior triangle is bound by
the sternocleidomastoid
anteriorly,
the trapezius posteriorly
he clavicle inferiorly.
The anterior
triangle is bound by
anterior to the anterior border of the sternocleidomastoid
divided into three zones:
Zone I neck
clavicle to the cricoid.
lung apex,
trachea,
brachiocephalic
subclavian artery and veins,
nerve roots
esophagus.
Zone II neck
cricoid to the angle of the mandible.
carotid
or
VERTEBRAL arteries,
the jugular veins,
esophagus or trachea.
Zone III neck
angle of the mandible to the skull base. I
external or internal carotid injury,
jugular injury,
cranial nerve injury
or
hypopharyngeal injury.
Work up of penetrating neck injury
In the absence of immediate operative indications, the primary and secondary surveys are continued.
A chest x- ray to evaluate hemo or pneumothorax, retropharyngeal air or apical capping.
If nonoperative intervention is chosen, evaluation for vascular, esophageal and tracheal injuries should take place.
four vessel angiography, color flow Doppler or CTA, esophagography or esophagoscopy
and laryngotracheaobronchoscopy.
Some older texts still advocate for operative exploration of all Zone II injuries, however, this is seldom the case in modern practice.
Peds Total blood volume may be estimated as
80mL/kg.
The earliest indicator of shock in a child
What is the hemodynamic phys is a kid
tachycardia.
As stroke volume is relatively FIXED in children,
cardiac output is maintained by increasing heart rate.
This is unreliable, however, as a greater than 25% blood loss may be required to produce tachycardia.
Hypotension in pediatrics may be defined as
<70 + 2 x age in years.
what percent of blood vol is lost to produce tachy in kid
a greater than 45% blood loss!
Absolute indications for surgical exploration with renal injuries include:
renal pedicle avulsion
expanding, uncontained retroperitoneal hematoma.
Patients with these injuries often present with severe shock states.
Renal pedicle avulsion and shattered kidney may not be amendable to operative repair and may require life saving nephrectomy.
