TRAUMA Flashcards
Retroperitoneal zones
Zone one –Great vessels requires exploration if the blunt trauma?
Zone two –lateral retroperitoneum
Zone three –pelvis
Any zone requires expiration if penetrating trauma
Any zone requires exploration if expanding hematoma
Forearm fasciotomy
This is a curvilinear incision that is made intermedia condyle obliquely across Cuba Fosse Milford is a form before aspect of the mobile wad coming centrally distal third of the Farm curvilinear me back or to be Radio distal form and across the carpal tunnel
Volar superficial fashion is released
Deep fascia released just raial to FCR exposing FPL and PQ
Dorsal forearm fashion release longitudinal incision older dorsal aspect mobile wad
Superficial fashion is released longitudinally
Dissection is carried down to the abductor pollicis longus and supinator to release deep compartment overlying these structures
Two important details to remember with splenectomy
Leave a dream because of risk of concomitant pancreatic detail injury
Immunize:
Pneumovax
Meningococcus
H flu
fall from hight abd distension, pelvic fracture, bone fragments on rectal exam.
Used a sheet for the pelvis, went to angio appro- priately.
Then went to OR for rectal injury, I did a proximal diversion with loop
What vessel will you tell the IR colleagues to embolize with pelvic fracture
small branches off internal iliac arteries.
after prevail in postrenal causes of Gary I have been evaluated what should you look for for renal causes
Gentamicin nephrotoxic medication!
Supra pubic catheter placement
2 fingerbreadths above the pubic symphysis in the midline;
avoid placing the catheter in natural skin creases.
Fill a 10-mL Luer-Lok syringe with 5 mL of 1% lidocaine and 5 mL of 0.25% bupivacaine.
Attach the syringe to a 22-gauge, 7.75-cm spinal needle.
Raise a skin wheal at the marked site, and infiltrate the anesthetic into the subcutaneous tissue and rectus abdominis muscle fascia,
aiming the needle at a 10-20° angle toward the pelvis.
Advance the needle in this direction, while aspirating the syringe; urine should be easily aspirated when the bladder is entered.
advance a guide wire through the needle into the bladder.
While holding the wire securely (this is now the route of access to the bladder), carefully remove the needle over the wire, leaving the wire in place.
Directly posterior to the wire, use a scalpel with a No. 11 blade to make a stab incision through the skin and subcutaneous tissue.
Pass the Peel-Away Sheath and the indwelling fascial dilator together over the wire and into the bladder.
Remove the guide wire and the fascial dilator, leaving only the Peel-Away Sheath inside the bladder.
Pass a Foley catheter (of appropriate size) through the indwelling intravesical sheath and into the bladder. Aspirate urine to confirm proper placement.
Inflate the Foley balloon with 10 mL of sterile water, using a Luer-Lok syringe.
Gently withdraw the Peel-Away Sheath from the bladder and anterior abdominal wall; using each side of the Peel-Away Sheath, split the sheath into 2 parts, leaving the catheter in place. Connect the indwelling suprapubic Foley catheter to a drainage bag.
secure the catheter to the skin of the anterior abdominal wall.
Cath-Secure
posterior approach to popliteal a /v
curvilinear incision watch small saph sural n open fascia retract semiMeninosis retreact Medially discect out tibial nerve protected popliteal artery most posterior popliteal vein most anterior
hard signs of neck penetrating injury
“Hard” signs mandating immediate operative exploration without the need for additional diagnostic workup include
shock/ hypotension, active hemorrhage, expanding or pulsatile hematoma, bruit, loss of pulse, neurologic deficit, significant subcutaneous emphysema, respiratory distress, air leaking through the neck wound.
neck zones
clavicle to crycoid
crycoid to angle mandible
angle mandible to base of skull
Work up for penetrating injury violating the platysma in a stable patient without hard signs
CTA
Barium swallow
esophagoscopy
Laryngoscopy bronchoscopy
neck exploration
neck exploration
operating room table with arms tucked, neck extended, and head rotated to the contralateral side
A vertical neck incision along the anterior border of the SCM muscle is routinely utilized
dissection is carried through skin, subcutaneous tissue, and platysma,
posterolateral retraction of the SCM provides exposure to all vital structures.
the vascular structures are typically explored first by opening the carotid sheath.
Division of the middle thyroid and facial veins will facilitate complete visualization the carotid artery, which lies deep and medial to the internal jugular vein.
Attention is then turned to the aerodigestive tract with care taken not to injure the recurrent laryngeal nerve, which lies in the tracheoesophageal groove.
Mobilization of the esophagus is accomplished
dissecting in the posterior areolar plane and then encircling the esophagus with a Penrose drain to facilitate rotation and circumferential inspection.
The larynx and trachea should be visualized and palpated for signs of injury.
This may require mobilization of the thyroid and/ or division of strap muscles.
Intraoperative esophagoscopy and bronchoscopy are often utilized to supplement direct open examination and minimize the incidence of missed injuries.
rule of nines
entire head / face = 9 (neck alone 1%) entire upper extremity = 9 entire lower extremity = 18 anterior trunk ( chest and abdomen) = 18 posterior trunk ( upper and lower back) = 18
parkland
start with burns over 10% (or 20% clinical scenarios)
Parkland and.. must add maintenance (+glucose): 4, 2, 1 1-10 kg: 4 mL/kilogram 10-20 kg: 40 mL / h + 2 mL /kg/hr >20 kg: 20 mL / h + 1 mL / kg / hr 40-60% Greater than 60% fatal
first 1/2 of parkland over first 8 hr
the rest over the next 16 hours
A general rule for burn excision
has been to limit the operative time to
Skin grafts thickness
very thin more likely to take on the wound
mount of contracture of the graft will be greater
due to the small amount of dermal tissue
Donor sites taken thicker will have more dermis and will contract less; therefore, these types of thicker grafts are more desirable in areas of high mobility, such as the hands, antecubital fossa, neck, and face.
Donor sites are typically taken at
0.010 to 0.012 inch thick,
“ten onethousandth of an inch”
and for areas needing thicker grafts the thickness is commonly 0.018 inch.
As a general rule, donor sites taken at 0.010 inch take about 10 to 14 days to heal.
A skin graft that is applied in a sheet fashion will commonly contract about 30%, and a graft that is meshed 1.5: 1 will commonly retain the original size of the donor site. Faces and necks are universally grafted with thick sheet grafts or full-thickness grafts. Hands are commonly grafted with either sheet or nonexpanded 1: 1 split-thickness grafts. Expanded mesh grafts are used to a variable degree based
trauma history
AMPLE
Allergies Medications Past medical illness/pregnancy Last meal Events such as environment related to the injury
What is the primary survey
A airway B breathing and ventilation C circulation with hemorrhage control D disability (narrow exam) E exposure/environment control (warm pt)
management of Urinary extravasation from kindey
Urinary extravasation does not mandate surgical repair.
Most lacerations to fornices and minor calyces stop spontaneously.
Non-operative management in the setting of urinary extravasation requires serial CT scanning.
Bladder injury work up
CT cystography is now the standard in most trauma centers.
This is performed by back-filling the bladder with 350 mL of contrast.
Sensitivity and specificity are 95% and 100%, respectively.
GCS
Eye: none pain voice spont
Verbal: none Incomprehensible Inappropriate Disoriented/confused Oriented
Motor: none Decerebrate Decorticate Withdraws Localizes follows
Brown-Sequard syndrome
“pain and temp are fancy they cross twice”
motor is simple
True injury to one half of the spinal cord.
ipsilateral loss of motor control
and
contralateral loss of pain and temperature sensation.
This injury may occur due to penetrating trauma, disc herniation, vasculitis and radiation exposure.
algorrhythm in order for trauma work up
PRIMARY survey:
A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) and F (Fast).
Each must be addressed prior to proceeding to the next.
Airway
BREATHING: A suspected pneumothorax should be decompressed at this stage.
(CAREFUL Chest radiograph is a component of the SECONDARY survey)
Circulation Weak or lack of carotid pulse indicated a SBP
Cerebral perfusion pressure should be kept at
60
50-70 mmHg.
Seizure prophylaxis is also recommended for what duration
the first 7 days with phenytoin.
Burn center referral guidelines:
ANY FULL thickness burn! electrical chemical inhalational burns
> 10% TBSA PARTIAL thickness burns
Burns to the:
face, hands, feet, genitalia, perineum and joints
Burns in patients with significant co-morbidities
Patients with advanced rehabilitation needs Burns in children
Answer E: Frostbite injuries do not mandate burn center transfer.
describe non op management of liver injury
hemoglobin monitoring, bed rest or reimaging.
repeat a CT in 8 weeks after the injury in order to document healing.
Other indications for imaging are suspicion of complications from liver injury, including:
biloma,
bilious ascites
hemoperitoneum
Bilious drainage may necessitate ERCP and sphincterotomy.
(no evidence that supports frequent)
Brain death relies primarily
Brainstem reflexes:
Not dead yet if ANY ONE is present..
gag cough oculovestibular (cold calorics) oculocephalic (doll's eyes) Pupils reactive
An apnea test prerequisites:
diabetes insipidus corrected to a positive fluid balance
Off of seditives
core temperature of 36.5 C
SBP greater than 90
PCO2 must be normal (35-45 mmHg).
preoxygenated with 100% O2 for 30 minutes.
A pulse oximeter is connected, and the patient is disconnected from the ventilator.
look closely for respiratory movements.
PO2, PCO2, and pH are
measured after ten minutes and then the patient is reconnected to the ventilator.
If respiratory movements are absent
and
arterial PCO2 is 60 mmHg, the apnea test
result is positive.
Ancillary tests
electroencephalography (EEG)
cerebral blood flow analysis
may also be employed as an adjunct to clinical findings.
Most institutions require at least two examiners with an appropriate period of observation between ranging from 6 to 24 hours.
Spinal reflexes may still be present.
Spinal reflexes, such as limb withdrawal, are not an indication of brain function and, therefore, do not rule out brain death.
according to ATLS guidelines what is the secondary survey
to identify any missed injuries
- History (AMPLE)
- head to toe physical examination,
- additional procedures
- specialized imaging
Hypotension in pediatrics may be defined as
when is appropriate to use interosseous infusion
less than 6
but also used as last resort and adults now
management of anal rectal injury with sphincter involvement
initial debridement
ELECTIVE overlapping sphincteroplasty after associated soft tissue injury as healed and sphincter is fibrosed
management of Combined rectal and genital urinary injury
Primary repair of both
Interposition of viable tissue between repairs
DIVERSION of fecal and urinary streams
Brown-Sequard syndrome
motor, propio, vibration are primal feelings - same side - simple
sensation pain and temp:
fancy fine contra latera and 2 verts down
1-4% and vital injury
right or left half of spinal cord was transected
below level of lesion
Loss: IPSILATERAL motor proprioception vibration?
preserved:
CONTRALATERAL
Pain
Temperature
Central cord syndrome seen in patients with
classic cervical spondylosis
Hyperextension
Loss:
UPPER extremity
Motor
bladder
Variable:
Sensory loss below level lesion
Can be preserved:
LOWER extremity
Anterior cord syndrome
Anterior ALS fancy perserved
AAA spinal cord ischemia - lumbar drain
poor prognosis
Loss:
COMPLETE paralysis
hyperesthesia and hypoesthesia at level
preserved:
Touch
proprioception
Vibration
