TRAUMA Flashcards
burr hole
Patient with reduced GCS ( 8
- No Imaging*
- Neurosurgical intervention available in a reasonable time frame.
The hand held drill (which can be a Hudson-Brace or air powered drill) should have a specific perforator (e.g. a 14 mm perforator clutch drill bit (26-1221, Codman, Johnson and Johnson, Chicago, USA),
Confirm position of haematoma on CT scan and be able to view images while performing procedure (Figure (Figure2).2).
Mark the patients shoulder that corresponds to the side of the haematoma.
Haematomas most commonly occur in the temporal region. Frontal, parietal, and rarely posterior fossa haematomas also occur.
Count down the number of slices to calculate how many centimetres below the vertex the burr hole should be.
(1, temporal (above zygoma), 2 frontal (over the coronal suture, approx 10 cm behind and in the mid-pupillary line) and 3 parietal (over the parietal eminence)
Shave
Mark a 3 cm incision.
chlorhexidine
Make an incision straight down to bone. Bleeding (e.g. from the superficial temporal artery) can be controlled with direct pressure while continuing the procedure.
Push the periosteum off the bone with knife/swab
insert self-retaining retractor
Push down firmly with drill and start drilling keeping drill perpendicular to the skull. Ensure an assistant is holding the head still and ideally apply saline wash as you drill.
Keep going - do NOT stop (as this will disengage the clutch mechanism which can be difficult to re-engage manually)
Drill until the drill bit stops spinning. Remove drill.
Use blunt hook to remove remaining bone fragments.
Extradural blood should now escape.
*If the blood is subdural, very carefully open the dura using a sharp hook to tent the dura up, and a new sharp knife to incise the dura in a cruciate manner. Subdural blood is likely to be more clotted and difficult to extrude than extradural. Manual removal of clot (e.g. with forceps or very careful suction) could be considered, but may damage brain and is unlikely to remove sufficient haematoma. If no blood is found either extra or sub-durally, stop, check side, and check location of hole. DO NOT DELAY TRANSFER.
If fresh blood is continuing to ooze from the wound, do NOT try to tamponade. Leaving the self-retainer in place may stop the bleeding. Try to diathermy skin edges; if not available, apply direct pressure to wound edges during transfer.
spleen preservation
: I would do everything I could to salvage the spleen in this 14 year old boy. I would compress it and do splenorrhaphy, wrapping the spleen with a vicryl mesh.
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
dissection through skin, subcutaneous tissue, and platysma,
posterolateral retraction of the SCM
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
care taken not to injure the recurrent laryngeal nerve, which lies in the tracheoesophageal groove.
Mobilization of the esophagus with 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
to supplement direct open examination and minimize the incidence of missed injuries.
Bladder lacerations are repaired how
AFTER inspecting the urethral oriphesous
2-0 Chromic
first layer mucosa and muscularis,
and
the second layer muscularis and serosa.
Closed suction drains are then placed.
10 to 14 days with either a Foley or suprapubic cystostomy.
Repeat cystography is performed prior to removal to ensure healing
To perform an open cricothyrotomy steps
First,
cricothyoid membrane is identified immediately caudad to the thyroid cartilage.
Over this area a longitudinal skin incision is made, approximately 3 cm long.
longitudinal incision has the benefit of easy extension if needed)
Next, the tissues above the cricothyroid membrane are bluntly dissected by use of finger or skin retractor. This must be done by palpation.
TRANSVERSE incision is made in the cricothyroid membrane,
dilated with the blunt handle of the scalpel.
It is important to preserve the cricoid cartilage by spreading transversely, NOT longitudinally.
A number 5 or 6 tracheostomy tube or normal size ET tube is inserted into the trachea and the cuff is inflated.
tracheoinnominate fistula management
first step should overinflation of the tracheostomy / endotracheal tube cuff for attempted tamponade.
If unsuccessful,
digital compression of the artery against the sternum
Pressure should be maintained on the artery during transport to the operating room.
insert oral endotracheal tube after successful arterial compression.
Diagnosis may require bronchoscopy and wound exploration if found early
NO Primary repair due to high risk for failure and associated mortality.
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!)
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.
Damage control moves if ureters transected
bring up to skin
temporary cutaneous ureterostomy over a
single-J ureteral stent
or
pediatric feeding tube
No extra time should be spent mobilizing ureter to bring it to the skin rather tie should be placed around the ureter and stent should be brought out through the skin
Last resort:
Ureter ligated proximal to injury followed by percutaneous nephrostomy when patient becomes stable (this is not intraoperative nephrostomy-time too time consuming)
Diagnosis of ureteral injury
gold standard:
CT urography with delayed cuts ( no longer intravenous urography)
Not reliable:
Microscopic/gross hematuria
Intravenous urography and-NO
too time-consuming:
retrograde pyelography
named vessels that may be ligated in trauma
INFRA- renal IVC
superior mesenteric VEIN - Repair is preferred
radial artery
Ulnar artery the
may ligate one out of 3 palpable vessels in the lower extremity
Subclavian artery ligation well-tolerated due to collaterals of shoulder
Name the vessels that cannot be ligated in trauma
superior vena
(cava-superior vena cava syndrome)
RIGHT Renal veins
(Left renal vein close to IVC is well-tolerated as drainage can occur from adrenal, gonadal, iliolumbar veins)
SUPRA-renal IVC
Portal vein
if ligated must compensate for dramatic transient edema and bowel
Carotid artery
(this is relative since can rely on contralateral)
(may ligate external carotid)
Innominate artery
Brachial artery
Superior mesenteric artery
Proper hepatic artery
Iliac artery (may ligate the internal iliac hypogastric)
Femoral artery
(may ligate profunda proably)
Popliteal artery
Aorta
exposure for innominate artery injury
median sternotomy
Exposure for left subclavian artery injury
left anterior lateral thoracotomy
list the preferred algorithm for access an 11-month-old, patient
antecubital fossa
Percutaneous saphenous vein
Intraoseus cannulation
Proximal tibia
Followed by a reattempt at peripheral access went resuscitation through IO
if bilateral tibial injury distal femur just above femoral condyle
Saphenous cutdown recommended age 1-6
alternatives:
Younger than 6 Percutaneous femoral vein - blood associated with thrombosis and kids
major vessels are accessed with median sternotomy
innominate
Proximal RIGHT subclavian
Proximal RIGHT common carotid
Proximal LEFT common carotid
Exposure for proximal vertebral artery
takeoff of this vessel is from subclavian artery
Access easy from the supraclavicular incision-
division anterior scalene
divide clavicle head of sternocleidomastoid
Protect phrenic nerve there overlies SMA
protect thoracic duct LEFT
