Trauma Flashcards
Where is a zone 3 neck injury? How to obtain distal control?
Above angle of mandible, distal control hard to obtain - fogarty balloon can be tried.
(NB this diagram is labelled wrong! Zone 1 and 3 should be switched)
Where is a zone 2 neck injury? How to obtain proximal control?
Between cricoid and angle of mandible. Proximal and distal control in neck.
Where is a zone 1 neck injury? How to obtain proximal control?
Below cricoid. Proximal control in the chest.
What zone neck injury is the most commonly injured?
Zone 2
What are 7 hard signs of vascular injury?
- shock
- refractory hypotension
- pulsatile bleeding
- bruit
- enlarging hematoma
- loss of pulse
- evolving neurologic deficit
What are 5 soft signs of vascular injury?
- Proximity to major vessel
- History of bleeding at scene of injury
- Unequal blood pressure
- Stable hematoma
- Nerve injury
What are 2 hard signs of a tracheobronchial injury?
- Respiratory distress
- Air bubbling from wound
What are 4 soft signs of cervical neck injury?
- painful swallowing
- subcu emphysema
- hematemesis
- CN injury or brachial plexus injury
What investigations should you order for patients with hard signs of vascular or tracheobronchial neck injury?
Immediately to OR. X-rays in trauma bay to determine track of injury and r/o occult hemothorax/pneumothorax
What investigations should you order for patients with a penetrating neck injury that are hemodynamically stable and no hard signs of vascular/airway injury?
CTA
Which neck zone injuries are more suitable for endovascular repair? which are more suitable for open?
Endo - 1 and 3
Open - 2
In trauma situations what is the risk of dying from internal carotid artery ligation?
45% (?!)
What are 3 basic mechanisms of blunt cerobrovascular injury?
1- extreme hypertension and rotation
2- direct blow to vessel
3 - laceration from adjacent bone fracture
What is the most common mechanism causing blunt carotid injury?
hyperextension of carotid over lateral articular process of C1-3 in high speed motor vehicle crashes
What are 5 symptoms of carotid cavernous fistula?
1-orbital pain
2-proptosis
3-seizure
4-cerebral swelling
5-hyperemia
What are 3 scoring systems to screen for blunt cerebrovascular injury?
1-Denver
2-Memphis
3-Modified
What signs/symptoms are included in the denver criteria for blunt cerebrovascular injury?
1-arterial hemorrhage or expanding hematoma
2-neuro deficit
3-cervical bruit
4-stroke on follow up CT head
5-neuroexam inconsistent with CT head
What risk factors are included in the denver criteria for blunt cerebrovascular injury?
1- le fort 2 or 3
2-basilar skull fracture involving carotid canal
3-diffuse axonal injury with GCS <6
4-cervical spine fracture
5-near hanging with anoxic brain injury
What angiographic findings are associated with a grade 5 blunt cerebrovascular injury
vessel transection
What angiographic findings are associated with a grade 4 blunt cerebrovascular injury
vessel occlusion
What angiographic findings are associated with a grade 3blunt cerebrovascular injury
pseudoaneurysm
What angiographic findings are associated with a grade 2 blunt cerebrovascular injury
dissection or IMH > 25% of lumen
What angiographic findings are associated with a grade 1 blunt cerebrovascular injury
luminal irregularity/dissection, IMH < 25% narrowing
what is the risk of death with a grade 1 blunt cerebrovascular injury?
11
what is the risk of death with a grade 2 blunt cerebrovascular injury?
11
what is the risk of death with a grade 3 blunt cerebrovascular injury?
11
what is the risk of death with a grade 4 blunt cerebrovascular injury?
22
what is the risk of death with a grade 5 blunt cerebrovascular injury?
100
what is the risk of stroke with a grade 5 blunt cerebrovascular injury?
100
what is the risk of stroke with a grade 4 blunt cerebrovascular injury?
44
what is the risk of stroke with a grade 3 blunt cerebrovascular injury?
33
what is the risk of stroke with a grade 2 blunt cerebrovascular injury?
11
what is the risk of stroke with a grade 1 blunt cerebrovascular injury?
3%
how do you treat most blunt cerebrovascular injuries?
anticoagulation, or if cannot tolerate - antiplatelet. either for 3 months. Serial imaging at 1 week and 3 months.
what are indications to repair blunt cerebrovascular injuries?
1-evolving dissections
2- worsening neuro deficit on anticoagulation
3-pseudoaneurysms that persist or enlarge despite anticoagulation
What is the stroke risk of blunt vertebral artery injuries?
20% irrespective of grade of injury (vs. carotid where stroke risk is goes up with higher grades of injury)
What is the natural history and complictions of traumatic transection?
What is the natural history and complictions of traumatic thrombosis
What is the natural history and complictions of traumatic pseudoaneurysms
What is the natural history and complictions of intimal dissetions or thrombosis > 25%
What is the natural history and complictions of intimal dissetions or thrombosis < 25%
What is the natural history and complictions of traumatic AV fistula
What is the natural history and complictions of contusion
What is the natural history and complictions of laceration
Name 6 categories of arterial injury
Penetrating or Iatrogenic:
- Laceration
- Contusion
- AV fistula
Blunt:
- Intimal dissection
- Pseudoaneurysm
- Thrombosis
- AVF
- Transection
Name 5 critical concepts for interventions in patient with noncompressible truncal hemorrhage
- Minimize delay to OR
- Permissive hypotension
- Balanced resuscitation with early plasma
- Procoagulant adjuncts like transexamic acid
- Damage control surgery and intravascular shunts when indicated.
Which major vessels are in Zone 4 of the retroperitoneum?
Retrohepatic IVC, hepatic veins
Which major vessels are in Zone 3 of the retroperitoneum?
Iliac arteries and veins
Which major vessels and organs are in Zone 2 of the retroperitoneum?
Organ: Kidneys
Vessels: renal vessels
Which major vessels are in Zone 1 of the retroperitoneum?
Supramesocolic: Suprarenal aorta, celiac axis, SMA, renal arteries, IVC, SMV
Inframesocolic: Infrarenal aorta and IVC
Name 3 mechanisms by which blunt abdominal trauma may cause vascular injuries
- Rapid deceleration (high speed MVC, fall from height) - avulsion/intimal tear and subsequent thrombosis
- Direct AP crush from seat belt or direct blow
- Direct laceration of major vessel by a bone fragment.
What are the 6 most commonly injured abdominal vessels, in order of most to least frequent
- IVC
- Aorta
- Iliac arteries
- Iliac veins
- SMV
- SMA
What are 3 indications for an immediate laparotomy in a patient with a penetrating abdominal injury?
- Hemodynamic instability
- Peritonitis
- Unevaluable patient
What are 3 indications for immediate laporotomy in a patient with blunt abdominal trauma?
- Peritonitis
- Hemodynamic instability
- Positive abdominal FAST
- Unstable patients with negative FAST but positive diagnostic peritoneal aspirate.
Should an abdominal hematoma associated with a penetrating trauma be explored?
Yes - except if in zone 4
When should retroperitoneal hematomas due to blunt trauma be explored (4 situations)?
- Zone 1
- Zone 2/3 only if hematoma is expanding, pulsatile or leaking
- Paraduodenal hematomas
- Hematomas at the root of the mesentery in presence of ischemic bowel
Whichof the following trauma patients should have exploration of their hematomas?
Blunt zone 3 hematoma?
Penetrating zone 2 hematoma?
Blunt peri-duodenal hematoma?
Blunt zone 3 hematoma? No
Penetrating zone 2 hematoma? Yes
Blunt peri-duodenal hematoma? Yes
How do you expose the supramesocolic aorta in the context of abdominal trauma?
Medial rotation of the viscera in the left upper abdomen: left colon, splenic flexure, spleen, tail of the pancreas, stomach, left kidney rotated to the right.
How do you expose the IVC for suspected supramesocolic injuries?
Medial rotation of right colon and hepatic flexure, kocher mobilization of duodenum and head of pancreas.
How to expose inframesocolic zone 1?
Like a regular infrarenal aortic exposure - transverse colon cephalad, small bowel to right, incise peritoneum over aorta/IVC.
How do you explore Zone 2 hematoma or bleeding?
Right side: mobilization and medial rotation of right colon, duodenum, head of pancreas
Left side: Mobilization of left colon
In damage control surgery, how do you manage:
1) Complex venous injuries
2) Arterial injuries
3) Retroperitoneal bleeding
4) Parenchymal bleeding
1) Complex venous injuries: Ligate
2) Arterial injuries: Shunt
3) Retroperitoneal bleeding: Tight gauze packing
4) Parenchymal bleeding: Tight gauze packing
What is the definition of abdominal compartment syndrome?
Elevated intra-abdominal pressure > 20 mm Hg and end-organ dysfunction
What intraabdominal pressure constitutes “intraabdominal hypertension”
> 12 mm Hg
Name 4 signs/symptoms of abdominal compartment syndrome
- Tense abdomen
- Tachycardia +/- hypotension
- Resp dysfunction, high peak inspiratory and plateau pressures
- Oliguria
Name 6 risk factors for abdominal compartment syndrome
- Massive transfusions
- Prolonged hypotension
- Hypothermia
- Aortic cross clamping
- Damage control procedures
- Closure of abdominal wall
Where is a “Zone 4” SMA injury? What happens if you ligate the SMA here?
Segmental intestinal branches.
Ligation in zones 3 and 4 may result in localized ischemia of the small bowel requiring segmental resection.
Where is a “Zone 3” SMA injury? What happens if you ligate the SMA here?
Distal to the middle colic artery
Ligation in zones 3 and 4 may result in localized ischemia of the small bowel requiring segmental resection.
Where is a “Zone 2” SMA injury? What happens if you ligate the SMA here?
Between inferior pancreaticoduodenal artery and middle colic
Ligation in zones 1 and 2 result in severe ischemia of small bowel and right colon.
Where is a “Zone 1” SMA injury? What happens if you ligate the SMA here?
Between aortic origin and inferior pancreaticoduodenal artery.
Ligation in zones 1 and 2 result in severe ischemia of small bowel and right colon.
What are your options for repairing an IVC injury?
- Lateral venorrhaphy
- Patch
- Interposition graft
- Ligate (only infrarenal!! cannot ligate suprarenal because patient will be in renal failure)
- Temporizing shunt
Name 10 arterial disorders associated with occupational or recreational activities
Manual Labour
- Hand arm vibration syndrome
- Hypothenar hammer syndrome
Exposure
- Acro-osteolysis
- Electrical burns
- Extreme thermal injuries
Athletic
- Chronic hand ischemia
- Quadrilateral space syndrome
- Humeral head compression of axillary artery
- Thoracic outlet syndrome.
What is a Stage 4 Hand arm vibration syndrome?
What is a Stage 3 Hand arm vibration syndrome?
What is a Stage 2 Hand arm vibration syndrome?
What is a Stage 1 Hand arm vibration syndrome?
What is a Stage 0 Hand arm vibration syndrome? 0T? 0N?
What causes hypothenar hammer syndrome?
The ulner artery and never travel in a tunnel (Guyon canal) that is bound by pisiform and hamate bones. In this region, the ulnar artery is very superficial and only covered by skin/subcu tissue/palmaris brevis.
When palm used as a hammer it compresses the ulnar artery against the hamate bone which acts as the hammer.
Which occupational trauma condition causes vascular damage from repetitive trauma and an underlying vessel abnormality like fibromuscular dysplasia?
Hypothenar hammer syndrome
What are 3 key signs/symptoms that differentiate hypothenar hammer syndrome from other conditions presenting with Raynaud’s?
- Male smokers with repetitive hand trauma history
- Asymmetrical - dominant hand
- Sparing of thumb
Which condition is associated with ischemic hand symptoms with resorption of the distal phalangeal tufts, similar to scleroderma?
Occupational acro-osteolysis
Which vessel and nerve pass through the quadrilateral space?
Posterior humeral circumflex artery
Axillary nerve
What are the borders of the quadrilateral space?
Superior: teres minor
Lateral: humaral shaft
Inferior: teres major
Medial: long head of triceps
