Trauma

Question 1

Cricothyroidotomy

Answer 1

• Should not be performed in children younger than 12 years (damage to the cricoid cartiage and subsequent risk of subglottic stenosis)
• inability to place a tube greater than 6 mm in diameter

Question 2

Signs of tension pneumothorax

Answer 2

• Respiratory distress with HYPOTENSION
• tacheall deviation away from the affected side
• lack or decreased breath sounds on the affected side
• distended neck veins due to impedance of venous return

Question 3

Differential diagnosis for cardiogenic shock in trauma

Answer 3

• Air embolism
• tension pneumothorax
• pericardial tamponade
• myocardial contusion

Question 4

A trauma patient arrives following a stab wond to the left chest with SBP of 86 mmHg, which improves slightly with IV fluids. CXR demonstraates clear lung fields. What is the most appropriate next steps

Answer 4

FAST

• During circulation section of priary survey, four life threathening injuries must be identified promptly
  
  • Massive hemothorax
  • cardiac tamponade
  • massive hemoperitoneum
  • mechanically unstable pelvic fractures with bleeding
• <100 mL of pericardial blood may cause pericardial tamponade

Question 5

Primary repair of the trachea should be carried out with

Answer 5

Absorbable monofilament suture

• if esophageal injuries is large or tissue is missing = SCM pedicle flap with closed suction drain
  
  • drain can be removed in 7 to 10 days if the suture line remains secure

Question 6

Contraindication for emergency department thoracotomy

Answer 6

Patient with chest stab wound, becae asystolic during transport with 20 minutes of CPR with no signs of life

Question 7

A patient with spontaneous eye opening, confused and localizes pain has a glassgow coma score of

Answer 7

13

Question 8

Neck injuries

Answer 8

• Less than 15% penetrating injuris require neck exploration, majority can be managed conservatively
• Patients with symptomatic zone I and zone III should ideally undergo diagnostic imaging before operation if stable (CTA)
• Asymptomatic patients are observed for 6 to 12 hours
  
  • if transcrvical gunshot wound = CTA pf the nec and chest
• Zone IIIinjuries can be managed by selective angioembolization

Question 9

Appropriate surgical management of a through and through gunshot wound to the lung with minimal bleeding and some air leak

Answer 9

Pulmonary tracotomy with stapler and oversewing

• Lobectomy is only indicated for complete devasculartization or destroyed lobe
• Parenchymal injuries severe enough to require pnemonectomy are rarely survivable, and major pulmonary hilar injuries necessitating pneumonectomy areusually lethal in the field

Question 10

Evaluation of Blunt abdominal trauma

Answer 10

• if FAST negative in a hemodynamically unstable patient then DPL is indicated to rule out abdominal bleeding
• After placement of the catheter, 10 ml syringe is connected and the abdominal contents aspirated
  
  • (+) if >10mL of blood is aspirated
  • if <10, a liter of normal saline is instilled. The effluent is withdrawn and sent to laboratory

Question 11

after an automobile accident, a 30 y/o woman is discovered to have posterior pelvic fracture. Hypotension and tachycardia respond marginally to volume replacement. Once it is eveident that her major problem is free intraperitoneal bleeding and a pelvic hematoma in association with the fracture, appropriate management would be

Answer 11

Celiotomy and pelvic packing

• unstable patient = celiotomy is mandatory
• most severe pelvic hemorrhage is venous in origin = so arterial emboization is not recommended
• Pelvic hematoma
  
  • stable = leave i undisturbed
  • ruptured into the peritoneal cavity = pelvic packing

Question 12

Vascular injuries of the extremities

Answer 12

Occult profunda femoris injuries can result in compartment syndrome and limb loss

• hard signs constitute indications for operative exploration
• Bony fracture and dislocation should be realigned before definitive vascular examniation
• The most ccommn evaluation is measuring SBP using doppler ultrasound and compare the injured and uninjured side
  
  • A-A index <10% = (-)
  • A-A index >10 % = CTA or arteriography is indicated

Question 13

Blunt carotid injuries

Answer 13

• Approximately 50 % of patients have delayed diagnosis
• Mechanism is facial conact resulting in ypertension and rotation
• May cause dissection, thrombosis, or pseudoaneurym
• employ CTA to reduce delayed recognition
• Currently accepted treatment for thrmbosis and dissection is anticoagulation with heparin followed by warfarin for 3 months
• Pseudoaneurysm may occur aat base of skull

Question 14

Massive transfusion protocols

Answer 14

• Should include transfusion of plasma and platelets in addition to packed RBCs
• 1:2 (RBC;plasma ratio)

Question 15

The most appropriate treatment for a duodenal hematoma that occurs from blunt trauma

Answer 15

Observation

• occur more often in children
• Accumulates between the seromuscular and submucosal layers
• eventually causing obstruction
• barium examination = coiled spring sign
• Managed nonoperatively by nasogastric suction and parenteral nutrition
• laparoscopic evacuation if the obstruction persists more than 7 days

Question 16

Damage control surgery

Answer 16

• Limits eneteric spillage by rapid repair of partial small bowel injuries with whipstitch and complete transection with GIA stapling device
• small GI injuries = 2-0 prolene
• Abdomen must be temporarily closed
  
  • bowel is covered with a fenestrated subfascial steril drape
  • 2 jackson pratt drains
  • covered with Ioban drape

Question 17

Therapy for increased intracranial pressure in a patient with closed head injury is instituted when ICP is greater than

Answer 17

20

• Indications for operative intervention to remove space occuping heamtmas are based on the clot volume, amount of midline shift, location of clot, GCS score, and ICP
  
  • A shift of >5mm is typically considered an indication for evacuation

Question 18

Cerebral perfusion pressure

Answer 18

• Can be increased by lowering ICP and avoiding hypotension
• yhe goal of resucitation and management with head injuries
  
  • avoid hypotension (SBP <100)
  • avoid hypoxia (PaO2 <60 or arterial oxygen saturation of <90 )
• CPP = MAP - ICP
  
  • target range is >50mm Hg
  • can be increased by lowering ICP or raising MAP

Question 19

an 18 y/o ,am is admitted in the ED shortly after being involved in an car accident. He is in coma (GCS 7), weak pulse, HR 140 and BP 60/0. Breathing is rapid and shallow. Abdomen distended with no audible peritalsis. (+)closed fractures of the Right forearm and the left lower leg. After rapid IV administration of 2 L LR, his pulse is 130 and BP 70/0. The next immediate step is

Answer 19

Explore the abdomen

• Ideally patients seriously injured in a car crash should undergo Xrays of the cervical spine, chest, and the abdomen
  
  • if widened mediastinum = aortograms
• CT scan of the head

Question 20

A 36 y/o patient arrives in the trauma bay with a stab wound to the left chest. After placement of a left thoracostomy tube and fluid resuscitation, his breathing is stable with BP 160/74 and HR od 110. CT scan reveals descending thoracic pseudoaneurysm and no intracranial or intraabdominal injury. What is the next step?

Answer 20

Esmolol drip

• Descending thoracic injuries may require urgen if not emergent interventions
  
  • However, intracranial or intraabdominal hemorrhage or pelvic fractures takes precedence
• target SBP <100
• target HR <100
• Endovascular techniques are appropriate for
  
  • patients who cannot tolerate single lung ventilation
  • >60 years old who are at risk for cardiac deompensation with aortic clamping
  • patients with uncontrollable intracranial hypertension

Question 21

A patient with penetrating injury to the chest should undergo thoracotomy if ______

Answer 21

there is more than 200 mL/h of blood for 3 hours from the chest tube

Question 22

After sustaining a gunshot wound to the right upper quadrant of the abdomen the patient has no signs of peritonitis, Stable VS and CT scan shows a grade III liver injury. What is the next step

Answer 22

Admission to SICU with serial complete blood count

• Nonoperative management of solid organ injuries is pursued in hemodynamically stable patients who do not have overt peritonitis other indications for laparotomy
• >grade II = SICU with serial hgb and abdominal examination
• The indicationfor angiography to control hepatic hemorrhage is transfusion of 4 units of RBC in 6 hours or 6 units of RBC in 24 hours

Question 23

A 25 y/o man has multile intra-abdominal injuries after a gunshot whound. Celiotomy reveals multiple injuries to small and large bowel and major bleeding from the live. After repair of the bowel injuries, the abdomen is closed with towel clips, leaving a large pack in the injured liver. Whithin 12 hours, there is massive abdominal seeling with edema fluid and intrabdominal pressure exceeds 35 mmHg. The immediate next step is?

Answer 23

Open the incision and decompress the abdomen

Question 24

traumatic spleen injury

Answer 24

• Common ccmplications after splenectomy include subdiaphragmatic abscess, pancreatic tail injury, and gastic perforation
• Delayed hemorrhage can occur up to weeks after injury
• An immediatie postsplenectomy CBC
  
  • Increase in platelets
  • normal WBC
• after post op day 5
  
  • WBC > 15000/m3
  • Platelet ration of <20
• Postsplenectomy vaccines at day 14

Question 25

A 19/yo man fell of his skateboard, reporting blunt injury to the upper abdomen. Abdominal CT and MRCP confirmed he suffered transection of the main pancreatic duct at the middle pancreaticbody. The management would be

Answer 25

Distal pancreatectomy with splenic preservation

• Pancreatic contusions = nonperative with closed suction drainage
• Proximal pancreatic injuries
  
  • right of the superior mesenteric vessels
  • closed suction drainage
• Distal pancratic injuries
  
  • based on ductal integrity
  • distal pacreatectomy
  • Roux-en-Y pancreaticojejunostomy
  • pancreaticogastrotomy
• Patient is physiologically compromised
  
  • distal pancreatectomy with splenectomy

Question 26

Most appropriate management for gunshot wound to the hepatic flexure of the colon that cannot be repaired primarily

Answer 26

Resection of the right colon with ileostomy

• proximal to the middle colic artery
  
  • the proximal portion of the right colon up to and including the inury is resected and an ileostomy performed
• Distal to the middle colic artery
  
  • end colostomy is created and the distal colon oversewn and left within the abdomen

Question 27

Traumatic genitourinary injury

Answer 27

• Explore all penertrating wounds to the kidneys. However over 90% of blunt injuries are treated nonoperatively
• Renal vascular injuries are common after penetrating trauma, and can ve deceptively tamponaded by surrounding fascia
• Success of renal artery repair after blunt trauma is slim, but can be attemted if injury occured within 5 hours
• Suspected ureteral injuries in patients with penetrating trauma or pelvic fractures can be evaluated intraoperatively with methylene blue or indigo carmine administered intravenously
• Bladder injuries with extraperitoneal extravasion can be managed with foley decompression for 2 weeks

Question 28

At what pressure is operative decompressionof a compartment syndrome mandatory

Answer 28

45 mmHg

Question 29

Trauma in geriatric patients

Answer 29

• rib fractures are associated with pulmonary contusion in 35 % of patients and complicated by pneumonia in 10 to 30% of patients
• Mortality in severe head injuries doubles after age of 55
• 25% of patients with a normal GCS score of 15
• admission GCS is a poor predictor
  
  • reevaluate after 72 hours
• 50% od patients older than 65 years sustained rib fractures from a fall of < 6ft