Trauma Flashcards
ED Thoracotomy
A left lateral thoracotomy incision is performed using a scalpel though the fourth or fifth intercostal space above the rib, starting at the left parasternal border and ending at the table.
Divide the subcutaneous tissue and both pectoralis major and minor muscles. Use large scissors to divide the remaining intercostal muscles just superior to the rib to avoid damage to the neurovascular bundle.
Insert the Finochietto retractor, with the crossbar closest to the bed, and spread the ribs maximally.
Using Duval clamps, retract the left lower lobe toward the patient’s head and laterally to improve exposure of the heart and mediastinal structures
Open the pericardium longitudinally to release any tamponade, avoiding the phrenic nerve.
At this point, assessment of any cardiac injuries can be performed and any injuries can be temporized
Evaluate the lung, and if there is hilar bleeding, cross-clamping should be performed.
Aortic cross-clamping is accomplished by incising the inferior pulmonary ligament. A small incision using scissors is made in the mediastinal pleura. Blunt dissection is then used to identify the aorta and encircle it. Only a small window is required, to avoid tearing the aorta or its branches. A vascular clamp is applied, avoiding injury to the esophagus.
A right chest tube should be placed concurrently. A clamshell incision should be performed if there is a massive right hemothorax. Scissors or a bone cutter can be used to cross the sternum. In survivors, the internal mammary arteries will need to be ligated
Pulmonary Tractotomy for Penetrating Lung Injury
Once the hemithorax is entered, control of the pulmonary hilum can be accomplished with finger occlusion or a clamp.
Place a lung clamp on either side of the tract created by the knife or the bullet.
Insert a gastrointestinal anastomosis stapler through the entrance and exit wound of the lung.
Fire the stapling device to fully expose the injury tract.
Directly ligate bleeding vessels or exposed bronchi with 3-0 Vicryl figure-eight sutures.
Z2 neck exploration
Perform a neck incision along anterior border of SCM muscle.
Open carotid sheath and divide facial and middle thyroid veins to expose carotid artery.
If carotid artery injury is present, obtain proximal and distal control before definitive repair.
Inspect internal jugular vein and attempt primary repair if necessary.
Mobilize esophagus and place Penrose drain to rotate circumferentially.
Palpate and visualize larynx and trachea.
Perform esophagoscopy and/or bronchoscopy.
Potential Pitfalls
Vagus or recurrent laryngeal nerve injury.
Missed esophageal injury.
Difficulty obtaining proximal or distal control of carotid artery.
Burn excision with skin grafting
Schedule early excision within 24 hours for patients with burns >30% TBSA.
Use a large blade (Watson) to excise areas on arms, trunk, and legs and a small blade (Weck) for areas on the hands and feet.
Use electrocautery to perform excision down to the underlying fascia for deep and large burns.
Obtain hemostasis of the burn excision site using a combination of laparotomy pads soaked in epinephrine/saline, topical thrombin, and electrocautery.
Consider cadaveric skin or xenograft in unstable patients or those with limited donor sites.
Choose the appropriate type of skin graft (full-thickness vs. split-thickness) based on the location and size of the excised burn.
For large burns, consider meshing of a split-thickness skin graft to prevent underlying seroma or hematoma.
Affix the graft using one of a variety of methods: staples, sutures, or fibrin glue.
Dress the wound with a moist nonadherent dressing and then cover it with bulky absorbent dressings.
If the skin graft crosses a joint, place a splint to immobilize the area.
Keep the skin graft immobilized for 48 h, then start range of motion exercises.
Liver Hemorrhage control
Laparotomy for trauma—midline incision, evacuation of hemoperitoneum, packing of four quadrants
Sequential removal of packing after resuscitation
Evaluation of the extent of liver injury
Bimanual compression of liver to control hemorrhage
Circumferential packing of the liver to achieve tamponade; if hemorrhage is controlled, perform temporary abdominal closure after completion of abdominal exploration
Planned removal of packing at 48 h
Pringle maneuver when packing does not control hemorrhage
Direct vessel ligation to control bleeding; may require mobilization, finger fracture, or stapled hepatotomy to expose the injury
Possible resection to expose or remove injury
Suspicion for injury to hepatic vein or retrohepatic vena cava when Pringle maneuver does not control bleeding
Preplanned strategies for addressing recurrent hemorrhage, bile leak, or devitalized tissue at take back for removal of perihepatic packing
Potential Pitfalls
Excessive perihepatic packing can obstruct venous return
Placement of packing into the injury will cause further parenchymal disruption and exacerbate hemorrhage
Deep liver sutures can injure intrahepatic structures; avoid in central locations
Injury to the common bile duct can result from Pringle maneuver; use appropriate clamp or vessel loop
Additional unnecessary surgical interventions on the liver can result in additional avoidable hemorrhage; if perihepatic packing achieves control of hemorrhage, this should be considered definitive
Pancreatic/duodenal repair
Obtain exposure to the pancreas, duodenum, and surrounding structures starting with a generous Cattell-Braasch maneuver or right medial visceral rotation.
Perform a Kocher maneuver to reflect the duodenum and pancreatic head to the left.
Obtain access to the lesser sac through the gastrocolic ligament.
Carefully assess the head, body, and tail of the pancreas for injury.
Subsequent surgical decision-making should be based on the grade and location of the injury and overall injury status and prognosis.
Consider intraoperative pancreatography in a stable patient if unable to assess if there is a main pancreatic ductal disruption. Alternatively, a postoperative MRCP or ERCP can be performed.
Consider placement of a nasojejunal or surgical jejunostomy tube.
Potential Pitfalls
Inadequate exposure and evaluation for pancreatic or duodenal injury.
Failure to evaluate the pancreatic duct resulting in a delayed diagnosis of ductal disruption.
Risk of tension resulting in a leak or luminal narrowing resulting in a stricture after primary repair of a duodenal injury.
Need for splenectomy during distal pancreatic resection.
Delay in diagnosis and/or treatment of postoperative complications such as fistula or abscess.
