Trauma Flashcards
how to manage large segment ureteral injuries
- middle and proximal 1/3 (>2cm)
- perc nephrostomy
- bring patient back for ileal interposition or trans-ureteroureterostomy
- distal 1/3 (>2cm)
- reimplant to bladder with psoas hitch
how to manage small segment ureteral injuries
- proximal 1/3
- ureteroureterostomy (mobilize ends and close over J stent)
- mobilize kidney and pexy to psoas
- middle 1/3
- ureteroureterostomy (mobilize ends and close over J stent)
- distal 1/3
- reimplant ureter in bladder with or without psoas hitch
what diagnostic procedures needed for severe pelvic trauma
- proctoscopy
- retrograde cystourethrogram
what structures are you concerned about with anterior pelvic fx and posterior pelvic fx
- anterior
- venous plexus
- posterior
- arterial
what are the borders of box injuries
- clavicles
- xiphoid process
- nipples
what diagnostic procedures do u need to do when there is an injury inside box
- pericardial window
- bronch
- esophagoscopy, barium swallow
what are sx and tx of tracheolaryngeal injury
- sx: crepitus, stridor, respiratory compromise
- tx: intubate if possible. if not, cricothyroidotomy
- later, can do primary repair and convert cricothyroidotomy to tracheostomy
surgical management of duodenal injuries
- try to debride and repair primarily (residual bowel circumference should be >50% of normal)
- may need to divert with pyloric exclusion and gastro J
- place distal J tube
- can also place proximal draining j tube that threads back to duodenal injury
- PLACE DRAINS
- if in 2nd portion of duodenum, place jejunal serosal patch, may need whipple later
complications of surgery for duodenal injury
fistula
- bowel rest, TPN, octreotide
- conservative managment for 4-6 weeks
how do late presenting paraduodenal hematomas present and how do you treat them
- 12-72 hours post injury
- presents with high SBO
- UGI shows stacked coins or coiled spring appearance
- should not have any extravasation of contrast
- tx:
- conservative (NGT and TPN)
- 90% get better over 2-3 weeks
which paraduodenal hematomas do you need to open
all of them that are >2cm
how to manage small bowel injuries
repair lacerations transversely
if laceration are >50% of bowel circumference, or if repair results in lumen diameter <1/3 of normal,then resect and reanastomose
which of these hematomas do you leave or open in penetrating/blunt trauma
- pelvic
- paraduodenal
- portal triad
- retrohepatic
- midline supramesocolic
- midline inframesocolic
- pericolonic
- pararenal
penetrating/blunt
- open/leave
- open/open
- open/open
- leave (if stable)/leave
- open/open
- open/open
- open/open
- open (unless CT says no injury)/leave (unless CT says there is injury)
what are the zones of peritoneum and what do you do with their hematomas
- central: open for both
- flank/perinephric: open for penetrating, leave for blunt
- pelvis: usually leave and go to angio
what are normal vital signs for:
- infant <1 year
- preschool <5 years
- adolescent >10 years
HR/SBP/RR
- infant: 160/80/40
- preschool: 140/90/30
- adolescent: 120/100/20
how do urethral injuries present and how to manage urethral injuries
- present with blood at meatus or hematuria
- RUG is best test
- if there is a significant tear:
- suprapubic cystostomy and repair in 2-3 months
- it small, partial tears
- might be able to bridge with foley and repair in 2-3 months
how to manage colonic injuries to right and transverse colon
- repair primarily
- resect and anastomosis for destructive injuries
- NO DIVERSION NEEDED
how to manage colonic injuries to left colon
- primary repair without diversion for <50% circumference and not devascularized
- if destructive:
- left colectomy
- diverting ileostomy IF:
- gross contamination
- > or =6 hours elapsed from injry
- significant comorbidities
- > or = 6U PRBCs given
how to manage CBD injury
- kocher maneuver, dissect out portal triad
- if <50% circumference, repair over stent
- if > 50%, choledochojejunostomy
- may need IOC to define the injury
retrohepatic caval injury
atriocaval shunt
how do you manage extra-peritoneal rectal trauma
-
high rectal (prox 1/3)
- its like intra-peritoneal (1° repair or LAR with diverting loop colostomy)
-
middle rectal
- if repair is not feasible or cant locate it, place end colostomy only
- it will heal and then take colostomy down
-
low rectal
- usually repaired primarily thru transanal approach
- if cant find it or is too expensive, place end colostomy only
how do you manage intraperitoneal rectal trauma
- primary repair WITHOUT DIVERSION if non-destructive
- if destructive (>50% circumference)⇒LAR with DIVERTING COLOSTOMY always
- if patient in shock, end colostomy only
how to manage portal vein injury
- repair (lateral venorrhaphy)
- may need to transect pancreas to get to injury, so then do distal pancreatectomy
- ligation of PV = 50% mortality
how do you manage pancreatic injury
- 80% are treated with just drains
- have to decide if duct is involved
- if distal pancreatic duct injury⇒distal pancreatectomy
- pancreatic head duct injury that is not reparable: place drains, can do whipple or ercp with stent later
- if left of SMV, distal panc
- if right of SMV, Whipple
- do kocher for visualization
- pancreatic hematoma always opened (zone 1)
what does it mean if have persistent or rising amylase
missed pancreatic injury
hard signs of vascular injury
- active hemorrhage
- pulse deficit
- expanding or pulsatile hematoma
- distal ischemia
- bruit or thrill
if patient has hard signs of vascular injury, how is it managed
go to OR for exploration
may need to do on-table angio in OR
what are soft signs of vascular injury
- h/o hemorrhage
- large stable/nonpulsatile hematoma
- ABI <0.9
- unequal pulses
how do you manage a patient with soft signs of vascular injury
get CT angio for any soft signs
may need angio if injury found
veins that NEED repair
- vena cava
- femoral
- popliteal
- brachiocephalic
- subclavian
- axillary
how do you manage venous injuries that need to be repaired
need vein graft if >2cm segment is missing
use contralateral saphenous vein
how do you manage IVC injury
repair primarily if residual stenosis would be <50% the diameter of IVC
if not, place SVG graft or synthetic patch
how do you repair posterior wall IVC injury
go through anterior wall
state injury
- anterior hip dislocation
- posterior hip dislocation
- distal femur fx
- posterior knee dislocation
- fibula neck fx
- femoral artery
- sciatic n.
- popliteal a.
- popliteal a.
- common peroneal a.
associated injuries:
- temporal or parietal bone fx
- maxillofacial fx
- sternal fx
- 1st or 2nd rib fx
- scapular fx
- rib fx (left 8-12)
- rib fx (right 8-12)
- pelvic fx
- epidural hematoma; facial n.
- cervical spine fx
- cardiac contusion
- aortic transection
- pulmonary contusion, aortic transection
- spleen lac
- liver lac
- bladder rupture, urethral transection
associated injuries:
- anterior shoulder dislocation
- posterior shoulder dislocation
- proximal humerus
- midshaft humerus
- distal humerus
- elbow dislocation
- distal radius fx
- axillary nerve
- axillary artery
- axillary nerve
- radial nerve
- brachial artery
- brachial artery
- median nerve
indications for operation for renal trauma
- acute
- ongoing hemorrhage with instability
- after acute phase
- major collecting system disruption
- non-resolving urine extravasation
- severe hematuria
If in OR and see:
- blunt renal injury with hematoma
- penetrating injury with hematoma
- leave unless CT/IVP shows no function or significant urine extravasation
- open hematoma unless pre-op IVP/CT shows good function without significant urine extravasation
how does bladder trauma present
how do you diagnose
- hematuria is best indicator
- blood at meatus
- sacral or scrotal hematoma
- dx: cystogram
cystogram finding for extraperitoneal and intraperitoneal bladder trauma and their treatments
- extraperitoneal: starburst on cysto
- tx with foley 7-14 days
- intraperitoneal: cysto shows leak
- tx with OR, repair defect and foley
approach to arterial injuries to distal right subclavian a.
midclavicular incision, resection of medial clavicle
arterial injuries requiring left thoracotomy
distal left subclavian a.
descending aorta
vascular injuries requiring median sternotomy
- ascending aorta
- innominate a.
- proximal R subclavian a.
- innominate vein
- proximal left common carotid
- proximal left subclavian a.
- trap door incision through left 2nd ICS
signs of aortic transection
- widened mediastinum
- 1st or 2nd rib fractures
- apical capping
- loss of AP window
- loss of aortic contour
- left hemothorax
- trachea deviation to right
dx and tx of aortic transection
dx: CT angio of chest
tx: place covered stent endograft or left thoracotomy and repair
*treat other life threatening injuries first
dx, tx of diaphragmatic injury
- usually in left diaphragm
- CXR: air fluid level in chest from stomach herniation
- repair
- if < 1 week do transabdominal approach
- if >1 week go through chest
- may need mesh
sx and dx tracheobronchial injury
- large continuous leak, large pneumomediastinum, persistent pneumothorax
- may need to mainstem intubate on unaffected side
- dx: bronchoscopy (most are within 1cm of carina)
tx of tracheobronchial injury
- repair if:
- large air leak and respiratory compromise
- after 2 weeks of persistent air leak
- if cant get lung up
- if injury is >1/3 diameter of trachea
- R thoracotomy (for right mainstem, trachea and proximal left mainstem)
- L thoracotomy for distal left mainstem (rare injury)
define “Massive hemothorax”
- 1,000-1,500 cc after initial insertion
- >250 cc/h for 3 hours
- >2500 cc/24h
- bleeding with instability
surgical approach to:
- massive hemothorax
- unresolved hemothorax
- persistent pneumothorax
massive hemothorax
- anterolateral thoracotomy on side of injury with patient supine
unresolved hemothorax
- thoracoscopy
persistent pneumothorax
- bronchoscopy
how to manage esophageal injuries
- esophagoscopy and esophagram
- contained injuries can be watched
- noncontained:
- if small injury and minimal contamination do primary repair
- if extensive inury then place drains
- if in neck, place drains
- if in chest, place chest tubes and spit fistula. esophagectomy later
lefort fractures and their treatments
- type I
- maxillary fx straight across
- tx: reduction, stabilization, IMF
- type II
- lateral to nasal bone, underneath eyes, diagonal toward maxilla
- tx: same as type I
- type III
- lateral orbital walls
- suspension wiring to stable frontal bone
- may need external fixation
describe splenectomy
- type and cross, preop abx
- prep from xyphoid to pubic symphysis
- midline incision
- enter lesser sac
- divide short gastric veins with harmonic scalpel
- divide splenocolic ligament
- retract spleen to right and divide splenorenal and splenophrenic ligaments
- splenic a. and v. are isolated and divided
- remove spleen
complications of splenectomy
- subphrenic abscess
- pancreatic leak
- necrosis of part of greater curve of stomach
do you have to leave drain after splenectomy?
no
treatment of caustic injuries
- no NGT
- do not induce vomiting
- NPO
- CT chest/abdomen to r/o perf
- endoscopy within 24 hours, but not too early
- abx if perf or 3rd degree burn
what is difference between alkali and acid caustic injuries
- alkali
- deep liquefaction necrosis
- acid
- coagulation necrosis
difference between compression and burst fx
- compression
- usually anterior column
- stable
- tx with TLSO
- burst
- unstable
- usually anterior and middle column
- tx with spinal fusion
how to treat elevated ICP
- sedation, paralysis
- raise head of bed
- hyperventilation (pco2 30-35)
- too low will cause increase vasoconstriction
- keep Na 140-150, serum osm 295-310
- hypertonic saline
- mannitol load 1g/kg, give 0.25mg/kg q4h
- try barbiturate coma
- if nothing working, then craniotomy
what is goal ICP and CPP in head trauma
ICP < 20
CPP >60
what is cushings triad
bradycardia, HTN, low RR
* intermittent bradycardia is sign of impending herniation
what is epidural hematoma, what is its shape, sx, and tx
- arterial bleed from MMA
- lenticular deformity
- sx: LOC, then lucid interval, then sudden deterioration
- tx: evacuate for significant neurologic degeneration or significant mass effect (shift >5mm)
what is a subdural hematoma, shape, sx, tx
- tearing of venous plexus
- crescent shaped deformity
- tx: evacuate for significant neurologic degeneration or mass effect >1cm
GCS-motor
- no response
- extension with pain
- flexion with pain
- withdraws from pain
- localizes pain
- follows commands
GCS verbal
- no response
- incomprehensible sounds
- inappropriate words
- confused
- oriented
GCS eye opening
- no response
- opens to pain
- opens to command
- spontaneous opening
how do you manage pancreatic injuries
- wide closed suction drains
- if there is a duct injury, check if its left or right of SMV
- if left, distal pancreatectomy, preserve spleen
- if right , depends on extent
- wide drainage
- pancreaticoduodenectomy
what do you do for all ureteral injuries
leave drains
