Trauma/ACS Flashcards
Management of possible blunt cardiac injury?
ECG–if abnormal observe on tele for 24-48h and get repeat ECG in 8h. Get TTE if unstable. Elevated cardiac enzymes do not predict BCI.
How to diagnose urethral injuries?
Retrograde urethrogram.
Urethral injuries are associated with…
inability to void, high riding prostate, “straddle fx” (pubic diastasis + inf pubic rami fx), blood at urethral meatus, perineal hematoma, palpable bladder
What is a left medial visceral rotation and what does it expose?
Also known as a Mattox maneuver, exposes abdominal aorta from entry at diaphragmatic hiatus to bifurcation
What is a right medial visceral rotation and what does it expose?
AKA Cattell-Braasch maneuver, exposes IVC from inf border of the liver to bifurcation
What size colonic injuries can be repaired primarily
<50% circumference
GCS scale
Eye opening: 4 spontaneous, 3 to voice, 2 to pain, 1 none
Verbal: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible, 1 none
Motor: 6 obeys commands, 5 localizes, 4 withdraws, 3 flexion (decorticate), 2 extension (decerebrate), none
Pathophysiologic changes seen in abd compartment syndrome:
- decreased CO from decreased venous return
- increased peak insp pressures and pulm failure
- decreased portal flow to liver
- oliguria
- decreased perfusion of intestines
Definition of compartment syndrome?
Bladder pressure >20 with new onset of organ dysfunction (oliguria, pulm failure)
What is Beck’s triad and what proportion of patients with tamponade have it?
muffled heart sounds, JVD, pulsus paradoxus. Only 15%.
When should you place an IO before trying a CVL in child? Initial and alternative sites?
Age 6 or under. Best site is prox tibia, alternative are sternum, iliac crest, malleoli, distal radius
How much spleen must be preserved for immunologic function? What are techniques to preserve?
33% must be preserved. Techniques are sutures buttressed with absorbable mesh vs omentum.
What is the incidence of OPSI after splenectomy?
0.5%
What organ is most sensitive to hypothermia? Describe changes seen.
Heart. ECG changes include prolonged PR interval, J waves–> eventual Vfib and asystole.
Indication for thoracotomy for bleeding?
CT output of 1500 cc initially or >200/hr for 3-4 hours.
What are the hard signs of vascular or tracheal injury in the neck?
vascular: expanding hematoma, arterial bleeding, bruit or thrill over area of injury. Trachea: subQ air or bubbling from the wound
Where to perform DPL on pregnant woman?
supraumbilical
What pelvic fx is associated with bladder injury?
diastasis + obturator ring fx
What percentage of bladder injuries are assoc with gross hematuria?
95%
What percent of pelvic fx have assoc bladder injuries?
5%
Indications for a damage control surgery are? Goals of resusc?
Temp 35, SBP<80, pH<7.2, Base deficit >14, INR or PTT >50% of normal, EBL >4L, Blood transfusion >10 units, Fluid replacement >10 L, peristent nonsurgical bleeding
Goals are PT <15 or INR <1.2 (FFP, vit K), Fibrinogen > 100 mg/dL (cryo), platelets >100k
Who should not get succinylcholine during RSI?
Spinal cord injury, massive tissue trauma, burn patients because it leads to hyper K. HyperK changes on ECG = peaked T–>wide complex tach–>torsades–>arrest.
What are the hemodynamic changes in pregnancy?
Increased cardiac output 2/2 increased HR and slightly increased stroke volume. Increased plasma volume (hypervolemia of pregnancy). Decreased BP 2/2 reduced SVR–>reached nadir during 2nd trimester and returns to normal during 3rd.
What grades of liver lac can be managed nonop?
Grade I-III. Can try nonop with higher grades if stable but usually they fail. Left lobe injuries are also more likely to fail (less contained than right lobe).
How to perform a needle decompression?
Place a 14 or 16 gauge needle in the second intercostal space at the midclavicular line
What is AVM bleeding caused by?
Obstruction of a submucosal vein.
When is operative intervention indicated for rectus sheath hematoma?
skin necrosis, bleeding and not stable for embolization
What size ETT is used for cricothyroidotomy?
6
What is the surgical airway of choice for a child under 12?
Needle cric (only after 3 failed intubation attempts, failed LMA and failed bag mask ventilation)
Describe the types of rectus sheath hematomas
Type I: small and confined within the rectus. Type II: confined within rectus but can dissect along transversalis fascial plane or cross midline. Type III: large and usually below arcuate line, often have hemoperitoneum or blood within space of Retzius.
What vessel should be embolized with expanding rectus sheath hematoma?
inferior epigastric
What causes Brown Sequard syndrome and what are the sxs?
Cord hemisection–ipsilateral loss of motor, contralateral loss of pain and temp
What is central cord syndrome?
motor weakness in the uppers > lowers, sacral sensory sparing. Usually from a cervical lesion.
What is cauda equina syndrome?
Injury to the lumbosacral nerve roots in the spinal canal–causing fecal and urinary incontinence + saddle anesthesia
Treatment of septic thrombophlebitis?
Abx and excision of the entire length of vein if superficial. If present in deep or central vein, then intensive abx and heparin are tried for 2-3 wks–surgery is last resort.
Treatment for mesenteric cyst?
Enucleation, unless very large and compromising mesenteric vasculature–in which case resect along with small bowel
Treatment of splenic artery aneurysms in pregnant women?
Must be repaired 2/2 high rupture rate of 20-50% and high (25%) rupture assoc mortality.
What is the most common splanchnic aneurysm?
Splenic artery
Detail pros and cons of tx for perf appendicitis
Early Surgical tx for perf is assoc with increased risk of SBO, wound infection, and reoperation but has earlier return to work and less hospital visits.
When should interval appy be performed?
6-8 weeks
Where is the swallowing center in the brain?
Medulla
What is iliopsoas sign?
Pain with extension of right thigh—indicates retrocecal appendix
What is obturator sign?
Pain with internal rotation of right thigh—indicates pelvic appendix
When can pt with splenic lac come off bedrest?
When abd pain is resolved and Hct stabilizes.
When can splenic injury patients go back to full activity?
Splenic injury grade + 2 weeks.
What vaccines do splenectomy patients need?
polyvalent pneumococcal (PPV 23), H flu type B, meningococcal
What is the most common cause of OPSI?
Pneumococcal infxn
Lucid interval, convex bleed, not crossing suture lines
Epidural, usually caused by middle meningeal artery bleed
Crescent shaped mass not crossing midline
subdural from tearing of bridging veins
Worst HA of life
subarachnoid hemorrhage
head injured patient with anisicoria and sluggish pupillary response
early uncal herniation
