Trauma and critical care

Question 1

What are the options for splenic preservation in trauma?

Answer 1

1. Control bleeding with direct pressure +/- use of haemostatic agents
2. Splenorrhaphy - using sutures (+/- buttress) to close lac
3. Partial splenectomy (stapled)
4. Mesh wrap

Question 2

What are the Hard signs and soft signs of vascular injury?

Answer 2

HARD SIGNS (Immediate intervention)

• pulsatile bleeding
• expanding hematoma
• bruit/thrill over artery
• distal ischaemia (5 Ps)

SOFT SIGNS

• Bleeding at scene
• stable hematoma
• Injury close to major artery
• Neurological deficit
• weak pulse distally
• Altered doppler signal
• reduced ABPI

Question 3

What are zones of neck in relation to trauma and how does it influence your decision making?

Answer 3

Zone 1 - sternal notch to cricoid

• has major vessels, needs angiogram and sternotomy may be needed for proximal control

Zone 2 - cricoid to angle of mandible

• has carotid sheath - relatively easier to control

Zone 3 - angle of mandible to base of skull

• bleeding difficult to control - consider embolization, get help

Question 4

In a patient with penetrating neck trauma who would you explore and who would you get a CTA initially? How would you access neck in trauma?

Answer 4

Immediate exploration -

• unstable patient with penetrating neck trauma
• hard signs of vascular injury

Post CTA exploration -

• all trauma penetrating the platysma
• signs of aerodigestive tract injury

CTA - all patients if stable.

Access is through anterior border of SCM - at upper end incision is curved backward for access to base of skull (if required after incising mastoid head of sternomastoid). At lower end incision can be carried into a sternotomy or supra/infraclavicular incision to get control of great vessels at root of neck.

zone 1 - divide Omohyoid (at junction of bellies). May need sternotomy with supraclav/infraclav extension for more proximal control. Vertebral artey may be injured - managed with embolization. (SCM incision not always needed for zone 1 injuries)

Zone 2 -

Zone 3 - Facial vein and middle thyroid V will need to be divided. To open the bifurcation, incise along posterior belly if digastric. Hypoglossal nerve crosses the carotid sheath and must be protected (usually at lower border of digastric or just deep to that). Vagus is posterior -> protect. For dissections higher up in carotid sheath, IX, XI and facial nerves are also at risk. IX crosses ICA at top, XI is encountered 3 cm below mastoid head (if mastoid head of SCM is resected), facial nerve encountered if styloid process and its muscles divided.