Trauma/Emergency Flashcards
How should anticoagulants be managed with UGIB?
Continue aspirin
Stop clopidogrel etc until haemostasis unless stents (40% risk of death/MI within 1 year), aim restart 5-7 days)
Stop warfarin/doacs
What medical treatments are required in the post operative period after perf DU repair?
Broad spectrum antibiotics covering gram+ve, gram-ve and anaerobes - e.g. Co-amoxiclav and gent
Collect fluid samples
Consider antifungals if immunocompromised, old or comorbid (Azoles if not previously exposed, if previously exposed then give echinocandins)
What is the most common complication of peptic ulcer disease?
Bleeding - 0.02-0.06% annual incidence, 30d mortality of 8.6%
Perforation less common but higher mortality
How are ERCP perforations classified?
Stapfer classification
1) Hole lateral/medial wall - endoscope mania
2) periampullary (sphincterotomy related)
3) Distal ductal
4) retroperitoneal air (guide wire)
What is an appropriate cerebral perfusion pressure (MAP-ICP) in adults and children?
70 in adults, 40-70 in children
What threshold should be used for CT in suspected appendicitis?
> 40 (WSES Jerusalem guidelines 2020)
What is the indication for vATS with traumatic pneumothorax?
Persistent air leak at 3 days
Which organ is most frequently injured by blunt trauma?
Spleen
How can entero-cutaneous fistulae be classified?
Output -
High >500ml in 24 hours
Moderate 200-500ml in 24 hours
Low - <200ml in 24 hours
Organ
Type 1 - Oesophageal/gastroduodenal
Type 2 - Small bowel
Type 3 - Colonic
Type 4 - enteroatmospheric
Which main vessel cannot be accessed easily through a midline sternotomy?
Proximal left subclavian (anterolateral thoracotomy at 3rd IC space)
Where does the brachial artery begin?
Lower border of Teres Major
What is the AAST splenic trauma classification?
1 - <1cm or <10%
2 - 1-3cm depth lac or 10-50% surface SCH
3 - >3cm lac or SC haematoma >50% or IC haematoma >5cm
4 - >25% devascularised
5 - shattered spleen/devascularised hilum
For patients with non-variceal UGI bleed, what adjunctive medical treatments should be used?
Prokinetics (erythromycin) and PPI infusion IV for 72 hours then 6-8 weeks -halves rebreeding risk.
If platelets <50 then infusion
Transfusion trigger of 70
What is the AAST liver trauma classification?
1: Lac <1cm depth or sc haematoma<10%
2: Lac 1-3 depth <10cm or sc haematoma 10-50%
3: Lac >3cm depth or SC >50% or IC haematoma >10cm
4: Disruption of 25-75% hepatic lobe
5: Disruption of >75% hepatic lobe
6: Hepatic Avulsion
How quickly will IV iron achieve results?
About 3 weeks
What are the mechanisms of injury with gunshot?
- Laceration/cutting
- Cavitation
- Direct energy transfer on impact
- Fragementation
What proportion of abdominal stab wounds do not penetrate the peritoneum
1/3
How is pancreatitis graded on CT?
Balthazar severity index
- Grade 1-4 + necrosis <30,30-50,>50
What are the Atlanta criteria for severity of pancreatitis?
Mild - interstitial oedematous, no failure, resolves in 1 week (80-85%)
Moderate - transient organ failure, local complications
Severe - persistent organ failure
What are risk factors for PUD?
NSAIDS (inhibit PDE synthesis) Smoking (inhibits HCO3- increases acid) H.Pylori Bariatric marginal ulcer FAsting Drugs Zollinger-Elliison Steroids Alcohol Bevacizumab
What is the most superficial structure in the popliteal fossa?
The tibial nerve. Starts laterally and passes medially
The artery is deepest
Encountered first in a medial exploration proximally then after the vein distally
What is the incidence of staple line bleed after colorectal surgery?
1-2%
If gallstones and alcohol are excluded as causes of pancreatitis, what other causes need to be investigated?
1 - metabolic (hypercalcaemia, hyperlipidaemia)
2 - prescription drugs
3 - microlithiasis
4 - hereditary causes PRSS1 mutation (AD)
5 - Autoimmune (IgG4)
6 - malignancy
7 - Anatomical abnormalities
If the CFA is inaccessible through haematoma how may proximal control be obtained?
Through dividing the inguinal ligament or posterior inguinal canal
How should patients with Cirrhosis be surveilled for varices?
OGD at diagnosis
- No varices –> rescope 2-3 years
- G1 varices –> rescope 1 year
- G2/G3 varices or red signs –> Propranolol or VBL
What single preendoscopy treatment has been shown to improve outcome in patients with variceal bleeds?
IV antibiotics
What are the classical signs of appendicitis?
Rosvings sign
Obturator sign - RLQ pain with int/ext rot right hip
Psoas sign - RLQ pain with extension of right hip
Which organ is most often damaged by penetrating stab wounds?
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
When is the recommended timing of OGD for UGI bleed?
Within 24 hours (unless unstable or variceal)
What are Cullen’s, Grey-Turner and Fox’s signs?
Retroperitoneal bleeding –> bruising around:
Cullens - umbilicus
Grey-Turner - flank
Fox - inguinal ligament
How is the brachial artery accessed?
Supine, arm abducted, incision in groove between biceps and triceps
Incise deep fascia, avoiding basilic vein at lower aspect
First aspect encountered is median nerve (starts lateral and passes anteriorly)
Distally - S shaped incision across ACF, with brachial artery bifurcation immdeidately deep to biceps tendon
What are the indications for clamshell thoracotomy?
Penetrating trauma with cardiocirculatory arrest, <15min of CPR
What technical aspects of appendicectomy are evidence based?
WSES Jerusalem guidelines
- Suction only in complicated disease
- no difference in mesoappendix control
- stump control loop or suture
- no drains
Which artery is the classical cause of a traumatic extradural haemorrhage?
Middle meningeal
What scoring systems are useful in appendicitis?
Acute appendicitis score in women
Appendicitis inflammatory response score in men
Most important factor is location/severity of pain
If low risk - <1% risk of advanced appendicitis
How do you perform a four compartment fasciotomy?
Anterior incision - for anterior and lateral compartments - 2 finger breadths lateral and below tibial tuberosity to two finger breadths proximal to lateral malleolus - then 2 x fascial incisions
Posterior incision - 2 finger-breadths posterior to medial border of tibia and 2 FB distal to head to 2FB sup to medial malleolus, then sup fascia opened and deep entered by taking gastrocneumeus/soleus down
Risk - Anterior - superficial peroneal
Posterior - long saphenous vein
What cranial nerve is most frequently involved after head injury and raised ICP?
3rd nerve - occulomotor - caused dilated pupils with poor light response
Often associated with 4,5 and 6th nerve palsies
Which organisms are involved in Post splenectomy sepsis?
Encapsulated organisms - Neisseria meningitides, Haemophilis Influenzae and Streptococcus Pneumoniae
When should a cholangiogram be performed after insertion of a cholecystostomy?
4 weeks
Where will an embolus most frequently lodge in mesenteric ischaemia?
SMA distal to origin of middle colic and pacnreaticoduodenal
How should WON and pseudocysts be managed?
Best is probably cystogastrostomy, with lumen apposing metal stent (LAMS) for WON
What proportion of pancreatic ductal disruptions are caused by penetrating injury?
70%
What is the most frequent biochemical abnormality seen in burns patients?
Hypernatraemia
How often is free air seen in a perf DU?
30-85% of cases
What is the trauma triad?
Hypothermia
Metabolic acidosis
Coagulopathy
When should OGD be performed with caustic ingestion?
<24 hours - risk of perforation maximal about 3 days
What is the management of choice for endoscopic oesophageal perforation?
Endoscopic closure and SEMS
SEMS>Surgery - WSES guidelines
Minimum of 2-4 weeks
What is the most prognostic criteria for pancreatitis?
Presence of SIRS - 2/4 of
T>38/<36, HR>90, RR>20, WCC<4/>12
At 48hrs >admission
CRP >150
Urea >20
What proportion of patients with an oesophageal FB obstruction will have underlying disease?
25% (Schatzki ring, eosinophilic oesophagi’s, achalsia, tumours)
What predictors of outcome are available for Perf DU?
NELA
Boey, PULP, ASA, Hypoalbuminaemia
What scores can be used to predict UGI bleeding risk pre OGD
Glagow-Blatchford - if ≤1 then very low chance of requiring intervention
if ≥7 very high risk
When should splenectomy be considered in variceal disease?
Gastric varices with splenic vein thrombosis or left side portal hypertension
When should enteral nutrition be instituted for patients with pancreatitis?
Within 48-72 hours. There is no difference between OG/NG if tolerated
(NICE)
Decreases sepsis, organ failure, surgery and mortality when compared to TPN (Frontline gastroenterology 2018)
Bakker RCT - no difference in Oral or NG feeding. Tolerated in 69% of severe
In major perineal wounds (E.g. devolving), what abdominal procedure is often required
End colostomy
What are the defining characteristics of the 4 stages of shock?
Stage 1: <750ml/15%
Stage 2:750-1500ml 15-30%
Stage 3:1500-2000ml 30-40%
Stage4: >2000ml, >40%
Stage 1 Normal
Stage 2 Tachypnoea, HR100-120, reduced UO
Stage 3 HR120-140, BP reduced, poor UO, confused
Stage 4 HR>140, v.low UO
What treatment should patients identified to have a Forest 2c lesion receive?
Medical only for 2c/3 (i.e. haematin on ulcer or clean based ulcer)
What are risk factors for failure of non-operative management in splenic trauma?
Age >55
High ISS
Moderate to severe splenic injury
How should patients with delayed presentation of traumatic diaphragmatic hernia be managed?
VATS/Thoracotomy
In whom with splenic injuries should angioembolisation be mandatory according to the WSES?
Stable patients with AAST 4/5 disease
What is the velocity of a high velocity gunshot wound?
> 300m/s
How would you fix a large perforated ulcer?
- suspicion of gastric malignancy - 10-16% of gastric perforations
- if Gastric/D1 - resection/reconstruction
- if ampullary - pyloric exclusion, gastric decompression and external biliary diversion
What are the most common organisms of infection after human bites?
Strep > Staph
What proportion of patients with oesophageal caustic injuries develop cancer?
7-15% adenocarcinoma (x 1000 risk)
What are indications for emergency OGD (<6hours) after FB ingestion?
Sharp (35% perforation)
Batteries
Complete obstruction
What are the hard signs of major vascular injury in the neck?
Rapidly expanding or pulsatile haematoma
visible exsanguination
thrill or bruit
dense neurological deficit
Presence of any –> theatre
When might non-operative management be appropriate for perf DU?
- demonstrated sealed on water soluble contrast study
- <70 and less comorbid
need - NBM, IVI< NGT, PPI+/-octreotide, Abx
What is the initial investigation for patients with caustic oesophageal injuries?
Contrast CT > OGD (absence of post contrast wall enhancement)
CT classification
1 - mucosal oedema
2a - mucosal/submucosal oedema - target appearance
2b - rim of external enhancement, necrotic muocsa
3 - necrotic (Absence of PCWE)
What proportion of blunt renal injuries can be managed conservatively?
Up to 90%, even with urine extravasation.
If required consider endo-ureterologic and percutaneous drainage (if stable)
When is the benefit of TXA seen in a trauma setting?
If given within 3 hours
What are the zones of the retroperitoneum?
Zone 1 - midline from hiatus to bifurcation
Zone 2- lateral kidneys to bifurcation
Zone 3 - bifurcation to pelvis
Zone 1 all need exploring (also divided supra/inframesocolic - supra/infrarenal control)
Zone 2/3 explore penetrating if expanding. Can be observed blunt and not expanding
What adjunctive therapies can be used for food boluses?
Buscopan and fizzy drinks
How is the popliteal artery accessed through a medial approach?
Proximal - Incision between vastus medialis and sartorius. Incise deep fascia posterior to femur and palpate artery immediately behind bone - artery is medial here
Distal - separate incision 1cm behind tibia from medial femoral condyle, through the deep fascia avoiding the vein which is medial to the artery here
What are the components of the GCS?
Eyes 1-4 None, Pain, Voice, Spontaneous
Motor 1-6 None, Extension, Flexion, Withdraws from pain, Purposeful to painful stimulus, Commands
Voice 1-5 None, Incomprehensivble, Inappropriate with discernible words, Confused, Oriented
How should patients presenting with bleeding oesophageal varices be managed?
Standard then VBL
+Antibiotics, terlipressin/somatostain/octreotide
Secondary prophylaxis after D5 with VBL+NSBB
If Childs B with bleeding or Childs C –> TIPSS
What are the types of Peptic Ulcer?
Johnson criteria 1 - lesser curve 2 - gastric and duodenal (acid hyper secretion) 3 - prepyloric (Acid hyper secretion) 4 - GOJ 5 - drug induced, anywhere
How do you access the infrarenal aorta?
Kocher Maneuver to access retroperitoneum and dissect proximally to renal veins
For patients managed non operatively for perforated appendicitis how should they be followed up?
<40 - nothing unless symptomatic
>40 3-17% risk of cancer –> colonoscopy and CT
What monitoring should patients with chronic pancreatitis undergo?
Exocrine function and malnutrition every 12 months, 2 yearly DEXA
(NICE)
How are liver injuries graded by the WSES?
Minor (AAST 1-2 stable)
Moderate (AAST 3 stable)
Severe (AAST 4-5 stable or 1-6 unstable)
How often is Mackler’s triad seen in Boerhaaves?
15%
How do you access the suprarenal aorta?
Open the gastrohepatic ligament and palpate the aorta against the vetebrae
Which organ is most often damaged by gunshot?
Small bowel (50%)
Colon (30%)
Liver (20%)
Are acid or alkali caustic injuries worse?
Acid –> Coagulation necrosis - protects against further damage
Alkali –> Liquifactive necrosis, saponification and cell death with threat to airway, more likely stricture
Where are areas of likely impaction in the oesophagus?
1) Cricopharyngeus
2) Aortic arch/tracheal bifurcation
3) Diaphragm
What are the aetiologies of oesophageal perforations?
60% OGD
15% Boerhaave
Other - trauma, malignancy, FB, caustics
What are the classification systems for splenic trauma?
AAST (1-5)
1 - sub capsular haematoma <10%, capsular tear <1cm depth
2 - sub capsular haematoma 10-50%, intraparenchymal <5cm, 1-3cm lac
3 - haematoma sub capsular >50%, ruptured haematoma, intraparenchymal haematoma >5cm or >3cm laceration
4 - devascularisation of >25% of spleen
5 - shattered spleen, hilar disruption
and WSES (1-4)
1- AAST 1-2, stable (NOM)
2- AAST 3 , stable (consider angio)
3 - AAST 4-5, stable (all angio)
4 - AAST 1-5, unstable - Operative managment
Which vessel injury carries the highest rate of limb loss?
Popliteal
What is the Forest Classification?
Endoscopic description of UGI bleeding findings 1-3 1- bleeding 2-pathology likely to bleed 3 - pathology
What is the mortality of patients with acute pancreatitis?
15-20% as inpatient
What is the rate of recurrence in the short term following gallstone pancreatitis?
18% recurrence in 6 weeks.
If have ERCP, still 10%
In which patients with oesophageal perforation can non-operative management be adopted?
Altorjay criteria
- Early
- Well
- Cervical or contained perforation
- No pre-existing pathology
- Can be surveilled
Also Pittsburgh classification
What is the Zargar classification of oesophageal caustic injury?
0 Normal 1 superficial mucosal edema 2a superficial ulceration, erosion 2b deep ulceration, erosion 3a focal necrosis 3b extensive necrosis 4 perforation
For grade 2b - 80% chance of strictures in future
Grade 1-2a usually recover quickly
Grade 3+ need surgery
Which vein is most at risk when dissecting out the PFA?
Lateral femoral circumflex vein
How should patients with infected pancreatic necrosis be managed?
Endoscopic if possible > Percutaneous
NICE
What pressure should a Sengstaken Blakemore tube be inflated to on insertion?
35-40mmHg then deflate to 25
Traction weight of 0.5-1kg after this
How should patients with gastric variceal bleeding be managed?
Cyanoacrylate injection or thrombin
+Antibiotics, terlipressin/somatostain/octreotide
Secondary prophylaxis after d5 with cyanoacrylate injection. Consider NSBB or thrombin
How should a colonic laceration be repaired?
In general with a primary closure
What is the incidence of microscopic abnormalities in a macroscopically normal appendix?
25-35%
How can oesophageal strictures be graded
Archand classification
Grade 1 Short non circumferential Grade 2 Short circumferential elastic, Grade 3 <1cm circumferential, fibrotic Grade 4a >1cm, easily dilated Grade 4b - deep fibrotic progressive
What is the most common cause of diaphragmatic injury?
Blunt trauma causing large radial tears (laceration –> smaller tears)
More common on left
Initial CXR normal in 50% of cases
Treatment with surgery
What is the incidence of recurrence of appendicitis treated with antibiotics?
26.4% at 1 year and 39.1% at 5 years (APPAC trial)
Of IV antibiotics - 8% initial failure
What is the major mechanism of pancreatic injury?
Deceleration injury
For patients managed non operatively for perforated appendicitis how should they be followed up?
<40 - nothing unless symptomatic
>40 3-17% risk of cancer –> colonoscopy and CT
What are the principles of surgery for oesophageal perforation (6)?
Exposure Debridement (mucosa>muscularis) Closure (2 layer - 25% breakdown +/- T-tube) Buttress Drainage Nutrition
When do strictures occur following caustic ingestion?
Within 4 months - usually should be attempted within 3-6 weeks here few (<3) and short <5cm
How would you gain access and to and control of the femoral artery?
- Longitudinal incision from midinguinal point down
- Through fascia lata to identify CFA, SFA and PFA, then sling and clamp
What are the defining characteristics of a massive haemorrhage?
Loss of 50% Circulating volume in 3 hours
Loss of 100% Circulating volume in 24 hours
Loss of >150ml/min
Transfusion of 4 units in 4 hours with bleeding
Transfusion of 10 units in 24 hours
What is the most reliable imaging where pancreatic injury is suspected?
MRCP >CT for ductal injuries
How is haemodynamic instability defined in adults?
1) SBP <90 with skin vasoconstriction, confusion, dyspnoea or:
2) SBP>90 but
- requiring vasopressors
- requiring bolus infusions
- BE ≥-5
- PRC requirement of >4 in 8 hours
WSES 2020
What threshold should be used for CT in suspected appendicitis?
> 40 (WSES Jerusalem guidelines 2020)
When should stable patients with liver trauma undergo angioembolisation?
Positive blush, early aneurysm irrespective of injury severity (perhaps not in children)
Which is the most frequently injured peripheral artery?
Brachial
When should a patients be taken back to theatre for a relook after having bowel stapled off inside?
24-48hrs
What is the Cushings reflex?
Hypertension and Bradycardia caused by raised ICP (Munroe Kellie doctrine)
How should patients with pancreatitis be fluid resuscitated?
Goal directed, with CSL at 5-10ml/kg/hr (APA guidelines)
Aim for HR< 120, MAP65-85, UO>0.5-1
What endoscopic interventions are suggested for UGI bleed?
If Forest 1a/1b/2a (i.e. vessel spurtin/oozing/visible) –> dual modality endoscopic
What is a normal intra abdominal pressure?
5-7mmHg in critically ill
What is the Catell Brasch manoeuvre?
Medial visceral rotation from the right
What is the most common cause of mortality in patients with chronic pancreatitis?
Cardiovascular
What complications are associated with chronic pancreatitis?
- Pancreatic duct obstruction (?surgery or ESWL)
- Pseudocysts (drain if symptomatic or duct disruption)
- Ascites
- Type 3c diabetes
(NICE)
How is the axillary artery best accessed?
Supine, arm abducted. Transverse incision inferior to clavicle through pectoralis major.
Exposure and division of clavipectoral fascia to identify axillary vein.
May need to divide thoracoacromial artery (superficial branch)
What evidence is there for laparoscopy in perf DU?
WSES guidelines recommend if stable then attempt laparoscopy.
Meta-analysis by Cirocchi - less pain, less wound infections
When would you endoscope following treatment of perf PUD?
for gastric at 6 weeks
How is abdominal compartment syndrome defined?
Pressure >20mmHg with new organ dysfunction
What is the WSES Splenic trauma classification
Minor WSES 1 - AAST 1-2 stable
Moderate WSES 2 - AAST 3 stable
Moderate WSES 3 - AAST 4-5 stable
Severe WSES 4 AAST 1-5 unstable
Which bacteria typically cause cellulitis?
Streptococcus pyogenes and staphylococcus aureus
What antibiotic prophylaxis is required after splenectomy?
Probably 250mg BD Amox.
Consider septrin if allergic
How would you fix a small perforated ulcer?
If <2cm, no evidence to support omental patch over suture closure alone (WSES 2020), however the additional risk appears small so its probably sensible
Single drain at suture site
What are the risk factors for non operative management of splenic injuries?
Age >55
High injury severity score
AAST IV-V injuries
What treatments should be instituted for a diagnosis of abdominal compartment syndrome?
Gastric decompression
Muscle relaxation/sedation
Drain collection
Consider fluid restriction/diuretics
If fails –> Laparotomy
What are the Atlanta criteria for fluid collections in pancreatitis?
<4 weeks - acute fluid collection or acute necrotic collection
>4 weeks - pseudocyst or walled off necrosis
A diagnosis of infection can be made from presence of gas on CT.
What blood products should be given in a major haemorrhage situation?
PRC, FFP and Platelets in a 1:1:1 ratio
Remember TXA (CRASH study)
What is the Mattox maneuver?
Complete left medial visceral rotation to access aorta
In patients with splenic injuries how long should bed rest be recommended for?
72 hours
How does the AAST grade renal injuries?
1 - Subcapsular/no parenchymal/haematuria
2 - <1cm parenchymal injury
3- >1cm parenchyma injury without damage to collecting system or urinary extravasation
4 - parenchymal injury extending through cortext, medulla and collecting system or main vessel injury with contained haemorrhage
5 - shattered kidney or avulsion of hilum
In delayed ureteral injury presentation with complete transection, how should these patients be managed?
Nephrostomy and delayed reimplantation
How should intraperitoneal bladder rupture be managed?
Operative repair
What is the management of choice for anterior urethral injuries?
Endoscopic realignment - if fails –> surgery
How should bleeding from the main renal vein be managed?
If not self limiting this is an indication for surgery
How should bleeding from the main renal vein be managed?
If not self limiting this is an indication for surgery
What is the success rate of conservative management of SBO?
70%
Bologna guidelines 2017
What is the benefit of laparoscopy in the surgical management of SBO?
Reduced LoS (LASSO trial 2019)
What is the recurrence rate of adhesive SBO after surgery for similar?
19-53% (Bologna guidelines)
How may adhesions be classified?
Zuhkle classification
Grade 0 - none/insignificant
Grade 1 - Fimly adhesions dissected bluntly
Grade 2- mostly blunt and some sharp
Grade 3 - sharp dissection only with clear vascularisation
Grade 4 - dense adhesions with no planes and difficult to avoid damage
What is the Peritoneal adhesion index?
Grade of adhesions from 0-3 (similar to Zuhkle without the intermediate grade 2 from filmy to strong)
In 10 regions
therefore 0-30
What is the benefits of non-operative management of adhesive SBO?
Hajbandeh meta-analysis 2017
operation –> higher risk of mortality and complications
no difference in LoS or reintervention
What types of anti-adhesive can be used?
For open surgery
- seprafilm (carboxymethylcellulose)
For lap
-adept (icodextrin) liquid
How is WSCS useful in SBO?
Bologna guidelines 2017
- if no contrast in colon at >24 hours, cons mx likely to fail
- reduces need for surgery (OR 0.6)
- reduces LoS, time to resolution, no effect on complications
How should SBO be managed in pregnancy?
High rate of failure of cons mx (94%)
Risk of foetal loss of 17%
When should laparoscopy be attempted in sBO?
If surgery indicated and:
- sufficient expertise
- ≤ 2laparotomies in history
- expecting single band
Bologna guidelines 2017
How is appendicitis graded by the AAST?
1 - acutely inflamed 2 - gangrenous intact 3 - perforated local contamination 4 - perforated with phlegm or abscess 5 - perforated with generalised peritonitis
What are the Zone for insertion of a Reboa?
1: Descending thoracic aorta above renal
2: Infradiaphragmatic Juxtarenal
3: Infrarenal to bifurcation
What is the key mediator of acute traumatic coagulopathy?
APC
How is the ISS score calculated?
The square of the 3 highest AIS scores
Maximum of 75
>16 is major trauma
What percentage of blunt trauma in the UK is caused by falls and MVCs?
50% and 30%
What percentage of cardiac index is produced by internal and external chest compressions?
Internal 40%
External 20%
How can traumatic brain injury be graded by GCS?
≤8 Severe
9-12 Moderate
13-15 Mild
When can rivaroxaban be restarted following removal of epidural?
6 hours
