Trauma & ICU Flashcards
TEG R time, K time, alpha, MA, LY30
FFP, Cryo, Cryo, Platelets, TXA
Cricothyroidotomy
Identify cricothyroid membrane
Horizontal stab incision through skin & cricothyoird
Place hook, retract larynx caudally
Place tracheostomy tube
REBOA placement
Insert a femoral arterial line, then upsize to REBOA system by exchanging over wire
Flush catheter, ensure balloon is deflated, connect pressure port to arterial transducer
Advance peel away sheath to cover curled tip of catheter, then advance catheter
ZONE I: mid sternum or 46 cm
ZONE III: umbilicus or 26 cm
Obtain XR to confirm placement
Inflate with dilute contrast
ZONE I: 8 cc
ZONE III: 2 cc
Secure REBOA to catheter and patient
Mark time of inflation
Anticoagulation reversal (warfarin, FXa inhibitors - xarelto/eliquis, dabigatran)
Hard signs of vascular injury
Pulsatile bleeding
Bruit
Absent distal pulse
Expanding hematoma
NEVER FORGET NEURO EXAM
Steps in every arterial repair
Proximal & distal control
Debride to healthy vessel
Confirm inflow/backflow
Heparinize
Place shunt & clamp
Repair
Check distal flow with doppler
Neck trauma zones
Penetrating carotid injury
<50% CAROTID INJURY → BOVINE PATCH; IF MORE, DO REVERSE SAPHENOUS GRAFT
Blunt carotid injury
Grade I: <25% lumen narrowing → Antiplatelet & repeat CTA in 7 days
Grade II: > 25% lumen narrowing → Repair if possible, anticoagulation otherwise
Grade III: PSA → Repair surgically or endovascular
Grade IV: Occlusion → Repair within 24h
Grade V: Transection → Repair if possible, otherwise have to ligate (20% risk of stroke)
Tracheal injury
Repair in 1 layer with interrupted, absorbable suture
Esophageal neck injury
Place NGT, may need methylene blue to identify injury
Expose extent of mucosal injury, debride devitalized tissue
Close in multiple, absorbable layers
Buttress repair
Drains!!!!
Pericardial tamponade/cardiac trauma management
Do not intubate if pericardial tamponade/signs of extremis, get to OR
Temporize cardiac injury w finger/foley/stapler
Repair lacerations w 3-0 prolene on SH w pledgeted sutures in horizontal mattress
Indications for ED thoracotomy
Steps in ED thoracotomy
- Raise R arm above head
- Incision from medial sternum to edge of bed, immediately below nipple in men, along IMF in women
- Heavy scissors to cut through intercostals, staying superior to rib
- Finochietto retractor
- Open pericardium anteriorly & longitudinally to release any tamponade/examine heart, start cardiac massage, cross clamp aorta
Indications for emergency thoractomy following chest tube
Initial chest tube output of 1500 mL of blood
Persistent drainage of 200 mL/hr for 4h
Management of pulmonary vessel injury
- Control hilum w clamp
- Tractotomy by dividing lung between entrance/exit wounds with linear stapler, suture ligate vessels
Last resort is total pneumonectomy
Exposure of tracheobronchial injuries - what do right & left posterolateral thoracotomies expose & what does a low collar incision expose
Right posterolateral thoracotomy → Right mainstem, trachea, & proximal left mainstem
Left posterolateral thoracotomy → Distal left mainstem
Low collar incision (T) → Proximal 2/3 trachea, proximal innominate A & V (instead of median sternotomy)
Exposure of great vessels
MEDIAN STERNOTOMY
Ascending aorta
Proximal innominate A & V (R supraclavicular for distal control)
Proximal R SCA (R supraclavicular for distal control)
L ANTEROLATERAL THORA in 3rd ICS (L supraclavicular for distal control) - trapdoor incision
L SCA
R MIDCLAVICULAR INCISION & RESECTION OF MEDIAL CLAVICLE
Distal R SCA
Trauma laparotomy exploration
- Inframesocolic
- Lift TC cranially
- Run bowel from ligament of trietz to rectum
- Examine pelvic organs - Supramesocolic (Right to Left)
- Liver, gallbladder, R kidney
- Stomach, duodenum
- Spleen, L kidney
- Diaphragm - Lesser sac
- Pancreas
- Posterior stomach - Retroperitoneum
Management of hematomas during an ex lap
Management of RP hematomas
Zone I: Midline RP (aorta & IVC) → Always explore
Zone II: Lateral RP (kidney, adrenals) → Selectively explore for penetrating & blunt (ie expanding hematoma or active hemorrhage); mobilize colon to rule out RP colonic injury
Zone III: Pelvic RP (pelvic vessels) → Explore for penetrating only
Right medial visceral rotation
- Mobilize hepatic flexure, extend dissection along white line of Toldt to mobilize right colon
- Kocher maneuver to mobilize the duodenum & pancreatic head medially
- Divide attachments between small bowel mesentery & RP toward LOT, gathering & retracting colon & small bowel cephalad & to the left
Left medial visceral rotation
- Retract L colon medially, incise white line of toldt to splenic flexure, sipe peritoneal contents downwards
- Detach lateral attachments of spleen, medialize stomach, L colon, spleen, pancreas,+/- L kidney
- Mobilize esophagus off supraceliac aorta anteriorly to isolate aorta for clamping; L crus of diaphragm can also be divided if needed
Supraceliac aorta control
- Open lesser sac through gastrohepatic ligament
- Bluntly dissect stomach & esophagus from aorta
Management of IVC injury
Before releasing tamponade, confirm w anesthesia they are ready for MBL
Control IVC with sponge sticks
Longitudinal venotomy through injury to repair IVC
Bovine pericardium to repair IVC if concern for restriction
Ligating the IVC is ok, need fasciotomies; no shunts. If rock solid stable, can use PTFE
Lower IVC injuries @ bifurcation may need to ligate R CIA to get adequate exposure but need to heparinize
Duodenal & pancreatic injuries
Two questions
Determine if CBD involved (pass catheter through cystic duct to identify); if involved, will likely need Whipple (staged) vs duodenal diverticulization
Can it be repaired primarily?
Try to get primary repair or anastomosis
If in 2nd portion of duodenum & can’t get primary repair
-If small, temporize with jejunal serosal patch; may need Whipple in future vs Roux en Y DJ
-Leave drains!!!
-Pass feeding tube distally
Soft signs of vascular injury
proximity of injury to artery
history of “significant” or arterial bleeding at the scene
diminished pulses
small nonpulsatile hematoma
fracture
knee dislocation
questionable neurological deficit
LE fasciotomies
Medial incision
- Open superficial posterior compartment along gastrocnemius fascia
- Open deep posterior compartment by dividing soleus muscle from tibia
Lateral incision, ending 5 cm below fibular neck to avoid injury to superficial peroneal nerve
- Open anterior compartment along intermuscular septum
- Open lateral compartment with second longitudinal fasciotomy
Pregnant trauma considerations
If viable (>23 weeks), in addition to ATLS:
Send Type/Screen & Fibrinogen
Assess fundal height & tenderness (Fundus reaches umbilicus at 20 weeks)
Assess vagina for signs of bleeding/amniotic fluid
Fetal monitoring - need at least 4 hours
All RhD NEGATIVE trauma patients need anti-D immunoglobulin (RhoGam) & Kleihauer Betke test
Quantifies size of fetomaternal hemorrhage
Used to calculate dosage of RhoGAM
Burn considerations: Initial management with rule of 9’s & IVF, & labs
Rule of 9’s to estimate burn size
Send carboxyhemoglobin with full labs
Calculate fluid needs in next 24h
Parkland formula: 4mL x TBSA (%) x weight (kg) → half over first 8h, half over next 16h
Consensus formula is half that…
2mL x TBSA (%) x weight (kg)
→ half over first 8h
Monitor over next 8 hours, if UO is >50 mL/hr, titrate fluid down 10-20%, if it is <30 mL/hr, titrate up 10-20%
Burn considerations: Management of cyanide exposure, carbon monoxide poisoning, inhalation injury injury
PLACE ON 100% humidified Oxygen
CYANIDE EXPOSURE
Persistently elevated Lactate & acidosis; difficult to diagnose
Tx w IV hydroxocobalamin or cyanokit
CARBON MONOXIDE POISONING
Elevated CARBOXYHEMOGLOBIN; trend until falls below 5%
60% - brain death
20% - confusion
10% - normal for smokers
5% - normal for nonsmokers
Supportive care + Hyperbaric oxygen if able
Bronchoscopy should be performed early to assess for inhalation injury
-Bronchodilators - albuterol q4h
-Mucolytic agents - nebulized NAC
-Nebulized heparin
Burn considerations: Management of burns
Assess burn size & depth
Burns >30% should go to OR within 24 hours for excision
Escharotomies for full thickness burns
Incise skin through dermis - looking for dermal separation
Use electrocautery
Keep affected extremities elevated
Excise burns in OR within 24 hours; tangential excision to healthy tissue in 2 staged approach
-First operation is to reduce burden of dead/unhealthy issue to minimize inflammatory response. Cover with integra or cadaveric skin, secure with staples
-Second operation is skin grafting. Use a dermatome to harvest STSG
Prep donor site, ensure clean and smooth surface
Measure out size of graft needed & draw, usually 3-4 inch plate
Set dermatome to 0.015 inches
Apply to 45 degree angle
Mesh grafting 3:1 or 4:1
Secure graft with fibrin glue +/- staples & bolster dressing
Cover donor site with epinephrine telfa then dress with mepilex
Keep graft immobilized for at least 48 hours
Liver failure work up
Work up - ask about drugs, travel, hx, ETOH
Send off:
Virus panel, auto-immune markers, tox screen, Acetaminophen level, serum copper & ceruloplasmin, serum ammonia
Liver failure treatments if 2/2 HBV, acetaminophen, HSV/VAV, CMV
HBV - entecavir
Acetaminophen - NAC
HSV/VZV - Acyclovir
CMV - Ganciclovir
Management of elevated ICP in liver failure (likely if ammonia is >150 mcg/dL)
CPP = MAP - ICP
Normal ICP is 10… > 20 needs treatment
Want CPP > 60
- Body position: HOB 30 degrees
- Analgesia/sedation: Keep sedated, decrease stimulation, use propofol
- Volume/fluids: Isotonic fluids, avoid volume overload, may need CRRT
- BP: Use NE then vasopressin to increase MAP
- Ventilation: Normal ventilation, hyperventilation may decrease ICP accutely, but goal CO2 35
- Temperature: Keep T 35-36 degrees
- IV 3% hypertonic NS to maintain Na<150. IV 25% mannitol to maintain serum Osm <320 mOsm/L
TBI management alglorithm
Dont forget reversal agents if on AC, early TXA 1g over 10 minutes then 1g/8h, Keppra, early hypertonic saline bolus
Diagnosis of SBP
Primary: Polymorphonuclear leukocyte (PMN) count of > 250 cells/mcL (0.25 × 10 9/L) is diagnostic of SBP
Secondary: 2 or more present
Total protein >1
Glucose < 50
LDH above upper limit of normal for serum
Acute liver failure management drugs (3)
Manage w IV PPI, Octreotide, Ceftriaxone
