Trauma & ICU

Question 1

TEG R time, K time, alpha, MA, LY30

Answer 1

FFP, Cryo, Cryo, Platelets, TXA

Question 2

Cricothyroidotomy

Answer 2

Identify cricothyroid membrane
Horizontal stab incision through skin & cricothyoird
Place hook, retract larynx caudally
Place tracheostomy tube

Question 3

REBOA placement

Answer 3

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

Question 4

Anticoagulation reversal (warfarin, FXa inhibitors - xarelto/eliquis, dabigatran)

Answer 4

Question 5

Hard signs of vascular injury

Answer 5

Pulsatile bleeding
Bruit
Absent distal pulse
Expanding hematoma

NEVER FORGET NEURO EXAM

Question 6

Steps in every arterial repair

Answer 6

Proximal & distal control

Debride to healthy vessel

Confirm inflow/backflow

Heparinize

Place shunt & clamp

Repair

Check distal flow with doppler

Question 7

Neck trauma zones

Answer 7

Question 8

Penetrating carotid injury

Answer 8

<50% CAROTID INJURY → BOVINE PATCH; IF MORE, DO REVERSE SAPHENOUS GRAFT

Question 9

Blunt carotid injury

Answer 9

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)

Question 10

Tracheal injury

Answer 10

Repair in 1 layer with interrupted, absorbable suture

Question 11

Esophageal neck injury

Answer 11

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!!!!

Question 12

Pericardial tamponade/cardiac trauma management

Answer 12

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

Question 13

Indications for ED thoracotomy

Answer 13

Question 14

Steps in ED thoracotomy

Answer 14

1. Raise R arm above head
2. Incision from medial sternum to edge of bed, immediately below nipple in men, along IMF in women
3. Heavy scissors to cut through intercostals, staying superior to rib
4. Finochietto retractor
5. Open pericardium anteriorly & longitudinally to release any tamponade/examine heart, start cardiac massage, cross clamp aorta

Question 15

Indications for emergency thoractomy following chest tube

Answer 15

Initial chest tube output of 1500 mL of blood
Persistent drainage of 200 mL/hr for 4h

Question 16

Management of pulmonary vessel injury

Answer 16

1. Control hilum w clamp
2. Tractotomy by dividing lung between entrance/exit wounds with linear stapler, suture ligate vessels

Last resort is total pneumonectomy

Question 17

Exposure of tracheobronchial injuries - what do right & left posterolateral thoracotomies expose & what does a low collar incision expose

Answer 17

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)

Question 18

Exposure of great vessels

Answer 18

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

Question 19

Trauma laparotomy exploration

Answer 19

1. Inframesocolic
   - Lift TC cranially
   - Run bowel from ligament of trietz to rectum
   - Examine pelvic organs
2. Supramesocolic (Right to Left)
   - Liver, gallbladder, R kidney
   - Stomach, duodenum
   - Spleen, L kidney
   - Diaphragm
3. Lesser sac
   - Pancreas
   - Posterior stomach
4. Retroperitoneum

Question 20

Management of hematomas during an ex lap

Answer 20

Question 21

Management of RP hematomas

Answer 21

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

Question 22

Right medial visceral rotation

Answer 22

1. Mobilize hepatic flexure, extend dissection along white line of Toldt to mobilize right colon
2. Kocher maneuver to mobilize the duodenum & pancreatic head medially
3. Divide attachments between small bowel mesentery & RP toward LOT, gathering & retracting colon & small bowel cephalad & to the left

Question 23

Left medial visceral rotation

Answer 23

1. Retract L colon medially, incise white line of toldt to splenic flexure, sipe peritoneal contents downwards
2. Detach lateral attachments of spleen, medialize stomach, L colon, spleen, pancreas,+/- L kidney
3. Mobilize esophagus off supraceliac aorta anteriorly to isolate aorta for clamping; L crus of diaphragm can also be divided if needed

Question 24

Supraceliac aorta control

Answer 24

1. Open lesser sac through gastrohepatic ligament
2. Bluntly dissect stomach & esophagus from aorta

Question 25

Management of IVC injury

Answer 25

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

Question 26

Duodenal & pancreatic injuries

Answer 26

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

Question 27

Soft signs of vascular injury

Answer 27

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

Question 28

LE fasciotomies

Answer 28

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

Question 29

Pregnant trauma considerations

Answer 29

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

Question 30

Burn considerations: Initial management with rule of 9's & IVF, & labs

Answer 30

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%

Question 31

Burn considerations: Management of cyanide exposure, carbon monoxide poisoning, inhalation injury injury

Answer 31

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

Question 32

Burn considerations: Management of burns

Answer 32

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

Question 33

Liver failure work up

Answer 33

Work up - ask about drugs, travel, hx, ETOH Send off: Virus panel, auto-immune markers, tox screen, Acetaminophen level, serum copper & ceruloplasmin, serum ammonia

Question 34

Liver failure treatments if 2/2 HBV, acetaminophen, HSV/VAV, CMV

Answer 34

HBV - entecavir Acetaminophen - NAC HSV/VZV - Acyclovir CMV - Ganciclovir

Question 35

Management of elevated ICP in liver failure (likely if ammonia is >150 mcg/dL)

Answer 35

CPP = MAP - ICP Normal ICP is 10… > 20 needs treatment Want CPP > 60 1. Body position: HOB 30 degrees 2. Analgesia/sedation: Keep sedated, decrease stimulation, use propofol 3. Volume/fluids: Isotonic fluids, avoid volume overload, may need CRRT 4. BP: Use NE then vasopressin to increase MAP 5. Ventilation: Normal ventilation, hyperventilation may decrease ICP accutely, but goal CO2 35 6. Temperature: Keep T 35-36 degrees 7. IV 3% hypertonic NS to maintain Na<150. IV 25% mannitol to maintain serum Osm <320 mOsm/L

Question 36

TBI management alglorithm

Answer 36

Dont forget reversal agents if on AC, early TXA 1g over 10 minutes then 1g/8h, Keppra, early hypertonic saline bolus

Question 37

Diagnosis of SBP

Answer 37

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

Question 38

Acute liver failure management drugs (3)

Answer 38

Manage w IV PPI, Octreotide, Ceftriaxone