trauma, inflammation, wound healing, burn, skin ICU Flashcards
phases of inflammation
injury-> exposed collagen-> plt activating factor release and tissue factor release from endothelium-> platelets bind collagen-> release growth factors (ie-ptl-derived GF PDGR)-> PMN and macrophage recruitment
role of macrophages in wound healing- what do they release
dominant role, release PDGF (plt derived GF) and cytokines (IL-1 and TNF-alpha)
Growth and activating factors in inflammation: role of the following1) PDGF (platelet derived growth factor)2) EGF (epidermal growth factor)3) FGF (fibroblastic growth factor)4) PAF (platelet-activating factor)
1) chemotactic and activates inflammatory cells (PMNs and macrophages) and activates fibroblasts-> ECM proteins and collagen. Imp for angiogenesis and epithelialization. Chemotactic for smooth muscle cells. accelerates wound healing2, 3) Chemotactic, activates fibroblasts, angiogenesis, epithelialization4) generated by phospholipase in endothelium (a phospholipid) which is chemotactic for inflam cells and inc adhesion mlqs
1) what are the chemotactic factors for inflammatory cells2) for fibroblasts3) angiogenesis factors4) epithelialization factors
1) PDGF, IL-8, LTB-4, C5a and C3a, PAF2) PDGF, EGF, FGF3) PDGF, EGF, FGF, IL-8 and hypoxia4) PDGF, EGF, FGF
1) How long do PMNs last in tissues and in blood2) how long do platelets last3) lymphocyte role in inflammation
1) 1-2 days in tissues, 7 days in blood2) 7-10 days3) involved in chronic inflammation (T cells) and Ab production (B cells)
Type 1 hypersensitivity rx:1) role of eosinophils2) what type of infections have increased eosinophils3) role of basophils, where aren’t they found4) Mast cells role5) role of histamine6) role of bradykinin7) what inactivates bradykinin and where is it found
1) release major basic protien once bound to allergin-> stimulates basophils and mast cells to release histamine2) parasitic3) main source of histamine in blood (not in tissue)4) main source of histamine in tissues, primary cell in type 1 hypersensitivity5) vasodilation, tissue edema, postcapillary leakage; primary effector type in type I hypersensitivity rxs (allergic rxs)6) peripheral vasodilation, increased permeability, pain, pulm vasoconstriction7) Angiotensin-converting enzyme located in lung
Nitric oxide1) what is its precursor2) what does it activate and end effect3) another name for it4) what has the opposite effect of NO
1) Arginine2) guanulate cyclase-> inc cGMP-> vascular smooth muscle dilation3) endothelium-derived relaxing factor4) Endothelin-> vascular smooth muscle constriction
cytokines1) main initial cytokine resonse to injury and infection is release of
1) TNF-alpha and IL-1
cytokines1) largest producer of TNF2) role of TNF-alpha3) what can high concentrations of TNF-a cause4) largest producer of IL-15) effects of IL-1 and what does it synergize with6) which cytokine causes cachexia in CA pts7) which cytokine is responsible for fever and how?8) how do NSAIDS reduce fever9) role of IL-6
1) Macrophages2) increases adhesion mlqs, procoagulant, activates neutrophils and macs-> more cytokine production and cell recruitment3) circulatory collapse and multisystem organ failure4) macs5) same as TNF-alpha, synergizes with TNF-alpha6) TNF-alpha7) IL-1 (how alveolar macs cause fever with atelectasis), PGE2 mediated in hypothalamus8) reduce PGE2 synthesis9) increases hepatic acute phase proteins (CRP, amyloid A -> activate complement), decreases albumin, pre-albumin and transferrin
Interferons1) what are they released by2) what stimulates release3) effect of release
1) lymphocytes2) viral infection or other stimulants3) activate macs, NK cells and cytotoxic T cells-> inhibit viral replication
Cell adhesion mlqs- where are they located, what they bind and type of adhesion1)Selectins2) Beta-2 integrins (CD11/18 molecules)3) ICAM, VCAM, PECAM, ELAM
1) L-selectins on leukocytes bind E- (endothelial) and P-(platelet) selectins-> rolling adhesion2) on leukocytes, bind ICAM etc-> anchoring adhesion3) on endothelial cells, bind beta-2 integrin mlqs located on leukocytes and platelets. Also involved in transendothelial migration
Complement- what activates the following pathways and what factors are only in each one1) classic pathway2) alternative pathway3) what complement factor is common to both pathways4) what electrolyte is required for both pathways
1) (IgG or IgM) Ag-Ab complex activates. Factors C1, C2, C42) endotoxin, bacteria, other stimuli activate. Factors B, D and P (properdin)3) C34) Mg
Complement1) factors that are anaphylatoxins and actions2) membrane attack complex factors and actions3) opsonization factors and action4) factors involved in chemotaxis for inflammatory cells
1) C3a, C4a, C5a. increase vascular permeability, bronchoconstriction and activate mast cells and basophils2) C5b-9b-> cell lysis (usually bacteria) by creating hole in the membrane3) C3b and C4b- targets Ag for immune response4) C3a and C5a
Prostaglandins1) precursor2) LTC4, LTD4, and LTE4 actions3) LTB4 actions
1) arachidonic precursors2) slow-reacting substances of anaphylaxis, bronchoconstriction, vasoconstriction followed by increased permeability3) chemotactic for inflammatory cells
Catecholamines1) when after injury do they peak2) where is norepinephrine released?2) where is epinephrine released?
1) 24-48hours2) sympathetic postganglionic neurons and adrenal medulla3) adrenal medulla (neural response to injury)
T/F thyroid hormone plays a major role in injury/inflammation
false
neuroendocrine response to injury
afferent nerves from site of injury stimulate CRF, ACTH, ADH, growth hormone, epi and norepi release
CXC chemokines1) what are they2) what is their role3)what does CXC stand for
1) IL-8 and platelet factor 42) chemotaxis, angiogenesis, wound healing3) C=cysteine, X= another amino acid
1) what oxidants are generated in inflammation2) what are cellular defenses against oxidative species
1) superoxide anion radical (NADPH oxidase), hydrogen peroxide (xanthine oxidase)2)superoxide anion radical- defense is superoxide dismutasehydrogen peroxide- defence is glutathione peroxidase, catalase
primary mediator of reperfusion injury
PMNs
Chronic granulomatous disease:1) enzyme defect and result
NADPH-oxidase system enzyme defect in PMNs-> decreased superoxide radical formation-> increased infection from bacteria and fungi
stages of wound healing- cells involved, what happens during each and time frame1)Inflammation2)proliferation3) remodeling
1) days 1-10. PMNs, macs. Epithelialization (1-2mm/day)2) 5days-3wks. fibroblasts. collagen deposition, neovascularization, granulation tissue formation; type III collagen replaced with type 13)3wk to 1 year. decreased vascularity. net amount of collagen unchanged despite sig production and degradation
rate of1) epithelialization2) peripheral nerve regeneration
1)1-2 mm/day2) 1mm/day
order of cell arrival in wound: PMNs, lymphoctes, macs, fibroblasts, platelets
1) platelets2) PMNs3) Macrophages4) lymphocytes5) fibroblasts
role of the following in wound healing1) macrophages2) fibronectin2) fibroblasts
1) release growth factors, cytokines, etc2) chemotactic for macs; anchors fibroblasts3) replace fibronectin-fibrin with collagen
predominant cell type by day:1) day 0-22) days 3-43)days 5+
1)PMNs2)macrophages3)fibroblasts
1) composition of the platelet plug2) composition of provisional matrix3) what wounds show accelerated wound healing
1) platelets and fibrin2) platelets, fibrin and fibronectin3)reopened wounds bc healing cells already present
Open wounds1) most imp factor in healing open wounds2) where does epithelium migrate from
1) epithelial integrity2)hair follicles (#1 site), wound edges and sweat glands-dependent on granulation tissue in wound-unepithelialized wounds leak serum and protein and promote bacteria
closed wounds1)most imp factor in healing
tensile strength- depends on collagen eposition and cross-linking of collagen
1) which layer of bowel provides the strength2) what is weakest time point for small bowel anastamosis
1) submucosa2) 3-5days
myofibroblasts- what are they, how do they communicate and what part of wound healing are they involved in
smooth muscle cell fibroblast. communicate by gap junction. Involved in wound contraction and healing by secondary intention.
t/F: perineum has better wound contraction than leg
true
which type of collagen is:1)MC type, found in skin, bone and tendons. Primary collagen in healed wound2) widepread, particularly found in cornea3) increased in healing wound, also in blood vessels and skin4) basement membranes5) cartilage
1) type I2) type V3) type III4) type IV4) type II
1) what aa improves wound tensile strength2) which of the following are not required for hydroxylation and subsequent cross-linking of proline residues: Alpha-ketoglutarate, Magnesium, Vitamin C, Oxygen and Iron
1) proline cross-linking. collagen has proline every 3rd aa.2) Magnesium
cause of scurvy
Vit C deficiency
1) max tensile strength of healed wound compared to pre-wound skin2) what is predominant collagen over days 1-23) collagen over days 3-44) at what point has all of the type of collagen in #2 been replaced by the collagen in #35)when does wound reach max tensile strength6) what inhibits collagen cross-linking
1) 80%2) III3) I4) 3 weeks5) 8 weeks6) d-Penicillamine
optimal wound healing1) is dry or moist environment better2)how to inc O2 delivery3)effect of edema4) which vitamin counteracts the effects of steroids on wound healing5) what amount of bacteria impedes wound healing and why6) what drugs impair wound healing in 1st 14d after injury
1) moist2) optimize fluids, no smoking, pain control, supp O2, arterial revascularization3) avoid it by leg elevation4) vit A5) >10^5 2/2 dec O2 content, collagen lysis, prolonged inflammation6) cytotoxic drugs- 5FU, methotrexate, cyclosporin, FK-506
1) how does DM contribute to poor wound healing2) what albumin level sig risk for poor wound healing3)mechanism via which steroids inhibit wound healing
1)impedes early-phase inflammation response (hyperglycemia causes poor leukocyte chemotaxis)2) dec tensile strength
Diseases associated with abnormal wound healing- name the defect1) Osteogenesis Imperfecta2) Ehlers-Danlos syndrome3) Marfan’s syndrome4) Epidermolysis bullosa and rx5) Scurvy6) what extraintestinal manifestation of IBD is associated with abnl wound healing
1) Type I collagen defect2) 10 types identifies, all collagen3) fibrillin defect (connective tissue protein)4) excessive fibroblasts. rx- phenytoin5) vit C def6) Pyoderma gangrenosum
Diabetic foot ulcers1) where they most commonly occur2) 2/2 what?3) cause of 90% of leg ulcers and rx
1) Charcot’s joint (2nd MTP joint) MC, also on toes2)peripheral neuropathy (can’t feel-> pressure from walking-> ischemia)3)venous insufficiency. rx- Unna boot (elastic wrap)
1) what are scars made of2) when to do scar revisions3) what pts heal with little to no scarring
1) proteoglycans, hyaluronic acid and water2) wait 1 year to allow for maturation, may improve with age3) infants
1) how does cartilage get nutrients and oxygen2) does denervation effect wound healing3) does chemo affect wound healing
1) diffusion. Doesn’t have blood vessels2)no3) no effect on healing after 14 days
Keloids1) inheritance pattern2) difference bw them and hypertrophic scars3) rx4) rx hypertrophic scars5) when do hypertrophic scars occur
1) autosomal dominant, more common in dark skinned ppl2) in keloids collagen goes beyond original scar where as hypertrophic scar collagen is confined to original scar3) intra-lesion steroid injection, silicone, pressure garments, XRT4) steroid injection, silicone, pressure garments5) burns or wounds that take a long time to heal
Platelet granules:1) what are the alpha granules and what is their role2) dense granules3) platelet aggregation factors
1) platelet factor 4- aggregationbeta thrombomodulin- binds thrombinplatelet derived growth factor- chemoattractantTransforming growth factor beta (TGF-beta)- modulates above responses2) adenosine, serotonin and Ca3) TXA2, thrombin, platelet factor 4
Trauma deaths by time after injury1) when does 1st peak occur and associated injuries2) when does 2nd peak occur and associated injuries3) when does 3rd peak occur and associated injuries
1) 0-30min- lac of heart, aorta, brain, brainstem, spinal cord. no hope to save2)30min-4hr-head injury (#1), hemorrhage (#2)- golden hour. pts can be saved with rapid assessment3)days to weeks-multi system organ failure and sepsis
1) what % of trauma is blunt injury and what is most commonly injured organ2) most commonly injured organ in penetrating injury3) biggest predictors of survival after fall4) what is the median lethal dose for fall (LD50)
1) 80%. Liver (although some texts say spleen)2) small bowel (some texts say liver3) age and body orientation4) 4 stories
kinetic energy calculation
1/2 MV^2; M=mass, V=velocity
1) when will you see a change in BP with hemorrhage?2) resuscitation- when to switch to blood
1) >30% blood loss2) 2L LR then switch to blood
MC cause of 1) death after reaching ER alive2) death long term3) upper airway obstruction
1) head injury2) infection3) tongue
1) injuries from seat belts2) best site for cutdown for venous access3) positive DPL- what makes it +4) what does DPL miss5) where to do DPL if pelvic fracture6) when might you get a false negative FAST
1) small bowel perf, lumbar spine fx, sternal fx2) saphenous vein at ankle3) >10cc blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500WBC/cc4) retroperitoneal bleeds, contained hematomas5) supraumbilical6) free fluid
1) where might pts with hypoTN and neg FAST be bleeding2) when do you need a CT scan following blunt trauma3) what might a CT scan miss in trauma4) when to go to OR for laparotomy (which doesn’t require it: peritonitis, evisceration, positive DPL, uncontrolled visceral hemorrhage, free air, diaphragm injury, indeterminant FAST, intraperitoneal bladder injury, contrast extravasation from hollow viscus, specific renal/pancreas/biliary tract injuries
1) pelvic fx, chest, extremity2) abdominal pain, need for gen anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria, negative DPL3) hollow viscus or diaphragm injury4) negative FAST
1) abdominal injuries- when do you need to go to the OR2) first step after pt with penetrating anterior abd trauma, no obv peritonitis/eviscer and local wound exploration shows fascial violation or equivocal
1) any penetrating abd injury (GSW, evisceration), local wound exploration with fascial violation or equivocal. If no fascial violation can observe2) diagnostic laparoscopy. If peritoneal violation-> explore. if no peritoneal violation-> d/c after recovery
Abdominal compartment syndrome1) when do you see it2) bladder pressure3) cause of decreased cardiac output4) result of low Cardiac output5) effect on ventilation/why?6) rx
1) after massive fluid resuscitation, trauma or abdominal surgery2) >25-303) IVC compression4) visceral and renal malperfusion-> dec UOP5) upward displacement of diaphragm affects ventilaton6) decompressive laparotomy
1) when to use Pneumatic antishock garment2) when to do ER thoracotomy aftera-blunt traumab-penetrating tauma3) how to perform thoracotomy4) when should pt be transfered to OR after ED thoracotomy
1) pts with SBP70mmHg, if not situation is futile
1) when do catecholamines peak after injury2) change in ADH, ACTH and glucagon after trauma3) type specific blood- why do ppl get reactions to it4)What should you do for all GCS </= 8
1) 24-48 hours2) fight or flight response-> increase ADH, etc3) blood is nonscreened, non cross-matched so can get effects from abs to HLA minor Ag in the donated blood4) Head CT5) Intubate6) ICP monitor
Epidural hematoma1) artery injured MC2) shape on head CT3) clinical picture4) when to operate
1) middle meningeal artery2) lenticular deformity3) LOC-> lucid interval-> sudden deterioration (vomiting, LOC, restlessness)4) significant neurologic degeneration or significant mass effect (shift >5 mm)
subderal hematoma1) vessel injured2) shape on CT3) when to go to OR4) who gets chronic subdural hematomas
1) tearing of venous plexus (bridging veins bw dura and arachnoid)2) crescent-shaped3) sig neurologic degeneration or mass effect (>1cm shift)
intracerebral hematoma-1) where does it usually occur2) when to operate3) type of injury with coup and countrecoup lesions
1) frontal or temporal2) significant mass effect3) cerebral contusion
1) treatment for traumatic intraventricular hemorrhage2) how to dxs diffuse axonal injury, treatment and prognosis
1) ventriculostomy if causing hydrocephalus2)MRI better than CT. Tx- supportive, craniectomy if elevated ICP, very poor prognosis
How to calculate Cerbral Perfusion Pressure (CPP)
CPP=MAP- ICP (intracranial pressure)
When to use an ICP monitor
GCS<=8, suspected inc ICP (dec ventricular size, loss of sulci, loss of cisterns) or pt with moderate to severe head injury and inability to follow clinical exam (ie- intubated pt)
1) Normal ICP2) When to treat ICP3) where to keep CPP
1) 102) >203) >60
How to increases Cerbral perfusion pressure? which of the following won’t:sedation and paralysislower head of bedrelative hyperventilation (CO2 30-35)MannitolBarbituate comaventriculostomy with CSF drainagecraniotomy decompression
must RAISE the head of the bed to increase CPP
1) which side is the temporal pressure increased in for a dilated pupil2)when does peak ICP occur3) what can be given prophylactically to prevent seizures with moderate to severe head injury4) how to dose mannitol5) what level to keep Na and serum Osm in head injury pts
1) same side (CNIII, oculomotor compression)2) 48-72hr after injury3) keppra and fosphenytoin4) load 1g/kg, give 0.25mg/kg q4hr after that (draws fluid from brain)5) Na 140-150. Serum Osm 295-310 (may need to use hypertonic saline)
1) What do Racoon eyes signal?2) Battle’s sign? and what is management3) Nerve injured in basal skull fracture4) nerves injured in temporal skull fx5) what kind of blows are associated with temporal skull fx6) when to operate for skull fx7) cause of coagulopthy in traumatic brain injury8) most common site of fascial nerve injury
1) per-orbital ecchymosis, anterior fossa fx2) mastoid echymossis- middle fossa fx; can injure facial nerve CNVII. rx-if acute facial nerve injury, need exploration and repair. if delayed, likely 2/2 edema and exploration not needed3) CN VII4) CNVII and VIII (vestibulocochlear nerve)5) orbital or lateral skull blows6) if signficantly depressed (>1cm), contaminated, or persistant CSF leak no responding to conservative therapy (lumbar CSF drainage)7) release of tissue factor8) geniculate ganglion
Spine trauma1) Jefferson fracture- what level, cause, rx2) Hangman’s fracture- level, cause, rx3)odontoid fx- level, 3 types and rx4) Facet fx/dislocation- how they occur and what else can be injured?
1) C1 burst 2/2 axial loading. Tx- rigid collar2) C2- caused by distraction and extension. rx- traction and halo3) C2. Type 1- above base, stable; Type 2- at base, unstable (need fusion or halo); Type 3- extends into vertebral body (needs fusion or halo)4) Can cause cord injury; associated with hyperextension and rotation with ligamentous disruption
Thoracolumbar Spine1) what comprises the 3 columns of the thoracolumbar spine?2) when is thoracolumbar spine considered unstable3) what column is affected by compression (wedge) fx?4) what fx is unstable and rx5) what fx is stable
1) Anterior- anterior logitudinal ligament and anterior 1/2 of vertebral bodyMiddle- posterior 1/2 of vertebral body and posterior logitudinal ligamentPosterior- facet joints, lamina, spinous processes, interspinous ligament2) if >1 column disrupted3) anterior column only, stable4) Burst fractures (>1 column) require spinal fusion5) Compression (wedge) fx
1) bones that are at risk for injury in upright fall2) when in spinal injury should you get an MRI?3) indications for emergent spinal decompression
1) calcaneous, lumbar, wrist/forearm2) neuro defects w/o bony injury to eval for ligamentous injury3) fracture/dislocation not reducible with distraction, open fx, soft tissue or bony compression of cord, progressive neuro dysfnc
1) most common cause of facial nerve injury in trauma2) technique for repairing facial lacerations3) Le Fort Classification of Facial Fractures I-III. describe. what is the rx
1) temporal bone fx2) preserve skin and don’t trim edges3) Le Fort I- maxillary fx straifht across (-). rx- reduce, stabilize, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires. Le Fort II- lateral to nasal bone, underneath eyes, diagonal toward maxilla (/ ). rx same as ILe Fort III-lateral orbital walls (- -). rx-suspension wiring to stablize frontal bone, may need external fixation
1) what type of facial fx have a 70% CSF leak and rx of CSF leak2) rx of nose bleeds
1) nasoethmoidal orbital fx. conservative therapy for up to 2 weeks. Can try epidural catheter to dec CSF pressure and help leak close, may need surgical closure of dura if above fail2) anterior- packingposterior- try balloon tamponade 1st. May need angioembolization of internal maxillary artery or ethmoidal artery
1) rx of orbital blowout fx and who needs repair2) Tripod fx- what is it and how to repair3) T/F: pts with maxillofacial fx are at high risk for cervical spine injuries
1) repair pts with upward gaze or diplopia with upward vision. rx- restoration of orbital floor with bone fragments or bone graft2) Zygomatic bone fx- ORIF for cosmesis3) True
1) what is the #1 indicator of Mandibular injury2) how to diagnose mandibular injury3) rx
1) malocclusion2) fine0cut facial CT with reconstruction3) IMF (intramaxillary fixation- metal arch bars to upper and lower dental arches for 6-8wks) or ORIF
Neck Trauma1) 3 neck zones of injury2) study to get in asymptomatic pt with blunt injury3) in asymptomatic penetrating (by 3 neck zones)4) in symptomatic blunt or penetrating injury (shock, bleeding, expanding hematoma, losing or lost airway, subq air, stridor, dysphagia, hemoptysis, neuro defect
1)ZOne I- clavical to cricoid cartilage. Zone II- Cricoid to angle of mandible. Zone III- angle of mandible to base of skull2) neck CT3) Zone I- (greater potential for intrathoracic great vessel injury) angiography, bronchoscopy, esophagoscopy and barium swallow. pericardial window may be indicated. May need medium sternotomy to reach lesionsZOne II-neck exploration in ORZone III-angiography and laryngoscopy. May need jaw subluxatin/digastric and SCM muscle release/mastoid sinus resection to reach vascular injuries in this location4) neck exploration in OR immediately
Esophageal injury1) how to diagnose2) rx of contained injuries3) rx of non-contained injuries if:a- small injury, minimal contaminationb- extensive injury or contamination4) Approach to esophageal injuries in:a- the neckb- upper 2/3 of thoracic esophagusc- lower 1/3 of thoracic esophagus
1) hardest neck injury to find. Do esophagoscopy and esophagogram (finds 95% of injuries when combined)2) observe3) a-primary closure. b-if in neck- just place drain (will heal). if in chest- chest tubes to drain injury and place spit fistula in neck (eventually will need esophagectomy)4) a-left side, b- right thoracotomy, c- left thoracotomy
Laryngeal fracture and tracheal injuries1) sx2) are these non-urgent, urgent or emergent?3) rx
1) stridor, crepitus, resp compramise2) emergent3) secure airway in ER (usually cricothydoidotomy). then primary repair (can use strap muscle for airway support) _ tracheostomy for most to allow edema to subside and check for stricture (convert the cric to a trach)
1) rx of thyroid gland injury2) rx of recurrent laryngeal nerve injury3) management of shotgun injures to neck4) of vertebral artery bleeds5) common carotid bleeds and complication
1) control bleed and drain (NOT thyroidectomy)2) try to repair or reimplant in cricoarytenoid muscle)3) get angiogram and neck CT, esophagus and trach evaluation4) embolize or ligate without any sequela5) ligation causes stroke in 20%
Chest trauma:1) when to go to OR for thoracotomy after CT placement2) how quickly do you need to drain blood in hemothorax and why3) management of unresolved hemothorax after 2 well-placed drains
1) >1500 cc after initial insertion in one side, >250cc/hr for 3 hours, >2500cc/24 hr or bleeding with instability2)
Sucking chest wound1) how big does it need to be to be clinically significant2) rx
1) >2/3 diameter of trachea2) cover wound with dressing that has tape on 3 sides to prevent tension pneumo
1) what should you think about if pt has worsening oxygenation after chest tube placement2) T/F Bronchus injuries are more common on the right3) dx of thracheobronchial injury4) rx- indications for repair and how to repair (type of incision)
1) tracheobronchial injury. one of the few indications to clamp NGT2) True3) bronchoscopy4) may need to mainstem intubate pt on unaggected side repair if large air leak and respirator compromise or after 2 weeks of persistent air leak.-right thoracotomy for right mainstem, trachea and and proximal left mainstem injuries (avoids aorta)-left thoracotomy for distal left mainstem injuries
Injuries of the diaphragm1) where are they more common?2) more common in blunt or penetrating trauma?3) signs on CXR4) type of approach for repair
1) on left2) blunt trauma3) air-fluid level in chest from stomach herniation4) transabdominal if 1wk bc will have to take down adhesions in the chest. May need mesh
1) what am I: widened mediastinum, 1st or 2nd rib fx, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to the right
1) aortic transection
1) where is aortic transection most common2) how good is CXR at diagnosing?3) when should you do aortic evaluation if nl CXR4) Dx of aortic transection5) operative approach6) if pt has aortic transection and + DPL twhat should be addressed first
1) ligamentum arteriosum (just distal to subclavian takeoff) is MC. also seen near ortic valve and where aorta traverses diaphragm2) nl in 5%3) significant mechanism (head on car crash >45 mph, fall >15ft)4) CT angio chest5) left thoracotomy and repair with left heart bypass of place covered stent endograft (distal transections only)6) abdominal ex-lap first. Rx other life-threatening injuries first.
What am I?: widened mediastinum, 1st or 2nd rib fx, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to the right
aortic transection
Aortic transection1) MC place for tear and other places2) How good is CXR at detecting3) Diagnostic study4) operative approach5) T/F: you can not defer treatment to treat other life-threatening injuries or positive DPL first
1) ligamentum arteriosum just distal to subclavian takeoff (MC). Also, near aortic valve where aorta traverses diaphragm2) misses 5%, need evaluation of aorta for pts with sig mech (head on car crash >45mph or fall >15ft3) CT angio chest4) left thoracotomy and repair with partial L heart bypass or place a covered stent endograft (distal transections only)5) false, you can defer for other life-threatening injuries
what operative approach should you use for the following injuries:1) ascending aorta, innominate artery, proximal right subclavian artery, inominate vein, proximal left common carotid2) left subclavian artery, descending aorta3) distal right subclavian artery
1) median sternotomy2) left thoracotomy3) midclavicular incision with removal of medial clavical
Myocardial contusion1) what is MC cause of death2) MC arrhythmia seen3) how long to monitor and when is risk highest
1) v-tach and v-fib2) SVT3) risk highest in 1st 24 hours, monitor for 24-48hrs
1) flail chest ddefinition and rx and biggest pulm impairment2) T/F: aspiration produces immediate CXR findings
1) 2+ consecutive rib fx with 2+ break sites. rx- occlusive dressing taped at 3 sides. can result in underlying pulm contusion2) false- may not be immediate
Penetrating Chest injuries1) first imaging study in stable pts2) penetrating “box” injuries- location and studies to do to dx injuries3) penetrating chest wound outside box w/o pneumo or hemothorax- what to do4) what to do if find blood on doing pericardial window?5) when do you need to go to OR for laparoscopy or laparotomy
1) CXR (if pneumothorax or hemothorax place a chest tube)2) borders are clavicles, xiphoid process, nipples-do pericardial window, bronchoscopy, esophagoschopy, barium swallow3) need chest tube if pt req intubation otherwise just follow serial CXR4) median sternotomy to fix possible injury to heart or great vessels, place pericardial drain5) penetrating injuries anterior-medial to midaxillary line below the nipples (may also need penetrating box injury eval)
1) traumatic causes of cardiogenic shock2) tension pneumo: what do you see for BP, airway pressures, breath sounds, neck veins, trachea3) cause of cardiac compromise in tension pneumo4) pts with what type of fx are at high risk for cardiac contusion5) what fx put pt at high risk for aortic transection
1) tension pneumo, cardiac tamponade, cardiac contusion2) hypotension, inc airway pressures, dec breath sounds, bulging neck veins, tracheal shift3) 2/2 ICV/SVC compression-> dec venous return4) sternal5) 1st and 2nd rib fx
Pelvic trauma1) what to do with hemodynamically unstable with pelvic fx and negative DPL, CXR and not other signs of blood loss or reason for shock2) what other structures may be injured3) 3 types of fx, mortality and bld loss
1) stabilize pelvis (C-clamp, external fixator, sheet) and go to angio for embolization2) genitourinary and abdominal injuries3) Type I- crush, unstable, mortality 20-30%, blood loss >10unitsType II- verticle incision completely transecting, unstable, mortality 8-12%, blood loss 2-10uType III- fx in rami, etc that doesn’t transect entire pelvis. stable.
Pelvic trauma1) can repair be delayed for other injuries2) Intra-op management of penetrating injury pelvic hematomas3) Intra-op management of blunt injury pelvic hematomas
1) yes2) open (can angio)3) leave. if expanding or unstable-> stabilize fx, pack if in OR and go to angio for embolization. remove packs after 24-48hr
Duodenal Trauma1) MC cause of injury2) MC area injured3) MC rx4) for what section is segmental resection with primary end-to-end closure not possible5) mortality6) MC source of morbidity
1) blunt (crash or deceleration injury)2) 2nd portion (descending portion near ampulla of Vater)3) 80% get debridement and primary closure4) second portion of duodenum5) 25%6) fistulas
1) rx of intra-op paraduodenal hematomas and where they are located with blunt injury2) presentation, dx and rx of paraduodenal hemotomas
1) 2+cm is significant- open for both blunt and penetrating (usually in third portion of duodenum overlying spine in blunt injury)2)SBO 12-72 hrs after injury, UGI shows stacked coins or coiled spring appearance (make sure no contrast extravasation). rx- conservative (NGT, TPN)- cures 90% over 2-3wk (hematoma resorbed)
1) what to do if at laparotomy and duodenal injury suspected
1) Kocker maneuver (to mobilize the duodenum) and open lesser sac through omentum. Chekc for hematoma, bile, succus and fat necrosis and if you see any do formal inspection of entire duodenum
1) how to diagnoses suspected duodenal injury
1) CT abd with contrast-1st then UGI (best)CT- bowel wall thickening, hematoma, fre air, contrast leak or retroperitoneal fluid/air. If CT worrisome but non diagnostic, can repeat CT in 8-12 hours
1)Tx of duodenal trauma2) What to do if in 2nd portion of duodenum and can’t do primary repair->
try to get primary repair/anastamosis-may have to divert with pyloric exclusion and gastrojejunostomy to allow healing.-place distal feeding jejunostomy and possibly proximal draining jejunostomy tube that threads back to injury site. Place drains.1) place jejunal serosal patch over hole (may need whipple in future), do pyloric exclusion and gastrojejunostomy, consider feeding and draining jejunostomies, leave drains-Trauma whipple rarely if ever indicated (v high mortality)
1) when to remove drains after duodenal injury repair1) rx of fistulas
1) when pt tol diet without increasing drainage2) bowel rest, TPN, octreotide, conservative management for 4-6wks.
Colon trauma1) MC type of injury2) repair for:a- right colonb- transverse colonc-left colond-paracolonic hematomas
1) penetrating injury2) a and b- perform primary repair/anastomosisc-primary repair/anastamosis, diverting ileostomyd-both blunt and penetrating need to be opened
rectal trauma1) MC type of injury2) repair of high rectal injuries3) repair of low rectal injuries (<5cm)4) when to place diverting ileostomy
1) penetrating2) extraperitoneal- generally not repaired bc of inaccessibility. can do serial debridement or consider diverting ileostomyintraperitoneal- rx- repair defect, presacral drainage, consider diverting ileostomy3) repair transanally4) shock, gross contamination, extensive injury
Liver trauma1) T/F- often need to do lobectomy2) can you ligate the common hepatic artery?3) what is the pringle maneuver? does it stop bleeding from hepatic veins?4) when to use an atriocaval shunt?5) management of portal triad hematoma
1) F2) yes- gastroduodenal artery has collaterals3)clamping portal triad. Does not stop bleeding from hepatic veins4) for retrohepatic IVC injury. Allows for control while performing repair5) explore
Liver trauma cont1) ideal repair of common biled duct injury2) repair of portal vein injury and should you ligate portal vein3) when to use omental graft4) should you leave drains?
1) if 50% circumference or complex injury- do choledochojejunostomy. May need intraop cholangiogram to define injury. ALSO- place drains bc 10% of duct anastamoses leak2) if you need to transect through pancreas to get to the injury in the portal vein need to perform distal pancreatectomy. Ligation of portal vein is associated with 50% mortality3) place in liver lac to help with bleeding and prevent bile leaks.4) yes!
Conservative management of blunt liver injuries1) activity level allowed for pt2) when should you go to the OR
1) bedrest for 5 days2) -if pt becomes unstable despite aggressive resucitation (HR>120 or SBP4u needed to keep HCT>25)- if active blush on CT abd or pseudoaneurysm: if posterior may be better going to angiogram (but if doubt go to OR), if anterior go straight to OR
spleen injury1) how long does it take spleen to fully heal2) when is postsplenectomy sepsis risk greatest3) T/F splenic salvage is associated with increased transfusions4) when to go to the OR/when has conservative management failed5) activity level with conservative management6) in what pts is threshold for splenectomy much higher7) what immunizations do you need after trauma splenectomy
1) 6 weeks2) greatest within 2 years of splenectomy3) true4) -pt unstable despite aggressive fluid resucitation (HR>120 or SBP2u needed to keep HCT>25)- if active blush on CT abd or pseudoaneurysm5) bedrest x 5days6) children7) Strept pneumo (pneumococcal), H flu (Hib), meningococcal
Pancreatic Trauma1) MC injury type2) what type of injury can cause pancreatic duct fractures and typical orientation of fx3) what are CT signs of injury4)rx of pancreatic contusion5) rx of distal pancreatic duct injury6) rx of pancreatic head injury that is not reparable7) how do you decide bw a whipple vs distal pancreatectomy
1) penetrating accounts fo 80%2) bunt injury-> fx perpendicular to duct3) edema or necrosis of peripancreatic fat4) leave if stable, place drains if in OR5) distal pancreatectomy (can take up to 80% of the gland)6) place drains initially. delayed whipple or possible ERCP with stent may eventually be necessary7) based on duct injury in relation to SMV