Trauma/Neurotrauma/random surg facts Flashcards
Most common site of laceration to aorta?
Distal to left subclavian artery (ligamentum arteriosum)
Most common site injured in blunt abdo trauma
SPLEEN…but Textbook and ABSITE say LIVER
Most common organ injured in penetrating trauma
small bowel
solid organ = LIVER
Trimodal distribution of death
seconds (50%) - bleeding and brainstem
hours (30%) - 1/2 bleeding, 1/2 brainstem
≥ 24 hours (10-20%) - infection, multi organ failure
What are the three categories of the revised trauma score?
GCS
sBP
RR
What is the AIS?
Abbreviated injury scale 1-6
minor
moderatte
serious
severe
critical
maximal (untreatable)
What is ISS?
Injury severity score. Take three worst regions from AIS, square the scores, add together.
A^2 + B^2 + C^2 = ISS
How do antishock garments work? What are indications and contraindications?
Increase PVR in arterial and venous channels
Indications: stop massive blood loss in pelvic #
Contraindications: cardiogenic shock, diaphragmatic rupture, pregnancy, significant chest injury
Classifications of hypovolemic shock
SEE ATLS table
Class I-IV
Based on EBL, HR, BP, PP, mentation, U/O, volume required
What are the components of GCS?
Motor (6)
Verbal (5… think V)
Eyes (4… think four-eyes)
Minimum score =3
Most commonly injured cranial nerve
olfactory CN1
What artery is involved in extradural/epidural hematoma from temporal-parietal skull fractures?
middle meningeal artery
Early complications from brain injury?
SIADH
DI
Cerebral edema + raised ICP»_space; herniation
seizures
Late complications from brain injury?
Seizures
meningitis
Hydrocephalus
Management of head trauma?
Elevated head of bed to 30 degrees
Keep ICP < 20 (ventriculostomy)
Hyperventilate to 30-35mmHg
Mannitol
Barbituates (last resort)
Diagnostic criteria for brain death
- No cortical function
- No brainstem reflexes
- Apnea test
- No cerebral blood flow
- No narcotic, sedatives, or anesthetics
- No relaxants
- No severe metabolic dysfunction
- Normal body temp
What is spinal shock?
When spinal cord is severed within or above sympathetic chain
Compromised cardiac sympathetic innervation and unopposed vagal parasympathetic stimulation
Hypotonia and loss of all reflexes below level of injury after acute SCI
Lasts days to weeks but usually recovery starts with 24hrs
How to treat spinal shock?
Alpha agonist (rule out hemorrhage first) - phenylephrine
Mixed chronotrope/inotrope (DA/NE)- if cardiac fxn affected
High dose corticosteroids x 24hr
What is neurogenic shock?
Combination of both primary and secondary injuries
Loss of sympathetic tone and unopposed vagal parasympathetic tone
Instability in BP, HR, and temperature regulation
What muscle and function controlled by C5 Nerve root?
Deltoid
Shoulder abduction
What muscle and function controlled by C6 nerve root?
biceps
elbow flexion
What muscle and function is controlled by C7 nerve root?
triceps
elbow extension
What muscle and function is controlled by C8 nerve root?
flexor carpi ulnaris
wrist flexion
What muscle and function is controlled by T1 nerve root?
Lumbricales
Finger abduction
What muscle and function is controlled by L2 nerve root?
Iliopsoas
Hip Flexion
What muscle and function is controlled by L3 nerve root?
Quadriceps
Knee extension
What muscle and function is controlled by L4 nerve root?
Tibialis anterior
Ankle dorsiflexion
What muscle and function is controlled by L5-S1 nerve root?
Extensor hallicus Longus
great toe extension
What muscle and function is controlled by S1 nerve root?
Gastrocnemius
Ankle plantar flexion
Review dermtaomal areas of sensation for nerve roots
look at a picture of dermatome :)
What are the anatomical triangles of the neck?
Submandibular
Submental
Carotid
Muscular
Occipital
Supraclavicular
What are the anatomic zones of the neck?
I - thoracic inlet to cricoid cartilage
II - cricoid cartilage to angle of mandible
III - angle of mandible upwards
How do you manage a neck injury?
Unstable = OR
Platysma penetration = further evaluation
Zone II penetration = OR
Zone I and III penetration = angio first for guidance… access to zone I can take hours
What blunt neck injuries are associated with delayed stroke?
GCS ≤8
LeFort fractures
c-spine injuries
some thoracic injuries
How do you manage a carotid artery laceration?
Alert and no deficit = re-anastomosis
Patient comatose = observe
Indications for ligation: no prograde flow, uncontrollable hemorrhage
Management of maxillofacial injuries
Secure airway
Emergent: wrap head and pack all pharynxes
If surgery can wait 3-6 hours do with other cranial surgery
Otherwise ideally wait 3-6 days
Most frequent thoracic injuries leading to immediate death after MVA?
blunt cardiac injuries with chamber disruption
Thoracic aorta injury
5 immediate killers in thoracic injuries
- Tension pneumothorax
- Open pneumothorax
- Hemothorax
- Flail chest
- Cardiac tamponade
When should you remove a chest tube
No airleak
≤100 cc drainage over 24hrs
Indications for emergent thoractomy? (7)
- cardiac arrest
- massive hemothorax (>1500ml or 200-300/hr after initial drainage)
- penetrating injuries of the anterior chest with cardiac tamponade
- large open wounds of the thoracic cage
- major thoracic vascular injuries in presence of hemodynamic instability
- major tracheobronchial injuries
- evidence of esophageal perforation
Non-emergent indications for thoracotomy? (6)
- empyema not resolved with chest tube
- clotted hemothorax
- lung abscess
- thoracic duct injury
- tracheoesophageal fistula
- chronic sequelae of vascular injuries (AV fistula, pseudoaneuyrsm)
What is flail chest?
Requires ≥2 fractures in ≥2 adjacent ribs
Paradoxical movement of chest wall
Increased WOB
May require intubation for respiratory distress
Becks triad of cardiac tamponade
- muffled heart sounds
- distended neck veins
- hypotension
BP / pulse pressure anomalies with tamponade?
pulsus paradoxus
pulsus alternans
NOT!!! a wide pulse pressure
Management of esophageal rupture
- get xray with contrast
- If walled off perforation and pt is well - conservative management
- If free perf <72 hrs: primary repair with flap
- If free perf >72 hrs: consider resection with gastrostomy or jejunostomy
Indications for laparotomy in blunt trauma to abdomen? (2)
positive exam
positive diagnostic peritoneal lavage or FAST
Indications for laparotomy in isolated penetrating trauma to abdo? (4)
Hypotension / shock
Evisceration
peritoneal signs
positive diagnostic peritoneal lavage or FAST
Indications for diagnostic peritoneal lavage in trauma? (2)
Pts you can’t examine well (unconscious, SCI, intoxicated, GA from other injury repair)
Injury consisted with possible abdo injury (high energy, multiple injuries and unexplained shock, major non-contiguous or thoracoabdominal injuries)
Criteria for positive diagnostic peritoneal lavage (8)?
> 10 ml gross blood aspirated
Bloody lavage effluent
RBC >100,000/ml or >1000 in penetrating trauma
WBC >500/ml
Amylase > 175IU/dl
Bile
Bacteria
Food
Contraindications to diagnostic peritoneal lavage?
Clear indication for ex lap
relative CI: previous ex lap, pregnancy, obesity
Next step for indeterminate DPL?
CT scan
Patients with penetrating trauma and fascia INTACT should have this many hours of observation
8 hours
Patients with penetrating trauma THROUGH fascia, but negative DPL, should have this many hours of observation?
8 hours
Criteria for non-operative management of splenic injury? (6)
Hemodynamic stability
Negative abdominal exam
Absence of coagulopathy
Absence of contrast extravasation on CT
Grade 1-3 injuries
Absence of other indications for laparotomy/surgical intervention
What management is required post-splenectomy?
Polyvalent pneumococcal vaccination with booster (pneumococcus, hemophilus, meningococcus)
How do you manage a renal injury?
If stable with microhematuria - discharge and repeat UA in 3 weeks
How do you manage testicular injury?
Need exploration if ANY suspicion of ruptured testicle
Presentation of fat embolism? (classic triad)
Classic triad: neuro signs, petechial rash, resp insufficiency (PO2 <60)
Other signs: pyrexia, tachy, retinopathy, oliguria
Management of fat emboli?
Supportive care with mechanical ventilation and ICU monitoring
Fix the fracture
Risk factors for fat embolism (3)
Long bone fracture
Younger age (more marrow in bones)
Ortho procedures
Two main killers in neck injuries?
Exsanguination
Airway issues
What happens to ATCH in response to surgery?
+++ release of ACTH from anterior pituitary
Increased cortisol for 24-48hours post op
Mobilizes arachidonic acid for ACP and gluconeogenesis
What happens to sympathetic nervous system in response to surgery?
EPI and NE from adrenal medulla
What happens with serum osmolality and tonicity in response to surgery?
Increased ADH and aldosterone = increased Na and H2O retention
diuresis of third spacing POD2-4
What happens to glucagon and insulin in response to surgery?
Increased glucagon
Decreased insulin
What are catabolic phases in response to surgery?
Adrenergic corticoid phase: POD1-3
Adreneregic corticoid withdrawal phase: POD1-6
When does anabolic state restart after surgery?
POD3-6
