Trauma Surgery Lecture Powerpoint

Question 1

“The golden hour”

Answer 1

The first hour after injury largely determining the critically injured patient’s chances for survival, concept that emphasizes the urgency of care required by major trauma patients to prevent early deaths predominantly from hemorrhage

Question 2

Guiding principle of initial trauma management

Answer 2

Airway
Breathing and ventilation
Circulation and hemorrhage control
Disability
Exposure

Question 3

Airway assessment in trauma bay

Answer 3

Goal is to establish patient airway and protect c spine, fastest way is to assess by asking name (if can tell then airway patent), consider establishing an airway with decreased mental status, excessive secretions, loss of cough, smoke/inhalation injury, facial trauma, consider surgical airway if endotracheal intubation is unsuccessful

Question 4

Breathing assessment in trauma bay

Answer 4

Goal is to ensure adequate oxygenation and ventilation, will auscultate for equal bilateral breath sounds while observing the respiratory rate (hook up to monitor), chest movement, and o2 sat, palpate for crepitus and tenderness

Question 5

Circulation assessment in trauma bay

Answer 5

Goal is to ensure end organ perfusion, palpate pulses, observe manual blood pressure, mental status assessment is one way, taking dorsal pedis pulse and radial pulses (want +2 bilaterally) is another, look at skin color and cap refill and temp is another

Question 6

Disability assessment in the trauma bay

Answer 6

Perform glascow coma score

Question 7

Exposure assessment in trauma bay

Answer 7

Completely undress patient for assessment then cover to protect against hypothermia

Question 8

Labs typically gotten in a trauma bay setting (9)

Answer 8

• CBC with diff
• BNP
• PT/INR
• lactic acid
• ETOH
• urine tox screen
• troponin
• creatinine
• ABG

Question 9

Imaging studies typically gotten in a trauma bay setting (4)

Answer 9

• CXR #1
• pelvic x ray in hemodynamic instability
• FAST exam
• if hemodynamically stable then CT of head and cervical spine without contrast and chest, abdomen and pelvis with CT with contrast if have time

Question 10

3 common types of shock in trauma setting from most common to least

Answer 10

• hemorrhagic/hypovolemic (most common)
• caridogenic
• neurogenic (MUST rule out hemorrhagic first)

Question 11

Classes of hemorrhage

Answer 11

I - Small amount of blood loss (10-19%), BP, HR, RR, and U/O remain the same
II - Decreased pulse pressure (20-29%), HR >100, RR increase, U/O decrease
III - (30-39%)decreased BP, HR >120, RR >30, U/O oligouric
IV - up to 40-50% blood loss, BP very low, >140HR, RR>40, aneuric

Question 12

5 major areas of blood loss in trauma

Answer 12

• chest
• abdomen
• pelvis
• femur
• floor (open wound)

Question 13

Rapid response to initial fluid resuscitation (with lactated ringer)

Answer 13

See vital signs return to normal, estimated blood loss is minimal, monitor and reassess patient

Question 14

Transient response to initial fluid resuscitation (with lactated ringer)

Answer 14

Sees Transient improvement of vital signs, estimated blood loss moderate, will need more fluid and likely will need blood

Question 15

Minimal or no response to initial fluid resuscitation (with lactated ringer)

Answer 15

Sees no change in vital signs, estimated blood loss is severe, need fluid and blood and massive transfusion protocol of 1:1:1 RBC to FFP to platelets

Question 16

Central venous access definition, benefits and cons, procedure

Answer 16

• Insertion of thin long catheter that terminates in superior or inferior vena cava, sterile procedure performed at bedside typically under ultrasound guidance, either accessed via internal jugular (preferred), femoral, or subclavian vein (most common in trauma setting)
• allows for CVP monitoring and rapid infusion of blood or crystalloid products as well as to get frequent blood draws, but risks include bleeding, infection, arterial stick, pneumothorax, etc
• Done by identifying vein with ultrasound, infiltrating the skin with local anesthetic, confirm intravenous location of needle, insert guidwire into vein thru access, remove needle while controlling guidwire, make small incision of skin at puncture site adjacent to guidwire, advance dilator to guide then remove dilator, threat catheter, remove guidwire, taking care to control catheter, flush with saline, suture catheter in place and address site with sterile technique, Get chest XR after to ensure in right place and haven’t caused a pneumothorax

Question 17

Tube thoracostomy (standard chest tube or pig tail catheter) definition, benefits and cons, procedure

Answer 17

• Tube or catheter is placed thru chest wall 4th or fifth intercostal space on mid anterior axillary line into pleural cavity and used to drain air or fluid
• indicated in trauma pneumothorax, tension pneumothorax, or hemothorax, risk of bleeding, infection, injury to lung or heart
• prep skin, inject local anesthesia, use curved clamp to blunty dissect and create tunnel over superior portion of rib, will confirm location by observing condensation within the tube with breathing and or drainage from tube, advance until the last drainage hole is fully within the thoracic cavity, and then confirm with CXR

Question 18

Chest tube drainage systems (2 types)

Answer 18

Wet system - tube from chest tube drains into collection chamber that can be measured, adjacent chamber is water seal chamber (keeps air from getting sucked back into chest tube) and suction chamber (prevents air from escaping by being hooked up to wall suction) (together the last 2 )tells if the patient is leaking air from their lungs into the system, if answer is yes need to continue using tube but if not then can consider changing system)
Dry - Tube from chest tube drains into collection chamber that can be measured, adjacent chambers simplified to not need water seal but can still be read easily

Question 19

Arterial line definition, considerations and risks, procedure

Answer 19

• Used for continuous BP monitoring or frequent ABG’s at the radial or femoral sites
• considerations include performing allens test for hand, using nondominant hand, risks include arterial injury, infection, bleeding, thrombosis
• placed similarly to central line by injecting needle, withdrawing till get blood, putting guidewire on, and inserting it

Question 20

Thoracotomy procedure

Answer 20

Procedure of last resort performed to gain rapid access to the heart and major thoracic vessels thru anterolateral chest incision to control exsanguinating hemorrhage or other life threatening chest injuries, incision made at margin of the sternum along intercostal space between 4th and 5th ribs and carried laterally to the left posterior axillary line following curvature of rib

Question 21

When are rib fractures surgically managed? (4)

Answer 21

• impending or actual respiratory fracture
• flail chest
• significantly displaced ribs
• sternal plating often occurs after open heart surgery

Question 22

When is exploratory laparotomy indicated in hepatic injury? (3)

Answer 22

• hemodynamically unstable patient
• positive FAST exam
• hemodynamically stable with CT grade 1 or 2 WITH extravasation (go to IR embolization) or if class 3-4

Question 23

When is exploratory laparotomy indicated in splenic injury? (3)

Answer 23

• hemodynamically unstable patient
• Positive FAST exam
• CT active extravasation (go to IR embolization) or class 3-4

Question 24

Retroperitoneal hemorrhage and how is it diagnosed?

Answer 24

Hard to detect (sometimes seen with “seatbelt” sign with bruising over abdomen), not seen on FAST exam or CXR, often found incidentally in surgery, CT with IV contrast best in hemodynamically stable patient to diagnose

Question 25

3 Zones of the retroperitoneum

Answer 25

I - aorta, inferior vena cava, portion of duodenum, pancreas
II - adrenal glands, kidneys, renal vessels, ureters, ascending/descending colon
III - right and left internal and external iliac arteries and veins, distal ureters, distal sigmoid colon and rectum

Question 26

For penetrating retroperitoneal hemorrhage in zone I, what is the likely choice of treatment? what about II and III?

Answer 26

I - Explore with major vascular surgery

II - Selectively explore area for expanding hematoma

III - Explore with major vascular surgery

Question 27

For blunt retroperitoneal hemorrhage in zone I, what is likey choice of treatment? What about II and III?

Answer 27

I - Explore, likely with major vascular surgery

II - Do NOT explore contained nonexpanding hematoma

III - Do NOT explore

Question 28

In hemodynamically stable retroperitoneal patients who do not have other indications for surgical exploration often do not require…

Answer 28

…operative exploration

Question 29

Post trauma care after acute injuires are stabilized (6)

Answer 29

• DVT prophylaxis (lovenox most often)
• avoiding pulmonary insufficiency
• bowel regimen
• GI prophylaxis
• insulin sliding scale in ICU patients
• disposition planning for PT/OT