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  1. 1st peak for trauma deaths:
    1) 0-30 min

    • 2) deaths due to:
    • 1- lacerations of heart, aorta, brain, brainstem, spinal cord

    3) cannot really save these patients, death is too quick
  2. 2nd peak for trauma deaths
    1) 30min - 4hrs

    2) deaths due to head injury #1

    3) hemorrhage #2

    4) these patients you can save with rapid assessment (golden hour)
  3. 3rd peak for trauma deaths:
    1) days to weeks

    2) deaths due to multisystem organ failure and sepsis
  4. Blunt injury:
    • 1) 80% of all trauma
    • 2) liver most commonly injured (some texts say spleen)
  5. Whats the formula for kinetic energy:
    kinetic energy= 1/2MV2
  6. Falls:
    1) age and body orientation are the biggest predictors of survival

    2) LD50 is 4 stories
  7. Penetrating injury:
    small bowel most commonly injured (some texts say liver)
  8. whats the most common cause of death in the first hour?
  9. When does blood pressure go down?
    blood pressure is usually ok until 30% of total blood volume is lost
  10. What is the most common cause of death after reaching the ER alive
    head injury
  11. What is the most common cause of death in the long term?
  12. What is the most common cause of upper airway obstruction and what do you do for it:
    • 1) tongue
    • 2) jaw thrust
  13. What can seat belts cause?
    • 1) small bowel perforations
    • 2) lumbar spine fractures
    • 3) sternal fractures
  14. What is the best site for cutdown for access?
    saphenous vein
  15. Diagnostic peritoneal lavage (DPL)
    • 1) used in hypotensive patients with blunt trauma
    • 2) Positive if:
    • 1- >10 cc blood
    • 2- >100,000 RBCs/cc
    • 3- food particles
    • 4- bile
    • 5- bacteria
    • 6- >500WBC/cc

    • 3) need laparotomy if DPL is positive
    • 4) DPL needs to be supraumbilical if pelvic fracture is present
    • 5) DPL misses:
    • 1- retroperitoneal bleeds
    • 2- contained hematomas
  16. FAST Scan:
    • 1) focused abdominal sonography for trauma
    • 2) Ultrasound scan used in lieu of DPL
    • 3) checks for blood in:
    • 1- perihepatic fossa
    • 2- perisplenic fossa
    • 3- pelvis
    • 4- pericardium
    • 4) examiner dependent
    • 5) obesity can obstruct view
    • 6) may not detect free fluid <60-80ml
    • 7) need laparotomy if FAST scan is positive
    • 8) FAST scan misses:
    • 1- retroperitoneal bleeding
    • 2- hollow viscous injury
  17. Need a CT scan following blunt trauma in patients with:
    • 1) abdominal pain
    • 2) need for general anesthesia
    • 3) closed head injury
    • 4) intoxicants on board
    • 5) paraplegia
    • 6) distracting injury
    • 7) hematuria

    • 8) patients requiring DPL that turned out negative will need an abdominal CT scan
    • 9)CT scan misses:
    • 1- hollow viscous injury
    • 2- diaphragm injury
  18. Need laparotomy with:
    • 1- peritonitis
    • 2- evisceration
    • 3- positive DPL
    • 4- clinical deterioration
    • 5- uncontrolled hemorrhage
    • 6- free air
    • 7- diaphragm injury
    • 8- intraperitoneal bladder injury
    • 9- positive contrast studies
    • 10- specific renal, pancreas, and biliary tract injuries
  19. Possible penetrating abdominal injuries (knife or low velocity injuries):
    • 1- local exploration and observation if fascia not violated
    • 2- diagnostic laparoscopy to see if fascia was violated
  20. Abdominal compartment syndrome
    • 1) occurs after:
    • 1- massive fluid resuscitation
    • 2- trauma
    • 3- abdominal surgery

    • 2) bladder pressure- >25-30
    • 3) IVC compression is final common pathway for decreased cardiac output
    • 4) gut malperfusion
    • 5) renal vein compression leading to decreased urinary output
    • 6) upward displacement of diaphragm affecting ventilation
    • 7) Treatment: decompressive laparotomy
  21. Pneumatic antishock garment:
    • 1) controversial
    • 2) use in patients with SBP <50 and no thoracic injury
    • 3) release compartments one at a time after reaching ER
  22. ER thoracotomy
    • 1) Blunt trauma: use only if pressure/pulse lost in the ER
    • 2) Penetrating trauma: use only if pressue/pulse lost on way to ER or in ER
    • 3) Thoracotomy: open pericardium anterior to phrenic nerve, cross clamp the aorta, watch for the esophagus

    Emergency department thoracotomies are performed through the fourth and fifth intercostal spaces using the anterolateral approach. If the thoracotomy is performed for abodminal injury, the descending thoracic aorta is clamped. If blood pressure improved to >70mmHg, the patient is transported to the operating room for laparotomy. For patients in whom blood pressure does not reach 70mmHg, further treatment if futile. If the thoracotomy is performed for a cardiac injury, the pericardium is opened longitudinally and anterior to the phrenic nerve. The heart can then be rotated out of the pericardium for repair.
  23. What substances increase after trauma?
    • catecholamines (peak 24-48 hours after injury)
    • ADH
    • ACTH
    • Glucagon
  24. Blood transfusion:
    Type O blood (universal donor): contains no A or B antigens; males can receive Rh-positive blood; females who are prepubescent or of child-bearing age should receive Rh-negative blood

    Type-specific blood (nonscreened, noncrossmatched)- can be administered relatively safely, but there may be effects from antibodies to minor antigens in the donated blood
  25. Comparison of blood availability
    • Type O:
    • Typing: No
    • Ab screen: No
    • Crossmatch: No
    • Time: immediate

    • Type Specific:
    • Typing: yes
    • Ab Screen: yes
    • Crossmatch: no
    • Time: <10min

    • Type and Screen:
    • Typing: Yes
    • Ab Screen: Yes
    • Crossmatch: Yes
    • Time: 20-30 min

    • Type and Crossmatch:
    • Typing: Yes
    • Ab Screen: Yes
    • Crossmatch: Yes
    • Time: 45-60 min
  26. Glasgow coma scale (GCS):
    • Motor:
    • 6- follows commands
    • 5- localizes pain
    • 4- withdraws from pain
    • 3- flexion with pain (decorticate)
    • 2- extension with pain (decerebrate)
    • 1- no response

    • Verbal:
    • 5- oriented
    • 4- confused
    • 3- inappropriate words
    • 2- incomprehensible sounds
    • 1- no response

    • Eye opening
    • 4- spontaneous opening
    • 3- open to command
    • 2- open to pain
    • 1- no response

    • GCS <14- head CT
    • GCS <10- intubation
    • GCS <8 - ICP monitor
  27. Indications for neurologic imaging:
    • 1) suspected skull penetration by a foreign body
    • 2) hemotympanum or discharge of blood or CSF from the ear
    • 3) protracted unconsciousness
    • 4) altered state of consciousness at the time of examination
    • 5) focal neurologic signs or symptoms
    • 6) any situation precluding proper surveillance
    • 7) head injury plus additional trauma
    • 8) possible head injury in the presence of additional pathologic findings, such as stroke
    • 9) head injury with alcohol or drug intoxication
  28. Epidural hematoma:
    • 1) most commonly due to arterial bleeding from middle meningeal artery
    • 2) Head CT- shows lenticular (lens-shaped) deformity
    • 3) patients initially have loss of consciousness (LOC)--> then lucid interval--> then sudden deterioration (vomiting, restlessness, LOC)
    • 4) operate for significant neurologic degeneration or significant mass effect (shift >5mm)
  29. Subdural hematoma:
    • 1) most commonly from tearing of venous plexus (bridging veins) between dura and arachnoid.
    • 2) Head CT- shows crescent-shaped deformity
    • 3) operate for significant mass effect
    • 4) chronic subdural hematomas- usually in elderly after minor fall
    • - need drinage if >1cm or causing significant symptoms
  30. Intracerebral hematoma:
    1) usually frontal or temporal; can cause significant mass effect requiring operation
  31. Cerebral contusions:
    can be coup or contracoup
  32. Traumatic intraventricular hemorrhage-
    need ventriculostomy if causing hydrocephalus
  33. Diffuse axonal injury
    • 1) shows up better on MRI than CT scan
    • 2) Tx: supportive; may need craniectomy if ICP elevated
    • 3) very poor prognosis
  34. Cerebral perfusion pressure (CPP) forumula
    CPP= mean arterial pressure (MAP) - intracerebral pressure (ICP)
  35. Signs of elevated ICP:
    • 1) decreased ventricular size
    • 2) loss of sulci
    • 3) loss of cisterns
  36. ICP monitors:
    • 1) indicated for GCS <8
    • 2) suspected increased ICP or patient with moderate to severe head injury and inability to follow clinical exam (pt is intubated)
  37. Supportive treatment for elevated ICP:
    • 1) normal ICP is 10; >20 needs treatment
    • 2) want CPP >60

    • 1) Sedation and paralysis
    • 2) raise head of bed
    • 3) relative hyperventilation for modest cerbral vasocontriction (CO2 30-35); do not want to overhyperventilate and cause cerebral ischemia from too much vasocontriction
    • 4) keep Na 140-150, serum Osm 295-310- may need to use hypertonic saline at times (draw fluid out of the brain)
    • 5) Mannitol: load 1g/kg, give 0.25 mg/kg q4h after that (draws fluid from brain)
    • 6) Barbiturate coma- consider if above not working
    • 7) ventriculostomy w/CSF drainage (keep ICP <20)
    • 8) craniotomy decompression- if not able to get ICP down medically (can also perform Burr hole)
    • 9) Phenytoin- given prophylactically to prevent seizures to most patients with traumatic brain injury
    • 10) peak ICP- occurs 48-72 hours after injury
    • 11) dilated pupil- temporal pressure on same side (CNIII compression)
  38. Basal skull fractures:
    • 1) racoon eyes- anterior fossa fracture
    • 2) battle sign- middle fossa fracture--> can injure facial nerve
    • 1- if acute, need exploration
    • 2- if delayed, likely secondary to edema and exploration not needed
    • 3) Can also have:
    • 1- hemotympanum
    • 2- CSF rhinorrhea/otorrhea
    • 3- injury to CNI, VII, and VIII
  39. Temporal skull fractures
    • 1) can injure CN VII and VIII
    • 2) most common site of facial nerve injury- geniculate ganglion
    • 3) temporal skull fractures most commonly associated with lateral skull or orbital blows
    • 4) most skull fractures do not require surgical treatment.
    • - operate if:
    • 1- significantly depressed (8-10mm)
    • 2- contaminated
    • 3- persistent CSF leak not responding to conservative therapy
    • 5) CSF leaks- treat expectantly
  40. Cervial spine:
    • 1) C1 burst (Jefferson fracture)- caused by axial loading
    • 1- Tx: rigid collar

    • 2) C2 Hangman's fracture- caused by distraction and extension
    • 1- Tx: traction and halo

    • 3) C2 odontoid fracture
    • - type I- above base, stable
    • - type II- at base, unstable (will need fusion or halo)
    • - type III- extends into vertebral body (will need fusion or halo)

    4) Facet fractures or dislocations- can cause cord injury; usually associated with hyperextension and rotation and with ligamentous disruption
  41. Thoracolumbar spine
    • 1) 3 columns of the thoracolumbar spine:
    • 1- Anterior: anterior longitudinal ligament and anterior 1/2 of the vertebral body
    • 2- Middle- posterior 1/2 of the vertebral body and posterior longitudinal ligament
    • 3- Posterior- facet joints, lamina, spinous processes, interspinous ligament

    • 2) If more than one column is disrupted, the spine is considered unstable.
    • 1- compression (wedge) fractures usually involve the anterior column only and are considered stable
    • 2- burst fractures are considered unstable (>1 column) and require spinal fusion

    3) upright fall- at risk for calcaneus, lumbar, and wrist/forearm fractures
  42. What test do you do for neurologic deficits without bony injury to check for ligamentous injury:
  43. Indications for emergent surgical spine decompression
    • 1) fracture or dislocation not reducible with distraction
    • 2) acute anterior spinal syndrome (loss of motor below injury and pain/temperature; you keep fine touch and proprioception)
    • 3) open fractures
    • 4) soft tissue or bony compression of the cord
    • 5) progressive neurologic dysfunction
  44. Maxillofacial trauma:
    • 1) facial nerve injuries need repair
    • 2) fracture of the temporal bone is the most common cause of facial nerve injury
    • 3) try to preserve skin and not trim edges with facial lacerations
  45. Le Fort Classification of Facial Fractures
    • Type I:
    • - Maxillary fracture straight across (--)
    • - Tx: reduction, stabilization, intramaxillary fixation (IMF), +/- circumzygomatic and orbital rim suspension wires

    • Type II:
    • - lateral to nasal bone, underneath eyes, diagonal toward maxilla (/ \)
    • - Tx: same as Le Fort I

    • Type III:
    • - lateral to orbital walls (- -)
    • -Tx: suspension wiring to stable frontal bone; may need external fixation
  46. Nasoethmoidal orbital fractures
    • 1) 70% have CSF leak
    • 2) conservative therapy for 2 weeks
    • 3) can try epidural catheter to decrease CSF pressure and help it close
    • 4) may need surgical closure of dura to deal with leak
  47. Nosebleeds:
    Anterior- packing

    Posterior- can be hard to death with try baloon tamponade 1st

    - may need angioembolization of internal maxillary artery or ethmoidal artery
  48. Orbital blowout fractures:
    patients with impaired upward gaze or diplopia with upward vision need repair, with restoration of orbital floor with bone fragments or bone graft
  49. Mandibular injury
    • 1) malocclusion #1 indicator of injury
    • 2) panorex film is often used to assess injury along with fine-cut facial CT scans with reconstruction
    • 3) most repaired with IMF (metal arch bars to upper and lower dental arches, 6-8 weeks) or open reduction and internal fixation (ORIF)
  50. Tripod fracture
    zygomatic bone- ORIF for cosmesis
  51. What are patients with maxillofacial fractures at high risk for?
    patients w/maxillofacial fractures are at high risk for cervical spine injuries
  52. Asymptomatic blunt neck trauma:
    neck CT scan
  53. Asymptomatic penetrating neck trauma:
  54. Neck Zones:
    • Zone I: clavical to cricoid cartilage
    • - Need:
    • 1- angiography
    • 2- bronchoscopy
    • 3- rigid esophagoscopy
    • 4- barium swallow
    • 5- pericardial window may be indicated
    • 6- may need sternotomy to reach these lesions

    • Zone II:
    • 1-Cricoid cartilage to angle of the mandible
    • 2- exploration in OR

    • Zone III-
    • 1- angle of the mandible to base of skull
    • 2- Need:
    • 1- angio
    • 2- laryngoscopy
    • 3- may need jaw subluxation/digastric and sternocleidomastoid muslce release/mastoid sinus resection to reach vascular injuries in this location
  55. Symptomatic blunt or penetrating neck trauma:
    • 1- shock
    • 2- bleeding
    • 3- expanding hematoma
    • 4- losing or lost airway
    • 5- subcutaneous air
    • 6- stridor
    • 7- dysphagia
    • 8- hemoptysis
    • 9- neurologic deficit

    * need neck exploration
  56. Esophageal injury
    • 1) hardest neck injury to find
    • 2) rigid esophagoscopy and esophagram- best combined modality (find essentially 95% of injuries when using both methods)
    • 3) contained injuries- can be observed
    • 4) noncontained injuries- if small injury, <24hrs, without significant contamination, and patient is stable --> primary closure; otherwise make spit fistula and drain leak with chest tube
    • 5) always drain esophageal and hypopharyngeal repairs- 20% leak rate
    • 6) Approach to esophageal injuries
    • 1- neck: left side
    • 2- upper 2/3 thoracic esophagus- right thoracotomy
    • 3- lower 1/3 of thoracic esophagus- left thoracotomy
  57. Laryngeal fracture and tracheal injuries
    • 1) these are airway emergencies
    • 2) symptoms:
    • 1- crepitus
    • 2- stridor
    • 3- respiratory compromise
    • 3) need to secure airway emergently in ER
    • 4) Treatment: primary repair, can use strap muscle for airway support; tracheostomy necessary for most to allow edema to subside and to check for stricture
  58. Thyroid gland injuries:
    control bleeding and drain
  59. Recurrent laryngeal nerve injury
    can try to repair or can reimplant in cricoarytenoid muscle (hoarseness)
  60. Shotgun injuries to the neck
    need angiogram and neck CT; esophagus/tracheal evaluation
  61. Vertebral artery bleeds
    can ligate or embolize without sequela
  62. Common carotid bleeds
    ligation will cause stroke in 20%
  63. Chest tube
    • Relative indications for thoracotomy in OR:
    • 1- >1500cc after initial insertion
    • 2- >250cc/h for 3 hrs
    • 3- 2,500 cc/24hrs
    • 4- bleeding with instability

    • 2) need to drain all of the blood (in <48hrs) to prevent:
    • 1- fibrothorax
    • 2- pulmonary entrapment
    • 3- infected hemothorax

    3) Unresolved hemothorax after 2 well-placed chest tubes --> thoracoscopic or open drainage
  64. Sucking chest wound:
    • 1) needs to be at least 2/3 the diameter of the trachea to be significant
    • 2) cover the wound with dressing that has tape on 3 sides--> prevents development of tension pneumothorax while allowing lung to expand with inspiration
  65. Tracheobronchial injury
    • 1) patient has worse oxygenation after chest tube placement
    • 2) one of the very few indications in which clamping the chest tube may be indicated
    • 3) bronchial injuries are more common on the right
    • 4) may need to mainstem intubate patient on unaffected side
    • 5) Dx: bronchoscopy
    • 6) Treatment: repair if large air leak and repiratory compromise or after 2 weeks of persistent air leak
    • 7) Right thoracotomy for:
    • 1- right mainstem
    • 2- trachea
    • 3- proximal left mainstem injuries (avoids aorta)
    • 8) Left thoracotomy for distal left mainstem injuries
  66. Diaphragm:
    • 1) injuries are more likely to be found on left and to result from blunt trauma
    • 2) CXR- see air-fluid level in chest from stomach herniation through hole (diagnosis may be made easily with CXR)
    • 3) Transabdominal approach if <1 week
    • 4) Chest approach if >1 week
    • 5) may need mesh
  67. Aortic transection signs
    • 1- widened mediastinum
    • 2- 1st rib fractures
    • 3- apical capping
    • 4- loss of aortopulmonary window
    • 5- loss of aortic contour
    • 6- left hemothorax
    • 7- trachea deviation to right
  68. Where is the tear usually in aortic transection
    - tear is usually at the ligamentum arteriosum (just distal to the subclavian takeoff).

    - other areas include near the aortic valve and where the aorta traverses the diaphragm
  69. CXR and aortic repairs:
    CXR normal in 5% of patients with aortic tears- need aortic evaluation in patients with significant mechanism (head on car crash >45mph, fall >15 feet)
  70. Diagnosis of aortic transection:
    aortogram or CT angiogram of chest
  71. Treatment of aortic transection:
    need to control blood pressure with nipride and esmolol

    Operative approach- left thoracotomy with partial left heart bypass

    Important to treat other life threatening injuries 1st --> patient with positive DPL or other life-threatening injury needs to have that addressed before the aortic transection.
  72. Median sternotomy
    • for injuries to:
    • 1- the ascending aorta
    • 2- innominate artery
    • 3- innominate vein
    • 4- proximal right subclavian artery
    • 5- proximal left common carotid artery
  73. Left thoracotomy
    • for injuries to:
    • 1- left subclavian artery
    • 2- descending aorta
  74. How do you fix distal right subclavian artery injury?
    midclavicular incision 1/2 resection of medial clavicle
  75. Myocardial contusion:
    • 1) V-tach and V-fib most common cause of death
    • 2) risk highest in 1st 24 hours
    • 3) SVT- most common arrhythmia overall in these patients
    • 4) need monitoring
  76. Flail chest
    • 1) >2 consecutive ribs broken at >2 sites--> results in paradoxical motion
    • 2) underlying pulmonary contusion- biggest pulmonary impairment
  77. Aspiration
    may not produce CXR findings immediately
  78. Penetrating "box" injuries to chest:
    • 1)borders are:
    • 1- clavicles
    • 2- xiphoid process
    • 3- nipples

    • 2) Need:
    • 1- pericardial window
    • 2- bronchoscopy
    • 3- esophagoscopy
    • 4- barium swallow
  79. Penetrating chest wound outside "box" (without pneumothorax or hemothorax)
    • 1) need chest tube if patient required intubation
    • 2) otherwise follow patient's CXRs
  80. Pericardial window
    1) if you find blood, need sternotomy to fix possible injury to heart; place pericardial drain
  81. Penetrating injuries anterior-medial to midaxillary line and below nipples:
    • 1) need laparotomy or laparoscopy
    • 2) may also need evaluation for penetrating "box" injury depending on the exact location
  82. Traumatic causes of cardiogenic shock
    • 1) cardiac tamponade
    • 2) cardiac contusion
    • 3) tension pneumothorax
  83. Tension pneumothorax
    • 1) hypotension
    • 2) increased airway pressures
    • 3) decreased breath sounds
    • 4) bulging neck veins
    • 5) tracheal shift

    • 6) can see bulging diaphragm during laparotomy
    • 7) cardiac compromise secondary to decreased venous return
    • 8) Tx: chest tube
  84. Which patients are high risk for cardiac contusion?
    pt with sternal fractures
  85. 1st and 2nd rib fractures:
    high risk for aortic transaction
  86. Pulmonary tractotomy
    dividing the pulmonary parenchyma between adjacent staple lines permits rapid direct access to injured vessels or bronchi along the tract of a penetrating injury.
  87. Pelvic trauma
    • 1) pelvic fractures can be a major source of blood loss
    • 2) if hemodynamically unstable with pelvic fracture and negative DPL, negative CXR, and no other signs of blood loss or reasons for shock--> stabilize pelvis (C-clamp, external fixator, or sheet) and go to angio for embolization
    • 3) patients at high risk for GU and abdominal injuries
  88. see page 80 for pictures of the three typs of pelvic fractures
  89. which pelvic fractures are more likely to have venous bleeding?
    anterior pelvic fractures
  90. which pelvic fractures are more likely to have arterial bleeding
    posterior pelvic fractures
  91. What may you need if there is a open pelvic fracture with rectal tears and perineal lacerations?
    may need colostomy
  92. when should pelvic fracture be repaired?
    pelvic fracture repair itself may need to be delayed until other associated injuries are repaired
  93. penetrating injury pelvic hematomas
  94. blunt injury pelvic hematomas
    leave unless expanding and patient unstable

    if unstable, stabilize pelvic fracture, pack pelvis if in OR, and get patient to angiography embolization
  95. Duodenal trauma
    • 1) usually blunt from crush or deceleration injury
    • 2) 2nd portion of duodenum (descending portion, near ampulla of vater)- most common area of injury
    • 3) can also get tears near ligament of treitz
    • 4) 70-80% of injuries requiring surgery can be treated with debridement and primary closure
    • 5) segmental resection with primary end-to-end closure possible with all segments except 2nd portion of the duodenum
    • 6) 25% mortality in these patients because of associated shock
    • 7) fistulas are the major source of morbidity
  96. Paraduodenal hematomas
    • 1) usually in third portion of duodenum overlying spine in blunt injury
    • 2) for blunt and penetrating injuries need to open these up if in the OR
  97. Missed hematomas
    • 1) can present with high SBO 12-72 hours after injury
    • 2) UGI study will show "stacked coins" or coiled spring" appearance
    • 3) conservative treatment (TPN and NGT) cures 90% of these over 2-3 weeks
  98. When do you do Kocher maneuver?
    If laparotomy and injury suspected, perform kocher maneuver and open lesser sac, check for hematoma, bile, petechiae, mucus, and fat necrosis.

    If found, need formal inspection of the entire duodenum.
  99. Diagnosing suspected duodenal injury
    • 1) abdominal CT with contrast initially
    • 2) UGI contrast study best
    • 3) CT scan may show bowel wall thickening, hematoma, air, contrast leak, retroperitoneal fluid/air
    • 4) if CT scan is worrisome for injury but nondiagnostic, can repeat the CT in 8-12 hours to see if the finding is getting worse
  100. Treatment for duodenal injury:
    • 1) try to get primary repair
    • 2) may need to divert with pyloric exclusion and gastrojejunostomy to allow healing
    • 3) place a distal feeding jejunostomy and possibly a proximal draining jejunostomy tube that threads back to duodenal injury site.
    • 4) place drains
    • 5) if not enough duodenum is present for repair or is in the 2nd portion of duodenum, need pyloric exclusion and gastrojejunostomy
    • 1- can then place jejunal patch over hole; may need Whipple procedure in future
    • 2- consider feeding and draining jejunostomies
  101. Trauma whipple-
    rarely if every indicated
  102. When can you remove drains?
    remove drains when patient is tolerating diet without an increase in drainage
  103. Fistulas
    • often close with time
    • Tx:
    • 1- bowel rest
    • 2- TPN
    • 3- decompression
    • 4- octreotide
    • 5- fistulogram to rule out abscess
    • 6- conservative management for 4-6 weeks
    • 7- consider distal obstruction
  104. Small Bowel Trauma
    • 1) most common organ injured with penetrating injury
    • 2) these injuries can be hard to diagnose early if associated with blunt trauma
  105. Occult small bowel injuries:
    • Occult small bowel injuries
    • 1- abdominal CT scan showing intraabdominal fluid not associated with a
    • solid organ injury, bowel wall thickening, or a mesenteric hematoma is
    • suggestive of injury
    • 2- Need close observation and possibly repeat abdominal CT after 8-12 hours or so to make sure finding is not getting worse
    • 3- need to make sure patients with these nonconclusive findings can tolerate a diet before discharge
  106. How do you repair lacerations of the small bowel?
    repair lacerations transversely --> avoids stricture
  107. Large lacerations >50% of the circumference or results in lumen diameter, 1/3 normal
    perform resection and reanastomosis
  108. multiple close lacerations
    just resect that segment
  109. mesenteric hematomas
    open if expanding or large (>2cm)
  110. Colon trauma
    • 1) most associated with penetrating injury
    • 2) right and transverse colon- can perform primary reanastomosis
    • 3) left colon- colostomy and hartman's pouch or mucous fistula the safest procedure
    • 4) paracolonic hematomas- both blunt and penetrating need to be opened
    • 5) 10% abscess rate after colon injury; 2% fistula rate, higher with primary repair
  111. Rectal Trauma
    1) most associated with penetrating injury

    • 2) High rectal:
    • 1- Extraperitoneal: generally not repaired because of inaccessibility
    • Tx: presacral drainage and fecal diversion with colostomy, serial debridement
    • 2- Intraperitoneal- Tx: repair defect, presacral drainage, fecal diversion with colostomy
    • 3) Low rectal (<5cm)- can probably be repaired transanally
  112. Liver Trauma
    1) lobectomy rarely necessary

    2) Common hepatic artery- can be ligated with collaterals through gastroduodenal artery

    3) Hepatic lobar arteries- can be ligated without complication unless the patient is hypotensive, which could lead to liver ischemia

    4) Pringle maneuver (clamping portal triad) does not stop bleeding from hepatic veins
  113. Atriocaval shunt
    for retrohepatic IVC injury, allows for control while performing repair
  114. Perihepatic packing
    • 1) can pack severe penetrating liver injuries if patient becomes unstable in the OR.
    • 2) Go to the ICU and get the patient resuscitated and stabilized.
    • Live to fight another day
  115. Portal triad hematomas
    need to be explored
  116. Common bile duct injury
    • 1) <50% of circumference- repair over stent
    • 2) >50% or complex injury- go with choledochojejunostomy
    • 3) may need intraoperative cholangiogram to define injury
    • 4) 10% of anastomoses leak
  117. Portal Vein injury
    • 1) need to repair
    • 2) may need to transect through the pancreas to get to the injury in the portal vein
    • 3) will need to perform distal pancreatectomy with that maneuver
    • 4) ligation of portal vein associated with 50% mortality
  118. Omental graft
    can be placed in liver laceration to help with bleeding and prevent bile leaks
  119. Drains and liver injuries
    leave drains with liver injuries
  120. Conservative management of blunt liver injuries, and what are indications for OR:
    1) Has failed if patient becomes unstable despite aggressive resuscitation, including 4 units of PRBCs (HR >120 or SBP <90) or requires >4 units of PRBCs to keep Hct >25. Go to OR.

    • 2) Active blush on abdominal CT or pseudoaneurysm also indication for OR
    • 1- if posterior may be better off going to angiogram (when in doubt--> OR)
    • 2- if anterior- go to OR

    3) with conservative management, need bed rest for 5 days
  121. Spleen trauma
    • 1) fully healed after 6 weeks
    • 2) postsplenectomy sepsis most common in 1st 5 years of life; greatest risk within 2 years of splenectomy
    • 3) splenic salvage is associated with increased transfusions
  122. Conservative management of blunt splenic injuries:
    1) Has failed if patient becomes unstable despite aggressive resuscitation, including 2 units of PRBCs (HR >120 or SBP <90) or requires >2 units of PRBCs to keep Hct >25. Go to OR.

    2) Active blush on abdominal CT or pseudoaneurysm also indication for OR

    3) with conservative management, need bed rest for 5 days

    4) threshold for splenectomy in children is much higher; hardly any children undergo splenectomy

    5) need immunizations after trauma splenectomy
  123. Pancreatic Trauma
    • 1) Penetrating injury- accounts for 80% of all pancreatic injuries
    • 2) Blunt injury- can result in pancreatic duct fractures, usually perpendicular to the duct
    • 3) Edema or necrosis of peripancreatic fat usually indicative of injury
    • 4) pancreatic contusion- leave if stable, place drain
  124. Distal pancreatic duct injury
    Distal pancreatectomy, can take up to 80% of the gland
  125. Pancreatic head injury that is not repairable
    1) place drains initially, delayed Whipple may eventually be necessary

    2) may be able to treat pancreatic duct injuries with ERCP and stent as opposed to resection
  126. Whipple vs Distal pancreatectomy
    1) based on duct injury in relation to the SMA/SMV

    2) injuries to the right of the SMA/SMV treated with drains instead of Whipple initially
  127. Whats the name of the maneuver that helps evaluate the pancreas operatively
    Kocher maneuver
  128. What should you do w/drains in pancreatic surgery
    leave drains in
  129. Pancreatic hematoma
    both penetrating and blunt need to be opened
  130. What may be an indicator of missed pancreatic injury
    persistent or rising amylase may indicate missed pancreatic injury
  131. CT scans and diagnosing initial pancreatic injuries
    CT scans are poor at diagnosing pancreatic injuries initially

    Delayed signs- fluid, edema, necrosis

    Dx: ERCP good at picking up duct injuries and may be able to treat with stent
  132. What is repaired first, vascular or orthopedic injuries?
    vascular repair performed before orthopedic repair
  133. Major signs of vascular injury:
    • 1) active hemorrhage
    • 2) pulse deficit
    • 3) expanding or pulsatile hematoma
    • 4) distal ischemia
    • 5) bruit/thrill

    6) go to OR for exploration (some say go to angio first)
  134. Moderate/soft signs of vascular injury
    • 1) history of hemorrhage
    • 2) deficit of anatomically related nerve
    • 3) large stable/nonpulsatile hematoma

    go to angio
  135. ABI <0.9
    go to angio
  136. Saphenous vein graft
    • 1) will be needed if segment >2cm missing
    • 2) use vein from the contralateral leg when fixing lower extremity arterial injuries (improves outflow)
  137. Vein injuries that need repair:
    • 1) vena cava
    • 2) femoral
    • 3) popliteal
    • 4) brachiocephalic
    • 5) subclavian
    • 6) axillary
  138. What do you do for transection of a single artery in the calf in an otherwise healthy patient?
  139. What do you do for coverage of site of anastomoses
    coverage of site of anastomoses with viable tissue and muscle important
  140. when do you do a fasciotomy? What does it prevent?
    Consider fasciotomy if ischemia >4 hours- prevents compartment syndrome
  141. Compartment syndrome
    1) consider with pressures >20mmHg or if clinical exam suggests elevated pressures

    2) pain->paresthesia-> anesthesia->paralysis->poikilothermia->pulselessness

    3) most commonly occurs after supracondylar humeral fractures, tibial fractures, crush injuries, or other injuries that result in a disruption and then restoration of blood flow
  142. IVC
    • 1) primary repair if residual stenosis <50% diameter of IVC; otherwise place saphenous vein or synthetic patch
    • 2) bleeding of IVC best controlled with proximal and distal pressure, not clamps--> can tear it
    • 3) repair posterior wall injury through the anterior wall
    • 4) may need to cut through the anterior IVC to get to posterior IVC injuries
  143. Orthopedic trauma (see also chapter 42)
    1) can have >2L blood loss from a femur fracture

    • 2) orthopedic emergencies:
    • 1- pelvic fractures in unstable patients
    • 2- spine injury with deficit
    • 3- open fractures
    • 4- dislocations or fractures with vascular compromise
    • 5- compartment syndrome

    3) Femoral neck fractures- high risk for avascular necrosis

    4) long bone fracture or dislocations with loss of pulse (or weak pulse) --> immediate reduction of fracture or dislocation and reassessment of pulse.
  144. Orthopedic trauma and comomitant nerve/artery injury
    Upper extremity:

    • Anterior shoulder dislocation- axillary nerve
    • Posterior shoulder dislocation- axillary artery
    • Proximal humerous- axillary nerve
    • Midshaft humerus (or spiral humerus fracture)- radial nerve
    • Distal (supracondylar) humerus- brachial artery
    • Elbow dislocation- brachial artery
    • Distal radius- median nerve

    • Lower Extremity
    • Anterior hip dislocation- femoral artery
    • Posterior hip dislocation- sciatic nerve
    • Distal (supracondylar) femur- popliteal
    • Posterior knee dislocation- popliteal artery
    • fibula neck- common peroneal nerve
  145. What do you do in an orothopedic injury if pulse does not return or if pulse is weak?
    If pulse does not return --> go to OR for vascular bypass or repair (some say proceed to angiography for diagnosis of location of injury and possible intervention).

    If pulse is weak- angiography
  146. What do you do for knee dislocations?
    All knee dislocations need to go to angiogram, unless pulse is absent, in which case some would go to OR
  147. What is the best indicator for renal trauma?
  148. What do all patients with hematuria need?
    CT scan
  149. When can IVP be useful?
    IVP can be useful if going immediately to OR without abdominal CT scan --> will identify presence of functional contralateral kidney, which could affect intraoperative decision making.
  150. Difference between R and L renal vein:
    Left renal vein- can be ligated near IVC; has adrenal and gonadal vein collaterals. Right does not
  151. Anterior --> posterior renal hilum structures:
    vein, artery, pelvis
  152. What percent of injuries are treated nonoperatively?
  153. Do all urine extravasation injuries require operation
  154. Indications for operation:
    Acutely- ongoing hemorrhage with instability

    • After acute phase-
    • - major collecting system disruption
    • - unresolving urine extravasation
    • - severe hematuria
  155. With exploration what do you want to get control of 1st?
    try to get control of the vascular hilum 1st
  156. Drains or no drains?
    place drains, especially if collecting system is injured
  157. What can you do to check for a leak at the end of a case?
    methylene blue dye can be used at the end of the case to check for leak
  158. When at exploration for another blunt injury or penetrating trauma
    Blunt renal injury with hematoma- leave unless preop CT/IVP shows no function or significant urine extravasation

    Penetrating renal injury with hematoma- open unless preop CT/IVP shows good function without significant urine extravasation
  159. Trauma to flank and IVP shows no uptake-
    Tx: angiogram; can stent if flap present
  160. Bladder Trauma
    • 1) hematuria best indicator of bladder trauma
    • 2) >95% associated with pelvic fractures
    • 3) Signs and symptoms: meatal blood, sacral or scrotal hematoma
    • 4) Dx: cystogram
    • 5) Extraperitoneal bladder rupture- cystogram shows starbursts (Tx: foley 7-14 days)
    • 6) Intraperitoneal bladder rupture- more likely in kids, cystogram shows leak
    • - Tx: operation and repair of defect, followed by Foley drainage
  161. Ureteral trauma
    Hematuria unreliable --> IVP and retrograde urethrogram (RUG) best tests
  162. If large ureteral segment is missing (>2cm) and cannot perform reanastomosis:
    • 1) Upper 1/3 injuries and middle 1/3 injuries that wont reach the bladder
    • 1- temporize with percutaneous nephrostomy (tie off both ends of the ureter) if patient unstable. Can go with ileal interpostition or trans-ureteroureterostomy later.
    • 2- if stable, most urologists would perform trans-ureteroureterostomy

    Lower 1/3 injuries- reimplant in the bladder; may need bladder hitch procedure
  163. If small ureteral segment is missing (<2cm)
    1) try to mobilize ends of ureter and perform primary repair over stent if in the upper or middle ureter or reimplant if in the lower 1/3 ureter
  164. Does one shot IVP evaluate the ureters sufficiently?
  165. What two things can be used to check for leaks?
    • IV indigo carmine
    • or
    • Methylene blue
  166. How is the blood supply arranged for the ureter?
    Blood supply is medial in the upper 2/3 of the ureter and lateral in the lower 1/3 of the ureter
  167. What about drains for ureteral injuries
    leave drains for all ureteral injuries
  168. Urethral trauma:
    What is the best sign?
    • 1) Hematuria or blood at meatus best sign
    • 2) free-floating prostate gland
    • 3) usually associated with pelvic fractures
  169. Do you use a foley in urethral trauma?
  170. Whats the best test for urethral trauma?
    urethrogram is best test
  171. Which portion is at risk for transection
    membranous portion
  172. Significant tears
    1) Tx: suprapubic cystostomy and repair in 2-3 months (safest method)

    2) high stricture and impotence rate if repaired early
  173. Small, partial tears
    Tx: may get away with bridging urethral catheter across tear area and repair in 2-3 months
  174. Genital trauma
    • 1) can get fracture in erectile bodies from vigorous sex
    • 2) need to repair the tunica and Buck's fascia
  175. Testicular trauma
    get ultrasound to see if tunica albuginea is violated, then repair if necessary
  176. Pediatric trauma:
    1) blood pressure is not a good indicator of blood loss in children- last thing to go

    2) Heart rate, respiratory rate, mental status, and clinical exam are best indicators of shock

    3) high risk of hypothermia (high BSA compared with weight)

    4) high risk of head injuries
  177. Normal vital signs by age
    • Infant <1yr
    • P- 160
    • SBP- 80
    • RR- 40

    • Preschool (<5 yrs)
    • Pulse- 140
    • SBP- 90
    • RR- 30

    • Adolescent (>10)
    • P- 120
    • SBP- 100
    • RR- 20
  178. Trauma during pregnancy:
    • 1) at all costs, save the mother
    • 2) pregnant patients can have up to a 1/3 total blood volume loss without signs
    • 3) Estimate pregnancy based on fundal height (20cm=20wks=umbilicus). Place fetal monitor
    • 4) Try to avoid CT scan with early pregnancy. If life-threatening and needed, get CT scan
    • 5) ultrasound (FAST scan) may have a role in pregnant patients
    • 6) Check for vaginal discharge- blood, amnion. Check for effacement, dilation, fetal station
    • 7) Maturity- lecithin:sphingomyelin (LS) ratio >2:1, positive phosphatidylcholine
  179. Placental abruption
    • 1) >50% results in almost 100% fetal death rate
    • 2) >50% of all traumatic placental abruptions result in fetal demise
    • 3) signs of abruption-
    • 1- uterine tenderness
    • 2- contractions
    • 3- fetal HR <120

    4) can be caused by shock (most common mechanism) or mechanical forces
  180. Kleihauer-Betke test
    test for fetal blood in the maternal circulation--> sign of placental abruption
  181. Uterine rupture
    • 1) most likely to occur in posterior fundus
    • 2) if occurs after delivery of child, aggressive resusciation even in he face of shock leads to the best outcome. The uterus will eventually clamp down after delivery; just have to aggressively resuscitate until then
  182. Indications for C-section during exploratory laparotomy for trauma
    • 1) persistent maternal shock
    • 2) pregnancy near term (>34 weeks) and mother with severe injuries
    • 3) pregnancy a threat to mother's life (hemorrhage, DIC)
    • 4) mechanical limitation to life-threatening vessel injury
    • 5) risk of fetal distress exceeds risk of immaturity
    • 6) direct uterine trauma
  183. add last few slides..
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