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DVG Trauma and Shock
Trauma and Shock stuff + some vascular trauma stuff from di Virgilia
74
Medical
Professional
01/01/2014

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Term
Management of extraperitoneal rectal injury
Definition
Primary repair or diverting colostomy to allow injury to heal
Term
Management of intraperitoneal rectal injuries
Definition
Primary repair; only need to divert if the pt has severe associated injuries with significant blood loss
Term
Management of blunt kidney injury
Definition
# do nothing unless injury is bilateral or if pt only has one kidney
# if leaving it in situ leads to persistant hypertension, delayed nephrectomy indicated.
Term
Management of distal ureter injury
Definition
# ideal: spatulate both ends and do end-to-end anastamosis over a double J stent.
# if not enough length: psoas hitch to mobilze the bladder; uretero-ureterostomy; mobilize the kidney and bring into pelvis;
# damage control: ligate both ends of ureter, perform nephrostomy later, and delayed repair of ureter; temporary cutaneous ureterostomy over J stent
Term
Clinically significant hemodynamic alterations in late term pregnant women to be aware of in trauma
Definition
Blood volume is increased but volume is increased proportionately more which would increase the amount of blood loss required to produce hypotension and tachycardia
Term
Clinically significant phsysiologic alterations in late term pregnant women to increase O2 delivery to fetus and to be aware of in trauma
Definition
# increased minute ventilation which causes mild respiratory alkalosis, but decreases mother's FRC and respiratory reserve
# increased 2,3-DPG to aid in O2 offloading from hemoglobin
Term
Anatomic changes of later pregnancy to keep in mind during trauma
Definition
# fetus may compress IVC, so lay mother on LLD position
# more prone to aspiration from cranially displaced stomach so early NGT placement
# constant stretching of peritoneum leads to desensitization making it possible that the mother will not show peritoneal signs
Term
Management of suspected bladder injury
Definition
# CT cystogram if hematuria in presence of pelvic fxs
# Intraperitoneal: open 3-layer repair with chromic suture and suprapubic cystostomy
# Extraperitoneal: foley catheter drainage for 7-10 days
Term
Management of suspected blunt cardiac injury
Definition
# Order troponin and EKG; If neg, repeat both in 8 hrs; 2 consecutive negatives rules it out.
# if either EKG or trop are positive, admit for obs in a monitored bed
# If unstable, stat echo to look for anatomic abnormality; if neg, invasive monitoring +/- pressor; if positive, problem is addressed
Term
Order of preference for peripher IV access in a child younger than 6
Definition
1. AC fossa
2. cutdown on superficial saphenous vein
3. intrerosseous cannulation of proximal tibia
4. interosseous cannulation of distal femur
Term
Cattell maneuver and what vascular structures it's good for exposing
Definition
# medial visceral rotation of the cecum and ascending colon;
# good for exposing retropertineal structures, like the IVC and R ureter
Term
Kocher maneuver and what vascular structures it's good for exposing
Definition
# mobilization and medial rotation of the duodenum
# exposes the suprarenal IVC below the liver
Term
Mattox maneuver and what vascular structures its' good for exposing
Definition
# medial rotation of the left colon, kidney and spleen toward the midline
# combined with division of the left crus of the diaphragm and dividing the celiac plexus, can expose the celiac axis
Term
Way to expose injuries to the distal IVC and iliac vein bifurcations
Definition
# division of the R CIA and primary repair
Term
Way to expose injuries to the SMA and the confluence of the portal vein
Definition
# division of the neck of the pancreas
Term
Indications for operative management of penetrating or blunt injuries to thoracic structures
Definition
1. Initial hemothorax drainage of > 1500 ml or hemothorax drainage of > 200 ml/hr x 3hrs
2. Caked hemothorax (persistance of a large hemothorax even after a 2nd chest tube
3. Large air leak with inadequate ventilation or persistant collapse of the lung
4. esophageal perforation
5. Cardiac tamponade
Term
Management of a through-and-through injuring to a single lung lobe with an active air leak and bleeding
Definition
Pulmonary tractotomy: insertion of linear staple into the bullet hole to create two staple lines and ligating the lung in between to allow access to the bleeding vessels and leaking bronchi
Term
Grading system of duodenal injuries
Definition
I-V; Grade I is a simple hematoma and grad V is a massive disruption of a pancreatico duodenal complex
Term
Management of a simple duodenal hematoma
Definition
# If recognized pre-operatively, NGT and TPN;
# If found intraoperatively and small, leave it alone
# If large (involving > 50% of lumen), incise the serosa, drain the hematoma, and reclose the serosa
Term
Management of a full-thickness duodenal laceration
Definition
Primary repair, closing transversely, with an omental patch
Term
management of a large ( > 50% of the luminal circumference) duodenal injury
Definition
# 1st or 4th portion: resection with a duodenoduodenostomy
# 2nd or 3rd and the ampula is not injuried: RNY duodenojejunostomy
# distal to the ampula, distal portion of the duodenum is oversewn and EEA anastamosis of jejunum to prox duodenum and drainage of distal duodenum into jejunum
Term
Trauma indication for a Whipple
Definition
Massive dissruption of the pancreatic head and duodenum
Term
Management of a pancreatic injury without ductal disruption
Definition
Drainage
Term
Management of a distal pancreatic injury with dictal disruption
Definition
distal pancreatectomy
Term
Physical exam suggestive of neurogenic shock
Definition
Hypotension, relative bradycardia, WWP extremities (reflecting loss of sympathetic tone), evidence of high spinal cord injury and priapism (unopposed parasympathetic stimulation)
Term
Management of hypotension in patient with neurogenic shock
Definition
Fluids; once adequately resuscitated, pure alpha agonist- phenylephrine (Neo)
Term
A positive DPL
Definition
1. > 10 mL of free blood aspirated
2. > 100,000/m3 RBC for blunt trauma and > 5000/m3 RBC for penetrating trauma
3. the detection of bile, amylase or vegetable or fecal matter
4. WBC > 500/m3
Term
Grades of a kidney injury
Definition
I: Contusion or subcapsular and non-expanding hematoma
II:
III: deep lacerations that do not involve the collecting system
IV: lacerations involving the collecting system or injury to the man renal artery
V: completely shattered kidney or avulsion of the renal hilum
Term
Management of kidney injury
Definition
any injury can be managed non-operatively as long as pt is HD stable
Term
management of renal trauma with urinary extravasation
Definition
Observation with possible percutaneous drainage or urinary stent placement if it does not resolve on it's own.
Term
Methods of lowering ICP
Definition
1. hypertonic saline with Na goal 155-160
2. mild hyperventilation with pCO2 > 30 (goal is to decrease swelling by causing vasoconstriction, too much vasoconstriction is bad)
3. Mannitol
4. EVD
5. Barbiturate coma to decrease metabolic demands of brain
Term
Management of colonic injuries
Definition
# primary repair if less than 50% of the circumference is involved
# resection for > 50% circumferential involvement with primary anastamosis if pt stable (and not required too much blood) or possibly if morbidly obese
# resection and colostomy if large wound and unstable
Term
Cushing reflex
Definition
Hypertension and bradycardia in setting of traumatic inctracranial bleeding
Term
Of the possible sources of significant bleeding, the one that takes precedence over the others
Definition
Peritoneal
Term
3 radiographic findings suspicious for aortic transection
Definition
1. depressed left mainstem bronchus
2. widened mediastinum
3. deviated trachea
Term
Factors that make primary amputation of the leg a better option
Definition
1. hemodynamic instability
2. ischemia > 6 hrs
3. complete traumatic amputation
4. tib/fib fx with large soft tissue defect and arterial injury
5. transection of the tibial nerve
Term
Way to diagnose duodenal perforation in the setting of an equivocal CT
Definition
Upper GI series with water solube contrast that shows "coiled spring" appearance of the duodenal wall
Term
Stages of damage control surgery
Definition
1. abreviate resuscitative surgery in which hemorrhage and bowel contamination are controled with packing and a temporary abd closure (delay repair of non-life threatening injuries)
2. rewarm, resuscitate and fix coagulopathy in ICU and look for other injuries
3. re-exploration after restoration of normal physiology to remove packs and complete any additional repairs
Term
Type of injury which is a contra-indication to damage control surgery
Definition
Arterial injuries
Term
Type of liver injury amenable to suturing and best method for liver suturing
Definition
# Superficial lacerations
# Chromic suture with blunt needle
Term
Indications for immediate OR explioration of neck wounds
Definition
# hard signs fo vascular injury: rapidly expanding hematoma or visible exanguination
# shock, even without hard signs b/c the presumption is that the pt exsanguinated in the field
Term
Management of penetrating neck trauma
Definition
# To OR if hemodynamically unstable or hard signs of vascular injury
# If hemodynamically stable, 4-vessel arteriography or CTA of neck
# When feasible, assessment for injuries to the aerodigestive tract (triple endoscopy and/or esophagoscopy) and C-spine
# Xray of head neck and chest to look for the bullet
Term
Management of Carotid artery injury
Definition
repair if neurological deficit
Term
Definition of flail chest
Definition
3 or more ribs fractured in at least 2 locations
Term
Indications for internal fixation of the chest wall
Definition
# flail chest in pts already undergoing thoracotomy for an intrathoracid injury
# Flail chest without pulmonary contusion
# noticeable paradoxical movement while pt is being weaned
# severe deformity of chest wall
Term
Pulsatile exophthalmos in a pt with racoon eyes and/or hemotympanum
Definition
Carotid-cavernous fistula
Term
Signs of carotid-cavernous fistula
Definition
# pulsatile exophthalmous
# eyelid edema
# auscultation of a bruit over the eye
# edema of the conjunctiva
# double vision
# swelling of the eye
Term
Management of caroitid-cavernous fistula
Definition
open neurosurgical approach or endovascular embolization
Term
Signs of compartment syndrome
Definition
# pain out of proportion to the injury
# pain on passive motion of the limb
# tense edema with tenderness on palpation fo the compartment
Term
# First compartment to be involved in compartment syndrome of the leg
# Sx of involvement of that compartment
# pathogenesis of said sx
Definition
# Anterior compoartment of the leg
# numbness in the first web space
# entrapment of the deep peroneal nerve which runs in the anterior compartment
Term
In compartment syndrome:
# compartment most difficult to decompress
# structure contained in that compartment
# best way to decompress that compartment
Definition
# deep posterior compartment
# tibial nerve
# detachment of the soleus muscle from the tibia
Term
Grades of traumatic peripheral nerve injuries and definition
Definition
# Neuropraxia- focal demyelination from stretch or compression; axon is intact so conduction proximal and distal to the lesion is in tact
# Axonotmesis- axon is damagamed but surrounding structures preserved which allows regeneration to occur
# Neurotmesis- complete transection or disruption;
Term
Type of peripheral nerve injury a/w distal wallerian degeneration
Definition
Axonotmesis
Term
Types of peripheral nerve injuries which are amenable to regeneration and which require surgical repair
Definition
# regeneration: neuropraxia and axonotmesis
# requires surgery: neurotmesis
Term
MC traumatic peripheral nerve injury
Definition
# Upper extremity more common than lower
# MC periph nerve injury: radial nerve a/w humerus fx
# MC lower extremity periph nerve injury is peroneal nerve a/w posterior knee dislocation
Term
Rate at which peripheral nerves regenerate
Definition
1 mm/day
Term
Grading of pancreatic injuries
Definition
# I- minor contusion or laceration
# II-
# III
# IV
# V: major disruption of pancreatic head
Term
Management of pancreatic injuries
Definition
# 1st step is to determine of the main pancreatic duct is injured and whether it is injured to the R or L of the superior mesenteric vessels--> pancreatography via contrast injected into the GB
# if duct disrupted to the left of mesenteric vessels: distal pancreatectomy
# if disrupted to R but no major head disruption: drainage and delayed pancreaticoenteric anastomosis if fistula fails to heal
# if disrupted to R with major head disruption: pancreaticoduodenectomy
# any such operation can be delayed if damage control laparotomy needed
Term
Indications for Whipple in trauma
Definition
# injury to main pancreatic duct to R of mesenteric vessels and massive disruption of pancreatic head
# devascularization of duodenum
Term
Beck's Triad
Definition
Distended neck veins, muffle heart sounds, hypotension==>> pericardial tamponade
Term
Management of tamponade
Definition
# IVF first, especially if early, because volume can overcome the tamponade
# if stable, fast exam looking for tamponade or abd free fluid; if tamponade confirmed --> OR for median sternotomy and repair
# if unstable, left anterolateral thoracotomy in ED, longitudinal incision in pericardium avoiding phrenic nerve, evacuate clot and finger in the injury
Term
Nerves in each compartment of the leg
Definition
# Anterior- deep peroneal
# Lateral- superficial peroneal
# Deep posterior- tibial nerve
# Superficial posterior- sural
Term
MC compartment affected in compartment syndrome
Definition
Anterior compartment (think anesthesia in first web space 2/2 deep peroneal n involvement)
Term
Earliest sign of compartment syndrome in an awake pt
Definition
# pain out of proportion to exam and pain with passive dorsiflexion
Term
Management of frostbite
Definition
# only initiate rewarming when it can be done rapidly and completely
# rewarm by immersing in warm water (40-42 C) until sensation returns
# remove clear blisters, leave hemorrhagic blisters
# elevate the extremity
# Abx and tetanus
# wait at least 3-4 months to do any surgery
Term
management of posterior knee dislocation with the loss of distal pulses
Definition
# reduce the dislocation and reassess the pulse,
# if still not there --> OR- interposition RSVG from contralateral leg
# if no other injuries, heparin
# if there are other orthopedic injuries that require surgery and the foot is ischemic (heparin is contraindicated) explore the artery and place a temporary shunt
# 4-compartment fasciotomy
# if pulse is restored with reduction, arteriography to eval for intimal damage
# if pulses are never lost, check ABIs and do arteriography for ABI < 0.9
Term
Important steps for addressing a RP hematoma in the OR
Definition
# obtain proximal control prior to entering; obtain control just below diaphragm for zones I or II; at infrarenal aorta for zone III
Term
Management of penetrating zone I injuries
Definition
# if on the right, obtain proximal control via a median sternotomy
# if on the left, obtain proximal contral via a left anterolateral thoracotomy
Term
Management of trauma with a SDH + shift and a traumatic aortic injury
Definition
If they are stable enough to make it to CT, they have survived the worst part of the thoracic injury and are a candidate for delayed repair of that injury and immediate repair of ICH. Keep MAP < 70 in meantime
Term
Management of Zone II penetrating injury
Definition
# if neuro deficit, pulsatile bleeding, expanding hematoma, or palapable thrill -> immediate OR exploration with goal of repair of carotid
# if no hard signs of injury, CTA first because it will also reveal injuries to c-spine and aerodigestive tract
Term
Zones of the RP
Definition
# Zone I: midline RP
# Zone II: peri-nephric RP
# Zone III: pelvic RP
Term
Management of traumatic RP hematomas
Definition
# Any caused by penetrating injury -> operative exploration (all zones)
# Any zone I should be explored regardless of whether blunt or penetrating
# blunt zone III: pelvic stabilization and IR embolization because likely from small deep vessels
Term
Delayed onset of lateralizing neuro deficits s/p blunt trauma with negative CTH
Definition
Suspect blunt carotid artery injury and perform angiography
Term
Zones of the neck
Definition
# I: thoracic inlet to the cricoid cartilage
# II: Cricoid to the angle of the mandible
# III: angle of the mandible to the base of the skull
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