Trauma Absite Flashcards

Front 1

A 40 yo man is kicked several times in the abdomen during an altercation. He comes to the ER complaining of being unable to void for 24 hours. Insertion of a Foley catheter shows gross hematuria with clots. Excretory urography followed by retrograde urethrocystography shows no kidney or urethral injury, but the presence of contrast material in the paracolic gutters. What is the most appropriate management?

Back 1

Bladder trauma:
-hematuria = best indicator (unlike ureteral trauma). meatal blood. sacral or scrotal hematomas.
->95% ass'd c/ pelvic fx
-Dx: cystogram
-INTRAperitoneal injury: leak on cystogram. more likely in kids. exploration, repair, keep foley.
-EXTRAperitoneal injury: cystogram shows starbursts. Foley 7-14 d.

Front 2

A 25 yo male presents after fall from tree with pelvic fracture. Upon examination in the trauma center, he is noted to have hematuria. A retrograde urethrogram rules out urethral injury, however, a cystogram reveals an intraperitoneal contrast extravasation and injury to bladder. What is the next step?

Back 2

Intraperitoneal injuries are primarily repaired by way of a transabdominal approach, including a three-layer closure. A suprapubic cystostomy may be necessary in large wounds. The management of extraperitoneal rupture of the bladder is primarily nonoperative by leaving the Foley catheter in place for 10-14 days - if the patient has no intra-abdominal injuries requiring surgical exploration

Front 3

Trauma pt has hematuria, then retrograde cytourethrogram shows extraperitoneal bladder rupture.
Tx is _

Back 3

Trauma pt has hematuria, then retrograde cytourethrogram shows extraperitoneal bladder rupture.
Tx: FOLEY x 7 DAYS

Front 4

Trauma pt has hematuria, then retrograde cytourethrogram shows intraperitoneal bladder rupture.
Tx is _

Back 4

Trauma pt has hematuria, then retrograde cytourethrogram shows intraperitoneal bladder rupture.
Tx: Laparotomy + surgical repair

Front 5

Management of traumatic bladder rupture depends on _

Back 5

Management of traumatic bladder rupture:
-INTRAperitoneal: laparotomy + operative repair
-EXTRAperioneal: foley x 7 days

Front 6

Pt has suffered blunt abdominal trauma and has (-) CT C/A/P on presentation, then can't tolerate PO the next day
-4 injuries which are known for presenting late…

Back 6

4 injuries which are known for presenting late after blunt abdominal trauma
1. Pancreatic injuries
2. Sm bowel tears
3. Duodenal injuries (e.g. hematoma)
4. Diaphragmatic injuries

Front 7

#1 preventable cause of blunt abdominal trauma = _

Back 7

#1 preventable cause of blunt abdominal trauma = missed intra-abdominal injury
-FAST detects free fluid > 50 mL in perihepatic fossa, perisplenic fossa, pelvis, pericardium
-FAST scan misses retroperitoneal bleeding, hollow viscous injury
-DPL for hypotensive pts c/ blunt trauma. (+) if >10cc, >100,000 RBCs, >500 WBCs, food, bile, bacteria. DPL missed retroperitoneal injury or contained hematoma
-Get CT if ab pain, need for gen anesthesia, closed head injury, intoxicants, paraplegia, distracting injury, hematuria. CT misses hollow viscous injury, diaphragm injury

Front 8

What is a Burr Hole?

Back 8

Burr Hole: to decompress elevated ICP
5 cm anterior, 5 cm superior to external auditory canal
-Alternative = place ICP bolt, check pressure, then Burr Hole if pressure elevated

Front 9

what are the signs of cardiac tamponade to look for in trauma bay?
to look for on pericardiocentesis?

Back 9

Cardiac tamponade:
-1st sign on echo = decreased RA filling
-Beck's triad = hypotension, JVD, muffled heart sounds
-ASPIRATED BLOOD DOESN'T CLOT

Front 10

Cattel-Braasch maneuver = _

Back 10

Cattel-Braasch maneuver = medial rotation of the right colon and small bowel
For midline inframesocolic hemorrhage or hematoma

Front 11

when is diverting colostomy mandatory after traumatic rectal injury

Back 11

Stab or low velocity (civilian) wounds to the colon with minimal contamination and hemodynamic stability, received within 4-6 hours can be managed by primary repair. A diverting colostomy, washout of distal rectal stump, and wide presacral drainage are mandatory in extraperitoneal rectal injuries

Front 12

what types of colonic injuries can be primarily repaired?

Back 12

Colon trauma:
-usually 2/2 penetrating injury.
-R + L transverse colon => primary reanastomosis
-L colon => colostomy + Hartman's or mucus fistula safest
-Paracolonic hematoma 2/2 blunt or penetrating should be opened
-Complications: abscess (10%), fistula (2%) - more c/ primary repair

Front 13

what is tx for paracolonic hematoma?

Back 13

Colon trauma:
-usually 2/2 penetrating injury.
-R + L transverse colon => primary reanastomosis
-L colon => colostomy + Hartman's or mucus fistula safest
-PARACOLONIC HEMATOMA 2/2 blunt or penetrating should be OPENED
-Complications: abscess (10%), fistula (2%) - more c/ primary repair

Front 14

Pt c/ severe closed head injury is suddenly making a lot of urine
-Suspect _
-Mechanism
-Tx

Back 14

DIABETES INSIPIDUS:
-EtOH or head injury ->
low ADH production from supraotic nucles of hypothalamus ->
high UOP, low urine specific gravity, high serum Na, high serum osmolarity
-Tx: DDVAP, free water

Front 15

Diaphragmatic injury:
Approach via the _ if pt presents w/in 1 week of injury

Back 15

Diaphragmatic injury:
-LEFT>right. usually 2/2 blunt trauma.
-X-ray: air-fluid level in chest.
Approach via the ABDOMEN if pt presents w/in 1 week of injury
-Approach via CHEST if >1 week after injury (adhesions have to be taken down)
-May require mesh

Front 16

Diaphragmatic injury:
Approach via the _ if pt presents >1 week after injury b/c _

Back 16

Diaphragmatic injury:
-LEFT>right. usually 2/2 blunt trauma.
-X-ray: air-fluid level in chest.
Approach via the ABDOMEN if pt presents w/in 1 week of injury
-Approach via CHEST if >1 week after injury (adhesions have to be taken down)
-May require mesh

Front 17

Are diaphragmatic injuries more common with blunt or penetrating trauma?

Back 17

Diaphragmatic injury:
-More common with BLUNT trauma
-8:1 L:R
-hard to find on CT unless gross herniation => see NG in chest
-Approach via the ABDOMEN if pt presents w/in 1 week of injury
-Approach via the CHEST if pt presents >1 week after injury (will have adhestions which have to be taken down via chest incision)

Front 18

DPL:
-Indication _
-Positive if >_ cc blood, >_ RBCs, >_ WBC
-Perform supra-umbilical if

Back 18

DPL for hypotensive pts c/ blunt trauma (or if child requires >10 cc/Kg fluid) -(+) if >10cc blood, >100,000 RBCs, >500 WBCs, food, bile, bacteria. DPL misses retroperitoneal injury or contained hematoma
-Get CT if indeterminate = 50,000-99,000 RBCs

Front 19

Pt has suffered blunt abdominal trauma and has (-) CT C/A/P on presentation, then can't tolerate PO the next day
-Best way to diagnose a duodenal hematoma is _
-Mgmt of duodenal hematoma depends on _

Back 19

Duodenal hematoma:
-most likely in 3rd portion = overlying the spine. Operate immediately if diagnosed in trauma bay
-can present after 24-72 hrs c/ SBO-type sx.
-Dx: UGI CONTRAST STUDY (or CT c/ PO + IV): "stacked coins" or "coiled spring" appearance
-Fresh injury or late dx + contrast leak => operate. Kocher maneuver to open lesser sac to eval for hematoma, bile, petichae, succus, fat necrosis
-Late dx + no leak => NPO + TPN for up to 3 weeks (90% resolve)

Front 20

Pt s/p GSW to R flank, bilous fluid on laparotomy -> Kocher maneuver severe "blow-out" duodenal injury proximal to Ampulla of Vater
Operation = _

Back 20

Duodenal trauma:
-70-80% of injuries can be treated c/ dbt + primary closure. Segmental resection + end-to-end closure possible for segments 1, 2, 4 Pyloric exclusion + gastro-jej if in 2nd portion or not enough duodenum left to repair.
-Proximal to Ampulla => staple off proximal + distal ends of duodenal injury ->
gastro-jejunostomy, place drains
(possible b/c ampulla still able to drain distally, food will go though gastro-jejunosomy)

Front 21

Pt s/p GSW to R flank, bilous fluid on laparotomy -> Kocher maneuver reveals severe "blow-out" duodenal injury distal to Ampulla of Vater
Operation = _

Back 21

Duodenal trauma:
-70-80% of injuries can be treated c/ dbt + primary closure. Segmental resection + end-to-end closure possible for segments 1, 2, 4 Pyloric exclusion + gastro-jej if in 2nd portion or not enough duodenum left to repair.
-Distal to Ampulla of Vater =>
duodenal-jejunosomy (necessary to control biliary flow)

If injury were proximal to ampulla, would staple off proximal + distal ends of injury, then do gastro-jejunostomy

Front 22

Pt s/p GSW to R flank, bilous fluid on laparotomy -> Kocher maneuver reveals severe duodenal injury involving the Ampulla of Vater
Next step depends on _

Back 22

Duodenal trauma:
-
-70-80% of injuries can be treated c/ dbt + primary closure. Segmental resection + end-to-end closure possible for segments 1, 2, 4 Pyloric exclusion + gastro-jej if in 2nd portion or not enough duodenum left to repair.
-Injury nvolving the Ampulla = functional Whipple
Unstable pt (most trauma cases) => drains only
Stable pt => formal Whipple (rarely indicated)

Front 23

2 most common regions of duodenal injury 2/2 blunt trauma

Back 23

Duodenal trauma:
-usually 2/2 crush or deceleration. 25% mortality 2/2 shock. Fistula = #1 morbidity.
-usually 2nd portion of duodenum (near ampulla) > near ligament of Treitz
-70-80% of injuries can be treated c/ dbt + primary closure. Segmental resection + end-to-end closure possible for segments 1, 2, 4 Pyloric exclusion + gastro-jej if in 2nd portion or not enough duodenum left to repair.

Front 24

where are the 3 types of Le Fort fractures?

Back 24

Le Fort classification:
1: maxillary fx straight across => reduction, stabilization, intramaxillary fixation +/- circumzygomatic + orbital rim suspension wires
2: lateral to nasal bone, underneath eyes, diagonal toward maxilla => same tx as Le Fort 1
-3: lateral orbital walls = suspension wiring to stable frontal bone. may need ex fix

Front 25

fracture of __ = #1 source of facial nerve injury
-tx is _

Back 25

temporal bone fracture = #1 source of facial nerve injury
-repair facial nerve injuries

Front 26

FAST scan misses 2 important injuries…

Back 26

FAST scan:
-Perihepatic fossa, perisplenic fossa, pelvis, pericardium
-May miss <50-80 mL free fluid
-Misses retroperitoneal bleeding, hollow viscous injury

Front 27

trauma pt has petichiae, hypoxia, confusion/agitation
-Suspect ...
-Lab test to confirm = _

Back 27

Fat embolism:
-Presents c/ petichiae, hypoxia, confusion/agitation
-Sudan stain (+) for fat in urine, sputum

Front 28

what are the "M" components of GCS?

Back 28

M6: follows commands
5: localizes to pain side
4: withdraws to pain
3: decorticate = flexes to pain
2: decerebrate = extends to pain
1: no response to pain

Front 29

What is this GCS?
Opens eyes to pain
Mumbles
Withdraws to pain

Back 29

GCS 8:
Opens eyes to pain (2)
Mumbles (2)
Withdraws to pain (4)

Front 30

Pt has (+) DPL, hypotensive despite fluid resuscitation, and has blown pupil
-What do you do?

Back 30

Pt has (+) DPL, hypotensive despite fluid resuscitation, and has blown pupil ->
OR for 1.) laparotomy, then 2.) Burr hole to decompress side c/ blown pupil = 5 cm anterior, 5 cm superior to external auditory canal
-Alternative = place ICP bolt, check pressure, then Burr Hole if pressure elevated

Front 31

Criteria (4) for thoracotomy following chest tube placement in trauma pt …

Back 31

Thoracotomy criteria after chest tube placement:
1. >1500 cc blood after initial placement
2. >250 cc/hr x 3 hrs or >200 cc/hr x 4 hrs
3. 2500 cc in 1st 24 hrs
4. Bleeding + instability (5. incomplete drainage of hemothorax despite 2 good tubes)

Front 32

Trauma pt has R chest tube placed + 2000 cc blood returns immediately
Thoracotomy site depends on _

Back 32

High output after R chest tube placement:
(+) Pulse => R thoracotomy
(-) Pulse => L thoracotomy + open pericardium + clamp aorta

Thoracotomy criteria after chest tube placement:
1. >1500 cc blood after initial placement
2. >250 cc/hr in 1st 3 hrs
3. 2500 cc in 1st 24 hrs
4. Bleeding + instability

Front 33

patient c/ head injury intubated for airway protection.
-CT shows loss of sulci, compression of cisterns-> intracerebral catheter placed
-What is minimal cerebral perfusion pressure goal?
-2 strategies to improve CPP...

Back 33

CPP = MAP-ICP
Should be at least 60
Mannitol decreases brain edema => decreases ICP
Mild hyperventilation (pCO2 30-35) causes mild cerebral vasocontriction => limits brain edema

Front 34

how is ISS calculated?

Back 34

ISS grades all body system using the same scale and given them the same weight.
(a traumatic finger amputation has the same influence on outcome as a trans-tentorial GSW)
It is purely anatomic, and it only takes the 3 worst body systems into account.

Front 35

pt c/ GSW to R flank undergoing laparotomy. Bile-stained fluid noted in RUQ.
Next step _

Back 35

Kocher maneuver;
peritoneum incised @ R edge of the duodenum ->
duodenum and head of pancreas reflected to L ->
expose the duodenum, portal triad, head of pancreas. also to see IVC injury.

Front 36

What is a Kocher maneuver?

Back 36

Kocher maneuver;
peritoneum incised @ R edge of the duodenum ->
duodenum and head of pancreas are reflected to the L ->
expose the duodenum, portal triad, head of pancreas

To control hemorrhage from the IVC or remove a pancreatic tumor

Front 37

what is the mangement of portal vein injury 2/2 trauma?

Back 37

Liver trauma:
-Common hepatic artery can be ligated. collaterals via gastroduodenal artery. Don't ligate hepatic lobar arteries if pt hypotensive b/c risk of ischemia
-Retrohepatic AVC injury => atriocaval shunt during repair
-Portal triad hematoma => explore
-Portal vein injury => repair. may need to transect through pancreas (then do distal pancreatectomy) to get to injury. 50% mortality c/ ligation of portal vein
-Omental graft can be placed in liver lac to reduce bleeding, prevent bile leak
-Perihepatic packs if unstable in OR + go to SICU

Front 38

what is the mangement of portal triad hematoma 2/2 trauma?

Back 38

Liver trauma:
-Common hepatic artery can be ligated. collaterals via gastroduodenal artery. Don't ligate hepatic lobar arteries if pt hypotensive b/c risk of ischemia
-Retrohepatic AVC injury => atriocaval shunt during repair
-Portal triad hematoma => explore
-Portal vein injury => repair. may need to transect through pancreas (then do distal pancreatectomy) to get to injury. 50% mortality c/ ligation of portal vein
-Omental graft can be placed in liver lac to reduce bleeding, prevent bile leak
-Perihepatic packs if unstable in OR + go to SICU

Front 39

what is the mangement of retrohepatic IVC injury 2/2 trauma?

Back 39

Liver trauma:
-Common hepatic artery can be ligated. collaterals via gastroduodenal artery. Don't ligate hepatic lobar arteries if pt hypotensive b/c risk of ischemia
-Retrohepatic AVC injury => atriocaval shunt during repair
-Portal triad hematoma => explore
-Portal vein injury => repair. may need to transect through pancreas (then do distal pancreatectomy) to get to injury. 50% mortality c/ ligation of portal vein
-Omental graft can be placed in liver lac to reduce bleeding, prevent bile leak
-Perihepatic packs if unstable in OR + go to SICU

Front 40

what is the mangement of common hepatic artery injury 2/2 trauma?
how is mgmt different for the lobar arteries?

Back 40

Liver trauma:
-Common hepatic artery can be ligated. collaterals via gastroduodenal artery. Don't ligate hepatic lobar arteries if pt hypotensive b/c risk of ischemia
-Retrohepatic AVC injury => atriocaval shunt during repair
-Portal triad hematoma => explore
-Portal vein injury => repair. may need to transect through pancreas (then do distal pancreatectomy) to get to injury. 50% mortality c/ ligation of portal vein
-Omental graft can be placed in liver lac to reduce bleeding, prevent bile leak
-Perihepatic packs if unstable in OR + go to SICU

Front 41

trauma pt has liver injury. pseudoaneurysm seen on CT
-management is +
-consider getting an angiogram 1st if _

Back 41

Liver trauma + active blush on CT or pseudoaneurysm => to OR
-Posterior injury => consider getting an angiogram. to OR if in doubt.
-Anterior injury => go to OR

Front 42

what is the rule of thumb for "failure" of conservative mgmt of blunt liver trauma?

Back 42

Blunt liver trauma - failure of conservative mgmt (bedrest x5 d) if
unstable (HR>120, SBP<90) or Hct <25 despite 4U PRBC =>
needs surgery

Front 43

#1 indication of mandibular injury = _

Back 43

Mandibular injury:
-Malocclusion = #1 sign
-Panorex film to assess injury, along c/ fine-cut facial CT + reconstruction
-Most reapired c/ IMF (metal arch bars to upper + lower dental arches, 6-8 wks) OR ORIF

Front 44

For a pt s/p massive transfusion who is persistently hypotensive, test the level of _ in their blood

Back 44

In a pt s/p massive transfusion who is persistently hypotensive, suspect HYPOCALCEMIA

Front 45

Mattox maneuver = _

Back 45

Mattox maneuver =retroperitoneal mobilization and medial rotation of L ab viscera to control retro-peritoneal hematoma
For midline supramesocolic hemorrhage or hematoma (ABOVE transverse mesocolon, BELOW celiac artery)
-Dissection of the white line of Toldt from L side of the colon to the RUQ -> frees up L side of colon, L kidney, pancreas, spleen

Cattell Maneuver for the vena cava and suprarenal aortic zone 1 on R; Mattox Maneuver for ab aorta (zone 2) on L; Visceral Sweep Maneuver to the RUQ with a division of the ligament of Treitz for infrarenal aorta and iliac arteries or veins (zones 3 and 4))

Front 46

what is tx for nasoethmoid orbital fx?
-what do you have to rule out?

Back 46

nasoethmoid orbital fx:
-70% have CSF leak => may need surgical closure of dura
-conservative tx x 2 wks

Front 47

neck trauma zone _ = below cricoid
-Tx is _

Back 47

Neck zones:
1: below cricoid => Angio, bronch, rigid esophagoscopy, barium swallow, +/- pericardial window. may need sternotomy to reach injuries
2: cricoid to angle of jaw (most amenable to OR exploration)
3. jaw to skull
Remember 1-> 3 low to high, like LeForte fx, embryology of POTH glands - inf glands + thymus from 3rd pouch, sup glands from 4th)

Front 48

neck trauma zone _ = cricoid to angle of mandible
-Tx is _

Back 48

Neck zones:
1: below cricoid
2: cricoid to angle of jaw => OR exploration
3. jaw to skull
Remember 1-> 3 low to high, like LeForte fx, embryology of POTH glands - inf glands + thymus from 3rd pouch, sup glands from 4th)

Front 49

neck trauma zone _ = angle of mandible to base of skull
-Tx is _

Back 49

Neck zones:
1: below cricoid
2: cricoid to angle of jaw (most amenable to OR exploration)
3. jaw to skull => angio, laryngoscopy. (may need jaw subluxation/digastric and SCM release/ mastoid sinus resection to reach vascular injuries)
Remember 1-> 3 low to high, like LeForte fx, embryology of POTH glands - inf glands + thymus from 3rd pouch, sup glands from 4th)

Front 50

what is the treatment for a posterior nose bleed

Back 50

Anterior nose bleed => pack
Posterior nose bleed => 1st try balloon tamponade ->
may need angioembolization of internal maxillary or ethmoidal artery

Front 51

2 indications for repair of orbital blowout fracture?

Back 51

Orbital blowout fracture:
-need repair if impaired upward gaze or diplopia c/ upward vision
-use bone fragments or bone graft to restore orbital floor

Front 52

57 yo male s/p MVA who is stabilized in the trauma bay presents with blood in urethral meatus. Several moments later, patient's blood pressure drops to 80/60 with tachycardia of 120. What is the next step?

Back 52

external fixation of the pelvis
This patient is likely to have a pelvic fracture with hemorrhage. The usual cause of hemorrhage from pelvic fractures is from posterior pelvic venous plexus and bleeding cancellous bone surfaces. Initial treatment should focus on control of venous bleeding via pelvic reduction and stablization to reduce pelvic volume and achieve temponade through compression of viscera and hematoma. If this maneuver does not achieve hemodynamic stability, arteriography should be done, as less than 10% of bleeding maybe caused by named arterial bleeding

Front 53

Pt c/ GSW to L flank is hypotensive despite fluid, (+) pulse
Next step = _

Back 53

Pt c/ GSW to abdomen + hypotension -> OR

Front 54

Pt s/p GSW to abdomen is hypotensive despite fluid + PRBC c/ large retroperitoneal hematoma extending above the level of the celiac artery found on laparotomy
-Next step = _

Back 54

Pt s/p GSW to abdomen is hypotensive despite fluid + PRBC c/ large retroperitoneal hematoma extending above the level of the celiac artery found on laparotomy ->
-INFRA-DIAPHRAGMATIC CLAMP CONTROL OF AORTA or
-L THORACOTOMY + CLAMP AORTA

-Mattox maneuver (retroperitoneal mobilization and medial rotation of all left-sided abdominal viscera) will not give proper exposure of hematoma unless BELOW CELIAC ARTERY

Front 55

Pt s/p GSW to R flank has bilious fluid in RUQ on laparotomy
Next step = _

Back 55

Bilous fluid in RUQ on trauma laparotomy ->
Kocher maneuver (peritoneum incised @ R edge of the duodenum -> duodenum and head of pancreas are reflected to the L -> expose structures in the retroperitoneum, examine duodenum, portal triad, head of pancreas)

Front 56

pt c/ posterior knee dislocation + loss of pulse -> knee shoved back in place -> pulse now present
-Must order a _ to r/o _

Back 56

After posterior knee dislocation, order ANGIOGRAM to r/o POPLITEAL ARTERY injury

Front 57

Pringle maneuver = _

Back 57

Pringle maneuver:
-Serial clamping of PORTA HEPATIS, @ hepato-duodenal ligament
-15 min on, 5 min off
-Doesn’t stop hepatic vein bleeding (connected to IVC posteriorly)

Front 58

Pt c/ severe liver injury. Unable to stop bleeding during laparotomy -> decide to do Pringle maneuver, but bleeding still doesn't stop
-Bleed is most likely coming from _

Back 58

Pringle maneuver:
-Serial clamping of PORTA HEPATIS, @ hepato-duodenal ligament
-15 min on, 5 min off
-Doesn’t stop hepatic vein bleeding (connected to IVC posteriorly)

Front 59

patient has rectal injury 2/2 penetrating trauma
-Intraperitoneal, >5 cm from anal verge. Tx = _

Back 59

Rectal trauma:
-usually 2/2 penetrating injury (like colon trauma)
-High + extraperitoneal = difficult to access => presacral drainage + colostomy. serial dbt
-High + intraperitoneal => repair defect, presacral drainage + colostomy
-Low (<5 cm) => probably able to repair transanally

Front 60

patient has rectal injury 2/2 penetrating trauma
-Intraperitoneal, <5 cm from anal verge. Tx = _

Back 60

Rectal trauma:
-usually 2/2 penetrating injury (like colon trauma)
-High + extraperitoneal = difficult to access => presacral drainage + diverting colostomy. serial dbt
-High + intraperitoneal => repair defect, presacral drainage + diverting colostomy
-Low (<5 cm) => probably able to repair transanally

Front 61

22m s/p GSW L flank is hypotensive, taken to OR. Found to have L retroperitoneal hematoma extending above the celiac =>
clamp infradiaphragmatioc aorta to control bleed, then perform Mattox maneuver to expose retroperitoneum =>
found to have complete avulsion of L renal vein from IVC.
-Next step = _

Back 61

renal trauma: 95% non-op
-hematuria =best indicator. CT scan for all pts c/ hematuria. IVP to ID contralateral kidney helpful if going to OR s/ CT.
-Surgery if: acute ongoing hemorrhage. disruiption of major collecting duct system, unresolving urine extrav., severe hematuria
-L renal vein can be ligated near IV b/c has adrenal + gonadal vein collaterals. NO collaterals for R renal vein.
-A->P hilum structures: vein, artery, pelvis. Control HILUM 1st on exploration. Place drains, esp. if collecting system injured
-Methylene blue can be used at end of case to r/o leak
-If exploring for other trauma: blunt renal injury + hematoma => leave unless CT/IVP showed no fx or sig. extrav. Penetrating injury + hematoma => open unless preop CT/IVP shows good fx, no extrav.
-Flank trauma + no uptake on IVP => angio. can stent if flap present

Front 62

Pt s/p GSW to L flank is hypotensive c/ large L retroperitoneal hematoma on laparotomy -> after infradiaphragmatic control of aorta, L renal vein found to be completely avulsed from aorta.
Next step = _

Back 62

L renal vein avulsion from aorta:
-Remove infradiagphragmatic aortic clamp ->
place supra-renal aortic clamp ->
OVER-SEW RENAL VEIN, LIGATE IVC CONNECTION
-L renal vein can be ligated b/c has has adrenal vein and gonadal vein collaterals
(R renal vein does not have those collaterals => must re-anastomose that side if stable or perform nephrectomy if unstable

Front 63

Pt s/p GSW to R flank is hypotensive c/ large R retroperitoneal hematoma on laparotomy -> after infradiaphragmatic control of aorta, R renal vein found to be completely avulsed from aorta.
Next step depends on _

Back 63

R renal vein avulsion from aorta:
-Remove infradiagphragmatic aortic clamp ->
place supra-renal aortic clamp ->
if STABLE => RE-ANASTOMOSE or
if UNSTABLE => nephrectomy (unlike L renal vein, R can't be ligated b/c no adrenal vein and gonadal vein collaterals)

Front 64

open mesenteric hematoma 2/2 sm bowel injury if expanding or >_ cm

Back 64

Small bowel trauma:
-Usually 2/2 penetrating injury. Hard to diagnose if blunt trauma
-Occult injuries: Ab CT showing intra-ab fluid but no solid organ injury, bowel wall thickening, mesenteric hematoma => observe, +/- repeat CT in 8-12 hrs. Must tolerate PO before d/c home
-Repair lacerations transversely to avoid stricture
-lacerations >50% circumference or lumen diameter <1/3 normal => resect
-Open mesenteric hematoma if expanding or >2cm

Front 65

when can sm bowel injury be primarily repaired?
<_% of circumference, final lumen diameter >_% of normal

Back 65

Small bowel trauma:
-Usually 2/2 penetrating injury. Hard to diagnose if blunt trauma
-Occult injuries: Ab CT showing intra-ab fluid but no solid organ injury, bowel wall thickening, mesenteric hematoma => observe, +/- repeat CT in 8-12 hrs. Must tolerate PO before d/c home
-Repair lacerations transversely to avoid stricture
-lacerations >50% circumference or lumen diameter <1/3 normal => resect
-Open mesenteric hematoma if expanding or >2cm

Front 66

Pt after chest trauma has WORSE oxygenation after chest tube placement
-Suspect _
Dx by _
-Tx depends on _

Back 66

Tracheobronchial injuries:
-R >L b/c takeoff of RUL occurs @ shorter distance from carina vs. LUL => LESS FLEXIBLE segment, PRONE TO TEARING
-Worse oxygenation s/p chest tube placement, one of few indiciations to clamp Ctube
-Dx: Bronchoscopy
-Tx: Repair if 1.) large air leak + resp compromise or 2.) air leak x 2 weeks
-L thoracotomy: distal L mainstem injuries (>1 cm)
-R thoracotomy: R mainstem, trachea, prox L mainstem (AVOID AORTA)

Front 67

Complete traumatic transection of ureter below pelvic brim is treated by _
-Do this b/c _

Back 67

Complete traumatic transection of ureter below pelvic brim is treated by REIMPLANTATION INTO BLADDER
-Cyto-ureteral anastomoses have higher success rate in general than uretero-ureteral

Front 68

Complete traumatic transection of ureter above pelvic brim is treated in two ways _, depending on

Back 68

Complete traumatic transection of ureter above pelvic brim:
-<2 cm missing => mobilize ureter as much as possible without devascularizing -> uretero-ureteral anastomosis +/- stent
->2 cm missing => percutaneous nephrostomy tube, tie off both ends of ureter -> urologist does uretero-ureteral anastomosis or ileal conduit @ later time

-Dx: IVP + retrograde urethrogram
-Blood supply is medial in upper 2/3 of ureter; lateral in lower 1/3 of ureter

Front 69

In pt c/ extremity trauma and ABI <_ => needs angiography

Back 69

Major signs of vascular injury => to OR:
-1. Active hemorrhage
2. Pulse deficit
-3. Expanding/pulsatile hematoma
4. Distal ischemia
5. Bruit/thrill

Moderate (soft) signs of vascular injury => ANGIOGRAPHY
1. Hx hemorrhage @ the scene
2. anatomically related nerve deficit
3. Large stable hematoma
4. Injury close to major artery (e.g. GSW to medial thigh)
5. ABI <0.9
6. Unequal pulses

Front 70

what is the treatment for Tripod fracture?

Back 70

Tripod fracture (zygomatic bone) => ORIF for cosmesis

Front 71

Le Fort _ fracture involves the nasal bones and may widen the inner canthi of the eyes

Back 71

Le Fort II fracture involves the nasal bones and may widen the inner canthi of the eyes

Front 72

A 22-year-old man sustained severe blunt trauma to the chest and abdomen. A chest x-ray shows opacity of the lower one half of the left chest and the nasogastric tube appearing to coil upward into the left chest. The most appropriate surgery is ...

Back 72

ex lap for diaphragmatic rupture <1 week old

Front 73

The most appropriate initial management of a patient with an extremity with obvious signs of frostbite is

Back 73

rewarming in a 40.0 C (104.0 F) water bath

Front 74

Traumatic injury of the lateral half of the spinal cord (Brown-Sequard syndrome) results in ...

Back 74

ipsilateral motor loss and contralateral sensory loss