Chapter 15 Trauma

Front 1

Describe the 3 peaks of trauma deaths

Back 1

1st peak- 0-30min laceration heart/aorta
2nd peak- 30min-4hrs #1 head injury #2 hemorrhage
3rd peak- days to weeks deaths due to multisystem organ failure and sepsis

Front 2

Most commonly injured organ with blunt trauma

Back 2

Liver

Front 3

Most commonly injured organ with penetrating injury

Back 3

small bowel

Front 4

What % of blood loss must occur before pt shows hypotension

Back 4

30%

Front 5

Stage/ Grade of Shock
Up to about 15% (~750ml) loss of effective blood volume, mild resting tachycardia

Back 5

Stage/ Grade of Shock
1

Front 6

Stage/ Grade of Shock
Between 15-30% loss of blood volume (750-1500ml) will provoke a moderate tachycardia and begin to narrow the pulse pressure. The time taken for the capillaries to refill after 5 seconds of pressure (capillary refill time) will be extended.

Back 6

Stage/ Grade of Shock
2

Front 7

Stage/ Grade of Shock
At 30 - 40% loss of effective blood volume (1500 - 2000 ml) the compensatory mechanisms begin to fail and hypotension, tachycardia and low urine output (<0.5ml/kg/hr in adults) are seen

Back 7

Stage/ Grade of Shock
3

Front 8

Stage/ Grade of Shock
At 40-50% loss of blood volume (2000 -2500 ml) profound hypotension will develop and if prolonged will cause end-organ damage and death.

Back 8

Stage/ Grade of Shock
4

Front 9

Describe the characteristic of a positive diagnostic peritoneal lavage (DPL)

Back 9

1. >10cc blood
2. >100,000 RBCs/cc
3. Food particles
4. Bile
5. Bacteria
6. >500 WBC/cc

Front 10

What does a DPL miss?

Back 10

1. Retroperitoneal bleeds
2. Contained Hematomas

Front 11

What does FAST scan stand for, and what areas are scanned?

Back 11

Focused Abdominal Sonography for Trauma
Chack for blood in the perihepatic fossa, perisplenic fossa, pelvis, and pericardium

Front 12

What does a FAST scan miss?

Back 12

retroperitoneal bleed, hollow viscous injury

Front 13

What type of injuries does a CT miss?

Back 13

hollow viscous injury, diaphragm injury

Front 14

In abdominal syndrome what is the final common pathway for decreased cardiac output

Back 14

IVC compression

Front 15

In abd compartment syndrome bladder pressure would be expected to be

Back 15

bladder pressure >25-30

Front 16

What is the tx for abdominal compartment syndrome?

Back 16

decompressive laparotomy

Front 17

When to do ER thoracotomy?

Back 17

1. Blunt Trauma pressure/ pulse lost in ER
2. Penetrating traumapressure/ pulse lost on way to ER or in ER

Front 18

Descirbe the approach for a ER thoracotomy.

Back 18

incision through the 4th and 5th intercostal spaces using anterolateral approach

Front 19

When do catecholamine peak after trauma?

Back 19

24-48 hours

Front 20

Most commonly due to arterial bleeding fromt the middle meningeal artery

Back 20

Epidural Hematoma
Head CT will show lenticular (lens-shaped) deformity

Front 21

When to operate for Epidural hematomas?

Back 21

neurological degenerationor significant mass effect (shift >5mm)

Front 22

Most commonly form tearing of venous plexus (bridging veins) between dura and arachnoid

Back 22

Subdural Hematoma

Front 23

What is the formula for Cerebral Perfusion Pressure

Back 23

CPP= MAP-ICP

Front 24

What are the signs of elevated ICP?

Back 24

1. decreased ventricular size
2. loss of sulci
3. loss of cisterns

Front 25

When should an ICP monitor be placed?

Back 25

1. GCS less than or equal to 8
2. suspected increased ICP
3. Pt. with moderate to severe head injury and inability to follow clinical exam

Front 26

What is normal ICP?

Back 26

10

Front 27

At what pressure shoul ICP be treated

Back 27

>20 needs treatment

Front 28

list supportive treatment for elevated ICP.

Back 28

1. sedation and paralysis
2. raise head of bed
3. relative hyperventilation (CO2 30-35) for modest cerebral vasoconstriction
4. Mannitol
5. barbiturate coma
6. Ventriculostomy w/ csf drainage keep ICP <20
7. Craniotomy decompression
8. Phenytoin

Front 29

What time frame do peak ICP occur after injury?

Back 29

48-72 hours

Front 30

Name the basal skull fx
Raccoon eyes

Back 30

anterior fossa fracture

Front 31

Name the basal skull fx
Battle's sign

Back 31

middle fossa fracture,
can injure facial nerve, if acute need exploration

Front 32

What CN can be injured with temporal skull fx?

Back 32

CN VII and VIII

Front 33

Most common site of facial nerve injury?

Back 33

geniculate ganglion

Front 34

Most skull fx do not require sx. When do you operate?

Back 34

1. significant skull depression 8-10mm
2. contamination
3. persistent CSF leak not responding to conservative therapy

Front 35

Tx for C-1 burst fx caused by axial loading (aka Jefferson Fx)

Back 35

Rigid Collar

Front 36

Tx foe C-2 fx (hangman's fx) caused be distraction and extension

Back 36

traction and halo

Front 37

Name the types and tx of C-2 odontoid fractures

Back 37

Type I- above base stable
Type II- at base, unstable tx fusion or halo
Type III- extends into vertebral body, fusion or halo

Front 38

What are the indications for emergent surgical spine decompression?

Back 38

1. fx or dislocation not reducible with distraction
2. acute anterior spinal syndrome
3.open fractures
4. soft tissue or bony cord compression
5. progressive neurologic dysfunction

Front 39

Most common cause of facial nerve injury?

Back 39

Fx of temporal bone

Front 40

Name the type of Le Fort Classification and the treatment:

Maxillary fx straight accross

Back 40

Le Fort Type I

Reduction, stabilization, intramaxillary fixation +/- circumzygomatic and orbital suspension wires

Front 41

Name the type of LeFort Classification and the treatment:

Lateral to nasal bone underneath eyes, diagonal toward maxilla

Back 41

Le Fort Type II

Reduction, stabilization, intramaxillary fixation +/- circumzygomatic and orbital suspension wires

Front 42

Name the type of LeFort Classification and the treatment:

Lateral orbital walls

Back 42

Le Fort Type III

suspension wiring to stable frontal bone may need external fixation

Front 43

Tx of posterior nosebleeds

Back 43

1. balloon tamponade 1st
2. angioembolizationof internal maxillary artery or ethmoidal artery

Front 44

Name the zones of the neck:

Clavical to cricoid cartilage

Back 44

Zone I: need angiography, bronchoscopy, rigid esophagoscopy, barium swallow, may need pericardial widow, sternotomy

Front 45

Name the zones of the neck:

Cricoid to the angle of the mandible

Back 45

Zone II: Exploration iin OR

Front 46

Name the zones of the neck:

Angle of the mandible to the base of the skull

Back 46

Zone III: need angiography, laryngoscopy

Front 47

What is the diagnostic of choice for esophageal injuries

Back 47

rigid esophagoscopy and esophagogram best combined modalities find 95% of injuries

Front 48

esophageal injury <24 hr without significant contamination, and pt is stable, what is the treatment?

Back 48

Primary closure

Front 49

Noncontained esophageal injury , > 24hrs, pt is unstable, what is the tx?

Back 49

spit fistulaand drain leak with chest tube

Front 50

What is the approach to the following esophageal injury:
Neck

Back 50

Left side

Front 51

What is the approach to the following esophageal injury:

Upper 2/3 of the thoracic esophagus

Back 51

Right Thoracotomy

Front 52

What is the approach to the following esophageal injury:

Lower 1/3 of the thoracic esophagus

Back 52

Left Thoracotomy

Front 53

What is the work up for shotgun injuries to the neck?

Back 53

angiogram, neck CT, esophagus/ tracheal evaluation

Front 54

List indication for thoracotomy in OR--- after placement of Chest tube

Back 54

1. >1,500 cc after intial insertion
2. >250 cc/hr for 3 hr
3. 2,500 cc/ 24 hr
4. Bleeding with instability

Front 55

A sucking chest wound need to be ___ the diameter of the trachea to be significant

Back 55

2/3 the diameter ot the trachea to be significant

Front 56

Bronchial injuries are more common on the _____.

Back 56

Right

Front 57

Left or Right thoracotomy?

Right mainstem, trachea, and proximal left mainstem injuries

Back 57

Right thoracotomy

Front 58

Left or Right thoracotomy?

Distal left mainstem injuries

Back 58

Left thoracotomy

Front 59

How do you dx and when do tx tracheobronchial injuries.

Back 59

Dx: Bronchoscopy
Tx: repair if lrg air leak and respiratory compromise or after 2 wks of persistent air leak

Front 60

Diaphragm injuries are more likely to be found on which side?

Back 60

Left, and to result from blunt trauma

Front 61

Diaphragm injury < 1 week, what is your approach?

Back 61

Transabdominal approach

Front 62

Diaphragm injury >1 week, what is your approach?

Back 62

Chest approach

Front 63

At what location is the aorta most likely to tear?

Back 63

ligamentum arteiosum
(just distal to subclavian takeoff)

Front 64

Dx of Aortic transection

Back 64

aortogram or CT angiogram of chest

Front 65

Tx of Aortic Transection

Back 65

control blood pressure
nipride and esmolol gtt

Front 66

What is the operative approach for aortic transection?

Back 66

Lef thoracotomy with partial left heart bypass

Front 67

What is the surgical approach for the following:
injuries to ascending aorta, innominate A, proximal right subclavian A, innominate V, Proximal left common carotid

Back 67

Median sternotomy

Front 68

What is the surgical approach for the following:
Injuries to left subclavian A., Descending aorta

Back 68

Left Thoracotomy

Front 69

What is the surgical approach for the following:
injury ot distal right subclavian A

Back 69

midclavicular incision 1/2 resection of medial clavicle

Front 70

What is the most common cause of death after a myocardial contusion?

Back 70

V-tach and V-fib most common cause of death, most common arrhythmia is SVT

Front 71

Def:> 2 consecutive ribs broken > 2 sites, results in paradoxical motion

Back 71

Flail chest

Front 72

Pentrating "Box" injuries, need pericardial window, bronchoscopy, esophagoscopy, barium swallow. Describe the borders of the "BOX"

Back 72

borders are clavicles, xiphoid process, niples

Front 73

Penetrating chest wound outside the "BOX" without pneumothorax or hemothorax should be tx how?

Back 73

1. if pt required intubation Chest tube is needed
2. if not intubated follow CXRs

Front 74

Trauma pt with a penetrating wound to the "BOX", upon doing a pericardial window you find blood, what is the next step?

Back 74

Sternotomy to fix possible injury to heart, place pericardial drain

Front 75

Pentrating injuries anterior-medial to midaxillary line and below the nipples require?

Back 75

Laparotomy or Laparoscopy

Front 76

List 3 traumatic causes of cardiogenic shock.

Back 76

1. cardiac tamponade
2. cardiac contusion
3. tension pneumothorax

Front 77

Hypotension, increase airway pressures, decreased breath sounds, JVD, tracheal shift, can see bulging diaphragm during laparotomy

Back 77

Tension pneumothorax

Front 78

With Tension pneumothorax cardiac compromise is due too?

Back 78

decreased venous return

Front 79

Sternal fx pt are at high risk for?

Back 79

cardiac contusion

Front 80

Pts with 1st and 2nd fib fx are at high risk for?

Back 80

aortic transection

Front 81

Name the type of pelvic fx:
Unstable (crush)
mortality 20-30%,
blood loss> 10U complications 60-75%

Back 81

Type I

Front 82

Name the type of pelvic fx:
Unstable
mortality 8-12%
blood loss 2-10U
complications 30-50%

Back 82

Type II

Front 83

Name the type of pelvic fx:
mortality <5%
blood loss 1-4 units
complications 10-20%

Back 83

Type III

Front 84

What type of pelvic fx is more likely to have venous bleeding?

Back 84

Anterior pelvic fx

Front 85

What type of pelvic fx is more likely to have arterial bleeding?

Back 85

Posterior pelvic fx

Front 86

Tx of blunt injury pelvic hematoma

Back 86

leave unless expanding and the pt is unstable (if pt is unstable, stablize the pelvic fx, pack pelvis if in OR and get pt to angiography for embolization)

Front 87

What part of the small bowel is the most common area of injury?

Back 87

2nd portion (descending portion, near ampulla of vater) is the most common area of injury

Front 88

70-80% of injuries to the duodenum can be tx with?

Back 88

debridement and primary closure

Front 89

segmental resection with primary end to end closure is possible with all segments of the sm bowel except/

Back 89

2nd portion of the duodenum

Front 90

can present with high sbo 12-72 hours after injury, UGI study will show "stacked coins or coiled spring" appearance, conservative tx (TPN and NGT) CURES 90% of these over 2-3wks

Back 90

missed paraduodenal hematomas

Front 91

With Duodenal Trauma and injury is suspected what sx approach should be performed and What should you check for?

Back 91

kocher maneuver and open lesser sac, check for hematoma, bile, petechiae, sucus, and fat necrosis (if found need formal inspection of the entire doudenum

Front 92

What test should be used for dx of suspected duodenal injury?

Back 92

abd CT with contrast, UGI is the best study (gold standard)

Front 93

What is the tx/ sx for duodenal trauma?

Back 93

Primary repair, may need to divert with pyloric exclusion and gastrojejunostomy to allow healing ( place a distal feeding jejunostomy and possibly a proximal draining jejunostomy tube that threads back to duodenal injury site, place drains

Front 94

What is the tx for duodenal fistulas?

Back 94

bowel rest, TPN, decompression, octreotide, fistulogram to rule out abscess, conservative management for 4-6 weeks

Front 95

Most common organ injured with penetrating trauma?

Back 95

Small Bowel

Front 96

abd CT showing intra-abdominal fluid not associated with a solid organ injury, or bowel wall thickening, or mesenteric hematoma is suggestive of what type of injury, after penetrating trauma

Back 96

occult small bowel injury

Front 97

How should SB lacerations be repaired in order to avoid strictures?

Back 97

Transversely

Front 98

How should Lrg SB lacerations >50% of the circumference or result in lumen diameter that is 1/3 of normal, be repaired?

Back 98

perform resection and reanastomosis

Front 99

Tx of mesenteric hematomas

Back 99

open if expanding or >2cm

Front 100

Tx of right and transverse colon trauma

Back 100

can perform primary reanastomosis

Front 101

Tx of Left colon trauma

Back 101

colostomy and Hartman's pouch or mucous fistula is the safest procedure

Front 102

Tx of high rectal extraperitoneal trauma

Back 102

generally not repaired bc of inaccessibility, Tx presacral drainage and fecal diversion with colostomy, serial debridement

Front 103

Tx of high rectal intraperitoneal trauma

Back 103

Tx: repair defect, presacral drainage, fecal diversion with colostomy

Front 104

Tx of low rectal trauma (<5cm)

Back 104

repair transanally

Front 105

Liver trauma-______ can be ligated with collaterals through gastroduodenal artery

Back 105

Common Hepatic Artery

Front 106

______ can be ligated without complication unless the pt is hypotensive, which could lead to liver ischemia

Back 106

Hepatic Lobar Arteries

Front 107

Describe the Pringle Maneuver

Back 107

compression of the portal triad structures (Common hepatic artery, Portal Vein, Common Bile duct) with noncrushing vascular clamp for hepatic inflow control. If possible, clamp time should be limited to 15-20 min intervals

Front 108

Pringle Maneuver does not stop bleeding from _______.

Back 108

hepatic veins

Front 109

For retrohepatic IVC injury, allows for control while performing repair

Back 109

Atriocaval shunt

Front 110

Tx of portal triad hematomas

Back 110

need to be explored

Front 111

Tx of CBD injury <50% circumference

Back 111

repair over stent

Front 112

Tx of CBD injury >50% circumference

Back 112

choledochojejunostomy

Front 113

When has conservative mngt. of blunt liver injuries failed?

Back 113

Pt. becomes unstable despite aggressive resuscitation,including the following:
1. 4U PRBC (HR>120 or SBP<90)
2. Requires >4U PRBCs to keep HCT>25
GO TO OR

Front 114

What are indications for tx of blunt liver injuries?

Back 114

1. failed conservative mngt
2. active blush on abd CT
3. pseudoaneurysm

Front 115

How are pancreatic injuries to the right of th SMA/SMV treated?

Back 115

Injuries to the right of the SMA /SMV treated with drains instead of Whipple
initially

Front 116

How should a Pancreatic hematoma be treated?

Back 116

Both penetrating and blunt Pancreatic hematomas need to be opened (explored)

Front 117

In a trauma pt, what should be repaired first Vascular or ortho?

Back 117

Vascular repair performed before orthopedic repair

Front 118

What are the Hard/ Major signs of vascular injury?

Back 118

1. active hemorrhage
2. pulse deficit
3. expanding or pulsatile hematoma
4. distal ischemia
5. bruit / thrill

Front 119

What is the next step in pt with a hard sign of vascular injury?

Back 119

OR

Front 120

What are the soft signs of vascular injury?

Back 120

1.history of hemorrhage
2.deficit of anatomically related nerve,
3.large stable/ nonpulsatile
hematoma

Front 121

What is the next step in pt with a soft sign of vascular injury?

Back 121

go to angio

Front 122

Moderate/soft signs of vascular injury, at what ABI do you go to Angio?

Back 122

ABI < 0.9

Front 123

When is a saphenous vein graft need in trauma?

Back 123

Saphenous vein graft - will be needed if segment > 2 cm missing

Front 124

When should a fasciotomy be consider with vascular injury?

Back 124

Consider fasciotomy if ischemia > 4 hours - prevents compartment syndrome

Front 125

What are the 5 Ps of compartment syndrome?

Back 125

1.Pain
2.Paresthesia
3.Paralysis
4.Poikilothermia
5.Pulselessness
( l ate fi n d i ng)

Front 126

At what pressure should you consider compartment syndrome?

Back 126

20 mm hg

Front 127

Blood loss from a femur fx

Back 127

> 2L

Front 128

Name the nerve/ artery injury:
Anterior shoulder dislocation
Posterior shoulder dislocation
Proximal humerus fx

Back 128

Axillary nerve

Front 129

Name the nerve/ artery injury:
Midshaft humerus ( or spiral humerus fracture )

Back 129

Radial nerve

Front 130

Name the nerve/ artery injury:
Distal ( supracondylar) humerus
Elbow dislocation

Back 130

Brachial artery

Front 131

Name the nerve/ artery injury:
Distal radius

Back 131

Median nerve

Front 132

Name the nerve/ artery injury:
Anterior hip dislocation

Back 132

Femoral artery

Front 133

Name the nerve/ artery injury:
Posterior hip dislocation

Back 133

Sciatic nerve

Front 134

Name the nerve/ artery injury:
Distal (supracondylar) femur fx

Back 134

Popliteal artery

Front 135

Name the nerve/ artery injury:
Posterior knee dislocation

Back 135

Popliteal artery

Front 136

Name the nerve/ artery injury:
Fibula neck fx

Back 136

Common peroneal nerve

Front 137

What is the best indicator of renal trauma?

Back 137

Hematuria
All patients with hematuria need CT scan

Front 138

Why can the Left renal vein be ligated but the right cannot?

Back 138

left renal vein - can be ligated near IVC; has adrenal and gonadal vein collaterals.
Right does not

Front 139

Describe anterior posterior renal hilum structures.

Back 139

vein, artery, pelvis

Front 140

How is most renal trauma treated?

Back 140

95% of injuries are treated
nonoperatively

Front 141

What are the indications for tx of renal trauma?

Back 141

Acutely - on going hemorrhage with instability
After acute phase - major collecting system disruption, unresolving urine extravasation,
severe hematuria

Front 142

What can be used to check for leak after sx for renal trauma?

Back 142

Methylene blue dye

Front 143

Blunt renal injury with hematoma, TX?

Back 143

leave unless preop CT/ IVP shows no function
or significant urine
extravasation

Front 144

Penetrating renal injury with hematoma, TX?

Back 144

open unless preop CT/ IVP shows good function without significant urine extravasation

Front 145

Trauma to flank and IVP shows no uptake, TX?

Back 145

angiogram can stent if flap
present

Front 146

Trauma to flank and IVP shows no uptake, What is the tx?

Back 146

Tx: angiogram; can stent if
flap present

Front 147

List three signs of bladder trauma

Back 147

meatal blood, sacral or scrotal hematoma

Front 148

Dx: of bladder trauma

Back 148

cystogram

Front 149

cystogram shows starbursts

Back 149

Extraperitoneal bladder rupture
Tx: Foley 7- 14 days

Front 150

cystogram shows leak

Back 150

Intraperitoneal bladder rupture more likely in kids,
• Tx: operation and repair of defect, followed by Foley drain age

Front 151

What is the best test for URETERAL TRAUMA?

Back 151

IVP and retrograde urethrogram ( RUG) best tests

Front 152

If large ureteral segment is missing ( > 2 e m ) and cannot perform reanastomosis :Upper 1/3. injuries and middle 1/3. injuries that won't reach bladder, What is the TX?

Back 152

Temporize with percutaneous nephrostomy (tie off both ends of the u reter) if patient unstable . Can go with
ileal intrerposition or
trans-ureteroureterostomy later

Front 153

If large ureteral segment is missing ( > 2 cm ) and cannot perform reanastomosis:
Lower 1/3 injuries tx?

Back 153

reimplant in the bladder; may need bladder hitch procedure

Front 154

Tx for small ureteral segment is missing ( < 2cm )

Back 154

try to m o b i l ize e n d s of u reter and
perform primary repair over stent if in the upper or mid ureter or reimplant if in the
lower 1/3 ureter

Front 155

What is the tx for significant urethral tears?

Back 155

Tx: suprapubic cystostomy and repair in 2-3 months
(safest method )

Front 156

What is the tx for Small, partial urethral tears?

Back 156

Tx: may get away with bridging urethral catheter across tear area and repair in 2-3 months

Front 157

Genital trauma - can get fracture in erectile bodies from vigorous sex, What is the tx?

Back 157

Need to repair the tunica and Buck's fascia

Front 158

What modality should be used and what are you evauating in testicular trauma?

Back 158

get ultrasound to see if tunica albuginea is violated

Front 159

Test for fetal blood in the maternal circulation + sign of
placental abruption

Back 159

kleihauer-Betke test

Front 160

Uterine rupture most likely to occur where?

Back 160

posterior fundus

Front 161

What are the Indications for C-section during exploratory laparotomy for trauma?

Back 161

-Persistent maternal shock
-Pregnancy near term (>34 weeks) and mother with severe injuries
-Pregnancy a threat to the mother's life (hemorrhage, DIC)
• Mechanical limitation to life-threatening vessel injury
• Risk of fetal distress exceeds risk of immaturity
• Direct uterine trauma