Fiser Absite. Ch 15. Trauma.

Front 1

1st peak for trauma deaths occur during what time period? Deaths due to lacerations of heart, aorta, brain, brainstem, spinal cord. Cannot really save these patients; death is too quick.

Back 1

0-30 minutes

Front 2

The 2nd peak in trauma deaths occurs in 30 min to 4 hrs. What classification of injury is the first and second most common cause? These are the patients you can save with rapid assessment (golden hour).

Back 2

Head injury (#1) and hemorrhage (#2)

Front 3

The 3rd peak for trauma deaths occurs in days to weeks. Deaths due to what two main reasons?

Back 3

multisystem organ failure and sepsis

Front 4

Blunt trauma accounts for 80% of all trauma; what is the most common injured organ?

Back 4

liver (some texts say spleen)

Front 5

What is the physics formula for kinetic entery?

Back 5

1/2 mv2

Front 6

What is the LD50 of height of fall.

Back 6

4 stories

Front 7

What is the most commonly injured organ in penetrating injury?

Back 7

small bowel (some texts say liver)

Front 8

What is the most common cause of death in the 1st hour of trauma?

Back 8

hemorrhage

Front 9

Blood pressure is usually OK until ___% of total blood volume is lost.

Back 9

30

Front 10

What is the most common cause of death after reaching the ER alive?

Back 10

head injury

Front 11

What is the most common cause of death long term in trauma patients?

Back 11

infection

Front 12

What is the most common cause of upper airway obstruction? and what is the tx?

Back 12

tongue, perform jaw thrust

Front 13

What injuries are associated with seat belts?

Back 13

small bowel perforations, lumbar spine fractures, sternal fractures

Front 14

What is the best site for cutdown for access?

Back 14

saphenous vein

Front 15

General indications for DPL or FAST?

Back 15

hypotensive pt with blunt trauma

Front 16

What is considered a positive DPL?

Back 16

>10cc of blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500 WBC/cc

Front 17

What do you do if DPL is positive?

Back 17

laparotomy

Front 18

What location should DPL performed if pelvic fracture is present?

Back 18

supraumbilical

Front 19

What 2 things can DPL miss?

Back 19

retroperitoneal bleed, contained hematoma

Front 20

What four places are checked for blood in FAST?

Back 20

perihepatic fossa, perisplenic fossa, pelvis, pericardium

Front 21

FAST can be obstructed by obesity and what amount of free fluid may not be detected?

Back 21

< 50-80

Front 22

What 2 things does FAST scan miss?

Back 22

retroperitoneal bleeding, hollow viscus injury

Front 23

Need a CT scan following blunt trauma in pts with ___, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria.

Back 23

abdominal injury

Front 24

Pt requiring DPL that turned out to be negative will need what?

Back 24

abdominal CT scan

Front 25

Name 2 injuries that CT scan misses.

Back 25

hollow viscous injury, diaphragm injury

Front 26

Peritonitis, evisceration, positive DPL, clinical deterioration, uncontrolled hemorrhage, free air, diaphragm injury, intraperitoneal bladder injury, positive contrast studies, specific renal, pancreas, and biliary tract injuries.

Back 26

Need laparotomy

Front 27

Possible penetrating abdominal injuries (knife or low-velocity injuries) - When would you just do local exploration and observation? What is the purpose of diagnostic laparoscopy?

Back 27

fascia not violated

to see if fascia is violated

Front 28

Name three situations that can cause abdominal compartment syndrome.

Back 28

massive fluid resuscitation, trauma or abdominal surgery

Front 29

What is the bladder pressure seen with abdominal compartment syndrome?

Back 29

>25-30

Front 30

What is the final common pathway for decreased cardiac output in abdominal compartment syndrome?

Back 30

IVC compression

Front 31

How does abdominal compartment syndrome lead to decreased urine output?

Back 31

renal vein compression

Front 32

What is the treatment for abdominal compartment syndrome?

Back 32

decompressive laparotomy

Front 33

Pneumatic antishock garment is controversial; use in pts with SBP < ___ and no ___ injury. Release compartments one at a time after reaching ER

Back 33

50, thoracic

Front 34

ER thoracotomy:

In what type of trauma is it used only if pressure/pulse lost ER? What type if lost on way to ER or in ER?

Back 34

Blunt

Penetrating

Front 35

If ER thoracotomy is performed for cardiac injury, the pericardium is opened anterior to what structure?

Back 35

phrenic nerve

Front 36

In ER thoracotomy, for what type of injury is the aorta cross clamped? and what structure must you watch out for?

Back 36

abdominal, esophagus

Front 37

After cross clamping the aorta in ER thoractomy, at what BP level is further treatment futile?

Back 37

if BP fails to reach 70 mmHg

Front 38

When to catecholamines peak after injury?

Back 38

24-48 hours

Front 39

What is the difference in males and females with regard to the Rh status of the blood?

Back 39

males can receive Rh positive blood, females who are prepubescent or of child-bearing age should receive Rh-negative blood.

Front 40

What is the time it takes for type specific blood? type and screen? type and crossmatch?

Back 40

<10 min

20-30 min

45-60 min

Front 41

Can you give nonscreened, noncrossmatched blood (Type specific)?

Back 41

can be administered relatively safely but there may be effects from antibodies to minor antigens in the donated blood

Front 42

List as much of the GCS as you can.

Back 42

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 – opens to command
2 – opens to pain
1 – no response

Front 43

Pt with head injury and GCS less than or equal to 14 what next? and 10? and 8?

Back 43

head CT, intubation, ICP monitor

Front 44

What is the most common artery injured with epidural hematoma?

Back 44

middle meningeal artery

Front 45

Head CT shows lenticular (lens-shaped) deformity?

Back 45

epidural hematoma

Front 46

Operation of epidural hematoma indicated for significant neurologic degeneration or significan mass effect (shift > ___)

Back 46

5 mm

Front 47

Subdural hematoma is most commonly from tearing of what?

Back 47

venous plexus (bridging veins) between dura and arachnoid

Front 48

What is the head CT finding with subdural hematoma?

Back 48

crescent-shaped deformity

Front 49

Chronic subdural hematoma is usually in elderly after minor fall. Need drainage if > ___ or causing significant symptoms.

Back 49

1 cm

Front 50

In which 2 lobes are intracerebral hematoma usually found?

Back 50

frontal, temporal

Front 51

Traumatic intraventricular hemorrhage needs what procedure if causing hydrocephalus?

Back 51

ventriculostomy

Front 52

Diffuse axonal injury shows up better on MRI or CT?

Back 52

MRI

Front 53

Tx for diffuse axonal injury is supportive; may need what if ICP elevated?

Back 53

craniectomy

Front 54

Mean arterial pressure minus intracranial pressure = ?

and what is the desired value

Back 54

Cerebral perfusion pressure

>60

Front 55

What are the following signs of on brain imaging?:

decreased ventricular size, loss of sulci, loss of cisterns

Back 55

elevated ICP

Front 56

ICP monitors are indicated for suspected elevated increased intracranial pressure and GCS <= ___ or pt with moderate to severe head injury and inability to follow clinical exam (e.g. is intubated)

Back 56

8

Front 57

Normal ICP is 10; >___ needs treatment

Back 57

20

Front 58

Name three interventions that are tried first with elevated ICP.

Back 58

sedation and paralysis
raise head of bed
relative hyperventilation

Front 59

When hyperventilating a pt due to increased ICP. What is a target CO2 range? and what is the effect and what can happen if overhyperventilated?

Back 59

30-35
cerebral vasoconstriction
cerebral ischemia from too much vasoconstriction

Front 60

What can be done with fluids to manage elevated ICP?

Back 60

give hypertonic saline at times to draw fluid out of brain. (keep Na 140-150, serum Osm 295-310)

Front 61

What medication can be given to pts with elevated ICP and what is the MOA?

Back 61

mannitol, draws fluid from the brain

Front 62

What are three procedural options for elevated ICP if other measures fail?

Back 62

ventriculostomy w/CSF drainage
craniotomy decompression
Burr hole

Front 63

What medication is given prophylactically to prevent seizures to most pts with TBI?

Back 63

phenytoin

Front 64

Peak ICP levels occur after how long after head injury?

Back 64

48-72

Front 65

In TBI, dilated pupil indicates temporal pressure on same side. Which CN is compressed?

Back 65

CN III

Front 66

Racoon eyes are a sign of fracture of what part of the basal skull?

Back 66

anterior fossa

Front 67

Battle's sign indicates fracture of what part of the basal skull? What nerve can be injured?

Back 67

middle fossa, facial

Front 68

What is difference in tx for acute and delayed Battle's sign?

Back 68

if acute need exploration, if delayed, likely secondary to edema and exploration not needed

Front 69

Temporal skull fractures can injure what 2 cranial nerves?

Back 69

CN VII and VIII

Front 70

What is the most common site of facial nerve injury with temporal skull fractures?

Back 70

geniculate ganglion

Front 71

Most skull fractures do not require surgical treatment. Operate if significantly depressed, how much? Or if contaminated or if ___ not responding to conservative therapy

Back 71

8-10 mm

CSF leak

Front 72

What is a Jefferson fracture and what is the tx?

Back 72

C-1 burst caused by axial loading. Tx: rigid collar

Front 73

C-2 hangman's fracture is caused by distraction and extension. What is the tx?

Back 73

traction and halo

Front 74

What are the 3 types of C-2 odontoid fractures and what is their tx?

Back 74

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)

Front 75

Cervical facet fractures or dislocations can cause ___ injury; usually associated with hyperextension and rotation and with ___ disruption.

Back 75

cord, ligamentous

Front 76

What are the three columns of the thoracolumbar spine?

Back 76

anterior - anterior longitudinal ligament and anterior 1/2 of the vertebral body
middle - posterior 1/2 of the vertebral body and posterior longitudinal ligament
posterior - facet joints, lamina, spinous processess, interspinous ligament

Front 77

What is the significance of more than one thoracolumbar spine column disruption.

Back 77

Considered unstable

Front 78

What is the difference between compression (wedge) fractures and burst fractures of the thoracolumbar spine?

Back 78

Compression fractures usually involve the anterior column only and are considered stable. Burst fractures are considered unstable and require spinal fusion.

Front 79

Upright fall. Look for fractures of what 3 areas?

Back 79

calcaneus, lumbar, wrist/forearm

Front 80

Neurologic deficits without bony injury. What injury should you consider and how to dx?

Back 80

Check for ligamentous injury with MRI

Front 81

The following are indications for what?:

fracture or dislocation not reducible with distraction
acute anterior spinal syndrome
open fractures
soft tissue or bony compression of the cord
progressive neurological dysfunction

Back 81

emergent surgical spine decompression

Front 82

Facial nerve injuries need repair. Fracture of what bone is most common cause of facial nerve injury?

Back 82

temporal bone

Front 83

Try to preserve skin and not trime edges with ___ lacerations

Back 83

facial

Front 84

Maxillary fracture straight across is called what?

Back 84

Le Fort type I

Front 85

Maxillary fracture lateral to nasal bone underneath eyes, diagonal. ( / \ ) What is that called?

Back 85

Le Fort type II

Front 86

Fracture of lateral orbital walls ( - - ) is called what?

Back 86

Le Fort type III

Front 87

Nasoethmoidal orbital fractures, what percentage have a CSF leak? Try conservative therapy for how long? What can you try to decrease CSF pressure to help it close? May need surgical closure of dura to deal with leak.

Back 87

70%, 2 weeks, epidural catheter

Front 88

What is the difference in tx for anterior vs posterior nose bleeds?

Back 88

anterior is just packing

posterior is harder to dea with; try ballon tamponade 1st; may need angioembolization of internal maxillary artery or ethmoidal artery

Front 89

Orbital blowout fractures - pts with impaired upward gaze or diplopia with upward vision need what?

Back 89

repair with restoration of orbital floor with bone fragments or bone graft

Front 90

What is the number one indicator of mandibular injury?

Back 90

malocclusion (misaligned teeth)

Front 91

What are two imaging modalities to assess mandibular injury?

Back 91

panorex film and fine-cut facial CT scan with reconstruction

Front 92

Most mandibular injuries are repaired with IMF (metal arch bars to upper and lower dental arches, 6–8 weeks) or what other option?

Back 92

ORIF

Front 93

What is the tx for tripod fracture (zygomatic bone)?

Back 93

ORIF for cosmesis

Front 94

Pts with maxillofacial fractures are at high risk for what other injury?

Back 94

cervical spine

Front 95

Asymptomatic blunt trauma to the neck. What is the best next step?

Back 95

neck CT scan

Front 96

What are the delineations between the zones of the neck?

Back 96

Zone I is clavicle to cricoid cartilage
Zone II is cricoid to angle of mandible
Zone III is angle of mandible to base of the skull

Front 97

Asymptomatic penetrating trauma to Zone I of the neck. What is the best next step?

Back 97

Zone I needs angiography, bronchoscopy, rigid esophagoscopy, barium swallow, pericardial window may be indicated. May need sternotomy to reach these lesions

Front 98

Asymptomatic penetrating trauma to Zone II of the neck. What is the best next step?

Back 98

Exploration in OR.

Front 99

Asymptomatic penetrating trauma to Zone III of the neck. What is the best next step?

Back 99

Need angio, laryngoscopy. May need jaw subluxation/digastric and sternocleidomastoid muscle release/mastoid sinus resection to reach vascular injuries in this location.

Front 100

What is the important implication of neck Zone I injuries?

Back 100

greater potential for intrathoracic great vessel injury

Front 101

What is the tx for symptomatic blunt or penetrating trauma to the neck? (shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit)

Back 101

neck exploration

Front 102

Injury to what structure is the hardest to find in neck trauma?

Back 102

esophagus

Front 103

What is the best combined modality for diagnosing esophageal injury (find essentially 95% of injuries when using both methods)

Back 103

rigid esophagoscopy and esophagogram

Front 104

What is the tx for a contained injury to the esophagus?

Back 104

observation

Front 105

Noncontained esophageal injury - if small, <24 hours, without significant contamination and pt is stable. What is the tx? and otherwise?

Back 105

primary closure, otherwise make spit fistula and drain leak with chest tube

Front 106

What is the leak rate with esophageal and hypopharyngeal repairs? drain?

Back 106

20%, yes

Front 107

What is the surgical approach to repairing esophageal injury in the neck? Upper 2/3 of thoracic esophagus? Lower 1/3 of thoracic esophagus?

Back 107

left side, right thoracotomy, left thoracotomy

Front 108

Laryngeal fracture and tracheal injuries are airway emergencies. Secure airway in ER. Tx: primary repair, can use ___ for airway support; ___ necessary for most to allow edema to subside and to check for stricture.

Back 108

stap muscle, tracheostomy

Front 109

Thyroid gland injuries - control bleeding and ___

Back 109

drain

Front 110

Recurrent laryngeal nerve injury - can try to repair or reimplant in ____ (hoarseness)

Back 110

cricoarytenoid muscle

Front 111

Shotgun injury to neck needs angiogram and ___; esophagus/tracheal evaluation

Back 111

neck CT

Front 112

Can vertebral artery bleeds be ligated or embolized without sequela?

Back 112

yes

Front 113

Common carotid bleeds - ligation will cause stroke in what percentage of patients?

Back 113

20

Front 114

What are the relative indications for thorocotomy in the OR based on chest tube output quantity? (there are 3 of them, bleeding with instability is another indication)

Back 114

>1,500 cc after initial insertion
>250 cc/h for 3 hours
2,500 cc/24 h

Front 115

Chest trauma and hemothorax - all blood needs to be drained in what timeframe and why?

Back 115

<48 hrs, to prevent fibrothorax, pulmonary entrapment, infected hemothorax

Front 116

Unresolved hemothorax after 2 well placed chest tubes. What next?

Back 116

thoracoscopic or open drainage

Front 117

Sucking chest wound needs to be at least 2/3 the diameter of the trachea to be significant. What is the tx and explain the concern with just plugging the hole?

Back 117

Cover wound with dressing that has tape on three sides. This prevents development of tension pneumothorax while allowing lung to expand with inspiration

Front 118

Patient has worse oxygenation after chest tube placement. What should you think of?

Back 118

tracheobronchial injury (one of the very few indications in which clamping the chest tube may be indicated)

Front 119

Bronchial injuries are more common on which side?

Back 119

right

Front 120

How should you intubate a pt with bronchial injury?

Back 120

may need to mainstem intubate pt on unaffected side

Front 121

How do you diagnose tracheobronchial injury?

Back 121

bronchoscopy

Front 122

Tracheobronchial injury should be repaired if large air leak and respiratory compromise or after how long of a persistant air leak?

Back 122

2 weeks

Front 123

Right mainstem, trachea, and proximal left mainstem injuries are all repaired via Right thoracotomy. Why? (left thoracotomy for distal left mainstem injuries)

Back 123

avoids the aorta

Front 124

Blunt trauma injuries to the diaphragm are more common on which side?

Back 124

left

Front 125

How can the diagnosis of diaphragm injury be made?

Back 125

CXR shows air-fluid level in chest from stomach herniation through hole

Front 126

To repair diaphragm injury transabdominal approach is used if what time frame of injury? Otherwise what approach?

Back 126

transabdominal approach if <1 week, chest approach if > 1 week

Front 127

What are the following signs of?:

widened mediastinum, 1st rib fractures, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to right

Back 127

Aortic transection

Front 128

The tear in aortic transection is usually at the ____ (just distal to subclavian takeoff). Other areas include near the aortic valve and where the aorta traverses the diaphragm.

Back 128

ligamentum arteriosum

Front 129

What percentage of patients with an aortic tear have a normal CXR?

Back 129

5%

Front 130

Indications for aortic evaluation include head on mva > ___ mph or fall >___ ft

Back 130

45, 15

Front 131

Name the two diagnostic modalities for aortic transection.

Back 131

aortogram or CT angiogram of chest

Front 132

Name two medications used to control BP in pts with aortic transection.

Back 132

Nipride and esmolol

Front 133

What is the operative approach to repairing aortic transection?

Back 133

left thoracotomy with partial left hear bypass

Front 134

When repairing aortic transection. Which do you treat first other life-threatening injury (ie positive DPL) or the transection?

Back 134

treat other injury first

Front 135

What is the approach for repairing injuries to ascending aorta, innominant artery, proximal right subclavian arter, innominate vein, proximal left common carotid?

Back 135

median sternotomy

Front 136

What is the approach for repairing injuries to the left subclavian arter, descending aorta?

Back 136

left thoracotomy

Front 137

What is the approach for repairing the distal right subclavian artery?

Back 137

midclavicular incision 1/2 resection of medial clavicle

Front 138

What are the 2 most common causes of death after myocardial contusion?

Back 138

v-tach and v-fib

Front 139

What is the timeframe for the highest risk of death with myocardial contusion?

Back 139

first 24 hours

Front 140

What is the most common arrhythmia overall in patients with myocardial contusion?

Back 140

SVT

Front 141

What is the biggest pulmonary impairment in pts with flail chest?

Back 141

the underlying pulmonary contusion

Front 142

Will aspiration produce CXR findings immediately?

Back 142

not always

Front 143

What defines the "box" in penetrating chest injury?

Back 143

clavicles, xiphoid process, nipples

Front 144

What 4 things are needed with penetrating "box" injuries to the chest?

Back 144

pericardial window, bronchoscopy, esophagoscopy, barium swallow

Front 145

Penetrating chest wound outside the "box" without pneumothorax or hemothorax.

Tx if required intubation? Otherwise?

Back 145

chest tube, follow CXRs

Front 146

Pericardial window - if you find blood, need ___ to fix possible injury to heart; also place ___

Back 146

sternotomy, pericardial drain

Front 147

Penetrating injuries anterior-medial to midaxillary line and below nipples needs ___ or ___

Back 147

laparotomy or laparoscopy

Front 148

Name three traumatic causes of cardiogenic shock?

Back 148

cardiac tamponade, cardiac contusion, tension pneumothorax

Front 149

What exactly causes the cardiac compromise in tension pneumothorax?

Back 149

decreased venous return

Front 150

Pts with sternal fractures are at high risk for ___. Pts with 1st and 2nd rib fractures are at high risk for ___

Back 150

cardiac contusion, aortic transection

Front 151

Hemodynamically unstable pt with a pelvic fracture and negative DPL, negative CXR and no other signs of blood loss or reasons for shock. Tx?

Back 151

stabilize pelvis (C-clamp, external fixator, or sheet) and go to angio for embolization

Front 152

Name the type of pelvic fracture with mortality, blood loss and complication rate.

Back 152

Type I. unstable (crush). Mortality 20%-30%. Blood loss >10 units. Complications 60%-75%

Front 153

Name the type of pelvic fracture with mortality, blood loss and complication rate.

Back 153

Type II. unstable. Mortality 8%-12%. Blood loss 2-10 units. Complications 30%-50%

Front 154

Name the type of pelvic fracture with mortality, blood loss and complication rate.

Back 154

Type III stable. Mortality <5%. Blood loss 1-2 units. Complications 10%-20%

Front 155

Anterior vs Posterior pelvic fractures. Which is more likely to have venous vs arterial bleeding

Back 155

Anterior - venous. Posterior - arterial

Front 156

Penetrating injury pelvic hematomas. open? Blunt injury pelvic hematoma?

Back 156

Penetrating - open
Blunt - leave unless expanding and patient unstable. If unstable, stablize pelvic fracture, pack pelvisi in OR, and get patient to angiography embolization

Front 157

Which portion of the duodenum is most commonly injured in trauma?

Back 157

2nd (descending portion near ampulla of Vater), can also get tears near ligament of treitz

Front 158

70-80% of duodenal trauma requiring surgery can be treated with what?

Back 158

debridement and primary closure

Front 159

Duodenal trauma - segmental resection with primary end-to-end closure possible with all segments except which one?

Back 159

second portion

Front 160

What is the % mortality in patients with duodenal trauma?

Back 160

25% (shock)

Front 161

What is the major source of morbidity with duodenal trauma?

Back 161

fistulas

Front 162

Paraduodenal hematomas usually occur with trauma to which portion of the duodenum and why?

Back 162

usually third portion because it is overlying the spine in blunt injury

Front 163

What is the tx for paraduodenal hematoma from blunt or penetrating trauma if in the OR?

Back 163

open

Front 164

High SBO 12-72 after abdominal injury could be due to what?

Back 164

missed paraduodenal hematoma

Front 165

UGI study shows "stacked coins" or "coiled spring" appearance in trauma pt. Dx?

Back 165

Missed paraduodenal hematoma causing SBO

Front 166

What is the tx for missed paraduodenal hematoma with SBO?

Back 166

conservative tx (TPN and NGT) cures 90% of these overy 2-3 weeks

Front 167

If duodenal trauma is suspected at laparotomy, then perform ____ and open ___ check for hematoma, bile, petechia, sucus and fat necrosis. If found then what do you do?

Back 167

Kocher, lesser sack

formal inspection of duodenum

Front 168

Diagnosing suspected duodenal injury – abdominal CT with contrast initially. UGI contrast study best. CT scan may show bowel wall thickening, hematoma, air, contrast leak, retroperitoneal fluid/air. If CT scan is worrisome for injury but nondiagnostic, what can you do?

Back 168

Repeat the CT in 8–12 hours to see if the finding is getting worse

Front 169

With duodenal trauma, what are 2 important surgical techniques?

Back 169

jejunal serosal patch (looping back a portion of jejunum to patch hole) or pyloric exclusion for complex duodenal injury

Front 170

Describe the 4 parts of pyloric exclusion for complex duodenal injury (ie not enough duodenum for repair or is in the 2nd portion of the duodenum)

Back 170

Front 171

How often is trauma whipple indicated in duodenal injury?

Back 171

rarely, if ever

Front 172

What is the most common organ injured with penetrating injury?

Back 172

small bowel

Front 173

Abdominal CT scan showing intra-abdominal fluid not associated with a solid organ injury, bowel wall thickening, or a mesenteric hematoma is suggestive of what injury?

Back 173

occult small bowel injury

Front 174

Initial tx for occult small bowel injury?

Back 174

close observation and possibly repeat abdominal CT after 8-12 hours to make sure finding is not getting worse.

Front 175

Pt with non occlusive small bowel injury from trauma, what do you need to make sure of before they are discharged?

Back 175

can tolerate diet

Front 176

How do you repair small lacerations to small bowel? and large (>50% of circumference or results in lumen diameter 1/3 normal)?

Back 176

transversely to avoid stricture

perform resection and reanastomosis

Front 177

When do you open a mesenteric hematoma?

Back 177

if expanding or large (>2 cm)

Front 178

What is the difference in repair of colon trauma between right/transverse colon vs left colon?

Back 178

right and transverse can perform primary reanastomosis

left colon it is safest to preform colostomy and Hartman's pouch or mucus fistula

Front 179

What is the abscess rate after colon trauma repair? and fistula rate?

Back 179

10%, 2%

(higher with primary repair)

Front 180

High rectal trauma (>5cm) can be extraperitoneal and intraperitoneal what is difference in repair?

Back 180

Both have presacral drainage with fecal diversion with colostomy. Extraperitonal is generally not repaired because of inaccessiblity. Intraperitoneal, the defect is repaired.

Front 181

What is approach to repairing low rectal trauma (<5 cm)?

Back 181

transanally

Front 182

Liver trauma to common hepatic artery, repair?

Back 182

ligated with collaterals through gastroduodenal artery

Front 183

Hepatic lobar arteries can be ligated without complication unless the patient is ____, which could lead to liver ischemia.

Back 183

hypotensive

Front 184

Does the pringle maneuver stop bleeding from hepatic veins?

Back 184

no, clamping of portal triad only

Front 185

If possible, clamp time intervals in the pringle maneuver should be limited to what?

Back 185

15-20 min

Front 186

In retrohepatic IVC injury, how can you control bleeding while performing repair?

Back 186

atriocaval shunt

Front 187

Severe penetrating liver injury and the patient becomes unstable in the OR, what do you do?

Back 187

perihepatic packing, stabilize in ICU

Front 188

Do portal triad hematomas need to be explored?

Back 188

yes

Front 189

Trauma to common bile duct. How do you repair if >50% of circumference? and <50%?

Back 189

>50% choledochojejunostomy
<50% repair over stent

Front 190

What percent of common bile duct anastomoses leak?

Back 190

10%

Front 191

Ligation of portal vein is associated with ___% mortality. What is the approach when repairing the portal vein and what additional procedure will need to be performed?

Back 191

50

transect through the pancreas to get to the injury, will need to perform distal pancreatectomy

Front 192

What type of graft can be placed in liver laceration to help wil bleeding and prevent bile leaks?

Back 192

omental graft

Front 193

Leave drains with liver injures?

Back 193

yes

Front 194

Initial approach to blunt liver injury is conservative management. Has failed if patient becomes unstable despite aggressive resuscitation, including how many units of PRBCs to keep Hct > 25?

Back 194

4

Front 195

In blunt liver injury or spleen trauma, active blush on abdominal CT or pseudoaneurysm are indications for what?

Back 195

indications for OR

Front 196

Anterior vs Posterior blunt liver injury, which may be better off going to angiogram vs OR?

Back 196

posterior (if in doubt go to OR)

Front 197

How long will pt with blunt liver injury or splenic trauma need bed rest with conservative mgmt?

Back 197

5 days

Front 198

How long does it take for splenic trauma to fully heal?

Back 198

6 weeks

Front 199

What age range is postsplenectomy sepsis most common? How long after splenectomy is the greatest risk of sepsis?

Back 199

1st 5 years of life. Within 2 years of splenectomy.

Front 200

Splenic salvage is associated with increased ___.

Back 200

transfusions

Front 201

Conservative management of blunt splenic injuries has failed if patient becomes unstable despite aggressive resuscitation, including __ units of PRBCs (HR >120 or SBP < 90) or requires 2 units of PRBCs to keep Hct > ___

Back 201

2, 25

Front 202

Is the threshold for splenectomy in children higher or lower?

Back 202

much higher; hardly any children undergo splenectomy

Front 203

Are immunizations after trauma splenectomy necessary?

Back 203

yes

Front 204

What is more common blunt or penetrating pancreatic trauma?

Back 204

penetrating (80%)

Front 205

Blunt injury to pancreas can result in duct fracture. What is the usually orientation of the fracture?

Back 205

perpendicular to the duct

Front 206

What is necessary in a distal pancreatic duct injury? How much of the gland can you take?

Back 206

distal pancreatectomy, 80%

Front 207

What do you do with a pancreatic head injury that is not reparable?

Back 207

place drains initially; delayed Whipple may be eventually necessary

Front 208

What is an alternative to resection in pancreatic duct injuries?

Back 208

ERCP with stent

Front 209

Whipple vs. distal pancreatectomy based on duct injury in relation to what structure(s)?

Back 209

SMA/SMV

Front 210

Pancreatic trauma to the right of the SMA/SMV treated with drains instead of what?

Back 210

Whipple (initially)

Front 211

Do you open a pancreatic hematoma with penetrating and blunt injury?

Back 211

yes

Front 212

What test is useful in evaluating a missed pancreatic injury?

Back 212

rising amylase

Front 213

CT scans poor at diagnosing pancreatic injuries initially. Name 3 delayed signs.

Back 213

fluid, edema, necrosis

Front 214

When there is vascular and orthopedic trauma, which is repaired first?

Back 214

vascular

Front 215

Major signs of vascular trauma are pulse deficit, expanding or pulsatile hematoma, distal ischemia, bruit, thrill.

Moderate/soft signs are deficit of anatomically related nerve, large stable/nonpulsatile hematoma.

What is the difference in tx between the two?

Back 215

Major signs go to OR for exploration (some say angio 1st)

Moderate/soft signs go to angio

Front 216

Vascular trauma suspected and ABI < 0.9 what do you do?

Back 216

go to angio

Front 217

In vascular trauma a saphenous vein graft will be needed if segment > ___ cm missing. When fixing lower extremity arterial injuries do you use ipsilateral or contralateral saphenous vein?

Back 217

contralateral (improves outflow)

Front 218

Name 6 veins that need repair if injured.

Back 218

vena cava, femoral, popliteal, brachiocephalic, subclavian, and axillary

Front 219

What is the tx for transection of single artery in the calf in an otherwise healthy pt?

Back 219

ligate

Front 220

Limb ischemia > 4 hours, what tx should you consider and why?

Back 220

fasciotomy to prevent compartment syndrome

Front 221

Consider compartment syndrome with pressures > __ mmHg

Back 221

20

Front 222

What are the "Ps" of compartment syndrome?

Back 222

pain -> parathesias -> anathesia -> paralysis -> poikilothermia -> pulselessness (late finding)

Front 223

Compartment syndrome most commonly occurs with what type of injuries?

Back 223

supracondylar humeral fractures, tibial fractures, crush injuries or other injuries that result in a disruption and then restoration of blood flow

Front 224

IVC trauma - primary repair if residual stenosis < ___% of original diameter of IVC otheriwse place saphenous vein or synthetic patch

Back 224

50

Front 225

How is bleeding of IVC best controlled?

Back 225

with proximal and distal pressure, not clamps -> can tear it

Front 226

What is a possible approach to repairing posterior IVC wall injuries?

Back 226

May need to cut through the anterior IVC to get to posterior IVC injuries

Front 227

How much blood loss is possible from a femur fracture?

Back 227

>2L

Front 228

Femoral neck fractures are at high risk for ___

Back 228

avascular necrosis

Front 229

Long bone fracture or dislocations with loss of pulse (or weak pulse). What next? And if pulse does not return?

Back 229

immediate reduction and reassessment of pulse

Go to OR for vascular bypass or repair (some say angio)

Front 230

Name the concomitant nerve or artery injury associated with anterior shoulder dislocation. and posterior?

Back 230

axillary nerve

axillary artery

Front 231

Name the concomitant nerve or artery injury associated with proximal humerus fracture.

Back 231

axillary nerve

Front 232

Name the concomitant nerve or artery injury associated with midshaft humerus (or spiral humerus fracture).

Back 232

radial nerve

Front 233

Name the concomitant nerve or artery injury associated with distal (supracondylar) humerus fracture.

Back 233

brachial artery

Front 234

Name the concomitant nerve or artery injury associated with elbow dislocation.

Back 234

brachial artery

Front 235

Name the concomitant nerve or artery injury associated with distal radius fracture.

Back 235

median nerve

Front 236

Name the concomitant nerve or artery injury associated with anterior hip dislocation? and posterior?

Back 236

femoral artery

sciatic nerve

Front 237

Name the concomitant nerve or artery injury associated with distal (supracondylar) femur fracture.

Back 237

popliteal artery

Front 238

Name the concomitant nerve or artery injury associated with posterior knee dislocation.

Back 238

popliteal artery

Front 239

Name the concomitant nerve or artery injury associated with fibular neck fracture.

Back 239

common peroneal nerve

Front 240

All knee dislocations need to go to ___, unless pulse is absent, in which case some would just go to ___

Back 240

angio, OR

Front 241

What is the best indicator of renal trauma? And what is the diagnostic study needed with the finding?

Back 241

Hematuria, CT scan

Front 242

With renal trauma what is the study that is useful if going to the OR without abdominal CT, to identify presence of functional contralateral kidney, which could affect intraoperative decision making?

Back 242

IVP

Front 243

Why is it possible to ligate the left renal vein near the IVC while this cannot be done on the right?

Back 243

Left has adrenal and gonadal vein collaterals

Front 244

From anterior to posterior, what are the renal hilum structures?

Back 244

vein, artery pelvis

Front 245

What percentage of renal trauma is treated nonoperatively?

Back 245

95%

Front 246

Do all urine extravasation injuries require operation?

Back 246

no

Front 247

Indications for operation in renal trauma include, acute ongoing ___ with instability

Back 247

hemorrhage

Front 248

Indications for operation in renal trauma include, after acute phase - major collecting system disruption, unresolved ___, hematuria

Back 248

urine extravasation

Front 249

In operation for renal trauma, with exploration, what do you get control of first?

Back 249

vascular renal hilum

Front 250

Place drains in operation for renal trauma?

Back 250

yes, especially if collecting system is injured

Front 251

How do you check for a leak at the end of an operation for renal trauma?

Back 251

methylene blue dye

Front 252

When at exploration for another blunt injury or penetrating trauma. Renal injury with hematoma is found. What is the difference in tx based on blunt vs penetrating?

Back 252

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

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

Front 253

Trauma to flank and IVP shows no uptake. Tx?

Back 253

angiogram; can stent if flap is present

Front 254

What is the best indicator of bladder trauma?

Back 254

hematuria

Front 255

>95% of bladder trauma is associated with what other injury?

Back 255

pelvic fractures

Front 256

How is the diagnosis of bladder trauma made?

Back 256

cystogram

Front 257

In what type of bladder rupture does cystogram show starbursts?

Back 257

extraperitoneal bladder rupture

Front 258

What is the tx for extraperitoneal bladder rupture?

Back 258

Foley 7-14 days

Front 259

What does the cystogram show in intraperitoneal bladder rupture?

Back 259

leak (as opposed to starbursts seen with intraperitoneal)

Front 260

What type of bladder rupture is more likely in kids?

Back 260

intraperitioeal

Front 261

What is the tx of intraperitoneal bladder rupture?

Back 261

operation and repair of defect, followed by foley drainage

Front 262

Hematuria is unreliable indicator of what type of trauma?

Back 262

ureteral (best for renal and bladder)

Front 263

What are the two best tests for ureteral trauma?

Back 263

IVP and retrograde urethrogram (RUG)

Front 264

With ureteral trauma, if a large ureteral segment is missing (>2cm) and cannot perform reanastomosis. Upper 1/3 and middle 1/3 injuries that won't reach bladder. What can be done to temporize in an unstable pt? What can be done later or if the pt is stable?

Back 264

percutaneous nephrostomy, trans-ureteroureterostomy

Front 265

What is the tx for ureteral trauma that is small (<2 cm)?

Back 265

mobilize the ends and perform primary repair over stent if upper or mid ureter, reimplant if lower 1/3

Front 266

What direction does the blood supply come from for the ureter?

Back 266

medially in the upper 2/3, laterally in the lower 1/3

Front 267

Leave drains for all ureteral injuries?

Back 267

yes

Front 268

Hematuria or blood at meatus best sign; free-floating prostate gland; usually associated with pelvic fractures. What is the injury?

Back 268

Urethral trauma

Front 269

You suspect urethral injury. Do you insert a foley? What is the best test?

Back 269

No, urethrogram

Front 270

Significant tears to the urethra vs. small partial tears. What is the difference in tx.

Back 270

Significant tears: suprapubic cystostomy and repair in 2-3 months. Small partial tears may get away with bridging urethral catheter across tear area and repair in 2-3 months.

Front 271

What are the possible problems with early urethral injury repair as opposed to the recommended 2-3 months?

Back 271

High stricture and impotence rate if repaired early

Front 272

Genital trauma - can get fracture in erectile bodies from vigorous sex. Need to repair the ___ and ___

Back 272

tunica, Buck's fascia

Front 273

Testicular trauma - order ___ to see if ___ is violated then repair if necessary.

Back 273

ultrasound, tunica albuginea

Front 274

___ is not a good indicator of blood loss in children - last thing to go.

Back 274

blood pressure

Front 275

What are the best indicators of shock in children (4)

Back 275

HR, RR, mental status and clinical exam

Front 276

In an infant <1 yr what is a normal pulse, SBP and RR?

Back 276

160, 80, 40

Front 277

In a preschool age child (1-5 yrs) what is a normal pulse, SBP and RR?

Back 277

140, 90, 30

Front 278

In an adolescent (>10 yr) what is a normal pulse, SBP and RR?

Back 278

120, 100, 20

Front 279

What fraction of total blood volume loss can occur in a pregnant pt without signs?

Back 279

1/3

Front 280

In trauma during pregnancy estimate age based on ___

Back 280

fundal height (20 cm = 20 wk = umbilicus)

Front 281

In trauma during pregnancy, maturity can be evaluated by lecithin:sphingomyelin ration > ___ or a positive ____ test

Back 281

2:1, phosphatidylcholine

Front 282

Trauma in pregnancy. What are the following signs of?:

uterine tenderness, contractions, fetal HR <120

Back 282

signs of abruption

Front 283

What is the most common mechanism of placental abruption?

Back 283

shock

Front 284

What is the Kleihauer-Betke test?

Back 284

tests for fetal blood in maternal circulation, sign of placental abruption

Front 285

What location is uterine rupture with trauma in pregnancy most likely to occur?

Back 285

posterior fundus

Front 286

If uterine rupture occurs after delivery of child. What intervention leads to the best outcome?

Back 286

Aggressive resuscitation even in the face of shock, uterus will eventually clamp down after delivery.

Front 287

In the management of hematomas in trauma, name the 4 scenarios (location and penetrating or blunt) where you would not open?

Back 287

Pelvic blunt, retrohepatic blunt and penetrating if stable, perirenal blunt.