absite trauma2
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| worse oxygenation s/p CT plcmt--what could be problm? How dx? Tx | tracheobronchial injury; bronchoscopy; consider clamping tube
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| which side bronchial injury more common | right
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| mgmt penetrating injury anterior medial to mid axillary chest | need laparotomy or laparoscopy, among others to r/o diaphragm injury; may need other evaluation of box injuries depending on location
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| sternal fx should also be suspicious for | cardiac contusion--get ECG, CKMB
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| which rib fx highest risk for Ao transection | 1st, 2nd
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| mgmt gun shot abd | immed ex lap, even if stable
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| name 3 types of pelvic fx, mortality, transfusion requirement | type I=unstable/crush, >10U pRBCs mortality 25%; II=unstable, all thru 1side, 2-10U, mortality 10%; III=stable, 1-4U, mortality <5%
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| which type of pelvic fx has arterial bldg? venous bldg? | anterior pelvis=venous; posterior=arterial
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| if abd injury requiring ex lap and pelvic fx what do next | ex lap, then if pelvis still hemorrhaging can do pelvic packing, intraop external fixation then arteriography/embolization
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| mgmt of blunt injury pelvic hematoma | leave, unless expanding and pt unstable (then stabilize fx, pack pelvis and if in OR get angio/emboliz)
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| MC portion duo injured | 2nd (desc portion near ampulla of vater)
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| mgmt duo injuries, incl drains | most can be repaired primarily w debridement, but may need pyloric exclusion and gastrojejunostomy if big lesion; place feeding j tube and draining jejunosotmy tube threading it back to injury site
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| mgmt of fistula s/p duo injury | most close w time 4-6wk, give bowel rest, TPN, decompression, octreotide, and do fistulogram to r/o abscess. Consider distal obstruction
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| where are paraduo hematomas located, mgmt | usu 3rd portion duo overlying spine in blunt injury; open if in OR (can present w high SBO12-72 h s/p injury); most resolve w conservative mgmt 2-3wks
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| MC GI injury w penetrating injury | small bowel
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| how does occult small bowel injury look on CT, mgmt? | intra abd fluid w/o solid organ injury, bowel wall thickening, mesenteric hematoma; repeat 8-12h
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| mgmt small bowel injury | transverse repair to avoid stricture, if >50% circumference need resxn and re-anastomosis
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| mgmt small bowel hematoma | open if expanding or large (>2cm)
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| when can colon injuries be repaired primarily | R and transverse; if L need colostomy
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| mgmt colon hematomas | both penetrating and blunt need to be opened!! (unlike small bowel, duo or pelvic)
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| mgmt rectal trauma depending on site | high rectal extraperitoneal: drainage and fecal diversion w colostomy; intraperitoneal repair and colostomy; low rectal (<5cm) repair transanal
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| can c hepatic artery be ligated? Why | yes, collateral thru gastroduo
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| can hepatic lobar arteries be ligated? | no, causes liver isch
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| what is Pringle maneuver | clamping portal triad, doesn't stop bleeding from hep veins, can only do for 10-15min
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| if retrohep IVC injury, how do you get to it? | use atriocaval shunt
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| mgmt portal triad hematomas | must be explored! (unlike duo, small bowel or pelvic)
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| mgmt of CBD injury | if <50% repair over stent, >50% do choledochojejunostomy…10% leak
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| how manage portal vein injury | must be repaired, may need to go thru pancreas to get
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| what does conservative mgmt of liver injury consist of, when is it considered a failure | bed rest, failed if unstable (HR>120, SBP<90, Hct<25) despite aggressive resuscitation (4U RBCs) -> go to OR
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| what does conservative mgmt of spleen injury consist of, when is it considered a failure | bed rest, failed if unstable (HR>120, SBP<90, Hct<25) despite aggressive resuscitation (2U RBCs) -> go to OR
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| what CT findings related to spleen and portal vein are indications to take to OR | active blush on CT, pseudoaneur
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| most pancreatic injury s/p trauma are blunt or penetrating? | penetrating
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| mgmt pancreatic contusion | place a drain and leave if stable
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| mgmt of distal pancreatic duct injury, pancreatic head injury that is not reparable | distal:distal pancreatectomy (can take 80%), head: place drain and may need Whipple eventually
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| mgmt pan duct injury | ERCP and stent
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| mgmt pan hematoma | need to be opened
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| if vascular injury >2cm in length, what do? | need saph vein graft from contralateral leg
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| if major signs vascular injury do what? Moderate? | major (active hemorr, expanding/pulsatile hematoma, distal isch, bruit) -> go OR to explore; if moderate (large stable hematoma, deficit of assoc nerve) -> go angio
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| if ABI<0.9 do what | angio
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| which vein injuries need repair | vena cava, femoral, popliteal, brachiocephalic, subclavian, axillary
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| when do fasciotomy | isch >4h
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| mgmt transected single artery calf | ligate
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| what pressure is compartment syndrome | >20
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| order of progression s/s compartment syndrome | pain -> paresthesia -> anesthesia -> paralysis -> poikilothermia -> pulselessness
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| 3 MC injuries leading to compartment syndrome | supracondylar humeral fx, tibial fx, crush injuries; key is disruption of flow followed by restoration
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| how repair IVC--use of clamps? Get to posterior wall? | don't use clamps bc will tear; to get to posterior wall go thru anterior wall
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| how manage loss of pulse w long bone fx | immed reduction, if pulse doesn't return go to OR
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| what n deficit w ant shoulder dislocation | Axillary n (deltoid numb, can’t ABD to horiz)
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| what n deficit w prox humerus fx | Axillary n (deltoid numb, can’t ABD to horiz)
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| what deficit at risk post shoulder dislocation | axillary a
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| which injuries risk brachial a disruption | distal/supracondylar humerus & elbow dislocation
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| what deficit at risk distal radius | Median n (thumb fxn ABD, opposition), can’t flex fingers, “As for MEdian: Thumb’s up, all’s OK, flex’ng yr nail polish w carpal tunnel.”
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| ant hip dislocation risks injury | fem a
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| post hip dislocation risks injury | sciatic n (butt, thigh)
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| popliteal a at risk when | distal femur and post knee dislocation
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| fibula neck fx risks injury… | c peroneal n (foot drop, anteriolat sensation leg)
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| what is best indicator renal trauma; next w/u | hematuria; CT (can use IVP if going to OR immed)
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| which renal artery/vein can be ligated safely, why? | L renal v can be ligated near IVC (adrenal and gonadal collaterals)
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| what's the order of renal hilum structures | vein, artery then pelvis from anterior to posterior
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| when surgery for renal trauma, incl acute v later | acutely: ongoign hemorr w instability; later if major collecting system disruption, unresolving urine extravasation, severe hematuria
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| penetrating renal injury w hematoma-what to do? | open, unless CT/IVP shows good fxn w/o significant urine extravasation
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| trauma to flank and IVP w/p uptake-do what? | angiogram, and can maybe stent
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| what best indicator of bladder trauma | hematuria
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| large majority bladder injury assoc w what | pelvic fx
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| dx bladder injury | cystogram
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| mgmt extraperitoneal bladder rx | foley 7-14d and usu resolves
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| mgmt intraperitoneal bladder rx | operation and repair followed by foley
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| hematuria is not reliable for dx of what injury | ureter! Good for bladder and renal
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| w/u ureteral injury | IVP and retrograde urethrogram (RUG)
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| mgmt of ureteral injury if can't reanastomose (ie 2cm) | if unstable: perQ nephrostomy (tie off both ends of ureter); stable: trans-reteroureterostomy
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| mgmt ureteral injury in lower 1/3, large segment can't reanastomose | reimplant in bladder
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| mgmt ureteral injury small segment | 1ry repair over stent or reimplant if lower 1/3
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| where is blood supply for ureter, upper 2/3 and lower 1/3 | upper blood supply is medial, lower is lateral
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| s/s urethral trauma | hematuria, blood at meatus best sign, also free floating prostate (assoc w pelvic fx)
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| blood at meatus-what to do | no foley, urethrogram best test
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| mgmt tear in urethra | suprapubic cystostomy and repair in 2-3mos bc high stricture and impotence rate
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| genital trauma usu involves what, tx? | fx in erectile bodies, need repair tunica and Buck's fascia
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| when do you need to leave drains | pancreatic, liver, biliary, urinary, duo
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