Trauma

When does the first mortality peak for trauma occur?

• Within seconds to minutes after injury

The trauma system and acute patient care has the greatest impact on patients in which mortality peak for trauma?

• Second mortality peak (golden hour)

Most of the deaths during the second mortality peak for trauma occur from?

• Hemorrhage, central nervous system injuries

When does the third mortality peak for trauma occur?

• 24 hours after injury, from multisystem organ failure and sepsis

How long should the primary survey in the initial evaluation of a trauma patient take?

• No more than 5 minutes, unless an intervention is needed.

What mnemonic is used to conduct the primary survey?

• ABCDE: Airway, Breathing, Circulation, Disability, Exposure

What are the goals during airway assessment?

• Secure the airway, protect the spinal cord

What is required for spinal immobilization?

• A rigid cervical collar, use of a full backboard

Contraindications to nasotracheal intubation:

• Apnea, maxillofacial fracture

What is the quickest way to test for an adequate airway in an awake, alert patient?

• Ask a question, if the patient is able to speak the airway is intact.

Indications for a surgical airway:

• Anatomic distortion as a result of neck injury, massive maxillofacial trauma, inability to visualize the vocal cords (blood, secretions, airway edema)

What are the goals during the breathing assessment?

• Secure oxygenation and ventilation; treat life-threatening thoracic injuries

What should be done on physical examination to adequately assess breathing?

• Inspection (air movement, cyanosis, tracheal shift, JVD, respiratory rate, asymmetric chest expansion, open chest wounds, use of accessory muscles of respiration)

• Auscultation/ percussion (hyperresonance or dullness over lung fields)

• Palpation (flail segments, subcutaneous emphysema)

What life-threatening conditions must be treated during the breathing assessment if encountered?

• Open pneumothorax, tension pneumothorax, massive hemothorax

What is the most common cause for upper airway obstruction?

• The tongue

What is the preferred emergency airway procedure?

• Cricothyroidotomy

In a patient with poor peripheral upper extremity access, what alternative routes can be considered for intravenous access?

• Femoral vein at the groin, venous cutdown on greater saphenous vein at the ankle, subclavian vein, IJ

What are the goals of the circulation assessment?

• Treatment of bleeding, assuring adequate tissue perfusion

What is the initial test for adequate circulation?

• Palpation of pulses

What systolic blood pressure are you expecting with a palpable radial pulse?

• 80 mm Hg

What systolic blood pressure are you expecting with a palpable femoral/carotid pulse?

• At least 60 mm Hg

What should be done of physical examination to adequately assess circulation?

• Obtain heart rate and blood pressure; check peripheral perfusion and capillary refill, mental status; examine the skin

Which patients may not demonstrate tachycardia with hypovolemic shock?

• Patients on beta-blockers, well-conditioned athletes, patients with concomitant spinal cord injury

During femoral catheter placement, what is the pneumonic used to remember the anatomy of the groin?

• NAVEL (from lateral to medial): Nerve, Artery, Vein, Extralymphatic space, Lymphatics

What is the preferred alternative route if intravenous access cannot be obtained on a small child?

• Intraosseous tibial plateau

What are the goals of the disability assessment?

• Determination of neurologic injury

What should be performed during the physical examination for an adequate assessment of disability?

• Mental status (GCS), pupils for size, appearance, and reactivity, motor/sensory examination for lateralizing extremity movement and sensory deficits

What are the goals during the exposure portion of the primary survey?

• Completely disrobe patient and thoroughly inspect and evaluate the patient; keep patient in warm environment.

What 3 elements are measured with the GCS?

• Eye opening, best verbal response, best motor response

What does a GCS score with a T signify?

• Patient is intubated

What is the highest GCS an intubated patient can have?

• 4 (eye) + 1 (verbal) + 6 (movement) = 11, GCS 11t

What is the secondary survey?

• A complete physical examination, obtain labs and x-rays, place additional lines, tube (foley, ngt), and monitoring devices

When should the tertiary examination be performed?

• Another complete head-to-toe physical examination should be performed 12 to 24 hours after the initial trauma and should be aimed at identifying injuries missed during the primary and secondary surveys.

What are the typical signs of a basilar skull fracture?

• Raccoon eyes, Battle sign, clear otorrhea or rhinorrhea, hemotympanum

What is the "halo" sign?

• A halo of clear fluid around drainage from nose and ears, representing basilar skull fracture with CSF leakage.

What conditions must be present before a cervical spine can be cleared by physical examination?

• No neck pain on palpation or full range of motion without neurologic injury, no ethanol/drug intoxication, no distracting injury, no pain medications

What vertebral bodies must be seen on lateral cervical spine film for adequate evaluation?

• C1 to T1

What view on x-ray can help visualize C7 to T1?

• Swimmer view

What imaging studies evaluate cervical spine ligamentous injury?

• Lateral flexion and extension c-spine films, MRI of c-spine

What is primary brain injury?

• Anatomic and physiologic disruption that occurs as a direct result of external trauma

What are the most significant factors leading to poor neurologic outcome or death in patients with traumatic brain injury?

• Hypotension and hypoxemia, which can lead to secondary brain injury

What is the Monro-Kellie doctrine?

• The doctrine states that the volume inside the cranium is a fixed volume and that the cranial compartment is incompressible.

• Blood, CSF, and brain are in a state of volume equilibrium and any increase in volume of one of the cranial constituents is compensated for by a decrease in the volume of another.

How do you calculate the cerebral perfusion pressure (CPP)?

• Mean arterial pressure (MAP)—Intracranial pressure (ICP)

What signs of elevated ICP can be seen on imaging studies?

• Decrease in ventricular size, loss of sulci, loss of cisterns, midline shift, herniation

Indications for ICP monitoring:

• GCS <8

• Patient with moderate to severe head injury and inability to follow clinical examination

• Suspicion of elevated ICP

What is the normal ICP?

• 10

What ICP requires treatment?

• 20

What CPP is desired in a head injured patient?

• CPP >60

How is serum osmolarity adjusted in head injured patients?

• 3% NSS or Mannitol

When do the peak ICPs occur after injury?

• 48 to 72 hours after injury

What does a unilateral dilated pupil in a head injured patient signify?

• Uncal herniation with compression of cranial nerve III

What GCS score indicates moderate head injury?

• 9> GCS <12

What GCS score indicates severe head injury?

• GCS <8

Which component of the GCS is the most predictive of serious anatomic injury to the brain and correlates most strongly with outcome?

• The motor component

What does a score of 0 on assessment of motor strength signify?

• No contraction of muscle

What does a score of 1 on assessment of motor strength signify?

• Palpable muscle contraction without limb movement

What does a score of 2 on assessment of motor strength signify?

• Able to move in a gravity-neutral plane

What does a score of 3 on assessment of motor strength signify?

• Able to move against gravity

What does a score of 4 on assessment of motor strength signify?

• Diminished strength

What does a score of 5 on assessment of motor strength signify?

• Normal strength

What artery is usually responsible for an epidural hematoma?

• Middle meningeal artery

What kind of deformity is seen on CT head with an epidural hematoma?

• Lenticular (lens-shaped) deformity

What kind of head injury is associated with a lucid interval?

• Epidural hematoma

How many mm of shift on CT head is considered significant mass effect?

• 5 mm

How does a subdural hematoma most commonly occur?

• Bridging veins between the dura and arachnoid are torn

What kind of deformity is seen on CT head with a subdural hematoma?

• Crescent-shaped deformity

What are indications for drainage of a chronic subdural hematoma?

• Significant symptoms, large size

Where do intracerebral hematomas usually occur?

• Frontal or temporal lobes

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

• Geniculate ganglion

Indications for operative intervention in a patient with skull fracture:

• Significant depression (8–10 mm), contaminated, persistent CSF leak not responding to conservative management

What is central cord syndrome?

• Hyperflexion or hyperextension of the neck leads to interference with blood flow in the spinal arteries leading to motor weakness and sensory loss primarily affecting the distal muscles of the upper extremities.

What is Brown-Séquard syndrome?

• Partial transection of the spinal cord, which results in loss of ipsilateral motor function and loss of contralateral sensory function.

What are the 3 columns of the spinal column?

• Anterior spinal ligament/anterior walls of the vertebral bodies, posterior spinal ligament/posterior walls of the vertebral bodies, posterior elements of the vertebral column (facet joints, lamina, spinous processes, interspinous ligaments)

How many columns need to be involved for a spinal column injury to be considered unstable?

• ≥2 columns

How are stable spinal column injuries treated?

• Immobilization (collar for cervical spine, molded jacket for thoracic and lumbar spine)

How are unstable spinal column injuries treated?

• Surgical stabilization (placement of hardware posteriorly, use of hardware and bone grafting anteriorly, both techniques simultaneously (3-column injury)

If you were going to give steroids to treat a spinal cord injury, what drug, dose, and schedule should be used?

• If within a few hours of injury: bolus with 30 mg/kg of methylprednisolone over a 1-hour period, followed by 5.4 mg/kg/h for next 23 hours.

• If injury is greater than 3 hours old but less than 8 hours old continue the steroids for a total of 48 hours—controversial and no longer recommended by ATLS.

What is the eponym for a C1 burst fracture?

• Jefferson fracture

What is a type I odontoid fracture?

• A stable fracture that occurs above the base

What is a type II odontoid fracture?

• An unstable fracture that involves the base that is treated with immobilization or fusion

What is a type III odontoid fracture?

• Fracture extends into the vertebral body that is treated with immobilization or fusion

What is known as SCIWORA?

• Spinal Cord Injury Without Radiologic Abnormality—usually transient motor/sensory symptoms attributable to spinal cord distribution but without injury noted by x-ray, CT scan, or MRI.

What study should be obtained in patients without bony injury to the spine with neurologic deficits?

• MRI, look for ligamentous injury

What is the #1 indicator of mandibular injury?

• Malocclusion

What injury is not to be missed during examination of nose?

• Septal hematoma

Where are the major vascular and aerodigestive structures in the neck, in the anterior triangle or the posterior triangle?

• Anterior triangle

Which zone of the neck extends from the sternal notch to the cricoid cartilage?

• Zone I

Which zone of the neck extends from the cricoid cartilage to the angle of the mandible?

• Zone II

Which zone of the neck extends from the angle of the mandible to the base of the skull?

• Zone III

What are the clinical indications for neck exploration with neck trauma?

• Airway: dysphonia/voice changes, hemoptysis, hoarseness, stridor, subcutaneous air

• Digestive tract: blood in oropharynx, dysphagia/odynophagia, subcutaneous air

• Neurologic: altered state of consciousness not caused by head injury, lateralized neurologic deficit consistent with injury

• Vascular: diminished carotid pulse, expanding hematoma, external hemorrhage

What is the most commonly injured vascular structure in the neck?

• Internal jugular vein

How should you treat an actively bleeding unstable patient with a penetrating neck injury?

• Take immediately to operating room for neck exploration

How would you manage an asymptomatic patient with a penetrating injury to the base of the neck (zone I)?

• CT neck/chest or 4-vessel arch angiography; bronchoscopy; rigid esophagoscopy; barium swallow

How would you manage an asymptomatic patient with a penetrating midcervical injury (zone II)?

• Neck exploration

• An acceptable alternative is 4-vessel angiography, bronchoscopy, esophagoscopy, and barium swallow.

How would you manage an asymptomatic patient with a penetrating injury above the angle of the mandible (zone III)?

• CT neck, 4-vessel arch angiography, laryngoscopy, rigid esophagoscopy, barium swallow

In a patient with an expanding neck hematoma, how do you perform a safe exploration of an anatomically hostile neck?

• Follow the "trail of safety": make a standard cervical incision along the anterior border of the sternocleidomastoid muscle, divide the platysma, identify the anterior border of the sternocleidomastoid muscle (first key structure), dissect and identify the internal jugular vein (second key structure), dissect along the anterior border of the internal jugular vein until you find the facial vein (marks the carotid bifurcation), ligate and divide the facial vein to gain access to the carotid bifurcation.

During a neck exploration for neck trauma, you encounter an injury to the internal carotid artery, how would you repair the artery?

• Debridement and primary repair if possible.

• If primary repair not possible because of loss of length perform a bypass with a short interposition graft (PTFE).

What would you do if during neck exploration for trauma you encountered a major injury to the left common carotid artery with uncontrollable hemorrhage making repair technically impossible?

• Ligate the common carotid artery (same goes for internal carotid and external carotid arteries), approximately 50% stroke rate, high mortality.

What methods have been described to control bleeding from the distal stump of an injured internal carotid artery at the base of the neck?

• Interventional angiography, place balloon catheter through the missile tract and tamponade bleeding, ligate and divide the internal carotid artery at the carotid bifurcation, and remove the balloon 3 days later, insert a balloon catheter into the distal stump of the internal carotid, and clip and cut the catheter, leaving the balloon inside the artery.

What would you do if during a neck exploration for trauma, you encountered hemorrhage emanating from a hole between the transverse processes of the cervical vertebrae, posterolateral to the carotid sheath?

• Tightly fill the bleeding hole in the transverse process with bone wax.

What are the typical mechanisms for blunt traumatic injury to the carotid/vertebral arteries?

• Direct blow to neck, hyperextension with contralateral neck rotation

What is the clinical hallmark of blunt carotid artery injury?

• Hemispheric neurologic deficit that is incompatible with CT findings

What is the treatment of blunt carotid/vertebral artery injury?

• Antiplatelet agents for low-grade injuries.

• Systemic anticoagulation for higher-grade injuries (if not prohibited by associated injuries).

• Consider endovascular techniques for inaccessible pseudoaneurysm or hemodynamically significant dissection or inaccessible pseudoaneurysm but controversial.

What percentage of asymptomatic minimal arterial injuries (small false aneurysms, and small arteriovenous fistulas, nonocclusive intimal flaps, segmental arterial narrowing) progress to require surgical or endovascular repair?

• ~10%

How should initial control of hemorrhage be obtained?

• Direct pressure over bleeding site with digital or manual compression

Under what 3 clinical situations can a temporary intraluminal shunt be used to maintain distal perfusion through an injured artery?

• Situations where skeletal alignment is accomplished before vascular repair in an ischemic limb in a patient with combined vascular and orthopedic extremity injuries.

• Transport of a patient from the field/remote facility with a peripheral arterial injury for vascular reconstruction at a trauma center.

• Damage control technique in a critically injured patient unlikely to survive a complex repair because of exhausted physiologic reserve.

Using damage control techniques for vascular injuries, how is hemorrhage control and distal perfusion maintained?

• Hemorrhage is controlled with balloon tamponade or ligation.

• Distal perfusion is maintained with temporary intra-arterial shunt.

How would you repair a simple laceration to the trachea?

• Debridement and primary repair with absorbable suture.

• If loss of more than 2 tracheal rings, may require tracheostomy/complex reconstructive procedures.

How would you repair a laryngeal injury?

• Closure of mucosal lacerations and reduction of cartilaginous fractures

How would you manage a facial fracture with significant hemorrhage?

• Secure the airway, obtain initial control with anterior and posterior nasal packing and direct packing of the oropharynx, then proceed to angiography and selective embolization versus ligation of external carotid artery.

When should sutures be removed from the face to prevent cross-hatching of the scar?

• ~3 days

What elements should be obtained with a functional eye examination?

• Visual acuity; pupillary response; assessment of extraocular eye movements, globe pressure (palpation or tonopen)

What procedure is performed if high intraocular pressure due to retrobulbar hematoma?

• Lateral canthotomy

What is the major morbidity and mortality associated with esophageal injuries?

• Delay in diagnosis

Describe how you would repair a traumatic esophageal perforation found in the upper two-thirds of the esophagus <24 hours old?

• Perform right thoracotomy, debride nonviable tissue, perform myotomy to define extent of mucosal injury, close in 2 layers over a nasogastric tube, cover repair with tissue flap (pleural/pericardial/intercostal muscle), place a chest tube (consider J tube), keep patient NPO and on TPN or feeds through J tube, and on IV antibiotics.

Describe how you would repair a traumatic esophageal perforation found in the lower one-third of the esophagus <24 hours old?

• Perform left thoracotomy, debride nonviable tissue, perform myotomy to define extent of mucosal injury, close in 2 layers over a nasogastric tube, cover repair with Thal patch/diaphragm/or fundoplication, place a chest tube (consider J tube), keep patient NPO and on TPN or feeds through J tube, and on IV antibiotics.

How you would manage a traumatic esophageal perforation in an unstable patient >24 hours old?

• Wide debridement and exclusion with cervical esophagostomy, wide drainage, possible T-tube in perforation, make patient NPO, feed with TPN or J tube feeds, continue antibiotics, high mortality.

What are the most frequent injuries leading to mortality after motor vehicle accident?

• Blunt cardiac injuries with chamber disruption, injuries to the thoracic aorta

Most frequent injury after blunt thoracic trauma:

• Chest wall trauma

Describe where to place a chest tube:

• The fifth or sixth intercostal space in the midaxillary line

General criteria for chest tube removal:

• Absence of air leak, <100 mL of fluid drainage over a 24-hour period

In regards to penetrating trauma, what are the borders of the "box"?

• Clavicles, xiphoid process, nipples

What injury must be ruled out in a penetrating "box" injury?

• Pericardial tamponade—cardiac injury

Indications for emergency thoracotomy after blunt chest trauma:

• Witnessed cardiac arrest (resuscitative thoracotomy), massive hemothorax (>1500 mL blood immediately after chest tube insertion or >200–300 mL/h after initial drainage)

What is the usual primary clinical manifestation after rib fracture?

• Pain on inspiration

How should you control the pain from rib fracture?

• Attempted control initially with oral or IV analgesics, consider intercostal nerve blocks with bupivacaine versus epidural analgesia

What is a flail chest?

• Two or more fractures in 3 or more consecutive ribs that causes instability of the chest wall

What are the most important components in the pathophysiology of the respiratory failure associated with flail chest?

• Underlying pulmonary contusion, pain during inspiration—leading to progressive atelectasis

Treatment for a sternal fracture:

• Conservative

• If significant chest wall instability/debilitating chest pain, open reduction and internal fixation

What is a pulmonary contusion?

• Hemorrhage and edema of the lung parenchyma in the absence of parenchymal disruption

Most common complication of a pulmonary contusion:

• Pneumonia

What clinical findings are suggestive of a pneumothorax?

• Decreased breath sounds, decreased expansion of the affected lung during inspiration, hyperresonance to percussion

Clinical signs and symptoms of a tension pneumothorax:

• Diaphoresis, dyspnea, distended neck veins, hypotension, tachypnea

How is a tension pneumothorax diagnosed?

• Clinically

Treatment for a tension pneumothorax:

• Chest decompression with a large-bore needle inserted in the second intercostal space, midclavicular line with subsequent tube thoracostomy (test answer)

• If you are a surgical resident/surgeon perform immediate tube thoracostomy (hard to get needle into pleural space, especially in the obese)

What is an open pneumothorax?

• A large defect in the chest wall (> laryngeal cross-sectional area) allows external air to enter into the pleural cavity resulting in lung collapse from rapid equilibration between intrathoracic (pleural) and atmospheric pressures.

Treatment for an open pneumothorax:

• Treat initially by sealing the defect with petroleum gauze and leave 1 side of the gauze unsecured to allow escape of air under pressure then perform a tube thoracostomy.

• Operative repair of the chest wall defect can be performed after other life-threatening injuries are addressed.

How many liters of blood can the pleural space accumulate?

• 3 L blood

Treatment options for massive hemorrhage from an extensive lung injury:

• Attempt oversewing or stapling of the wound.

• If initial measures fail, consider performing wedge or lobar resection.

• Pneumonectomy is a last resort.

What is hemodynamic consequence on traumatic pneumonectomy?

• Acute right heart failure

How would you manage hemorrhage from a gunshot wound causing through-and-through injury to the lung?

• Tractotomy (opening up the missile trajectory by making a communication between the entrance and exit wounds), anatomic resection is also an option.

What injury might you suspect if a trauma patient is noted to have continuous flow of air from his chest tube with inability to adequately ventilate, oxygenate, or re-expand his lung?

• Major tracheobronchial injury

How would you manage the chest tube in a patient with a major tracheobronchial injury? Why?

• Disconnect the suction apparatus on the collection system and leave the tube to water seal; minimizes air leak and allows egress of air under pressure

Treatment for a minor tracheobronchial injury:

• Perform bronchoscopy (before intubation if possible), place an endotracheal tube (ET) beyond the injury; if endotracheal intubation not possible, perform a tracheostomy

How would you treat a tracheobronchial injury > one-third the circumference of the airway?

• Perform bronchoscopy to determine site of injury and appropriate operative approach, selectively intubate the contralateral bronchus, make a posterolateral thoracotomy on the affected side and primarily repair.

Which chamber of the heart is most commonly ruptured with blunt chest trauma?

• Right ventricle (close to sternum)

Time period for a patient with blunt cardiac injury will develop a complication:

• Within 24 hours (if abnormal ECG: admit for 24 hours; if normal EKG: discharge)

What tests can rule out significant blunt cardiac injury?

• ECG and serum troponin I levels at admission and 8 hours after injury

• If normal at both time points, the patient can be safely discharged

What is the most frequent arrhythmia seen on ECG with blunt cardiac injury?

• Sinus tachycardia

What is cardiac tamponade?

• Bleeding into the pericardial sac with subsequent constriction of the heart, which results in decreased inflow and decreased cardiac output

What are the signs/symptoms of cardiac tamponade?

• Tachycardia and shock with Beck triad

• Kussmaul sign, pulsus paradoxus

What is Beck triad?

• Muffled heart tones, distended neck veins, and hypotension

How does the blood from pericardiocentesis differ from blood drawn from a peripheral artery/vein?

• Blood from pericardiocentesis does not form clot

What is Kussmaul sign?

• JVD with inspiration

Treatment for cardiac tamponade:

• Immediate IV fluid bolus and pericardiocentesis, followed by surgical exploration

What various methods are used to control hemorrhage with a penetrating cardiac injury?

• Skin staples for the temporary control of hemorrhage

• If cardiac hole small: accept the blood loss while you suture the hole versus place a peanut sponge (on a hemostat) into the wound while you repair.

• If cardiac hole is large: insert a 16-French Foley catheter with a 30-mL balloon into the wound and inflate with 10 mL of saline and apply gentle traction on the catheter while progressively closing the ends of the wound toward the middle of the wound until the amount of blood loss is acceptable without the balloon (can clamp superior and inferior vena cavae for short periods to control inflow).

What is the approach for injuries of the posterior trachea or mainstem bronchi near the carina?

• Right posterolateral thoracotomy

What is the approach for a tear of the descending thoracic aorta?

• Left posterolateral thoracotomy

What side are diaphragmatic injuries after blunt trauma usually found?

• Left side

How would you repair an acute diaphragmatic injury?

• Perform a midline laparotomy, grab the torn edges of the diaphragm with a clamp (Allis clamps) to make injury more accessible for repair, repair the diaphragmatic defect primarily (if large defect may need prosthetic mesh)

How would you approach a chronic (months to years after the initial trauma) diaphragmatic rupture?

• Transthoracic secondary to adhesions (can perform combined approach with laparotomy)

What is the classic mechanism of blunt aortic injury?

• Sudden deceleration resulting from a fall from height or frontal impact motor vehicle collision

Radiographic findings on supine chest radiograph to suggest aortic transection:

• Widened mediastinum (>8 cm), obscured/indistinct aortic knob, deviation of left main-stem bronchus, off-midline position of nasogastric tube, obliteration of aortopulmonary window, apical capping, first rib/scapula fractures, loss of aortic contour, left hemothorax, tracheal deviation to the right

Gold standard imaging modality to identify blunt aortic injury:

• Aortography

What is the estimated risk of free aortic rupture with blunt aortic injury?

• 1% per hour

What is the reported operative mortality following open repair of a blunt descending thoracic aorta injury?

• 5% to 25%

What is the rate of paraparesis/paraplegia in patients undergoing open repair of a blunt descending thoracic aorta injury?

• 5% to 10%

What is the second most common blunt thoracic vascular injury?

• Tear of the innominate artery at its origin

Where is the most expedient place to clamp the supraceliac aorta via a laparotomy?

• At the diaphragmatic hiatus

How is supraceliac clamping of the aorta performed?

• An opening in the lesser omentum is created using rapid blunt dissection, the left diaphragmatic crus is opened longitudinally in the direction of its fibers with finger dissection, the minimal required space is created on both sides of the aorta to accommodate the aortic clamp or manual compression.

What kind of injuries does abdominal CT scan miss?

• Hollow viscous injury, diaphragm injury

What kind of injuries does focused abdominal sonography for trauma (FAST) miss?

• Retroperitoneal bleeds, hollow viscous injury, diaphragm

What does diagnostic peritoneal lavage (DPL) miss?

• Retroperitoneal bleeds/injury, contained hematomas, diaphragm

How would you rule out intra-abdominal injury in a hemodynamically stable patient after blunt trauma?

• CT scan of the abdomen and pelvis (vs abdominal ultrasound)

How would you rule out intra-abdominal injury in a hemodynamically unstable patient with multiple other injuries?

• FAST, DPL, laparotomy

How would you manage a patient with an isolated penetrating abdominal trauma with hypotension/shock?

• Take patient to operating room

How would you manage a stab wound victim without peritoneal signs, evisceration, or hypotension?

• Local wound exploration and DPL versus diagnostic laparoscopy to check for violation of posterior sheath versus observation and serial examinations.

What are the standard criteria for a positive DPL in blunt trauma?

• Aspiration of at least 10 mL of gross blood, a bloody lavage effluent, a red blood cell count >100,000/mm³, a white blood cell count >500/mm³, amylase level >175 IU/dL, or detection of bile, bacteria, or food fibers

Contraindications for DPL:

• Clear indication for exploratory laparotomy

What injuries are frequently underdiagnosed by DPL alone?

• Diaphragmatic tears, retroperitoneal hematomas, and renal, pancreatic, duodenal, minor intestinal, and extraperitoneal bladder injuries

What red blood cell count is usually used to determine a positive DPL in a patient with a stab wound?

• Red blood cell count 1000 to 5000/mm³, but no real consensus

What are the zones of retroperitoneal hemorrhage?

• I, II, III

Which Zone is bilateral, and what structures are at risk?

• II—kidney, adrenals, renal vasculature

What is Zone III usually associated with?

• Pelvic fractures, iliac artery, and vein injuries

What is Zone I?

• Central hematoma—can be supramesocolic involving—pancreas, SMV, SMA, portal vein, aorta, cava, or inframesocolic—aorta, IVC

How do you fix a penetrating gastric wound?

• Debridement of the wound edges and primary closure in layers

• If major tissue loss, may need to perform gastric resection

What is the most common mechanism of blunt duodenal injury?

• Impact of the steering wheel on the epigastrium from a motor vehicle accident

Most portion of the duodenum to be injured with trauma:

• Second portion of the duodenum

What findings on abdominal x-ray might you see with a duodenal injury?

• Absence of air in duodenal bulb, mild scoliosis, obliteration of the right psoas shadow, retroperitoneal air outlining the kidney

What studies will provide diagnosis in a hemodynamically stable patient with suspected duodenal injury?

• CT scan of the abdomen with oral and IV contrast, gastrografin upper gastrointestinal series

What is the test of choice with equivocal CT findings in a hemodynamically stable patient with a suspected duodenal injury?

• Upper gastrointestinal series with diluted barium

What injury must you have a high suspicion for if you encounter a retroperitoneal hematoma around the duodenum?

• Pancreatic injury

According to the duodenum injury scale, what is a grade I duodenal injury?

• Hematoma: involving a single portion of the duodenum

• Laceration: partial thickness, no perforation

According to the duodenum injury scale, what is a grade II duodenal injury?

• Hematoma: involving more than 1 portion

• Laceration: disruption <50% of the circumference

According to the duodenum injury scale, what is a grade III duodenal injury?

• Laceration: disruption 50% to 75% of the circumference of D2 or disruption 50% to 100% of the circumference of D1, D3, D4

According to the duodenum injury scale, what is a grade IV duodenal injury?

• Laceration: disruption >75% of the circumference of D2 and involving the ampulla or distal common bile duct

According to the duodenum injury scale, what is a grade V duodenal injury?

• Laceration: massive disruption of the duodenopancreatic complex

• Vascular: devascularization of the duodenum

Treatment for grades I and II duodenal injuries diagnose within 6 hours of injury:

• Primary repair

Treatment for grades I and II duodenal injuries diagnose after 6 hours of injury:

• Repair and duodenal decompression (transpyloric nasogastric tube, tube jejunostomy, or tube duodenostomy) because of increased risk of leakage

Treatment for a grade III duodenal injury:

• Primary repair, pyloric exclusion, and drainage versus Roux-en-Y duodenojejunostomy

Treatment for a grade IV duodenal injury:

• Primary repair of the duodenum, repair of the common bile duct, and placement of a T-tube with a long transpapillary limb versus choledochoenteric anastomosis.

• If repair of common bile duct impossible, perform ligation and a second intervention for a biliary enterostomy

Treatment for a grade V duodenal injury:

• Pancreaticoduodenectomy (trauma whipple) versus closure of the duodenal wound, debridement of pancreas if necessary, and pyloric exclusion with wide drainage

What is the most significant complication after duodenal injury?

• The development of a duodenal fistula

How do you manage a duodenal fistula?

• Nonoperatively with nasogastric suction, IV nutrition, and aggressive stoma care (usual closure within 6–8 weeks)

• Percutaneously drain any abscesses that develop or perform surgical drainage if multiple abscesses present or if abscesses located between small bowel loops.

Treatment for a distal pancreatic injury with suspected ductal injury:

• Distal pancreatectomy ± splenectomy

Most frequent complications after pancreatic trauma:

• Pancreatic fistula and peripancreatic abscess

What is the most frequently injured organ after penetrating trauma?

• Small bowel

What are suggestive findings on CT scan for small bowel injury?

• Free fluid without solid organ injury, free air, thickening of the small bowel wall or mesentery

How would you repair a small injury to the small bowel caused by a firearm?

• Debridement and primary repair

How are extensive lacerations, devascularized segments, or multiple lacerations in a short segment of mall intestine repaired?

• Small bowel resection and primary anastomosis

What are the general criteria for primary closure of a traumatic colon injury?

• Absence of prolonged shock/hypotension, absence of gross contamination, absence of associated colonic vascular injury, early diagnosis (within 4–6 hours), <6 units of blood transfused, no requirement for the use of mesh

How should stab and low-velocity wounds to the colon with minimal contamination in a hemodynamically stable patient be repaired?

• Primary repair versus resection with primary anastomosis

How should traumatic colon injuries at high-risk or associated with other severe injuries be repaired?

• Colonic resection and colostomy

How would you manage an extraperitoneal rectal injury (distal one-third of the rectum)?

• Attempt primary closure of the extraperitoneal rectal injury but not necessary, create a diverting colostomy, wash out the distal rectal stump with +/- wide presacral drainage.

How would you manage an intraperitoneal rectal injury?

• Primary closure with a diverting colostomy

How would you control the bleeding from a small superficial hepatic laceration?

• Simple suture repair, argon beam coagulator, electrocautery, topical hemostatic agents, fibrin glue

How would you control the bleeding from a severe hepatic laceration that continues to bleed despite attempts at local control?

• Finger fracture hepatotomy along nonanatomic planes with direct ligation of any bleeding vessels with placement of an omental flap in the laceration, Pringle maneuver, pack the liver wound, consider angiography with second look operation in 48 to 72 hours, if multiple lacerations and no major vascular injury mesh hepatorrhaphy (wrap each lobe of liver individually with absorbable mesh and attach to falciform ligament), less attractive options include formal hepatic resection and hepatic artery ligation.

What injury might you suspect if bleeding continues after performing a Pringle maneuver in a patient with traumatic hepatic injury?

• Hepatic vein or retrohepatic vena cava injury

How would you control the bleeding from a hepatic vein injury?

• Perform a pringle maneuver, place a rummel tourniquet around infrahepatic IVC, perform a median sternotomy, open the pericardium; place a rummel tourniquet around intrapericardial IVC ± atriocaval shunt (total hepatic isolation)

Reported incidence of biliary fistula after hepatic trauma:

• 7% to 10%

Usual treatment for hemobilia:

• Angiographic embolization

How would you manage a blunt hepatic injury in hemodynamically stable patient without extravasation on the arterial phase of CT scan?

• Nonoperatively: follow with serial hematocrit, vital signs, serial abdominal examinations, repeat CT scan to evaluate and quantify hemoperitoneum if the hematocrit drops, angiography with superselective embolization with persistent bleeding/fluid requirement

What procedure would you perform for an obvious traumatic injury to the gallbladder?

• Cholecystectomy

How would you repair a minor injury to the common bile duct <50% of the duct's circumference?

• Primary repair and placement of a T-tube with a closed suction drain in the vicinity of the repair

How would you repair a major injury to the common bile duct >50% of the duct's circumference?

• Choledochoenteric anastomosis with placement of a closed suction drain near the anastomosis

What is the commonly used estimation of the incidence of overwhelming post splenectomy sepsis (OPSI) in children and in adults?

• 0.6% in children and 0.3% in adults

How would you manage a hemodynamically stable patient with a splenic injury with contrast extravasation on the arterial phase of abdominal CT scan?

• Controversial: operative intervention versus angiographic embolization versus observation

How would you manage a hemodynamically stable patient with a splenic injury without contrast extravasation on abdominal CT scan?

• Admission to ICU, serial hematocrit, vital signs, serial abdominal examinations, bed rest, NPO

What classic criteria are used for the nonoperative management of splenic injury?

• Absence of contrast extravasation on CT, absence of other associated injuries requiring surgical intervention, absence of health conditions with an increased risk for bleeding (coagulopathy, hepatic failure, anticoagulants, specific coagulation factor deficiency), hemodynamic stability, negative abdominal examination, splenic injury grade I to III

How long will you tell your patient with a splenic injury treated nonoperatively to avoid intense physical activity/contact sports?

• 3 months

After performing an exploratory laparotomy for trauma, you incidentally discover a capsular tear of the spleen; how should you control the bleeding?

• With compression or with topical hemostatic agents.

What are your options for controlling bleeding from a splenic laceration?

• Closing the laceration with horizontal absorbable mattress sutures, argon beam coagulator/fibrin glue

• If major laceration involving <50% of splenic parenchyma and not extending into hilum, can perform segmental or partial splenic resection

• Splenectomy/splenorrhaphy

How should you manage a patient with an injury to the central portion of the spleen extending into the hilum?

• Splenectomy

What measures are taken to help prevent OPSI

• Vaccinate against Streptococcus pneumoniae, Hemophilus influenzae, and Neisseria meningitidis; prophylactic penicillin for all minor illnesses/infections; immediate medical evaluation if febrile

What is abdominal compartment syndrome?

• Increasing intra-abdominal pressure that reduces blood flow to abdominal organs leading to impaired pulmonary, cardiovascular, renal, and gastrointestinal function causing multiple organ dysfunction syndrome and death.

Which physiologic parameters are decreased with abdominal compartment syndrome?

• Renal blood flow, cardiac output, central venous return, glomerular filtration, visceral blood flow

Which physiologic parameters are increased with abdominal compartment syndrome?

• Central venous pressure, heart rate, intrapleural pressure, peak inspiratory pressure, pulmonary capillary wedge pressure, systemic vascular resistance

What is the treatment for abdominal compartment syndrome?

• Decompressive laparotomy

What is the most frequent sign associated with a urinary tract injury?

• Gross hematuria

What are the usual manifestations of a lower urinary tract injury?

• Blood in the urethral meatus; floating or displaced prostate on rectal examination; distended bladder; inability to void; large perineal hematoma/perineal injury

Usual manifestation of upper urinary tract injury:

• Gross or microscopic hematuria

What is your workup to rule out urethral/bladder injury in a blunt trauma patient with blood at the urethral meatus?

• Urethrocystography before bladder catheterization (rule out urethral injury)

• If negative, perform cystography by injecting 250 to 300 mL of contrast through foley to maximally distend bladder and obtain films with the bladder fully distended and empty

When performing cystography to rule out bladder injury, why do you need to obtain a postvoid film?

• To rule out posterior extravasation of contrast not seen on AP films with the bladder maximally distended

What is the most commonly injured part of the urinary tract?

• Kidney

Usual treatment for a small parenchymal injury to the kidney caused by a penetrating wound:

• Debridement, primary repair, and drainage

Usual treatment for an extensive hilar injury to the kidney caused by a penetrating wound:

• Total nephrectomy

What should you do before opening a major perinephric hematoma?

• Obtain proximal control of the renal pedicle before opening Gerota fascia

What surgery would you perform for a ureteral injury located in the upper (or middle) third of the ureter with minimal tissue loss?

• Ureteroureterostomy with placement of a double-J stent

What surgery would you perform for a ureteral injury located in the distal third of the ureter with minimal tissue loss?

• Ureteral implantation into the bladder

What are your surgical options for a patient with a ureteral injury where primary repair is not possible (long segment of ureter lost; poor clinical condition of patient)?

• Percutaneous nephrostomy with delayed repair, transureteroureterostomy if possible, kidney autotransplantation into iliac fossa

Approximate percentage of patients with bladder rupture that have an associated pelvic fracture:

• ~70%

How would you repair an intraperitoneal bladder rupture?

• Using a transabdominal approach, perform a primary repair with a 3-layer closure leaving a Foley catheter in place for decompression (if large defect, consider suprapubic cystostomy).

What is the usual management of an extraperitoneal bladder rupture?

• Nonoperative: leave Foley catheter in place for 10 to 14 days

What is the study of choice to diagnose a urethral injury?

• Retrograde urethrogram

What physical examination findings can be associated with urethral injuries?

• High riding prostate on rectal, blood at meatus, perineal or scrotal hematoma/ecchymosis

Usual management for a patient with a urethral injury:

• Bladder decompression with suprapubic cystostomy and delayed urethroplasty

What kind of bone fracture involves young, soft bone that bends and leads to an incomplete disruption of the bone?

• Greenstick fracture

What types of bone fracture occur when a bending moment is applied to the bone?

• Transverse and oblique fractures

What type of bone fracture generally results from a rotational force about the long axis of the bone?

• Spiral fracture

What fracture results bone be stressed beyond its failure point from chronic, repetitive trauma resulting in microscopic disruption?

• Stress fracture

Term for a fracture that occurs through an area weakened by pre existing disease?

• Pathologic fracture

What is an open fracture?

• A fracture with a communication between the fracture site and the outside environment from an overlying wound

What are the 3 main mechanisms leading to cervical spine injury?

• Direct trauma to the neck, motion of the head relative to the axial skeleton, direct axial load imparted on the cranium causing axial compression forces across the cervical vertebrae

How can a burst fracture be differentiated from a compression fracture?

• Burst fractures involve injury to the middle column (posterior third of vertebral body)

• Compression fractures involve injury to the anterior column only (anterior two-thirds of vertebral body)

When filming long bone injuries, what must be done to assess the integrity of adjacent limb segments?

• Include the joints above and below the level of injury

• If the joint is injured, image the long bones above and below the joint injury

Why do you immobilize a fracture?

• Splinting reduces bleeding, helps avoid additional soft tissue injury (prevents conversion of a closed fracture to an open fracture), reduces patient discomfort, and facilitates transportation and radiographic evaluation of the injury.

What should you do for a patient with a clear indication for abdominal exploration with a bleeding pelvic fracture with a ruptured retroperitoneum?

• Pack the pelvis (can pack space of Retzius), temporarily close the abdomen, follow with external fixation and angiography as needed

If you are to perform a DPL on a patient with an obvious pelvic fracture, where should you place your incision?

• Supraumbilical

Rotational instability of a pelvic ring disruption is defined as:

• Widening of the pubic symphysis; displacement of pubic rami fractures >2.5 cm

Vertical instability of a pelvic ring disruption is defined as:

• Superior translation of a hemipelvis through fractures of the sacrum or ilium with disruption of the sacroiliac joint >1 cm

What type of compression injury to the pelvis has the greatest risk of retroperitoneal hemorrhage?

• Anteroposterior compression

What is the most common cause of death in a patient with a lateral compression injury of the pelvis?

• Associated closed head injury

In a patient with an unstable pelvic ring disruption and a positive abdominal study, what must you do before laparotomy?

• Stabilize the pelvis (external fixation, C clamp), if still hemodynamically unstable after pelvic stabilization perform arteriography

What are indications for performing an arteriogram in patients with suspected vascular trauma?

• Any pulse deficit, ankle-brachial index <0.90

What are the hallmarks of successful treatment of an open femoral fracture?

• Antibiotic prophylaxis, irrigation and debridement, compartment decompression, stabilization, and early wound coverage

What kind of complications can arise from prolonged joint dislocation?

• Ankylosis, avascular necrosis, cartilage cell death, neurovascular injury, posttraumatic arthritis

What position does the thigh assume with a posterior hip dislocation?

• Flexed and internally rotated

What position does the arm assume with an anterior shoulder dislocation?

• Adducted and externally rotated

If the hip remains dislocated for 24 hours, what percentage of patients will develop avascular necrosis of the femoral head?

• 100%

What is the treatment of choice for closed femoral fractures and type I to IIIA open femoral fractures?

• Closed, locked intramedullary nailing

What is the most common fractured diaphyseal long bone?

• Tibia

What nerve is evaluated by testing sensation of the first dorsal web space and foot and toe dorsiflexion?

• Deep peroneal nerve

What nerve is evaluated by testing sensation along the dorsum of the foot and foot eversion strength?

• Superficial peroneal nerve

What nerve is evaluated by testing sensation of the sole of the foot and motor function to the foot and toe plantar flexors?

• Tibial nerve

What nerve is evaluated by testing sensation to the lateral aspect of the heel?

• Sural nerve (purely sensory)

How is a closed tibial fracture with minimal displacement treated?

• Cast immobilization and functional bracing

What is the treatment of choice for open moderate and severe tibial fractures?

• Open reduction and internal fixation; use of reamed intramedullary nailing debatable

What is entailed in the typical nonoperative treatment of a humeral fracture?

• Application of a coaptation splint in the acute setting with subsequent replacement by a functional fracture brace 3 to 7 days later when the pain from the initial fracture has passed.

Indications for operative intervention in patients with humeral shaft fractures:

• Concomitant neurologic/vascular injury, failed closed reduction, intra-articular fractures, ipsilateral forearm or elbow fractures ("floating elbow"), open fractures, polytrauma patients, segmental fractures

Surgical options for a humeral shaft fracture include:

• Intramedullary nailing, plate and screw fixation, external fixation

What 3 conditions must be met before a patient can be allowed to bear weight on an injured extremity?

• There must be bone-to-bone contact at the fracture site, demonstrated intraoperatively or on postreduction radiographs, stable fixation of the fracture must be achieved, the patient must be able to comply with the weight-bearing status