Term
| Management of extraperitoneal rectal injury |
|
Definition
| Primary repair or diverting colostomy to allow injury to heal |
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|
Term
| Management of intraperitoneal rectal injuries |
|
Definition
| Primary repair; only need to divert if the pt has severe associated injuries with significant blood loss |
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Term
| Management of blunt kidney injury |
|
Definition
# do nothing unless injury is bilateral or if pt only has one kidney
# if leaving it in situ leads to persistant hypertension, delayed nephrectomy indicated. |
|
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Term
| Management of distal ureter injury |
|
Definition
# ideal: spatulate both ends and do end-to-end anastamosis over a double J stent.
# if not enough length: psoas hitch to mobilze the bladder; uretero-ureterostomy; mobilize the kidney and bring into pelvis;
# damage control: ligate both ends of ureter, perform nephrostomy later, and delayed repair of ureter; temporary cutaneous ureterostomy over J stent |
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Term
| Clinically significant hemodynamic alterations in late term pregnant women to be aware of in trauma |
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Definition
| Blood volume is increased but volume is increased proportionately more which would increase the amount of blood loss required to produce hypotension and tachycardia |
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Term
| Clinically significant phsysiologic alterations in late term pregnant women to increase O2 delivery to fetus and to be aware of in trauma |
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Definition
# increased minute ventilation which causes mild respiratory alkalosis, but decreases mother's FRC and respiratory reserve
# increased 2,3-DPG to aid in O2 offloading from hemoglobin |
|
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Term
| Anatomic changes of later pregnancy to keep in mind during trauma |
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Definition
# fetus may compress IVC, so lay mother on LLD position
# more prone to aspiration from cranially displaced stomach so early NGT placement
# constant stretching of peritoneum leads to desensitization making it possible that the mother will not show peritoneal signs |
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Term
| Management of suspected bladder injury |
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Definition
# CT cystogram if hematuria in presence of pelvic fxs
# Intraperitoneal: open 3-layer repair with chromic suture and suprapubic cystostomy
# Extraperitoneal: foley catheter drainage for 7-10 days |
|
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Term
| Management of suspected blunt cardiac injury |
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Definition
# Order troponin and EKG; If neg, repeat both in 8 hrs; 2 consecutive negatives rules it out.
# if either EKG or trop are positive, admit for obs in a monitored bed
# If unstable, stat echo to look for anatomic abnormality; if neg, invasive monitoring +/- pressor; if positive, problem is addressed |
|
|
Term
| Order of preference for peripher IV access in a child younger than 6 |
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Definition
1. AC fossa
2. cutdown on superficial saphenous vein
3. intrerosseous cannulation of proximal tibia
4. interosseous cannulation of distal femur |
|
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Term
| Cattell maneuver and what vascular structures it's good for exposing |
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Definition
# medial visceral rotation of the cecum and ascending colon;
# good for exposing retropertineal structures, like the IVC and R ureter |
|
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Term
| Kocher maneuver and what vascular structures it's good for exposing |
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Definition
# mobilization and medial rotation of the duodenum
# exposes the suprarenal IVC below the liver |
|
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Term
| Mattox maneuver and what vascular structures its' good for exposing |
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Definition
# medial rotation of the left colon, kidney and spleen toward the midline
# combined with division of the left crus of the diaphragm and dividing the celiac plexus, can expose the celiac axis |
|
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Term
| Way to expose injuries to the distal IVC and iliac vein bifurcations |
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Definition
| # division of the R CIA and primary repair |
|
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Term
| Way to expose injuries to the SMA and the confluence of the portal vein |
|
Definition
| # division of the neck of the pancreas |
|
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Term
| Indications for operative management of penetrating or blunt injuries to thoracic structures |
|
Definition
1. Initial hemothorax drainage of > 1500 ml or hemothorax drainage of > 200 ml/hr x 3hrs
2. Caked hemothorax (persistance of a large hemothorax even after a 2nd chest tube
3. Large air leak with inadequate ventilation or persistant collapse of the lung
4. esophageal perforation
5. Cardiac tamponade |
|
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Term
| Management of a through-and-through injuring to a single lung lobe with an active air leak and bleeding |
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Definition
| Pulmonary tractotomy: insertion of linear staple into the bullet hole to create two staple lines and ligating the lung in between to allow access to the bleeding vessels and leaking bronchi |
|
|
Term
| Grading system of duodenal injuries |
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Definition
| I-V; Grade I is a simple hematoma and grad V is a massive disruption of a pancreatico duodenal complex |
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Term
| Management of a simple duodenal hematoma |
|
Definition
# If recognized pre-operatively, NGT and TPN;
# If found intraoperatively and small, leave it alone
# If large (involving > 50% of lumen), incise the serosa, drain the hematoma, and reclose the serosa |
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Term
| Management of a full-thickness duodenal laceration |
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Definition
| Primary repair, closing transversely, with an omental patch |
|
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Term
| management of a large ( > 50% of the luminal circumference) duodenal injury |
|
Definition
# 1st or 4th portion: resection with a duodenoduodenostomy
# 2nd or 3rd and the ampula is not injuried: RNY duodenojejunostomy
# distal to the ampula, distal portion of the duodenum is oversewn and EEA anastamosis of jejunum to prox duodenum and drainage of distal duodenum into jejunum |
|
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Term
| Trauma indication for a Whipple |
|
Definition
| Massive dissruption of the pancreatic head and duodenum |
|
|
Term
| Management of a pancreatic injury without ductal disruption |
|
Definition
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|
Term
| Management of a distal pancreatic injury with dictal disruption |
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Definition
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|
Term
| Physical exam suggestive of neurogenic shock |
|
Definition
| Hypotension, relative bradycardia, WWP extremities (reflecting loss of sympathetic tone), evidence of high spinal cord injury and priapism (unopposed parasympathetic stimulation) |
|
|
Term
| Management of hypotension in patient with neurogenic shock |
|
Definition
| Fluids; once adequately resuscitated, pure alpha agonist- phenylephrine (Neo) |
|
|
Term
|
Definition
1. > 10 mL of free blood aspirated
2. > 100,000/m3 RBC for blunt trauma and > 5000/m3 RBC for penetrating trauma
3. the detection of bile, amylase or vegetable or fecal matter
4. WBC > 500/m3 |
|
|
Term
| Grades of a kidney injury |
|
Definition
I: Contusion or subcapsular and non-expanding hematoma
II:
III: deep lacerations that do not involve the collecting system
IV: lacerations involving the collecting system or injury to the man renal artery
V: completely shattered kidney or avulsion of the renal hilum |
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|
Term
| Management of kidney injury |
|
Definition
| any injury can be managed non-operatively as long as pt is HD stable |
|
|
Term
| management of renal trauma with urinary extravasation |
|
Definition
| Observation with possible percutaneous drainage or urinary stent placement if it does not resolve on it's own. |
|
|
Term
|
Definition
1. hypertonic saline with Na goal 155-160
2. mild hyperventilation with pCO2 > 30 (goal is to decrease swelling by causing vasoconstriction, too much vasoconstriction is bad)
3. Mannitol
4. EVD
5. Barbiturate coma to decrease metabolic demands of brain |
|
|
Term
| Management of colonic injuries |
|
Definition
# primary repair if less than 50% of the circumference is involved
# resection for > 50% circumferential involvement with primary anastamosis if pt stable (and not required too much blood) or possibly if morbidly obese
# resection and colostomy if large wound and unstable |
|
|
Term
|
Definition
| Hypertension and bradycardia in setting of traumatic inctracranial bleeding |
|
|
Term
| Of the possible sources of significant bleeding, the one that takes precedence over the others |
|
Definition
|
|
Term
| 3 radiographic findings suspicious for aortic transection |
|
Definition
1. depressed left mainstem bronchus
2. widened mediastinum
3. deviated trachea |
|
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Term
| Factors that make primary amputation of the leg a better option |
|
Definition
1. hemodynamic instability
2. ischemia > 6 hrs
3. complete traumatic amputation
4. tib/fib fx with large soft tissue defect and arterial injury
5. transection of the tibial nerve |
|
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Term
| Way to diagnose duodenal perforation in the setting of an equivocal CT |
|
Definition
| Upper GI series with water solube contrast that shows "coiled spring" appearance of the duodenal wall |
|
|
Term
| Stages of damage control surgery |
|
Definition
1. abreviate resuscitative surgery in which hemorrhage and bowel contamination are controled with packing and a temporary abd closure (delay repair of non-life threatening injuries)
2. rewarm, resuscitate and fix coagulopathy in ICU and look for other injuries
3. re-exploration after restoration of normal physiology to remove packs and complete any additional repairs |
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|
Term
| Type of injury which is a contra-indication to damage control surgery |
|
Definition
|
|
Term
| Type of liver injury amenable to suturing and best method for liver suturing |
|
Definition
# Superficial lacerations
# Chromic suture with blunt needle |
|
|
Term
| Indications for immediate OR explioration of neck wounds |
|
Definition
# hard signs fo vascular injury: rapidly expanding hematoma or visible exanguination
# shock, even without hard signs b/c the presumption is that the pt exsanguinated in the field |
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|
Term
| Management of penetrating neck trauma |
|
Definition
# To OR if hemodynamically unstable or hard signs of vascular injury
# If hemodynamically stable, 4-vessel arteriography or CTA of neck
# When feasible, assessment for injuries to the aerodigestive tract (triple endoscopy and/or esophagoscopy) and C-spine
# Xray of head neck and chest to look for the bullet |
|
|
Term
| Management of Carotid artery injury |
|
Definition
| repair if neurological deficit |
|
|
Term
| Definition of flail chest |
|
Definition
| 3 or more ribs fractured in at least 2 locations |
|
|
Term
| Indications for internal fixation of the chest wall |
|
Definition
# flail chest in pts already undergoing thoracotomy for an intrathoracid injury
# Flail chest without pulmonary contusion
# noticeable paradoxical movement while pt is being weaned
# severe deformity of chest wall |
|
|
Term
| Pulsatile exophthalmos in a pt with racoon eyes and/or hemotympanum |
|
Definition
| Carotid-cavernous fistula |
|
|
Term
| Signs of carotid-cavernous fistula |
|
Definition
# pulsatile exophthalmous
# eyelid edema
# auscultation of a bruit over the eye
# edema of the conjunctiva
# double vision
# swelling of the eye |
|
|
Term
| Management of caroitid-cavernous fistula |
|
Definition
| open neurosurgical approach or endovascular embolization |
|
|
Term
| Signs of compartment syndrome |
|
Definition
# pain out of proportion to the injury
# pain on passive motion of the limb
# tense edema with tenderness on palpation fo the compartment |
|
|
Term
# First compartment to be involved in compartment syndrome of the leg
# Sx of involvement of that compartment
# pathogenesis of said sx |
|
Definition
# Anterior compoartment of the leg
# numbness in the first web space
# entrapment of the deep peroneal nerve which runs in the anterior compartment |
|
|
Term
In compartment syndrome:
# compartment most difficult to decompress
# structure contained in that compartment
# best way to decompress that compartment |
|
Definition
# deep posterior compartment
# tibial nerve
# detachment of the soleus muscle from the tibia |
|
|
Term
| Grades of traumatic peripheral nerve injuries and definition |
|
Definition
# Neuropraxia- focal demyelination from stretch or compression; axon is intact so conduction proximal and distal to the lesion is in tact
# Axonotmesis- axon is damagamed but surrounding structures preserved which allows regeneration to occur
# Neurotmesis- complete transection or disruption; |
|
|
Term
| Type of peripheral nerve injury a/w distal wallerian degeneration |
|
Definition
|
|
Term
| Types of peripheral nerve injuries which are amenable to regeneration and which require surgical repair |
|
Definition
# regeneration: neuropraxia and axonotmesis
# requires surgery: neurotmesis |
|
|
Term
| MC traumatic peripheral nerve injury |
|
Definition
# Upper extremity more common than lower
# MC periph nerve injury: radial nerve a/w humerus fx
# MC lower extremity periph nerve injury is peroneal nerve a/w posterior knee dislocation |
|
|
Term
| Rate at which peripheral nerves regenerate |
|
Definition
|
|
Term
| Grading of pancreatic injuries |
|
Definition
# I- minor contusion or laceration
# II-
# III
# IV
# V: major disruption of pancreatic head |
|
|
Term
| Management of pancreatic injuries |
|
Definition
# 1st step is to determine of the main pancreatic duct is injured and whether it is injured to the R or L of the superior mesenteric vessels--> pancreatography via contrast injected into the GB
# if duct disrupted to the left of mesenteric vessels: distal pancreatectomy
# if disrupted to R but no major head disruption: drainage and delayed pancreaticoenteric anastomosis if fistula fails to heal
# if disrupted to R with major head disruption: pancreaticoduodenectomy
# any such operation can be delayed if damage control laparotomy needed |
|
|
Term
| Indications for Whipple in trauma |
|
Definition
# injury to main pancreatic duct to R of mesenteric vessels and massive disruption of pancreatic head
# devascularization of duodenum |
|
|
Term
|
Definition
| Distended neck veins, muffle heart sounds, hypotension==>> pericardial tamponade |
|
|
Term
|
Definition
# IVF first, especially if early, because volume can overcome the tamponade
# if stable, fast exam looking for tamponade or abd free fluid; if tamponade confirmed --> OR for median sternotomy and repair
# if unstable, left anterolateral thoracotomy in ED, longitudinal incision in pericardium avoiding phrenic nerve, evacuate clot and finger in the injury |
|
|
Term
| Nerves in each compartment of the leg |
|
Definition
# Anterior- deep peroneal
# Lateral- superficial peroneal
# Deep posterior- tibial nerve
# Superficial posterior- sural |
|
|
Term
| MC compartment affected in compartment syndrome |
|
Definition
| Anterior compartment (think anesthesia in first web space 2/2 deep peroneal n involvement) |
|
|
Term
| Earliest sign of compartment syndrome in an awake pt |
|
Definition
| # pain out of proportion to exam and pain with passive dorsiflexion |
|
|
Term
|
Definition
# only initiate rewarming when it can be done rapidly and completely
# rewarm by immersing in warm water (40-42 C) until sensation returns
# remove clear blisters, leave hemorrhagic blisters
# elevate the extremity
# Abx and tetanus
# wait at least 3-4 months to do any surgery |
|
|
Term
| management of posterior knee dislocation with the loss of distal pulses |
|
Definition
# reduce the dislocation and reassess the pulse,
# if still not there --> OR- interposition RSVG from contralateral leg
# if no other injuries, heparin
# if there are other orthopedic injuries that require surgery and the foot is ischemic (heparin is contraindicated) explore the artery and place a temporary shunt
# 4-compartment fasciotomy
# if pulse is restored with reduction, arteriography to eval for intimal damage
# if pulses are never lost, check ABIs and do arteriography for ABI < 0.9 |
|
|
Term
| Important steps for addressing a RP hematoma in the OR |
|
Definition
| # obtain proximal control prior to entering; obtain control just below diaphragm for zones I or II; at infrarenal aorta for zone III |
|
|
Term
| Management of penetrating zone I injuries |
|
Definition
# if on the right, obtain proximal control via a median sternotomy
# if on the left, obtain proximal contral via a left anterolateral thoracotomy |
|
|
Term
| Management of trauma with a SDH + shift and a traumatic aortic injury |
|
Definition
| If they are stable enough to make it to CT, they have survived the worst part of the thoracic injury and are a candidate for delayed repair of that injury and immediate repair of ICH. Keep MAP < 70 in meantime |
|
|
Term
| Management of Zone II penetrating injury |
|
Definition
# if neuro deficit, pulsatile bleeding, expanding hematoma, or palapable thrill -> immediate OR exploration with goal of repair of carotid
# if no hard signs of injury, CTA first because it will also reveal injuries to c-spine and aerodigestive tract |
|
|
Term
|
Definition
# Zone I: midline RP
# Zone II: peri-nephric RP
# Zone III: pelvic RP |
|
|
Term
| Management of traumatic RP hematomas |
|
Definition
# Any caused by penetrating injury -> operative exploration (all zones)
# Any zone I should be explored regardless of whether blunt or penetrating
# blunt zone III: pelvic stabilization and IR embolization because likely from small deep vessels |
|
|
Term
| Delayed onset of lateralizing neuro deficits s/p blunt trauma with negative CTH |
|
Definition
| Suspect blunt carotid artery injury and perform angiography |
|
|
Term
|
Definition
# I: thoracic inlet to the cricoid cartilage
# II: Cricoid to the angle of the mandible
# III: angle of the mandible to the base of the skull |
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