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Surgery: Trauma

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What are the 5 steps of the primary survey?
Airway (and C-spine stabilization)
Breathing
Circulation
Disability
Exposure and Environment
What are the three elements of the ATLS protocol
1. Primary survey
2. Secondary Survey
3. Definitive Care
ATLS
Advanced Trauma Life Support
What are the goals during the assessment of the airway?
Securing the airway and protecting the spinal cord
In addition to the airway, what must be considered during the airway step?
Spinal Immobilization
What comprises spinal immobilization?
Use a full backboard and a rigid cervical collar
In an alert patient, what is the quickest test for an adequate airway?
Ask a question; if the patient can speak, the airway is intact.
What is the first maneuver to establish an airway?

If these methods are unsuccessful, what is the next maneuver used to establish an airway?
Chin lift, jaw thrust, or both;
If successful: often an oral or nasal airway can be used to temporarily maintain the airway

Endotracheal intubation, either nasal or oral (oral if the pt is not breathing with inline C-spine traction)
When is nasotracheal intubation contraindicated?
if the patient has a maxillofacial fracture or apnea
If all other methods are unsuccessful, what is the definitive airway?
Cricothyroidotomy, A.K.A. "surgical airway": incise the cricothyroid membrane between the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an ET or tracheostomy tube into the trache.
Make sure you immobilize the spine and maintain oxygenation
What must always be kept in mind during difficult attempts at establishing an airway?
Spinal immobilization and adequate oxygenation; if at all possible, patients must be adequately ventilated with 100% oxygen using a bag and mask ebfore any attempt at establishing an airway
What are the goals in assessing breathing?
Securing oxygenation and ventilation
Treating life-threatening thoracic injuries
Injury to lung, resulting in release of air into the pleural space b/t the normally apposed parietal and visceral pleura causing dyspnea, JVD, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal shift away from the affected side, hyperresonance on the affected side. DX?
Tension pneumothorax
Pneumothorax...
a. What is the Tx of a tension pneumothorax?
b. What is the medical term for a sucking chest wound?
c. How is an open pneumothorax diagnosed
d. TX?
a. Immediate decompression by needle thoracostomy in the 2nd ICS midclavicular line, followed by tube thoracostomy in anterior/midaxillary line int he 4th ICS (nipple level)
b. Open pneumothorax
c. Dx: usually obvious, with air movement through a chest wall defect and pneumothorax on CXR
d. Tx in ER: +/- intubation with positive-pressure ventilation, tube thoracostomy (chest tube), occlusive dressing over chest wall defect
CXR shows loss of lung markings; may see edge of lung-air interface. DX?
pneumothorax
2 separate FXs in 3+ consecutive ribs that causes the chest wall to movesparadoxically (sucks in with inspiration and pushes out with expiration opposite the rest of the chest wall)
a. Major cause of respiratory compromise?
b. Tx?
Flail chest
a. Underlying pulmonary contusion
b. Intubation with positive pressure ventilation and PEEP as needed (let ribs heal on their own)
Define the following:
a. Beck's triad
b. Kussmaul's sign
a. 1) Hypotension; 2) Muffled heart sounds; 3) JVD
b. JVD with inspiration
Bleeding into pericardial sac, resulting in constriction of heart, decreasing inflow and resulting in decreased cardiac output (the pericardium doesn't stretch) causing tachycardia/shock with Beck's triad, pulsus paradoxus, and Kussmaul's sign
a. How is it definitely diagnosed?
b. What is Tx?
Cardiac tamponade
a. Ultrasound (echocardiogram)
b. Immediate IV fluid bolus; pericardiocentesis, subsequent surgical exploration is mandatory (pericardiocentesis is only temporary)
What widely accepted protocol does trauma care in the US follow?

What are the 3 main elements of this protocol?
The Advanced Trauma Life Support (ATLS)

1) Primary survey/resuscitation - this is when you obtain Hx
2) Secondary survey
3) Definitive care
What principles are followed in completing the primary survey?
Life-threatening problems discovered during the primary survey are always addressed BEFORE proceeding to the next step
What comprises adequate assessment of breathing?
1. Inspection: air movement, respiratory rate, cyanosis, tracheal shift, jugular venous distention, asymmetric chest expansion, use of accessory muscles of respiration, open chest wounds
2. Auscultation: breath sounds
3. Percussion: hyperresonance/dullness over either lung field
4. Palpation: presence of SQ emphysema, flail segments
What are the 3 life-threatening conditions that MUST be diagnosed and treated during the breathing step?
Tension pneumothorax, open pneumothorax, massive hemothorax
Patient presents with hypotension; unilaterally decreased or absent breath sounds; dullness to percussion
a. What studies should you obtain?
b. Tx?
c. Indications for emergent thoracotomy for hemothorax?
Massive hemothorax
a. CXR, CT scan, chest tube output
b. Volume replacement; tube thoracostomy (chest tube)**, use of cell saver, removal of the blood
c. 1) > 1500 cc blood on initial placement of chest tube
2) persistent > 200 cc of bleeding via chest tube per hour x
4 hours
a. What are the goals in assessing circulation?
b. What is the initial test for adequate circulation?
a. Securing adequate tissue perfusion; treatment of external bleeding
b. Palpation of pulses: if radial pulse is palpable, then systolic pressure is at least 80 mm Hg; if a femoral or carotid pulse is palpable, then systolic pressure is at least 60 mm Hg
What comprises adequate assessment of circulation?
HR, BP, peripheral perfusion, urinary output, mental status, capillary refill (normal < 2 seconds)

Exam of skin: cold, clammy = hypovolemia
Who can be hypovolemic with normal BP?
The young: autonomic tone can maintain BP until cardiovascular collapse is imminent
Which patients may not mount a tachycardic response to hypovolemic shock?
Those with concomitant spinal cord injuries
Those on Beta blockers
Well-conditioned athletes
How are sites of external bleeding treated?
By direct pressure, +/- tourniquets
What is the best and preferred IV access in the trauma patient?

What are alternate sites?
Two large bore IV's (14-16 gauge), IV catheters in the upper extremities (peripheral IV access)

Percutaneous and cutdown catheters in the lower leg saphenous; central access into femoral, jugular, subclavian veins
For a femoral vein catheter, how can the anatomy of the right groin be remembered?
Lateral to medial: NAVEL
Nerve
Artery
Vein
Extralymphatic material
Lymphatics
(Thus, the vein is medial to the femoral artery pulse - or think "venous close to penis")
What is the trauma resuscitation fluid of choice?
Lactated Ringer's (LR) solution - isotonic, and the lactate helps buffer the hypovolemia-induced metabolic acidosis
What types of decompression do trauma patients receive?
Gastric decompression with an NG tube and Foley catheter bladder decompression after normal rectal exam
What are the contraindications to placement of a Foley?
Signs of urethral injury - severe pelvic fracture in men, blood at the urethral meatus (penile opening), High-riding ballotable prostate (loss of urethral tethering), scrotal/perineal injury/ecchymosis
What test should be obtained prior to placing a Foley catheter if urethral injury is feared?
A retrograde urethrogram (RUQ; dye in penis retrograde to the bladder and X-ray looking for extravasation of dye)
How is gastric decompression achieved with a maxillofacial fracture?
NOT with an NG tube bc the tube may perforate through the cribriform plate into the brain; place an oral-gastric tube (OGT), not an NG tube
Disability...
a. What are the goals in assessing it?
b. What comprises adequate assessment?
a. Determination of neurologic injury (think: neurologic disability)
b. Mental status - Glasgow Coma Scale (GCS); Pupils - a blown pupil suggests ipsilateral brain mass (blood) as herniation of the brain compresses CN III); Motor/sensory - screening exam for lateralizing extremity movement, sensory deficits
Describe the GCS scoring system:
a. Eye opening
b. Motor response
c. Verbal response
a. 4 - opens spontaneously; 3 - opens to voice command; 2 - opens to painful stimulus; 1 - does not open eyes
b. 6 - obeys commands; 5 - localizes painful stimulus; 4 - withdraws from pain; 3 - decorticate posture; 2 - decerebrate posture; 1 - no movement
c. 5 - appropriate and oriented; 4 - confused; 3 - inappropriate words; 2 - incomprehensible sounds; 1 - no sounds
What is the GCS score for a dead man?

What is the GCS score for a patient in a coma?
3

greater than or equal to 8
How does GCS scoring differ if the patient is intubated?
The verbal evaluation is omitted and replaced with a "T"
Thus, the highest score for an intubation patient is 11 T
Exposure and Environment...
a. What are the goals in obtaining adequate exposure?
b. What is the "environment" of the E?
a. Complete disrobing to allow a thorough visual inspection and digital palpation of the pt during the secondary survey
b. Keep a warm environment (keep pt warm; a cold pt can become coagulopathic)
a. What principle is followed in completing the secondary survey?
b. Why look in the ears?
c. Exam of what part of the trauma patient's body is often forgotten?
a. Complete PE, including all orifices: ears, nose, mouth, vagina, rectum
b. Hemotympanum is a sign of basilar skull fracture; otorrhea is a sign of basilar skull fracture
c. The pt's back! Logroll the pt and examine!
a. What are typical signs of basilar skull fracture?
b. What Dx int eh anterior chamber must not be missed on the eye exam?
a. Racoon eyes, Battle's sign, clear otorrhea or rhinorrhea, hemotympanum
b. Traumatic hyphema = blood in the anterior chamber of the eye
What potentially destructive lesion must not be missed on the nasal exam?

What is the best indication of a mandibular fracture?
Nasal septal hematoma; the hematoma must be evacuated; if not, it can result in pressure necrosis of the septum

Dental malocclusion; tell the patient to "bite down" and ask: "Does that feel normal to you?"
What signs of thoracid trauma are often found on the neck exam?
Crepitus or subQ emphysema from tracheobronchial disruption / PTX; trachael deviation from tension pneumo; JVD from cardiac tamponade; carotid bruit heard with seatbelt neck injury resulting in carotid artery injury
What is the best PE for broken ribs or sternum?

What physical signs are diagnostic for thoracic great vessel injury?
Lateral and anterior-posterior compression of the thorax to elicit pain/instability

None; Dx of great vessel injury requires a high index of suspicion based on the mechanism of injury, associated injuries, and CXR/radiographic findings (e.g., widened mediastinum)
What must be considered in every penetrating injury of the thorax at or below the level of the nipple?

What is the significance of subQ air?
Concomitant injury to the abdomen; remember, the diaphragm extends to the level of the nipples int he male on full expiration

Indicates pneumothorax, until proven otherwise
What is the proper technique for examining the thoracic and lumbar spine?
Logrolling the pt to allow complete visualization of the back and palpation of the spine to elicit pain over fractures, step off (spine deformity)
What conditions must exist to pronounce an abdominal physical exam negative?
Alert pt without any evidence of head/spinal cord injury or drug/ETOH intoxication (even then, the abd exam is not 100% accurate)
a. Tenderness; guarding, peritoneal signs; progressive distention (always use a gastric tube for decompression of air); seatbelt sign
b. Ecchymosis on lower abdomen from seatbelt (approx 10% of pts with this sign have a small bowel perforation)
a. intra-abdominal injury
b. seatbelt sign
What must be documented from the rectal exam?
Sphincter tone (indication of spinal cord injury)
presence of blood (colon or rectal injury)
prostate position (urethral injury)
What is the best PE technique to test for pelvic fractures?
Lateral compression of the iliac crests and greater trochanters and anterior-posterior compression of the symphysis pubis to elicit pain/instability
Cerebrospinal fluid from nose/ear will form a clear "halo" around the blood on a cloth
halo sign
What physical signs indicate possible urethral injury, thus contraindicating placement of a Foley cath?
High-riding ballotable prostate on rectal exam**
presence of blood at meatus
scrotal or perineal ecchymosis
What must be documented from the extremity exam?
Any Fx's or joint injuries; any open wounds; motor and sensory exam, particularly distal to any fractures; distal pulses; peripheral perfusion
What complication after prolonged ischemia to the lower extremity must be treated immediately?

What is the Tx?
Compartment syndrome

Fasciotomy (four-compartment below the knee)
What injuries must be suspected in a trauma pt with a progressive decline in mental status?
Epidural hematoma, subdural hematoma, brain swelling with rising intracranial pressure

But hypoxia/hypotension must be ruled out!!**
What are the classic blunt trauma ER x-rays?

Will the hematocrit be low after an acute massive hemorrhage?
AP chest film; AP pelvis film

No (no time to equilibrate)
What pts can have their C-spines cleared by a PE?

How do you rule out a C-spine bony fracture?
No neck pain on palpation with FROM with no neurologic injury (GCS 15), no ETOH/drugs, no distracting injury, no pain meds

With a CT scan of the C-spine
What do you do if no bony C-spine fracture is apparent on CT scan and you can't obtain an MRI in a COMATOSE patient?

Which X-rays are used for evaluation of cervical spine ligamentous injury?
Controversial; easiest answer is to leave the cervical collar on

MRI, lateral flexion and extension
C-spine films
Chest film shows...
Widened mediastinum (MC finding);
apical pleural capping; loss of aortic contour/KNOB/AP window; depression of left mainstem bronchus; NG tube/tracheal deviation; pleural fluid; elevation of right mainstem bronchus; clinical suspicion; high-speed mechanism
thoracic aortic injury
a. What study is used to rule out thoracic aortic injury?
b. What is the MC site of thoracic aortic traumatic tear?
a. spiral CT of mediastinum looking for mediastinal hematoma with CTA; thoracic arch aortogram (gold standard)
b. just distal to the take off of the left subclavian artery
a. What is a FAST exam? What does it look for?
b. What is DPL?
c. Which is the test of choice for eval of the unstable pt with blunt abdominal trauma?
d. What is the indication for DPL or FAST in blunt trauma?
a. Focused Assessment with Sonography for Trauma (ultrasound); blood in peritoneal cavity looking at Morison's pouch, bladder, spleen, and pericardial sac
b. Diagnostic peritoneal lavage
c. FAST
d. unstable vital signs (hypotension)
a. How is a DPL performed?
b. What is a "grossly positive" DPL?
c. Where should the DPL catheter be placed in a pt with a pelvic fx?
a. Place catheter below umbilicus into peritoneal cavity; aspirate for blood and if less than 10 cc, infuse 1 L of saline or LR; drain the fluid (by gravity) and analyze
b. 10 + cc blood aspirated
c. above the umbilicus; a common error - if you go below, you may get into a pelvic hematoma and obtain a false-positive DPL
a. What constitutes a positive peritoneal tap?
b. What are the indicators of a positive peritoneal lavage in blunt trauma?
c. What must be in place before a DPL is performed?
a. Prior to starting peritoneal lavage, the DPL cath should be aspirated. If more than 10 mL of blood or enteric contents, this is a positive tap and requires laparotmy
b. Classic: inability to read newsprint through lavaged fluid; RBC > 100,000/mm; WBC > 500 mm cubed; lavage fluid (LR/NS) drained from chest tube, foley, NG tube
c. NG tube and Foley catheter (to remove the stomach and bladder from the firing line)
a. What injuries does CT miss?
b. What injuries does DPL miss?
c. What study is used to evaluate the urethra in cases of possible disruption due to blunt trauma?
a. Small bowel injuries and diaphragm injuries
b. Retroperitoneal injuries
c. Retrograde urethrogram (RUG)
What are the most emergent ortho injuries?
Hip dislocation
Exsanguinating pelvic fracture
What findings would require a celiotomy in a blunt trauma victim?
Peritoneal signs, free air on CXR/CT, unstable pt with positive FAST exam or positive DPL results
What is the Tx of a gunshot wound to the belly?

What is the eval of a stab wound to the belly?
Exploratory laparotomy

If there are peritoneal signs, heavy bleeding, shock, unstable vital signs, perform exploratory laparotomy. Otherwise, observe the asymptomatic stab wound pt closely, use local wound exploration to rule out fascial penetration, or use DPL.
What depth of neck injury must be further evaluated?
Penetrating injury through the platysma - do so by surgical or selective exploration (angiogram, CT angiogram, bronchoscopy, esophagoscopy, etc)
Define the anatomy of the neck by trauma zones:
a. Zone III
b. Zone II
c. Zone I
a. angle of mandible and up
b. angle of mandible to the cricoid cartilage
c. Below the cricoid cartilage
What are the indications for surgical exploration in all penetrating neck wounds (no matter the zone)?
"Hard signs" of significant neck damage: shock, exsanguinating hemorrhage, expanding hematoma, pulsatile hematoma, neurologic injury, SubQ emphysema
What is the "3-for-1" rule in trauma?
The trauma pt in hypovolemic shock requires 3 L of crystalloid (LR) for every 1 L of blood loss
What is the minimal urine output for an adult trauma patient?
50 mL/hr
How much blood can be lost into the thigh with a closed femur fracture?
Up to 1.5 L
Can an adult lose enough blood in the skull from a head injury to cause hypovolemic shock?

Can a patient by hypotensive after an isolated head injury?
No - but infants can, because the skull isn't "closed"

Yes, but rule out hemorrhagic shock
What is the brief ATLS history?
an "AMPLE" history
Allergies
Medications
PMH
Last meal (when)
Events (of injury)
In what population is a surgical cricothyroidotomy not recommended?

What are the signs of a laryngeal fx?
Any pt under 12; instead, do needle cric

SubQ emphysema in neck, altered voice, palpable laryngeal fracture
What is the Tx of a rectal penetrating injury?
Diverting proximal colostomy; closure of perforation (if easy and definitely if intraperitoneal); and presacral drainage
What intra-abd injury is associated with seatbelt use?
Small bowel injuries (L2 fracture, pancreatic injury)
What is the Tx of a pelvic fracture?
+/- Pelvic binder until the external fixator is placed
IV fluids/blood
+/- Angiogram to embolize bleeding pelvic vessels
Is bleeding from pelvic Fx's most commonly caused by arterial or venous bleeding?
Venous
What is the Tx of extensive irreparable biliary, duodenal, and pancreatic head injury?

What is the MC intra-abd organ injured with penetrating trauma? With blunt trauma?
trauma Whipple procedure

Small bowel; liver
How high up do the diaphragms go?
To the nipples - intercostal space 4
thus, intra-abd injury with penetrating injury below the nipples must be ruled out
If you have only one vial of blood from a trauma victim to send to the lab, what test should be ordered?
Type and cross (for blood transfusion)
What is the Tx of penetrating injury to the colon?
If pt is in shock - resection and colostomy
If pt is stable - primary anastomosis/repair
What is the Tx of minor pancreatic injury?

Tx for massive tail of pancreas injury?
Drainage (e.g., JP drains)

Distal pancreatectomy (usually perform splenectomy as well)
What is the lethal triad?
"ACHe"
1. Acidosis
2. Coagulopathy
3. Hypothermia
You successfully place an NG tube into the stomach in a trauma patient. Subsequent CXR shows that the NGT is in the chest. What is the Dx?
Ruptured diaphragm with stomach in the pleural cavity
What lab tests are used to look for intra-abd injury in children?
Liver function tests (LFTs) - elevated AST and/or ALT
What is the only real indication for MAST pants?
Prehospitalization, pelvic fracture
What is the Tx for human and dog bites?
Leave wound open, irrigation, antibiotics