Pestana's Surgery Notes - Trauma

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Trauma
trauma
3 situations when an airway is needed
1. pt is unconscious
2. pt's breathing is noisy or gurgly
3. sever inhalation injury
airway or c-spine injury dealt with first?
airway
when is the use of a fiberoptic bronchoscope mandatory?
when securing an airway if there is subcutaneous emphysema in the neck
clinical signs of shock
low BP (<90), fast feeble pulse, low urinary output (under 0.5 mg/kg/hr), cold pale, shivering, sweating, thirsty
3 causes of shock in the trauma setting
1. bleeding
2. pericardial tamponade
3. tension pneumonothorax
what is the CVP in shock caused by 1.bleeding 2.tamponade 3. tension pneumo
1. low
2. high
3. high
First steps in tx of hemorrhagic shock
1. volume replacement - 2L of LR via 2 peripheral 16 gauge IV lines
2. blood
- do until urinary output reaches 0.5-2 ml/kh/hr while not exceeding CVP of 15 mm Hg
what do if cannot get peripheral IV line?
1. percutaneous femoral vein cather
2. sapenous vein cut downs
3. intraosseous cannulation (children)
How to diagnosis pericaridal tamponade? tx?
- clinical diagnosis
- evacuation of pericardial sac
tx of tension pneumothorax
1. big needle or big IV catheter
2. chest tube connected to underwater seal
tx of vasomotor/anyphylactic shock?
epinephrine (vasopressor)
When are linear skull fractures treated or left alone?
closed = left alone
open = require wound closure
Unconscious + head trauma --> ___
CT SCAN
- if negative an neurologically intact, they can go home if the family will wake them frequently during the next 24 hours to make sure they are not going into coma
signs of fracture affecting the base of skull
racoon eyes, rhinorrhea, otorrhea, ecchymosis behind the ear
3 components of neurologic damage from trauma
1. initial blow - no tx
2. subsequent development of a hematoma - relieved with surgery
3. increased ICP - medical mdasures
Tx of acute subdural hematoma
ICP monitoring, elevate head, hyperventilate, avoid fluid overload, mannitol or furosemide
- goal PCO2 = 35
Neck trauma
1. upper zone
2. middle zone
3. base of neck
1. arteriographic diagnosis and management
2. surgical exploration regardless of symptoms
3. arteriography, esophagogram, esophagoscopy, bronchoscopy before surgery to help decide specific surgical apporach
What is the best way to assess status of cervical spine?
CT scan
Brown sequard
paralysis and loss of proprioception distal to the injury and ipsilateral
- loss of pain distal to the injury and contralateral
Anterior cord syndrome
- seen in burst fracutres of the vertebral bodies
- loss of motor function and pain/temp on both sides distal to the injury
- preservation of vibratory and position sense
central cord syndrome
- elderly, forced hyperextension of neck
- paralysis and burning pain in the upper extremities with preservation of most functions in the lower extremities
Management of spinal cord injuries
1. imaging
2. meds?
1. MRI
2. some use high dose corticosteroids
Rib fracture tx
- local nerve block and epidural catheter
When is surgery needed in hemothorax?
- recovering >1500 ml from chest tube
- collecting over 600 ml in tube draining over ensuing 6 hours
Sucking chest wound tx
occlusive dressing that allow air out (Taped on 3 sides)
Flail chest tx
- real problem = underlying pulmonary contusion
- fluid restriction, diuretics
- blood gases monitoring
pulmonary contusion
- deteriorating blood gases
- white out of lungs on chest x-ray
- can appear immediately or up to 48 hours later
traumatic rupture of diaphgram
- diagnosis?
- always on what side?
- tx?
- physical exam and x-ray (bowel in chest)
- left side
- evaluated with laparoscpy
Traumatic rupture of aorta
- mechanism of injury
- when should you be suspicious?
- diagnostic tests
- deceleration injury
- 1. mechanism of injury 2. presence of fracutres in chest bones that are very hard to break 3. wide mediastinum
- TEE, CT angiogram, MRA
subcutaneous emphysema in the chest and lower neck = what injury? how to identify lesion?
traumatic rupture of trachea, major bronchus, esophagus
- identify lesion with fiberoptic bronchoscopy (also allows intubation)
DDx of subcutaneous emphysema
rupture of esophagus, tension pneumo thorax
Fat embolism
multiple trauma, long bone fractures, petechial rashes, low platelet count, bilateral patchy infiltrates on chest x-ray
gunshot wounds to abdomen --> tx?
exploratory laparatory
when is exploratory laparatomy done in stab wounds to abdomen?
- if it is clear that penetration has occurred (protruding viscera)
- hemodynamic instability
- peritoneal irritation
Blunt trauma to abdomen -->
requires exploratory laparotomy if signs of peritoneal irritation develop
signs of shock occur with loss of how much blood volume?
1500 ml
3 places in body where 1500 ml of blood can hide?
1. abdomen
2. thighs
3. pelvis
what form of imaging used to most accurately diagnosis bleeding?
CT
most common source of signiciant intraabdominal bleeding in blunt trauma?
spleen - every effort is made to repair rather than remove it --> otherwise need vaccinations again SHiN
when are pelvic hematomas left alone?
if they are not expanding
what organ injuries have to be ruled out in pelvic injury?
rectum, bladder, vagina, urethra
Pelvic fracures with ongoing bleeding
- tx (3)
- blood replacement, external fixation, arteriographic embolization for arterial bleeding of iliac arteries
hallmark of urologic injuries =
blood in the urine in someone who has sustained penetrating or blunt abdominal trauma
urethral injury - a/w a ____ fracture and may present with _______. more complicated picture may include a _____ (3)
pelvic
blood at the meatus
scrotal hematoma, sensation of wanting to void but not being able to, high riding prostate on rectal exam

DO NOT INSERT FOLEY
dx of urethral injury?
retrograde urethrogram done INSTEAD OF FOLEY
bladder injury
- dx
retrograde cystogram - must include post void films to see extra peritoneal leaks at the base of the bladder that might be obscured by the bladder full of dye
renal injuries are usually a/w what kind of fracture? dx? tx?

what weird thing can develop after renal injury?
rib fracture
CT scan
managed without surgical intervention

AV fistula leading to heart failure
tx of fracture of the penis
emergency surgical repair
what determines treatment in penetrating injuries of the extremities?
whether a vascular injury has occurred or not
if penetration of extremity is near major vessels --> dx? tx?
doppler studies or CT angio
surgical exploration
combined injuries of arteries nerves and bone in extremities --> order of repair?
1. stabilize the bone
2. delicate vascular repair
3. leave nerve for last
concerns in crushing injuries
kyperkalemia, myoglobinemia, myoglubinuria, renal failure
chemical burns
- tx?
- which type of burns is worst?
- massive irrigation
- alkaline burns (liquid Plumr, Draino) are worse than acid burns (battery acid)
high voltage electircal burns -->
massive debridements or amputations may be required
respiratory burns
- Dx with fiberoptic bronchoscopy
- key issue is whether a respirator is needed or not --> use blood gases to make determination
- levels of carboxyhemoglobin have to be monitored --> give 100% O2
circumferential burns
can lead to cutoff of the blood supply as edema accumulates underneath the unyielding eschar --> escharotomies provide immediate relief
fluid needs in the first 48 hrs after burn
initial rate of infusion of 1 L an hour in the adult with extensive burns, and then adjust fluid on the basis of urine output
goal urinary output in burn patient?
1-2 ml/kg/hr and avoiding CVP over 15
topicals used in burn care
- standard topical agent =
- if deep penetration is required =
- burns near the eye =
- silver sulfadiazine
- mafenide acetate (do not use everywhere else, can produce acidosis)
- triple antibiotic oinment (silver sulfadiazine is irritating to eyes)
Dog bites
- provoked
- unprovoked
- provoked = when dog was eating, petted, or otherwise provoked --> do not need rabies vaccine, must observe dog for signs of rabies for 24 hours

unprovoked = from wild animals - can kill animal and examine brain for signs of rabies, otherwise rabies prophylaxis is mandatory
snakebites
- signs/symptoms
- studies?
- tx
- severe local pain, discoloration developing within 30 minutes
- type and corss, coaglaiton studies, lfts and renal function
- Antivenin, splint the extremity during transport
dosage of antivenin
related to size of envenomation not size of patient
Bee sting tx
- epinephrine
Black widow spider tx
calcium gluconate
Brown recluse spider tx
- dapsone is helpful
- may need surgical excision but should be delayed until the full extent of the damage is evident (1 week)
human bite tx
- require extenisev irrigation and debridement in the OR
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