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Trauma - SArora-1 - Trauma Abdomen Trauma Extremities Spine...

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Unformatted text preview: Trauma: Abdomen, Trauma: Extremities, Spine Extremities, Shalini Arora, PGY 3 Shalini Basic Science January 5th, 2006 36 year old man, restrained driver in rollover motor vehicle crash. Blood pressure on arrival is 83/57 and HR 102. Hypotension unresponsive to resuscitation. Tender abdomen. Abdominal ultrasound obtained. abdomen. Next step? Next a. b. c. d. Exploratory laparotomy Diagnostic peritoneal lavage Abdominal CT scan Serial observation 28 y/o woman, unrestrained driver in a motor vehicle crash. Stable vital signs and LUQ tenderness, but no signs of peritonitis. Next step? Next a. Exploratory laparotomy b. Diagnostic peritoneal lavage c. Serial observation d. Abdominal CT scan e. Abdominal ultrasonography Abdomen Abdomen q q 25% of all trauma patients require ex lap. Physical exam can be unreliable Physical – AMS, compensated hemoperitoneum, retroperitoneal, AMS, pelvic injuries pelvic q Diagnostic tools: – – – – Diagnostic peritoneal lavage (DPL) Ultrasound CT Laparoscopy Diagnosis Diagnosis Test of choice dependent on hemodynamic Test stability and severity of associated injuries. stability q Stable blunt trauma → FAST or CT Stable q Unstable blunt trauma → FAST or DPL Unstable q Stab wounds without peritoneal signs, Stab evisceration, or hypotension → wound exploration or DPL. exploration q Gun shot wounds → surgical exploration. Gun q DPL DPL q Standard criteria – – – – – q 10cc gross blood RBC>100,000/mm2 (5% miss) WBC>500/mm2 Amylase>175 IU/dL Bile, bacteria, or food Contraindications – – – – Clear indication for ex lap Prior abdominal surgeries Pregnancy Obesity *NGT, foley DPL DPL q q q Highly sensitive to intraperitoneal blood, but low Highly specificity → nontherapeutic explorations. Supraumbilical if pelvic fracture present Significant injuries may be missed – – – – – Diaphragm Retroperitoneal hematomas Renal, pancreatic, duodenal Minor intestinal Extraperitoneal bladder injuries Extraperitoneal Focused Assessment with Sonography for Trauma (FAST) Sonography FAST FAST q Pros – Noninvasive – Fast – Low cost q Cons – – – – User dependent Obesity, gas interposition Misses retroperitoneal/hollow viscus injury May not detect free fluid <50-80 cc CT Scan CT Hemodynamically stable patient q Pros q – – – q Retroperitoneal assessment Nonoperative management of solid organ injury High specificity Cons – Hardware, cost, radiation – Hollow viscus injuries, diaphragm injury Laparoscopy Laparoscopy Role still being defined q Good for diaphragm injury evaluation q Cons q – Invasive – Expensive – Missed small bowel, splenic, retroperitoneal Missed injuries injuries Gastric Injury Gastric q q Mostly penetrating trauma. Mostly <1% from blunt trauma – Including iatrogenic injury from CPR q q q q q NGT + aspirate for blood Intraop evaluation includes complete visualization Intraop of posterior wall of Most penetrating wounds treated by debridement Most and primary closure in layers. and Evacuation of hematomas. Major tissue loss may necessitate resection. Gastric Injury Gastric q Post-op complications – Bleeding, abscesses, Bleeding, gastric fistula, empyema gastric q Recent meal → Recent neutralization of gastric acidity → increased lower GI tract bacteria (Bacteroides, E. coli, Bacteroides, Strep faecalis) → Strep increased infection increased Duodenal Injury Duodenal Majority due to penetrating trauma. q Blunt injury usually secondary to steering Blunt wheel blow to the epigastrium wheel q Retroperitoneal location is protective, but Retroperitoneal also prevents early diagnosis. also q Isolated injury to the duodenum is rare q Hyperamylasemia in 50% with blunt injury. q Duodenal Injury Duodenal q q q q q Gastrograffin UGI or Gastrograffin CT w/ contrast CT Extravasation of Extravasation contrast → OR If CT eqivocal –dilute If barium UGI barium May see retroMay peritoneal air on CT peritoneal DPL unreliable but DPL may be positive from an associated injury an You suspect a duodenal injury and get an UGI w/ following result. Which of the following are true? Which 1. 2. 2. 3. 4. 4. This patient needs a This laparotomy This patient may be This managed non operatively operatively This is the stacked This coin sign and indicates a duodenal rupture Usually resolves in 2 Usually weeks weeks Duodenal Hematoma Duodenal NGT until NGT peristalsis resumes. peristalsis q Slow introduction Slow of food. of q OR if obstruction OR persists > 10 –15 days. days. q Duodenal Injury Duodenal Appropriate repair depends Appropriate on injury severity and elapsed time elapsed q 80-85% can be primarily 80-85% repaired. q Duodenal decompression Duodenal advisable if injury >6 hours old. old. q The upper abdomen of a 42 y/o male strikes the steering wheel during a MVA. After a positive DPL, he undergoes an ex lap, at which time transection of the pancreas at the neck is found. Next step? the Next step? Next a. b. c. d. Distal pancreatectomy with oversewing Distal and drainage of proximal stump. and Primary repair and drainage of the Primary pancreatic duct. pancreatic Roux-en-Y pancreaticojejunostomy to the Roux-en-Y distal pancreas with oversewing and drainge of the proximal stump. drainge Total pancreatectomy Pancreatic Injury Pancreatic q q q q q q q Rare 10-12% of abdominal injuries, but mortality Rare 10-25%, mostly from associated intra-abd injury 10-25%, Most caused by penetrating trauma - 75% Most associated with major vascular injury associated Blunt trauma → compression of pancreas against Blunt vertebral column vertebral Retroperitoneal location delays diagnosis. Elevated amylase/lipase Role of CT improving Pancreatic duct injury key factor in morbidity. Pancreatic Injury Pancreatic GSW to Pancreatic Head GSW Pancreatic Injury Pancreatic q q q q Divided into proximal or distal according to Divided location on the R or L of SMV location Contusions (Grade I-II) should be drained. Distal duct injury (Grade III) → distal resection Distal with splenic preservation with Proximal injury (Grade IV) – Oversewing and distal resection or Oversewing pancreaticojejunostomy in diabetic patients. pancreaticojejunostomy q Extensive pancreatic head injuries (Grade V) – – 40% pancreatic fistula development Simple external wide drainage Complications after Pancreatic Trauma Trauma q q q q q q q High complication rate 35-40% Most common are pancreatic fistulas & abscesses Most fistulas close spontaneously if well drained Somatostatin to expedite healing Abscesses - surgical debridement & drainage Incidence of pancreatitis 8-18% Pseudocysts are infrequent Small Intestine Injury Small q q Most common organ Most injured after penetrating trauma trauma Blunt trauma – Crushing injury against Crushing vertebral bodies vertebral – Shearing at fixed points – Closed loop rupture q q Seat-belt sign should raise Seat-belt suspicion. suspicion. DPL/CT not reliable Small Intestine Injury Small Small Intestine Injury Small q q 13% w/ perforated small 13% bowel have a normal CT scan scan Suggestive findings Suggestive include free air, free fluid w/o solid organ injury, thickening of small bowel wall or mesentery mesentery Operative management Operative q q q q q q Bleeding initially Bleeding controlled/leakage clamped controlled/leakage Penetrating injuries by Penetrating firearms should be debrided. firearms Small tears closed primarily. Adjacent holes connected and Adjacent closed transversely. closed Extensive lacerations and Extensive devascularization require resection and reanasatomosis. resection Explore all mesenteric Explore hematomas hematomas Colon Injury Colon q q q q q q q Second most frequent injured organ, usually from Second penetrating trauma penetrating Repair within 2 hours dramatically reduces Repair infectious complications. infectious Pre-operative antibiotics important adjunct. PE blood per rectum, stab to flanks or back CT w/rectal contrast, XR- pneumoperitoneum WWI primary repair led to 60% mortality. WWII colostomy led to 35% mortality. Colon Injury Colon q Primary repair criteria – – – – – – q Early diagnosis (within 4-6 hours) Absence of prolonged shock/hypotension Absence of gross contamination Absence of associated colonic vascular injury Less than 6 units blood transfusion No requirement for use of mesh for closure Extensive wounds – Right colon → hemicolectomy +/- ileostomy Right – Left colon → resection + colostomy Left Rectal Injury Rectal q q q q q q Most from GSW Other causes - foreign body, impalement, pelvic Other fractures, and iatrogenic fractures, Lower abdomen/buttock penetrating injury should Lower raise suspicion. raise May be intra- or extraperitoneal Rectal exam may reveal blood or laceration Work-up includes anoscopy and rigid Work-up sigmoidoscopy. sigmoidoscopy. Rectal Injury Rectal q Extraperitoneal injury – Primary closure – Diverting colostomy – Washout of rectal Washout stump stump – Wide presacral Wide drainage drainage q Intraperitoneal injury – Primary closure – Diverting colostomy Liver Trauma Liver q q Frequently injured in both blunt & penetrating Frequently trauma. trauma. Control of profuse bleeding from deep lacerations Control a formidable challenge. formidable – Simple suture, mattress sutures, packing, debridement, Simple resection, mesh hepatorrhaphy resection, q Nonoperative treatment (blunt trauma) – Stable without peritoneal signs → U/S → CT Stable – Low-grade liver lesions (1-3, 95% success) – ICU monitoring Liver Trauma Liver Liver Trauma Liver In the event of continued bleeding a vascular clamp can be placed around porta hepatis Pringle Maneuver Pringle If bleeding continues… A. It is coming from the It portal vein or hepatic artery artery OR B. It is coming from the B. retrohepatic vena cava or hepatic veins cava Finger Fracture Hepatotomy Finger q q q q q Alternative approach for Alternative deep lacerations deep Extend laceration along Extend non anatomical plains to expose and directly ligate bleeding vessels bleeding Low mortality 10.7% Large defect in liver Large parenchyma parenchyma Should only be performed Should by experienced surgeons by Packing Packing q q q q q q Used when other techniques Used fail in controlling hemorrhage hemorrhage Use in patients that are Use hypothermic, acidotic, coagulopathic coagulopathic ICU for rewarming Re-explore 48-72 hours Intra-abd abscesses <15% Arteriography/embolization Arteriography/embolization useful adjunct Of the following hemodynamically stable patients, who is most likely to fail non-operative management. most A. B. C. D. E. 8 y/o girl s/p left lateral abdominal blow playing soccer. CT y/o with 3cm laceration with blood around spleen and liver. with 22 y/o male restrained low speed MVA with left lower rib 22 fractures. CT with 3cm laceration with blood around spleen and liver. and 15 y/o boy tackled playing football. CT with 3 splenic 15 lacerations, blood around spleen, liver, and in pelvis. lacerations, 21 y/o intoxicated restrained high speed MVA. CT with deep 21 splenic laceration, upper pole contusion, and perisplenic blood. blood. 25 y/o male pinned under car when it feel from its lumberjack 25 and landed on his upper chest. CT with deep splenic laceration, blush of intravenous contrast by laceration, and perisplenic blood. perisplenic Splenic Injury Splenic Most frequently injured intra-abdominal Most organ in blunt trauma. organ q Splenic preservation when possible q q q OPSI (0.6% in children, 0.3% in adults) More than 70% can be treated nonoperatively Splenic Injury Splenic q Nonoperative criteria – Hemodynamic stability – Negative abdominal examination – Absence of contrast extravasation q Angiography/embolization an option – No other clear indications for ex lap – No coagulopathy – Low grade injuries (1-3) Splenic Injury Splenic Splenic Injury Splenic Splenic Injury Splenic 30 year-old man ejected from automobile after head-on collision at high speed. Sustained pelvic fracture. Grossly positive supra-umbilical DPL. On exploration, a pelvic hematoma and an expanding central hematoma are noted. Next step? are a. Observation of both hematomas. b. Exploration of both hematomas. c. Exploration of central hematoma after obtaining Exploration proximal and distal vascular control; observation of the pelvic hematoma. pelvic d. Observation of central hematoma, and exploration of the Observation pelvic hematoma after application of external fixators. pelvic Retroperitoneal hematoma Retroperitoneal q Zone 1 – Explore regardless of Explore mechanism. mechanism. q Zone 2 – Explore penetrating Explore trauma. trauma. – Observe blunt trauma Observe (nonexpanding, nonpulsatile, no urologic indications) q Zone 3 – Explore penetrating. – Observe blunt. Damage Control Damage Abbreviated laparotomy and temporary Abbreviated packing packing q Effort to blunt physiologic response to Effort shock and hemorrhage shock q – Severe metabolic acidosis, coagulopathy, and Severe hypothermia hypothermia ICU resuscitation q Return to OR in 48-72 hours q Damage Control Damage 30 y/o woman sustained crushing injury to right lower leg. Arrived at hospital 12 hours later. PE reveals tense calf and closed tibia-fibula fracture. Unable to dorsiflex foot, absent pedal pulses. Next step? pulses. a. b. c. d. e. Angiography Below knee amputation Four compartment fasciotomy Surgical exploration of popliteal artery Internal fixation of tibial fracture Compartment Syndrome Compartment Common in forearm and lower leg Common secondary to defined fascial boundaries. secondary q Four Ps: pressure, pain, paresthesia, and Four intact pulses intact q Compartment pressure measurement q – Critical pressure? (20-30mm Hg) – MAP - compartment pressure < 40mm Hg Compartment Syndrome Compartment Fasciotomy Fasciotomy Extremity Injuries Extremity With regard to cervical spine injury, which of the following is/are true? the a. Jefferson fractures (C1) are usually caused Jefferson by axial load and involve blowout of the ring. ring. b. Hangman’s fractures are unstable and are Hangman’s best treated by operative spinal fusion. best c. Type II odontoid fractures are considered Type stable. stable. Spine Trauma Spine q C1 burst fractures (Jefferson’s) – Axial loading force – Considered stable – Treat with rigid cervical collar q Hangman’s fracture – – – – Extension and distraction force Posterior C2 elements Unstable fracture Traction → halo vest Traction Odontoid Fractures Odontoid q Type I Type – – – q Type II – – – – q Above base Above base Stable Cervical collar or halo jacket At base Usually unstable <5mm displacement → halo jacket <5mm >5mm displacement → surgical tx >5mm Type III – Extension into vertebral body – Halo jacket – >5mm displacement → surgical tx >5mm Spine Trauma Spine q q Strict immobilization during Strict ABCDEs ABCDEs Neurogenic shock – High spine injuries – Loss of sympathetic tone – Hypotension, bradycardia, and good Hypotension, peripheral perfusion peripheral q Cervical spine films – Must visualize all 7 vertebrae including Must articulation with T1 articulation – Lateral, AP, open-mouth odontoid Spinal Cord Injury Spinal q q q q Preservation of remaining Preservation function function Optimize perfusion and prevent Optimize ischemic secondary injury ischemic High-dose corticosteroids for High-dose first 24 hours first Surgical therapy – Restoration of anatomy, removal of Restoration foreign bodies, and removal of bone, disc, hematoma bone, q Traction devices Motor Function of spinal roots Nerve Root Upper Extremity Muscle Motor Examination C5 Shoulder abduction C6 Biceps Elbow flexion C7 Triceps Elbow extension C8 Flexor carpi ulnaris Wrist flexion T1 Lumbricales Finger abduction L2 Iliopsoas Hip flexion L3 Quadriceps Knee extension L4 Lower Extremity Deltoid Tibialis anterior Ankle dorsiflexion Extensor hallucis longus Great toe extension Gastrocnemius Ankle plantarflexion L5-S1 S1 Score Functional Ability 0 No contraction of muscle 1 Palpable muscle contraction, no limb movement 2 Able to move in gravity-neutral plane 3 Able to move against gravity 4 Diminished strength 5 Normal strength ...
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