1
Q
What is an AMPLE history?
A
- allergies
- medications
- PMH
- last PO
- events leading to injury
2
Q
What are the indications for thoracotomy after chest tube placement?
A
- immediate return of 1500cc of blood
- more than 200cc of blood/hr over 4 hours
3
Q
What are the hard and soft signs of vascular injury?
A
- hard: pulsatile bleeding, expanding hematoma, loss of distal pulse, vascular thrill or bruit
- soft: non-expanding hematoma, history of significant blood loss, proximity to neuromuscular bundle, ABI < 0.9
4
Q
A unilateral fixed pupils suggests what?
A
an ipsilateral space occupying lesion
5
Q
What are considered signs of life?
A
- pupillary response
- spontaneous ventilation
- electrical cardiac activity
- extremity movement
- measurable BP or presence of a pulse
6
Q
How would you correct for abnormal TEG values?
A
- R time: FFP
- K time: cryo
- A angle: cryo
- MA: platelets
- LY30: TXA
7
Q
What are the indications for damage control trauma surgery?
A
- acidosis
- coagulopathy
- hypothermia
- large volume resuscitation
- anticipate further resuscitation with risk of compartment syndrome
- additional injuries requiring immediate repair (ICH)
8
Q
Which intra-cranial hemorrhages typically require decompression?
A
- EDH > 15mm or with >5mm of shift
- SDH > 10mm or with > 5mm of shift
9
Q
What is Cushing’s reflex?
A
bradycardia and hypertension suggestive of impending herniation
10
Q
What is the standard goal for ICP and CPP?
A
- ICP less than 20
- CPP greater than 60
11
Q
What is the main regulator of CPP?
A
PaCO2, although TBI disrupts this autoregulation
12
Q
How would you reverse warfarin?
A
- KCentra
- FFP
- vitamin K
13
Q
How would you reverse Xarelto?
A
- AndexXa (andexanet alpha) is main reversal agent
- Kcentra provides partial reversal
14
Q
How would you reverse Eliquis?
A
- AndexXa (andexanet alpha) is main reversal agent
- Kcentra provides partial reversal
15
Q
How would you reverse lovenox?
A
protamine
16
Q
How would you reverse Dabigatran?
A
- prdxbind (idarucizumab)
- dialysis
17
Q
Why do we use SQH in those with ESRD?
A
because lovenox does not dialyze as well as heparin
18
Q
Rather than zones of the neck, how do we approach penetrating injuries to the neck?
A
- look for violation of the platysma
- then consider soft and hard signs of injury to determine if CTA or immediate operative exploration is indicated
19
Q
What are soft signs of injury with penetration of the platysma?
A
- mild hemoptysis
- mild hematemesis
- non-expanding hematoma
- dysphagia
- dysphonia
- pneumomediastinum
20
Q
What are hard signs of injury in the neck that would prompt immediate operative exploration?
A
- massive hemoptysis
- massive hematemesis
- expanding hematoma
- respiratory distress
- air bubbling from the wound
21
Q
What has to be ligated to access the internal carotid artery?
A
the facial vein
22
Q
What is the best surgical exposure for zone 1 injuries to the neck?
A
sternotomy
23
Q
What is a reasonable approach to heparinization of a patient during non-cardiac vascular operations?
A
- initial bolus of 70-100 U/kg
- ACT goal > 200-250
24
Q
What type and size of suture would you use to repair a cardiac injury?
A
pledgeted 3-0 proline on a tapered needle in a horizontal mattress fashion
25
What is the most common location for a blunt aortic injury?
ligamentum arteriosum
26
What are the goals of impulse control in those with blunt aortic injury?
SBP < 120
HR < 70
27
What are the three zones of the retroperitonum?
I: between the renal hilum, down to the aortic bifurcation
II: outside the renal hilums
III: inferior to the aortic bifurcation
28
How should you manage the three zones of the retroperitoneum?
- explore all if there is expansion regardless of mechanism
- explore all if they were secondary to penetrating mechanism
- explore all zone 1 if they were secondary to blunt
29
How would you manage a traumatic duodenal hematoma?
- gastric decompression for 5-7 days with or without parenteral nutrition and then an UGI prior to initiating PO
- reserve surgical management for those that don't resolve by 21 days
- generally perform hematoma evacuation and close seromuscular layer over a T-tube
30
Which full thickness duodenal injuries require reconstruction rather than primary repair?
a full thickness injury to > 50% of the circumference, the same as for small bowel and colonic injuries
31
How would you manage an extra-peritoneal rectal injury?
diversion with primary repair if able to reach it trans-anally
32
How would you manage a mid- or distal ureteral injury?
- mid: generally can primarily repair by spatulating the ends and closing them over a double J stent
- distal: can generally reimplant +/- a poses hitch
33
What suture would you use to repair a bladder injury?
two layer PDS repair
34
What is the preferred diagnostic test for a urethral injury?
retrograde urethrogram
35
What is diagnostic of compartment syndrome in the extremity?
a pressure within 30mmHg of the diastolic blood pressure
36
What cardiac problem is often triggered by direct laryngoscopy in pediatric patients? What is the treatment?
bradycardia treated with atropine
37
How would you size an ETT for a peds patient?
- size of patient's pink nail
- age/4 + 4
38
Describe the cardiopulmonary and hematologic changes that occur during pregnancy.
- increased circulating volume and physiologic anemia
- leukocytosis, thrombocytosis, increased fibrinogen
- increased TV
- decreased functional residual capacity
- respiratory alkalosis
39
Which trauma patients should be considered for Rhogam?
those who are Rh- with an Rh+ fetus
40
What are the contraindications for succinylcholine?
- hyperkalemia
- burn
- crush injuries
- muscular dystrophy
41
What is the gateway structure for the great vessels during median sternotomy?
the left innominate vein
42
How much energy is used for internal cardiac defibrillation?
50J
43
What are the WEST guidelines for resuscitative thoracotomy?
indicated when up to 15 minutes of CPR has been performed for penetrating thoracic injuries or 10 minutes of CPR for blunt injuries
44
What are the advantages of an anterolateral thoracotomy in trauma?
- allows exposure to the pericardium and a large percentage of the heart and left lung
- allows for easy extension to a clamshell
- allows for abdominal access without repositioning
45
What are the advantages of a posterolateral thoracotomy in trauma?
- better access to the aorta
- better access to the posterior lung and hilar vessels
- better access to the esophagus
46
Most superficial lung injuries can be managed in what fashion?
non-anatomic resection
47
Where can you get proximal control of the pulmonary hilar vessels?
within the pericardium
48
When would you use a horizontal mattress suture when repair a cardiac injury?
when you are adjacent to a main coronary vessel and don't want to include it in the repair
49
What incision should be used to access the ascending or transverse aortic arch?
a median sternotomy
50
What incision can be used to expose the subclavian arteries?
a median sternotomy with supraclavicular extension or a high (3rd IC) anterolateral thoracotomy
51
What incision can be used to access the common carotid?
a median sternotomy with cervical extension
52
What structure should you be aware of when dissecting ou the right subclavian artery origin?
the recurrent laryngeal nerve
53
Describe the key steps in a trauma neck exploration.
- incision along the anterior border of the SCM, retracting it laterally
- open the carotid sheath and divide the facial and middle thyroid veins to expose the artery
- inspect and repair the carotid if needed
- inspect and repair the IJ if needed
- mobilize the esophagus, protecting the RLN, and encircle it with a Penrose to allow for manipulation
- palpate and visualize the larynx and trachea, dividing the strap muscles and thyroid gland if needed
- perform esophagoscope and bronchoscopy as indicated
54
If having difficulty controlling hemorrhage from zones I and III in the neck, what are your options?
- zone I: extend incision via median sternotomy or convert to endovascular management
- zone III: resect or disarticulate the mandible or convert to endovascular management
55
Describe abdominal packing for blunt trauma.
pack in all four quadrants taking care to pack above and below the liver, around the spleen, in the pelvis, and in the paracolic gutters
56
In the case of a patient who goes straight to the OR after trauma, what should be completed after initial stabilization?
get post-op scans to look for brain, spine, and other bony injuries
57
When removing packs after liver trauma, what should you be sure to look for?
bile staining on packs, if present leave a drain
58
What threshold is acceptable for permissive hypotension in the trauma setting?
MAP > 50 or SBP > 70 has been shown to have decreased mortality and reduced transfusion volumes
59
How should you manage a diaphragm injury during damage control laparotomy for trauma?
- irrigate through the defect
- place a chest tube
- close the defect with permanent suture
60
What are signs of compartment syndrome?
- increased airway pressures
- shock/reduced preload
- diminished urine otuput
61
What are the definition of intra-abdominal hypertension and abdominal compartment syndrome?
- IAH = bladder pressure > 12mmHg
- ACS = IAH and signs of organ dysfunction
62
What would be a concerning bladder pressure?
- IAH is defined as pressure > 12mmHg
- pressures > 20mmHg become worrisome
63
Describe how to create a Barker vac for temporary abdominal closure.
- perforate a plastic sheet (1010 drape or bowel bag)
- encase the bowel
- cover with OR towels and lay two JP drains in the towel with exits through the superior aspect of the wound to aid in creating a seal
- cover everything with an Ioban
64
What is a potential downside to using OR towel in a Barker vac? What's an alternative?
- potentially hides ischemic bowel from visualization
- can omit the towels and just sandwich drains between a 1010 drape and the Ioban
65
If someone's belly can't be closed and you are forced to do an inlay mesh repair with skin graft, when should you perform a definitive repair?
at least 9-12 months later when the patient is recovered and the skin graft lifts off the underlying bowel
66
Is it okay to start tube feeds in a patient with an open abdomen?
yes, the data encourages it
67
What is the danger of fully mobilizing the liver during trauma laparotomy?
potentially releases any tapenade on the IVC and hepatic veins
68
How is the liver mobilized?
- divide the falciform between clamps and carry this division up the IVC
- divide the left and right triangular ligaments
69
How should you divide liver parenchyma during damage control operations?
vascular staple load is a reasonable answer
70
How do you balloon tamponade a tract through the liver?
insert a RRC in a Penrose drain and tie off both ends of the drain before filling it with fluid via the RRC
71
Describe methods for controlling a liver injury.
- electrocautery
- topical hemostatic agents
- bimanual compression
- packing
- Pringle maneuver
- total hepatic isolation with or without extension into the chest
- VV ECMO
- Schrock shunt
72
What instrument is used to perform a Pringle maneuver?
a Rummel tourniquet
73
How do you perform total hepatic vascular isolation.
- Kocherize the duodenum to expose the infra-hepatic IVC
- control the infra-hepatic supra-renal IVC
- apply a Pringle maneuver
- clamp the supra-hepatic IVC
- may need to divide the diaphragm and enter the pericardium to clamp the supra-hepatic IVC
- alternatively can perform a sternotomy and do it through the chest
74
Describe how you would perform a Shrock atrial-caval shunt.
- sternotomy and pericardotomy
- create additional holes on a chest tube and clamp the end
- insert the tube through the right atrium until the tip is below the IVC injury
- purse string in the chest tube, leaving the end external and clamped
- supra hepatic and supra renal IVC are then controlled with a Rummel tourniquet that occludes the IVC against the tube
75
How is hemobilia managed?
with IR angiography and embolization of the feeding arterial branch
76
What options are available for managing a traumatic duodenal injury?
- primary repair in transverse fashion
- side to side duodenojejunostomy
- graham patch
- pyloric exclusion with some combination of G-tube or gastrojejunostomy, J-tube, retrograde duodenostomy
77
How would you perform a duodenal exclusion?
- would not staple given the risk of stapling the antrum
- instead, perform a longitudinal gastrotomy
- pull the pylorus into the gastrotomy with a babcock
- sew it shut in running or purse string fashion with PDS
78
How are pancreatic injuries graded?
- I: minor contusion or laceration without duct involvement
- II: major contusion or laceration without duct involvement
- III: distal PD involvement
- IV: proximal PD involvement
- V: devastating head injury
79
If you're concerned for significant intra-abdominal and pelvic bleeding, what incision should you make?
need to make a separate supra-pubic incision for pre-peritoneal packing and a supra-umbilical laparotomy incision for abdominal exploration
80
What does a left median visceral rotation access that a right median visceral rotation does not?
the supramesocolic aorta mainly
81
ABSCE
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