Surgery Marrow Pg 417-426 (Trauma)
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Surgery Marrow Pg 417-426 (Trauma)

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What is the primary aim of Phase I in the Damage Control Surgery process?

  • Correct anatomy, close abdomen
  • Stop bleeding, prevent contamination (correct)
  • Resuscitate the patient
  • Identify patients for DCS

    • Early Total Care (ETC) allows for definitive management of injuries to be shifted to Damage Control Surgery (DCS) if the patient remains stable.

    False

    List two components of the Terrible Triad in Damage Control Surgery.

    Hypothermia, Acidosis, Coagulopathy

    What is a disadvantage of using active space in abdominal trauma assessment?

    <p>It may require repeating or additional imaging.</p> Signup and view all the answers

    A patient presenting with peritonitis may require an _________ for diverting stoma or colostomy.

    <p>emergency laparotomy</p> Signup and view all the answers

    Exploratory laparotomy is always needed if peritonitis is present.

    <p>True</p> Signup and view all the answers

    What should be done if a pseudoaneurysm or arterial blush is detected on a CT scan?

    <p>Interventional radiology evaluation</p> Signup and view all the answers

    Match the following phases of Damage Control Surgery with their descriptions:

    <p>Phase 0 = Stop bleeding, prevent contamination Phase I = Temporary abdominal closure Phase II = Correction of physiology in ICU Phase III = Correct anatomy, close abdomen</p> Signup and view all the answers

    If a person has a peritoneal breach, signs may include ____, rebound tenderness, and rigidity.

    <p>peritonitis</p> Signup and view all the answers

    Match the following symptoms with their meanings in the context of penetrating abdominal trauma assessment:

    <p>Rebound tenderness = Indicates irritation of the peritoneum Guarding = Muscle tensing in response to pain Omentum hanging out = Presence of tissue outside the abdominal cavity Bile staining = Suggests injury to the biliary tract</p> Signup and view all the answers

    What is the primary goal of the Pringle's maneuver during surgery?

    <p>To control bleeding</p> Signup and view all the answers

    If bleeding continues after performing the Pringle's maneuver, the source of bleeding is likely from the Portal vein.

    <p>False</p> Signup and view all the answers

    What are the contents that are compressed during the Pringle's maneuver?

    <p>Common bile duct, Portal vein, Hepatic artery</p> Signup and view all the answers

    The Pringle's maneuver typically involves compressing the hepatic pedicle for _____ minutes.

    <p>15-20</p> Signup and view all the answers

    What is the management for a transverse tear in the mesentery?

    <p>Resection and anastomosis</p> Signup and view all the answers

    Match the potential complications with their corresponding type:

    <p>Hemorrhage = Vascular Biliary = Biliary Sepsis = Mixed Complication Vascular = Vascular</p> Signup and view all the answers

    A duodenal hematoma is considered the most severe type of duodenal injury.

    <p>False</p> Signup and view all the answers

    What is the most important prognostic factor in pancreatic injury?

    <p>Injury to the main pancreatic duct</p> Signup and view all the answers

    In the case of a bile leak, the management involves ligating the ______ and repairing over a T-tube.

    <p>radicles</p> Signup and view all the answers

    Match the following pancreatic injuries with their management strategies:

    <p>Duodenal Perforation = Omental patch repair Injury to the main pancreatic duct = Conservative management Body and tail of pancreas injury = Distal Pancreatectomy Head and neck injury = Begger's procedure</p> Signup and view all the answers

    What imaging technique is used to monitor vascular injuries that may present with an arterial blush?

    <p>CECT (IOC)</p> Signup and view all the answers

    Active bleeding from a vascular injury does not show an increase in arterial blush in delayed imaging.

    <p>False</p> Signup and view all the answers

    What is the recommended management for a patient with Grade IV splenic injury who is unstable?

    <p>Laparotomy with splenectomy</p> Signup and view all the answers

    The complication of splenectomy characterized by amylase-rich secretions is called a __________.

    <p>pancreatic fistula</p> Signup and view all the answers

    Match the following complications of splenectomy with their descriptions:

    <p>Hemorrhage = Injury to pancreas, particularly the tail close to hilum Pancreatic fistula = Leakage of amylase-rich secretions Hematological changes = Transient increase in cell lines for 2 weeks Permanent hematological changes = Basophilic stippling, Reticulocytes, Howell-Jolly bodies, Hypersegmented WBC's</p> Signup and view all the answers

    Which of the following is a common cause of blunt thoracic trauma?

    <p>Tracheobronchial injury</p> Signup and view all the answers

    Tension pneumothorax is classified under life-threatening injuries during the initial survey.

    <p>True</p> Signup and view all the answers

    What is the primary investigation used to assess thoracic trauma?

    <p>Chest X-ray</p> Signup and view all the answers

    In cases of rib fractures, the most commonly fractured ribs during CPR are the ________ ribs.

    <p>3rd to 5th</p> Signup and view all the answers

    Match the following types of thoracic trauma with their associated injuries:

    <p>Blunt trauma = Tracheobronchial injury Penetrating trauma = Hemothorax Rib fractures = Apex of lung injury Flail chest = Brachial plexus injury</p> Signup and view all the answers

    What is the increase in Intra-abdominal Pressure (IAP) that signifies Intra-abdominal Hypertension (IAH)?

    <p>12 mmHg</p> Signup and view all the answers

    Abdominal Compartment Syndrome (ACS) occurs when the IAP is 15 mmHg or higher.

    <p>False</p> Signup and view all the answers

    What urinary procedure is used to measure intra-abdominal pressure?

    <p>Foley's catheter</p> Signup and view all the answers

    In order to assess renal function in abdominal trauma, there is a decrease in __________.

    <p>GFR</p> Signup and view all the answers

    Match the following effects of intra-abdominal pressure elevation with their corresponding functions:

    <p>↓ Venous return = Cardiovascular function ↓ Inspiratory volumes = Respiratory function ↓ GFR = Renal function ↑ Intracranial tension = Intracranial effects</p> Signup and view all the answers

    What is a positive result in a Diagnostic Peritoneal Lavage indicated by the presence of blood?

    <p>More than 10cc</p> Signup and view all the answers

    A positive Kehr sign is associated with splenic trauma.

    <p>True</p> Signup and view all the answers

    What is the minimum blood count of RBC per cubic millimeter that indicates a positive result in Diagnostic Peritoneal Lavage?

    <blockquote> <p>1 lakh</p> </blockquote> Signup and view all the answers

    Fracture of the _____ ribs on the left side is an indication of splenic trauma.

    <p>9–11th</p> Signup and view all the answers

    Match the grade of splenic trauma with its description:

    <p>Grade 1 = Subcapsular haematoma 3 cm depth. Grade 4 = Injury with splenic vascular injury or active bleeding. Grade 5 = Shattered spleen with &gt;25% devascularisation. Grade 2 = Laceration involving &lt; 5 cm depth.</p> Signup and view all the answers

    In blunt abdominal trauma, which organ is most likely to be injured?

    <p>Spleen</p> Signup and view all the answers

    The eFAST procedure only assesses the abdominal cavity for free fluid.

    <p>False</p> Signup and view all the answers

    Name one advantage of using FAST in trauma assessment.

    <p>Can be performed quickly</p> Signup and view all the answers

    In cases of penetrating trauma, the order of organ injuries is often liver > _________.

    <p>small intestine</p> Signup and view all the answers

    Match the imaging techniques with their primary usage:

    <p>FAST = Initial trauma assessment CECT = Further evaluation in unstable patients Ultrasound = Fluid collection detection X-Ray = Fracture or pneumothorax identification</p> Signup and view all the answers

    What is the primary focus of the FAST procedure?

    <p>Detecting free fluid</p> Signup and view all the answers

    Gunshot wounds primarily affect the small intestine before the liver.

    <p>True</p> Signup and view all the answers

    The site targeted in the left upper quadrant ultrasound is primarily around the ________.

    <p>spleen</p> Signup and view all the answers

    What is the most common encapsulated bacteria responsible for OPSI?

    <p>Pneumococcus</p> Signup and view all the answers

    OPSI is more frequently observed in adults than children.

    <p>False</p> Signup and view all the answers

    What is the time frame in which OPSI is commonly seen after splenectomy?

    <p>within the first 2 years</p> Signup and view all the answers

    The vaccination for Pneumococcal should be repeated every ___ years.

    <p>5</p> Signup and view all the answers

    Match the grades of liver trauma with their features:

    <p>Grade 1 = Hematoma: Subcapsular, &lt;10% surface area Grade 2 = Laceration: Capsular tear, 1-3 cm parenchymal depth Grade 3 = Vascular injury with active bleeding contained within liver parenchyma Grade 4 = Laceration: Parenchymal disruption involving 25-75% hepatic lobe Grade 5 = Laceration: Parenchymal disruption involving &gt; 75% of hepatic lobe</p> Signup and view all the answers

    Which of the following vaccinations needs to be administered yearly?

    <p>Influenza</p> Signup and view all the answers

    A laceration classified as Grade 3 involves active bleeding breaching the liver parenchyma into the peritoneum.

    <p>False</p> Signup and view all the answers

    What happens to the grade classification for liver trauma if multiple injuries are present?

    <p>Advance one grade up to grade 111</p> Signup and view all the answers

    Study Notes

    Abdominal Trauma Assessment

    • Active space: a tool used to detect free blood in the abdomen, but it has limitations. It cannot reliably detect free blood less than 100 ml, does not identify hollow viscous injuries, and is not accurate for retroperitoneal assessment.
    • Blunt abdominal trauma: Patients should be examined. If there is peritonitis or hemodynamic instability, an exploratory laparotomy is needed. If there is no peritonitis and no hemodynamic instability, an abdominal CT scan is performed.
    • Hollow organ injury: If present, proceed to exploratory laparotomy. If not, assess for solid organ injury.
    • Solid organ injury: If present, proceed to exploratory laparotomy or diagnostic laparoscopy. If not, manage other injuries.
    • Pseudoaneurysm or arterial blush: In CT scan, if present refer to interventional radiology for evaluation. If not, opt for non-operative management.
    • Penetrating abdominal trauma: Never remove sharp objects from the body.
    • Penetrating abdominal trauma -- superficial to peritoneum: Conduct a local examination. If a peritoneal breach is suspected, perform a midline laparotomy (no further imaging needed).
    • Colon & rectal injury: This can lead to peritonitis. Emergency laparotomy may require diverting stoma/colostomy or a Hartman procedure.
    • Early Total care (ETC): Definitive management of injuries within 36 hours. If the patient deteriorates, shift to damage control surgery (DCS).
    • Damage control surgery (DCS): Simultaneous resuscitation with early rapid life and limb-saving surgery. Definitive surgery is delayed until the patient stabilizes.
    • Terrible Triad: Hypothermia, acidosis, coagulopathy.
    • ETC: Stable haemodynamics, no hypoxaemia/hypercapnia, no acidosis, normal coagulation.
    • Phases of DCS (ACS guidelines): Phase 0: Resuscitate, phase I: Emergency laparotomy, phase II: Correction of physiology, phase III: Re-laparotomy.
    • Stage 1 Abdominal Compartment Syndrome: Can be caused by massive burns or bowel obstruction.
    • Abdominal trauma complications: Bleeding, bile leak, liver abscess, strictures in the common bile duct, AV malformations, vascular injury to the portal vein.
    • Mesenteric injury: Longitudinal tear: repair the tear. Transverse tear: resection and anastomosis.
    • Duodenal and pancreatic injury: Duodenal hematoma: keep the patient NPO (nothing by mouth) and on bowel rest. Pancreatic injury: Injury to the main pancreatic duct is the most significant prognostic factor. Duodenal perforation: features of peritonitis, X-ray shows gas under the diaphragm. Management: Omental patch repair.
    • Injury to the main pancreatic duct: If yes, proceed with conservative management: Body and tail of the pancreas: Distal pancreatectomy. Head and neck of the pancreas: Begger's procedure.
    • Pringle's maneuver: This procedure involves compressing the hepatic pedicle for 15-20 minutes, to control bleeding and locate its source.
    • Packing procedure: Cut right and left triangular ligaments, separate the liver from the diaphragm, place mops above and below the liver. This is used to control bleeding for 24-48 hours by tamponading.
    • Trauma Management - Vascular Injury:
      • Grade I & II: Monitor vitals, hematocrit, and do serial 24-hour CECT. If contrast blush increases, perform angioembolization.
      • Grade III: Manage as per Grade I & II. If unstable, manage as per Grade IV & V.
      • Grade IV & V: If FAST positive, perform laparotomy. Splenectomy is often necessary.
    • Splenectomy complications: Hemorrhage, pancreatic fistula, hematological changes.
    • Thoracic trauma: Most common in polytrauma patients. The most common cause of death.
    • Blunt thoracic trauma: Tracheobronchial injury. Penetrating thoracic trauma: Hemothorax, pulmonary laceration.
    • Life-threatening thoracic trauma: Airway obstruction, tracheobronchial tree injury, tension pneumothorax, open pneumothorax, massive hemothorax, cardiac tamponade, traumatic circulatory arrest.
    • Thoracic trauma investigation: Chest X-ray, eFAST, pulse oximetry.
    • Rib fractures and flail chest: The most common type of thoracic trauma. Usually caused by CPR.
    • Intra-abdominal pressure measurement: Insert saline via Foley catheter to measure bladder pressure (indicative of abdominal pressure).
    • Intra-abdominal pressure grades: Intra-abdominal hypertension (IAH): IAP > 12 mmHg. Abdominal compartment syndrome (ACS): 20 mmHg with new organ dysfunction.
    • Intra-abdominal pressure effects: ↓ GFR, ↓ venous return, ↓ SBP, ↓ Cardiac output, ↓ Urine output, ↓ Inspiratory volumes & capacities, ↓ visceral perfusion, ↑ intracranial tension.
    • Retroperitoneal trauma: Involves the kidney, ureter, renal vessels.
    • Retroperitoneal trauma management: In unstable cases: Angiogram. Stable cases: CECT. Unstable cases: Single shot IV urogram. Pelvic structures: most commonly injured zone.
    • Left lower lobe atelectasis/pneumonia: Decreased expansion of the left side of the chest. OPSI (Opportunistic/Overwhelming Post Splenectomy Infection)
    • OPSI: Etiology: Encapsulated bacteria (Pneumococcus, meningococcus, H. influenzae). Most frequent in children. Commonly seen within the first 2 years after splenectomy. High mortality rates are often associated with hematological conditions and trauma.
    • OPSI prevention: Vaccination with pneumococcal, meningococcal, H. influenzae, and annual influenza vaccine.
    • Liver trauma grades: Grades 1-5 classified based on Hematoma, Laceration, and Vascular injury. Advance one grade for multiple injuries up to grade 111.
    • Diagnostic Peritoneal Lavage (DPL): Used when FAST is not available. Interpretation: Decompress stomach and bladder. Insert a needle and aspirate just below the umbilicus.
    • DPL Results: Positive if blood > 10cc. Other positive indicators: RBC > 1 lakh/cumm, WBC > 500/cumm, amylase > 175 IU/L, fecal content present.
    • Splenic trauma: Indications for splenic trauma: Fracture of 9–11th ribs on the left side, bruising of the left lower chest wall, Positive Kehr sign.
    • Splenic trauma grades: Grades 1-5 classified based on subcapsular hematoma and vascular injury.
    • Abdominal trauma: Mechanism of injury: Spleen is most common overall, liver most common in blunt trauma.
    • Blunt abdominal trauma: Hemodynamically stable patients: Perform FAST scan. Hemodynamically unstable patients: Perform FAST scan and CECT.
    • Management: Midline laparotomy, FAST scan in the ER.
    • FAST Procedure: Epigastrium, right upper quadrant, left upper quadrant, suprapubic.
    • eFAST: FAST + assessment of the thoracic cavity.
    • Advantages: FAST detects free fluid in the abdomen or pericardium.

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    Description

    This quiz covers the assessment of abdominal trauma, focusing on active space detection, blunt and penetrating trauma management, and the approach for hollow and solid organ injuries. Test your knowledge on when to perform exploratory laparotomy, CT scans, or refer for interventional radiology. Perfect for medical students and professionals in emergency medicine.

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