29 Questions
What is the most important risk factor for empyema?
Retained hemothorax
In case of unresolved hemothorax after 2 well-placed chest tubes, what is the recommended treatment?
VATS drainage
What is the indication for thoracotomy in the operating room in the context of chest trauma?
Bleeding with instability
What is the recommended management for a sucking chest wound (open pneumothorax)?
Cover wound with dressing that has tape on three sides
What is the defining characteristic of flail chest?
> 2 consecutive ribs broken at > 2 sites
"Deteriorating blood gases and lung opacities can occur up to how many hours after initial trauma?"
< 48 hours
What is the most sensitive factor for fluid overload in pulmonary contusion?
Lung opacities
What should be considered in case of multiple painful rib fractures to prevent splinting and hypoxia?
Consider local nerve block and thoracic epidural
What is the recommended diagnostic procedure for persistent pneumothorax despite two well-placed chest tubes?
Bronchoscopy
What is the recommended position to keep the patient during thoracotomy in the operating room?
Supine position
What is the most likely source of bleeding in anterior pelvic fractures?
Venous bleeding from the pelvic venous plexus
What is the characteristic feature of an 'open book' horizontally unstable pelvis (type B)?
Wide pubic diastasis
What is the recommended management for expanding intraoperative blunt injury pelvic hematomas in an unstable patient?
Stabilize pelvic fracture and pack pelvis if in OR, then go to angiography for embolization
What imaging study is best for diagnosing suspected duodenal injury?
CT scan with contrast
What is the most common area of injury in duodenal trauma?
'D' loop near ampulla of Vater
What are the characteristic findings on UGI study for duodenal hematoma?
Stacked coins or coiled spring appearance
What is the recommended treatment for significant intraoperative duodenal hematomas?
Immediate surgical exploration and evacuation
What is indicated if a patient has a duodenal injury in the 2nd portion and primary repair cannot be achieved?
Pyloric exclusion and gastrojejunostomy with possible Whipple in future
What is recommended when there is free intraperitoneal air or contrast leak on imaging?
Immediate surgical exploration and evacuation
What is indicated for fistulas associated with duodenal injuries?
Conservative management with bowel rest, TPN, and octreotide for 4–6 weeks
What is the initial treatment for aortic transection?
Maintaining blood pressure between 100 and 120 mm Hg until definitive repair
Which imaging technique is typically used for the diagnosis of tracheobronchial injuries?
Bronchoscopy
What are some symptoms of blunt cardiac injuries like myocardial contusion?
Arrhythmias such as V-tach and V-fib
In which side are diaphragm injuries more likely to be found?
Left side
What is a common symptom of tracheobronchial injuries?
Large continuous air-leak
Which type of injury may require mainstem intubation on the unaffected side?
Bronchus injury on the right side
What may not be immediately evident on chest X-rays in cases of significant trauma?
Aortic tears
What type of incision is utilized for distal right subclavian artery injuries?
Midclavicular incision
What do sternal fractures and 1st and 2nd rib fractures pose high risks for?
Cardiac contusion and aortic transection, respectively.
Study Notes
Trauma Management Pearls
- Tracheobronchial injuries are common with blunt trauma and can present with symptoms like large continuous air-leak, persistent pneumothorax, and subcutaneous air.
- Bronchus injuries occur more frequently on the right side and may require mainstem intubation on the unaffected side.
- Diagnosis of tracheobronchial injuries is typically done through bronchoscopy, with 90% of injuries located within 1 cm of the carina.
- Esophageal injuries can be challenging to diagnose, and diaphragm injuries are more likely to be found on the left side, often resulting from blunt trauma.
- Aortic tears may not be evident on chest X-rays, so a high index of suspicion is necessary, especially in cases of significant trauma.
- Initial treatment for aortic transection involves maintaining blood pressure between 100 and 120 mm Hg until definitive repair, identifying and treating other life-threatening injuries first.
- For specific injuries, different operative approaches are utilized, such as median sternotomy for certain aortic and vascular injuries, left thoracotomy for specific arterial injuries, and midclavicular incision for distal right subclavian artery injuries.
- Blunt cardiac injuries like myocardial contusion can be associated with sternal fractures and may present with arrhythmias such as V-tach and V-fib.
- Aspiration may not immediately show on chest X-rays, and penetrating chest injuries require specific management based on the location and associated findings.
- Traumatic causes of cardiogenic shock, such as cardiac tamponade, cardiac contusion, and tension pneumothorax, require prompt identification and management.
- Sternal fractures and 1st and 2nd rib fractures are associated with high risks for cardiac contusion and aortic transection, respectively.
- Pelvic fractures can lead to significant blood loss, and hemodynamically unstable patients with pelvic fractures may require stabilization and further intervention, such as embolization or pre-peritoneal packing.
Learn about indications for thoracotomy in chest trauma, chest tube placement criteria, and treatment for unresolved hemothorax. Understand the management of chest trauma to prevent complications such as fibrothorax, pulmonary entrapment, infected hemothorax, and empyema.
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