High Yield Topics of the ABSITE: Trauma/Critical Care Jacob D. Edwards, MD PGY5-General Surgery Resident East Carolina University Vidant Medical Center Outline • Trauma • Critical Care • Head • Ventilator management • Neck • ARDS • Chest • Hemodynamic monitoring and • Abdominal parameters • Retroperitoneal • Shock • Pelvic • Cardiovascular Pharmacology • Extremity • Nutrition • Pregnacy • AKI/ARF • Indications for hemodialysis Trauma Feature Response Score Head Trauma Motor Follows Commands 6 Localizes to pain 5 Withdraws to pain 4 • GCS calculation Flexion w/ pain (decort) 3 • Indications for Head CT Extension w/ Pain (decer) 2 • Penetrating trauma No response 1 • CSF from Nose or Ears Verbal Oriented 5 • Hemotympanum Confused 4 • EtOH/Drugs Inappropriate words 3 Incomprehensible sounds 2 • AMS or depressed GCS No response 1 • Focal Neurologic signs Eye Spontaneous 4 opening Open to command 3 Open to pain 2 No response 1 Head Trauma • Epidural hematomaMiddle meningeal artery • LOClucid perioddeterioration • Operate for MLS>5mm • Subdural Hematomabridging veins/venous plexus • Operate for MLS >1cm • Intraventricular hemorrhage • Cause Hydrcephalusventriculostomy • DAI • MRI>CT • If elevated ICPcraniectomy Photo credit: Medscape.com Head Trauma • ICP Monitors • Brain trauma foundation • GCS <9 w/ abnormal CT • Normal CT w/ GCS <9 and >40 yo or posturing or hypotensive • Peak ICP 48-72hrs after injury • CPP = MAP – ICP • ICP management >20mmHg (newer guidelines >22mmHg) • Goal to obtained CPP >60 • Raise HOB • Relative Hyperventilation • Hypertonic Saline bolus: Na goal 140-150, Osm 295-310 • Mannitol (loading dose 1g/kg, then 0.25g/kg q4H) • Sedation • Paralysis • Barbiturate coma • Craniotomy/Craniectomy Head Trauma • Common Associations • Basilar Skull fxraccoon eyes/Battle’s sign (facial nerve injury) • Temporal Skull FxCN VII (geniculate ganglion) and VIII • Brain injuryincrease tissue factor releasecoagulopahtic Neck Trauma • C-spine • C1 burst fx = Jefferson Fracture TX: rigid collar • C2 Hangmans TX: traction/halo • C2 odontoid fx • Type 1 = above the base (stable) • Type 2 = at the base (unstable) Tx: Fusion/halo • Type 3 = extension in to body (unstable) Tx: Fusion/halo • Facet fxcord injury w/ ligamentous disruption • MRI to eval cord/ligamentous injury • Surgical decompression of cord if progressing neuro symptoms or open fractures Neck Trauma • Historically based on zone of injury • Zone 1 (Clavicle to cricoid) = CTA, Bronch, EGD, Barium Swallow (if operative, then sternotomy) • Zone 2 (cricoid to angle of mandible) = Neck exploration in OR • Zone 3 (angle of mandible to skull base) = CTA, laryngoscopy (if operative, may have to sublux mandible and dived the digastric and SCM) • Now based on hard signs of bleeding, airway injury, or esophageal injury • Shock, arterial bleeding, expanding hematoma, subq air, stridor, dysphagia, hemoptysis , neuro deficit Neck Trauma • Esophageal Injury (hard to find/diagnosis) • EGD, Barium swallow (get both) • Contained Injuries can be observed • Noncontained Injuries • Primary closuresmall and minimal contamination • Wide drainage (Cervical esophagus) extensive injury or contamination (Left Side approach) • Chest tube, spit fistula w/ delayed esophagectomy (thoracic esophagus) Neck Trauma • Tracheal or Laryngeal injury • Secure airway (cric) • Take to OR—convert cric to trach • Thyroid injury • NO thyroidectomy, just drain Chest Trauma • Chest tube—When to go to the OR • >1500ml initially • >250ml/h for 3 hours • >2500ml/24hr • Instability • Drainage after 48hours increase risk of: • Fibrothorax • Entrapment • Infected hematoma Chest Trauma • Tracheobronchial injuries • Worse oxygenation after placement of chest tube, may need to clamp chest tube • Right side more common • Consider mainstem ventilation • Dx: Bronch • Tx: immediate repair if large air leak or respiratory compromise, OR if persistent air leak for 2 weeks Chest Trauma • Diaphragm • Left most common • Air-fluid level in chest from herniated stomach (CXR) • Operative approach • <1 weektransabdominal • >1 weekTransthoracic • Depending on size may need mesh repair Chest Trauma • Aortic Transection • Widen mediastinum, 1st/2nd rib fx, apical capping, loss of the aortic knob, left hemothorax, tracheal deviation to right • Location: ligamentum arteriosum, aortic root, diaphragmatic hiatus • Dx: CTA chest • OR: left thoracotomy with partial left heart bypass or if distal injuryendograft • Treat other life-threatening injuries first (i.e. if +fast and hypotensive gets ex lap first) Chest Trauma • Penetrating “Box” injuries • Dx: pericardial window/FAST, bronchoscopy, esophagoscopy, barium swallow • +pericardial FASTPericardial window if bloodSternotomy • Penetrating Thoracoabdominal injuries • Laparotomy/laparoscopy Chest Trauma • Myocardial Contusion • Sternal fracture • Cause of death: VTach/Vfib • Most common arrhythmia: SVT • Troponin, EKG • Traumatic Causes of Cardiogenic shock • Tampenade • Tension PTX • Cardiac contusion Chest Trauma • Operative Approcaches • Median Sternotomy • Right Thoracotomy • Ascending Aorta • Right mainstem bronchus • Innominate Artery/Vein • Trachea • Proximal Right Subclavian • Proximal left mainstem bronchus • Proximal Left Common Carotid • Upper 2/3 of the esophagus • Heart • Right hemidiaphragm • Midclavicular incision w/ resection • Left Thoractomy of medial clavical • Distal left mainstem bronchus • Distal right subclavian artery • Descending Aorta • Lower 1/3 of the esophagus • Left subclavian artery Abdominal Trauma • Small Bowel (Most common hollow viscus injury with penetrating) • CT scan: free fluid with no solid organ injury, bowel wall thickening, mesenteric stranding/hematoma • If no peritonitis: serial exams, +/- repeat CT in 8-12 hours • Repair Rules • >50% of circumference or reduction of luminal diameter to <1/3 normal Resection • Multiple close lacerationsresection of segment • Mesenteric hematoma • Explore if expanding or if >2cm Abdominal Trauma • Colorectal • Right colon and Transverse colon primary repair or resection with anastomosis • Left colonprimary repair or resection • If in shock or has extensive gross contamination temporize with end colostomy/mucus fistula or diverting loop ileostomy • High rectal • Intraperitonealrepair defect, presacral drainage, diverting ileostomy • Extraperitoneal general not accessablediverting ileostomy • Low rectal • Repair transanally Abdominal Trauma • Liver • If need Common hepatic artery can be ligated • Collateral supply via the GDA • Okay to temporize with packing and temporary abdominal closure to allow time for resuscitation • Retrohepatic IVC injury may need atriocaval shunt • Lacerations • Failure of conservative management if: • Unstable vitals despite resuscitation including >4 units PRBC • Active blush/pseudoaneurysm on CT • Posteriorangio • AnteriorOR Abdominal Trauma • CBD injury • <50% circumference repair of stent • >50% circumference choledochojejunostomy • Leave drains • Portal Vein Injury • Okay to transect pancreas to access the injury (later will need distal pancreatectomy) • Ligation of portal vein = 50% mortality Abdominal Trauma • Spleen • Failure of conservative management • Unstable despite resuscitation including >2 units of PRBC • Active blush/pseudoaneurysm on CT • Post splenectomy sepsis up to 2 years after splenectomy • Post splenectomy vaccines • H.flu, meningococcal, pneumococcal Retroperitoneal Trauma • Duodenum • Blunt mechanism, 2nd portion near ampulla or near ligament of Treitz • Morbidity: Fistula • Hematoma most common in 3rd portion—if in OR open it if >2cm • Hematoma on CT (commonly missed/delayed presentation) • SBO symptoms 12-72 hours post injury • UGI series shows “stack of coins” • Tx: NGT, TPN for 2-3 weeks • Operative Management • Debridement and primary closure, wide drainage, okay to resect with end-to-end anastomosis, except for the 2nd portion • 2nd portionjejunal serosal patch, pyloric exclusion, GJ Feeding and draining jejunostomy, wide drainage, NGT Retroperitoneal Trauma • Pancreas • CT: edema or necrosis of peripancreatic fat • Contusion: if already in OR leave drain • Distal pancreatic duct injurydistal pancreatectomy • Pancreatic head duct injury • Wide drainage • Delayed Whipple or ERCP for stenting • Hematomas (Blunt mechanism) • Zone 1—Aorta/IVC—always explore • Zone 2—Kidneys/Flank—explore if expanding • Zone 3—Pelvic—explore if expanding Retroperitoneal Trauma • Renal • >2cm injury Lower 1/3 reimplant • Hematuria CT with delayed onto bladder phase imaging • <2cm mobilize and primary • Anatomy VAP (vein, artery, anastomosis over stent pelvis) • Leave drains • If already in OR • Blood supply • Blunt mechanism hematoma—explore • Upper 2/3 = medial only if expanding • Lower 1/3 = lateral • Penetrating mechanism hematoma— explore all • Bladder • Extraperitonealfoley 7-14 days • Ureteral • IntraperitonealOR 2 layer closure, • >2 cm injury Upper 2/3 foley temporize with nephrostomy, tie off ureteral ends Extremity trauma Trauma in Pregnancy • Mother first • 1/3 volume loss without any signs • Placental abruption>50% fetal mortality • Kleihaur-Betke test—test for fetal blood in maternal circulation • Uterine ruptureposterior fundus • Fluid resuscitation only, let the uterus contract down after delivery • Indications for C-section if in OR already • Persistent maternal shock, GA >34 weeks • DIC • Unable to access life threatening injury due to gravid urterus Critical Care Pulmonary • Compliance • Decreased with: ARDS, fibrotic lung disease, pulmonary edema, atelectasis