Trauma short note by S.

Wichien (SNG KKU)

Primary survey 1.Airway -first priority in 1survey -require cervical spine immobilization -abnormal voice require aw evaluate -most com I/C ETT= alter mental status Prophylactic ETT -penetrating inj to neck -chemical/thermal inj -extensive subcu air in neck -complex maxillofacial inj -airway bleeding Definite AW Nasotracheal tube -breathing spontaneous pt -contraindicate in apnic pt Orotracheal tube -direct visualize of cord -apnic pt Cricothyroidotomy -emergency -max tube in adult = no.6 mm -C/I in pt < 8 yr = subglottic stenosis -vertical incision (avoid ant jugu v.) Emergency tracheostomy -Fx.laryngeal--clothesline inj if cricothyroidotomy--further damage 2.Breathing Tension pneumothorax -contralateral lung is compressed -heart is rotated about SVC&IVC -dec cardiac output -immediate tube thoracostomy -4 or 5th ICS ant axillary line Open pneumothorax -sucking chest wound -Temporary Rx = occlusive dressing -definite Tx = ICD Flail chest/pulmo contusion ->=3 ribs Fx -at least 2 locations -paradoxical movement -often have pulmo contusion :progress during 12 hr 3.Circulation -tachycardia : earliest sign -pt on b-block may not inc PR -carotid pulse = 60 femoral pulse =70 radial pulse = 80 -iv resus = 2 peri.line, >=no.16 <6yr = fail iv*2 -interosseous cannulation -proximal tibia, if Fx--distal femur -femoral v = relative C/I -venous thrombosis 4 life threatening 1.massive hemothorax (>1500 ml) -blunt=ICS a inj -penetrate=systemic/pulmo.hilar vv 2.cardiac tamponade -100 ml in acute can tamponade -Tx=pericardiocentesis 3.massive hemoperitoneum 4.unstable Fx pelvis Emer.department thoracotomy (EDT) I/C 1.post arrest -penetrate trauma <15m -blunt trauma <5m 2.persist hypoT due to -cardiac tamponade -hmg -air embolism C/I -penetrate trauma >15m -blunt trauma >5m +no sign of life Procedure -lt anterolateral thoracotomy 5th ICS -tamponade=longitudianl peicardiotomy :ant to phrenic n :release tamponade, cardiac repair -air emboi=hilar x clamp -extrathorasic hmg=aortic x clamp -if SBP>70mmhg=go to OR Survival -highest=isolated cardiac inj shock=35% no v/s=20% -penetrating inj=15% -blunt inj=1-2% 4.Disability&exposure GCS -13-15 = mild head inj -9-12 = moderate inj -<9 = severe inj

*GCS<14 should CT scan

Trauma short note by S.Wichien (SNG KKU)

Secondary survey AMPLE hx A-allergy M-medications P-past illness /preg L-last meal E-event relate inj PE -head to toe -back,axilla,perineum -PR--sphincter,high riding prostate Adjunct -foley cath to decompress,Uo -NG tube to decrease risk of aspirate -FAST -CXR,lat cervical spine,pelvis (big three in blunt) Mechanism of inj 1.blunt inj a.hi energy -MCA,car >40 km/hr -fall from height >20 feet b.low energy -bicycle 2.penetrating inj a.GSW -hi velocity >2000 ft/s b.SGW -close range wound <7m (hi velocity) -long range wound General principle -NOM of solid inj replaced EL who require sx -less radical resection :splenorrhaphy,partial nephrectomy :1repair colon -limited initial sx -definite repair delay after resus unstable Fx pelvis -preperitoneal pelvic packing -as well as EF Transfusion Guideline -Hb >10gldL -INR <1.5 -PTT <45 sec -plt >50,000 (normal plt fxn) (MBT=plt dysfxn kerp >100,000) -fibrinogenn <100 mg/dL--cryo Massive blood Txn -1o unit in 6 hr -Type O in emer transfusion Situation 1.MCA c hypotension -Tear aorta vs Splenic inj -should emergency laparotomy first -if hypotension from aorta=not survive 2.hit a tree -epidural hematoma vs intraab fluid -can done silmutaneous 3.serious fx vs major thoracoabdo sx -can't silmutaneous -poor metabolic condition -defer until ok despite inc risk OM

Trauma short note by S.Wichien (SNG KKU)

Shock DDx of cardiogenic shock 1.tension pneumothorax 2.cardiac tamponade 3.myocardial contussion 4.air embolism -inj bronchus-->air to-->inj pulmo v. -bronchovenous fistula-->air in LV -in systolic-->air to coronary a Typical -penetrating chest inj + cvs stable -but sudden arrest after ETT/+ve P. Rx -Trendelenburg position -emer thoracotomy -cross clamping pulmo hilum -aspirate air from LV+aortic root c 18 gauge needle+50 ml syringe -vigorous massage--force air in coro :fail=tuberculin syring use in coro a -control pulmo.venous 5 source of bl loss -scalp-chest-abdo-pelvis-extremity Fx related blood loss Rib Fx 100-200 ml Tibia Fx 300-500 ml Femur Fx 800-1000 ml Pelvis Fx >1000 ml

class1 bl loss 750 %bl loss 15% PR <100 BP normal PP nor/inc RR 14-20 urine >30 CNS anxious class3 bl loss 1500-2000 %bl loss 30-40% PR >120 BP dec PP dec RR 30-40 urine 5-15 CNS confuse

class2 750-1500 15-30% >100 normal dec 20-30 20-30 anxious class4 >2000 >40% >140 dec dec >35 lethargy

Initial fluid resus -2L iv bolus , 20 ml/kg -NSS,RLS Urine output -indicator of organ perfusion 0.5 ml/kg in adult 1 ml/kg in child (2 ml/kg in <1yr) Respond to fluid resus 1.responder 2.transient responder 3.non responder (persistent hypoT)

Trauma short note by S.Wichien (SNG KKU)

Damage control sx -limit sx, break vicious cycle -temporary technic,delay definite sx Goal -control sx bleeding -lint GI spillage I/C -BT<35 -PH<7.2 -base def <15 (<6 in over 55yr) -INR/PTT >50% normal Abdo.inj -aorta inj must be repair--PTFE -celiac a may be ligate -SMA must flow :intravascular tempo shunt -illiac , infrainguinal vv :intravascular tempo shunt -vein can ligate, except :suprarenal IVC, popliteal v -spleen/1KN--excision > repair -liver inj :packing :translobar GSW=ballo0n catheter :deep LW tract=foley catheter Thorasic inj -bleed peipheral pulmo inj :wedge resection by GIA -penetrating inj :pulmo tractotomy :ligate bronchi 3-0 PDS suture -cardiac inj :running 3-0 prolene :pledgeted repair Blunt cerebrovascular injury (BCVI) Denver grading 1=wall irregular, <25%stenosis 2=>25%stenosis 3=pseudoaneurysm 4=vv transection Risk hi energy mech with -displace mid face Fx (Le Fort 2/3) -basilar skull Fx c carotid canal involve -DAI & GCS<6 -c-spine Fx -hanging c anoxic brain inj -clothesline inj S+S -bright red blood from nose/mouth -cervical bruit in<50yr -expanding cervical hematoma -focal nuro def--TIA,horner,paresis -stroke Tx 1.S+SCTA -ve--but hi suspectangiogram +ve--can sxrepair ECAunstableligation CCA/ICAunstableligation (N/S def 50%) Vertebral Aunstableligation (N/S def 3-5%) 2.can't sx -antithrombotic (not have C/I) -repeat study in 7-10d heal--discon not heal--continu 6 mo+re-immaging

Trauma short note by S.Wichien (SNG KKU)

Head injury -orbital Fx--ocular entrapment -otorrhea/rhinorrhea/battle sign -ant facial Fx--step off -abnormal dental closure -nasal Fx -EDH--middle meningeal a/skull Fx -SDH--venous disruption DAI -hi speed decerelation inj -direct axonal inj -CT--blurring of grey white matter -multiple small puncture hmg Neck injury 1.cervical spine -r/o in all blunt inj until not -sx--nuro def,angulate>11, >3.5 cm 2.Fx larynx -direct blow -result in aw compromise -horseness -subcu.emphysema -palpable Fx 3.Trachea inj -end to end single layer -interrupt nonabsorb suture 4.SC inj Central cord synd -hyperextend inj -dec motor,pain,temp in upper ext -preserve lower ext Ant cord synd -loss motor,pain,temp below level inj -intact position,vibrate -poor pronosis Brown sequard synd -transect half of SC -ipsil--loss motor,propio,vibrate -contralat--loss pain,temp Methyl pred (non penetrating inj) -30 mg/kg iv bolus then 5.4 mg/kg (inj in 3hr=24hr , 3-8 hr=48hr) Neck injury (cont) 5.Penetrating neck inj zone1--clavicle-cricoid zone2--cricoid-angle of mandible zone3--above angle of mandible Tx 1.hemodynamic unstable -operative exploration 2.hemodynamic stable+symp (expand hematoma,aw compromise dysphagia,subcu.emphy,hoarseness) zone1=CT neck/chest,eso/broncho zone2=sx zone3=angio+emboize 3.asymptomatic zone1=CT neck/chest,eso/broncho zone2=observe (trancervical GSW=as zone 1) zone3=observe Cervical exposure Midline structure -trachea,thyroid,carotid sheath -collar incision -2 FB above sternum notch Unilat.neck exploration -mastoid to clavicle,ant border SCM -carotid sheath=carotid a+v, vagus -facial v=carotid bifurcation -usually ligate facial v expose ICA Expose distal carotid a (zone 3) -divide ansa cervicalis--mobilize CN12 -transect post part of digastric m -mobilize CN9,10 -may remove styloid process -may ant displace of mandible Maxillofacial injury 3 region 1.upper face--frontal sinus, brain 2.mid face--orbit, nose, zygomaticomaxilla 3.lower face--mandible Bleeding from facial Fx -nasal packing -foley tamponade post nasal -angiembolization Aware -Fx tooth bearing bone=ATB -orbital Fx=diplopia -nose Fx=lacrimal inj, rhinorrhea

Trauma short note by S.Wichien (SNG KKU)

Chest injury Large air leak s/p thoracostomy -fiberoptic bronchoscopy -search bronchial tear or FB Persist hemothorax s/p 2 ICD -caked hemothorax -Tx=thoracotomy Thorasic vascular inj -lt side hematoma=des.aortic inj rt side hematoma=innominate inj ->95% inj distal to lt subclavian a :tether by lig arteriosum Suggest des.thoracic aortic inj 1.widening mediastinum 2.abnormal aortic contour 3.trachea shift 4.NG shift 5.rt/lt paraspinal thickening 6.depress lt main bronchus 7.lt apical cap 8.obliterate aorticopulmo window 9.lt pulmo hilar hematoma I/C for sx -ICD>1L (penetrate) >1.5L(blunt) -ICD>200ml/hr *3hr -caked hemothorax -select des.aorta inj,great vv -cardiac tamponade -massive air leak s/p ICD + inadequate ventilation -trachea/main bronchus inj -open pneumothorax -eso.perforation Thorasic incision Anterolateral thoracotomy -5th ICS, inframammary line Clamshell thoracotomy -expose bilat pleural cavity Trap door thoracotomy -expose lt subclavian -4th ICS, sup sternal extension -lt supraclavicular incision Sternotomy+supraclavi incision -expose prox. lt subclavian, innominate v, prox.carotid -sternotomy--control vascular -supraclavi--definite sx Median sternotomy -limit in cardiac trauma -use for ant heart stab wound Posterolateral thoracotomy -post of trachea,main bronchus -des.aorta,intrathorasic eso

Trauma short note by S.Wichien (SNG KKU)

Vascular injury Hard sign -pulsatile bleeding -thrill/ bruit -no pulse -expanding hematoma ABI/API <0.9 (sens 95%, spec 97%) >0.9 (can r/o) Ix 1.uncomplicated penetrate injPE 2.complicated penetrate injangiogram -false aneurysm/traumatic AVF -missile pararell A -multiple site inj -chronic vv inj 3.blunt vv injangiogram Operating room angiogram -inject 50 ml contrast via CFA -x ray 2 film 1.45 mllook inj site 2.50 ml+wait 5 slook distal run off Tx Step for sx 1.suitable preparation--unijured site for graft 2.proper sx incision 3.prox/distal control 4.local heparinization 5.debride vv 6.repair vv 7.tissur repair+coverage (full thickness) Repair technique -non absorb suture -atraumatic needle -end-end anastomosis -if cantgraft -unstableligate except SVC, suprarenal IVC, bilat IJV -repair in extend position -if cross jointring graft Post op sx -no routine heparin -not drain -elevate leg -splinting Sx adjunct 1.complete angiogramstd Tx 2.intraluminal shunt -bridging Tx -can 52 hr 3.fasciotomy -ischemic > 5hr -shock -crush inj -combine skeletal+vv inj -ligate major vv -intra compart P >25 mmhg Combined vv inj 1.Temp intraluminal shunt 2.skeletal stabilization 3.tissue DB 4.definite vv repair 5.tissue coverage 6.phophylactic fasciotomy Venous inj -no Ix -often asso A inj -if no C/Iattempt repair :lateral/end to end repair -no complex repair :thrombosis -dextran improve patency -no role of anti ply/coag -ligate should fasciotomy -no role of Ix for F/U

Trauma short note by S.Wichien (SNG KKU)

Vascular injury (cont) 1.subclavian vv Temp bleeding control -balloon tamponade Incision -sternoclavicular jxndeltopectoral groove Step -may cut medial half clavicle -cut clavicular head of SCM, omohyoid -identify ant scalene m & phrenic n subclavian V ant to m subclavian A post to m -cut ant scalene m to approach A -ligate thyrocervical trunk easily mobilized A Cant proximal control -rtmedian sternotomy -ltsame or lt 3rd thoracotomy 2.axillary vv Infraclavicular incision -below mid-clavicledeltopectoral groove Step -split pectoralis major -cut pectolaris minor 3.brachial vv Incision -medial of bicipital sulcus -cubital fossas incision Aware -deep brachial A (lateral of proximal A) 4.ulnar+radial A -should repair ulnar A -1 artery can ligate 5.illiac vv Approach -EL -medial visceral rotation Proximal control -aorta then apply clamp to inj site Distal control -if cantretractor compress femoral vv Repair 1.primary repair 2.prosthesis graft 3.illiac a transposition Unstable -Temp shunt+fasciotomy 6.common femoral A Incision -vertical btw ASIS & PS 7.superficial femoral A Incision -groove btw vastus medialis & adductor magnus -Hunter canal 8.popliteal vv Incision -1 cm behind distal femur & prox tibia 9.shank vv ATA Incision -1-2 cm lateral of tibia Tibioperoneal trunk Incision -as popliteal Operative repair Defect 1-2 cm -end to end Defect > 2 cm -interposition graft Suture -fine monofilament non absorbable -illiac 4/0 -subclavian/axillary/femoral 5/0 -brachial/popliteal 6/0 Pros Cons RSVG -better patency across knee -time consuming -donor site MM PTFE -time saving -good patency -hi infect -hi fail in PA

Trauma short note by S.Wichien (SNG KKU)

Great vessel inj 90%=penetrating inj Simple lacerate of asc/transv Aorta -lateral aortorrhaphy Post inj,need interposition graft -require cardiopulmo.bypass Innominate a inj -use bypass exclusion technic :avoid need cardiopulmo.bypass -PTFE graft :end to side from prox aorta :end to end innominate a -oversewn at inj part Des.thoracic aorta inj -esmolol ,SBP<100mmhg, HR<100 Open sx -lt posterolat thoracotomy,4th ICS -partial lt heart bypass :perfuse SC when clamp aorta :sup pulmo v-->lt common FA :maintain distal perfuse P>65 mmhg Endovascu stent -in can't 1 lung ventilate ->65yr,risk cardiac decompensate -uncontrol IC HT Heart inj most result of penetrating inj Control hmg -atria=clamped c Satinsky -ventricle=digital control -larger lesion=foley cath occlusion Definite repair -running 3/o prolene or interrupt pledgeted 2/o prolene Coronary a inj -horizontal mattress -if running=stenosis Repair valve -rare necessary Blunt cardiac inj Clinical -arrhytmia -tamponade--rupture atirum/RV commotio cordis -blow to precordium--sudden arrest Tracheobronchial inj (blunt=within 2.5 cm of carina) Massive air leak -initial Tx = ETT one lung to contralat -end to end with 3/0 PDS Non sx -no persist major air leak -inj <1/3 circum Peripheral bronchial inj -bronchoscope+fibrin glue Pulmo.parenchyma inj Peripheral inj -stapled wedge resection Central inj -lobectomy/pneumonectomy -Pulmonary tractomy Pneumatocele -posttrauma pulmo pseudocyst Empyema -most com c/p after sx Esophageal inj Can mobilize -1 single lay,end to end GE jxn perforate -segmental resect+gastric pull up Large destruct inj -eso.exclusion -loop esophagos + gastros Diaphragm inj Blunt -75%=left -tear in central tendon Sx -ICD -no.1 prolene,running -using simple running technique -large avulsion=polypropylene mesh

Trauma short note by S.Wichien (SNG KKU)

Abdominal inj DPL +ve Ant abdo stap wound RBC >100,000 WBC >500 amylase >19 ALP >2 bili >0.01 Bleed midline in retroperitonium -direct manaul pressure by pad -clamp aorta at diphragmatic hiatus Bleed from pelvis -clamp infrarenal aorta Illiac vv inj -multiple vascular inj=common -pelvis vascular isolation Missed inj in penetrating inj -wound tract not follow entire distan -retroperitonium :asc-desc colon :2nd-3rd duodenum :ureter Abdo.compartment syndrome 1-intra Abdo.inj 2-after massive resuscitation Physiology -comp KN--dec RBF,Uo -dec VR--dec CO--ext/splanchnic ische -inc intrathorasic P--hypoxia Dx 1.bladder pressure -50 ml nss in bladder -can't in BD rupture,pelvic packing, neurogenic BD gr 1 2 3 4 bladder P 10-15 mmhg 16-25 mmhg 26-35 mmhg >35 mmhg--sx

Thoracoabdo stab wound >10,000 >500 >19 >2 >0.01

u/s -sense to detect fluid >250cc :morison pouch,LUQ,pelvis CT when -alter mental status -confounding injury -gross hematuria -signi pelvis fx -persistent LUQ tender -unexplain hct<35 % (ped<33%) Penetrating inj 1.hemodynamic unstable=sx 2.hemodynamic stable GSW -ant abdo=sx -RUQ=CT -tangential, back/frank=CT SGW -back/flank=CT -ant abdo stab+local w explor :DPL vs CT Blunt abdo 1.hemodynamic stable -peritonitis--sx -no peritonitis--FAST -ve--criteria for CT +ve--NOM--no=sx/yes=CT 2.hemodynamic unstable -FAST+ve--sx -FAST not sure--DPL Emergency abdo exploration -long midline incision -<6yr=transverse incision -if active bleed when opening :Liver,aorta,inf venacava,illiac vv Bleed from liver inj -clamp at pedicle (pringle maneuver) -laparotomy pad packing

Blunt inj 1.stable -peritonitisSx -no peritonitisFAST+ve=CT, -ve=+/-CT 2.unstable -FAST+veSx -FAST-veDPL Penetrating inj 1.stable -GSW : ant abdomensx, back/frankCT -SGW : ant abdoCT/DPL, back/frankCT 2.unstable -Sx

Trauma short note by S.Wichien (SNG KKU)

Abdominal exploration midline incision <6yr=transverse incision Blunt -spleen,liver should be palpate -packing if Fx -inspect infracolic mesentery r/o inj If SBP<70 mmhg -clamp aorta at diaphragmatic hiatus -localized source hmg -liver=pringle maneuver -spleen=clamp splenic hilum Expose vascular -lt medial visceral rotation -incise white line of Toldt -distal desc.colon--post spleen--eso -lt colon,spleen,stomach to medial -prefer leave KN in situ Expose IVC -rt medial visceral rotation -prox.control=direct P SMA inj Fullen zone1 -post to pancreas--lt medial rotation Fullen zone2 -pancreatic edge to middle colic -approach via lesser sac -along inf edge of pancreas -may divide pancreatic body Fullen zone3/4 -direct in mesentery Illiac vv -infrarenal aortic clamping Pelvic vascular isolation -initial,clamp aorta,IVC,bilat EI vv -move clamp progressively close to inj -limit unwanted ischemia Expose bifurcate of IVC,rt CIV -can divide rt CIA -repair rt CIA after repair v Enteric contaminate -after control hmg -serial running look all smb/colon -look ant/post stomach :need open lesser sac -look duodenum=kocher maneuver -visual & palpate pancreas :just palpate is not sufficient :because fascia may mask inj :mobilize post pancreas is critical Morel Lavallee lesion -complex soft tissue wound of abdo -such as degloving inj after blunt inj Principle of Sx 1.control bleeding -blunt=4 Q packing -penetrate=along tract -supraceliac control -aortic clamping 2.identify inj site -supramesocolicduo,GB,stomach -inframesocoliclig Treitz to rectum -retroperitoneum Z1=explore all Z2=penetrateexplore all Bluntexplore expand hematoma Z3=explore penetrate inj 3.Exposure 1.aorta=lt sidel visceral rotation -mattox maneuver -white line of Toldt 2.IVC=rt side visceral rotation -kocher maneuver -cattell Braasch maneuvercaecum to L of treitz 4.control contamination 5.Decision -definite repair vs Damage sx control

Trauma short note by S.Wichien (SNG KKU)

Stomach inj -oversewn running single layer -most com miss=post wall :theough & through penetrating inj -question inj=methylene blue via NG Destructive inj -partial gastrectomy -Billoth 1,2 Damage both Latarjet n -drainage procedure Small bowel inj <1/3 circum -transverse running 3/o PDS Destructive inj/multi penetrate inj -segmental resection -end to end anastomosis -prolene 3/o Duodenal inj 1.duodenal hematoma -direct blow to abdomen -occur children > adult -vomiting following blunt abdomen -barium=coiled spring sign or obstr -most tx by nonoperative :NG tube and parenteral nutrition -surgical intervention :evacuation of hematoma :bypass procedure :laparoscopic evacuation 2.duodenal perforation -blunt,penetrating inj -difficult to dx due to neutral pH,few bacteria,retroperitonium -most can be treat by primary repair :running, single layer of 3-0 monofilament Suspect duodenal injury 1.crepitus along duodenal sweep 2.bile staining of paraduodenal area 3.document bile leak 4.rt side retroperito/ periduodenal hematoma Duodenal inj (cont) Grading Gr1=1 part hematoma Tx=conservative Gr2=>1 part hematoma, <50% circum Tx=duodenorrhaphy Gr3=D2 50-75%, D134 50-100 circum 1.duodenorrhaphy+Tube duodenostomy 2.pyloric exclusion 3.jejunal serosal patch 4.duodenal resection+E to E RYDJ Gr4=involved ampulla/CBD, D2>75% circum Tx=as Gr3 Gr5=disrupt of duodenopancreatic complex Tx=DCSx Pyloric exclusion -divert GI stream -high risk/complex duodenal repair -create end duodenal fistula Procedure -gastrostomy on greater curve -grasp pylorus via gastrostomy -oversewn w 0 prolene -gastrojejunostomy -not vagotomy--low risk margins ulcer Expose duodenum -Kocher maneuver -Transect lig of Treitz -Cattell & Braasch maneuver

Trauma short note by S.Wichien (SNG KKU)

Colon injury 3 concepts method 1.primary repair -lateral suture or resection c ileocolos or colocolstomy -running single layer -safe&effective in all penetrating inj 2.end colostomy -damage control sx 3.primary repair+diverting ileostomy -hi risk pt Grading Gr1=contusion Gr2=LW<50%circum Gr3=LW>50%circum Gr4=transaction Gr5=tissue loss Rectum inj Grading Gr1=contusion Gr2=LW<50%circum Gr3=LW>50%circum Gr4=extend to peritoneum Gr5=devascularized segment Intraperitoneum part -Tx as colon inj -primary repair or Hartmann Extraperitoneum part -Tx=4D 1.distal wash out (not used now) 2.diversion 3.drainage (?) -presarcal w penrose drain -along Waldeyer fascia -via perianal incision 4.direct repair Intestinal diversion 1.sigmoid loop colostomy 2.loop ileostomy Sigmoid colostomy 1.adequate mobilization 2.maintain common wall of prox & distal limb above skin with one half inch nylon rod 3.longitudinal incision in tenia coli 4.immediate maturation in OR GB & EHBD 1.GB inj -cholecystectomy 2.extrahepatic duct inj Small laceration -T tube or lat suture -4/0,5/0 monofil, absorb suture Signi tissue loss/transect -RYHJ or RYCJ Pancreatic inj Grading G1=minor contusion, no duct inj Tx=observe Gr2=major contusion, no duct inj Tx=drainage Gr3=distal transaction, duct inj Tx=distal pancreatectomy+splenectomy Gr4=proximal transaction Tx=if spared CBDRYPancJ Gr5=massive disruption of pancreatic head Tx=DCSx, recons when stable Identify pancreatic duct inj 1.direct exploration -of parenchymal laceration 2.operative pancreatography -through duodenotomy -canulate duct under fluorosope 3.ERCP Pancreatic fistula -after d5 -amylase >3x -drain >30cc/d

Trauma short note by S.Wichien (SNG KKU)

Liver inj Grading Gr1=LW <1cm, H<10% Gr2=LW1-3cm, H10-50% Gr3=LW>3cm, H>50% Gr4=1-3 segment Gr5=>3segment, hepatic avulsion NOM -stable pt -no overt peritonitis Radio intervention -stable pt -PRC 4u/6hr or 6u/24hr Initial control hmg Perihepatic packing -lt lobe=not effective (mobilize+comp btw surgeon hand) Pringle manuver -can't HV, retrohepatic vena cava can ligate celiac to com HA (but HA proper should repair) rt or lt HA/PV may be ligate ligate rt HA=cholecystectomy hmg despite packing-->direct repair SX Hepatic vascular isolation 1.clamp -diaphragmatic aorta -suprarenal vena cava -suprahepatic vena cava 2.atriocaval shunt 3.Moore Pilcher balloon shunt Topical hemostatic -argon beam coagulator -microcrystalline collagen -topical thrombin -fibrin glu Suture -cause hepatic necrosis -no.0 chromic,running suture -large curve blunt needle -shallow=simple running -deeper=interupt horizontal mattress Translobar penetrating inj Foley/balloon occlusion Hepatotomy c selective ligation -finger fracture technique -with ligate bleeder Angioemboization Complication Hemorrhage Biloma Biliary ascites -disrupt major bile duct -often require sx Sx--resection debridement Pseudoaneurysm -rupture to bile=hemobilia :RUQ pain+UGI+jx -rupture to PV=portal HT Tx-angioemboization Fistula Biliovenous fistula -rapid jx -Tx-ERCP+EST Bronchobiliary/peurobiliary fistula -asso diaphragm inj

Trauma short note by S.Wichien (SNG KKU)

Splenic inj Grading Gr1=LW<1cm, H<10% Gr2=LW1-3cm, H10-50% Gr3=LW>3cm,H>50% Gr4=devascularized>25% Gr5=shattering spleen Splenectomy -hilar inj -pulverized splenic parenchyma autuTxn to greater omentum Partial splenectomy -only sup/inf pole inj -horizontal mattress Splenorrhaphy -topical methods :electrocautery,glue -absorbable mesh -pledgeted suture repair Post sx -inc plt/wbc=normal -abnormal if (>5d) Wbc >15000 Plt/wbc <20 -Howell jolly body -Heinz body -basophilic strippling C/p 1.subphrenic abscess 2.unrecognized iatro pancreatic inj -pancreatic ascites/fistula 3.overwhelming postsplenec sepsis -encapsulated bact -s.pneumo,h.influ,n.meningitis Tx--vaccine at 14 d SMA inj Penetrating inj -GSW -black bowel+supramesocolic hemato (pathognomonic) Blunt inj -seat belt -epigastric pain+hypoT Sx -damage CS -Pruitt Inahara shunt :prevent bowel necrosis :control contaminate before graft Definite repair 1.no pancreatic inj -end to end interposition RSVG 2.asso pancreatic inj -graft should be tunneled -from aorta beneath duo to distal SMA SMV inj -digital compression -attempt venorrhaphy -ligation in life threatening situation (bowel edema) -should temp abdo closure Illiac a inj -transpelvic GSW -blunt asso pelvic Fx Sx -Pruitt Inahara shunt for DCS -interposition grafting

Trauma short note by S.Wichien (SNG KKU)

Kidney inj Grading Gr1=contusion Gr2=LW<1cm Gr3=LW>1cm, no collecting system inj Gr4=collecting system inj Gr5=shattering kidney Renorrhaphy -vascular occlusion control bleeding -preserve renal capsule -close collecting system separately -closed capsule over collecting system -one Fxn kidney or bilat inj Renal vascular inj -in penetrating inj -graft interposition for preserve renal -can't repair=nephrectomy -must palpate contralat KN :unilat renal agenesis=0.1% Blunt inj -90%=NOM *can ligate lt renal vein at closed to IVC Due to has lt gonodal vein Ureter inj -pelvic Fx, penetrating inj -may not identify,until c/p (urinoma) -if suspect btw EL :iv methylene blue/indigo carmine Sx -primary anastomosis--5/o absorb monofilament -distal ureter=reimplant (Boari flap) Bladder inj 1.intraperitoneum -sx=run single layer 3/o mono,absorb -foley 2 wk 2.extraperitoneum -non sx=BD decomp 2 wk Pelvic Fx Hemodynamic unstable FAST +ve -ve | | sx 2 u PRC/ED | | P.packing unstable=sx P.fixation stable=SICU | | Stable--yes----> SICU+/-CT | | no ongoing bleed | | Angiogram Pelvic packing -6 pads in paravesical space -small suprapubic incision Ant external fixation -dec pelvic volume -tamponade effect Vascular inj Hard sign--open sx -pulsatile hmg -absent pulse -acute ischemia Soft sign--further evaluation -signi hematoma -asso n inj -AA index <0.9 (SBP inj/SBP un-inj) -thrill/bruit Repair -prox+distal control -heparin (50 u:1ml) prevent clot Artery should repair -carotid,innominate,brachial, sup.mesenteric,proper hepatic, renal,illiac,femoral,popliteal Vein should repair -SVC, IVC prox.to renal V,PV

Trauma short note by S.Wichien (SNG KKU)

Vascular inj (cont) Aretry injury 1.Observe -small pseudoaneurysm -intimal dissection -small intimal flap -small AVF in ext 2.Lateral suture -small a inj c little or no loss tissue 3.End to end anastomosis -transect or nearly, defect 1-2 cm -mobilize end of vv by ligate small br -aorta,subcla,BA--difficult to mobilize -beveling--inc diameter/avoid stenosis 4.Interopsition graft -autogenous v/a,PTFE,dacron VV<6mm -int carotid,brachial,sup femoral,PA -should use SV from contralat groin -PTFE--thrombosis Larger a -subclavian,innominate,aorta,CIA -PTFE graft Enteric contaminate -aorta,illiac vv inj -can use graft -irritation before place graft 5.Transposition -use when has bifurcation Prox.inj of int carotid -mobilize ext carotid,divide distal -end to end anastomosis CIA/EIA -rt CIA transpose to lt CIA -lt IIA transpose to distal rt CIA -rt IIA transpose to rt EIA 6.Extra anatomic bypass 7.Interventional radiology -for tx a,v inj that can't surgery -stent in int carotid a,in base of skull -control hmg in hepatic inj or pelvic fx Vein injury -more difficult to repair--thrombosis -SVC,suprarenal VC,PV--can't ligate -other v may be ligate chronic hypertensive avoid by 1.EB toe to hip at end of procedure 2.continu elevate lower ext 30-45 ( 1wk) Extremity inj Common combine inj 1.Fx clavicle/1st rib 2.dislocate shoulder/ prox.humerous Fx 3.dislocate elbow/ Supracondyle Fx 4.Fx femur 5.dislocate knee

subclavian a axillary a brachial a femoral a popliteal a

Fx fixation vs repair a -controversy which be done 1st -prefer temp intravascular shunt Sx -artery access for on table angiogram in OR in pt evidence of limb threat :percu femoral vv or direct cannulate :SFA just above medial knee subclav/axillary a -exam brachial plexus before sx -RSVG/6mm PTFE Brachial a -medial upper longitu incision -RSVG SFA -RSVG Popliteal a -medial one incision approach -detach semiten,semimem,graccilis if have v inj -repair v 1st c PTFE graft -a is shunted Isolate a inj -RSVG Compartment synd -early sign=numbness 1st/2nd toe compartment Pressure -handheld Stryker device -gradient=DBP-comp P (>35mmhg=fasciotomy) Fasciotomy -2 incision 1.lateral incision=ant & lat comp 2.medial incisin=deep & superficial flex comp Arterial spasm guidelines step1-intra a. Alteplase bolus step2-intra a. NTG bolus step3-intra a. Verapamil bolus step4-intra a. Papaverine drip