Notebook

3/21/16 Trauma Conference, Las Vegas

-whole body CT scanning may have increased survival in trauma pts.

 

 

Subclavian injury:

·       OR for hard signs (hemothorax, pulsetile bleeding, large hematoma, loss of pulse)

·       CTA for soft signs

Tx:

·       Clavicular incision: only incision needed for R or L

·       anterior scalene m overlies subclavian, phrenic n is on medial aspect of this (preserve)

·       can do delto pectoral extension

·       can do sternotomy extension= opens medial extension

·       just over clavicle, remove soft tissue attachments, remove clavicle from sternum with gigli saw (minimal functional deficit), or can just cut medial end and move.

·       PTFE often used

·       venous injury can be ligated

 

Concussion:

·       =occures immeditely, transient, causes disturbance of function but not structure, LOC not needed

·       there is no grading

·       SCAT3 is a cuncussion assessment tool

·       types of concussion: cognitive, vestibular, affective, somatic

Tx:

·       no return to play if symptomatic

·       gradual return

·       no brain rest

 

 

-vascular injuries below knee or shoulder should be repaired with venous grafts

 

Esophageal perforation

-eval with swallow study, CT, endoscopy

-explore cervical esophagus, even if only for drainage

-Criteria for nonop management of esophageal perforation:

Well contained/ localized

Contrast drains back into esophagus

Minimal sx, no sepsis

Cervical or thoracic esophagus

No maligancy

No distal esophageal obstruction

Detected early, or late with minimal sx

 

 

Aortic root injuries:

-R coronary comes off directly anterior

Blunt: usually need bypass, have time.

Access:

-midline, median sternotomy

 

Colonic Surgical Emergencies:

-primary anastamosis has ok outcome than for diverticulitis (MAY have improved morbidity/mortality over hartman's)

-Diverticulitis laparoscopic lavage has 2% conversion, 10% Morbidity. Not yet indicated for feculant or purulant peritonitis

 

 

Transition zone challenges:

Neck

·       -SCM incision initially

·       -Zone 3: detach scm, digastric, sternohyoid & styloid m devision

·       -beware of facial n posterior to mandible , inferior alveolar n anterior to mandible

·       -vertibral a travels in canal C6-C2

Thoracoabdominal

·       -suprahepatc vena cava can be accessed through central tendon via abdomen (like a pericardial window)

·       -diaphragm can be taken down radially laterally (preserves innervation of diaphram which comes centrally)

Popliteal

·       -usually accesed with incision parallel to sartorius m., divide gracilis, semimembranous, semitendinous, and medial head of gastrocnemius.

 

 

Residual Hemothorax:

·       = retained blood > 300-500ml (blunted costophrenic angle)

·       large size tube not found to help decrease

·       <300ml usually resorbed spontaneously

·       Large residual hemothorax can worsen resp function, risk empyema (27% incidence), entrap lung

·       Risk for empyema: no abx at time of insertion, penetrating trauma, duration of chest tube, multiple chest tubes.

Tx:

·       replace tubes (not recommended)

·       percutaneous drain: for encased collections

·       thrombolysis: TPA 25mg or Urokinas 100,000 U in 50ml NS via chest tube. Clamp. Walk for 4hrs. Unclamp. Repeat for 3d. After trauma, usually wait 3-5d; longer for head injury.

·       VATS- good for < 10d. lat decubitus; dbl lumen tube; two ports, 6th intercostal ant/post axillary lines; 3rd in mid axillary 4th intercostal

·       thoracotomy- for > 10d

 

Biliary Bailouts

·       Dome down is an option

·       subtotal cholecystectomy= GB drained, opened, evacuated, anterior wall excised, back wall may be left on; mucosa may be obliterated; cystic duct can be left open or closed with suture/endoloop/clips; drained.

o   For severe cholecystitis preventing safe dissection; cirrhosis (bleeding during dissection)

o   18% bile leak, usually resolves spontaneously; may need ERCP/stent; 2% need re-operation

·       Cholecystostomy hasn’t been shown to lower conversion rate of lap chole.; good for poor surgical candidates

 

Necrotizing pancreatits

·       Nasogastric feeds may be ok

·       Wait 5-7d before starting TPN (enteral better than tpN)

·       Infected pacreatic necrosis= Air in retroperitoneum, bacteria in necrotic fluid

o   Tx: abx, necrosectomy

o   Open: debride, can pack or drain.

o   Step up: IR drainage, if doesn't improve after a few days (try ~4wks from initial pancreatitis) --> do cutdown on drain, 10mm scope to access retroperitoneum, can debride with yankaur and ring forcepts; has lower DM, hernia, pancreatic insufficency, death.

 

Ostomies in obese pts

·       Preoperative stoma siting= 5cm of flat skin despite position changes; ostomy triangle is umbilius, ASUS, pubic symphisis

o   Obese pts may need higher on abdomen

o   Avoid prior radiation fields

·       Intraabdominal options

o   Clamp IMA to ensure blood flow is preserved

o   Don't dissect close to mesentary

o   Mobilize flexures

o   Make a large trephine (hole for bowel to go through ab wall)

o   Pseudo loop end colostomy

o   Pie crusting= cut mesentery perpendicular to vessel to gain length

·       Abdominal wall options:

o   Siting

o   Contouring, take subcutaneous fat

o   Can use Alexis Wound retractor to allow bowel to slide into site easier

 

 

3/22/16

 

EFAST (Extended focused assessment for trauma)

·       FAST (detects 200ml fluid, 80% sensitive, 100% specific for free fluid) + thoracic views

o   25-50% false negative for solid organ injury

o   Pediatric fast is < 50% sensitive

o   Doesn't eval retroperitoneum

·       Thoracic views detect pleura-pleura apposition and movement.

o   Comet tail= normal finding (no ptx)

o   HTX can be seen just above diaphram on liver/splene views

o   Pleura not moving with respiration (no moving comet tail) is ptx

 

IVC filters

·       TID heparin is comparable to lovenox for DVT prophylaxis

·       PE is #1 delayed death following trauma

·       Guidelines:

o   Known DVT/PE and can't anticoagulate

o   GCS < 8 tbi, spinal chord with plegia, complex pelvic/long bone -- little/no clinical evidence

o   PE while adequately anticoagulated

o   Too sick to tolerate a second PE

·       In general: Above knee DVT --> anticoagulate; if high risk/bleeding place a filter

·       About 20% PE's are actually primary pulmonary thrombosis

·       If unable to give DVT prophylaxis, can do surveillance US for DVT (weekly or biweekly)

·       Only 21% of retrievable filters are retrieved

·       Recommendations by Dr. Sise:

o   Filter for DVT/PE when can't anticoagulate

o   PE despite anticoagulation

o   Consider if unable to tolerate 2nd PE due to cardio/pulmonary instability

o   No role for SVC filters for upper extremity clot -- unless this caused a PE

o   No prophylactic IVC filter, do surveillance

 

Fibrinogen= Normal rxn to trauma is to increase; low (<230) in trauma is associated with bleeding and death. Early cryo may help, but doesn't effect mortality.

·       Should keep level > 200

 

 

Open Abdomen

·       Use: packing, bowel edema, ACS, sepsis/ischemic bowel

o   Diffuse non-surgical bleeding

o   hypothermia < 34C

o   acidosis < 7.3

o   volume overload > 7

o    bowel edema

·       Risk:

o   15% EC fistula

o   Protein loss

o   Hernia

·       Recommend:

o   Bowel anastamosed in 24hrs to prevent SBO

o   34% of pts are able to be closed 1st take back and can decrease infection/complications

o   Leaving abdomen open for sepsis has increased morbidity, fistulas, hernias, inflammatory response = don't do serial washouts for sepsis. Do re-exploration on demand.

o   Ischemic bowel only 20% need further resection for ischemia

 

TBI Management

·       ICP monitor does not effect outcome (NEJM Dec 27, 2012)

·       Decompressive craniectomy in diffuse TBI has worse outcome (NEJM 4/21/11)

·       Rescue craniectomy

o   Leaving bone flap off has complication of new surgery

o   Replacing bone flap has rick of inc ICP and needing removal

·       Targeted temperature measurement only indicated in neonates (hypothermia)

·       Mannitol v. HTS - no clear preference for eaither over the other

 

ABCDEF Initiative = ICU care

·       A= assess pain

o   Use scoring

o   Treat in 30min

o   Pain control before procedure/dressing change

·       B= spontaneous awake/breath trial

o   Decrease time in ICU, vent, mortality, delerium

o   Use RAS or SAS

o   Hold sedation until open eyes, squeeze, follow commands; then restart 50% of dose

·       C= choice of analgesia/sedation

o   Benzo's are bad

o   Analgesias first

o   Precedex has lower delerium than propofol lower than benzo

·       D= delerium assess

o   Can be hyper/hypo active or mixed

o   Delerium has 1% increased 1yr mortality for every day deleriuc

o   CAM-ICU is scoring system (poor for TBI)

o   Modifiable factors: sleep, choice of home meds, procedures, mobilization, pain

·       E= early mobility

o   Decreased incidence and duration of delerium

o   Avoid bedrest

·       F= family engagement

o   Presence in unit, in rounds (open ICU policy), shared decision making, ICU diaries

o   Decreases falls, agitation, cardiac complications

 

ECMO

·       Passive venous drainage, oxygenation, then pump blood back (to vein VV or artery VA, only VA is good for cardiac support as well)

·       Increased survival for H1N1 flu in 2009

·       40% survival in cardiac shock

·       Indications

o   Respiratory failure with > 50% expected mortality done within 7d

o   Failed Prone positioning, APRV, inhaled NO

·       1 additional survivor for 6 treated

 

Antibiotics in Acute Care Surgery

·       Intraabdoinal infection

o   No flouroquinolone for ecoli

o   Mefoxin for moderate perfoated

o   Primaxin, zosyn, cef/flag for severe infection, immunocompromised, extremes of age

·       Trauma laparotomy

o   Single dose broad spectrum (mefoxin, GN and anaerobe)

o   24hrs for hollow viscus injury

·       VAP

o   Late= after 4 d

o   Fluroquinolones are 100% penetration

o   B lactams low penetration

o   Ex: zosyn 1st, imipenem for escalation

o   7-10d duration

o   Use singe drug for single bug

o   CIPS: temp, wbc, trach secretio, oxygenation, cxr, tracheal aspirate cx

·       Cdiff

o   Most common healthcare infection

o   Metronidazle, vancomycin, fidoxamicin

o   Tx: Vanc 500mg/500cc q6hr per rectal lavage in addition to oral vanc and IV flag

 

Fluids in the ICU

·       Albumin may have increased mortality in TBI (SAFE trial), but is safe in sepsis

·       HES starches increase renal failure, not for acute resuscitation

·       Use lactate or base deficit, CVP 8-12, MAP > 65, SVO2 70%, UOP > 0.5 cc/kg/hr  as endpoints for resuscitation

 

Anticoagulation in TBI

·       Prophylaxis decreases DVT, not PE or death

·       Neurocritical Care Society guidelines:

o   Mechanical prophylaxis early

o   Add LMWH 24-48hrs if bleeding is stable on CT

·       Chemoprophylaxis and SCD reduce dvt risk

·       Chemo is better then mechanical prophylaxis

·       Lovenox is better than heparin to prevent DVT

·       Heparin can increase bleeding in the brain more

 

 

Lung Protection Strategies

·       Use PEEP/FiO2 table

·       Prone ventiolation trial 4-6hrs for ARDS (PF<200)

o   Works best in the first 5d

·       Ventilator strategies

·       NM blockade

o   Helps with pt-vent dissynchrony

o   Can have increased survival with PF<150

·       NO

o   Transient improvement in oxygenation

o   No survival advantage

·       Can trend SVO2 to identify limitation in oxygen delivery

o   Best ways to improve O2 delivery are Hb and CO

o   Increasing PaO2 only helps up to about 90% O2 sat

o   Ensure O2 demand is lessened (pain, sedation)

 

ICU nutrition

·       NPO better than TPN for normal Pt

·       TPN

o   Uses

·       Short gut

·       Preoperative malnourished pts without oral intake

·       Complicated or unusable GI tract (not open abdomen)

o   Complications:

·       Cholecystitis

·       Line complications

·       Liver dz

·       infection

·       Postpyloric feeds decrease PNA

 

 

 

TXA

·       Contraindicated with active clotting and acquired defective color vision

·       Must be given within 3 hrs of bleeding

 

 

Pain Control

·       Can judge opiod use with MME.

·       NSAIDS increase fracture non-union

·       Ketamine reduces pain severity, continuous or intermittent.

·       Alpha agonists (clonidine, Precedex) work

 

Addicted patient

·       Replacement therapy (methadone, buporphenone)

o   Can morphine titrate

o   Need to cover withdraw and pain control

o   Local/regional pain control, paracetamol

o   Careful with PCA

·       Drug addiction

o   Try to avoid opioids

·       1mg Oral morphine = 3mg IV morphine = 2mg oxycodone = 7.5mg hydromorphone = 1/6mg codein = 1/5mg tramadol

 

Cervical Spine imaging

·       Who to image (Nexus criteria):

o   Not alert

o   Intoxicated

o   Distracting injury

o   Midline c-spine tenderness

o   Neuro deficit

·       Unevaluable pt can consider remove collar based on CT alone (high NPV to exclude unstable injury)

·       Midline tenderness 100% sensitivity/specificity of CT (Jama 2014)

·       In adequate CT, can likely clear with CT unless there are neurodeficits

 

 

Death and dying in ICU

·       Advanced directive= written expression of how a pt would want to be treated in medical circumstances

·       DNR= MD order limiting medical treatment

o   Pts can suspend DNR perioperatively

·       Medical futility

o   Quantitative= when tx has minimal probability of success

o   Qualitative= perceived benefit is exceedingly poor

o   TX and CA has futility policy, MD can decide, must let family know, ethics, allow time to transfer

 

 

Delerium Tremens (DTs)

·       Mortality of 5-15%

·       15-30% of trauma pts go into alcohol withdraw

·       Older and higher BAL have higher risk of withdraw

·       Stages of AWS

o   1- 24hrs, anxiety, tachycardia, HTN

o   2- after 24hrs hallucinations, irritability

o   3- 3d, sz, hallucinations

o   4- 3-5d, adrenergic crisis, HTN, fever, cerebral edema (DTs)

·       Symptom triggered benzo tx is best; can use CIWA scale

·       Tx:

o   Benzo- 1st line

o   Precedex- adds alpha agonist

 

 

Hartford Consensus= group of experts on how to improve survival with active shooter

 

 

Brachial Plexus injuries

·       Erb’s palsy= C5,6, upper arm with waiters tip deformity

o   From overheas stretch

·       Klumpke’s palsy= C5-T, hand with claw hand

·       Penetrating injurà explore and repair

·       Blunt

o   Avulsion (no nerve root remaining)- can’t repair

o   Rupture- needs surgical repair

o   Axonotemesis- stretch injury, regenerates in 4-6wk

o   Neuropraxia- reverses rapidly

o   Dx:

§  Shoulder/arm film

§  CXR

§  Electrophysiology

§  MRI/CT myelogram to eval root avulsion

o   Tx:

§  OT, splints

§  Follow for 3mo

 

 

Pediatric Trauma

·       Airway

o   ETT size= (age+4)/4; nailbed width

o   Bradycardia with RSI= atropine 0.02mg/kg

o   Surgical airway= Avoid in kids due to subglottic stenosis

·       Breating

o   Similar to adults

o   Look at trachea on xray, more likely to shift in kids

·       Circulation

o   Blood volume of 80cc/kg

o   10cc/kg PRBC or FFP

o   20cc/kg crystalloid per ATLS

o   MTP started at 40cc/kg, hypotension

o   Use 1:1:1 ratio

o   Hyperkalemia is risk from blood through small IV’s

o   Bleeding in kids has higher mortality than in adults

 

 

Hernia Repair in contaminated field

·       30% laparotomies have incisional hernia

·       STITCH trial= Small biles 5mmx5mm with 2-0PDS reduce recurrence; excluded morbidly obese.

·       Lap v open repair

o   No clear defined difference

o   Lower wound infection

o   Increased enterotomies

o   Less hospital stay

o   Maybe < 3cm should not be lap, >10 should not be lap

·       PRIMA trial will address prophylactic mesh

 

 

Surgical Soul

·       Vascular structures

o   Deep= cava, kidney, IVC; Compress

o   Middle= mesenteric, portal; do double pringle

o   Superficial= pancreatico-duodenal arcade, need Kocher to find

o   Tx:

§  Wide kocher, Cattell Braasch, R kidney mobilization

§  Portal v- repair; ligate if dying and hepatic a intact

§  Hepatic a- repair

§  Bile duct- deal with later

§  SMV- transect head of pancreas

§  Proximal SMA- repair

§  SMV- repair, ligate in extremis

§  IVC- compress with sponge sticks; statinsky clamp, repair; ligate in extremis

§  Superficial vessels @ head of pancreas- ligate, pack

·       Pancreas

o   Consider bailout

o   Tx:

§  Drain!!

§  Whipple- only when injury already did the resection

·       Bile duct

o   Prijmary repair

o   Consider T-tube through a separate area

o   Can leave GB to leave as a conduit (roux limb)

·       Duodenum

o   Primary repair, tenuous suture line

o   Pyloric exclusion after repair (open antrum, oversew pyloris, loop gastro J)

 

 

Recurrant Adhesive Small bowel Obstruction

·       49% of sbo

·       5% of prior surgery will develop SBO due to adhesions

·       Recurrence rate increases after recurrence

·       Dx: Hx, px

o   SB > 3cm dilation

·       Tx:

o   Urgent surgery after resuscitation for complete SBO if no evidence of adhesions

o   Use lactate as an endpoint for resuscitation

o   Gastrograffin SBFT done after resuscitation and NG decompression

§  Reduces need for surgery

§  Reduces time for resolution

§  Reduce hospital stay

§  Failure of passage at 8hrs may need surgery; however, contrast in colon at 24hrs will likely resolve

o   PSBO resolves 55-75%

o   Complete SBO resolves ~35%

o   Fluorescein dye 1 ampule and Woods lamp to eval vascular compromise

·       Small bowel syndrome= <200cm SB

·       Hyaluronic acid/carboxymethylcellulose – reduces severity of obstruction

·       Icodextrin 4% irrigation solution reduces adhesions and SBO

 

 

 Unnecessary transfers

·       Inappropriate: closed distal radius, fami, closed anle, femur, tib/fib, clavicle, elbow dislocation, proximal humerus, felon, closed midshaft radius/ulna, closed metacarpal, femoral neck, intertrochanteric, patella, fibula, metatarsal

·       But accept.

 

Air ambulances

·       Has a role in long distance, hostile environment, difficult geography

·       No proven benefit for urban environment

 

 

EMTALA

·       Pt in emergency department must be evaluated and astabilized

·       On call physician availability

o   Each hospital must maintain community need on-call list

o   Coverage within reason depending on number of MDs

o   ER MD determins if on call MD must come in

o   Cannot refer to office unless it is in the hospital (rather than come in)

o   Simultaneous call is ok (unless critical access hospital)

o   Physician extender is ok unless ER MD says they want the MD

·       EMTALA does not apply to in-patients

·       EMTALA can get waived during certain emergency cirucmstances

 

 

Antibiotics Only for Acute Appendicitis

·       APPAC trial: RCT

o   Uncomplicated appendicitis

o   27% abx only failure rate over a 1yr

§  Still only7% complication versus 21% complication with immediate OR

o   Lower complications

o   Better pain and recovery

o   Protocol

§  3d IV abx (irtapenem)

§  OR group was open appy

·       NOTA study: prospective study

o   Brief course of abx

o   14% failure rate (66% still only managed with abx)

·       ABx only safe for kids as well

o   76% success at 1 yr (JAMA 2015)

·       10-20% complication rate with surgery

·       Choose surgery:

o   More certainty for future

o   High risk occupation or remote travel

·       Very low perforation rate from time of diagnosis

·       Protocol by Dr Martin:

o   Immunocompetent adult, no perforation, no abscess, no fecolith, no peritonitis, reliable pt

o   Initial IV abx

o   Can immediately convert to PO if tolerating PO

o   Admission if fever, worsening pain, abnormal vitals, not tolerating PO

o   F/u within 72hrs: pain, PO tolerance, bowel function, other complaints, vital signs

o   Appendectomy for worsening status, failure to improve, patient preference.

o   f/u imaging or endoscopy for suspicion of mass.

 

 

Organ donation

·       as of 2006, OPO (organ procurement organization) authorization on license is legally binding (Uniform Anatomical Gift Act)

·       Donation after circulatory death (DCD) starts ~1hr after pronounced death


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