TRAUMATRAUMA

Firas Madbak,MDFiras Madbak,MD

In a stable patient with pelvic, abdominal and In a stable patient with pelvic, abdominal and retroperitoneal injuries, the most sensitive and retroperitoneal injuries, the most sensitive and specific test to identify the injuries:specific test to identify the injuries:

A.A. DPLDPL

B.B. U/SU/S

C.C. MRIMRI

D.D. CTCT

E.E. Physical examPhysical exam

Most common nerve injury associated Most common nerve injury associated with fracture of the humeral surgical with fracture of the humeral surgical neck?neck?

Axillary nerveAxillary nerve

Most common nerve injury associated Most common nerve injury associated with fracture of the midshaft humerus?with fracture of the midshaft humerus?

Radial nerveRadial nerve

Deficit?Deficit?

Wrist dropWrist drop

Most common nerve injury associated Most common nerve injury associated with fracture of the supracondylar with fracture of the supracondylar humerus?humerus?

Median nerveMedian nerve

Trauma pt opens his eyes with painful Trauma pt opens his eyes with painful stimuli, is confused, and localizes to stimuli, is confused, and localizes to pain pain

1111

Type II odontoid fracture?Type II odontoid fracture?

Unstable fracture involving baseUnstable fracture involving base

Tx?Tx?

Halo/fusionHalo/fusion

Stable trauma pt with scrotal Stable trauma pt with scrotal hematoma, blood at urethral meatus, hematoma, blood at urethral meatus, high riding prostate..next test?high riding prostate..next test?

RUG is negative. Now what?RUG is negative. Now what?

Cystogram shows intraperitoneal Cystogram shows intraperitoneal

rupture..Tx?rupture..Tx?

2 layer closure with absorbable suture, 2 layer closure with absorbable suture, drainage, Foleydrainage, Foley

Best diagnostic test for diaphragmatic Best diagnostic test for diaphragmatic injury from penetrating injury from penetrating thoracoabdominal trauma?thoracoabdominal trauma?

LaparoscopyLaparoscopy

Management for an isolated Management for an isolated extraperitoneal vesical rupture? extraperitoneal vesical rupture?

FoleyFoley

An 18-year-old man was stabbed in the epigastrium. An 18-year-old man was stabbed in the epigastrium. On arrival to the center, he is obtunded, hypotensive, On arrival to the center, he is obtunded, hypotensive,

has elevated neck veins and a scaphoid abdomen.has elevated neck veins and a scaphoid abdomen. Next step?Next step?

Intubate !!Intubate !!

Stab to the right ventricle in a patient Stab to the right ventricle in a patient with no BP, sinus rhythm..Incision?with no BP, sinus rhythm..Incision?

L anterolateral thoracotomyL anterolateral thoracotomy

Three months following a MVC in which she suffered a grade III Three months following a MVC in which she suffered a grade III liver laceration, a 34-year-old female presents with hematemesis. liver laceration, a 34-year-old female presents with hematemesis. Following initial stabilization, the next most appropriate test?Following initial stabilization, the next most appropriate test?

AngiogramAngiogram

II

In a stable patient with pubic rami fractures and a small In a stable patient with pubic rami fractures and a small extraperitoneal laceration of the peri-trigonal area of the extraperitoneal laceration of the peri-trigonal area of the bladder, a frequent and major complication of operative bladder, a frequent and major complication of operative repair is:repair is:

A.A. ImpotenceImpotence

B.B. Massive hemorrhageMassive hemorrhage

C.C. InfectionInfection

D.D. Bony stability and non-unionBony stability and non-union

E.E. Ureteral ligationUreteral ligation

The most reliable predictor for the The most reliable predictor for the success of nonoperative treatment success of nonoperative treatment of splenic trauma in this patient isof splenic trauma in this patient is

Hemodynamic statusHemodynamic status

Repair of diaphragmatic rupture?Repair of diaphragmatic rupture?

Monofilament nonabsorbable sutureMonofilament nonabsorbable suture

Positive pericardial window. Next step?Positive pericardial window. Next step?

Median sternotomyMedian sternotomy

Tx for sucking chest wound?Tx for sucking chest wound?

Occlusive dressing taped on 3 sidesOcclusive dressing taped on 3 sides

Define massive hemothoraxDefine massive hemothorax

> 1500 cc blood in chest> 1500 cc blood in chest

Fascial compartments of the legFascial compartments of the leg

A 75-year-old woman presents to the ED following an A 75-year-old woman presents to the ED following an MVA. She has decreased strength and sensation in her MVA. She has decreased strength and sensation in her arms. She has normal strength and sensation in her legs. arms. She has normal strength and sensation in her legs.

The most likely diagnosis isThe most likely diagnosis is

Central cord syndromeCentral cord syndrome

Hydrofluoric acid burn tx?Hydrofluoric acid burn tx?

Topical calciumTopical calcium

Side effect of sulfamylonSide effect of sulfamylon

Metabolic acidosisMetabolic acidosis

Side effect of silver nitrateSide effect of silver nitrate

Hyponatremia, hypochloremiaHyponatremia, hypochloremia

Side effect of silvadeneSide effect of silvadene

neutropenianeutropenia

Loss of ipsilat motor, contralat pain Loss of ipsilat motor, contralat pain and temperature and temperature

• Brown-Sequard syndromeBrown-Sequard syndrome

Bilat loss of motor, pain, temp.Bilat loss of motor, pain, temp.Preserve position-vibratoryPreserve position-vibratory

• Ant spinal artery syndromeAnt spinal artery syndrome

The following are acceptable The following are acceptable maneuvers to control a cardiac maneuvers to control a cardiac laceration EXCEPT:laceration EXCEPT:

A.A. Direct digital pressure on the wound Direct digital pressure on the wound

B.B. Total manual inflow occlusion techniqueTotal manual inflow occlusion technique

C.C. Foley catheter tamponade Foley catheter tamponade

D.D. Tamponade by digital insertion into the wound Tamponade by digital insertion into the wound

E.E. Pledgeted suture of the wound Pledgeted suture of the wound

The performance of a pericardial The performance of a pericardial window to diagnose a myocardial right window to diagnose a myocardial right ventricular injuryventricular injury

A.A. Should be performed before ultrasonography Should be performed before ultrasonography B.B. Should be performed before endotracheal intubation Should be performed before endotracheal intubation C.C. Should always precede median sternotomyShould always precede median sternotomyD.D. Should always follow a median sternotomy Should always follow a median sternotomy E.E. Is not necessary if an ultrasound shows tamponadeIs not necessary if an ultrasound shows tamponade

Volkmann’s contractureVolkmann’s contractureWhat’s the fracture?What’s the fracture?What vessel is involved?What vessel is involved?

• Supracondylar humerus fractureSupracondylar humerus fracture• Anterior interosseous arteryAnterior interosseous artery

Nerve most commonly injured with Nerve most commonly injured with lower extremity fasciotomylower extremity fasciotomy

• Superficial peroneal nerve (which does Superficial peroneal nerve (which does foot eversion)foot eversion)

Operative management of injury second portion Operative management of injury second portion of the duodenum involving 25% of the of the duodenum involving 25% of the antimesenteric border close to the ampulla is antimesenteric border close to the ampulla is

best treated by:best treated by:

• Primary closure with omental buttress, Primary closure with omental buttress, drainage, and nasogastric suction drainage, and nasogastric suction

Epidural hematoma caused by what Epidural hematoma caused by what vessel injury?vessel injury?

• Middle meningeal arteryMiddle meningeal artery

Pringle maneuverPringle maneuver

• Still see dark bloodStill see dark blood• Retrohepatic caval injuryRetrohepatic caval injury

• Still see bright, red blood (is he kidding?)Still see bright, red blood (is he kidding?)• Replaced left hepatic arteryReplaced left hepatic artery

Management of duodenal hematoma?Management of duodenal hematoma?

Conservative; TPN/NGTConservative; TPN/NGT

Indications for surgery?Indications for surgery?

Nonresolution, perforation on UGINonresolution, perforation on UGI

A 26-year-old male involved in a tree-cutting accident presents with A 26-year-old male involved in a tree-cutting accident presents with blunt trauma to the thoracic outlet. Arteriography confirms a left blunt trauma to the thoracic outlet. Arteriography confirms a left subclavian artery injury. He is taken to the operating room where subclavian artery injury. He is taken to the operating room where proximal control is obtained through an anterolateral thoracotomy proximal control is obtained through an anterolateral thoracotomy while a separate supraclavicular incision provides distal control. In while a separate supraclavicular incision provides distal control. In obtaining exposure, it is imperative to avoid injuring which nerve?obtaining exposure, it is imperative to avoid injuring which nerve?

A.A. phrenic nervephrenic nerveB.B. recurrent laryngeal nerverecurrent laryngeal nerveC.C. median nervemedian nerveD.D. axillary nerveaxillary nerveE.E. vagus nervevagus nerve

Operative management of stab wound Operative management of stab wound to cecum (< 50% wall)to cecum (< 50% wall)

• Primary repairPrimary repair

• Abx?Abx?

24 hrs24 hrs

Operative management of injury to Operative management of injury to antimesenteric area of the third portion of the antimesenteric area of the third portion of the duodenum involving 60% of the lumen is most duodenum involving 60% of the lumen is most

effectively treated byeffectively treated by

• Primary closure, pyloric exclusion, gastric Primary closure, pyloric exclusion, gastric suction, gastroenterostomy, feeding suction, gastroenterostomy, feeding jejunostomy, and periduodenal drainage jejunostomy, and periduodenal drainage

Operative management of 3 large Operative management of 3 large rents in ileum 6 inches apartrents in ileum 6 inches apart

• Resection of all three wounds in continuity Resection of all three wounds in continuity with primary anastomosis with primary anastomosis

A hypotensive patient with a through A hypotensive patient with a through and through laceration to the stomach and through laceration to the stomach and a pancreatic and splenic injury and a pancreatic and splenic injury should be treated by:should be treated by:

A.A. Gastric resection with primary closure Gastric resection with primary closure B.B. Primary closure of both gastric wounds Primary closure of both gastric wounds C.C. Closure of the anterior wound and a posterior Closure of the anterior wound and a posterior

gastroenterostomy gastroenterostomy D.D. Pyloric exclusion through the anterior wound and Pyloric exclusion through the anterior wound and

a posterior gastroenterostomy a posterior gastroenterostomy E.E. Partial gastrectomy and gastroenterostomy Partial gastrectomy and gastroenterostomy

The most effective management of a The most effective management of a lacerated kidney found at laparotomy lacerated kidney found at laparotomy in a patient with a BP of 90 systolic is:in a patient with a BP of 90 systolic is:

A.A. Proximal control of the renal pedicle and digital pressure on the Proximal control of the renal pedicle and digital pressure on the kidney kidney

B.B. To open Gerota's fascia, deliver the kidney and repair the To open Gerota's fascia, deliver the kidney and repair the laceration laceration

C.C. Nephrectomy Nephrectomy D.D. Nephrectomy bench repair of the laceration and groin Nephrectomy bench repair of the laceration and groin

reimplantation reimplantation E.E. To pack the right upper quadrant and perform a right medial To pack the right upper quadrant and perform a right medial

rotation of the right colon and small bowel rotation of the right colon and small bowel

A 20-year-old male presents to the ED following a stabbing to the right A 20-year-old male presents to the ED following a stabbing to the right lower abdomen. On exploration he has a 2 cm cecal laceration with lower abdomen. On exploration he has a 2 cm cecal laceration with gross contamination as well as a laceration to the right iliac vein. The gross contamination as well as a laceration to the right iliac vein. The best treatment option with regard to the iliac vein isbest treatment option with regard to the iliac vein is

A.A. primary repairprimary repair

B.B. ligationligation

C.C. repair with PTFErepair with PTFE

D.D. extraanatomic bypass graftextraanatomic bypass graft

E.E. repair with autogenous veinrepair with autogenous vein