Trauma Surgery Review

1. Describe the management of rib fractures with an associated traumatic hemothorax.
[Townsend: Sabiston Textbook of Surgery, 17th ed., 506-509]

Rib fractures are the most common injuries after blunt chest injuries. Ribs 4 through 10 are usually fractured. One or two rib fractures without pleural or lung involvement are usually treated on an outpatient basis. However, in the elderly, owing to decreased bone density, reduced chest wall compliance, and increased incidence of underlying parenchymal disease, rib fractures may lead to decreased ability to cough, reduced vital capacity, and infectious complications. Pain on inspiration is usually the primary clinical manifestation after rib fractures. Epidural analgesia is adequate for patients with multiple or bilateral fractures and provides adequate pain control and appropriate pulmonary toilette, decreasing the number of complications. [NB: There is a body of literature suggesting that epidurals are the gold standard of pain control and there is a diminished rate of severe complications with them, particularly with elderly patients. Patient controlled analgesia is another promising approach, may supplement with rib bocks. My personal practice is also to add non-steroidal anti-inflammatory meds and muscle relaxants when able to, and send patients home on a mixture of medications]

Hemothoraces are initially treated by chest tube placement (36 French), and in approximately 85% of the cases, the bleeding will stop as the lung is re-expanded owing to the low pressure in the systemic circulation. A small number of cases will have continued bleeding and will require a thoracotomy. [NB: generally those injuries that produce >1500 cc output initially or >200 cc/hr for more than two or more hours.] These are usually injuries in systemic arteries (intercostal arteries or internal mammary artery) or veins or major pulmonary vessels or are cardiac in origin. Autotransfusion should be considered in these circumstances.

2. What are the indications and techniques for operation in renal trauma (both blunt and penetrating) [Trauma - 5th Ed. (2004)]

Indications: Hemodynamic instability, ongoing hemorrhage requiring significant transfusion, pulsatile or expanding hematoma on exploration, or avulsion of the pedicle. Relative indications for surgical intervention have included high-grade injuries, large perirenal hematoma, presence of urinary extravasation on contrast studies, significant devitalized fragments of parenchyma, and presence in the operating room during laparotomy with an incompletely staged injury.

Techniques: (Trauma 5th ed. 2004)

A number of indications for renal exploration following injury have been suggested by McAninch and Carroll.
1. hemodynamic instability
2. ongoing hemorrhage requiring significant transfusion
3. pulsatile or expanding hematoma on exploration
4. avulsion of the pedicle.

Relative indications for surgical intervention have included:
1. high-grade injuries
2. large perirenal hematoma
3. presence of urinary extravasation on contrast studies
4. significant devitalized fragments of parenchyma
5. presence in the operating room during laparotomy with an incompletely staged injury.

Renal exploration for trauma begins with prioritization of the injuries and determining that the initial operation is in fact the appropriate time to embark on the renal exploration. intraoperative IVP can be performed by administering 1 to 2 mL/kg of iodinated contrast intravenously and then obtaining a 10-min excretion film. This can occur while other general surgical tasks are being accomplished to avoid wasting time. There has been some controversy regarding the importance of first obtaining vascular control of the renal pedicle prior to renal exploration as previously described. Some proponents claim a markedly reduced nephrectomy rate if the renal vessels are first dissected and controlled with vessel loops. Others claim that this maneuver is unnecessary to successful renal exploration and repair. If there is an injury to the pedicle, central vascular control should be the initial maneuver. If, based on the anatomy of the injury, the kidney is not considered reconstructible, a nephrectomy is performed. It is preferable to separately ligate the renal artery and vein to avoid the potential for arteriovenous fistula. For trauma nephrectomies, the ureter and adjoining vessels are ligated near the kidney, while the gonadal vein is ligated and divided when necessary, with no need for concern for adverse impact on the gonadal structures. Technique involves incising the posterior peritoneum lateral to the aorta [NB incise MEDIAL to the inferior mesenteric vein, a generally recognizable landmark] and individually dissecting and looping the renal vessels on the side of injury. Following pedicle control or access, the colon and mesocolon on the side of injury is reflected medially following incision of the peritoneal reflection. When the anterior surface of Gerota's fascia is fully exposed, a generous, vertical, anterior incision is made through the fascia, and the kidney is fully mobilized.

. If the kidney is felt to be reconstructible in an unstable patient, the kidney can be packed off with laparotomy pads as other surgical injuries are treated. After repair of other injuries, or at the time of a secondary surgical procedure, formal exploration and reconstruction of the kidney is performed. If, based on the anatomy of the injury, the kidney is not considered reconstructible, a nephrectomy is performed.


3. How is a gunshot wound to the left flank treated in a stable patient? [Trauma - 5th Ed. (2004)]

Below is an algorithm suggested by Trauma - 5th Ed. (2004). Depending on the CT findings, possible treatments could include; observation, laparoscopy or laparotomy. [NB I would not call a labile patient ‘stable’. Furthermore I would get a CT scan first in a stable patient specifically to assess the ipsilateral kidney even if I had made the decision to operate. Otherwise, see previous question].


4. What might be some injuries associated with the previous GSW and how would they be treated?


Bowel injuries – Operative resection or repair
Solid organ injuries – Depending on extent of injury, treatment could range from removal of the organ to hemorrhage control and ICU observation. [NB: Differentiate renal injuries, which may not require exploration, with ureteral injuries which should always be repaired or diverted if repair is not feasible, as in damage control]
Pneumothorax – Chest tube
Hemothorax – Chest tube [NB: Diaphragm injuries may be present, and should be repaired. That is why I made the question a LEFT GSW. If in doubt and no formal indication for laparotomy exists, a laparoscopy can be done to assess the diaphragm]
Injury to Vascular structures – Operative exploration with repair or ligation
Injury to spinal cord – MRI with possible Operative intervention by neurosurgery [NB MRI may not be feasible in the patient with a bullet in him or her; operative intervention is controversial. Role of the trauma surgeon is basically supportive]


5. Describe the workup and management of a gunshot wound to the thigh.
[Trauma - 5th Ed. (2004)]

The location and extent of the injury will guide our work up and interventions. After stabilizing the patient, one should focus on all anatomical structures in the area of injury. Evaluation for vascular trauma should be assessed first following the below mentioned algorithm. Open fractures need to be irrigated and repaired in the OR. Injury to nerves can be assessed by physical exam and possible surgical intervention by neurosurgery. Soft tissue and muscle injuries can be washed out and approximated with the skin left open. Because of the wide range of guns (22 – shotgun) there is a wide variance in surgical management.


Figure 43-8. Algorithm for evaluation of injured extremities for vascular trauma. Dotted lines indicate possible alternative modalities that require further study.

[NB: I particularly want everyone to focus on the right and left side of the algorithm. Dr. Frykberg, in his bipolar style, has made it quite clear that normal physical examination is quite reliable to rule out the presence of a significant vascular injury, and, conversely the presence of hard signs requires urgent intervention, and, in fact recommends on table arteriography in the OR followed by whatever procedure is necessary ]

6. What are the grades of pancreatic injury & describe the operative approach to each?
[ACS Surgery]

Table 1 - AAST Organ Injury Scales for Pancreas and Duodenum
Injured Structure
AAST Grade*
Characteristics of Injury
AIS-90 Score

Pancreas
I
Small hematoma without duct injury; superficial laceration without duct injury
2

II
Large hematoma without duct injury or tissue loss; major laceration without duct injury or tissue loss
2; 3

III
Distal transection or parenchymal laceration with duct injury
3

IV
Proximal† transection or parenchymal laceration involving ampulla
4

V
Massive disruption of pancreatic head
5

Duodenum
I
Single-segment hematoma; partial-thickness laceration without perforation
2; 3

II
Multiple-segment hematoma; small (< 50% of circumference) laceration
2; 4

III
Large laceration (50%–75% of circumference of segment D2 or 50%–100% of circumference of segment D1, D3, or D4)
4

IV
Very large (75%–100%) laceration of segment D2; rupture of ampulla or distal CBD
5

V
Massive duodenopancreatic injury; devascularization of duodenum
5






[NB: Management of grade 5 injuries is not universally accepted and should be tempered by common sense, like wide drainage may be the most appropriate initial intervention followed by delayed reconstruction, with Whipple procedures being reserved for the stable patient with destruction of the pancreatic head accompanied by destruction of the ampulla]

7. What is the sequence of approach used to decrease intracranial pressure in patients with severe closed head injury? [Trauma - 5th Ed. (2004)]

TABLE 19-3. CONTROL OF ELEVATED INTRACRANIAL PRESSURE
EEliminate factors that can elevate ICP
• Straighten head to prevent kinking of jugular vein, raise head of bed slightly (no more than 30), eliminate hypercarbia, etc.
• Repeat CT (if not done recently) to look for mass lesion requiring surgical intervention.
T Treat pain with narcotics, e.g., morphine 2-10 mg IV for adults. Sedating effects may also help lower ICP. If response inadequate: consider benzodiazepines or propofol infusion (watch blood pressure).
I If ICP still elevated: neuromuscular blockade. Monitor depth of paralysis with nerve stimulator.
Note: try to hold sedation and paralysis at least once a day (such as before morning rounds) so that a valid neurologic examination can be performed.
If ICP still elevated: drainage of cerebrospinal fluid (CSF) via ventriculostomy.
If CSF drainage fails or is not possible: mannitol 0.25-1.0 g/kg bolus. May repeat prn as long as fluid balance is followed closely and serum osmolality stays below 320 mOsm/L.
If ICP elevation persists: may try mild hyperventilation (keeping Paco2 > 30 mmHg), especially if cerebral oxygenation is monitored by Sjvo2 catheter and/or by Pbto2 monitor.
Next step: pentobarbital-induced coma. Meticulous attention must be paid to avoiding arterial hypotension. Consider having pressors hanging and ready to be infused as pentobarbital is given.
Other treatments:
• Hypothermia was not beneficial when tested in a multicenter trial, but it is possible that select subgroups of patients may benefit.
• Decompressive craniectomy may be an option in some cases (especially with unilateral pathology), but this treatment still awaits validation in a rigorous trial.



8. What are some indications for Emergency Department thoracotomy? (www.trauma.org) [NB: ED thoracotomy is a costly and drastic episode of drama best reserved for patients with rapid deterioration in the ED, or who have undergone cardiac arrest just before arrival with signs of life still present. Patients who have undergone prolonged CPR or patients with blunt trauma who sustain cardiac arrest at the scene should not have this procedure done. I prefer to teach residents on live patients, not dead ones].

1. Penetrating thoracic injury &;
- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-
hospital)
- Unresponsive hypotension (BP < 70mmHg)
2. Blunt thoracic injury
- Unresponsive hypotension (BP < 70mmHg)
- Rapid exsanguination from chest tube (>1500ml). [NB These patients should be expediently transported to the OR. The results of ED thoractomy for blunt trauma patients are uniformly dismal. See previous comment]


9. Describe the management options in a patient with a grade 4 splenic injury?
[Trauma - 5th Ed. (2004)]

Grade IV splenic injury =
Hematoma: ruptured intraparenchymal hematoma with active bleeding

Laceration: laceration involving segmental or hilar vessels producing major devascularization (> 25% of spleen)


Treatment options include:
1. Operative management – Pre-op abx. Trauma laparotomy. Pack off the abdomen in all 4 quadrants and localize injuries and bleeding. Splenectomy or splenorrhaphy for injured spleen. Postoperative immunizations to reduce incidence of OPSI.

2. Non – Operative management – Appropriate patient selection is the most important element of nonoperative management. Although it is certainly true that nonoperative management is possible in a large number of patients with splenic injury, emergency surgery is still sometimes necessary to stop life-threatening hemorrhage. Of paramount importance is the hemodynamic stability of the patient. Assuming hemodynamic stability, the other important prerequisite is the patient's abdominal examination. In patients who are awake and alert and can cooperate with a physical exam and provide feedback, it is important that they not have diffuse, persistent peritonitis. Nonoperative management should only be undertaken if it will be possible to closely follow the patient. ICU admission with serial blood draws, checking Hematocrit and serial abdominal exams is best. Reported success rates for nonoperative management are 95% or higher for pediatric patients and approximately 80% or higher in adults
[NB: CT scanning is mandatory in these patients and should be repeated if there is any suspicion of a bowel injury]

10. Name some late complications of non-operative treatment of blunt hepatic injuries. How are they managed? [Trauma - 5th Ed. (2004)]

Bile Leaks: Bilomas or bile leak can occur in 3 to 20% of nonoperatively managed patients. Evidence of bile leak by HIDA scan does not mandate intervention. Abnormal liver function tests, abdominal distention, and intolerance to feeding may all indicate a bile leak. CT scan evaluation with drainage percutaneously usually remedies the problem completely. Bile leaks or bilomas are drained percutaneously, sometimes for up to 4 to 6 weeks, and they nearly always resolve without ERC or other decompressive maneuvers.

Abscess: Abscesses, such as biliary collections, can often be managed by CT-guided drainage catheters. However, if the patient fails to improve with drainage and antibiotics, wide surgical drainage should be performed.

Hemorrhage: Using the same criteria that was originally utilized to manage these patients nonoperatively, namely hemodynamic stability without ongoing blood loss, patients with delayed hemorrhage can undergo hepatic angiographic embolization and observation with success. Therefore, it seems that delayed hemorrhage is actually a rare and manageable complication.

Compartment syndrome of the liver: Operative drainage

Hemobilia: The authors concluded that hepatic artery pseudoaneurysm with hemobilia is predisposed by a bile leak and that angiographic embolization was appropriate for patients without sepsis and with small cavities. However, formal hepatic resection or drainage, after angiographic vascular control, may be necessary for septic patients or those with large cavities. Hemobilia is much less common with the prevalence of nonoperative management. With operative interventions of the past including large parenchymal suturing and vessel ligation, communications between vessels and bile ducts often occurred iatrogenically. Now that nonoperative care is practiced, hemobilia is rare.