1. High Yield Topics of the ABSITE: Trauma/Critical Care
Jacob D. Edwards, MD
PGY5-General Surgery Resident
East Carolina University
Vidant Medical Center

2. Outline Trauma Critical Care Head Ventilator management Neck ARDS
Chest
Hemodynamic monitoring and parameters
Abdominal
Shock
Retroperitoneal
Cardiovascular Pharmacology
Pelvic
Nutrition
Extremity
AKI/ARF
Pregnacy
Indications for hemodialysis

3. Trauma

4. Head Trauma GCS calculation Indications for Head CT Penetrating trauma
Feature
Response
Score
Motor
Follows Commands 6
Localizes to pain 5
Withdraws to pain 4
Flexion w/ pain (decort) 3
Extension w/ Pain (decer) 2
No response 1
Verbal
Oriented
Confused
Inappropriate words
Incomprehensible sounds
Eye opening
Spontaneous
Open to command
Open to pain
GCS calculation
Indications for Head CT
Penetrating trauma
CSF from Nose or Ears
Hemotympanum
EtOH/Drugs
AMS or depressed GCS
Focal Neurologic signs

5. Head Trauma Epidural hematomaMiddle meningeal artery
LOClucid perioddeterioration
Operate for MLS>5mm
Subdural Hematomabridging veins/venous plexus
Operate for MLS >1cm
Intraventricular hemorrhage
Cause Hydrcephalusventriculostomy
DAI
MRI>CT
If elevated ICPcraniectomy
Photo credit: Medscape.com

6. Head Trauma ICP Monitors CPP = MAP – ICP
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 , Osm
Mannitol (loading dose 1g/kg, then 0.25g/kg q4H)
Sedation
Paralysis
Barbiturate coma
Craniotomy/Craniectomy

7. Head Trauma Common Associations
Basilar Skull fxraccoon eyes/Battle’s sign (facial nerve injury)
Temporal Skull FxCN VII (geniculate ganglion) and VIII
Brain injuryincrease tissue factor releasecoagulopahtic

8. Neck Trauma C-spine MRI to eval cord/ligamentous injury
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 fxcord injury w/ ligamentous disruption
MRI to eval cord/ligamentous injury
Surgical decompression of cord if progressing neuro symptoms or open fractures

9. 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

10. Neck Trauma Esophageal Injury (hard to find/diagnosis)
EGD, Barium swallow (get both)
Contained Injuries can be observed
Noncontained Injuries
Primary closuresmall and minimal contamination
Wide drainage  (Cervical esophagus) extensive injury or contamination (Left Side approach)
Chest tube, spit fistula w/ delayed esophagectomy (thoracic esophagus)

11. Neck Trauma Tracheal or Laryngeal injury Thyroid injury
Secure airway (cric)
Take to OR—convert cric to trach
Thyroid injury
NO thyroidectomy, just drain

12. 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

13. 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

14. Chest Trauma Diaphragm Left most common
Air-fluid level in chest from herniated stomach (CXR)
Operative approach
<1 weektransabdominal
>1 weekTransthoracic
Depending on size may need mesh repair

15. 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 injuryendograft
Treat other life-threatening injuries first (i.e. if +fast and hypotensive gets ex lap first)

16. Chest Trauma Penetrating “Box” injuries
Dx: pericardial window/FAST, bronchoscopy, esophagoscopy, barium swallow
+pericardial FASTPericardial window if bloodSternotomy
Penetrating Thoracoabdominal injuries
Laparotomy/laparoscopy

17. 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

18. Chest Trauma Operative Approcaches Median Sternotomy Right Thoracotomy
Ascending Aorta
Innominate Artery/Vein
Right mainstem bronchus
Proximal Right Subclavian
Trachea
Proximal Left Common Carotid
Proximal left mainstem bronchus
Heart
Upper 2/3 of the esophagus
Midclavicular incision w/ resection of medial clavical
Right hemidiaphragm
Left Thoractomy
Distal right subclavian artery
Distal left mainstem bronchus
Descending Aorta
Lower 1/3 of the esophagus
Left subclavian artery

19. 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 lacerationsresection of segment
Mesenteric hematoma
Explore if expanding or if >2cm

20. Abdominal Trauma Colorectal
Right colon and Transverse colon primary repair or resection with anastomosis
Left colonprimary repair or resection
If in shock or has extensive gross contamination temporize with end colostomy/mucus fistula or diverting loop ileostomy
High rectal
Intraperitonealrepair defect, presacral drainage, diverting ileostomy
Extraperitoneal general not accessablediverting ileostomy
Low rectal
Repair transanally

21. 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
Posteriorangio
AnteriorOR

22. Abdominal Trauma CBD injury Portal Vein 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

23. 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

24. 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 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 portionjejunal serosal patch, pyloric exclusion, GJ
Feeding and draining jejunostomy, wide drainage, NGT

25. Retroperitoneal Trauma
Pancreas
CT: edema or necrosis of peripancreatic fat
Contusion: if already in OR leave drain
Distal pancreatic duct injurydistal 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

26. Retroperitoneal Trauma
Renal
>2cm injury Lower 1/3 reimplant onto bladder
Hematuria  CT with delayed phase imaging
<2cm mobilize and primary anastomosis over stent
Anatomy  VAP (vein, artery, pelvis)
Leave drains
Blood supply
If already in OR
Upper 2/3 = medial
Blunt mechanism hematoma—explore only if expanding
Lower 1/3 = lateral
Penetrating mechanism hematoma— explore all
Bladder
Extraperitonealfoley 7-14 days
Ureteral
IntraperitonealOR 2 layer closure, foley
>2 cm injury Upper 2/3 temporize with nephrostomy, tie off ureteral ends

27. Extremity trauma

28. 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 ruptureposterior 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

29. Critical Care

30. Pulmonary Compliance PEEP (affects oxygenation)
Decreased with: ARDS, fibrotic lung disease, pulmonary edema, atelectasis
PEEP (affects oxygenation)
Alveolar recruitmentimproves FRC
Excessive PEEPpreload reduction and reduction in CO
Rate and Volume affect CO2 (ventilation)
6cc/kg of IBW = set TV for lung protective strategy
FiO2 <60% to reduce free radicals
Barotraumaplateau pressure >30, peak pressures >50
Dead Spacelow CO, PE, pulm HTN, ARDS
ARDS
Due to PMNs *Berlin Criteria: Timing w/in 1 week, CXR-bilat
Increased A-a gradient whiteout, cardiogenic cause r/o, PF ratio <300
Pulmonary shunting <300 = mild; <200 = mod; <100 = severe

31. Pulmonary Aspiration Pulmonary vasoconstriction Pulmonary vasodilation
pH<2.5
Medelson’s syndromechemical pneumonitis
Pulmonary vasoconstriction
Hypoxia, Acidosis, TXA2
Pulmonary vasodilation
PGE1, Prostacylcin, bradykinin, alkalosis

32. Pulmonary Function FRC is decreased by reduction in compliance -ARDS
-Atelectasis
-contusions
Restrictive Lung Disease
--Low TV
--Low RV
--Low FVC
--Normal FEV1
Obstructive Lung Disease
--high TV
--High RV
--normal FVC
--Low FEV1

33. Cardiovascular Shock Normal Parameters
CO = 4-8
CI = 2.5-4
SVR =
PCWP = 7-15
CVP = 5-9
PAP = 20-30/10
SvO2 = 70-80
Increase SvO2  shunting, sepsis, cirrhosis, cyanide toxicity
Decrease SvO2 low hemoglobin, cardiogenic shock

34. Cardiovascular Oxygen Delivery CaO2 (arterial O2 content)
CO x CaO2 x 10
CaO2 (arterial O2 content)
Hgb x 1.34 x O2 sat + (PaO2 x0.003)
Hemoglobin most important factor
Oxyhemoglobin dissociation Curve
Right shift (unloading)
Hypercarbia, fever, 2,3-DGP, acidosis

35. Cardiovascular Receptors (all g-protein coupled) Drugs
Alpha 1&2vascular smooth muscle contraction
Beta 1myocardial contraction, HR
Beta 2relaxes vascular smooth muscle
Doparelax renal and splanchnic smooth muscle
Drugs
Dopalow dose dopa, mod dose Beta, high dose alpha
DobutamineBeta-1
PhenylephrineAlpha-1
Norepi/EpiBeta 1, Alpha 1&2

36. GI/Nutrition Respiratory Quotient ColonocytesSCFA (acetate/butyrate)
>1.0overfeeding
Enterocytesglutamine
1.0 carbohydrate oxidation
Chyle leakMCFA diet
0.8protein oxidation
Essential FAalpha linolenic and linolenic (omega 3 and 6)
0.7fat oxidation
<0.7starvation (ketosis)
Fat Soluble VitADKE
Calories
Goal 25 kcal/kg/day
Refeeding
Fats  9kcal/g
Protein 4kcal/g
EtOH, Malnutrished, Starved
Carbs4kcal/g
Hypophosphatemialow ATPRespiratory distress
Dextrose3.4kcal/g

37. Renal AKI w/ oliguria Indications for HD Renal toxic drugs
FeNA <1% pre renal; >3% renal
Indications for HD
Acidosis, Electrolyte abnormalities, Intoxication, Fluid overload, Uremic encephalopathy
Renal toxic drugs
Aminoglycosides
Myoglobin (alkalinize the urine)
Vancomycin
Contrast dyes

38. Thank you!