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- 1^st 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

5/1/17 TOPIC course