Notebook

5/5/17 TMD Course Notes

9/13/17 AAST Notes

B-blocker in TBI

-propranolol at SICU admission decreases mortality without bradycardia

-no difference in hypotensive episodes

-propranolol IV 1mg q6hr (from separate study) — 40mg BID

-length of stay is longer for Bblocker, may be due to survival

Timing of rib stabilization

-EAST conditionally recommends for flail chest

-Later= 3-7days to see if patient fails non-op tx

-early= 0-2 days based on clinical/radiographic features predicting failure--

Fail chest (>= 3 consecutive rib fractures with at least 2 fractures each), >= 3 severely fxr ribs (bicortical displacement), volume loss.

-early group has less prolonged mechanical ventilation, less pneumonia.

-other study reports contraindications as pulmonary contusion requiring mechanical ventilation, other injury requiring prolonged mechanical ventilation.

High Grade Renal Trauma

-Grade 3-5 is high grade

-60% nephrectomy rate for grade 5

-grade 5 nephrectomy rate has not dropped significantly over time

-penetrating injury has higher nephrectomy rate

Cribrari modification

-want < 35% overtriage, want < 5% undertriage

-Need for trauma intervention (NFTI) may be a better indicator of appropriate triage

-NFTI= PRBC in first 4 hrs, discharge from ed to OR in 90min, ED to IR, ICU stay > 3edays, placed on vent outside of procedural anesthesia.

-use NFTI to analize the level 1 overtriages and other undertriages.

Red book (resources for the optimal surgical care)

Stop The Bleed

-B-Con course

-texas is #1 in instructors and in classes.

-Blueprint from UPMC:

1) identify need (active shooter, mass casualty, MTA, industrial accidents, MVC)

2) expert consultation

3) find people who know people who can advance program further, can use high volume non-trauma centers. Include EMS/fire/police and educators/schools. Include active community groups

4) build team (steering commitee) from region. For subcommtties in education, law enforcement, and educations

5) fundraising: look at hospital outreach budget, hospital foundations, philanthropy

6) implementation: find passionate advocates (prior regional events, law enforecement, EMS liaison). Train-the-trainer is high yield. Advertise the effort, can use the media. Can use a county-by-county roll out using a hospital and EMS in each region. Can get police officer continuing education credit.

9-14-17

Sepsis and advanced age

-age is strong risk factor for adverse outcomes

-age >= 55 is advanced age

-aged have delayed immunorecovery, greater organ dysfunction, increased catabolism.

Emergency general surgery volume and hospital mortality

-7 procedures account for majority of inpatient mortality: colon rxcn, sb rsxn, choley, bleeding PUD, LOA, appy, laparotomy

-technical complications had no difference from low to high volume hospitals

-low volume had higher sepsis, pulmonary complications, in patient mortality

**Idea**

-look at mortality/hospital stay/narcotic usage with hip fxrs admitted prior to and after Emcare start

REBOA versus Resuscitative Thoracotomy

-overall, REBOA has 6% complication versus RT 4% complication

-REBOA seems to be used more in blunt injury

-REBOA had increased survival out of ER and survival to discharge

-47% or REBOA need femoral cutdown

-REBOA outcomes improved when used prior to arrest.

Timing of venousthromboprophylaxis in severe pelvic fracture

-PE can be thromboembolic or primary pulmonary thrombosis

-pelvic fractures have high risk of bleeding and risk of DVT

-Early VTEp after TBI gives lower dvt and pe

-LMWH ma have improved survival over UH

-early VTEp is <=48hrs after admission

-early VTEp gives lower mortality in pelvic fxrs and less VTE

Interrupted versus continuous closures of abdomen in emergency laparotomy

-Annals of Surgery 1983 with 571 randomized pts had no difference; multiple other studies showed no difference

-most of the studies were elective surgeries

-European Hernia Society guidelines: small bite, continuous, absorbable suture is the way to go; but cannot comment on emergency surgery

-Tolstrup showed decreased dehiscence with interrupted in emergency surgery

-Technique: 0 non-looped PDS, 1cm from edge and between stitches—why did the study use 1x1cm bites when 0.5x0.5cm gives less hernia.

-interrupted is slower, no statistical difference in outcomes (limited by followup and sample size).

EGS mortality in high quality trauma center

-looking at relationship between trauma mortality and EGS mortality

-EGS has 8x mortality compared to elective

-looked at facilities with 200EGS cases and > 400 trauma admissions

-7 procedures caccounted for 8% of all cases, complications, deaths, and cost

-hospitals with lower TQIP trauma mortality also have lower EGS mortality

ICU management of Geriatric TBI

ICP monitoring= give advanced warning

-CPP may need to be higher in older (>60yo)

-studies show dec mortality and inc mortality or no change survival with ICP

-BEST TRIP study (ICP v clinical/CT monitoring)= no change in outcome with monitoring

          -done outside US

          -ICP monitor gave more ‘efficient’ care with less interventions to dec ICP

-ACS TQIP and guidelines for management of severe TBI recommend ICP but don’t tell us who to place it in.

-Brain org= age>40, SBP<90 should have ICP monitor

Prognostic Models for Geriatric TBI

GTOS= specifically for geriatric trauma

-predicts in-hospital mortality

-requires ISS or AIS, not TBI specific

-GTOS II predicts disposition

Impact= predicts 6mo mortality and adverse outcome

-TBI specific

-overestimation of geriatric mortality

CRASH

-country specific

-TBI specific

-small overestimation of mortality

Palliative Care

-early provision of palliative care inc quality and length of life for life limiting conditions

-should not apply TQIP recommendation for not discussing prognosis in 1st 72hrs for geriatric TBI

-avoid #s in giving prognosis

-fluid situation

-address “palliative care bundle” daily

-Answer to pt/family Q’s: “it would surprise me if …” Ex ‘pt went home’

Helicopter versus ground transport

-helecopter advantages include speed, advanced capabilities, transfusions, airway management, experience.

-increased survival for abnormal RR (<10 or > 29), GCS < 14, hemo/pneumothorax even if helicopter transport takes longer than ground.

BIG= brain injury guidelines, modification below is being studied to minimize consults and resources

BIG-MaC 1= gcs 13-15, no focal neuro exam, no intoxication, no anticoagulation, no skull fracture, <4mm sdh, no edh, <4mm iph, <3 sulci and <1mm sah, no ivh

BIG-MaC 2= gcs 13-15, no focal neuro exam, yes intoxication, no anticoagulation, nondisplaced skull fracture, 4-7.9mm sdh, no edh, 4-7.9mm iph, single hemisphere or 1-3mm sah, no ivh

BIG-MaC 2= gcs any, yes focal neuro exam, yes intoxication, yes anticoagulation, displaced skull fracture, >8mm sdh, yes edh, >8mm or multiple iph, bi hemisphere or >3mm sah, yes ivh

Tx based on BIG-MaC score:

1-      No admission, 6hr ER observation, no repeat CT, no NSG consult,

2-   Hospital admission to floor, 24hr q8h observation, no repeat head CT, no NSG consult, GCS 15 for discharge

3-      Standard care

ICP monitoring

-67-55 yo may have increased mortality

-NTDB suggest < 45 yo have increased survival

-3rd brain trauma foundation guidelines state: ICP should be monitored in all salvageable patients with severe tbi (GCS 3-8) and abnormal CT scan

-4th edition state it only decreases in hospital and 2 wk mortality

Early Complications of Bariatric Surgery

Leaks

RYGB= from tension on anastomosis; w/in 7d of OR

          Dx: tachycardia > 120 à or

          -CT with 100cc contrast 60-80% sensitive

          -flouro gastrgraffin then thin barium

          -above tests look at GJ anastomosis only

          Tx: stable can be drained (95% close w/in 1mo); TPN, NPO

          -Unstable (HR >120) à OR

          -wide drain

          -repair leak if able (omental patch with interrupted sutures)

          -Gtube in remnant stomach

          -control sepsis

Sleve= more common, less blood supply, higher pressure; can be associated with twist/kink/stenosis; most @ angle of His

          Dx: tachy > 120; flouro

          Tx: drainage / repair for unstable

          -endoscopic stenting early can help with decreasing king (w/in 1 week)

Stenosis

RYGB

    Dx: inability to swallow, can’t pass EGD scope (<9mm)

    Tx: IVF, thiamine, neurology exam

    -goal 10-16mm anastomosis

    -only increase 2-3mm at a time

Sleve= may be twist/kink/stricture

    Dx: flouro & EGD may be negative

    Tx: stricture à balloon or surgical myotomy

    -Twist/Kink à conversion to RYGB or total gastrectomy

Bleeding

-EGD to dx and tx; could be GJ or JJ

Balloons are meant to come out after 6mo.

Late Complications of Bariatric Surgery

Band

-Obstruction= vomit, PO intolerance, severe GERD

          Dx: PA AXR (Phi Angle= spine to band angle nl 45-58degrees, 10:00 to 2:00)

          -slipped band= stomach slipped under band, phi angle > 60degrees, can result in ischemia

          Tx: deflate balloon (remove all fluid with 25g needle to port (max 4-13cc fluid)

          -band erosion= subtle pain, GERD, slow erosion, not emergent, can see infection;

          Tx: deflate balloon and endoscopic removal

          -emergent OR for unresolved pain, obstructive sx.

          -lesser curve of stomach is safe zone to cut band

Sleve= late complications are rare

RYGB  (common internal hernia, PUD/marginal ulcer, gallstone

-SBO= dilated gastric remnant needs OR, gtube

          -no blind NG tube

          -Start exploration @ terminal ileum to approach retrograde

          -close defect

-Marginal Ulcer= usually at GJ; epigastric pain

          -Risks are smoking, NSAID, pouch dilation

          -Emergent OR indications similar to PUD

                         -do graham patch or modified patch

                         -tx ulcer with PPI, stop smoking, stop NSAID; can address ulcer surgically later

-Biliary disease options include PTCD, CBDE, transgastric ERCP (put hole in gastric remnant, secure with stitch to hold through abdominal wall, place scope through abdomen)

SESAP Notes 3/5/22

-Pressors

• NE is pressor of choice for sepsis

  • a-adrenergic vasoconstriction > B-adrenergic inotrope

• Dopamine= inotrope from B-adrenergic > a-adrenergic vasoconstriction

• Phenylephrine= pure a-adrenergic vasocontriction

  • no tachyarrhythmia

  • can have reflex bradycardia if no sympathetic tone (spinal injury)

  • can be used PIV

• Vasopressin= 2nd line in sepsis

• epinephrine= acts at all 5 adrenergic receptors

3/30/22 Trauma Conference, Las Vegas

• TXA 2g bolus once

• vascular repair:

  • 5-0 proline

  • 10U/ml heparin saline

  • Fogarty up and down

  • Shunt

  • Use 2 sutures

  • Longitudinal lacerations should use patch

• Venous injuries:

  • Simple= repair

  • If 50% narrowing may be better to luggage

  • Stable but destructive = ligate

  • Physiologically strained= ligate or shunt or compress

  • Poorly tolerate ligation:

    • R renal close to kidney

    • SMV

    • PORTAL 

    • BILATERAL Ij

    • Suprarenal ivc

• Dislocations 

  • Shoulder- relocation with external rotation

  • Elbow- usually posterior/posterior lateral; reduce with traction on elbow

  • Hip- posterior most common; AVN risk if not reduced within 6hrs; CT postreduction; reduction needs paralysis

  • Knee- aw peroneal n (foot drop), vascular injury; longitudinal reduction

  • Exfix can decrease fat emboli, less risk of pulmonary second hit

• Thoracic damage control 

  • Pack thoracic apex

  • Right atrial line

  • Hilar clamp

  • Lung twist

  • Tractotomy- oversew bleeding and air leak

  • Hilar injuries may need lobectomy; has high mortality but improved with early decision

  • Wound near coronary- sew beneath

  • Trachea

  • Esophagus- drain

• CPR in acute trauma

  • Chest compressions Not of benefit in penetrating trauma and traumatic cardiac arrest

    • No benefit for empty heart

    • If mechanism of arrest is unclear, chest compressions may be of benefit (MI)

  • Pressors no use until restore volume, don’t use bicarb

  • Traumatic Cardiac arrest

    • STOP CPR

    • Airway

    • Control bleeding

    • Relief of tension ptx

    • thoracotomy

    • EtCO2 can guide resuscitation 

• Size of chest tube for hemothorax

  • 50% less pain with 14F pigtail v 28F chest tube 

  • Pigtail has fewer VATS for retained HTX (Rhee 2018)

  • VATS should be </= 4d (EAST)

• Difficult duodenum

  • Posterior bleeding ulcer

    • From: 

      • Posterior superior and ant superior pancreaticoduodenal

      • GDA

      • Dorsal pancreatic a

    • Ligation risks pancreatic duct

    • Surgical Tx

      • Longitudinal incision distal stomach through pyloris

      • 4-quadrant sutures to cover above arteries

      • Pyloroplasty

  • Giant duodenal blowout

    • Dx: >2cm

    • Tx:

      • restor/repair continuity

      • Most require antrectomy, divide stomach at incisura

      • Wide Kocher

      • Elevate duodenum leave ulcer bed in situ

      • Close duodenal stump in 2 layers if cant do d1 reconstruction

      • Plan nutrition

        • Large stam with 3 tubes through stomach

        • 1- prograde feeding

        • 1- retrograde edrainge

        • 1- gastrostomy

      • PPI unless truncal vagotomy

      • Contain

• Hemorrhage control

  • Duval clamp - can grab apex of heart to elevate

  • Balloon tamponade of liver with penrose drain and red-rubber

  • Supraceleiac aorta clamp

    • Penrose to stomach and pull esophagus

    • Divide diaphragm crus at 2:00

    • Go around esophagus to put clamp on aorta

• VTE prophylaxis in TBI and spinal cord injury

  • Low risk injury safe for VTEp in 24hr

  • High risk injury safe for VTEp in 72hr

  • Spinal cord

    • VTEp < 48hr does not increase cord hematoma

    • VTEp within 48hrs postop from spinal cord surgery

    • No IVC filter for prophylaxis

• Solid organ injury VTE prophylaxis

  • Splenic, liver, renal laceration NOM equally effective for LMWH <3d or >3d prophylaxis

  • 2019, Skarupa LMWH in <48hr does not increase transfusion or NOM failure

  • Waiting > 48h increases VTE

  • Optimal is < 48h after admission

    • Caution with grd IV and V injuries because less data

    • AAST recommends 24-48hr

• Ortho VTE prophylaxis

  • Half hip fxr VTE was > 6wk postop

  • ACCP guidlelines rx against asa alone

  • Hip

    • Start on admission

    • Stop 12hr preop

    • Restart 6-12hr postop

    • Duration 6wk

• Vascular injury VTE prophylaxis

  • Caprini predicts risk of VTE

    • Can use to determine who needs VTEp at home

    • Caprini > = 9 give lovenox 30d

    • 5-8 10d postop

    • 1-4 no vtep on discharge

• Pedi VTE prophylaxis

  • Poor data

  • J trauma 2017 

    • Give for > 15yo  or ISS>25 and postpubertal

  • J trauma 2021;91: 605-611 scoring system for pediatric trauma vtep decision

TBI and Spinal Cord

• ICP and EVD

  • Indications for ICP monitoring

    • All salvageable patients severe TBI (gcs 3-8) and abnormal CT

    • Normal CT if >= 2 age > 40 posturing , sbp < 90

  • Goals

    • SBP >=100 50-69yo

    • SBP >= 110 for 15-49yo or > 70

    • Tx ICP > 22

    • CPP 60-70

  • When to crani

    • 1hr ICP > 25?

• Target MAP after sci

  • MAP 85-90 for first 7d after surgery concensus

  • Currently being studied

  • Vasopressor should be NE

  • Penetrating injuries may have higher risk of cardiac abnormalities from vasopressor than benefit from targeted MAP

  • Optimal sbp varies with age

• Palliative care

• Decompressive craniectomy

  • Fixed pupils has poor prognostic significance with craniectomy

  • For refractory ICP after Teir 1 and Teir 2 interventions

  • Impact TBI calculator gives prediction for 6mo

• TBI advanced monitoring

  • PbtO2 

  • Lactate:pyruvate > 40 a/w poor outcomes

ICU

• ICU nutrition

  • Assessment of state on ad mission

  • Assessment of needs

    • Needs ~ 25-30kcal/kg

    • Ireton-Jones & Penn state equations

    • Target 60% of estimated energy needs in first 5d of icu care

  • Early protein improves survival

    • Rx 1.2-2g/kg/d (higher obese, burn, trauma) = 2k/kg/d protein need

  • TPN / PPN

    • Start on arrival for severely malnourished

    • Start if unable to obtain 60% on energy needs in 1st week

  • Immune enhancing diets are recommended for surgical/trauma in 1st week

  • Gastric v postpyloric

    • No difference in aspiration or PNA

    • Start gastric if not problem with gastric emptying

  • Gastric residual

    • Most agree that 500ml is too high

  • Perioperative / NPO p MN

    • CLD up to 2hr prior

    • Light meal 6hr prior

    • Tube feed 2hr prior to induction

    • Small bowel tube feed continue until OR

  • Inotropic support

    • 12.14mg/min NE or equivalent is ok for continued TF

      • Less tolerance with dopamine

      • Start slow

      • Ok once improving

  • Prone

    • Ok to use, postpyloric if not tolerating

  • No difference in high/low intake in acute phase of illness – target 60% of calculated energy needs.

  • Early feeding, including postop anastamosis

• Hemodynamic monitoring

  • FLoTrac

    • Not accurate in sepsis, liver failure, pressors

    • Need good aline tracing

  •  TEG / Rotem

    • 50% reduction in mortality

• Sedation in ICU

  • PADIS guidelines 2018 update

    • Light sedation preferred RAS >= -2

      • Eye open to voice

      • Shorter time to extubation

      • Less trach

    • SAT and nursing protocolized sedation no difference

    • Non-benzo preferred

    • Choice of sedative

      • Cardiac

        • Propofol gives shorter time to extubation

      • Med/surgical

        • Propofol recommended (small risk of self extubation)

        • Precedex less delirium at 48hrs

    • Restraints

      • Can be reduced by early mobility

  • Propofol v precedex

    • Not much difference

    • may be better vent synchrony, delirium with precedex

    • Beware propofol infusion syndrome after 48hr (met acidosis, renal failure, rhabdo)

  • Prevention of delirium

    • Precedex may help prevent

  • Tx of delirium

    • No difference in haldol v olanzapine

    • Lack of benefit for haldol or ziprasodone for hypoactive delirium

    • Precedex decreases vent

  • Sleep

    • Ramelteon has sleep and decreased delirium

    • Melatonin (off label, may help)

• MIcrobiology

  • ICU sepsis incerasing gram - 

  • 30% culture positive sepsis die

  • Treating sepsis (no longer early goal directed therapy)

    • Mortality inc 6% every hr delay for appropriate abx

  • EVD infections

    • Decrease with extended IV abx prophylaxis and silver coated catheter

  • Necrotizing soft tissue infection

    • Prolonged abx not needed

• Delirium

  • 50% of ICU pts develop

  • Subtypes

    • Hypoactive (lethargic) 44%

    • Mixed (fluctuate) 55%

    • Hyperactive (agitation) 2%

  • Predictor of long term cognitive impairment

  • Risk factors

    • Older, cog impairment, depression, smoking, hearing/vision impared, high ASA score

    • Restraints, catheters, benzos, sleep deprivation, hypoxemia, sepsis, anemia

  • SCCM screeing

    • CAM-ICU

      • Sensitive and specific even for ventilated

    • ICDSC

  • Tx

    • Manage pain

    • SAT, SBT

    • Sedation

    • Early mobility

    • Do not routinely use antipsychotics to treat (low quality evidence)

    • Use precedex

• Ambulating in ICU

  • Post ICU syndrome= new and persistent decline in physical, cognitive, mental health function

  • Decreased duration of ICU delirium by 50%

  • Improves mortality

  • Mobility protocol based on level of consciousness

    • 1- passive ROM

    • 2- progressie active assistance

    • 3- ambulate

• GI bleed prophylaxis

  • Risk factors for bleeding → Rx prophylaxis

    • ISS >= 16

    • Spinal cord injury

    • Age > 55

    • Coagulopathic

    • Mechanically ventilation

    • TBI

    • Steroid

    • Acute renal failure

    • Polytrauma

    • Sepsis

  • Grindlinger 2016- H2 blocker or PPI has increased pna over sucralfate

  • Aseeri- Cdiff associated with PPI use

  • Marik 2010- H2 blocker only decreases bleeding in pts not on enteral nutrition; otherwise can increase PNA and mortality

  • SUP ICU trial Krag 2018- PPI v placebo, no difference in mortality

  • PEPTIC RCT- 

  • Rx = Stop H2blocker once enteral nutrition started

• Ventilators

  • Non-invasive

    • HFNC best for hypoxia

      • Works for mild hypercapnea

      • FIO2 21-90%

      • May have some PEEP

      • Can be 60L/min

    • CPAP / BIPAP

      • Plan 2-4hr on, 1hr off and repeat

  • ARDS

    • Prone

      • Decrease dead space

      • Wet lung increases negative pressure zone to target recruitment

      • PROSEVA trial 2013- P:F ratio < 150 in 1st 72hrs, must be early

    • Paralytic

      • Only 48-72hrs to optimize

      • Use early to decrease mortality

      • Can use as soon intubation to optimize (<48hr)

    • PEEP

      • Use a peep/FiO2 table

    • Driving pressure = plateauP - PEEP

      • Keep 7cmH2O or below

      • Better predictor of mortality than PEEP or plateauP

    • Do all above prior to consider ECMO

  • VAP

    • Dx with >= 3

      • Temp > 30 or K<M 36

      • Wbc > 10

      • CXR change

      • Purulent sputum

    • Bronch in 24hr

    • Start abx

      • < 7d ICU - Unasyn 3g q6

      • >7d vanc 20mg/kg q12 + cefepime 2g q8

    • If Cx negative (<100k) after 72hr, stop abx

    • Decreases abx

• Low value practices in ICU

  • Choosing Wisely campaign:

    • Avoid regular interval testing

    • Dont transfuse for HB > 7

    • No TPN in 1st 7d (unless severely malnourished)

    • Daily SAT

    • Off or comfort measures

    • Get rid of catheters / drains

    • Extubate ASAP

    • Anx stewardship

    • Mobilize ICU pts

    • Care according to pt goals

  • Trauma low value

    • CXR after chest tube removal in pts not on vent who can communicate Sx

    • ICU admissionfor mild TBI not on anticoagulation

• Assessing volume status

  • Negative fluid balance increases survival with sepsis

  • When to give fluids

    • Passive leg raise

    • Inc lactate

    • Pulse pressure variation

  • NS= Acidic, not balanced, reduces renal perfusion

  • Albumin being looked at for some benefit in septic shock

Acute Care Surgery Emergencies

• Hostile Abdomen

  • Tx

    • 1- aggressive source control, manage sepsis, resuscitation

      • 
        

      • Manage fluid

      • Nutrition

    • 2- define anatomy, feeding access, nutritional assessment

      • How much bowel available for enteric feeding

      • If < 120cm small bowel, at risk for short bowel syndrome

      • <75cm needs TPN long term

      • Serum citrulline < 20uMol/L predicts permanent intestinal failure

      • Wound management

        • “Wound manager”

        • Fistula VAC

        • Suction drains, 10-10s, dry kerlix

    • 3- metabolic support

      • 20-30kcal/kg/d calories, 1.5-2.5g/kg/d protein

      • Zn, 5-x10x VitC

      • Want positive nitrogen balance

      • Feed distal limb of fistula

      • Reduce fistula output

        • Antimotility, bulking, antisecratory

        • Clonidine, octreotide 100-250mcg sq TID, sucralfate, PPI, fiber, pancreatic enzymes.

• Colorectal cancer emergencies

  • Large bowel obstruction

    • Do you have time for workup

      • Stenting can bridge to surgery; risk perforation; not for the rectum due to stent migration

    • Subtotal colectomy

      • For distal obstruction with cecal perforation

      • For synchronous resections

  • Malignant perforation

    • Drain, divert, delayed resection if possible

    • If can’t get negative margins, don’t plan resection

• Disaster gallbladder management

  • Grading

    • Tokyo Guidelines (TG2018)

      • Mild- healthy pt, no organ dysfunction, mild inflammation on imaging

      • Moderate- any

        • Wbc > 18k

        • RUQ palpable mass

        • >72hr sx

        • Marked inflammation on imaging (gangrenous, abscess, biliary peritonitis)

      • Severe- organ dysfunction

        • Pressor, AMS, hypoxic, Cr > 2, INR > 1.5

    • AAST grading

      • 1- acute chole

      • 2- gangrenous

      • 3- local perf

      • 4- abscess or fistula

      • 5- free perforation

    • If place cholecystostomy tube, don’t operate w/in 9d due to inc complications

    • Parkland scale is intraoperative grading

  • Plan

    • Start laparoscopic

    • IOC 

    • Conversion to open

    • Lap assisted cholecystostomy tube

    • Bail

      • No chole

      • Subtotal cholecystectomy

        • Partial chole low recurrence

        • Open gb and leave back wall- 20 bile leak

• Esophageal injuries

  • Dx

    • Usually penetrating

    • FAST - if pericardial fluid, go strait to sternotomy (low likelihood of esophagus)

    • CXR- if htx treat that

    • CT- use tract of injury to look at esophagus risk for injury

      • Can determine level of injury

    • Scope or swallow for equivocal CT

      • Swallow- use for awake pt

      • Scope

  • Tx

    • Want tx within 24hr

    • Access

      • Higher or middle- right thoracotomy (5 or 6 rib)

      • Lower- left thoracotomy (7 or 8 rib)

    • Double lumen tube

    • Fix lung

    • Isolate injury, can take azygose v.

      • Dont forget the back wall

      • Expose muscular layer and mucosal layer

      • Close in two layers

    • Don’t need bougie - stenosis can be dilated later

    • Buttress if needed, can use pleural flap or intercostal flap if needed

    • Feeding- NG, Gtube all options

    • Stent alone

      • Minimal data

      • For small injuries, minimal leak, patients that won’t tolerate operation

• Pregnant emergencies

  • TV and MV increase in pregnancy, pCO2 is lower

  • 2nd trimester nl HR 10-15bpm higher

  • Blood volume increases

  • FAST less sensitive

  • Fetal monitoring

    • Most 4-6hrs

  • Abruption

    • Leading cause of fetal mortality after trauma

    • Dx on CT, US, contractions

  • Uterine injury

  • Preterm labor

  • Maternal cardiac arrest

    • Consider csection if unsuccessful maternal resuscitation after 4min

  • Appendicitis

    • Dx: US, MRI

    • Tx: OR; Nonoperative management not indicated

  • Cholecystitis

    • Dx: US; HIDA; HELP is on ddx

    • Tx early cholecystectomy

      • Safe in all trimesters

  • Biliary Colic

    • Often recur

    • Consider surgery 

    • 3rd trimester should wait due to preterm labor risk

• Complex Ventral Hernia

  • Primary repair has 50% recurrence

  • Don’t repair if BMI > 50

  • Tx:

    • Rives stoppa

    • TAR- transversus abdominus release

      • Mobilize posterior rectus

      • No large flaps

      • For > 10cm width

      • Retromuscular dissection, behind rectus, transect transversus fascia to mobilize transversus m. (MUST avoid n/v bundle going to internal oblique)

      • Want 5cm mesh overlap

• Difficult Ostomy

  • Site ostomy even in emergency

    • Through rectus sheath

    • Ostomy triangle

      • Umbilicus

      • ASIS

      • Pubic symphysis

    • May use upper abdomen in obese, thinner ab wall

  • Intra-ab - mobilize flexure, mesentery

  • Ab wall- proper siting, ab wall contouring, big enough hole

  • Gaining length

    • dissect close to mesentery

    • Mobilize retroperitoneally

    • Ligate a vessel with bulldog to see if bowel needs it

    • Pseudo-loop end colostomy

    • Pie crusting the mesentery to allow more length

    • De-fat sub q tissue

    • Alexis wound protector with crunch down ab wall

• Pediatric Trauma

  • Pediatric pancreas trauma- may be able to treat non-op

    • Dx: ERCP

    • Tx: non op for grd I-II and IV; grd III/IV may be best with OR?

  • Pediatric BCVI

    • Unteated carotid have CVA 30-64%

    • Untreated Vertebral a injury have CVA 10-50%

    • Screen in peds is low

    • Controversy in tx

• Less than Lethal Weapon Injuries

  • Baton Rounds= projectile (wood, rubber, plastic)

  • Bean bag rounds= 12g shotgun shell with lead shot in nylon bag

    • Tx

      • Wad and beanbag must be removed

  • Lachrymatory agents= tear gas

    • Tx: gets better with time, wash out

  • Acoustic control= 

  • Flash Bangs= instant light, 165db bang

    • Tx: supportive

  • Taser= sharp hooks deliver 50kV, 3.6mA

    • Tx: nothing unless have dysrhythmia (no need for obs)

• Limb reimplantation

  • Lower extremity

    • Rarely re-implanted

  • Upper extremity

    • Reimplant

  • Tx

    •  stop bleeding, can use tourniquet

      • 2hr- start irreversible nerve damage

      • 6hr- muscle damage

      • 12-24hr full digit survival

    • Bring the part

      • Ice water bath

      • Proximal injuries tolerate less ischemia time

      • Thumb is very important (ulnar digital a)

    • Restore blood

      • Shunt

      • Thrombectomy

      • Vascular reconstruction

      • Try to avoid pressors

    • Reduce fracture

    • Soft tissue 

      • Excise devitalized

      • Irrigate

      • IV abx

      • VAC

      • Preserve maximal soft tissue

• Minor TBI

  • Trauma ICU has less time in ICU than MICU/neuro ICU

  • BIG- brain injury guideline, safe for no NSG with mild TB

    • BIG1= observe 6hr

    • BIG2= admit

    • BIG3= NSG consult, repeat CT head

• Prehospital blood products

  • Plasma+blood gives best survival (compared to RBC v plasma v crystalloid)

  • If transport > 20min, there is benefit for plasma

• Ketamine

  • 0.3mg/kg= analgesia

  • 1mg/kg= sedation

  • 2mg/kg= anesthesia

  • 20mg bumps is quick analgesia dosing

Complications

• Tourniquets

  • Applied prior to shock give improved survival

• Geriatric trauma complications

  • Trauma Specific Frailty Index

  • Shock index

• Iatrogenic time management complications

  • REBOA

    • Do not use prehospital

    • No high grade evidence that it improves survival or outcome

  • Craniectomy

    • <2hr gives better outcome

    • Don’t do central line

  • Routine daily cxr in icu is not needed

• Gastric residual

  • If going to check, don’t stop unless >500ml/6hr

• Incision and exposures

  • Cricothyroidotomy

    • Too low hits thyroid

    • Too high may loose airway

    • Four finger technique= base at sternal notch and top finger points to cryo thyroid membrane

    • Trach hook helps immobile trachea

    • Use bougie

  • EC thoracotomy

    • Curve under nipple towards axilla

  • Duodenal exposure

    • Can’t use kochar to see distal 3d or 4d due to sma injury — need CattelBrash 

  • Iliac veins

    • Don’t transect iliac a

  • Distal external iliac a

    • Extend incision obliquely across inguinal ligament

  • Thoracoabdominal injuries

    • 25% get wrong cavity

    • Higher mortality for wrong cavity

    • If in doubt, go to abdomen

    • Right posterilateral thoracotomy 5-6th intercostal space (2 fingers below scapula) for upper/middle esophagus

• Contrast

  • High osmolar agents have higher risk of AKI

  • Iodixanol is iso-osmolar

  • Prevention of AKI

    • PRESERVE trial

      • No different in bicarb or NS or mucomyst

    • Can use NS, limit contrast dose, iso-osmolar contrast

• End of life order set

4/1/22 Rib Fracture Plating 

Studies

• Bulger, 1996. Elderly rib fxr mortality mortality increases 19% per rib

• Voggenreiter, 1998. Flail chest with pulmonary contusion not helped by orif— pul contusion not helped by orif. Excluded tbi. Had vent requirement. 

• Complications of rib fxr

  • 9yr 64% pain

  • 2mo 66% disability

• Tanaka. RCT. Fewer vent, trach, in quality of life

• Pieracci, 2015. IS values increase with orif. 

• Becks, 2019. Orif give improved mortality, vent, trach. 

• Cwisociety.org

  • >= 3 rib displaced 50%

  • Rib 3-10

  • Fix in 72hr

  • >= 2 Physiologic factors

• Prins, 2020. Rib fxr and TBI with orif had improved survival, PNA. No change in vent. 

• Indication for OR

• Orif in >80yo

  • Improved mortality, pna, narcotic use

Timing and indications for SSRF

• When

  • <72hr

  • Decreased or time, los, pna, trach

  • What comes first: spine, +/- long bone. 

• Indications

  • flail chest = clinical flail with paradoxical motion

  • radiographic flail with >/= 2 ribs with >/= 2 fxrs

  • chest wall deformity with > 30% volume loss

  • partial displacement >/= 3 levels

  • CWIS Guidelines

  • Use fracture map. Dieffenbaugher rib fxr mapping tool. 

  • Physiology: PIC score

    • Consider for any PIC >4. 

• Expanded indications

  • Consider if have reason to wash out chest

  • Post cpr

  • Displacement on follow up imaging

  • Failure of non op

Chest wall approaches

• 3d recon with/without scapula

• Measure ribs- cortical thickness

• Inframammary incision

  • High medial anteriolateral

• AnteroLateral incision

  • Serrated m is in the way (stabilizes shoulder)

  • Avoid Long thoracic n

    • Identify

    • Avoid high muscle splitting incision due to risk of injury (incise seratus anteriorly, 2-3cm posterior from anterior insertion) 

    • 
      

• Longitudinal

  • Medial fxrs (posterior)

  • Ausculatory triangle (lat/trap)

  • Mobilize skin flaps

  • Muscle splitting outside of triangle. 

  • Leave paraspinous muscles in place (they help fixation) - angle of ribs

    • Don’t fix medial to paraspinous

• For gaps >1cm recommend ortho consult for prosthetic due to risk of non union

• Posterior and anterior fxrs do 2 incisions. 

• Identify fxrs

  • US

  • Make line between highest and lowest fxrs

• Plate should be flush to bone

• Aim plate to upper/middle of rib as thinnest portion is inferior

Rib fracture program

• Pieracci program

• Doben 

• Long program

• Can use kinetic taping of rib

• Selective bronchoscopy versus routine

• Consider spot film in OR bc screws aren’t counted

• Billing

  • By number of ribs

  • Vats bundled in

  • On Q is separate

• Rib cryoablation 

  • Only for rib 3-9

  • High gives Horner syndrome

  • Low gives an wall pseudo hernia

• Risks

  • 3% have plate problems

  • Infection

  • Wing scapula (long thoracic n)

  • Numbness

  • Non union

  • Exposed hardware

    • If in 2wk can do salvage

• Closing

  • Ribs #1

  • Muscle interrupted 0

  • Fascia 0

  • Scarpas 0

  • Deep dermis 2-0

  • Skin staples