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- 1st 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
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)