Trauma

·         "Golden hour":

The first hour after injury provides a unique opportunity to provide life-saving interventions. Because more than half of trauma deaths occur early due to bleeding or brain injury, rapid transport, appropriate triage, evaluation, resuscitation, and intervention can affect outcomes. The "golden hour" concept needs to be extended to several hours in the rural setting, but with the same structured approach. Trauma surgeons harbor the unique idea that an injured patient is their responsibility before they reach the hospital.

·         Soft Cervical collars allow for almost 100% of normal flexion, extension, and rotation. A semirigid (Philadelphia) collar allows 30% normal flexion and extension, > 40% normal rotation, and > 60% lateral movement. Proper immobilization of the cervical spine is achieved with the patient on a backboard in a semirigid collar, lateral sandbags, and anterior 3-inch adhesive taping.

·         Injury to the cervical spine (C-spine) must be excluded before moving the head or neck of the trauma patient. Alert patients without other significant injuries may be moved without x-rays if they are asymptomatic and have no cervical spine tenderness to direct palpation. Patients with symptoms or other major (distracting) injury require a three-view cervical spine series (anteroposterior, lateral, and odontoid) to evaluate the cervical spine. Visualization to the level of C7-T1 is mandatory because 10% of unstable cervical spine fractures occur at this level. If the standard three-view series is inadequate, a "swimmer's view" (patient's arm extended above the head with the x-ray focused through the axilla) can be performed. In high-risk patients with symptoms and equivocal films or sedated/intubated intensive care unit patients, computed tomography (CT) scan of the neck may be necessary to rule out unstable bony injury. Persistent symptoms in the absence of bony injury may require evaluation of potential ligamentous injury with flexion-extension films, CT, or magneticresonance imaging.

·         A GCS score of ≤ 8 mandates endotracheal intubation.

·         FAST: Focused assessment for the sonographic examination of the trauma patient. The four areas examined in this sequence are pericardial area, right upper quadrant, left upper quadrant, and the pelvis.

·         The mesenteric circulation is a hotbed of proinflammatory cytokine synthesis (the gut is the "motor for MOF"). In addition to directly activating neutrophils, the mesenteric circulation appears to release agents (probably phospholipases and other toxic lipids) into the mesenteric lymph that cause neutrophil activation and lung injury.

·         Thoracic aortic dissection may present as a T4 region cord injury. T4 is a watershed zone in the cord between the vertebral arterial distribution and the aortic radicular arteries.

·         Spinal cord injury without radiographic abnormality (SCIWORA) is common in children; 30% of children with spinal cord injuries have no radiographic abnormality. SCIWORA is less common in adults (about 5% of spinal cord injuries).

·         TRAUMATIC SPINAL CORD INJURY

1. Complete traverse myelopathy: complete distal motor, sensory, and reflexive deficit.
2. Anterior cord syndrome: loss of motor, pain, and temperature sensation with preservation of light touch and proprioception since the posterior columns are intact.
3. Central cord syndrome: deficits more severe in upper than lower extremities and motor function affected more than sensory function.
4. Brown-Séquard syndrome: loss of ipsilateral motor, position, and vibratory senses and contralateral pain and temperature sense.

·         Violation of the platysma muscle defines a penetrating neck wound. This investing fascial layer of the neck is superficial to vital structures. If the platysma is not penetrated, the wound is managed as a simple laceration.

·         Three Zones Of The Neck:

Zone I extends from the sternal notch to the cricoid cartilage.

Zone II extends from the cricoid cartilage to the angle of the mandible.

Zone III comprises the area cephalad to the angle of the mandible.

These zones have distinct management implications.

·         The left side side of the neck is more likely to be injured because most assailants are right-handed.

·         In a patient with a penetrating chest injury, an upright chest radiograph with no evidence of pneumothorax after 6 hours makes the likelihood of delayed pneumothorax or occult injury to an intrathoracic organ vanishingly small. The "6-hour rule" identifies patients who can be safely discharged.

·         Clam shell thoracotomy:

Bilateral anterolateral thoracotomies with extension across the sternum. This procedure allows rapid access to both pleural spaces, pulmonary hilae, and the mediastinum.

·         Blurry bullet on a chest radiograph indicate a bullet lodged in the myocardium. Movement of the heart causes the bullet's image to be blurry on x-ray. Beware the blurry bullet.

·         Whereas one third of stab wounds to the anterior abdomen do not penetrate the peritoneum, 80% of gunshot wounds violate the peritoneum. Furthermore, penetration of the peritoneum by a bullet is associated with visceral or vascular injuries in > 95% of cases, whereas only one third of stab wounds violating the peritoneal cavity produce significant injury.

Gunshot wounds to the abdomen generally require operative exploration (> 80% violate the peritoneum).

Stab wounds with evisceration or hypotension are operatively explored.

       Stab wounds in stable patients are managed with local wound exploration (66% violate the peritoneum) plus DPL, ultrasound, or CT scan. If tests are positive, the patient goes to the operating room.

·         The Pringle maneuver is a manual or vascular clamp occlusion of the hepatoduodenal ligament to interrupt blood flow into the liver. Included in the hepatoduodenal ligament are the hepatic artery, portal vein, and common bile duct. Failure of the Pringle maneuver to control liver hemorrhage suggests either (1) injury to the retrohepatic vena cava or hepatic vein or (2) arterial supply from an aberrant right or left hepatic artery.

·         Finger fracture hepatotomy or tractotomy is the method of exposing bleeding points deep within liver lacerations by blunt dissection. Pushing apart the liver parenchyma enables points to be identified and ligated. This method is most commonly required for penetrating injuries.

·         BLOOD SUPPLY AND DRAINAGE OF THE LIVER

1. Hepatic artery delivers 30% of blood flow.
2. Portal vein delivers 70% of blood flow.
3. In 15% of the population the right hepatic artery originates from the superior mesenteric artery.
4. In 15% of the population the left hepatic artery originates from the celiac artery.
5. In 5% of the population neither hepatic artery originates from the celiac artery.
6. Venous drainage: right, middle, and left hepatic veins drain into the inferior vena cava.

·         EXPECTANT MANAGEMENT OF SPLENIC INJURIES

1. Nonoperative management is successful in 95% of grades I-III injuries.
2. 60% of all splenic injuries are managed nonoperatively, with a 12% failure/conversion rate.
3. Factors that predict failure/conversion to operative treatment include injury > grade III, age > 55 years, and blood transfusion requirements.
4. Patients with evidence of ongoing bleeding (e.g., contrast "blush" on CT or ongoing transfusion requirements) may be managed with selective arterial embolization.

·         Elevations in white blood cell (WBC) count and platelet count (PC) after splenectomy are a common physiologic event. After the fourth postoperative day, however, a WBC > 15 x 103 and a PC/WBC < 20 are highly associated with sepsis and should not be confused with the physiologic response to splenectomy.

·         Overwhelming post splenectomy sepsis (OPSS) is a devastating bacteremia (typically encapsulated bacteria) that occurs in 2% of patients after splenectomy. The risk of OPSS is greatest when splenectomy is performed during infancy. The most common organisms are pneumococcus (50%), meningococcus, Escherichia coli, Haemophilus influenzae, staphylococcus, and streptococcus. Although rare, OPSS carries a mortality rate of 75% and has spurred interest in splenic preservation. OPSS is primarily prevented by postoperative vaccination. Pneumococcal, meningococcal, and Haemophilus flu vaccines should be given 2 weeks after splenectomy and are recommended every 5 years. Sepsis can occur despite vaccination; consequently, long-term prophylaxis with oral penicillin is recommended for children.

·         PELVIC FRACTURES

1. 90% of deaths related to pelvic bleeding result from venous and bony bleeding.
2. The remaining 10% are due to arterial bleeding-most commonly from the superior gluteal artery.
3. Normally the pelvis can hold 4-6 L of blood before a tamponade effect occurs.
4. Pelvic wraps or fixation can limit bleeding, reduce bony shear, and promote clot formation.
5. Angiography is therapeutic and diagnostic, but only 10% of injuries are predominantly arterial.

·         URETERAL REPAIR

1. Primary tension-free anastomosis is preferred over stent with absorbable suture.
2. For a distal injury in the lower third of the ureter, perform ureteroneocystostomy; suspend the bladder if tension exists.
3. For middle third injuries, perform end-to-side transretroperitoneal ureteroureterostomy.
4. For proximal injury with significant length loss, use nephrostomy tube for drainage.

·         BLADDER INJURY DUE TO BLUNT TRAUMA

1. Diagnose with CT cystography and retrograde cystourethrography.
2. Extraperitoneal injuries are more common and may be managed conservatively with a Foley catheter for 10 days.
3. Intraperitoneal injuries are more likely if the bladder is distended at the time of injury; they require surgical repair with suprapubic and Foley drainage postoperatively.

·         URETHRAL INJURY

For incomplete transection regardless of site, either catheter stenting across the defect or diversion by suprapubic cystostomy permits resolution.

With complete urethral transection, the bladder should be decompressed initially via suprapubic cystostomy. Early restoration of continuity by placement of a bridging urethral catheter should be performed endoscopically. A bridging catheter reduces complex scarring and avoids subsequent surgery in many patients.

·         An API value < 0.9 has a sensitivity of 95% and specificity of 97% for major arterial injury.

An API > 0.9 has a negative predictive value of 99%.

·         Hypothenar hammer syndrome (HHS): The mechanism is thought to be repetitive palmar trauma in patients with preexisting palmar artery fibrodysplasia. (The arteriogram shows digital artery occlusions with segmental ulnar artery occlusion or "corkscrew" elongation.)

·         N-butyl-2-cyanoacrylate (Dermabond)  may suffice for cutaneous closure of low-tension lacerations in children (preferred method) and adults. This adhesive effectively closes low-tension lacerations. This method is fast and relatively painless. It has a low complication rate and produces excellent cosmetic outcomes. In many instances, if initial wound orientation is against Langer's lines, it may, in fact, offer an advantage over conventional manual suturing.

·         SCAR REVISION: A scar usually has its worst appearance at 2 weeks to 2 months after suturing. Scar revision should await complete maturation, which may take 4-24 months. A good rule of thumb is to undertake no revisions for at least 6-12 months after initial repair. The maturation of the wound may be assessed by its degree of discomfort, erythema, and induration.

·         PEDIATRIC HEMODYNAMICS

1.       Blood volume: 80 mL/kg.

2.       The first sign of hypovolemia is tachycardia, which progresses to bradycardia.

3.       Hypotension is not a reliable indicator of blood loss; children can lose 30% of blood volume without detectable change in blood pressure.

4.       Preferred IV access routes in order: (1) two large-bore upper extremity IVs; (2) distal saphenous vein or cutdown; (3) intraosseous access.

5.       Resuscitation fluid is lactate Ringer's, 20 mL/kg × 2; then packed red blood cells (10 mL/kg) if instability continues.

·         Similar to Olympic ski jumpers, children lead with their heads. Until age 10 years, children's heads are larger in relation to the body than heads of adults. Central nervous system injury is the leading cause of death among injured children and, thus, is the principal determinant of outcome.

Epidural hemorrhage is the most common; subdural hemorrhage is relatively rare. However, mortality from subdural hemorrhage is 40% versus 4% for an epidural bleed.

·         The seat-belt complex consists of ecchymosis of the abdominal wall, a flexion-distraction injury to the lumbar spine (Chance fracture), and intestinal injury. Approximately 30% of children with the seat-belt sign have an associated intestinal injury.

A handlebar injury classically causes disruption of the pancreas at the junction of the body and tail, where the pancreas crosses the vertebral column and is vulnerable to anterior blunt compression.

·         With equivalent injury severity, multiple organ failure in children is much lower than in adults and carries a much lower mortality.