What findings would require a celiotomy in a blunt trauma victim?

What is the treatment of a gunshot wound to the belly?

What is the evaluation of a stab wound to the belly?

Peritoneal signs, free air on CXR/CT scan, unstable patient with positive FAST exam or positive DPL results

Exploratory laparotomy

If there are peritoneal signs, heavy bleeding, shock, perform exploratory laparotomy; otherwise, many surgeons either observe the asymptomatic stab wound patient closely, use local wound exploration to rule out fascial penetration, or use DPL

What depth of neck injury must be further evaluated?

Define the anatomy of the neck by trauma zones:

Zone III

Zone II

Penetrating injury through the platysma

Angle of the mandible and up

Angle of the mandible to the cricoid cartilage

How do most surgeons treat penetrating neck injuries (those that penetrate the platysma) by neck zone:

Zone III

Zone II

Zone I

What is selective exploration?

What are the indications for surgical exploration in all penetrating neck wounds (Zones I, II, III)?

How can you remember the order of the neck trauma zones and Le Forte fractures?

Chapter 38 / Trauma 241

Selective exploration

Surgical exploration vs. selective exploration

Selective exploration

Selective exploration is based on diagnostic studies that include A-gram or CT A-gram, bronchoscopy, esophagoscopy

“Hard signs” of significant neck damage: shock, exsanguinating hemorrhage, expanding hematoma, pulsatile hematoma, neurologic injury, subQ emphysema

In the direction of carotid blood flow

What is the “3-for-1” rule?

Trauma patient in hypovolemic shock acutely requires 3 L of crystalloid (LR) for every 1 L of blood loss

Can an adult lose enough blood in the “closed” skull from a brain injury to cause hypovolemic shock?

Can a patient behypotensive after an isolated head injury?

What is the brief ATLS history?

Absolutely not! But infants can lose enough blood from a brain injury to cause shock

Yes, but rule out hemorrhagic shock!

“AMPLE” history: Allergies Medications PMH

Last meal (when) Events (of injury, etc.)

In what population is a surgical cricothyroidotomy not recommended?

What are the signs of a laryngeal fracture?

What is the treatment of rectal penetrating injury?

What is the treatment of EXTRAperitoneal minor bladder rupture?

What intra-abdominal injury is associated with seatbelt use?

What is the treatment of a pelvic fracture?

Bleeding from pelvic fractures is most commonly caused by arterial or venous bleeding?

Any patient younger than 12 years; instead perform needle cricothyroidotomy

Subcutaneous emphysema in neck Altered voice

Palpable laryngeal fracture

Diverting proximal colostomy; closure of perforation (if easy, and definitely if intraperitoneal); and presacral drainage

“Bladder catheter” (Foley) drainage and observation; intraperitoneal or large bladder rupture requires operative closure

Small bowel injuries (L2 fracture, pancreatic injury)

/ pelvic binder until the external fixator is placed; IVF/blood; / A-gram to embolize bleeding pelvic vessels

Venous ( 85%)

If a patient has a laceration through an eyebrow, should you shave the eyebrow prior to suturing it closed?

Chapter 38 / Trauma 243

No—20% of the time, the eyebrow will not grow back if shaved!

How high up do the diaphragms go?

To the nipples (intercostal space #4); thus, intra-abdominal injury with penetrating injury below the nipples must be ruled out

What is the treatment of penetrating injury to the colon?

What is the treatment of small bowel injury?

What is the treatment of minor pancreatic injury?

What is the most commonly injured abdominal organ with blunt trauma?

If the patient is in shock, resection and colostomy

If the patient is stable, the trend is primary anastomosis/repair

Primary closure or resection and primary anastomosis

Drainage (e.g., JP drains)

Liver (in recent studies)

244 Section II / General Surgery

What is the treatment for massive tail of pancreas injury?

What is “damage control” surgery?

Distal pancreatectomy (usually perform splenectomy also)

Stop major hemorrhage and GI soilage Pack and get out of the O.R. ASAP to

bring the patient to the ICU to warm, correct coags, and resuscitate

Return patient to O.R. when stable, warm, and not acidotic

What films are typically obtained to evaluate extremity fractures?

Complete views of the involved extremity, including the joints above and below the fracture

(+)FAST ( )FAST

O.R. ex lap (+) DPL (–)

Chest CT

Ext films

C-spine/head CT PRN

ICU

What finding on ABD/pelvic CT scan requires ex lap in the blunt trauma patient with normal vital signs?

Can you rely on a negative FAST in the unstable patient with a pelvic fracture?

Free air; also strongly consider in the patient with no solid organ injury but lots of free fluid both to rule out hollow viscus injury

No—perform DPL (above umbilicus)

What is sympathetic ophthalmia?

What can present after blunt trauma with neurological deficits and a normal brain CT scan?

Blindness in one eye that results in subsequent blindness in the contralateral eye (autoimmune)

Diffuse Axonal Injury (DAI), carotid artery injury

Are acid or alkali chemical burns more serious?

Why are electrical burns so dangerous?

In general, ALKALI burns are more serious because the body cannot buffer the alkali, thus allowing them to burn for much longer

Most of the destruction from electrical burns is internal because the route of least electrical resistance follows nerves, blood vessels, and fascia; injury is usually worse than external burns at entrance and exit sites would indicate; cardiac dysrhythmias, myoglobinuria, acidosis, and renal failure are common

Fourth-degree burns

How do first-degree burns present?

How do second-degree burns present?

How do third-degree burns present?

What is the major clinical difference between secondand third-degree burns?

By which measure is burn severity determined?

Burn injury into bone or muscle

Painful, dry, red areas that do not form blisters (think of sunburn)

Painful, hypersensitive, swollen, mottled areas with blisters and open weeping surfaces

Painless, insensate, swollen, dry, mottled white, and charred areas; often described as dried leather

Third-degree burns are painless, and second-degree burns are painful

Depth of burn and TBSA affected by secondand third-degree burns

TBSA is calculated by the “rule of nines” in adults and by a modified rule in children to account for the disproportionate size of the head and trunk

248 Section II / General Surgery

What is the “rule of nines”?

What is the “rule of the palm”?

What is the burn center referral criteria for the following?

Second-degree burns

Third-degree burns

In an adult, the total body surface area that is burned can be estimated by the following:

Each upper limb 9% Each lower limb 18%

Anterior and posterior trunk 18% each Head and neck 9%

Perineum and genitalia 1%

Surface area of the patient’s palm is 1% of the TBSA used for estimating size of small burns

20% TBSA

5% TBSA

Second degree 10% TBSA in children and the elderly

Any burns involving the face, hands, feet, or perineum

Any burns with inhalation injury Any burns with associated trauma Any electrical burns

What is the treatment of first-degree burns?

What is the treatment of second-degree burns?

Chapter 39 / Burns 249

Keep clean, Neosporin®, pain meds

Remove blisters; apply antibiotic ointment (usually Silvadene®) and dressing; pain meds

Most second-degree burns do not require skin grafting (epidermis grows from hair follicles and from margins)

What are the signs of smoke inhalation?

Smoke and soot in sputum/mouth/nose, nasal/facial hair burns, carboxyhemoglobin, throat/mouth erythema, history of loss of consciousness/explosion/fire in small enclosed area, dyspnea, low O2 saturation, confusion, headache, coma

How should the airway be managed in the burn patient with an inhalational injury?

With a low threshold for intubation; oropharyngeal swelling may occlude the airway so that intubation is impossible; 100% oxygen should be administered immediately and continued until significant carboxyhemoglobin is ruled out

What burns qualify for the Parkland formula?

What is the Brooke formula for burn resuscitation?

How is the crystalloid given?

Can you place an IV or central line through burned skin?

What is the adult urine output goal?

20% TBSA secondand third-degree burns only

Replace 2 cc for the 4 cc in the Parkland formula

Through two large-bore peripheral venous catheters

YES

30–50 cc (titrate IVF)

Why is glucose-containing IVF contraindicated in burn patients in the first 24 hours postburn?

Chapter 39 / Burns 251

Patient’s serum glucose will be elevated on its own because of the stress response

What fluid is used after the first 24 hours postburn?

Why should D5W IV be administered after 24 hours postburn?

Colloid; use D5W and 5% albumin at 0.5 cc/kg/% burn surface area

Because of the massive sodium load in the first 24 hrs of LR infusion and because of the massive evaporation of H2O from the burn injury, the patient will need free water; after 24 hours, the capillaries begin to work and then the patient can usually benefit from albumin and D5W

What is the minimal urine output for burn patients?

How is volume status monitored in the burn patient?

Adults 30 cc; children 1–2 cc/kg/hr

Urine output, blood pressure, heart rate, peripheral perfusion, and mental status; Foley catheter is mandatory and may be supplemented by central venous pressure and pulmonary capillary wedge pressure monitoring

252 Section II / General Surgery

What are the common organisms found in burn wound infections?

How is a burn wound infection diagnosed?

How are minor burns dressed?

How are major burns dressed?

Why are systemic IV antibiotics contraindicated in fresh burns?

Note some advantages and disadvantages of the following topical antibiotic agents:

Silver sulfadiazine (Silvadene®)

Mafenide acetate (Sulfamylon®)

Polysporin®

Staphylococcus aureus, Pseudomonas, Streptococcus, Candida albicans

Send burned tissue in question to the laboratory for quantitative burn wound bacterial count; if the count is 105/gram, infection is present and IV antibiotics should be administered

Gentle cleaning with nonionic detergent and débridement of loose skin and broken blisters; the burn is dressed with a topical antibacterial (e.g., neomycin) and covered with a sterile dressing

Cleansing and application of topical antibacterial agent

Bacteria live in the eschar, which is avascular (the systemic antibiotic will not be delivered to the eschar); thus, apply topical antimicrobial agents

Painless, but little eschar penetration, misses Pseudomonas, and has idiosyncratic neutropenia; sulfa allergy is contraindication

Penetrates eschars, broad spectrum (but misses Staphylococcus), causes pain on application; triggers allergic reaction in 7% of patients; may cause acid-base imbalances (Think: Mafenide ACetate Metabolic ACidosis); agent of choice in already-contaminated burn wounds

Polymyxin B sulfate; painless, clear, used for facial burns; does not have a wide antimicrobial spectrum

What is the major infection complication (other than wound infection) in burn patients?

Is tetanus prophylaxis required in the burn patient?

Pneumonia, central line infection (change central lines prophylactically every 3 to

4 days)

Yes, it is mandatory in all patients except those actively immunized within the past 12 months (with incomplete immunization: toxoid 3)

C h a p t e r 40

What is it?

What are the signs/ symptoms?

Why is it possible to have hematochezia?

Are stools melenic or melanotic?

How much blood do you need to have melena?

What are the risk factors?

Upper GI Bleeding

Bleeding into the lumen of the proximal GI tract, proximal to the ligament of Treitz

Hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guaiac-positive stools

Blood is a cathartic and hematochezia usually indicates a vigorous rate of bleeding from the UGI source

Melenic (melanotic is incorrect)

50 cc of blood

Alcohol, cigarettes, liver disease, burn/ trauma, aspirin/NSAIDs, vomiting, sepsis, steroids, previous UGI bleeding, history of peptic ulcer disease (PUD), esophageal varices, portal hypertension, splenic vein thrombosis, abdominal aortic aneurysm repair (aortoenteric fistula), burn injury, trauma

What is the uncommon differential diagnosis of UGI bleeding?

Gastric cancer, hemobilia, duodenal diverticula, gastric volvulus, Boerhaave’s syndrome, aortoenteric fistula, paraesophageal hiatal hernia, epistaxis, NGT irritation, Dieulafoy’s ulcer, angiodysplasia

Which diagnostic tests are useful?

What is the diagnostic test of choice with UGI bleeding?

What are the treatment options with the endoscope during an EGD?

Which lab tests should be performed?

Why is BUN elevated?

What is the initial treatment?

History, NGT aspirate, abdominal x-ray, endoscopy (EGD)

EGD ( 95% diagnosis rate)

Coagulation, injection of epinephrine (for vasoconstriction), injection of sclerosing agents (varices), variceal ligation (banding)

Chem-7, bilirubin, LFTs, CBC, type & cross, PT/PTT, amylase

Because of absorption of blood by the GI tract

1.IVFs (16 G or larger peripheral IVS 2), Foley catheter (monitor fluid status)

2.NGT suction (determine rate and amount of blood)

3.Water lavage (use warm H2O—will remove clots)

4.EGD: endoscopy (determine etiology/ location of bleeding and possible treatment—coagulate bleeders)