B. Belingon Notes from case session & case session slides, Annas notes (Dr.

. Esterl), Beckys notes (Dr. Sideman)

Week 1 Trauma M 07.01.13
A 45 year old male is involved in a high speed motor vehicle accident. EMS transfers the patient to
Emergency Room at UH. The vital signs are temp 98, P 110, RR 34 and BP 100/70. He is confused and
smells of alcohol. The jugular veins are flat. There is a left closed clavicular fracture. There is an imprint of
the steering wheel on his left anterior chest. There are multiple left closed rib fractures. The left chest has
decreased breath sounds and dullness to percussion. The abdomen is distended and dull to percussion with
scant bowel sounds. There is an open left tibia fibula fracture. The left calf is markedly edematous.
Multiply injured blunt trauma patient
o A : Airway: assess, supplemental oxygen, orotracheal intubation with in-line neck stabilization
Can do orotracheal intubation even on cervical fracture hyper-extend neck
If massive midface injury perform cricothyroidotomy
Tracheostomy is elective done in OR, never emergent procedure
Suction if needed to clear airway
o B : Breathing: looking for pneumothorax or hemothorax
o C : Circulation: place two large bore IV catheters in upper extremities (cephalic or brachial v),
resuscitation with Lactated Ringers (2L bolus)
Give 1L of fluid every 10 mins (2 L over 20 mins) if still bleeding, give blood
Rate of fluid infusion much faster bc IV has smaller diameter than central line (IJ or
subclavian)
Signs of shock: low BP, tachycardic, pale extremities, altered mental status or
unconscious or agitated and combative
Dont put in lower extremity (saphenous vein) b/c pt may have caval injury may go
retroperitoneal
o D : Disability: get quick neuro exam, GCS score (speech, motor, eye opening) [be able to calc],
assess movement of all four extremities
o E : Exposure: remove clothing and examine injuries
Make sure room is uncomfortably warm cold can interfere w protein fx, coagulation
Case assessment
o Pt talking patent airway
o Concern about hemothorax place L chest tube
o Give 2L fluid b/c sx of shock hemorrhage until proven otherwise, can be from thorax, abd,
pelvis, extremities
CXR of lungs to look for blood
Distended abd, dull to percussion likely site of bleeding
DPL (Diagnostic Peritoneal Lavage: 800cc of warm saline into abdomen under
gravity, flip & drain pt)
FAST (Focused Abdominal Sonography for Trauma): four windows of pelvis,
RUQ (Morrisons pouch), LUQ, pericardial window
Extremity bleeding do careful exam
o Thoracotomy if pt puts out too much fluid from chest tube (1.5L on placement, or hourly output
for 3-4 hr of 200cc/hr)
Workup
o Tubes: place nasogastric and urinary catheters
Hemothorax: place chest tube @ 5
th
ICS mid-axillary, want to know immediate output,
I&O
Pneumothorax: place chest tube; life-threatening b/c can progress to tension
pneumothorax
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
Dont place NG tube if suspect injury to oro-tracheal bones (may go into brain) or mid-
facial injury do cricothyroidotomy
Dont place Foley if suspect pelvic fracture (do rectal exam first and ensure no blood at
meatus)
o Labs: CBC, Chem 20, coagulation profile, UA, T&C for PRBCs, drug screen
o Radiographs: lateral C spine, chest, pelvic, left lower extremity
o If unstable despite resuscitation, do not transport patient to CT scan-instead do FAST vs DPL
To assess intra-abdominal hemorrhage in unstable pt 1
st
do ultrasound to assess for
injury then move pt to OR; never leave unstable pt in CT scanner
Results
o FAST-positive test includes fluid around heart, in LUQ, RUQ, colonic gutters and pelvis
o DPL-positive test includes gross blood, RBC>100, 000,WBC>500, bile, bacteria, food particles
Indicates intra-abdominal organ injury =/= retroperitoneal
o A positive FAST or DPL mandates abdominal exploration
Dx: Left tib-fib open fracture-
o ortho consultation
o Stryker intracompartmental pressure measurements?
o 4 compartment fasciotomy allows muscle to expand b/c fascia very tight
Indicated for venous engorgement, vascular insufficiency, ischemic leg gets blood
flow to partially edematous leg (do w/i 6h or pt will get ischemia)
Lt clavicular fx decr percussion, dullness = fluid in pleural space (blood hemothorax from mult rib
fx), no JVD tx: drain w chest tube at mix-axillary line @ 5
th
ICS
A 19 year old male is involved in a high speed motor vehicle accident. He presents to the Emergency
Department in a near comatose state. His vital signs are temp 100, P 115, RR 30 and BP 90/50. He has a
large scalp laceration. His neck veins are flat. His breath sounds are equal bilaterally. The heart shows
tachycardia but there are no gallops, rubs or clicks and the heart tones are not distant. His abdomen is soft
but slightly distended with decreased bowel sounds. He has an obvious closed pelvic ring fracture. He has
marked perineal ecchymosis. The rectal examination shows a boggy high riding prostate and there is blood
at the urethral meatus.
Pt w GCS 8 or less intubate bc implied that pt cant protect airway
Dx: Unstable pelvic fracture
o Treatment
decrease volume of the pelvis to control hemorrhage
wrap pelvis with sheet tightly (separates pubis bones and SI joint)
ortho consultation for external fixation
if no other sites of hemorrhage except for pelvis (isolated retroperitoneal
hemorrhage), do angiography with embolization of internal iliac artery branches (the
only time an unstable pt should be in radiology)
Blood at meatus, high riding boggy prostate gland
o Implies injury to membranous portion of urethra
o DO NOT place urinary catheter
o Workup
do retrograde urethrogram
if positive, suprapubic catheter
if negative, cystogram with bladder full and empty with contrast
o Treatment: urethral injury not emergency delayed surgery
if retroperitoneal bladder injury, urinary catheter for 10-14d
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
if intra-abdominal bladder injury, abdominal exploration
if cystogram negative, CT of abdomen and pelvis
Isolated retroperitoneal hemorrhage need to control hemorrhage, can still be unstable even w
good resuscitation
A 15 year old male presents to the Emergency Center at University Hospital with a stab wound to the left
lower quadrant. He complains of diffuse abdominal pain. The vital signs are temp 99, P 110, RR 26 and
BP140/86. The patient is alert. The lungs are clear. The heart has tachycardia. The abdomen is tense and
distended with decreased bowel sounds. There is omentum protruding through the stab wound. The rectal
examination shows good rectal tone but is guaiac positive.
ABCDE of resuscitation
Labs: CBC, chem panel, coagulation profile, UA, drug screen, T&C for PRBCs
Radiographs: chest and pelvis, CT for retroperitoneal injury
o Ultrasound will only show fluid
Treatment
o observation
o local wound exploration
o DPL? If positive, abdominal exploration find penetrated fascia b/c omentum exposed
suspect bowel injury
o laparoscopy? Not sensitive for SB injuries
o ometum exposed? ligate stump and observation vs abdominal exploration
if fascia not penetrated and no hard signs of peritonitis discharge to home once pt is
sober
if unable to operate (too busy) do not have to do exploratory surgery send pt home
or observe
o r/o source of hemorrhage and source of bowel injury
o abdominal exploration d/t hard signs of peritonitis
indicated b/c anterior fascia penetrated, signs of peritonitis, omentum protrusion
A 17 year old male sustains a low caliber gunshot wound to the mid abdomen. He complains of diffuse
abdominal pain. The vital signs are temp 99, P 120, RR 28 and BP 110/60. He appears anxious. The jugular
veins are flat. The lungs are clear bilaterally. The heart has tachycardia but no gallops, rubs, or clicks. The
heart sounds are not distant. The abdomen shows a 1 cm entrance wound just above the umbilicus and there
is no exit wound. The abdomen is tense and distended with absent bowel sounds. The rectal examination
reveals a normal prostate, good rectal tone and is guaiac negative.
ABCDE of resuscitation
Labs: CBC, chem panel, coagulation profile, UA, drug screen, T&C for PRBCs
Radiographs: chest and pelvis
o Image with one shot IVP to see if kidneys penetrated
KUB shows bullet in midline
o Still want CXR and pelvic film to find bullet
Treatment
o GSW to abdomen abdominal exploration to r/o other sources of bleeding and assoc bowel
injury
A 25 year unrestrained male is involved in a high speed motor vehicle accident. EMS transfers the patient to
Emergency Room at UH. The vital signs are temp 99, P 115, RR 26 and BP 120/70. He is confused and
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
smells of alcohol. The jugular veins are flat. There is an imprint of the steering wheel on his left anterior
chest. The left lung has decreased breath sounds. The heart has tachycardia but no gallops, rubs or clicks.
You intubate the patient, place a nasogastric tube and urinary catheter. You draw laboratory tests including
CBC, serum chemistry, INR/PTT, urinalysis and T/C for 6 units PRBCs. You order a lateral cervical spine,
chest and pelvis radiograph. The cervical spine and pelvic radiographs reveal no fractures. The chest
radiograph shows left first rib and left scapular fractures, a small left apical cap and a slightly deviated
course of the nasogastric tube to the right side of the chest.
Dx: Traumatic aortic injury
o Diagnosis
Chest radiographic findings-
1
st
and 2
nd
rib fractures, scapular fracture esp if high impact trauma
widened mediastinum
apical cap (both sides)
deviated NG tube
deviated bronchi
obliteration of aortic knob
Can also see pleural effusion rhonchi
o Similar to aortic dissection but not necessarily d/t incr BP
Treatment
o Should do exploratory laparotomy first
o Thoracotomy with primary repair or graft vs endoluminal stent placement
Cause of death: hypovolemia from hemorrhage
A 60 year old male unrestrained driver is involved in a high speed motor vehicle accident. He injures his
right chest on the steering wheel. In the emergency department the vital signs are temp 100, P 110, RR 34
and BP 110/76. He is alert and complains of exquisite right chest wall pain. He is significantly dyspneic. The
neck is nontender and the jugular veins are flat. The trachea is in the midline. The heart has tachycardia but
the heart tones are normal. There are several palpable closed rib fractures. The right chest is dull to
percussion with decreased breath sounds.
Dx: Hemothorax
o Diagnostic physical findings
tachycardic and hypotensive
palpable rib fractures
decreased breath sounds, dullness to percussion, decreased vocal fremitus
o Chest radiographic findings [dont wait for CXR before treating]
rib fractures, hemothorax
Treatment: chest tube thoracostomy
Cause of death: hypovolemia from hemorrhage
A 17 year old gang member is stabbed in the left chest. The vital signs are temp 99, P118, RR 30 and BP
90/60. The neck has prominent jugular venous distension. The trachea is shifted to the right side. The left
thorax is hyper-resonant to percussion with decreased breath sounds and decreased vocal fremitus. The right
thorax is normal. The heart has tachycardia but normal heart tones.
Dx: Tension pneumothorax
o Diagnostic physical findings
tachycardic and hypotensive
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
JVD
tracheal deviation to other side
normal heart tones
decreased breath sounds, hyperresonant to percussion, decreased vocal fremitus
o Do NOT wait for chest radiographic findings
Treatment
o needle decompression (temporizing measure) in 2
nd
ICS in mid-clavicular space will see rush
of air when needle inserted
o chest tube thoracostomy
Cause of death: kinking of cavae, decreased venous return (causing JVD)
A 15 year old male was stabbed in the left chest at the 4th intercostal space at the left sternal border with a
long stiletto knife. EMS takes him immediately to the emergency room at UH. The vital signs are temp 98, P
120 and RR 40 and BP 70/40. The neck shows tense, distended jugular veins. The heart tones are distant.
The trachea is in the midline. The breath sounds are equal bilaterally.
Dx: Cardiac tamponade
o Diagnostic physical findings
Tachycardic and hypotensive
JVD
Normal breath sounds, trachea in midline
Decreased heart tones
o FAST to look for cardiac tamponade
Treatment
o Pericardiocentesis (temporizing measure)
o Pericardial window
o If positive pericardial window, sternotomy
o If unsure of tension pneumo vs pericardial tamponade put in chest tube to see if corrects
Cause of death: inadequate ventricular filling
A 60 year old male unrestrained driver is involved in a high speed motor vehicle accident. He injures his
right chest on the dashboard. The vital signs are temp 100, P 110, RR 38 and BP 110/76. He is alert and
complains of right chest wall pain. He is markedly dyspneic. His neck is nontender and the jugular veins are
flat. The trachea is in the midline. The heart has tachycardia but the heart tones are normal. There appears
to be paradoxical movement of the lateral right chest wall. When the patient inspires, a segment of the
right lateral chest wall goes inward. The right chest has scattered crackles, slightly decreased breath sounds
and dullness to percussion. The left chest appears to be absolutely normal.
Dx: Flail chest
o Diagnostic physical findings
paradoxical chest wall movement
Inspiration chest cage goes inward (paradoxical)
palpable rib fractures
decreased breath sounds, rales, dullness to percussion, decreased vocal fremitus
o Chest radiographic findings
multiple A/P rib fractures
pulmonary contusion
Treatment
o Supplemental oxygen, intubation with PEEP to re-inflate contused lung
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
Good pulmonary toilet
Good pain control
Prevent pneumonia
Titanium stenting of rib fractures?
Problem is not the rib fractures necessarily but underlying pulmonary contusion
A 23 year old male on a snowmobile runs into a steel fence at a high rate of speed. He complains of left chest
wall pain and shortness of breath. EMS takes him immediately to the Emergency Center near the
Steamboat Springs ski resort. The vital signs are temp 100, P 116, RR 36 and BP 90/40. There is a 3 cm
large sucking chest wound in the left lateral chest. You can hear air move in and out through the large chest
wound. The jugular veins are flat and the trachea is in the midline. The heart shows tachycardia and heart
tones are normal. You can see the visceral pleural of the lung thorough the chest wall wound. The left chest
is slightly tympanic to percussion and the breath sounds are slightly decreased.
Dx: Sucking chest wound
Diagnostic physical findings
o Tachycardic and hypotensive
o decreased breath sounds, dullness to percussion, decreased vocal fremitus, air rushes in and out
Imaging
o CXR pneumothorax in pleural space air doesnt go trachea goes in/out of chest wall
Treatment
o occlusive dressing over wound, tape on 3 of 4 sides so dressing will occlude air goes into lung
chest tube thoracostomy
be careful of creating tension pneumothorax if visceral pleura is injured insert
chest tube
Cause of death: hypoxia and hypercarbia
A 40 year old male who weighs 70 kg presents to the Emergency Center at BAMC 10 minutes after he
sustains multiple burns in a house fire. He complains of hoarseness and dyspnea. The vital signs are temp
100, P 110, RR 28 and BP 130/85. He has superficial (first degree) burns of the entire head. He has singed
nasal hairs. He has a nasal voice. He has deep partial thickness (second degree) burns of the anterior left
lower extremity. He has full thickness (third degree) burns which cover his entire anterior torso. He has full
thickness burns of the entire left lower extremity. The pulses in the right arm are strong. The pulses in the
left leg are only dopplerable compared to those in the right leg that are strongly palpable.
Workup
o ABCDE of resuscitation
o Early intubation for inhalation injury, bronchoscopy is most sensitive diagnostic test for
inhalation injury; if emergency setting cricothyroidotomy, then can covert to tracheostomy
later
hoarseness not moving air well; sputum = carbon-like granules
o Labs: CBC, chem panel, coagulation profile, UA, drug screen, T&C for PRBCs, CO Hg
o Tubes: nasogastric and urinary catheter
o Radiographs: chest
o Early nutrition
o Calculate percent of burn (second and third degree) by rule of nines
o Administer Lactated Ringers solution with Parkland Formula-
3-4mL/kg/%burn
give half of IVF in first 8 hours and other half in next 16 hours
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
o Determine adequacy of resuscitation by urine output
Dx: Myoglobinuria
o Dark red or purple urine
o UA has hemoglobin on dipstick but no RBC on microscopic exam
Treatment
o aggressive hydration
o alkalinization of urine
o brisk diuresis after hydration (mannitol)
o On transport of patient to burn unit cover burn wound with dry dressings
o Cover burn wound with topical antibiotics
silver sulfadiazine: SE sulfa allergy, dec WBC
sulfamylon: SE pain, carbonic anhydrase inhibitor leads to metabolic acidosis
silver nitrate solution: SE messy, requires multiple applications, leaches Na and Cl from
wound
o 1
st
degree burn- topical triple antibiotics
Deep second and third degree burn-tangential excision of the burn wound
Early skin grafts for facial, hands and feet, genital burns
o Early rehabilitation, prevention of contractures; dont give abx until evidence of sepsis (otherwise
risk resistant strains)
o Decr pulses suspect compartment syndrome, vascular insufficiency
Escharotomy eschar restricts ventilation
Full thickness burn has no room to expand decompress eschar to
subcutaneous fat immediately b/c can become ischemic as pressure in
compartment rises could be left with non-functional limb
May need to do fasciotomy if muscles are burned
o Ultimate tx = tangential excision of burn wound, then skin grafting (do early!)
A 50 year old male is involved in a high speed motor vehicle accident. EMS transfers the patient to
Emergency Room at UH. The vital signs are temp 98, P 110, RR 34 and BP 100/70. He is confused and
smells of alcohol. The jugular veins are flat. There is an imprint of the steering wheel on his left anterior
chest. There are multiple left closed rib fractures. There is ecchymosis on the left lateral flank. The left
chest has decreased breath sounds and dullness to percussion. You intubate the patient. You place 2 large
bore peripheral intravenous catheters in the upper extremities and give lactated ringers 2 liters over 10
minutes. You place a foley catheter. You draw laboratory values and order a lateral cervical spine, chest and
pelvis radiographs. The cervical spine and pelvis radiographs reveal no fractures but the chest radiograph
shows multiple rib fractures and the curl of the nasogastric tube in the left chest.
Blunt trauma acute diaphragmatic hernia
Diagnosed in delayed fashion
Dx: Diaphragmatic injury
o Physical findings
decreased breath sounds, dullness to percussion, decreased vocal fremitus, bowel sounds
in chest, most findings on left side, ecchymosis
SOB sm bowel in L chest
o Chest radiographic findings
bowel in left chest, curl of NG tube in chest above diaphragm
Treatment
o 1
st
time repair- abdominal approach, primary or patch repair of diaphragm
o Recurrent repair-thoracic approach, primary or patch repair
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
Other notes:
Airway
o Cervical spine stabilization
o Indications to intubate
GCS < 8, abnormal voice, altered mental status, penetrating injuries to neck, expanding
hematoma, chemical or thermal injury to mouth/nares/hypopharynx, extensive
subcutaneous air in neck, complex maxillofacial trauma, airway bleeding
o Airway can be patent, obstructed (by blood/emesis/foreign body), unprotected
Breathing
o Goal: to ensure adequate oxygenation and ventilation
o All trauma pts should get supplemental O2
o All burn pts should get 100% FiO2 b/c of possible CO poisoning (t1/2 of COHb is 4-6 hrs)
o Life threatening ventilation issues: tension pneumo, open pneumo, pulmonary contusions
o Breath sounds can be clear, diminished, absent
Circulation
o Rough first approximation of pts CV status
o Palpate femoral and peripheral pulses, establish IV access, external control of hemorrhage (manual
compression, splints), fluid or blood resuscitation
o Look for palpable pulses, evaluate GCS & BP
o Initial fluid resuscitation
Adult: 1 L LR/NS (never give hypotonic solution or glucose can worsen brain injury);
repeat once prior to administering blood
Children: 20 mL/kg bolus; repeat twice prior to administering blood
o Shock: inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function
Earliest sign of ongoing blood loss = tachycardia
Hypotension, tachypnea, mental status change, diaphoresis, pallor, cool extremities,
diminished capillary refill

Table 6-1 Signs and Symptoms for
Different Classes of Shock
Class I Class II Class III Class IV
Blood loss (mL) Up to 750 7501500 15002000 >2000
Blood loss
(%BV)
Up to 15% 1530% 3040% >40%
Pulse rate <100 >100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure
(mm Hg)
Normal or
increased
Decreased Decreased Decreased
Respiratory rate 1420 2030 3040 >35
Urine output
(mL/h)
>30 2030 515 Negligible
CNS/mental
status
Slightly
anxious
Mildly
anxious
Anxious and
confused
Confused and
lethargic

DDx of shock in trauma: hemorrhage!!!, septic shock, cardiogenic shock
(pneumothorax, tamponade, MI, air embolus), neurogenic shock (high spinal cord injury,
bradycardia, hypotension)
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
Pts in which you may not see tachycardia as earliest sign of ongoing blood loss = elderly
on beta blockers, athletes
Other common causes of tachycardia: hypoxia, pain, apprehension, drugs (cocaine,
amphetamines)
Disability
o Neurologic exam: GCS and obvious neurologic deficits
Exposure
o Fully expose pt, warm resuscitation room
Secondary survey
o Head to toe exam for all other injuries
Classic injuries
o Blood at meatus: urethral injury; high-riding prostate, perineal or scrotal hematoma
Dx: RUG, dont place Foley
Tx: Foley to bridge injury or suprapubic tube w later reconstruction by urology
o Battles sign: ecchymosis behind ear and around periorbital region, basilar skull fx, raccoon eyes,
otorrhea, rhinorrhea
Dx: confirm w CT scan, look at nose/ears for CSF leak
Tx: give meningitis antibiotic prophylaxis
Cord syndromes
o Anterior cord syndrome
characterized by injury to the anterior two-thirds of the cord, on the opposite site of spine
injury.
The mechanism of injury is usually a compression or flexion type
Clinically, patients present with complete loss of motor function, sharp pain, and
temperature below the level of injury, but retain proprioception and the ability to sense
vibration and deep pressure.
o Central cord syndrome
Typically results from a hyperextension injury in an older patient with a preexisting
cervical spondylosis.
The injury involves the central portion of the cord.
Clinically, the upper extremities present with more sensory/motor deficit than the lower
extremities, due to the more peripheral positioning of the lower extremity axons within
the spinal cord tracts.
o Brown-Sequard syndrome
This syndrome results from hemitransection of the spinal cord w/unilateral damage to
corticospinal & spinothalamic tracts
Subsequent loss of ipsilateral motor, proprioception, and vibratory sensation
Loss of contralateral pain and temperature sensation.
Penetrating injuries of neck
o Zone III (above angle of mandible)
o Zone II (cricoid to angle of mandible)
o Zone I (between clavicle and cricoids)
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)

Great injuries to great vessels, esophagus, airway r/o and treat b/c lifethreatening
o Zone II if penetrates platysma go to OR
o Above Zone III harder to access; if unstable, actively bleeding go to OR
o Work up zone I & III
Scan for subcutaneous air extravasation of contrast if carotid injury, bronchoscope,
esophageal (EGD, contrast swallow study for extravasation of contrast outside bronchus)
CT angio***
Vascular or aerodigestive injury OR
o Hard findings Airway compromise, shock, or active bleeding, pulsatile hematomas, extensive
subcutaneous emphysema
o Soft findings dysphagia, voice change, hemoptysis, wide mediastinum
Symptomatic but stable must further evaluate
Completely asymptomatic all Zone I injuries should get full evaluation w angiography of great vessels +
soluble contrast
Penetrating wounds DPL
MVC, pelvic fx, hematuria bladder rupture, voiding cystourethrogram
o If residual contrast where bladder was, then implies extravasation, Intraperitoneal injury OR
o Extraperitoneal Foley for 10-14 days, cystogram prior to removal of Foley
Penetrating injury to extremity
o Hard signs (operation mandatory): pulsatile hemorrhage, significant hemorrhage, thrill or bruit,
acute ischemia
o Soft signs (further eval req): proximity, minor hemorrhage, sm hematoma, assoc nerve injury
o Neurovascular exam: palpating all pulses and compare R to L; can Doppler pulses or get systolic
pressures
Significant difference between R & L could have significant arterial injury CT angio
Veins that you MUST repair:
o SVC can result in sudden blindness d/t compression of optic n from venous HTN
o IVC proximal to renal v results in acute renal failure from venous HTN
o Portal vein risk of bowel infarction do second look operation
Abdominal compartment syndrome
o Post-op trauma pt w decreasing UOP, increasing peak inspiratory pressures, hypotension
Dx: bladder pressure > 30 mmHg (clamp off Foley, reflect bag to monitor, get abdominal
pressure)
B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)
Absolute # for compartment syndrome > 30 automatic laparotomy to decompress
sterile drapes and dressings
Compartment syndrome of extremity
o Acute increase in pressure in a closed space which impairs blood flow to structures 1
st
sign =
paresthesias, pain, pallor, poichilothermia, pulselessness is last sign
o Tx: decr pressure in 4 cmpartments
Injury patterns
o Clavicle or first rib fx distal subclavian artery
o Shoulder dislocation or proximal humerus fx axillary artery
o Supracondylar fracture of distal humerus or elbow dislocation brachial artery
o Dislocation of the knee popliteal artery