18 ABSITE Trauma 2_edited

Okay, welcome back to Behind the Knife's Ab Site Review. This is Trauma Part 2, and now we're going to dive a little bit more in detail into specific organ injuries. And we're going to start with gastric injuries. So, John, can you walk me through some principles of, of gastric injury? So, what kind of patients are at high risk for this?

How, what are some pearls for exploring these injuries? And how do you, you know, manage these and classify them and plan your repair? So the goal for the specific organ injuries is to go through the very high yield questions that you might see on the test. So gastric injury is often associated with thoracodomal penetrating injury.

When you think of a thoracodomal the other, you must consider a diaphragm injury. Anytime you see a diaphragm injury, you have to have a high suspicion for a gastric injury. Another big pearl is if you have an anterior penetrating gastric injury, You also must evaluate the posterior surface posterior surface for an injury.

And this can be done by opening the lesser

sac. If a posterior gastric wall injury is identified, the pancreas then must be examined for another additional associated injury. There's a AASD injury scale chart that's posted in our book and I recommend reviewing this. There's not a lot of questions that specifically come from the chart like this, but in general, it's good to know how these are classified.

So Jason, if we have a gastric injury, how do we typically approach them? Yeah, so fortunately the stomach is a pretty hardy organ and it has a good blood supply from various sources. So it's pretty resilient to injury. So you can often repair injuries primarily or with a wedge resection if you can get away with it.

Now injuries that involve the antrum, the pylorus or the proximal duodenum may require a distal or subtotal gastrectomy with some form of a reconstruction. Where's the highest place that we often miss gastric injuries in penetrating trauma? So it's easy to miss a

proximal injury. You can fold the stomach over on itself, occlude an injury.

So, I think going back to your point, if you see one hole in the stomach, you have to have a really high suspicion that there's another hole somewhere. And you need to look everywhere to try and find it, which means mobilization. Maybe you have to take down some of the short gastrics in order to see that proximal injury folded over on itself.

And don't forget to use things like an NG tube or a leak test or an EG. EGD to look for a missed injury. Yeah. I've also seen them near the GE junction is proximal stomach, obviously. And a lot of times there'll be associated with. Diaphragm injuries as well. So if you have a diaphragm injury near, especially the hiatus, you also need to be concerned about GA junction.

Let's travel downstream a little bit now, past the stomach and, and look at the duodenum. Duodenal injuries are very challenging. So, what kind of advice can you give as far as finding these duodenal and dealing with these duodenal injuries? Yeah, as we'll dive into it, there's a kind of a spectrum of duodenal injuries that, you know, happen in both blunt and

penetrating trauma.

The basis are, is if ever a duodenal injury on a CT scan that you're worried about, you know, a laceration or, you know, some type of injury to the duo the best way to do it is take the patient and at least explore them in the operating room. And the best approach to this is usually the Cochlear Maneuver.

You also consider the use of an EGD once you pass it past the ploilorus. Now like the gastric injury, you know, there's a double ASD injury scale. And I don't think that's as useful for the outside. It is useful in practice but we'll put a reference to that in the companion book. John, what about hematomas, duodenal hematomas?

This is something that we can see sometimes in children, sometimes after blunt trauma. What's some management principles for duodenal hematomas? Yeah, so most of these duodenal hematomas will resolve without intervention. They can just be watched observation, repeat imaging studies. If a gastric outlet obstruction is present, which they will not usually develop until after 24

hours you can try decompressing the NG tube for five to seven days.

And then I usually at that point need to start talking about TPN. And then repeat oral contrast studies to see how the contrast pass the hematoma. Okay. Now let's, let's talk a little bit more specifically about duodenal injuries. You have the patient open, you've done your COCR, it's in your hands and you have an injury.

What are some general guiding principles to dealing with those injuries and repair? Yeah, it's a stepwise approach to duodenal injuries. So you first need to expose the duodenum and get a good look of all the critical structures. Those critical structures are specifically the common bowel duct and the ampulla and whether they're involved.

The best way to evaluate them, as I previously mentioned, is with an extended coca maneuver. So you want to do a full coca and evaluate the entirety of the duodenum. If you can't identify the ampulla while you're there, you can pass a catheter through the cystic duct into the duodenum and help locate it.

To increase exposure of the third and fourth portions of the duodenum,

You can do a right to left medial visceral rotation and also release the ligamentotrites. So Jason, how do we repair the duodenum when we're in the operating room? Yeah, so that can be really challenging. There's a number of described approaches.

I think the basic principle is you need to be sure that you debride any non viable tissue. And then you kind of see what you're left with. If you're able to perform a two layer primary closure, that's preferred. Of course, leave a drain. Other options include an end to end duodenal duodenostomy, which is technically very challenging because it's difficult to, to mobilize that duodenum.

There are duodenal jejunostomies with Roux en Y reconstruction that can be used for larger defects in which, you know, primary repair is not feasible. Again, very technically challenging. And so it gives you a You know, two high risk anastomosis and this all the way up to even, you know, a staged pancreatic duodenectomy or a Whipple procedure, which if you're doing a, you

know, a Whipple and trauma the, it's a, it's a very technically challenging and a high risk with high morbidity, high mortality.

And the key there is you want to stage it. And you want to damage control that patient, resuscitate them and then come back with somebody, you know, your most experienced hepato biliary surgeon to tackle that. Yeah, you know what you often see, I mean, I've never seen an ab site question or a practice question even that Whipple was the correct answer on the ab site.

Clinically, how this is usually employed is that you have a gunshot wound or a stab injury to their surgical sole. These injuries are never single injuries. So you have multiple different surrounding structures that are injured. And what will happen is that you control the bleeding, you control the contamination the best you can.

And then you do your operative planning. After the patient is stable and getting resuscitated. Yeah, that's a great point. I've never seen a trauma Whipple be the answer on an ab site. And I don't think it ever will be

the answer. Just know that, you know, in reality, if you're damage controlled, sometimes they, they, they will need that, but that's not going to be the answer on the ab site.

Now, John, what about the, some of the adjuncts? So sometimes we'll hear about things like pyloric exclusion. We'll hear about you know, duodenal decompression. You know, where's placing drains via a duodenostomy or jejunostomy. You know, duodenal diverticulization. What are these things? And what should we, how should we handle these on the upside?

Yeah, I, I personally feel like it's not fair to, to test these types of questions because every single Injury to the, that this area of the body is, is different. They never see the same injury over and over again. It's not even similar to ulcer disease where you have like a standardized approach to them.

So those, these are all options of how you can approach and they can be debated to the time's end, but just know that these are all options that are available. Yeah. And also, you know, very unlikely that these are going to be the answers on the app site. They're bailout procedures that

aren't that well supported with the evidence, so not likely to find their way on the test.

But what is, is, is just be sure that you leave an NG tube in the stomach and pass a feeding tube past the repairs at the time of surgery and be thinking about that enteral access in these critically ill patients. Yeah. Now let's move on from the duodenum, keep moving downstream to the small bowel injuries.

When we talk about bowel injuries, we often talk about them being destructive versus non destructive. What do we mean by that and how does that affect what we're going to do? Yeah, this is a good way to break down these injuries have some sort of algorithm, right? So we talked about destructive injuries being greater than 50 percent of the circumference of the bowel wall that's involved, or devascularization, such as a bucket handle of that bowel.

Non destructive, we usually classify as less than 50 percent of the circumference and no vascular compromise. The way we use this clinically is that we can usually repair non destructive injuries. primarily. It's using, you know, suture repair. Dissective

injuries, well, you typically need some sort of resection and anastomosis, or if the patient is unstable, or you're playing for a temporary abdominal closure, just do a resection and leave in discontinuity.

Now, what about dealing with this injuries to the small bowel mesentery? They either, you mentioned a bucket handle or even a penetrating, you have penetrating injuries to the mesentery. How can you approach that and what do you have to worry about and how can you evaluate the bowel? Yeah, like large mesentery hematomas or, you know, active bleeding within the mesentery after you've controlled that bleeding.

And determine the source. You always need to inspect the bowel to ensure viability. If there's a large bucket handle injury, such as the bowel, the bowel being torn away from the mesentery, it's rare, unless it's very small, that you can leave that bowel and feel good at the end of that surgery. Okay. So moving on to colon and rectal injuries.

So let's, let's first tackle penetrating colon injuries. So with these, we have the same classification of destructive and non destructive.

So non destructive being less than 50 percent of the lumen circumference and destructive being over 50%. And that is a decision point for us deciding between primary repair or the need for a resection and anastomosis.

But what else do we have to consider with the colon? We approach the colonic injuries very similar to a to small bowel injuries. Some specific considerations are the chronic anastomosis are at higher risk. It's perfectly safe on the ab site to Say if a patient is sick, so they have hematic instability, they have significant blood loss or they have multiple concurrent injuries such as associated vascular injury that you're going to perform a damage control surgery.

And other options would be resection and then colostomy for these patients as well, or you can perform an anastomosis. And what about left sided injuries? I remember always hearing that a left sided injury, you have to do a colostomy. Yeah, that's kind of an old school way of thinking about this. When that is no

longer, it's been proven that you can perform a left sided anastomosis.

And that is very safe for the patient, even you don't need to include like a proximal diversion. So I guess what you're saying is less so, like I said, the old adage used to be, you know, right sided injuries, you can do a primary anastomosis left side to do an end colostomy or at the, you know, very least a proximal diversion, but that's no longer the case and it's more just kind of based on the patient's, you know, physiologic status.

Yeah. But in general. Especially in test taking, you should err on the side of more conservative and if there's a question, there's nothing wrong with a diversion. Yeah, I really hope they wouldn't put both those options on there for you, but it's always possible. Okay. We talked briefly about devascularization injuries or these bucket handle injuries.

Can you talk to me a little bit about bucket handle injuries with the colon? What's the mechanism of these and where are they more likely to occur? Yeah, the, if you happen to see a bucket handle injury to the colon, you have to assume there was a significant amount of

force that caused that to happen.

The most common site for this to happen is near the sigmoid colon, being torn off the abdominal wall. Additionally, you can see it on the sacral side as well. It's like really where you have any thick attachments to the abdominal wall and it can be torn. If that happens and you have a bucket handle injury to your colon.

It's always recommended to resect it, an osmosis, or do a damage control surgery. Okay, great. Let's move on to rectal injuries. Rectal injuries are very challenging. I've always struggled with these. So, what kind of patients do you suspect, you know, what kind of mechanism, what kind of things do you see on a physical exam that would suspect you of having a patient with a rectal injury?

And how do you approach these patients? Yeah, as part of your initial evaluation. So your proxy, your primary and secondary surveys, you should be examining the rectum for any blood or any concern for bleeding additional. It's things that would raise suspicion for that area. Is any penetrating pelvic trauma, any penetrating trauma to the

perineum, pelvic fractures or other injuries within the pelvis should also make your concern for rectal injury higher.

Now, is there any utility to any like rectal contrasted scans or is that all institution specific or Yeah, you'll still see the, the, some of the colonic or sort of the rectal contrast being used. But typically the best way to evaluate these is with proctoscopy or sigmoidoscopy in the operating room.

Okay. Now let's say that you have a patient that had a, a positive FAST and was unstable. And you, they had a, you know, penetrating pelvic injury and he took them to the OR. What do you have to remember about these, you know, specifically rectal injuries or those extra peritoneal rectal injuries? Yeah, you're not going to be able to see the extra peritoneal injuries.

through an exploratory laparotomy. And they may only be able to be visualized on proctoscopy. You know, it may not be a question of the ab site, but it's something you might consider if you're taking a patient to the operating room that has penetrating or blunt

pelvic trauma, placing them in lithotomy prior to the operation, so it makes that scope easier to do.

Great. Okay. So, okay, let's say we're in the OR and we've done our abdominal portion of our procedure. We suspect a rectal injury. And so you, you asked me to come in. I look from below with a rigid procto and, and lo and behold, yeah, we do have an extra peritoneal rectal injury. How should we manage that?

There are a few different ways you can manage this. The safe answer for the abscite is fecal diversion from usually a sigmoid loop colostomy. The traditional rectal irrigation and presacral drainage are no longer appropriate to the higher risk of infections. Yeah, I think I remember all those D's from back when I was in training, distal washout, diversion and drainage.

So what you're saying is really the most important part is that diversion. Diversion, yeah. I would say that's a good safe answer on the ab side. Okay. So, let's get out of the rectum and let's move into pancreatic injuries. So, blunt injury mechanisms to the pancreas. What, what type

of mechanisms should raise our suspicion that we may have a pancreatic and or duodenal injury?

Yeah. So, these go hand in hand. If you suspect, suspect one, you must also consider the other. The traditional questions you may see and also in real life are handlebar injuries so a kid riding a bike goes over them. handlebars seatbelt injuries coming across, not necessarily associated with seatbelt signs or a steering wheel hitting the patient in the abdomen.

Like the rest of these injuries, there's a double AST injury scale that we'll reference to in the, in the companion, probably not. Super high yield to memorize that for, for the ab side, but certainly something to be aware of and can help guide management. But with regard to management, what, you know, what are the, the, the key factors and what do we want to kind of be looking for on our imaging and associate or assessing when it comes to pancreatic blunt injuries?

Yeah. The one thing that comes up a lot is that if you have a patient that, you know, had significant abdominal trauma,

Maybe emitted for, you know, solid organ injury or some other source, spleen or liver. And you also have persistently elevated or increased levels of amylase and lipase after the trauma.

You must have that much prompt you to do evaluation for a pancreatic injury. The management of this, if you're in the operating room, the key factors. are whether you have involvement of the pancreatic duct and is there an associational, associated duodenal injury. So Jason, the management of pancreatic injuries is kind of broken down to where it's out of the pancreas.

How do we approach a patient, you know, has a significant injury to the head of the pancreas? I want to say it was Ken Maddox that once said you know, treat the pancreas like a crawfish. You suck on the head and you throw away the rest. So if we're dealing with a main pancreatic duct injury, that's the head of the pancreas.

I'm going to manage that with wide local drainage. And that might be a damage control type procedure. If it's a distal injury I would manage that with a distal pancreatectomy. Oftentimes, that's going to

involve a splenectomy in the trauma situation. Although, you know, in children, if they're hematopoietic stable or certainly anybody who's hematopoietic stable, I would make some effort to preserve the spleen.

Yeah, the one caveat to that is that if you have a, you know, pancreatic hematoma that you happen to find when you open the lesser sac, that's not necessarily an indication to remove the pancreas. You can just place strains back there and observe them if you don't, if you don't feel that there's a ductal injury.

Alright, moving on to splenic injuries in the spleen. So Jason, what's the general approach to management of splenic injuries? Yeah, so the majority of splenic injuries can actually be managed non operatively without surgery. Especially if we're talking about blunt trauma, MBCs and the like. The key is to, you know, place the patient in a monitored bed and the management for non operative or non interventional management should definitely be protocolized.

include things like serial hematocrits abdominal

exams monitoring very closely for hemodynamic stability. Now in our initial imaging, if we see things like a blush on that CT scan, well, that's where we may want to involve our interventional radiology colleagues for angioembolization. And then also for high grade injuries, we'll want to consider some.

type of interval CT scan to watch for the development of pseudoaneurysms or delayed hemorrhage. But, you know, really initially the most important thing is watching for that hemonymic instability. Yeah, and the one thing that catches for the questions on the ab site regarding spleen, so if you have an unstable patient when they walk in the door, no matter what the grade of the...

Spleen is you need to consider considering the operating room and don't ever take an unstable patient on the ab site to angio embolization. Additionally, in the, in the text we have the AAC injury scale. Like we mentioned before, these are a great reference for clinical use. They're rarely tested on the

ab site where you're expected to know what grade the injury is, just based on the description within the question stem.

So Jason, moving on, what do we do post splenectomy? How do we... How do we manage these patients after they're recovered from their their injury? Okay. Yeah. So after splenectomy or even after angioembolization we'll want to treat patients and, and vaccinate them for encapsulated bacteria. Those encapsulated bacteria being pneumococcus, meningococcus, or H influenza.

Ideally we would do that vaccination 14 days after either the splenectomy or the angioembolization. In real, you know, in, in reality. With, with trauma patients generally will want to make sure that they're, they're vaccinated before they leave the hospital. Yeah. So what are some of the complications?

After performing an open splenectomy. Yeah, so, typically I like to break these down into early and late complications. So, early in the hours to days after a splenectomy, you can get bleeding, fleeting, and also

bleeding. Another thing to worry about would be gastric perforation, and this all has to do with the, you know, the, the intimate relationship between the spleen and the short gastrics and that greater curvature of your stomach, which is the site of perforation and also the most common site of bleeding after a splenectomy.

Now, late, we worry about things like a pancreatic injury that could result in a fluid collection there or even a pancreatic fistula. So that's why we oftentimes like to leave drains in that area if we're worried about a pancreatic injury. And then finally, you know, down the road looking for a post splenectomy infections or Opsy overwhelming post splenectomy infection, which is the reason why it's so important to get those patients vaccinated.

Yeah. And, you know, talking about the pancreas injury and fistula, drainage is not necessary after an open splenectomy, but as mobilization of the spleen, and especially if you have trauma to the hilum of the spleen, you may have a pancreatic

tail injury. So if you notice... You know, the pancreas is, is even slightly injured in the operating room.

It's always safer to leave drains. So Jason, what's the most common organism that causes the overwhelming post splenectomy infection? Yeah, that's strep pneumo. How would that usually present? So usually it occurs, it's very rare. That's important to remember, but often it occurs many years after the splenectomy.

So patient will have, you know, some early prodromal syndromes of fevers, chills, rigors, diarrhea myalgia, but it can very rapidly progress to DIC, multi system organ failure, and possibly even death. So it's something that we need to have a high index for suspicion for and to treat patients aggressively post splenectomy.

Okay. So now moving on to liver injuries. So, you know, we know this is, we've all probably heard that liver injuries are the most common solid organ injury. So initial management John, how do you, how do we typically approach liver injuries? Yeah, I would say the majority of liver injuries can be managed without surgery, very similar to any other

solid organ injury.

The patient should be in a monitored setting and the type of approach should be protocolized to include repeat hematocrit checks and abdominal exams. And similar to spleen, if you have blush on CT scan, especially on the initial CT scan, you need to consider IR colleagues about that, and also consider a repeat CT scan if you have a high grade injury to rule out a pseudoradnerism.

And then both for spleen and liver, that's usually done around 72 hours after injury. And I think I'll come back at you with what you came at me with, with the spleen injury, is the first thing we need to do is determine whether or not the patient is stable versus unstable. You know, obviously we have a solid organ injury, unstable patient.

That patient belongs in, in the operating room and certainly not in the CT scanner or interventional radiology. So we need to clearly make that distinction first. Like the other things that we're talking about, there is a double AST injury scale that we'll reference to. So let's, let's take a step back and say that, you know, we are in the OR with this

unstable patient that has a liver injury.

Can you kind of walk me through your, your stepwise approach to how you handle these? Yeah, liver injuries can be quite difficult and there's, you know, multiple tests techs out there explaining the best approach to these injuries. But it's important to have, you know, great control of the room, have anesthesia buy in for these.

You always want to start with the least invasive. And in this case, for liver injuries that would include you know, liver packing to get hemorrhage control. If that doesn't work, especially if a patient's still bleeding, you want to consider doing a Pringle maneuver. So that includes your portal venous and hepatic arteries.

And then finally, if you're still having bleeding past that now you have to be concerned with one of the worst injuries in trauma, which is a retropathic IVC injury, and you want to move to total vascular isolation. Okay. Let's say that, you know, the liver's cracked open and you're getting a lot of bleeding from the liver itself.

What are some how do you manage bleeding from liver parenchymal? Yeah, this is not particularly important for the abscite

specifically. So same thing as, you know, getting hemorrhage control, there is a stepwise and kind of least to most invasive way. Okay, hemorrhage control that includes just electrocautery to suture ligation to anatomic liver resections.

Like it once again, that's not going to be necessarily questions on the ab site or how you're going to deal with this. What is important to deal with for the ab site is when to consider damage control surgery and just packing rapid transfer back to the ICU or to IR. If you're having, you know, significant bleeding.

Yeah, I would agree with that. You know, I think I could see yourself in that situation on the outside, you know, with a patient that's coagulopathic, hypothermic and acidotic, and the, the answer is, you know, damage control with temporary packing and, and get them to the ICU where they can get resuscitated and trying to stabilize them to, to fights another day.

Well, let's say we get our patient through, you know, their injury. What are the complications down the road both immediate and early and late that we need to worry about?

Yeah, I kind of generalize them. So, the two big ones, you always need to consider bleeding anytime you take a patient to the operating room.

So, if you're having a patient with hypotension and in lab data that supports, you know, downtrend, downtrending hematocrits, you need concern that the liver is bleeding again in a patient who belongs back in the operating room, even during resuscitation. The other things that happen later on are bile leak and hepatic necrosis that present in a myriad of ways.

So bioleak, you'll get constant fluid collections around the liver that may require percutaneous drainage. You may need to do an ERCP with placement of common bowel duct stents to optimize flow through the the duct system. And then also put them in place of patient antibiotics. So pachynecrosis will often come and, and show as an abscess.

And this also may need antibiotics. percutaneous drainage or resection unfortunately if it's clinically significant. One of the more commonly tested things, luckily not, and that happens a lot is an arterial biliary

fistula. This is a patient that will present with hematemesis and you'll have a CTA showing a fistula.

and they will need angioembolization to deal with that. A lot of times what you'll see that is you'll see and what they'll give you is that you see blood coming from the ampulla on upper endoscopy and so if you see that a patient with a history of liver trauma think arterial biliary fistula and again as John says here the answer is angioembolization.

So, another high yield specific injury to discuss are pelvic fractures. It's very common. So John, what can you tell us about pelvic fractures? Why are they so commonly tested and important? Yeah. The high yield things you want to know for the outside for pelvic fractures is that bad pelvic fractures are no joke and they can quickly lead to deterioration.

The things that are tested are when do we place pelvic binders. Specifically, we're not going to get into all the different types of pelvic fractures, but if you have an open book fracture you want to

place a pelvic finder at the level of greater trochanter, and this should be done in the pre hospital setting.

Additionally, 85 percent of pelvic hemorrhage is venous. It's not arterial hemorrhage is a very low component of this. If you do have a blush on CTA, and the patient is relatively stable, you want to consider angioembolization once again. If the patient is unstable or IR is not available, which is something that you often get on your oral board scenarios, you want to take the patient to the operating room for preperitoneal packing.

Then, after you pack the preperitoneal space, they can go to IR after the bleeding persists. When would you think about using, or is there any rule for using a Roboa in pelvic fractures? Yeah, I think rubella has a very I'm not sure if this would be on the app site But as a very a good consideration in pelvic fractures placing a zone 3 rubella just above the The bifurcation

can be a very good adjunct to control the bleeding in these patients.

Okay, right? Well, yeah, I think you hit the key points that what they're really getting out on the outside is to recognize that patients can bleed to death in their pelvis and that most of that hemorrhage is venous. So, you know, pelvic binder combined with either preperitoneal packing as well as IR will, will stop most of that bleeding.

I think the other thing to think about is the associated injuries that they'll want you to recognize. So pelvic fractures can, you know, think about the organs that live within the pelvis, the bladder, urethra, vagina, rectum. You need to have a very high index of suspicion of these. So let's say you may get somebody with a pelvic fracture that has gross hematuria.

So what should we be thinking about in that scenario, John? Yeah, I need to be concerned about a urethra or bladder injury in that instance. And you'd want to get a retrograde urethrogram or cystogram, but we're going to talk about that in the next section under urologic trauma. All right, so Jason, renal injury, how are these, how do

these patients typically present?

Well, sometimes you'll get hematuria, either gross or microscopic, but just be aware that, you know, this is not always present. So, don't be, you know, reassured if you don't see this and you can see, well, mechanism can kind of kind of clue you in as to a patient might have a renal injury. You may see flank ecchymosis or the patient may have flank pain.

Yeah. And how we evaluate them typically. Generally with the, we'll put them in the answering machine. So, CT abdomen, pelvis with IV both IV contrasts, both immediate and want to get those delayed images. Yeah. Delayed images are particularly useful. How I've seen this work is that you get the IV contrast study.

If there's a concern for. A renal injury based on the initial reads and you just leave the patient on the table and then get delayed images while they're still there. Jason, how do we deal with renal locks that are identified on CT scan? So, if the patient's hemodynamically stable, they can generally be managed non

invasively or non operatively and often just as supportive care.

CT imaging should be performed for a grade four and five injuries for those developing signs of complications such as fever, increased pain and distention. Just another thing to put on your, as a question pops up, as a patient's a few days after an injury like this, what should you do? CT imaging would be the right thing.

Now, what I think is a more interesting question is what do you do in the OR with retroperitoneal hematomas? So, let's say a Zone 2. You know, retroperitoneal hematoma or in the OR, what are important considerations and what are some decision points? Yeah. So most of these hematomas are, you know, are usually seen on your first evaluation of the abdomen.

If the hematoma is not expanding, if it's not quite large, and there's just, you know, some staining back there in the zone to your area, you can usually leave it alone and do not violate the hematoma mainly going to, because you're going to increase your body bleeding by opening that space. If it's expanding pulsatile or if it's uncontained and

the retroperitoneum is, has been ruptured, it should be explored and the bleeding should be managed.

Okay. I think an important caveat there is where I think in this instance, we're talking about blunt, a blunt mechanism. Now, if a penetrating mechanism, of course, the book answer is to explore that hematoma. But you know, as you say for a lot of these renal injuries specifically blunt can be managed non operatively or without exploring that stable hematoma.

Staying within the urologic system. So ureteral injuries how do we, how do we manage these, John? Yeah, you see a handful of questions on ureter injuries. So, it's best to kind of break these up into the sections. And the most commonly section that you'll see injured, especially in the general surgery ab site is the distal ureter injury.

This can just mostly be re implanted back into the bladder. And then the kind of the follow up questions, if it doesn't reach, what do you do? Jason, what do we do if that's the case? Psoas hitch. Yeah, psoas hitch. And they

often, I've, I've, I've seen this on the outside, they won't often say psoas hitch, but there'll be a description of a psoas hitch, so make sure you're familiar with that.

So yeah, again, that's a distal ureteral injury that you can't get to reach to re implant into the bladder. All right. How do we deal with mid urethral injuries? So, yeah, mid urethral injuries, we want to, you know, spatulate our hands and perform a primary anastomosis over a double J urethral stent with fine absorbable, important to use absorbable sutures there.

And it goes without saying that you want to involve your urology colleagues, but that often will not be an option for you on the outside. Yep. So just quick distal urethral injury, re implantation, mid urethral injury. You want to do a primary anastomosis after debriding all of the damaged tissue.

Alright, moving on to bladder injuries. So we know that 90 percent of bladder injuries are associated with pelvic fractures. The injury that is often laceration from fractured bone within the pelvis. How do these patients typically present? Let's

say you're in the trauma bay, Jason. Yeah, so, kind of like we talked about with pelvic fractures.

You certainly need to have a very high suspicion with with bad pelvic fractures. Typically, you'll see the patients will present with hematuria, and that should be kind of your indicator. It's hematuria is more reliable with a bladder injury than it is with a renal injury, so. If I see hematuria with a pelvic fracture, I know that that needs to be investigated further.

And typically that's with a cystography, either retrograde cystography or a CT cystogram. All right. How do we manage these people? Let's say let's break it up into intraperitoneal and extraperitoneal injury. Okay. So you have a intraperitoneal injury to the bladder. Yeah, this is important and this is a question that you could very possibly get on the ab site.

So intraperitoneal bladder injury requires immediate operative repair. So that one's going to the OR. For extraperitoneal injuries, so if these are, you know, uncomplicated and those can be managed with a Foley catheter to drainage and

operatively. However, if they're complicated in an, in an OR patient that's undergoing.

Repair, operative repair of that pelvic fracture you'll typically want to repair those bladder injuries to avoid, you know, leaking into that pelvic repair. Yep. So once again, reiterate intraperitoneal bladder injury. Operative repair, extra peritoneal, typically can be managed with a conservative management with a Foley catheter.

Alright, what's the general principle in managing into surgically repairing these injuries? Yeah, there's a lot of different ways of doing it. You know, which is, you kind of remember, is a two layer watertight closure with absorbable suture. Again, it's very important in, in anywhere in the urinary tract to use absorbable suture, because permanent suture can be a night.

forming, you know, bladder stones and those type of things. And then you're going to want to leave a catheter in place usually for 10 to 14 days. And we get a retrograde cystography before removing that that Foley catheter. Yeah. And that goes for both intraperitoneal and extraperitoneal injuries.

Okay.

Moving on to urethral injuries. How do these usually present? So these are, you know, patients that you'll see, you know, blood at the meatus, you get a scrotal or peroneal ecchymosis often described high riding prostates as well as inability to void or pass a Foley catheter should all raise suspicion for a urethral injury.

And again, have a high index of suspicion for those pelvic fractures. Yeah, and what's the classic imaging study we asked for for urethral injuries? Yeah, so retrograde urethrogram is what you're gonna want All right, and so we once again kind of break the management up of urethral injuries into two different types So for blunt posterior injuries, how do we manage them?

So blunt posterior injuries are, that's the answer is a percutaneous suprapubic tube. Yep. And anterior injuries? Anterior penetrating injury will be an exploration and primary closure. Good. Moving on to extremity trauma. We're not going to dive really far into extremity trauma, but there are specific musculoskeletal injuries

and the associated neurovaxial structures that you have to know for the ab scythe.

So starting with the upper extremity, Jason, and I'll just list these out. If you have a patient to present with a shoulder dislocation, what nerve is associated with that injury? Shoulder dislocation, axillary nerve injury. All right, humeral shaft fracture. Humeral shaft fracture, that's a radial nerve. All right, moving to the lower extremity, a hip dislocation.

Now with hip dislocation, you need to worry about your sciatic nerve. All right, a knee dislocation or a medial tibial plateau fracture. Okay, so knee dislocation, tibial plateau fractures, that's you worry about your popliteal artery or your common peroneal nerve. Moving into compartment syndrome, so we rarely measure pressures of the extremities clinically.

But if we were to measure that pressure what would be the threshold for diagnosing compartment syndrome? Yeah. So technically the compartment pressure with over 30 millimeters mercury of the diastolic pressure is considered consistent with compartment pressure. More recently

we've, you know, gone with the Delta pressure, which is kind of equivalent to the cerebral perfusion pressure.

It's the compartment version of the cerebral perfusion pressure. So that's what we more commonly use now. But really, I mean, compartment syndrome should be a clinical diagnosis, right? And then what, if you had being a clinical diagnosis, what type of injuries are high risk for compartment syndrome specifically in trauma?

Yeah. So crush injuries certainly a tibial plateau or tibial shaft fractures are very high risk. So you should have a very high risk of suspicion there. Ballistic fractures, you know, again, the high energy tibial fractures. As well as a radius ulnar fractures for the upper arm. So don't forget about the forearm as well.

Alright, continuing with extremity trauma, there are some vascular principles that we need to address, but this will also be covered in the vascular chapter as well. For trauma specifically, what are some general operative principles that we need to follow? So, we can make some just broad generalizations when it comes to extremity

vascular trauma.

First non circumferential injuries may be patched with autogenous tissue or a prosthetic patch. In defects less than two centimeters where the two ends can reach each other without tension, primary repair after spatulating the edges for an endonasmosis can be performed. Longer gaps between two vessel ends can be bridged using an interposition graft.

The type of interposition graft that you choose is based upon the type of vessel injured. So for extremity arterial trauma, the general answer is reverse saphenous vein. However, more proximal injuries like things above the knee is generally accepted to, to use a synthetic graft in a non contaminated field.

For extremity venous injury you generally primary repair these if possible, but it's, it's generally usually safe to, to, to ligate these if necessary. One last thing to add to if you have a unstable patient with, you know, multi traumatic injuries that, you know, shunting is definitely

an option. for these patients.

The one thing, if you're looking at order, I don't think this would be a question on the ab sites, but you have a patient with, you know, an extremity fracture and a vascular, associated vascular injury, do the shunt, fix the orthopedic injury first and then perform your repair. And I'll just add one additional thing.

So when you're, you're talking about combined arterial and venous injuries you, you, you want to be less inclined to ligate that vein. So typically you'll want to repair the artery and vein if possible. And with any of these, always consider ischemia time and consider a fasciotomies with any of these injuries as well.

Okay. So now we're going to dive right into some special populations and these are just high yield pearls. This is by no means meant to be comprehensive. So let's, let's talk about pediatric trauma patients. What are some pearls high yield for pediatric trauma patients when it comes to airway, John?

Yeah. Something to know about pediatric patients is that the airway is narrower, shorter and

more anterior than adults. So when you're going to intubate these patients, it often requires the use of a straight laryngoscope blade. With some upward angulation. Additionally, bradycardia is a common side effect of direct laryngoscopy in patients.

And we want to treat this with atropine. We want to only want to intubate with cuff tubes only infants received uncuffed tubes. A good way to predict the size of the ET tube ET tube that's gonna be needed for your patient is use the size of the patient's pinky nail bed with, or use the equation age divided by four plus four.

equals the ET tube size. Now, what about when it comes to resuscitation? I know this can be confusing because infants or children are different sizes and vary greatly and this provides a lot of anxiety for people. Is this somebody we want to give two and two to? Or how do we decide how to resuscitate them?

Yeah, obviously the pediatric patients will need weight base for suscetation. So when we talk about

boluses of either crystalloid or blood, we use 20 bolus for crystallite kilogram bolus for blood products. Great. Okay, so our next special patient population is pregnant trauma patients. And one thing we need to be aware of is that there are physiologic changes in pregnancy.

So what are some of those, John? Yeah, in regards to circulation, pregnant patients will have increased circulating blood volume. That's accompanied by a physiologic anemia of pregnancy. Additionally, what you'd see on their lab data is leukocytosis, thrombocytosis, increased fibrinogen, and increased clotting factors 7, 8, 9, and 10.

Now how about you know, the placental vascular characters and, and, and the fetus? How does that react to some physiologic changes in trauma in pregnant? Yeah, the placental vasculature is extremely sensitive to catecholamines, and it can lead to abrupt decrease in maternal intravascular volume.

which can result in profound increased resistance in the uterus,

reducing fetal oxygenation despite normal maternal vital signs. So you have to have a high suspicion of fetal compromise during impregnant patients. Yeah. I think the other thing to be aware of is the respiratory changes of pregnancy. So, you know, pregnant women will have increased tidal volume and increased O2 consumption.

So apnea is very poorly tolerated, so they should get supplemental O2 and, you know, Pregnant women are constantly in a state of compensated respiratory alkalosis. So that's certainly something to consider as well. Yeah, the increase of abdominal pressure and, and, and pregnancy, you know, displaces the diaphragm upwards.

leading to a higher respiratory rate, that which can lead to a respiratory alkalosis. Okay, so let's say we have a pregnant female that comes in with abdominal trauma. What do you want to do for this patient in the trauma bay? This can be a complicated question because they might bring you A bunch of different things you want to do specifically for pregnant,

but you remember you have to approach every single pregnant or every trauma patient very similarly.

So A, B, C, D, E's. Start with your primary survey and then move forward. But in general you do want to place pregnant patients left side down to take pressure off the IVC. and allow for appropriate blood return. You also need to have a high vigilance of placental abruption and maternal fetal hemorrhage.

Jason, what are ways that you might see this in a trauma patient? Yeah. So, you know, for a placental abruption, you might see abdominal pain. You might feel uterine rigidity or tenderness. Patient may be having contractions and or vaginal bleeding, you know, but it's important to remember that abruption can present even in the absence of some of these things.

thing, specifically vaginal bleeding with abruption. You could see some lab abnormalities and decreased platelets decreased fibrinogen concentration, you know, all things that you would see in patients that are hemorrhaging. But in these patients, you may not see the hemorrhage. I think the other thing you mentioned was the maternal

fetal hemorrhage.

So, you know, there's a Kleinhauer Betke test, which measures the percentage of red cells containing fetal hemoglobin in maternal circulation. So this should be routinely performed in RH negative patients. Patients and considered an RH positive patients who sustained blunt trauma as a positive test is a predictor for preterm labor and associated with a placental abruption.

Additionally, RH negative mothers with a concern for maternal fetal hemorrhage or have a positive Klein Hauer Bettke test. Should receive RhoGAM, which is, you know, RH immunoglobulin to prevent Alloimmunization. Yeah, the last thing you the, you know, one of the major complications can be uterine rupture as well.

This is a very serious injury. It can present with shock, and you can palpate fetal parts outside of the uterus. that can lead to abnormal fetal heart tracings, uterine tenderness, and vaginal bleeding. Now, something that comes up frequently is, is fetal monitoring in these patients. So, you know, maybe you have a,

it happens all the time.

We get a pregnant patient with a low mechanism of injury and they'll want to admit for fetal monitoring. Who needs fetal monitoring? Typically, the cutoff 24 or more weeks.

gestation, and they will usually need for about two to six hours. There are some indications for more than 24 hours of observation, and those include high risk mechanisms such as vehicle ejection, motorcycle crash, or death of another occupant in an MVC, abdominal bruising, or any other abdominal injury.

Injury severity score greater than nine. There's concern for a placental abruption or ultrasound persistent abdominal or abdominal or uterine pain, a maternal heart rate greater than 110, regular contractions, vaginal bleeding, and coagulopathy. Okay, great. Well, let's move into our last special patient population and that's geriatric trauma patients.

So how is the, you know, how are geriatric patients different than young patients? The geriatric patients have a lower physiological

reserve than younger patients, which then places them, you know, at a pretty high risk category and then lower threshold for admission to an ICU or transfer to a designated trauma center.

While there aren't a lot of specific questions for geriatric trauma patients on the ab sites many institutions will have their own protocols in place for which patients belong in the ICU who you can admit to the floor. And which patients, if they're at a lower level of care, need to be transferred to a designated trauma center?

Yeah, I think you might get into, you know, a geriatric patient with rib fractures and they'll ask you where the patient should go. Just keep in mind that, you know, they have a low physiologic reserve and can decompensate and those patients need to be admitted to the ICU in general. All right, moving on to our quick hits.

Let's do it. All right, Jason, you ready? Born ready. What patients should not receive succinylcholine? So it would be your burn patients, patients, crush injury patients patients with muscular dystrophy patients who are hyperkalemic or those with a history of

significant spinal cord trauma.

All right, what are the earliest signs of hemorrhagic shock? Tachycardia and a narrowed pulse pressure. What if you have a patient in the trauma bay with hypotension with paradoxical bradycardia? Okay, so, trauma patient, bradycardic, hypotensive, I'm worried about neurogenic shock. All right, what's the most common mechanism of urital injury?

Iatrogenic actually through ureteroscopy or during even hysterectomy or, or colectomy. Bladder injury is most commonly associated with what injury? Pelvic fracture 90 percent of the time. What should you always consider for lower extremity vascular injury, especially after prolonged ischemia?

Yeah, fasciotomies to prevent compartment syndrome. Yeah, you're pretty much guaranteed a question on that. Initial management of open book pelvic fracture. So you want to emergent reduction with a binder and or traction in order to tamponade that venous bleeding from the shared blood vessels.

Yeah. We want to close the space and restore normal anatomy. All right. You see

bubbles in resuscitative thoracotomy. Yeah. That's usually due to an air embolism. And typically from a pulmonary injury. Alright, what do you have to be concerned about in a patient with an MVC with a lumbar chance fracture and a seatbelt sign?

Okay, well, I'd be worried about duodenal injury, pancreatic injury, or a holobiscus injury. With a, what's the classic scenario of a kid with a handlebar blow to the abdomen? A duodenal injury, specifically a duodenal hematoma. Yep, and always be worried about pancreatic trauma there too. Alright, initial treatment of a hemodynamically stable duodenal hematoma.

Okay, hemodynamically stable hematoma duodenum, observation, NG tube, well, NG tube decompression if they develop gastric outlet obstruction. Alright, you have a patient with a left thoracal abdominal stab injury. With negative imaging and normal exam, what do you do? Well, thoracodominal stab injuries, I'd be highly suspicious for a diaphragm injury, which is not well seen on imaging.

So I would want to do

a laparoscopy to evaluate for a diaphragm injury. All right, you got a patient comes into the trauma bay, call it a trauma because they're found down. They're known to be 5. What are you concerned about? Yeah I'd be concerned about rhabdomyolysis. Alright, you have a history of tracheostomy, patient, nurse reports 10 cc's of bright red blood from the tracheostomy site.

Yeah, so I'd be worried that that's my sentinel bleed for a developing tracheoenominate fistula. Alright, next is a severe TBI patient with a sodium of 155 and 5 liters up in resuscitation. Okay, so with a TBI patient in those labs and that urine output, I'd be worried about diabetes insipidus. Alright, the treatment?

DDAVP. Okay, you got a trauma patient that's paralyzed from the head down with no cremasteric reflex, so that's a spinal shock, right? Stab wound to the abdomen, benign exam, eviscerated omentum. Evisceration is going to the OR for a laparotomy. Yeah, you could consider laparoscopy

but for the lab site, you know, just perform a laparotomy.

Liver bleeding that's unchanged after a PRNCL maneuver. Yeah, so we talked about this, so that would make me concerned for a hepatic vein or a retrohepatic vena cava injury. Alright, and the procedure you do to secure all blood flow to the liver. Yeah, it's a total vascular isolation of the liver.

You got a chest x ray that shows an apical cap. What should you be worried about? Apical cap, I'm worried about a blunt injury to the thoracic aorta. All right, you have major arterial bleeding posterior and a neck expiration. Yeah, it's a most likely a vertebral artery injury. Alright. Stab wound to the flank.

So, I'd be worried about injury to my retro, er retroperitoneal organ, so kidney, colon injury. So I'd want to evaluate that with a triple contrast CT. Yeah, remember, you're not going to see these types of injuries present on, you know, traditional abdominal imaging and trauma and that's why you may need to follow up

with a triple contrast CT.

Trauma patient with an elevated LY30 on tag. Okay, LY30 that patient needs TXA. Alright, the gateway structure to the carotid bifurcation. The common facial vein. Alright, gateway structure to the great vessels during a median sternotomy. What's your indominate vein? And hopefully you didn't come through it with your sternal saw.

Yeah, can we ligate that? You can. Okay. Hematomasis two weeks after MVC with a grade four. liver laceration. So I'd be worried about hemobilia from arterial bilious fistula. And how do we treat that? So angioembolization. Okay. We have a patient with an open pelvic fracture with a complex perineal wound.

Yeah. So I'd want to divert that patient. So diverting colostomy. Okay. We have a gunshot wound to the pelvis with a rectal wall hematoma seen on rigid proctoscopy. Yeah. So that, that one's kind of tough, but it was the rectal wall hematoma. Even though I don't see an injury, I'm going to divert that patient with a diverting colostomy.

Okay, good. All right. Well, that

rounds out the second portion of our trauma ab site review. Trauma is a significant portion of the ab site every single year, so I highly recommend reviewing this multiple times as well as doing a bunch of questions. And we'll see you next time.