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ABSITE Review: Trauma, Part 1 (Podcast)
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ABSITE Review: Trauma, Part 1 (Podcast)
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>> Behind The Knife, the surgery podcast where we take a behind-the-scenes intimate look at surgery from leaders in the field. [ Music ] >> Alright and welcome back to the Behind the Knife ABSITE Review series and this week we're covering trauma and we're lucky enough to have Dr. Matthew Martin who is going to lead us through trauma review.
So Dr. Martin, welcome, and tell us a little bit about yourself. >> Yeah, thanks for having me back. This is Matt Martin. I'm a trauma and critical care surgeon at Madigan Army Medical Center and also at Legacy Emanuel Medical Center in Portland, Oregon, and happy to be here again. I am also one of the moderators on the EAST Traumacast Podcast program. So if you're interested in some focused trauma topics, come on over and listen to us. But happy to be here and help out with some ABSITE review. >> One of my recent favorites on there was the war surgery discussion panel that you had the EAST Traumacast and you also had a really good one recently about ventilation modes and ARDS.
I found it really helpful. >> Oh, yeah. That was a great one. Whenever you get two staff arguing, it's always entertaining. >> Very. >> Yeah, so I also just wanted to give a little plug to the Traumacast. Anybody out there who hasn't heard it who's a fan of Behind the Knife should definitely go over and check out the EAST Traumacast Podcast. A lot of really great discussions over there.
If you like this program, you're definitely going to like that one. >> They are lacking the final five and the rain impacted today but they make up for it in other areas. Alright, Dr. Martin, take it away. Like every other ABSITE review, this is high yield, not meant to be comprehensive and we're just hitting points. >> Okay. In keeping with, I think, the optimal method for ABSITE prep, I think it's less helpful to have kind of in-depth conversations about a topic and I think a lot of the ABSITE test taking is recognizing key buzz words or phrases and you almost should know the answers they're looking for by the time you get to the end of the question.
So I think we'll run through this. We won't have a whole lot of discussion about ancillary stuff and we'll just really focus on a lot of these topics as if it was a question being asked and what the right answer would be. Okay, so all of trauma starts off with what? >> ABCs. >> That's right or A. So first pointer whenever they give you a question of you're evaluating a patient who just comes in, the answer is usually A for airway. That's the first part of the primary survey. So the primary survey is ABCD and that's focused on identifying only life-threatening or major pathology.
So everyone's familiar with airway breathing circulation. We won't get into that too much. Disability, so Kevin, what is disability? What exactly are we doing when we get to D? >> Right. When we refer to the primary survey, there's two aspects of disability. It's the GSC and the pupillary exam. >> Okay. Good. And what are we looking for on D? What life-threatening pathology?
>> Intracranial hemorrhage. >> Good. We're looking for intracranial pressure rising. So GCS and pupils. And you might get a question that asks what component of the GCS is the most useful or most predictive, in terms of outcome? >> I believe that's your motor function is the most predictive. >> Yeah, so the motor score has actually been shown to be almost as predictive as the entire GCS. There's often a question where they'll give you all the components and ask you to calculate a GCS.
So just make sure you remember the scoring of the GCS. And obviously, the old adage, GCS of less than eight? >> Intubate. >> Intubate. I think that's almost always a question. Okay, so you get to your GCS and pupil exam and you have a unilateral fixed pupil. We'll say the left pupil is fixed and dilated. What does that make you worried about? >> I'm worried about that there is herniation on the left side of the brain.
>> Good. So the fixed dilated pupil, unilateral, remember it's indicating pathology on that side. So in that scenario, it would be a left intracranial, usually hemorrhage that's causing compression on the optic nerve. Okay, patient with bilateral pinpoint pupils. So probably the most common thing would be narcotic use but if you have bilateral pinpoint pupils from a significant brain injury. This is a less common, okay, so it's from pontine hemorrhage.
It's one of the only ones that'll give you pinpoint pupils and I just remember it as the Ps, pinpoint pupils pontine. Okay, so we already talked about a head injury, GCS of less than eight. So one of the things we always need to know about is who should get an intracranial pressure monitor. So who would be a candidate for an ICP monitor? >> So someone with a severe head trauma that has intracranial bleed or concern for intracranial hypertension and someone that you cannot get a good exam on. And so I think generally with a GCS less than eight would be a person that would qualify.
>> Good. So yeah, those are the Brain Trauma Foundation Guidelines, GCS less than eight with an abnormal head CT. There are additional guidelines for even with a normal head CT but if they have a GCS less than eight and they're older or they have unilateral localizing signs but generally anybody with a GCS less than eight and they have an abnormal head CT, that's criteria for an ICP monitor. And what kind of ICP monitor can we use?
Where can they place that? >> I mean, they can place it at the bedside in the ICU. You can place it -- >> I mean what areas of the brain? >> Oh, into the ventricles. >> Okay, so that would be called? >> Intraventricular drain. >> Yep. Or a ventriculostomy. >> And the nice thing about that is you can drain fluid off if you need to.
>> Exactly. >> They can place it in the epidural space but I think the one I'm most familiar with is the one that they place in the ventricles. >> Yeah, so ventriculostomy allows you to drain CSF, so it can be therapeutic. But if we say they're placing a bolt, which is probability one of the more common ones. Where are they actually placing that? >> Is it just intraparenchymal? >> Yeah, just intraparenchymal. You can put it anywhere in the brain and get the pressure because they equalize but generally a bolt is intraparenchymal.
A ventriculostomy is in the ventricle. Okay, the golden rule of head trauma or I'll give you the question. You have a patient who's got a bad brain injury and they're going to ask which of these factors would most affect their outcome or be the biggest factor in having a worse outcome. And they'll give you a list of things like say hypernatremia, hyponatremia, hypotension, acidosis or temperature of 39. >> Yes, I think they're getting at avoiding secondary injury with brain injury.
So hypotension and hypoxia I think would be the two big things. >> Good. Yeah, so any drop in blood pressure, any desat and those are obviously things you focus on managing these patients is you want to keep their blood pressure elevated and you want to avoid any desaturations. Okay, so as we talked about, the D is looking for signs of elevated intracranial pressure. So what would be some of those signs at the bedside of a patient who has elevated intracranial pressure or is developing high intracranial pressure?
>> Right, so you'd look for unilateral or bilateral pupil dilatation. You'd look for Cushing's triad, which would see bradycardia, hypertension, and altered respiratory pattern. They could have motor posturing, which would be very concerning, one of the more likely and then a rapid decline in their mental status. >> Yeah, excellent. And Cushing's triad, that's a pattern you will see in almost no other trauma patient, the bradycardia and hypertension as well as the altered respirations.
Good. And what should we do that patient? >> So there's multiple, you know, potentially they need to go to the operating room to get their craniotomy but -- >> Like just in general, can we start treating ICP based off that physical exam? >> We can. >> Okay, good. >> So we can elevated the head of the bed. We can ventilate them to a pCO2 of 35. You can use sedation and paralysis.
You can give them mannitol or hypertonic saline is some of the main methods used. >> Great. And we'll get to how to approach that in a minute. But the point is you start treatment right away. Oftentimes, they'll give you a question that has some of those factors and the answer is not go get a head CT and then base your treatment. It's not rush to the OR blind. It's you start your ICP management and then you get your imaging and get neurosurgery involved. So classic questions on types of head bleeds. Okay, the kid who's hit in the head with a baseball and he's not feeling great, vomits a couple times but he's awake and GCS 15 and then suddenly he declines and he's a GCS of three.
What's the answer? >> That's an epidural hematoma. That's your classic lucid interval that you will clinically experience with that and that's from a damage to generally the middle meningeal artery. >> Great. And what does that look like on head CT? >> You have the typical crescent shape on the head CT. >> Yeah and so it's a very focal and limited lesion because the epidural attachments will keep it in place or it's also called lenticular. Okay, now we have a 90-year-old, say they're on Coumadin.
They fell and hit their head and they've got a skull fracture. What's their intracranial bleed going to be? >> Right. This is the classic subdural hematoma where they tear the bridging veins and this, I'm forgetting the name for it but this is the long, thin, sort of bleed along the just underneath the dura. >> Yes. >> Crosses suture lines. >> Yes. So it'll typically go along the whole hemisphere of the brain. And which of those two has a better outcome, epidural or subdural?
>> The epidural hematoma does. >> Yeah, epidural has a much better outcome. You know, it's something you can put a bur hole in, drain it, stop the bleeding. They're usually better. The subdural has a much worse outcome. It's usually because there's much more underlying brain injury. Okay, now you have a patient who is the high-speed motor vehicle collision. Let's say they starred the windshield and their GCS is seven. What's their likely intracranial process?
>> So these are typically intraparenchymal contusions, intraparenchymal hemorrhages. >> Okay, great. And that's probably -- That's the most common injury we see, much more common than epidural or subdural. And what's your management for that? >> Avoiding secondary brain injury. >> Good. These are not typically managed by any surgical intervention. Okay. And then just to round it out, the spontaneous bleed, person who has the worst headache of their life.
>> Yes, that's a hemorrhage in the subarachnoid, subarachnoid hemorrhage. >> Okay, great. Alright, well let's move on to intracranial pressure, which we already mentioned a bit. So the formula that we always use for relating to intracranial pressure is what? >> So It's your cerebral perfusion pressure. So it's kind of the pressure that reaches the brain and this is -- The way you calculate this is the mean arterial pressure and subtract the intracranial pressure. >> Good. And this formula, you can adopt this to any compartment, right.
It's just a compartment syndrome, just like any compartment. And the compartment perfusion pressure is always going to be what's the pressure in that compartment versus what's the driving pressure driving blood into that compartment. So why do we care about CPP, cerebral perfusion pressure? What's it telling us? >> It's telling you how much blood pressure is actually reaching the brain cells and you generally want it greater than 60 know that you're getting adequate perfusion.
>> Okay, so greater than 60 would be about the absolute minimum we would accept. We'd like it if it's 70 or better. So if you think about somebody who has, say they have a MAP of 80, right, if once their ICP gets above 10, they're under that 70 number. But what would we really want to measure? We're using CPP as a surrogate for something. What are we using CPP as a surrogate for because we don't really want to know about pressure, right? >> Flow.
>> We want to know about blood flow. So CPP is a surrogate for cerebral blood flow, which is what if we could measure that directly we would really want to know. And sometimes there's a question about what CPP is actually trying to give you. Okay, so -- And we want our CPP above 60, preferably above 70. How about our ICP? >> Well, generally, you know, if we have a ventriculostomy or some type of intracranial pressure monitor, we want to try and keep those pressures less than 20.
>> Good. And obviously the lower than 20, the better. Once it gets above 20, that's typically the threshold for treating. Of course, you'll also base that on your CPP measure. Okay, so -- And there's some things that can affect cerebral blood flow and thereby cerebral perfusion pressure. But what's the major regulator of cerebral perfusion? >> Yeah, I've seen this on the test a couple times. It's pretty common. So this is your pCO2 is the major regulator of cerebral perfusion.
>> Good. And there are some other factors like acidosis, like temperature, but the pCO2 is by far the major regulator of cerebral perfusion and it's also one of the most reliable interventions you can do to lower ICP. >> Is that based on arterial dilatation? >> Yes. So if you hyperventilate somebody, what's going to happen to their ICP? >> You hyperventilate them, their ICP should go down. >> Good. But of course, the question is why is it going down? >> So vasoconstriction of the arteries decreases pCO2.
>> Yeah, so you're decreasing the cerebral blood flow, right, which lowers the pressure, but you have to remember a person's got a brain injury, is decreasing their cerebral blood flow necessarily good? >> No. >> Yeah, well, to a certain point. So you have to remember, you will lower the ICP but you're doing it by decreasing the blood flow to the brain to some extent. And the corollary to that being if you let their pCO2 rise, then what's going to happen? >> If their pCO2 rises, then they're going to have hyperperfusion of their brain.
>> Yeah. So they'll get vasodilation. They'll get increased flow to the brain. And typically that will raise their ICP. Okay and so -- But in you right now if we hyperventilated you or, you know, gave you a bunch of oxycodone and let your CO2 go up to 90, or dropped your pressure to a MAP of 50, your cerebral blood flow would be about the same. And why is that? >> Because of autoregulation. >> Good. And what happens in somebody with severe TBI?
>> They lose that ability to autoregulate their pressure. >> Good. And so that means that their cerebral perfusion pressure is directly dependent on the mean arterial pressure, which is again why we focus so much on keeping the mean arterial pressure up because whereas there's almost no relationship between in a normal status. In a brain injury, it's a direct reflection. Okay, so we talked a little bit about ICP and now you have this patient who they've got Cushing's triad and they've got a fixed dilated left pupil.
So what are the interventions we can do for that person? We'll start from simplest to more complex. >> Well, the simple things you can do immediately at the bedside is one, you can raise the head of the bed. So make sure the head of the bed is elevated. Something you got to think about in trauma patients a lot of times they'll have a lot of things around their neck. They'll have C-collars, they'll have other things putting compression on their neck. So make sure that their neck is free of anything that's compressing the blood flow.
And then a lot of these patients are already intubated, so you can do some mild hyperventilation, especially in the short term, to drive their pCO2 down around 35. >> Yeah, 35 to 40 range is good. Okay. And then we get into the medical interventions we can do. And so what would be the targeted interventions we can do to lower ICP? >> So one of the favorites I've seen at least in the ERs recently is the hypertonic saline, as mannitol has gone a little bit out of favor, but I think either of those would be a correct answer on that ABSITE for lowering ICP.
And then additionally always is with sedation and paralysis and then hyperventilation are all good ways to help manage, help lower the ICP. >> Good. So yeah, and so I think it comes down to hypertonic saline or mannitol for your pharmacologic therapies. If they give you a scenario where you have a multisystem trauma patient and they've got a bad brain injury, you know, but they're severely injured and let's say they're bleeding, they're hypotensive, then hypertonic saline would be the correct answer because that will resuscitate them and volume expand them as well as lower their ICP.
The standard patient isolated head injury, I think it's either one, dealer's choice, mannitol and usually one gram per kilogram is fine. Hypertonic saline is fine. And how are those lowering ICP? >> They are, you know, osmotic diuretics, essentially. And it's bringing fluid out of the brain into the vessels. >> Good. So they're both creating a hyperosmotic state. Hypertonic saline doing it by increasing your natural regulator of osmolarity, your sodium.
And mannitol just introducing a false, a false agent to elevate that. Okay, so some adjuncts to head injury. How about seizure prophylaxis? >> Well, it seems like this is changing a lot. It's good at preventing -- So I think most neurosurgeons nowadays are using it if there is an intracranial bleed but not necessarily for just blunt head injury and it's good for preventing, you know, early seizures, the seizures that you would see within the first week after the injury.
>> Okay. And there's a difference between what the neurosurgeon will do and what's on the ABSITE. So for the ABSITE purposes, if you have, you know, a trauma patient with intracranial hemorrhage and they're asking you about this, the answer will be you give them seizure prophylaxis and it can either be Dilantin or now a lot of places move to Keppra. And how long would you do that for? >> Just short term. Like I said, I think most people are just doing it for a week post injury.
>> Yeah. So it's just a week. It helps prevent early seizures. Continuing it has not been shown to prevent longer-duration seizures. So it's typically a short course. Okay, how about feeding these patients? >> Just like where everything's going in surgery, early enteral feeding is the best to help prevent brain injury. >> Good, so enteral feeding within 24 to 48 hours for severe brain injury patients. Obviously, correcting coagulopathy.
Many of these patients are on anticoagulants which actually we'll get to on a later slide. How about steroids for head injury? >> There's been shown no benefit in these patients. >> Yeah. How about one step further? >> It can actually harm them. >> Yeah, so steroids are gone for head injury. And if you get this question, it's an easy answer for you. It's steroids have no benefit. Okay, so we'll talk about one of these patients.
A 75-year-old female in this motor vehicle collision and she has a significant intracranial hemorrhage. She's on Coumadin. Her INR is 4.5. So what should we do for that patient in terms of reversing her coagulopathy? >> So nowadays I think the safe answer is even on the outside is PCC. So you give them PCC. You can rapidly and predictably reduce or reverse their coagulopathy. >> Okay. And what's PCC for someone who might've never heard of it?
>> Prothrombin complex concentrate. >> Good. And what else can you give this person? >> You can give vitamin K. You could give FFP. >> Good. So vitamin K, I would always give to them. But I think now the board answer would be PCC for rapid reversal. And I don't think the dose you would need to know for the ABSITE. Okay, so now we'll say this patient is on one of the novel oral anticoagulants. This patient is on Pradaxa, which is also dabigatran.
>> So it's a trickier situation. Where I've been is you -- We actually start with PCC because you do get some reversal in it and that's really our only option. If their bleed is severe, you can progress on to dialysis. >> Okay, so for the ABSITE test question, they're on Pradaxa. They've got significant bleeding. What's your answer? >> Dialysis. >> Good. That's the one that has to be dialyzed.
How about apixaban or rivaroxaban, either one? >> Again, there's no antidote and PCC gives some partial reversal. >> Yeah, so this is the one that PCC will partially reverse. So you can consider it. Actually and I think we're going to be doing critical care review in a separate session and we'll be talking about those agents in a little more detail. Okay, let's talk about the spine. So obviously we immobilize almost all of our trauma patients but there are some patients we need imaging and some patients we can clear clinically.
And this is also I think a favorite question, so who can we clear clinically? >> So there has to be a few things. There has to be no distracting injuries. They have to be examinable. So they have to have a GCS of I'd say at least 14, 15. >> Non-negotiable, 15. >> Fifteen. They have to be not intoxicated, not on any sedating medications. >> Okay. And then how about their exam and complaints?
>> So they have to have no neurologic findings on exam. If you -- No, you know, midline tenderness. If we're talking about clearance of C-spine, no bony tenderness or midline tenderness. Like I said, no neurologic findings. >> Yeah, those are the big ones. Good. So awake, alert, examinable, no intoxicants, no distracting injury, which means a significantly painful injury that they can't focus on your exam, no midline tenderness, and you can take the collar off, and no neurologic deficits, obviously.
Okay, then if you can't clear them clinically, what's next? >> There's actually a great review on the Traumacast about this big debate on C-spine clearance but for the ABSITE, plain x-rays. Flexion and extension, that's out of favor. We don't do those for C-spine injuries. So generally you'll get a CT scan of their C-spine to clear their C-spine. >> Yeah. So the answer in today's day and age is CT scan. And if they give you a choice of x-rays and clearing, that is the wrong answer for adults.
I'll give that caveat. For pediatric patients, that's still debated a little more. But for adults, that's pretty much been settled. Okay, a favorite of the boards, spinal syndromes, spinal cord injury syndromes. So let's start with central cord syndrome. Why don't you just -- >> So this is generally the old lady who fell who has weakness in her arms and otherwise a normal motor exam. >> Okay, good.
So can they have weakness in their legs? Yeah, they'll typically have both but it's the arms are much more affected than the legs, which you'll see in almost no other spinal cord injury syndrome or it's also called the cape and glove distribution. So it's like they're wearing a cape and that's where their symptoms are. And what's the underlying pathology? >> They generally have spinal stenosis. >> Good. It's this is the old patient with spinal stenosis who gets a spinal cord contusion.
Okay, Brown-Sequard syndrome, also called hemisection. >> Yes, so this is a hemisection of the spinal cord and on physical exam you'll find ipsilateral motor deficits and contralateral pain and temperature deficits below the level of the injury. >> Good. Again, something you'll see almost nowhere else and pretty uncommon. What's the mechanism? >> It's normally like a stab wound to the spine. >> Yeah, it's usually a penetrating and even that stab more than a gunshot wound. Okay, anterior cord syndrome?
>> So anterior cord syndrome, you could see possibly after some aortic case where they cause malperfusion to the spine and this is you get exclusively motor deficits with anterior cord syndrome. >> Good. Or just a trauma with a vascular injury to the anterior spinal artery. Okay, how about the pediatric patient who comes in and can't move their legs and their spinal imaging is normal?
>> So this is the spinal cord injury without radiographic abnormality, I think SCIWORA. >> SCIWORA. >> I think it's becoming less common with the, you know, the better scanning, you know, the higher resolution MRIs, we're able to pick up some abnormalities. I think it's becoming less common but -- >> Okay. And then the other pathology just to be aware of in the pediatric population is pseudosubluxation and that's typically where they'll give you a finding where you have a C-spine, a small amount of subluxation anteriorly but they have no tenderness, they have no neurologic deficit, and that's basically that's a normal variant a pediatric patients can have pseudosubluxation.
So no further imaging is required and you can clear their C-spine. Alright, another favorite for the boards and just one of my personal favorites in these is, is the confusing terms about shock, spinal and neurogenic. Okay, so there's always some confusion about spinal shock versus neurogenic shock. So why don't we start with what's the difference between spinal shock and neurogenic shock? >> I think the way you can distinguish these is by your autonomic reflexes.
So with spinal shock, you lose your motor reflexes and basically the reflexes that are along the spinal cord. But neurogenic shock, you're losing your autonomic regulation. So you'll get things like bradycardia, hypotension, that type of thing. >> Yeah. And so the big difference is one is talking about hemodynamics and that's neurogenic and one is talking about your neurologic exam and how bad of a spinal cord injury you have and that's spinal shock.
The way I remember it is, you know, when you talk about hemodynamic shock, you talk about septic, cardiogenic, and so I just remember the "genic" cardiogenic and the neurogenic, those are the hemodynamic ones. And neurogenic shock typically presents how? >> Generally, they have the warm extremities and they're hypotensive and bradycardiac. >> Good. So yeah, and if you get a question of they're warm and perfused and hypotensive, that's almost always a spinal cord injury.
Now spinal shock, this is one that confuses a lot of people. So spinal shock is in the setting of spinal cord injury and how do you diagnose spinal shock because everyone who -- Let's just say, everyone who has a bad spinal cord injury, they're paralyzed from the waist down. Some may have spinal shock. Some might not. >> So one way is you can test their reflexes such as their bulbocavernosus reflex. And if that's intact, they do not have spinal shock. >> Good. So if their reflexes, the bulbocavernosus and the cremasteric are the two most common ones.
If those are not present, it means they're in spinal shock. And those reflexes will come back even with a complete spinal cord injury whereas most other reflexes won't. So once their reflexes come back, now they're paralyzed from the waist down and they have a cremasteric reflex, what does that tell you about their spinal cord injury? Is that a good thing or a bad thing? >> Probably a bad thing. >> Yeah. That tells you that they are now out of spinal shock and whatever deficits they have are likely permanent.
So when you examine someone and they're in spinal shock, you can say, well, some function might come back. We'll have to wait and see. When they're out of spinal shock, their deficits are permanent. >> So that's the importance of the term "spinal shock" is determining if it's, you can depend on their neuro exam at that time or not. >> Yep. And once they're out of spinal shock, whatever deficits they have are usually permanent. And that's why it's an important part of the exam, especially when spine surgeons will talk about that a lot.
Okay, and so management now. So management of spinal injury. >> I mean first and foremost stabilization and immobilization. >> Okay. How about steroids? >> Again, we kind of touched on this but no longer indicated in trauma. We actually had a case of this recently where with central cord syndrome, there's not a lot of good data but some people will still use it for that, but for the most part, no longer indicated.
>> Yeah. So now if you now get an ABSITE question with a typical spinal cord injury and they ask about giving steroids, the answer is no, you don't give steroids. It's just really been shown not to improve outcomes and obviously has some adverse side effects. Okay, a lot of times we like to talk about is this a stable or an unstable fracture. So how do we determine stable versus unstable? >> So when referring to the spine, you have three columns of the spine and if they have all three columns that are damaged, that would be an unstable fracture.
>> Yeah. And those columns correspond to ligaments. Right? So the rule is usually you have to have two of the three columns disrupted, which means two of the three major ligaments disrupted, and that's unstable. And what type of injuries will usually give you that and we'll just say blunt or penetrating? >> Blunt. >> Yeah. Very uncommon to have an unstable penetrating spine injury. Okay, so real quick. Respiratory issues in spinal cord injury. What are the spinal cord levels that control the diaphragm?
>> C3, 4, and 5. >> Good. So sometimes on the ABSITE they'll give you a patient who's got a high cervical cord injury but they're breathing okay, you know, they might be a little tachypneic and their sats are 92%. And what do you want to do with that patient? >> If they're breathing okay, I mean, the concern is that they need to be intubated. But if chest x-ray shows that their diaphragm is intact and, you know, working, they don't necessarily need to be intubated, I would think.
>> Yeah. And what will happen with those people in terms of how will they fail from a respiratory standpoint? Will they come in in respiratory distress? >> No, because they can use their other muscles of respiration initially and then they'll wear out. >> Yeah. So they often have a slow insidious and 12 hours later, they're having a respiratory arrest. So generally somebody above a C4 usually we just intubate them and then evaluate them and see whether they need a tracheostomy or not later.
Okay, let's move on down from the head to the neck. Penetrating neck trauma. Again, another favorite board question although I think it's becoming less relevant clinically is the zones of the neck when we talk about penetrating neck trauma. So what are the zones of the neck, just anatomically? >> So the zones of the neck, it goes in reverse order and you start in the chest with the great vessels. From the clavicle to the cricoid.
And then it goes from there you have zone two which primarily as far as vessels go contains the carotid. Again, you have the esophagus and trachea and that goes up to the base of the mandible, the angle of the mandible, I'm sorry. And then zone three is the zone that we can't reach and we can't really operate on and that's from the angle of the mandible to the base of the skull. And that has the carotids with the pharynx and the larynx. >> Okay, good, good. And yeah, from the angle of the mandible, so obviously a small space.
And what part of the neck are we talking about? Anterior, lateral, posterior? >> Generally anterior and lateral. >> Yeah. So remember, this doesn't apply to posterior neck. So we're talking about really the anterior and the lateral neck. Okay. And what are the structures we're worried about in the neck? Any question about the neck is generally going to come down to one of these three or four structures. >> So, I mean, the neck is tiger country.
So you have a lot of high-stakes real estate. You have great vessels, your carotids, esophagus, trachea, and those are pretty much the main ones that you're looking for. >> Good. And those are the three that you're really worrying about and trying to figure out if they're injured. So the vessels, the carotid or jugular, the esophagus, and the trachea, right, aerodigestive tract or vessels. Alright, so the patient comes in and they have a penetrating neck injury and they're hypotensive.
>> With an isolated penetrating neck injury, that patient would need to go to the operating room immediately. >> Yeah, so that's an easy answer. They're unstable. You take them to the operating room and do a neck exploration. Okay, now they have hard signs of a vascular injury. >> That patient would also need to go directly to the operating room. >> Okay. And we can talk about hard signs when we get to extremity stuff. Now they don't have those.
>> So depending on platysma violation or not, those patients will likely get a CT neck angiogram. >> Okay. And you made a great point. So if it hasn't violated the platysma, if you're able to tell that, then you wouldn't even characterize that as a penetrating neck injury. If it has violated the platysma, then you really have a couple options on how to proceed based on your exam. So remember, you want to do a full exam and you want to look for other signs of an injury.
And what are some of those other signs? We already said hard signs of an injury are easy. You go to the OR. What are some of the other signs that might not mean you need to go to the OR but you need further evaluation? >> Maybe if they had a motor deficit. >> Good. >> If they had a hematoma of some sort. >> Good. So soft signs, a vascular injury.
So a nonexpanding hematoma. >> Crepitus. >> Good. How about air coming from the wound? Is air coming from the wound and then the other ones are any signs of hemoptysis or hematemesis. All those you at least need to do some further workup. And in, we'll say 2017, this will be when they're taking their ABSITEs, what's the evaluation of choice? >> It is a CT neck angiogram. >> Yeah. We used to talk a lot about triple endoscopy and bronchoscopy, esophagoscopy, and angiography.
Now I think the screening study is a CT scan of the neck, including a CT angiogram that gives you the carotid vessels. And then you can base further workup on that. If you have a high suspicion for an esophageal injury, so you have say some hematemesis or you think there's some air from the wound or they're having, you know, trouble swallowing, then what would you do? >> Then we would need an EGD. >> Yeah. And this -- And some people would say a swallow study.
So an esophagram. So it'd either be an esophagram or an esophagoscopy. But otherwise, the CT scan is your initial study of choice. Okay, so you decide you need to explore this neck. What's your incision, your approach for standard penetrating neck trauma? >> So similar to if it's a unilateral neck trauma, I would do a large incision along the sternocleidomastoid. >> Middle of it, posterior border? >> I'm sorry, anterior border.
>> Good. So right along anterior border of sternocleidomastoid, essentially from the almost from the base of the ear down to the sternal notch. And what are you exploring, what structures? >> So initially I'll be focused on the blood vessels, the jugular and the carotid. And then I would move to the trachea and then as much of the esophagus as you could get to from that. >> Good. And those are your big structures you're looking at, same as you are worried about, you know, on the workup.
And which side of the neck would it be easier to explore the esophagus? >> The left side. >> Good. And then that's also sometimes a question. It's easier to get to the esophagus from the left side. So if you have to do an esophageal exploration, the left side is easier. You can do it from either side though. Okay, now we'll say you had this patient who got stabbed in the neck, didn't have any hard signs. You got a swallow study and you see a small leak of contrast coming from the esophagus. And you explore them but you don't see an esophageal injury.
You see a little bit of inflammation but no injury. >> For that I would probably just leave, I would just widely drain the area and leave drains. >> Good. I mean, you do everything you can to identify the injury but if you can't see it, you just leave a closed suction drain and close. Okay, so now you found a 4-centimeter esophageal laceration. How do you want to repair this? >> So I want to make sure that I see, you know, the mucosal extent of my injury and then I'll repair it in two layers. So I'd repair with a, you know, an inner layer of an absorbable suture, 4-0 or 5-0 absorbable suture and an outer layer of permanent suture.
>> Yeah and so how do you ensure that you've seen the entire mucosal -- >> A lot of times you'll have to extend the myotomy. >> Good. Yeah. So the answer is you extend the myotomy enough to see the entire mucosal defect and then you do the suture repair. So let's talk a little bit about esophageal perforation. So is there any such thing as nonoperative management of esophageal perforation? >> On the ABSITE, I don't believe so. >> Well, there are some situations where you can do nonoperative management.
What types of injuries do you think would be amenable to nonoperative management? >> I believe, you know, the small contained maybe from a dilation on an EGD or something like that. >> Yeah. Good. And far and away it's the endoscopic injuries that you can manage nonoperatively. And what are your criteria for an injury that you think could be managed nonoperatively? We'll start off with location.
>> Location? So it'd have to be -- >> And we'll clarify. So the esophagus really has three zones. Right? Cervical, thoracic, and abdominal. Which of those would you not manage nonoperatively? >> Intra-abdominal. >> Yes. So intra-abdominal, you usually cannot manage that nonoperatively. So it's usually cervical or thoracic.
And which of those would you manage nonoperatively, potentially? >> So if it was small, it was contained, the patient was not septic in appearance, didn't have a large pleural effusion, and then no distal obstruction and no kind of cancer pathology. >> Good. Good. And those are criteria outlined by [inaudible]. So you want to get a swallow study and you want to see a small contained perforation.
They characterize you want to see the flow of the contrast back into the lumen of the esophagus. No communication with the pleural space and no distal obstruction or pathology. The patient stable and there's no signs of sepsis. Those are the ones that you can manage nonoperatively. And how would you do that? >> So generally, you want to get drainage of the area. So potentially a chest tube to help -- >> Well, no.
They have no communication with the pleural space. They're fine. What are you going to do to treat them nonoperatively? >> NPO, antibiotics. >> Good. Good. There you go. NPO and antibiotics and then you get a repeat swallow study at some interval. Okay, let's move on to blunt neck trauma. So you have a high-speed motor vehicle collision patient and they have an acute mental status decline and you get a head CT and it's normal.
What else would you be worried about? >> You have two vascular structures that go to the brain that could be injured in these patients. >> Good. So blunt cerebrovascular injury, particularly in someone who has an unexplained neurologic or mental status deficit and you're worried about the carotids or the vertebrals. So you have the patient who has symptoms, so they deteriorated neurologically or they essentially present with deficits similar to a stroke. You're worried about a carotid injury.
That's easy. Those are the ones you evaluate. How about patients that have no symptoms, no neurologic deficits? Is there anyone we should screen for a blunt cerebrovascular injury? >> So yes. So if they have fractures, either a cervical spine fracture, a base of skull fracture, severe facial fractures, a seatbelt sign above the clavicle, and then also the patients that have GCS less than eight or infarcts on head CT would be some of the highest-yield patients.
>> Good. Good. And so, any of those patients we should be screening them for a blunt cerebrovascular injury and the big ones are the high-risk fractures that are right around the carotid vessels and the vertebral vessels, right. So C-spine, base of the skull and mandible, the Le Fort fractures, seatbelt sign, as you mentioned. Also on exam, if you hear a cervical bruit or a thrill or feel a thrill, then those are all criteria. And how would you screen them?
Again, it's 2017, how would we screen them? >> CTA. >> Yes. CT has clearly become the screening study of choice. This was a debate up until at least a couple years ago, angio versus CT and CT scan is now the study of choice. Where are these blunt cerebrovascular injuries usually located? >> So for the carotid artery, it's, for both of them, they're both distal and the carotid, it's in an area that's not surgically accessible, generally. >> Good. So it's usually distal internal carotid, which again it's difficult to access surgically which is usually why we do not do much intervention.
And what would your treatment be? >> So generally just an antiplatelet is all that will be needed and sometimes anticoagulation. If it's a large enough dissection or progressing injury, they could maybe need an endovascular stent. >> Good. Yeah, so generally, you know, for the standard dissection of the internal carotid, the treatment is usually an antiplatelet agent or anticoagulation. There is now a role for endovascular intervention and that would usually be for a pseudoaneurysm or an AV fistula.
I think an AV fistula, that's the one where there's clearly a role for endovascular intervention. Okay, so let's keep on moving down the body and get to thoracic trauma. So flail chest, how would we define a flail chest? >> So for a flail chest, you have to have three consecutive ribs with fractures in two places that can create a flail segment. >> Good. And what's the cause of that patient's hypoxia? >> The cause is just pain and not breathing well enough.
>> So and this is also a favorite board question. The actual cause usually of the hypoxia, is it the flail segment, is it the paradoxical motion? >> No. >> So what is it? So it's usually the underlying pulmonary contusion. >> Oh, okay. >> And so they'll give you a question where they ask, you know, about the cause of the patient's hypoxia and it's not the flail segment, it's not the paradoxical motion.
It's usually because they have an underlying pulmonary contusion. So management? >> So like all chest trauma patients, you need good pain control. >> Which would usually be what for a flail chest? >> An epidural. >> Yeah. Epidural is your pain control of choice. >> And then if it's severe enough and they have [inaudible] contusion, you would consider early intubation and then potentially if they do have paradoxical motion and severe pain, you could consider plating them.
>> Okay. Good. Now we'll talk about the patient who car crashed and they slammed into their steering wheel and now they're hypotensive and, you know, you have clearly identified that they are not bleeding and they have no other injuries you can identify other than they've got a pretty good sternal fracture and they're throwing some PVCs. So what are you concerned about? >> So I'm concerned about blunt cardiac injury in this patient. >> Good. And what would you do to confirm that?
>> I think I would get an echo to confirm. So first to start the EKG. >> Good. So the most common finding is an EKG abnormality and confirmation would be with an echocardiogram. You can check troponins although that's controversial in this and I don't think that would be an ABSITE answer. >> I've definitely seen questions on this and the answer at first is EKG. >> Yeah. The answer is always EKG for cardiac contusion. Okay, and then just to round it out.
So pulmonary contusions, patient comes in and has a big pulmonary contusion. What's the typical history of that going to be over the first couple days? >> Generally on day two or day three, it'll blossom when their fluids are mobilizing and they'll have kind of an ARDS-like picture in that side of the lung. >> Good. So the typical pattern is that it'll progress 24 to 48 hours later is when they'll usually have their worst point and get hypoxic.
Okay, so this same patient. Car crash, slammed the steering wheel and you think they have a blunt aortic injury. So what would lead you to suspect a blunt aortic injury? >> So for a blunt aortic injury, the mechanism is a strong chest trauma hitting the steering wheel. If they had a widened mediastinum, if they have a hemothorax on one side, if they had maybe a recurrent laryngeal nerve paralysis would be kind of a [inaudible] reason to be concerned about that.
>> Okay, so typically you'll have some concerning chest x-ray findings and you mentioned one, widened mediastinum. There's probably at least ten to 12 chest x-ray findings. Widened mediastinum would be the most common one. What would some other ones be? >> The aortic knob is -- >> Obscured. >> Obscured. >> Good.
>> You could have like pneumomediastinum. >> Yeah, that wouldn't really be for blunt aortic injury though. And it's all related to you have blood building up around that aortic arch. >> So you have the little blush in the top of the chest that has a pseudonym. >> That's called an apical cap. >> Apical cap. >> It'll push the left mainstem bronchus down, so you have depression of the left mainstem bronchus. What's it going to do to the mediastinum?
>> It can compress the mediastinum and cause -- >> So it'll push it to the right, so you'll have rightward deviation of the mediastinum. Those are the big ones. And then possibly an associated left pleural effusion if the blood has communicated with the left chest. So what are you going to do to confirm that diagnosis, in 2017? >> A CTA. >> Good. And again, the diagnostic study of choice now is a CT angiogram for blunt aortic injury.
Where is the tear going to be? >> Just distal to the ligamentum arteriosum. >> Which is where, using your vessel landmarks? >> Just distal to the subclavian artery. >> Good. Which subclavian? >> I'm sorry. The left subclavian. >> Good. So yeah, so for the ones we're talking about, it's always distal to the left subclavian.
You can also get injury at the aortic root or at the diaphragmatic hiatus. Those are less common. But when we're talking about the standard blunt thoracic aortic injury, that's where the injury is. So what's your answer going to be on managing this patient? Give me in two words. What's your therapy going to be for this patient, initially? >> Blood pressure control. >> Good. With what?
>> Beta-blockers. >> Good. So yes, remember these are no longer rush them to the operating room immediately and crack them open. It's managing their blood pressure and typically your first agent is going to be a beta-blocker. That's an easy answer for the ABSITE. And what are our options now if we think this needs to be repaired? There's really two options. >> So you have the endovascular option of a TEVAR, essentially to seal the defect, and then you still have your potential open thoracic graft that you could place if it was -- >> Good. So you can do an open repair or an endovascular repair.
And I think endovascular has now become the preferred approach for most of these. But if you do have to do an open, how would you do it? >> I would do a left posterolateral thoracotomy, potentially thoracoabdominal incision depending on how big my graft would need to be and place a graft that way. >> Okay. But what would you do as an adjunct? Would you just clamp, clamp? >> No. I'd get cardiac bypass.
>> Yes. So the answer today is for an open I think would be left heart bypass. So your option is either going to be -- The answer on your ABSITE is either going to be if they're leading you towards an open, it's going to be a left posterolateral thoracotomy with left heart bypass or it's going to be an endovascular graft. And what are the big risks that we worry about with when we fix these? >> Paralysis. >> Good. And higher with open or endovascular? >> Open. >> Yeah. So the rate seems to be definitely higher with an open approach.
Okay, endovascular repair, which patients are candidates for it? >> So they have to have adequate inflow vessels to be able to access the thoracic aorta. They have to be stable to some extent. >> Good. And really that's it. This used to be it was the lousy open candidates who you'd do an endovascular are the high risk and now I think it's the standard. So it's really if you're physically unable to shove that graft in there, it's probably about the only real contraindication now.
Okay, another favorite question. You do an endovascular repair for this injury and it's postop day one and the patient's left hand is now cold and turning dusky. >> Right. This always makes me nervous because they generally cover the left subclavian. And so when you're covering left subclavian with a TEVAR graft, it can sometimes cause this problem and the treatment for this would be a carotid-to-subclavian bypass. >> Good. This is another one of those you should know the answer as you're reading the question. The answer is carotid-subclavian bypass.
Fortunately, this happens relatively uncommonly even with covering the left subclavian. Most patients will not require that. Okay, so you now have this thoracic trauma patient, you put a chest tube in and what would make you go to the operating room, in terms of bleeding? >> So if I had an initial chest tube output I think of 1500 -- >> So let's start -- What's the first thing that would drive you to the operating room? The patient is? >> Hypotensive. >> Yeah. So hemodynamic instability and you don't have another identified source.
Good. And then in terms of output? >> So the initial output I believe is 1500. >> Yeah. And I think that would be the one that would be the board answer, would be greater than 1500 initially. >> And then I think hourly, it's over like a four-hour period if it averages over about 300 cc's per hour. >> Yeah. Most would say 200 an hour for four hours. So just think a total of 800 cc's. So 200 an hour for four hours or 100 an hour for eight hours.
>> So if you get 800 cc's, you go to the OR. >> Yeah, in general, ongoing bleeding. Okay, you have a question about a elderly patient who fell and they've got five rib fractures. And what are you going to do with that patient? And your options are discharge them home with an oral regimen, admit them to the ward, admit them to the ICU? >> The patient has a very high mortality, so they're going to be admitted to the ICU. >> Good. So rib fractures in elderly patients now, I mean, we now realize that's a high morbidity and mortality group.
And what else are you going to do for them? >> You're going to consider either a rib block, depending on what your anesthesia is comfortable with, rib block versus epidural in these patients. >> Good. Okay, so now you have this thoracic trauma patient and you get some imaging and they've got a diaphragmatic rupture. >> So the patient, you would stabilize them first and take them to the operating room and generally I would perform a laparotomy on them and fix their diaphragm with some prosthetic mesh if needed to the diaphragm.
>> And what's the common associated injury they're going to have, usually with a -- Let's say they have a left diaphragm rupture. What else is typically injured? >> Their spleen. >> Good. Yeah, you almost always see that with a splenic laceration. >> Until next time, dominate the day. [ Music ]