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ABSITE Review: Trauma, Part 2 (Podcast)
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ABSITE Review: Trauma, Part 2 (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 ] >> All right and welcome back to the second part of the ABSITE trauma series. Once again, we are joined by Dr. Matthew Martin who's going to take us to through the second half of the trauma.
So, thank you Dr. Martin for joining us again, and we also have one of our colleagues here at Madigan, John Cocamen [assumed spelling] who will be helping with the second part of trauma and critical care. >> Thanks, Kevin glad to be here. >> All right. Dr. Martin, take it away. >> Okay, so blunt abdominal trauma. The evaluation. And I think most of patients are evaluated with now a FAST exam plus minus a CT scan.
So, real quickly on the FAST exam. What are we looking for? And this is the Focused Abdominal Sonography for Trauma. >> Right, so you're looking at the kidney, liver interface, the spleen. >> Well, what are we looking for? >> Oh, you're looking for free fluid, >> Good. And just remember the ultrasound is only looking for free fluid in the abdomen, or? Where else do you look for fluid besides the abdomen? >> Oh, at the paracardial.
>> Or, the paracardial window. Good. And what is that fluid? >> Well, I guess we don't know exactly, but the concern is. >> What could it be? >> Blood or succus. >> Blood, succus, or? >> Urine. >> Blood, succus, or urine, right? So, compared to a CT scan, we've got to talk about the pros and cons.
Which one is more sensitive? >> A CT scan. >> Good. Although a FAST exam is reasonably sensitive, especially for the pericardial view, which one is more specific? >> The CT scan is also more specific. >> Yeah, the CT scan is much more specific, because it will actually tell you what's injured. The FAST will not tell you what organ is injured, it will just tell you there's bleeding. And what's the big weakness of the FAST exam in terms of false positives, false negatives?
>> I guess, I think two come to my head. But user dependence and the body habitus of patient. >> Assuming the user knows what they're doing, I mean as a test is it false positives or false negatives? >> It's false negatives. >> Good. So, the point is you have an unstable patient and you have a negative FAST that still has not ruled out that the source is the abdomen. Okay. Abdominal seat belt sign, what are you concerned about?
>> Well, I'm concerned about small bowel injury. And we're concerned about pancreas injury. >> Good. And plain and simple. They give you question with seat belt sign, they're heading towards, usually a bowel injury, sometimes a pancreatic injury. Okay, so just blunt abdominal trauma, what are the most common injuries? >> Blunt abdominal trauma would be so solid organ injuries, so spleen, liver. >> Good. Solid organ injuries. And what are the most common missed injuries?
>> The hollow viscus, the small bowel. >> Hollow viscus would be one. And then probably pancreas. Good. Okay, so management of solid organ injury. I think this is something probably most people are comfortable with because we do it a lot. So, solid organ injury and they're hemodynamically unstable. >> OR. >> Good. >> Or IR.
>> Operative intervention. Well, if they give it to you on the ABSITE? >> OR. >> The answer is operating room. If you get a CT scan that has free fluid and you see no solid organ injury? >> So, I would think about a hollow viscus injury. >> Good. And that's a hollow viscus injury until proven otherwise. And again, if they give you that on the ABSITE, I think they're heading towards you should be exploring that patient.
Okay, so now you have a CT scan in a stable patient. And it shows a solid organ injury. Just what are your principles of managing that person? >> So, principles of management would be you know admitting to a monitored bed. So, make sure they're in the ICU, you can nonoperatively manage them, watch the hematocrit, grade their injury. >> Okay, and what would make you take them to the OR? >> If they had an ongoing, if they became unstable, or if they had an ongoing transfusion requirement.
>> Good. And now angioembolization. You mentioned that as an option. What would be the indication for angioembolization? >> So, if you had an active blush on your CT scan. Good, so ABSITE exam, they give you the patient who's got a blush, and they're hemodynamically stable. The answer they're generally looking for is angioembolization. And it doesn't matter if it's spleen, liver, or kidney. That's usually the answer they're looking for.
Any other indications for angioembolization? >> So, you know in a place that's not easily reachable, operatively. So, pelvic injuries would be an indication. >> Good. And then probably the only other ones would be some vascular complication of the injury. Typically a pseudoaneurysm. Okay, abdominal stab wounds. So, we generally talk about abdominal stab wounds, we like to classify them by location. Because I would say the location determines the workup.
So, what are the general locations that you would distinguish for stab wounds. >> For abdominal stab wounds? Right upper quadrant, potentially. >> Okay, so we'll say anterior abdominal. >> Anterior abdominal, posterior abdominal. >> Flank and back. >> Flank and back. >> And then, the third one would be thoracoabdominal, or subcostal where you have to also worry about thoracic structures.
Okay, so abdominal stab wounds, what would be your immediate criteria for surgery? >> Hypotension. >> Hemodynamic instability. >> If they have succus or an organ protruding through the injury. >> Okay, so evisceration. >> Evisceration. >> How about their physical exam? >> Peritoneal. >> Good. So, peritonitis.
Evisceration. Hemodynamic instability. You know, obviously if they have succus coming from the wound an obvious bowel injury. So, let's say they don't. How do you want to evaluate t his person? >> So hemodynamically stable patient with abdominal stab wound. You can do a local wound exploration. >> Good. >> Depending on your ER.
>> And that's I think another common question. So, a local wound exploration, what are you looking for? >> Fascial penetrance. >> What fascia? What abdominal wall fascia? It's a very specific layer that you're looking for. So anterior rectus sheath or posterior rectus sheath? >> Posterior sheath. >> Fifty-fifty; 90.
>> Anterior rectus sheath. >> Yeah, so a local, and this is often causing, a local wound exploration is looking for anterior rectus sheath penetration. And the utility of it is if you do a local wound exploration and it's negative. So, there's no anterior rectus perforation, what do you do next? >> Well, you can observe those patients, or you can CT them. >> Or? Now convinced yourself it did not go any further than the anterior rectus sheath.
>> Discharge them home. >> Yeah, so a true negative, where you say, I've explored it and it didn't perforate anterior rectus sheath is discharge them. The problem is what if it did perforate the anterior rectus sheath? And the reason we say it's not looking at the posterior rectus sheath is because you can't do that effectively at the bedside. You know, digging through the muscle. So, really all you can do effectively is look at the anterior rectus sheath. So, now it's perforated the anterior rectus sheath.
Now what should we do? >> So, this patient, if they're stable, you could certainly, you get some imaging, and you could certainly, if they're stable, observe with serial exams. >> Good. And I think that's probably one of the biggest points in that question. Because the old answer used to be anybody that had perforated you explore them. That has now gone away. Now it is if they're examinable, you can do serial clinical exams. If they're not examinable, that's where some people would probably say, explore them, or at least put a laparoscope in.
Some people would say image them with a CT scan. But again on the ABSITE it will be, if they're examinable, it's going to be serial clinical exams. Okay, flank stab wound. Little different. What would you do for a flank or back stab wound? And again, if they ask you this question, what's the answer they're looking for? >> Three-phase CT. >> Good. CT scan, and the classic answer is the triple contrast or rectal IV.
Just because you can't assess retroperitoneal structures and that's what's at risk of being injured. Thoracoabdominal stab wound. >> So, just so everybody; with the triple contrast. Oral, rectal and IV is what we go for. >> Yes. Although do we really do that? Most people now probably do oral and IV, or rectal and IV. But again, for the board, the answer would be a triple contrast CT. Okay, and then thoracoabdominal, beyond the abdomen, what else are we concerned about?
>> What are we going to image them with, or what are we concerned about. >> What injuries are you concerned about? >> So, you're a pneumothorax, a hemothorax. >> Good. So, you're concerned about the thoracic structures. >> Diaphragm injuries. >> Diaphragm if they give you a you know, stab wound of the costal margin and their stable normal exam and you send them home, you've missed the question. They're heading you toward you still need to evaluate all those patients for a diaphragm injury.
And it's always going to be at left sided thoracoabdominal stab wound. And how do you do that? >> I think the best way to evaluate that is laparoscopically. >> Yeah, you do a laparoscopic exploration. You can also do it thoracoscopically, most would do it laparoscopically. Good. Okay traumatic bowel injuries. How do we generally categorize a traumatic bowel injury? You categorize it, it's a binary. >> So you're going for destructive or non-destructive?
>> Yes, exactly. So, destructive, or non-destructive, what's a destructive? >> Generally it's over 50% of the circumference. >> Good. Or? >> Or, de-vascularized portion? >> Good. So, it's greater than 50%, or de-vascularized. And quickly the management of a destructive? >> For destructive it's resection. >> Good, resection and?
>> Diversion. Or I'm sorry, resection primary anastomosis. >> Yeah. That should be your default unless they give you some odd, odd scenario. And that's for anywhere in the bowel. Small bowel or colon. And nondestructive? >> Generally, primary repair. >> Good. Primary repair unless, if they give you multiple in the same area, you'd probably resect that segment.
Okay, what if now you're in the damage control setting. And you've got destructive bowel injuries. >> So, for damage control, you just, I mean you control sepsis, control bleeding. So, you staple off things. Lead things in discontinuity with the abdomen open. Resuscitate. >> So, you staple, staple and you don't do an anastomosis. You don't do a primary repair, you generally just staple the bowel off, remove the injured segment and get out.
Penetrating colon injuries, what's our management for those? Again, 2017. >> Right. So, a lot more of these are being primarily repaired, so if it's a nondestructive injury. >> How about left colon versus right colon? >> It doesn't matter. >> Good. It doesn't matter anymore. The answer is you're generally your answer is going to be either a primary repair, or it's going to be a resection and anastomosis.
We don't do many ostomies for these anymore. Now, you have the classic bucket handle injury, which is the injury of the small bowel where the mesentery has been torn, but the bowel is intact. What are you going to do with that? >> I would resect it and do a primary anastomosis. >> Good. And the answer is you resect that segment. Because it will look fine, but it's going to be ischemic and then it's going to perforate. Okay, so as long as we're in the abdomen. Okay, so retroperitoneal hematoma.
We talk about three zones. Zones 1, 2, and 3. And what are those zones? What's zone one? >> So, zone one is in the midline and contains the aorta and IVC. >> Good, so zone one is central. Zone two? >> Zone two is the lateral retroperitoneal structures. Includes the kidney and colon.
>> Good, and zone three? >> Is the pelvis. >> Good. And the key there is you're worried about the major blood vessels in each zone. Right? You want to prove there's an injury or there's not. So, zone one you're worried about aorta vena cava. Zone two, you're worried about the renal artery and vein. Zone three, you're worried about ileac. Okay, so now you have a penetrating injury that's got a hematoma, retroperitoneal hematoma, zone one.
>> Zone one, you'd explore. >> Zone two? >> Zone two. >> You don't have to think about this. >> Penetrating, you explore. >> Zone three? >> You explore. >> Good. On the ABSITE, you explore all penetrating retroperitoneal hematomas. Now, blunt.
So, blunt you have a zone one hematoma? >> You explore. >> Yeah, again on the ABSITE you would explore that because it's an aortic or vena cave injury you have to rule out. But now, zone two or zone three? >> So, zone two or zone three, this would depend on further imaging and. >> You're in the OR, you're looking at it. >> So, I would not explore it. >> Well, when would and when wouldn't you explore it?
>> So, if it's an expanding hematoma, I would explore. >> Expanding or pulsatile hematoma. And if it's not expanding and non-pulsatile? >> I would leave it. >> Leave it alone. Because what is it in zone two, what's causing that? >> Renal artery, renal vein. >> The kidney. >> The kidney.
>> Right? So, by far and away it's going to be a kidney lack that we know if you start exploring, you're probably going to end up doing a nephrectomy. And zone three, what's causing that in blunt trauma? >> Pelvic fracture. >> Yeah, which we also know you don't want to get into, right? So, much lower suspicion for a true vascular injury in blunt. And that's why we don't go into those, other than zone ones. Okay, well and as long as we mentioned pelvic fracture, so what are some of the associated injuries you always have to evaluate the patient for who has a significant pelvic fracture?
>> So, you just have to think about what lives in the pelvis. You know rectum, bladder, vagina, urethra. >> Okay, good. So, you have a patient who has an open book pelvic fracture and systolic blood pressure is 90? >> So, those are typically with open book pelvic fractures you're talking about bleeding from veins, and they're usually easily compressed. So, you want to do pelvic binder, slings, to stabilize them. >> Good. Intervention number one is you close the volume.
So, you place them in a pelvic binder or a sling, or a wrap. And then, what's your next step in the management? >> Generally, you're taking that patient to the interventional radiology quite for angioembolization. >> Good. And if they give you a scenario where the patient is too unstable? They're severely unstable. You've put the binder on. >> So, you're going to the OR to pack the pelvis. >> Yeah, I think the answer today would be, and what do you mean by pack the pelvis?
Laparotomy and pack the pelvis? >> Basically, you're packing the extraperitoneal space. >> Good. So, now there would be an extraperitoneal pelvic packing, and probably then to angiography. Okay, so speaking of pelvic massive hemorrhage, we'll talk about shock. So, what is shock? How would you define shock? Or how does ATLS define shock? >> So, shock is when you have hypoperfusion to the organ system.
>> Good. So, it's just, it's end organ hypoperfusion. It's not a blood pressure, or it's not a lactate, those are markers. But shock, is end organ hypoperfusion. So, in trauma we talk a lot about class of hemorrhagic shock. Everyone who's taken ATLS and had to memorize that painful table of class 1 through 4 shock. But that classifies it by the percentage of blood loss. Right? And the simple system for remembering that is? >> The tennis score system. >> Good. So, how do you do that?
>> So, I might be able to figure this one out. So, it goes 15. >> Well, what do you start at before 15? >> Zero. >> So, yeah, you start at zero. >> And then, so class 1 would be 15% body loss. >> Okay would be 0 to 15. >> Zero to 15. Class 2 would be 15 to 30%.
And then, class three would be 30 to 45%. >> Thirty to 40. >> Thirty to 40. >> Okay, and then? >> Greater than that would be class 4. >> Yeah, and so, like you said, I use the Tennis system. You just write down on your sheet of paper from top to bottom; 0, 15, 30, 40 game over. And then in between each of those numbers is class 1, class 2, class 3, class 4. And that's your percentage of the blood you've lost.
So, what's the first class where you develop hypotension? >> It's class three. >> Good. So, and usually if they're asking you a question about a class, they'll give you hypotension and ask you what that is and that's class three. And the earliest signs of shock? There's usually two that they'll ask about. >> Tachycardia. >> Tachycardia. >> One they'll ask about and altered mental?
>> So, altered mental you shouldn't get until you're three or four. >> Oh, yeah, so decreased pulse pressure. >> Narrowed pulse pressure. Yeah. So, if they give you a question about the class 1 shock, the answer is either tachycardia or narrow pulse pressure. All right. >> So, they do have that in class one shock 0 to 15 they can get? I thought you didn't have any signs in 0 to 15%. >> Well, the first sign will usually be mild tachycardia.
>> Mild tachycardia, okay. So, class two I think is when at least the ABSITE starts defining, you'll get the narrowed pulse pressure. And that's really the only that and tachycardia you'll see in class two. >> Yeah, and usually the question is hypotension. And what they're getting at is now you're in class three. >> Okay. >> Okay, and now and we touched on this earlier. You have a patient who's clearly profusing their extremities and their systolic is 60, what's your diagnosis?
>> That's neurogenic shock. >> Good. That spinal cord injury, again until proven otherwise. Okay, you mentioned damage control surgery. So, we talk about the lethal triad, or the triad of death, which is what? >> It is hypothermia, a coagulopathy and acidosis. >> Good. And so, if you're doing damage control surgery, there's four phases of any trauma laparotomy and for damage control, you only get to the first two and then you're done. And what are those first two?
>> So, you want to control the hemorrhage first, and then you want to control sepsis or GI spillage. >> Good. And then, if you weren't in damage control, phase three would be fully explore and diagnose all the injuries, phase four is reconstruction. So, in damage control all you're doing is stop blood, stop GI spillage and then temporary abdominal closure. And then, what do you do with the patient? >> You bring them back to the ICU and resuscitate them. >> Okay. and then?
>> At 24 hours, you go back to the operating room if they're stable. >> What about at 23? >> You wait until 24. >> It's actually, it's once they're stabilized and normalized. There's no time set. In fact, if they give you a question about that, and they'll give you choices of like, you know when the patient's coagulopathy's corrected, or at 24 hours. The answer's going to be when they're physiologically corrected. Okay. Now, they had their damage control procedure.
And they're in the ICU, and you're worried about abdominal compartment syndrome. So, what would be some of the signs you're looking for? >> So, some of the first of the signs you'll see is decreased urine output. And increased peak pressures on your vent. >> Good, and the increased peak pressures is the key. A lot of patients will have low urine output for various reasons. But, especially on the ABSITE, they'll give you this, the patient's peak airway pressure is going up, and if you start to read that, the answer is abdominal compartment syndrome.
And how would you confirm that? >> You can measure bladder pressure. >> Good. You can measure bladder pressure and you can use the absolute bladder pressure, generally when we start to get above 20, we're worrying about compartment syndrome. Like we talked about with the head bleeds, same thing with abdominal, you can also calculate the profusion pressure. But, generally a pressure above 20, if they start to have the other signs, especially elevated mean airway pressures, then that's abdominal compartment syndrome. And what are you going to do?
>> It's decompressive laparotomy. >> Good, yeah, that's the answer on the ABSITE, I would say. Other than there's probably one scenario. So, you have a burn patient who is developing abdominal compartment syndrome. You know they've gotten their massive resuscitation. >> Go for SCAR, like? >> No, that's a separate area. So, let's assume, they don't have a circumferential chest wall burn. But that's the scenario where, they'll develop an abdominal compartment syndrome from just massive ascites building up and so, the preferred intervention there would be that you put a drain in and drain the ascites.
Any other compartment syndrome they give you the answer is laparotomy. Okay. we talked about damage control surgery, now there's damage control resuscitation. So, you have a patient who's shot in the abdomen their systolic blood pressure is 80. The medics are bringing them in from the field. And the question is how much fluid, and what type should they give this patient. >> This is similar to the treatment for ruptured aortic aneurysms now is the permissive hypotension.
The thought being that the more you; if you over resuscitate them it will allow them to bleed easier. >> So, what's your answer going to be? >> To the medic? >> It's going to say gunshot wound to the abdomen systolic of 80, and which of the following would you do? >> I would do. >> Then, it's going to say 500 cc, a liter, albumin, hep block IV. >> I would do one liter.
>> No, the answer is no fluid. >> No fluid. >> That's the constant of hypotension. So, it would be help block IV, you know, let them run hypotensive. You know unless they have altered mental status. And you get them to the operating room. That's the concept of permissive hypotension. >> Is that really going to be the answer on the ABSITE? I feel like they're still on the TLS, you give 2 liters of fluid, do you think that's going to be?
>> Well, for blunt trauma, yeah. But if they're giving you a penetrating trauma and you know, systolic is 80, and I especially think now, since damage control resuscitation studies have come out. >> I'm purposely missing questions to highlight these interesting and controversial areas to help you guys in the ABSITE so I hope you appreciate that. >> Okay, and then blood products. So, it's going to give you a choice of resuscitating this patient and it's going to give you know a choice of give them some PRBCs now.
Give them some PRBCs check coags and then wait until they're back and then correct them. Or, it's going to give them some PRBCs and FFP and platelets upfront. >> So, yeah, we're going to you start with the blood product resuscitation in a penetrating injury. Hypotensive patient. So, you know blood or platelets upfront and then FFP is generally the protocols I've seen. >> Yeah, so the answer is going to be the one where you're starting off giving the packed cells, FFP and some platelets and not the, we're going to give them six units of packed check coags and wait four hours and then start plasma.
So, that's called damage control, or balance resuscitation. All right. And there was a just a big study on this called this proper trial, which we don't need to get into but that did show a decrease in bleeding deaths with a 1 to 1 resuscitation. You might get asked about hemostasis adjuncts or drugs you can give to the bleeding patient. So, if they give you a question and you come across it's multiple choice and one of the answers is factor 7, is that going to be the wrong answer or the right answer?
>> I think that would be the wrong answer. >> Good, but that's one that will be in there as one of those ones to fake you. Factor 7 has pretty much gone out of use for trauma. But if they do give you a question about a bleeding trauma patient and is there anything pharmaceutically you can give them, what would be the right answer? >> I Think it's TXA. >> Yeah, tranexamic acid. >> That's for fibrinolysis. >> Good. And who would you give that to?
>> The massively bleeding patient that's had resuscitation. >> And when would you give it to them? >> Early, within the first hour, I think they say, is improved survival. >> Yeah, so it's within three hours. So, bleeding patient within three hours, tranexamic acid would be, that would be the answer on the ABSITE. It's been shown to have a survival benefit in the big study called the Crash 2 trial. And what does that drug do? >> It is a plasminogen activator inhibitor.
>> Okay, which does what? What does it do for you? >> So, it stops the breakdown of fibrin, essentially. >> Good, stops you from breaking down clot. Right, because you activate a hypofibrinolytic response, usually if you're massively bleeding. Okay, and how would you be able to tell if somebody was having massive fibrinolysis? >> Then you would need your TEG or your ROTEM. >> Okay. So, TEG and ROTEM has become a hot topic in trauma. It has now reached the point where it's on board exams.
It's on our surgical critical care and trauma exam. So, and a lot of people aren't real comfortable with reading TEGs. And you don't have to know a lot that's in-depth about reading a TEG. I think a general system that's easy to think about. They'll give you a lot of parameters that are confusing, R time, alpha angle, max amplitude. And for example, when they give you R time, don't worry about the R part, look at the second word of the parameter they're giving you.
So, the second word is either going to be time, angle, amplitude, or lysis. Right, and so time think about time just like a PT or PTT, prothrombin time, partial thromboplastin time. That's telling you how long it takes you to start clotting, right? So, the R time is just the time it takes you to start clotting. So, if that's prolonged, then what would you do for that patient? Or what's their problem? >> They have a platelet deficit or coagulation deficit.
They have a clotting factor problem. And that's the usual one. And what do you do with someone who's got an elevated INR? What would you give them? >> PCC. >> Not on novel oral anticoagulants. >> Okay, FFP. >> Yeah. >> So, that's the patient.
So, they've got a prolonged R time, you give them FFP. Angle tells you about the velocity of something, right? So, that's just telling you how fast they're forming a strong clot. And so, if they're not forming a clot very quickly, their fibrin and fibrinogen isn't functioning, what are you going to give them? >> Cryo. >> Good. That would be the patient you give cryo. The maximum amplitude, so amplitude is the width of the graph and all that's telling you is the clot strength.
So, if their maximum amplitude is smaller, so they're not forming a strong clot, or a platelet plug, what are you going to give them? >> Platelets. >> Good. And then the last parameter will be a measure of the lysis, or how much fibrinolysis they're having. And that's typically a LY30. And if they're having a lot of clot lysis, so they're LY30 is high, what would you give them? >> TXA. >> Good. And that's the simple, I think way to think about a TEG.
All right. We'll move into I think the last couple minutes of this. So, kidney and bladder injuries, usual mechanism? >> There's usually blunt. >> And especially for bladder, what's that usually associated with? >> Deceleration injuries with you know seat belts, or car accidents. >> But what associated injury do they usually have? >> Oh, urethral injury. Pelvic fractures.
>> Yes, that's almost always a pelvic fracture and they've got hematuria. So, will a bladder injury always have hematuria? A true bladder injury, full thickness laceration? >> It should. >> Yes. Will a kidney injury always have hematuria? >> Not necessarily. >> Yeah. So, a bladder injury if they do not have hematuria, that essentially rules it out. A kidney injury, they can, or they might not have hematuria, because it would just take a while for the blood to get down to the bladder.
So, when do you operate for a bladder injury? Or what type of bladder injury would you operate on? >> So, if there's an intraperitoneal, or spillage into the intraperitoneal space. >> Good and what about an extraperitoneal injury? >> Oh, those you can generally mange with a Foley catheter drainage. >> Good. And I think for the ABSITE, those would be the standard answers. Ureteral injuries. So, first off, just a little anatomy. If you were to tell someone how to find the ureteral, or how to find the ureter?
The most reliable location in the abdomen? >> Yeah, it's usually at the pelvic rim, along the iliacs when the internal external iliac split, over top of it. >> It crosses over the front of the bifurcation of the iliac and of the common, into the internal and external iliac. Good. So, management of ureteral injuries. Generally, they'll give you, if it's a proximal, mid, or distal injury. So, and the standard that they usually give you is a mid-ureteral injury.
It's transected and how would you manage that? >> So, if it's transected, it was a clean transaction, you spactulate the ends. Perform a primary anastomosis over a double J stent. >> Okay, using what type of suture? >> Absorbable suture. >> Yeah, remember anywhere in the urinary tract, so bladder, kidney, or ureter, it's always absorbable suture, because you don't want stones to form. Okay, and you always want to do that repair over a stent. Now, they give you a distal ureteral injury.
>> So, those you can generally re-implant into the bladder. You may have to immobilize a portion of the bladder, so it's hitch, those type of things. >> Good, if it doesn't reach the bladder, then you just bring the bladder to it, which so essentially, it's just you're bringing the bladder to the ureter and sewing it to the psoas. All right. You already mentioned urethra injury. So, just real quick, the physical exam signs of urethral injury? >> I've seen this on every test I've ever taken.
So, the high points are the meatal blood. And then if they have any scrotal or peritoneal hematoma, or high riding prostate on the DRE. >> Okay, and if you have those what are you going to do? >> You're going to do a retrograde urethrogram, before you place a Foley before you do anything else, as far as your urology system's concerned. >> That's your ABSITE answer. All right. Real quickly on extremity trauma, we mentioned hard and soft signs of vascular injury.
So, what would the hard signs of a vascular injury be? And this is for extremity trauma. >> Pulsatile bleeding. Expanding hematoma. >> Expanding of pulsating hematoma, good. >> Absent pulses. >> Good, what else? >> Thrill. >> On palpation or auscultation?
Good, a bruit or a thrill. >> And that's it as far as I know. >> And some people would include unexplained anemia. Unexplained severe anemia. And then, the other would be just observed pulsatile bleeding from the wound. How about soft signs? >> So, a non-expanding hematoma, decreased pulses. Non-pulsatile bleeding. >> And then, anything about location?
>> If it's near major vessels. >> Yeah. So, proximity injuries. So injury to a nearby nerve or a bone. Like a mid-femur fracture, you'd consider a superficial femoral artery injury. Okay, so you mentioned decreased pulses. So, what would you consider a decreased? Or, how would we assess that? >> Doppler signals. I mean so palpation is traditional.
So. >> Is there any number we can generate that will help us guide our? >> And ABI? >> Good. And what would be concerning for you for an ABI? >> Less than .9. >> Good. Less than .9 is the hard indication of you need vascular imaging. So, they'll often give you extremity injury. And you have a strong palpable pulse. And there's no active hemorrhage.
You know, they'll say gunshot wound to the thigh. But you have a strong palpable pulse. And they ask you what you want to do next, and the answer is not an angiogram, it's not CT angio. If you have a normal vascular exam, you've essentially ruled out a significant vascular injury. Now, that's for extremity. So, that's distal to the shoulder, distal to the hip. Now, you can have a subclavian injury where you can still feel a pretty normal pulse, but for extremity the exam has really become king.
If you have soft signs what are you going to do? >> That's generally further imaging. >> Good. Yeah, that's an indication for the CT angiogram or standard angiogram. And just what are the principles of management of the artery injury? >> Generally, you know, operative repair is the standard and if you can primarily repair it, which is rare, or you can use the most common would be an interposition graph at the saphenous vein, harvested. >> It's going to be a reverse saphenous vein graft, for an extremity arterial trauma.
How about a vein injury? >> A vein injury, many of them you can just ligate. >> Good. If it's a simple laceration you can do a primary repair, if it's anything above that, then ligation is fine, especially in the extremities. Anything else to consider? Now, they give you the patient who had a popliteal artery and vein injury that you just fixed. And they're going to say any other treatments you would. >> So, depending on the time of ischemia, you'd want to do a fasciotomy.
>> Good, always consider fasciotomy for extremity vascular injury. If they give you a popliteal artery and vein injury, then the answer is fasciotomy. That's going to be the answer. And how would you do that fasciotomy? We'll say for the calf? >> So, you do two incision on the medial and lateral aspect for compartment fasciotomy. >> Good. And what are those compartments? >> You have the lateral compartment, anterior compartment, and you have the superficial posterior compartment, and then the deep posterior compartment.
>> And which compartment are the blood vessels in? >> Deep compartment contains the popliteal artery. >> Deep posterior compartment. That's one of the ways you know you've opened it, is because you're looking at those vessels. Okay, well in first talking about hemorrhagic shock. I think we should clarify in the clinical signs of the different classes. We talked about class 1 through 4 and the tennis system of identifying the percentage of blood loss.
So, as we discussed the first sign of hypotension is in which class? >> Class 3. >> Good. So, that's probably the most common question. But for class 1, the initial clinical signs, would be what? >> I believe it's just some anxiety. >> Yeah, exactly. So, there's no tachycardia. There's no hypotension, yet at least in most patients. And then, in class 2 is where you get the earliest clinical signs of hemorrhage, which would be what two factors?
>> Is it decreased pulse pressure and maybe tachypnea? >> Yeah. So, a narrowed pulse pressure and tachycardia. So, oftentimes you'll get asked what is the earliest vital sign change and usually the answer is narrow pulse pressure. Okay, let's move on next to finish out our abdominal trauma. Obviously, the three rules of general surgery residency? John? >> Don't screw with the pancreas. >> So, that's going to start with rule number 3.
>> Rule number 3 first. >> So, eat when you can, sleep when you can. Don't mess with the pancreas. >> Don't mess with the pancreas. That's right. >> Okay, but we're going to mess with the pancreas. So, we talk about pancreatic trauma and I like to think about it as not so bad pancreatic injuries and bad pancreatic injuries are the ones that are going to be a problem.
And so, what do you think the factors are that make a pancreatic injury a bad injury? >> So, bad pancreatic injuries are going to be those that have issues with the main ducts. >> Okay, so number one factor, are you going to manage this nonoperatively or operatively is the duct injured. Good. >> The amount of parenchyma that is violated or that is involved. >> Okay, that's another factor. But I wouldn't say that would be a key factor. The next one would be location.
So, what would be bad and good? >> So, bad location, I'm guessing it would be the head of the pancreas. And a better location would be the tail or body of the pancreas. >> Good, and then probably the third factor is associated injuries. So, what's the associated injury you get with the pancreas that really, that bumps it up a grade? >> I think it would be a vascular injury that would be? >> That would also be bad. But what's right next to the pancreas, in the C loop.
>> Oh, well injury to the duodenum would be a real problem. >> Yeah, so when you have associated duodenal injury, that's probably your most complex pancreatic injury. Okay, so let's just talk about operative management. You have a pancreatic laceration and you were exploring the abdomen and you see this laceration at the tail. There's clearly no duct injury. >> Clearly no duct injury laceration at the tail. You have two options here.
You could just lay drains and get out of there, revert to a distal pancreatectomy. >> Okay, and on the ABSITE which one are you going to do? >> No ductal injury? >> No ductal injury. >> I'm just going to lay drains. >> Good. Drain it only. Now you have a distal pancreatic injury with a duct injury. >> Then I would perform the distal pancreatectomy. >> Okay, with or without splenectomy?
>> In a trauma situation I would probably do a splenectomy. >> Yes. So, that would be your answer, except in a certain scenario that we'll talk about next. Okay, now you have an injury to the pancreatic hear. Laceration to the pancreatic head. >> Laceration to the pancreatic head. Is there ductal injury? >> We'll say no. >> No ductal injury. So, I will lay drains and get out of there.
>> Okay, and now there is a ductal injury. >> I probably will still lay drains and get out of there. >> Probably didn't need to ask that, yeah. And I think we talked about this in morning report the other day, the quote from Top Knife about pancreatic injuries? >> You treat it like you'd eat a crawfish. So, you eat the tail and suck the head. >> Good. And I think that's a good principle to follow. So, resect the tail, especially if there's a ductal injury drain the head.
The only situation where especially on the ab site, I think you would do a spleen preserving distal pancreatectomy would be in what patient population? >> In a child? >> Yeah. So, if they give you a child who is stable, and they will have to give you that, then you can do a spleen preserving distal pancreatectomy. If they give you a child who is unstable, which they often will, just because they know you'll want to try to save the spleen because it's a kid, if they're unstable, the answer is still do a distal pancreatectomy, splenectomy.
Okay, and then real quickly. How do we surgically expose the pancreas? And we don't need to get into details. But there's maneuvers to expose the head, the body, and the tail. So, we'll start with exposing the head, this is the easy one. >> So, you typically would Kocherize the duodenum to expose the head of the. >> Good. So, you have to mobilize usually the hepatic flexion of the colon and then Kocherize the duodenum. You can expose and palpate the entire head.
Now, the body. >> The body, I think you're find your SMV as your landmark and following that to the body of the pancreas just to dissect that plain between the body. >> So, what do you have to open to expose the pancreas? >> You have to get in your lesser sac? >> So, how do you do that? What do you have to divide? >> You come through your greater omentum. >> Yeah, so you divide the gastric.
>> So, you widely open the gastric colic ligament and now you're looking at the body of the pancreas. And where is your avascular plain for mobilizing the pancreas? Inferior border or superior border? >> It's on the inferior border. >> The inferior border is completely avascular. So, that's always where you mobilize. And then, exposing the tail fo the pancreas? >> Exposing the tail of the pancreas, you're going to bring down your splenic flexure and it should be right there.
>> Well, what do you have to mobilize up to fully mobilize the tail? What comes along with the pancreatic tail? >> The spleen. >> Yeah. So, usually you have to mobilize the spleen. Take down the lateral attachments, mobilize the spleen medially and that will life up the tail. Also, known as? The AIRD maneuver, a-i-r-d. Little piece of trivia. Okay, compartment syndrome, we talked about the leg and the calf yesterday, which is the most common.
One other question you might get that we'll run through real quickly is the forearm. So, forearm, how many compartments? >> You have two compartments in the forearm. >> Okay. There's actually three. >> Oh. >> There's two that matter, okay, so what are the compartments? >> The two that matter are the anterior and the posterior compartments. >> Yeah, or extensor and flexor, or dorsal and volar. And then, there's a third compartment that's known as the mobile wad, which is essentially the brachioradialis muscle.
And the only two you need to open are the extensor and the flexor compartments. And I think that would be the only thing you would be asked about compartment syndrome. So, we will finish off with the main part of our trauma session with at the end of ATLS, you always get the two lectures on special populations. And these always are favorites for the boards. One is pediatric trauma patient the other is the pregnant trauma patient. I think every ABSITE I ever took had at least one or two questions on each of those. So, the nice thing is you can usually predict what they're going to ask.
There's a very finite amount of questions they can ask. So, pediatric trauma. So, one of the things they talk about is pediatric is just like adult, but then there's a whole talk on how they're different. So, airway differences in the pediatric patient. What are the differences in terms of the airway in the pediatric patient, anatomic differences? >> With getting an airway, they have a larger occiput. So sometimes you have to put some towels under the chest to help with it.
They have a smaller airway obviously with a narrow. >> Smaller and shorter airway. Size of the tongue? >> Size of the tongue is larger. >> Good. And position of the airway? Is it more anterior than adults or more posterior? >> It's more anterior. >> Good which means you have to pull up harder when you're doing direct laryngoscopy. Okay, you're going to intubate a kid for trauma, what are you doing to intubate them with, cuffed or uncuffed tube?
>> An uncuffed tube. >> Okay, that has actually changed. It is now a cuffed tube. In essentially anything but a baby, we not use cuffed tubes. You know they're low pressure, very save cuff tubes now, you don't necrosis like we did with high pressure tubes. So, the answer for pediatric trauma now is a cuffed tube. >> So, that was the concern before was necrosis of the trachea in kids? >> Yeah, because the cuffs were much higher pressure cuffs.
But now, it's a cuff tube you want to fully protect airway. And how would you estimate the size of the tube you're going to need? It's one of those annoying formulas. >> I like those little charts they have in the ER. >> Good. That's your best answer is use the Broselow Tape in clinical practice. But on your ABSITE, they're probably going to ask you to name a size tube. So, there's one easy way is you look at the width of the patient's pinky nailbed and find the tube that's that same width.
If you're going to just go by age, there's a formula. Yeah, so the formula is it's usually age in years divided by 4 plus 4. Some formulas have adopted that to age divided 4 plus 3 for cuffed tubes, but most of us use the age divided 4 plus 4. So, for example, for the four-year-old, that would be a 4 divided by 4 is 1, plus 4, so a size 5 cuff endotracheal tube. All right. So, what problems can you have with intubating a kid?
>> You can main stem. >> So, right main stem intubation that's a very common one they'll give you that the patient has no breath sounds on the right and what are the answers? The answer is you pull back the tube first before you put a chest tube in. And then, you intubate a kid and now his heart rate is 40. As they're doing the directly laryngoscopy. >> So they're just much more sensitive to the manipulation of the? >> Yeah, bradycardia during direct laryngoscopy is pretty common.
So, most algorithms either pre-medicate with? >> Bradycardia would be atropine. >> With atropine or you always have it standing by to give if they develop bradycardia. Okay, pediatric response to hemorrhage compared to adults? >> So, these patients can compensate really well in the beginning and where a typical adult patient would not be able to compensate. You're going to see clinical signs earlier with an adult, you won't see those in a pediatric patient, which means that when they do crash, they crash hard.
>> So, what is a pediatric patient going to do as they're bleeding, vital signs wise? >> They're going to remain mainly stable, and tachycardic. >> Good, so they get tachycardic. They get tachycardic, tachycardic, more tachycardic, and then they fall off the cliff. Now you want a bolus this patient. So, how do you bolus the pediatric trauma patient. Start with crystalloid. >> So, with a crystalloid bolus, it's actually simpler I think than the adult, just 20 cc per kg.
And you can do that twice. >> Okay, and now you want to give them blood products. >> So, I just half that, which would be 10 cc per kilogram. >> Ten cc per kilogram for blood products. Okay. And what should always be on the differential diagnosis for a pediatric trauma patient? >> Well, whenever you have a pediatric patient come into the emergency room, you have to be concerned about non accidental trauma. >> Good, and that's especially for head trauma, for head bleeds, especially in babies and younger children.
Always remember to keep that on your differential. Okay, now we'll move on to the pregnant trauma patient. So, there's a whole bunch of physiologic changes that we get with pregnancy. There's really only a couple that are really relevant to trauma. So, the first one is what happens to their circulating blood volume? >> They have an increase in their circulating blood volume. >> Okay. And their hematocrit? >> It's actually less. >> Okay, so they have physiologic delusion or anemia.
How about changes in their respiratory status? >> They have an increase respirations and decreased tidal volume. >> Okay. So, what will that do to their acid base status? >> So, they will actually be respiratory alkalosis. >> Good. And so, how does that affect you in terms of your trauma management, or looking for signs of respiratory failure? >> Potentially you might be reassured by either the CO2 values on EBG or on the acid base status thinking that they're not as acidotic as they maybe.
>> Yeah, so a PCO2 of 45 would probably not raise many flags in a normal person, but in a pregnant patient whose baseline is 35, that may represent respiratory failure. Okay, so, this patient comes in and they're hypotensive. She's 7 months pregnant. >> So, I'm going to have them lay on their left lateral decubitus to take the pressure off the IVC. >> Good, so you want to put them left side down, take the pressure off the IVC. And this patient had abdominal trauma and you do your workup and you know she has some injuries.
Let's say there was a pelvic fracture baby looks okay. And anything else now we want to consider? >> Right, so I'm concerned about placental abruption in a trauma patient, has a very high mortality for both the child and the mother. So, I would do the blood test, the Kleihauer-Betke test where you test for fetal blood within the maternal circulation. >> Okay. And not only placental abruption, any significant abdominal trauma can cause some degree of maternal fetal hemorrhage.
So, the Kleihauer-Betke test is looking for fetal blood cells in maternal circulation. And how do you use that? What does that change for you? >> I think you would be lean more toward observation with fetal monitoring in a situation that you had a positive test. >> Okay, but does that drive any intervention you would do if you found fetal maternal hemorrhage? >> I would do a transvaginal ultrasound to evaluate the placenta. >> Any medication you might administer?
>> The RhoGAM. >> Okay, who are you going to give that to? So, a negative mother, because if she gets exposed to a Rh positive blood cells from the fetus, she's going to develop antibodies, right? And then the concern is, the next pregnancy, that is a Rh positive fetus, those antibodies are going to be attacking, right? So, you want to prevent her forming those anti-Rh antibodies. So, any Rh negative mother who you strongly suspect had major abdominal trauma, fetal internal hemorrhage or a positive Kleihauer-Betke test, you get RhoGAM.
All right. Well, there's a lot of stuff in the literature about scanning pregnant patients. What are the actual risks of CT scanning the pregnant trauma patient? >> So, what I always think is that if you feel like you need to CT scan the mother, then do it. >> Good. >> The risk of one CT scan, a total body CT scan for a pregnant patient is relatively low over the course of their life and the risk to the baby is also very low. >> Okay, so what are the risks to the baby?
There's really two categories of risk. >> So, I think the risk that a lot of people are concerned about or thinking about is the teratogenicity of and then the developmental. >> And when would that happen? >> That would happen at that time. And would be. >> But what stage of a developing fetus? >> Oh, sure in the first trimester of the pregnancy. >> So, if they're past the first trimester, you're not worrying about developmental defects from radiation.
Now, what about any other? At any age? >> At any age, they are at increased risk for developing malignancy down the road from radiation exposure. >> Good. And what do we say that risk is, about? >> It's less than 1%, I think. >> Yeah, generally it's 1 in 1000. We say it increases their risk by 1 in 1000 for future cancer. But you're exactly right.
If the patient needs to be scanned, then you scan them. And the risk of one CT scan is pretty negligible. Okay, and then, last question, who need admission for fetal monitoring? >> So, any abdominal trauma or trauma to the area of the uterus is a patient that I'm going to want to admit and have continuous fetal monitoring on I believe. >> Okay, but do you have any criteria based on where they are in their pregnancy? >> So, so but so, in general, you really only need to do fetal monitoring on patients where you're going to do some intervention.
So, basically the fetus has to be past the point of viability if they have early labor and delivery. So generally it's 24 weeks. If they're at 24 weeks or greater than you usually admit them for at least 24 hours of fetal monitoring. If they're less than 24 weeks, you might still be admitting them, but there's not a whole lot of reason to do continuous fetal monitoring. >> Okay, so 24 weeks is the cutoff there. >> Yes, 24 weeks is the cutoff.
And that will probably get shorter, as we get better at keeping premature babies alive. But as of right now it's 24 weeks. Okay? So, what we're going to do right now is with the last 10 minutes, we're going to do trauma quick fire round. A new feature that I'm introducing. So, we talked about how you want to look for those buzzwords and you kind of know what the answer is a lot of times before you get to even the answer choices. So, I'm just going to read you some phrases taken in isolation and you tell me what the answer to the question is.
There's no discussion, there's no explaining. There's no asking for more information, okay? All right. You have a trauma patient and you're in their chest. They've arrested and there's bubbles in the coronary vessels. What's your diagnosis? And either one of you can answer. You see air bubbles in the coronary vessels. >> Air embolism?
>> Air embolism. Good. And if they're in coronary vessels it's usually a left-sided one from a pulmonary injury. Okay, you have an MVC patient who has a lumbar chance fracture and a seatbelt sign. >> Pancreatic injury. >> I'd also be worried about a missed hollow viscus injury. >> Good and actually in that scenario the answer is going to be a hollow viscus injury. That's the set up for a hollow viscus injury. Now you have a kid with a handlebar blow to his abdomen.
>> Pancreatic injury. >> Or? >> Duodenal. >> Good that's pancreatic or duodenal hematoma. See, you guys are great at this. Left thoracic abdominal stab wound has a negative FAST exam, a completely benign abdominal exam. What else are you worried about? >> Diaphragm.
>> Good, that's the patient who even if you don't think they have anything else, they should probably have a laparoscopy to look for a diaphragm injury. All right posterior knee dislocation. >> Popliteal artery disruption. >> Excellent. Patient found down, was lying for 24 hours on their back and their creatinine is 3.5 and they're allegoric. >> So, I'm worried about rhabdomyolysis. >> Excellent.
You have a tracheostomy patient who's had a trache for a month. Nurse reports 10 cc of bright red blood came from it and was suctioned out and then stopped. >> So, I'm worried about a tracheal innominate fistula. >> Good. And that would be a sentinel bleed, which you don't want to wait for the real thing, okay. You have severe TBI patient and the sodium is up to 155. And they're making 5 liters of urine. >> That's diabetes insipidus. >> Good, and bonus for the treatment.
>> Desmopressin. >> DDAVP. Excellent. Okay, now your patient is paralyzed from the waist down. And has no cremasteric reflex. >> Spinal shock. >> Okay, now they're paralyzed the waist down and they have a cremasteric reflux. >> They're paralyzed. >> Yeah, so they're out of spinal shock and their deficits are probably permanent. Okay. You have a stab wound to the abdomen, a benign exam.
But there is eviscerated omentum. >> I need to do an exploratory laparotomy. >> Good. Evisceration is a criteria for laparotomy. You have liver bleeding that continues and is unchanged after Pringle maneuver. >> Then I can definitively say that I have. >> What's your injury? >> Hepatic vein injury. >> Good, or? >> IVC.
>> Retro hepatic vena cava. That's the classic retro hepatic vena cava. You have a chest x-ray that has an apical cap. >> I have a blunt thoracic injury. >> Blunt thoracic? >> Aorta. >> Aorta injury good. You have major bleeding during your neck exploration, that it's not coming from the carotid or jugular?
There's arterial bleeding coming from posterior. >> Vertebral artery. >> Excellent. Okay. You have a stab wound to the flank and I'm telling you there's in injury to some structure. What structure is it? >> Kidney. >> Flank or back. Good. It's going to be kidney. >> Diaphragm?
>> Colon? >> Colon. Kidney and colon. Those are the two big ones. And that's why we do the triple contrast, right? Okay. You have a major trauma patient you get a TEG and it shows an elevated LY30 of 10%, and the normal is 3%. So, this is high lysis. >> Fibro? Fibrolysis. >> So, what's the answer going to be?
>> They need TXA. >> Good. Tranexamic acid. Excellent. A lot of times they talk about getting exposure to vessels. And there's a gateway structure that you have to divide. So, what's the gateway structure to the carotid bifurcation? >> The facial vein. >> Good. Common facial vein. Needs to be divided.
What's the gateway structure to the great vessels in the aortic arch? So you did a median sternotomy and you have to expose the great arch vessels. >> Innominate vein? >> The innominate vein. Yeah. Innominate vein you have to either retract it or divide it. Okay. Patient has hematemesis two weeks after a motor vehicle crash with a grade 4 liver lac. >> A biliary fistula to the hepatic artery. >> Okay. So, you have haemobilia.
And bonus for the treatment. >> Angiographic embolization. >> Excellent. Okay, you have an open pelvic fracture and the patient has a big complex perineal wound. >> Colostomy. >> Excellent. Diverting colostomy. All right. Gunshot wound to the pelvis.
Patient has benign abdominal exam, but you do a rigid proctoscopy in the OR and you see a hematoma in the rectal wall. >> Exploratory laparotomy? >> And? What are you going to do during your laparotomy? So, it's in the extra peritoneum perineum rectum. And it's just a is just a hematoma. What's the most important thing you're going to do for that extra peritoneal rectal injury? >> Colostomy. >> Diversion.
Yeah. So, and that's a common one they'll give you and you'll hum and ha because it's a hematoma. In fact all you need to do is a colostomy. You can just do a laparoscopic colostomy. That's near. >> Well, thank you Dr. Martin for this hour and a half pimp session that we hope will be beneficial to all of our colleagues out there and the things we do for Behind the Knife listeners is go to all extremes. >> Yeah, I can't thank you enough Dr. Martin you've always been a great friend of the program and I just encourage everybody to follow Dr. Martin on Twitter, it's @docmartin?
>> Docmartin22. >> Docmartin22 and check out these trauma casts. I can't speak highly enough of it. >> Yep, thanks a lot and good luck to everyone on the ABSITE, remember read the question, read all the answers, but look for those keywords and a lot of times you'll know the answer before you get there. And you'll often have a first reaction of this is the right answer. And usually you're right. So, don't start looking at some other details and then try to convince yourself otherwise.
If you have that gut reaction, that's usually the right answer. >> And we're looking to Dr. Martin back to do a critical care outside review as well, so watch for that coming up. >> Until next time, dominate the day. [ Music ]