Chapter 18 Trauma Surgery

Discontinue the catheter insertion.

A 26-year-old woman is rushed to the operating room after a primary and secondary survey in the emergency department. She was hit by a small truck as she was riding her bicycle through a busy intersection. She has sustained rib fractures and several fractured transverse vertebral processes. Renal injury is suspected. As the circulator prepares to insert a urinary catheter, she notices blood at the urinary meatus. What should the circulator's next action be?

Definitive procedure

A planned surgical procedure, usually with specific objectives for reconstruction or restoring continuity of anatomical structures

Metabolic acidosis

A potentially lethal physiological condition occurring in shock, characterized by abnormally low blood pH

Focused Assessment with Ultrasound for Trauma (FAST)

A protocol of ATLS in which ultrasound is used in a focus area to diagnose severe trauma

Prep the patient from the suprasternal notch to the mid-thigh.

A trauma patient is rushed to the OR after a primary survey is completed in the emergency department. He is a 36-year-old male with multiple penetrating gunshot and knife wounds to the abdomen. He is bleeding profusely. What appropriate actions are critical in the rapid preparation for this procedure?

Hemorrhagic shock

A type of shock characterized by vascular failure due to severe bleeding

Hemothorax

Bleeding into a pleural space

Assist the anesthesia provider with securing the airway while applying cricoid pressure.

Blunt force to the larynx can result in a fracture and impose immediate airway obstruction. These patients are at risk for a lost airway and may require immediate tracheotomy followed by repair of the fracture when the fracture is unstable or displaced. It is also important to consider that a trauma patient is assumed to have a full stomach; thus these patients are at high risk for aspiration and resultant pneumonia. What is an appropriate action in the event of a lost airway after anesthesia induction and before intubation?

CT scan of the head

Blunt trauma injuries may not fully reveal the degree or depth of injury. What noninvasive diagnostic test is critical to diagnosis in potential traumatic brain injury?

Contusion

Bruising

head neck cervical radiograph

Cervical Spine Precautions: A trauma team member can stabilize the ________ and ________, if necessary, until a cervical collar is placed. Once placed, the team does not remove it until a ________ clears the neck of injury.

Coagulopathy

Condition in which the body's normal blood clotting mechanism ceases to function, characteristic im severe multitrauma

A cervical radiograph is obtained to rule out injury to the neck.

If cervical spine precautions were not implemented before arrival at the hospital, the emergency department team initiates them before performing any other procedures on the patient. A trauma team member can stabilize the head and neck, if necessary, until a cervical collar is placed. What event needs to take place before the team removes the cervical collar and continues care?

Plastic bags may trap moisture and allow mold growth, destroying evidence.

If the injury to the patient is a result of a violent crime, the team must give special attention to preservation of evidence during the course of patient care. When clothing is removed from the patient, why must it be placed and secured in a paper bag rather than a plastic bag?

Resuscitation

In trauma medicine, the process of restoring physiological balance following severe trauma.

Compartment syndrome

Increase pressure in any compartment of the body such as the cranium, abdominal cavity, or a limb caused by trauma

spleen liver (because of its large size)

Injuries of the Abdomen- What is the most common organ injured in blunt trauma? What is the most common organ injured in penetrating trauma?

arch aortogram

Injuries of the Chest and Heart- Rupture of the thoracic aorta is an injury requiring surgical intervention and includes the use of extracorporeal bypass. This injury is an obvious life threat but may be difficult to diagnose. An ________ is indicated in trauma patients who may have sustained such an injury.

retrograde urethrogram

Injuries of the Genitourinary System- Blood at the urinary meatus may indicate a tear in the anterior urethra. A ________ maybe performed to evaluate for extravasation of urine and potential injury.

computerized tomography (CT)

Injuries of the Head and Spinal Cord- Hematoma evacuation is based on its location as well as the size and number of hematomas present. Before performing a craniotomy or drilling a borehole, the ________ scan, the neurologic status of the patient, the morbidity and mortality associated with medical problems, are evaluated.

methylprednisolone (Solu-Medrol)

Injuries of the Head and Spinal Cord- What medication is given to decrease initial spinal cord swelling which can cause potential respiratory distress?

Cerebral arteriography

Injuries of the Head and Spinal Cord- _________ may be used to screen patients with cervical vertebral fractures for blunt vertebral artery injuries (BVIs).

Pneumothorax

Injury that results in air in the pleural space causing displacement or collapse of the respiratory structures

cricoid endotracheal (ET) tube

Pressure is maintained over the ________ area until the cuff on the ________ is inflated and tube placement is verified by the anesthesia provider.

Cardia tamponade

Pressure on the heart causing restriction and damage to the conduction system

Flail chest

Rib fracture in at least three adjacent ribs in two locations each. This condition requires immediate surgery

radiographs

Skeletal Injuries- Trauma to the skeletal system usually results in contusion or fracture. After stabilisation of the patient, ________ are taken of any body part that is distorted, edematous, painful, or highly suspicious for fracture or dislocation.

Damage control surgery

Surgery whose objective is to stop hemorrhage and prevent sepsis without attempting reconstruction or anatomical continuity

compartment syndrome

Swelling of the muscles below the faccia covering may compromise circulation and result in the eventual loss of the extremity because of tissue necrosis, this is known as ________.

Cardiac rupture

Tearing of the atria or ventricles as a result of trauma

- Determine the severity of injury and initiate medical treatment. - Identify the most appropriate facility to which to transport the victim.

The emergency medical services system consists of trained prehospital personnel who arrive at the scene and perform definitive interventions designed to reduce morbidity and mortality. What is the primary role of the prehospital personnel?

Penetrating injury

Tissue damage that occurs when an object enters the body through the skin, or the body is propelled against an object, breaking the skin

Level I TC

Trauma Center classification: - capable of providing total care for every type of injury - severely injured patients over a region - qualified personnel and equipment necessary for rapid diagnosis and treatment on a 24 hour basis

Level IV TC

Trauma Center classification: - has the ability to provide Advanced Trauma Life Support for patient transfer - may be located in rural areas with limited access and may be a clinic or a hospital

Level II TC

Trauma Center classification: - provides comprehensive care for all injuries but lacks some of the specialized conditions and resources required for the Level I designation - may provide surgical intervention if the critical nature of the injury dictates immediate intervention before transfer to a level 1 facility - ACS recommends an OR team is readily available at all times which may be met with an on-call staff

Level III TC

Trauma Center classification: - provides prompt evaluation, resuscitation, emergency surgery, and stabilization before transfer to a higher level facility - ACS recommends an OR team is readily available at all times which may be met with an on-call staff

Blount injury

Trauma that results in deep tissue injury without rupture of the skin

Blunt injury

Trauma that results in deep tissue injury without rupture of the skin

Assist in setting up the autotransfusion system and resuscitation equipment.

Trauma to the chest area is the primary cause of death in approximately 25% of trauma victims. Involvement of the heart, great vessels, lungs, and diaphragm, attributable to penetrating or blunt injury, can provide multiple unexpected findings when the chest is opened. Because of the nature of the potential findings and expected surgical intervention, what would be an appropriate preparatory action for the surgical technologist to take?

Phase II

Traumatic deaths may occur in three phases, or time frames. The first phase occurs immediately after the injury, the second phase within the first 1 to 2 hours after the injury, and the third phase occurs days to weeks after the injury. Approximately 30% of total fatalities from trauma could be prevented with definitive trauma care, including appropriate and aggressive resuscitation with rapid transport to an appropriate facility. Which phase, or timeframe, of potential for trauma death, does this group represent?

osmotic diuretics such as Mannitol

What drug can be used in the treatment of intracranial pressure?

Surgery at a non-level I center before transfer to a level I; intentional retained sponges

What is the description of damage control surgery, and what conditions may be present?

fasciotomy

What procedure is done when compartment pressure is more than 30 mm HG?

d. All of the options can negatively impact the geriatric patient's perioperative experience.

What special consideration should be made when assessing a geriatric trauma patient before surgery? a. They may have preexisting diseases and conditions. b. They may take many prescription and nonprescription drugs. c. They have decreased physiologic reserves. d. All of the options can negatively impact the geriatric patient's perioperative experience.

Use the modified Glasgow Coma Scale for children.

What special consideration should be made when assessing a pediatric trauma patient for level of consciousness?

They are at risk for retained foreign bodies related to the size of the abdominal cavity.

What special consideration should the perioperative team be alert to in order to prevent a negative surgical outcome in bariatric trauma patients?

A level I trauma center provides care for every type of injury, while a level II lacks some specialized resources.

What statement regarding level I and level II trauma centers best describes the difference between the two types of centers?

Airway (the cervical spine precautions) Breathing Circulation Disability (freeze neurologic examination) Exposure

When the patient arrives in the ED, the trauma team initiates a primary assessment based on protocols for Advanced Trauma Life Support (ATLS):

D = a brief neurologic examination; E = exposure to reveal all life-threatening injuries

When the patient arrives in the ED, the trauma team initiates a primary assessment. This is a logical, orderly process of patient assessment for potential life threats. These assessment activities are based on established protocols for advanced trauma life support (ATLS). The mnemonic "ABCDE" is used, representing assessment of the following: Airway, Breathing, Circulation, Disability, and Exposure. The D and E represent what degree of investigation?

Focused assessment with sonography (FAST)

________ in trauma is a non-invasive scan that can be used to determine the presence of free fluid in the chest or abdomen. This skin consists of chest, pelvic, and four abdominal scan.

Occult injury

An injury that is not detected in normal assessment procedures

A chest, pelvic, and four abdominal scans; collections of fluid and free air

Focused assessment with sonography in trauma (FAST) may assist with diagnosis in difficult situations. What group of scans is performed and what do they identify?

Exsanguinating

Hemorrhage with the potential to deplete the patient's total blood volume

computerized tomography (CT) focused assessment with ultrasound for trauma (FAST)

2 ways in which a stable patient is diagnosed with abdominal injury:

32 89.6 36 96.8

Hypothermia- A core body temperature of ____ degrees C/ ____ degrees F is associated with a nearly 100% mortality rate. generalized hypothermia is considered to be present when the core temperature is below ____ degrees C/ ____ degrees F.

hypothermia acidosis coagulopathy

Hypothermia- The combination of ________, ________, and ________ is known as the trauma triad of death.

Blood contaminated with food, bowel contents, or antibiotic irrigation

Autotransfusion can present a vital asset in trauma care, when considering the high blood loss associated with many traumatic injuries. This process provides immediate volume replacement, decreases the amount of bank blood used, and reduces the possibility of transfusion reactions or risk of transfusion with bloodborne pathogens. What are the contraindications to using autotransfusion as a blood replacement source?

pericardial fluid hepatorenal splenorenal free fluid, bladder

Diagnostic Procedures (Focused assessment with sonography/ FAST)- -The chest scan examines right and left chest views and can determine the presence of _________. -The upper right abdominal skin evaluates the _________ area, the first area that shows the presence of air. -The left upper scan examines the ________ area. -The pelvic scan assesses for ________ near the ________.

lateral, cervical spine anterior posterior, chest lateral thoracic and lumbar spine anterior posterior, pelvis

Diagnostic Procedures- Depending on the trauma center protocol, a blunt trauma radiographic series may be part of the resuscitative phase. This minimally includes a ________ view of the ________ and an ________ view of the ________. In addition the patient also undergoes ________ films and an ________ view of the ________.

20 30

Diagnostic Procedures- Normal compartmental pressures are less than ____ mm HG. Pressure is more than ____ mm HG require a fasciotomy.

manometer/stopcock/syringe

Diagnostic Procedures- Surgeons may measure compartment pressures with a ________ or a commercial compartment pressure-measuring device.

Diagnostic peritoneal lavage (DPL)

Diagnostic Procedures- ________ maybe performed to determine the presence of abdominal injury. This tool is of particular benefit when evaluation in the abdomen is difficult, such as when the patient is intoxicated, unconscious, or hemodynamically unstable.

Focused assessment with sonography (FAST)

Diagnostic Procedures- _________ is also used in pregnant patients with blunt abdominal trauma; it is both faster and safer and a computerized tomography (CT) scan, which is contraindicated in the pregnant patient because of the use of iodinated contrast medium and ionizing radiation.

coagulopathy

Dysfunction of the normal blood clotting process

Definitive diagnosis

Evidence-based diagnosis of a medical problem using normal investigative procedures such as imaging studies

1. age older than 65 years 2. dangerous MOI (mechanism of injury) 3. paresthesias in the extremeties

Existing factors that place the patient at high risk for spine injury when reviewing the cervical spine films for cervical spine injury clearance: (3)