Trauma
According to EAST guidelines, what is the management of pancreatic injuries?
C. Level III Delay in the recognition of main pancreatic duct injury causes increased morbidity. CT scan is suggestive but not diagnostic of pancreatic injury Amylase/Lipase levels are suggestive but not diagnostic of pancreatic injury Grade I and II injuries can be managed by drainage alone. Grade III injuries should be managed with resection, and drainage. Closed suction is preferred to sump suction.
What are the indications of ED thoracotomy?
Patients who have demonstrated more favorable results are those with penetrating thoracic injuries who have signs of life on reaching the emergency department. An assessment of all applicable studies yielded a survival rate of 11.2% after resuscitative thoracotomy for penetrating chest injury.14 Blunt trauma patients have uniformly dismal results and therefore are not candidates, except in the most select situations. Survival rates of 1.6% were noted when appropriate studies were pooled, and most of these survivors had a poor neurologic outcome.
What is the management of penetrating splenic injury?
Penetrating abdominal injuries due to gunshot wounds are usually managed by laparotomy. Isolated stab wounds to the spleen may undergo a trial of NOM. However, splenic injuries from penetrating trauma are often accompanied by injuries to the bowel. Penetrating injuries to the spleen tend to violate intraparenchymal anatomic planes, and as a consequence, arterial injury and subsequent pseudoaneurysm formation are common. Because of the risk of delayed bleeding, splenectomy should be considered at the initial exploration. If it is an isolated splenic pole injury that can be treated by resection of the injured segment of the spleen, splenorrhaphy may be considered in the absence of accompanying bowel injury.
What is the management of knee dislocation?
Popliteal artery injury is the most dangerous potential complication following tibiofemoral dislocation. Delay in diagnosis and repair increases the risk for irreparable injury requiring above-knee amputation. A meticulous evaluation of the extremity's circulatory status is mandatory and should include: palpating the distal and popliteal pulses, measuring an ankle-brachial index (ABI), and performing a screening duplex ultrasound, if available. Obtain emergent bedside consultation by a vascular surgeon if the limb manifests ANY sign of vascular compromise. Such signs may include diminished or absent pulses, pale or dusky skin, paresthesias, and paralysis.
According to EAST guidelines, what is the ideal tracheostomy timing in trauma patients?
Recommendations Level I There is no mortality difference between patients receiving early tracheostomy (3-7 days) and late tracheostomy or extended endotracheal intubation. Level II Early tracheostomy decreases the total days of mechanical ventilation and ICU LOS in patients with head injuries. Therefore, it is recommended that patients with a severe head injury receive an early tracheostomy. Level III Early tracheostomy may decrease the total days of mechanical ventilation and ICU LOS in trauma patients without head injuries. Early tracheostomy may decrease the rate of pneumonia in trauma patients. Therefore, it is recommended that early tracheostomy should be considered in all trauma patients who are anticipated to require mechanical ventilation for >7 days, such as those with neurologic impairment or prolonged respiratory failure.
What is the management of duodenal injuries?
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How should BCVI be treated?
* Grade I—intimal irregularity with <25% narrowing; * Grade II—dissection or intramural hematoma with >25% narrowing; * Grade III—pseudoaneurysm; * Grade IV—occlusion; and * Grade V—transection with extravasation. Level I: No level I recommendations can be made. Level II: 1. Barring contraindications, grades I and II injuries should be treated with antithrombotic agents such as aspirin or heparin. Level III: 1. Either heparin or antiplatelet therapy can be used with seemingly equivalent results. 2. If heparin is selected for treatment, the infusion should be started without a bolus, a guideline for activated partial thromboplastin time goal cannot be determined. 3. In patients in whom anticoagulant therapy is chosen conversion to warfarin titrated to a prothrombin time-international normalized ratio of 2 to 3 for 3 months to 6 months is recommended. 4. Grade III injuries (pseudoaneurysm) rarely resolve with observation or heparinization, and invasive therapy (surgery or angiointerventional) should be considered. N.B. carotid stents placed without subsequent antiplatelet therapy have been noted to have a high rate of thrombosis in this population.[7] 5. In patients with an early neurologic deficit and an accessible carotid lesion operative or interventional repair should be considered to restore flow. 6. In children who have suffered an ischemic neurologic event (INE), aggressive management of resulting intracranial hypertension up to and including resection of ischemic brain tissue has improved outcome as compared with adults and should be considered for supportive management. No recommendations can be made on duration of anti-thrombotic therapy. Follow-up angiography is recommended in grades I to III injuries. To reduce the incidence of angiography-related complications, this should be performed 7 days postinjury.
What are the EAST guidelines regarding penetrating zone II neck trauma?
A. Selective Workup-Operation Versus Selective Nonoperative Management Recommendations Level I: Selective operative management and mandatory exploration of penetrating injuries to zone II of the neck have equivalent diagnostic accuracy. Therefore, selective management is recommended to minimize unnecessary operations. Level II: High resolution CT angiography offers appropriate diagnostic accuracy with minimal risk, making this the initial diagnostic study of choice when available. Level III: No recommendations. B. Diagnosis of Arterial Injury Recommendations Level I: No recommendations. Level II: CT angiography or duplex US can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to zone II of the neck. Level III: CT of the neck (even without CT angiography) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed. C. Diagnosis of Esophageal Injury Recommendations Level I: No recommendations. Level II: Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours. Level III: No recommendations. D. Value of the Physical Examination Recommendations Level I: No recommendations. Level II: No recommendations. Level III: Careful physical examination using protocols for serial examinations, including auscultation of the carotid arteries, is >95% sensitive for detecting arterial and aerodigestive tract injuries that require repair. Given the potential morbidity of missed injuries, clinicians should have a low threshold for obtaining imaging studies.
About spleen preservation in pancreatic injury:
Another discussion that is common in the management of pancreatic injury is the issue of splenic preservation. While this approach might make intuitive sense, the data supporting this approach in traumatic pancreatic injury is not adequate. Pachter et al looked at splenic preservation with distal pancreatectomy in 9 patients and showed that it could be done in 51 minutes with minimal complications[34] . The power of this study is low and cannot be used to make general recommendations regarding this aspect of management.
What are the indications for angioembolization in blunt splenic trauma?
Contrast "blush" on CT with evidence of ongoing hemorrhage, pseudoaneurysm, AAST grades IV and V, moderate hemoperitoneum, or clinical evidence of continued hemorrhage. Patients with high-grade injury, large hemoperitoneum, vascular blush, pseudoaneurysm, and arteriovenous fistula are all at high risk of failure of NOM.
What is the management of carotid artery injury?
For the injured internal carotid artery, a shunt may be used as a temporizing measure in the setting of systemic extremis and higher treatment priorities overall. Additionally, a carotid shunt should be considered intraoperatively at the time of internal carotid repair if there is minimal backbleeding from the distal segment. Systemic heparinization is not necessary. Instead, instillation of a heparin solution proximal and distal into the vessels is recommended in the setting of acute traumatic injury. In patients with a neurologic deficit and concomitant carotid injury, there is debate as to whether the internal carotid should be repaired or ligated due to fear of converting an ischemic stroke into a hemorrhagic one. Despite this concern, the best data to date suggest that repair of the artery provides for the best chances of a favorable outcome unless the neurologic deficit has been present for a prolonged period of time. Strict postoperative blood pressure control is indicated in all such circumstances.
What are hard signs of significant zone II neck injury?
For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, immediate operative management may be indicated.
What are the EAST guidelines regarding the management of penetrating colon injuries?
III. Recommendations A. Level I There is sufficient class I and class II data to support a standard of primary repair for nondestructive (involvement of < 50% of the bowel wall without devascularization) colon wounds in the absence of peritonitis. B. Level II 1. Patients with penetrating intraperitoneal colon wounds which are destructive (involvement of > 50% of the bowel wall or devascularization of a bowel segment) can undergo resection and primary anastomosis if they are: Hemodynamically stable without evidence of shock (sustained pre- or intraoperative hypotension as defined by SBP < 90 mm Hg), Have no significant underlying disease, Have minimal associated injuries (PATI < 25, ISS < 25, Flint grade < 11), Have no peritonitis. 2. Patients with shock, underlying disease, significant associated injuries, or peritonitis should have destructive colon wounds managed by resection and colostomy. 3. Colostomies performed following colon and rectal trauma can be closed within two weeks if contrast enema is performed to confirm distal colon healing. This recommendation pertains to patients who do not have non-healing bowel injury, unresolved wound sepsis, or are unstable. 4. A barium enema should not be performed to rule out colon cancer or polyps prior to colostomy closure for trauma in patients who otherwise have no indications for being at risk for colon cancer and or polyps.
What are the complications of non-operative management of blunt splenic injury?
Major, potentially life-threatening complications include continued hemorrhage, total splenic infarction, splenic abscess, contrast-induced nephropathy, pancreatitis, and pneumonia. Minor, non-life-threatening complications include fever, pleural effusion, partial splenic infarction, pain, coil migration, and puncture site injuries. Bleeding is the most common complication and has been reported in 5% to 24% of those undergoing embolization.
What is the management of IVC injury?
In many ways, IVC injuries are potentially more lethal than abdominal aortic injuries. In theory, one can ligate any injury below the renal veins; however, there is an approximately 30% morbidity rate from venous hypertension in the lower extremities. The infrarenal IVC has several lumbar veins that are posterior on the IVC, and rotation of the IVC during repair can be problematic. Initial control is another issue and can be achieved with a side-biting Satinsky clamp; however, this must be carefully handled to avoid torsion and iatrogenic tear of the thin and friable IVC. Our personal recommendation is to use sponge sticks initially to control the bleeding. Alternatively, the surgeon's index and middle finger can be placed on the hole, and a running stitch of 3-0 polypropylene can be started with gentle traction to avoid stenosis of the vessel.
What is the management of mild traumatic brain injury?
Level 1 There are no level 1 recommendations Level 2 Clinicians should perform brain CT scan on patients that present with suspected brain injury in the acute setting if it is available. If CT resources are limited, consideration may be given to the use of a set of standardized criteria (e.g., the Canadian CT Head Rule [CCHR], New Orleans Criteria [NOC]) to determine which patients with MTBI receive a brain CT scan. Clinicians should be aware that this practice is associated with a nonzero missed injury rate. Level 3 Clinicians should not routinely use magnetic resonance imaging (MRI), positron emission tomography, or nuclear magnetic resonance in the clinical management of patients with MTBI at the present time (Level 3). Patients with an isolated MTBI and a negative brain CT scan result may be discharged from the ED if they have no other injuries or issues requiring hospital admission (Level 2). Patients taking warfarin who present in the acute setting with an MTBI should have their international normalized ratio (INR) level determined. (Level 3). Anticoagulated patients with supratherapeutic INR values and a normal initial brain CT scan result remain at significant risk for interval development of intracranial hemorrhage and should be admitted for a period of observation (Level 3). Patients may be advised that measurable deficits in cognition and memory usually resolve at 1 month but that in 20% to 40% of cases, postconcussive symptoms may persist for 3 months or longer (level 3). The ability to safely operate a motor vehicle may be impaired for a variable length of time in patients with MTBI. The timing of resumption of driving should be individualized (Level 3). The timing of returning to work for patients with MTBI should be individualized. Formal neuropsychologic testing can be considered in some cases (Level 3). Biochemical markers such as S-100, neuron-specific enolase, and serum tau should not be routinely used in the clinical management of patients with MTBI except in the context of a research protocol (Level 3).
According to EAST guidelines, what is the management of blunt hepatic injury?
Level 1 1. Patients who are hemodynamically unstable or who have diffuse peritonitis after blunt abdominal trauma should be taken urgently for laparotomy. Level 2 1. A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury. 2. In the hemodynamically stable blunt abdominal trauma patient without peritonitis, an abdominal CT scan with intravenous contrast should be performed to identify and assess the severity of injury to the liver. 3. Angiography with embolization may be considered as a first-line intervention for a patient who is a transient responder to resuscitation as an adjunct to potential operative intervention. 4. The severity of hepatic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age of more than 55 years, and/or the presence of associated injuries are not absolute contraindications to a trial of nonoperative management in a hemodynamically stable patient. 5. Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation (a contrast blush) on abdominal CT scan. 6. Nonoperative management of hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Level 3 1. After hepatic injury, clinical factors such as a persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, or an otherwise unexplained drop in hemoglobin should prompt reevaluation by CT scan. 2. Interventional modalities including endoscopic retrograde cholangiopancreatography, angiography, laparoscopy, or percutaneous drainage may be required to manage complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) that arise as a result of nonoperative management of blunt hepatic injury. 3. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt hepatic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined. There was not enough literature available to make recommendations regarding the following: 1. Frequency of hemoglobin measurements 2. Frequency of abdominal examinations 3. Intensity and duration of monitoring 4. Time to reinitiating oral intake 5. Duration and intensity of restricted activity (both in hospital and after discharge) 6. Optimum length of stay for both the intensive care unit (ICU) and hospital 7. Timing of initiating chemical deep venous thrombosis (DVT) prophylaxis after hepatic injury
According to EAST guidelines, how should medication-induced coagulopathy be addressed during the early postinjury period?
Level 3 All elderly patients who were taking medications for systemic anticoagulation before their injury should have appropriate assessment of their coagulation profile as soon as possible after admission. All elderly patients with suspected head injury (e.g., those with altered GCS, headache, nausea, external trauma, or high-energy mechanism) who were taking medications for systemic anticoagulation before their injury should be evaluated with head computed tomography as soon as possible after admission. Patients receiving warfarin with a posttraumatic intracranial hemorrhage should receive initiation of therapy to correct their international normalized ratio (INR) toward a normal range (e.g., <1.6× normal) within 2 hours of admission. Substantial variation exists in practice patterns related to correction of iatrogenic and therapeutic coagulopathy after injury despite the work of Ivascu et al., which demonstrated a more than 75% decrease in mortality related to posttraumatic intracranial hemorrhage in elderly patients with Coumadin-related coagulopathy after implementation of a protocol to ensure rapid head computed tomography, initiation of INR-correcting therapy within 1.9 hours, and full correction of coagulopathy within 4 hours of admission. The same authors suggested that reversal of INR is not necessary in the absence of intracranial bleeding. The degree of correction indicated in elderly patients with intracranial bleeding is not completely clear, but several authors have concluded that INR should be rapidly corrected to a value of less than 1.6 with fresh-frozen plasma (15 mg/kg or ∼4 units) and vitamin K IV. Those who stop their Coumadin-based anticoagulation after injury are at lower risk for major hemorrhage after discharge but at increased risk for thromboembolism. Little is known regarding the optimal means for correcting iatrogenic platelet dysfunction in injured patients, although it seems clear that patients taking antiplatelet agents are at an increased risk for postinjury hemorrhage.
According to EAST guidelines, what is the management of trauma in pregnancy?
Level I There are no level I standards. Level II a. All pregnant women >20-week gestation who suffer trauma should have cardiotocographic monitoring for a minimum of 6 hours. Monitoring should be continued and further evaluation should be carried out if uterine contractions, a nonreassuring fetal heart rate pattern, vaginal bleeding, significant uterine tenderness or irritability, serious maternal injury, or rupture of the amniotic membranes is present. b. Kleihauer-Betke analysis should be performed in all pregnant patients >12 week-gestation. Level III a. The best initial treatment for the fetus is the provision of optimum resuscitation of the mother and the early assessment of the fetus. b. All female patients of childbearing age with significant trauma should have a human chorionic gonadotropin (β-HCG) performed and be shielded for X-rays whenever possible. c. Concern about possible effects of high-dose ionizing radiation exposure should not prevent medically indicated maternal diagnostic X-ray procedures from being performed. During pregnancy, other imaging procedures not associated with ionizing radiation should be considered instead of X-rays when possible. d. Exposure to <5 rad has not been associated with an increase in fetal anomalies or pregnancy loss and is herein deemed to be safe at any point during the entirety of gestation. e. Ultrasonography and magnetic resonance imaging are not associated with known adverse fetal effects. However, until more information is available, magnetic resonance imaging is not recommended for use in the first trimester. f. Consultation with a radiologist should be considered for purposes of calculating estimated fetal dose when multiple diagnostic X-rays are performed. g. Perimortem cesarean section should be considered in any moribund pregnant woman of ≥24-week gestation. h. Delivery in perimortem cesarean sections must occur within 20 minutes of maternal death but should ideally start within 4 minutes of the maternal arrest. Fetal neurologic outcome is related to delivery time after maternal death. i. Consider keeping the pregnant patient tilted left side down 15 degrees to keep the pregnant uterus off the vena cava and prevent supine hypotension syndrome. j. Obstetric consult should be considered in all cases of injury in pregnant patients.
According to EAST guidelines, what is the management of blunt aortic injury?
Level I There is insufficient evidence to support a standard of care on this topic. Level II The possibility of a BAI should be considered in all patients who are involved in a motor vehicle collision, regardless of the direction of impact. The chest x-ray is a good screening tool for determining the need for further investigation. The most significant chest x-ray findings include (but are not limited to) widened mediastinum, obscured aortic knob, deviation of the left mainstem bronchus or nasogastric tube, and opacification of the aortopulmonary window. Angiography is a very sensitive, specific, and accurate test for the presence of BAI. It is the standard by which most other diagnostic tests are compared. Computed tomography of the chest is a useful diagnostic tool for both screening and diagnosis of BAI. Spiral or helical computed tomographic scanners have an extremely high negative predictive value and may be used alone to rule out BAI. When these scanners are used, angiography may be reserved for patients with indeterminate scans. Prompt repair of the BAI is preferred. If the patient has more immediately life-threatening injuries that require intervention such as emergent laparotomy or craniotomy, or if the patient is a poor operative candidate because of age or comorbidities, the aortic repair may be delayed. Medical control of blood pressure is advised until surgical repair can be accomplished. Level III The presence of physical findings such as pseudocoarctation or intrascapular murmur should be investigated further. Transesophageal echocardiography is also a sensitive and specific test. There are several limitations to this test. It does require training and expertise that may not be as readily available as angiography. Repair of the aortic injury is best accomplished with some method of distal perfusion, either bypass or shunt. Neurologic complications seem to correlate with ischemia time; therefore, this time should be kept to a minimum.
What is the appropriate modality for the screening and diagnosis of BCVI?
Level I: No level I recommendations can be made. Level II: 1. Diagnostic four-vessel cerebral angiography (FVCA) remains the gold standard for the diagnosis of BCVI. 2. Duplex ultrasound is not adequate for screening for BCVI. 3. Computed tomographic angiography (CTA) with a four (or less)-slice multidetector array is neither sensitive nor specific enough for screening for BCVI. Level III: 1. Multislice (eight or greater) multidetector CTA has a similar rate of detection for BCVI when compared with historic control rates of diagnosis with FVCA and may be considered as a screening modality in place of FVCA. Conflicting studies have been published however (see the Scientific Rationale section).
What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI?
Level I: No level I recommendations can be made. Level II: 1. Patients presenting with any neurologic abnormality that is unexplained by a diagnosed injury should be evaluated for BCVI. 2. Blunt trauma patients presenting with epistaxis from a suspected arterial source after trauma should be evaluated for BCVI. Level III: 1. Asymptomatic patients with significant blunt head trauma as defined below are at significantly increased risk for BCVI and screening should be considered. Risk factors are as follows: * Glasgow Coma Scale score ≤8; * Petrous bone fracture; * Diffuse axonal injury; * Cervical spine fracture particularly those with (i) fracture of C1 to C3 and (ii) fracture through the foramen transversarium; * Cervical spine fracture with subluxation or rotational component; and * Lefort II or III facial fractures 2. Pediatric trauma patients should be evaluated using the same criteria as the adult population.
What is the definition of mild brain injury?
MTBI is defined as an acute alteration in brain function caused by a blunt external force and is characterized by a Glasgow Coma Scale (GCS) score of 13 to 15, loss of consciousness for 30 minutes or less, and duration of posttraumatic amnesia of 24 hours or less. If a brain CT scan has been performed, its result must be normal. The terms mild traumatic brain injury and concussion may be used interchangeably.
What are the EAST guidelines regarding the management of blunt splenic injury?
Recommendations Level 1 Patients who have diffuse peritonitis or who are hemodynamically unstable after blunt abdominal trauma should be taken urgently for laparotomy. Level 2 A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated splenic injury. The severity of splenic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age >55 and/or the presence of associated injuries are not contraindications to a trial of nonoperative management in a hemodynamically stable patient. In the hemodynamically normal blunt abdominal trauma patient without peritonitis, an abdominal CT scan with intravenous contrast should be performed to identify and assess the severity of injury to the spleen. Angiography should be considered for patients with American Association for the Surgery of Trauma (AAST) grade of greater than III injuries, presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding. Nonoperative management of splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Level 3 After blunt splenic injury, clinical factors such as a persistent systemic inflammatory response, increasing/persistent abdominal pain, or an otherwise unexplained drop in hemoglobin should dictate the frequency of and need for follow-up imaging for a patient with blunt splenic injury. Contrast blush on CT scan alone is not an absolute indication for an operation or angiographic intervention. Factors such as patient age, grade of injury, and presence of hypotension need to be considered in the clinical management of these patients. Angiography may be used either as an adjunct to nonoperative management for patients who are thought to be at high risk for delayed bleeding or as an investigative tool to identify vascular abnormalities such as pseudoaneurysms that pose a risk for delayed hemorrhage. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined.
What is the management of rectal injuries?
Rectal injuries that result in perforation present a significant risk of developing pelvic sepsis and thus require operative management. The mainstays of treatment for rectal injuries are fecal diversion and presacral drainage until healing has occurred, at which time the colostomy is reversed. This can be achieved with an end colostomy or a loop configuration as long as complete fecal diversion can be achieved. Historically, drainage of the presacral space has been considered an important part of managing rectal perforations because of data generated in the military theater. More recently, some have countered this edict, concluding that presacral drainage is an unnecessary component, especially in the setting of low-energy, nonmilitary types of penetrating rectal trauma.50 Without definitive studies, one approach is to drain injuries that occur posteriorly or laterally, if in the lower third of the rectum, because these have likely entered the presacral space and are at greater risk of abscess formation. Other injuries to the extraperitoneal rectum can be managed with fecal diversion alone. Destructive rectal injuries that involve more than 50% of the rectal wall circumference may require resection of the rectum above the injury with the creation of an end colostomy.
What is the management of retroperitoneal hematoma?
Retroperitoneal hematomas are classified according to their location: zone 1 (central), zone 2 (lateral), and zone 3 (pelvic). This classification helps with surgical planning (Figure 7). All zone 1, some penetrating zone 2, and all penetrating zone 3 should be explored. Blunt zone 2 and blunt zone 3 hematomas should not be explored unless they are ruptured, pulsatile, or rapidly expanding.
What is the management of rib fractures?
Rib fractures can vary greatly in severity, depending on the number present and patient characteristics. Associated pain can be severe and a great concern is the development of respiratory infections. Aggressive analgesia should be provided to allow adequate pulmonary toilet and promote comfort. Adequate analgesia can be achieved with IV narcotics in mild cases but, in more severe cases, patients benefit greatly from the provision of epidural analgesia.
What is the diagnosis and treatment of SIADH?
SIADH can be diagnosed by the presence of high urine osmolality (>150 mmol/kg) and high urine sodium (>20 mmol/L); it must be differentiated from adrenal insufficiency, which is accompanied by hypokalemia. SIADH is treated with fluid restriction (<1 L/d). Isotonic fluids actually worsen the hyponatremia because sodium is filtered in the glomerulus and free water is reabsorbed in the distal tubule.
Which vaccines should be given to post-splenectomy patients?
The Surgical Infection Society guidelines recommend that patients undergoing splenectomy should receive pneumococcal vaccine and meningococcal vaccine, and for high-risk patients, Haemophilus influenza vaccine. The optimal time for vaccinations for patients undergoing splenectomy for trauma is 14 days postoperatively. However, due to concern for lack of follow-up, many institutions give vaccinations prior to discharge. Pneumococcal vaccination should be repeated 5 years after the first dose.
What is the management of tracheal injuries?
The trachea is easily visualized via the anterior sternocleidomastoid incision. Blunt dissection posterior to the trachea will allow for mobilization and visualization of its posterior aspect. As above, the thyroid may be divided along the isthmus to facilitate anterior visualization. For injuries to the trachea through significant portions of the thyroid gland, resection of the affected thyroid tissue is recommended. The trachea is best repaired with a single-layer 3-0 absorbable suture, being sure to tie all knots on the outside. Sutures may need to be placed in the innerspace above and below the adjacent tracheal rings to provide stability. If necessary, up to one or two cartilaginous rings may be resected while still maintaining the ability to perform a primary anastomosis. For significant injuries that involve near to full loss of a ring level, placement of a tracheostomy is indicated to ensure a secure airway. Locating the tracheostomy at the level of the second cartilaginous ring is still preferred, even if this is above the level of the injury. For injury to the arytenoids, reattachment and mucosal repair with absorbable suture are required. When concomitant esophageal and tracheal injuries are present, a vascularized muscle flap from the omohyoid or sternocleidomastoid should be placed between the repairs to promote healing and decrease the chance of fistulization or leak.
What are the EAST guidelines for penetrating abdominal trauma regarding selective non-operating management?
a. Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (Level 1) b. Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation done for intraperitoneal injury or undergo exploratory laparotomy (Level 1). c. A routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (Level 2). d. A routine laparotomy is not indicated in hemodynamically stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs (Level 2). e. Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (Level 2). f. In patients selected for initial nonoperative management, abdominopelvic computed tomography should be strongly considered as a diagnostic tool to facilitate initial management decisions (Level 2). g. Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness (Level 3). h. The vast majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after twenty-four hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (Level 3). i. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations as well as peritoneal penetration (Level 2).
According to EAST guidelines, what is the management of cervical spine injuries?
a. Removal of cervical collars: I. Cervical collars should be removed as soon as feasible after trauma (level 3). b. In the patient with penetrating trauma to the brain: I. Immobilization in a cervical collar is not necessary unless the trajectory suggests direct injury to the CS (level 3). c. In awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion of the CS: I. CS imaging is not necessary and the cervical collar may be removed (level 2). d. All other patients in whom CS injury is suspected must have radiographic evaluation. This applies to patients with pain or tenderness, patients with neurologic deficit, patients with altered mental status, and patients with distracting injury. I. The primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions (level 2). II. Plain radiographs contribute no additional information and should not be obtained (level 2). III. If CT of the CS demonstrates injury: 1. Obtain spine consultation. IV. If there is neurologic deficit attributable to a CS injury: 1. Obtain spine consultation. 2. Obtain MRI. V. For the neurologically intact awake and alert patient complaining of neck pain with a negative CT: 1. Options. A. Continue cervical collar. B. Cervical collar may be removed after negative MRI (level 3). C. Cervical collar may be removed after negative and adequate F/E films (level 3). VI. For the obtunded patient with a negative CT and gross motor function of all four extremities: 1. F/E radiography should not be performed (level 2). 2. The risk/benefit ratio of obtaining MRI in addition to CT is not clear, and its use must be individualized in each institution (level 3). Options are as follows: A. Continue cervical collar immobilization until a clinical examination can be performed. B. Remove the cervical collar on the basis of CT alone. C. Obtain MRI. 3. If MRI disclosed nothing abnormal, the cervical collar may be safely removed (level 2).
