2 incision fasciotomy for compartment syndrome of extremity fractures – a common problem is incision is made too far laterally to help the anterior compartment (missed)
After 24-48 h of open abdomen management, fistula rate is approx 15% if abdomen is not closed.
If stable hemothorax – 24-48 h to see if evac. By day 2-3 it would be increasingly difficult to evacuate blood beyond that time, thorascopically.
Thoracic aortic injuries. Endovascular repair typically not used in young patients or less than 20mm diameter aorta.
Complication of LMA = vomiting
Splenic injury, > or = 20% do not heal in three months.
Elderly patients with elevated INR, small head bleed on coumadin. Rx with early plasma infusions, and early factor 7A use.
Carotid injuries do not occur commonly in easily accessible locations; put patient on antiplatelet therapy and most of these injuries will heal.
Serial cardiac enzymes are rarely needed in patients with suspected blunt cardiac injury.
Zone I retroperitoneal hematomas = central periaorta hematomas. Explore gun shot wound Zone I retrperitoneal hematomas even without expanding hematoma.
To evaluate distal perfusion, proximity GSW to both extremities, use ankle brachial index rather than arterial pressure index. (The API is the ratio between systolic blood pressures measured distal to a penetrating injury in one extremity and the systolic pressure measured at the same location in the contralateral uninjured extremity.)
solid organ injury, CT vascular extravasation should not determine management approach – instead depend on hemodynamics.
Injury to kidney after blunt trauma – prefer nonoperative treatment for better renal salvage even with urinary extravasation.
Head trauma, small epidural hematoma, no other injuries, observation in ICU x 24h – neuro exams, and repeat CT in 6h.
Leg with crush type wound with venous injury. Re-establish blood flow quickly with shunt. Tie a suture around shunt, do not debride the vessel back before placing shunt because the vessel will be injured more with the shunt tying.
Blunt traumatic arrest cases – not likely to survive to discharge from hospital. Consider terminating resusitation.
Comatose patients, can remove cervical-collar if a good helical CT scan of the spine is completely normal.
A true transpelvic GSW (gunshot wound) should go to OR even with (or without) gross blood on rectal exam.
Complication and mortality rates with rib fractures are twice higher in elderly patients than younger patients.
Physical exam with seatbelt sign is often not helpful, small bowel injury association is not 100%.
Side curtain airbags are more helpful than frontal airbags for additional protection in addition to seatbelts which do not do as well with lateral movement.