- Apr 2020
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Immobilization of injuries also is achieved with spinal orthoses (braces), particularly in those with associated thoracolumbar injuries.
spinal orthoses are also used especially thoracolumbar inj.
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In general, physician-supervised axial traction, via cervical tongs or the more commonly used halo vest, is used to reduce subluxations and stabilize the injury.
halo vest or cervical tongs are used to stabilize ond decrease sublax via axial traction
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After initial stabilization, a systematic physical examination of the head and neck should be performed that also includes cranial nerve examination and three-dimensional CT scanning of the maxillofacial complex
systematic PE of head-neck like CN exam and maxillofacial 3d CT should be considered after initial stabilization
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Nose and nasoethmoidal fractures should be assessed carefully to identify damage to the lacrimal drainage system or to the cribriform plate producing cerebrospinal fluid rhinorrhea.
inj of lacrimal drainage sys or cribriform plate should be assessed (possible CSF rhinorrhea)
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Temporizing measures include nasal packing, Foley catheter tamponade of posterior nasal bleeding, and oropharyngeal packing.
packing of nose and oropharynx, foley tamponade for pos nasal bleeding are temporizing measures.
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Fractures of tooth-bearing bone are considered open fractures and require antibiotic therapy and semiurgent repair to preserve the airway as well as the functional integrity of the occlusion (bite) and the aesthetics of the face.
tooth-bearing bone fracture is considered open fracture so is given antibiotic and semiurgent repair,
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High-impact kinetic energy is required to fracture the frontal sinus, orbital rims, and mandible, whereas low-impact forces will injure the nasal bones and zygoma.
strong kinetic energy will break frontal sinus, rim of orbit, mandible, contrary to nasal bone and zygoma
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Moderate hypothermia (32°–33°C [89.6°–91.4°F]) has been shown experimentally to improve neurologic outcomes, but clinical studies have not validated this concept.
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The maxillofacial complex is divided into three regions; the upper face containing the frontal sinus and brain; the midface containing the orbits, nose, and zygomaticomaxillary complex; and the lower face containing the mandible.
maxillofacial complex is up face (brain, frontal sinus) midface (orbits,zygomaticomaxillary, nose,) low face (mandible)
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The typical clinical course of an epidural hematoma is an initial loss of consciousness, a lucid interval, and recurrent loss of consciousness with an ipsilateral fixed and dilated pupil. While decompression of subdural hematomas may be delayed, epidural hematomas require evacuation within 70 minutes.
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General surgeons in communities without emergency neurosurgical coverage should have a working knowledge of burr hole placement in the event that emergent evacuation is required for a life-threatening epidural hematoma
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Patients with diffuse cerebral edema resulting in excessive ICP may require a decompressive craniectomy, although a recent AAST multicenter trial questioned the benefits.
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Patients with open or depressed skull fractures, with or without sinus involvement, may require operative intervention.
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The partial pressure of carbon dioxide (PCO2) should be maintained in a normal range (35–40 mmHg), but for temporary management of acute intracranial hypertension, inducing cerebral vasoconstriction by hyperventilation to a PCO2 of <30 mmHg is occasionally warranted.
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Sedation, osmotic diuresis, paralysis, ventricular drainage, and barbiturate coma are used in sequence, with coma induction being the last resort.
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The role of decompressive craniectomy for refractory ICH remains controversial.
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Fullen zone II SMA injuries, extending from the pancreatic edge to the middle colic branch, on the other hand, are approached via the lesser sac along the inferior edge of the pancreas at the base of the transverse mesocolon; the pancreatic body may be divided to gain proximal vascular access.
from pancreatic edge to middle colic branch is fullen zone II SMA inj is explored via lesser sac along pancreas at inferior edge on base of transverse mesocolon; for vascular access, pancreatic body may be divided
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n patients with abnormal findings on CT scans and GCS scores of ≤8, intracranial pressure (ICP) should be monitored using fiber-optic intraparenchymal devices or intraventricular catheters.
Abnormal CTs and GCS <9 patients should get ICP monitoring.
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The final stages of this sequence are caused by blood accumulation that forces the temporal lobe medially, with resultant compression of the third cranial nerve and eventually the brain stem.
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Attention, therefore, is focused on maintaining cerebral perfusion rather than merely lowering ICP.
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Cerebral perfusion pressure (CPP) is equal to the mean arterial pressure minus the ICP, with a target range of >60 mmHg.
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CPP can be increased by either lowering ICP or raising mean arterial pressure.
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Resuscitation efforts aim for a euvolemic state and a SBP of >100 mmHg.
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The goal of resuscitation and management in patients with head injuries is to avoid hypotension (SBP of <100 mmHg) and hypoxia (partial pressure of arterial oxygen of <60 or arterial oxygen saturation of <90%).
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Penetrating injuries to the head may require operative intervention for hemorrhage control, evacuation of blood, skull fracture fixation, or debridement.
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The burr hole is made on the side of the dilated pupil to decompress the intracranial space. After stabilization, the patient is transferred to a facility with neurosurgical capability for formal craniotomy.
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A shift of >5 mm typically is considered an indication for evacuation, but this is not an absolute rule. Smaller hematomas that are in treacherous locations, such as the posterior fossa, may require drainage due to brain stem compression or impending herniation.
shifts >5 mm candidates for evacuation, bu smaller but treacherous locations (pos fossa) also my need that (BS compression,waiting herniation)
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Indications for operative intervention to remove space-occupying hematomas are based on the clot volume, amount of midline shift, location of the clot, GCS score, and ICP.
clot location, volume, midline shift magnitude and GCS, determines intervention to remove hematomas
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The newest neurosurgery guidelines additionally recommend maintaining the cerebral perfusion pressure (CPP) at >60 mmHg.
and CPP should be >60 mmHg
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Although an ICP of 10 mmHg is the upper limit of normal, therapy is targeted to maintain an ICP of <20 mmHg.
target ICP is <20 mmHg
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A venous injury behind the pancreas, from the junction of the superior mesenteric, splenic, and portal veins, is accessed by dividing the neck of the pancreas.
inj of veins post to pancreas are reached via dividing pancreatic neck.
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More distal SMA injuries, Fullen zones III and IV, are approached directly within the mesentery.
Fullen Zones 3 and 4 are reached via mesentery
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Fullen zone I SMA injuries, located posterior to the pancreas, are best exposed by a left medial visceral rotation.
left medial visceral rotation is used t o expose fullen zone I at back of pancreas
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Supracolic injuries (aorta, celiac axis, proximal superior mesenteric artery [SMA], and left renal arteries) are best approached via a left medial visceral rotation (Fig. 7-40). This is done by incising the lateral peritoneal reflection (white line of Toldt) beginning at the distal descending colon and extending the incision along the colonic splenic flexure, around the posterior aspect of the spleen, and behind the gastric fundus, ending at the esophagus.
inj of supracolic are approached via medial visceral rotation of left by incising Toldt from distal descending colon along colonic splenic flexure, around back of spleen, and behind fundus, unto esophagus.
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When the spleen is mobilized, it should be gently rotated medially to expose the lateral peritoneum; this peritoneum and endoabdominal fascia are incised, which allows blunt dissection of the spleen and pancreas as a composite from the retroperitoneum anterior to Gerota’s fascia
spleen is rotated medially to explore lateral peritoneum; which beside endoabdominal fascia are incised for spleen and pancreas dissection.
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if an aortic injury is supraceliac, transecting the left crus of diaphragm or extending the laparotomy via a left thoracotomy may be necessary.
for supraceliac aortic inj, diaphragm left crus transection or left thoracotomy mediated laparatomy may be ness
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After the source of hemorrhage is localized, direct digital occlusion (vascular injury) or laparotomy pad packing (solid organ injury) is used to control bleeding
for localized bleeding source, finger occlusion (vascular inj) or laparotomy pad packing (solid organ)
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If the liver is the source in a hemodynamically unstable patient, additional control of bleeding is obtained by clamping the hepatic pedicle with a vascular clamp or Rummel tourniquet (termed the Pringle maneuver)
if the liver is the bleeding source of unstable patient, additional control with finger or clamp or Rummel torniquet (Pringle maneuver)
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If the liver is the source in a hemodynamically unstable patient, additional control of bleeding is obtained by clamping the hepatic pedicle with a vascular clamp or Rummel tourniquet (termed the Pringle maneuver)
if the liver is the bleeding source of unstable patient, additional control with finger or clamp or Rummel torniquet (Pringle maneuver)
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If the patient has an SBP of <70 mmHg when the abdomen is opened, digital pressure or a clamp should be placed on the aorta at the diaphragmatic hiatus.
in SBP <70 mmHg in opened abdomen, clamp or finger pressure should be done on diaphragmatic hiatus level of aorta.
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After blunt trauma, the spleen and liver should be palpated first and packed if fractured, and the infracolic mesentery should be inspected for zone I vascular injury
in blunt trauma, liver and spleen should be palpated and if fractured, packed and infracolic mesentry zone I inj should be assessed.
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Posterolateral thoracotomies are used for exposure of injuries to the trachea or main stem bronchi near the carina or the upper esophagus (right posterolateral thoracotomy) and tears of the descending thoracic aorta or lower esophagus (left posterolateral thoracotomy).
for trachea inj or main stem bronchi or, posterolateral thoracotomy is used, up esophagus (right PLT) and lower esophagus and descending gthoracis aorta (left PLT)
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. Care must be taken to avoid injury to the phrenic and vagus nerves that pass over the subclavian artery and to the recurrent laryngeal nerve passing posteriorly
Be careful that vagus and phrenic nrvs pass over subclavian and recurrent nrv comes posteriorly
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Median sternotomy with cervical extension is used for rapid exposure in patients with presumed proximal subclavian, innominate, or proximal carotid artery injuries
For proximal subclavian, carotid and innominate inj median sternotomy with extension to the neck is considered
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Typically, these patients have pericardial tamponade and may undergo placement of a pericardial drain before a semiurgent median sternotomy is performed
Pericardial drain for the possible tamponade of this condition is considered
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through the supraclavicular incision. Emergent median sternotomy is optimal for anterior stab wounds to the heart
Median sternotomy for stabbed heart is the option
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Similarly, without time for blood typing, AB plasma is the universal donor, although A plasma appears to be a safe option
A plasma is another safe emergent donor
Tags
- typical clinical course of an epidural hematoma
- Nose and nasoethmoidal fractures
- blood accumulation that forces the temporal lobe medially
- burr hole
- compression of the the brain stem.
- PCO2 maintainance
- decompressive craniectomy for refractory ICH
- Patients with open or depressed skull fractures, with or without sinus involvement
- formal craniotomy
- loss of consciousness
- decompression of subdural hematomas
- patients with head injuries Resuscitation target
- patients with head injuries attention
- lucid interval
- ipsilateral fixed and dilated pupil
- goal of resuscitation and management in patients with head injuries
- Patients with diffuse cerebral edema resulting in excessive ICP
- lowering ICP
- Cerebral perfusion pressure (CPP)
- how to increase CPP
- patients with head injuries
- epidural hematomas evacuation
- recurrent loss of consciousness
- compression of the third cranial nerve
- emergent evacuation is required for a life-threatening epidural hematoma
- improve neurologic outcomes
- decompress the intracranial space
- PCO2 maintenance for temporary management of acute intracranial hypertension
- Penetrating injuries to the head
- maintaining cerebral perfusion
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