Surgery Notes

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3 pathophysiological factors of Thoracic trauma are Hypoxia, Hypercarbia, Acidosis Best inv for chest injury is Chest X ray 2 Signs to rule out Pneumothorax in USG chest 1) Lung Sliding Sign 2) Comet tail arteact Tube thoracostomy inserted in 5th/6th ICS (Triangle of Safety) Indication for thoracostomy tube removal a)Absence of air leak b)Less than 100ml fluid drainage Indications of Emergency thoracotomy a)Cardiac arrest(resuscitative b)Massive hemothorax >1500m stat / >300ml/hr c) Penetrating inj of chest with cardiac tamponade d)Large open wounds of thoracic cage e)Major thoracic vascular injuries with hemodynamic instability f)Major tracheobronchial injuries g) Esophageal perforation Most imp part of management of rib# is Pain management Flail chest Presence of 2/more # in 3 or more consecutive ribs causing chestwall instability Mc associated wound with flial chest  Closed head inj Mc cause of death at scene is Tracheobronchial injuries Arrhythmias common with blunt heart inj  RBBB Beck triad in cardiac tamponade  Muffled heart sounds, Distended neck veins, Hypotension Esphageal injuries has pain out of proportion to clinical findings, pleural effusion without rib# Treatment of Espohageal injury is early debridement & repair 24hrs cervical esophagostomy and distal feeding access Unstable blunt trauma inv  DPL, FAST Stable blunt abd trauma inv  USG, CT Very sensitive test for abd inj is Diagnostic peritoneal lavage Indications of DPL Equivocal pulm embolism Unexplained shock/Hypotension Altered sensorium GA for extraabd procedures Cord inj Std criteria for positive test in DPL Aspiration of 10ml gross blood Bloody lavage effluent RBC >1,00,000/mm3 WBC >500/mm3 Amylase >175 IU/dl Detection of blood, bile, food fiber FAST- Focussed Abdominal Sonography for Trauma  main purpose is to document free fluid in abdomen. Seeing solic organs done but not primary aim CI for DPL  Clear indication of exploratory laparotomy

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Gastric and duodenal inj are mostly due to penetrating injuries, Blunt injuries rare Dx of gastric inj by blood in NG tube aspirate Rx is debridement and primary closure in layers Mc blunt trauma ass with duodenal inj  Steering wheel inj Xray duodenal injuries Mild scoliosis Obliterated right psoas Absent air in duodenal bulb Air in retroperitoneum outlining kidney Leak of gastrograffin is definitive indication for  Exploration Coil spring appearance & Stacked coin sign seen in Duodenal hematoma Duodenal hematoma not an indication for surgery CECT findings of duodenal inj  Retroperitoneal air Rx og grade 1 2 duodenal inj  Simple primary closure Rx of grade 3  Primary repair, pyloric exclusion & exclusion, roux-en-Y duodenojejunostomy Rx of grade 4  Primary repair of duodenum + CBD repair Rx of grade 5  Pancreatico duodenectomy Cycle handle inj Mc mode of inj of : Pancreas Pancreas inj has signs more than symptoms Urine/serum amylase levels not diagnostic, Widened C loop of duodenum, DPL is not suggestive Mc inj after penetration & blunt trauma  Liver Colon is 2nd Mc inj in gunshot & 3rd after stab inj If bleeding stops after Pringels maneuver  Culprit is Portal vein/Hepatic artery If bleeding continues after pringel maneuver  Source is hepatic vein Warm ischemia time of liver  1hr Superficial penetrating renal inj  Primary closure Deep penetrating renal injuries  Partial/Total nephrectomy Extraperitoneal bladder injuries Rx conservatively by Foleys for 2weeks Intraperitoneal bladder injuries occurs at dome of bladder. Rx by primary repair and SPC(transabdominal approach) Posterior urethral injuries associated with Pelvic # Anterior urethral injuries associated with Straddle # Grade 1 ACS 12-15mmHg Grade 2 ACS 16-20mmHg Grade 3 ACS 21-25mmHg Grade 4 ACS >25mmHg ACS causes both Metabolic and Respiratory acidosis