Lower Limb 4 Compartment Fasciotomy

Compartments:
- Anterior
- Lateral
- Superficial Posterior
- Deep Posterior

Lateral incision: (Over fibula)
- releases anterior and lateral compartments
- watch out for superficial peroneal nerve which can be in lateral but also anterior compartment near intermuscular septum

Medial incision: (2-3 cm medial to edge of tibia)
- releases superficial and deep posterior compartments
- incise superficial compartment then release soleus muscle from posterior edge of tibia to arrive at deep compartment
- watch for saphenous vein which is superficial and runs at the posterior edge of tibia
- watch out for posterior tibial neurovascular bundle and achilles tendon which runs in superficial posterior compartment

http://www.youtube.com/watch?v=-1NDJkFH1vM&feature=related
http://www.youtube.com/watch?v=6c5r5brMOso

Moore Retreat: Colon and Rectum

To Divert or Not?
- 2-3% leak rate with primary repair
- although low leak rate consider whether patient "can take a joke?"

Rectum:
- Pendulum has swung from primarily diverting to observational management more popular now
- A situation where observation might be dangerous is with a massive open pelvic # where diversion can prevent pelvic sepsis/osteomyelitis

Diversion:
- EEM uses loop ileostomy as his primary diversion technique (without on-table lavage)
- sigmoid end colostomy might be done if there is destructive injury to sigmoid where simpler just to take out sigmoid as colostomy
- don't just do a small local exicision: especially in watershed areas
- need to resect from one named vessel to the next! (ie; R hemi/L hemi)tra

Moore Retreat: Liver

Severe injuries:
- Grade 3 central, Grade IV and Grade V
- treat all as severe liver injuries
- Biliary stent can be used to manage a bilious fistula injury
- Tolerate permissive hypotension and decreased pRBC transfusion if suspect a liver injury

- increased blood pressure can aggravate liver bleeding

- CT very helpful in mapping hepatic injury

Perform pringle early!

- pack and don't keep looking at the liver

- Packing can be used to control even retrohepatic injuries

- EEM also uses veno-veno bypass with a femoral/SMV line feeding into a subclavian line

Moore Retreat: Pancreas and duodenum injuries

Retroperitoneal air:
- represents a duodenal injury until proven otherwise
- repeat the CT with a po contrast agent

Examining the pancreas:
- Mobilize the duodenum and pancreas:
- Kocher, take down lig of Trietz
- open lesser sac
- incise the peritoneum above and below the pancreas
- you must get to the posterior surface of the pancereas
- classic missed injury is a posterior disruption of the pancreas where the anterior surface looks normal but if you slip your finger behind the pancreas is fractured where it lies over the spine.

Duodenal Injuries:
- EEM closes the duodenum with a 1 layer continuous suture
- duodenal injuries: most can close primarily unless the ampulla is involved
- if there is extensive blowout of the duodenum options include bringing up a R-en-Y limb and plugging it into the blowout
- ? duodenal diverticulization
- Wide drainage is an option with pyloric exclusion
- should not need to do a Whipple's for duodenal injuries

Pancreatic Injuries:
- Stents in neck of pancreatic duct; better than performing a 90% pancreatectomy with risk of leak
- if do distal pancreatectomy should be able to leave the spleen
- if need to can take splenic artery, just be sure you leave the short gastrics as you are opening the lesser sac
- can also perform intraoperative ERCP - even after having done Kocher - just clamp bowel @ LT and help guide scope down

Moore Retreat: CT imaging in Trauma

CT imaging of diaphragmatic injuries:

- Collar sign: narrow waist of herniated hollow organs as they herniate through diaphragmatic defect

- Disrupted diaphragm sign

- Dependent viscus sign: posterior wall of stomach lies in contact with posterior wall of the chest (which it normally doesn't)

Use of Triple contrast for colon injuries:

- with multidetector CT, may not need po/pr contrast to detect a colonic injury

- there are usually secondary signs such as a hematoma or air bubbles

- instilling rectal contrast has an inherent false negative rate as well

- pt may still need an exploration if suspicion high enough.

- ?if rectal bleed and penetrating stab or pelvic fracture just explore abdomen, rectal contrast perhaps useful if mechanism present but no clinical suspicion of injury and it may prevent an OR

Houndsfield Units:

- Fresh blood: 20-30 HFU (decreased intensity if old blood, or mixed with ascites, urine)

- Blood with IV contrast: 30-40 HFU

- Fat: <-10 HFU

- Water: 0-10 HFU

- Urine: 0-10 HFU

- Non-contrast (fatty) liver: 10-15 HFU

- Fatty liver contrast phase: 35-40 HFU

- Normal contrast phase liver: 70-80 HFU

- Bone: 400-500 HFU

- Metal: 1000 HFU

- Enhanced aorta: 190

- po contrast: 50-200 (depends on dilution)

Oral contrast can be negative or positive: use of a positive (ie; enhances) contrast agent prevents you from visualizing the bowel wall

- if you want to visualize the bowel wall then water contrast (negative) better

Radiation Exposure:

CT/Abdo/Pelvis:

- old scanners 10-15 mSi

- newer generation of scanners 3-4 mSi

10mSi of radiation carries a 1:2000 lifetime risk of cancer

- consider that everyone has a 1:5 lifetime of risk of caner without any exposure risk

- Therefore if CT is clinically indicated then theoretic risk of inducing cancer should not be a barrier

Moore Retreat: Role of ED Thoracotomy

Blunt Trauma:
- consider the institutional resources

When is ED Thoracotomy futile?
Blunt trauma:
- CPR > 5 min and no signs of life
- Asystole (without cardiac tamponade)

Penetrating trauma:
- CPR >15 min and no signs of life
- Asystole (without cardiac tramponade)

Once you've done it have an exit plan:
- what are your indications to stop your ED thoracotomy resuscitation?
- was a tamponade present?
- is the heart filling?
- don't let your ED physicians/anesthesiologists get to carried away with transfusion/epinepherine; SBP 90 is enough
- Base deficit >20 is a very, very strong predictor of mortality

Moore Retreat: Thoracic Great Vessels

Pearls:

- Consider forearm fasciotomies if upper arm ischemia (how?)

- know course of phrenic and vagus nerves as these come into play

Anterior lateral thoracotomy is the defacto incision for any thoracic vascular injury

- if you need access to the other side: Clamshell

- if you need access to proximal great vessels: T-up with a sternotomy +/- supraclavicular trap-door incision

Pneumonectomy in trauma patients is associated with a 95% mortality

- places significant right heart strain that unstable patient won't tolerate

Moore Retreat: Neck Injuries

Mandatory Zone 2 neck exploration:

- was the surgical dogma dating from Korean and Vietnam war

- This dogma is now changing with improvements in CT imaging and additional diagnostic testing to rule out injuries

- Mandatory exploration carries a 60% negative exploration rate

Selective Zone 2 neck exploration:

- now the approach in most centres

Zone 1 injuries:
- Use CT imaging to determine trajectory of injury
- trajectory helps you to guide further management

Quadroscopy not mandatory anymore
- With improvements in imaging, CT can guide further investigations if the tract is in proximity to other structures

Airway injuries
- Supraglottic injuries: ENT
- Below cricothyroid membrane: general surgery in Denver repairs primarily with 2-0 PDS interrupted sutures
- large injuries can be managed with a tracheostomy tube

Esophageal Injuries:
- rare
- Drain
- place a muscle interposition with SCM flap
- air in the mediastinum more commonly from a tracheal injury
- flexible esophagoscopy is first test: if you make a hole larger it need operative repair anyways
In OR: if unsure
- do an air leak test
- instill methylene blue or charcoal into esophagus and look for leak in neck or chest tube

Carotid Artery Injuries:
- Be wary of using shunts: any debris that flies past shunt can cause a devestating stroke
- Dr. Moore believes ALL carotid artery injuries should be repaired
- doesn't feel risk of hemorrhagic stroke is significant: short presentation times

Internal jugular veins:
- unilateral injury can be ligated

Vertebral artery injuries:
- Angio is primary treatment modality
- if vessel bleeds continuously in ER, can take to OR: make incision at base of neck, place balloon tamponade to get the patient to angio

Moore Retreat: Damage Control Laparotomy

Identify who needs a damage control lap:
- Temperature, acidosis, coagulopathy
- temperature should be largely controlled: bear huggers in ER, warm fluids; in Denver not an issue as pts rarely get to OR with temp<36.  With longer transports most of our pts hypothermic, pre-hospital bear huggers?
- Acidosis can be controlled with bicarb, Denver is quite liberally with use of bicarbonate during trauma resuscitation
- Most significant factor is coagulopathy
- Need for resuscitation should not be indication of damage control. Can resuscitate as well or better in OR vs. ICU

Newer evidence to demonstrate that ARDS is better with isofluorane vs. propofol sedation
- pt in OR on volatile anesthetics may in fact be safer than in ICU from respiratory standpoint

30 Minute Time out:
- pack site of bleeding for 30 mins
- close abdomen with towel clips and then go back and check for further bleeding
- warm patient, resuscitate
- when you go back look for arterial bleeding
- better than sending back to ICU with arterial bleeding

Temporary Abdominal Closures:
- all pts in Denver get abdominal compartment syndrome
- Vac closure is preferred method of closure
- They even apply this to select abdominal sepsis patients
- Relaparotomy in 12-24 hours: especially if shunts used or contamination
- patients very quickly go from being hypocoaguable to hypercoaguable

Abdominal Closure techniques:
- staged tension closure
1) Plastic drape
2) Nylon retention sutures
3) Repeat laparotomy every 48hours and place interrupted sutures each time gradually closing the abdomen
(AJS 2007)

Diuresis:
- Gives a 10mg Lasix trial
- if the patient responds and diureses he then starts a lasix gtt to aggressively diurese for closure
- if pt doesn't respond then he waits

Pearls:
- Chest can also be closed temporarily with plastic drapes

Moore Retreat: Zone I retroperitoneal injuries

Important aspects of managing retroperitoneal injuries:
1) identify if the injury is arterial or venous?
- arterial: hematoma extends into mesentery, pulsatile

ACCESS: 
Supraceliac aortic injury - becuase of dense neural plexus network at celiac plexus unable to really get much above renal arteries with a Mattox maneuver
- therefore a thoracotomy to get supradiaphragmatic control of aorta necessary

"Mattox" maneuver - start incision 1 cm lateral to the white line of toldt: keeps you from damaging ?retroperitoneal structures
- leave kidneys in place generally

Superior Mesenteric Vessel injuries: 
Fullen's zones: (1-4) - describes areas of injury to SMA
Zone 1: proximal to infero-pancreaticoduodenal branch
Zone 2: between IPD and middle colic branches
Zones 1-2 are proximal and sit behind the pancreas
- access in trauma situation can be gained by simply cutting pancreas with scissors
Zone 3: between middle and ileocolic branches
Zone 4: distal to ileocolic
Moore advocates repairing ALL SMA injuries with possible exception of most distal SMA where you just accept some dead SB and resect it.
- this is a long process and a temporary shunt can be used

Inferior Vena Cava:
- control: use sponge sticks proximally and distally, a vascular clamp is likely to lacerate the IVC even further
- a posterior IVC injury can be difficult to access, enlarging your anterior injury to gain access to the posterior wall is probably your easiest option.
- try to close transversely as a longitudinal repair is likely to cause hourglass deformity

Pearls: - if you can't find your injury after exploring the hematoma, perform an immediate CTA as the injury is probably temporarily sealed but if it lets loose in ICU it will be catastrophic

ED Thoracotomy

Source: Cameron

Discussion revolves around definition of Presence of Vital Signs vs. Signs of Life.
- vital signs include blood pressure, palpable pulse and spontaneous respirations
- signs of life include electrical cardiac activity, respiratory effort, pupillary reactivity.

Indications for EDT
1) salvagable post injury cardiac arrest
2) hypotension from
- cardiac tamponade
- intrathoracic hemorrhage
- air embolism
- active intra-abdominal hemorrhage

Relative indications:
1) refractory moderate hypotension from the same reasons as 2) above.

Incision:
- start just lateral to the sternum just inferior to the nipple.
- curvilinear incision following inferior border of pec major
- continue all the way down to the lattisimus dorsi
- using mayo scissors cut intercostal muscles just above the rib

Things you can do after chest accessed
1) pericardiotomy
- open longitudinally, parallel to phrenic nerve
- extend up to root of aorta and down to the apex
2) Aortic cross-clamping
- divide pulmonary ligmament with straight scissors
- bluntly dissect away mediastinal pleura from aorta and esophagus
- dissect away esophagus and prevertebral fascia to the point where you can encircle the aorta.
- with aorta encircled with left hand apply a curves aortic clamp with the right hand.
- be judicious about aortic cross clamping. It increases cardiac work and will result in post-clamp shock when reperfusion occurs.
3) Open cardiac massage
- begin bimanual cardiac massage if arrest has occured
4) control non cardiac hemorrhage
- great vessel damage is almost impossible to repair in ED. Apply pressure and get to the OR
- pulmonary hemorrhage can be controlled with Duvall clamp or vascular clamp
- last resort is to clamp or occlude inflow at the hilum. Which will require division of the pulmonary ligament. Similar to aortic clamping will result in increase in cardiac afterload and may supress cardiac index.

Risks assoated with EDT.
- HIV. Trauma pt 4%. EDT pt 14%
- acutely injured pt. HIV 4% HepB 20% HepC 14%

Sent from iPhone

Glasgow Coma Scale (GCS)

Adults: EVM (456):

Eyes:
1- none
2- open to pain
3- open to voice
4- spontaneously

Verbal:
1- none/intubated
2- incomprehensible
3- inappropriate
4- confused
5- oriented

Movement:
1- none
2- decorticate posturing
3- decrebrate posturing
4- withdraws from pain
5- localizes to pain
6- spontaneous

Western Trauma Association Pelvic Fracture Algorithm