Professional Documents
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Initial fluid resus -2L iv bolus , 20 ml/kg -NSS,RLS Urine output -indicator of organ perfusion 0.5 ml/kg in adult 1 ml/kg in child (2 ml/kg in <1yr) Respond to fluid resus 1.responder 2.transient responder 3.non responder (persistent hypoT)
u/s -sense to detect fluid >250cc :morison pouch,LUQ,pelvis CT when -alter mental status -confounding injury -gross hematuria -signi pelvis fx -persistent LUQ tender -unexplain hct<35 % (ped<33%) Penetrating inj 1.hemodynamic unstable=sx 2.hemodynamic stable GSW -ant abdo=sx -RUQ=CT -tangential, back/frank=CT SGW -back/flank=CT -ant abdo stab+local w explor :DPL vs CT Blunt abdo 1.hemodynamic stable -peritonitis--sx -no peritonitis--FAST -ve--criteria for CT +ve--NOM--no=sx/yes=CT 2.hemodynamic unstable -FAST+ve--sx -FAST not sure--DPL Emergency abdo exploration -long midline incision -<6yr=transverse incision -if active bleed when opening :Liver,aorta,inf venacava,illiac vv Bleed from liver inj -clamp at pedicle (pringle maneuver) -laparotomy pad packing
Duodenum inj 1.duodenal hematoma -direct blow to abdomen -occur children > adult -vomiting following blunt abdomen -barium=coiled spring sign or obstr -most tx by nonoperative :NG tube and parenteral nutrition -surgical intervention :evacuation of hematoma :by pass procedure :laparoscopic evacuation 2.duodenal perforation -blunt,penetrating inj -difficult to dx due to neutral pH,few bacteria,retroperitonium -most can be treat by primary repair :running,single layer of 3-0 monofila 1st part (prox to duct of santorini) -debridement and anastomosis -due to mobility and rich bl.supply 2nd part -tethered to head pancreas -no more than 1 cm can mobilized -end to end=narrow lumen Tx 1.patched w vascularized jejunal graft 2.Roux en Y duodenojejunostomy (best Tx in distal to papilla of vater) 3rd,4th part (behind mesenteric vv) -resect & duodenojejunostomy on lt side of sup mesenteric vv
Vascular inj Hard sign--open sx -pulsatile hmg -absent pulse -acute ischemia Soft sign--further evaluation -signi hematoma -asso n inj -AA index <0.9 (SBP inj/SBP un-inj) -thrill/bruit Repair -prox+distal control -heparin (50 u:1ml) prevent clot Artery should repair -carotid,innominate,brachial, sup.mesenteric,proper hepatic, renal,illiac,femoral,popliteal Vein should repair -SVC, IVC prox.to renal V,PV
Fx fixation vs repair a -controversy which be done 1st -prefer temp intravascular shunt Sx -artery access for on table angiogram in OR in pt evidence of limb threat :percu femoral vv or direct cannulate :SFA just above medial knee subclav/axillary a -exam brachial plexus before sx -RSVG/6mm PTFE Brachial a -medial upper ext longitu incision -RSVG SFA -RSVG Popliteal a -medial one incision approach -detach semiten,semimem,graccilis if have v inj -repair v 1st c PTFE graft -a is shunted Isolate a inj -RSVG