After an automobile accident, a 30-year-old woman is discovered to have a posterior pelvic fracture. Hypotension and tachycardia respond marginally to volume replacement. Once it is evident that her major problem is free intraperitoneal bleeding and a pelvic hematoma in association with the fracture, appropriate management would be:
Severe pelvic bleeding is a major problem in the trauma patient. Neither external fixation nor the use of medical antishock trousers control free intra-abdominal hemorrhage regardless of its source. In the unstable patient, celiotomy is mandatory. If there is a ruptured retroperitoneal hematoma bleeding into the peritoneal cavity, control is a major problem. Internal iliac artery ligation has been abandoned as it is rarely effective. Angiography and arterial embolization may be effective with an arterial bleeding problem, but most severe pelvic hemorrhage is venous in origin. If the hematoma is stable, it is best to leave it undisturbed. However, if the hematoma has ruptured into the peritoneal cavity, pelvic packing offers the best hope of control.
Which is true of vascular injuries of the extremities?
Physical examination often identifies arterial injuries, and findings are classified as either hard signs or soft signs of vascular injury (Table below). In general, hard signs constitute indications for operative exploration, whereas soft signs are indications for further testing or observation. Bony fractures or knee dislocations should be realigned before definitive vascular examination. In management of vascular trauma, controversy exists regarding the treatment of patients with soft signs of injury, particularly those with injuries in proximity to major vessels. It is known that some of these patients will have arterial injuries that require repair. The most common approach has been to measure SBP using Doppler ultrasonography and compare the value for the injured side with that for the uninjured side, termed the A-A index. If the pressures are within 10% of each other, a significant injury is unlikely and no further evaluation is performed. If the difference is > 10%, CTA or arteriography is indicated. Others argue that there are occult injuries, such as pseudoaneurysms or injuries of the profunda femoris or peroneal arteries, which may not be detected with this technique. Ifhemorrhage occurs from these injuries, compartment syndrome and limb loss may occur. Although busy trauma centers continue to debate this issue, the surgeon who is obliged to treat the occasional injured patient may be better served by performing CTA in selected patients with soft signs.
Signs and symptoms of peripheral arterial injury:
A-A index = systolic blood pressure on the injured side compared with that on the uninjured side.
Which of the following statements about blunt carotid injuries is true?
Blunt injury to the carotid or vertebral arteries may cause dissection, thrombosis, or pseudoaneurysm. More than one half of patients have a delayed diagnosis. Facial contact resulting in hypertension and rotation appears to be the mechanism. To reduce delayed recognition, the authors employ CTA in patients at risk, to identify these injuries before neurologic symptoms develop. The injuries frequently occur at or extend into the base of the skull and are usually not surgically accessible. Currently accepted treatment for thrombosis and dissection is anticoagulation with heparin followed by warfarin for 3 months. Pseudoaneurysms also occur near the base of the skull. If they are small, they can be followed with repeat angiography. If enlargement occurs, consideration should be given to the placement by an interventional radiologist of a stent across the aneurysm. Another possibility is to approach the intracranial portion of the carotid by removing the overlying bone and performing a direct repair. This method has only recently been described and has been performed in a limited number of patients.
Massive transfusion protocols
In the critically injured patient requiring large amounts of blood component therapy, a massive transfusion protocol should be followed. This approach calls for administration of various components in a specific ratio during transfusion to achieve restoration of blood volume and correction of coagulopathy. Although the optimal ratio is yet to be determined, current scientific evidence indicates a presumptive 1:2 RBC: plasma ratio in patients at risk for massive transfusion. Because complete typing and cross-matching takes up to 45 minutes, patients requiring emergent transfusions are given type 0, type-specific, or biologically compatible RBCs. Blood typing, and to a lesser extent cross-matching, is essential to avoid life-threatening intravascular hemolytic transfusion reactions (Fig. below).
Injured patients with life-threatening hemorrhage develop an acute coagulopathy of trauma (ACOT). Activated protein C is a key element, although the complete mechanism remains to be elucidated. Fibrinolysis is an important component of the ACOT; present in only 5% of injured patients requiring hospitalization, but 20% in those requiring massive transfusion.
The most appropriate treatment for a duodenal hematoma that occurs from blunt trauma is:
Duodenal hematomas are caused by a direct blow to the abdomen and occur more often in children than adults. Blood accumulates between the seromuscular and submucosal layers, eventually causing obstruction. The diagnosis is suspected by the onset of vomiting following blunt abdominal trauma; barium examination of the duodenum reveals either the coiled spring sign or obstruction. Most duodenal hematomas in children can be managed nonoperatively with nasogastric suction and parenteral nutrition. Resolution of the obstruction occurs in the majority of patients if this therapy is continued for 7 to 14 days. If surgical intervention becomes necessary, evacuation of the hematoma is associated with equal success but fewer complications than bypass procedures. Despite few existing data on adults, there is no reason to believe that their hematomas should be treated differently from those of children. A new approach is laparoscopic evacuation if the obstruction persists more than 7 days.
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