A 19-year-old man fell off his skateboard, reporting blunt injury to his upper abdomen. Abdominal CT and magnetic resonance cholangiopancreatography (MRCP) confirmed he suffered transection of the main pancreatic duct at the middle of the pancreatic body.
Which of the following would be the most appropriate next step in management?
Optimal management of pancreatic trauma is determined by where the parenchymal damage is located and whether the intrapancreatic common bile duct and main pancreatic duct remain intact. Patients with pancreatic contusions (defined as injuries that leave the ductal system intact) can be treated nonoperatively or with closed suction drainage if undergoing laparotomy for other indications. Patients with proximal pancreatic injuries, defined as those that lie to the right of the superior mesenteric vessels, are also managed with closed suction drainage. In contrast, distal pancreatic injuries are managed based upon ductal integrity. Pancreatic duct disruption can be identified through direct exploration of the parenchymal laceration, operative pancreatography, endoscopic retrograde pancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP). Patients with distal ductal disruption undergo distal pancreatectomy, preferably with splenic preservation. An alternative, which preserves both the spleen and distal transected end of the pancreas, is either a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy. If the patient is physiologically compromised, distal pancreatectomy with splenectomy is the preferred approach.
The most appropriate treatment for a gunshot wound to the hepatic flexure of the colon that cannot be repaired primarily is:
Numerous large retrospective and several prospective studies have now clearly demonstrated that primary repair is safe and effective in the majority of patients with penetrating injuries. Colostomy is still appropriate in a few patients, but the current dilemma is how to select them. Exteriorized repair is probably no longer indicated since most patients who were once candidates for this treatment are now successfully managed by primary repair. Two methods have been advocated that result in 75 to 90% of penetrating colonic injuries being safely treated by primary repair. The first is to repair all perforations not requiring resection. If resection is required due to the local extent of the injury, and it is proximal to the middle colic artery, the proximal portion of the right colon up to and including the injury is resected and an ileocolostomy performed. If resection is required distal to the middle colic artery, an end colostomy is created and the distal colon oversewn and left within the abdomen. The theory behind this approach is that an ileocolostomy heals more reliably than colocolostomy, because in the trauma patient who has suffered shock and may be hypovolemic, assessing the adequacy of the blood supply of the colon is much less reliable than in elective procedures. The blood supply of the terminal ileum is never a problem. The other approach is to repair all injuries regardless of the extent and location (including colocolostomy), and reserve colostomy for patients with protracted shock and extensive contamination. The theory used to support this approach is that systemic factors are more important than local factors in determining whether a suture line will heal. Both of these approaches are reasonable and result in the majority of patients being treated by primary repairs. When a colostomy is required, regardless of the theory used to reach that conclusion, performing a loop colostomy proximal to a distal repair should be avoided because a proximal colostomy does not protect a distal suture line. All suture lines and anastomoses are performed with the running single-layer technique.
Which of the following statements is FALSE regarding traumatic genitourinary injury?
When undergoing laparotomy for trauma, the best policy is to explore all penetrating wounds to the kidneys. However, over 90% of blunt injuries are treated nonoperatively; the indications for surgery include parenchymal injuries leading to hypotension and evidence of renovascular injury. If laparotomy is performed in the setting of blunt kidney injury for other reasons, expanding or pulsatile perinephric hematomas should be explored. Injuries to the ureters are uncommon but may occur in patients with pelvic fractures and penetrating trauma. An injury may not be identified until a complication (ie, a urinoma) becomes apparent. If an injury is suspected during operative exploration but is not clearly identified, methylene blue or indigo carmine is administered IV with observation for extravasation. Bladder injuries are subdivided into those with intraperitoneal extravasation and those with extraperitoneal extravasation. Extraperitoneal ruptures are treated nonoperatively with bladder decompression for 2 weeks, whereas injuries with intraperitoneal extravasation can be closed primarily. Urethral injuries are managed by bridging the defect with a Foley catheter, with or without direct suture repair. Strictures are not uncommon but can be managed electively.
At what pressure is operative decompression of a compartment mandatory?
In comatose or obtunded patients, the diagnosis is more difficult to secure. A compatible history, firmness of the compartment to palpation, and diminished mobility of the joint are suggestive. The presence or absence of a pulse distal to the affected compartment is notoriously unreliable in the diagnosis of a compartment syndrome. A frozen joint and myoglobinuria are late signs and suggest a poor prognosis. As in the abdomen, compartment pressure can be measured. The small, hand-held Stryker device is a convenient tool for this purpose. Pressures greater than 45 mm Hg usually require operative intervention. Patients with pressures between 30 and 45 mm Hg should be carefully evaluated and closely watched.
Which is true regarding trauma in geriatric patients?
Mortality in patients with severe head injury more than doubles after the age of 55 years. Moreover, 25% of patients with a normal GCS score of 15 had intracranial bleeding, with an associated mortality of 50%. Just as there is no absolute age that predicts outcome, admission GCS score is a poor predictor of individual outcome. Therefore, the majority of trauma centers advocate an initial aggressive approach with reevaluation at the 72-hour mark to determine subsequent care. Secondly, one of the most common sequelae of blunt thoracic trauma is rib fractures. In fact, in one study, 50% of patients older than 65 years sustained rib fractures from a fall of <6 ft, compared with only 1% of patients younger than 65 years. Concurrent pulmonary contusion is noted in up to 35% of patients, and pneumonia complicates the injuries in 10 to 30% of patients with rib fractures.