Vsite Upper Extremity And Trauma

Front 1

best exposure for an upper abdominal midline hematoma

Back 1

upper abdominal midline hematoma => *-Mattox maneuver = most expeditious way to expose the suprarenal abdominal aorta while gaining proximal control of an injury. *-L visceral rotation - rotation of the stomach, colon, spleen, kidney, and pancreas to the R in a plane posterior to the kidney

Front 2

what arch anomay happens if R 4th aortic arch and R dorsal aorta involute cranial to 7th intersegmental artery?

Back 2

aberrant right SCA = #1 congenital anomaly of the aortic arch (0.5- 1% of the population. but 21% of population has a bovine arch). *-Arises from the proximal descending thoracic aorta (posterior and inferior to the arch) *-Crosses midline b/w esophagus and spine in 80%, b/w esophagus and trachea in 15%, anterior to the trachea in 5%. *- Ass'd c/ other anatomic features: nonrecurrent R inferior laryngeal nerve, thoracic duct emptying on the R, common trunk of both CCAs, R vertebral artery arising from R CCA **-During embryologic development, L 4th arch becomes part of the aortic arch; R 4th arch becomes the root of R SCA. Aberrant R SCA if R 4th aortic arch and R dorsal aorta involute cranial to 7th intersegmental artery. *-Up to 60% get degenerative aneurysmal changes in the proximal portion of the aberrant R SCA or its aortic origin *-Can compress the esophagus against the posterior trachea ->dysphagia lusoria. *-Can also have have UE embolism or ischemia

Front 3

Aneurysmal degeneration of the aberrant SCA occurs in approximately _% of patients. *Kommerell's diverticulum is present in approximately _% of patients

Back 3

Aneurysmal degeneration of the aberrant SCA occurs in approximately 5% of patients. Kommerell's diverticulum is present in approximately 20% of patients, and appears as a wide-mouthed origin of the aberrant SCA. *-No R RLN *-Intervention indicated for symptomatic pts or if large or expanding aneurysms involving the aberrant artery

*-Tx: ligation of the R SCA origin + carotid-subclavian bypass.

*-Alternative endovascular options may not result in sufficient decompression of the aneurysmal segment to relieve dysphagia. (VESAP3)

Front 4

elective open repair of aneurysmal abherrent R SCA: Simple side-biting clamp exclusion in ~_%, interposition graft resection of the aorta necessary in up to ~_%

Back 4

Elective open repair: staged extra-anatomic bypass to reconstruct the aberrant SCA -> thoracotomy to oversew the origin of Kommerell's diverticulum. *-Simple side-biting clamp exclusion in ~70%, interposition graft resection of the aorta necessary in up to 30%.

*-may be accomplished via a R or L posterolateral thoracotomy (depending on the position of the aortic arch) or a median sternotomy

*-Hybrid endovascular repair of a symptomatic aberrant R SCA +/- aneurysm: thoracic aortic endografts combined + distal ligation or occlusion device placed in antegrade fashion at the origin of the aberrant R SCA (better control of the deployment and to avoid embolization of the occluder into the aortic arch).

Front 5

Open repair of non-aneurysmal abherrant R SCA is usually performed through a __ incision

Back 5

Open repair of non-aneurysmal abherrant R SCA is usually performed through a supraclavicular incision. *-Aberrant R SCA is divided via a R supraclavicular incision after dissecting it to the left of the esophagus. *-The distal end of the SCA is then anastomosed to the R CCA *- Ligation to the left of the esophagus relieves local pressure symptoms. **-Hybrid endovascular repair of a symptomatic aberrant R SCA +/- aneurysm: thoracic aortic endografts combined + distal ligation or occlusion device placed in antegrade fashion at the origin of the aberrant R SCA (better control of the deployment and to avoid embolization of the occluder into the aortic arch). To effectively occlude the origin of the aberrant vessel with a thoracic endograft, its placement usually requires exclusion of both subclavian arteries +/- L CCA -> need to revasc all those vessels

Front 6

__% mortality of acute UE ischemia *most common cause is _

Back 6

-mean age 74 (70 for acute LE ischemia)

-seldom limb-threatening but 50% of untreated pts develop arm pain long-term

-Cardiac embolism = #1 cause

-typical presentation: cold feeling, numbness -20% mortality

-rare causes: thoracic outlet syndrome, proximal SCA aneurysm, HD access (aneurysm and thrombosis)

Front 7

_% of people have a typical 3-vessel aortic arch *-_% have a common origin of the innominate and left common carotid

Back 7

70% have typical pattern of three independent vessels arising from the arch

-13% have a common origin of the innominate and left common carotid arteries

-9% have left common carotid artery originating directly from the innominate artery, typically within 1 - 2.5 cm from the aortic arch.

Front 8

The most common location for blunt abdominal aortic trauma is _____, and the clinical presentation is ______.

Back 8

Blunt trauma to the abdominal aorta is very rare, usually the result of motor vehicle collision with impingement of the steering wheel or a seat belt. The most common location is the origin of the inferior mesenteric artery, and the clinical presentation is that of acute aortic thrombosis secondary to intimal disruption. The diagnosis is made at angiography, and operative repair usually requires a synthetic interposition graft.

Front 9

medial and lateral humeral circumflex arteries are branches of the __ artery

Back 9

medial and lateral humeral circumflex arteries are branches of the axillary artery

Front 10

due to anastomosis b/w suprascapular artery and dorsal scapular artery, the axillary artery may be clamped proximal to the subscapular

Back 10

axillary artery anatomy: *-starts @ lateral border of 1st rib. 3 parts based on relationship to pec minor *-1st part proximal. Branches: superior thoracic *-2nd posterior, intimately associated with brachial plexus cord. Branches: thoracoacromial, lateral thoracic *-3rd lateral. Branches: subscapular, 2 circumflex arteries to head of humerus *-???due to anastomosis b/w suprascapular artery (branch of thyrocervical trunk) and dorsal scapular artery (from 2nd or 3rd part of SCA), the axillary artery may be clamped proximal to the subscapular (from 3rd part of axillary) - do they mean anastomosis b/w dorsal scapular and subscapular???

Front 11

how do you expose a subclavian-axillary artery injury?

Back 11

Most axillary artery injuries are penetrating, resulting in hemorrhage or distal ischemia.

- Extending a subclavian incision into the medial aspect of the abducted upper arm exposes the axillary artery. The incision is carried through the pectoral fascia, and the pectoralis major muscle can be either split or divided depending on the exposure required. The pectoralis minor muscle is then retracted or divided, and the clavipectoral fascia is opened, exposing the neurovascular bundle in the axillary sheath.

Front 12

___ nerve injury results in weakness of shoulder abduction and sensory deficit over the deltoid muscle.

Back 12

-Axillary nerve injury => weakness of shoulder abduction and sensory deficit over the deltoid muscle.

-Median nerve injury => sensory deficit in the first, second, third, and radial aspects of the fourth digits, as well as concomitant weakness in the thenar muscles +/- flexors of the digits and wrist.

-Ulnar nerve injury => numbness of the fifth digit and the ulnar aspect of the fourth digit, weakness of the hypothenar muscles, abduction and adduction of all digits, flexion of 4th and 5th fingers.

-Radial nerve injury => weakness of wrist and finger extension.

Front 13

__ nerve injury results in numbness of the fifth digit and 1/2 of fifth digit, weakness of the hypothenar muscles

Back 13

-Axillary nerve injury results in weakness of shoulder abduction and sensory deficit over the deltoid muscle.

-Median nerve injury gives rise to sensory deficit in the first, second, third, and radial aspects of the fourth digits, as well as concomitant weakness in the thenar muscles and on occasion extending to the flexors of the digits and wrist.

-Ulnar nerve injury results in numbness of the fifth digit and the ulnar aspect of the fourth digit, weakness of the hypothenar muscles, abduction and adduction of all digits, flexion of 4th and 5th fingers. *-Radial nerve is rarely involved but would result in weakness of wrist and finger extension.

Front 14

CXR shows wide mediastinum in _% of pts c/ ruptured thoracic aorta.

Back 14

Victims of high-speed MVCs are at risk for rupture of the thoracic aorta. Cause of death in up to 15% of MVCs *-Most common sites of thoracic aortic rupture: descending aorta just distal to L SCA, ascending aorta just proximal to the innominate artery. *-Shearing, bending, twisting, and "water hammer effect" => aortic rupture (twisting and "water hammer effect" lead to ascending aortic rupture). The intima and media rupture, with free bleeding contained by the adventitia in surviving patients. *-Suspect blunt rupture of the thoracic aorta in pts c/ severe direct chest trauma or falls from great heights. CXR shows wide mediastinum in 90% of pts c/ ruptured thoracic aorta. *-Thin-slice helical CT angiography should also be considered if normal-appearing mediastinum but a significant mechanism of injury *-Do angio if equivocal findings on CT or other great vessel injuries are suspected. *-Treatment options: operative repair, endovascular stent placement, or nonoperative mgmt in stable high-risk pts with anti-HTN meds. *-First address other life-threatening injuries e.g. ruptured spleen or bleeding from a pelvic fracture *-Pts with acute pulmonary insufficiency or severe head injuries should not undergo repair of the aorta until their overall condition has improved.

Front 15

blunt cerebrovascular injury: *-originally thought to be rare, Denver grp published rate of _-_% using their screening criteria: *-displaced midface fx (LeFort II-III), basilar skull fx with carotid canal involvement, closed head injury c/w diffuse axonal injury and GCS <6, cervical vertebral body or transverse process fx/subluxation/ligamentous injury, any fx C1-C3, near-hanging c/ anoxia, closthesline-type injury or seatbelt abrasion c/ any significant swelling/pain/AMS

Back 15

blunt cerebrovascular injury: *-originally thought to be rare, Denver grp published rate of 1-2% using their screening criteria. *-CTA neck indicated for pts fufilling Denver Criteria: displaced midface fx (LeFort II-III), basilar skull fx with carotid canal involvement, closed head injury c/w diffuse axonal injury and GCS <6, cervical vertebral body or transverse process fx/subluxation/ligmaentous injury, any fx C1-C3, near-hanging c/ anoxia, closthesline-type injury or seatbelt abrasion c/ any significant swelling/pain/AMS *-Carotid and vertebral injuries 2/2 stretching or tearing of intima of the vessels from rapid extension/flexion or direct blunt force *-Carotid in close proximity to secondhand 6th transverse process *-Vertebral artery can be vulnerable to stretch injury or fracture of the transverse processes of the cervical vertebrae of the foramen transversum *-Tx: anticoagulation unless contraindication. Aspirin if anticoagulation not possible.

Front 16

mgmt of zone 1/3 blunt cerebrovasc injury

Back 16

stable pt with suspected zone 1 or 3 blunt cerebrovascular injury => preop imaging is mandatory to confirm the injury and plan proximal and distal control *-Imaging also recommended for stable pts with zone 2 injuries (neck exploration without imaging for pts with expanding neck hematoma or impending airway compromise (hoarseness, tracheal deviation) *-In unstable pt, fogarty catheter can be inserted the wound for temporary tamponade. *-Catheter-based angio can be diagnostic and therapeutic in zones 1 and 3 - coiling of bleeding vessels or PSA in zone 3 or placement of a covered stent in zone 1

Front 17

grade __ blunt cerebrovascular injury : *dissection or intramural hematoma with luminal narrowing of 25% or more, intramural thrombus, or raised intimal flap *-__% are expected to heal *-Recommended approach to treatment _

Back 17

Grade II injury—defined as a dissection or intramural hematoma with luminal narrowing of 25% or more, intramural thrombus, or raised intimal flap—has a 70% risk of progression to grade III or IV despite full anticoagulation; only 10% of these wounds heal. Despite this progression to a higher grade lesion, anticoagulation seems to be protective against stroke and is recommended. It is also recommended that these patients have repeated imaging studies 7 days after the injury to evaluate for progression. (Moore)

Front 18

Grade 3 blunt cerebrovasc injuries (defined as __): *Recommended approach to tx is _

Back 18

Grade III injuries are pseudoaneurysms that develop secondary to egress of blood into the subadventitial layer and often result from progression of grade II injuries. Pseudoaneurysms pose a risk for rupture and hemorrhage, as well as thromboembolism; they rarely resolve with anticoagulation. *The acutely injured artery, however, should not be subjected to angioplasty or stenting within 48 to 72 hours after injury. *Should be initially given anticoagulants and reimaged at 7 days after the injury. If the pseudoaneurysm persists (or has developed), consider stent placement with or without coil embolization and convert the patient to antiplatelet therapy; heparin and warfarin therapy may be continued or discontinued at the discretion of the surgeon based on the patient’s overall risk and catalog of injuries. *-EC-IC bypass is also an option

Front 19

Brachial access site complications in ~_% of pts *-stroke rate is __%

Back 19

Brachial = overall safe for endovasc access *-Brachial access site complications in 2-6% of pts, more common in women (VESAP3) *-similar stroke rate to femoral access (0.4% in a large trial) *-spasm with the loss of a distal pulse commonly occurs following brachial artery puncture *-neurological symptom in the hand following brachial puncture should raise concern for brachial sheath hematoma. *-In women, the complication rate for radial access is greater than femoral access. *Alvarez-Tostado JA, Moise MA, Bena JF, Pavkov ML, Greenberg RK, Clair DG, et al. The brachial artery: A critical access for endovascular procedures. J Vasc Surg 2009; 49:378-85.

Front 20

Medially, the upper half of the brachial artery is in relation with these 2 nerves_____ , and in its lower half with the median nerve

Back 20

Brachial artery: *-superficial throughout its entire extent in the arm. Covered in front by superficial and deep fasciae. *-median nerve crosses from lateral -> medial of brachial art. opposite the insertion of the coracobrachialis muscle. *-Behind, it is separated from the long head of the triceps brachii by the radial nerve and superior profunda artery. It then lies upon the medial head of the triceps brachii, next upon the insertion of the coracobrachialis, and lastly on the brachialis. *-Laterally, it is in relation above with the median nerve and the coracobrachialis muscle, below with the biceps brachii, the two muscles overlapping the artery to a considerable extent. Medially, its upper half is in relation with the medial antibrachial cutaneous and ulnar nerves, and in its lower half with the median nerve. The basilic vein lies on its medial side, but is separated from it in the lower part of the arm by the deep fascia.

Front 21

at the elbow, the median nerve is _ to brachial artery

Back 21

Branchial artery travels anterior to humerus with (anterior -> posterior): basilic vein -> medial antebrachial cutaneous nerve -> brachial artery -> median nerve -> ulnar nerve and brachial veins) *(posterior to humerus is a bunch that contains radial nerve and deep brachial artery) *(cephalic vein and deltoid branch of the axillary artery travel superficially, anterior to deltoid) *-at the elbow, the median nerve is MEDIAL to brachial artery. *-Median nerve starts on top of the brachial artery at the deltoid, then moves medial to it by the distal 1/3 of the humerus

Front 22

what structures travel with the brachial artery in the upper arm?

Back 22

Branchial artery travels anterior to humerus with (anterior -> posterior): basilic vein -> medial antebrachial cutaneous nerve -> brachial artery -> median nerve -> ulnar nerve and brachial veins) *(posterior to humerus is a bunch that contains radial nerve and deep brachial artery) *(cephalic vein and deltoid branch of the axillary artery travel superficially, anterior to deltoid)

Front 23

what is the 1st branch of the brachial artery

Back 23

profunda brachii is typically the first branch of the brachial artery.

Front 24

elderly F presents with cool, numb L hand and A fib *-Exam: hand cool and pale, weak sensation and motor *-Water hammer pulse in branchial art. above elbow crease. (-) radial/ulnar pulse or signals *-Heparin started. Next step = _

Back 24

Brachial artery embolus *-Start heparin -> surgical exploration c/ thromboembolectomy *-cardiac = 80-90% of peripheral emboli, A fib most commonly. *-17% of cardiac emboli go to UE, usually brachial bifurcation (no more imaging needed) *-Lytics are an option if elderly pt can't even handle local anesthesia but slower resolution and higher risk of hemorrhage

Front 25

Complications requiring operative intervention occur in up to _% of patients who undergo access via a brachial artery approach.

Back 25

Pseudoaneurysm after brachial access in 1- 3% *- more common with larger sheath sizes and in women. *-Complications requiring operative intervention occur in up to 4% of patients who undergo access via a brachial artery approach.

Front 26

most common organisms are __ for brachial/radial artery PSA in IVDU

Back 26

brachial/radial artery PSA in IVDU: may cause distal emboli *-most common organisms are Gram-positive (like most superficial infected PSAs); MRSA increasingly prevalent. *-Infections tend to be extensive, require wide debridement *-Autogenous conduit is preferred, but cryopreserved grafts can be used in the setting of a patient with no autogenous options

Front 27

__ = most injured artery in the body, 20-30% of peripheral arterial injuries *-exposed through what incision?

Back 27

Brachial = most injured artery in the body, 20-30% of peripheral arterial injuries *-Exposed through a medial arm incision in the groove between the biceps and triceps muscles. *-Median nerve = 1st structure encountered in the neurovascular bundle, must be isolated and preserved. *-If the brachial artery is exposed in the proximal arm, the deep brachial artery is identified and controlled at the lateral border of the teres major muscle. *-Blunt injuries ass'd c/ supracondylar fractures of the humerus. *-injuries below the origin of the profunda brachii may not show signs of ischemia

Front 28

Pt undegoes SMA angiogram via L brachial access, then c/o hand weakness. *No punture site heamtoma. Radial and ulnar pulses are palpable. *What do you suspect? *How will you treat the patient?

Back 28

The most common and treatable cause of neurologic dysfunction is compression from an axillary sheath hematoma causing medial brachial fascial compartment syndrome. The clinical finding of hand weakness can, however, occur without evidence of a puncture site hematoma and in the setting of a palpable radial and ulnar pulse. Surgery is indicated for nerve compression symptoms and should be undertaken as soon as possible to minimize functional loss. It involves decompression of the fascial compartment with exposure of the brachial artery and repair of the arteriotomy. *-Technique to apply the right amount of pressure when pulling a brachial sheath: apply a pulse oximeter to the finger to confirm normal perfusion to the hand but know you are not thrombosing the vessel

Front 29

2 meds to manage Buergers

Back 29

Buerger's = thromboangiitis obliterates *-#1 tx = smoking cessation *-medical tx = ca channel blockers, prostacyclin, used as vasodilators *-sympathectomy *-exercise to develop collaterals

Front 30

what disease is this? highly cellular thrombus in mid-sized arteries, extensive intimal inflammation, recanalization

Back 30

Buerger's: highly cellular thrombus in mid-sized arteries, extensive intimal inflammation, recanalization

Front 31

most common iatrogenic injury during an anterior fasciotomy

Back 31

A longitudinal incision is made about 2 fingerbreadths lateral to the tibial crest, beginning immediately below the tibial tuberosity and extending to the ankle. Dividing the fascia along the line of incision decompresses the muscles of the anterior compartment, with special care being taken to divide the superior extensor retinaculum above the ankle. *-ID the crural fascia between the anterior and lateral compartments and divide it along the entire length of the incision; avoid the lateral peroneal nerve in the superior aspect of the incision (most common iatrogenic injury during an anterior fasciotomy) *-posterior compartments are decompressed through a separate medial incision placed immediately posterior to the posterior edge of the tibia, carefully avoiding injury to the long saphenous vein. The superficial posterior compartment is decompressed by incising the deep fascia. Detaching the soleus muscle from the posterior aspect of the tibia using the electrocautery opens the deep posterior compartment and completes the procedure.

Front 32

what is the standard diagnostic modality for blunt injury to the ICA?

Back 32

Arteriography is the standard daignostic modality for blunt ICA injury *-Blunt carotid injury often has no sx until several days after the injury *-Ultrasound does not show the injury *-Heparin is still controversial except in highly specific cases *-Most patients do not require surgery

Front 33

With injuries of the left carotid origin, what is the recommended aproach to repair? (what operation)

Back 33

The surgical approach to injuries of the proximal left carotid artery mirrors that of the innominate artery—a sternotomy with a left cervical extension if needed. With injuries of the left carotid origin, bypass graft repair is generally preferred over end-to-end reanastomosis

Front 34

5 year patency for carotid-SCA bypass vs. stenting? *-For endovasc repair, what is the patency for stenosis vs. occlusion?

Back 34

Analysis of extra-anatomic arch vessel reconstruction: 5 yr patency > 90%, well tolerated in patients 70 years+ *-In another study of surgery vs stenting: primary patency rates at 1, 3, and 5 years were 100%, 98%, and 96% for bypass and 93%, 78%, and 70% for the stent group, respectively (p<0.0001). *-In another study of endo mgmt of SCA occlusive disease, technical success for stenosis 100%, for occlusion 65% . *-Prosthetic bypass using PTFE has longer patency than vein (95 vs. 64%). **-Byrne J, Darling RC III, Roddy SP, et al. Long-term outcome for extra-anatomic arch reconstruction. An analysis of 143 procedures.Eur J Vasc Endovasc Surg 2007; 35: 444-450. *-AbuRahma AF, Bates MC, Stone PA, et al. Angioplasty and stenting versus carotid-subclavian bypass for the treatment of isolated SCA disease. J Endovasc Ther 2007; 14(5): 698-704. *-de Vries JP, Jager LC, van den Berg JC, et al. Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal SCA: long-term results. J Vasc Surg 2005; 41:19–23. *-Law M, Colburn M, Moore W, et al. Carotid-subclavian bypass for brachiocephalic occlusive disease. Choice of conduit and long-term follow-up. Stroke 1995, 26; 1565-7.

Front 35

what maneuver is used to expose the aorta, IVC, iliac, and renal vessels?

Back 35

Right-sided medial visceral rotation (extended Kocher maneuver) consists of medial reflection of the right colon and duodenum by incising their lateral peritoneal attachments *-exposure can be extended medially by detaching the posterior attachments of the small bowel mesentery toward the duodenojejunal ligament (Cattell-Braasch maneuver) The small bowel and the colon are reflected onto the lower chest => widest possible exposure of the retroperitoneum, including the aorta, inferior vena cava, and iliac and renal vessels.

Front 36

how do you expose a central RP hematoma? R or L?

Back 36

A central retroperitoneal haematoma likely represents injury to a major vascular structure. Access to the inferior vena cava or abdominal aorta in this setting is best achieved by complete medial visceral rotation of the right or left side of the abdomen. *-on R: colon is mobilised -> extended Kocher manoeuvre to mobilise the duodenum. -> root of the small bowel mesentery is mobilised up to the SMA and inferior border of the pancreas. *-L colon, spleen and kidney are mobilized and the visceral rotated medially to expose the entire length of the abdominal aorta (the Cattell or Mattox manoeuver).

Front 37

most common complication of cervicadorsal sympathectomy for hyperhidrosis = _

Back 37

most common complication of cervical sympathectomy for hyperhidrosis is compensatory hyperhidrosis of the chest = 30% *-Used for palmar hyperhidrosis, causalgia (complex regional pain syndrome), Raynaud's, Buergers *-thorascopic sympathectomyhas less morbidity and improved outcomes but significant unwanted side-effects continue to be reported: hyperhidrosis of chest, increased facial sweating while eating = Frey's syndrome. *-Horner's syndrome less common (miosis, ptosis, enophthalmos (sunken eye) and anhidrosis)

Front 38

for common carotid injury, repositioning of the ___ can be used to bridge a gao for a proximal ICA injury

Back 38

Common carotid artery injury: *-Arterial switch using branches of the external carotid can used as a conduit for proximal ICA injuries *-No data to support saphenous vein vs. synthetic patch or graft if needed *-No benefit has been shown with use of heparinization or shunting for carotid artery injuries

Front 39

what UE compartment is most commonly affected in compartment syndrome?

Back 39

anterior or volar forearm is most commonly affected in compartment syndrome *-dorsal forearm and hand and upper arm may also be affected by reperfusion syndrome

Front 40

branches of the SCA *-what branch comes off the part posterior to the anterior scalene?

Back 40

SCA: *-1st part travels to medial border of ant scalene. anterior to vagus and phrenic nerves. posterior to sternohyoid, SCM. *-branches = vertebral, internal thoracic, thyrocervical trunk *-2nd part travels posterior to ant scalene. branch = costocervical trunk. SCV located inferior and anterior. *-3rd part starts at lateral border of ant scalene *-becomes axillary @ lateral border of 1st rib, gives rise to dorsal scapular

Front 41

subclavian vein passes through what space to exit the thorax? what are the borders of the space?

Back 41

Costoclavicular space: *-clavicle superior, 1st rib inferior, costoclavicular ligament anterior, middle scalene posterior

Front 42

what 5 vessels should be considered for shunting in trauma?

Back 42

Ligation: for vessels with distal collateral flow (physical exam and doppler in OR first) - SCA, innominate artery, celiac, IMA, proximal axillary, distal radial or ulnar, a single tibial vessel *-Shunt: any vessel with evidence of poor colalteral flow, always the SMA, brachial, EIA, SFA, popliteal. *-Venous shunt (instead of ligation) can improve extremity perfusion and lower the risk of compartment syndrome

Front 43

what 3 locations of non-expanding hematomas in the abdomen (for trauma) should not be explored and may be treated with abdominal packing. Subsequent angiographic embolization may be required.

Back 43

Nonexpanding perirenal haematomas, retrohepatic haematomas or blunt pelvic haematomas should not be explored and may be treated with abdominal packing. Subsequent angiographic embolization may be required.

Front 44

If the aorta is difficult to identify in a hypovolaemic patient =>direct visualization by division of __

Back 44

Relief of intraperitoneal pressure with muscle paralysis and opening of the abdominal wall may result in dramatic haemorrhage and hypotension. Immediate control is necessary and this is initially achieved with four quadrant packing with multiple large abdominal packs. If continued arterial haemorrhage with packs in place => aortic control at the diaphragmatic hiatus with blunt finger dissection and finger pressure by an assistant, then aortic cross-clamping. *- If the aorta is difficult to identify in a hypovolaemic patient =>direct visualization by division of the right crus of the diaphragm *-Some prefer a L anterolateral thoracotomy to control the descending thoracic aorta in the chest, but rarely necessary

Front 45

which pancreati injuries don't have to be repaired?

Back 45

Pancreatic injury rarely requires or allows definitive surgery in the damage control setting. *-Minor injuries not involving the duct (AAST I,II,IV) require no treatment. A closed suction drain may be placed, but not if the abdomen is packed and left open. *-If the injury is distal (to the SMV- AAST III) and there is extensive tissue destruction including the pancreatic duct, it may be possible to perform a rapid distal pancreatectomy. *-Massive injuries to the pacreaticoduodenal complex (AAST V) are almost always associated with injuries to the surrounding structures. Patients will not survive complex operations such as pancreaticoduodenectomy. The pancreas should be debrided only. *-Small duodenal injuries can be repaired with a single layer suture, but large duodenal injuries should be debrided and the ends closed temporarily with suture or umbilical tape to be dealt with at the second procedure.

Front 46

The central tenet of damage control surgery is that patients die from a triad of _____

Back 46

The central tenet of damage control surgery is that patients die from a triad of coagulopathy, hypothermia and metabolic acidosis. *The principles of the first 'damage control' procedure then are control of haemorrhage, prevention of contamination and protection from further injury. *Some state that conversion to a damage control procedure should take place if the pH is below 7.2, core temperature is below 32C or the patient has received more than one blood volume transfusion. However, once these levels are reached, physiological exhaustion is already established. The trauma surgeon must make the decision to convert to a limited procedure within 5 minutes of starting the operative procedure. This decision is made on the initial physiological state of the patient and the rapid initial assessment of internal injuries. Do not wait for physiologic exhaustion to set in.

Front 47

approach to damage control surgery for lung trauma.

Back 47

Pulmonary resection may be necessary to control haemorrhage or massive air leaks and to remove devitalised tissue. *-Linear stapling device controls most vascular and bronchial injuries. Non-anatomical approach to preserve the max amt of functional lung tissue. Can overrun the staple line with a continuous suture. Formal pulmonary lobar or segmental resection is difficult and unnecessary in the multiply injured patient. (-Be carfeul controlling superficial injuries with simple suture => may control only superficial haemorrhage and bleeding into deeper tissues continues. *-Hilar injuries: control initially with finger pressure. Most injuries will then be found to be more distal to the hilum. If hilar control is necessary => vascular clamp (Satinsky) or umbilical tape. Up to 50% will die of acute R heart failure following clamping of hilar structures *-Pulmonary tractotomy may be useful for a deep penetrating injury to the lung. Two long clamps are placed through the tract of the injury. The wall of the tract is opened. Tie off bleeding vessels or bronchi. Clamps are then overrun with a suture to control the wound edges.

Front 48

Standard criteria for positive DPL findings in blunt trauma : *-10 mL of gross blood *-bloody lavage effluent *-RBC count >_/mm3 *-WBC count >_/mm3 *-Amylase > _ IU/dL *-bile, bacteria, or food fibers.

Back 48

Standard criteria for positive DPL findings in blunt trauma : *-10 mL of gross blood *-bloody lavage effluent *-RBC count >100,000/mm3 *-WBC count >500/mm3 *-Amylase > 175 IU/dL *-bile, bacteria, or food fibers. *-Diaphragmatic tears, retroperitoneal hematomas, and renal, pancreatic, duodenal, minor intestinal, and extraperitoneal bladder injuries are frequently underdiagnosed by DPL alone. *-Debate still exists regarding the most appropriate positive criteria to determine the threshold for surgical exploration after stab wounds to the abdomen. If a red blood cell count of 1000/mm3 is considered, the number of negative explorations may be higher than 20%. If 100,000/mm3 is considered, the missed injury rate will approach 5%. There is no consensus on this matter, although most trauma centers use a low threshold (cell count between 1000 and 5000/mm3) for exploration.

Front 49

SCA: 1st part travels to medial border of ant scalene. (Anterior or posterior?) to vagus and phrenic nerves. (anterior or posterior?) to sternohyoid, SCM.

Back 49

SCA: *-1st part travels to medial border of ant scalene. anterior to vagus and phrenic nerves. posterior to sternohyoid, SCM. branches = vertebral, internal thoracic, thyrocervical trunk *-2nd part travels posterior to ant scalene. branch = costocervical trunk. SCV located inferior and anterior. *-3rd part starts at lateral border of ant scalene *-becomes axillary @ lateral border of 1st rib, gives rise to dorsal scapular

Front 50

Electrical burns: >__ V => extensive damage, possibly arterial injury

Back 50

Electrical burns: *-<1000 V => skin + soft tissue injury. *->1000 V => extensive damage, possibly arterial injury *-Arterial necrosis with thrombus or bleeding, occasionally digital gangrene. Arterial spasm may also be present. Damage to media may cause aneurysm. *-Treatment depends on soft tissue and bone injuries. Occlusion of a major artery equires bypass and good results have been reported.

Front 51

Erb's palsy is 2/2 severing of the __ nerves => loss of sensation in the arm, atrophy of the deltoid, biceps, and brachialis => arm hangs by the side, rotated medially; forearm is extended and pronated. The arm cannot be raised from the side; no elbow flexion or forearm supination (waiter tip position)

Back 51

Erb's palsy or Erb–Duchenne palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5–C6 nerves, usually from shoulder dystocia during birth *- loss of sensation in the arm, atrophy of the deltoid, biceps, and brachialis => arm hangs by the side, rotated medially; forearm is extended and pronated. The arm cannot be raised from the side; no elbow flexion or forearm supination (waiter tip position)

Front 52

what is the first incision for life-threatening bleeding from the arm

Back 52

life-threatening bleeding from the arm => *proximal control of axillary artery via incision over infraclavicular region of the chest

Front 53

forearm fasciotomy: how many compartments? *-what is the first incision?

Back 53

forearm fasciotomy technique: 3 compartments = dorsal and vola compartments with deep and superficial muscles, and the "mobile wad" innervated by the radial nerve *-First do a "lazy S" incision to release dorsal and volar compartments. *-full decompression requires release of the individual fascial compartments of each of the superficial and deep muscles in both the volar and dorsal compartments, as well as the mobile wad with concomitant carpal tunnel release. *Ronel DN, Mtui E, Nolan WB III. Forearm compartment syndrome: Anatomical analysis of surgical approaches to the deep space. Plast & Reconstr Surg 2004; 114: 697-705.

Front 54

how much thrombin do you inject into a femoral PSA?

Back 54

Rutherford ch. 45 Reliable pt c/ PSA < 2 cm in diameter can be d/c'd c/ follow-up and frequent duplex assessment. If enlarging or symptomatic: US-guided thrombin injection.*-Thrombin injection:1-mL syringe is attached to a spinal needle (22 gauge). Identify the tip of the needle w/in the sac, direct the tip away from the inflow neck of the PSA -> inject 0.1 to 0.2 mL of thrombin -> if continued flow in sac, inject additional 0.1 to 0.2 mL -> final US to confirm thrombosed PSA, patent native artery. Repeat duplex in 24-48 hours to confirm resolution *-Recurrence rate is approximately 3%. *-Other options: surgical repair, covered stent in pt c/ high operative risk (risk of stent fracture then occlusion), coil embolization by accessing the PSA percutaneously with a large-bore catheter and inserting coils under US guidance (for pts on high-level anticoagulation or allergy to thrombin or cow products)

Front 55

normal finger-brachial index is _ to _

Back 55

normal finger-brachial index may range from 0.8 to 1.3. *A difference of more than 15 mm Hg between fingers or an absolute finger systolic blood pressure of less than 70 mm Hg may indicate occlusive disease. *when the fingers are warm, finger systolic blood pressure may be lower than arm pressure by 10 mm Hg.

Front 56

__ arteritis can be triggered by environmental factors. mycoplasma pneumoniae, parvovirus B19, parainfluenza

Back 56

Giant cell arteritis: *-Angio: tapered stenosis in the distal SCA, axillary artery *-In the active phase, ESR and CRP are elevated , pts c/o inflammatory shoulder and arm pain that may be exacerbated by exertion. *-In the quiescent stage, the systemic inflammatory symptoms may be replaced by ischemic symptoms due to arterial obstruction and the ESR and CRP may be only mildly elevated or in the normal range. *-Pathology: inflammation arising in adventitia, T cells and macrophages. multiniucleated giant cells adjacent to fragmented IEL. inflammation amplified -> cytokines induce tissue damage c/ MMPs, ROS -> artery releases PDGF, VEGF -> proliferation of myofibroblasts, tickening of intima. *-population most common = northern european. 4:1 F:M. (VESAP3 says GCA is equally male and female). *- genetic polymorphisms for HLA class II DRB1 04, 1 01 alleles. triggered by environmental factors. mycoplasma pneumoniae, parvovirus B19, parainfluenza, Chalmydia pneumoniae **-extracranial involvement in 10-15%. upper ext ischemia. 17x risk thoraic aneurysms, 2.4x risk of AAA. increased dissection risk. *-Tx: prednisone 40-60 mg qd x 4 wks, then taper q2-4 wks

Front 57

how to expose hepatic vein trauma

Back 57

Median sternotomy with division of the central tendon of the diaphragm to expose injured hepatic veins

Front 58

patient with supracondylar humeral fracture is at risk for what vascular injury?

Back 58

Supracondylar humeral fracture => brachial art injury

*-Collaterals arising more proximally usually avoid acute hand ischemia

--deep brachial branches anastomose to with recurrent branches of radial, inferior ulnar collateral *-superior and inferior ulnar collateral arteries

Front 59

what deformity comes from supracondyler humerus fractures in kids?

Back 59

treatment of type III supracondylar fractures of the humerus in children who lack a palpable radial pulse *-Long-term ischemia => Volkmann's contracture = permanent flexion and a clawlike deformity *-brachial artery may be pinched, avulsed, or thrombosed as it wraps around the fracture site. *-Orthopedic reduction is the accepted first treatment, with neurovascular re-evaluation after stabilization. If the pulse returns, no further treatment is necessary besides observation. If it does not and the hand appears white, pale, and ischemic, operative exploration is preferred. *-Debate in the literature re: treatment when the pulse is not palpable but the hand is pink and viable. Some describe a conservative approach with serial examination. Others favor either direct arterial repair with patch angioplasty or bypass using GSV

Front 60

treatment for hypothenar hammer syndrome with thromboses ulnar aneurysm

Back 60

hypothenar hammer syndrome: *-Repetitive trauma to the palmar surface damages the palmar branch of the ulnar artery. *-Ulnar artery is vulnerable when it becomes superficial in the palm as it passes laterally to the hook of the hamate bone *-Ulnar aneurysm can develop, can send distal emboli *-Ulnar artery aneurysms are typically fusiform and may have a "corkscrew" appearance due to tortuosity and/or irregular intraluminal thrombus - don't necessarily look like an aneurysm on angio (VESAP3 example looked like a stenosis) *-If artery thromboses +/- aneurysm, local lyrics can be helpful w/in 2 weeks to repefuse hand and show anatomy -> then resect aneurysm. *-Bypass with an appropriately-sized vein graft is recommended. Longitudinal palmar incision

Front 61

Current theory re: etiology of hypothenar hammer syndrome

Back 61

hypothenar hammer syndrome: *-Repetitive trauma to the palmar surface of the hand => damage to underlying palmar branch of the ulnar artery. *-The ulnar artery has a superficial course in the palm as it passes laterally to the hook of the hamate bone *-Current theory that it's underlying FMD in presence of repetitive palmar trauma

Front 62

prognosis for small iatrogenic femoral AVF

Back 62

Rutherford ch 45: Iatrogenic AVF is usually 2/2 low groin puncture through the superficial or deep femoral artery together with an adjacent vein. *-Small incidental AVFs usually have a benign natural history, either close spontaneously or remain asymptomatic. *-Kelm et al, ref 11: 38% of AVF spontaneously closed w/in 1 year, >2/3 closed w/in 4 months. Of those that didn't resolve, no adverse outcomes reported (R heart failure, limb swelling) *-Toursarkissian et al, ref 29: monitored 81 AVFs, 81% of which closed spontaneously *-Surgical mgmt: proximal and distal control, divide the PSA and repair vessels with interrupted prolenes *-Endovascular options: balloon-expandable stent-graft (ref 30-32) for poor operative candidates who failed nonop mgmt, embolization of long fistula tracts with N-butyl-cyanoacrylate (ref 34)

Front 63

approach to exploration of a penetrating iliac injury

Back 63

Penetrating injuries to the iliac vessels -> high mortality 25%-40% because exposure and control can be difficult, and associated injuries to abdominal organs

Proximal control away from the injury, on the inframesocolic aorta and vena cava. distal control is achieved on the external iliac vessels at the inguinal ligament by “towing in” with a large retractor to compress the iliac vessels against the edge of the bony pelvis. Reflection of the colon from its lateral peritoneal attachment on the relevant side unroofs the pelvic hematoma. Vascular control is then optimized by gradually advancing the clamps closer and closer to the injury as the dissection proceeds.

Front 64

innominate trauma - what incision to get proximal control?

Back 64

Proximal control requires either a median sternotomy for the innominate and right subclavian arteries or a high left anterolateral thoracotomy with potential clavicular resection for the left SCA.

Front 65

what type of neuropathy is 2/2 retraction of myelin from the node of Ranvier, a reversible process if the ischemia is treated rapidly?

Back 65

presentation of IMN is acute pain, weakness, or paralysis of the muscles of the hand and forearm, often with prominent sensory loss and dysesthesias within hours of AVF *-usually elderly pts with preexisting PAD+ DM neuropathy (nerves maybe preconditioned to not tolerate ischemia) and brachial AV access *-antecubital area is a “watershed” for the vasa nervorum of the 3 upper limb nerves *-EP studies support the hypothesis of IMN's being a steal syndrome involving only the nerves. Nerve conduction studies done as soon as 1 hour after AVF: motor conduction block and conduction slowing. *-2/2 retraction of myelin from the node of Ranvier, a reversible process if the ischemia is treated rapidly (not by demyelination)

Front 66

complications related to IVC filters: pulmonary embolism (_%), vena cava penetration (_%)

Back 66

incidence of complications related to IVC filters is closely related to the intensity and methods of surveillance. *-PE (2-5%), fatal PE (0.7%), access site thrombosis (2-28%), filter migration (3-69%), IVC penetration (9-24%), IVC obstruction (6-30%) and fracture (1%).

Front 67

mortality of retrohepatic IVC injury

Back 67

IVC has 4 zones: 1.) infrarenal: iliac bifurcation -> renal veins. Incidence ~45%, mortality ~32%. accessible for repair or early ligation.

2.) suprarenal: renal veins -> inferior surface of the liver. Incidence ~27%, mortality 38-75% - less able to tolerate ligation for damage control.

3.) retrohepatic: inferior border of the liver ->diaphragm. Incidence ~21%, mortality 66-93%. IVC is encircled by suspensory ligaments, the diaphragm, and liver parenchyma and accepts the hepatic veins at its superior extent. Bleed through a disrupted liver capsule and/or disrupted suspensory ligaments and diaphragm - challenging access, often exsanguination once the hematoma is unroofed.

4.)supradiaphragmatic: diaphragm ->atriocaval junction. Incidence ~9%, mortality 50%-100% due to proximity to cardiac structures and difficulty of exposure

Front 68

Retrohepatic IVC injury => reported mortality >__%. what is one temporizing measure?

Back 68

Injuries to IVC: mortality >50%, esp. for the least accessible segments (iliac bifurcation, suprarenal and retrohepatic IVC). *-IVC is exposed by R medial visceral rotation -> initial control by direct pressure above and below the injury *-Mgmt options for the infrarenal IVC: lateral repair or ligation. *-Retrohepatic IVC injuries: typical operative findings are massive venous bleeding either through a deep hepatic wound or from the posterior aspect of a severely injured liver. Bleeding is unaffected by a Pringle maneuver. Pt usually in profound shock by the time diagnosis is made. Direct repair options for retrohepatic IVC are complex, dismal results. Atriocaval shunt with a chest tube or ET tube inserted through the RA to exclude the injured segment without compromising cardiac preload - reported mortality >80%. *-Some reports of successful packing of retrohepatic IVC injuries

Front 69

Klumpke's palsy = partial palsy of which roots of the brachial plexus? *What muscles are affected?

Back 69

Klumpke's palsy: lower roots of brachial plexus (C8-T1) *- intrinsic muscles of the hand (interossei, thenar and hypothenar muscles) and the flexors of the wrist / fingers (flexor carpi ulnaris and ulnar half of the flexor digitorum profundus) => “claw hand” where the forearm is supinated and the wrist and fingers are flexed. If Horner syndrome is present, there is miosis (constriction of the pupils) in the affected eye.

Front 70

what is a kocher maneuver?

Back 70

Kocher manoeuvre: to expose structures in the retroperitoneum behind the duodenum and pancreas; for example to control hemorrhage from the inferior vena cava or aorta, or to facilitate removal of a pancreatic tumour.*- peritoneum is incised @ R edge of the duodenum -> *duodenum and the head of pancreas are reflected to the L

Front 71

what do you do for a liver laceration that continues to bleed despite attempts at local control?

Back 71

Simple lacerations that are not bleeding at the time of surgery do not require drainage unless they are deep into the parenchyma with the possibility of a postoperative biliary fistula. *-Subcapsular hematomas: can simply be observed or surgically evacuated if there is no associated parenchymal injury. *-Lacerations that continue to bleed despite attempts at local control require tractotomy = opening the liver wound and directly approaching the bleeding vessels. Bleeding vessels and biliary radicles should be individually ligated. In the event that bleeding continues despite directly ligating small vessels, a vascular clamp or vessel loops can be placed around the porta hepatis (Pringle's maneuver) *-If the bleeding stops after clamping the portal triad, it can be assumed to be from the portal veins or hepatic artery branches. If the bleeding continues despite clamping the portal triad, an injury to the hepatic veins or the retrohepatic vena cava is suspected. The portal triad can also be intermittently clamped to allow visualization during the placement of sutures as the parenchymal vessels are ligated.

Front 72

A 62-year-old woman underwent left mastectomy for breast cancer 8 years ago and subsequently developed lymphedema in her arm. Five months ago a raised, pigmented, and slightly tender lesion appeared on her forearm. What do you suspect?

Back 72

Stewart-Treves syndrome = angiosarcoma in setting of lymphedema *-often develop as multicentric lesions that are likely to metastasize. Most of these lesions have been described in breast cancer survivors who have chronic, significant arm lymphedema. They are rarely seen in other forms of lymphedema. The prognosis for survival is poor.

Front 73

what are the RFs for poor prognosis of mangled extremity (there are 3)

Back 73

mangled extremity is defined as injury that involves at least three of the four major tissue systems (bone, soft tissue, vessels, and nerves). *-Several scoring systems, but amputation decision hinges on surgical judgment and the patient's specific circumstances.*-As a general rule, a totally interrupted distal innervation, extensive soft tissue destruction, and bone loss>6 cm in length all portend a grave prognosis for the limb.

Front 74

what is a mattox maneuver?

Back 74

Left-sided medial visceral rotation (Mattox maneuver) exposes the abd aorta and its branches (except the R renal artery). *-Incise the lateral peritoneal attachment of the sigmoid and L colon -> hand is then swept upward lateral to the left colon, kidney, and spleen (RP hematoma greatly facilitates the dissection) *-plane of dissection is developed bluntly in front of the L CIV/CIV and behind the kidney, with the back of the dissecting hand sliding on the posterior abdominal wall muscles. *-The left-sided viscera (left colon, kidney, spleen, and pancreas) are brought to the midline, and the entire length of the abdominal aorta is thus exposed.

Front 75

medial and lateral humeral circumflex arteries originate from the _ artery

Back 75

medial and lateral humeral circumflex arteries: *- both usually originate from the axillary artery

Front 76

__ nerve injury => sensory deficit in the first, second, third, and radial aspects of the fourth digits, weakness in the thenar muscles

Back 76

Median nerve injury => sensory deficit in the first, second, third, and radial aspects of the fourth digits, weakness in the thenar muscles

Front 77

what nerve palsy causes inability to abduct and oppose the thumb due to paralysis of the thenar muscles?

Back 77

median nerve palsy => "ape hand deformity" = inability to abduct and oppose the thumb due to paralysis of the thenar muscles *-Sensory loss in the thumb, index finger, long finger, and the radial aspect of the ring finger *-Weakness in forearm pronation and wrist and finger flexion

Front 78

define minimal arterial injury

Back 78

Can use nonoperative approach for: *-low-velocity injury *-minimal (<5 mm) arterial wall disruption for intimal defects and pseudoaneurysms *-adherent or downstream protrusion of intimal flaps *-intact distal circulation *- no active hemorrhage. **-follow-up vascular imaging is advisable to document healing or stabilization.

Front 79

when a "minimal" vascular injury is treated non-op, what % progress to need surgery

Back 79

Minimal vascular injury (Sabiston): normal vascular exam plus *-asymptomatic nonocclusive intimal flap *-segmental arterial narrowing *-small (<2 cm) pseudoaneurysms *-small AV fistulas seen on imaging

-10% progress to needing open or endovasc repair, most in 1st week

-Failure of the extremity to return to normal perfusion pressure indicates that a more serious injury is present and repair is indicated *-Must follow small PSAs with duplex, more likely than other injuries to progress to needing repair *-"Arteriovenous fistulas always enlarge over time and should be promptly repaired"

Front 80

Because of the extensive collateral blood supply to the upper extremities, arterial infections there can often be treated with simple ligation and excision, esp. if the involved segment is b/w __ + __ artery or distal to the __

Back 80

Because of the extensive collateral blood supply to the upper extremities, arterial infections there can often be treated with simple ligation and excision, esp. if the involved segment is b/w thyrocervical trunk + subscapular artery or distal to the deep brachial artery. *-Reconstruction, when required, should be accomplished with autogenous conduit

Front 81

the "gatekeeper" of a neck dissection for trauma is _

Back 81

the "gatekeeper" of a neck dissection for trauma is the facial vein *-Use a "trail of safety" for safe exploration of an anatomically hostile neck distorted by an expanding hematoma

*1. cervical incision along SCM *2. divide platsyma *3. Dissection to identify the anterior border of SCM, then IJ, then the anterior facial vein along the anterior border of IJ *4. divide facial vein to get access to carotid bifurcaction

Front 82

what is the concern about doing a surgical airway in a patient with an expanding neck hematoma

Back 82

patient presenting to ED with expanding neck hematoma =>

1st priority is orotracheal or nasotracheal airway before the anatomy is distorted

-With surgical airway, the fascial compartments containing the hematoma are opened and tamponade is lost => possible uncontrolled bleeding

-Once airway is secure, imaging is done for zone I and III injuries, zone II may go straight to OR

Front 83

2 options for w/u of asymptomatic zone 2 neck trauma

Back 83

Patients with asymptomatic midcervical injuries (zone 2) may undergo either neck exploration (very low morbidity) or a combination of four-vessel angiography, esophagoscopy, and barium swallow to rule out significant arterial and esophageal injury.

Front 84

Upper extremity ischemia: *-how to differentiate Raynauds vs. other sources of digital ischemia using non-invasive testing

Back 84

Upper extremity ischemia: *-Digital pressures, PPG (photophethysmography) to check waveforms in fingertips

-In vasospastic Raynaud's, digital pressures normal and PPGs are normal or have "peaked pulse" pattern due to increased resistance

-Decreased digital pressures and dampened PPG waveforms in obstruction: Buergers, autoimmune dz, vibratory injury, ESRD, DM

-Can also check PPGs while compressing dialysis fistula to check for steal

Front 85

what percentage of patients with "minimal vascular injury" stabilize or need surgery eventually?

Back 85

Nonop mgmt for arterial trauma: may be appropriate for *-Low-velocity injury *-minimal (<5 mm) arterial wall disruption for intimal defects and pseudoaneurysms *-adherent or downstream protrusion of intimal flaps *-intact distal circulation andn no active hemorrhage. **-follow-up imaging to document healing or stabilization (87% heal/stabilize, but <10% need surgery)

Front 86

what occupational exposure causes ischemic hand sx (initial sx like Raynaud's) with resorption of the distal phalangeal tufts, similar to scleroderma. *-multiple arterial stenoses and occlusions of the digital arteries, along with nonspecific hypervascularity adjacent to the areas of bony resorption.

Back 86

occupational acro-osteolysis: *-in workers exposed to vinyl choloride (used to make PVC, used to be an aerosol propellant in hair spray, also causes liver failure and angiosarcoma)-> ischemic hand sx (initial sx like Raynaud's) with resorption of the distal phalangeal tufts, similar to scleroderma. *-multiple arterial stenoses and occlusions of the digital arteries, along with nonspecific hypervascularity adjacent to the areas of bony resorption. The reason for the hypervascularity is not clear, but it may be related to stasis of contrast medium in digital pulp arteries secondary to shortening and retraction of the fingers. *-Tx = supportive

Front 87

Man presents c/ effort-induced thrombosis of subclavian vein. *Arm pain and swelling increases with activity, decreases with rest. *What is this disease called?

Back 87

Paget- Schrotter disease: *-Effort-induced thrombosis of SCV (upwards of 50% have no recollection of recent strenuous activity)*-Venous thrombosis >> Arterial *-80% have associated thoracic outlet syndrome *-Dx: venography = gold standard *-Presentation: male, pain and swelling increased with activity, decreased with rest *-Tx: THROMBOLYTICS, HEPARIN, WARFARIN, -> may eventually need operation for thoracic outlet syndrome if persistant sx (1st rib resection). Stenting a lesion between the first rib and clavicle is contraindicated, as the stent will be crushed. *- spontaneous recanalization of the axillary and subclavian veins following thrombosis is rare

Front 88

what % of padget schrotter occurs in dominant arm?

Back 88

Paget-Shroetter = effort thrombosis of axillary-SCV due to microtrauma of venous intima with repetitive use. RFs: repitive overhead shoulder movements, coagulopathy => thrombus formation. 90% occurs in dominant arm.

Front 89

approach to pediatric vascular trauma with an occluded vessel but viable limb

Back 89

Few differences from adult vascular trauma: *-Diagnostic arteriography can exacerbate vasospasm and limb ischemia. Consequently, when diagnostic studies are indicated, a noninvasive alternative such as CFD should be considered. *-In a viable, neurologically intact limb with an occlusive injury, the arterial repair can be deferred; in a very young child, this may be preferable.[88] If repair is not performed, careful follow-up of limb growth is necessary, and arterial repair is indicated if a limb-length discrepancy develops.

Front 90

what segment of aortic penetrating trauma is most lethal?

Back 90

high-grade penetrating injury to the abdominal aorta with near transection is rarely seen in the OR b/c usually fatal.*-50-90% mortality for abdominal aortic injuries *

Perirenal aortic segment the most lethal (>80% mortality) > suprarenal (50%-70%) > infrarenal (50%-60%). *-Clean lacerations of the aorta can sometimes be primarily repaired by transverse approximation of the lumen, but more often destruction of the aortic wall mandates prosthetic graft interposition. Despite theoretical concerns that spillage of intestinal content may cause synthetic graft infection, a synthetic graft is the only practical option, and graft infections after placement for penetrating trauma to the aorta have not been reported.

Front 91

Proximal control of penetrating injuries to the innominate vessels and proximal carotid can be obtained from w/in the pericardium. Exposure is enhanced by division of the __

Back 91

Penetrating injuries to the innominate vessels and proximal carotid arteries present intraoperatively as a mediastinal hematoma.

Proximal control can be obtained from within the pericardium where the anatomy is not obscured by the hematoma.

Exposure is enhanced by division of the innominate vein.

Front 92

which 3 arteries need to be repaired

Back 92

must be repaired: *-axillary *-popliteal *-EIV/CFV

Front 93

popliteal trauma -> amputation in up to __% *-repair the vein?

Back 93

Popliteal trauma: *-Amputation in up to 20%, mostly blunt trauma and if nearby musculoskeletal injury *-limited approach with separate above-and below-knee incisions not adequate *-Have to do medical incision from the proximal popliteal space to the distal popliteal space with division of the medial head of the GC, semimembranosus, semitendinosus to expose popliteal artery, vein, and tibial nerve. Approximate the divided muscles when the wound is closed . OR posterior approach if posterior injury, can harvest lesser saphenous vein *-Repair the vein if the clinical circumstances allow, but venous reconstruction does not affect the eventual outcome of the arterial repair.

Front 94

sensitivity and specificity of pedal pulse exam for detecting popliteal artery injuries needing surgery

Back 94

Rutherford ch 155: Another series of blunt injuries focused on 115 patients with knee dislocations. Popliteal artery injury was on angio in 23%. Abnormal pedal pulse ID'd injury with sensitivity 85%, specificity 93%. All injuries that required intervention were associated with a diminished pulse.

Front 95

__ is typically the first branch of the brachial artery

Back 95

profunda brachii is typically the first branch of the brachial artery

Front 96

treatment for massive bleeding from a pulmonary hilum injury

Back 96

In patients who are massively bleeding from pulmonary hilar injuries, the mortality rate is in excess of 70%. In practice, these injuries usually involve more than one element of the pulmonary hilum. Instead of attempting vascular repair of the pulmonary artery or vein in these exsanguinating patients, a rapid pneumonectomy using a linear stapler may prove lifesaving.

Front 97

pitcher presents with finger emboli. *What TWO syndromes need to be considered?

Back 97

quadrilateral space syndrome: area bordered by the teres minor superiorly, the humeral shaft laterally, the teres major inferiorly, and the long head of the triceps muscle medially *-w/in this space= posterior humeral circumflex artery and axillary nerve. *-Compression of the posterior humeral circumflex artery with the arm in the “cocked” position (abduction and external rotation)-> aneurysmal dilatation, emboli, occlusion. Tx: ligation of the posterior humeral circumflex artery.*-anterior humeral circumflex artery provides enough blood to avoid avascular necrosis of the humeral head,

Front 98

rate of radial artery thrombosis after cardiac cath

Back 98

Thrombosis of the radial artery is noted in up to 12% of patients after radial artery cannulation (VESAP 3 says 5-10% thrombosis and 25% stenosis on one question; another question says temporary radial artery occlusion in up to 20% and permanent ischemia .09%. ) *-higher risk with larger sheaths *-improved patient comfort with earlier ambulation and discharge, as well as fewer complications (bleeding, false aneurysms, neuropathic pain syndromes) than with a femoral approach *-If tx'd c/ 4 weeks of anticoagulation are more likely to have arterial recanalization, compared to those patients treated expectantly.

Front 99

what nerve palsy causes wrist drop?

Back 99

radial nerve palsy: *-most common presentation is wrist drop *-If lesions is high above the elbow (eg humerus fracture), then numbness of the forearm and hand may be an additional symptom. *-If the lesion is in the forearm, sensation typically is spared despite the wrist drop. *-If the lesion is at the wrist, patients report isolated sensory changes and paresthesias over the back of the hand without motor weakness.

Front 100

what layers of vessel wall are damaged in radiation arteritis?

Back 100

pathogenesis of radiation-induced arteritis: damage to all layers of the arterial wall. Endothelial cell damage may lead to thrombus formation and inflammation. Medial necrosis has been described with late fibrosis. The vasa vasorum may be obliterated as a result of adventitial scarring. The structural abnormalities that result from radiation exposure may also predispose to later atherogenesis, with lipid deposition and atheroma formation in the region of prior scarring. The result is usually stenosis that may resemble the lesion of atherosclerosis but is located in the region of prior radiation exposure rather than a more typical location

Front 101

treatment for Raynauds

Back 101

Raynaud's: *-rate of progression to connective tissue disorder 11-65% (least for vasospastic type plus negative serology) *-arteriolar vasospasm -> color change from white to blue to red *- up to 90% F, mostly <40 y/o *- hypothesis of increased levels of alpha2 Rs, increased responsiveness to them *-90% respond to avoidance of cold and other stimuli -*remainder need other tx: vasodilators (30-60% response rate) - ca channel blockers diltiazem or nifedipine > phenoxybenzamine, losartan, nitroglycerine SL before cold *-cilostazol can be added if ulceration *-stop beta blockers, ergot alkaloids *-fluoxetine reduces frequency, duration of vasospastic attacks but not 1st line *-IV prostaglandins for severe sx in patients not responding to other meds *-sympathectomy => improvement in 60-70% of pts, but 60% recur w/in 10 yrs. Controversial in UE, less so in LE.

Front 102

Predictors of ulceration, amputation in Raynaud's

Back 102

OBSTRUCTIVE Raynaud's predicts ulceration, amputation, esp if neg. serology:

-Spastic, - serology => 5% ulceration, 2% amputation

-Spastic, + serology (57% have CTD) => 15% ulceration, 2% amputation

-Obstructive, - serology (10% have CTD) => 50% ulceration, 20% amputation

-Obstructive, + serology (80% have CTD) => 55% ulceration, 12% amputation

Front 103

3 indications for angiogram in Raynaud's pt

Back 103

indications for angiogram in Raynaud's: *-suspected proximal obstruction (finger pressure <70 or 20-30 mmHg less than brachial) *-abnormal pulse exam *-digital ulceration *-unilateral symptoms

Front 104

noninvasive testing for Raynauds

Back 104

Digital plethysmography waveforms, digital pressures, cold challenge to diagnose, define vasospastic vs. obstructive Raynaud's: *-in pt c/ symptomatic episodic vasospasm, no tricolor change or ulceration *-Vasospastic: "peaked pulse" @ apex of waveform or in proximal portion of systolic downstroke *-Obstructive: blunted or dampened waveform *(digital pressure 20-30 mmHg less than brachial = digital artery obstruction) *-Cold challenge: check % drop in cold finger vs. control finger

Front 105

obstructive RS: in patients monitored>10 years, ~__ required digital or phalangeal amputations

Back 105

Patients with obstructive RS follow a more virulent course. >50% get digital ulcerations, 20% digital or phalangeal amputations

Front 106

definition of primary Raynauds

Back 106

Primary Raynaud's= episodic pallor or cyanosis of the fingers due to vasoconstriction of the small arteries or arterioles in the fingers occurring in response to exposure to cold or emotional stress. *-young women most common, usually benign course. *-Prolongation of the fingertip temperature recovery time on the cold immersion testing is usually seen. *-primary Raynaud's syndrome defined by normal UE pulse exam, no underlying occlusive disease such as scleroderma or other collagen vascular diseases.

Front 107

treatment for pt with obstructive Raynaud's and digital ulceration, no longer responding to nifedipine

Back 107

add cilostazol to vasodilator therapy for Raynaud's patient with ulcer

Front 108

usual presentation of blunt renovascular injury *-If revasc is done, must be done within what period of time?

Back 108

Penetrating injuries to the renal arteries usually require nephrectomy b/c complex reconstruction of the renal artery is difficult in the setting of ass'd injuries. *-Blunt renovascular deceleration trauma: usually asymptomatic, discovered when a kidney doesn't opacify on CT. *-Dx: arteriography required, may document injuries ranging from intimal tear to complete renal artery thrombosis. Diagnostic delay is common b/c usually accompanied by other serious injuries; renal salvage by major vascular reconstruction usually not practical option. *-Even in good operative candidate, do not repair if > 4-6 hours since the injury and the renal artery is occluded

Front 109

a large, contained R-sided suprarenal retrohepatic hematoma is best managed by __

Back 109

Large, contained R-sided suprarenal retrohepatic hematoma is best managed by leaving the hematoma alone *-No evidence that pseudoaneurysm or thrombosis will happen if a contained R sided RP hematoma is left alone => no need to control bleeding that is not going into the peritoneal cavity

Front 110

what nerve is in close proximity to EIA when doing RP exposure? *Where is the ureter?

Back 110

genitofemoral nerve *Ureter is descending anterior and a little medial to EIA **How to: extend the femoral incision through the inguinal ligament or make a separate incision parallel to the lateral border of the rectus sheath and 2 cm above the inguinal ligament (Fig. 155-4). Rectus muscle is retracted medially, the transversalis fascia is incised, and the retroperitoneal space is entered. Peritoneum and its contents are reflected medially

Front 111

biggest RF for UE vascular disease

Back 111

RFs for UE vascular dz: *-smoking = #1 *-non-atherosclerotic (e.g. giant cell) up to 20% of lesions requiring intervention or surgical bypass

Front 112

what is the anatomic boundary marking the transition between the subclavian and axillary arteries

Back 112

lateral border of the first rib is the anatomic boundary marking the transition between the subclavian and axillary arteries

Front 113

3 portions of SCA

Back 113

SCA: *-1st part travels to medial border of ant scalene. anterior to vagus and phrenic nerves. posterior to sternohyoid, SCM. branches = vertebral, internal thoracic, thyrocervical trunk

-2nd part travels posterior to ant scalene. branch = costocervical trunk. SCV located inferior and anterior.

-3rd part starts at lateral border of ant scalene *-becomes axillary @ lateral border of 1st rib, gives rise to dorsal scapular

Front 114

where is the SCA located?

Back 114

The structures of the lateral neck from anterior to posterior are: *Subclavian Vein, Phrenic Nerve, Ant. Scalene, SCA, Brachial Plexus, Middle Scalene, Long Thoracic nerve, Posterior Scalene

Front 115

what incision for trauma to L SCA and descending thoracic aorta?

Back 115

trauma to L SCA and descending thoracic aorta => left thoracotomy

Front 116

Stroke and amputation with axillosubclavian arterial trauma occur in < _ of patients, all-cause mortality of _-_%

Back 116

While no mortality benefit has been appreciated comparing the endovascular and open approach, endovascular management takes less time, less IV fluid and blood loss. *-Reasonable mid-term outcomes of stent-grafting. Reintervention in <10%, mostly percutaneous *-Stroke and amputation with axillosubclavian arterial injury occur in < 2% of patients, all-cause mortality of 10-20%. *-DuBose JJ, Rajani R, Gilani R, Arthurs ZA, Morrison JJ, Clouse WD, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury 2012; 43:1785-92. *-Sinha W, Patterson BO, Ma J, Holt PJ, Thompson MM, Carrell T, et al. Sytematic review and meta-analysis of open surgical and endovascular management of thoracic outlet vascular injuries. J Vasc Surg 2013; 57:547-67.

Front 117

Asymptomatic SCA stenosis occurs in up to __% of large angiographic series

Back 117

Asymptomatic SCA stenosis occurs in up to 17% of large angiographic series. In this group of patients, proximal stenosis or occlusion is often well tolerated as collateral circulation can maintain adequate flow to the arm. If reversal of flow from the vertebral artery causes subclavian steal symptoms, intervention is warranted by open surgical or endovascular means.

Front 118

what is problematic about SCA injury

Back 118

SCA injury: *-often with major musculoskeletal injury *-brachial plexus injury

Front 119

most appropriate management strategy for a patient who sustains a low velocity gun shot wound (GSW) to the mid-right SCA?

Back 119

low velocity gun shot wound (GSW) to the mid-R SCA -> *femoral access, innominate, subclavian selective arteriography and stent-graft **-Open control of R SCA injury is via a median sternotomy with clavicular extension. *-L SCA artery control may require 4th ICS anterior thoracotomy. Selective use of a supraclavicular incision +/- clavicular resection, or combined supraclavicular and infraclavicular incisions, depending on injury location. May use proximal inflow balloon occlusion. **endovascular mgmt: less time, less IV fluid and blood loss. *Reasonable mid-term outcomes of stent-grafting for SCA injury. Reintervention in <10%, mostly percutaneous. stroke and amputation with axillosubclavian arterial injury in <2%, all-cause mortality of 10-20%.

Front 120

brachial plexus and SCA pass through what anatomic space to leave the thorax? *what are the borders?

Back 120

Scalene triangle: *-anterior = anterior scalene *-posterior = middle scalene *-inferior = 1st rib *-w/in traingle: spinal nerve roots C5-T1 (coalesce to be brachial plexus) and SCA *(SCV coarses anterior to anterior scalene, not in triangle)

Front 121

shunting of arterial injuries: *-miltary report _% patency above elbow/knee, __% patency below. Limb viabiliaty in _% of shunted limbs.

Back 121

shunting of arterial injuries: *-miltary report 86% patency above elbow/knee, 12% patency below. Limb viabiliaty in 92% of shunted limbs. *-Early occlusion RFs include lack of venous outflow, compartment syndrome

Front 122

SMA originates from the anterior surface of the aorta, immediately below the celiac artery, behind the pancreas at the L_ level. *Exposure of the infrapancreatic SMA can be achieved by 2 approaches

Back 122

SMA originates from the anterior surface of the aorta, immediately below the celiac artery, behind the pancreas at the L1 level. It then proceeds over the uncinate process of the pancreas and the third part of the duodenum and enters the root of the mesentery. *-SMA branches: inferior pancreaticoduodenal artery, middle colic, arterial arcade with 12-18 intestinal branches, R colic artery, and ileocolic artery

-Exposure of the retropancreatic SMA by medial rotation of the left colon, gastric fundus, spleen, and tail of the pancreas,

-Exposure of the infrapancreatic SMA can be achieved by cephalad retraction of the inferior border of the pancreas and direct dissection, or it can be achieved through the root of the small bowel mesentery by incising and dissecting the tissues to the left of the ligament of Treitz. An extensive Kocher maneuver may be required to expose this segment of the SMA. More distal sections of the SMA can be approached directly.

Front 123

IF SMA must be ligated proximally for trauma, ligation proximal to the origin of the __ artery may preserve collaterals to proximal jejunum

Back 123

SMA penetrating injury => 50% survival *25% survival if repair more complex than lateral arteriorrhaphy is needed *-Because mobilization of the SMA is restricted by the surrounding dense neuroganglionic tissue and its multiple branches, an end-to-end anastomosis is rarely possible. **-IF SMA must be ligated proximally, ligation proximal to the origin of the inferior pancreaticoduodenal artery may preserve collaterals to proximal jejunum *-For penetrating trauma or blunt trauma + ischemic bowel => all hematomas around the SMA should be explored. *-Don't explore stable hematomas after blunt trauma without ischemia. Get postop angio or duplex.

Front 124

Patients with what grade of blunt spleen trauma should be treated with embolization if nonoperative management is chosen

Back 124

patients with high-grade blunt splenic injuries (grades 4 and 5) should be treated with embolization if nonoperative management of BSI is chosen. *-Grade 3 = subcapsular/ intraparenchymal hematoma >50% of SA or expanding, laceration >3 cm deep or involving trabecular vessels, ruptured subcapsula/parenchymal hematoma *-Grade 4 = laceration involving segmental or hilar vessels with major devascularisation (>25% of spleen) *-Metaanalysis of non-op mgmt and splenic embolization for blunt splenic injury (2GL Moneta: Nonoperative Management of Adult Blunt Splenic Injury With and Without Splenic Artery Embolotherapy: A Meta-Analysis. J Vasc Surg. 55 (3):886 2012): *_failure rate for nonoperative management was 8.3% (95% CI, 6.7%-10.2%). *-Failure of non-op mgmt increased from 5 % to 83% in patients with splenic injury grades from 1 -> 5. *-In grades 4 and 5, less failure if embolization done: 44% vs 17% and 83% vs 25%. **-Lovenox at <72 hrs post-injury does not increase the risk of failure of non-op mgmt, although no consensus on when to start treatment

Front 125

A 20-year-old man is brought to the emergency department with a gunshot wound to the sternal notch. He is hemodynamically stable. An arteriogram shows two major vascular injuries: a false aneurysm of the proximal left common carotid artery 3 cm from its origin and contained extravasation of contrast from the proximal left SCA 4 cm from its origin. Which of the following is the ideal operative exposure for open repair of both injured arteries?

Back 125

left anterior trapdoor incision (left anterior thoracotomy, partial superior median sternotomy, left supraclavicular incision). *-left anterior thoracotomy (4th ICS) would allow for proximal control of the left SCA and possibly the left common carotid artery, but repair of either artery would be extremely difficult through this incision alone *-best exposure = trapdoor incision = anterior thoracotomy with partial superior median sternotomy and left supraclavicular incision (rarely used due to morbidity) *-left supraclavicular incision alone would not allow proximal control of either artery. *-median sternotomy alone would provide excellent exposure of the left common carotid artery, but difficult to gain proximal control and repair the left SCA.

Front 126

risk of cerebrovascular ischemia during SCA angioplasty and stenting

Back 126

Cerebrovascular ischemia complicates 3-9% of SCA angioplasty and stenting cases, R>L due to proximity of the common carotid artery to the subclavian lesion. *-most likely cause of this is embolization secondary to wire manipulation in the arch *Higashimori A, Morioka N, Shiotani S, et al. Long-term results of primary stenting for SCA disease. Catheter Cardiovasc Interv 2013, 82: 696-700.

Front 127

A 56 year old female experiences lightheadedness when peeling potatoes. When she stops using her right arm, the symptoms rapidly resolve. Extensive workup reveals a stenosed artery. Where is the anatomical location of the stenosis?

Back 127

Right SCA proximal to the vertebral artery

Front 128

treatment for subclavian steal

Back 128

Treatment for subclavian steal *-Angioplasty of SCA stenosis *-Carotid subclavian bypass if carotid is patent. Patency rates with prosthetic superior to saphenous vein *-Bypass grafting from the ascending aorta requires a median sternotomy: endarterectomy of proximal L SCA requires a thoracotomy.

Front 129

what BP gradient suggests subclavian steal?

Back 129

Subclavian steal - steals from the posterior brain, upper extremity and, following internal mammary coronary bypass, the coronary circulation. *-30 mmHg pressure gradient b/w 2 arms*-Vertebrobasilar sx may be exacerbated by upper extremity activity but this occurs in a minority of patients. *-Coronary-subclavian steal has been reported in patients with internal mammary coronary grafts that arise distal to a subclavian stenosis or occlusion. *-Asymptomatic subclavian steal, manifest as reversal of flow in the ipsilateral vertebral artery, represents a normal physiological response to proximal subclavian occlusion, is not associated with an increased risk of stroke and rarely warrants intervention.

Front 130

incisions for R and L SCA trauma

Back 130

R SCA: median sternotomy + R cervical extension. *-L SCA: proximal control via L anterior thoracotomy, separate supraclavicular incision for distal control. Can connect the 2 incisions c/ sternotomy to facilitate exposure ("book thoracotomy'). Used sparingly b/c risk of postop causalgia

Front 131

Phrenic nerve - *from cervical nerves C_-C_ *-where is it found in relation to the SCV?

Back 131

SCV travels through triangular space bounded by subclavius muscle and tendon, 1st rib, and anterior scalene muscle *-SCV and SCA separated by attachment of ant. scalene to scalene tubercle on superior surface of 1st rib. *-Phrenic nerve arises from cervical nerves C5-7, crosses diagonally from lateral-> medial on anterior surface of the ant. scalene. Lies DEEP to SCV, NOT encountered during dissection of the anterior surface of the subclavian vein.

Front 132

L SCA transposition onto L CCA: *1. transverse supraclavicular incision over the two heads of the SCM. *2. develop subplatysmal flap *3. carry dissection down b/w 2 heads of SCM. *4. ligate + divide the __ and __ *5. divide the __ muscle to improve exposure of the proximal SCA and origin of the vertebral artery...

Back 132

L SCA transposition onto L CCA: *1. transverse supraclavicular incision over the two heads of the SCM. *2. develop subplatysmal flap *3. carry dissection down b/w 2 heads of SCM. *4. ligate + divide the thoracic duct and L vertebral vein. *5. divide the omohyoid muscle to improve exposure of the proximal SCA and origin of the vertebral artery. (anterior scalene not usually divided b/c dissection involves the more proximal segment of the SCA. *6. ligate + divide the L SCA proximal to L vertebral artery *7. anastomose L SCA to the side of L CCA posterior to the jugular vein.

Front 133

__= largest branch of the axillary artery *-courses towards the inferior angle of the scapula, where it anastomoses with the lateral thoracic and intercostal arteries and descending branch of the dorsal scapular artery

Back 133

Subscapular artery = largest branch of the axillary artery *-Arises at the lower border of the Subscapularis muscle, which it follows to the inferior angle of the scapula, where it anastomoses with the lateral thoracic and intercostal arteries, descending branch of the dorsal scapular artery *-2 branches ~ 4 cm. from its origin: scapular circumflex artery and thoracodorsal artery.

Front 134

SMA trauma: *-proximal SMA is exposed by _ *- infrapancreatic SMA is accessed 2 possible ways__

Back 134

SMA/SMV injuries *-present as exsanguinating hemorrhage from the root of the mesentery, supramesocolic central RPH, or ischemic bowel.

-proximal SMA is exposed by L-sided medial visceral rotation (Mattox)

- infrapancreatic SMA is accessed by pulling the small bowel down and to the L and incising the peritoneum of the root of the mesentery OR Cattell-Braasch maneuver (mobilize colon -> extended Kocher manoeuvre to mobilise the duodenum -> mobilize the root of the small bowel mesentery up to the SMA and inferior border of the pancreas) *-Close proximity of the mesenteric vessels to the pancreatoduodenal complex, IVC, and R renal pedicle means that severe associated injuries are the rule, opportunities for reconstruction are rare, and mortality is very high. *-Temporary SMA shunt for damage control has been reported. *-If an SMA interposition graft is required, should takeoff from the distal aorta above the bifurcation to keep the suture line away from an injured pancreas. *-2nd-look laparotomy is mandatory to assess the viability of the bowel. *-SMV injury is repaired by lateral venorrhaphy when possible. Often the only technical option is ligation, which requires aggressive postoperative fluid resuscitation to compensate for ensuing massive splanchnic sequestration and may lead to venous gangrene of the bowel. 2nd-look laparotomy is mandatory.

Front 135

53yr old steel mill worker who presents to the Emergency Room with a right arm redness, rash, and Horner’s syndrome should have what test ordered?

Back 135

CT chest. This patient is presenting with SVC compression with associated Horner Syndrome. These are classically associated with an apical lung neoplasm, known as as a Pancoast Tumor. Pancoast lesions generally occur in the superior lung sulcus causing impingment on the sympathetic chain with SVC compression. Horner’s Syndrome, aka: oculosympathetic palsy, is defined by: pitosis, meiosis, ipsilateral anhidrosis, enopthalmos.

Front 136

when doing a sympathectomy, dissection of what ganglion is associated with postop horner's syndrome?

Back 136

Horner's syndrome: 2/2 direct or indirect injury to the stellate ganglion. From transmission of heat when performing T2 thermoablation or from excessive traction on the sympathetic chain *-SE of complete sympathetic denervation of the upper limb when the stellate, T2, and T3 ganglia are resected. *-Rare for HH sympathectomy b.c only T3 or T4 is manipulated nowadays

Front 137

cervical sympathectomy: to reduce the incidence of Horner's, the proximal extent of sympathetic resection is marked by __

Back 137

Patients with disabling nTOS may have painful vasospasm 2/2 sympathetic overactivity, delayed healing of digital skin lesions, and type 1 CRPS (RSD). *(CRPS-I can be confirmed with nononvasive studies showing abnormal vasoconstrictive responses (cold pressor tests) or imaging studies of the hand microcirculation) *-Thoracic outlet decompression can be accompanied by cervical sympathectomy *The cervical sympathetic chain is first identified by palpation through the supraclavicular wound as a rubber band–like structure passing vertically over the neck of the first or second rib *To reduce the incidence of Horner's syndrome, the proximal extent of sympathetic resection is marked by the lower half of the stellate ganglion.

Front 138

decrease compensatory HH by performing thermoablation of only the __ ganglia for palmar or axillary HH

Back 138

Compensatory HH has a high correlation with the level and extent of resection. The higher the interruption/ resection of the sympathetic chain, the more the afferent fibers responsible for inhibition of sweating would be harmed *-decrease compensatory HH by performing thermoablation of only the T4 ganglia for palmar or axillary HH

Front 139

what is the kuntz nerve?

Back 139

Kuntz nerve: present in 40-80% of population *-connecting nerve from 2nd thoracic nerve to 1st intercostal nerve (which is 1 of the 2 main branches of the 1st thoracic nerve) *-Sympathetic denervation of the upper limb needs to be as complete as possible if sympathectomy is used for CPRS, PAD, and Raynaud's; hence, the stellate ganglion, T2, and T3 should be included. To avoid incomplete denervation of the limb, the communicating branches of T1 and Kuntz's nerve have to be ablated as well.This approach is always associated with the presence of Horner's syndrome.

Front 140

sympathectomy level of denervation: what level for CRPS, vascular dz, and Raynaud's?

Back 140

sympathectomy level of denervation: *-T2: craniofacial HH, facial rubor *-Stellate ganglion, T2, T3: CRPS, vascular dz, Raynaud's *-T3 or T4: palmar HH *-T4: axillary HH *-L side from stellate ganglion to T4 or T5: Long QT syndrome **-Not recommended for Raynaud's b/c vasospasm recurs in 50% and compensatory HH in >60%. Doesn't work for CPRD if joint contracture or nerve atrophy has already occured

Front 141

what is the stellate ganglion? *-where is it located in relation to the SCA?

Back 141

The inferior cervical ganglion is generally fused with the first thoracic ganglion (T1) to form the cervicothoracic ganglion (stellate ganglion) *- located anterior to the head of the first rib, covered by pleura. located anterior to the transverse process of C7, superior to the neck of the first rib, and just below the SCA. behind the verebral artery origin. **-Sympathetic preganglionic fibers to sm muscle of eye are rostral to roots of T1, T2 => resection of stellate ganglion causes Horner syndrome (enopthalmos, myosis, ptosis)

Front 142

indications for thoracic sympathectomy

Back 142

Rutherford 121: Indications for thoracic/cervicodorsal sympathectomy:

*T3 and T4 for essential hyperhidrosis (+/- T2 for face) *-selected cases of critical ischemia of the hand (TAO and distal arterial obstructions, ulcers in the fingers, or ischemic pain)

-stellate ganglion, T2, and T3 for complex regional pain syndrome (CRPS, type I = reflex sympathetic dystrophy, type II = causalgia)

-L stellate ganglion to T4 or T5 for long QT syndrome c/ syncopal episodes refractory to clinical treatment

-Raynaud's syndrome.

Front 143

Thoracoscopic sympathectomy is most effective for treatment of __ . *Most common complication is of sympathectomy for this indication is __

Back 143

Thorascopic sympathectomy has been used to treat a number of upper extremity conditions, best for palmar hyperhidrosis. It is a less effective treatment for complex regional pain syndrome of the upper extremity or for Raynaud's-related ulceration. Local (digital) sympathectomy may assist healing of an ulceration caused by digital vasoocclusive disease. The most common complication of thoracoscopic sympathectomy for palmar hyperhidrosis is axillary and truncal sweating. Injury to the stellate ganglion during sympathectomy results in Horner's syndrome.

Front 144

avoid horner syndrome after upper extremity sympathectomy by preserving __

Back 144

avoid horner syndrome after upper extremity sympathectomy by preserving the upper half of the stellate ganglion *-used for palmar hyperhidrosis, complex regional pain syndrome, sometimes Buergers and Raynaud's with tissue loss not controlled with non-surgical mgmt

Front 145

30F presents with progressive ischemia of L hand over 3 months. Pprolonged febrile illness 1 year ago. L brachial pressure is 60 mmHg. ESR normal. Angio: occlusion of L SCA,reconstitution @ vertebral artery. Moderate disease in the innominate and L CCA. Best tx = _

Back 145

Takayasu's arterities: *-suggested by prior febrile illness and occluded great vessel at the AORTA in a young female *-8:1 female:male *-First line: corticosteroids. other anti-inflammatory agents e.g. azathioprine and methotrexate for refractory disease *-<20% require revascularization. Indications for intervention: persistent arm claudication, TIAs, or global cerebral ischemia *-Several reports state better patency of open bypass over endovascular *-If revascularization needed, the general principle is to use an UNINVOLVED VESSEL (e.g., the ascending aorta). *-Not endarterectomy b/c inflammation is full-thickness *- Extraanatomic bypass using cervical vessels for inflow is vulnerable to progression of disease. *-angioplasty has restenosis in> 50% of patients at mid-term f/u. Some suggestions that stent grafts may be superior to BMS *-Steroids are beneficial during the inflammatory phase, but little benefit during the later "pulseless" phase Gallagher KA, Tracci MC, Scovell SD.Vascular arteritides in women. J Vasc Surg 2013; 57:27S-36S. *Qureshi MA, Martin Z, Greenberg RK. Endovascular management of patients with Takayasu arteritis: stents versus stent grafts. Semin Vasc Surg 2011; 24(1):44-52.

Front 146

what vasculitis affects the more proximal elastic arteries, with destruction of medial elastic fibers.

Back 146

Takayasu's arteritis: large vessel vasculitis *-affects the more proximal elastic arteries, with destruction of medial elastic fibers. *-subclavian, carotid > aorta and its branches, PA, coronaries, heart valves *-Path: granulomatous panarteritis with a skip pattern. Positively and negatively associated with certain HLA haplotypes. *-Sx: angina, stroke, renovisceral insufficiency, or claudication. *-Some sx 2/2 systemic inflammation: constitutional sx, fever, HA, myalgia. *-Some sx are 2/2 arterial inflammation e.g. carotodynia *-ESR usually elevated during the active phase BUT absence of ESR, fever, and vessel tenderness are not reliable indicators of quiescence *-Imaging: thickened arterial walls on duplex/ MRA,/CTA, arteriographic evidence of stenosis, occlusion, or aneurysm. *-18F-FDG-CT-PET: active increased uptake in arterial walls c/w active inflammation *-Revascularization may be needed urgently (15-70% according to the study; VESAP3 days <20% need intervention) *-durability after reconstruction is related to steroid dependence and clinical activity of disease. *-Restenosis rates of 20-40%, anastomotic aneurysm formation in 10-20% *-Endovascular intervention is controversial, but good results reported for in focal stenoses without active disease

Front 147

6 diagnostic crteria for Takayasu's arteritis *(must have 3/6)

Back 147

American College of Rheumatology diagnostic criteria for Takayasu arteritis (at least 3 of the 6 criteria): *1. ) onset age 40 or earlier *2.) extremity claudication *3.) decreased unilat/bilat brachial pulses *4.) 10 mmHg difference in UE BPs *5.) Bruit over SCA or aorta *6.) Arteriographic narrowing or occlusion of the aorta, its primary branches, or large arteries in the proximal upper or lower extremities, not due to arteriosclerosis, fibromuscular dysplasia, or other causes ***- affects women in 80-90% of cases, with the age of onset typically between 10 and 40 years *-Acute phase reactants, including elevated erythrocyte sedimentation rate (ESR), increased serum C-reactive protein (CRP) and α-2 globulin concentrations, and hypoalbuminemia, reflect the inflammatory process characteristic of the early, active phase of the disease. Inflammatory symptoms and biomarkers are often absent in the later stages of the disease.

Front 148

A 75 year old woman has had 4 weeks of occipital head and neck pain and over the past several days has been experiencing exercise-induced pain in the left upper extremity. Radial and ulnar pulses are not palpable on the affected side. Her erythrocyte sedimentation rate is 98 mm/ hr. The most common finding on arteriography of the extremity would be

Back 148

Temporal arteritis and polymyalgia rheumatica: overlapping inflammatory conditions : *-Typical pt: >50 y/o (ave. onset @ 70), no. European ancestry, 2:1 F:M. *-polymyalgia rheumatica more common, 1:200 persons >50 y/o (vs. 1.8:100,00 for temporal arteritis -more dangerous b/c of risk of sudden blindness and arterial stenoses) *-50-90% of temporal arteritis pts initially have signs of polymyalgia rheumatic - suspect if fever, nonspecific somatic complaints, pain and stiffness in the shoulder and pelvic girdles, elevated ESR. *-temporal arteritis: headaches and tenderness to palpation over the involved artery. angio shows bilateral tapered stenosis or occlusions of the axillary arteries. *-Treatment: 6-24 months of corticosteroids

Front 149

what incisions for thigh compartment syndrome? how many compartments?

Back 149

thigh compartment syndrome: *-3 compartments: lateral incision for lateral compartment, medial incision for medial and posterior compartments *-most common cause of thigh compartment syndrome = thigh crush injury associated femur fracture

Front 150

mortality of open repair of thoracic aortic injury *-Paraplegia rate

Back 150

mortality of open repair of thoracic aortic injury = 19% (11-40% in Sabiston) vs. 3% for endograft *-Average paraplegia rate of open repair 13%

Front 151

nerve conduction velocities for neurogenic TOS: 60-85 m/sec => tx should be __

What is threshold for needing surgery?

Back 151

nerve conduction velocities for neurogenic TOS: *Normal >85 m/sec *60-85 m/sec => PT *<60 m/sec probably needs surgery

Front 152

Pt works as a pitcher, presents c/ funny arm symptoms. *Suspect _ *(maximal arm abduction -> absent radial pulse)

Back 152

Thoracic outlet syndrome: *-Normal anatomy: Branchial plexus + SCA superior to 1st rib, posterior to ant scalene, anterior to middle scalene. *-Pitchers can get anterior scalene hypertrophy -> SCA compression. (-) RADIAL PULSE WITH MAXIMAL ARM ABDUCTION. *-Adson's test: turn head to ipsilateral side -> compresses SCA -> decreases radial pulse *-Tinsel's test: tapping reproduces sx *-Dx: CXR, C spine x-ray, angiography if thought to be vascular etiology, EMG *-Tx for PITCHERS: cervical rib + 1st rib resection, divide anterior scalenes, BYPASS GRAFT

Front 153

For a superior approach for thoracic outlet syndrome repair, where is the phrenic nerve

Back 153

Thoracic outlet syndrome: *-Phrenic nerve is anterior to anterior scalene *-Long thoracic nerve is posterior to middle scalene (or does it traverse middle scalene?)*-Branchial plexus + SCA go through a triangle = superior to 1st rib, posterior to ant scalene, anterior to middle scalene. SCV also over 1st rib but anterior to ant scalene.

Front 154

pt has TOS and imaging shows cervical rib or anomalous 1st rib. *What type of TOS do you expect them to have? *-Treatment is _

Back 154

Arterial TOS *-cervical rib 63% > anomalous 1st rib 22% > fibrocartilagenous band 10% > clavicle fx 4% > enlarged C7 transverse process 1% *-Complication: poststenotic aneurysmal dilatation of SCA, possible embolism *-Resect the problematic rib, divide anterior scalene, reconstruct artery if intimal damage, mural thrombus, and/or aneurysm. - tran axillary can't be done if arterial reconstruction needed

Front 155

pt has TOS and imaging shows congenital narrowing of the thoracic inlet (or pt reports history of trauma) *What type of TOS do you expect them to have?

Back 155

Congenital narrowing of the thoracic inlet (or history of trauma), compression of brachial plexus roots within scalene triangle => neurogenic TOS *-Preop PT and CT guided block. Scalenectomy + 1st rib resection.

Front 156

what type of TOS is an MVC most likely to cause?

Back 156

Neurogenic TOS (Rutherford ch 122): *-95% of TOS *-Etiology: neck trauma e.g. whiplash, repetitive stress injury at work, falls on floor or ice *-RFs: cervical rib, congenital band, scalene triangle muscle variations *-Pathology: scalene muscle fibrosis. occasionally anaomalous 1st rib or cervical rib Sx: extremity pain, paresthesia, weakness (ulnar 90%, radial 10%), neck pain + occipital HA, Raynaud's phenomenon, chest pain for pec minor syn *-Exam:(+) provocative maneuvers, tenderness over scalenes and pec minor *-neurogenic TOS suggested by relief of symptoms with scalene muscle block; also predicts success with surgery *-May get MRI preop to r/o other conditions *-Tx: physical therapy 1st. Scalenectomy +/- rib resection or transaxillary rib resection, pec minor tenotomy

Front 157

what type of TOS is caused by whiplash?

Back 157

Neurogenic TOS: *-neck trauma (auto accident c/ whiplash), RSI @ work, falls on floor or ice

Front 158

athlete presents with paresthesias of L 4th + 5th fingers, supraclavicular tenderness. *Sx reproduced with 90 abduction and external rotation. *-Treatment: first and second line

Back 158

neurogenic TOS: compression w/in scalene triangle *-lower 2 roots of branchial plexus (C8, T1) involved in 90% => ULNAR distribution *-2nd most common = upper 3 roots of brachial plexus (C5-7) => sx referred to neck, ear, upper chest, upper back, outer arm in RADIAL distribution *- relief of symptoms with scalene muscle block; also predicts success with surgery (be sure not to inject the entire brachial plexus) *-Nerve conduction studies and electromyography (EMG) usually (-) b/c nerve dysfx may be intermittent and b/c nerve roots are compressed @ the thoracic outlet = proximal to the location of the nerves evaluated by NCS and EMG *often intermittent *-1st line = physical therapy *-2nd line = anterior scalenectomy +/- rib resection or transaxillary 1st rib resection, pec minor tenotomy

Front 159

scalene muscle hypertrophy predisposes to what type of TOS?

Back 159

Scalene muscle hypertrophy plays an etiologic role in neurogenic thoracic outlet, but is less important in contributing to arterial compression.

Front 160

Pt has cervical rib, presents c/ triceps weakness and atrophy, weakness of intrinsic hand muscles, weak wrist flexion. *What nerve is affected? *C_-T_?

Back 160

Thoracic outlet syndrome: *-Normal anatomy: Branchial plexus + SCA go through a triangle = superior to 1st rib, posterior to ant scalene, anterior to middle scalene. SCV also over 1st rib but anterior to ant scalene. *-#1 anatomic abnormality = CERVICAL RIB Others: congential band, scalene triangle muscle variations *-Ulnar distribution 90% (C8-T1) = inferior brachial plexus: weakness of triceps, intrinsic hand muscles, wrist flexion *-Radial distribution = superior brachial plexus: finger extensors, wrist extension *-Tinsel's test: tapping reproduces sx *-Dx: CXR, C spine x-ray, scalene muscle block, EMG *-Tx: anterior scalenectomy +/- rib resection or transaxillary 1st rib resection, pec minor tenotomy

Front 161

What is the most common anatomic abnormality causing thoracic outlet syn? *Most common presentation?

Back 161

Thoracic outlet syndrome: *-Normal anatomy: Branchial plexus + SCA go through a triangle = superior to 1st rib, posterior to ant scalene, anterior to middle scalene. SCV also over 1st rib but anterior to ant scalene. *-Scalene muscle hypertrophy plays an etiologic role in neurogenic thoracic outlet, but is less important in contributing to arterial compression. *-#1 anatomic abnormality = CERVICAL RIB Others: congential band, scalene triangle muscle variations *-Ulnar distribution 90% (C8-T1) = inferior brachial plexus: weakness of triceps, intrinsic hand muscles, wrist flexion *-Radial distribution = superior brachial plexus: finger extensors, wrist extension *-Tinsel's test: tapping reproduces sx *-Adson's test: sx reproduced with pt seated, breathes in, moves head towards effected side (but 11-49% of healthy people have loss of the radial pulse with the Adson test) Also when ipsilateral arm extended at 180 deg *-Dx: CXR, C spine x-ray, scalene muscle block, EMG *-Tx: anterior scalenectomy +/- rib resection or transaxillary 1st rib resection, pec minor tenotomy

Front 162

when doing supraclavicular scalenectomy and neurolysis - *when detaching the middle scalene from 1st rib with a periosteal elevator - protect the _ nerve

Back 162

Supraclavicular scalenectomy and neurolysis: *1) cercumferentially mobilize the anterior scalene from the SCA and roots of the brachial plexus *2.) cut insertion of the ant scalene on 1st rib with scissors . *3). anterior scalene reflected superiorly, dissected free of underlying structures to its origin. Remove muscle fibers passing b/w the upper roots of the brachial plexus, including the scalene minimus muscle *4.). resect all perineural scar tissue to complete dissection of the brachial plexus nerve roots from C5 to T1 *5.) detach middle scalene from 1st rib with a periosteal elevator - protect the long thoracic nerve! (supplies serratus anterior, injury causes winged scapula) All muscle tissue lying anterior to the long thoracic nerve is resected.

Front 163

treatment for subclavian vein thrombosis 2/2 TOS

Back 163

1. fibrinolysis, anticoagulation *2. If thrombolysis successful, assess for extrinisic compression (do not do PTA at this point) *3, Thoracic outlet decompression (1st rib resection) and intraoperative PTA if necessary or endovenectomy with vein patch. *(Rutherford ch 122, 125)

Front 164

treatment for subclavian vein thrombosis 2/2 TOS

Back 164

subclavian vein thrombosis 2/2 thoracic outlet obstruction. *-2:1 male : female. average age ~30 *-often c/ history of repetitive/strenuous arm activity. 60% in dominant arm. -*treatment of choice = catheter-directed thrombolysis followed by first rib resection, +/- open or endovasc treatment of defect in vein. *(stenting has high recurrence rate and direct open thrombectomy and resection is morbid, so don't treat a significant stenosis unless symptomatic). *-in pt c/ vein stenosis not adequately treated with angioplasty, and vein is totally occluded or vein patch not desired => jugulosubclavian bypass

Front 165

what % of TOS is venous?

Back 165

Thoracic outlet syn: neurogenic 95% < venous 4-5% < arterial **-up to 25% of venous TOS patients have symptoms of pain and swelling due to compression of the subclavian vein in the absence of thrombosis. *-Diagnostic studies will often be normal with the arm in a neutral position and will show signs of venous outflow obstruction only with provocative abduction of the affected arm. *-Abnl 1-second venous outflow fraction measured with venous plethysmography with the arm in abduction may be predictive of symptomatic relief with first rib resection.

Front 166

What is the rate of symptom resolution after surgery for venous thoracic outlet syndrome?

Back 166

Thoracic outlet syndrome: *- 60-80% success rate after surgery for venous throacic outlet syndrome. 20% have recurrence

Front 167

46M presents with LUE swelling and pain, cyanosis, distended veins over shoulder and chest. Historically gets worse with overuse . *-Most likely underlying anatomic defect = _

Back 167

Venous TOS (Rutherford ch 122): *-Etiology: congenital narrowing costoclavicular space (costoclavicular ligament or subclavius muscle/subclavian tendon surround SCV as it passes b/w 1st rib and clavicle) *-subclavius muscle plays a significant role in venous thoracic outlet syndrome by compressing the anterior/cranial surface of the subclavian vein. *-Pathology: SCV stenosis +/- thrombosis *-Diagnostic test: venogram (best), duplex *-Nonsurg tx: fibrinolysis, anticoagulation *-Surgery: 1st rib resection and SCV lytic plus postop PTA if necessary or endovenectomy c/ vein patch

Front 168

subclavius muscle hypertrophy predisposes to what type of TOS?

Back 168

Venous TOS is 2/2 narrowing (usually congenital) of the costoclavicular space by the costoclavicular ligament or the subclavian tendon compressing the subclavian vein *-Subclavius muscle (clavicle to 1st rib) becomes hypertrophied in athletes => tightens costoclavicular space => *effort thrombosis of subclavian vein *(congenital fibromuscular bands predispose to neurogenic TOS; cervical rib predisposes to arterial TOS)

Front 169

blunt injuries at the takeoff of the innominate artery are best repaired by what approach?

Back 169

blunt injury at the takeoff of the innominate artery => Bypass and exclusion without heparinization, shunts, or hypothermia *-Avoid hypothermia and anticoagulation in the setting of trauma. Can't insert a shunt if there is no proximal length of innominate artery to encircle with an occluding tape *(Sabiston)

Front 170

incision for chest injury with life-threatening hemorrhage

Back 170

incision for chest injury with life-threatening hemorrhage = anterolateral thoracotomy through L 4th intercostal space (below nipple) *-Can be extended to clamshell incision by extending it to R 3rd intercostal space (above nipple) *-Thoracic outlet and proximal neck vascular injuries may require median sternotomy with extension above the claviccle along the ipsilateral SCM

Front 171

Supraclavicular arterial injuries => __ intercostal space anteriolateral throacotomy -> distal control of carotid injuries by ___

Back 171

Proximal innominate, proximal R SCA, proximal R carotid => sternotomy *L SCA proximal control => posterolateral thoracotomy *Supraclavicular arterial injuries => 3rd intercostal space anteriolateral throacotomy -> distal control of carotid injuries by extending the median sternotomy superiorly anblong the border of the SCM *Distal SCA control => supraclavicular incision. Resection of clavicle has low morbidity, if it needs to be done to control hemorrhage

Front 172

what incision for penetrating wounds to ascending aorta, innominate artery, R SCA

Back 172

penetrating wounds to ascending aorta, innominate artery, R SCA => median sternotomy, +/- extrathoracic extensions to obtain proximal and distal control

Front 173

what is an apical cap (blunt thoracic trauma)

Back 173

intrathroacic great vessel injuries: *-Penetrating injury may require resuscitative thoracotomy => can extend across the sternum to create a clamshell incision to access the braches of the aortic arch and pulmonary vessels. *-Blunt injury to great vessels: thoracic aorta most commonly affected, PSA most common injury. 2/2 rapid deceleration in high-speed head-on collision, fall from height. Ant-posterior CXR shows widened mediastinum, apical cap (extrapleural blood on top of apex of lung), widened paravertebral stripe (suggests blood around descending aorta or depression of L mainstem bronchus *-Endografts ass'd c/ lower risk-adjusted mornality but device complications (leak, migration, collapse) as high as 20%

Front 174

anterior tibial artery is approached through an anterolateral incision between the __ and __ muscles.

Back 174

Exposure of the lower leg arteries is best begun proximally, away from the area of injury (Fig. 67-13). The distal popliteal artery is exposed below the knee through a medial approach, and dissection is continued distally by detaching the soleus muscle from the posterior border of the tibia, thus providing access to the posterior tibial and peroneal arteries. *-AT is approached through an anterolateral incision b/w tibialis anterior and extensor hallucis longus

Front 175

approach to expose IVC + portal vein *-how can this be carried further to expose the aorta and iliacs?

Back 175

R-sided medial visceral rotation (rotate the viscera from R->L) to expose vena cava, portal vein -> be extended medially along the root of the mesentery (Cattell-Braasch maneuver) to expose the IVC, renal arteries, infrarenal aorta, iliacs

Front 176

hard signs of vascular trauma

Back 176

Hard signs: pulsatile bleeding, arterial thrill, bruit near injury, absent distal pulse, visible expanding hematoma *-Soft signs: significant hemorrhage by history, neurologic abnormality, diminished pulse compared with contralateral extremity, proximity of bony injury to or penetrating wound.

Front 177

2 locations where ulnar nerve is typically injured

Back 177

in the upper part of the arm, the median nerve is associated with the brachial artery (wraps around the brachial artery in a lateral-to-medial direction) and the ulnar nerve is just deep to the basilic vein (Fig. 47-2). *In the forearm, the ulnar nerve runs adjacent to the ulnar artery into the hand, and can be injured when the distal ulnar artery is dissected free. *-Location of the ulnar nerve at the elbow makes it vulnerable to compression injury from improper positioning during surgery *-Median nerve injury => sensory deficit in 1st, 2nd, 3rd, and radial aspects of 4th digits; weakness in the thenar muscles +/- flexors of the digits and wrist. *-Ulnar nerve injury =>numbness of the 5th digit and ulnar aspect of the 4th digit; weakness of the hypothenar muscles; weak abduction and adduction of all digits and flexion of 4th and 5th fingers

Front 178

what is the hand deformity associated with ulnar nerve palsy?

Back 178

sensation over the medial half of the fourth digit and the entire fifth digit (the ulnar aspect of the palm) and the ulnar portion of the posterior aspect of the hand (dorsal ulnar cutaneous distribution). *-ulnar claw = 4th and 5th fingers drawn towards the back of the hand at the first knuckle and curled towards the palm at the second and third knuckles

Front 179

A 26-year-old woman with a recent history of cocaine-induced anterior myocardial infarction (MI) presents with 6 hours of numbness and coolness of the right hand. Her right radial and ulnar pulses are not palpable, but her right axillary and left upper extremity pulses are easily palpable. The motor function of her right hand is diminished. What is the most probable diagnosis?

Back 179

the most likely diagnosis in this young patient is a brachial embolus from a cardiogenic source. The additional history of recent MI supports cardiogenic embolus as the best choice. Reports indicate that cardiac thrombus formation occurs in up to 40% of cases after myocardial infarction and is more common following anterior wall infarctions. The risk of embolism associated with myocardial thrombus approximates 5%.

Front 180

Exposure of the ulnar artery in the proximal forearm is more difficult because it is deep to the antebrachial fascia, between the _and __ muscles.

Back 180

Most isolated ulnar or radial artery injuries can be ligated. *-If bone and soft tissue injuries, begin the radial artery exposure proximally at the brachial bifurcation, then proceed distally. *-A lower medial arm incision is carried into the antecubital fossa in an S-shaped configuration to avoid a longitudinal incision across the antecubital skin crease. *-Divide the bicipital aponeurosis to expose the brachial bifurcation *- Exposure of the ulnar artery in the proximal forearm is more difficult because it is deep to the antebrachial fascia, between the flexor carpi ulnaris and flexor digitorum superficialis muscles.

Front 181

_% of pts c/ upper extremity arterial injury have significant neuro injury, usually involving _ nerve, present in

Back 181

upper extremity vascular trauma: significant neuro injury, usually involving median nerve, present in 60% of pts c/ upper extremity arterial injury *-Go straight to OR if obvious arterial/venous laceration from penetrating trauma or hard signs after blunt trauma. Absent pulse despite resuscitation in the setting of complex fracture or crush injury => assess with imaging (CT or catheter-based angio). *-Venous injuries can be ligated unless extensive soft tissue injury and loss of venous collaterals *-Brachial artery and forearm vessels => expose, catheter thrombectomy, and repair *-No PTFE for injuries distal to the axillary artery *-Consider forearm fasciotomy *-must repair either radial or ulner if both out; ulnar is usually larger in the proximal forearm and a better target for direct repair or vein bypass

Front 182

__mmHg difference between extremities raises suspicion for vascular injury

Back 182

10 mmHg difference between extremities raises suspicion for vascular injury

Front 183

PTFE patency (short term) for arterial injurues proximal to popliteal

Back 183

PTFE: patency equivalent to vein for injuries proximal to popliteal artery, 70-90% in short term *-Rarely get infected, even in contaminated wounds *-PTFE graft <6mm should not be used

Front 184

with gross fecal contamination and a penetrating iliac injury, the most safe reconstruction is ___

Back 184

The use of a synthetic graft for iliac artery reconstruction in the presence of peritoneal contamination is a cause for concern.[39] In the presence of limited spillage of small bowel content, use of a synthetic graft (after the bowel injury has been repaired and the field irrigated) is an acceptable option. However, with gross fecal contamination, ligation of the injured iliac artery and a subsequent femorofemoral bypass is the safe course of action. *Low threshold for fasciotomy after iliac vessel injuries because leg edema is common (esp. after iliac vein ligation) and repair of an iliac artery injury may be time-consuming and associated with prolonged ischemia. A hypotensive critically injured pt is esp. susceptible to damage 2/2 elevated compartment pressures.

Front 185

in the field or ED, for torrential bleeding from a penetrating injury in an inaccessible site the surgeon should do what?

Back 185

balloon catheter tamponade with a foley inserted into the missile tract can obtain rapid temporary control in an inaccessible vessel, e.g. in pelvis or high in neck

Front 186

prognosis for use of PTFE in extremity vein trauma

Back 186

Rutherford ch 155: venous injury + ischemic arterial injury => * vein should be repaired before the arterial repair is initiated. improved hemostasis in the operative field and venous drainage of the leg during the arterial reconstruction. *-In patients with significant limb ischemia times, approximately 200 mL of distal venous blood should be removed before restoring in-line flow to help minimize the reperfusion insult. **The most commonly injured major veins of the extremities: Sup femoral (42%), popliteal (23%), CFV (14%).[89] *Series of 130 military+civilian traumas: CFV, SFV, and popliteal vein patency 100%, 100%, and 86%, at 1 year and 89%, 78%, and 60% at 6 years. *-Baylor series of ePTFE conduit for venous injury => near universal stenosis or occlusion on follow-up venography. However, less bleeding from distal blast defects and fasciotomy sites.[61]

Front 187

patency of repairs for venous trauma

Back 187

Kuralay et al. - outcome of venous repairs using postoperative duplex *-Repaired common femoral, superficial femoral, and popliteal veins had patency rates of 100%, 100%, and 86%, respectively, at 1 year and 89%, 78%, and 60%, respectively, at 6 years

Front 188

what is the most commonly injured vein in the extremity?

Back 188

The most commonly injured major veins of the extremities: superficial femoral vein (42%), popliteal vein (23%), common femoral vein (14%). *-When the venous injury is localized and end-to-end or lateral venorrhaphy is possible, repair should be performed unless the patient is hemodynamically unstable. *-When more extensive venous injuries exist, an interposition, panel, or spiral graft can be configured for repair - controversial

Front 189

fix vein or artery trauma in an extremity 1st?

Back 189

venous injury + ischemic arterial injury => * vein should be repaired before the arterial repair is initiated. improved hemostasis in the operative field and venous drainage of the leg during the arterial reconstruction. *-In patients with significant limb ischemia times, approximately 200 mL of distal venous blood should be removed before restoring in-line flow to help minimize the reperfusion insult.

Front 190

penetrating injuries to the vertebral artery that are found to be bleeding at neck exploration are best managed by what technique?

Back 190

penetrating injury to the vertebral artery found to be bleeding at neck exploration => *-Forcefully place bone wax into the area of bleeding, then arteriography after operative control **-Unroofing teh vertebral canal is extremely difficuly and ass'd c/ horner's syndrome, may precipitate uncontrollable bleeding *-Ligation of the vertebral artery proximally does not stop collateral or retrograde bleeding

Front 191

meds to treat vibration-induced raynauds

Back 191

Vibration-induced white finger (AKA Raynaud's of occupational origin, traumatic vasospastic dz): similar presentation to Raynaud's *-blanching and numbness of the hands after using pneumatic drills *-5 categories, by severity (interference c/ activities, tingling, blanching, whether it happens also in summer) *-1% progress to ulceration, gangrene *-vibration -> endothelial injury -> platelet adhesion. *-Attacks precipitated by symp hyperactivity, cold *-Dx: cold provocation -> time until digital temp recovers. *-Detect digital occlusion by trancut doppler or angio. May see multiple segmental occlusions, corkscrewing *-Tx: stop vibration. Ca channel blocker (niferipine -> inhibit response to NE in arterial sm muscle), IV prostanoid (prostaglandin E1, prostacyclin ,iloprost) if gangrene. *-Cervical or digital sympathectomy rarely indicated or needed

Front 192

what type of nerve injury? from ischemia of the forearm flexor muscles, esp flexor digitorum profundus and flexor pollicis longus; ulnar and median nerve palsy

Back 192

Volkmann's ischaemic contracture, is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. more common in children. Passive extension of fingers is restricted and painful *-commonly from supracondylar fracture of the humerus and brachial artery injury, compartment syndrome-> ischemia of the forearm flexor muscles, esp flexor digitorum profundus and flexor pollicis longus; ulnar nerve and median nerve palsy

Front 193

_ = dividing line b/w supramesocolic and inframesocolic compartments *-Zone 1a hematoma is 2/2 injury to __. Exposure is __

Back 193

zone 1 hematoma mandates exploration for penetrating or blunt injury *-Transverse mesocolon = dividing line b/w supramesocolic and inframesocolic compartments. *-Supramesocolic hematoma= behind the lesser omentum, pushes stomach forward. 2/2 injury to the suprarenal aorta, celiac axis, proximal SMA, or proximal renal artery. Proximal control by clamping (or compressing) the aorta @ diaphragmatic hiatus -> injured vessel exposed by L medial visceral rotation. *-Inframesocolic hematoma = behind the root of the small bowel mesentery, pushes it forward similar to ruptured AAA. 2/2 injury to the infrarenal aorta or IVC. Proximal control @ supraceliac aorta - by opening the posterior peritoneum in the midline, similar to infrarenal AAA

Front 194

Zone 2 hematoma is 2/2 injury to __ or __ *-Mgmt is __ *-get proximal control in 2 ways __

Back 194

Zone 2 hematoma is 2/2 injury to the renal vessels or parenchyma *-If penetrating => exploration. Exception: stable hematoma in severely injured pt who may not tolerate a long revascularization *-Blunt trauma + nonexpanding stable hematoma => do not explore b.c opening Gerota's fascia may produce further damage to the renal parenchyma. *-Traditional teaching advocates proximal control of a perinephric hematoma by midline looping of the ipsilateral artery and vein at the midline, but this is time-consuming and often unnecessary. If active hemorrhage, can incise the posterior peritoneum and Gerota's fascia lateral to it, lift the injured kidney up and medially, and then clamp the entire renal hilum.

Front 195

mgmt of pelvic retroperitoneal hematoma (zone 3) secondary to penetrating trauma

Back 195

A pelvic retroperitoneal hematoma (zone 3) secondary to penetrating trauma mandates exploration because of the likelihood of iliac vessel injury. *-zone 3 hematomas from blunt trauma are usually associated with pelvic fractures and are not explored because mgmt is based on external fixation or angiographic embolization of the bleeding vessels.Exception: a rapidly expanding hematoma in which the surgeon suspects a major iliac vascular injury that requires operative repair.