TCRN NEW EXAM REVIEW COMPLETE 2022 SOLUTION
Kehr's sign - Referred left shoulder pain, usually indicates a splenic injury
Base deficit - Base deficit more than -6 indicates the need for agressive resuscitation and
determination of the etiology
CXR - Most important tool providing useful information in the early minutes. Can identify
major sources of blood loss from injuries in the chest or elevated diaphragm with displacement
of abdominal organs
Tracheobronchial injury - Should be suspected if after chest tube placement a significant air
leak is present
Diagnostic Peritoneal Lavage - Alternative to FAST scan to detect abd bleeding. A urinary
catheter and gastric tube should be in place prior to procedure.
FAST - Focused Assessment with Sonography in Trauma. Used to detect free fluid in
peritoneum or hemoperitoneum. Free fluid appears "black" on the screen. Has replaced DPL
when available.
Positive FAST scan - Hemodynamically unstable trauma patient with a positive fast are taken
directly to the OR for laparotomy
Ultrasound abd exam - Not useful to detect injuries to the diaphragm, intestine and pancreas.
In patients with obesity, ascites and/or subQ emphysema the accuracy is reduced.
CT scan - Hemodynamically stable patients may be taken to CT
Angiography - Embolization is useful in treating patient with unstable pelvic fractures, liver
and splenic hemorrhage. Use of hybrid OR suites to allow for surgical and interventional
radiology methods of treatment simultaneously.
Diagnostic laparoscopy - Can be used to detect or exclude finding so f hemoperitoneum, organ
injury, intestinal spillage or peritoneal penetration. Most useful in evaluating possible
diaphragmatic injuries, espectially in penetrating thoracoabdominal injuries on the left site
Diaphragmatic injuries - Usually resultant of penetrating throacoabdominal injuries on the left
side, including 11-12 rib fractures on the left.
Small intestine injuries - Result from shearing forces in MVC or direct blows that crush
intestine between force and the vertebrae. Most commonly intra-abd injury in penetrating
trauma. Occurs often with spinal injury. Pancreatic/solid organ injury are predictive of
increased risk for hollow viscus injury. Signs of peritonitis develop. Any blow to the
abd/penetrating injury to the lower chest/abd should increase suspicion of injury
, Treatment of small intestine injury - Control bleeding prior to exploration. Debridement and
closure and ligation of bleeders. Resection for multiple defects. Observe for wound
infection/abscess development
Cause of duodenum injuries - Penetrating trauma most frequent cause. Usually conconcurrent
mult-organ injuries. Usually found intraoperatively, commonly missed during exlap. Blunt
force injury cause by vetebral compression.
Duodenal injury treatment - Identification with CT scan. Commonly patients have
midepigastric or back pain with evolving peritoneal signs 6-24 hrs after injury. Primary closure
in OR, closed drainage system. Goals are to control hemorrhage, debride devitalized tissue and
provide drainage. Non operative management requires close observation for expanding or
ruptured hematomas causing bleeding or peritoneal contamination.
Jejunum and ileum injuries - Jejunum lies in umbilical region, ileum lies in the
hypogastric/pelvice regions. Lap belt can cause bowel to be crushed between the vertebrae and
a solid object. Incorrect wearing of seatbelt increases chance for injury
Stomach injury - Rare, more common in children. Penetrating trauma most common cause.
May find free air on cxr/fua. Pain to epigastric/abd area, tenderness, signs of peritonitis.
Bloody output from gastric tube. Surgical intervention, is gastric content leakage, copious
peritoneal irrigation and delayed primary closure
Large intestine - Rectal injuries may be associated with severe pelvic fracture. Lethal due to
sepsis related to fecal contamination. Most are due to penetrating trauma. Transverse colon
most often injured. Most injuries are contusions. Laparotomy with primary repair and
colostomy is performed when perforation to the colon or rectum is suspected. Abscesses can be
percutaneously drained.
Liver injuries - Commonly injured due to size and location. Cause of injury is blunt and
penetrating trauma. MVC most common cause. Greatest mortality risk is hemorrhage.
High velocity GSW cause more widespread damage that creates massive hemorrhage. Suspect
liver injury in any patient with blunt injury to right side. FAST scan to rule out free fluid. CT
scan in hemodynamically stable patient. Graded I to IV.
Treatment of liver injuries - Nonoperative in select patient. OR for complex
lacerations/arterial blush. Angioembolization for patients with contrast pooling or arterial
blush. Pack and stabilize bleeding and return to OR 24-36 hours later for removal of packing
and definitive management of liver/possible closure. Aggressive intraoperative resuscitation to
prevent hypothermia, coagulopathy and hemodynamic stability. Damage control surgery.
Hemobilia - In patients with liver injury RUQ pain and jaundice may present days and weeks
post injury so follow up care is important
Splenic injuries - Most commonly injured intra-abd organ. 25% of all blunt visceral injuries.
LUQ trauma, lower rib fractures to left. Kehr's sign is caused by blood irritation to the phrenic
nerve that causes referred pain to the left shoulder. CT scan is the imagining of choice for
stable patients.
Kehr's sign - Referred left shoulder pain, usually indicates a splenic injury
Base deficit - Base deficit more than -6 indicates the need for agressive resuscitation and
determination of the etiology
CXR - Most important tool providing useful information in the early minutes. Can identify
major sources of blood loss from injuries in the chest or elevated diaphragm with displacement
of abdominal organs
Tracheobronchial injury - Should be suspected if after chest tube placement a significant air
leak is present
Diagnostic Peritoneal Lavage - Alternative to FAST scan to detect abd bleeding. A urinary
catheter and gastric tube should be in place prior to procedure.
FAST - Focused Assessment with Sonography in Trauma. Used to detect free fluid in
peritoneum or hemoperitoneum. Free fluid appears "black" on the screen. Has replaced DPL
when available.
Positive FAST scan - Hemodynamically unstable trauma patient with a positive fast are taken
directly to the OR for laparotomy
Ultrasound abd exam - Not useful to detect injuries to the diaphragm, intestine and pancreas.
In patients with obesity, ascites and/or subQ emphysema the accuracy is reduced.
CT scan - Hemodynamically stable patients may be taken to CT
Angiography - Embolization is useful in treating patient with unstable pelvic fractures, liver
and splenic hemorrhage. Use of hybrid OR suites to allow for surgical and interventional
radiology methods of treatment simultaneously.
Diagnostic laparoscopy - Can be used to detect or exclude finding so f hemoperitoneum, organ
injury, intestinal spillage or peritoneal penetration. Most useful in evaluating possible
diaphragmatic injuries, espectially in penetrating thoracoabdominal injuries on the left site
Diaphragmatic injuries - Usually resultant of penetrating throacoabdominal injuries on the left
side, including 11-12 rib fractures on the left.
Small intestine injuries - Result from shearing forces in MVC or direct blows that crush
intestine between force and the vertebrae. Most commonly intra-abd injury in penetrating
trauma. Occurs often with spinal injury. Pancreatic/solid organ injury are predictive of
increased risk for hollow viscus injury. Signs of peritonitis develop. Any blow to the
abd/penetrating injury to the lower chest/abd should increase suspicion of injury
, Treatment of small intestine injury - Control bleeding prior to exploration. Debridement and
closure and ligation of bleeders. Resection for multiple defects. Observe for wound
infection/abscess development
Cause of duodenum injuries - Penetrating trauma most frequent cause. Usually conconcurrent
mult-organ injuries. Usually found intraoperatively, commonly missed during exlap. Blunt
force injury cause by vetebral compression.
Duodenal injury treatment - Identification with CT scan. Commonly patients have
midepigastric or back pain with evolving peritoneal signs 6-24 hrs after injury. Primary closure
in OR, closed drainage system. Goals are to control hemorrhage, debride devitalized tissue and
provide drainage. Non operative management requires close observation for expanding or
ruptured hematomas causing bleeding or peritoneal contamination.
Jejunum and ileum injuries - Jejunum lies in umbilical region, ileum lies in the
hypogastric/pelvice regions. Lap belt can cause bowel to be crushed between the vertebrae and
a solid object. Incorrect wearing of seatbelt increases chance for injury
Stomach injury - Rare, more common in children. Penetrating trauma most common cause.
May find free air on cxr/fua. Pain to epigastric/abd area, tenderness, signs of peritonitis.
Bloody output from gastric tube. Surgical intervention, is gastric content leakage, copious
peritoneal irrigation and delayed primary closure
Large intestine - Rectal injuries may be associated with severe pelvic fracture. Lethal due to
sepsis related to fecal contamination. Most are due to penetrating trauma. Transverse colon
most often injured. Most injuries are contusions. Laparotomy with primary repair and
colostomy is performed when perforation to the colon or rectum is suspected. Abscesses can be
percutaneously drained.
Liver injuries - Commonly injured due to size and location. Cause of injury is blunt and
penetrating trauma. MVC most common cause. Greatest mortality risk is hemorrhage.
High velocity GSW cause more widespread damage that creates massive hemorrhage. Suspect
liver injury in any patient with blunt injury to right side. FAST scan to rule out free fluid. CT
scan in hemodynamically stable patient. Graded I to IV.
Treatment of liver injuries - Nonoperative in select patient. OR for complex
lacerations/arterial blush. Angioembolization for patients with contrast pooling or arterial
blush. Pack and stabilize bleeding and return to OR 24-36 hours later for removal of packing
and definitive management of liver/possible closure. Aggressive intraoperative resuscitation to
prevent hypothermia, coagulopathy and hemodynamic stability. Damage control surgery.
Hemobilia - In patients with liver injury RUQ pain and jaundice may present days and weeks
post injury so follow up care is important
Splenic injuries - Most commonly injured intra-abd organ. 25% of all blunt visceral injuries.
LUQ trauma, lower rib fractures to left. Kehr's sign is caused by blood irritation to the phrenic
nerve that causes referred pain to the left shoulder. CT scan is the imagining of choice for
stable patients.
