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Injuries causing death 0-30 min after trauma
Lacerations of heart/aorta, brain, brainstem, spinal cord
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Injuries causing death 30m-4h after trauma
Head injury, hemorrhage
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Most commonly bluntly injured organ
Liver
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Kinetic energy equation
= ? MV2 (m=mass, v=velocity)
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most commonly penetratingly injured organ
small bowel
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amount of blood volume that must be lost to be symptomatic
30%
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most common cause of death after reaching ED alive
head injury
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most common cause of all death long-term
infection
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injuries associated with seatbelts
SB perforation, lumbar spine fx, sternal fx
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Best cutdown site for access
Saphenous vein at ankle
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Criteria for positive DPL
>10cc blood, >100,000 RBC/cc, food particles, bile, bacteria, >500 WBC/cc
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location of DPL in pelvic fx
supraumbilical
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injuries missed by DPL
retroperitoneal bleeds, contained hematomas
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amount of fluid needed to see on FAST
>50-80 mL
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injuries missed by FAST
retroperitoneal bleeds, hollow viscus injury
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injuries missed by CT scan
hollow viscus, diaphragmatic
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complication of massive fluid resuscitation, trauma, or abdominal surgery
abdominal compartment syndrome
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bladder pressures to diagnose abdominal compartment syndrome
>25-30
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complications of abdominal compartment syndrome
IVC compression, gut malperfusion, renal vein compression, decreased tidal volume
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Use of ED thoracotomy
Loss of vitals in the bay OR en route (for penetrating only)
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Hormones that increase following trauma
ADH, ACTH, glucagon
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GCS motor scoring
6 to 1, follows commands, localizes, withdraws, flexes, extends, no response
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GCS verbal scoring
5 to 1, oriented, confused, inappropriate, incomprehensible, no response
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GCS eyes scoring
4 to 1, spontaneous, to command, to pain, none
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arterial bleeding from middle meningeal artery
epidural hematoma
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indications to operate on epidural hematoma
significant neuro degeneration, significant mass effect (>5mm shift)
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tearing of venous plexus between dura and arachnoid
subdural hematoma
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indications to operate on subdural hematoma
>1cm, significant mass effect, significant symptoms
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treatment of traumatic intraventricular hemorrhage
ventriculostomy
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cerebral perfusion pressure
= MAP � ICP
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CT signs of elevated ICP
Dec ventricular size, loss of sulci, loss of cisterns
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methods to decrease CPP
sedation, paralytic, elevate HOB, hyperventilation, Na 140-150, mannitol, craniotomy decompression
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mannitol dose
1 g/kg load, 0.25 mg/kg q4h afterward
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medication given prophylactically to prevent seizures
phenytoin
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time of peak ICP following injury
48-72 hours
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sign of uncal herniation
dilated pupil on same side as herniation (CN III compression)
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sign of anterior fossa fracture
raccoon eyes
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sign of middle fossa fracture
battle�s sign
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associated injuries in temporal skull fractures
CNVII, CNVIII
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C1 burst fracture caused by axial loading
Jefferson fracture
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Fracture of C2 caused by distraction and extension
Handman�s fracture
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Treatment of Jefferson fracture
Rigid collar
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Treatment of hangmans fracture
Traction and halo
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Odontoid fracture above base (stable)
Type I
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Odontoid fracture at base (unstable)
Type II
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Odontoid fracture extending into vertebral body (unstable)
Type III
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Types of odontoid fractures requiring halo
II and III
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Fractures associated with hyperextension and rotation with ligmentous disruption
Facet fractures and dislocations
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contents of anterior column of spine
Anterior longitudinal ligament, anterior ? of vertebral body
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Contents of middle column of spine
Posterior ? of veterbral body, posterior longitudinal ligament
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Contents of posterior column of spine
Facet joints, lamina, spinous processes, interspinous ligament
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Stable spinal fractures
Wedge/compression
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Unstable spinal fractures
Burst
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Indications for emergent spine surgical decompression (5)
Fracture/dislocation not reducible, acute anterior spinal syndrome, open fx, soft tissue or bony compression of cord, progressive neurologic dysfunction
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Most common cause of facial nerve injury
Maxillofacial trauma
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Maxillary fracture straight across
LeForte I fx
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Treatment of LeForte I and II
Recduction, stabilization, intramaxillary fixation
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Fracture lateral to nasal bone, underneath eyes, diagnonal toward maxilla
LeForte II fx
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Fracture of lateral orbital walls
LeForte III fx
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Treatment of LeForte III fx
Suspension wiring to stabilize frontal bone
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Fractures with high incidence of CSF leak
Nasoethmoidal orbital fractures
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Orbital fractures needing repair
Impaired upward gaze, diplopia with upward vision
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Primary indicator of mandibular injury
Malocclusion
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Repair of mandibular injury
IMF (metal arch bars) or ORIF
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Tx of zygomatic bone fx (tripod fx)
ORIF for cosmesis
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Diagnostic study for blunt neck trauma
CT
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Diagnostic study for penetrating neck trauma
Angiography (zone I, III), OR exploration (zone II) laryngoscopy (zone III), bronchoscopy, esophagoscopy, swallow (zone I)
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Symptoms requiring neck exploration
Shock, bleeding, expanding hematoma, airway compromise, subcutaneous air, stridor, dysphagia, hemoptysis
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Methods to diagnose esophageal injury
Rigid esophagoscopy, esophagogram
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Injuries presenting with crepitus, stridor, respiratory compromise
Laryngeal fracture, tracheal injury
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Treatment of recurrent laryngeal injury
Nerve repair or reimplant in cricoarytenoid
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Treatment of vertebral artery injuries
Ligation or embolization
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Stroke rate after ligation of carotid artery
20%
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indications for thoracotomy following chest tube
>1500 cc on insertion, >250 cc/hr for 3 hours, 2500 cc/24h, bleeding + instability
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complications of inadequate thoracic drainage
fibrothorax, lung entrapment, infected hemothorax
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significant sucking chest wound: significant size?
2/3 size of trachea
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patient with worse oxygenation after chest tube placement: what is the injury?
Tracheobronchial injury
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Tx for tracheobronchial injury
Mainstem intubate on inaffected side
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Indications for repair of tracheobronchial injury
Large air leak, respiratory compromise, 2 weeks of persistent leak
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Signs of aortic transection
Widened mediastinum, 1st rib fx, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviates to right
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Site of common tear of aorta
Ligamentum arteriosum, near aortic valve, where aorta traverses diaphragm
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Surgical approach of aortic tears
Left thoracotomy, with partial left heart bypass
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Surgical approach for ascending aorta, innominate, proximal right subclavian artery, and proximal left carotid injury
Median sternotomy
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Surgical approach for injuries to left subclavian, discending aorta
Left thoracotomy
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Surgical approach for distal right subclavian artery
Midclavicular incision +/- resection of clavicle
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Cause of death in myocardial contusion
Arrhythmias
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Most common overall arrhythmia in myocardial contusion
SVT
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>=2 consecutive ribs broken at >=2 sites
flail chest
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borders of �the box�
clavicles, xyphoid process, nipples
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treatment for injury to the box
pericardial windown, bronchoscopy, esophagoscopy, barium swallow
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treatment for penetrating wound outside the box
chest tube
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treatment for penetrating injuries below nipples and medial to midaxillary line
laparotomy/laparoscopy
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traumatic causes of cardiogenic shock (3)
cardiac tamponade, cardiac contusion, tension pneumo
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injuries associated with pelvic fx
GU and abdominal injuries
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Unstable, crush pelvic fractures
Type I
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Predicted mortality of type I pelvic fx
20-30%
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unstable, vertical pelvic fx
type II
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predicted mortality of type II pelvic fx
8-12%
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stable pelvic fx
type III
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pelvic fx more likely to have venous bleeding
anterior pelvic fx
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pelvic fx more likely to have arterial bleeding
posterior pelvic fx
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common mechanism for duodenal trauma
crush or deceleration injury
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most common area of duodenum effected by trauma
2nd portion
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area of duodenum where hematomas often occur
3rd portion
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treatment of bowel hematomas
conservative (TPN, NGT)
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treatment for duodenal injury in 2nd portion (or not enough duodenum for repair)
pyloric exclusion and gastrojejunostomy
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diagnostic study for hollow viscus injury
repeat CT scan with contrast 8-12 hours after initial study
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treatment of extraperitoneal rectal injury
presacral drainage and colostomy
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treatment of intraperitoneal rectal injury
repair defect, presacral drainage and colostomy
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technique to decrease arterial bleeding from liver
pringle maneuver
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method to allow control while performint repair of retrohepatic IVC injury
atriocaval shiun
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repair of common bile duct injury with <50% circumference damage
repair over stent
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repair of CBD injury with >50% circumference or complex
choledochojejunostomy
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technique to help with bleeding of liver laceration and prevent bile leaks
omental graft
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indications for OR with splenic injury
>2U PRBCs, HR>120, SBP<90, active blush on CT
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potential treatment for pancreatic duct injury
distal pancreatectomy, delayed whipple, ERCP/stent
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major signs of vascular injury
hemorrhage, pulse deficit, expanding/pulsatile hematoma, distal ischemia, bruit, thrill
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vein injuries needing repair (6)
vena cava, femoral, popliteal, brachiocephalic, subclavian, axillary
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consider fasciotomy if (7):
ischemia >4h, pressure >20mmHg, clinical findings (pain, paresthesia, paralysis, poikothermia, pulselessness
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orthopedic emergencies (5)
unstable pelvic fx, spine fx w/deficit, open fx, fx/disloc w/vascular compromise, compartment syndrome
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injured structure in anterior shoulder disloc
axillar nerve
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injured structure in posterior shoulder disloc
axillary artery
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injured structure in proximal humerus fx
axillary nerve
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injured structure in midshaft humerus fx
radial nerve
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injured structure in distal humerus fx
brachial artery
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injured structure in elbow disloc
brachial artery
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injured structure in distal radius fx
median nerve
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injured structure in anterior hip disloc
femoral artery
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injured structure in posterior hip disloc
sciatic nerve
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injured structure in distal femur fx
popliteal artery
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injured structure in fibular neck fx
common peroneal nerve
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diagnostic exam needed for all posterior knee dislocations
angiography (unless pulseless, then go to OR)
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best indicator of renal trauma
hematuria
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renal vein that has good collaterals and can be ligated
Left (collaterals through adrenal and gonadal veins)
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Order of renal hilar structures (anterior to posterior)
Vein, artery, pelvis
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Indications for operation after renal injury (4)
Hemorrhage + instability, collecting system disruption, urine extravasation, severe hematuria
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Best indicator of bladder trauma
Hematuria
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Operative management of blunt renal hematoma seen during exploration for another injury
Leave unless no function or significant urine extravasation
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Operative management of penetrating renal hematoma seen during exploration for another injury
Open unless good function or no urine extravasation
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Treatment of extraperitoneal bladder rupture
Foley 7-14d
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Treatment of intraperitoneal bladder rupture
Operation and repair, postoperative foley
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Diagnostic studies in ureteral trauma
IVP and RUG
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Operative treatment of upper 1/3 or middle 1/3 of ureter
Temporary urostomy, fix with ileal interposition or trans-ureteroureterostomy later
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Operative management of lower 1/3 ureteral injuries
Reimplant +/- bladder hitch
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Operative management of missing small segment of ureter
Mobilize ends and perform primary repair over stent OR reimplant
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Treatment of urethral trauma
Suprapubic cystostomy, delayed repair
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Best indicators of shock in pediatric patients
HR, RR, mental status, clinical exam (BP is last to go)
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Indicator of fetal lung maturity
Lecithin: sphingomyelin (LS) ratio >2:1; positive phosphatidylcholdine
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Test for fetal blood in maternal circulation (sign of abruption)
Kleihauer-Betke test
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Most common location of uterine rupture
Posterior fundus
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Treatment of uterine rupture after delivery
Supportive resusciation; uterus will clamp down on own
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Indications for c-section during exploratory laparotomy for trauma (5)
Maternal shock, near term + mother has significant injury, pregnancy a threat to mother�s life, mechanical limitation to life-threatening vessel injury, direct uterine trauma
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In blunt trauma patients, hematoms that are opened operatively (5)
Paraduodenal, portal triad, midline supramesocolic, midline inframesocolic, pericolonic
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In penetrating trauma patients, hematomas that are opened operatively
All types except retrohepatic (leave if stable)
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