SCORE 16-17

Using a regular Foley catheter: disconnect from drainage tubing, directly inject 50 mL, clamp, insert needle, and measure.
Using a three-way Foley catheter: inject saline into one port and measure IAP through the other.
Serially connecting a regular Foley catheter to a three-way stopcock and a transducer
IAP should be measured at end-expiration, with the patient in the supine position without abdominal muscle contr

sedation/chemical paralysis to improve abdominal muscle relaxation, gastric and bladder decompression, reduced tidal volume ventilator strategies, fluid restriction, and diuresis.

1. Epinephrine IM 1:1000 0.5mg , every 5-15 mins up to 3 times
2. Remove trigger allergen ,obtaining IV /IO access, supine position
3. albuterol
4. antihistamine and steroids

1. Known cause of coma
2. No hypothermia
3. No drug effect (sedatives, neuromuscular blockade)
4. No endocrine, acid -base or electrolyte abnormality that can cause coma
5. No shock

Pupillary (light)
Oculocephalic (doll eyes)
Oculovestibular (cold caloric)
Corneal
Facial (masseter)
Pharyngeal (gag)
Tracheal (cough)
A positive apnea test—that is, no respiratory effort despite a PaCO2 of more than 60 mm Hg after 8 minutes—confirms brain death.

Penetrating cardiac injuries arriving shortly after onset with objectively measured signs of life (cardiac arrest < 15 minutes)
Penetrating noncardiac thoracic injuries—as in a massive hemothorax
Exsanguinating abdominal vascular injuries in patients who present with signs of life or cardiac arrest of less than 5 minutes. However, these patients experience high mortality if the site of hemorrhage is not quickly controlled.
Blunt trauma cardiac arrest <10mins

12-lead ECG
Cardiac enzymes
Basic laboratory studies (complete blood count, basic metabolic panel, magnesium, phosphate)
Chest x-ray
Echocardiogram (if stable or controlled)

Lidocaine
Procainamide
Amiodarone

1. BMP
2. Early morning cortisol, ACTH levels(high ACTH , low cortisol = primary adrenal gland insufficiency)
3. ACTH stim test (baseline cortisol, then 0.01-0.25mg of IV cosyntropin, draw repeat cortisol in 30-60 mins --> rise of more than 9 , or total >15-18ng/ml is normal)
4.For minor surgeries (eg, open inguinal hernia repair)—hydrocortisone 25 to 50 mg intravenously on the day of surgery, with a return to normal dose thereafter
5.For major surgeries (eg, colectomy)—hydrocortisone 50 to 75 mg intravenously every 8 hours for 24 to 48 hours, with a return to normal dose thereafter

Crystalloid infusion to provide IV hydration, correction of electrolyte abnormalities, and insulin infusion. It should be noted that insulin infusion can worsen hypokalemia, which needs to be corrected prior to insulin infusion to prevent arrhythmia. In addition, these patients often have a "relative hypokalemia" despite a seemingly normal potassium level on routine laboratory studies; this is due to hyperosmolality and insulin deficiency. Patients should be monitored closely with frequent electrolyte and blood glucose testing.

Careful history and physical exam (toxin ingestion, family history of autoimmune or Wilson disease, history of suicide attempts, viral exposures)
Viral serologies
Serum acetaminophen
Toxicology screen
Serum ceruloplasmin
Autoimmune markers (ANA, anti–smooth muscle Ab, anti–liver microsomal Ab)
Pregnancy test
Ultrasound to evaluate venous outflow obstruction or chronic liver disease
Liver biopsy if etiology remains unknown, potentially diagnostic in autoimmune hepatitis and Wilson disease

Octreotide (somatostatin) causes splanchnic vasoconstriction.
Terlipressin (vasopressin analog) causes splanchnic vasoconstriction, not FDA approved in the United States.
Midodrine (α-adrenergic agonist) causes systemic vasoconstriction.
Refractory hepatorenal syndrome may lead to renal replacement therapy with dialysis.
More than 6 weeks of renal replacement therapy should trigger combined liver–kidney transplant evaluation.

1. 2L IVF
2. Vasopressors - both inotropic , chronotropic and vasoconststrictive for cervical and T1-6 --> doapmine, NE .
3. Vasopressors for lower thoracic lesions and lumbar - phenylephrine (peripheral vasoconstrictor)

1. Coma cocktail = thiamine + dextrose + naloxone + flumazenil.
2. BMP, LFT, Utox electrolytes, renal and liver function tests, and a urine toxicity screen.
3. Seizure treatment
4 Maintain cerebral perfusion pressure. CPP = [mean arterial pressure (MAP) – ICP]

1.Elevate the patient's bed angle to 30º to 45º to help with venous return of blood from the head.
2.Hyperventilate the patient to keep CO2 less than 25 mEq/L. Hyperventilation will only give a transient response and should not be used for longer-term management due to increased cerebral ischemia.
3.Use hypertonic/hyperosmolar therapy: 23.4% NaCl, 3% NaCl, and mannitol

Protein: 0.8 g/kg/d
Glucose: 7.2 g/kg/d
Fat: 1 g/kg/d

1. PTT 60-90

Parkland formula (resuscitative fluid requirement in 24 hours): 4 mL/kg per percent total body surface area burned
Give half the volume over the first 8 hours.
Give the remaining half over the next 16 hours.

For the extremities, escharotomies are necessary for circumferential third-degree burns with signs of extremity swelling. These escharotomies are performed on the medial and lateral aspects of the extremity while held in the anatomic position.
For the trunk, escharotomies are necessary for circumferential third-degree burns with signs of reduced inspiratory volumes. These escharotomies are performed down the midaxillary line from the axilla to edge of the burn wound inferiorly and across the infraclavicular and subxiphoid line.

Use a midline incision, which is optimal for exposure when the spleen is ruptured or massively enlarged.
Mobilize the spleen by dividing ligamentous attachments, beginning with the splenocolic ligament.
Enter the lesser sac.
Realize that in patients with significant splenomegaly, early ligation of the splenic artery along the superior border of the pancreas is an option and may be preferred. This allows safer manipulation of the spleen and dissection of the hilum. This allows for some shrinkage of the spleen itself. This provides an autotransfusion of red blood cells and platelets.
Incise the lateral peritoneal attachments, most importantly the splenophrenic ligament, and gently develop a plane deep to the spleen and tail of the pancreas.
Next perform individual ligation and sequential division of the short gastric vessels.
Identify the tail of the pancreas and protect it from harm. The tail of the pancreas often lies within 1 cm of the splenic hilum.
Ligate the splenic artery and vein before dividing them.
Remove the spleen.
Look for accessory spleens. Common locations are the splenic hilum, splenic pedicle, greater omentum, the tail of the pancreas, and splenocolic ligaments.
Close the abdomen without drainage.

Patients with chest trauma and poor pain management often have poor inspiratory effort and splinting, leading to hypoventilation, atelectasis, pneumonia (due to retained secretions), and respiratory failure.
Respiratory support with mechanical ventilation for several days is sometimes required in the management of significant pulmonary contusion and flail chest.
Aggressive pulmonary toilet, incentive spirometry, adequate analgesia, and multimodal pain management are critical in the nonoperative management of these patients.

debridement of obviously necrotic tissue, eversion of borders for adequate approximation (when primary repair is feasible) either with stay sutures or Allis clamp, the use of nonabsorbable sutures, and interrupted or running suture primary repair (surgeon preference).

If gastric outlet obstruction is present, 5 to 7 days of nasogastric decompression and total parenteral nutrition may be required.
Prior to resuming oral intake, a repeat study with oral contrast should be obtained to confirm resolution of the obstruction.

Upper third: Perform a left collar incision or anteromedial sternocleidomastoid incision. Divide the omohyoid muscle (can serve as buttress), perform blunt posterior tracheal dissection to avoid injury of recurrent laryngeal nerve, and place a Penrose drain around the esophagus for exposure. Debride, close in two absorbable layers (submucosa/mucosa, muscle), buttress, and drain widely. Buttress options include the omohyoid, sternocleidomastoid, and strap muscles.
Middle third: Perform a right posterolateral thoracotomy at the fifth intercostal space. Debride, close in two absorbable layers (submucosa/mucosa, muscle), buttress, and drain widely. Buttress options include the pericardium, intercostal, anterior serratus, latissimus dorsi, and diaphragm (for low thoracic injuries).
Distal third: Perform a left thoracotomy at the seventh intercostal space. Debride, close in two absorbable layers (submucosa/mucosa, muscle), buttress, and drain widely. Additionally, insert draining gastrostomy tube and feeding jejunostomy. Buttress options include Thal patch, partial fundoplication, omentum, and diaphragm.

A T tube can be inserted to create a controlled fistula.
An esophagectomy with cervical esophagostomy placed in the subclavicular area may be indicated if repair and drainage is not possible.
Formal reconstruction should not be performed in a trauma patient because of the length and difficulty of the procedure.
The thoracic esophagus may be removed or left in situ at the index procedure, depending on hemodynamic stability.

The operating room should be warmed; infrared lights should be brought in if available.
The patient should have hot blankets or a forced-air warmer placed.
All intravenous fluids and blood products should be warmed and/or run through an inline warmer.
Peritoneal lavage with warmed fluids can be considered.
Coagulation factor abnormalities should only be treated if the prothrombin time/partial thromboplastin time is prolonged at plasma temperature of 37ºC. Platelet abnormalities should be treated as identified.

Hypothermia should be addressed first because it is life threatening.
Jewelry should be removed from affected extremities because of the potential for edema.
Affected areas should be immersed in a warm water bath at 37ºC to 39ºC.
Opioids are likely to be needed during rewarming to control pain.

1.Monitoring of cardiac rhythm, pulse, and blood pressure is critical during rewarming of hypothermia patients.
2.Passive external rewarming involves moving the patient from a cold environment to an environment that allows for spontaneous rewarming; it is recommended only for mild hypothermia.
3.Active external rewarming measures include warm blankets and/ or heating pads, infrared heating lights, and immersion in warm water.
Active core rewarming is the most efficient but is not typically required for mild to moderate hypothermia.

Begin by infusing warm isotonic fluid.
Arrange for cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO) in cases of severe hypothermia.
Adjunctive measures while establishing bypass or ECMO include peritoneal lavage, chest cavity lavage, and an intravascular warming catheter.
Ventricular fibrillation at core temperatures below 30ºC is due to hypothermia.

blister unroofing or drainage, topical aloe vera with daily changes, and monitoring for infection.
thrombolytic therapy

The stomach must be examined completely starting from the gastroesophageal junction at the diaphragm.
The small intestine must be examined from the ligament of Treitz to the terminal ileum.
Penetrating trauma from a stab wound can be easily missed because of clean edges and small size. The stomach and small intestines must be examined very carefully to avoid missing an injury.
Gastric injury needs to be considered in penetrating injury to the upper abdomen or chest (thoracoabdominal region) because of the proximity to the diaphragm.
If there is an anterior penetrating gastric injury, the posterior surface must be examined for an injury. To examine the posterior gastric wall, it is necessary to open the lesser sac. If a posterior gastric injury is identified, the pancreas must be carefully examined for an associated injury.
Injury to the mesentery of the small bowel requires consideration for compromised blood flow to the bowel, especially injuries near the root of the mesentery.

idaricizumab (praxbind)

andexanet alpha
or PCC

Common signs of cerebral herniation include a decline in neurological function on one side of the body (lateralizing signs), unilateral mydriasis (blown pupil), or the presence of the Cushing reflex.
Emergency treatment of cerebral herniation includes elevation of the head of the bed, administration of intravenous hyperosmolar bolus therapy (eg, mannitol), and mild hyperventilation.
Patients with signs of cerebral herniation generally require emergency surgical evaluation.

Standard methods for ICP reduction include elevating the head of the bed, maintaining a neutral neck position, and ensuring the patient has a normal body temperature, adequate oxygenation, and normoventilation.
Targeted therapies for ICP reduction include sedation, neuromuscular blockade, intermittent CSF drainage via an externalized ventricular drain, and intermittent intravenous hyperosmolar therapy with mannitol or hypertonic saline.

Gross hematuria and pelvic fracture
Gross hematuria and mechanism concerning for bladder injury
Pelvic ring fractures with clinical indicators of bladder rupture (such as an abnormal FAST)

Retrograde cystography (either plain film or CT) should be performed in patients with suspected bladder trauma.
Adequate filling is necessary for either test—at least 300 mL of contrast via passive fill or to patient tolerance.
Images should be taken before filling, during filling, and after drainag

concomitant vaginal lacerations, concomitant rectal injuries, bony fragments within the bladder, uncontrolled hematuria, or failure of conservative management.

The upper most node

The operative approach depends on the location of the injury. Bronchoscopy should be performed first to locate the injury (see Learning Objective 3).
For injuries to the trachea, right bronchus, and proximal left mainstem bronchus, a right thoracotomy incision is needed.
For injures to the distal left airways, a left thoracotomy is needed.
Devitalized tissue should be debrided and primary anastomosis using absorbable suture should be performed. An intercostal tissue flap to improve healing should be considered.

For tracheobronchial injuries that are less than one-third of the circumference of the bronchus, if the air leak is controlled by a chest tube, they may be treated nonoperatively. Patients must be admitted and closely observed, given humidified oxygen, and carefully suctioned.

stridor, hypoxia, impending airway loss or respiratory failure, and hemodynamic instability from concomitant vascular injuries.

Significant mid-face trauma, distorted anatomy from hematoma or subcutaneous emphysema, severe hemoptysis or hematemesis, proximal airway obstruction, and suspected laryngotracheal disruption

penetrating wound, massive hemoptysis or hematemesis, and significant respiratory distress.

esophagus, subcutaneous emphysema, pneumomediastinum, mild hemoptysis or hematemesis, dysphagia, and dysphonia

unexplained subcutaneous or mediastinal emphysema or other clinical signs of airway injury should be evaluated further with laryngoscopy and bronchoscopy

Absent distal pulse
Thrill or bruit
Expanding hematoma
Active pulsatile bleeding

A median sternotomy provides access to the proximal right subclavian, innominate, and proximal left carotid arteries.
A left anterolateral thoracotomy will provide access to the proximal left subclavian artery.
Extension of a median sternotomy incision to the anterior neck can provide additional exposure of the carotid artery.
A supraclavicular incision can be used gain access to the right subclavian artery and the distal left subclavian artery.
A trap door incision (left anterolateral thoracotomy, partial sternotomy, and left supraclavicular incision) can be used to gain additional access to the left subclavian artery.

mobilization of the left colon, spleen, pancreatic tail, and left kidney (Mattox maneuver)–providing access to the suprarenal aorta and its branches.

right colon medially to the ligament of Treitz and duodenum (Kocher maneuver)–providing access to the inferior vena cava, infrarenal aorta, and distal duodenum.

Complete Kocher maneuver, which allows for evaluation of the first, second, and proximal portions of the duodenum
Sharp division of the ligament of Treitz, which allows for visualization of the third and fourth portions of the duodenum
Cattell-Braasch maneuver (right medial visceral rotation), which also facilitates exposure of the third and fourth portions of the duodenum

Opening the lesser sac through the gastrocolic ligament
Downward retraction on the transverse colon and upward retraction on the stomach
Completion of the Kocher maneuver to provide adequate visualization of the pancreatic head and uncinate process
Mobilization of the hepatic flexure to facilitate visualization of the pancreatic head and neck
Exposure of the splenic hilum to inspect the pancreatic tail

Opening the lesser sac through the gastrocolic ligament
Downward retraction on the transverse colon and upward retraction on the stomach
Completion of the Kocher maneuver to provide adequate visualization of the pancreatic head and uncinate process
Mobilization of the hepatic flexure to facilitate visualization of the pancreatic head and neck
Exposure of the splenic hilum to inspect the pancreatic tail

Injury to the MPD to the left of the SMV is managed by distal pancreatectomy, with or without splenectomy, depending on the hemodynamic status of the patient.
Injury to the MPD to the right of the SMV results in a risk of exocrine and endocrine pancreatic insufficiency after distal pancreatectomy. Closure of the proximal pancreatic segment and distal Roux-en-Y pancreaticojejunostomy has traditionally been performed.
Although the above recommendations for repair of high-grade pancreatic injuries have been cited historically, recent literature suggests foregoing major resections, providing wide drainage of the injury, and using ERCP and pancreatic duct stenting.
Massive disruption of the pancreatic head may still require pancreaticoduodenectomy and reconstruction.

arresting ongoing muscle damage, avoidance of nephrotoxic medications, and providing adequate fluid hydration to ensure urine output averaging 100-300 mL/h for at least 24 hours or until CK levels have peaked and renal function is recovering. administertion of sodium bicarb ?

After recognizing hemorrhage from the liver, temporary hemostasis can be achieved with manual compression to reduce the liver anatomically.
Packing is performed with laparotomy pads above and below the injured segments, mimicking the manual compression maneuvers that were effective and taking advantage of the hepatic parenchyma to achieve tamponade. Undue pressure toward the diaphragm or on the inferior vena cava should be avoided.
If hemorrhage continues despite compression and packing, the next step is to achieve portal venous and hepatic arterial inflow control via compression (Pringle maneuver).
Failure of packing and portal/hepatic arterial inflow occlusion to control hemorrhage suggests injury to the retrohepatic vena cava or hepatic veins.
Total vascular isolation (portal/hepatic arterial inflow occlusion, infrarenal and intrapericardial caval control, and aortic occlusion) may be necessary to definitively treat injuries to the inferior vena cava and hepatic veins that are not controlled with packing.

Exposure requires mobilization along the medial border of the sternocleidomastoid muscle (SCM).
Retraction of the SCM laterally exposes the IJV.
Dissection medial to the IJV exposes the CCA.
The facial vein typically crosses over the bifurcation of the CCA into the internal carotid artery and external carotid artery.
Dissection close to the CCA avoids injury to the vagus nerve, which lies posteriorly in the carotid sheath the majority of the time.

The ascending aorta and aortic arch, up to and including the proximal left subclavian artery, are approached via a median sternotomy.
The descending thoracic aorta distal to the left subclavian artery can be exposed via a left thoracotomy, usually in the second to fourth intercostal space, depending on the location of injury (proximal vs distal).

The distal subclavian artery can be exposed via a supraclavicular approach. A transverse incision is made lateral to SCM just superior to the clavicle. This entails identification of the phrenic nerve as well as ligation of lymphatics/thoracic duct.
The axillary artery can be exposed by an infraclavicular transverse incision made in the deltopectoral groove followed by identification and mobilization of the axillary vein, which exposes the axillary artery posterior to it.
The brachial artery can be exposed by making an incision in the fascia of the biceps muscle and dissecting in the brachial sheath, and mobilizing and preserving the brachial vein and median nerve.

This involves mobilization of the lateral segment of the left lobe of the liver by dividing the triangular ligament; identification of the right crus of the diaphragm and the esophagus just lateral to it; and dissection through the right crus of the diaphragm. Care should be taken not to injure the esophagus.
This can also be approached via a left-sided medial visceral rotation. It is necessary to incise the line of Toldt along the lateral edge of left colon; bring the colon, left kidney, and spleen all to the midline and dissect in the retroperitoneal space; and divide the left crus of the diaphragm.

(1) cephalad mobilization of the transverse colon and bringing all the small bowel to the patient's right and (2) incising the ligament of Treitz and exposing the infrarenal aorta. Care should be taken not to injure the left renal vein as it crosses anterior to the aorta.

Exposure of the retrohepatic IVC is technically challenging and usually requires extensive mobilization of the liver by dividing its ligaments and extending the incision to include a right subcostal incision, right thoracotomy, or sternotomy.
The infrarenal and juxtarenal IVC are best exposed by mobilization and medial rotation of the right colon, the hepatic flexure of the colon, and the duodenum.

Exposure of the common femoral artery involves a longitudinal incision in groin at the midinguinal point, dissection through the soft tissue, and incision of the femoral sheath.
Exposure of the superficial femoral artery involves longitudinal incision in the thigh just medial to the sartorius muscle and mobilization of the sartorius laterally.

Above-knee popliteal artery. This involves a longitudinal incision in the lower thigh, mobilization of the sartorius laterally, and incision of the fascia of the adductor magnus to enter Hunter canal and identify the artery.
Below-knee popliteal artery. This involves longitudinal incision just medial to the tibia and division of the fascia of the gastrocnemius with mobilization inferiorly. Then it is possible to enter the popliteal fossa and isolate the artery.