1. TRAUMA (LIFE IN THE ER) William Beaumont Hospital
Department of Emergency Medicine

2. CASE
40 y/o male on a MCA, car pulled out to turn in front of him, he hit the side of the car and flew over it landing on his face. He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.
Where should we begin???

3. Where to begin…. A, B, C ‘s O2 – NC, mask, intubation
IV – how many or central line?
Monitor – HR, BP, sPO2, RR q15 (min)
Initial actions = secure the airway, maintain ventilations, control hemorrhage, and treat shock
What is the Golden Hour?

4. “Golden Hour”
The idea is to emphasize the importance of the initial evaluation and treatment of the trauma patient
It is our “window of opportunity” to have a significant impact on morbidity and mortality
One must have a concise, expeditious, well thought out plan of action for evaluation and treatment of life threatening injuries
We accomplish this through ATLS guidelines of the Primary and Secondary Surveys
Injuries that will kill the patient in minutes to hours post injury if left untreated –ie epidural, subdural, hemopneumothorax, ruptured spleen, liver lacs, femur fxs, hemorrhage secondary to multiple injuries

5. Primary Survey: ABCDEs
A = airway maintenance with cervical spine protection
B = breathing and ventilation
C = circulation and hemorrhage control
D = disability and neurological status
E = exposure and environmental control, undress the pt, log roll the patient and put a blanket on them
D – LOC (AVPU – awake, responds to verbal stimuli, responds to painful stimuli, unresponsive;
pupil size
E – log roll the patient

6. Primary Survey: ABCDEs
As you proceed through the list, an identified injury should be treated at the time of discovery
= the airway should be secured before the fracture is stabilized
= PTX should be treated before the patient is completely exposed
A decision about transferring the patient should be made before proceeding to the secondary survey

7. Secondary Survey: head to toe
Complete the history (AMPLE) and physical exam
Reassessment of vital signs and interventions
If GCS not obtained in primary survey, now is a good time
Special procedures (lines), specific x-rays, and labs are now obtained

8. Secondary Survey: Rectal Tone
Rectal exam is done in every trauma and before urinary catheter placement (WHY?)
Check for blood and integrity = tear or pelvis fracture
High riding prostate = potential urethral injury
Tone = brain or spinal injury

9. Ok, everyone remember our CASE
40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.
Where should we begin???
Usually the EC doc goes to the head of the bed to assess A, assume that there are 15 people cutting clothes, starting the IVs, and exposing the patient.

10. Tackling the CASE at hand
40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.
Where should we begin???
A – deformity to the face, nose looks flat, lots of abrasions, eyes swollen closed, broken teeth, blood in the mouth, noisy breathing, and no response to questions

11. Tackling the CASE at hand
Where should we begin??? A
Oral intubation of the patient using RSI with in line cervical traction
I usually place an orogastric tube at the time of intubation (why not an NGT in this pt?)

12. Tackling the CASE at hand
A - the pt is intubated
What’s next? B
Despite intubation, O2 sats are still low and the pt is difficult to BVM
? Decreased breath sounds on the R chest and there is crunching under the bell of your stethoscope, you also imagine that the trachea appears deviated

13. Tackling the CASE at hand
A - the pt is intubated
What’s next? B
Needle decompression followed by tube thoracostomy of the R chest

14. Tackling the CASE at hand
A – pt is intubated
B – surgery is putting in the chest tube
Let’s move to C – BP 90/40, HR 130
The nurses have established two 16g IVs
How about 2L of fluid and a type and cross for 4 units of pRBCs (what do you give if immediate transfusion is needed?)

15. Tackling the CASE at hand
A-intubation, B-R CT, C-fluids and blood
What was D? Disability and Neuro exam
Our pt is intubated and paralyzed at this point, but any pt with a GCS of 8 or less should be intubated to protect their airway
What is a GCS you ask?

17. Tackling the CASE at hand
A-intubation, B-R CT, C-fluids and blood,
D – neuro
E – exposure and environmental
All the clothes are cut off and a warm blanket applied to the pt
Deformity to L femur probably from a fracture so the splint is re-applied

18. Tackling the CASE at hand
Now that the ABCDE is accomplished, a more thorough evaluation of the patient can be performed, orders, repeat vital signs, FAST exam, and talk to EMS for additional information.

19. What are the usual orders? Or, what would you order for this guy?

20. LABS AND FILMS Basic: CBC, BMP, PT/PTT, T&S, etoh, B-hcg
Other labs ordered at the discretion of the practitioner, institution, or clinical situation such as drug screen, lactic acid, or hepatic panel
XR standard: c-spine, CXR, pelvis
Obviously x-ray anything that looks injured
CT: head and abd/pelvis are usually standard
Chest CT for chest trauma or CXR findings
Neck CT based upon mechanism, age, injury

21. What are the 4 views of the FAST exam?

22. FAST Exam Primary role is detection of hemoperitoneum
Sensitivity of 75-90% compared to CT (depending on the user and injury)
Four Views of the FAST
Morison’s Pouch = hepatorenal
Splenorenal
Rectovesicular = Pouch of Douglas
Cardiac
-> some of us also do pleural windows for PTX

23. FAST: Normal or Abnormal?

24. FAST
Normal
Abnormal

25. FAST: Morison’s Pouch
Normal
Abnormal

26. FAST: Vesicoureteral
Normal
Abnormal

27. OOPS!

28. CT vs DPL vs FAST
DPL is very sensitive but not specific, invasive, need NGT/foley placed, good for visceral injury
Unstable trauma where US is unavailable or equivocal
CT is noninvasive, locates and delineates solid organ injury, but is expensive, time consuming, and located away from the resuscitation bay
Pt must be stable
FAST is quick, easy, decent sensitivity and done at the bedside for unstable pts
Not as good for bowel, mesentery, diaphragm, or pancreatic injuries

29. Let’s Move on to the Specifics…
Any Questions?
Let’s Move on to the Specifics…

30. Head Case
15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region.

31. Head Case
On exam he moans, withdraws to pain, but does not open his eyes…
What is his GCS?

32. Head Case On exam he moans, withdraws to pain,
but does not open his eyes…
What is his GCS?
What should you do FIRST?

33. Head Case GCS = 7 What should you do first?
Intubate the pt using RSI (sucs and etomodate)
Brief neuro exam if possible before paralysis
Lidocaine Prophylaxis for Intubation (1.5mg/kg)
Blunts the cough reflex, hypertensive response, and increased ICP associated with intubation

34. This is his Head CT… What does it show?

35. This is his Head CT… Subarachnoid Hemorrhage
Most common CT abnormality in head injury
Amount of blood correlates directly with outcome
Patients c/o HA and photophobia
Nimodipine is used to prevent vasospasm which would worsen ischemia

36. Compare it to these
Subdural Hematoma
Epidural Hematoma

37. So what do you do with Head Injured Patients?

38. Head Injury Complete the primary/secondary survey
Initial goal is to maximize O2 and BP to prevent secondary ischemic brain injury
Primary Brain Injury = mechanical irreversible damage that occurs at the time of the trauma (laceration, contusion, hemorrhage)
Secondary Brain Injury = intracellular and extracellular metabolic derangements initiated at the time of the trauma
All therapies for TBI are aimed at reversing or preventing secondary brain injury

39. Head Injury: Increased ICP
Increased ICP = CSF pressure > 15 mm Hg
The cranium can accommodate about mL of blood before ICP raises
CPP = MAP – ICP
CPP < 40, autoregulation is lost
All you really need to know is that CBF depends on the MAP (=maximize BP)

40. Recognizing Increased ICP
What is Cushing’s Reflex?

41. Cushing’s Reflex Hypertension Bradycardia
Diminished Respiratory Effort
Indicates that ICP has reached life threatening levels
Only occurs in 1/3 of cases

42. Head Injuries Recognizing Increased ICP
Ipsilateral to Mass Lesion
Anisocoria, ptosis, impaired EOMs, sluggish pupil
Contralateral to Mass Lesion
Hemiparesis
Positive Babinsky
As ICP continues to increase…
Posturing – decorticate then decerebrate
Ataxic respiratory patterns
Rapid fluctuations in BP and HR, arrhythmias
Lethargy to Coma

43. Methods to Reduce ICP Hyperventilation = PCO2 30-35
Lowering PCO2 by 1mmHg will decrease cerebral vessel diameter 2% which will decrease cerebral blood flow -> good initially but too long will cause reflex vasodilation
Diuretics = Mannitol (sometimes lasix)
Cranial Decompression = trephination, ventriculostomy, OR craniotomy
Seizure Prophylaxis = ativan, dilantin, pentobarbital

44. Head Injury: To CT or not to CT
Reasons to CT
History of LOC or Amnesia to the Event
Intoxication: drug and alcohol
Headache, vomiting, focal neuro deficit
Moderate (GCS 9-13) and High Risk (GCS<8)
Age > 60 or < 2
Anti-coagulants – ASA, Plavix, Coumadin
Posttraumatic Seizure
Any signs of trauma above the clavicles
Not to CT (how many people actually meet these criteria)
Low risk (GCS 14-15) patient who is not intoxicated and fully awake without focal neuro deficits, no evidence of skull fracture, and who can be observed for hours

45. Back to our Head Case What does this suggest??? On further exam….
15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region.
On further exam….
You notice that he has bruising behind his left ear, blood in the ear canal, and hemotympanum.
What does this suggest???

46. Basilar Skull Fracture
Signs: blood in the ear canal, rhinorrhea, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4, 5
These are linear fractures through the base of the skull and usually involve the temporal bone
Significance = requires a lot of force to break and can involve the internal carotid artery
These pts need a HCT and admission
Most CSF otorrhea and rhinorrhea will resolve spontaneously within a week
Prophylactic antibiotics are not usually given

47. What does this sound like?
40 y/o cashier at 7-11 is hit in the side of the head with a baseball bat. He was initially knocked out, but then woke up complaining of HA, dizziness, and feels nauseated. EMS says he just passed out again in the bus before arriving and now is minimally responsive to stimuli.

48. Epidural Hematoma
80% associated with skull fractures across the middle meningeal artery or a dural sinus in the temporoparietal region
The classic lucid interval occurs in 30%
Patients needs to go to the OR for evacuation

49. How about this?
80 y/o lady who fell yesterday at home. Today her family says that she is confused and moving more slowly than usual.
50 y/o drunk male brought in by police for stumbling on the side of the road. He eventually fell down and was unable to get back up.

50. Subdural Hematoma
Occur commonly in people with atrophic brains = old people and drunks
Bridging vessels traverse a greater distance so are more easily torn (venous blood)
Slow bleeding can delay presentation
Optimal treatment is evacuation in the OR

51. Head Injuries
ANY QUESTIONS?

52. Next case…
24 y/o male is smacked in the face with a whiskey bottle. He is complaining of mid facial pain and mal occlusion of his upper teeth.
When you grasp his upper teeth and move them, his maxilla and nose move together.
What kind of fracture is this?

53. Le Fort Fractures Le Fort I Le Fort II Le Fort III
Transverse fracture through the maxilla = upper teeth move
Le Fort II
Fx of the maxilla, nasal bridge, lacrimal bones, orbital floor and rim = teeth and nose move
Le Fort III
Craniofacial dysjunction = whole face moves

54. Airway Management in Facial and Neck Trauma
Orotracheal intubation: procedure of choice but can be difficult with deformity or bleeding, and is contraindicated with massive facial trauma or suspected laryngeal injury
Nasotracheal intubation: contraindicated in apneic pts and those with facial, skull, or laryngeal fractures as you may cause further injury
Cricothyroidotomy: indicated when oral intubation fails, when there is severe edema or deformity of the face and oropharynx, fracture of the larynx, or hemorrhage in the airway. Contraindicated with anterior neck hematoma or laryngeal injury.

55. Moving on…
78 y/o lady with a history of heart disease and afib presents after a syncopal episode in her yard. She was raking leaves when she felt her heart race, passed out, and fell forward to hit her head on a bucket.
She now complains of this intense burning sensation in both arms, hyperasthesia to the touch, and on exam has weakness in the arms more than the legs.
What spinal syndrome is this????

57. Central Cord Syndrome
Most common lesion and often seen in people with degenerative changes of the C-spine (=old)
Hyperextension injury that causes the ligamentum flavum to buckle into the cord
Results in concussion or contusion of the central portion of the spinal cord -> affects the pyramidal and spinothalamic tracts (motor and sensory)
Fibers that innervate distal structures are located more in the periphery of the cord, so deficit is greater in the upper extremities
More than 50% of people recover spontaneously

58. Anterior Cord Syndrome
Hyperflexion injury that causes anterior cord contusion through protrusion of a bony fragment or herniated disc
Also from laceration or thrombosis of the anterior spinal artery
Causes paralysis and hypoalgesia below the level of the lesion while preserving posterior column functions (position,touch,vibration)
This is a neurosurgical emergency as some causes are amendable to surgery
Variable degrees of recovery in the first 24 hours

59. Brown Sequard Syndrome
Hemisection of the spinal cord
Usually from penetrating trauma but can also be from fracture of the lateral mass in the c-spine
Ipsilateral motor and contralateral sensory deficits but either can predominate depending on the size and location of the injury
Most maintain bowel and bladder function
Treatment and prognosis depend on the injury

60. Other c-spine injuries will be covered in the ortho lecture.
Any Questions?
Other c-spine injuries will be covered in the ortho lecture.

61. Pedestrian vs MVC
45 y/o intoxicated female is crossing Woodward at 3am. She walks into traffic and is hit by a big truck before it can slow down (50mph). She is hit mainly in the abdomen and chest then propelled 30 feet onto the road.
EMS is called and she is on her way to your trauma bay.

62. Pedestrian vs MVC In the trauma bay…
EMS is bagging the patient who is unresponsive. She has poor respiratory effort when you stop the BVM. She has decreased breath sounds to both lung files: crepitus over the R chest wall with dull/distant breath sounds on the L.
What should we do first?

63. Pedestrian vs MVC
Intubate the patient using RSI and oral endotracheal insertion (OGT too).
Now that the patient is intubated, you notice poor chest rise and fall, o2 sat of 89%, HR 140s, and still with poor breath sounds -> absent on the R and decreased on the L.
Now what should we do next???

64. Pedestrian vs MVC
Bilateral chest tubes are placed -> surgery takes one side and the ER takes the other.
On the R, the ER resident receives a whoosh of air and a little bit of blood.
On the L, the surgery resident receives about 400cc of blood.
What does this mean?

65. Pedestrian vs MVC You auscultate the lungs again…
- on the R, there is improved air exchange still with crepitus and now you notice extensive bruising along the anterolateral CW
- on the L, there is better air exchange, but it is still decreased at the base
Re-evaluation of the vitals shows that the HR is now in the 110s and o2 sat is 96%. You decide this is good enough for now and continue with fluid resuscitation and further examination.

66. Pedestrian vs MVC Here is your portable CXR, What do you think?
OK, pretend that there are bilateral chest tubes.

67. Ruptured Diaphragm Most frequently from penetrating trauma
Rupture due to blunt trauma occurs in less than 5% of pts hospitalized with chest trauma
If there is fracture of the pelvis, incidence of diaphragm rupture increases
Incidence of L and R sided rupture about equal, but L side usually symptomatic as R side is protected by the liver
Clues:
Respiratory Insufficiency
Bowel Sounds in the Chest
NGT passes back into chest
Surgery is definitive treatment

68. Thoracic Trauma: Rib Fractures
1st and 2nd rib fractures used to be called the “hallmark of severe chest trauma”
Small, broad, thick bones that take significant force to break
Brachial plexus, great vessels, and lungs are in close proximity and at great risk
Therefore, you should think twice with this injury and do a very thorough neurovascular exam

69. Thoracic Trauma: Rib Fractures
Fractures of the 9th, 10th, and 11th ribs suggest an associated intra-abdominal injury: Liver on the R, Spleen on the L
Most heal within 3-6 weeks
Other than pain, rib fractures are associated with hemo/pneumothorax, atelectasis, and pneumonia
Each rib fracture can lose cc of blood
Patients with displaced rib fractures should have a repeat CXR at 3 hours for delayed PTX
Admit vs D/C: depends on the extent of injury, age, and ability to breathe

70. Thoracic Trauma: Flail Chest
2 or more ribs are fractured at two points to allow a freely mobile segment of the chest wall with inspiration/expiration -> the segment moves paradoxical to normal breathing
Major problems are underlying pulmonary contusion and chest pain with
splinting that causes atelectasis
-> results in major respiratory
insufficiency

71. Thoracic Trauma: Sternal Fracture
Most commonly from anterior chest trauma (MVC)
Using restraints increases the risk of fracture at the location the belt crosses the sternum
Older people are more likely to fracture their sternum than younger people (more likely to suffer mediastinal soft tissue injury)
Intuition would lead you to believe that these would be life threatening injuries, but again you must just think about the structures beneath the sternum and carefully evaluate them (heart, lungs, and mediastinum)

72. Thoracic Trauma: Pneumothorax
Simple PTX: collapse of lung but no communication with the atmosphere or shift of the mediastinum or hemidiaphragm; can observe these if <20% and they are not ventilated, unstable, going to OR, or being transferred to a trauma center
Tension PTX: accumulation of air under pressure causes shift of the mediastinum resulting in compression of the contralateral lung and great vessels leading to decreased cardiac output from decreased venous return
Open PTX: sucking chest wound. Place occlusive dressing – taped on 3 sides only. Place CT at a different site
DIB and CP are the most common complaints
Signs and symptoms do not always correlate well with the degree of PTX

73. Thoracic Trauma: Pneumothorax
Tension PTX:
Pts usually develop severe cardiopulmonary collapse within minutes as the mediastinum is crushed
Classic signs: tachycardia, JVD, absent breath sounds on the ipsilateral side with trachea deviated away
JVD may not be present in a hypovolemic state
Hypoxia occurs first, then hypotension, then cardiac arrest
Tension PTX is a clinical (not radiographic) diagnosis
Immediate treatment is needle decompression followed by tube thoracostomy
*At what anatomical location are these procedures perfomed?
14 g angiocath 2nd ICS, MCL

74. What do these films show?

75. Thoracic Trauma: Hemothorax
Injured lung parenchyma is usually the source followed by intercosatal/IMA vessels then hilar and great vessels
Clinically there may be DIB with decreased breath sounds on the affected side
CXR – upright may have blunting or obliteration of the diaphragm, supine will have diffuse haziness on the affected side
Rx: Tube thoracostomy if respiratory compromise
1500mL of blood = OR for thoracotomy
200 mL/Hr for 3 hours = OR

76. What is this?
22 y/o male is stabbed in the epigastrium at a bar while flirting with another man’s girlfriend. He is complaining of abdominal pain, head pressure, and difficulty breathing.
HR 130s BP 80/55 RR 32 sPO2 96

77. Pericardial Effusion or Tamponade
Beck’s Triad: hypotension, distended neck veins, and distant heart sounds
Tamponade occurs in 2% of pts with penetrating chest or abdomen trauma and rarely occurs with blunt trauma
Rx: initially fluid resuscitation, pericardiocentesis if there is time, ED thoracotomy, or definitive management in the OR
Subxyphoid pericardiocentesis with 20 g spinal needle. Thoracotomy if penetrating trauma that loses vital signs. Will not see electrical alternans, like you see with chronic, progressive tamponade. Pt may present with PEA. The problem with both tension PTX and tamponade is loss of venous return.

78. Next…
17 y/o kid out joy riding on Saturday night in his mom’s car with a suspended license. He rolls through a stop sign on his phone and is t-boned on the driver’s side. PD is called. He initially gets out of the car, ambulates, and says that he is fine other than some mid back pain. He refuses EMS transport until he realizes that it is the hospital or jail.

79. Joy Ride
He arrives with c-collar and back board to the trauma bay. He is now complaining of mid and lower back pain with tingling in both of his legs. He is afraid that he is going to be paralyzed and starts to hyperventilate. You complete your exam, roll the pt, and obtain your portable films.
As you start to roll to CT scan you try to talk to him to calm him down saying that everything is going to be OK. He looks at you and says that he is going to die, but of course you continue with your reassurances that everything is fine. Suddenly he is unresponsive and you cannot find a pulse when you check.

80. Joy Ride Portable CXR What do you think?
What do you want to do next?

81. ED Thoracotomy Indications
Penetrating Trauma
Cardiac arrest at any point with initial vitals or signs of life in the field
Persistent hypotension (SBP<50) despite aggressive resuscitation
Severe shock with signs of tamponade
Blunt Trauma
Cardiac arrest in the EC
= blunt traumatic arrest in the field is not an indication for thoracotomy

82. Blunt Traumatic Aortic Injury
Thoracic aorta is the most common vessel injured by blunt trauma and must be considered in every rapid deceleration injury (usually MVC)
80-90% of tears occur just distal to the L subclavian artery where the ligamentum arteriosum is located in the descending aorta (aorta is tethered around a fixed point)
Patients who suffer an ascending aortic injury usually die at the scene
CXR: mediastinum widening (>8cm on supine), obscured aortic knob, loss of the clear space between the aorta and pulmonary artery, displaced NGT, widened paratracheal stripe, trachea deviated to the right, depression left mainstem bronchus

83. Let’s shift gears and talk about the Belly.

84. Abdominal Trauma Who do you think is more likely to survive?
What internal organs are most likely to be injured?
18 y/o kid who…
Is stabbed in the mid abdomen.
Falls 12 feet off the roof of a house.

85. Abdominal Trauma
Blunt injuries actually carry a greater risk of mortality than penetrating injuries
Blunt injury is more difficult to evaluate and diagnose
Blunt injury is more often associated with injury to multiple internal organs and systems outside of the abdomen

86. Abdominal Trauma Penetrating Injury Blunt Injury
Small intestine, colon, and liver
Blunt Injury
Spleen>>>>liver, intestine
Seat Belt Sign = contusion or abrasion across the lower abdomen
Correlates with intraperitoneal lesions or lumbar spinal injury

87. Abdominal Trauma Evaluation
Inspect and Palpate most importantly
FAST exam
CT scan
Labs
CBC – not usually helpful initially, mild leukocytosis is normal, serial Hgb more helpful
Tox Screen and Ethanol level

88. Abdominal Trauma: Treatment
Hemorrhage is the main concern so two large bore IVs for fluids followed by blood products
Antibiotics if concern for bowel injury
Stable – FAST, CT, then OR if necessary
Unstable – consider FAST, but really go straight to the OR for ex-lap without delay
Penetrating trauma – determine whether or not the peritoneum was violated as this dictates management

89. Abdominal Trauma: ED standpoint
2 IVs or a central line for aggressive resuscitation
If the pt is hypotensive/unstable with a high suspicion for intra-abdominal injury -> they need to go for ex-lap not CT
If the pt is stable, they can go to CT for evaluation of the internal organs and management then depends on the findings
If the pt is unstable and you are unsure if the injury is intra-thoracic vs abdominal, a good PE and FAST exam can help the surgeons start somewhere

90. Trauma: “A Good PE” Where does blood hide in the body?
How much blood do you lose with fractures?

91. Where does blood hide in the body?
Chest
Abdomen
Pelvis
Femur
In kids, the cranium is a possibility as the sutures are still open

92. Blood Loss with Fractures
Pelvis – cc
Femur – 1000cc
Ribs – cc
Tibia/Fibula – 500cc
Humerus – 250cc
Radius/Ulna – cc

93. Trauma: In the End
Trauma can be cool to look at, but don’t be distracted by the gore
Start with your ABCs and don’t move to the next step until you have solved a problem
ANY QUESTIONS?

94. THE END