1. William Beaumont Hospital Department of Emergency Medicine
Trauma
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”
Emphasize the initial evaluation and treatment of the trauma patient
Our “window of opportunity” to have a significant impact on morbidity and mortality
Must have a concise, expeditious, well thought out plan for evaluation and treatment of life threatening injuries
Accomplished 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 and cervical spine protection
B = breathing and ventilation
C = circulation and hemorrhage control
D = disability and neurological status
E = exposure and environmental control
D – LOC (AVPU – awake, responds to verbal stimuli, responds to painful stimuli, unresponsive;
pupil size
E –undress the pt, log roll the patient and put a blanket on them

6. Primary Survey: ABCDE’s
An identified injury should be treated at the time of discovery
Examples:
The airway should be secured before the fracture is stabilized
PTX should be treated before the patient is completely exposed
The decision to transfer a patient should be made before proceeding to the secondary survey

7. Secondary Survey: Head to Toe
Complete the history (AMPLE)
Head to toe physical exam
Reassess vital signs and interventions
Obtain GCS if not done in primary survey
Special procedures (lines), specific x-rays, and labs should be obtained

8. Secondary Survey: Rectal Tone
Rectal exam is done in every trauma and before urinary catheter placement (WHY?)
Check for blood  tear or pelvic fracture
High riding prostate  potential urethral injury
Decreased 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???
The Emergency physician starts at 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. Airway
Oral intubation of the patient using RSI with in line cervical traction
An orogastric tube is placed at the time of intubation
Why not an NGT in this patient?

12. Breathing A - Patient is intubated What’s next? B - Breathing
Despite intubation, O2 sats are still low and the patient is difficult to BVM
Decreased breath sounds on the R chest, crunching under the bell of your stethoscope, and the trachea appears deviated…
What’s the problem? How do we fix it?

13. Breathing A - Patient is intubated Hemo/pneumothorax
Needle decompression followed by tube thoracostomy of the R chest

14. Circulation A – Patient is intubated B – Chest tube placed
What’s next? C – Circulation
Vitals: BP 90/40, HR 130
RN 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. Disability and Neuro Exam
A – Patient is intubated
B – Chest tube placed
C – Fluids and blood given
Now for D – Disability and Neuro exam
Patient is intubated and paralyzed
GCS = 3TP (T = tube, P = paralyzed)
GCS =/<8  intubated for airway protection
What is a GCS you ask?

16. Glasgow Coma Scale
Used for head injury

17. Exposure and Environmental
A – Patient is intubated
B – Chest tube placed
C – Fluids and blood given
D – GCS = 3TP
E – Exposure and Environmental
All clothes are cut off
Warm blanket applied to the pt
Deformity to L femur probably from a fracture  splint re-applied

18. Tackling the Case at Hand
Secondary survey
Orders
Repeat vital signs
FAST exam
Talk to EMS for additional information

19. What should we order for our patient?

20. Labs and Imaging 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 standard for a severely injured intubated patient
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
Can also perform pleural windows for PTX

23. FAST: Cardiac Subcostal View
Normal
Abnormal

24. FAST: Morison’s Pouch
Normal
Abnormal

25. FAST: Retrovesical
Normal
Abnormal

26. OOPS!

27. CT vs. DPL vs. FAST DPL CT FAST Noninvasive
Very sensitive but not specific
Invasive
Good for visceral injury
Unstable trauma where US is unavailable or equivocal CT
Noninvasive
Delineates solid organ injury
Expensive
Patient must be stable
FAST
Quick
Sensitive
Bedside
Operator dependent
Misses bowel, mesentery, diaphragm and pancreatic injuries

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

29. 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.

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

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

32. Head Case GCS = 7 What should you do first? Intubate using RSI
Brief neuro exam, if possible, before paralysis
?? Lidocaine prophylaxis for intubation
Blunts the cough reflex, hypertensive response, and increased ICP associated with intubation

33. This is his head CT… What does it show?

34. 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 worsens ischemia

35. Compare It To This…
Subdural Hematoma
Epidural Hematoma

36. 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

37. Head Injury: Increased ICP
Increased ICP = CSF pressure > 15 mm Hg
The cranium can accommodate ~50-100mL of blood before ICP increases
CPP = MAP – ICP
CPP < 40, autoregulation is lost
Remember CBF depends on the MAP therefore maximize the BP.

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

39. Cushing’s Reflex Hypertension Bradycardia
Diminished respiratory effort
ICP has reached life threatening levels
Occurs in 1/3 of cases

40. Recognizing Increased ICP
Ipsilateral to mass lesion
Anisocoria, ptosis, impaired EOMs, sluggish pupil
Contralateral to mass lesion
Hemiparesis
Positive Babinski
As ICP continues to increase…
Posturing – decorticate then decerebrate
Ataxic respiratory patterns
Rapid fluctuations in BP and HR, arrhythmias
Lethargy  coma  death

41. Methods to Reduce ICP Hyperventilation = PCO2 30-35
Lowering PCO2 by 1mmHg decrease cerebral vessel diameter 2%  decreased ICP
Good initially but over time will cause reflex vasodilation
Diuretics = mannitol
Cranial decompression
Seizure prophylaxis = Ativan, Dilantin

42. Head Injury: 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
Post-traumatic seizure

43. Head Injury: CT Unnecessary?
Low risk (GCS 14-15)
Not intoxicated
Fully awake without focal neuro deficits
No evidence of skull fracture
Able to be observed for hours

44. 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?

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

46. 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.

47. 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

48. 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.

49. 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

50. Any Questions?
Head Injuries

51. 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?

52. Le Fort Fractures Le Fort I Le Fort II Le Fort III
Transverse fracture through the maxilla
Upper teeth move
Le Fort II
Fraxture of the maxilla, nasal bridge, lacrimal bones, orbital floor and rim
Teeth and nose move
Le Fort III
Craniofacial dysjunction
Whole face moves

53. Alternative Airways Orotracheal intubation Nasotracheal intubation
Procedure of choice with facial or neck trauma
Contraindicated w/ massive facial trauma or suspected laryngeal injury
Nasotracheal intubation
Contraindicated in apneic pts
Contraindicated in those with facial, skull, or laryngeal fractures
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.

54. Another Case…
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?

55. Central Cord Syndrome Most common lesion Common in elderly
Hyperextension injury  ligamentum flavum buckles into the cord  contusion of the central portion of the spinal cord  affects the pyramidal (motor) and spinothalamic tracts (sensory)
Fibers that innervate distal structures are located more in the periphery of the cord  deficit greater in the upper extremities
Prognosis: >50% of people recover spontaneously

56. Anterior Cord Syndrome
Hyperflexion injury  anterior cord contusion through protrusion of bone fragment or herniated disc or laceration of anterior spinal artery  paralysis and hypoalgesia below the level of the lesion
Preserved posterior column functions (i.e. position, touch, vibration)
Neurosurgical emergency as some causes are amenable to surgery
Prognosis: variable degrees of recovery in the first 24 hours

57. Brown Sequard Syndrome
Hemisection of the spinal cord
Ipsilateral motor
Contralateral sensory deficits (pain and temperature)
Usually from penetrating trauma but can also be from fracture of the lateral mass in the C-spine
Most maintain bowel and bladder function
Treatment and prognosis depend on the injury

58. Other C-spine injuries are covered in the orthopedics lecture.
Any Questions?

59. 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.

60. 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 fields, crepitus over the R chest wall with dull/distant breath sounds on the L. What should we do first?

61. 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?

62. Thoracostomy Tubes Bilateral chest tubes are placed.
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?

63. Thoracostomy Tubes You auscultate the lungs again…
Right: improved air exchange, still with crepitus and extensive bruising along the anterolateral CW
Left: 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.

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

65. Ruptured Diaphragm Most frequently from penetrating trauma
<5% from blunt trauma
If there is a pelvic fracture, incidence rupture increases
Incidence of L and R sided rupture about equal
L side usually symptomatic as R side is protected by the liver
Signs/Symptoms:
Respiratory insufficiency
Bowel sounds in the chest
NGT passes back into chest
Surgery is definitive treatment

66. 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
Think twice with this injury and do a very thorough neurovascular exam

67. Thoracic Trauma: Rib Fractures
Fractures of the 9th-11th ribs suggest an associated intra-abdominal injury
Most heal within 3-6 weeks
Rib fractures are associated with hemo/pneumothorax, atelectasis, and pneumonia
Each rib fracture can lose ~200cc of blood
Admit vs. discharge: depends on the extent of injury, age, and ability to breathe

68. 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

69. Thoracic Trauma: Flail Chest
Major problems are underlying pulmonary contusion and chest pain
Splinting that causes atelectasis  results in major respiratory insufficiency

70. Thoracic Trauma: Sternal Fracture
Most commonly from anterior chest trauma
Using restraints increases the risk of fracture at the location the belt crosses the sternum
Older > younger more likely
Younger  more likely to suffer mediastinal soft tissue injury
Think about the structures beneath the sternum and carefully evaluate them (heart, lungs, and mediastinum)

71. Thoracic Trauma: Pneumothorax
DIB and CP are the most common complaints
Signs/symptoms do not always correlate well with the degree of PTX
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

72. Thoracic Trauma: Pneumothorax
Tension PTX
Accumulation of air under pressure causes shift of the mediastinum  compression of the contralateral lung and great vessels
Leads to decreased cardiac output from decreased venous return
Classic signs: tachycardia, JVD, absent breath sounds on the ipsilateral side with trachea deviated away
Tension PTX is a clinical diagnosis (not radiographic)
Management: needle decompression and chest tube

73. Thoracic Trauma: Pneumothorax
Open PTX
Sucking chest wound
Management: place occlusive dressing, taped on 3 sides only and place CT at a different site

74. What Do These Films Show?

75. Thoracic Trauma: Hemothorax
Injured lung parenchyma most common > intercostal/IMA vessels > hilar vessels > great vessels
Signs/Symptoms: DIB, decreased breath sounds on the affected side
Upright CXR: blunting or obliteration of the diaphragm
Supine CXR: diffuse haziness on the affected side
Treatment: chest tube 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, distant heart sounds
Tamponade occurs in 2% of pts with penetrating chest or abdomen trauma
Rarely occurs with blunt trauma
Treatment: IVF, pericardiocentesis vs. ED thoracotomy, then 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 Case…
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. 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 ED
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
80-90% of tears occur distal to the L subclavian artery
Ligamentum arteriosum is located in the descending aorta (aorta is tethered around a fixed point)
Patients suffering an ascending aortic injury usually die at the scene
CXR findings: 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
18 y/o kid who… Is stabbed in the mid abdomen. -OR- Falls 12 feet off the roof of a house. Who do you think is more likely to survive? What organs are most likely to be injured?

85. Abdominal Trauma
Blunt injuries 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/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 ETOH level

88. Abdominal Trauma: Treatment
Hemorrhage is the main concern
Two large bore IVs or central line
IVF followed by blood products
Antibiotics if concern for bowel injury
Stable – FAST, CT, then OR if necessary
Unstable –FAST then OR for ex-lap
Penetrating trauma – determine if the peritoneum was violated as this dictates management

89. Where Does Blood Hide in the Body?
Chest
Abdomen
Pelvis
Femur
In kids, the cranium is a possibility as the sutures are still open

90. Blood Loss with Fractures
Pelvis – cc
Femur – 1000cc
Ribs – 200cc
Tibia/Fibula – 500cc
Humerus – 250cc
Radius/Ulna – cc

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

92. Any Questions?
The End