1. Case Based Presentation
TRAUMA # 2

2. Case
You’re on call on a Saturday in the ICU at VGH when the head nurse tells you that 2 traumas from an MVA had just come into the ER. Both the driver and the passenger were belted when their car lost control and hit a tree. The trauma team is currently assessing them and will let you know if they need any ICU services.

3. Case
After speaking to the trauma senior, you find out that the driver is unstable. A FAST showed free fluid in the abdomen, and the patient is now being rushed to the OR for an exploratory laparotomy. She thinks that the patient will likely need to come to the ICU post-operatively.

4. Question 1
What are the most common organ injuries associated with a) blunt and b) penetrating abdominal trauma? What organ injuries are associated with deceleration injury? (Yoan)

5. Liver and spleen : most frequently.
What are the most common organ injuries associated with blunt abdominal trauma?
Liver and spleen : most frequently.
Small and large intestines : next most injured.
Crush, Deceleration, trapped air
Pancreas (10-12%): in crush injury, direct blow, seat belt...
Kidney, bladder
Source: emedicine 2007, Salomone et al 5

6. What are the most common organ injuries associated with penetrating abdominal trauma ?
Stab
liver (40%)
small bowel (30%)
diaphragm (20%)
colon (15%)
pancreas, duodenum, vascular, gastric, rectum, porta hepatis, kidneys, ureters
Gunshot wound
small bowel (50%)
colon (40%)
liver (30%)
vascular (25%)
Source: emedicine 2008, Testa et al 6

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

13. What organ injuries are associated with deceleration injury?
Classic deceleration injuries include hepatic tear along the ligamentum teres and intimal injuries to the renal arteries. As bowel loops travel from their mesenteric attachments, thrombosis and mesenteric tears, with resultant splanchnic vessel injuries, can result.
Source: emedicine 2007, Salomone et al 13

14. 14

15. 15

16. Case
The senior then tells you that the passenger of the car is currently stable after aggressive resuscitation. He has a pelvic fracture and is complaining of chest pain. The CXR shows a widened mediastinum. The ECG is unremarkable. A CT chest is ordered and pending.

17. Question 2
Discuss the different types of pelvic fractures, their associated mechanism of injury, risk of bleeding, and initial management

18. Biomechanics of pelvic fractures
Lateral compression injury
Most common
Acute shortening of diameter across pelvis
Rarely destroy ligamentous integrity
Do not typically cause large blood loss

19. Anterior/Posterior Compression
Force causes pelvic diameter to widen
Ligamentous disruption
Manifest itself as a widened pubis symphysis and SI joint
Often associated with substantial vascular damage: LS plexus and common/external iliac artery

20. Vertical shear injury Fall from a height Severe ligamentous injury
Vascular injury less severe than AP injuries
Disruption of all restraining ligament of the hemipelvis,

21. Pelvic Fracture Classification
Tile Classification
Concentrate on rotational component of injury to address long-term reconstructive plans
Young and Burgess Classification
Subdivide LC and AP compression injuries according to increasing level of energy

22. The American Journal of Surgery 192 (2006) 211ﾐ223

23. The American Journal of Surgery 192 (2006) 211ﾐ223

24. Mechanism of injury

25. Blood loss in pelvic fractures

26. Initial Management ABC’s Xmatch and IV access Compressive device
Temporal control of hemorrhage
Design to reduce the volume of the pelvis
Less useful in LC injuries

27. Critical Care2007, 11:204

28. The American Journal of Surgery 192 (2006) 211ﾐ223

29. Indications for Angiography
4 U transfused for pelvic bleeding in <24 h
>6 U transfused for pelvic bleeding in <48 h
Hemodynamic instability with a negative FAST or DPL
Large pelvic hematoma on CT
Pelvic pseudoaneurysm on helical CT
Large and/or expanded pelvic hematoma seen at the time of laparotomy
TRAUMA - 6th Ed. (2008)

30. External Fixation
Used as definitive anterior fixation for open book fracture
Used if condition does not permit internal fixation
Used as a bridge to internal fixation
“damage control” approach

31. Question 3
What associated injuries should you look for in patients with pelvic fractures?

32. Which injuries may be associated with pelvic fractures?UK
So Cal

33. The Pelvis Doesn’t Fracture Easily…
Associated with high energy-transfer situations…
Falls
Crashes
Assault
Sports injuries
(including, of course… falls and crashes)

34. In UK Trauma Audit Research Network, associated with:
Chest trauma (21%)
Head trauma (17%)
Hepatic/Splenic injury (8%)
2 or more long bone fractures (8%)
Urogenital (4%) (!?)

35. But wait… there’s more!
Longer mean hospital LOS (15 vs 8 days in trauma pts without pelvic fracture)
More likely to be admitted to critical care setting (25% vs 12%)
3 month mortality 14% vs 6%.
Shorter period from injury to death in pelvic # patients (6 hrs vs 40 hrs)

36. Trauma Registry at LA County/ USC Trauma Center 1993-2000

37. Similar to UK data: falls
And crashes!

38. Associated Injuries Intraabominal/urogenital injury:17%
Bladder/Urethral: 6%
Solid organ: 12%
6% hepatic
GI perforation: 4%
Urogential: 6%
Thoracic Aortic Rupture: 1.4% (vs 0.4% of trauma pts without pelvic fracture)
Mortality: 28% (vs 14%)

39. Case
The CT chest showed a descending thoracic aortic dissection with no contrast extravasation. The patient arrives in the unit and is hemodynamically stable.

40. Question 4
Discuss the diagnosis, the radiographic features as well as the management of blunt aortic injury.

41. Blunt aortic injury occurs in less than 1% of MVCs but is responsible for 16% of the deaths
Up to 80% of patients die before their arrival at a hospital
Untreated, approximately 30% of surviving patients who are admitted to a hospital will die within the first 24 hours

42. Mechanism
N Engl J Med 2008;359:

43. Diagnosis CXR findings
Wide mediastinum: >8cm on upright, mediastinal/chest width ratio of >0.38
obscure or indistinct aortic knob
depression of the left mainstem bronchus
deviation of the nasogastric tube
opacification of the aortopulmonary window

44. CXR Also suggestive widened paratracheal and paraspinous stripes
apical capping
1st and 2nd rib fractures have less an association
Between 7.3% and 44% of patients with blunt aortic injury may have a normal mediastinum on chest radiography

45. CT Scan
Helical CT of the thorax is more sensitive for blunt aortic injury than angiography and is estimated to have a sensitivity of 100%, as compared with 92% for angiography
Fabian TC, et a l . Ann Surg 1998;227:666-76

46. CT Scan
28% rate of missed diagnoses and recommend that CT be performed in all patients with a hx of MVC at a speed of >15 km/h for unrestrained drivers and >50 km/h for restrained drivers
Exadaktylos AK, et al. Cardiovasc J S Afr 2005;16:162-5.

47. Bruckner B. A. et al.; Ann Thorac Surg 2006;81:1339-1346
CT vs Angio
Bruckner B. A. et al.; Ann Thorac Surg 2006;81:
Copyright ©2006 The Society of Thoracic Surgeons

48. Other Modalities
Other options for the diagnosis of BAI include transesophageal echocardiography, intravascular ultrasonography, and magnetic resonance imaging

49. Management Immediate operative repair used to be the rule
Several studies have demonstrated the relative safety of a delayed approach, particularly if there are substantial co-injuries, using a regimen of beta-blockers and antihypertensive agents to decrease the shear force on the aortic wall
Demetriades et al J Trauma 2009, 66:

50. Medical Mgt
Fabian et al: a prospective study using beta-blockers with or without vasodilators to maintain a systolic blood pressure of 100 mm Hg (or 110 to 120 mm Hg in older patients) and a pulse rate of under 100 beats/min
no patient had an aortic rupture while awaiting repair.
Potential problem with severe HI and SCI

51. Repair There are basically 3 option Open “clamp and sew”
Open Bypass or shunt
Endovascular repair

54. Paraplegia
Demetriades et al J Trauma 2009, 66:
Clamp and sew has an associated mortality of 16% and a striking 19% incidence of paraplegia

55. Endovascular Repair
Majority of the repairs currently done as seems much safer especially in multi-trauma patients
the durability of endografts is unknown.
There are questions about long-term device integrity as well as the natural history of the aorta itself after this type of injury and repair. These issues are particularly important considering the relatively young age of trauma patients

56. Case
Shortly after admitting these 2 patients, the head nurse tells you another trauma came into the ER, and was wondering if you were called about it. The patient is a 19 year-old man who was also involved in a MVA. On the scene, the patient was alert and oriented but unable to move or feel his extremities.

57. Question 5
Summarize the clinical findings and anatomical lesions of the related to the following clinical syndromes: (Neil)
Central cord syndrome
Brown-Sequard syndrome
Anterior cord syndrome
Conus medullaris syndrome
Spinal shock.

64. Anterior cord
Brown Sequrd
Central Cord
Pain/Temp
Bilateral
Contralateral
Shawl distribution
Motor
Ipsilateral
Arms>Legs
Vibration/position
Intact

66. Conus medullaris
Cauda Equina Syndrome
Location:
L1-L2 vertebral level
Injury to sacral cord (S1-5)
L2-Sacrum vert level
Injury to lumbosacral roots
Causes:
L1 fracture
Tumors, gliomas
Vascular injury
Spina bifida, tethering of cord
L2 or below fracture/disc
Sacral Fractures
Fracture of pelvic ring
Spondylosis
Signs and symptoms
Normal motor function of lower extremeties,(unless motor S1-S2 involvement)
Saddle anesthesia
No pain
Symmetric abnormalities
Severe bowel, bladder, sexual dysfunction
BCR may be present
Flacid paralysis of involved lumbar roots
Areflexic LE Sensory loss in root distribution
Pain
Asymmetric
High lesions spare bowel and bladder
BCR often absent
EMG Normal
EMG root findings

67. Spinal Shock
Concussive injury to spinal cord that results in complete dysfunction below level of injury
Usually lasts <24 hours but can be days
Bulbocavernosus reflex is not present during spinal shock
Important in prognosis

68. Case
In the trauma bay, the patient is hypotensive and bradycardic. He is on 10 mcg/min of dopamine. His c-spine films show a blowout fracture of his C5 vertebra.

69. Question 6
What are the cardiovascular complications of spinal cord injuries and how should you manage them? (Marios)

70. Cardiovascular complications of SCI
Occur in patients with cervical or high thoracic cord injury (T6 or higher).
Degree of dysfunction is related to the location and severity of the injury, and is manifested by:
Low resting blood pressure and orthostatic hypotension
Heart rate abnormalities
Autonomic dysreflexia
Neurogenic shock typically lasts up to 5 weeks.

71. Degree of SCI and cardiovascular dysfunction

72. Low blood pressure and orthostatic hypotension
Hypotension occurs due to the reduced sympathetic outflow to the cardiovascular system.
Mechanisms involved in orthostatic hypotension include:
Loss of reflex vasoconstriction caudal to the injury
Lack of muscular effects to counteract venous pooling
Reduced plasma volumes secondary to hyponatremia
Cardiovascular deconditioning secondary to prolonged bedrest

73. SBP over time

74. DBP over time

75. Heart rate abnormalities
SCI alters cardiac electrophysiology and increase susceptibility to arrhythmias such as:
Sinus bradycardia
Repolarization changes
AV blocks
Supraventricular tachycardia
Ventricular tachycardia
Cardiac arrest
Secondary to a loss of sympathetic tone in the presence of intact parasympathetic tone.
The most pronounced changes are seen during the acute phase post injury (weeks 2 to 6)

76. Repolarization changes

77. Heart rate over time

78. Autonomic dysreflexia
An increase in SBP of at least 20% associated with a change in heart rate and accompanied by one of the following signs or symptoms:
Sweating
Piloerection
Facial flushing
Headache
Blurred vision
Stuffy nose
Often associated with a triggering factor such as bladder distension or bowel impaction.
Relatively common in the chronic phase of SCI, but can also occur in the acute stage following SCI.

79. Autonomic dysreflexia

80. Management Hypotension
R/O other causes of hypotension, including adrenal insufficiency.
Guidelines recommend the use of fluids +/- vasopressors to maintain a MAP of 85 mmHg or greater during the first 7 days following SCI.
Based on Grade III evidence, this is thought to improve spinal cord perfusion and therefore possibly neurological outcome.
High thoracic or cervical cord lesions, where hypotension is often accompanied by bradycardia should be treated with dopamine or norepinephrine.
Lower thoracic cord lesions which are primarily affected by vasodilation can be treated with phenylephrine.

81. Management Symptomatic bradycardia
May occur with noxious stimuli such as suctioning.
Can be treated with atropine or vasopressors that have both alpha- and beta-adrenergic actions such as dopamine, norepinephrine, and epinephrine.

82. Management Autonomic dysreflexia If supine  place in sitting position
Loosen constrictive clothing or devices
R/O bladder distention or bowel impaction
If SBP > 150, consider nitroprusside

83. Question 7
Is there any evidence for steroids in spinal cord trauma? (Naisan)

84. Question 7 - Is there any evidence for steroids in spinal cord trauma?
NO…
I think

85. Clinical Practice Guideline SCI 2008
No clinical evidence exists to definitively recommend the use of any neuroprotective pharmacologic agent, including steroids, in the treatment of acute spinal cord injury to improve functional recovery.

86. The Studies
MP has been investigated in three large-scale, multicenter clinical trials collectively referred to as NASCIS (National Acute Spinal Cord Injury Study; Bracken et al.1984, 1990, 1997)
NASCIS 1 trial compared 2 doses of MP after traumatic SCI (100mg vs 1000mg for 10 days)
second clinical trial compared the effects of a much higher dose of MP (30 mg/kg then infusion) with those of naloxone and a placebo
and the third clinical trial evaluated the timing of initiation and duration of MP treatment following injury (8 vs 3 hours; 24 vs 48 hrs)

87. The Outcomes NASCIS I: no difference found between groups
NASCIS II: if <8hrs, improved motor function was statistically significant at 6 months and even after 1 year in the MP group compared with the control group (17.2 and 12.0 points improvement, p=.030)

88. The Results
NASCIS III: Follow-up after 6 months revealed no significant difference between the groups
At that point, patients were divided into treatment within 3 hours and after 3 hours but less than 8 hours after SCI
After this statistical maneuver, there was a significant difference in motor score who received MP for 47 hours compared with 24hrs, in the groups treated between 3 and 8 hours

89. The Problems
neither NASCIS II or NASCIS III addressed some of the potential confounding variables
the NASCIS II trial did not include details about other interventions such as radiology , surgical manipulations, or the extent of rehabilitative therapies, which may have contributed to improvements or recovery

90. The Problems
subsequent post hoc analysis failed to demonstrate improvement in outcome measures (motor scores, pinprick scores,and light-touch scores)
meaning that improved recovery with MP may represent random events, thus weakening the overall study findings (Coleman et al., 2000; Hurlbert, 2000, 2006; Short et al., 2000).

91. The Problems
Only right-sided motor scores were reported in NASCIS II, but bilateral sensory scores were reported. Lack of evidence describing left-sided motor scores and total body motor scores in NASCIS II is confusing
The data were presented as obtained from the whole study population; however, the fact is that in the groups that presented within 8 hours, only 62 patients of the placebo group and 65 of the MP group were analyzed

92. NASCIS III :Had no difference at one year in the Functional Independence Measure (FIM) developed by the American Spinal Injury Association
So seems no clinically significant difference

93. Side effects
All studies showed a significant increase in infection rates, ICU/Vent times, and GI bleeding

94. Question 8
Discuss DVT prophylaxis in spinal cord injury. (Todd)

95. Venous Thromboembolism Prophylaxis in Spinal Cord Injury
Spine trauma, immobility and paralysis all conspire to place SCI pts at risk for VTE.
Options include:
Pneumatic calf compression devices
Unfractionated heparin
Low molecular-weight heparin
IVC filters
Screening doppler U/S
Which is best?

96. Chest Guidelines 2004
VTE prophylaxis is recommended for “…all trauma patients with at least one risk factor.” Grade 1A.
Data on pneumatic compression devices is conflicting, but they may be useful in patients with a contraindication to anticoagulants.
IVC filters not recommended as routine treatment unless absolute contraindication to anticoagulation.
Not cost-effective to screen with U/S.
Continue until discharge.

97. Venous Thromboembolism Prophylaxis in Spinal Cord Injury
Low Molecular-Weight Heparin (LMWH).
Spine uses it; we use it…and it’s worked out pretty well so far.

98. Low-dose UFH vs LMWH: Geerts, WH, Jay, RM, Code, KI, et al A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N ENGL J MED 1996;335,
Contraindications:
Intracranial hemorrhage.
Active bleeding.
Uncontrolled coagulopathy.
Known or suspected perispinal hematoma (incomplete sci).