Presentation on theme: "TRAUMA (LIFE IN THE ER) William Beaumont Hospital"— Presentation transcript:
1TRAUMA (LIFE IN THE ER) William Beaumont Hospital Department of Emergency Medicine
2CASE40 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???
3Where 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 shockWhat is the Golden Hour?
4“Golden Hour”The idea is to emphasize the importance of the initial evaluation and treatment of the trauma patientIt is our “window of opportunity” to have a significant impact on morbidity and mortalityOne must have a concise, expeditious, well thought out plan of action for evaluation and treatment of life threatening injuriesWe accomplish this through ATLS guidelines of the Primary and Secondary SurveysInjuries 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
5Primary Survey: ABCDEs A = airway maintenance with cervical spine protectionB = breathing and ventilationC = circulation and hemorrhage controlD = disability and neurological statusE = exposure and environmental control, undress the pt, log roll the patient and put a blanket on themD – LOC (AVPU – awake, responds to verbal stimuli, responds to painful stimuli, unresponsive;pupil sizeE – log roll the patient
6Primary 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 exposedA decision about transferring the patient should be made before proceeding to the secondary survey
7Secondary Survey: head to toe Complete the history (AMPLE) and physical examReassessment of vital signs and interventionsIf GCS not obtained in primary survey, now is a good timeSpecial procedures (lines), specific x-rays, and labs are now obtained
8Secondary Survey: Rectal Tone Rectal exam is done in every trauma and before urinary catheter placement (WHY?)Check for blood and integrity = tear or pelvis fractureHigh riding prostate = potential urethral injuryTone = brain or spinal injury
9Ok, 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.
10Tackling 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
11Tackling the CASE at hand Where should we begin??? AOral intubation of the patient using RSI with in line cervical tractionI usually place an orogastric tube at the time of intubation (why not an NGT in this pt?)
12Tackling the CASE at hand A - the pt is intubatedWhat’s next? BDespite 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
13Tackling the CASE at hand A - the pt is intubatedWhat’s next? BNeedle decompression followed by tube thoracostomy of the R chest
14Tackling the CASE at hand A – pt is intubatedB – surgery is putting in the chest tubeLet’s move to C – BP 90/40, HR 130The nurses have established two 16g IVsHow about 2L of fluid and a type and cross for 4 units of pRBCs (what do you give if immediate transfusion is needed?)
15Tackling the CASE at hand A-intubation, B-R CT, C-fluids and bloodWhat was D? Disability and Neuro examOur pt is intubated and paralyzed at this point, but any pt with a GCS of 8 or less should be intubated to protect their airwayWhat is a GCS you ask?
17Tackling the CASE at hand A-intubation, B-R CT, C-fluids and blood,D – neuroE – exposure and environmentalAll the clothes are cut off and a warm blanket applied to the ptDeformity to L femur probably from a fracture so the splint is re-applied
18Tackling 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.
19What are the usual orders? Or, what would you order for this guy?
20LABS 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 panelXR standard: c-spine, CXR, pelvisObviously x-ray anything that looks injuredCT: head and abd/pelvis are usually standardChest CT for chest trauma or CXR findingsNeck CT based upon mechanism, age, injury
22FAST Exam Primary role is detection of hemoperitoneum Sensitivity of 75-90% compared to CT (depending on the user and injury)Four Views of the FASTMorison’s Pouch = hepatorenalSplenorenalRectovesicular = Pouch of DouglasCardiac-> some of us also do pleural windows for PTX
28CT vs DPL vs FASTDPL is very sensitive but not specific, invasive, need NGT/foley placed, good for visceral injuryUnstable trauma where US is unavailable or equivocalCT is noninvasive, locates and delineates solid organ injury, but is expensive, time consuming, and located away from the resuscitation bayPt must be stableFAST is quick, easy, decent sensitivity and done at the bedside for unstable ptsNot as good for bowel, mesentery, diaphragm, or pancreatic injuries
29Let’s Move on to the Specifics… Any Questions?Let’s Move on to the Specifics…
30Head Case15 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.
31Head CaseOn exam he moans, withdraws to pain, but does not open his eyes…What is his GCS?
32Head Case On exam he moans, withdraws to pain, but does not open his eyes…What is his GCS?What should you do FIRST?
33Head Case GCS = 7 What should you do first? Intubate the pt using RSI (sucs and etomodate)Brief neuro exam if possible before paralysisLidocaine Prophylaxis for Intubation (1.5mg/kg)Blunts the cough reflex, hypertensive response, and increased ICP associated with intubation
35This is his Head CT… Subarachnoid Hemorrhage Most common CT abnormality in head injuryAmount of blood correlates directly with outcomePatients c/o HA and photophobiaNimodipine is used to prevent vasospasm which would worsen ischemia
36Compare it to theseSubdural HematomaEpidural Hematoma
38Head Injury Complete the primary/secondary survey Initial goal is to maximize O2 and BP to prevent secondary ischemic brain injuryPrimary 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 traumaAll therapies for TBI are aimed at reversing or preventing secondary brain injury
39Head Injury: Increased ICP Increased ICP = CSF pressure > 15 mm HgThe cranium can accommodate about mL of blood before ICP raisesCPP = MAP – ICPCPP < 40, autoregulation is lostAll you really need to know is that CBF depends on the MAP (=maximize BP)
40Recognizing Increased ICP What is Cushing’s Reflex?
41Cushing’s Reflex Hypertension Bradycardia Diminished Respiratory EffortIndicates that ICP has reached life threatening levelsOnly occurs in 1/3 of cases
42Head Injuries Recognizing Increased ICP Ipsilateral to Mass LesionAnisocoria, ptosis, impaired EOMs, sluggish pupilContralateral to Mass LesionHemiparesisPositive BabinskyAs ICP continues to increase…Posturing – decorticate then decerebrateAtaxic respiratory patternsRapid fluctuations in BP and HR, arrhythmiasLethargy to Coma
43Methods 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 vasodilationDiuretics = Mannitol (sometimes lasix)Cranial Decompression = trephination, ventriculostomy, OR craniotomySeizure Prophylaxis = ativan, dilantin, pentobarbital
44Head Injury: To CT or not to CT Reasons to CTHistory of LOC or Amnesia to the EventIntoxication: drug and alcoholHeadache, vomiting, focal neuro deficitModerate (GCS 9-13) and High Risk (GCS<8)Age > 60 or < 2Anti-coagulants – ASA, Plavix, CoumadinPosttraumatic SeizureAny signs of trauma above the claviclesNot 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
45Back 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???
46Basilar Skull Fracture Signs: blood in the ear canal, rhinorrhea, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4, 5These are linear fractures through the base of the skull and usually involve the temporal boneSignificance = requires a lot of force to break and can involve the internal carotid arteryThese pts need a HCT and admissionMost CSF otorrhea and rhinorrhea will resolve spontaneously within a weekProphylactic antibiotics are not usually given
47What 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.
48Epidural Hematoma80% associated with skull fractures across the middle meningeal artery or a dural sinus in the temporoparietal regionThe classic lucid interval occurs in 30%Patients needs to go to the OR for evacuation
49How 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.
50Subdural HematomaOccur commonly in people with atrophic brains = old people and drunksBridging vessels traverse a greater distance so are more easily torn (venous blood)Slow bleeding can delay presentationOptimal treatment is evacuation in the OR
52Next 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?
53Le Fort Fractures Le Fort I Le Fort II Le Fort III Transverse fracture through the maxilla = upper teeth moveLe Fort IIFx of the maxilla, nasal bridge, lacrimal bones, orbital floor and rim = teeth and nose moveLe Fort IIICraniofacial dysjunction = whole face moves
54Airway 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 injuryNasotracheal intubation: contraindicated in apneic pts and those with facial, skull, or laryngeal fractures as you may cause further injuryCricothyroidotomy: 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.
55Moving 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????
57Central Cord SyndromeMost 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 cordResults 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 extremitiesMore than 50% of people recover spontaneously
58Anterior Cord Syndrome Hyperflexion injury that causes anterior cord contusion through protrusion of a bony fragment or herniated discAlso from laceration or thrombosis of the anterior spinal arteryCauses 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 surgeryVariable degrees of recovery in the first 24 hours
59Brown Sequard Syndrome Hemisection of the spinal cordUsually from penetrating trauma but can also be from fracture of the lateral mass in the c-spineIpsilateral motor and contralateral sensory deficits but either can predominate depending on the size and location of the injuryMost maintain bowel and bladder functionTreatment and prognosis depend on the injury
60Other c-spine injuries will be covered in the ortho lecture. Any Questions?Other c-spine injuries will be covered in the ortho lecture.
61Pedestrian vs MVC45 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.
62Pedestrian 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?
63Pedestrian vs MVCIntubate 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???
64Pedestrian vs MVCBilateral 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?
65Pedestrian 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 baseRe-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.
66Pedestrian vs MVC Here is your portable CXR, What do you think? OK, pretend that there are bilateral chest tubes.
67Ruptured Diaphragm Most frequently from penetrating trauma Rupture due to blunt trauma occurs in less than 5% of pts hospitalized with chest traumaIf there is fracture of the pelvis, incidence of diaphragm rupture increasesIncidence of L and R sided rupture about equal, but L side usually symptomatic as R side is protected by the liverClues:Respiratory InsufficiencyBowel Sounds in the ChestNGT passes back into chestSurgery is definitive treatment
68Thoracic 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 breakBrachial plexus, great vessels, and lungs are in close proximity and at great riskTherefore, you should think twice with this injury and do a very thorough neurovascular exam
69Thoracic Trauma: Rib Fractures Fractures of the 9th, 10th, and 11th ribs suggest an associated intra-abdominal injury: Liver on the R, Spleen on the LMost heal within 3-6 weeksOther than pain, rib fractures are associated with hemo/pneumothorax, atelectasis, and pneumoniaEach rib fracture can lose cc of bloodPatients with displaced rib fractures should have a repeat CXR at 3 hours for delayed PTXAdmit vs D/C: depends on the extent of injury, age, and ability to breathe
70Thoracic 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 breathingMajor problems are underlying pulmonary contusion and chest pain withsplinting that causes atelectasis-> results in major respiratoryinsufficiency
71Thoracic Trauma: Sternal Fracture Most commonly from anterior chest trauma (MVC)Using restraints increases the risk of fracture at the location the belt crosses the sternumOlder 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)
72Thoracic 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 centerTension 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 returnOpen PTX: sucking chest wound. Place occlusive dressing – taped on 3 sides only. Place CT at a different siteDIB and CP are the most common complaintsSigns and symptoms do not always correlate well with the degree of PTX
73Thoracic Trauma: Pneumothorax Tension PTX:Pts usually develop severe cardiopulmonary collapse within minutes as the mediastinum is crushedClassic signs: tachycardia, JVD, absent breath sounds on the ipsilateral side with trachea deviated awayJVD may not be present in a hypovolemic stateHypoxia occurs first, then hypotension, then cardiac arrestTension PTX is a clinical (not radiographic) diagnosisImmediate treatment is needle decompression followed by tube thoracostomy*At what anatomical location are these procedures perfomed?14 g angiocath 2nd ICS, MCL
75Thoracic Trauma: Hemothorax Injured lung parenchyma is usually the source followed by intercosatal/IMA vessels then hilar and great vesselsClinically there may be DIB with decreased breath sounds on the affected sideCXR – upright may have blunting or obliteration of the diaphragm, supine will have diffuse haziness on the affected sideRx: Tube thoracostomy if respiratory compromise1500mL of blood = OR for thoracotomy200 mL/Hr for 3 hours = OR
76What 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
77Pericardial Effusion or Tamponade Beck’s Triad: hypotension, distended neck veins, and distant heart soundsTamponade occurs in 2% of pts with penetrating chest or abdomen trauma and rarely occurs with blunt traumaRx: initially fluid resuscitation, pericardiocentesis if there is time, ED thoracotomy, or definitive management in the ORSubxyphoid 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.
78Next…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.
79Joy RideHe 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.
80Joy Ride Portable CXR What do you think? What do you want to do next?
81ED Thoracotomy Indications Penetrating TraumaCardiac arrest at any point with initial vitals or signs of life in the fieldPersistent hypotension (SBP<50) despite aggressive resuscitationSevere shock with signs of tamponadeBlunt TraumaCardiac arrest in the EC= blunt traumatic arrest in the field is not an indication for thoracotomy
82Blunt 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 sceneCXR: 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
84Abdominal 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.
85Abdominal TraumaBlunt injuries actually carry a greater risk of mortality than penetrating injuriesBlunt injury is more difficult to evaluate and diagnoseBlunt injury is more often associated with injury to multiple internal organs and systems outside of the abdomen
86Abdominal Trauma Penetrating Injury Blunt Injury Small intestine, colon, and liverBlunt InjurySpleen>>>>liver, intestineSeat Belt Sign = contusion or abrasion across the lower abdomenCorrelates with intraperitoneal lesions or lumbar spinal injury
87Abdominal Trauma Evaluation Inspect and Palpate most importantlyFAST examCT scanLabsCBC – not usually helpful initially, mild leukocytosis is normal, serial Hgb more helpfulTox Screen and Ethanol level
88Abdominal Trauma: Treatment Hemorrhage is the main concern so two large bore IVs for fluids followed by blood productsAntibiotics if concern for bowel injuryStable – FAST, CT, then OR if necessaryUnstable – consider FAST, but really go straight to the OR for ex-lap without delayPenetrating trauma – determine whether or not the peritoneum was violated as this dictates management
89Abdominal Trauma: ED standpoint 2 IVs or a central line for aggressive resuscitationIf the pt is hypotensive/unstable with a high suspicion for intra-abdominal injury -> they need to go for ex-lap not CTIf the pt is stable, they can go to CT for evaluation of the internal organs and management then depends on the findingsIf 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
90Trauma: “A Good PE” Where does blood hide in the body? How much blood do you lose with fractures?
91Where does blood hide in the body? ChestAbdomenPelvisFemurIn kids, the cranium is a possibility as the sutures are still open
92Blood Loss with Fractures Pelvis – ccFemur – 1000ccRibs – ccTibia/Fibula – 500ccHumerus – 250ccRadius/Ulna – cc
93Trauma: In the EndTrauma can be cool to look at, but don’t be distracted by the goreStart with your ABCs and don’t move to the next step until you have solved a problemANY QUESTIONS?