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10/06/2009 Basic Science Jen Dixon, PGY-4

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1 10/06/2009 Basic Science Jen Dixon, PGY-4
Chapter 6: TRAUMA 10/06/2009 Basic Science Jen Dixon, PGY-4

2 No, not emotional trauma……
No, not emotional trauma…….today we are going to talk about physical trauma

3 major public health issue
Why Should You Care? trauma call #3 killer $expensive$ major public health issue We won’t be talking about emotional trauma today, we’ll be talking about physical trauma, as seen here…this is penetrating trauma. So why should you care about trauma. There are a few good reasons. First, you have to take trauma call. Second, trauma is prevalent and deadly….it’s the 3rd leading cause of death across all age groups. Third, even when it’s not fatal, it’s really expensive! in 2000 there were approximately 148,209 trauma-related deaths, but 29,549,711 patients with nonfatal injuries required hospital treatment. The aggregate lifetime costs for all injured patients was estimated to be in excess of $260 trillion

4 Trauma Roadmap Primary Survey Resuscitation Secondary Survey
Diagnostic Evaluation Definitive Care For every patient that arrives in the trauma bay,you’ll follow the same roadmap: primary survey, resuscitation, secondary survey, diagnostic evaluation, and definitive care. In reality these events happen simultaneously. Always start with the identification and treatment of conditions that pose an immediate threat to life.

5 Airway Anyone?

6 Primary Survey: Airway
C-spine immobilization (Philly collar) If pt. responsive with normal voice, airway likely stable and no intubation needed… Unless…….. Expanding neck hematoma? Thermal injury to mouth/nares? Airway bleeding? Complex maxillofacial trauma? Airway always comes first! Start by making sure the c-spine is adequately immobilized (which requires a hard collar like a philly collar, not a soft collar, chapter also mentions you can use sandbags around the head). If the pt is conscious and has a normal voice, the airway is considered stable on initial assessment, unless one of the following is present: penetrating neck trauma w/ expanding hematoma, chemical/thermal injury to nares/mouth/hypopharynx, extensive subQ air in neck, airway bleeding, complex maxillofacial trauma……these pts airways may become unstable and intubation should be performed. INTUBATE!

7 Primary Survey: Airway
Pt. w/abnormal voice, AMS (GCS<8): Clear mouth of debris, suction airway Nasotracheal intubation NOT FOR APNEIC Pt! Orotracheal intubation w/ c-spine protection, RSI Pts. With abnormal voice or altered mental status require further airway evaluation. You can first visually inspect the mouth and try to clear any obstructing foreign objects or suction vomit, etc. AMS often means the pt can’t protect their airway and is indication for airway access via either nasotracheal, orotracheal or surgical airway. Nasotracheal intubation can’t be done in apneic pts! Orotracheal intubation requires in line manual c-spine immobilization, then perform rapid sequence intubation to prevent aspiration.

8 Primary Survey: Airway
Surgical Airway: Needle or Open Cricothyroidotomy ≤6mm Patients who fail intubation or are precluded from intubation due to extensive facial injuries require a surgical airway. Cricothyroidotomy and percutaneous transtracheal ventilation are preferred over tracheostomy in most emergency situations because of their simplicity and safety. One disadvantage of cricothyroidotomy is the inability to place a tube greater than 6 mm in diameter due to the limited aperture of the cricothyroid space. Cricothyroidotomy is also relatively contraindicated in patients under the age of 12 because of the risk of damage to the cricoid cartilage and the subsequent risk of subglottic stenosis. *not for those <12 years old! Vertical Incision!

9 Percutaneous transtracheal ventilation
Needle criocothyroidotomy is done by inserting a large-bore, IV catheter through the cricothyroid membrane and into the trachea, and attaching it with tubing to an oxygen source that can deliver 50 pounds per square inch (psi) or greater. A hole cut in the tubing allows for intermittent ventilation by occluding and releasing the hole. Adequate oxygenation can be maintained for more than 30 minutes. However, since exhalation occurs passively, ventilation is limited and carbon dioxide retention may occur.

10 Primary Survey: ABC’s Breathing: Look for Life Threatening Issues
Oxygen, pulse ox Look for Life Threatening Issues Tension ptx Open ptx Flail chest Pulmonary contusion Once airway is secured, move onto breathing. First, all trauma pts get some type of supplemental oxygen and a pulse ox for monitoring. Focus your exam on looking for life threatening issues first, like tension or open ptx, flail chest, or pulm contusion (also look at cxr).

11 Tension Pneumothorax Exam Findings Absent breath sounds
Distended Neck Veins Hypotension Respiratory Distress Sub-q emphysema Needs Chest Tube! Don’t wait for X-ray!

12 Tension Pneumothorax Neg intrapleural space becomes positive
Trachea, mediastinum shift contralateral Heart rotates about SVC/IVC, ↓ VR, ↓CO ‘IVC kinking’ Simple ptx>tension ptx w pos pressure ventilation

13 Chest Tube Placement 4-5th I.C. Space, Infra-mammary fold
Ant. Axillary line Over the rib Tube thoracostomy for trauma is performed in the fourth or fifth intercostal space at the anterior axillary line to avoid iatrogenic injury to the liver or spleen. B. A curved clamp is used to enter the pleural space. It is directed over the top of the rib to avoid injury to the intercostal bundle located just beneath the rib. C. The incision should be digitally explored to identify pleural adhesions. D. 36F to 40F chest tubes are employed. The tube is directed superiorly and posteriorly with the aid of a large clamp. 36-40F chest tube

14 ABC’s: Breathing Open Pneumothorax Flail Chest
Cover with dressing taped on 3 sides only to prevent tension ptx Needs wound closure, chest tube Flail Chest four or more ribs fractured in at least 2 locations Paradoxical mov’t compromises respiration Pulmonary contusion associated, monitor progression

15 Primary Survey: ABC’s Circulation: Palpable pulses?
Carotid = SBP 60 Femoral = SBP 70 Radial = SBP 80 HypoTN>>>think hemorrhage! Control external bleeding w/pressure Scalp bleeding needs addressed Check BP, HR q15 min….at least No Blind Clamping! With a/w and breathing stable, it’s time to move on to CIRCULATION! An initial exam of pulses can indicate the systolic blood pressure: if you can feel the carotid the SBP is at least 60, the femoral is at least 70, and the radial is at least 80. At this point in the pt.’s course, hypotension should be thought of as resulting from hemorrhage. Check the BP and HR q 15 min. (should be continuously on monitor in bay) Pt can bleed to death from a scalp lac, so stitch or staple them as necessary! And the best way to control external hemorrhage is a gloved finger, Dr.Norcross loves that question. Remember blind clamping is a bad idea!

16 IV Access 16 G, B/l antecubital fossa for adults
Place cordis for rapid resusciation Femoral access or even saphenous cutdown if needed Kids <6yo: No femoral vein cannulation Interosseous cannulation if 2 failed peripheral IV attempts In hypovolemic pediatric patients less than 6 years of age, percutaneous femoral vein cannulation is relatively contraindicated because of the risk of venous thrombosis. If two attempts at percutaneous peripheral access are unsuccessful, interosseous cannulation should be performed in the proximal tibia or distal femur if the tibia is fractured. This is a safe emergency technique; however, once alternative access has been established, the cannula should be removed because of the risk of osteomyelitis.

17 Interactive Question:
? Interactive Question: ? ? ? ? What landmark is used to find the saphenous vein for a cutdown procedure? ? ? ? ?

18 Answer: The vein is consistently found 1 to 1.5 cm anterior to the medial malleolus Proximal and distal traction sutures are placed. Distal suture is ligated. Short 10- to 14-gauge intravenous catheters should be used secure with both sutures and tape to prevent dislodgment

19 Intraosseous infusions
<6 years old! for children <6 years of age in whom one or two attempts at intravenous access have failed. A. The proximal tibia is the preferred location. Alternatively, the distal femur can be used if the tibia is fractured. B. The needle should be directed away from the epiphyseal plate to avoid injury. The position is satisfactory if bone marrow can be aspirated or if saline can be easily infused without evidence of extravasation. Several different proprietary devices are available for intraosseous infusion, and the surgeon should be familiar with their design.

20 Initial Fluid Resuscitation
1L IV bolus of normal saline, Ringer's lactate, or other isotonic crystalloid in an adult 20 mL/kg Ringer's lactate in a child repeated one time in an adult and twice in a child before PRBC transfusion Hypotension is not a reliable early sign of hypovolemia! In healthy patients blood volume must decrease by 30 to 40% before hypotension occurs. Younger patients with good sympathetic tone can maintain systemic blood pressure with severe intravascular deficits until they are on the verge of cardiac arrest. In contrast, pregnancy increases circulating blood volume and a relatively larger volume of blood loss must occur before signs and symptoms become apparent.

21 Know This Class 1 Class 2 Class 3 Case 4 Blood loss (mL) Up to 750
>2000 Blood loss (%) Up to 15% 15-30% 30-40% >40% Pulse <100 >100 >120 >140 BP Normal Decreased Pulse Pressure Normal or ↑ Resp Rate 14-20 20-30 30-40 >35 Urine Output >30 5-15 Negligible Mental Status Slightly anxious Mildly anxious Anxious/ confused Confused/ lethargic Classes of Shock

22 Initial Response to Resuscitation
Responders Transient Responders Nonresponders Under-resuscitated? Ongoing hemorrhage? Nonsurvivable multisystem injury ? Tension pneumothorax? Uncontrolled hemorrhage? Cardiogenic? Normal vitals Normal mentation Normal UOP Good tissue perfusion Stable pt. Con’t work-up Distended neck veins? ↑ CVP?

23 Cardiogenic Shock in Trauma
Tension Ptx Pericardial tamponade Myocardial contusion or infarction Air embolism This is the differential for cardiogenic shock in a trauma pt. Tension ptx should be treated w/a chest tube or needle decompression STAT. Pericardial tamponade is discussed further…..

24 Pericardial Tamponade
Can have transient reponse to fluid Beck’s triad, pulsus paradoxus not reliable Subxiphoid or parasternal U/S view

25 Pericardiocentesis 80% success rate for decompression
Prepare for transport to OR! If SBP remains <70, do ED thoracotomy! Evacuation of as little as 15 to 25 mL of blood may dramatically improve the patient's hemodynamic profile

26 Cardiac Injury Repair Horizontal Mattress Pledgets good for RV
A variety of techniques may be necessary to repair cardiac injuries. Wounds in proximity to coronary arteries must be repaired with horizontal mattress sutures placed under the artery to avoid infarctions distal to the repair. Pledgeted sutures may be necessary to prevent the sutures from pulling through the myocardium, particularly in the right ventricle. A variety of techniques may be necessary to repair cardiac injuries. Wounds in proximity to coronary arteries must be repaired with horizontal mattress sutures placed under the artery to avoid infarctions distal to the repair. Pledgeted sutures may be necessary to prevent the sutures from pulling through the myocardium, particularly in the right ventricle. Pledgets good for RV

27 ED Thoracotomy best accomplished using a left anterolateral thoracotomy and a longitudinal pericardiotomy anterior to the phrenic nerve, followed by evacuation of the pericardial sac and temporary control of the cardiac injury. The patient is then transported to the OR for definitive repair

28 Myocardial Contusion occurs in ~1/3 of blunt chest trauma pts
EKG: ventricular dysrhythmias, a-fib, sinus brady, bundle-branch block cardiac enzymes not helpful Common dx, not usually life threatening Tx: pharmacologic suppression Echo STAT

29 Air Embolism lethal complication of pulmonary injury
air from an injured bronchus enters adjacent injured pulmonary vein>LV Trendelenburg, trap air in LV apex Emergency thoracotomy, cross-clamp pulmonary hilum, aspirate air w 18G from LV, aortic root apex

30 Interactive Question A 36 yo WM sustains blunt abd trauma, arrives A&O x 3, vitals stable except BP 80/55, 1 L NS bolus given, BP then stable at 125/80. CXR nl, Fast scan negative. Pt goes to CT. Is this a good time to grab a snack?

31 Answer No. Someone needs to stay with the pt in the scanner, if hypoTN recurrs it’s a sign of ongoing hemorrhage and they will likely need operative intervention or I/R, etc.

32 Secondary Survey Which of the following should not be done in the secondary survey of a seriously injured pt? Pt undressed, head to toe exam Rectal exam Foley catheter NG tube None of the above; the chapter says to do them all

33 Secondary Survey Which of the following should not be done in the secondary survey of a seriously injured pt? Pt undressed, head to toe exam Rectal exam Foley catheter NG tube None of the above; the chapter says to do them all

34 Mechanism of Injury Question
What are the greatest risk factors reflecting magnitude of injury that are strongly associated with life-threatening injuries?

35 Mechanism of Injury Question
What are the greatest risk factors reflecting magnitude of injury that are strongly associated with life-threatening injuries? death of another occupant in the vehicle and an extrication time greater than 20 minutes.

36 Secondary Survey Question
When attempting to clear a pt’s C-spine, which approach is best? Move the pt’s head for them Let the pt move their own head

37 Secondary Survey Question
When attempting to clear a pt’s C-spine, which approach is best? Move the pt’s head for them Let the pt move their own head Pt is unlikely to hurt themselves, they’ll stop when they feel pain

38 Secondary Survey Question
Otorrhea, rhinorrhea, raccoon eyes, and Battle's sign (ecchymosis behind the ear) can be seen with what type of fractures?

39 Secondary Survey Question
Otorrhea, rhinorrhea, raccoon eyes, and Battle's sign (ecchymosis behind the ear) can be seen with what type of fractures? basilar skull fractures

40 Neck Trauma What are the zones of the neck, how does injury work-up and management differ among them?

41 Neck Trauma *unstable pt goes to the OR!
Zone 3=carotid/vertebral angio if evidence of arterial bleeding above hyoid Zone 2: platysma penetration? If yes 12 hr obs vs carotid/vertebral angio, direct laryngoscopy, tracheo-esophagoscopy & esophagram may be necessary (i.e. R>L GSW) b/t clavicles&hyoid Zone 1=angiography of great vessels, soluble contrast esophagram >>barium esophagram, Esophagoscopy & bronchoscopy below the clavicles

42 Don’t Text & Drive!

43 Multiple Injuries Blunt trauma pt. w recurrent hypoTN, free fluid in the abd, suspected aortic tear on CXR and splenic injury on FAST scan What do you fix first?

44 Multiple Injuries Blunt trauma pt. w recurrent hypoTN, aortic tear suspected, splenic injury, free fluid in abd Ex lap, splenectomy first, then aortic repair Pt. can bleed to death from splenic injury, address first. Aortic tear can be addressed after, it’s not the likely source of recurrent hypoTN.

45 Multiple Injuries Efficient OR session Optimize metabolic status ASAP
Treat hypothermia, acidosis, coagulopathy PRBC’s (type O or matched), FFP, platelets! The goal should be to treat the immeadiate life threatening injuries quickly and then continue to resuscitate the patient, postponing further surgeries for secondary injuries (like ortho frx, etc). The combination of hypothermia, metabolic acidosis, and coagulopathy which often accompanies massive resusciation and emergent surgery can be fatal. Platelet dysfunction is associated with this state, so use plt transfusion to keep plts >100, Use FFP also to combat coagulopathy.

46 Prophylactic Measures
2nd generation cephalosporins pre-op for laparotomy, 1st gen for all other surgeries Tetanus DVT prophylaxis (SCDs, lovenox) Blankie! (keep ‘em warm)

47 Chest Trauma

48 Blunt Chest Trauma What are the most common locations for an aortic tear from shearing forces?

49 Blunt Chest Trauma What are the most common locations for an aortic tear from shearing forces? just distal to the left subclavian artery (ligamentum arteriosum) In 2 to 5% of cases the tear occurs in the ascending aorta, transverse arch, or at the diaphragm.

50 Blunt Chest Trauma indications for thoracotomy include pericardial tamponade, tear of the descending thoracic aorta, rupture of a mainstem bronchus, and rupture of the esophagus.

51 Cardiorrhexis The heart can rupture from blunt trauma.
The Right Atrium and Ventricle are the most likely chambers to rupture.

52 Yuck

53 Penetrating Chest Trauma
What are the indications for Operative Treatment of Penetrating Thoracic Injuries?

54 Indications for Operative Treatment of Penetrating Thoracic Injuries
Caked hemothorax Large air leak w inadequate ventilation or persistent lung collapse Drainage of >1500 mL blood when chest tube is first inserted Continuous hemorrhage of > 200 mL/h for 3 consecutive h Esophageal perforation Pericardial tamponade

55 Penetrating Chest Trauma
What exams should be done to evaluate potential bronchial or esophageal injury?

56 Penetrating Chest Trauma
What exams should be done to evaluate potential bronchial or esophageal injury? Bronchoscopy Esophagoscopy soluble contrast esophagram (then barium if neg)

57 Questions?


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