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

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Presentation on theme: "Chapter 6: TRAUMA 10/06/2009 Basic Science Jen Dixon, PGY-4."— Presentation transcript:

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

2

3 Why Should You Care? trauma call #3 killer $expensive$ major public health issue

4 Trauma Roadmap Primary Survey Resuscitation Secondary Survey Diagnostic Evaluation Definitive Care

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? 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

8 Primary Survey: Airway Surgical Airway: Needle or Open Cricothyroidotomy *not for those <12 years old! ≤6mm Vertical Incision!

9 Percutaneous transtracheal ventilation

10 Primary Survey: ABC’s Breathing: –Oxygen, pulse ox Look for Life Threatening Issues –Tension ptx –Open ptx –Flail chest –Pulmonary contusion

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 36-40F chest tube Over the rib 4-5 th I.C. Space, Infra-mammary fold Ant. Axillary line

14 ABC’s: Breathing Open Pneumothorax –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!

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

17 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!

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!

21 Know This Class 1Class 2Class 3Case 4 Blood loss (mL)Up to >2000 Blood loss (%)Up to 15%15-30%30-40%>40% Pulse<100>100>120>140 BPNormal Decreased Pulse Pressure Normal or ↑ Decreased Resp Rate >35 Urine Output> Negligible Mental StatusSlightly anxiousMildly anxious Anxious/ confused Confused/ lethargic

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

23 Cardiogenic Shock in Trauma Tension Ptx Pericardial tamponade Myocardial contusion or infarction Air embolism

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!

26 Cardiac Injury Repair Horizontal Mattress Pledgets good for RV

27 ED Thoracotomy

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.

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

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 below the clavicles b/t clavicles&hyoid above hyoid *unstable pt goes to the OR! Zone 1=angiography of great vessels, soluble contrast esophagram >>barium esophagram, Esophagoscopy & bronchoscopy 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) Zone 3=carotid/vertebral angio if evidence of arterial bleeding

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

45 Multiple Injuries Efficient OR session Optimize metabolic status ASAP Treat hypothermia, acidosis, coagulopathy PRBC’s (type O or matched), FFP, platelets!

46 Prophylactic Measures 2 nd generation cephalosporins pre-op for laparotomy, 1 st 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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