TRAUMA (LIFE IN THE ER) William Beaumont Hospital Department of Emergency Medicine

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???

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?

“Golden Hour” The idea is to emphasize the importance of the initial evaluation and treatment of the trauma patient It is our “window of opportunity” to have a significant impact on morbidity and mortality One must have a concise, expeditious, well thought out plan of action for evaluation and treatment of life threatening injuries We accomplish this 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

Primary Survey: ABCDEs A = airway maintenance with cervical spine protection B = breathing and ventilation C = circulation and hemorrhage control D = disability and neurological status E = exposure and environmental control, undress the pt, log roll the patient and put a blanket on them D – LOC (AVPU – awake, responds to verbal stimuli, responds to painful stimuli, unresponsive; pupil size E – log roll the patient

Primary 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 exposed A decision about transferring the patient should be made before proceeding to the secondary survey

Secondary Survey: head to toe Complete the history (AMPLE) and physical exam Reassessment of vital signs and interventions If GCS not obtained in primary survey, now is a good time Special procedures (lines), specific x-rays, and labs are now obtained

Secondary Survey: Rectal Tone Rectal exam is done in every trauma and before urinary catheter placement (WHY?) Check for blood and integrity = tear or pelvis fracture High riding prostate = potential urethral injury Tone = brain or spinal injury

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??? 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.

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

Tackling the CASE at hand Where should we begin??? A Oral intubation of the patient using RSI with in line cervical traction I usually place an orogastric tube at the time of intubation (why not an NGT in this pt?)

Tackling the CASE at hand A - the pt is intubated What’s next? B Despite 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

Tackling the CASE at hand A - the pt is intubated What’s next? B Needle decompression followed by tube thoracostomy of the R chest

Tackling the CASE at hand A – pt is intubated B – surgery is putting in the chest tube Let’s move to C – BP 90/40, HR 130 The nurses have 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?)

Tackling the CASE at hand A-intubation, B-R CT, C-fluids and blood What was D? Disability and Neuro exam Our pt is intubated and paralyzed at this point, but any pt with a GCS of 8 or less should be intubated to protect their airway What is a GCS you ask?

Tackling the CASE at hand A-intubation, B-R CT, C-fluids and blood, D – neuro E – exposure and environmental All the clothes are cut off and a warm blanket applied to the pt Deformity to L femur probably from a fracture so the splint is re-applied

Tackling 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.

What are the usual orders? Or, what would you order for this guy?

LABS 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 panel XR standard: c-spine, CXR, pelvis Obviously x-ray anything that looks injured CT: head and abd/pelvis are usually standard Chest CT for chest trauma or CXR findings Neck CT based upon mechanism, age, injury

What are the 4 views of the FAST exam?

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 -> some of us also do pleural windows for PTX

FAST: Normal or Abnormal?

FAST Normal Abnormal

FAST: Morison’s Pouch Normal Abnormal

FAST: Vesicoureteral Normal Abnormal

OOPS!

CT vs DPL vs FAST DPL is very sensitive but not specific, invasive, need NGT/foley placed, good for visceral injury Unstable trauma where US is unavailable or equivocal CT is noninvasive, locates and delineates solid organ injury, but is expensive, time consuming, and located away from the resuscitation bay Pt must be stable FAST is quick, easy, decent sensitivity and done at the bedside for unstable pts Not as good for bowel, mesentery, diaphragm, or pancreatic injuries

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

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.

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

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

Head Case GCS = 7 What should you do first? Intubate the pt using RSI (sucs and etomodate) Brief neuro exam if possible before paralysis Lidocaine Prophylaxis for Intubation (1.5mg/kg) Blunts the cough reflex, hypertensive response, and increased ICP associated with intubation

This is his Head CT… What does it show?

This is his Head CT… 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 would worsen ischemia

Compare it to these Subdural Hematoma Epidural Hematoma

So what do you do with Head Injured Patients?

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

Head Injury: Increased ICP Increased ICP = CSF pressure > 15 mm Hg The cranium can accommodate about 50-100mL of blood before ICP raises CPP = MAP – ICP CPP < 40, autoregulation is lost All you really need to know is that CBF depends on the MAP (=maximize BP)

Recognizing Increased ICP What is Cushing’s Reflex?

Cushing’s Reflex Hypertension Bradycardia Diminished Respiratory Effort Indicates that ICP has reached life threatening levels Only occurs in 1/3 of cases

Head Injuries Recognizing Increased ICP Ipsilateral to Mass Lesion Anisocoria, ptosis, impaired EOMs, sluggish pupil Contralateral to Mass Lesion Hemiparesis Positive Babinsky As ICP continues to increase… Posturing – decorticate then decerebrate Ataxic respiratory patterns Rapid fluctuations in BP and HR, arrhythmias Lethargy to Coma

Methods 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 vasodilation Diuretics = Mannitol (sometimes lasix) Cranial Decompression = trephination, ventriculostomy, OR craniotomy Seizure Prophylaxis = ativan, dilantin, pentobarbital

Head Injury: To CT or not to CT 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 Posttraumatic Seizure Any signs of trauma above the clavicles Not 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 12-24 hours

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???

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

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.

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

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.

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

Head Injuries ANY QUESTIONS?

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?

Le Fort Fractures Le Fort I Le Fort II Le Fort III Transverse fracture through the maxilla = upper teeth move Le Fort II Fx of the maxilla, nasal bridge, lacrimal bones, orbital floor and rim = teeth and nose move Le Fort III Craniofacial dysjunction = whole face moves

Airway 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 injury Nasotracheal intubation: contraindicated in apneic pts and those with facial, skull, or laryngeal fractures as you may cause further injury 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.

Moving 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????

Central Cord Syndrome Most 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 cord Results 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 extremities More than 50% of people recover spontaneously

Anterior Cord Syndrome Hyperflexion injury that causes anterior cord contusion through protrusion of a bony fragment or herniated disc Also from laceration or thrombosis of the anterior spinal artery Causes 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 surgery Variable degrees of recovery in the first 24 hours

Brown Sequard Syndrome Hemisection of the spinal cord Usually from penetrating trauma but can also be from fracture of the lateral mass in the c-spine Ipsilateral motor and contralateral sensory deficits but either can predominate depending on the size and location of the injury Most maintain bowel and bladder function Treatment and prognosis depend on the injury

Other c-spine injuries will be covered in the ortho lecture. Any Questions? Other c-spine injuries will be covered in the ortho lecture.

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.

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

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???

Pedestrian vs MVC Bilateral 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?

Pedestrian 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 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.

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

Ruptured Diaphragm Most frequently from penetrating trauma Rupture due to blunt trauma occurs in less than 5% of pts hospitalized with chest trauma If there is fracture of the pelvis, incidence of diaphragm rupture increases Incidence of L and R sided rupture about equal, but L side usually symptomatic as R side is protected by the liver Clues: Respiratory Insufficiency Bowel Sounds in the Chest NGT passes back into chest Surgery is definitive treatment

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 Therefore, you should think twice with this injury and do a very thorough neurovascular exam

Thoracic Trauma: Rib Fractures Fractures of the 9th, 10th, and 11th ribs suggest an associated intra-abdominal injury: Liver on the R, Spleen on the L Most heal within 3-6 weeks Other than pain, rib fractures are associated with hemo/pneumothorax, atelectasis, and pneumonia Each rib fracture can lose 200-300cc of blood Patients with displaced rib fractures should have a repeat CXR at 3 hours for delayed PTX Admit vs D/C: depends on the extent of injury, age, and ability to breathe

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 Major problems are underlying pulmonary contusion and chest pain with splinting that causes atelectasis -> results in major respiratory insufficiency

Thoracic Trauma: Sternal Fracture Most commonly from anterior chest trauma (MVC) Using restraints increases the risk of fracture at the location the belt crosses the sternum Older 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)

Thoracic 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 center Tension 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 return Open PTX: sucking chest wound. Place occlusive dressing – taped on 3 sides only. Place CT at a different site DIB and CP are the most common complaints Signs and symptoms do not always correlate well with the degree of PTX

Thoracic Trauma: Pneumothorax Tension PTX: Pts usually develop severe cardiopulmonary collapse within minutes as the mediastinum is crushed Classic signs: tachycardia, JVD, absent breath sounds on the ipsilateral side with trachea deviated away JVD may not be present in a hypovolemic state Hypoxia occurs first, then hypotension, then cardiac arrest Tension PTX is a clinical (not radiographic) diagnosis Immediate treatment is needle decompression followed by tube thoracostomy *At what anatomical location are these procedures perfomed? 14 g angiocath 2nd ICS, MCL

What do these films show?

Thoracic Trauma: Hemothorax Injured lung parenchyma is usually the source followed by intercosatal/IMA vessels then hilar and great vessels Clinically there may be DIB with decreased breath sounds on the affected side CXR – upright may have blunting or obliteration of the diaphragm, supine will have diffuse haziness on the affected side Rx: Tube thoracostomy if respiratory compromise 1500mL of blood = OR for thoracotomy 200 mL/Hr for 3 hours = OR

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

Pericardial Effusion or Tamponade Beck’s Triad: hypotension, distended neck veins, and distant heart sounds Tamponade occurs in 2% of pts with penetrating chest or abdomen trauma and rarely occurs with blunt trauma Rx: initially fluid resuscitation, pericardiocentesis if there is time, ED thoracotomy, or 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.

Next… 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.

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.

Joy Ride Portable CXR What do you think? What do you want to do next?

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 EC = blunt traumatic arrest in the field is not an indication for thoracotomy

Blunt 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 scene CXR: 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

Let’s shift gears and talk about the Belly.

Abdominal 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.

Abdominal Trauma Blunt injuries actually 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

Abdominal Trauma Penetrating Injury Blunt Injury Small intestine, colon, and liver Blunt Injury Spleen>>>>liver, intestine Seat Belt Sign = contusion or abrasion across the lower abdomen Correlates with intraperitoneal lesions or lumbar spinal injury

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 Ethanol level

Abdominal Trauma: Treatment Hemorrhage is the main concern so two large bore IVs for fluids followed by blood products Antibiotics if concern for bowel injury Stable – FAST, CT, then OR if necessary Unstable – consider FAST, but really go straight to the OR for ex-lap without delay Penetrating trauma – determine whether or not the peritoneum was violated as this dictates management

Abdominal Trauma: ED standpoint 2 IVs or a central line for aggressive resuscitation If the pt is hypotensive/unstable with a high suspicion for intra-abdominal injury -> they need to go for ex-lap not CT If the pt is stable, they can go to CT for evaluation of the internal organs and management then depends on the findings If 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

Trauma: “A Good PE” Where does blood hide in the body? How much blood do you lose with fractures?

Where does blood hide in the body? Chest Abdomen Pelvis Femur In kids, the cranium is a possibility as the sutures are still open

Blood Loss with Fractures Pelvis – 1500-3000cc Femur – 1000cc Ribs – 200-300cc Tibia/Fibula – 500cc Humerus – 250cc Radius/Ulna – 150-250cc

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

THE END