Trauma Board Review Part II Dr. Grumpy

Disclosure Drug rep dinners STC Linezolid Ertapenem Keppra Levofloxacin Cardene STC

Topics C-spine trauma Pediatric trauma Pelvic trauma

6yoM. Rear-seated passenger in a moderate-speed MV crash 6yoM. Rear-seated passenger in a moderate-speed MV crash. “legs were numb” immediately following, but symptoms resolved in 30 min. Normal exam. Normal radiographs. Correct statement Needs urgent MRI. Discharge with close f/u as long as his exam remains normal during a 4-hr observation. Flexion-extension radiographs should be performed to rule out any ligamentous injury. CT scan of the C-spine should be performed to assess for surrounding soft tissue swelling.

Spinal Cord Injuries Central Cord Syndrome Brown Sequard Syndrome Hyperextension injury Upper ext weaker than lower ext Brown Sequard Syndrome Penetrating – hemisection of spinal cord Loss of ipsilateral motor, position, vibration Contralateral loss of pain and temp below level of injury

Spinal Cord Injuries Anterior Cord Syndrome Cauda Equina Flexion of cervical spine Bilateral paralysis of arms and legs equally Due to arterial occlusion, disruption blood flow to spinal cord Cauda Equina Distal sacral roots - peripheral nerve injury Variable motor/sensory loss in LE, sciatica, bowel/bladder dysfunction, saddle anesthesia

Spinal Cord Injuries Spinal Shock (misnomer) Partial or complete injury Areflexia, loss of sensation, flaccid paralysis below level of lesion Flaccid bladder and loss of rectal tone

16 yo football player c/o neck pain s/o “speared” another player with helmet. Paramedics immobilized his neck on scene. Neurologically intact. Which cervical spine injury is most likely? Bilateral facet dislocation Hangman fracture Jefferson fracture Odontoid fracture Teardrop fracture

C-Spine Fxs Jefferson fx (unstable) Hangman fx (unstable) Axial loading force C1 burst fx Hangman fx (unstable) Hyperextension (hanging) Located in pedicles of C2, with C2 displacing anteriorly on C3 Head on MVC Associated with prevertebral swelling and cause respiratory obstruction

C-Spine Fxs Odontoid fx Teardrop fx (unstable) Type I – tip superiorly. Ligaments intact and stable fx Type II – junction of odontoid and body Most common Type III – superior portion of C2 at base of odontoid Teardrop fx (unstable) Extreme flexion Complete disruption of all ligamentous structures at the level of injury Unstable

Flexion Injuries Simple wedge fx Clay shoveler’s fx Associated with post ligament disruption Clay shoveler’s fx Avulsion of spinous process of lower vertebrae  stable Atlantooccipital and atlantoaxial dislocation w/ fx High instability and mortality Bilateral facet dislocation w/ fx

Extension Injuries Ant arch of atlas avulsion fx – unstable Post arch of atlas fx Compression. Look for other fxs. Extension teardrop fx Most common at C2. Unstable

Atlanto-occipital Joint Injury Severe flexion/extension Disruption of all ligaments between occiput and atlas. Death usually immediately from stretching of brainstem Cervical traction absolutely contraindicated

Atlanto-occipital Joint Injury Very difficult to diagnose (CT 84% sens) Basion-dens distance > 12mm Posterior dens axial line > 12mm posterior or > 4mm anterior to basion

Power Calculation BC/AD < 1 normal

Atlanto-axial Joint Injury Disruption of transverse ligament Extremely unstable

Which is classified as low probability of C-spine injury? 21yoM, no neck tenderness, intoxicated after MVC 24yo, no neck tenderness and LLE weakness, pedestrian struck by motor vehicle 32yoF, no neck tenderness, through-and-through lip laceration after MVC 48yoM, no neck tenderness and R shoulder dislocation s/p falling from scaffolding 82yoF, no neck tenderness and a L femoral neck fx s/p fall

Nexus No midline tenderness No pain with neck movement No distracting injury Long Bone Fracture (Most common DPI) Visceral Injury Necessitating surgical consultation Large laceration, degloving injury, or crush injury Large Burns Any injury producing acute functional impairment No Neurodeficit No Alcohol or Drugs No Altered Mental Status 

CCR Dangerous mechanism Fall from > 3ft or 5 stairs Axial load to head MVC >100km/hr Collision with motorized recreational vehicle Bicycle collision

Pediatric Head Trauma Can bleed enough intracranially for hypotension Vomiting, seizures, LOC are all poor in sensitivity and specificity Scalp hematoma is indication

2yo s/p struck by car after running out into the street 2yo s/p struck by car after running out into the street. Most likely thoracic injury? Aortic dissection Commotio cordis Esophageal rupture Pulmonary contusion Rib fractures

Pediatric Chest Trauma Compliant chest walls and ribs relatively resistant to fracture  forces transmitted to internal structures Pulmonary contusions Commotio cordis Relatively mild blow to the chest (boards usually pitched baseball)  ventricular fibrillation No structural damage to the heart Death usually instantaneous, and successful resuscitation is uncommon.

8 yoM s/p hit a car door while riding bike 8 yoM s/p hit a car door while riding bike. Crying and c/o abdominal pain. Vital signs age appropriate, abrasion across his epigastrium, and diffuse tenderness w/o rebound or guarding. Amylase 220. UA 2-5 RBCs PHF. Which of the following is correct? Despite a nl abd CT, the child could have pancreatic injury and should be admitted for observation. An IV pyelogram should be performed for evaluation of hematuria. The bowel is the most commonly injured organ following this mechanism. Duodenal hematoma is unlikely if a repeat exam reveals no abdominal tenderness.

Pediatric Abdominal Trauma Pancreatic trauma often missed on CT and presents later Spleen > liver >> bowel Duodenal hematoma needs observation

Traumatic Pancreatitis Clinical: mild epigastric tenderness, resolve in early stages of injury, then increased severity w/I 6 hrs when pancreatic enzymes begin irritating the peritoneum, which may become superinfected and produce retroperitoneal abscess. CT scan can’t exclude blunt pancreatic, diaphragmatic, or bowel injury. Serum amylase is normal in up to 37% of pts with pancreatic injury Rapid deceleration or severe crush injury

Pediatric Vascular Access IO Medial tibia (unless fx) Fluid resuscitation, blood, medications Complications (rare) Growth plate injury Compartment syndrome Fluid leakage Fat emboli Osteomyelitis

Child Abuse Injury inconsistent with history, delay in treatment Abuser Young age Increased stress Unemployed History of Abuse Substance abuse Boyfriend

Child Abuse Burns Contact Immersion Stocking glove Cigarette

Child Abuse Contusions Buttocks Genitalia Neck Face Low back

Child Abuse Shaken Baby Syndrome: diffuse cerebral injury with edema, retinal hemorrhages, poor prognosis Suspicious fractures Any < 1 years Rib (posterior) Skull, spine, sternum Bilateral/multiple various stages of healing Long bone Metaphyseal

Child Abuse Head injury Subdural Cerebral SAH Shaken baby syndrome

25yoM s/p hit by car. You are assigned the task of checking the pelvis. Push down on the greater trochanters Push down on the iliac crest Squeeze together on the iliac crest Squeeze and rock the greater trochanters

Pt. has unstable pelvis and binder is applied Pt. has unstable pelvis and binder is applied. Persistently hypotensive s/p 2 units of blood. FAST, DPA, CXR all negative. Next action? ED thoracotomy Repeat FAST/DPA OR Laparotomy Angiography Pack

Angio ready in 15 minutes. Well resuscitated. Intubated Angio ready in 15 minutes. Well resuscitated. Intubated. Surgical medical student wants to put in foley so he can check it off on his list. You… Make the senior surgeon assist Get a coude catheter Insist on urology resident for insertion Rudely stop the medical student

GU trauma Signs of GU trauma somewhere – hematuria Urethral injury Perineal ecchymosis Unable to urinate Blood at meatus High-riding/absent prostate Blood in scrotum/scrotal hematoma Obvious penile trauma Pelvic fracture Dx Retrograde urethrogram Do not blindly put foley (unless you’re really skilled) – partial tear into complete disruption Tx Foley over wire. Foley in for 2 weeks. Suprapubic catheter placement and surgical repair. Posterior urethral injury from blunt trauma

Normal urethrogram

Urethral tear

Which of the following statements regarding lightning injuries is correct? A. Aggressive fluid loading is indicated. B. Fetal death is common in pregnant victims. C. Lower extremity paralysis is rare. D. Rhabdomyolysis is a frequent complication. E. Tympanic membranes usually are normal.

ANSWER: B A. Aggressive fluid loading is indicated. Overly aggressive fluid admin may worsen cerebral edema. B. Fetal death is common in pregnant victims. (50% fetal mortality rate). C. Lower extremity paralysis is rare. 2/3 p/w LE paralysis and 1/3 with UE paralysis. D. Rhabdomyolysis is a frequent complication. Rhabdomyolysis occurs in only 6% of pts. E. Tympanic membranes usually are normal. More than 50% of lightening injury victims have perforated TMs.

Lightning Electrical and most lightning burns have an entrance and exit point Death usually secondary to cardiac arrest, lightening causes massive countershock and produces asystole. Burns are superficial, deep muscle damage rare. Cataracts are common and may occur immediately or develop up to 2 yrs after incident. Secondary injuries: ruptured TMs, spinal fractures at multiple levels, bilateral scapular fractures, internal organ injuries, long-bone fractures, intracranial bleeding, seizures, cardiac arrhythmias, and cardiac arrest.

Which does not need burn unit? 4yo, 10% BSA superficial partial-thickness burns to arms after pulling a pan of boiling water off a stove 12yo 26% BSA superficial partial-thickness burns to chest and arms from setting a blanket on fire 38yo 3% BSA full-thickness burn to his hand from a mechanical injury 42yo, DM, 5% BSA superficial partial-thickness burns to her feet from scalding bathtub water 75yo, 5% BSA superficial partial-thickness burn to back from a heating pad

Burn Unit Criteria Major Moderate Minor Partial-thickness burns > 25% BSA in 10-50yo Partial-thickness burns >20% BSA in <10yo or >50yo Full-thickness >10% BSA Burns in hand, face, feet, perineum, cross major joints or circumferential burns Burns with inhalation injury, fxs/other trauma, electrical burns Burns in infants, elderly or poor-risk Moderate Partial-thickness 15-25% BSA in 10-60yo Partial-thickness 10-20% <10yo or >50yo Full-thickness < 10% BSA Minor Partial-thickenes < 15% BSA 10-50yo Partial-thickness < 10% BSA <10yo or >50yo Full-thickness <2% BSA

Burn Percentage