Case scenario- Multiple trauma M K Alam

Case scenario 1 A 20 year old man was brought to ED of a small hospital. His small car skidded and hit a lamp post.

Report from ambulance man Not wearing seat belt Front wind screen was shattered BP 90/60 mmHg Pulse 112/ min RR 32/ min Management: Oral airway, cervical collar, O₂, iv fluid, spinal board

Pre-hospital management Oral airway Cervical collar IV crystalloid infusion O₂ Spinal board

Vital signs on arrival to ED BP 90/66 mmHg Pulse 116/ min RR 34/ min Temperature 36.8° C What to do?

A Unresponsive to your questions. Bleeding from facial lacerations What to do?

A- Airway Clear airway by suctioning Unstable jaw Oxygen Open collar Distended neck vein Orotracheal intubation Surgical cricothyroidotomy

Slight improvement in respiration. What to do?

B- Breathing Right chest: Diminished movement on Soft tissue crepitation Hyper resonant Diminished breath sound Normal heart sound

? Diagnosis Tension pneumothorax Management Needle thoracocenteasis ICT Improvement in RR (22/ min) BP - 98/ 66 mm Hg, pulse 112/ min. What next? What other life threatening injuries?

C- Circulation Why hypotension? ?Haemorrhage ?Cardiogenic ?Neurogenic

C- Circulation 2nd IV line started (1st iv line – pre-hospital) 2L RL- rapid infusion Pulse oximetry, ECG ? Foley catheter (?PR exam)- clear urine Facial laceration bleeding- minimal Abdomen slightly distended, pelvis stable Limbs- no swelling, deformity or laceration BP – 100/ 70 mmHg, Pulse 98/ min. NG tube (? Which route) FAST

FAST- Focused abdominal sonography in trauma Rapid & accurate. Sensitivity up to 99%. Detects small amount (100 ml) of blood. Four views: 1.Pericardiac 2.Perihepatic 3 Perisplenic 4.Pelvic Helpful in management of unstable patients.

FAST

FAST Free fluid in abdomen Multiple liver laceration Management ?

D- Disability What to do?

Glasgow Coma Scale (GCS), Total = 15 Eye response Vocal response Motor response Spontaneous 4 Oriented 5 Obeys commands 6 To voice 3 Confused 4 Purposeful movement to pain 5 To pain 2 Inappropriate words 3 Withdraw from pain 4 None 1 Incomprehensible words 2 Flexion to pain 3 *** None 1 Extension to pain 2 None 1

D- Disability E2, M4, V1 Pupil- R= 4 mm, L= 5.5mm, both reacting to light >1 mm suggests intracranial injury Neurosurgery consultation

E- Exposure/ environment control What to do?

E- Exposure/ environment control Full exposure Areas missed? Protect from hypothermia.

Preparation for Surgery ?Priority Consent Blood Skin preparation Laparotomy: ? Incision Intraoperative: Suture liver laceration, perihepatic packing

Liver injury Spontaneous hemostasis- 50% of small lacerations. Profuse bleeding from deep hepatic lacerations. Mortality : 8%- 10% Morbidity : 18%-30%. Diagnosis: Hemodynamically unstable- FAST Hemodynamically stable- FAST, CT scan Management based on hemodynamic status

Liver injury- pathophysiology Susceptible to injury due to large size(1200-1600 g) Covered by bony thoracic cage Injury frequency - only 2nd after spleen( personal series) Highly vascular- only 4% of body weight but 28% of total body blood flow Double blood supply- portal vein & hepatic artery Draining hepatic veins- short and thin walled

Liver injury- CT scan

Liver injury- Non-operative management Hemodynamically stable. patients CT scan. No other indications for abdominal exploration. ICU admission for close observation. Serial hemoglobin estimation. Transfusion requirements of <2 units of blood. Surgery- if become unstable.

Liver injury-Surgical management Principles of surgical management: control of bleeding, removal of devitalized tissue, and adequate drainage. Bleeding vessels & biliary radicles are individually ligated. Pringle’s maneuver. Perihepatic packing- fail to control bleeding. Packs removed in 48 hours.

Abdominal injuries 25% of all trauma victims require abdominal exploration. PE: inadequate to identify intra-abdominal injuries Diagnostic modalities- CXR, FAST, DPL,CT & laparoscopy Blunt trauma: Hemodynamically stable- FAST , CT scan Hemodynamically unstable- FAST

Diagnostic peritoneal lavage (DPL) Insert catheter below umbilicus under LA. Bloody aspirate- laparotomy. 1L NS infusion into peritoneum. Returning fluid is bloody- positive lavage. Rapid and safe Do not determine origin of blood Too sensitive Does not evaluate retroperitoneal injury Replaced by FAST and CT scan

Diagnostic peritoneal lavage (DPL)

Splenic injury Most frequently injured in blunt trauma (personal series) History of injury to the left side of the chest, flank, or left upper part of the abdomen Bruising, pain tenderness- lower chest and upper abdomen on left side Diagnosis- CT in hemodynamically stable patients FAST or exploratory laparotomy in an unstable patients

Splenic injury (CT scan)

Splenic injury-Non-surgical management (70%) Hemodynamically stable. FAST, CT scan. No other intra-abdominal injury requiring operation ICU admission for continuous monitoring. Serial hemoglobin. Repeated abdominal assessment. If hypotension develops - for surgery.

Splenic injury-Surgical management Hemodynamically unstable. FAST: splenic injury, free fluid (hemoperitoneum). Surgery- splenectomy . Polyvalent pneumococcal vaccine (pneumovax).

Pancreatic injuries Uncommon. Penetrating injury or direct blow. Diagnosis: difficult CT scan, elevated serum amylase may help No duct injury: simple drainage Ductal injury: distal resection

Bowel injuries Mostly- penetrating trauma. Less common after blunt trauma. Features of peritonitis. CT scan free air in peritoneum/ contrast leak. Small bowel: Suture repair Colon: Suture repair ± proximal colostomy

Bowel injuries CT: contrast leak (C) & free air Intraoperative

Renal injuries Minor- renal contusion (85%) Conservative management Major: Deep medullary injuries with extravasation Vascular injuries Surgical repair

Case scenario- 2 A young male was stabbed in a car park after a dispute over parking space ABCDE: Fully conscious, hemodynamically stable, well oriented of time and place Abdomen: 2 cm wound just above the umbilicus. Abdomen moving well with respiration. No active bleeding from the wound. Non tender Bowel sound present

Penetrating Abdominal injuries Gun shot injuries- urgent surgery Stab (knife) injury: Hemodynamically stable- wound exploration under LA, CT scan, Surgery- if intra-abdominal injuries found. Hemodynamically unstable- surgery

Thank you!