Presentation on theme: "William Beaumont Hospital Department of Emergency Medicine"— Presentation transcript:
1 William Beaumont Hospital Department of Emergency Medicine TraumaWilliam Beaumont HospitalDepartment of Emergency Medicine
2 CASE40 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???
3 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 shockWhat is the Golden Hour?
4 “Golden Hour”Emphasize the initial evaluation and treatment of the trauma patientOur “window of opportunity” to have a significant impact on morbidity and mortalityMust have a concise, expeditious, well thought out plan for evaluation and treatment of life threatening injuriesAccomplished through ATLS guidelines of the primary and secondary surveysInjuries 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
5 Primary Survey: ABCDEs A = airway and cervical spine protectionB = breathing and ventilationC = circulation and hemorrhage controlD = disability and neurological statusE = exposure and environmental controlD – LOC (AVPU – awake, responds to verbal stimuli, responds to painful stimuli, unresponsive;pupil sizeE –undress the pt, log roll the patient and put a blanket on them
6 Primary Survey: ABCDE’s An identified injury should be treated at the time of discoveryExamples:The airway should be secured before the fracture is stabilizedPTX should be treated before the patient is completely exposedThe decision to transfer a patient should be made before proceeding to the secondary survey
7 Secondary Survey: Head to Toe Complete the history (AMPLE)Head to toe physical examReassess vital signs and interventionsObtain GCS if not done in primary surveySpecial procedures (lines), specific x-rays, and labs should be obtained
8 Secondary Survey: Rectal Tone Rectal exam is done in every trauma and before urinary catheter placement (WHY?)Check for blood tear or pelvic fractureHigh riding prostate potential urethral injuryDecreased tone brain or spinal injury
9 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???The Emergency physician starts at the head of the bed to assess A.Assume that there are 15 people cutting clothes, starting the IVs, and exposing the patient.
10 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
11 AirwayOral intubation of the patient using RSI with in line cervical tractionAn orogastric tube is placed at the time of intubationWhy not an NGT in this patient?
12 Breathing A - Patient is intubated What’s next? B - Breathing Despite intubation, O2 sats are still low and the patient is difficult to BVMDecreased breath sounds on the R chest, crunching under the bell of your stethoscope, and the trachea appears deviated…What’s the problem? How do we fix it?
13 Breathing A - Patient is intubated Hemo/pneumothorax Needle decompression followed by tube thoracostomy of the R chest
14 Circulation A – Patient is intubated B – Chest tube placed What’s next? C – CirculationVitals: BP 90/40, HR 130RN established two 16g IVsHow about 2L of fluid and a type and cross for 4 units of pRBCsWhat do you give if immediate transfusion is needed?
15 Disability and Neuro Exam A – Patient is intubatedB – Chest tube placedC – Fluids and blood givenNow for D – Disability and Neuro examPatient is intubated and paralyzedGCS = 3TP (T = tube, P = paralyzed)GCS =/<8 intubated for airway protectionWhat is a GCS you ask?
17 Exposure and Environmental A – Patient is intubatedB – Chest tube placedC – Fluids and blood givenD – GCS = 3TPE – Exposure and EnvironmentalAll clothes are cut offWarm blanket applied to the ptDeformity to L femur probably from a fracture splint re-applied
18 Tackling the Case at Hand Secondary surveyOrdersRepeat vital signsFAST examTalk to EMS for additional information
20 Labs and Imaging 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 panelXR standard: c-spine, CXR, pelvisObviously x-ray anything that looks injuredCT:Head and abd/pelvis are standard for a severely injured intubated patientChest CT for chest trauma or CXR findingsNeck CT based upon mechanism, age, injury
22 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 FASTMorison’s Pouch = hepatorenalSplenorenalRectovesicular = Pouch of DouglasCardiacCan also perform pleural windows for PTX
27 CT vs. DPL vs. FAST DPL CT FAST Noninvasive Very sensitive but not specificInvasiveGood for visceral injuryUnstable trauma where US is unavailable or equivocalCTNoninvasiveDelineates solid organ injuryExpensivePatient must be stableFASTQuickSensitiveBedsideOperator dependentMisses bowel, mesentery, diaphragm and pancreatic injuries
29 Head Case15 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.
30 Head CaseOn exam he moans, withdraws to pain, but does not open his eyes… What is his GCS?
31 Head Case On exam he moans, withdraws to pain, but does not open his eyes…What is his GCS?What should you do FIRST?
32 Head Case GCS = 7 What should you do first? Intubate using RSI Brief neuro exam, if possible, before paralysis?? Lidocaine prophylaxis for intubationBlunts the cough reflex, hypertensive response, and increased ICP associated with intubation
34 Subarachnoid Hemorrhage Most common CT abnormality in head injuryAmount of blood correlates directly with outcomePatients c/o HA and photophobiaNimodipine is used to prevent vasospasm which worsens ischemia
35 Compare It To This…Subdural HematomaEpidural Hematoma
36 Head Injury Complete the primary/secondary survey Initial goal is to maximize O2 and BP to prevent secondary ischemic brain injuryPrimary 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 traumaAll therapies for TBI are aimed at reversing or preventing secondary brain injury
37 Head Injury: Increased ICP Increased ICP = CSF pressure > 15 mm HgThe cranium can accommodate ~50-100mL of blood before ICP increasesCPP = MAP – ICPCPP < 40, autoregulation is lostRemember CBF depends on the MAP therefore maximize the BP.
38 Recognizing Increased ICP What is Cushing’s Reflex?
39 Cushing’s Reflex Hypertension Bradycardia Diminished respiratory effortICP has reached life threatening levelsOccurs in 1/3 of cases
40 Recognizing Increased ICP Ipsilateral to mass lesionAnisocoria, ptosis, impaired EOMs, sluggish pupilContralateral to mass lesionHemiparesisPositive BabinskiAs ICP continues to increase…Posturing – decorticate then decerebrateAtaxic respiratory patternsRapid fluctuations in BP and HR, arrhythmiasLethargy coma death
41 Methods to Reduce ICP Hyperventilation = PCO2 30-35 Lowering PCO2 by 1mmHg decrease cerebral vessel diameter 2% decreased ICPGood initially but over time will cause reflex vasodilationDiuretics = mannitolCranial decompressionSeizure prophylaxis = Ativan, Dilantin
42 Head Injury: Reasons to CT History of LOC or amnesia to the eventIntoxication: drug and alcoholHeadache, vomiting, focal neuro deficitModerate (GCS 9-13) and high risk (GCS<8)Age > 60 or < 2Anti-coagulants – ASA, Plavix, CoumadinPost-traumatic seizure
43 Head Injury: CT Unnecessary? Low risk (GCS 14-15)Not intoxicatedFully awake without focal neuro deficitsNo evidence of skull fractureAble to be observed for hours
44 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?
45 Basilar Skull Fracture Linear fracture through the base of the skull and can involve the temporal boneSignificance = requires a lot of force to break and can involve the internal carotid arterySigns: blood in the ear canal, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4 and 5Management:Head CT and admissionMost CSF otorrhea and rhinorrhea will resolve spontaneously within a weekProphylactic antibiotics are not usually given
46 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.
47 Epidural Hematoma80% associated with skull fractures across the middle meningeal artery or a dural sinus in the temporoparietal regionThe classic lucid interval occurs in 30%Patients needs to go to the OR for evacuation
48 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.
49 Subdural HematomaOccur commonly in people with atrophic brains = old people and drunksBridging vessels traverse a greater distance so are more easily torn (venous blood)Slow bleeding can delay presentationOptimal treatment is evacuation in the OR
51 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?
52 Le Fort Fractures Le Fort I Le Fort II Le Fort III Transverse fracture through the maxillaUpper teeth moveLe Fort IIFraxture of the maxilla, nasal bridge, lacrimal bones, orbital floor and rimTeeth and nose moveLe Fort IIICraniofacial dysjunctionWhole face moves
53 Alternative Airways Orotracheal intubation Nasotracheal intubation Procedure of choice with facial or neck traumaContraindicated w/ massive facial trauma or suspected laryngeal injuryNasotracheal intubationContraindicated in apneic ptsContraindicated in those with facial, skull, or laryngeal fracturesCricothyroidotomyIndicated when oral intubation fails, when there is severe edema or deformity of the face and oropharynx, fracture of the larynx, or hemorrhage in the airwayContraindicated with anterior neck hematoma or laryngeal injury.
54 Another Case…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?
55 Central Cord Syndrome Most common lesion Common in elderly Hyperextension injury ligamentum flavum buckles into the cord contusion of the central portion of the spinal cord affects the pyramidal (motor) and spinothalamic tracts (sensory)Fibers that innervate distal structures are located more in the periphery of the cord deficit greater in the upper extremitiesPrognosis: >50% of people recover spontaneously
56 Anterior Cord Syndrome Hyperflexion injury anterior cord contusion through protrusion of bone fragment or herniated disc or laceration of anterior spinal artery paralysis and hypoalgesia below the level of the lesionPreserved posterior column functions (i.e. position, touch, vibration)Neurosurgical emergency as some causes are amenable to surgeryPrognosis: variable degrees of recovery in the first 24 hours
57 Brown Sequard Syndrome Hemisection of the spinal cordIpsilateral motorContralateral sensory deficits (pain and temperature)Usually from penetrating trauma but can also be from fracture of the lateral mass in the C-spineMost maintain bowel and bladder functionTreatment and prognosis depend on the injury
58 Other C-spine injuries are covered in the orthopedics lecture. Any Questions?
59 Pedestrian vs. MVC45 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.
60 Pedestrian vs. MVCIn 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 fields, crepitus over the R chest wall with dull/distant breath sounds on the L. What should we do first?
61 Pedestrian vs MVCIntubate 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?
62 Thoracostomy Tubes Bilateral chest tubes are placed. 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?
63 Thoracostomy Tubes You auscultate the lungs again… Right: improved air exchange, still with crepitus and extensive bruising along the anterolateral CWLeft: better air exchange, but it is still decreased at the baseRe-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.
64 Here is your portable CXR, What do you think? OK, pretend that there are bilateral chest tubes.
65 Ruptured Diaphragm Most frequently from penetrating trauma <5% from blunt traumaIf there is a pelvic fracture, incidence rupture increasesIncidence of L and R sided rupture about equalL side usually symptomatic as R side is protected by the liverSigns/Symptoms:Respiratory insufficiencyBowel sounds in the chestNGT passes back into chestSurgery is definitive treatment
66 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 breakBrachial plexus, great vessels, and lungs are in close proximity and at great riskThink twice with this injury and do a very thorough neurovascular exam
67 Thoracic Trauma: Rib Fractures Fractures of the 9th-11th ribs suggest an associated intra-abdominal injuryMost heal within 3-6 weeksRib fractures are associated with hemo/pneumothorax, atelectasis, and pneumoniaEach rib fracture can lose ~200cc of bloodAdmit vs. discharge: depends on the extent of injury, age, and ability to breathe
68 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
69 Thoracic Trauma: Flail Chest Major problems are underlying pulmonary contusion and chest painSplinting that causes atelectasis results in major respiratory insufficiency
70 Thoracic Trauma: Sternal Fracture Most commonly from anterior chest traumaUsing restraints increases the risk of fracture at the location the belt crosses the sternumOlder > younger more likelyYounger more likely to suffer mediastinal soft tissue injuryThink about the structures beneath the sternum and carefully evaluate them (heart, lungs, and mediastinum)
71 Thoracic Trauma: Pneumothorax DIB and CP are the most common complaintsSigns/symptoms do not always correlate well with the degree of PTXSimple PTXCollapse of lung but no communication with the atmosphere or shift of the mediastinum or hemidiaphragmCan observe these if <20% and they are not ventilated, unstable, going to OR, or being transferred to a trauma center
72 Thoracic Trauma: Pneumothorax Tension PTXAccumulation of air under pressure causes shift of the mediastinum compression of the contralateral lung and great vesselsLeads to decreased cardiac output from decreased venous returnClassic signs: tachycardia, JVD, absent breath sounds on the ipsilateral side with trachea deviated awayTension PTX is a clinical diagnosis (not radiographic)Management: needle decompression and chest tube
73 Thoracic Trauma: Pneumothorax Open PTXSucking chest woundManagement: place occlusive dressing, taped on 3 sides only and place CT at a different site
75 Thoracic Trauma: Hemothorax Injured lung parenchyma most common > intercostal/IMA vessels > hilar vessels > great vesselsSigns/Symptoms: DIB, decreased breath sounds on the affected sideUpright CXR: blunting or obliteration of the diaphragmSupine CXR: diffuse haziness on the affected sideTreatment: chest tube if respiratory compromise1500mL of blood = OR for thoracotomy200 mL/hr for 3 hours = OR
76 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
77 Pericardial Effusion or Tamponade Beck’s Triad:hypotension, distended neck veins, distant heart soundsTamponade occurs in 2% of pts with penetrating chest or abdomen traumaRarely occurs with blunt traumaTreatment: IVF, pericardiocentesis vs. ED thoracotomy, then definitive management in the ORSubxyphoid 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.
78 Next Case…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.
79 Joy RideHe 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.
80 Portable CXR What Do You Think? What do you want to do next?
81 ED Thoracotomy Indications Penetrating TraumaCardiac arrest at any point with initial vitals or signs of life in the fieldPersistent hypotension (SBP<50) despite aggressive resuscitationSevere shock with signs of tamponadeBlunt TraumaCardiac arrest in the EDBlunt traumatic arrest in the field is NOT an indication for thoracotomy
82 Blunt Traumatic Aortic Injury Thoracic aorta is the most common vessel injured by blunt trauma80-90% of tears occur distal to the L subclavian arteryLigamentum arteriosum is located in the descending aorta (aorta is tethered around a fixed point)Patients suffering an ascending aortic injury usually die at the sceneCXR findings: 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
84 Abdominal Trauma18 y/o kid who… Is stabbed in the mid abdomen. -OR- Falls 12 feet off the roof of a house. Who do you think is more likely to survive? What organs are most likely to be injured?
85 Abdominal TraumaBlunt injuries carry a greater risk of mortality than penetrating injuriesBlunt injury is more difficult to evaluate and diagnoseBlunt injury is more often associated with injury to multiple internal organs and systems outside of the abdomen
86 Abdominal Trauma Penetrating Injury Blunt Injury Small intestine, colon, and liverBlunt InjurySpleen>>>>liver, intestineSeat belt sign = contusion/abrasion across the lower abdomenCorrelates with intraperitoneal lesions or lumbar spinal injury
87 Abdominal Trauma Evaluation Inspect and palpate most importantlyFAST examCT scanLabsCBC – not usually helpful initially, mild leukocytosis is normal, serial Hgb more helpfulTox screen and ETOH level
88 Abdominal Trauma: Treatment Hemorrhage is the main concernTwo large bore IVs or central lineIVF followed by blood productsAntibiotics if concern for bowel injuryStable – FAST, CT, then OR if necessaryUnstable –FAST then OR for ex-lapPenetrating trauma – determine if the peritoneum was violated as this dictates management
89 Where Does Blood Hide in the Body? ChestAbdomenPelvisFemurIn kids, the cranium is a possibility as the sutures are still open
90 Blood Loss with Fractures Pelvis – ccFemur – 1000ccRibs – 200ccTibia/Fibula – 500ccHumerus – 250ccRadius/Ulna – cc
91 Trauma: In the EndTrauma can be cool to look at, but don’t be distracted by the gore.Start with your ABCDEs and don’t move to the next step until you have solved a problem.