1. Saving Lives By Strengthening Our Region’s Trauma Care System COMPLICATIONS OF TRAUMA ANN O’ROURKE, MD, MPH SCRTAC TRAUMA CARE BEYOND THE ED DECEMBER 4, 2014

2. OUR CASE 31 yo man MVC with prolonged extrication Presents to ED: Confused, HR 120, RR35, BP90/65 Diminished breath sounds on right with palpable chest crepitus Unequal leg length Abdominal bruising What are your concerns?

5. OUR PATIENT Right hemopneumothorax-facility placed 28Fr chest tube Liver laceration-managed non-operatively Right acetabular fracture dislocation with proximal femur fx-traction with planned operation C3 fracture with small epidural hematoma- managed with PMT collar

6. POST INJURY DAY 2 OUR PATIENT STILL COMPLAINS OF DIFFICULTY BREATHING What are your concerns? Worsening pulmonary contusion Pneumothorax Hemothorax Pain from fractures Abdominal fluid/blood Pneumonia/pneumonitis Pulmonary embolism

7. RETAINED HEMOTHORAX Our chest tube did a good job of evacuating air and most of the blood, but some clotted blood remained. This can lead to: Empyema Chronic fibrothorax with trapped lung

8. RETAINED HEMOTHORAX Prevention: Properly positioned, LARGE chest tube (36-42Fr) Post placement CXR Retained hemothorax post chest tube placement independent predictor of empyema in up to 33% of patients

9. RETAINED HEMOTHORAX Treatment: Operative Early VATS (3days) significant reduction in operative difficulty, con­ tamination/infection of clot, and hospital length After day 5 more likely to need thoracotomy Fibrinolytic VATS is a more effective procedure than intrapleural streptokinase VATS patients having a statistically significant shorter hospital stay and decreased need for additional therapy Fibrinolytic agents would have to be seen as a second-line agent behind surgery when the risks of surgery are too great to the patient’s overall outcome

10. EMPYEMA Approximately 3% of patients with chest trauma will develop a posttraumatic empyema. Risk factors persistent pleural effusion/hemothorax duration of a tube place­ment of multiple tubes No good evidence for or against prophylactic abx prior to chest tube for prevention As with retained hemothorax, first line treatment is operative in patients who will tolerate

11. EMPYEMA

12. PNEUMONIA Our patient had difficulty coughing and clearing secretions What risk factors for this? Rib fractures with impaired mechanics Pulmonary contusion Inadequate analgesia C-collar impaired swallowing

13. FROM THE NTDB ALL AGES Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25

14. RIB FRACTURE CORRELATION WITH MORTALITY Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25

15. OUR PATIENT DEVELOPED RLE SWELLING What are your concerns? DVT Compartment syndrome Morel-Lavallée

16. DVT What are his risk factors for DVT? Prolonged extrication Immobility LE/pelvic fracture Holding DVT prophylaxis

17. WHEN SHOULD WE BEGIN DVT PROPHYLAXIS? AND WHAT MEDICATION DO WE USE? What factors in to the decision for this patient? Solid organ injury (liver) Pelvic fracture Spinal epidural hematoma Other factors: Head bleed Planned operations Epidural catheters

18. DVT PROPHYLAXIS IN SOLID ORGAN INJURY DVT prophylaxis is safe in patients with solid organ injury BUT timing of initiation is not established Some retrospective trials suggest OK to begin early

19. DVT PROPHYLAXIS IN TRAUMA

20. MOREL-LAVALLÉE

21. OUR PATIENT DEVELOPS ABDOMINAL PAIN, TACHYCARDIA AND FEVER What are your concerns? Biloma/bile leak Missed bowel injury Delayed bleed Urinary tract infection Hepatic necrosis Abscess Cholecystitis

22. DELAYED LIVER COMPLICATIONS Delayed bleed 1-6% severe liver injuries Expanding bleed Pseudoaneurysm Biliary leak 2-7% Mean 7-10d post injury Most in grade 4-5 injuries Treat with drainage and ERCP and stent

23. BILIARY COMPLICATIONS Table 2 Analysis of factors influenced development of complications, including biliary complications in the study group ComplicationsNo complicationsBiliary complications P value (n = 22)(n = 24)(n = 15) Male17 13NS Age (years)23.7 ± 11.920.6 ± 1522.5 ± 12.2NS ISS (mean ± SD)36 ± 1432.6 ± 1535 ± 15NS Grade of liver injury (mean ± SD) 4 ± 0.63.8 ± 0.64 ± 0.75NS Angioembolization (%)6 (27.2)5 (20.8)5 (33.3)NS OR (%)15 (68.2)*8 (33.3)9 (60)0.038 Penetrating injury (%)7 (31.8)5 (20.8)5 (33.3)NS OR - operative group; ISS - Injury severity score; NS - Differences not significant; * - p < 0.05 - complication rate was higher in OR patients. Bala et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012 20 :20 doi:10.1186/1757-7241-20-20

24. SMALL BOWEL INJURY

25. MISSED SMALL BOWEL INJURY

26. OUR PATIENT DEVELOPS MENTAL STATUS CHANGES What are your concerns? Hypoxia or hypercarbia Sepsis Stroke Medications Drug withdrawal

27. BLUNT CEREBROVASCULAR INJURY

28. BCVI

29. OUR PATIENT IS BACK IN CLINIC WITH SLEEP DISTURBANCES What are your concerns Inadequately treated pain Medication withdrawal Post traumatic stress disorder Sleep apnea Insomnia related to stroke

30. PTSD IN CIVILIAN TRAUMA More than 20% of trauma patients have PTSD at 12 months following injury Risk factors: Post-injury emotional distress Pain Pre-injury depression Benzodiazepine use Zatzick, et al. Annals of Surgery Volume 248, Number 3, September 2008

31. PTSD CRITERIA

32. Historically, benzodiazepines were used for treatment of acute stress and ptsd change: use with caution or discourage use theoretical, animal, and human evidence to suggest that benzodiazepines may actually interfere with the extinction of fear conditioning or potentiate the acquisition of fear responses and worsen recovery from trauma

33. Very high co-morbidity of PTSD with alcohol misuse and substance use disorders (upwards of 50 percent of co-morbidity) and potential problems with tolerance and dependence. Once initiated, benzodiazepines can be very difficult, if not impossible, to discontinue due to significant withdrawal symptoms compounded by the underlying PTSD symptoms.