Trauma Overview

David B. Reedy, M.D., FACEP

Contra Costa Regional Medical Center

Assistant Clinical Professor UCSF/SFGH

Trauma is an injury caused by a physical force Motor vehicle collisions Falls Gun shot Stabbing Burns Blunt assault

Advanced Trauma Life Support American College of Surgeons Provides a framework for the

management of the injured patient Intended to allow the single doctor

in a rural hospital to assess and manage trauma patients

ATLS Origins

Nebraska, 1976 Plane crash in a Nebraska field

changed the face of trauma care throughout the world

Medical, EMS, and Nursing groups began to collate protocols for trauma management

ACS publishes ATLS in 1980

Blunt Thoracic Trauma

Blunt Thoracic Trauma Airway

Look for associated injuries

Remember c-spine

Blunt Thoracic Trauma Breathing

Respiratory rate Paradoxical motion Crepitus Subcutaneous air Auscultation

Blunt Thoracic Trauma CXR-pneumothorax

Tracheal deviation, hypotension, hypoxemia

Blunt Thoracic Trauma Circulation

Hypotension Hypovolemia Pneumothorax Cardiac tamponade Aortic Injury Blunt cardiac injury

• Arrhythmia• NSR

Blunt Thoracic Trauma CXR-widened mediastinum

Blunt Thoracic Trauma Aortic injury

80-90% of patients with thoracic aortic rupture die in the pre-hospital setting

Those who survive may have minimal initial symptoms

CXR may be first clue

Penetrating Thoracic Trauma Emergency Department

Thoracotomy “The surgeon who should attempt

to suture a wound of the heart would lose the respect of his surgical colleagues” - Theodore Bilroth, 1882

Penetrating Thoracic Trauma Emergency Department

Thoracotomy

Penetrating Thoracic Trauma Emergency Department

Thoracotomy Indications

Penetrating thoracic traumatic arrest with previously witnessed cardiac activity

Penetrating thoracic unresponsive hypotension

Penetrating Thoracic Trauma

Emergency Department Thoracotomy

Penetrating Thoracic Trauma Emergency Department

Thoracotomy Contraindications

Blunt thoracic injuries with no witnessed cardiac activity

Multiple blunt trauma Severe head injury

Penetrating Thoracic Trauma Emergency Department

Thoracotomy ACLS algorithms do NOT apply to

traumatic arrest

Trauma Ultrasonography The FAST Exam

Trauma Ultrasonography

Focused Assessment with Sonography for Trauma (FAST) Limited ultrasound exam Directed solely at identifying the presence of free intraperitoneal or pericardial fluid Free fluid is usually due to hemorrhage Helps determine the need for OR, CT, or angiography

Trauma Ultrasonography FAST examines four areas for free

fluid

Low Frequency Probe 2.5 - 5.0 MHz

Tissue Penetration

Trauma Ultrasonography

Trauma Ultrasonography Perihepatic and hepato-renal

Trauma Ultrasonography

Trauma Ultrasonography

Trauma Ultrasonography

Trauma Ultrasonography

Trauma Ultrasonograpy Spleno-renal

Trauma Ultrasonography

Trauma Ultrasonography

Trauma Ultrasonography Pelvis

Trauma Ultrasonography

Trauma Ultrasonography

Trauma Ultrasonography Pericardium

Trauma Ultrasonography

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Trauma Ultrasonography

Blunt Abdominal Trauma Not for bowel injury, solid organ

injury, or retroperitoneal injury Detection of free intraperitoneal or

pericardial fluid

Trauma Ultrasonography

EFast Exam Extended Fast Exam

Anterior lung apices for pneumothorax Lung bases for pleural fluid

Trauma Ultrasonography

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Trauma Ultrasonography

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Trauma Ultrasonography Conclusions

Clinician based ultrasound has changed the way trauma care is practiced and is rapidly becoming standard of care

Noninvasive, straightforward, relatively short training period

Multiple training courses exist Focused exam, goal specific

ATLS 8th Edition, 2008

30 year anniversary

“Best evidence” based (i.e. spinal steroids)

Revised pediatric guidelines

Disaster management

The Knife and Gun Club