Chapter 6: TRAUMA

10/06/2009

Basic Science

Jen Dixon, PGY-4

Why Should You Care?

•trauma call

•#3 killer

•$expensive$

•major public health issue

Trauma Roadmap

• Primary Survey

• Resuscitation

• Secondary Survey

• Diagnostic Evaluation • Definitive Care

Airway Anyone?

Primary Survey: Airway

• C-spine immobilization (Philly collar)

• If pt. responsive with normal voice, airway likely stable and no intubation needed…

• Unless……..– Expanding neck hematoma?– Thermal injury to mouth/nares?– Airway bleeding?– Complex maxillofacial trauma?

INTUBATE!

Primary Survey: Airway

• Pt. w/abnormal voice, AMS (GCS<8):

– Clear mouth of debris, suction airway

– Nasotracheal intubation NOT FOR APNEIC Pt!

– Orotracheal intubation w/ c-spine protection, RSI

Primary Survey: Airway

• Surgical Airway: Needle or Open Cricothyroidotomy

*not for those <12 years old!

≤6mm

Vertical Incision!

Percutaneous transtracheal ventilation

Primary Survey: ABC’s

• Breathing: – Oxygen, pulse ox

• Look for Life Threatening Issues– Tension ptx– Open ptx– Flail chest– Pulmonary contusion

Tension PneumothoraxExam Findings

Absent breath soundsDistended Neck Veins

HypotensionRespiratory DistressSub-q emphysema

Needs Chest Tube!Don’t wait for X-ray!

Tension Pneumothorax

• Neg intrapleural space becomes positive

• Trachea, mediastinum shift contralateral

• Heart rotates about SVC/IVC, ↓ VR, ↓CO– ‘IVC kinking’

• Simple ptx>tension ptx w pos pressure ventilation

Chest Tube Placement

36-40F chest tube

Over the rib

4-5th I.C. Space, Infra-mammary foldAnt. Axillary line

ABC’s: Breathing

• Open Pneumothorax– Cover with dressing taped on 3 sides only to prevent

tension ptx– Needs wound closure, chest tube

• Flail Chest– four or more ribs fractured in at least 2 locations – Paradoxical mov’t compromises respiration– Pulmonary contusion associated, monitor progression

Primary Survey: ABC’s

• Circulation:– Palpable pulses?

• Carotid = SBP 60• Femoral = SBP 70• Radial = SBP 80

– HypoTN>>>think hemorrhage!• Control external bleeding w/pressure• Scalp bleeding needs addressed

– Check BP, HR q15 min….at least– No Blind Clamping!

IV Access

• 16 G, B/l antecubital fossa for adults

• Place cordis for rapid resusciation

• Femoral access or even saphenous cutdown if needed

• Kids <6yo: No femoral vein cannulation– Interosseous cannulation if 2 failed peripheral

IV attempts

Interactive Question:

• What landmark is used to find the saphenous vein for a cutdown procedure?

?

?

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? ?

Answer:

• The vein is consistently found 1 to 1.5 cm anterior to the medial malleolus – Proximal and distal traction sutures are

placed. Distal suture is ligated.– Short 10- to 14-gauge intravenous catheters

should be used – secure with both sutures and tape to prevent

dislodgment

 Intraosseous infusions

<6 years old!

Initial Fluid Resuscitation

• 1L IV bolus of normal saline, Ringer's lactate, or other isotonic crystalloid in an adult

• 20 mL/kg Ringer's lactate in a child

• repeated one time in an adult and twice in a child before PRBC transfusion

• Hypotension is not a reliable early sign of hypovolemia!

Know This

Class 1 Class 2 Class 3 Case 4Blood loss (mL) Up to 750 750-1500 1500-2000 >2000

Blood loss (%) Up to 15% 15-30% 30-40% >40%

Pulse <100 >100 >120 >140

BP Normal Normal Decreased Decreased

Pulse Pressure Normal or ↑ Decreased Decreased Decreased

Resp Rate 14-20 20-30 30-40 >35

Urine Output >30 20-30 5-15 Negligible

Mental Status Slightly anxious Mildly anxiousAnxious/

confused

Confused/

lethargic

Initial Response to Resuscitation

Responders Transient Responders Nonresponders

Normal vitalsNormal mentationNormal UOPGood tissue perfusion

Stable pt.Con’t work-up

Under-resuscitated?Ongoing hemorrhage?

Nonsurvivable multisystem injury ?Tension pneumothorax?Uncontrolled hemorrhage?Cardiogenic?

Distended neck veins?↑ CVP?

Cardiogenic Shock in Trauma

• Tension Ptx

• Pericardial tamponade

• Myocardial contusion or infarction

• Air embolism

Pericardial Tamponade

• Can have transient reponse to fluid

• Beck’s triad, pulsus paradoxus not reliable

• Subxiphoid or parasternal U/S view

Pericardiocentesis

80% success rate for decompression

Prepare for transport to OR!

If SBP remains <70, do ED thoracotomy!

Cardiac Injury Repair

Horizontal Mattress

Pledgets good for RV

ED Thoracotomy

Myocardial Contusion

• occurs in ~1/3 of blunt chest trauma pts

• EKG: ventricular dysrhythmias, a-fib, sinus brady, bundle-branch block

• cardiac enzymes not helpful

• Common dx, not usually life threatening

• Tx: pharmacologic suppression

• Echo STAT

Air Embolism

• lethal complication of pulmonary injury

• air from an injured bronchus enters adjacent injured pulmonary vein>LV

• Trendelenburg, trap air in LV apex

• Emergency thoracotomy, cross-clamp pulmonary hilum, aspirate air w 18G from LV, aortic root apex

Interactive Question

• A 36 yo WM sustains blunt abd trauma, arrives A&O x 3, vitals stable except BP 80/55, 1 L NS bolus given, BP then stable at 125/80. CXR nl, Fast scan negative. Pt goes to CT. Is this a good time to grab a snack?

Answer

• No.

Secondary Survey

• Which of the following should not be done in the secondary survey of a seriously injured pt?– Pt undressed, head to toe exam– Rectal exam– Foley catheter– NG tube– None of the above; the chapter says to do

them all

Secondary Survey

• Which of the following should not be done in the secondary survey of a seriously injured pt?– Pt undressed, head to toe exam– Rectal exam– Foley catheter– NG tube– None of the above; the chapter says to do

them all

Mechanism of Injury Question

• What are the greatest risk factors reflecting magnitude of injury that are strongly associated with life-threatening injuries?

Mechanism of Injury Question

• What are the greatest risk factors reflecting magnitude of injury that are strongly associated with life-threatening injuries?

• death of another occupant in the vehicle and an extrication time greater than 20 minutes.

Secondary Survey Question

• When attempting to clear a pt’s C-spine, which approach is best?– Move the pt’s head for them

– Let the pt move their own head

Secondary Survey Question

• When attempting to clear a pt’s C-spine, which approach is best?– Move the pt’s head for them

– Let the pt move their own head

Secondary Survey Question

• Otorrhea, rhinorrhea, raccoon eyes, and Battle's sign (ecchymosis behind the ear) can be seen with what type of fractures?

Secondary Survey Question

• Otorrhea, rhinorrhea, raccoon eyes, and Battle's sign (ecchymosis behind the ear) can be seen with what type of fractures? – basilar skull fractures

Neck Trauma

• What are the zones of the neck, how does injury work-up and management differ among them?

Neck Trauma

below the clavicles

b/t clavicles&hyoid

above hyoid

*unstable pt goes to the OR!

Zone 1=angiography of great vessels, soluble contrast esophagram >>barium esophagram, Esophagoscopy & bronchoscopy

Zone 2: platysma penetration? If yes 12 hr obs vscarotid/vertebral angio, direct laryngoscopy, tracheo-esophagoscopy & esophagram may be necessary (i.e. R>L GSW)

Zone 3=carotid/vertebral angio if evidence of arterial bleeding

Don’t Text & Drive!

Multiple Injuries

• Blunt trauma pt. w recurrent hypoTN, free fluid in the abd, suspected aortic tear on CXR and splenic injury on FAST scan– What do you fix first?

Multiple Injuries

• Blunt trauma pt. w recurrent hypoTN, aortic tear suspected, splenic injury, free fluid in abd– Ex lap, splenectomy first, then aortic repair

Multiple Injuries

• Efficient OR session

• Optimize metabolic status ASAP

• Treat hypothermia, acidosis, coagulopathy

• PRBC’s (type O or matched), FFP, platelets!

Prophylactic Measures

• 2nd generation cephalosporins pre-op for laparotomy, 1st gen for all other surgeries

• Tetanus

• DVT prophylaxis (SCDs, lovenox)

• Blankie! (keep ‘em warm)

Chest Trauma

Blunt Chest Trauma

• What are the most common locations for an aortic tear from shearing forces?

Blunt Chest Trauma

• What are the most common locations for an aortic tear from shearing forces?– just distal to the left subclavian artery

(ligamentum arteriosum)– In 2 to 5% of cases the tear occurs in the

ascending aorta, transverse arch, or at the diaphragm.

Blunt Chest Trauma

• indications for thoracotomy include pericardial tamponade, tear of the descending thoracic aorta, rupture of a mainstem bronchus, and rupture of the esophagus.

Cardiorrhexis

• The heart can rupture from blunt trauma.

• The Right Atrium and Ventricle are the most likely chambers to rupture.

Yuck

Penetrating Chest Trauma

• What are the indications for Operative Treatment of Penetrating Thoracic Injuries?

Indications for Operative Treatment of Penetrating Thoracic Injuries

• Caked hemothorax• Large air leak w inadequate ventilation or

persistent lung collapse• Drainage of >1500 mL blood when chest

tube is first inserted• Continuous hemorrhage of > 200 mL/h for

3 consecutive h• Esophageal perforation• Pericardial tamponade

Penetrating Chest Trauma

• What exams should be done to evaluate potential bronchial or esophageal injury?

Penetrating Chest Trauma

• What exams should be done to evaluate potential bronchial or esophageal injury?– Bronchoscopy– Esophagoscopy– soluble contrast esophagram (then barium if

neg)

Questions?