Professor Conference

Professor ConferenceTrauma Service3/5/2015

Ryan JeffersonDenise LiuAttention All personnel, trauma alert ER, Level 121yom restrained right rear passenger in an MVAT-boned on right by pickup truck going at 50-60mphLOC+Airbag status unknown

What do you do next? Tick tock tick tock

Organized chaosGCS 15FAST +Blood in Morisons pouch (hepatorenal recess) b/w liver & Rt kidneySuprapubic (-)Left side (-)Subxyphoid (-)IV access: L groin Cordis (femoral v)Monitor: VS 97F88HR12RR120/82BP100%RAFoley: minimal blood tinged urineCXR: Right PTX!Pelvic Xray NL

Now WHAT?

Still in the trauma bayEmergent thoracostomy tube (chest tube) placedChecked ABC: intactInspection: Bloody face (Rt>Lf), multiple facial lacerations, Lf chest deformity, 4-5 small abrasions RLETenderness with spinal palpation around C5-6

Whats next?

CT scaN of?HeadFacialNeckChestAbdomenPelvis

Xrays:Rt knee, ankle, tib-fib(general RLE pain)FINDINGS:Rt eye globe fractureRt LeFort IIILf LeFort IIMinimally displaced nasal bone fractureGrade 2 splenic ruptureGrade 4 liver laceration w/hemoperitoneumSmall hemothorax

Rt proximal fibular fx with 1.5cm posterior displacement

Labs1353.51022680.791087.98.47.324.1121Mg 1.4Phos 2.3Who to Consult?OphthalmologyPlastics/OMFS

www.google.com/images/corneallaceration

OrthopaedicsSurgeries2/27Ophth: Rt orbital exploration with watertight restorationfor future reconstruction2/28OMFS: Close reduction of Rt LeFort III, ORIF ZMC fx, intermaxillary fixation2/28Ortho: Splint RLE; No surgeries at the moment

Basic principles of traumaImportant to be aware. Why?The leading cause of death in people < 44 y.o.> 2,000,000 years of potential life lost per yearIncreased survival over last decades due to:RegionalizationDiagnostic modalitiesCT and U/SDamage Control Surgery

Initial AssessmentPurpose: Identify and treat life threatening, potentially life threatening, and life altering conditionsIn that order!Four phasesPrimary SurveyResuscitationSecondary SurveyDefinitive CarePrimary survey: ABCDEAIRWAYMust Be Patent and Protected: establish if neededAssessmentCompromisedBE CAREFUL WITH THE CERVICAL SPINE!!!OptionsBREATHINGTo be determined after establishment of an airwayAssessmentTension PneumothoraxCIRCULATIONConcern: SHOCK vs. No ShockIdentify and resuscitate (faster=better)Symptoms#1 cause of shock in trauma patientTx: Lactated Ringers or Normal Saline; Transfusion if neededPrimary survey: ABCDEDISABILITYNeurologic stateAssessed via the Glasgow Coma Scale (GCS)Max: 15, Min: 3Eye openingVerbalMotor

WHY?

Primary survey: ABCDEEXPOSURERemove clothing for complete examRemove toxins and wet clothesKeep patient warmhypothermia can lead to acidosis and coagulopathy and increases demand on patientSecondary surveyamplePurpose: identify and treat injuries not found during primary. Usually less urgentA- AllergiesM- MedicationsP- Past Medical and Surgical HistoryL- Last MealE- Events leading up to the Trauma2 Survey also includes a COMPLETE head to toe physical examFurther studiesPrimary and Secondary Survey determine what to do nextUTMC: everyone gets a FAST scanCT Pan-ScanHeadNeckChestAbdomen/PelvisFacial bones if neededDefinitive careThis is the overarching goal of the trauma assessmentSometimes surgical, sometimes medicalSurgery is not always urgentMultidisciplinary treatment: consults are commonLefort fractures

Named after Rene Le Fort in early 1900'sOccur secondary to high energy blunt force to the faceThree ClassesLeFort I, II, IIILefort iHorizontalForce directed low to the alveolar rim in an inferior directionNasal septum and along the top of the teethBelow the zygomaticomaxillary junctionInterrupts pterygoid plates

Lefort iIPyramidal shapedForce directed at the lower/mid maxillaNasal bridge inferolaterally down the maxillaUnder that zygomaticInterrupts pterygoid plates

Lefort iIITransverse- Crainiofacial dissociationNasofrontal through medial wall of orbit Along the floor of the orbit through the zygomaticofrontal junction and zygomatic archThrough the pterygoid to the base of sphenoid

TreatmentABCDE'sGoal is to restore anatomical relationshipsFix loose structure to fixed onesTreatment

LeFort II

LeFort ILeFort IIIThank you!

Any Questions?