Chapter 6: TRAUMA 10/06/2009 Basic Science Jen Dixon, PGY-4
Dec 14, 2015
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?