Trauma“This ain’t ER”

Ben Zarzaur, MD

UNC Department of Surgery

Section of Trauma and Critical Care

What is trauma?

Real Life & Death

What is trauma?

Trauma Epidemiology

Years of Potential Life Lost

18.00%

16.40%

24.80%

40.80%

Injury

Cancer

Heart Disease

All Other Diseases

MMWRMMWR 1982;31,599. 1982;31,599.

Mechanisms of Injury: Blunt Trauma

• MVC

• Pedestrian vs Vehicle

• Falls

Mechanisms of Injury:Special Situations

• Explosions– Blunt + penetrating + burns

• Burns• Crush injuries• Drowning• Hypothermia/ exposure

Compression injury

• Frontal brain contusion

• Pneumothorax • Rupture of Left

hemidiaphragm • Small bowel

rupture• Chance fracture

Deceleration Injury

• Aortic tear– Fixed descending

aorta– Mobile arch

• Acute subdural brain hematoma

• Kidney avulsion• Splenic pedicle

Mechanisms of Injury: Penetrating Trauma

• Gun shot wounds• Stab wounds• Impalement

Gun Shot Wounds: Mechanism• Energy transfer

– Shape/size of bullet– Distance to target

• Velocity (most important)– Kinetic energy = (Mass × Velocity2 )/2

• Surface area distributed– Tumble and yaw– Fragmentation

• Anatomy– Viscoelasticity

• Muscle• organs

Stab wounds• Mechanism

– Blunt: Crush injury – Sharp:Tissue disruption

• Extent of Injury– Weapon size, length,

sharpness, penetration

• Severe injury– Chest and abdomen– 4+ wounds

What happens when the

patient comes to a Level I

Trauma Center?

Trauma Team“Doin it 24/7”

• ED Physicians• Anesthesiology• Surgeons

– General and Trauma and Critical Care– Neurosurgery– Orthopedics

• Medical Students• Nurses• Radiology Techs• Radiologists

What happens when this patient comes to the ER where you are

moonlighting?

What the heck do I do now?

Don’t panic!

Trauma is not rocket science!

• Air goes in & out

• Oxygen is good

• Blood goes round & round

• Stop bleeding

• Put things back where and how they belong

Initial Assessment: Prerequisites

• Wide-angled view

• Pattern recognition skills

• Ability to triage and set priorities

• Organized structure

Trauma is not rocket science!

ABCDEF

Initial Assessment: Primary Survey

• A = Airway• B = Breathing • C = Circulation• D = Disability• E = Exposure• F = Fracture

• Clear & establish a good airway– Consider intubation

for coma, shock, and thoracic injuries

• C-spine stabilization

Initial Assessment: Airway

Airway: Cricothyrotomy

Initial Assessment: Breathing

• Chest excursion & breath sounds– Flail chest

• Pneumothorax– Open – Tension

• Massive Hemothorax

Initial Assessment: Circulation• Perfusion (mental status, skin, pulse)• Control bleeding with pressure• Pericardial Tamponade

– Beck’s Triad

• Establish 2 large bore (16G or larger) IV’s in upper extremity peripheral veins

• Resuscitate with Lactated Ringers– After 4 L think about resuscitation with

blood

Initial Assessment: Disability

• Neurologic status– Glasgow Coma Scale

• Eye• Motor-best predictor of long term

outcome• Verbal

– Spinal Cord Injury

Initial Assessment: Exposure

• Remove clothes

• Temperature– warm blankets

• Finger and tube in every orifice

• Maintain full spine precautions– Log Roll

Initial Assessment: Fracture• Stabilize Fractures

• Relocate dislocated joints

• Reassess pulses

Secondary Survey• Patient history• Head to toe physical exam• Radiography

– Lateral C-spine, C-xray, pelvis– One cavity above/below entrance/exit wounds– FAST

• Urinary bladder drainage• NGT• Blood sampling/monitoring

Does this patient need to go to the

OR ?

Penetrating Abdominal Trauma

GSW KSW

OR HD Unstable HD Stable/No peritonitis

OR Peritoneal Penetration

Positive Negative

OR Observation

Penetrating Abdominal Trauma

Blunt Trauma

Peritonitis Indeterminate

OR HD Stable HD Unstable

CT FAST/DPL

Positive Negative

OR Keep Looking

Blunt Abdominal Injuries

Liver Injury

Liver Injury

• blunt or penetrating injury • mortality: 10 - 20% • may be associated with right lower rib

fracture• Signs / Symptoms

– RUQ pain abdominal wall spasm ,guarding hypoactive or absent BS signs of hemorrhage

Liver Injury: ManagementBlunt Injury

• ICU monitoring– For more severe injuries– Serial HCT

• Floor Monitoring– Less severe injuries– Serial HCT

• OR if patient becomes unstable or requires excessive blood transfusions

Surgical Management

Surgical Management

Surgical Management

Spleen Injury

Splenic Injury

• Blunt or Penetrating • Signs / Symptoms

– LUQ pain – Kehr’s sign– involuntary guarding hypoactive or absent BS– signs of hemorrhage– point tenderness

Splenic Injury Management

• ICU monitoring– Serial Physical exams– Serial HCT

• Floor Monitoring– Not indicated at this time

• Further intervention needed if patient becomes unstable or requires blood transfusion– Embolization vs Splenectomy

Splenectomy

• Complications– postsplenectomy infection

• Vaccination

– wound infection – subdiaphragmatic abscess – pulmonary complications– hypovolemic shock

Stomach and Small Bowel Injury

• Stomach & Small Bowel – Blunt vs penetrating

• Diagnosis – Pneumoperitoneum or free fluid on CT scan– small bowel injury may be difficult to detect– Found at laparotomy

• Management– Primary repair or resection

Colon and Rectal Injury• Colon

– Diagnosis • Pneumoperitoneum or free fluid on CT scan• injury may be difficult to detect• Found at laparotomy

– Management• Colostomy vs primary repair

• Rectum– Intraperitoneal- treat as colon injury– Extraperitoneal- primary repair with diversion

• +/- presacral drains

Pancreas & Duodenum

• Diagnosis – often delayed diagnosis – frequently seen together – most often contused due to blunt injury– Seen on CT Scan or at laparotomy– intramural hematoma in wall of duodenum

obstruction bilious vomiting severe abdominal pain distention

Pancreas Injury• Management

– if the result of blunt trauma• nonoperative management NG/OG decompression

serial physical exams monitoring signs of infection controversial - 3 weeks of bowel rest with TPN

– Complications of nonoperative care• pancreatic fistula pseudocyst formation

– Operative management is necessary if: pain fever ileus elevated serum amylase

Duodenal Injury• Management

– For hematoma• NG/OG decompression serial physical

exams monitoring signs of infection– controversial - 3 weeks of bowel rest with TPN

– For perforation• Primary repair with duodenal exclusion• Efferent/Afferent Duodenal tubes

Pelvic Injury

• Introduction– significant blood loss if bilateral

– may settle in retroperitoneal space

– 3% of all fractures

– mortality 8 - 50%

– 2nd most common cause of traumatic death

Pelvic Fracture

• Signs & Symptoms – pelvic instability – pain (suprapubic also) – crepitus – bloody meatus – neurovascular deficits

Pelvis

• Interventions– Stable patient

• analgesia • Repair vs mobilization

– Unstable patient• Immobilize• Ex-fix• Angiography

– embolization