Douglas S. Ander, MDProfessor of Emergency

MedicineEmory University School of

Medicine

DisclosureI have no actual or potential conflict of

interest in relation to this program/presentation

Case #124 year old female single

car MVC. She lost control on a patch of ice and struck a tree. Significant front end damage. Older model car with no airbag.

She was restrained with 3-point restraint.

Primary survey normal.Secondary survey

significant for abrasion and slight swelling to neck.

Blunt Neck InjuryIncidence: 1% of blunt trauma admissionsIncidence of stroke amongst 27 patients with

CAI was 33%48 untreated BCVI patients, 10(21%) had an

adverse neurologic eventsEstimated that 32 asymptomatic patients

averted strokes with appropriate treatment

Cothren CC et al. Amer J Surg 2005;190:849-854Miller et al. Ann Surgery 2002;236:386-395.

Signs/Symptoms of BCVIArterial hemorrhage from neck/nose/mouthExpanding cervical hematomaCervical bruit in pt < 50 yrs oldFocal neurologic defect: TIA, hemiparesis,

vertebrovasilar symptoms, Horner’s Syndrome

Stroke on CT or MRINeurologic deficit inconsistent with head CT

Horner’s Syndrome

Risk Factors for BCVIHigh energy transfer mechanism associated with

Displaced mid-face fracture (LeFort II or III)Basilar skull fracture with carotid canal involvementCHI consistent with DAI and GCS < 6Cervical vertebral body or transverse foramen

fracture, subluxation, or ligamentous injury at any level; any fracture at C1-C3

Near hanging with anoxiaClothesline type injury or seat belt abrasion

with significant swelling, pain or altered mental status

EvaluationAngiography

Gold StandardInvasive and resource intensive

Duplex UltrasonographySensitivity 38.5% Specificity 100%

CTA (16 slice or higher)Current recommendation for suspected BCVI

with angiography for negative CTA with high suspicion

TreatmentInjury Grade Description

I Luminal irregularity or dissection <25% luminal narrowing

II Dissection or intramural hematoma with >25% luminal narrowing, intraluminal thrombus, or raised intimal flap

III Pseudoaneuryms

IV Occlusion

V Transection with free extravasation

Grades 1-4Heparin

Grade 5 Surgical

repair

Case #238 year old male

restrained driver head on collision. Airbags deployed. Significant front end damage. 20 minute extrication from the vehicle.

Case #358 year old female, restrained rear passenger

in an MVC. Rollover at highway speeds. Airbags deployed. No LOC. Self extricated and was ambulatory at the scene. Complains of neck pain and was immobilized by EMS. Upon arrival to ED was hemodynamically stable, had some mild neck tenderness around C4, no obvious injuries, abd was soft and nontender.

Whole Body CT (Pan) ScanDefinition

CT Head and Cervical Spine without IV contrast Followed by

CT Chest, Abdomen, and Pelvis with IV contrastOral contrast case dependent

Whole Body CT for Blunt Trauma

Of 143 patients with at least one unsupported scan an injury would have been missed in 53 (36%)

Abnormal CT Scans by Indication

UnsupportedN(%) EM

Head 5/62 (8)

Neck 2/50 (4)

Chest 33/116 (28)

Abd/Pelvis

12/83 (14)

TOTAL 52/311 (17)

Tillou et al. J Trauma 2009;67:779-787. UCLA Medical Center

Whole Body CTTrauma patients with no signs injury1000 patients over 18 monthsClinically significant abnormalities found in:

3.5% of Head CTs5.1% of Cervical CTs19.6% of Chest CTs7.1% of Abdominal CTs

Salim A et al. Arch Surg 2006;141:468-475

Change in treatment for the 592 patients who had a CT for mechanism is 120 (20.3%)

Whole Body CT

Change in Treatment Based on CT Findings for the 592 Patients Evaluated for Mechanism Only

No. (%)

Abdominal CT Results

Changed (n=120)

Unchanged (n=472)

Abnormal 24 (57.1) 18 (42.9)

Normal 96 (17.5) 454 (82.5)

Whole Body CT and SurvivalRetrospective multicenter studyData from German Trauma Society registry1494 (32%) of 4621 patients received a whole body

CTRelative reduction in mortality based on Trauma

and Injury Severity Score was 25% (14-37)and 13% (4-23) based on Revised Injury Severity Score

Multivariate analysis confirmed that whole body CT is an independent predictor of survival (p<0.002)

Number needed to scan was 17 and 32 respectively based on TRISS and RISC calculation

Humber-Wagner S et al. Lancet 2009;373:1455-1461

Whole Body CT600 patients underwent pan-scanEmergency physicians and trauma surgeons

documented whether pan-scan was necessaryOf the 992 scans that one or both physicians

indicated could be omitted, 102 (10%) were abnormal

3 (0.3%) led to a critical actionT8 burst fracture to ORSAH – empiric platelets for aspirin use (OR for

femur fx)Rib fxs, pulmonary contusion and lung lac – ICU

admit Gupta M et al. Ann Emerg Med 2011;58:407-416

Whole Body CT ConclusionNo clear guidelinesCurrent studies provide no definitive answer

due to study limitationsClinical judgment based on history, physical,

initial studies and ultrasoundHigh risk criteria:

MVC >35 mphFalls >15 ftPed vs auto with ped thrown >10 ftAssaulted with depressed level of consciousness

Case #417 year old male presents with a stab wound

to his left chest. EMS initially reported vital signs but as they arrive to the resuscitation room with CPR in progress state that he lost vitals as they pulled up to the ambulance ramp.

RationalePhysiologic Rationale for ED Thoracotomy

Release of pericardial tamponade

Control of intrathoracic vascular or cardiac hemorrhage

Permit open cardiac massage

Occlusion of descending aorta (cross-clamping)

Control of massive air embolism or bronchopleural fistula

Blunt TraumaVery low survival rate and poor neurologic

outcomePatients presenting pulseless even with

myocardial electrical activity are not candidates for emergency thoracotomy

Penetrating traumaPatients who arrive pulseless but with

myocardial electrical activity may be candidates for thoracotomy

Time frame of CPR??15 minute

Other considerationsAgePre-existing conditionsAvailability and accessibility of specialist

personnelProximity to appropriate operating facilities

and equipmentExperience of the unit carrying out the

procedure

Fluid Resuscitation“Controlled”, “Balanced”, “Hypotensive”,

“Permissive”Goal is balance, not the hypotensionBridge to definitive surgical control of

bleeding

Hypotensive ResuscitationRandomized trialTwo groups: Target SBP >100 mmHg or SBP of

70 mmHgEqual survival rates, 92.7%

Dutton et al. J Trauma 2002;52:1141-1146

Delayed Fluid ResuscitationRandomized trialTwo groups: immediate and delayed resuscitation

in patients with penetrating torso trauma and BP<90 mmHgVariable Immediate

Resuscitation

Delayed Resuscitation

P Value

Survival to discharge

62% 70% 0.04

Length of hospital stay (days)

14 + 24 11 + 19 0.006

Length of ICU stay (days)

8 + 16 7 + 11 0.30

Patients with > 1 complication

30% 23% 0.08Bickell et al. NEJM 1994;331:1105-1109.

Other ATLS update highlightsDigital rectal examination selective prior to

placement of foleyLMA plays a role in the “cannot intubate,

cannot ventilate” scenarioMethylprednisolone in spinal cord injuries

No evidence exists to support routine use

Trauma in pregnancyRetrospective chart review271 patientsRisk factors of fetal death

Maternal HR > 110Injury Severity Score > 9Evidence of placental

abruptionFetal heart rate > 160 or <

120Ejection from motor vehicleMotorcycle or pedestrian

collisions

>20-24 week gestationNo risk factors

6 hours monitoringRisk factors

24 hours monitoring

Curet et al. J Trauma 2000;49:18-24

Airway updatesAssess for difficult airway, LEMON mnemonic

Look externallyEvaluate using the 3-3-2 rule, Mallampati,

Obstruction, and neck mobility

Pelvis Fracture

Minor Head Injury (GCS 13-15)Witness LOC, amnesia, or witnessed

disorientationHigh risk

GCS < 15 at two hours after injurySuspected open or depressed skull fractureAny sign of basal skull fractureVomiting (> 2 episodes)Age > 65 years

Moderate riskAmnesia before impact (>30 minutes)Dangerous mechanism

Other ATLS update highlightsWarmed isotonic solutions (LR or NS)Tamponade best managed by thoracotomy

Pericardiocentesis is temporizingBase deficit and/or lactate play a role in

determining presence and severity of shock