Surgery 542 Trauma

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    Med 542 Review

    Trauma

    Ken Stewart MD, FRCSC

    Assistant ProfessorDivision of Thoracic Surgery, University

    of Alberta

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    Trauma

    Precipitous, ubiquitous phenomenon

    affecting all ages, races.

    Various forms (blunt, penetrating, burns)

    Disease or process in evolution

    Outcomes based on severity of injury, pre-

    existing conditions, and timing andappropriateness of treatment.

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    Objectives

    Describe theprinciples ofassessment of theinjured patient

    Describe theprinciples ofresuscitation of theinjured or critically-ill

    patient

    Describe the

    indications for and

    the important steps in

    the procedure ofemergency

    cricothyroidotomy

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    Objectives --2

    Outline the principles

    of assessment and

    management of blunt

    and penetrating injuryof the chest

    List the indications for

    trauma thoracotomy

    List the indications fortube thoracostomy

    Describe the propertechnique for tubethoracostomy

    List the indications foremergency needledecompression of thechest

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    Objectives --3

    Define shock, andlist the signs andsymptoms of thedifferent types of

    shock

    Describe themanagement of thedifferent types of

    shock

    Outline the principles

    of assessment and

    management of blunt

    and penetrating injuryof the abdomen

    List the indications for

    a trauma laparotomy

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    Internet Resources

    American College of Surgeons

    www.FACS.org

    Links to ATLS

    Trauma.org

    www.trauma.org

    trauma care website with links to care

    related areas

    http://www.facs.org/http://www.trauma.org/http://www.trauma.org/http://www.facs.org/
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    ATLS

    Advanced Trauma Life Support

    Program developed by the American

    College of Surgeons Emerged as a result of experience with

    conflict, and health care revision in the US.

    Need for organized approach torecognition, assessment and treatment of

    all types of trauma

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    ACS outline on ATLS

    Injury is precipitous and indiscriminate

    The doctor who first attends to the

    injured patient has the greatestopportunity to impact outcome

    The price of injury is excessive in

    dollars as well as human suffering

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    ATLS--2

    Program: CME program developed by theACS Committee on Trauma

    One safe, reliable method for assessing andinitially managing the trauma patient

    Revised every 4 years to keep abreast ofchanges

    Audience: Designed for doctors who carefor injured patients Standards for successfulcompletion established for doctors

    ACS verifies doctors' successful course

    completion

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    ATLS--3

    Benefits: An organized approach for

    evaluation and management of

    seriously injured Patients A foundation of common knowledge for

    all members of the trauma team

    Applicable in both large urban centersand small rural emergency departments

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    ATLS--4

    Objectives: Assess the patient's conditionrapidly and accurately

    Resuscitate and stabilize the patientaccording to priority

    Determine if the patient's needs exceed afacility's capabilities

    Arrange appropriately for the patient'sdefinitive care

    Ensure that optimum care is provided

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    ATLS--5

    Trauma Team, and Team Leader

    concept

    One person responsible for makingdecisions and starting treatment

    Organized into algorithms for the benefit

    of systematic recognition and treatment

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    Assessment and Treatment

    Ongoing assessment from the time of

    original notification to response to any

    treatment measures.

    Mechanism of injury, timing and pre-

    existing conditions are importanthistorical features

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    Systematic Assessment by

    Trauma Team Leader

    Primary SurveyAirway

    Ensure patency

    Breathing Rule out distress

    Circulation Provision for large

    bore (14-16 gauge)IV access

    Crossmatch for bloodfor severely injured

    Secondary Survey

    ABC again

    Disability C-spine precautions and

    neuro assessment

    Exposure

    exam front and back ofpatient, then keep warm

    Fingers in every orifice

    and foley catheter

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    Assessment Principles

    Primary survey

    Try to recognize the immediately life-threatening

    injuries1. Tension Pneumothorax

    2. Massive Hemothorax

    3. Open Pneumothorax

    4. Cardiac Tamponade

    5. Flail Chest

    Airway,Breathing,Circulation

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    Assessment Principles

    Secondary Survey

    More detailed and complete examination,

    aimed at identifying all injuries andplanning further investigation and

    treatment.

    Airway,Breathing,Circulation, Disability, Exposure, Fingers, Foley

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    Resuscitation/Treatment

    After airway and breathing have been assured, infuse IVfluids, keep npo and decide on relevant imaging, andlab testing.

    C-spine immobilization and any limb injuries need to beaddressed with dressings, splints and fracturereduction if vascular or nerve injury apparent.

    Decision on where patient should be treated definitivelyneeds to be determined. Consideration of personel and resources.

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    Airway Assessment

    Midline position of trachea

    Stridor,presence of hemoptysis

    Work of breathing Use of accessory muscles

    Respiratory rate

    SaO2and hypoxemia and hypercapnea on ABG

    Level of consciousness Depressed GCS--inability to protect the airway

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    Airway--treatment

    Classified as Simple to Surgical

    Mask, Oropharyngeal airway,

    nasopharyngeal airway, laryngeal

    mask, endotracheal tube,

    cricothyrotomy, tracheostomy

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    Airways

    QuickTime and aTIFF (Uncompresse d) decompress or

    are needed to see this picture.

    QuickTime and aTIFF (Uncompress ed) decompress or

    are needed to see this picture.

    QuickTime and aTIFF (Uncompres sed) decompressor

    are needed to see this picture.

    QuickTime and aTIFF (Uncompressed) decompressor

    are needed to see this picture.

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    Endotracheal intubation

    QuickTime and aTIFF (Uncompresse d) decompresso

    are needed to see this picture.

    QuickTime and aTIFF (Uncom pressed) decompressor

    are needed to see this picture.

    QuickTime and aTIFF (Uncompresse d) decompress

    are needed to see this picture.

    QuickTime and aTIFF (Uncompress ed) decompress or

    are needed to see this picture.

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    Endotracheal intubation

    Indications Hypoxemia

    Hypercapnea

    Impending respiratoryarrest

    Cardiac arrest, multitrauma

    Readying for OR

    Need suction,Laryngoscope, Muscleparalysis (?rapidsequence induction)

    QuickTime and aTIFF (Uncompresse d) decompressor

    are needed to see this picture.

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    Surgical Airways

    Cricothyroidotomy

    Needle

    tube

    Tracheostomy

    QuickTime and aTIFF (Uncompressed) decompressor

    are needed to see this picture.

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    Cricothyroidotomy

    Indications Severe facial or nasal injuries (that

    do not allow oral or nasal intubation)

    Massive midfacial trauma

    Anaphylaxis Chemical inhalation injuries

    Contraindications inability to identify landmarks

    (cricothyroid membrane)

    Underlying anatomical abnormality

    (tumor)

    Tracheal transection, acutelaryngeal disease by infection ortrauma

    QuickTime and aTIFF (Uncompressed) decompressor

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    Cricothyroidotomy

    technique1.With a scalpel, create a 2 cm

    horizontal incision through thecricothyroid membrane

    2.Open the hole by rotating the scalpel90 degrees or by using a clamp

    3.Insert a size 6 or 7 endotrachealtubeor tracheostomy tube

    4.Inflate the cuff and secure the tube

    5.Provide venilation via a bag-valvedevice with the highest availableconcentration of oxygen

    6.Determine if ventilation wassuccessful (bilateral ausculation andobserving chest rise and fall)

    7.No attempt should be made to removethe endotrachealtube in aprehospital setting.

    QuickTime and aTIFF (Uncompres sed) decompressor

    are needed to see this picture.

    http://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Tracheostomyhttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Tracheostomyhttp://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Endotracheal_tube
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    Assessment of treatment

    Auscultate

    CXR

    End tidal CO2

    SaO2

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    Tracheostomy

    Definitive surgical

    airway

    Dedicted appliance or

    endotracheal tube

    Indications similar for

    cricothyroidotomy

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    are needed to see this picture.

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    Chest trauma

    Assessment with physical exam, CXR,

    ABGs and SaO2monitoring

    CT scan

    Echocardiography, ECG

    Serum studies for cardiac injury

    (troponin and creatinine kinaseMB

    fraction)

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    Tension Pneumothorax

    Typically from penetrating trauma.

    Can be spontaneous

    Bronchopleural fistula from lacerated, ordisrupted lung, open pneumothorax

    Symptoms of dyspnea, syncope, surgical

    emphysema, impending doom

    Signs of hypotension, tachypnea, tachycardia,

    distended neck veins, cyanosis

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    Hemodynamic mechanism

    Axis of the cavae,

    point of fixation with

    the aorta and greatvessels

    Lack of right heart

    filling, leading to

    shock

    QuickTime and aTIFF (Uncompressed) decompressor

    are needed to see this picture.

    QuickTime and aTIFF (Uncompressed) decompressor

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    Tension pneumothorax

    Treatment Suspected: needle

    decompression

    14 gauge angiocath Midclavicular line

    Use syringe withplunger removed

    Leave in place and theninsert standard chest

    tube thoracostomy What to do if patient is

    too thick?

    What if there is notension noted with needle

    insertion?

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    are needed to see this picture.

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    Tension pneumothorax vs

    Cardiac tamponade In contrast to a pericardial tamponade in

    setting of penetrating chest trauma

    Pulse--both elevated Percussion-- tympani with tension

    Pulsus paradoxus with tamponade

    Neck veins distended with both Trachea shifted with tension

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    Chest tube thoracostomy

    Indications Pneumothorax

    Hemothorax

    Unstable patientfollowing blunt orpenetrating trauma

    Non trauma Pleural effusion,

    chylothorax,

    empyema,postoperative

    Relativecontraindication=diaphragm disruption

    Technique Local anesthetic*

    Sterile field*

    Scalpel, kelly orhemostat forcep

    Chest tube andpleurevac device

    Securing suture

    *if time permits

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    Chest tube insertion

    Location is typically,nipple height, mid-axilla sparing the

    latissimus, andpectoralis muscle

    No tunnels needed

    CXR post procedure Connect topleurevac

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    are needed to see this picture.

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    Trauma thoracotomy

    Emergency situation

    with penetrating

    chest injury Rarely of benefit inblunt trauma

    Suspect major

    vessel laceration orcardiac laceration

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    Indications

    Penetrating injury to

    chest, abdomen or

    retroperitoneum

    Signs of life prior to

    assessment in ER

    then shock normothermia

    Clamp aorta

    Defibrillate heart

    Internal cardiacmassage

    Pericardialdecompression

    Repair of laceratedvessel or heart

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    Shock

    Hypovolemic

    Following blood loss

    Burns andhypothermia

    Cardiogenic

    Pump failure

    Ischemia, contusion,acute valvular

    dysfunction

    Distributive Sepsis

    Neurogenic

    Obstructive Pulmonary embolism

    Tamponade, tensionpneumothorax

    Endocrine Manifests like distributive

    shock

    Hypothyroidism,hypoadrenalism

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    Diagnosis

    Mechanism of injury,

    illness

    CXR Bloodwork

    ABG, lactate, Hgb,

    Creatinine

    Response to trial of

    IV fluids

    Monitoring of blood

    pressure

    CVP SVRI from swan

    ganz catheter

    measurements

    Response to

    vasopressor therapy

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    Treatment

    Directed at specificdiagnosis Fluid resuscitation

    Crystalloid, colloid

    Blood and bloodproducts

    Vasopressors

    Specific agents forspecific types ofshock

    Definitive treatment

    where possible

    depending onetiology.

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    Blunt Injuries to the

    abdomen Physical signs

    Distension

    Peritonitis

    Retroperitoneal

    bleeding

    Intraabdominal

    pressure ( measured

    with foley catheter

    and tonometer)

    Diagnosis

    Fast scan

    (ultrasound)

    CT scan

    Hemodynamic

    monitoring

    Diagnostic peritoneallavage

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    Diagnostic peritoneal lavage

    Used to assess need for

    laparotomy following

    trauma

    Cutdown technique tomidline of abdomen

    Initial aspiration, if

    clear..

    Infusion of one litre of

    saline with IV tubing and

    then collection

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    Diagnostic peritoneal lavage

    Indications forlaparotomy GI contents on aspirate

    or lavage Feces, bile, peas andcorn

    Urine on aspirate

    Blood 10 mLs of gross blood

    on aspirate >100 000 rbc/ mL on

    analysis (newspapertest)

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    Role of CT scan

    Use for blunt injurymanagementAssess liver and

    spleen injuries Presence of

    pneumoperitoneum,free fluid

    Vascular injuries Retroperitoneal

    injuries

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    Indications for laparotomy

    following trauma Blunt

    Hemodynamic instability

    despite resuscitation

    Positive DPL Findings on CT scan

    High grade spleen or

    liver injury

    Pneumoperitoneum

    Retroperitoneal organinjury

    Vascular injury

    Penetrating

    Hemodynamic

    instability despite

    resuscitation

    Evisceration,

    pneumoperitoneum

    Positive DPL

    CT scan findings

    similar to blunt