Trauma

Amjad Fayyad Khadr

Objectives What is Trauma

Epidemiology of Trauma Care

Mechanisms of Injury

Basics of Trauma Management – Primary Survey

– Resuscitation

– Secondary Survey

– ABCDE Format

– Cervical Spinal Immobilization

Specific Case Examples

2

What is

trauma?

Real Life & Death

Trauma, or injury

Defined as cellular disruption caused by an exchange with environmental energy that is beyond the body's resilience.

Epidemiology Road Traffic Accidents are major cause of long term morbidity and

mortality in developing nations

WHO predicts that by 2020, Road Traffic Accidents will be second leading cause of loss of life for world’s population

High Morbidity = Loss of income to society

6

Injury: Scale of the Global Problem

7

• 5.8 million deaths/year

• 10% of worlds deaths

• 32% more deaths than HIV, TB and

Malaria combined

Sourc

e:

Glo

bal B

urd

en o

f D

isease, W

HO

, 2

00

4

Years of Potential Life Lost

18.00%

16.40%

24.80%

40.80%

Injury

Cancer

Heart Disease

All Other Diseases

MMWR 1982;31,599.

Injury: Scale of the Global Problem

9

Source: World Report on Road Traffic Injury Prevention 2004

World Health Organization, who.int

Epidemiology

Golden Hour = 80% of trauma deaths in first hour after injury

Rapid trauma care has greatest level of impact in these patients

10

Immediately Hours Days/Weeks

50%

30%

20%

Trimodal Distribution of Trauma Deaths

History of Trauma System Development

Trauma Systems Development – First developed my military in wartime

i.e. MASH Units

– Expanded in US to Level 1, 2, 3 Trauma Centers Urban Systems Statewide networks of systems Level 1 – Highest level of care, Leaders in research, clinical

care and education Level 2 – Provides definitive care in wide range of complex

traumatic patients Level 3 – Provides initial stabilization and treatment. May

care for uncomplicated trauma patients Level 4 – Provides initial stabilization and transfers all

trauma patients for definitive care

11

Otisarchives1 (flickr)

Mechanisms of Injury: Blunt Trauma

• MVC motor vehicle collisions

• Pedestrian vs Vehicle

• Falls

Mechanisms of Injury Frontal Impact Collisions

Lateral Impact Collisions (T bone)

Rear Impact Collisions

Rollover Mechanism

Open Vehicle or Motorcycle

Pedestrian Vs. Car

Penetrating Injury (Guns vs. Knives)

13

Vincent J Brown (flickr)

Knockhill (flickr)

Nxtiak (flickr)

Nico.se (flickr)

Juicyrai (flickr)

Compression injury Cells in tissues are compressed and crushed

• 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

Overpressure

Body cavity compressed at a rate faster than the tissue around it, resulting in rupture of the closed space

E.g. Plastic bag

E.g. in trauma = diaphragmatic rupture, bladder injury

Mechanisms of Injury: Special Situations

• Explosions

– Blunt + penetrating + burns

• Burns

• Crush injuries

• Hypothermia/ exposure

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 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

What happens

when the

patient comes

to a Level I

Trauma Center?

Trauma Team

• ED Physicians

• Anesthesiology

• Surgeons – General and Trauma and Critical Care

– Neurosurgery

– Orthopedics

• Medical Students

• Nurses

• Radiology Techs

• Radiologists

Preparation for Patient Arrival

24

Organize Trauma

Response Team

Top and bottom images:

http://www.trauma.org/archive/resus/traumateam.html

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!

Basics of Trauma Assessment Preparation

– Team Assembly

– Equipment Check

Triage – Sort patients by level of acuity (SATS)

Primary Survey – Designed to identify injuries that are immediately life threatening and to treat

them as they are identified

Resuscitation – Rapid procedures and treatment to treat injuries found in primary survey

before completing the secondary survey

Secondary Survey – Full History and Physical Exam to evaluate for other traumatic injuries

Monitoring and Evaluation, Secondary adjuncts

Transfer to Definitive Care – ICU, Ward, Operating Theatre, Another facility

31

Primary Survey

Airway and Protection of Spinal Cord

Breathing and Ventilation

Circulation

Disability

Exposure and Control of the Environment

32

Primary Survey

Key Principles

–When you find a problem during the primary survey, FIX IT.

– If the patient gets worse, restart from the beginning of the primary survey

–Some critical patients in the Emergency Department may not progress beyond the primary survey

33

Airway and Protection of Spinal Cord

Why first in the algorithm? – Loss of airway can result in death in < 3 minutes – Prolonged hypoxia = Inadequate perfusion, End-organ damage

Airway Assessment – Vital Signs = RR, O2 sat – Mental Status = Agitation, Coma – Airway Patency = Secretions, Stridor, Obstruction – Ventilation Status = Accessory muscle use, Retractions, Wheezing

Clinical – Patients who are speaking normally generally do not have a need

for immediate airway management – Hoarse or weak voice may indicate a subtle tracheal or laryngeal

injury – Noisy respirations frequently indicates an obstructed respiratory

pattern

34

Airway Interventions Maintenance of Airway Patency

– Suction of Secretions – Chin Lift/Jaw thrust – Nasopharyngeal Airway – Definitive Airway

Airway Support – Oxygen – NRBM (100%) – Bag Valve Mask – Definitive Airway

Definitive Airway – Endotracheal Intubation

In-line cervical stabilization

– Surgical Crichothyroidotomy

35

Dept. of the Army, Wikimedia Commons

Ignis, Wikimedia Commons

U.S. Navy photo by Photographer's

Mate 2nd Class Timothy Smith,

Wikimedia Commons

• Clear & establish a good airway

– Consider intubation for coma, shock, and thoracic injuries

• C-spine stabilization

Initial Assessment: Airway

Airway: Cricothyrotomy

Protection of Spinal Cord General Principle: Protect the entire spinal cord until injury has been

excluded by radiography or clinical physical exam in patients with potential spinal cord injury.

Spinal Protection – Rigid Cervical Spinal Collar = Cervical Spine – Long rigid spinal board or immobilization on flat surface such as

stretcher = T/L Spine Etiology of Spinal Cord Injury (U.S.)

– Road Traffic Accidents (47%) – High energy falls (23%)

Clinical – Treatment (Immobilization) before diagnosis – Return head to neutral position – Do not apply traction – Diagnosis of spinal cord injury should not precede resuscitation – Motor vehicle crashes and falls are most commonly associated with

spinal cord injuries – Main focus = Prevention of further injury

39

C-spine Immobilization Return head to neutral position

Maintain in-line stabilization

Correct size collar application

Blocks

Sandbags

40 James Heilman, MD, Wikimedia Commons

Paladinsf

(flickr)

Breathing and Ventilation General Principle: Adequate gas exchange is required to

maximize patient oxygenation and carbon dioxide elimination Breathing/Ventilation Assessment:

– Exposure of chest – General Inspection

Tracheal Deviation Accessory Muscle Use Retractions Absence of spontaneous breathing Paradoxical chest wall movement

– Auscultation to assess for gas exchange Equal Bilaterally Diminished or Absent breath sounds

– Palpation Deviated Trachea Broken ribs Injuries to chest wall

41

Identify Life Threatening Injuries – Tension Pneumothorax

Air trapping in the pleural space between the lung and chest wall

Sufficient pressure builds up and pressure to compress the lungs and shift the mediastinum

Physical exam – Absent breath sounds – Air hunger – Distended neck veins – Tracheal shift

Treatment – Needle Decompression

2nd Intercostal space, Midclavicular line – Tube Thoracostomy

5th Intercostal space, Anterior axillary line

42

Breathing and Ventilation

Author unknown,

www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.ht

m

Delldot (wikimedia)

Breathing and Ventilation Hemothorax

– Blood collecting in the pleural space and is common after penetrating and blunt chest trauma

– Source of bleeding = Lung, Chest wall (intercostal arteries), heart, great vessels (Aorta), Diaphragm

– Physical Exam Absent or diminished breath sounds

Dullness to percussion over chest

Hemodynamic instability

– Treatment = Large Caliber Tube Thoracostomy 10-20% of cases will require Thoracostomy for control of bleeding

43

Author unknown,

http://www.trauma.org/index.php/mai

n/images/C11/

INDICATIONS FOR THORACOTOMY

• 1,500 cc initial drainage from the chest tube.

• 200 cc/hr for 4 hours continued drainage:

– Thoracic great vessel injury.

– Esophageal injury.

– Patients who decompensate after initial stabilization.

DIAGNOSTIC MODALITIES

• Angiography to localize injury and plan appropriate operation.

• CT scan for patients with normal initial CXR but suspicious mechanism and requiring CT for other reasons. If CT identifies injury, angiography still required for precise delineation of injury.

• Transesophageal echocardiogram (TEE): – Fast, no contrast required, concurrent evaluation of cardiac

function, versatile in terms of location. – Contraindicated if potential airway problem or C-spine injury. – Not as sensitive or specifi c as angiography or CT scan. – User dependent.

Breathing and Ventilation Flail Chest

– Direct injury to the chest resulting in an unstable segment of the chest wall that moves separately from remainder of thoracic cage

– Typically results from two or more fractures on 2 or more ribs

– Typically accompanied by a pulmonary contusion

– Physical exam = paradoxical movement of chest segment

– Treatment = improve abnormalities in gas exchange Early intubation for patients with respiratory

distress Avoidance of overaggressive fluid resuscitation

46

http://images1.clinicaltools.com/images/trauma

/flail_chest_wounded.gif

Author unknown, http://www.surgical-

tutor.org.uk/default-

home.htm?specialities/cardiothoracic/chest_trauma

.htm~right

Breathing and Ventilation

Open Pneumothorax – Sucking Chest Wound – Large defect of chest wall

Leads to rapid equilibration of atmospheric and intrathoracic pressure

Impairs oxygenation and ventilation

– Initial Treatment Three sided occlusive dressing Provides a flutter valve effect Chest tube placement remote to site of

wound Avoid complete dressing, will create a

tension pneumothorax

47

Middle and bottom images:

Author unknown,

http://www.brooksidepress.org/Products/Ope

rationalMedicine/DATA/operationalmed/Pro

cedures/TreataSuckingChestWound.htm

Author unknown,

http://www.trauma.org/index.php/main/image/

902/

Needle Thoracostomy

Needle Thoracostomy – Midclavicular line

– 14 gauge angiocath

– Over the 2nd rib

– Rush of air is heard

49

Author unknown,

www.trauma.org/index.php/main/article

/199/index.php?main/image/95/

Tube Thoracostomy Insertion site

– 5th intercostal space, – Anterior axillary line

Sterile prep, anesthesia with lidocaine 2-3 cm incision along rib margin with #10

blade Dissect through subcutaneous tissues to

rib margin Puncture the pleura over the rib Advance chest tube with clamp and direct

posteriorly and apically Observe for fogging of chest tube, blood

output Suture the tube in place Complications of Chest Tube Placement

– Injury to intercostal nerve, artery, vein – Injury to lung – Injury to mediastinum – Infection – Allergic reaction to lidocaine – Inappropriate placement of chest tube

50

Circulation Shock

– Impaired tissue perfusion – Tissue oxygenation is inadequate to meet metabolic demand – Prolonged shock state leads to multi-organ system failure and cell

death Clinical Signs of Shock

– Altered mental status – Tachycardia (HR > 100) = Most common sign – Arterial Hypotension (SBP < 120)

Femoral Pulse – SBP > 80 Radial Pulse – SBP > 90 Carotid Pulse – SBP > 60

– Inadequate Tissue Perfusion Pale skin color Cool clammy skin Delayed cap refill (> 3 seconds) Altered LOC Decreased Urine Output (UOP < 0.5 mL/kg/hr)

51

Circulation Types of Shock in Trauma

– Hemorrhagic Assume hemorrhagic shock in all trauma patients until proven

otherwise Results from Internal or External Bleeding

– Obstructive Cardiac Tamponade Tension Pneumothorax

– Neurogenic Spinal Cord injury

Sources of Bleeding – Chest – Abdomen – Pelvis – Bilateral Femur Fractures

52

Circulation Emergency Nursing Treatment

– Two Large IV Lines – Cardiac Monitor – Blood Pressure Monitoring

General Treatment Principles – Stop the bleeding

Apply direct pressure Temporarily close scalp lacerations

– Close open-book pelvic fractures Abdominal pelvic binder/bed sheet

– Restore circulating volume Crystalloid Resuscitation (2L) Administer Blood Products

– Immobilize fractures Responders vs. Nonresponders

– Transient response to volume resuscitation = sign of ongoing blood loss – Non-responders = consider other source for shock state or operating room

for control of massive hemorrhage

53

Circulation

Pericardial Tamponade – Pericardium or sac around heart fills with

blood due to penetrating or blunt injury to chest

– Beck’s Triad Distended jugular veins Hypotension Muffled heart sounds

– Treatment Rapid evacuation of pericardial space Performed through a pericardiocentesis

(temporizing measure) Open thoracotomy

54

Blood

Pericardium

Epicardium

Aceofhearts1968(Wikimedia)

Pericardiocentesis Puncture the skin 1-2 cm inferior to xiphoid process Advance needle to tip of left scapula Withdraw on needle during advance of needle Preferable under ultrasound guidance or EKG lead V

attachment Complications

– Aspiration of ventricular blood – Laceration of coronary arteries, veins,

epicardium/myocardium – Cardiac arrhythmia – Pneumothorax – Puncture of esophagus – Puncture of peritoneum

55

Author unknown,

http://www.trauma.org/images/image_library/ch

est0054_thumb.jpg

Author unknown,

www.brooksidepress.org/ProductsTrauma_Surgery?M=A

Circulation A word about cardiac arrest . . .

– Care of the trauma patient in cardiac arrest CPR Bilateral Tube Thoracostomy Pericardiocentesis Volume Resuscitation

– Traumatic cardiac arrest due to blunt injury has very low survival rate (< 1%) No point for emergency thoracotomy

– Selected cases of cardiac arrest due to penetrating traumatic injury may benefit from emergent thoracotomy Pericardial tamponade Cross clamp aorta

56

Author unknown,

http://www.trauma.org/images/image_library/chest0

046.jpg

Disability Baseline Neurologic Exam

– Pupillary Exam Dilated pupil – suggests transtentorial herniation on ipsilateral side

– AVPU Scale Alert Responds to verbal stimulation Responds to pain Unresponsive

– Gross Neurological Exam – Extremity Movement Equal and symmetric Normal gross sensation

– Glasgow Coma Scale: 3-15 – Rectal Exam

Normal Rectal Tone

Note: If intubation prior to neuro assessment, consider quick neuro assessment to determine degree of injury

57

Disability Glasgow Coma Scale

– Eye Spontaneously opens 4

To verbal command 3

To pain 2

No response 1

– Best Motor Response Obeys verbal commands 6

Localizes to pain 5

Withdraws from pain 4

Flexion to pain (Decorticate Posturing) 3

Extension to pain (Decerebrate Posturing) 2

No response 1

– Verbal Response Oriented/Conversant 5

Disoriented/Confused 4

Inappropriate words 3

Incomprehensible words 2

No response 1

58

GCS ≤ 8

Intubate

Disability Key Principles

– Precise diagnosis is not necessary at this point in evaluation

– Prevention of further injury and identification of neurologic injury is the goal

– Decreased level of consciousness = Head injury until proven otherwise

– Maintenance of adequate cerebral perfusion is key to prevention of further brain injury Adequate oxygenation Avoid hypotension

– Involve neurosurgeon early for clear intracranial lesions

59

Disability

Cervical Spinal Clearance

– Patients must be alert and oriented to person, place and time

– No neurological deficits

– Not clinically intoxicated with alcohol or drugs

– Non-tender at all spinous processes

– No distracting injuries

– Painless range of motion of neck

60

Exposure Remove all clothing

– Examine for other signs of injury

– Injuries cannot be diagnosed until seen by provider

Logroll the patient to examine patient’s back – Maintain cervical spinal immobilization

– Palpate along thoracic and lumbar spine

– Minimum of 3 people, often more providers required

Avoid hypothermia – Apply warm blankets after removing clothes

– Hypothermia = Coagulopathy

Increases risk of hemorrhage

61

Exposure

62

Author unknown,

http://www.trauma.org/index.php/main/image/98/C11

Exposure

63

Author unknown, http://www.trauma.org/images/image_library/chest0044b.jpg

Trauma Logroll One person =

Cervical spine

Two people = Roll main body

One person = Inspect back and palpate spine

64

Cdang, Wikimedia Commons

Initial Assessment: Fracture

• Stabilize Fractures

• Relocate dislocated joints

• Reassess pulses

Other said that F is Foley Catheter

• We must placement of urinary catheter unless there is a contraindicated when transection is suspected, such as in the case of pelvic fracture. If transection suspected, perform retrograde urethrogram before Foley.

• Signs of urethral transection – Blood at the meatus

– A “high-riding” prostate

– Perineal or scrotal hematoma

– Be suspicious with any pelvic fracture

Secondary Survey

Secondary Survey is completed after primary survey is completed and patient has been adequately resuscitated.

No patient with abnormal vital signs should proceed through a secondary survey

Secondary Survey includes a brief history and complete physical exam

67

History

AMPLE History

–Allergies

–Medications

–Past Medical History, Pregnancy

–Last Meal

–Events surrounding injury, Environment

History may need to be gathered from family members or ambulance service

68

Physical Exam

Head/ENT

Neck

Chest

Abdomen

Pelvis

Genitourinary

Extremities

Neurologic

69

Physical Exam

Difficult airway

70

Source unknown

Physical Exam Seatbelt sign

71 http://www.itim.nsw.gov.au/images/seat_belt_mark_2.jpg

Accessed 9/20/09 – Google Image Search

Physical Exam

Battle Sign (ecchymosis behind the ear)

suggest a basilar skull fracture

Raccoon's Eyes

Cullen’s Sign

around the umbilicus

Grey-Turner’s Sign

in the flanks

72

http://sfghed.ucsf.edu/Education/Cli

nicImages/Battle's%20sign.jpg

Accessed 9/20/09 – Yahoo Images

http://health-

pictures.com/eye/Periorbital-

Ecchymosis.htm

Accessed 9/20/09 – Yahoo Images

H. L. Fred and H.A. van

Dijk (Wikimedia)

H. L. Fred and H.A. van Dijk

(Wikimedia)

Adjuncts to Secondary Survey

Radiology – Standard emergent films

C-spine, CXR, Pelvis

– Focused Abdominal Sonography in Trauma (FAST)

– Additional films Ct scan imaging Angiography

Pain Control Tetanus Status Antibiotics for open fractures

73

Trauma in Special Populations

Pregnancy – Supine Hypotensive Syndrome

After 20 weeks, enlarged uterus with fetus and amniotic fluid compresses inferior vena cava

Decreases venous return and decrease cardiac output

Keep pregnant patients in left lateral decubitus position to avoid excessive hypotension

– Optimal maternal and fetal outcome is determined by adequate resuscitation of mother

– Fetal Monitoring

74

Trauma in Special Populations Pediatric Trauma Resuscitation

– Differences in head to body ratio and relative size and location of anatomic features make children more susceptible to head injury, abdominal injury

– Underdeveloped anatomy leads to chest pliability and less protection of thoracic cage

– Cardiac Arrest Typically result from respiratory arrest degrading into

cardiac arrest – Resuscitation

• Broselow Tape: which allows effective approximation of the patient's weight, medication doses, size of endotracheal tube, and chest tube size

ABCDE

75

Classic Radiographical Findings

Pelvic Fracture

76

Author unknown,

http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jpg

Classic Radiographic Findings

Femur Fracture

77

Author unknown,

www.flickr.com/photos/40939239@N08/3771820

024/

Classic Radiographic Findings Epidural Hematoma

– Middle Meningeal Artery

Subdural Hematoma

– Bridging Veins

78

Author unknown,

http://rad.usuhs.mil/medpix/tachy_p

ics/thumb/synpic4098.jpg

Author unknown,

http://rad.usuhs.edu/medpix/tac

hy_pics/thumb/synpic519.jpg

Classic Radiographic Findings Diaphragmatic rupture w/ spleen herniation

79 Author unknown, http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg

Classic Radiographic Findings Widened Mediastinum – Aortic Injury

80

Author unknown, www.trauma.org/index.php/main/image/45/print

Does this patient

need to go to the

OR ?

Penetrating Abdominal

Trauma

GSW

OR

KSW

HD Unstable

OR

HD Stable/No peritonitis

Peritoneal Penetration

Positive

OR

Negative

Observation

Penetrating Abdominal Trauma

Blunt Trauma

Peritonitis

OR

Indeterminate

HD Stable

CT

HD Unstable

FAST/DPL

Positive

OR

Negative

Keep Looking

Blunt Abdominal Injuries

Definitive Care Secondary Survey followed by radiographic

evaluation – Ct Scan

– Consultation

Neurosurgery

Orthopedic Surgery

Vascular Surgery

Transfer to Definitive Care – Operating Room

– ICU

– Higher level facility

85

Neck Injury

Neck Injury

• General Described in broad terms as penetrating vs. blunt injuries even though considerable overlap exists between the management of the two. • Anatomy

The neck is divided into zones – Zone I lies below the cricoid cartilage. – Zone II lies between I and III. – Zone III lies above the angle of the mandible.

These divisions help drive the diagnostic and therapeutic management decisions for penetrating neck injuries.

Penetrating Injuries

Any injury to the neck in which the platysma is violated.

• VASCULAR INJURIES

– Very common and often life threatening.

– Can lead to exsanguination, hematoma formation with compromise of the airway, and cerebral vascular accidents (e.g., from transection of the carotid artery or air embolus).

Penetrating Injuries

• NONVASCULAR INJURIES

– Injury to the larynx and trachea including fracture of the thyroid cartilage, dislocation of the tracheal cartilages and arytenoids, for example, leading to airway compromise and often a difficult intubation.

– Esophageal injury does occur and, as with penetrating neck injury, is not often manifest initially (very high morbidity/mortality if missed).

Resuscitation

• Obtain soft-tissue films of the neck for clues to the presence of a soft tissue hematoma and subcutaneous emphysema, and a chest x-ray (CXR) for possible hemopneumothorax.

Surgical exploration is indicated for: • Expanding hematoma • Subcutaneous emphysema • Tracheal deviation • Change in voice quality • Air bubbling through the wound Pulses should be palpated to identify deficits and thrills, and auscultated for bruits. A neurologic exam should be performed to identify brachial plexus and/ or central nervous system (CNS) deficits as well as Horner’s syndrome.

Management

• Zone II injuries with instability or enlarging hematoma require exploration in the OR.

• Injuries to Zones I and III may be taken to OR or managed conservatively using a combination of angiography, bronchoscopy, esophagoscopy, gastrografi n or barium studies, and computed tomographic (CT) scanning.

ABDOMINAL TRAUMA

• General Penetrating abdominal injuries (PAIs) resulting from a gunshot wound create damage via three mechanisms: 1. Direct injury by the bullet itself. 2. Injury from fragmentation of the bullet. 3. Indirect injury from the resultant “shock wave.” PAIs resulting from a stabbing mechanism are limited to the direct damage of the object of impalement. Blunt abdominal injuries (BAIs) also have three general mechanisms of injury: • 1. Injury caused by the direct blow. • 2. Crush injury. • 3. Deceleration injury.

Physical Examination

SIGNS • Seat-belt sign—ecchymotic area found in the distribution

of the lower anterior abdominal wall and can be associated with perforation of the bladder or bowel as well as a lumbar distraction fracture (Chance fracture).

• Cullen’s sign (periumbilical ecchymosis) is indicative of intraperitoneal hemorrhage.

• Grey-Turner’s sign (flank ecchymoses) is indicative of retroperitoneal hemorrhage.

• Kehr’s sign—left shoulder or neck pain secondary to splenic rupture. It increases when patient is in Trendelenburg position or with left upper quadrant (LUQ) palpation (caused by diaphragmatic irritation).

• GENERAL • Inspect the abdomen for evisceration, entry/exit

wounds, impaled objects, and a gravid uterus. • Check for tenderness, guarding, and rebound. • DIAGNOSIS • Perforation: AXR and CXR to look for free air. • Diaphragmatic injury: CXR to look for blurring of

the diaphragm, hemothorax, or bowel gas patterns above the diaphragm (at times with a gastric tube seen in the left chest).

FAST Exam • Focused Abdominal Sonography in Trauma

• 4 views of the abdomen to look for fluid.

– RUQ/Morrison’s pouch

– Sub-xiphoid – view of heart

– LUQ – view of spleno-renal junction

– Bladder – view of pelvis

96

FAST • Has largely replaced deep peritoneal lavage

(DPL)

• Bedside ultrasound looking for blood collection in an unstable patient.

• If the patient is unstable and a blood collection is found, proceed emergently to the operating theater.

97

FAST • Sensitivity of 94.6%

• Specificity of 95.1%

• Overall accuracy of 94.9% in identifying the presence of intra-abdominal injuries.

98

FAST Right Upper Quadrant - Morrison’s Pouch

• Between the liver and kidney in RUQ.

• First place that fluid collects in supine patient.

99

FAST Exam - RUQ

100

University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

FAST – Sub-xiphoid

• Evaluate for pericardial fluid

• View through liver

– Transhepatic or Parasternal

• Searches for fluid between heart and pericardium

101

FAST – Sub-xiphoid

102

University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

University of Louisville ED. www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

FAST – Left Upper Quadrant

• View between the spleen and kidney

• Another dependent place that fluid collects

• Also see diaphragm in this view

103

FAST - LUQ

104

University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

FAST – Bladder View

• Evaluates for fluid in the pouch of Douglas

– Posterior to bladder

• Dependent potential space

105

FAST – Bladder View

106

University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

ADVANTAGES

• A rapid bedside screening study.

• Noninvasive.

• Not time consuming.

• Eighty to ninety-five percent sensitivity for intra-abdominal blood.

DISADVANTAGES

• Operator dependent.

• Low specificity for individual organ injury.

Diagnostic Peritoneal Lavage (DPL)

• OPEN DPL

• Similar to open port placement in laparoscopic surgery (peritoneal cavity is entered under direct vision) using the Hassan port.

• CLOSED DPL

• Using the Seldinger technique, a catheter is placed through the needle and advanced into the peritoneum. The needle placement is similar to the closed technique of port placement in laparoscopy using the Veress needle.

Diagnostic Peritoneal Lavage (DPL)

ADVANTAGES • Performed at bedside. • Widely available. • Highly sensitive for hemoperitoneum. • Rapidly performed. DISADVANTAGES • Invasive. • Risk for iatrogenic injury (< 1%). • Low specificity (many false positives). • Does not evaluate the retroperitoneum.

CT Scanning

• Useful for the hemodynamically stable patient.

• Has a greater specificity than DPL and ultrasound (US).

• Noninvasive.

• Relatively time consuming when compared with FAST.

Angiography

• May be used to identify and embolize pelvic arterial bleeding secondary to pelvic fractures, or to assess blunt renal artery injuries diagnosed by CT scan.

• Otherwise limited use for abdominal trauma.

Serial Hematocrits

• Serial hematocrits (every 4–6 hours) should be obtained during the observation period of the hemodynamically stable patient.

Laparoscopy

• Usage is increasing (mainly to identify peritoneal penetration from gunshot/ knife wound), especially for the stable or marginally stable patient who would otherwise require a laparotomy.

• Helpful for evaluation of diaphragm.

• May help to decrease negative laparotomy rate.

• However, may miss hollow organ injuries.

Indications for Exploratory Laparotomy

• Abdominal trauma and hemodynamic instability. • Peritonitis. • Diaphragmatic injury. • Hollow viscus perforation: Free intraperitoneal air. • Intraperitoneal bladder rupture (diagnosed by cystography). • Positive DPL. • Surgically correctable injury diagnosed on CT scan. • Removal of impaled weapon. • Rectal perforation. • Transabdominal missile (bullet) path (e.g., a gunshot wound to the

buttock with the bullet being found in the abdomen or thorax).

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

NONOPERATIVE MANAGEMENT

• Approximately one half of patients are eligible. • For penetrating trauma: Operative management

remains standard of care. • For blunt trauma: May attempt trial of observation if:

– Patient is stable or stabilizes after fluid resuscitation. – There are no peritoneal signs. – There are no associated injuries requiring laparotomy. – There is no need for excessive hepatic-related blood

transfusions – Repeat CT scan in 2–3 days to look for expansion or

resolution of injury. – Patients may resume normal activities after 2 months

Surgical Management

OPERATIVE MANAGEMENT

• As a rule, any hemodynamically unstable patient due to a liver injury should be explored.

• Generally needed for 20% of patients with grade III or higher injuries who present with hemodynamic instability due to hemorrhage.

• Laparotomy is undertaken through a long midline incision.

• The primary goal is the control of bleeding with direct pressure and packing.

• Patient should then be resuscitated as needed, with attention to temperature control, volume status, and acid-base balance.

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

Nonoperative management criteria

• Stable.

• Injury grade I or II.

• No evidence of injury to other intra-abdominal organs.

• Consists of bed rest, nasogastric tube (NGT) decompression, monitored setting, serial exam, and hematocrits.

Operative management indications

• Signs and symptoms of ongoing hemorrhage.

• Injury ≥ grade III.

• Failure of nonoperative management

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

Case Example Mr. Jones – 45 y/o male involved in

a rollover road traffic accident and was ejected from the vehicle. Patient was unrestrained. Patient was not ambulatory on scene of accident and is brought into trauma bay for evaluation.

– What concerns you about story?

– First steps of evaluation and management

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Pete Prodoehl (flickr)

Case Example

Exam

– Awake, diaphoretic

– Pulse = 120

– BP = 90/60

– RR = 18

– O2 sat = 94%

What do you want to do next?

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Case Example Preparation Primary Survey

– Awake, alert, talking to provider – Breathing

Absent breath sounds on left What do you want to do next?

– Circulation Vital Signs? Access? Resuscitation?

– IV/O2/Monitor – Disability

GCS = 14 – Exposure

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Case Example Chest tube placed

– Rush of air heard consistent with pneumothorax Repeat Vital Signs

– Pulse 120 – BP 80/40 – RR = 15 – O2 sat = 99% NRBM

What do you want to do next? – Patient complaining of abdominal pain – Ecchymosis noted over left flank – Resuscitation?

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Case Example Blood Product Administration

Transfer to definitive care = Operating Theatre

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Bonemesh (flickr)

Conclusion Assessment of the trauma patient is a standard

algorithm designed to ensure life threatening injuries do not get missed

Primary Survey + Resuscitation

– Airway

– Breathing

– Circulation

– Disability

– Exposure

Secondary Survey

Definitive Care

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Questions?

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Dkscully (flickr)

References American College of Surgeons. Advanced Trauma Life

Support. 6th Edition. 1997.

Feliciano, David et al. Trauma. 6th Edition. McGraw Hill. New York. 2008.

Hockberger, Robert et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th Edition. Mosby. 2006.

Tintinalli et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 6th Edition. McGraw Hill. 2003.

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