Download - Surgery 542 Trauma

7/28/2019 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


QuickTime and aTIFF (Uncompres sed) decompressor


QuickTime and aTIFF (Uncompressed) decompressor



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Endotracheal intubation

QuickTime and aTIFF (Uncompresse d) decompresso


QuickTime and aTIFF (Uncom pressed) decompressor


QuickTime and aTIFF (Uncompresse d) decompress


QuickTime and aTIFF (Uncompress ed) decompress or



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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



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Surgical Airways

Cricothyroidotomy

Needle

tube

Tracheostomy




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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




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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

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

QuickTime and aTIFF (Uncompress ed) decompressor



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Tracheostomy

Definitive surgical

airway

Dedicted appliance or

endotracheal tube

Indications similar for

cricothyroidotomy




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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






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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?

QuickTime and aTIFF (Uncompressed) decom pressor



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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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Trauma thoracotomy

Emergency situation

with penetrating

chest injury Rarely of benefit inblunt trauma

Suspect major

vessel laceration orcardiac laceration

QuickTime and aTIFF (Uncompressed) d ecompressor



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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