Trauma Lecture

Principles of Trauma Principles of Trauma ManagementManagement

TraumaTrauma

• Prehospital phase and triagePrehospital phase and triage• Primary SurveyPrimary Survey• ABCDEABCDE• ResuscitationResuscitation• Adjuncts to primary survey and Adjuncts to primary survey and

resuscitationresuscitation• Secondary Survey Secondary Survey • Records, Consent, Forensic evidenceRecords, Consent, Forensic evidence

Primary SurveyPrimary Survey

• AAirway and cervical spine controlirway and cervical spine control

• BBreathingreathing

• CCirculation with control of irculation with control of hemorrhagehemorrhage

• DDisabilityisability

• EExposure/environment (expose xposure/environment (expose patient, but avoid hypothermia)patient, but avoid hypothermia)

ResuscitationResuscitation

• Oxygenation and VentilationOxygenation and Ventilation

• Shock managementShock management

• IV lines—Normal SalineIV lines—Normal Saline

• Management of life-threatening Management of life-threatening problemsproblems

Adjuncts to Primary Survey Adjuncts to Primary Survey and Resuscitationand Resuscitation

• Monitoring:Monitoring:– ABGs and ventilatory rateABGs and ventilatory rate– End-tidal CO2End-tidal CO2– EKGEKG– Pulse oximetryPulse oximetry– Blood pressureBlood pressure

Adjuncts to Primary Survey Adjuncts to Primary Survey and Resuscitationand Resuscitation

• Urinary and gastric cathetersUrinary and gastric catheters

• X-rays and diagnostic studiesX-rays and diagnostic studies– ChestChest– PelvisPelvis– C-spineC-spine– FAST / CT SCAN / DPLFAST / CT SCAN / DPL

Trauma MortalityTrauma Mortality

• 35 per 100,000 population35 per 100,000 population

• Most common cause of death in childrenMost common cause of death in children

Airway and VentilationAirway and Ventilation

• These are first priorities!!!!These are first priorities!!!!

• Risks for obstruction:Risks for obstruction:– ComaComa– AspirationAspiration– Maxillofacial traumaMaxillofacial trauma– Neck traumaNeck trauma

Airway and ventilationAirway and ventilation

• Neck trauma: disruption of the larynx or Neck trauma: disruption of the larynx or trachea-or compression by soft tissue trachea-or compression by soft tissue injuryinjury

• Laryngeal trauma:Laryngeal trauma:– HoarsenessHoarseness– Subcutaneous emphysemaSubcutaneous emphysema– Palpable fracturePalpable fracture

Airway and ventilationAirway and ventilation

• Obstruction:Obstruction:– Agitation or obtundationAgitation or obtundation– Abnormal airway soundsAbnormal airway sounds– Trachea not in midlineTrachea not in midline

Airway and ventilationAirway and ventilation

• Inadequate ventilationInadequate ventilation– Asymmetric chest riseAsymmetric chest rise– Asymmetric chest soundsAsymmetric chest sounds– Poor oxygenationPoor oxygenation

Airway and ventilationAirway and ventilation

• Airway MaintenanceAirway Maintenance– Chin liftChin lift– Jaw thrustJaw thrust– Oropharyngeal airwayOropharyngeal airway– Nasopharyngeal airwayNasopharyngeal airway

• Definitive AirwayDefinitive Airway– Endotracheal tubeEndotracheal tube– CricothyroidotomyCricothyroidotomy

Airway and ventilationAirway and ventilation

PaOPaO2 2 LevelsLevels

90 mm Hg90 mm Hg

60 mm Hg60 mm Hg

30 mmHg30 mmHg

27 mmHg27 mmHg

OO22 Hgb Saturation Hgb Saturation

100%100%

90%90%

60%60%

50%50%

Pulse OximetryPulse Oximetry

• LED absorbed differently between LED absorbed differently between oxygenated and non-oxygenated Hgboxygenated and non-oxygenated Hgb

• Affected by:Affected by:– Poor perfusionPoor perfusion– AnemiaAnemia– Carboxyhemoglobin or methehemoglobinCarboxyhemoglobin or methehemoglobin– Circulating dyeCirculating dye– Patient movement, ambient light or signalsPatient movement, ambient light or signals

ThoraxThorax

• Breathing:Breathing:

– Tension pneumothoraxTension pneumothorax

– Open pneumothorax (“sucking wound”)Open pneumothorax (“sucking wound”)

– Flail chestFlail chest

– Massive hemothoraxMassive hemothorax

ThoraxThorax

• Tension PneumothoraxTension Pneumothorax

– Collapse of affected lungCollapse of affected lung

– Decreased venous returnDecreased venous return

– Decreased ventilation of opposite lungDecreased ventilation of opposite lung

ThoraxThorax

• Tension pneumothorax:Tension pneumothorax:– Respiratory distressRespiratory distress– Distended neck veinsDistended neck veins– Unilateral decrease in breath soundsUnilateral decrease in breath sounds– HyperresonanceHyperresonance– CyanosisCyanosis

• Needs immediate decompression!Needs immediate decompression!

ThoraxThorax

• Open pneumothorax:Open pneumothorax:

– Occlusive dressingOcclusive dressing

• Flail chest:Flail chest:

– Trauma principles and Trauma principles and ventilationventilation

• Massive hemothoraxMassive hemothorax

– Chest decompressionChest decompression

ThoraxThorax

• Circulation:Circulation:– Massive hemothoraxMassive hemothorax

• Flat v. distended neck veinsFlat v. distended neck veins• Shock with no breath soundsShock with no breath sounds• Treat with decompressionTreat with decompression

ThoraxThorax

• Circulation:Circulation:– Cardiac tamponadeCardiac tamponade

• Decreased arterial pressureDecreased arterial pressure• Distended neck veinsDistended neck veins• Muffled heart soundsMuffled heart sounds• PEA (pulseless electrical activity)PEA (pulseless electrical activity)• Treat with decompressionTreat with decompression

ThoraxThorax

• Resuscitative thoracotomy:Resuscitative thoracotomy:– Penetrating traumaPenetrating trauma– Pulseless with myocardial activityPulseless with myocardial activity– Evacuate bloodEvacuate blood– Stop bleedingStop bleeding– Cardiac massageCardiac massage– Cross clamp of aortaCross clamp of aorta– Infusion of fluids and bloodInfusion of fluids and blood

ThoraxThoraxSecondary SurveySecondary Survey

• Simple pneumothoraxSimple pneumothorax

• HemothoraxHemothorax

• Pulmonary contusionPulmonary contusion

• Tracheobronchial tree injuryTracheobronchial tree injury

• Blunt cardiac injuryBlunt cardiac injury

• Aortic disruptionAortic disruption

• Diaphragm injuriesDiaphragm injuries

• Mediastinal traversing woundsMediastinal traversing wounds

• Esophageal ruptureEsophageal rupture

• Rib, sternum, scapular fracturesRib, sternum, scapular fractures

ShockShock

• Hemorrhage is the most Hemorrhage is the most common cause of shock in the common cause of shock in the injured patient!!injured patient!!

ShockShock

• Hemorrhagic shockHemorrhagic shock

• Non-hemorrhagic shock:Non-hemorrhagic shock:

– CardiogenicCardiogenic

– Tension pneumothoraxTension pneumothorax

– Neurogenic shockNeurogenic shock

– Septic shockSeptic shock

ShockShock

• Blood volume:Blood volume:– 5 liters in the 70 kg adult5 liters in the 70 kg adult– 80-90 ml/kg in the child80-90 ml/kg in the child

• Classes of Hemorrhage (% loss)Classes of Hemorrhage (% loss)– I: <15%I: <15%– II: 15-30%II: 15-30%– III: 30-40%III: 30-40%– IV: >40%IV: >40%

ShockShock• Initial Therapy:Initial Therapy:

– Stop the bleeding!Stop the bleeding!– Vascular Access linesVascular Access lines

• 2 large bore IV lines2 large bore IV lines• Intraosseous linesIntraosseous lines• Central linesCentral lines

– Fluid bolus Fluid bolus • 2 Liters NS: adult2 Liters NS: adult• 20ml/kg: Child20ml/kg: Child

ShockShock

• Assess:Assess:

– Capillary refill (should be < 2 sec)Capillary refill (should be < 2 sec)

– Peripheral pulsesPeripheral pulses

– Heart rateHeart rate

– Temperature and color of skinTemperature and color of skin

– SensoriumSensorium

– Pulse pressurePulse pressure

ShockShock

• Signs of hemodynamic recovery:Signs of hemodynamic recovery:

– Slowing of pulseSlowing of pulse

– Decrease in skin mottlingDecrease in skin mottling

– Increase in extremity temperatureIncrease in extremity temperature

– Clearing of sensoriumClearing of sensorium

– Urinary output > 1ml/kg/hourUrinary output > 1ml/kg/hour

– Increased systolic blood pressureIncreased systolic blood pressure

AbdomenAbdomen

• Mechanisms:Mechanisms:– BluntBlunt– PenetratingPenetrating

• Spaces:Spaces:– Peritoneal cavityPeritoneal cavity– PelvisPelvis– RetroperitoneumRetroperitoneum

AbdomenAbdomen

• Physical exam:Physical exam:– InspectionInspection– AuscultationAuscultation– PercussionPercussion– PalpationPalpation– Evaluate penetrating wounds Evaluate penetrating wounds – Local exploration of stab woundsLocal exploration of stab wounds

AbdomenAbdomen

• Physical exam:Physical exam:– Assess pelvic stabilityAssess pelvic stability– Genital and rectal examGenital and rectal exam– Gluteal examGluteal exam

AbdomenAbdomen

• Diagnostic studies:Diagnostic studies:– CT scanCT scan– Ultrasound Ultrasound – DPLDPL– Urethrography/cystographyUrethrography/cystography

AbdomenAbdomen• Indications for exploration:Indications for exploration:

– Blunt trauma with instability and positive US or DPLBlunt trauma with instability and positive US or DPL– Blunt trauma with recurrent hypotensionBlunt trauma with recurrent hypotension– PeritonitisPeritonitis– Hypotension from penetrating woundHypotension from penetrating wound– Bleeding from stomach/rectum/GU (penetrating)Bleeding from stomach/rectum/GU (penetrating)– Gunshot woundGunshot wound– EviscerationEvisceration

AbdomenAbdomen• Special Special

considerations:considerations:– DiaphragmDiaphragm– DuodenumDuodenum– PancreasPancreas– Liver/SpleenLiver/Spleen– GUGU– Small bowelSmall bowel

Left: Massive hemothoraxLeft: Massive hemothoraxRight: Chest tube decompressionRight: Chest tube decompression

Tension pneumothoraxTension pneumothorax

Chest tube placed and pneumo-Chest tube placed and pneumo-thorax resolvedthorax resolved

CirculationCirculation

Heart rate Systolic BP UrineHeart rate Systolic BP Urineml/kg/hrml/kg/hr

Infants 100-160 60 2Infants 100-160 60 2

Preschool 80-140 80 1.5Preschool 80-140 80 1.5

School age 80-140 90 1-1.5School age 80-140 90 1-1.5

Adolescent 60-120 100 0.5-1Adolescent 60-120 100 0.5-1

Head TraumaHead Trauma

• 500,000 cases per year in US500,000 cases per year in US

• 10% die prior to hospital10% die prior to hospital

Head TraumaHead Trauma

• Cerebral Perfusion PressureCerebral Perfusion Pressure– CPP=MAP-ICPCPP=MAP-ICP

• MAP =Mean arterial pressureMAP =Mean arterial pressure

• ICP = Intracranial pressureICP = Intracranial pressure

• Cerebral Blood FlowCerebral Blood Flow– 50ml/ 100g of brain/minute50ml/ 100g of brain/minute– <25-EEG activity disappears<25-EEG activity disappears– 5 – brain death5 – brain death

Head TraumaHead Trauma• Mechanism:Mechanism:

– Blunt v. PenetratingBlunt v. Penetrating• Severity:Severity:

– Mild: GCS 14-15Mild: GCS 14-15– Moderate: GCS 9-13Moderate: GCS 9-13– Severe: GCS 3-8Severe: GCS 3-8

• Morphology:Morphology:– Skull fracturesSkull fractures– Intracranial lesionsIntracranial lesions

Head TraumaHead Trauma

• Skull fractures:Skull fractures:– Battle’s SignBattle’s Sign– Racoon eyesRacoon eyes– Rhinorrhea/otorrheaRhinorrhea/otorrhea– Linear vault fracturesLinear vault fractures

• 400 X risk hematoma in awake patients400 X risk hematoma in awake patients• 20 X risk in comatose patients20 X risk in comatose patients

Head TraumaHead Trauma

• Intracranial lesionsIntracranial lesions

– Epidural hematomasEpidural hematomas

– Subdural hematomasSubdural hematomas

– Contusions/hematomasContusions/hematomas

– ConcussionConcussion

– Diffuse axonal injuriesDiffuse axonal injuries

Head TraumaHead Trauma

• Management;Management;– ABCs! (GCS ABCs! (GCS < < 8 intubate patient)8 intubate patient)– Hypotension is never presumed to be from Hypotension is never presumed to be from

head traumahead trauma– CT scanCT scan– HyperventilationHyperventilation– Mannitol/lasixMannitol/lasix– SteroidsSteroids– BarbituratesBarbiturates

Spinal InjuriesSpinal Injuries• LevelLevel• SeveritySeverity• C-spine-protect always!!C-spine-protect always!!

– 10% have another vertebral fracture10% have another vertebral fracture– Respiratory function may be lostRespiratory function may be lost

• Spinal shockSpinal shock• High dose methylprednisolone in first 8 hoursHigh dose methylprednisolone in first 8 hours• Pediatric considerations (SCIWORA)Pediatric considerations (SCIWORA)

• SCIWORA – SCIWORA – SSpinal pinal CCord ord IInjury njury WWithithOOut ut RRadiographic adiographic AAbnormalitybnormality

Subluxation Subluxation C-5 on C-6C-5 on C-6

Musculoskeletal InjuriesMusculoskeletal Injuries

• May have significant bleeding sourceMay have significant bleeding source

• Evaluate vascular and neurologic statusEvaluate vascular and neurologic status

• Immobilize/tractionImmobilize/traction

• Pelvic fracturePelvic fracture– StabilizeStabilize– EmbolizeEmbolize

Musculoskeletal InjuriesMusculoskeletal Injuries

• Crush injuries:Crush injuries:– MyoglobinuriaMyoglobinuria

• Open fracturesOpen fractures– ImmobilizeImmobilize– Antibiotics/tetanusAntibiotics/tetanus

Musculoskeletal InjuriesMusculoskeletal Injuries

• Compartment Syndrome:Compartment Syndrome:– Pain (especially with passive stretching)Pain (especially with passive stretching)– ParesthesiaParesthesia– Decreased sensation or functionDecreased sensation or function– Paralysis or loss of pulse are LATE changes Paralysis or loss of pulse are LATE changes

and loss of limb is imminentand loss of limb is imminent– Tissue pressures >35-45 mm Hg threaten Tissue pressures >35-45 mm Hg threaten

limblimb

Cerebral contusion with cerebral swelling and skullCerebral contusion with cerebral swelling and skullfracturefracture

Tear drop fracture Tear drop fracture anterior C-4anterior C-4

Massive left hemothorax with compressed lungMassive left hemothorax with compressed lung

Tension pneumothorax on right with shifted mediastinumTension pneumothorax on right with shifted mediastinum

Fractured vertebral body on CT scan viewFractured vertebral body on CT scan view

Stomach herniated through diaphragmStomach herniated through diaphragm

Epidural hematomaEpidural hematoma

Massive facial traumaMassive facial trauma

Contusion of right lobe of liverContusion of right lobe of liver

Fracture through body of pancreasFracture through body of pancreas

Intra-osseous access Intra-osseous access

Technique for pericardiocentesisTechnique for pericardiocentesis

Lap belt abrasion-indicates force of injuryLap belt abrasion-indicates force of injuryand high risk of internal injuriesand high risk of internal injuries

View of normal vocal cordsView of normal vocal cords

Fractured larynxFractured larynx

MRI image of thoracicMRI image of thoracicvertebral fracture and vertebral fracture and injured spinal cordinjured spinal cord

Subdural hematomaSubdural hematoma

Lines of escarotomy in Lines of escarotomy in burn injuriesburn injuries