The Multiple Trauma Patient Shawn Dowling, PGY-2 Preceptor: Rhonda Ness

The Multiple Trauma Patient

Shawn Dowling, PGY-2

Preceptor: Rhonda Ness

Objectives

Will not go over these topics in great detailHead traumaC-spine traumaChest traumaAbdo traumaPediatric trauma

Why it’s important

Leading Cause of Death for those aged 1-44yrs (in developed countries)

MVC’s account for most injuriesFollowed by assaults, drownings, falls, burns

Distribution of Death

050

100150200250300350400

# of

deaths

0 2hrs 4hrs 3weeks

Trimodal Distribution of Deaths

Death

What is ATLS?

Structured algorithm designed to prioritize management issues

Designed as a team-based approach Applicable to both Academic and Rural Settings It’s useful – take it.

What ATLS isn’t? A substitute for clinical

acumen – trust your instinct

Most up-to-date, most evidence based approach (revised q4yrs, most recently 2004)

Why is the ATLS protocol so nice?

Overall, the tenets are

1. Greatest threats to life are identified and treated 1st

2. Lack of definitive Tx should never impede the application of an indicated Tx

3. Detailed Hx was not essential to begin the evaluation of the acutely injured patient

ATLS overview Preparation Triage Primary Survey

(ABCDE’s) Resuscitation Adjuncts to primary

survey and Resus

Secondary Survey Adjuncts to Secondary

survey Continued post-resus

monitoring and R/A Definitive Care

ATLS Overview

Primary Survey

Adjuncts

Secondary Survey

Reassess

Reassess

CANNOT MOVE ONUNTIL YOU ADDRESSTHE PROBLEM!!!

ATLS – Primary Survey

Airway & C-spine Immobilization Breathing Circulation Disability Exposure/Environmental Control Full Vital Signs

Case 1 60ishM Coming in by STARS, ETA 10 mins MVC – no more details Facial fractures, unable to intubate Significant Chest trauma, hypotense

Great...I’ll just go see this LBP patient and wait till I hear the call to the Trauma Bay



survey and Resus




Organizing the Trauma Bay What do you want?

Who do you want?

What do you want prepare before he arrives?

1° SURVEY Airway: Intubation equipment incl difficult

airway cart, drugs, +/- anasthesia Breathing: RT, bilateral CT set-up Circulation: fluids hung, blood ready, level 1

infuser primed, +/- central access Adjuncts

X-ray, FAST, B.W., U/S

What’s the best way to mobilize the right people…a) Soil your scrubs and hope someone notices and calls

for help

b) Call Trauma Code

c) Consult Hospitalist

Who do you want? RT, RN’s – 3 ideal, DI

techs, U.C. ER res/doc +/- Level 1 Call-out

(trauma, gen surg, ICU) FAST provider – ER IP or

Radiology Others: Ortho, NA, SW,

Trauma Team Activation

6. ER doc discretion

Muco Man

ICU Rez

ER #1

ER #2/TTL

FAST

Organizing the Trauma Bay ONE leader:

only leader should be talking and giving orders FMC ER doc 1o survey and stabilization THEN trauma

junior/ortho/plastics 2o survey Small rural centers you’re it

Be decisive Short window of opportunity for sick patients

Rapid decision making important Err on the side of being aggressive

Thanks Trevor

Learn names and use them Be directive Minimize noise/people in room Close the Loop Verbalize your findings and thought process.

i.e. I think he has a tension PTX – I’m gonna fix it

Now what?

What do you want to know from EMS?

Important Historical Features MVC

Wgt/size vehicle Speed Location of pt in veh

?ejected Mech’m of accident Amt of damage (esp windshield,

steering wheel) ?seatbelt (type) Airbag ?Other deaths

Motorcycle Same + ?helmet

Pedestrian vs MVC Speed Damage to windshield

Assault Weapon used ?trajectory ?sexual assault

GSW’s Type of gun

Handgun: low velocity Rifles: high velocity

Type of Ammunition Distance shot from Route of Entry

Injury Patterns

Frontal/Side Impact Side Impact Rear Impact MVC versus pedestrian

AdultPeds

Frontal/Side Impact C-spine InjuryChest: PTX, flail, AoDAbdo: liver/spleenPelvisHip/knee #/disloc

Rear Impact C-spine InjurySoft-Tissue Injury Neck

Ejection No specific pattern, but significant risk of severe injury to all systems

MVC versus Pedestrian

Adults triad of Tib/fib/femurTruncal injuryCraniofacial injury

Peds: tend to be run over



survey and Resus




AirwayLOOK LISTEN FEEL MANAGE

A

I

R

W

A

Y

LOC

Facial trauma

UAW burn

Stridor

Gurgling

Hoarseness

Crepitus

Tenderness

Edema

Trachea midline

Cervical Collar

Temporize:

Suction

Jaw Thrust

OP/NP airways

Remove FB

Prepare and perform ETT: draw meds, start iv, get BP/ tools

Thanks Trevor/Rob

BreathingLOOK LISTEN FEEL MANAGE

B

R

E

A

T

H

I

N

G

Resp effort

Resp rate

Cyanosis

Chest wall

movements

Flail segment

AE = Crepitus

Tenderness

Chest mvmt

100% oxygen

BVM

Pulse ox

Decompress chest

Seal open chest wounds

Thanks Trevor/Rob

CirculationLOOK LISTEN FEEL MANAGE

C

I

R

C

U

L

A

T

I

O

N

Pale

Sweaty

LOC

External

Bleeding

JVD

Heart

Sounds

Murmur

Pulse rate,

Quality

Quick feel of abdomen,

pelvis,

femurs

Obtain HR, BP

Cardiac and BP monitors

Two large iv.s

Pressure to external bleeding

Bolus crystalloid

Blood

Consider SOURCE OF BLEEDING

Thanks Trevor/Rob

Disability

GCS Pupils

Exposure/Environment/Full VS Fully Expose patient

Prevent heat loss, warm blankets, warm fluids*

*NABISH II (Pre-hospital Enrolment)

*NABISH II (ED Enrollment)

Goal is moderate hypothermia (32-33°) for 48 hr

3. w/i 2 hrs of injury



survey and Resus




Adjuncts

X-rays: which ones do you want Blood Work: which ones do we get routinely Foley, NG: do we need the NG? FAST/dpl: Who can do it? More to come in the

future.

X-rays

CXR C-spine(we’ll come back to this) Pelvis

Do we need to this in every trauma patient?

Order others you deem necessary (but if unstable prioritize them until after secondary survey)

Routine pelvic radiography in severe blunt trauma: is it necessary?

ALL STUDIES ARE LEVEL II or III, so interpret w/caution…Civil ID, Ross SE, Botehlo G and Schwab CW. Ann Emerg Med 17(5):488-490.

(1988)All patients were classified as unconscious; impaired; awake, alert, and symptomatic;

or alert, oriented, and asymptomatic for pelvic fracture on admission. All underwent a plain anterior- posterior radiograph of the pelvis.

N=265, 26 pelvic #. 7/26 were unconscious,11/26 were impaired, 8/36 Sx.No fractures were identified in 110 awake, alert, oriented, and asymptomatic patients

(P less than .0001). They conclude that pelvic radiographs are required in unconscious or impaired

victims of severe blunt trauma and those with signs or symptoms of pelvic fractures but are not required in the awake, alert, and asymptomatic patient.

CONCLUSION: Err on the Side of Caution

Preserve clot - minimal movement, gentle handling, minimum of rolling. Punch anyone who tries to 'spring' the pelvis. Fit pelvic belt (elasticated version of the old 'many-tailed-bandage' with velcro fastening) on basis of mechanism of injury. Minimal iv fluid to preserve systolic of 70 (90 mmHg if associated head injury). Take to a hospital that understands the condition!

Timothy J Coats MD FRCS FFAEMSenior Lecturer in Accident and Emergency/Pre-Hospital CareRoyal London Hospital, UK.

Trauma/B.W.

What blood work do we get when this is ordered? If you had only one blood test what would it be

Sultana or Heather?

Trauma/B.W. What blood work do we get when this is ordered? If you had only one blood test what would it be Sultana or

Heather? T&S, T&C

What’s the diff?

Unmatched – immediate (F: 0-, M: 0-/+) T&S – approx 10 min (screens for ABO &Rh) T&C- approx 30min-1 hr (screens for ABO, Rh, other

antibodies)

Utility of CBC

Utility of CBCHgb – helpful if low, not helpful if N Initial hgb fxns more as baselineWBC- who caresPlts-helpful if low

CoagsProbably useful, some good evidence for HI, ?elderly

Lytes 913 Trauma pts bw – 54 had clinically significant abN, only 6 changed

Tx (all hypokalemia) authors concluded that a history of hypertension, age older than 50,

and a Glasgow Coma Scale (GCS) score less than or equal to 10 appeared to be useful criteria

Tortella B, Lavery R, Rekant M. Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med 1995;2:190-194

Cr/BUN No evidence but likely worthwhile, esp if potential for CT and contrast

EtOH Allows you to correlate clinical picture with EtOH

Amylase No role Mure A, Josloff R, Rothberg J, et al. Serum amylase determination and blunt abdominal trauma. Am Surg 1991;57:210-213.

LFT’s No Role in detecting liver injuries

Lactate/Base Deficit Multiple studies showing that the higher/more –ve these values are the

sicker the patients are and more aggr mngmt is needed – DUHH! Trop

No helpful, unless you think it’s the cause of accident For cardiac contusion – may be a role, but not likely in the ED

?Trops

Case 2

64M, Farmer Brought in by STARS Bucked off horse, c/o of mild lower abdo/pelvis

pain, walked to his house to get help

What do you want to do? What do you think is going on?

Airway/Breathing N Circulation: BP140/50, HR 80 Disability: GCS- 14, PERLA Exposure - N Rest of vitals N

Now what?

What films?

CXR – Yes Pelvis – Yes (symptomatic) Can you clear his C-spines clinically?

According to CCR?According to NEXUS?

Stiell. NEJM Dec 2003; 349:2519-8.Stiell. NEJM Dec 2003; 349:2519-8.

Canadian C-spine Rule

NEXUS

S ensorium altered

P ain the the midline

I njury that is distracting

N eurologic deficits

E tOH, Rx

Hoffman et al. NEJM 2000Hoffman et al. NEJM 2000

W ho should get "routine" CT neck?

C T if p la in film sab n , in ad eq u a te ,o r h ig h su sp ic ion

P la in film s

M in or Trau m a

S tart w ith p la infilm s th en

C T p rn

N ot g o in g fo r C Th ead

R ou tin e C TS B -T4

G oin g fo r C T h ead

M od era te Trau m a(G C S 9 -1 4 , n o t p o ly)

C T S B - T4 in a ll

P o lytrau m a(in tu b a ted )

Missed C-spine #’s



survey and Resus




Secondary Survey

HEENT Abdomen + GU

Maxillofacial Pelvis

Neuro (incl CNS/PNS, CN, M/S/R)

Vertebral Column (C/T/L)

Chest Back

CVS Extremeties

•Look, listen and feel when possible•Finger (only one)/tubes in every orifice•AMPLE Hx:•Systematic: head to toe

Back to the Case

The trauma jr asks the nurse to put a foley in and she notesScrotal hematomaBlood at meatusPerineal EcchymosisRectal N (and I’ve got short fingers)

What do you want to do?

Retrograde Urethrogram What is it?

Retrograde injection of contrast urethral integrity and x-ray

How do you do it? Plain KUB 1st Sterile, insert foley 1-2cm,

inflate baloon w/2-4cc H20

OR Insert 60cc syringe with x-mas

tree adaptor

Slowly inject 60cc of radio-opaque dye (avoid forceful inj)

Ensure not to spill any (spurious results)

Two x-rays, one AP, one lateral/oblique when 10cc left to inject

Partial tear+/- talk to urology, attempt to pass 12-14F foley If resistance/difficulties, speak to urology – may need

suprapubic catheter Complete tear

Talk to urology (actually, page them, wait 6 hours and then talk to them) and they’ll likely need a suprapubic catheter

Retrograde Cystogram

KUB Foley Gravity fill bladder with 400cc of contrast (age +

2) x 30 for peds AP and Oblique/Lateral x-rays Then AP post-evacuation X-ray

Case #

18M, Story from EMS Brought in from Coventry Hills by STARS who

“Scooped and Ran” with him Hx: MVC (car vs cement abutment), prolonged

extrication (>1hr), hwy speeds, couldn’t intubate P/E: hypotense, pale, concerned about chest/abdo,

bilateral femur #, L humerus

What do you want to do? Airway:

Do you want to do anything?How, ?Rx

Breathing:Post-intubation - a/e @ L DDx: InterventionWhat if the CXR is N, can they still have a PTX

103 PTX, 57 (55%) were not seen on AP CXR

Likely of little significance in the non-ventilated pt But for those who are intubated or going to OR- thought

that they may progress One small study, RCT of CT or nothing for oPTX (ventilated

and non-ventilated) – NO difference J Trauma. 1999 Jun;46(6):987-90

Primary Survey

What are six(seven) life-threatening injuries you need to identify and Tx in the primary survey?

Primary Survey

What are six(seven) life-threatening injuries you need to identify and Tx in the primary survey? Airway: Obstruction Breathing:

Tension PTX Open PTx Massive Hemothorax +/-Flail

Circulation Cardiac Tamponade (?Beck’s) Life-Threatening Bleeds

CirculationBP - unable to measureBut palpable radials – what’s his BP?, Only Femorals,

Only Carotid? Where’s he bleeding from?

What are the three big areas you can bleed into?How about kids?

Fluid Resus

Crystalloids 2 L then blood Level 1 infuser Goal is sBP 90ish

What do you want to do know?

RA

Summarizing Intubated, needle thoracostomy, no CT yetL humerus, bilateral femurs, VS pelvic #FAST –veGross blood from FoleyBP still very tenuous

What next?Let the TTL decide - OR

What about the kidneys?

When do you worry enough about renal injuries to image the kidneys?

Nicholaisen G, McAninch J, Marshall G, et al. Renal trauma: Re-evaluation of the indications for radiographic assessment. J Urol 1985;133:183-187.

CT Renal

What Grade of Renal Injury?

Renal Injury Classification Grade 1: subcapsular hematoma – non-operative Grade 2: superficial renal laceration with perirenal

hemorrhage – non-operative Grade 3: deep laceration w/o extension into the collecting

system of the kidney – serial exams, usu non-op Grade 4: parenchymal injury: deep laceration that

extends into collecting system, – serial exams, usu non-op, +/- embolization/OR

Grade 5: parenchymal injury: multiple deep lacerations that result in a shattered kidney OR Renal Artery Avulsion - OR

Harris A., Zwirewich C CT Findings in Blunt Renal Trauma, Radiographics, 2001

CT Chest

Case #3

27M Transferred from 8th and 8th – Single stab wound to the right chest. Chest had been needle decompressed Intubated in ED for hypotension Chest Tube on R side.

After chest tube (which is not draining any blood) and intubation, his vitals are…BP80/40, HR 120, Sats 100% on vent

What do you want to do? Move onto your secondary survey? CT scanner?

CANNOT MOVE ONTO THE NEXT STEP UNTIL YOU’VE DEALT WITH ALL THE ISSUES.

WHAT ABOUT LOG ROLLING?

Case # 4

23F, 28wks pregnant Brought into trauma bay pt begins to c/o of severe

cramping VS – 70/30,HR-100, RR-12, sats 94%, c/s-N What do you want to do?

Supine Hypotension Syndrome IVC compressionMay have vasovagal bradycardia90% of term pregnant women have COMPLETE

obstruction of IVC when supineMx: tilt spine board, towel roll under on hip, manually

displace uterus

Thanks Rob

PEARL

Pregnant patient may lose up to 40% of blood volume before manifesting typical signs of shock. The fetus is compromised before signs of shock.

So you put her into the LLD position and she goes into asystolic arrest.

What do you do?

Perimortem C-section Indications

Gestation must be at least 24-26 wks - progress if fundal hgt 25wks?Less if doing for mom

CPR w/no response to other Tx modalities (LLD, fluids, needle chest, ACLS Tx, ) w/i four minutes

Ideal, start by four minutes/finish 5 minutes Mother hemodynamics improve considerably

ProcedureDo not stop CPRDon’t prep/drapeVertical incision from epigastrium to pubis right

through peritoneumScapel to upper uterus, extend with scissorsDeliver babyNRP for baby

Perimortem C-Section Results Katz VL. Obstet Gynecol. 1986.

61 cases b/w 1900-85 that survivedTIME NUMBER NORMAL NEUROSQL<5 42 42 06-10 8 7 111-15 7 6 116-20 1 0 1>21 3 1 2

Case #5

69F MVC, restrained driver, hwy speeds PMHx – o Stable, A & O x 3, ++ agitated

When to order CT abdo? Abnormal vitals Abdominal pain/tender Unreliable physical

examination (EtOH, Rx, HI, SCI, sedated).

Inability to do serial examinations

Dangerous mechanism of injury

Gross Hematuria

Stable: CT abdomen +/- FAST

Unstable: FAST or DPL

What Injuries does CT abdo miss?

Diaphragmatic Pancreatic Bowel

Should we add Telebrex then?

Oral Contrast in Trauma CT

Case #6

57M, working in the Foothills Industrial Area Working inside a metal structure welding, when a

explosion occurred Pt was found unresponsive inside EMS has intubated the patient (for GCS of 3)

Blast Injuries

What injury patterns are seen in Blasts? What bodily structures would you expect to be

involved? What do you want to know about accident scene?

Incidence

In NA tend to be industry related, accidental (fireworks), bombings/Sept.11

1° blast injury is caused solely by the direct effect of blast overpressure on tissue. Air is easily compressible, unlike water. As a result, a primary blast injury almost always affects air-filled structures

2° blast injury is caused by flying objects that strike people.

3° blast injuries occurs when people fly through the air and strike other objects.

Miscellaneous blast-related injuries encompass all other injuries caused by explosions, i.e. fires

Location is important

An explosion that occurs in an enclosed space tends to cause more serious injury.

Intensity of an explosion pressure wave declines increasing distance from the explosion.

Blast waves are reflected by solid surfaces; thus, a person standing next to a wall may suffer increased primary blast injury.

Complications Barotrauma

TM’s: perforation, hemotympanum, ossicle #

Lungs: PTX, contusion, ARDS

GI: pneumoperitoneum, hemotoma, solid organ damage

Acute Gas embolism - ?Tx DIC

Injuries from projectile objects,

Injuries from being thrown (MSK, CNS)

Inhalational, Burns, Toxins (CN, CO)

Work-Up Look at their TM’s B.w. – CO/CN if explosion/fire and entrapped, lytes, CXR (PA and Lat) preferred) Urine Serial Abdo Exams or AXR/CT abdo if abdo pain Other tests PRN – CT head as PRN CT head rule

Management TM’s – avoid putting stuff in their ears, Lung – manage PTX as per N

If PTX, probably worth monitoring to ensure no contusion develops

Belly: high index of suspicion for bowel hematoma – may need to be Admitted for serial exams

AGE – LL decubitus, 100% O2, hyperbaric 02, ASA

PEA/Asystole 75M MVC, prolonged extrication Lost vitals en route EMS Unable to intubate

What do you want to do? What’s you Ddx for PEA/Asystole? What can we reverse?

Intubate Bilateral CT 2L wide open FAST ABG – correct lytes CXR Then decide whether to continue

Suicide/Jump from a building

38F Attempted suicide by jumping off a local seven

story downtown building, landed feet first. Brought in by EMS Combative, hypotense, c/o pain at lower

extremeties

What injury patterns do you look for in this situation?

What x-rays do you want to order?

What’s the likelihood of dying from a 4 story fall? 7 story fall? If feet first.

Now what? Any other films to order?

Where do you usually see spinal #’s

What other films?

Why is she hypotense Neurologic shock – but she’s moving here legs Belly – her abdo FAST is –ve, where else could the

blood be Heart – Autopsy study: 33/61 had cardiac injuries

and in 16/33, the heart was felt to be cause of death – pericardial /transmural tears, epicardial tears

SO, WE SHOULD AT THE HEART w/FAST Blunt Cardiac Trauma Caused by Fatal Falls From Height: An Autopsy-Based

Assessment of the Injury Pattern. Journal of Trauma-Injury Infection & Critical Care. 57(2):301-304, August 2004.Turk, E E. MD; Tsokos, M MD

Missed injuries

Important because… Long-term disability (i.e.

scaphoids) Litigation Overshadow our heroic

measures, “sure they saved my life, but they missed my sprained ankle”

Missed cuz… Tx life-threatening stuff 1st

Altered sensorium Distracting injuries Inadequate p/e Misinterpretation of

investigations

MI defined as injury detected >24hrs after A or missed by 3° survey

Intervention: 3° form required to be filled out for ever patient admitted to the TICU or trauma service

Results: significant decrease in MI’s post intervention

Results

Missed Injuries Unavoidable to some extent To prevent…

Think of MOI3° Exam – no studies in ED, but makes senseD/c instructions Interpret your x-rays If they’re not going to trauma – ENSURE NOTHING

ELSE IS GOING ON

Documents

The Multiple Trauma Patient Shawn Dowling, PGY-2 Preceptor: Rhonda Ness