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William Beaumont Hospital Department of Emergency Medicine. Trauma. CASE.

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william beaumont hospital department of emergency medicine
William Beaumont Hospital

Department of Emergency Medicine

Trauma

slide2
CASE

40 y/o male on a MCA, car pulled out to turn in front of him, he hit the side of the car and flew over it landing on his face. He is still fully clothed with his leathers on, C-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.

Where should we begin???

where to begin
Where to begin….
  • A, B, C ‘s
  • O2 – NC, mask, intubation
  • IV – how many or central line?
  • Monitor – HR, BP, sPO2, RR q15 (min)
  • Initial actions = secure the airway, maintain ventilations, control hemorrhage, and treat shock

What is the Golden Hour?

golden hour
“Golden Hour”
  • Emphasize the initial evaluation and treatment of the trauma patient
  • Our “window of opportunity” to have a significant impact on morbidity and mortality
  • Must have a concise, expeditious, well thought out plan for evaluation and treatment of life threatening injuries
  • Accomplished through ATLS guidelines of the primary and secondary surveys
primary survey abcdes
Primary Survey: ABCDEs
  • A = airway and cervical spine protection
  • B = breathing and ventilation
  • C = circulation and hemorrhage control
  • D = disability and neurological status
  • E = exposure and environmental control
primary survey abcde s
Primary Survey: ABCDE’s
  • An identified injury should be treated at the time of discovery
    • Examples:
      • The airway should be secured before the fracture is stabilized
      • PTX should be treated before the patient is completely exposed
  • The decision to transfer a patient should be made before proceeding to the secondary survey
secondary survey head to toe
Secondary Survey: Head to Toe
  • Complete the history (AMPLE)
  • Head to toe physical exam
  • Reassess vital signs and interventions
  • Obtain GCS if not done in primary survey
  • Special procedures (lines), specific x-rays, and labs should be obtained
secondary survey rectal tone
Secondary Survey: Rectal Tone
  • Rectal exam is done in every trauma and before urinary catheter placement (WHY?)
  • Check for blood  tear or pelvic fracture
  • High riding prostate  potential urethral injury
  • Decreased tone  brain or spinal injury
ok everyone remember our case
Ok, Everyone Remember Our Case

40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.

Where should we begin???

The Emergency physician starts at the head of the bed to assess A.

Assume that there are 15 people cutting clothes, starting the IVs, and exposing the patient.

tackling the case at hand
Tackling the Case at Hand

40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.

Where should we begin?

A – Deformity to the face, nose looks flat, lots of abrasions, eyes swollen closed, broken teeth, blood in the mouth, noisy breathing, and no response to questions

airway
Airway
  • Oral intubation of the patient using RSI with in line cervical traction
  • An orogastric tube is placed at the time of intubation
    • Why not an NGT in this patient?
breathing
Breathing

A - Patient is intubated

What’s next? B - Breathing

  • Despite intubation, O2 sats are still low and the patient is difficult to BVM
  • Decreased breath sounds on the R chest, crunching under the bell of your stethoscope, and the trachea appears deviated…
  • What’s the problem? How do we fix it?
breathing1
Breathing

A - Patient is intubated

  • Hemo/pneumothorax
  • Needle decompression followed by tube thoracostomy of the R chest
circulation
Circulation

A – Patient is intubated

B – Chest tube placed

What’s next? C – Circulation

  • Vitals: BP 90/40, HR 130
  • RN established two 16g IVs
  • How about 2L of fluid and a type and cross for 4 units of pRBCs
    • What do you give if immediate transfusion is needed?
disability and neuro exam
Disability and Neuro Exam

A – Patient is intubated

B – Chest tube placed

C – Fluids and blood given

Now for D – Disability and Neuro exam

  • Patient is intubated and paralyzed
    • GCS = 3TP (T = tube, P = paralyzed)
    • GCS =/<8  intubated for airway protection

What is a GCS you ask?

exposure and environmental
Exposure and Environmental

A – Patient is intubated

B – Chest tube placed

C – Fluids and blood given

D – GCS = 3TP

E – Exposure and Environmental

  • All clothes are cut off
  • Warm blanket applied to the pt
  • Deformity to L femur probably from a fracture  splint re-applied
tackling the case at hand1
Tackling the Case at Hand
  • Secondary survey
  • Orders
  • Repeat vital signs
  • FAST exam
  • Talk to EMS for additional information
labs and imaging
Labs and Imaging
  • Basic: CBC, BMP, PT/PTT, T&S, ETOH, B-hcg
    • Other labs ordered at the discretion of the practitioner, institution, or clinical situation such as drug screen, lactic acid, or hepatic panel
  • XR standard: c-spine, CXR, pelvis
    • Obviously x-ray anything that looks injured
  • CT:
    • Head and abd/pelvis are standard for a severely injured intubated patient
    • Chest CT for chest trauma or CXR findings
    • Neck CT based upon mechanism, age, injury
fast exam
FAST Exam
  • Primary role is detection of hemoperitoneum
  • Sensitivity of 75-90% compared to CT (depending on the user and injury)
  • Four Views of the FAST
    • Morison’s Pouch = hepatorenal
    • Splenorenal
    • Rectovesicular = Pouch of Douglas
    • Cardiac
      • Can also perform pleural windows for PTX
fast retrovesical
FAST: Retrovesical

Normal

Abnormal

ct vs dpl vs fast
CT vs. DPL vs. FAST
  • DPL
    • Very sensitive but not specific
    • Invasive
    • Good for visceral injury
    • Unstable trauma where US is unavailable or equivocal
  • CT
    • Noninvasive
    • Delineates solid organ injury
    • Expensive
    • Patient must be stable
  • FAST
    • Quick
    • Sensitive
    • Bedside
    • Operator dependent
    • Misses bowel, mesentery, diaphragm and pancreatic injuries
head case
Head Case

15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region.

head case1
Head Case

On exam he moans, withdraws to pain, but does not open his eyes…

What is his GCS?

head case2
Head Case

On exam he moans,

withdraws to pain, but

does not open his eyes…

What is his GCS?

What should you do FIRST?

head case3
Head Case
  • GCS = 7
  • What should you do first?
    • Intubate using RSI
    • Brief neuro exam, if possible, before paralysis
    • ?? Lidocaine prophylaxis for intubation
      • Blunts the cough reflex, hypertensive response, and increased ICP associated with intubation
subarachnoid hemorrhage
Subarachnoid Hemorrhage
  • Most common CT abnormality in head injury
  • Amount of blood correlates directly with outcome
  • Patients c/o HA and photophobia
  • Nimodipine is used to prevent vasospasm which worsens ischemia
compare it to this
Compare It To This…

Subdural Hematoma

Epidural Hematoma

head injury
Head Injury
  • Complete the primary/secondary survey
  • Initial goal is to maximize O2 and BP to prevent secondary ischemic brain injury
  • Primary Brain Injury = mechanical irreversible damage that occurs at the time of the trauma (laceration, contusion, hemorrhage)
  • Secondary Brain Injury = intracellular and extracellular metabolic derangements initiated at the time of the trauma
  • All therapies for TBI are aimed at reversing or preventing secondary brain injury
head injury increased icp
Head Injury: Increased ICP
  • Increased ICP = CSF pressure > 15 mm Hg
  • The cranium can accommodate ~50-100mL of blood before ICP increases
  • CPP = MAP – ICP
  • CPP < 40, autoregulation is lost
  • Remember CBF depends on the MAP therefore maximize the BP.
cushing s reflex
Cushing’s Reflex
  • Hypertension
  • Bradycardia
  • Diminished respiratory effort
  • ICP has reached life threatening levels
  • Occurs in 1/3 of cases
recognizing increased icp
Recognizing Increased ICP
  • Ipsilateral to mass lesion
    • Anisocoria, ptosis, impaired EOMs, sluggish pupil
  • Contralateral to mass lesion
    • Hemiparesis
    • Positive Babinski
  • As ICP continues to increase…
    • Posturing – decorticate then decerebrate
    • Ataxic respiratory patterns
    • Rapid fluctuations in BP and HR, arrhythmias
    • Lethargy  coma  death
methods to reduce icp
Methods to Reduce ICP
  • Hyperventilation = PCO2 30-35
    • Lowering PCO2 by 1mmHg decrease cerebral vessel diameter 2%  decreased ICP
    • Good initially but over time will cause reflex vasodilation
  • Diuretics = mannitol
  • Cranial decompression
  • Seizure prophylaxis = Ativan, Dilantin
head injury reasons to ct
Head Injury: Reasons to CT
  • History of LOC or amnesia to the event
  • Intoxication: drug and alcohol
  • Headache, vomiting, focal neuro deficit
  • Moderate (GCS 9-13) and high risk (GCS<8)
  • Age > 60 or < 2
  • Anti-coagulants – ASA, Plavix, Coumadin
  • Post-traumatic seizure
head injury ct unnecessary
Head Injury: CT Unnecessary?
  • Low risk (GCS 14-15)
  • Not intoxicated
  • Fully awake without focal neuro deficits
  • No evidence of skull fracture
  • Able to be observed for 12-24 hours
back to our head case
Back to our Head Case

15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region.

On further exam….

You notice that he has bruising behind his left ear, blood in the ear canal, and hemotympanum.

What does this suggest?

basilar skull fracture
Basilar Skull Fracture
  • Linear fracture through the base of the skull and can involve the temporal bone
  • Significance = requires a lot of force to break and can involve the internal carotid artery
  • Signs: blood in the ear canal, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4 and 5
  • Management:
    • Head CT and admission
    • Most CSF otorrhea and rhinorrhea will resolve spontaneously within a week
    • Prophylactic antibiotics are not usually given
what does this sound like
What Does This Sound Like?

40 y/o cashier at 7-11 is hit in the side of the head with a baseball bat. He was initially knocked out, but then woke up complaining of HA, dizziness, and feels nauseated. EMS says he just passed out again in the bus before arriving and now is minimally responsive to stimuli.

epidural hematoma
Epidural Hematoma
  • 80% associated with skull fractures across the middle meningeal artery or a dural sinus in the temporoparietal region
  • The classic lucid interval occurs in 30%
  • Patients needs to go to the OR for evacuation
how about this
How About This?

80 y/o lady who fell yesterday at home. Today her family says that she is confused and moving more slowly than usual.

50 y/o drunk male brought in by police for stumbling on the side of the road. He eventually fell down and was unable to get back up.

subdural hematoma
Subdural Hematoma
  • Occur commonly in people with atrophic brains = old people and drunks
  • Bridging vessels traverse a greater distance so are more easily torn (venous blood)
  • Slow bleeding can delay presentation
  • Optimal treatment is evacuation in the OR
next case
Next case…

24 y/o male is smacked in the face with a whiskey bottle. He is complaining of mid facial pain and mal occlusion of his upper teeth.

When you grasp his upper teeth and move them, his maxilla and nose move together.

What kind of fracture is this?

le fort fractures
Le Fort Fractures
  • Le Fort I
    • Transverse fracture through the maxilla
    • Upper teeth move
  • Le Fort II
    • Fraxture of the maxilla, nasal bridge, lacrimal bones, orbital floor and rim
    • Teeth and nose move
  • Le Fort III
    • Craniofacial dysjunction
    • Whole face moves
alternative airways
Alternative Airways
  • Orotracheal intubation
    • Procedure of choice with facial or neck trauma
    • Contraindicated w/ massive facial trauma or suspected laryngeal injury
  • Nasotracheal intubation
    • Contraindicated in apneic pts
    • Contraindicated in those with facial, skull, or laryngeal fractures
  • Cricothyroidotomy
    • Indicated when oral intubation fails, when there is severe edema or deformity of the face and oropharynx, fracture of the larynx, or hemorrhage in the airway
    • Contraindicated with anterior neck hematoma or laryngeal injury.
another case
Another Case…

78 y/o lady with a history of heart disease and afib presents after a syncopal episode in her yard. She was raking leaves when she felt her heart race, passed out, and fell forward to hit her head on a bucket.

She now complains of this intense burning sensation in both arms, hyperasthesia to the touch, and on exam has weakness in the arms more than the legs.

What spinal syndrome is this?

central cord syndrome
Central Cord Syndrome
  • Most common lesion
  • Common in elderly
  • Hyperextension injury  ligamentum flavum buckles into the cord  contusion of the central portion of the spinal cord  affects the pyramidal (motor) and spinothalamic tracts (sensory)
  • Fibers that innervate distal structures are located more in the periphery of the cord  deficit greater in the upper extremities
  • Prognosis: >50% of people recover spontaneously
anterior cord syndrome
Anterior Cord Syndrome
  • Hyperflexion injury  anterior cord contusion through protrusion of bone fragment or herniated disc or laceration of anterior spinal artery  paralysis and hypoalgesia below the level of the lesion
  • Preserved posterior column functions (i.e. position, touch, vibration)
  • Neurosurgical emergency as some causes are amenable to surgery
  • Prognosis: variable degrees of recovery in the first 24 hours
brown sequard syndrome
Brown Sequard Syndrome
  • Hemisection of the spinal cord
    • Ipsilateral motor
    • Contralateral sensory deficits (pain and temperature)
  • Usually from penetrating trauma but can also be from fracture of the lateral mass in the C-spine
  • Most maintain bowel and bladder function
  • Treatment and prognosis depend on the injury
pedestrian vs mvc
Pedestrian vs. MVC

45 y/o intoxicated female is crossing Woodward at 3am. She walks into traffic and is hit by a big truck before it can slow down (50mph). She is hit mainly in the abdomen and chest then propelled 30 feet onto the road.

EMS is called and she is on her way to your trauma bay.

pedestrian vs mvc1
Pedestrian vs. MVC

In the trauma bay…

EMS is bagging the patient who is unresponsive. She has poor respiratory effort when you stop the BVM. She has decreased breath sounds to both lung fields, crepitus over the R chest wall with dull/distant breath sounds on the L.

What should we do first?

pedestrian vs mvc2
Pedestrian vs MVC

Intubate the patient using RSI and oral endotracheal insertion (OGT too).

Now that the patient is intubated, you notice poor chest rise and fall, o2 sat of 89%, HR 140s, and still with poor breath sounds  absent on the R and decreased on the L.

Now what should we do next?

thoracostomy tubes
Thoracostomy Tubes
  • Bilateral chest tubes are placed.
  • On the R, the ER resident receives a whoosh of air and a little bit of blood.
  • On the L, the surgery resident receives about 400cc of blood.

What does this mean?

thoracostomy tubes1
Thoracostomy Tubes
  • You auscultate the lungs again…
    • Right: improved air exchange, still with crepitus and extensive bruising along the anterolateral CW
    • Left: better air exchange, but it is still decreased at the base

Re-evaluation of the vitals shows that the HR is now in the 110s and o2 sat is 96%. You decide this is good enough for now and continue with fluid resuscitation and further examination.

here is your portable cxr what do you think
Here is your portable CXR, What do you think?

OK, pretend that there are bilateral chest tubes.

ruptured diaphragm
Ruptured Diaphragm
  • Most frequently from penetrating trauma
    • <5% from blunt trauma
  • If there is a pelvic fracture, incidence rupture increases
  • Incidence of L and R sided rupture about equal
    • L side usually symptomatic as R side is protected by the liver
  • Signs/Symptoms:
    • Respiratory insufficiency
    • Bowel sounds in the chest
    • NGT passes back into chest
  • Surgery is definitive treatment
thoracic trauma rib fractures
Thoracic Trauma: Rib Fractures
  • 1st and 2nd rib fractures used to be called the “hallmark of severe chest trauma”
    • Small, broad, thick bones that take significant force to break
    • Brachial plexus, great vessels, and lungs are in close proximity and at great risk
  • Think twice with this injury and do a very thorough neurovascular exam
thoracic trauma rib fractures1
Thoracic Trauma: Rib Fractures
  • Fractures of the 9th-11th ribs suggest an associated intra-abdominal injury
  • Most heal within 3-6 weeks
  • Rib fractures are associated with hemo/pneumothorax, atelectasis, and pneumonia
  • Each rib fracture can lose ~200cc of blood
  • Admit vs. discharge: depends on the extent of injury, age, and ability to breathe
thoracic trauma flail chest
Thoracic Trauma: Flail Chest
  • 2 or more ribs are fractured at two points to allow a freely mobile segment of the chest wall with inspiration/expiration  the segment moves paradoxical to normal breathing
thoracic trauma flail chest1
Thoracic Trauma: Flail Chest
  • Major problems are underlying pulmonary contusion and chest pain
  • Splinting that causes atelectasis  results in major respiratory insufficiency
thoracic trauma sternal fracture
Thoracic Trauma: Sternal Fracture
  • Most commonly from anterior chest trauma
  • Using restraints increases the risk of fracture at the location the belt crosses the sternum
  • Older > younger more likely
    • Younger  more likely to suffer mediastinal soft tissue injury
  • Think about the structures beneath the sternum and carefully evaluate them (heart, lungs, and mediastinum)
thoracic trauma pneumothorax
Thoracic Trauma: Pneumothorax
  • DIB and CP are the most common complaints
  • Signs/symptoms do not always correlate well with the degree of PTX
  • Simple PTX
    • Collapse of lung but no communication with the atmosphere or shift of the mediastinum or hemidiaphragm
    • Can observe these if <20% and they are not ventilated, unstable, going to OR, or being transferred to a trauma center
thoracic trauma pneumothorax1
Thoracic Trauma: Pneumothorax
  • Tension PTX
    • Accumulation of air under pressure causes shift of the mediastinum  compression of the contralateral lung and great vessels
    • Leads to decreased cardiac output from decreased venous return
    • Classic signs: tachycardia, JVD, absent breath sounds on the ipsilateral side with trachea deviated away
    • Tension PTX is a clinical diagnosis (not radiographic)
    • Management: needle decompression and chest tube
thoracic trauma pneumothorax2
Thoracic Trauma: Pneumothorax
  • Open PTX
    • Sucking chest wound
    • Management: place occlusive dressing, taped on 3 sides only and place CT at a different site
thoracic trauma hemothorax
Thoracic Trauma: Hemothorax
  • Injured lung parenchyma most common > intercostal/IMA vessels > hilar vessels > great vessels
  • Signs/Symptoms: DIB, decreased breath sounds on the affected side
  • Upright CXR: blunting or obliteration of the diaphragm
  • Supine CXR: diffuse haziness on the affected side
  • Treatment: chest tube if respiratory compromise
    • 1500mL of blood = OR for thoracotomy
    • 200 mL/hr for 3 hours = OR
what is this
What Is This?

22 y/o male is stabbed in the epigastrium at a bar while flirting with another man’s girlfriend. He is complaining of abdominal pain, head pressure, and difficulty breathing.

HR 130s BP 80/55 RR 32 sPO2 96

pericardial effusion or tamponade
Pericardial Effusion or Tamponade
  • Beck’s Triad:
    • hypotension, distended neck veins, distant heart sounds
  • Tamponade occurs in 2% of pts with penetrating chest or abdomen trauma
  • Rarely occurs with blunt trauma
  • Treatment: IVF, pericardiocentesis vs. ED thoracotomy, then definitive management in the OR
next case1
Next Case…

17 y/o kid out joy riding on Saturday night in his mom’s car with a suspended license. He rolls through a stop sign on his phone and is T-boned on the driver’s side. PD is called. He initially gets out of the car, ambulates, and says that he is fine other than some mid back pain. He refuses EMS transport until he realizes that it is the hospital or jail.

joy ride
Joy Ride

He arrives with C-collar and back board to the trauma bay. He is now complaining of mid and lower back pain with tingling in both of his legs. He is afraid that he is going to be paralyzed and starts to hyperventilate. You complete your exam, roll the pt, and obtain your portable films.

As you start to roll to CT scan you try to talk to him to calm him down saying that everything is going to be OK. He looks at you and says that he is going to die, but of course you continue with your reassurances that everything is fine. Suddenly he is unresponsive and you cannot find a pulse when you check.

portable cxr what do you think
Portable CXRWhat Do You Think?

What do you want to do next?

ed thoracotomy indications
ED Thoracotomy Indications
  • Penetrating Trauma
    • Cardiac arrest at any point with initial vitals or signs of life in the field
    • Persistent hypotension (SBP<50) despite aggressive resuscitation
    • Severe shock with signs of tamponade
  • Blunt Trauma
    • Cardiac arrest in the ED
    • Blunt traumatic arrest in the field is NOT an indication for thoracotomy
blunt traumatic aortic injury
Blunt Traumatic Aortic Injury
  • Thoracic aorta is the most common vessel injured by blunt trauma
  • 80-90% of tears occur distal to the L subclavian artery
    • Ligamentum arteriosum is located in the descending aorta (aorta is tethered around a fixed point)
  • Patients suffering an ascending aortic injury usually die at the scene
  • CXR findings: mediastinum widening (>8cm on supine), obscured aortic knob, loss of the clear space between the aorta and pulmonary artery, displaced NGT, widened paratracheal stripe, trachea deviated to the right, depression left mainstem bronchus
abdominal trauma
Abdominal Trauma

18 y/o kid who…

Is stabbed in the mid abdomen.

-OR-

Falls 12 feet off the roof of a house.

Who do you think is more likely to survive?

What organs are most likely to be injured?

abdominal trauma1
Abdominal Trauma
  • Blunt injuries carry a greater risk of mortality than penetrating injuries
  • Blunt injury is more difficult to evaluate and diagnose
  • Blunt injury is more often associated with injury to multiple internal organs and systems outside of the abdomen
abdominal trauma2
Abdominal Trauma
  • Penetrating Injury
    • Small intestine, colon, and liver
  • Blunt Injury
    • Spleen>>>>liver, intestine
  • Seat belt sign = contusion/abrasion across the lower abdomen
    • Correlates with intraperitoneal lesions or lumbar spinal injury
abdominal trauma evaluation
Abdominal Trauma Evaluation
  • Inspect and palpate most importantly
  • FAST exam
  • CT scan
  • Labs
    • CBC – not usually helpful initially, mild leukocytosis is normal, serial Hgb more helpful
    • Tox screen and ETOH level
abdominal trauma treatment
Abdominal Trauma: Treatment
  • Hemorrhage is the main concern
    • Two large bore IVs or central line
    • IVF followed by blood products
  • Antibiotics if concern for bowel injury
  • Stable – FAST, CT, then OR if necessary
  • Unstable –FAST then OR for ex-lap
  • Penetrating trauma – determine if the peritoneum was violated as this dictates management
where does blood hide in the body
Where Does Blood Hide in the Body?
  • Chest
  • Abdomen
  • Pelvis
  • Femur
  • In kids, the cranium is a possibility as the sutures are still open
blood loss with fractures
Blood Loss with Fractures
  • Pelvis – 1500-3000cc
  • Femur – 1000cc
  • Ribs – 200cc
  • Tibia/Fibula – 500cc
  • Humerus – 250cc
  • Radius/Ulna – 150-250cc
trauma in the end
Trauma: In the End
  • Trauma can be cool to look at, but don’t be distracted by the gore.
  • Start with your ABCDEs and don’t move to the next step until you have solved a problem.
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