TRAUMA

1. TRAUMA (LIFE IN THE ER) William Beaumont Hospital Department of Emergency Medicine

2. 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???

3. 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?

4. “Golden Hour” • The idea is to emphasize the importance of the initial evaluation and treatment of the trauma patient • It is our “window of opportunity” to have a significant impact on morbidity and mortality • One must have a concise, expeditious, well thought out plan of action for evaluation and treatment of life threatening injuries • We accomplish this through ATLS guidelines of the Primary and Secondary Surveys

5. Primary Survey: ABCDEs • A = airway maintenance with cervical spine protection • B = breathing and ventilation • C = circulation and hemorrhage control • D = disability and neurological status • E = exposure and environmental control, undress the pt, log roll the patient and put a blanket on them

6. Primary Survey: ABCDEs • As you proceed through the list, an identified injury should be treated at the time of discovery • = the airway should be secured before the fracture is stabilized • = PTX should be treated before the patient is completely exposed • A decision about transferring the patient should be made before proceeding to the secondary survey

7. Secondary Survey: head to toe • Complete the history (AMPLE) and physical exam • Reassessment of vital signs and interventions • If GCS not obtained in primary survey, now is a good time • Special procedures (lines), specific x-rays, and labs are now obtained

8. Secondary Survey: Rectal Tone • Rectal exam is done in every trauma and before urinary catheter placement (WHY?) • Check for blood and integrity = tear or pelvis fracture • High riding prostate = potential urethral injury • Tone = brain or spinal injury

9. 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??? Usually the EC doc goes to the head of the bed to assess A, assume that there are 15 people cutting clothes, starting the IVs, and exposing the patient.

10. 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

11. Tackling the CASE at hand Where should we begin??? A • Oral intubation of the patient using RSI with in line cervical traction • I usually place an orogastric tube at the time of intubation (why not an NGT in this pt?)

12. Tackling the CASE at hand A - the pt is intubated What’s next? B • Despite intubation, O2 sats are still low and the pt is difficult to BVM • ? Decreased breath sounds on the R chest and there is crunching under the bell of your stethoscope, you also imagine that the trachea appears deviated

13. Tackling the CASE at hand A - the pt is intubated What’s next? B • Needle decompression followed by tube thoracostomy of the R chest

14. Tackling the CASE at hand A – pt is intubated B – surgery is putting in the chest tube Let’s move to C – BP 90/40, HR 130 • The nurses have 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?)

15. Tackling the CASE at hand A-intubation, B-R CT, C-fluids and blood What was D? Disability and Neuro exam • Our pt is intubated and paralyzed at this point, but any pt with a GCS of 8 or less should be intubated to protect their airway What is a GCS you ask?

17. Tackling the CASE at hand A-intubation, B-R CT, C-fluids and blood, D – neuro E – exposure and environmental • All the clothes are cut off and a warm blanket applied to the pt • Deformity to L femur probably from a fracture so the splint is re-applied

18. Tackling the CASE at hand Now that the ABCDE is accomplished, a more thorough evaluation of the patient can be performed, orders, repeat vital signs, FAST exam, and talk to EMS for additional information.

19. What are the usual orders?Or, what would you order for this guy?

20. LABS AND FILMS • 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 usually standard • Chest CT for chest trauma or CXR findings • Neck CT based upon mechanism, age, injury

21. What are the 4 views of the FAST exam?

22. 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 -> some of us also do pleural windows for PTX

23. FAST: Normal or Abnormal?

24. Normal Abnormal FAST

25. Normal Abnormal FAST: Morison’s Pouch

26. Normal Abnormal FAST: Vesicoureteral

27. OOPS!

28. CT vs DPL vs FAST • DPL is very sensitive but not specific, invasive, need NGT/foley placed, good for visceral injury • Unstable trauma where US is unavailable or equivocal • CT is noninvasive, locates and delineates solid organ injury, but is expensive, time consuming, and located away from the resuscitation bay • Pt must be stable • FAST is quick, easy, decent sensitivity and done at the bedside for unstable pts • Not as good for bowel, mesentery, diaphragm, or pancreatic injuries

29. Any Questions? Let’s Move on to the Specifics…

30. 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.

31. Head Case On exam he moans, withdraws to pain, but does not open his eyes… What is his GCS?

32. Head Case On exam he moans, withdraws to pain, but does not open his eyes… What is his GCS? What should you do FIRST?

33. Head Case • GCS = 7 • What should you do first? • Intubate the pt using RSI (sucs and etomodate) • Brief neuro exam if possible before paralysis • Lidocaine Prophylaxis for Intubation (1.5mg/kg) • Blunts the cough reflex, hypertensive response, and increased ICP associated with intubation

34. This is his Head CT…What does it show?

35. 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 would worsen ischemia This is his Head CT…Subarachnoid Hemorrhage

36. Subdural Hematoma Epidural Hematoma Compare it to these

37. So what do you do with Head Injured Patients?

38. 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

39. Head Injury: Increased ICP • Increased ICP = CSF pressure > 15 mm Hg • The cranium can accommodate about 50-100mL of blood before ICP raises • CPP = MAP – ICP • CPP < 40, autoregulation is lost • All you really need to know is that CBF depends on the MAP (=maximize BP)

40. Recognizing Increased ICP What is Cushing’s Reflex?

41. Cushing’s Reflex • Hypertension • Bradycardia • Diminished Respiratory Effort • Indicates that ICP has reached life threatening levels • Only occurs in 1/3 of cases

42. Head InjuriesRecognizing Increased ICP • Ipsilateral to Mass Lesion • Anisocoria, ptosis, impaired EOMs, sluggish pupil • Contralateral to Mass Lesion • Hemiparesis • Positive Babinsky • As ICP continues to increase… • Posturing – decorticate then decerebrate • Ataxic respiratory patterns • Rapid fluctuations in BP and HR, arrhythmias • Lethargy to Coma

43. Methods to Reduce ICP • Hyperventilation = PCO2 30-35 • Lowering PCO2 by 1mmHg will decrease cerebral vessel diameter 2% which will decrease cerebral blood flow -> good initially but too long will cause reflex vasodilation • Diuretics = Mannitol (sometimes lasix) • Cranial Decompression = trephination, ventriculostomy, OR craniotomy • Seizure Prophylaxis = ativan, dilantin, pentobarbital

44. Head Injury: To CT or not to CT • 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 • Posttraumatic Seizure • Any signs of trauma above the clavicles • Not to CT (how many people actually meet these criteria) • Low risk (GCS 14-15) patient who is not intoxicated and fully awake without focal neuro deficits, no evidence of skull fracture, and who can be observed for 12-24 hours

45. 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???

46. Basilar Skull Fracture Signs: blood in the ear canal, rhinorrhea, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4, 5 • These are linear fractures through the base of the skull and usually involve the temporal bone • Significance = requires a lot of force to break and can involve the internal carotid artery • These pts need a HCT and admission • Most CSF otorrhea and rhinorrhea will resolve spontaneously within a week • Prophylactic antibiotics are not usually given

47. 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.

48. 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

49. 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.

50. 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