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Med 542 Review Trauma. Ken Stewart MD, FRCSC Assistant Professor Division of Thoracic Surgery, University of Alberta. Trauma. Precipitous, ubiquitous phenomenon affecting all ages, races. Various forms (blunt, penetrating, burns) Disease or process in evolution

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med 542 review trauma

Med 542 ReviewTrauma

Ken Stewart MD, FRCSC

Assistant Professor

Division of Thoracic Surgery, University of Alberta

trauma
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 and appropriateness of treatment.
objectives
Describe the principles of assessment of the injured patient

Describe the principles of resuscitation of the injured or critically-ill patient

Describe the indications for and the important steps in the procedure of emergency cricothyroidotomy

Objectives
objectives 2
Outline the principles of assessment and management of blunt and penetrating injury of the chest

List the indications for trauma thoracotomy

List the indications for tube thoracostomy

Describe the proper technique for tube thoracostomy

List the indications for emergency needle decompression of the chest

Objectives --2
objectives 3
Define “shock”, and list the signs and symptoms of the different types of shock

Describe the management of the different types of shock

Outline the principles of assessment and management of blunt and penetrating injury of the abdomen

List the indications for a trauma laparotomy

Objectives --3
internet resources
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
slide7
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 to recognition, assessment and treatment of all types of trauma
acs outline on atls
ACS outline on ATLS
  • Injury is precipitous and indiscriminate・
  • The doctor who first attends to the injured patient has the greatest opportunity to impact outcome・
  • The price of injury is excessive in dollars as well as human suffering
atls 2
ATLS--2
  • Program:・CME program developed by the ACS Committee on Trauma・
  • One safe, reliable method for assessing and initially managing the trauma patient・
  • Revised every 4 years to keep abreast of changes
  • Audience:・Designed for doctors who care for injured patients・Standards for successful completion established for doctors・
  • ACS verifies doctors' successful course completion
atls 3
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 centers and small rural emergency departments
atls 4
ATLS--4
  • Objectives:・Assess the patient's condition rapidly and accurately
  • ・Resuscitate and stabilize the patient according to priority・
  • Determine if the patient's needs exceed a facility's capabilities・
  • Arrange appropriately for the patient's definitive care・
  • Ensure that optimum care is provided
atls 5
ATLS--5
  • Trauma Team, and Team Leader concept
    • One person responsible for making decisions and starting treatment
  • Organized into algorithms for the benefit of systematic recognition and treatment
assessment and treatment
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 important historical features
systematic assessment by trauma team leader
Primary Survey

Airway

Ensure patency

Breathing

Rule out distress

Circulation

Provision for large bore (14-16 gauge) IV access

Crossmatch for blood for severely injured

Secondary Survey

ABC again

Disability

C-spine precautions and neuro assessment

Exposure

exam front and back of patient, then keep warm

Fingers in every orifice and foley catheter

Systematic Assessment by “Trauma Team Leader”
assessment principles
Assessment Principles

Primary survey

Try to recognize the immediately life-threatening injuries

  • Tension Pneumothorax
  • Massive Hemothorax
  • Open Pneumothorax
  • Cardiac Tamponade
  • Flail Chest

Airway,Breathing,Circulation

assessment principles16
Assessment Principles

Secondary Survey

More detailed and complete examination, aimed at identifying all injuries and planning further investigation and treatment.

Airway,Breathing,Circulation, Disability, Exposure, Fingers, Foley

resuscitation treatment
Resuscitation/Treatment

After airway and breathing have been assured, infuse IV fluids, keep npo and decide on relevant imaging, and lab testing.

C-spine immobilization and any limb injuries need to be addressed with dressings, splints and fracture reduction if vascular or nerve injury apparent.

Decision on where patient should be treated definitively needs to be determined.

  • Consideration of personel and resources.
airway assessment
Airway Assessment

Midline position of trachea

Stridor,presence of hemoptysis

Work of breathing

  • Use of accessory muscles
  • Respiratory rate
  • SaO2 and hypoxemia and hypercapnea on ABG

Level of consciousness

  • Depressed GCS--inability to protect the airway
airway treatment
Airway--treatment

Classified as “Simple to Surgical”

Mask, Oropharyngeal airway, nasopharyngeal airway, laryngeal mask, endotracheal tube, cricothyrotomy, tracheostomy

endotracheal intubation22
Endotracheal intubation

Indications

  • Hypoxemia
  • Hypercapnea
  • Impending respiratory arrest
  • Cardiac arrest, multi trauma
  • Readying for OR

Need suction, Laryngoscope, Muscle paralysis (?rapid sequence induction)

surgical airways
Surgical Airways

Cricothyroidotomy

  • Needle
  • tube

Tracheostomy

cricothyroidotomy
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, acute laryngeal disease by infection or trauma
cricothyroidotomy technique
Cricothyroidotomy technique

1.With a scalpel, create a 2 cm horizontal incision through the cricothyroid membrane

2.Open the hole by rotating the scalpel 90 degrees or by using a clamp

3.Insert a size 6 or 7 endotracheal tube or tracheostomy tube

4.Inflate the cuff and secure the tube

5.Provide venilation via a bag-valve device with the highest available concentration of oxygen

6.Determine if ventilation was successful (bilateral ausculation and observing chest rise and fall)

7.No attempt should be made to remove the endotracheal tube in a prehospital setting.

assessment of treatment
Assessment of treatment

Auscultate

CXR

End tidal CO2

SaO2

tracheostomy
Tracheostomy

Definitive surgical airway

Dedicted appliance or endotracheal tube

Indications similar for cricothyroidotomy

chest trauma
Chest Trauma

Commonest cause of death in blunt and penetrating trauma

  • Immediate causes of death
    • Tension pneumothorax, massive hemothorax, cardiac tamponade, flail, open pneumothorax
  • Delayed causes of death
    • Pulmonary contusion, cardiac contusion, pneumothorax, hemothorax, aortic disruption, tracheobronchial disruption, diaphragmatic disruption
chest trauma29
Chest trauma
  • Assessment with physical exam, CXR, ABGs and SaO2 monitoring
  • CT scan
  • Echocardiography, ECG
  • Serum studies for cardiac injury (troponin and creatinine kinaseMB fraction)
tension pneumothorax
Tension Pneumothorax

Typically from penetrating trauma.

  • Can be spontaneous
  • Bronchopleural fistula from lacerated, or disrupted lung, open pneumothorax
    • Symptoms of dyspnea, syncope, surgical emphysema, “impending doom”
    • Signs of hypotension, tachypnea, tachycardia, distended neck veins, cyanosis
hemodynamic mechanism
Hemodynamic mechanism

Axis of the cavae, point of fixation with the aorta and great vessels

Lack of right heart filling, leading to shock

tension pneumothorax32
Tension pneumothorax

Treatment

  • Suspected: needle decompression
    • 14 gauge angiocath
    • Midclavicular line
    • Use syringe with plunger removed
  • Leave in place and then insert standard chest tube thoracostomy
  • What to do if patient is too thick?
  • What if there is no tension noted with needle insertion?
tension pneumothorax vs cardiac tamponade
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
chest tube thoracostomy
Indications

Pneumothorax

Hemothorax

Unstable patient following blunt or penetrating trauma

Non trauma

Pleural effusion, chylothorax, empyema,post operative

Relative contraindication=diaphragm disruption

Technique

Local anesthetic*

Sterile field*

Scalpel, kelly or hemostat forcep

Chest tube and pleurevac device

Securing suture

*if time permits

Chest tube thoracostomy
chest tube insertion
Chest tube insertion
  • Location is typically, nipple height, mid-axilla sparing the latissimus, and pectoralis muscle
  • No tunnels needed
  • CXR post procedure
  • Connect to pleurevac
trauma thoracotomy
Trauma thoracotomy
  • Emergency situation with penetrating chest injury
    • Rarely of benefit in blunt trauma
    • Suspect major vessel laceration or cardiac laceration
indications
Penetrating injury to chest, abdomen or retroperitoneum

Signs of life prior to assessment in ER then shock

normothermia

Clamp aorta

Defibrillate heart

Internal cardiac massage

Pericardial decompression

Repair of lacerated vessel or heart

Indications
shock
Hypovolemic

Following blood loss

Burns and hypothermia

Cardiogenic

Pump failure

Ischemia, contusion, acute valvular dysfunction

Distributive

Sepsis

Neurogenic

Obstructive

Pulmonary embolism

Tamponade, tension pneumothorax

Endocrine

Manifests like distributive shock

Hypothyroidism, hypoadrenalism

Shock
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

Diagnosis
treatment
Directed at specific diagnosis

Fluid resuscitation

Crystalloid, colloid

Blood and blood products

Vasopressors

Specific agents for specific types of shock

Definitive treatment where possible depending on etiology.

Treatment
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 peritoneal lavage

Blunt Injuries to the abdomen
diagnostic peritoneal lavage
Diagnostic peritoneal lavage
  • Used to assess need for laparotomy following trauma
    • Cutdown technique to midline of abdomen
    • Initial aspiration, if clear…..
    • Infusion of one litre of saline with IV tubing and then collection
diagnostic peritoneal lavage43
Diagnostic peritoneal lavage
  • Indications for laparotomy
    • GI contents on aspirate or lavage
      • Feces, bile, peas and corn
    • Urine on aspirate
    • Blood
      • 10 mLs of gross blood on aspirate
      • >100 000 rbc/ mL on analysis (newspaper test)
role of ct scan
Role of CT scan
  • Use for blunt injury management
    • Assess liver and spleen injuries
    • Presence of pneumoperitoneum, free fluid
    • Vascular injuries
    • Retroperitoneal injuries
indications for laparotomy following trauma
Blunt

Hemodynamic instability despite resuscitation

Positive DPL

Findings on CT scan

High grade spleen or liver injury

Pneumoperitoneum

Retroperitoneal organ injury

Vascular injury

Penetrating

Hemodynamic instability despite resuscitation

Evisceration, pneumoperitoneum

Positive DPL

CT scan findings similar to blunt

Indications for laparotomy following trauma