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Trauma Board Review Part I. Dr. Grumpy. Disclosure. Drug rep dinners Linezolid Ertapenem Keppra Levofloxacin STC. Blunt Trauma. High speed head-on MVC. 2 cars. 3 passengers in each car. Front passenger of car #1 pronounced on scene. The rest are coming to your trauma center.

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disclosure
Disclosure
  • Drug rep dinners
    • Linezolid
    • Ertapenem
    • Keppra
    • Levofloxacin
  • STC
blunt trauma
Blunt Trauma
  • High speed head-on MVC. 2 cars. 3 passengers in each car. Front passenger of car #1 pronounced on scene. The rest are coming to your trauma center.
patient 1
Patient #1

Driver of car #1. 23yoM. Moaning and sonorous respirations; will not open his eyes to pain but withdraws to pain. GCS?

  • 4
  • 5
  • 6
  • 7
  • 8
slide5
GCS
  • Eyes
  • Verbal
  • Motor
slide6
You notice severe midface fractures. You want to intubate patient with RSI. You know that:
  • Thiopental can raise both systemic and intracerebral blood pressure.
  • Etomidate is contraindicated.
  • Ketamine reduces intracerebral pressure, but may cause severe laryngospasm.
  • Pretreatment with lidocaine is not indicated.
  • Succinylcholine should be avoided unless a defasciculating dose of a nondepolarizing agent has first been given.
trauma intubation
Trauma Intubation
  • Lidocaine effectively attenuates the cough reflex, hypertensive response, and increased ICP associated with intubation.
  • Thiopental may also be effective but should not be used in hypotensive patients (consider it to be a less severe form of propofol)
  • If succinylcholine is used, premedication with a subparalytic dose of a nondepolarizing agent should be considered if time permits, since fasciculations produced by succinylcholine may increase ICP
    • Blunts ICP and cough response, no evidence for clinical difference
  • Etomidate has beneficial effects on ICP by reducing cerebral blood flow and metabolism.
  • Ketamine should be avoided because it increases ICP (although studies have bore out no outcome difference)
  • *Careful intubating peri-hypotensive trauma patients
quick word on etomidate
Quick word on Etomidate
  • Don’t use it
  • Don’t use it
  • Don’t use it
  • Don’t use it
slide9
Contraindications to nasotracheal intubation in a trauma patient include
  • Apnea
  • Cervical spine fracture
  • Depressed mental status
  • Hypotension
  • Pneumothorax
nasotracheal intubation
Nasotracheal intubation
  • Must be breathing spontaneously
  • Contraindications
    • Apnea, basilar skull fractures (or suspicion)
  • Just don’t do it
slide11
Astutely, you suspect head trauma. The most common CT scan abnormality found after severe closed head injury is:
  • cerebral contusion
  • epidural hematoma
  • intracerebral hemorrhage
  • subdural hematoma
  • traumatic subarachnoid hemorrhage
head trauma
Head Trauma
  • 50% (#1) of trauma deaths
  • Cushing’s (late and unreliable) – htn, bradycardia, apnea
head trauma13
Head Trauma
  • Urgent head CT is indicated if:
    • headache
    • vomiting
    • drug or alcohol intoxication
    • short-term memory deficits
    • posttraumatic seizure
    • coagulopathy
    • physical evidence of trauma above the clavicle
    • older than 60 years
    • GCS <14 or <15 s/p 2 hours
    • Amnesia before impact >30min
    • Witnessed LOC > 15min
    • Object recall < 3/3
    • Signs of basilar skull fx
epidural hemorrhage
Epidural hemorrhage
  • Arterial bleed (middle meningeal artery) between skull and dura
  • “Coup”
  • Underlying brain injury usually not severe
  • Presentation
    • LOC then lucid interval
    • Dilated ipsilateral pupil (lateralize if high) and contralateral hemiparesis – late findings
  • CT: biconcave or lenticular
subdural hemorrahge
Subdural Hemorrahge
  • Bridging veins between dura and ararchnoid
  • “Contracoup”
  • Presentation
    • Decreased mental status and LOC
    • May have lucid period also?!?!
  • 6x more common than epidural
  • Higher mortality rate than epidurals
  • CT scan: sickle shaped
subarachnoid hemorrhage
Subarachnoid hemorrhage
  • Blood within the CSF, caused by disruption of subarachnoid vessels
  • Most common CT finding in mod/severe TBI
herniation
Herniation
  • Transtentorial
    • Uncus → tentorial notch
    • CN III, brainstem symptoms
      • Ipsilateral pupil fixed and dilated
      • Respiratory depression
  • Tonsillar (Central) (rare)
    • Cerebellar tonsil → foramen magnum
    • Small bilateral pupils, posturing, bradycardia, respiratory arrest
head injury tidbits
Head Injury Tidbits
  • Isolated linear nondepressed skull fx: no treatment
  • Basilar skull fx: temporal bone, hemotympanum, CSF otorrhea/rhinorrhea, periorbital ecchymosis, retriauricular ecchymosis
  • Diffuse axonal injury is the most common brain injury resulting in coma.
  • Bullet to brainstem/basal ganglia  zero survival
increased icp
Increased ICP
  • Abnormal > 15, treat > 20
  • CPP = MAP – ICP, keep it >60
    • Systolic > 90 and goal = 120
    • MAP >85
    • ICP <20
    • Use pressors if needed keep CPP < 70
  • Avoid Sat < 90% or PaO2 < 60
  • PCO2 30-35 (too low  excessive vasoconstriction)
    • Hyperventilation only as temporary salvage
  • Mannitol (0.25-1g/kg)
    • “Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurological deterioration not attributable to extracranial causes.”
    • Dilutes blood and decreases viscosity  increased blood flow  reactive vasoconstriction and decrease ICP
    • Replace loss of fluids
    • Contraindicated when hypotensive
  • Hypertonic
slide20
Pt is intubated. BP 78/48, HR 122, R 16, T 37.5. Neck veins flat. Most likely cause of hypotension?
  • Cardiac tamponade
  • Cardiogenic shock
  • Hypovolemia
  • Spinal Shock
  • Tension PTX
blunt traumatic shock
Blunt Traumatic Shock
  • Hemorrhagic shock until proven otherwise.
  • Spinal Shock – bradycardic, hypotension
  • Cardiogenic shock/tamponade
    • FAST
    • Distended neck veins
  • Tension PTX
    • Distended neck veins, tracheal deviation, tachypnea, decrease BS on side of PTX
slide22
After resuscitation, vitals stabilize. CT reveals traumatic rupture of aorta. Which finding is most indicative of this entity on the patient’s initial CXR?
  • Deviation of esophagus 1-2cm to the right
  • 1st and 2nd rib fractures
  • L clavicle fx
  • Pulmonary contusion
  • Upward displacement of the L mainstem bronchus 40o
thoracic aortic disruption
Thoracic Aortic Disruption
  • Rapid deceleration injuries.
  • Most common cause of death in blunt trauma, 80% die at scene, 10-20% die w/in 1st hour.
  • Signs & sx: include chest pain, back pain, dyspnea, intrascapular murmur, and extremity pain caused by ischemia.
  • CXR: widen mediastinum (8 cm) most common. Nl in 2–7% of patients with aortic injury.
  • Aortogram gold standard, but now CT
    • False positives with mediastinal hematoma
  • Tx: BP management and surgical repair.
aortic rupture x ray
Aortic Rupture X-ray
  • Widened mediastinum
  • Obscured aortic knob
  • Opacification of the aortic-pulmonary window/apical capping
  • Widened paratracheal stripe
  • Displacement of the esophagus/NG tube to the right
  • Inferior displacement of the left mainstem bronchus.
  • L hemothorax, 1st & 2nd rib fx
traumatic aortic transection
Traumatic Aortic Transection
  • 80-90% tear at isthmus from deceleration and instant death
  • Survivors to ED – tear at ligamentum arteriosum
  • Retrosternal pain, dyspnea, stridor, dysphagia
  • Harsh systolic murmur
  • Pulse difference between upper and lower extremities
  • May have delayed presentation
ruptured diaphragm
Ruptured Diaphragm
  • Left > Right, as liver protects the right side
  • Location: 80-90% left posterolateral
  • CXR abnormal in 60%, but often not diagnostic
  • 50% diagnosed at laparotomy
  • Treatment: surgical repair
  • Often missed or delayed
tracheobronchial injury
Tracheobronchial Injury
  • Seen with deceleration/shear forces
  • Most blunt injury occurs within 2cm of carina
    • This is where it is teathered
  • Mortality with rupture=30%
  • Continuous bubbling in chest tube is a sign of a bronchopleural fistula
patient 2
Patient #2

50yoM, driver of 2nd car, has bruising over his sternum. Hit chest against steering wheel. VS unremarkable. Asymptomatic except for anterior chest wall tenderness at site of bruising. CXR and sternal view reveal sternal fx. EKG is nl. Which of the following is the MOST appropriate management plan for this pt?

  • Admit for 24 hr telemetry monitoring
  • Perform 2 sets of CE and TPN tests, and dc if neg.
  • Perform echocardiogram in the ED, and dc if neg.
  • After a repeat EKG in 6 hrs, dc the pt with pain medication, without any further testing.
blunt myocardial injury aka myocardial contusion
Blunt Myocardial Injury (aka Myocardial Contusion)
  • Clinical features: pt in MVA > 35 MPH c/o chest pain
    • Sternal rub or rib fracture, dyspnea, tachycardia (70%), S3 gallop, rales, elevated CVP
  • CXR greatest value for finding assoc injuries: pulmonary contusion, rib fx
    • Sternal fx no longer considered important.
  • Initial EKG predictive of subsequent clinically significant EKG events – recommend initial EKG followed by repeat EKG in 4-6 hrs.
    • PVCs, 1st degree av block, RBBB (RV closest to anterior chest wall), T wave flattening or elevation,  QT
myocardial contusion
Myocardial contusion
  • Dx: echo (but not as screening), increased CE (poor sensitivity)
  • Most heal without specific treatment
    • Complications: effusion, infarction, dysrhythmia, aneurysm, thrombosis, vasospasms
  • Monitor for 12h  d/c (not life-threatening)
  • If young, ekg and 1 or 2 CE (normal)  d/c
  • Abnormal  telemetry
  • Unstable  echo
    • If decreased CO  dobutamine or IABP
patient 3
Patient #3

Complains of tinnitus and headache. Normal neuro exam. What is the injury?

  • Frontal bone fracture
  • Parietal contusion
  • Subarachnoid hemorrhage
  • Subdural hemorrhage
  • Temporal bone fracture
basilar skull fx
Basilar Skull Fx
  • Most common fracture involves the petrous portion of the temporal bone, the external auditory canal, and the tympanic membrane
  • Fractures  dural tear  communication between subarachnoid space, paranasal sinuses, and middle ear
  • Compress and entrap cranial nerves passing through basal foramina
  • CSF otorrhea or rhinorrhea, mastoid ecchymosis (Battle sign), periorbital ecchymoses (raccoon eyes), hemotympanum, vertigo, tinnitus, decreased hearing, and 7th nerve palsy.
  • Ring test-halo on sheet-target lesion
basilar skull fracture
Basilar Skull Fracture

Need thin temporal bone cuts

battle s sign
Battle’s Sign

Can take 12 hours to show up

skull fractures
Skull fractures
  • Abuse=stellate, complex fractures
  • Linear non-depressed does not require treatment
  • Temporal skull fracture=middle menigeal=epidural hematoma
  • Open or depressed skull fracture (one bone table width)→antibiotics + neurosurgery
    • At risk for post-traumatic seizures
  • Occipital skull fracture: SAH, contrecoup injury, posterior fossa hematoma, cranial nerve injury
slide38
On exam, your abdominal findings are c/w lap belt injury. Compared to other patients with blunt abdominal trauma, this patient is at increased risk for injury to which of the following organs?
  • Intestine
  • Kidney
  • Liver
  • Pancreas
  • Spleen
slide39
ANSWER: A

A. intestine. When lap belt bruises are present, there is a higher incidence of intestinal injury. Although seat belt sign is seen in only 1/3 of cases, its presence is highly correlated with injury. Diaphragmatic injury can been seen secondary to compressive forces.

B. kidney

C. liver

D. pancreas

E. spleen

abdominal trauma
Abdominal Trauma
  • Lap belt injury: hollow viscous rupture, mesenteric tear, lumbar fracture, bladder injury or rupture (chest seatbelt sign ok)
  • Laparotomy indications: evisceration, GSW, impalement, gross blood by NG, rectal, DPL
abdominal trauma imaging
Abdominal Trauma Imaging
  • CT scan increasingly important in trauma management
    • Insensitive to hollow organ injury, pancreas, diaphragm
    • Sensitive to retroperitoneum, solid organs, bony structures
  • Role of FAST
easy to image
Easy to Image
  • Liver
    • Most common in penetrating (large)
  • Spleen
    • Most common in blunt
hard to image
Hard to Image
  • Pancreas
    • Blunt > penetrating
    • Handle bars, steering wheel, think peds
    • Nonspecific pain due to delayed diagnosis
    • DPL may be falsely negative and amylase usually normal
  • Small intestine
    • Multiple in penetrating
    • Often delayed symptoms
    • Associated with lap belt injury and lumbar spine fx (chance)
  • Colon
    • Usually transverse (pinned by spine and gas)
dpl dpa
DPL/DPA
  • Relative contraindications: obesity, pregnancy, previous abdominal surgery, pelvic fracture
  • False negative
    • Pancreas
    • Bowel
    • Retroperitoneum
    • Splenic hematoma
  • False positive: pelvic fracture
  • Positive lavage:
    • 10ml gross blood
    • Blunt > 100,000 RBC/ml
    • Penetrating > 10,000 RBC/ml (this number a moving target)
    • WBC > 500/ml
    • Bile, feces, urine
    • Increased amylase
  • Too sensitive! Grade I-II liver and spleen lacs
abdominal signs
Abdominal Signs
  • Grey Turner’s sign: flank discoloration, a late sign of retroperitoneal hematoma; can be seen with hemorrhagic pancreatitis
  • Kehr’s sign: referred left shoulder pain due to subdiaphragmatic irriatation/splenic rupture
  • Cullen’s sign: periumbilical ecchymosis due to retroperitoneal bleeding; can also be see with hemorrhagic pancreatitis, ectopic pregnancy
seat belt sign
Seat Belt Sign
  • Low-lying transverse abdominal ecchymosis has a strong association with hollow viscus injury and mesenteric tears .
  • Hollow viscus injury often does not produce any pain or tenderness until 6-8 hours following the traumatic event.
  • At minimum, patients with lap-belt contusions should undergo serial abdominal examinations.
  • Findings of abdominal tenderness should prompt diagnostic study (e.g., abdominal CT and/or DPL) or laparotomy.
slide47
Still on Patient #4. Blood is noted at the urethral meatus, and there is perineal ecchymosis. Which of the following is the next management step?
  • Insertion of a coude catheter
  • IV pyelogram
  • Pelvic CT scan
  • Retrograde urethrogram
  • Urinalysis with sample obtained by suprapubic route.
gu trauma
GU trauma
  • Signs of GU trauma somewhere – hematuria
  • Urethral injury
    • Signs
      • Perineal ecchymosis
      • Unable to urinate
      • Blood at meatus
      • High-riding/absent prostate
      • Blood in scrotum/scrotal hematoma
      • Obvious penile trauma
      • Pelvic fracture
    • Dx
      • Retrograde urethrogram
      • Do not blindly put foley (unless you’re really skilled) – partial tear into complete disruption
    • Tx
      • Foley over wire. Foley in for 2 weeks.
      • Suprapubic catheter placement and surgical repair.
  • Posterior urethral injury from blunt trauma
slide51
What is the most commonly injured organ of the genitourinary tract?
  • Urethra
  • Kidney
  • Bladder
  • Ureter
renal trauma
Renal Trauma
  • Most commonly injured organ of the GU system
    • Contusions (92%), followed by lacerations, renal pedicle injuries, and renal ruptures or shattered kidneys; 1-2% vascular
    • Diagnosed by CT
  • Rapid deceleration, compression, penetrating trauma
  • Associated with lower rib, L1-2 transverse process fractures
  • 25% of vascular injuries have no hematuria (no kidney perfusion)
    • Must revascularize < 12 hours
  • IVP indication: gross hematuria
  • Penetrating injury (15%)→IVP and/or CT
  • Most renal injuries are managed conservatively
rest of gu trauma
Rest of GU trauma
  • Bladder – 2nd most commonly injured
    • Assoc with blunt trauma and pelvic fx
    • Dx
      • Retrograde cystogram s/p foley or retrograde cystoscopy
      • Antegrade cystocopy (IV contrast, renal excretion fill bladder) – incomplete and spurious findings
  • Ureter – rarest
    • 90% penetrating trauma  IVP
  • Testicular trauma
    • Most common straddle injury
    • Presentation – edema, ecchymosis, tenderness, hematuria
    • Diagnosis – u/s, nuclear scan, exploration
    • Complications: abscess, hydrocele, infertility
patient 4
Patient #4

76yoF. Respiratory distress on arrival and has paradoxical movement of R chest during labored respirations. 138/76, 118, 28, 88% RA. BS auscultated on both sides of chest. Which of the following is correct?

  • Can be treated with supplemental oxygen and admission to stepdown unit.
  • Injury mandates early ventilatory support.
  • Most likely cause of hypoxia is splinting from pain
  • R chest wall moves outward with inspiration and inward with expiration.
  • Tx involves analgesia and adhesive tap or rib belt to stabilize chest.
slide55
ANSWER: B

A. Can be treated with supplemental oxygen and admission to stepdown unit. High potential for deterioration. Early ventilatory support and ICU.

B. Injury mandates early ventilatory support.

C. Most likely cause of hypoxia is splinting from pain. Pulmonary contusion.

D. R chest wall moves outward with inspiration and inward with expiration. Inward with inspiration and outward with expiration.

E. Tx involves analgesia and adhesive tap or rib belt to stabilize chest. Inhibit expansion of chest and aggravate atelectasis, worsening gas exchange.

flail chest
Flail Chest
  • Segmental fracture of 3 or more ribs
  • Paradoxical chest wall movement
  • Decreased ventilation and venous return
  • Tx
    • Intubation, consider chest tube
  • Main cause of hypoxemia=pulmonary contusion
flail chest57
Flail Chest
  • Initially compensate for reduce TV by hyperventilate, when fatigue or underlying pulmonary injury develops  respiratory failure.
  • Tx
    • Supplemental oxygen
    • Pain control – allows pt to fully expand lungs and improve ventilation
    • Early intubation considered
  • External chest wall support reduce VC  worsen respiratory function
  • Indications for early vent support: shock, three or more associated injuries, severe head injury, comorbid pulmonary disease, fracture of eight or more ribs, or age greater than 65 years
pulmonary contusion
Pulmonary Contusion
  • Interstitial edema, capillary damage, bleeding
  • Dec compliance, hypoxemia, atelectasis
  • CXR: opacification (often delayed 6-12 hours), CT better
  • Tx: oxygen, ventilation, PEEP vs. permissive hypercapnea, keep dry if possible
slide59
This patient also has a clavicle fracture. Which of the following statements regarding clavicle fractures is correct?
  • 80% involve the distal third of the clavicle
  • Closed reduction alleviates pain and allows for improved recovery
  • Frequently require surgical intervention to achieve alignment
  • Most common location is the middle third of the clavicle
  • Most common mechanism of injury is forced abduction of the shoulder
clavicle fx
Clavicle Fx
  • 5% proximal 3rd
    • Usually direct blow to anterior chest
    • More like complications/other injuries (vasculature)
    • Subclavian
  • 80% middle 3rd
    • Usually direct force to lateral aspect of shoulder
  • 15% distal 3rd
    • Usually direct blow to top of shoulder
  • Treatment
    • Most do not need surgery
    • Sling
    • Figure-of-eight brace for displaced fxs
    • Surgery indications
      • Fracture penetrate skin
      • Nerve/vessel injuries
rib fractures
Rib Fractures
  • Look for ptx, pulmonary contusion, vascular injury
  • Multiple rib fractures
    • Lower ribs:  risk of liver, renal, spleen injury
    • Admit: elderly, pre-existing pulmonary disease
  • Treatment
    • pain control (meds and nerve block)
bad fractures
Bad fractures
  • 1st & 2nd Ribs Fxs
    • 40% have associated occult injury
    • Great force involved
      • Well protected, more sturdy rings
    • Rule out
      • Myocardial contusion
      • Bronchial tear
      • Vascular injury (consider angio)
  • Scapula Fx
    • Associated with occult chest injury
slide63
Patient #5 is a 22yoF, 28wks pregnant. She denies abdominal pain, contractions, and vaginal bleeding. Her PE is unremarkable other than a small contusion to her right flank. Which of the following is the appropriate management?
  • D/c home with precautions and 24-hr follow up.
  • External tocodynamics monitoring for 4 hrs
  • US followed by external tocodynamics monitoring for 24 hrs
  • US with discharge home if negative
patient 5
Patient #5

23yoF. 28wks pregnant. 110/78, 105, and 25. Which of the following statements regarding her vital signs is correct?

  • Cardiac output is increased in pregnancy, which means that she can tolerate larger blood losses than a nonpregnant trauma patient can
  • Elevation of the diaphragm and reduced functional residual capacity are causing the elevated respiratory rate
  • Heart rate increases in the second trimester, which means that the tachycardia is caused by pregnancy, not hypovolemia
  • Hypotension might not develop until 35% of her blood volume is lost due to relative hypervolemia of pregnancy
  • Systolic and diastolic blood pressure decrease in the second trimester, which means that the blood pressure indicates she is not hypovolemic
pregnancy trauma
Pregnancy Trauma
  • CO inc 40% by 10wks, HR inc 10-15 beats/min; SVR dec, widened pulse pressure, low blood pressure
  • If hypotensive, roll or move uterus off IVC
  • Blood volume inc 50% by 28wks; can lose up to 35% without vital signs change (but fetus in trouble)
  • MV inc 40%, normal PCO2 is 30
  • High diaphragm  dec functional residual capacity
  • Chest tube 1-2 ribs higher
pregnancy in trauma
Pregnancy in Trauma
  • Pt is at risk for Placental Abruption although her trauma appears minor.
  • Major prospective study showed that minimal of 4 hrs of external tocodynamic monitoring was able to predict immediate adverse pregnancy outcome:
    • < 3 contractions her hour – discharge
    • 3-7 C/H: monitor 24 hours
    • > 8 contractions: higher risk of placental abruption, none occurred in patients < 8 C/H
  • US is not sensitive to exclude placental abruption.
traumatic placental abruption
Traumatic Placental Abruption
  • Leading cause of fetal loss aside from maternal death is traumatic placental abruption is #1 cause of fetal loss aside from material death. (This is what we have to work-up and why we’re consulting ob/gyn.)
  • Shearing and deceleration forces separate placenta from uterine wall
    • Lack of external signs of abdominal trauma means nothing
    • Placental position does not affect incidence
    • Disrupts gas exchange between fetus and mother  hypoxia  fetal distress.
    • In blunt trauma, 50-70% fetal loss result from placental abuption.
  • Signs
    • Vag bleeding (<40%), abd pain/cramping, amniotic fluid leakage, uterine tetany(???)
    • Fetal distress – cardiotocographic monitoring (>20wk gestation)
      • U/S < 50% accurate
  • Placental substances cause coagulopathy (DIC from high levels of ATP III)
kleihauer betke test
Kleihauer-Betke test
  • Test for fetomaternal hemorrhage (FMH) (ie, transplacental bleeding of fetal blood into the normally separate maternal circulation)
  • Complications
    • Rh sensitization of the mother
    • Fetal anemia/distress/death from exsanguination.
  • Acid elution test on maternal blood to determine ratio of fetal:maternal circulation
  • Regardless of result, must get rhogam if mother is Rh-
  • Used to identify Rh- women at risk of massive FMH  needs more rhogam
  • Lecithin-to-sphingomyelin ratio: fetal lung maturity
  • Fetal fibronectin test: predicts premature delivery
blunt abd trauma
Blunt Abd Trauma
  • Stable
    • Abdominal CT
    • DPL/DPA
      • Does not define extent or location of injury
      • No retroperitoneal
      • 1-2% complication rate
  • Unstable
    • Resuscitate
    • Go to OR if
      • Positive FAST/DPA or Peritonitis
  • Arresting
    • Resuscitative Thoracotomy
    • R Chest Tube
take a breath
Take a breath
  • Meant for me…not you.
penetrating trauma
Penetrating Trauma

The bat-phone rings. A fight has broken out 5 blocks away from Elmhurst. Multiple patients coming in.

slide72
32yoM. Stab in L side of neck with pocket knife. Injury is inferior to angle of mandible, superior to cricoid cartilage, posterior of sternocleidomastoid. Penetrates platysma. No bleeding, no evidence of tracheal deviation or JVD. PE: no carotid bruits, no stridor, no SQ emphysema, strong carotid pulses b/l, nl neuro exam. Other than pain to wound area, pt is asymptomatic. 128/82, 86, 16, 99% on RA. Correct statement?
  • Can d/c after neg local wound exploration.
  • Must get esophagram and esophagoscopy
  • Must get laryngoscopy and bronchoscopy
  • Must get local wound exploration in the ED
  • Observation alone is appropriate.
slide74

For STABLE patient only

  • Zone III
  • above mandible
  • Angiograph
    • May need esophogram/endoscopy/bronchoscopy
  • Zone II
  • between cricoid and mandible
  • go to OR or…
    • Esophagography/esophagoscopy and CT angiography
  • Zone I
  • below cricoid,
  • Angio, esophogram/endoscopy, bronchoscopy
penetrating neck injury76
Penetrating Neck Injury
  • Any wound which violates platysma
  • Injuries-most occur in Zone II
    • Vascular > CNS
    • Peripheral nerve > brachial plexus
  • Vascular injuries require proximal and distal control
  • Death=CNS, exsanguination, airway compromise (intubate early)
blunt neck trauma
Blunt Neck trauma
  • Rare due to protection of head, shoulders and chest
  • Mechanism: steering wheel, dashboard, shoulder belt shearing forces, clothes line injuries
  • Laryngotracheal and pharyngoesophageal injuries can be subtle require diagnostic imaging
  • Carotid artery injury: pseudoaneurysm or dissection
    • Mechanism: hyperextension, hyperflexion, direct blow, intra-oral trauma, basilar skull fracture
    • Neurologic symptoms may be delayed
strangulation blunt neck injuries
Strangulation / Blunt Neck Injuries
  • Soft-tissue neck x-rays
    • Look for SubQ emphysema (fractured larynx), hyoid bone fx, or tracheal deviation because of edema or hematoma.
  • CT of neck structures
  • Neck MRI
    • Soft tissue
    • Carotid arteries from aortic arch to circle of Willis, making it particularly applicable in the setting of blunt cervical injuries where the level of injury is unknown
  • Carotid doppler U/S
    • Angiography remains the gold standard for diagnosing blunt carotid artery injury
    • Helical CT scans efficacy unvalidated
  • Laryngosocopy - vocal cord and tracheal evaluation
    • Particularly with dyspnea, dysphonia/hoarseness, odynophagia
carotid artery dissection
Carotid Artery Dissection

Neck trauma + TIA/Stroke/Horner’s

slide80
Also has GSW through R leg. Which of the following findings on PE suggest the presence of an arterial injury requiring expeditious angiography or surgical intervention?
  • Diminished distal pulses
  • Injury to an anatomically related nerve
  • Unexplained hypotension
  • Proximity of the injury to major vascular structures
arterial injury penetrating extremity trauma82
Arterial Injury: Penetrating Extremity Trauma
  • Hard signs: expeditious angiography and/or surgical intervention
  • Soft signs: inpatient admission for observation and repeat exams
  • No hard or soft: Observe in ED 3-12 hrs, discharge home with close fu.
    • No signs of arterial bleed
    • No bone or nerve injury
    • No developing compartment syndrome
    • Minimal soft tissue defect
slide84
Upon ripping his clothes off, you find a single stab wound to L flank. VS are BP 110/80, HR 90. Which of the following is the most appropriate next step in management of the flank stab wound?
  • DPL
  • Wound exploration with a cotton swab.
  • CT with IV contrast.
  • CT with oral, rectal, and IV contrast.
slide85
ANSWER: D

A. DPL. In a pt who is hemodynamically stable after penetrating flank trauma, DPL would be helpful for intraperitoneal injury but does not sample the retroperitoneal injury (kidney).

B. Wound exploration with a cotton swab. Difficult and limited, esp with deeper wounds that extends to muscle layer.

C. CT with IV contrast.

D. CT with oral, rectal, and IV contrast. Triple contrast should be used to identify rectal and sigmoid injury. Oral contrast may not extend down to these areas. Accuracy of CT for flank stab wounds approaches 98%.

flank or back wound
Flank or Back Wound
  • Associated with to retroperitoneal injuries such as the colon, kidney, ureters and major vascular structures
  • Colon is the injury most often missed. If colon injury is suspected, serial physical examination is extended to 72 hours, watching for fever or a rise in WBC
  • An alternative is to perform a triple-contrast CT scan. Where the wound track extends up to the colon, or there is evidence of abnormal bowel wall thickening, laparotomy is indicated.
slide87
Another patient rolls in – an anterior abdominal wall stab wound. What is the likelihood he will need surgery due to this wound?
  • 10%
  • 30%
  • 50%
  • 70%
  • 90%
anterior abdominal stab wounds
Anterior Abdominal Stab Wounds
  • 1/3 don’t penetrate peritoneum, 1/3 penetrate but don’t require laparotomy, 1/3 require laparotomy.
  • Local wound exploration followed by
    • Discharge home if no violation anterior fascia
    • Admission for observation/serial PE/DPL if superficial muscle fascia violated.
    • Indications for exploration: progressive abdominal tenderness, increasing leukocytosis, fever, abdominal distension, etc.
slide89
If the stab wound was in the LUQ, which of the following is the BEST method for diagnosing a diaphragmatic injury?

A. Computed tomography.

B. Diagnostic peritoneal lavage.

C. Upper gastrointestinal series.

D. Laparoscopy.

diaphragmatic injuries
Diaphragmatic Injuries
  • Majority caused by penetrating trauma.
  • Occur predominately on L side b/c liver protects right side. Most likely sight of injury posterio-lateral portion of L diaphragm
  • Laparoscopy. CT misses a lot of penetrating injuries.
  • DPL may be used but must use low cut-off (5000 RBCs/ml) as diaphragm bleeds little.
  • NG tube/Upper GI series good for blunt, but not penetrating diaphragmatic injuries
  • Delays in diagnosis lead to increased morbidity and mortality.
slide91
His CXR comes back with this. You realized you missed an axillary injury and pt. has pneumo/hemothorax. Which of the following is true?
  • Once the blood has been drained from the chest, clamp the thoracostomy tube while the patient undergoes further evaluation
  • Perform needle aspiration of the hemothorax if the volume is less than 300 cc
  • Perform needle decompression prior to tube thoracostomy
  • Place a 28 Fr thoracostomy tube directed anteriorly in the right anterior axillary line
  • Place a 36 Fr thoracostomy tube directed posteriorly in the right anterior axillary line
pneumothorax
Pneumothorax
  • Open pneumothorax
    • Open >2/3 diam. of trachea (air moves in and out of wound
    • 3 sided petroleum gauze, one way valve, chest tube
    • Dressing can create a tension PTX; remove dressing if patient has increased SOB

Expiratory chest x-ray is the most helpful diagnostic maneuver

tension pneumothorax
Tension Pneumothorax
  • Severe dyspnea, ↓ breath sounds, distended neck veins
  • Classic=tracheal deviation to opposite side, hyperresonance, no breath sounds
  • Decreased venous return, hypoxemia, arrest
  • Treatment: immediate needle thoracostomy, chest tube

Don’t wait for the x-ray!

pneumomediastium
Pneumomediastium
  • Subcutaneous emphysema
  • Hamman’s sign: crunching during systole (not a rub)
  • Spontaneous due to increased intrabronhcial pressure
    • Mechanical ventilation
    • Valsalva
    • Sneezing
    • Emesis
    • Ruptured bleb
    • Drug use
  • Tension pneumomediastinum
    • Decreased cardiac output
    • Decompression via neck dissection
cardiac tamponade
Cardiac Tamponade
  • Beck’s triad: hypotension, JVD, muffled heart tones
  • Pulsus paradoxicus: weaker pulse (lower BP) than usual with inspiration
  • Electrical alternans: alternating QRS on EKG
  • Diagnosis: Echo
  • Treatment: pericardiocentesis, thoracotomy
    • If you crack the chest, you MUST skin the heart
chest tubes
Chest tubes
  • Position – 5th interspace, anterior axillary line
    • No needle
    • Prevent over-intrusion
    • Slide along chest wall
  • For blood – large-bore tube (36-40 Fr), direct posteriorly
  • For pure air – 28 Fr, directed anteriorly
slide98
Which of the following is an indication for emergency department cesarean delivery after maternal trauma?

A. Absence of fetal heart tones

B. Fundal height at 19 cm

C. GSW to uterus with vaginal bleeding

D. Maternal death after 5 minutes of profound shock and a 26-week fetus.

E. Solitary GSW to head with stable vitals signs of the mother.

answer d
Answer D
  • Indications for Perimortem C-section:
    • Fetus viable – cardiac activity on US
    • Gestational age > 23 weeks
  • Survival from postmortem cesarean delivery unlikely 15 mins after maternal death.
  • No specific duration of death beyond which C section is contraindicated.
  • GSW to uterus or solitary GSW to head with stable VS are not indication for emergency ED C section.
what are the 4 accepted indications for ed thoracotomy
What are the 4 accepted indications for ED thoracotomy?
  • Penetrating thoracic injury
    • Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
    • Unresponsive hypotension (BP < 70mmHg)
  • Blunt thoracic injury
    • Unresponsive hypotension (BP < 70mmHg)
    • Rapid exsanguination from chest tube (>1500ml)
what are the 4 uses for ed thoracotomy
What are the 4 uses for ED Thoracotomy?
  • Relief of tamponade
  • Control hemorrhage from intrathoracic source
  • Cross clamping of pulmonary hilum after suspected air embolism
  • Cross clamp aorta with open heart massage