Med 542 Review Trauma Ken Stewart MD, FRCSC Assistant Professor Division of Thoracic Surgery,...

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– 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 --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 --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

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

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

• 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

• 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

• 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

• 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

• 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

• 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 SurveyAirway

• Ensure patency

Breathing• Rule out distress

Circulation• Provision for large

bore (14-16 gauge) IV access

• Crossmatch for blood for severely injured

Secondary SurveyABC 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

Assessment Principles

Primary surveyTry to recognize the immediately life-threatening

injuries1. Tension Pneumothorax

2. Massive Hemothorax

3. Open Pneumothorax

4. Cardiac Tamponade

5. Flail Chest

Airway,Breathing,Circulation

Assessment Principles

Secondary SurveyMore detailed and complete examination,

aimed at identifying all injuries and planning further investigation and treatment.

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

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

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

Classified as “Simple to Surgical”

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

Airways

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Endotracheal intubation

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Endotracheal intubation

Indications– Hypoxemia– Hypercapnea– Impending respiratory

arrest– Cardiac arrest, multi

trauma– Readying for OR

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

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Surgical Airways

Cricothyroidotomy– Needle– tube

Tracheostomy

QuickTime™ and aTIFF (Uncompressed) decompressor

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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

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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 tube5.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.

QuickTime™ and aTIFF (Uncompressed) decompressor

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Assessment of treatment

Auscultate

CXR

End tidal CO2

SaO2

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Tracheostomy

Definitive surgical

airway

Dedicted appliance or

endotracheal tube

Indications similar for

cricothyroidotomy

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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 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

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

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

Lack of right heart filling, leading to shock

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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?

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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 insertion

• Location is typically, nipple height, mid-axilla sparing the latissimus, and pectoralis muscle

• No tunnels needed• CXR post procedure• Connect to

pleurevac

QuickTime™ and aTIFF (Uncompressed) decompressor

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Trauma thoracotomy

• Emergency situation with penetrating chest injury– Rarely of benefit in

blunt trauma– Suspect major

vessel laceration or cardiac laceration

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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

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

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

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.

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

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

QuickTime™ and aTIFF (Uncompressed) decompressor

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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)

QuickTime™ and aTIFF (Uncompressed) decompressor

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Role of CT scan

• Use for blunt injury management– Assess liver and

spleen injuries– Presence of

pneumoperitoneum, free fluid

– Vascular injuries– Retroperitoneal

injuries

QuickTime™ and aTIFF (Uncompressed) decompressor

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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