Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
2/11/2021
1
TRAUMAEMRAM ITE REVIEW COURSE
Kristen Palomba, MD
Beaumont Health System – Troy
Disclosure
• I have no actual or potential conflicts of interest in relation
to this program/presentation.
Overview
What this lecture is:
• Rapid review of frequently tested content
• Highlighting pearls and buzz words
• Broken down systematically
• Sporadically placed questions
What this is lecture not:
• An exhaustive presentation of all things trauma
• Comprehensive
Initial Trauma
• ATLS – know it backward and forward
• ABCDE → if clinical status worsens or changes, restart at airway• Airway
• GCS <8, severe facial burns or airway trauma → intubation
• Breathing
• Identify and treat life threats: tension PTX, open PTX, flail chest, massive hemothorax
• Circulation
• Classes of hemorrhage
• 1:1:1 transfusion ratio, +/- TXA
• Disability
• GCS – memorize it
• Exposure
QUESTION
• During which of the classes of hemorrhage does the
patient become hypotensive?
• Class I
• Class II
• Class III
• Class IV
1 2
3 4
5 6
2/11/2021
2
ANSWER
• During which of the classes of hemorrhage does the
patient become hypotensive?
• Class I
• Class II
• Class III
• Class IV
Classes of Hemorrhage
QUESTION
• Which of the following is NOT part of Cushing Reflex?
• Bradycardia
• Hypertension
• Irregular respirations
• Altered mental status
ANSWER
• Which of the following is NOT part of Cushing Reflex?
• Bradycardia
• Hypertension
• Irregular respirations
• Altered mental status
Head Trauma
• Basilar Skull Fracture
• Temporal CT
• Hemotympanum
• Raccoons eyes and Battle sign → 1-3 days AFTER injury
• CSF otorrhea or rhinorrhea
• Target lesion (double target sign, halo sign) on filter paper w/ ring of
CSF around blood
QUESTION
• Which of the following is NOT associated with a subdural
hematoma?
• Alcoholics and elderly patients
• Lucid interval after LOC
• Crescent shaped hematoma
• Bridging veins
7 8
9 10
11 12
2/11/2021
3
ANSWER
• Which of the following is NOT associated with a subdural
hematoma?
• Alcoholics and elderly patients
• Lucid interval after LOC
• Crescent shaped hematoma
• Bridging veins
Head Trauma
• Intracranial Hematomas
• Epidural
• Middle meningeal artery, lucid interval after LOC, biconvex or lens
shaped hematoma
• Subdural
• Alcoholics or elderly, bridging veins, crescent shaped hematoma
• Traumatic Subarachnoid
• Any age, + meningeal signs, acceleration-deceleration mechanism,
blood in basilar cisterns, ventricles, hemispheric sulci, fissures
• Intracerebral hematoma
• Severe blunt or penetrating trauma, shaken baby
QUESTION
• What are the anatomical landmarks that designate the
neck “zones”?
ANSWER
• What are the anatomical landmarks that designate the
neck “zones”?
• Cricoid cartilage, angle of the mandible
Neck Trauma
• Penetrating
• Zone I: CTA, esophageal
and tracheal evaluation
• Zone II: surgery if hard signs,
otherwise as per zone I
• Zone III: CTA
• Platysma violation → surgical c/s
Neck Trauma
13 14
15 16
17 18
2/11/2021
4
Neck Trauma
• Blunt
• Laryngotracheal injury
• Subcutaneous emphysema, stridor, dysphonia
• Cerebrovascular injury: carotid or vertebral artery injuries
• +/- neuro Sx, “hard signs”, Horner syndrome (ptosis, miosis,
anhidrosis)
• Pharyngoesophageal injury
• RARE
QUESTION
• Which of the following is considered a stable cervical spinal
fracture?
• Odontoid type II fracture
• Clay shoveler’s fracture
• Jefferson’s fracture
• Teardrop fracture
ANSWER
• Which of the following is considered a stable cervical spinal
fracture?
• Odontoid type II fracture
• Clay shoveler’s fracture
• Jefferson’s fracture
• Teardrop fracture
Spinal Injuries
• Cervical Spinal Fractures
• STABLE
• Wedge fractures (<50% vertebral body height)
• Transverse process fractures
• Clay shoveler’s fracture
• spinous process avulsion
• MC at C7
• flexion against contracted posterior muscles
Spinal Injuries
• Cervical Spinal Fractures
• UNSTABLE
• Jefferson Bit Off A Hangman’s Thumb
Type Mechanism Notes
Jefferson axial load with
vertical compression
C1 burst fx
Bilateral facet dislocation flexion anterior displacement
>50%
Odontoid type II/III flexion II – neck, III - body
Atlantoaxial or atlantooccipital flexion or extension C1/C2 dislocation
Hangman’s hyperextension bilateral C2 pedicle fx
Teardrop flexion > extension teardrop = anteroinferior
portion of vertebral body
QUESTION
• Hyperflexion injury to C spine with negative CT scan, but
persistent neuro symptoms (paralysis, loss of pain & temp
below level of lesion). Diagnosis? Prognosis?
19 20
21 22
23 24
2/11/2021
5
ANSWER
• Hyperflexion injury to C spine with negative CT scan, but
persistent neuro symptoms (paralysis, loss of pain & temp
below level of lesion). Diagnosis? Prognosis?
• Anterior cord syndrome, POOR
Spinal Injuries
• Incomplete Cord Lesions
Syndrome Mechanism Clinical Prognosis
Anterior cord flexion or
vascular
Loss of motor, pain &
temperature below lesion,
intact proprioception &
vibratory sensation
POOR
Central cord forced
hyperextension
Sensory & motor deficits, upper
> lower extremities
AVERAGE/FAIR
Brown-Séquard penetrating Ipsilateral loss of motor,
vibratory sensation and
proprioception, contralateral
loss of pain & temperature
sensation
GOOD
QUESTION
• How do you diagnose a tension pneumothorax?
ANSWER
• How do you diagnose a tension pneumothorax?
• CLINICALLY!
• JVD
• Hypotension/tachycardia
• Tracheal deviation
• Decreased BS
Chest Trauma
• Pneumothoraces
• Simple
• CXR: deep sulcus sign, absent lung markings (check periphery)
• US: loss of lung sliding (higher sensitivity than CXR)
• <12-25%, stable pt: 100% O2 NRB, repeat CXR
• IF INTUBATING → THORACOSTOMY
• Tension
• Mediastinal shift, obstruction of venous return, decrease CO
• JVD, tracheal deviation, hypotension
• CLINICAL DIAGNOSIS → needle decompression, then thoracostomy
Chest Trauma
• Pneumothoraces
• Open
• Large open wound, sucking chest wound
• Three-sided dressing + thoracostomy
• If you completely occlude wound → tension PTX
25 26
27 28
29 30
2/11/2021
6
Chest Trauma
• Hemothorax
• CXR blunting of costophrenic angle: >250 mL
• Massive hemothorax → mediastinal shift away from hemothorax
• Large-bore chest tube (36-40 Fr)
• Thoracotomy Indications
• Initial chest tube output > 1500 mL (> 20 mL/kg)
• Persistent output > 200 mL/hr (> 3 mL/kg/hr)
• Persistent hypotension despite thoracostomy output
Chest Trauma
• Sternal Fracture
• Restrained > unrestrained passengers
• Lateral CXR, +/- CT
• Eval for dysrhythmias
• ECG and troponin normal → low likelihood of blunt myocardial
injury
QUESTION
• Becks triad, pulsus paradoxus, and electrical alternans
are all associated with what condition?
Answer
• Becks triad, pulsus paradoxus, and electrical alternans
are all associated with what condition?
• Cardiac tamponade
Chest Trauma
• Cardiac Tamponade
• Becks triad: hypotension, JVD, muffled heart sounds
• Pulsus paradoxus: reduction in SBP > 10 mmHg on inspiration
• Electrical alternans: QRS amplitude changes beat to beat
Chest Trauma
• Traumatic Aortic Injury
• High-speed deceleration
• MC occur at aortic isthmus
• Most reliable CXR signs: widened mediastinum (>8 cm), loss of
aortic knob
• Beta blockade, permissive hypotension
• High mortality
• Blunt Diaphragmatic Injury
• Rare, often missed
• Left >>> right
• +/- abdominal contents herniate into thorax
31 32
33 34
35 36
2/11/2021
7
QUESTION
• Biking accident with associated handlebar injury in a 5yo
male presenting with upper abdominal pain is concerning
for what type of injury?
ANSWER
• Biking accident with associated handlebar injury in a 5yo
male presenting with upper abdominal pain is concerning
for what type of injury?
• Hollow viscous injury (eg duodenum/jejunum), pancreatic
injuries
Abdominal Trauma
• Blunt Hollow Viscous Injury
• Seat belt, steering wheel or handle bar
• Stomach, intestines (duodenum/jejunum), pancreas, Chance fx of
lumbar spine (+ lap belt)
• Delayed peritoneal signs
• Imaging often NEGATIVE
Abdominal Trauma
• Blunt Solid Organ Injury
• MC injured organ = spleen, then liver
• eFAST→ hepatorenal (Morison’s pouch) space
• Even MORE sensitive = caudal edge of the liver
• Penetrating Injury
• MC injured organs based on mechanism
• Stab wounds = liver, then small bowel
• GSW = small bowel, then colon, then liver
QUESTION
• 32yo F at 25w gestation based on LMP presents following
minor MVC. No external signs of trauma. Abdominal exam
benign. Next steps?
• Discharge home
• Observe for 6 hours
• CT A/P
• Continuous fetal monitoring
ANSWER
• 32yo F at 25w gestation based on LMP presents following
minor MVC. No external signs of trauma. Abdominal exam
benign. Next steps?
• Discharge home
• Observe for 6 hours
• CT A/P
• Continuous fetal monitoring
37 38
39 40
41 42
2/11/2021
8
Trauma in Pregnancy
• Mechanism: MVC, intimate partner violence
• Beware baseline VS and lab value changes in pregnancy
• Minor trauma, >24 weeks gestation = continuous fetal
monitoring to eval for placental abruption
• Kleihauer-Betke test
• >20 weeks gestation
• Evaluates fetomaternal hemorrhage
• Guides RhoGAM
Trauma in Pregnancy
• Fetal viability: 24 week gestation
• Dome of uterus above umbilicus
• Resuscitate the mother first - ALWAYS
• If no ROSC by 4 minutes → perimortem C-section
• Tube thoracostomy
• ABOVE 4th intercostal space
• ANTERIOR axillary line
Pelvic Fractures
• Types
• Acetabular
• Bimodal (young: high energy, elderly: low energy)
• Avulsion
• Adolescents, occur at tendon attachments, rapid/strong muscle
contractions
• Major Ring Fractures
• Pelvis instability
• Evaluate perineum
• Destot sign: hematoma above inguinal ligament or scrotum
• Retroperitoneal bleeding common
• Grey Turner sign (flank ecchymosis)
• Cullen sign (bruising around umbilicus)
QUESTION
• At what anatomical landmark is a pelvic binder placed?
ANSWER
• At what anatomical landmark is a pelvic binder placed?
• Greater trochanter
Pelvic Fractures
43 44
45 46
47 48
2/11/2021
9
Pelvic Fractures
• Major Ring Fractures
① Lateral Compression
• Most common type
• T-bone MVC, pt struck on side
② Anteroposterior Compression
• e.g. open book
• Second most common
• Head on MVC
③ Vertical Sheer
• Least common, highest incident of severe hemorrhage
• Fall/jump from height
Pelvic Fractures
• Management Pearls
• IV/IO access ABOVE the pelvis
• Pelvic instability → binder application at greater trochanter
• Abnormal prostate position or blood at urethral meatus →
urethrogram prior to Foley placement
• Angioembolization > OR:
• No other operative injuries identified
• Large pelvic hematoma or active IV extravasation on CT
• OR > Angioembolization:
• Concurrent injuries which require emergent operative stabilization
QUESTION
• Traumatic hip dislocation – MC anterior or posterior?
ANSWER
• Traumatic hip dislocation – MC anterior or posterior?
• Posterior
Traumatic Hip Dislocation
• Posterior
• 80-90%
• MVC, knee on the dashboard
• +/- acetabular fractures
• Shortened, internally rotated, adducted
• Reduce ASAP
• Complications
• Sciatic nerve injury
• Prolonged dislocation → AVN femoral head
QUESTION
• Which of the following is most commonly associated with
a POSTERIOR urethral injury?
• Saddle injury
• Pelvic fracture
• Butterfly perineal hematoma
• Female sex
49 50
51 52
53 54
2/11/2021
10
ANSWER
• Which of the following is most commonly associated with
a POSTERIOR urethral injury?
• Saddle injury
• Pelvic fracture
• Butterfly perineal hematoma
• Female sex
Genitourinary Trauma
• Urethral Injuries
• MC in MALES
• Sx: blood at meatus, inability to void, dysuria/hematuria
① Anterior: saddle injury (MC), instrumentation, direct trauma
• A “butterfly” perineal hematoma
② Posterior: pelvic fracture
• High-riding prostate
• Retrograde urethrogram
Genitourinary Trauma
• Bladder Injuries
① Extraperitoneal bladder rupture
• Occurs at bladder neck 2/2 sheering forces
• No communication with peritoneum
• Tx: Foley decompression 10-14d
② Intraperitoneal bladder rupture
• Distended bladder ruptures at its dome
• Urine leaks into peritoneum → peritonitis
• Tx: Surgery
• Dx: retrograde cystogram
Genitourinary Trauma
• Penile Trauma
• Fracture – rupture of corpus cavernosum
• Blunt trauma to erect penis, + “cracking” sound w/ severe pain
QUESTION
• What is considered to be a normal compartment
pressure?
• 0-10 mmHg
• 5-15 mmHg
• 20-30 mmHg
• 30-40 mmHg
ANSWER
• What is considered to be a normal compartment
pressure?
• 0-10 mmHg
• 5-15 mmHg
• 20-30 mmHg
• 30-40 mmHg
55 56
57 58
59 60
2/11/2021
11
Soft Tissue Trauma
• Compartment Syndrome
• Mechanism: casts or burns (external constriction), hemorrhage,
fractures, crush injuries, reperfusion injuries
• Normal compartment pressure: 0-10 mmHg
• 20 mmHg: capillary flow affected → observe, repeat measurements
• > 30-40 mmHg: muscle and nerve ischemia → consider fasciotomy
• PEARLS
• MC affected compartment: anterior compartment of the leg
• First affected structure: nerves (loss of two point discrimination)
• Late finding: loss of pulse
• Primarily a clinical diagnosis
• Avoid fasciotomy following snake bites
Soft Tissue Trauma
• Compartment Syndrome
• FIVE Ps
• Pain out of proportion
• Pain with passive stretch of muscle
• Paresthesia, decreased sensation
• Paralysis
• Perfusion (distal pulses, capillary refill)
QUESTION
• What is the feared complication of a knee dislocation?
ANSWER
• What is the feared complication of a knee dislocation?
• Popliteal artery injury
Soft Tissue Trauma
• Peripheral Vascular Injuries
• Check for HARD signs of arterial injury → warrants immediate
surgery
• Pulsatile bleeding, thrill or bruit, rapidly expanding hematoma, arterial
occlusion
• No hard signs → duplex, arteriography
• ABI: normal > 0.9
Soft Tissue Trauma
• Amputation/Replantation
• Transportation of appendage
① Wrap in saline-soaked gauze
• Do NOT use antiseptics or scrub the appendage
② Put in closed plastic bag
③ THEN place on ice
• NEVER DIRECTLY PLACE ON ICE
• High Pressure Injection Injuries
• Often grease or paint, innocuous exam
• Surgical emergency → exploration and debridement
• Do NOT digital block
61 62
63 64
65 66
2/11/2021
12
Burns
• Thermal Burns
• Evaluate airway
• Know WHEN to intubate → inhalation injury, resp distress or AMS,
facial or perioral burns
• Carbon monoxide, cyanide exposures
• Burn depth
① Superficial: red, painful
② Superficial partial thickness: red, blistering, painful, blanching
③ Deep partial thickness: red to pale white-yellow, blistering, no
blanching
④ Full-thickness: dry, insensate, charred white/black, leathery
• Circumferential burns → eval for escharotomy
QUESTION
• What is the Parkland Formula?
ANSWER
• Parkland Formula
• 4 mL x %burn x weight (kg) = fluid requirement
(mL) over first 24 hours• Half of fluid over first 8 hours
• Second half of fluid over remaining 16 hours
• Do NOT include superficial burns in TBSA
Burns
• TBSA
• Rule of Nines
Burns
• Who do I transfer to a burn center?
• TBSA > 10%
• Burns involving face, hand, feet, genitalia, perineum or MAJOR
joints
• ANY full thickness burn of ANY age group
• Electrical or chemical burns
• Inhalation injuries
Burns
• Chemical Burns
• Acids → coagulative necrosis
• Alkalis → liquefactive necrosis
• WORSE PROGNOSIS
• Deep burns
• Treatment PEARLS
• 1st step is ALWAYS to remove offending agent
• Ophthalmologic irrigation until pH = 7.0 (neutral)
• Primary treatment for almost all chemical exposures EXCEPT metals,
dry powder lime and phenol = copious water irrigation
67 68
69 70
71 72
2/11/2021
13
References
• https://doctorlib.info/surgery/principles-surgery/5.html
• https://rebelem.com/penetrating-neck-injuries/
• https://smhs.gwu.edu/urgentmatters/news/keep-it-simple-acute-gcs-score-binary-decision
• https://www.slideshare.net/manbachan/csf-for-upload
• https://www.nejm.org/doi/full/10.1056/nejmicm1408805
• https://westjem.com/articles/diaphragmatic-rupture-secondary-to-blunt-thoracic-trauma.html
• https://www.aliem.com/management-major-pelvic-trauma/
• https://www.physio-pedia.com/Pelvic_Fractures
• https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=hw262650&lang=en-ca
References
• https://emedicine.medscape.com/article/1277360-
overview
• Blok, B., Cheung, D., & Platts-Mills, T. (2016). First Aid for
the Emergency Medicine Boards Third Edition (3rd ed.).
McGraw-Hill Education / Medical.
• Tintinalli, J., Ma, J. O., Yealy, D., Meckler, G., Stapczynski,
J., Cline, D., & Thomas, S. (2019). Tintinalli’s Emergency
Medicine: A Comprehensive Study Guide, 9th Edition (9th
ed.). McGraw-Hill Education / Medical.
• https://wikem.org/
• Rosh Review
References
• Life in the Fastlane (https://litfl.com/)
73 74
75