TRAUMA
Time of death
Immediate: laceration of brain, brainstem, spinal cord, heart, major vessels
Mins-hours: major hemorrhage of head, chest, abdomen, or multiple injuries
Days-weeks: sepsis, multi organ dysfunction
Initial assessment
---Primary survey (and resuscitation)
ABCDE (airway, breathing, circulation, disability (neuro), exposure & environment
Oxygen to all patients
Agitated / belligerent patients – always rule out hypoxia
Needle cricothyroidotomy
temporary airway because hypercarbia develops
emergency airway of choice in kids
Oropharyngeal or nasopharyngeal airway also temporary
Definitive airway: orotracheal intubation
Femoral/carotid pulse = BP >60mmHg
Radial pulse = BP >80mmHg
Inadequate cerebral perfusion: anxiety→confusion→lethargy→unconsciousness
IV access options
Prefer 2 large bore (14-16 gauge) peripheral IVs
Saphenous vein cutdown if IV cannot be placed
Kids <6 years: interosseous (IO) in tibia
LR #1 for resuscitation (more physiologic concentrations than NS)
NS #2 (can cause hyperchloremic metabolic acidosis with large resuscitation)
Fluid bolus of 1-2L (20ml/kg in kids); if no response, transfuse blood
Neurogenic shock: hypotension without tachycardia; give pressors and atropine
Cardiogenic shock: due to myocardial contusion or cardiac tamponade (rarely MI)
GCS (memorize it)
Eyes (open to): 4-spontaneous, 3-voice, 2-pain, 1-no eye opening
Verbal: 5-oriented, 4-confused, 3-inappropriate words, 2-incomprehensible sounds, 1-none
Motor: 6-follows commands, 5-localizes to pain, 4-withdraws from pain, 3-flexion to pain, 2-extension to pain, 1-none
---Secondary survey
AMPLE hx: allergies, meds, PMHx, last meal, events around injury
Continuous EKG monitoring
XRay: cervical, AP chest and pelvis
Rectum / perineum exam
Foley – if no blood at meatus and no abnormal findings on prostate exam (if so need retrograde urethrogram)
---Definitive care
Prioritize injuries, further imaging
Thoracic injuries
---Immediately lethal
Airway obstruction
Tension PTX
Open PTX
Rx: impermeable dressing – tape 3 sides; chest tube
Massive hemothorax
Rx: chest tube; if >1500ml total or >200ml/hr, thoracotomy required
Cardiac tamponade (Beck’s triad: hypotension, JVD, muffled heart sounds)
Rx: pericardiocentesis w/ EKG or U/S guidance
Needle 1-2cm to left and inferior to xiphochondrial junction 45 degrees toward L shoulder
Flail chest (2 or more fractures per rib) with pulmonary contusion
Injury + hypoventilation leads to respiratory failure
Rx: analgesia, PEEP on vent
---Potentially lethal
Pulmonary contusion (hemorrhage + atelectasis)
Rx: ventilation, PEEP
Blunt cardiac injury
Usually R ventricle
Need EKG to assess for dysrhythmias (if normal BP and normal EKG, no further tests)
Rx: antiarrhythmics or inotropic support
Blunt aortic injury – shearing at fixation points
At ligamentum arteriosum in horizontal deceleration (MVA)
At aortic arch in vertical deceleration (fall)
At diaphragmatic hiatus (T12) in ant-post compression inj (MVA)
Dx: chest CT or TEE
Rx: prevent HTN initially, then surgical or endovascular repair
Diaphragm rupture
90% on left
Dx: NG tube – will see in chest on Xray
Rx: surgical repair
Tracheobronchial tree or esophageal injury
Crepitus, PTX, hemoptysis
May quickly lead to sepsis
Dx: bronchoscopy, esophagoscopy
Rx: intubate, esophageal resection and diversion
---Nonlethal
Simple PTX, hemothorax, rib fractures, mandible fractures (dental malocclusion)
Abdominal injuries
Unrecognized intraabdominal hemorrhage is a leading cause of death
4 zones: 1. upper abd; 2. lower abd; 3. pelvis; 4. retroperitoneum
Remember to palpate iliac crests, pubic symphysis, check rectal tone
Dx: FAST good for hemo- pericardium/ thorax/peritoneum
DPL (diagnostic peritoneal lavage): 1st decompress bladder and stomach
If >10ml blood, need laparotomy
Otherwise infuse 1L LR/NS: laparotomy if bacteria, or bile present, or >500 WBC or 100,000 RBC/ mm3
Can’t rule out retroperitoneal bleed
CT if patient stable (however, CT may miss small bowel injury)
Spleen
#1 injured organ with blunt trauma
Rx: splenectomy, possibly splenic embolization
1% develop OPSI (high mortality)
Stab wound
In flank or back – requires triple contrast CT (IV, PO, rectal)
Diaphragm laceration requires laparoscopy
Pelvic fractures
1st rule out intraabdominal bleed
Stabilize pelvis with external fixation (or at least place pelvic binder or wrap tightly)
Do not enter pelvic hematoma (usually venous, allow it to tamponade)
If bleeding continues, perform arteriography, embolization
Head injuries
#1 cause of trauma death
Goal of Rx: prevent secondary brain injury
Scalp laceration can cause major hemorrhage because vessels held tightly in subcutaneous tissue
Temporal lobe uncal herniation
Compresses CN III = ipsilateral pupil fixed + dilated
Sometimes compresses corticospinal tract = contralateral weakness
CBF=CPP/CVR; CPP=MAP-ICP; normal ICP < 10
If ICP >20 Cushing reflex (↑BP, ↓HR, ↓RR) bilateral dilated pupils; Rx needed
Monitoring ICP: ventricular catheter (lateral ventricle) or subarachnoid bolt
Combatative / somnolent patient: assume hypoperfusion
Skull fracture signs: 1.raccoon eyes, 2. battle sign, 3. hemotympanum, 4. CSF oto/rhino-rhea
Cribiform plate fx
Raccoon eyes
“Target sign” on paper to test for CSF
Avoid putting NG tube into cranium
C spine XR (or CT C spine) in all head trauma patients – 15% have associated fracture
Concussion: brief LOC, 60% of all head injuries
Diffuse axonal injury (DAI): grey white junction injury, coma for weeks; in 45% of severe head injuries
Contusion: focal injury, 15% of all head injuries
Epidural hemorrhage: 0.5% of head injuries, good prognosis
Temporal skull fracture, lucid interval, lens shape on CT, ipsilateral blown pupil
Rx: burr hole, craniotomy
Subdural hemorrhage: 30% of head injuries
Accel/decel injury, DAI; crescent shape on CT
Acute, subacute, or chronic
Rx: open dura, craniotomy
Subarachnoid hemorrhage (SAH)
No mass effect
Due to trauma > berry aneurysm
Rx: anticonvulsants, EVD, observe
Head injury Rx
Reverse trendelenberg (head up)
Intubate / hyperventilate – keep PaCO2 30-35mmHg
Mannitol
Hypothermia
Sedation – phenobarbital, propofol
Enteral nutrition within 24-48 hours
Other injuries
---Neck injuries
Zone 1: sternal notch to cricoid – hi mortality due to vessels, trachea; need CT angio
Zone 2: cricoid to mandible – lower mortality due to easy exposure; CT angio or U/S
Zone 3: mandible to skull base – difficult exposure; CT angio
Violation of playsma requires further workup
---Spine and spinal cord injuries
Assume C spine fracture with injury above clavicles and priapism
Spinal shock: completely flaccid for days to weeks, then spastic
Rx: methylprednisolone within 8 hours may help
---Pediatric trauma
Keep child warm
No nasotracheal intubation
Normal SBP = 80+2(age in years); normal DBP =2/3 SBP
IV access: IO into tibia
IVF bolus: 20mg/kg up to 3 times
If still unstable, transfuse 10ml/kg
Child’s blood volume =8% (80ml/kg)
---Elderly
Meds may mask symptoms (e.g. beta blockers prevent tachycardia)
Meds may make problem worse (e.g. coumadin, ASA)
---Pregnant women
No vasopressors!
Keep patients in left lateral tilt position
Early NG tube decreases aspiration
Uterine rupture = fetal extremities palpable
---Extremity trauma
Limb threatening: crush injury, major dislocation, open fracture vascular injury, compartment syndrome
Check Doppler pressures (use blood pressure cuff and Doppler to measure pressure in injured extremity)
Tetanus prophylaxis
Reduce dislocations ASAP (reduces risk of AVN –avascular necrosis of hip)
Open fracture: STAT ABX, irrigation, reduction
Compartment syndrome: if compartment >30mmHg
1st sign = decreased sensation (usually 1st web space if leg injured)
Pain w/ passive stretch
Pulses may still be present even in ischemic leg (loss of pulse is a very late finding)
Myoglobin induced acute renal failure possible with severe muscle injury
Maintain UOP at >1ml/kg/hr