Med 542 Review Trauma

1. Med 542 ReviewTrauma Ken Stewart MD, FRCSC Assistant Professor Division of Thoracic Surgery, University of Alberta

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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”

15. 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

16. 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

17. 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.

18. 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

19. Airway--treatment Classified as “Simple to Surgical” Mask, Oropharyngeal airway, nasopharyngeal airway, laryngeal mask, endotracheal tube, cricothyrotomy, tracheostomy

20. Airways

21. Endotracheal intubation

22. Endotracheal intubation Indications • Hypoxemia • Hypercapnea • Impending respiratory arrest • Cardiac arrest, multi trauma • Readying for OR Need suction, Laryngoscope, Muscle paralysis (?rapid sequence induction)

23. Surgical Airways Cricothyroidotomy • Needle • tube Tracheostomy

24. 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

25. 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.

26. Assessment of treatment Auscultate CXR End tidal CO2 SaO2

27. Tracheostomy Definitive surgical airway Dedicted appliance or endotracheal tube Indications similar for cricothyroidotomy

28. 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

29. 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)

30. 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

31. Hemodynamic mechanism Axis of the cavae, point of fixation with the aorta and great vessels Lack of right heart filling, leading to shock

32. 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?

33. 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

34. 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

35. 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

36. Trauma thoracotomy • Emergency situation with penetrating chest injury • Rarely of benefit in blunt trauma • Suspect major vessel laceration or cardiac laceration

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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)

44. Role of CT scan • Use for blunt injury management • Assess liver and spleen injuries • Presence of pneumoperitoneum, free fluid • Vascular injuries • Retroperitoneal injuries

45. 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