Trauma

1. William Beaumont Hospital Department of Emergency Medicine Trauma

2. CASE 40 y/o male on a MCA, car pulled out to turn in front of him, he hit the side of the car and flew over it landing on his face. He is still fully clothed with his leathers on, C-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity. Where should we begin???

3. Where to begin…. • A, B, C ‘s • O2 – NC, mask, intubation • IV – how many or central line? • Monitor – HR, BP, sPO2, RR q15 (min) • Initial actions = secure the airway, maintain ventilations, control hemorrhage, and treat shock What is the Golden Hour?

4. “Golden Hour” • Emphasize the initial evaluation and treatment of the trauma patient • Our “window of opportunity” to have a significant impact on morbidity and mortality • Must have a concise, expeditious, well thought out plan for evaluation and treatment of life threatening injuries • Accomplished through ATLS guidelines of the primary and secondary surveys

5. Primary Survey: ABCDEs • A = airway and cervical spine protection • B = breathing and ventilation • C = circulation and hemorrhage control • D = disability and neurological status • E = exposure and environmental control

6. Primary Survey: ABCDE’s • An identified injury should be treated at the time of discovery • Examples: • The airway should be secured before the fracture is stabilized • PTX should be treated before the patient is completely exposed • The decision to transfer a patient should be made before proceeding to the secondary survey

7. Secondary Survey: Head to Toe • Complete the history (AMPLE) • Head to toe physical exam • Reassess vital signs and interventions • Obtain GCS if not done in primary survey • Special procedures (lines), specific x-rays, and labs should be obtained

8. Secondary Survey: Rectal Tone • Rectal exam is done in every trauma and before urinary catheter placement (WHY?) • Check for blood  tear or pelvic fracture • High riding prostate  potential urethral injury • Decreased tone  brain or spinal injury

9. Ok, Everyone Remember Our Case 40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity. Where should we begin??? The Emergency physician starts at the head of the bed to assess A. Assume that there are 15 people cutting clothes, starting the IVs, and exposing the patient.

10. Tackling the Case at Hand 40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity. Where should we begin? A – Deformity to the face, nose looks flat, lots of abrasions, eyes swollen closed, broken teeth, blood in the mouth, noisy breathing, and no response to questions

11. Airway • Oral intubation of the patient using RSI with in line cervical traction • An orogastric tube is placed at the time of intubation • Why not an NGT in this patient?

12. Breathing A - Patient is intubated What’s next? B - Breathing • Despite intubation, O2 sats are still low and the patient is difficult to BVM • Decreased breath sounds on the R chest, crunching under the bell of your stethoscope, and the trachea appears deviated… • What’s the problem? How do we fix it?

13. Breathing A - Patient is intubated • Hemo/pneumothorax • Needle decompression followed by tube thoracostomy of the R chest

14. Circulation A – Patient is intubated B – Chest tube placed What’s next? C – Circulation • Vitals: BP 90/40, HR 130 • RN established two 16g IVs • How about 2L of fluid and a type and cross for 4 units of pRBCs • What do you give if immediate transfusion is needed?

15. Disability and Neuro Exam A – Patient is intubated B – Chest tube placed C – Fluids and blood given Now for D – Disability and Neuro exam • Patient is intubated and paralyzed • GCS = 3TP (T = tube, P = paralyzed) • GCS =/<8  intubated for airway protection What is a GCS you ask?

16. Glasgow Coma Scale

17. Exposure and Environmental A – Patient is intubated B – Chest tube placed C – Fluids and blood given D – GCS = 3TP E – Exposure and Environmental • All clothes are cut off • Warm blanket applied to the pt • Deformity to L femur probably from a fracture  splint re-applied

18. Tackling the Case at Hand • Secondary survey • Orders • Repeat vital signs • FAST exam • Talk to EMS for additional information

19. What should we order for our patient?

20. Labs and Imaging • Basic: CBC, BMP, PT/PTT, T&S, ETOH, B-hcg • Other labs ordered at the discretion of the practitioner, institution, or clinical situation such as drug screen, lactic acid, or hepatic panel • XR standard: c-spine, CXR, pelvis • Obviously x-ray anything that looks injured • CT: • Head and abd/pelvis are standard for a severely injured intubated patient • Chest CT for chest trauma or CXR findings • Neck CT based upon mechanism, age, injury

21. What are the 4 views of the FAST exam?

22. FAST Exam • Primary role is detection of hemoperitoneum • Sensitivity of 75-90% compared to CT (depending on the user and injury) • Four Views of the FAST • Morison’s Pouch = hepatorenal • Splenorenal • Rectovesicular = Pouch of Douglas • Cardiac • Can also perform pleural windows for PTX

23. FAST: Cardiac Subcostal View Normal Abnormal

24. FAST: Morison’s Pouch Normal Abnormal

25. FAST: Retrovesical Normal Abnormal

26. OOPS!

27. CT vs. DPL vs. FAST • DPL • Very sensitive but not specific • Invasive • Good for visceral injury • Unstable trauma where US is unavailable or equivocal • CT • Noninvasive • Delineates solid organ injury • Expensive • Patient must be stable • FAST • Quick • Sensitive • Bedside • Operator dependent • Misses bowel, mesentery, diaphragm and pancreatic injuries

28. Let’s Move on to the Specifics… Any Questions?

29. Head Case 15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region.

30. Head Case On exam he moans, withdraws to pain, but does not open his eyes… What is his GCS?

31. Head Case On exam he moans, withdraws to pain, but does not open his eyes… What is his GCS? What should you do FIRST?

32. Head Case • GCS = 7 • What should you do first? • Intubate using RSI • Brief neuro exam, if possible, before paralysis • ?? Lidocaine prophylaxis for intubation • Blunts the cough reflex, hypertensive response, and increased ICP associated with intubation

33. This is his head CT…What does it show?

34. Subarachnoid Hemorrhage • Most common CT abnormality in head injury • Amount of blood correlates directly with outcome • Patients c/o HA and photophobia • Nimodipine is used to prevent vasospasm which worsens ischemia

35. Compare It To This… Subdural Hematoma Epidural Hematoma

36. Head Injury • Complete the primary/secondary survey • Initial goal is to maximize O2 and BP to prevent secondary ischemic brain injury • Primary Brain Injury = mechanical irreversible damage that occurs at the time of the trauma (laceration, contusion, hemorrhage) • Secondary Brain Injury = intracellular and extracellular metabolic derangements initiated at the time of the trauma • All therapies for TBI are aimed at reversing or preventing secondary brain injury

37. Head Injury: Increased ICP • Increased ICP = CSF pressure > 15 mm Hg • The cranium can accommodate ~50-100mL of blood before ICP increases • CPP = MAP – ICP • CPP < 40, autoregulation is lost • Remember CBF depends on the MAP therefore maximize the BP.

38. What is Cushing’s Reflex? Recognizing Increased ICP

39. Cushing’s Reflex • Hypertension • Bradycardia • Diminished respiratory effort • ICP has reached life threatening levels • Occurs in 1/3 of cases

40. Recognizing Increased ICP • Ipsilateral to mass lesion • Anisocoria, ptosis, impaired EOMs, sluggish pupil • Contralateral to mass lesion • Hemiparesis • Positive Babinski • As ICP continues to increase… • Posturing – decorticate then decerebrate • Ataxic respiratory patterns • Rapid fluctuations in BP and HR, arrhythmias • Lethargy  coma  death

41. Methods to Reduce ICP • Hyperventilation = PCO2 30-35 • Lowering PCO2 by 1mmHg decrease cerebral vessel diameter 2%  decreased ICP • Good initially but over time will cause reflex vasodilation • Diuretics = mannitol • Cranial decompression • Seizure prophylaxis = Ativan, Dilantin

42. Head Injury: Reasons to CT • History of LOC or amnesia to the event • Intoxication: drug and alcohol • Headache, vomiting, focal neuro deficit • Moderate (GCS 9-13) and high risk (GCS<8) • Age > 60 or < 2 • Anti-coagulants – ASA, Plavix, Coumadin • Post-traumatic seizure

43. Head Injury: CT Unnecessary? • Low risk (GCS 14-15) • Not intoxicated • Fully awake without focal neuro deficits • No evidence of skull fracture • Able to be observed for 12-24 hours

44. Back to our Head Case 15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region. On further exam…. You notice that he has bruising behind his left ear, blood in the ear canal, and hemotympanum. What does this suggest?

45. Basilar Skull Fracture • Linear fracture through the base of the skull and can involve the temporal bone • Significance = requires a lot of force to break and can involve the internal carotid artery • Signs: blood in the ear canal, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4 and 5 • Management: • Head CT and admission • Most CSF otorrhea and rhinorrhea will resolve spontaneously within a week • Prophylactic antibiotics are not usually given

46. What Does This Sound Like? 40 y/o cashier at 7-11 is hit in the side of the head with a baseball bat. He was initially knocked out, but then woke up complaining of HA, dizziness, and feels nauseated. EMS says he just passed out again in the bus before arriving and now is minimally responsive to stimuli.

47. Epidural Hematoma • 80% associated with skull fractures across the middle meningeal artery or a dural sinus in the temporoparietal region • The classic lucid interval occurs in 30% • Patients needs to go to the OR for evacuation

48. How About This? 80 y/o lady who fell yesterday at home. Today her family says that she is confused and moving more slowly than usual. 50 y/o drunk male brought in by police for stumbling on the side of the road. He eventually fell down and was unable to get back up.

49. Subdural Hematoma • Occur commonly in people with atrophic brains = old people and drunks • Bridging vessels traverse a greater distance so are more easily torn (venous blood) • Slow bleeding can delay presentation • Optimal treatment is evacuation in the OR

50. Any Questions? Head Injuries