Trauma “This ain’t ER”

1. Trauma“This ain’t ER” Ben Zarzaur, MD UNC Department of Surgery Section of Trauma and Critical Care

2. What is trauma?

4. Real Life & Death

5. What is trauma?

6. Trauma Epidemiology

7. Years of Potential Life Lost MMWR 1982;31,599.

8. Mechanisms of Injury: Blunt Trauma • MVC • Pedestrian vs Vehicle • Falls

9. Mechanisms of Injury:Special Situations • Explosions • Blunt + penetrating + burns • Burns • Crush injuries • Drowning • Hypothermia/ exposure

10. Compression injury • Frontal brain contusion • Pneumothorax • Rupture of Left hemidiaphragm • Small bowel rupture • Chance fracture

11. Deceleration Injury • Aortic tear • Fixed descending aorta • Mobile arch • Acute subdural brain hematoma • Kidney avulsion • Splenic pedicle

12. Mechanisms of Injury: Penetrating Trauma • Gun shot wounds • Stab wounds • Impalement

13. Gun Shot Wounds: Mechanism • Energy transfer • Shape/size of bullet • Distance to target • Velocity (most important) • Kinetic energy = (Mass × Velocity2 )/2 • Surface area distributed • Tumble and yaw • Fragmentation • Anatomy • Viscoelasticity • Muscle • organs

14. Stab wounds • Mechanism • Blunt: Crush injury • Sharp:Tissue disruption • Extent of Injury • Weapon size, length, sharpness, penetration • Severe injury • Chest and abdomen • 4+ wounds

16. What happens when the patient comes to a Level I Trauma Center?

17. Trauma Team“Doin it 24/7” • ED Physicians • Anesthesiology • Surgeons • General and Trauma and Critical Care • Neurosurgery • Orthopedics • Medical Students • Nurses • Radiology Techs • Radiologists

19. What happens when this patient comes to the ER where you are moonlighting?

21. What the heck do I do now?

22. Don’t panic!

23. Trauma is not rocket science!

24. Air goes in & out • Oxygen is good • Blood goes round & round • Stop bleeding • Put things back where and how they belong

25. Initial Assessment: Prerequisites • Wide-angled view • Pattern recognition skills • Ability to triage and set priorities • Organized structure

26. Trauma is not rocket science!

27. ABCDEF

28. Initial Assessment: Primary Survey • A = Airway • B = Breathing • C = Circulation • D = Disability • E = Exposure • F = Fracture

29. Initial Assessment: Airway • Clear & establish a good airway • Consider intubation for coma, shock, and thoracic injuries • C-spine stabilization

31. Airway: Cricothyrotomy

32. Initial Assessment: Breathing • Chest excursion & breath sounds • Flail chest • Pneumothorax • Open • Tension • Massive Hemothorax

35. Initial Assessment: Circulation • Perfusion (mental status, skin, pulse) • Control bleeding with pressure • Pericardial Tamponade • Beck’s Triad • Establish 2 large bore (16G or larger) IV’s in upper extremity peripheral veins • Resuscitate with Lactated Ringers • After 4 L think about resuscitation with blood

36. Initial Assessment: Disability • Neurologic status • Glasgow Coma Scale • Eye • Motor-best predictor of long term outcome • Verbal • Spinal Cord Injury

37. Initial Assessment: Exposure • Remove clothes • Temperature • warm blankets • Finger and tube in every orifice • Maintain full spine precautions • Log Roll

38. Initial Assessment: Fracture • Stabilize Fractures • Relocate dislocated joints • Reassess pulses

39. Secondary Survey • Patient history • Head to toe physical exam • Radiography • Lateral C-spine, C-xray, pelvis • One cavity above/below entrance/exit wounds • FAST • Urinary bladder drainage • NGT • Blood sampling/monitoring

40. Does this patient need to go to the OR ?

42. Penetrating Abdominal Trauma

43. Blunt Abdominal Injuries

44. Liver Injury

45. Liver Injury • blunt or penetrating injury • mortality: 10 - 20% • may be associated with right lower rib fracture • Signs / Symptoms • RUQ pain abdominal wall spasm ,guarding hypoactive or absent BS signs of hemorrhage

47. Liver Injury: ManagementBlunt Injury • ICU monitoring • For more severe injuries • Serial HCT • Floor Monitoring • Less severe injuries • Serial HCT • OR if patient becomes unstable or requires excessive blood transfusions

48. Surgical Management

49. Surgical Management

50. Surgical Management