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Chapter 6: TRAUMA

Chapter 6: TRAUMA. 10/06/2009 Basic Science Jen Dixon, PGY-4. Why Should You Care? trauma call #3 killer $expensive$ major public health issue. Trauma Roadmap. Primary Survey Resuscitation Secondary Survey Diagnostic Evaluation Definitive Care . Airway Anyone?.

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Chapter 6: TRAUMA

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  1. Chapter 6: TRAUMA 10/06/2009 Basic Science Jen Dixon, PGY-4

  2. Why Should You Care? • trauma call • #3 killer • $expensive$ • major public health issue

  3. Trauma Roadmap • Primary Survey • Resuscitation • Secondary Survey • Diagnostic Evaluation • Definitive Care

  4. Airway Anyone?

  5. Primary Survey: Airway • C-spine immobilization (Philly collar) • If pt. responsive with normal voice, airway likely stable and no intubation needed… • Unless…….. • Expanding neck hematoma? • Thermal injury to mouth/nares? • Airway bleeding? • Complex maxillofacial trauma? INTUBATE!

  6. Primary Survey: Airway • Pt. w/abnormal voice, AMS (GCS<8): • Clear mouth of debris, suction airway • Nasotracheal intubation NOT FOR APNEIC Pt! • Orotracheal intubation w/ c-spine protection, RSI

  7. Primary Survey: Airway • Surgical Airway: Needle or Open Cricothyroidotomy ≤6mm *not for those <12 years old! Vertical Incision!

  8. Percutaneous transtracheal ventilation

  9. Primary Survey: ABC’s • Breathing: • Oxygen, pulse ox • Look for Life Threatening Issues • Tension ptx • Open ptx • Flail chest • Pulmonary contusion

  10. Tension Pneumothorax Exam Findings Absent breath sounds Distended Neck Veins Hypotension Respiratory Distress Sub-q emphysema Needs Chest Tube! Don’t wait for X-ray!

  11. Tension Pneumothorax • Neg intrapleural space becomes positive • Trachea, mediastinum shift contralateral • Heart rotates about SVC/IVC, ↓ VR, ↓CO • ‘IVC kinking’ • Simple ptx>tension ptx w pos pressure ventilation

  12. Chest Tube Placement 4-5th I.C. Space, Infra-mammary fold Ant. Axillary line Over the rib 36-40F chest tube

  13. ABC’s: Breathing • Open Pneumothorax • Cover with dressing taped on 3 sides only to prevent tension ptx • Needs wound closure, chest tube • Flail Chest • four or more ribs fractured in at least 2 locations • Paradoxical mov’t compromises respiration • Pulmonary contusion associated, monitor progression

  14. Primary Survey: ABC’s • Circulation: • Palpable pulses? • Carotid = SBP 60 • Femoral = SBP 70 • Radial = SBP 80 • HypoTN>>>think hemorrhage! • Control external bleeding w/pressure • Scalp bleeding needs addressed • Check BP, HR q15 min….at least • No Blind Clamping!

  15. IV Access • 16 G, B/l antecubital fossa for adults • Place cordis for rapid resusciation • Femoral access or even saphenous cutdown if needed • Kids <6yo: No femoral vein cannulation • Interosseous cannulation if 2 failed peripheral IV attempts

  16. ? Interactive Question: ? ? ? ? • What landmark is used to find the saphenous vein for a cutdown procedure? ? ? ? ?

  17. Answer: • The vein is consistently found 1 to 1.5 cm anterior to the medial malleolus • Proximal and distal traction sutures are placed. Distal suture is ligated. • Short 10- to 14-gauge intravenous catheters should be used • secure with both sutures and tape to prevent dislodgment

  18.  Intraosseous infusions <6 years old!

  19. Initial Fluid Resuscitation • 1L IV bolus of normal saline, Ringer's lactate, or other isotonic crystalloid in an adult • 20 mL/kg Ringer's lactate in a child • repeated one time in an adult and twice in a child before PRBC transfusion • Hypotension is not a reliable early sign of hypovolemia!

  20. Know This

  21. Initial Response to Resuscitation Responders Transient Responders Nonresponders Under-resuscitated? Ongoing hemorrhage? Nonsurvivable multisystem injury ? Tension pneumothorax? Uncontrolled hemorrhage? Cardiogenic? Normal vitals Normal mentation Normal UOP Good tissue perfusion Stable pt. Con’t work-up Distended neck veins? ↑ CVP?

  22. Cardiogenic Shock in Trauma • Tension Ptx • Pericardial tamponade • Myocardial contusion or infarction • Air embolism

  23. Pericardial Tamponade • Can have transient reponse to fluid • Beck’s triad, pulsus paradoxus not reliable • Subxiphoid or parasternal U/S view

  24. Pericardiocentesis 80% success rate for decompression Prepare for transport to OR! If SBP remains <70, do ED thoracotomy!

  25. Cardiac Injury Repair Horizontal Mattress Pledgets good for RV

  26. ED Thoracotomy

  27. Myocardial Contusion • occurs in ~1/3 of blunt chest trauma pts • EKG: ventricular dysrhythmias, a-fib, sinus brady, bundle-branch block • cardiac enzymes not helpful • Common dx, not usually life threatening • Tx: pharmacologic suppression • Echo STAT

  28. Air Embolism • lethal complication of pulmonary injury • air from an injured bronchus enters adjacent injured pulmonary vein>LV • Trendelenburg, trap air in LV apex • Emergency thoracotomy, cross-clamp pulmonary hilum, aspirate air w 18G from LV, aortic root apex

  29. Interactive Question • A 36 yo WM sustains blunt abd trauma, arrives A&O x 3, vitals stable except BP 80/55, 1 L NS bolus given, BP then stable at 125/80. CXR nl, Fast scan negative. Pt goes to CT. Is this a good time to grab a snack?

  30. Answer • No.

  31. Secondary Survey • Which of the following should not be done in the secondary survey of a seriously injured pt? • Pt undressed, head to toe exam • Rectal exam • Foley catheter • NG tube • None of the above; the chapter says to do them all

  32. Secondary Survey • Which of the following should not be done in the secondary survey of a seriously injured pt? • Pt undressed, head to toe exam • Rectal exam • Foley catheter • NG tube • None of the above; the chapter says to do them all

  33. Mechanism of Injury Question • What are the greatest risk factors reflecting magnitude of injury that are strongly associated with life-threatening injuries?

  34. Mechanism of Injury Question • What are the greatest risk factors reflecting magnitude of injury that are strongly associated with life-threatening injuries? • death of another occupant in the vehicle and an extrication time greater than 20 minutes.

  35. Secondary Survey Question • When attempting to clear a pt’s C-spine, which approach is best? • Move the pt’s head for them • Let the pt move their own head

  36. Secondary Survey Question • When attempting to clear a pt’s C-spine, which approach is best? • Move the pt’s head for them • Let the pt move their own head

  37. Secondary Survey Question • Otorrhea, rhinorrhea, raccoon eyes, and Battle's sign (ecchymosis behind the ear) can be seen with what type of fractures?

  38. Secondary Survey Question • Otorrhea, rhinorrhea, raccoon eyes, and Battle's sign (ecchymosis behind the ear) can be seen with what type of fractures? • basilar skull fractures

  39. Neck Trauma • What are the zones of the neck, how does injury work-up and management differ among them?

  40. Neck Trauma *unstable pt goes to the OR! Zone 3=carotid/vertebral angio if evidence of arterial bleeding Zone 2: platysma penetration? If yes 12 hr obs vs carotid/vertebral angio, direct laryngoscopy, tracheo-esophagoscopy & esophagram may be necessary (i.e. R>L GSW) above hyoid b/t clavicles&hyoid Zone 1=angiography of great vessels, soluble contrast esophagram >>barium esophagram, Esophagoscopy & bronchoscopy below the clavicles

  41. Don’t Text & Drive!

  42. Multiple Injuries • Blunt trauma pt. w recurrent hypoTN, free fluid in the abd, suspected aortic tear on CXR and splenic injury on FAST scan • What do you fix first?

  43. Multiple Injuries • Blunt trauma pt. w recurrent hypoTN, aortic tear suspected, splenic injury, free fluid in abd • Ex lap, splenectomy first, then aortic repair

  44. Multiple Injuries • Efficient OR session • Optimize metabolic status ASAP • Treat hypothermia, acidosis, coagulopathy • PRBC’s (type O or matched), FFP, platelets!

  45. Prophylactic Measures • 2nd generation cephalosporins pre-op for laparotomy, 1st gen for all other surgeries • Tetanus • DVT prophylaxis (SCDs, lovenox) • Blankie! (keep ‘em warm)

  46. Chest Trauma

  47. Blunt Chest Trauma • What are the most common locations for an aortic tear from shearing forces?

  48. Blunt Chest Trauma • What are the most common locations for an aortic tear from shearing forces? • just distal to the left subclavian artery (ligamentum arteriosum) • In 2 to 5% of cases the tear occurs in the ascending aorta, transverse arch, or at the diaphragm.

  49. Blunt Chest Trauma • indications for thoracotomy include pericardial tamponade, tear of the descending thoracic aorta, rupture of a mainstem bronchus, and rupture of the esophagus.

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