Trauma Board Review Part I

1. Trauma Board ReviewPart I Dr. Grumpy

2. Disclosure • Drug rep dinners • Linezolid • Ertapenem • Keppra • Levofloxacin • STC

3. Blunt Trauma • High speed head-on MVC. 2 cars. 3 passengers in each car. Front passenger of car #1 pronounced on scene. The rest are coming to your trauma center.

4. Patient #1 Driver of car #1. 23yoM. Moaning and sonorous respirations; will not open his eyes to pain but withdraws to pain. GCS? • 4 • 5 • 6 • 7 • 8

5. GCS • Eyes • Verbal • Motor

6. You notice severe midface fractures. You want to intubate patient with RSI. You know that: • Thiopental can raise both systemic and intracerebral blood pressure. • Etomidate is contraindicated. • Ketamine reduces intracerebral pressure, but may cause severe laryngospasm. • Pretreatment with lidocaine is not indicated. • Succinylcholine should be avoided unless a defasciculating dose of a nondepolarizing agent has first been given.

7. Trauma Intubation • Lidocaine effectively attenuates the cough reflex, hypertensive response, and increased ICP associated with intubation. • Thiopental may also be effective but should not be used in hypotensive patients (consider it to be a less severe form of propofol) • If succinylcholine is used, premedication with a subparalytic dose of a nondepolarizing agent should be considered if time permits, since fasciculations produced by succinylcholine may increase ICP • Blunts ICP and cough response, no evidence for clinical difference • Etomidate has beneficial effects on ICP by reducing cerebral blood flow and metabolism. • Ketamine should be avoided because it increases ICP (although studies have bore out no outcome difference) • *Careful intubating peri-hypotensive trauma patients

8. Quick word on Etomidate • Don’t use it • Don’t use it • Don’t use it • Don’t use it

9. Contraindications to nasotracheal intubation in a trauma patient include • Apnea • Cervical spine fracture • Depressed mental status • Hypotension • Pneumothorax

10. Nasotracheal intubation • Must be breathing spontaneously • Contraindications • Apnea, basilar skull fractures (or suspicion) • Just don’t do it

11. Astutely, you suspect head trauma. The most common CT scan abnormality found after severe closed head injury is: • cerebral contusion • epidural hematoma • intracerebral hemorrhage • subdural hematoma • traumatic subarachnoid hemorrhage

12. Head Trauma • 50% (#1) of trauma deaths • Cushing’s (late and unreliable) – htn, bradycardia, apnea

13. Head Trauma • Urgent head CT is indicated if: • headache • vomiting • drug or alcohol intoxication • short-term memory deficits • posttraumatic seizure • coagulopathy • physical evidence of trauma above the clavicle • older than 60 years • GCS <14 or <15 s/p 2 hours • Amnesia before impact >30min • Witnessed LOC > 15min • Object recall < 3/3 • Signs of basilar skull fx

14. Epidural hemorrhage • Arterial bleed (middle meningeal artery) between skull and dura • “Coup” • Underlying brain injury usually not severe • Presentation • LOC then lucid interval • Dilated ipsilateral pupil (lateralize if high) and contralateral hemiparesis – late findings • CT: biconcave or lenticular

15. Subdural Hemorrahge • Bridging veins between dura and ararchnoid • “Contracoup” • Presentation • Decreased mental status and LOC • May have lucid period also?!?! • 6x more common than epidural • Higher mortality rate than epidurals • CT scan: sickle shaped

16. Subarachnoid hemorrhage • Blood within the CSF, caused by disruption of subarachnoid vessels • Most common CT finding in mod/severe TBI

17. Herniation • Transtentorial • Uncus → tentorial notch • CN III, brainstem symptoms • Ipsilateral pupil fixed and dilated • Respiratory depression • Tonsillar (Central) (rare) • Cerebellar tonsil → foramen magnum • Small bilateral pupils, posturing, bradycardia, respiratory arrest

18. Head Injury Tidbits • Isolated linear nondepressed skull fx: no treatment • Basilar skull fx: temporal bone, hemotympanum, CSF otorrhea/rhinorrhea, periorbital ecchymosis, retriauricular ecchymosis • Diffuse axonal injury is the most common brain injury resulting in coma. • Bullet to brainstem/basal ganglia  zero survival

19. Increased ICP • Abnormal > 15, treat > 20 • CPP = MAP – ICP, keep it >60 • Systolic > 90 and goal = 120 • MAP >85 • ICP <20 • Use pressors if needed keep CPP < 70 • Avoid Sat < 90% or PaO2 < 60 • PCO2 30-35 (too low  excessive vasoconstriction) • Hyperventilation only as temporary salvage • Mannitol (0.25-1g/kg) • “Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurological deterioration not attributable to extracranial causes.” • Dilutes blood and decreases viscosity  increased blood flow  reactive vasoconstriction and decrease ICP • Replace loss of fluids • Contraindicated when hypotensive • Hypertonic

20. Pt is intubated. BP 78/48, HR 122, R 16, T 37.5. Neck veins flat. Most likely cause of hypotension? • Cardiac tamponade • Cardiogenic shock • Hypovolemia • Spinal Shock • Tension PTX

21. Blunt Traumatic Shock • Hemorrhagic shock until proven otherwise. • Spinal Shock – bradycardic, hypotension • Cardiogenic shock/tamponade • FAST • Distended neck veins • Tension PTX • Distended neck veins, tracheal deviation, tachypnea, decrease BS on side of PTX

22. After resuscitation, vitals stabilize. CT reveals traumatic rupture of aorta. Which finding is most indicative of this entity on the patient’s initial CXR? • Deviation of esophagus 1-2cm to the right • 1st and 2nd rib fractures • L clavicle fx • Pulmonary contusion • Upward displacement of the L mainstem bronchus 40o

23. Thoracic Aortic Disruption • Rapid deceleration injuries. • Most common cause of death in blunt trauma, 80% die at scene, 10-20% die w/in 1st hour. • Signs & sx: include chest pain, back pain, dyspnea, intrascapular murmur, and extremity pain caused by ischemia. • CXR: widen mediastinum (8 cm) most common. Nl in 2–7% of patients with aortic injury. • Aortogram gold standard, but now CT • False positives with mediastinal hematoma • Tx: BP management and surgical repair.

24. Aortic Rupture X-ray • Widened mediastinum • Obscured aortic knob • Opacification of the aortic-pulmonary window/apical capping • Widened paratracheal stripe • Displacement of the esophagus/NG tube to the right • Inferior displacement of the left mainstem bronchus. • L hemothorax, 1st & 2nd rib fx

25. Traumatic Aortic Transection • 80-90% tear at isthmus from deceleration and instant death • Survivors to ED – tear at ligamentum arteriosum • Retrosternal pain, dyspnea, stridor, dysphagia • Harsh systolic murmur • Pulse difference between upper and lower extremities • May have delayed presentation

26. Ruptured Diaphragm • Left > Right, as liver protects the right side • Location: 80-90% left posterolateral • CXR abnormal in 60%, but often not diagnostic • 50% diagnosed at laparotomy • Treatment: surgical repair • Often missed or delayed

27. Tracheobronchial Injury • Seen with deceleration/shear forces • Most blunt injury occurs within 2cm of carina • This is where it is teathered • Mortality with rupture=30% • Continuous bubbling in chest tube is a sign of a bronchopleural fistula

28. Tracheobronchial Injury

29. Patient #2 50yoM, driver of 2nd car, has bruising over his sternum. Hit chest against steering wheel. VS unremarkable. Asymptomatic except for anterior chest wall tenderness at site of bruising. CXR and sternal view reveal sternal fx. EKG is nl. Which of the following is the MOST appropriate management plan for this pt? • Admit for 24 hr telemetry monitoring • Perform 2 sets of CE and TPN tests, and dc if neg. • Perform echocardiogram in the ED, and dc if neg. • After a repeat EKG in 6 hrs, dc the pt with pain medication, without any further testing.

30. Blunt Myocardial Injury (aka Myocardial Contusion) • Clinical features: pt in MVA > 35 MPH c/o chest pain • Sternal rub or rib fracture, dyspnea, tachycardia (70%), S3 gallop, rales, elevated CVP • CXR greatest value for finding assoc injuries: pulmonary contusion, rib fx • Sternal fx no longer considered important. • Initial EKG predictive of subsequent clinically significant EKG events – recommend initial EKG followed by repeat EKG in 4-6 hrs. • PVCs, 1st degree av block, RBBB (RV closest to anterior chest wall), T wave flattening or elevation,  QT

31. Myocardial contusion • Dx: echo (but not as screening), increased CE (poor sensitivity) • Most heal without specific treatment • Complications: effusion, infarction, dysrhythmia, aneurysm, thrombosis, vasospasms • Monitor for 12h  d/c (not life-threatening) • If young, ekg and 1 or 2 CE (normal)  d/c • Abnormal  telemetry • Unstable  echo • If decreased CO  dobutamine or IABP

32. Patient #3 Complains of tinnitus and headache. Normal neuro exam. What is the injury? • Frontal bone fracture • Parietal contusion • Subarachnoid hemorrhage • Subdural hemorrhage • Temporal bone fracture

33. Basilar Skull Fx • Most common fracture involves the petrous portion of the temporal bone, the external auditory canal, and the tympanic membrane • Fractures  dural tear  communication between subarachnoid space, paranasal sinuses, and middle ear • Compress and entrap cranial nerves passing through basal foramina • CSF otorrhea or rhinorrhea, mastoid ecchymosis (Battle sign), periorbital ecchymoses (raccoon eyes), hemotympanum, vertigo, tinnitus, decreased hearing, and 7th nerve palsy. • Ring test-halo on sheet-target lesion

34. Basilar Skull Fracture Need thin temporal bone cuts

35. Battle’s Sign Can take 12 hours to show up

36. HEMOTYMPANUM

37. Skull fractures • Abuse=stellate, complex fractures • Linear non-depressed does not require treatment • Temporal skull fracture=middle menigeal=epidural hematoma • Open or depressed skull fracture (one bone table width)→antibiotics + neurosurgery • At risk for post-traumatic seizures • Occipital skull fracture: SAH, contrecoup injury, posterior fossa hematoma, cranial nerve injury

38. On exam, your abdominal findings are c/w lap belt injury. Compared to other patients with blunt abdominal trauma, this patient is at increased risk for injury to which of the following organs? • Intestine • Kidney • Liver • Pancreas • Spleen

39. ANSWER: A A. intestine. When lap belt bruises are present, there is a higher incidence of intestinal injury. Although seat belt sign is seen in only 1/3 of cases, its presence is highly correlated with injury. Diaphragmatic injury can been seen secondary to compressive forces. B. kidney C. liver D. pancreas E. spleen

40. Abdominal Trauma • Lap belt injury: hollow viscous rupture, mesenteric tear, lumbar fracture, bladder injury or rupture (chest seatbelt sign ok) • Laparotomy indications: evisceration, GSW, impalement, gross blood by NG, rectal, DPL

41. Abdominal Trauma Imaging • CT scan increasingly important in trauma management • Insensitive to hollow organ injury, pancreas, diaphragm • Sensitive to retroperitoneum, solid organs, bony structures • Role of FAST

42. Easy to Image • Liver • Most common in penetrating (large) • Spleen • Most common in blunt

43. Hard to Image • Pancreas • Blunt > penetrating • Handle bars, steering wheel, think peds • Nonspecific pain due to delayed diagnosis • DPL may be falsely negative and amylase usually normal • Small intestine • Multiple in penetrating • Often delayed symptoms • Associated with lap belt injury and lumbar spine fx (chance) • Colon • Usually transverse (pinned by spine and gas)

44. DPL/DPA • Relative contraindications: obesity, pregnancy, previous abdominal surgery, pelvic fracture • False negative • Pancreas • Bowel • Retroperitoneum • Splenic hematoma • False positive: pelvic fracture • Positive lavage: • 10ml gross blood • Blunt > 100,000 RBC/ml • Penetrating > 10,000 RBC/ml (this number a moving target) • WBC > 500/ml • Bile, feces, urine • Increased amylase • Too sensitive! Grade I-II liver and spleen lacs

45. Abdominal Signs • Grey Turner’s sign: flank discoloration, a late sign of retroperitoneal hematoma; can be seen with hemorrhagic pancreatitis • Kehr’s sign: referred left shoulder pain due to subdiaphragmatic irriatation/splenic rupture • Cullen’s sign: periumbilical ecchymosis due to retroperitoneal bleeding; can also be see with hemorrhagic pancreatitis, ectopic pregnancy

46. Seat Belt Sign • Low-lying transverse abdominal ecchymosis has a strong association with hollow viscus injury and mesenteric tears . • Hollow viscus injury often does not produce any pain or tenderness until 6-8 hours following the traumatic event. • At minimum, patients with lap-belt contusions should undergo serial abdominal examinations. • Findings of abdominal tenderness should prompt diagnostic study (e.g., abdominal CT and/or DPL) or laparotomy.

47. Still on Patient #4. Blood is noted at the urethral meatus, and there is perineal ecchymosis. Which of the following is the next management step? • Insertion of a coude catheter • IV pyelogram • Pelvic CT scan • Retrograde urethrogram • Urinalysis with sample obtained by suprapubic route.

48. GU trauma • Signs of GU trauma somewhere – hematuria • Urethral injury • Signs • Perineal ecchymosis • Unable to urinate • Blood at meatus • High-riding/absent prostate • Blood in scrotum/scrotal hematoma • Obvious penile trauma • Pelvic fracture • Dx • Retrograde urethrogram • Do not blindly put foley (unless you’re really skilled) – partial tear into complete disruption • Tx • Foley over wire. Foley in for 2 weeks. • Suprapubic catheter placement and surgical repair. • Posterior urethral injury from blunt trauma

49. Normal urethrogram

50. Urethral tear