Med 542 Review

Trauma
Ken Stewart MD, FRCSC Assistant Professor Division of Thoracic Surgery, University of Alberta

Trauma
Precipitous, ubiquitous phenomenon affecting all ages, races.
Various forms (blunt, penetrating, burns) Disease or process in evolution Outcomes based on severity of injury, preexisting conditions, and timing and appropriateness of treatment.

Objectives
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 --2
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 --3
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

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

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

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

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

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

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

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

Assessment and Treatment

Ongoing assessment from the time of original notification to response to any treatment measures. Mechanism of injury, timing and preexisting conditions are important historical features

Systematic Assessment by Trauma Team Leader

Primary Survey
Airway
Ensure patency

Secondary Survey
ABC again Disability
C-spine precautions and neuro assessment

Breathing
Rule out distress

Circulation
Provision for large bore (14-16 gauge) IV access Crossmatch for blood for severely injured

Exposure exam front and back of patient, then keep warm Fingers in every orifice and foley catheter

Assessment Principles
Primary survey
Try to recognize the immediately life-threatening injuries
1. 2. 3. 4. 5. Tension Pneumothorax Massive Hemothorax Open Pneumothorax Cardiac Tamponade Flail Chest Airway,Breathing,Circulation

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

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.

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

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

Airways
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Endotracheal intubation
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Endotracheal intubation
Indications
Hypoxemia Hypercapnea Impending respiratory arrest Cardiac arrest, multi trauma Readying for OR

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Need suction, Laryngoscope, Muscle paralysis (?rapid sequence induction)

Surgical Airways
Cricothyroidotomy
Needle tube

Tracheostomy

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Cricothyroidotomy
Indications
Severe facial or nasal injuries (that do not allow oral or nasal intubation) Massive midfacial trauma Anaphylaxis Chemical inhalation injuries
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Contraindications
inability to identify landmarks (cricothyroid membrane) Underlying anatomical abnormality (tumor) Tracheal transection, acute laryngeal disease by infection or trauma

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.

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Assessment of treatment
Auscultate CXR End tidal CO2 SaO2
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Tracheostomy
Definitive surgical airway Dedicted appliance or endotracheal tube Indications similar for cricothyroidotomy
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

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

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)

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

Hemodynamic mechanism
Axis of the cavae, point of fixation with the aorta and great vessels Lack of right heart filling, leading to shock
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Tension pneumothorax
Treatment
Suspected: needle decompression
14 gauge angiocath Midclavicular line Use syringe with plunger removed

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

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?

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

Chest tube thoracostomy

Indications
Pneumothorax Hemothorax Unstable patient following blunt or penetrating trauma Non trauma
Pleural effusion, chylothorax, empyema,post operative

Technique
Local anesthetic* Sterile field* Scalpel, kelly or hemostat forcep Chest tube and pleurevac device Securing suture
*if time permits

Relative contraindication=diaphra gm disruption

Chest tube insertion

Location is typically, nipple height, midaxilla sparing the latissimus, and pectoralis muscle No tunnels needed CXR post procedure Connect to pleurevac

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Trauma thoracotomy
Emergency situation with penetrating chest injury
Rarely of benefit in blunt trauma Suspect major vessel laceration or cardiac laceration
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Indications
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

Shock
Hypovolemic
Following blood loss Burns and hypothermia Distributive
Sepsis Neurogenic

Obstructive
Pulmonary embolism Tamponade, tension pneumothorax

Cardiogenic
Pump failure Ischemia, contusion, acute valvular dysfunction

Endocrine
Manifests like distributive shock Hypothyroidism, hypoadrenalism

Diagnosis
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

Treatment
Directed at specific diagnosis
Fluid resuscitation
Crystalloid, colloid Blood and blood products

Definitive treatment where possible depending on etiology.

Vasopressors
Specific agents for specific types of shock

Blunt Injuries to the abdomen

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

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
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

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)

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

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

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Indications for laparotomy following trauma

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