Trauma This ain t ER Ben Zarzaur MD UNC

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

What is trauma?

Real Life & Death

What is trauma?

Trauma Epidemiology

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

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

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

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

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

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

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

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

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

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

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

What the heck do I do now?

Don’t panic!

Trauma is not rocket science!

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

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

Trauma is not rocket science!

ABCDEF

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

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

Airway: Cricothyrotomy

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

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

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

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

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

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

Does this patient need to go to the OR ?

Penetrating Abdominal Trauma GSW OR KSW HD Unstable HD Stable/No peritonitis OR Peritoneal Penetration Positive Negative OR Observation

Blunt Abdominal Injuries Blunt Trauma Peritonitis OR Indeterminate HD Stable HD Unstable CT FAST/DPL Positive Negative OR Keep Looking

Liver Injury

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

Liver Injury: Management Blunt 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

Surgical Management

Spleen Injury

Splenic Injury • Blunt or Penetrating • Signs / Symptoms – LUQ pain – Kehr’s sign – involuntary guarding hypoactive or absent BS – signs of hemorrhage – point tenderness

Splenic Injury Management • ICU monitoring – Serial Physical exams – Serial HCT • Floor Monitoring – Not indicated at this time • Further intervention needed if patient becomes unstable or requires blood transfusion – Embolization vs Splenectomy

Splenectomy • Complications – postsplenectomy infection • Vaccination – wound infection – subdiaphragmatic abscess – pulmonary complications – hypovolemic shock

Stomach and Small Bowel Injury • Stomach & Small Bowel – Blunt vs penetrating • Diagnosis – Pneumoperitoneum or free fluid on CT scan – small bowel injury may be difficult to detect – Found at laparotomy • Management – Primary repair or resection

Colon and Rectal Injury • Colon – Diagnosis • Pneumoperitoneum or free fluid on CT scan • injury may be difficult to detect • Found at laparotomy – Management • Colostomy vs primary repair • Rectum – Intraperitoneal- treat as colon injury – Extraperitoneal- primary repair with diversion • +/- presacral drains

Pancreas & Duodenum • Diagnosis – often delayed diagnosis – frequently seen together – most often contused due to blunt injury – Seen on CT Scan or at laparotomy – intramural hematoma in wall of duodenum obstruction bilious vomiting severe abdominal pain distention

Pancreas Injury • Management – if the result of blunt trauma • nonoperative management NG/OG decompression serial physical exams monitoring signs of infection controversial - 3 weeks of bowel rest with TPN – Complications of nonoperative care • pancreatic fistula pseudocyst formation

Duodenal Injury • Management – For hematoma • NG/OG decompression serial physical exams monitoring signs of infection – controversial - 3 weeks of bowel rest with TPN – For perforation • Primary repair with duodenal exclusion • Efferent/Afferent Duodenal tubes

Pelvic Injury • Introduction – significant blood loss if bilateral – may settle in retroperitoneal space – 3% of all fractures – mortality 8 - 50% – 2 nd most common cause of traumatic death

Pelvic Fracture • Signs & Symptoms – pelvic instability – pain (suprapubic also) – crepitus – bloody meatus – neurovascular deficits

Pelvis • Interventions – Stable patient • analgesia • Repair vs mobilization – Unstable patient • Immobilize • Ex-fix • Angiography – embolization