William Beaumont Hospital Department of Emergency Medicine

William Beaumont HospitalDepartment of Emergency Medicine

40 y/o male on a MCA, car pulled out to turn in front of him, he hit the side of the car and flew over it landing on his face. He is still fully clothed with his leathers on, C-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.

Where should we begin???

A, B, C ‘s O2 – NC, mask, intubation IV – how many or central line? Monitor – HR, BP, sPO2, RR q15 (min)

Initial actions = secure the airway, maintain ventilations, control hemorrhage, and treat shock

What is the Golden Hour?

Emphasize the initial evaluation and treatment of the trauma patient

Our “window of opportunity” to have a significant impact on morbidity and mortality

Must have a concise, expeditious, well thought out plan for evaluation and treatment of life threatening injuries

Accomplished through ATLS guidelines of the primary and secondary surveys

A = airway and cervical spine protection

B = breathing and ventilationC = circulation and hemorrhage

controlD = disability and neurological

statusE = exposure and environmental

control

An identified injury should be treated at the time of discovery Examples: ▪ The airway should be secured before the

fracture is stabilized▪ PTX should be treated before the patient is

completely exposedThe decision to transfer a patient

should be made before proceeding to the secondary survey

Complete the history (AMPLE)Head to toe physical examReassess vital signs and

interventionsObtain GCS if not done in primary

surveySpecial procedures (lines), specific x-

rays, and labs should be obtained

Rectal exam is done in every trauma and before urinary catheter placement (WHY?)

Check for blood tear or pelvic fracture High riding prostate potential urethral

injury Decreased tone brain or spinal injury

40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.

Where should we begin???

The Emergency physician starts at the head of the bed to assess A.

Assume that there are 15 people cutting clothes, starting the IVs, and exposing the patient.

40 y/o male on a MCA, ... He is still fully clothed with his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity.

Where should we begin?

A – Deformity to the face, nose looks flat, lots of abrasions, eyes swollen closed, broken teeth, blood in the mouth, noisy breathing, and no response to questions

Oral intubation of the patient using RSI with in line cervical traction

An orogastric tube is placed at the time of intubation Why not an NGT in this patient?

A - Patient is intubated

What’s next? B - Breathing• Despite intubation, O2 sats are still low

and the patient is difficult to BVM• Decreased breath sounds on the R

chest, crunching under the bell of your stethoscope, and the trachea appears deviated…

• What’s the problem? How do we fix it?

A - Patient is intubated

Hemo/pneumothorax Needle decompression followed by

tube thoracostomy of the R chest

A – Patient is intubatedB – Chest tube placed

What’s next? C – Circulation Vitals: BP 90/40, HR 130 RN established two 16g IVs How about 2L of fluid and a type and

cross for 4 units of pRBCs What do you give if immediate transfusion

is needed?

A – Patient is intubatedB – Chest tube placedC – Fluids and blood given

Now for D – Disability and Neuro exam Patient is intubated and paralyzed

GCS = 3TP (T = tube, P = paralyzed) GCS =/<8 intubated for airway protection

What is a GCS you ask?

A – Patient is intubatedB – Chest tube placedC – Fluids and blood givenD – GCS = 3TP

E – Exposure and Environmental All clothes are cut off Warm blanket applied to the pt Deformity to L femur probably from a

fracture splint re-applied

Secondary surveyOrdersRepeat vital signsFAST examTalk to EMS for additional information

Basic: CBC, BMP, PT/PTT, T&S, ETOH, B-hcg Other labs ordered at the discretion of the practitioner,

institution, or clinical situation such as drug screen, lactic acid, or hepatic panel

XR standard: c-spine, CXR, pelvis Obviously x-ray anything that looks injured

CT: Head and abd/pelvis are standard for a severely

injured intubated patient Chest CT for chest trauma or CXR findings Neck CT based upon mechanism, age, injury

Primary role is detection of hemoperitoneum

Sensitivity of 75-90% compared to CT (depending on the user and injury)

Four Views of the FAST Morison’s Pouch = hepatorenal Splenorenal Rectovesicular = Pouch of Douglas Cardiac▪ Can also perform pleural windows for PTX

NormalAbnormal

Normal

Abnormal

NormalAbnormal

DPL Very sensitive but not

specific Invasive Good for visceral injury Unstable trauma where

US is unavailable or equivocal

CT Noninvasive Delineates solid organ injury Expensive Patient must be stable

FAST Quick Sensitive Bedside Operator dependent Misses bowel, mesentery,

diaphragm and pancreatic injuries

Let’s Move on to the Specifics…

15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region.

On exam he moans, withdraws to pain, but does not open his eyes…

What is his GCS?

On exam he moans, withdraws to pain, but does not open his

eyes…

What is his GCS?

What should you do FIRST?

GCS = 7

What should you do first? Intubate using RSI Brief neuro exam, if possible, before

paralysis ?? Lidocaine prophylaxis for intubation▪ Blunts the cough reflex, hypertensive response,

and increased ICP associated with intubation

Most common CT abnormality in head injury

Amount of blood correlates directly with outcome

Patients c/o HA and photophobia

Nimodipine is used to prevent vasospasm which worsens ischemia

Subdural Hematoma

Epidural Hematoma

Complete the primary/secondary survey Initial goal is to maximize O2 and BP to

prevent secondary ischemic brain injury Primary Brain Injury = mechanical

irreversible damage that occurs at the time of the trauma (laceration, contusion, hemorrhage)

Secondary Brain Injury = intracellular and extracellular metabolic derangements initiated at the time of the trauma

All therapies for TBI are aimed at reversing or preventing secondary brain injury

Increased ICP = CSF pressure > 15 mm Hg The cranium can accommodate ~50-100mL

of blood before ICP increases CPP = MAP – ICP CPP < 40, autoregulation is lost

Remember CBF depends on the MAP therefore maximize the BP.

What is Cushing’s Reflex?

HypertensionBradycardiaDiminished respiratory effort

ICP has reached life threatening levels

Occurs in 1/3 of cases

Ipsilateral to mass lesion Anisocoria, ptosis, impaired EOMs, sluggish pupil

Contralateral to mass lesion Hemiparesis Positive Babinski

As ICP continues to increase… Posturing – decorticate then decerebrate Ataxic respiratory patterns Rapid fluctuations in BP and HR, arrhythmias Lethargy coma death

Hyperventilation = PCO2 30-35 Lowering PCO2 by 1mmHg decrease cerebral

vessel diameter 2% decreased ICP Good initially but over time will cause reflex

vasodilationDiuretics = mannitolCranial decompressionSeizure prophylaxis = Ativan, Dilantin

History of LOC or amnesia to the event Intoxication: drug and alcoholHeadache, vomiting, focal neuro

deficitModerate (GCS 9-13) and high risk

(GCS<8)Age > 60 or < 2Anti-coagulants – ASA, Plavix,

CoumadinPost-traumatic seizure

Low risk (GCS 14-15) Not intoxicated Fully awake without focal neuro

deficits No evidence of skull fracture Able to be observed for 12-24 hours

15 y/o boy riding his bike with no helmet tries to jump a home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the frontal region.

On further exam….You notice that he has bruising behind his left ear, blood in the ear canal, and hemotympanum.

What does this suggest?

Linear fracture through the base of the skull and can involve the temporal bone

Significance = requires a lot of force to break and can involve the internal carotid artery

Signs: blood in the ear canal, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4 and 5

Management: Head CT and admission Most CSF otorrhea and rhinorrhea will resolve

spontaneously within a week Prophylactic antibiotics are not usually given

40 y/o cashier at 7-11 is hit in the side of the head with a baseball bat. He was initially knocked out, but then woke up complaining of HA, dizziness, and feels nauseated. EMS says he just passed out again in the bus before arriving and now is minimally responsive to stimuli.

80% associated with skull fractures across the middle meningeal artery or a dural sinus in the temporoparietal region

The classic lucid interval occurs in 30%

Patients needs to go to the OR for evacuation

80 y/o lady who fell yesterday at home. Today her family says that she is confused and moving more slowly than usual.

50 y/o drunk male brought in by police for stumbling on the side of the road. He eventually fell down and was unable to get back up.

Occur commonly in people with atrophic brains = old people and drunks

Bridging vessels traverse a greater distance so are more easily torn (venous blood)

Slow bleeding can delay presentation

Optimal treatment is evacuation in the OR

Any Questions?

24 y/o male is smacked in the face with a whiskey bottle. He is complaining of mid facial pain and mal occlusion of his upper teeth.

When you grasp his upper teeth and move them, his maxilla and nose move together.

What kind of fracture is this?

Le Fort I Transverse fracture

through the maxilla Upper teeth move

Le Fort II Fraxture of the maxilla,

nasal bridge, lacrimal bones, orbital floor and rim

Teeth and nose move Le Fort III

Craniofacial dysjunction Whole face moves

Orotracheal intubation Procedure of choice with facial or neck trauma Contraindicated w/ massive facial trauma or suspected

laryngeal injury Nasotracheal intubation

Contraindicated in apneic pts Contraindicated in those with facial, skull, or laryngeal

fractures Cricothyroidotomy

Indicated when oral intubation fails, when there is severe edema or deformity of the face and oropharynx, fracture of the larynx, or hemorrhage in the airway

Contraindicated with anterior neck hematoma or laryngeal injury.

78 y/o lady with a history of heart disease and afib presents after a syncopal episode in her yard. She was raking leaves when she felt her heart race, passed out, and fell forward to hit her head on a bucket.

She now complains of this intense burning sensation in both arms, hyperasthesia to the touch, and on exam has weakness in the arms more than the legs.

What spinal syndrome is this?

Most common lesion Common in elderly Hyperextension injury ligamentum

flavum buckles into the cord contusion of the central portion of the spinal cord affects the pyramidal (motor) and spinothalamic tracts (sensory)

Fibers that innervate distal structures are located more in the periphery of the cord deficit greater in the upper extremities

Prognosis: >50% of people recover spontaneously

Hyperflexion injury anterior cord contusion through protrusion of bone fragment or herniated disc or laceration of anterior spinal artery paralysis and hypoalgesia below the level of the lesion

Preserved posterior column functions (i.e. position, touch, vibration)

Neurosurgical emergency as some causes are amenable to surgery

Prognosis: variable degrees of recovery in the first 24 hours

Hemisection of the spinal cord Ipsilateral motor Contralateral sensory deficits (pain and

temperature) Usually from penetrating trauma but can

also be from fracture of the lateral mass in the C-spine

Most maintain bowel and bladder function Treatment and prognosis depend on the

injury

Other C-spine injuries are covered in the orthopedics lecture.

45 y/o intoxicated female is crossing Woodward at 3am. She walks into traffic and is hit by a big truck before it can slow down (50mph). She is hit mainly in the abdomen and chest then propelled 30 feet onto the road.

EMS is called and she is on her way to your trauma bay.

In the trauma bay…

EMS is bagging the patient who is unresponsive. She has poor respiratory effort when you stop the BVM. She has decreased breath sounds to both lung fields, crepitus over the R chest wall with dull/distant breath sounds on the L.

What should we do first?

Intubate the patient using RSI and oral endotracheal insertion (OGT too).

Now that the patient is intubated, you notice poor chest rise and fall, o2 sat of 89%, HR 140s, and still with poor breath sounds absent on the R and decreased on the L.

Now what should we do next?

Bilateral chest tubes are placed.

On the R, the ER resident receives a whoosh of air and a little bit of blood.

On the L, the surgery resident receives about 400cc of blood.

What does this mean?

You auscultate the lungs again… Right: improved air exchange, still with crepitus

and extensive bruising along the anterolateral CW

Left: better air exchange, but it is still decreased at the base

Re-evaluation of the vitals shows that the HR is now in the 110s and o2 sat is 96%. You decide this is good enough for now and continue with fluid resuscitation and further examination.

OK, pretend that there are bilateral chest tubes.

Most frequently from penetrating trauma <5% from blunt trauma

If there is a pelvic fracture, incidence rupture increases

Incidence of L and R sided rupture about equal L side usually symptomatic as R side is protected by the

liver Signs/Symptoms:

Respiratory insufficiency Bowel sounds in the chest NGT passes back into chest

Surgery is definitive treatment

1st and 2nd rib fractures used to be called the “hallmark of severe chest trauma” Small, broad, thick bones that take

significant force to break Brachial plexus, great vessels, and lungs

are in close proximity and at great riskThink twice with this injury and do a

very thorough neurovascular exam

Fractures of the 9th-11th ribs suggest an associated intra-abdominal injury

Most heal within 3-6 weeksRib fractures are associated with

hemo/pneumothorax, atelectasis, and pneumonia

Each rib fracture can lose ~200cc of blood

Admit vs. discharge: depends on the extent of injury, age, and ability to breathe

2 or more ribs are fractured at two points to allow a freely mobile segment of the chest wall with inspiration/expiration the segment moves paradoxical to normal breathing

Major problems are underlying pulmonary contusion and chest pain

Splinting that causes atelectasis results in major respiratory insufficiency

Most commonly from anterior chest trauma

Using restraints increases the risk of fracture at the location the belt crosses the sternum

Older > younger more likely Younger more likely to suffer mediastinal

soft tissue injury Think about the structures beneath the

sternum and carefully evaluate them (heart, lungs, and mediastinum)

DIB and CP are the most common complaints

Signs/symptoms do not always correlate well with the degree of PTX

Simple PTX Collapse of lung but no communication with the

atmosphere or shift of the mediastinum or hemidiaphragm

Can observe these if <20% and they are not ventilated, unstable, going to OR, or being transferred to a trauma center

Tension PTX Accumulation of air under pressure causes shift

of the mediastinum compression of the contralateral lung and great vessels

Leads to decreased cardiac output from decreased venous return

Classic signs: tachycardia, JVD, absent breath sounds on the ipsilateral side with trachea deviated away

Tension PTX is a clinical diagnosis (not radiographic)

Management: needle decompression and chest tube

Open PTX Sucking chest wound Management: place occlusive dressing, taped

on 3 sides only and place CT at a different site

Injured lung parenchyma most common > intercostal/IMA vessels > hilar vessels > great vessels

Signs/Symptoms: DIB, decreased breath sounds on the affected side

Upright CXR: blunting or obliteration of the diaphragm

Supine CXR: diffuse haziness on the affected side

Treatment: chest tube if respiratory compromise 1500mL of blood = OR for thoracotomy 200 mL/hr for 3 hours = OR

22 y/o male is stabbed in the epigastrium at a bar while flirting with another man’s girlfriend. He is complaining of abdominal pain, head pressure, and difficulty breathing.

HR 130s BP 80/55 RR 32 sPO2 96

Beck’s Triad: hypotension, distended neck veins, distant heart

sounds Tamponade occurs in 2% of pts with

penetrating chest or abdomen trauma Rarely occurs with blunt trauma Treatment: IVF, pericardiocentesis vs. ED

thoracotomy, then definitive management in the OR

17 y/o kid out joy riding on Saturday night in his mom’s car with a suspended license. He rolls through a stop sign on his phone and is T-boned on the driver’s side. PD is called. He initially gets out of the car, ambulates, and says that he is fine other than some mid back pain. He refuses EMS transport until he realizes that it is the hospital or jail.

He arrives with C-collar and back board to the trauma bay. He is now complaining of mid and lower back pain with tingling in both of his legs. He is afraid that he is going to be paralyzed and starts to hyperventilate. You complete your exam, roll the pt, and obtain your portable films.

As you start to roll to CT scan you try to talk to him to calm him down saying that everything is going to be OK. He looks at you and says that he is going to die, but of course you continue with your reassurances that everything is fine. Suddenly he is unresponsive and you cannot find a pulse when you check.

What do you want to do next?

Penetrating Trauma Cardiac arrest at any point with initial vitals or

signs of life in the field Persistent hypotension (SBP<50) despite

aggressive resuscitation Severe shock with signs of tamponade

Blunt Trauma Cardiac arrest in the ED Blunt traumatic arrest in the field is NOT an

indication for thoracotomy

Thoracic aorta is the most common vessel injured by blunt trauma

80-90% of tears occur distal to the L subclavian artery Ligamentum arteriosum is located in the descending

aorta (aorta is tethered around a fixed point) Patients suffering an ascending aortic injury

usually die at the scene CXR findings: mediastinum widening (>8cm on

supine), obscured aortic knob, loss of the clear space between the aorta and pulmonary artery, displaced NGT, widened paratracheal stripe, trachea deviated to the right, depression left mainstem bronchus

18 y/o kid who…Is stabbed in the mid abdomen.

-OR-Falls 12 feet off the roof of a house.

Who do you think is more likely to survive?

What organs are most likely to be injured?

Blunt injuries carry a greater risk of mortality than penetrating injuries

Blunt injury is more difficult to evaluate and diagnose

Blunt injury is more often associated with injury to multiple internal organs and systems outside of the abdomen

Penetrating Injury Small intestine, colon, and liver

Blunt Injury Spleen>>>>liver, intestine

Seat belt sign = contusion/abrasion across the lower abdomen Correlates with intraperitoneal lesions or

lumbar spinal injury

Inspect and palpate most importantlyFAST examCT scanLabs

CBC – not usually helpful initially, mild leukocytosis is normal, serial Hgb more helpful

Tox screen and ETOH level

Hemorrhage is the main concern Two large bore IVs or central line IVF followed by blood products

Antibiotics if concern for bowel injuryStable – FAST, CT, then OR if

necessaryUnstable –FAST then OR for ex-lapPenetrating trauma – determine if the

peritoneum was violated as this dictates management

Chest Abdomen Pelvis Femur

In kids, the cranium is a possibility as the sutures are still open

Pelvis – 1500-3000ccFemur – 1000ccRibs – 200ccTibia/Fibula – 500ccHumerus – 250ccRadius/Ulna – 150-250cc

Trauma can be cool to look at, but don’t be distracted by the gore.

Start with your ABCDEs and don’t move to the next step until you have solved a problem.

Any Questions?