Week 1 - Trauma [BB]

B. Belingon Notes from case session & case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Sideman)

Week 1 Trauma M 07.01.13

A 45 year old male is involved in a high speed motor vehicle accident. EMS transfers the patient to

Emergency Room at UH. The vital signs are temp 98, P 110, RR 34 and BP 100/70. He is confused and

smells of alcohol. The jugular veins are flat. There is a left closed clavicular fracture. There is an imprint of

the steering wheel on his left anterior chest. There are multiple left closed rib fractures. The left chest has

decreased breath sounds and dullness to percussion. The abdomen is distended and dull to percussion with

scant bowel sounds. There is an open left tibia fibula fracture. The left calf is markedly edematous.

Multiply injured blunt trauma patient

o A : Airway: assess, supplemental oxygen, orotracheal intubation with in-line neck stabilization

Can do orotracheal intubation even on cervical fracture hyper-extend neck

If massive midface injury perform cricothyroidotomy

Tracheostomy is elective done in OR, never emergent procedure

Suction if needed to clear airway

o B : Breathing: looking for pneumothorax or hemothorax

o C : Circulation: place two large bore IV catheters in upper extremities (cephalic or brachial v),

resuscitation with Lactated Ringers (2L bolus)

Give 1L of fluid every 10 mins (2 L over 20 mins) if still bleeding, give blood

Rate of fluid infusion much faster bc IV has smaller diameter than central line (IJ or

subclavian)

Signs of shock: low BP, tachycardic, pale extremities, altered mental status or

unconscious or agitated and combative

Dont put in lower extremity (saphenous vein) b/c pt may have caval injury may go

retroperitoneal

o D : Disability: get quick neuro exam, GCS score (speech, motor, eye opening) [be able to calc],

assess movement of all four extremities

o E : Exposure: remove clothing and examine injuries

Make sure room is uncomfortably warm cold can interfere w protein fx, coagulation

Case assessment

o Pt talking patent airway

o Concern about hemothorax place L chest tube

o Give 2L fluid b/c sx of shock hemorrhage until proven otherwise, can be from thorax, abd,

pelvis, extremities

CXR of lungs to look for blood

Distended abd, dull to percussion likely site of bleeding

DPL (Diagnostic Peritoneal Lavage: 800cc of warm saline into abdomen under

gravity, flip & drain pt)

FAST (Focused Abdominal Sonography for Trauma): four windows of pelvis,

RUQ (Morrisons pouch), LUQ, pericardial window

Extremity bleeding do careful exam

o Thoracotomy if pt puts out too much fluid from chest tube (1.5L on placement, or hourly output

for 3-4 hr of 200cc/hr)

Workup

o Tubes: place nasogastric and urinary catheters

Hemothorax: place chest tube @ 5th ICS mid-axillary, want to know immediate output,

I&O

Pneumothorax: place chest tube; life-threatening b/c can progress to tension

pneumothorax


Dont place NG tube if suspect injury to oro-tracheal bones (may go into brain) or mid-

facial injury do cricothyroidotomy

Dont place Foley if suspect pelvic fracture (do rectal exam first and ensure no blood at

meatus)

o Labs: CBC, Chem 20, coagulation profile, UA, T&C for PRBCs, drug screen

o Radiographs: lateral C spine, chest, pelvic, left lower extremity

o If unstable despite resuscitation, do not transport patient to CT scan-instead do FAST vs DPL

To assess intra-abdominal hemorrhage in unstable pt 1st do ultrasound to assess for

injury then move pt to OR; never leave unstable pt in CT scanner

Results

o FAST-positive test includes fluid around heart, in LUQ, RUQ, colonic gutters and pelvis

o DPL-positive test includes gross blood, RBC>100, 000,WBC>500, bile, bacteria, food particles

Indicates intra-abdominal organ injury =/= retroperitoneal

o A positive FAST or DPL mandates abdominal exploration

Dx: Left tib-fib open fracture-

o ortho consultation

o Stryker intracompartmental pressure measurements?

o 4 compartment fasciotomy allows muscle to expand b/c fascia very tight

Indicated for venous engorgement, vascular insufficiency, ischemic leg gets blood

flow to partially edematous leg (do w/i 6h or pt will get ischemia)

Lt clavicular fx decr percussion, dullness = fluid in pleural space (blood hemothorax from mult rib

fx), no JVD tx: drain w chest tube at mix-axillary line @ 5th ICS

A 19 year old male is involved in a high speed motor vehicle accident. He presents to the Emergency

Department in a near comatose state. His vital signs are temp 100, P 115, RR 30 and BP 90/50. He has a

large scalp laceration. His neck veins are flat. His breath sounds are equal bilaterally. The heart shows

tachycardia but there are no gallops, rubs or clicks and the heart tones are not distant. His abdomen is soft

but slightly distended with decreased bowel sounds. He has an obvious closed pelvic ring fracture. He has

marked perineal ecchymosis. The rectal examination shows a boggy high riding prostate and there is blood

at the urethral meatus.

Pt w GCS 8 or less intubate bc implied that pt cant protect airway

Dx: Unstable pelvic fracture

o Treatment

decrease volume of the pelvis to control hemorrhage

wrap pelvis with sheet tightly (separates pubis bones and SI joint)

ortho consultation for external fixation

if no other sites of hemorrhage except for pelvis (isolated retroperitoneal

hemorrhage), do angiography with embolization of internal iliac artery branches (the

only time an unstable pt should be in radiology)

Blood at meatus, high riding boggy prostate gland

o Implies injury to membranous portion of urethra

o DO NOT place urinary catheter

o Workup

do retrograde urethrogram

if positive, suprapubic catheter

if negative, cystogram with bladder full and empty with contrast

o Treatment: urethral injury not emergency delayed surgery

if retroperitoneal bladder injury, urinary catheter for 10-14d


if intra-abdominal bladder injury, abdominal exploration

if cystogram negative, CT of abdomen and pelvis

Isolated retroperitoneal hemorrhage need to control hemorrhage, can still be unstable even w

good resuscitation

A 15 year old male presents to the Emergency Center at University Hospital with a stab wound to the left

lower quadrant. He complains of diffuse abdominal pain. The vital signs are temp 99, P 110, RR 26 and

BP140/86. The patient is alert. The lungs are clear. The heart has tachycardia. The abdomen is tense and

distended with decreased bowel sounds. There is omentum protruding through the stab wound. The rectal

examination shows good rectal tone but is guaiac positive.

ABCDE of resuscitation

Labs: CBC, chem panel, coagulation profile, UA, drug screen, T&C for PRBCs

Radiographs: chest and pelvis, CT for retroperitoneal injury

o Ultrasound will only show fluid

Treatment

o observation

o local wound exploration

o DPL? If positive, abdominal exploration find penetrated fascia b/c omentum exposed

suspect bowel injury

o laparoscopy? Not sensitive for SB injuries

o ometum exposed? ligate stump and observation vs abdominal exploration

if fascia not penetrated and no hard signs of peritonitis discharge to home once pt is

sober

if unable to operate (too busy) do not have to do exploratory surgery send pt home

or observe

o r/o source of hemorrhage and source of bowel injury

o abdominal exploration d/t hard signs of peritonitis

indicated b/c anterior fascia penetrated, signs of peritonitis, omentum protrusion

A 17 year old male sustains a low caliber gunshot wound to the mid abdomen. He complains of diffuse

abdominal pain. The vital signs are temp 99, P 120, RR 28 and BP 110/60. He appears anxious. The jugular

veins are flat. The lungs are clear bilaterally. The heart has tachycardia but no gallops, rubs, or clicks. The

heart sounds are not distant. The abdomen shows a 1 cm entrance wound just above the umbilicus and there

is no exit wound. The abdomen is tense and distended with absent bowel sounds. The rectal examination

reveals a normal prostate, good rectal tone and is guaiac negative.

ABCDE of resuscitation

Labs: CBC, chem panel, coagulation profile, UA, drug screen, T&C for PRBCs

Radiographs: chest and pelvis

o Image with one shot IVP to see if kidneys penetrated

KUB shows bullet in midline

o Still want CXR and pelvic film to find bullet

Treatment

o GSW to abdomen abdominal exploration to r/o other sources of bleeding and assoc bowel

injury

A 25 year unrestrained male is involved in a high speed motor vehicle accident. EMS transfers the patient to



smells of alcohol. The jugular veins are flat. There is an imprint of the steering wheel on his left anterior

chest. The left lung has decreased breath sounds. The heart has tachycardia but no gallops, rubs or clicks.

You intubate the patient, place a nasogastric tube and urinary catheter. You draw laboratory tests including

CBC, serum chemistry, INR/PTT, urinalysis and T/C for 6 units PRBCs. You order a lateral cervical spine,

chest and pelvis radiograph. The cervical spine and pelvic radiographs reveal no fractures. The chest

radiograph shows left first rib and left scapular fractures, a small left apical cap and a slightly deviated

course of the nasogastric tube to the right side of the chest.

Dx: Traumatic aortic injury

o Diagnosis

Chest radiographic findings-

1st and 2nd rib fractures, scapular fracture esp if high impact trauma

widened mediastinum

apical cap (both sides)

deviated NG tube

deviated bronchi

obliteration of aortic knob

Can also see pleural effusion rhonchi

o Similar to aortic dissection but not necessarily d/t incr BP

Treatment

o Should do exploratory laparotomy first

o Thoracotomy with primary repair or graft vs endoluminal stent placement

Cause of death: hypovolemia from hemorrhage

A 60 year old male unrestrained driver is involved in a high speed motor vehicle accident. He injures his

right chest on the steering wheel. In the emergency department the vital signs are temp 100, P 110, RR 34

and BP 110/76. He is alert and complains of exquisite right chest wall pain. He is significantly dyspneic. The

neck is nontender and the jugular veins are flat. The trachea is in the midline. The heart has tachycardia but

the heart tones are normal. There are several palpable closed rib fractures. The right chest is dull to

percussion with decreased breath sounds.

Dx: Hemothorax

o Diagnostic physical findings

tachycardic and hypotensive

palpable rib fractures

decreased breath sounds, dullness to percussion, decreased vocal fremitus

o Chest radiographic findings [dont wait for CXR before treating]

rib fractures, hemothorax

Treatment: chest tube thoracostomy

Cause of death: hypovolemia from hemorrhage

A 17 year old gang member is stabbed in the left chest. The vital signs are temp 99, P118, RR 30 and BP

90/60. The neck has prominent jugular venous distension. The trachea is shifted to the right side. The left

thorax is hyper-resonant to percussion with decreased breath sounds and decreased vocal fremitus. The right

thorax is normal. The heart has tachycardia but normal heart tones.

Dx: Tension pneumothorax


tachycardic and hypotensive


JVD

tracheal deviation to other side

normal heart tones

decreased breath sounds, hyperresonant to percussion, decreased vocal fremitus

o Do NOT wait for chest radiographic findings

Treatment

o needle decompression (temporizing measure) in 2nd ICS in mid-clavicular space will see rush

of air when needle inserted

o chest tube thoracostomy

Cause of death: kinking of cavae, decreased venous return (causing JVD)

A 15 year old male was stabbed in the left chest at the 4th intercostal space at the left sternal border with a

long stiletto knife. EMS takes him immediately to the emergency room at UH. The vital signs are temp 98, P

120 and RR 40 and BP 70/40. The neck shows tense, distended jugular veins. The heart tones are distant.

The trachea is in the midline. The breath sounds are equal bilaterally.

Dx: Cardiac tamponade


Tachycardic and hypotensive

JVD

Normal breath sounds, trachea in midline

Decreased heart tones

o FAST to look for cardiac tamponade

Treatment

o Pericardiocentesis (temporizing measure)

o Pericardial window

o If positive pericardial window, sternotomy

o If unsure of tension pneumo vs pericardial tamponade put in chest tube to see if corrects

Cause of death: inadequate ventricular filling

A 60 year old male unrestrained driver is involved in a high speed motor vehicle accident. He injures his

right chest on the dashboard. The vital signs are temp 100, P 110, RR 38 and BP 110/76. He is alert and

complains of right chest wall pain. He is markedly dyspneic. His neck is nontender and the jugular veins are

flat. The trachea is in the midline. The heart has tachycardia but the heart tones are normal. There appears

to be paradoxical movement of the lateral right chest wall. When the patient inspires, a segment of the

right lateral chest wall goes inward. The right chest has scattered crackles, slightly decreased breath sounds

and dullness to percussion. The left chest appears to be absolutely normal.

Dx: Flail chest


paradoxical chest wall movement

Inspiration chest cage goes inward (paradoxical)

palpable rib fractures

decreased breath sounds, rales, dullness to percussion, decreased vocal fremitus

o Chest radiographic findings

multiple A/P rib fractures

pulmonary contusion

Treatment

o Supplemental oxygen, intubation with PEEP to re-inflate contused lung


Good pulmonary toilet

Good pain control

Prevent pneumonia

Titanium stenting of rib fractures?

Problem is not the rib fractures necessarily but underlying pulmonary contusion

A 23 year old male on a snowmobile runs into a steel fence at a high rate of speed. He complains of left chest

wall pain and shortness of breath. EMS takes him immediately to the Emergency Center near the

Steamboat Springs ski resort. The vital signs are temp 100, P 116, RR 36 and BP 90/40. There is a 3 cm

large sucking chest wound in the left lateral chest. You can hear air move in and out through the large chest

wound. The jugular veins are flat and the trachea is in the midline. The heart shows tachycardia and heart

tones are normal. You can see the visceral pleural of the lung thorough the chest wall wound. The left chest

is slightly tympanic to percussion and the breath sounds are slightly decreased.

Dx: Sucking chest wound

Diagnostic physical findings

o Tachycardic and hypotensive

o decreased breath sounds, dullness to percussion, decreased vocal fremitus, air rushes in and out

Imaging

o CXR pneumothorax in pleural space air doesnt go trachea goes in/out of chest wall

Treatment

o occlusive dressing over wound, tape on 3 of 4 sides so dressing will occlude air goes into lung

chest tube thoracostomy

be careful of creating tension pneumothorax if visceral pleura is injured insert

chest tube

Cause of death: hypoxia and hypercarbia

A 40 year old male who weighs 70 kg presents to the Emergency Center at BAMC 10 minutes after he

sustains multiple burns in a house fire. He complains of hoarseness and dyspnea. The vital signs are temp

100, P 110, RR 28 and BP 130/85. He has superficial (first degree) burns of the entire head. He has singed

nasal hairs. He has a nasal voice. He has deep partial thickness (second degree) burns of the anterior left

lower extremity. He has full thickness (third degree) burns which cover his entire anterior torso. He has full

thickness burns of the entire left lower extremity. The pulses in the right arm are strong. The pulses in the

left leg are only dopplerable compared to those in the right leg that are strongly palpable.

Workup

o ABCDE of resuscitation

o Early intubation for inhalation injury, bronchoscopy is most sensitive diagnostic test for

inhalation injury; if emergency setting cricothyroidotomy, then can covert to tracheostomy

later

hoarseness not moving air well; sputum = carbon-like granules

o Labs: CBC, chem panel, coagulation profile, UA, drug screen, T&C for PRBCs, CO Hg

o Tubes: nasogastric and urinary catheter

o Radiographs: chest

o Early nutrition

o Calculate percent of burn (second and third degree) by rule of nines

o Administer Lactated Ringers solution with Parkland Formula-

3-4mL/kg/%burn

give half of IVF in first 8 hours and other half in next 16 hours


o Determine adequacy of resuscitation by urine output

Dx: Myoglobinuria

o Dark red or purple urine

o UA has hemoglobin on dipstick but no RBC on microscopic exam

Treatment

o aggressive hydration

o alkalinization of urine

o brisk diuresis after hydration (mannitol)

o On transport of patient to burn unit cover burn wound with dry dressings

o Cover burn wound with topical antibiotics

silver sulfadiazine: SE sulfa allergy, dec WBC

sulfamylon: SE pain, carbonic anhydrase inhibitor leads to metabolic acidosis

silver nitrate solution: SE messy, requires multiple applications, leaches Na and Cl from

wound

o 1st degree burn- topical triple antibiotics

Deep second and third degree burn-tangential excision of the burn wound

Early skin grafts for facial, hands and feet, genital burns

o Early rehabilitation, prevention of contractures; dont give abx until evidence of sepsis (otherwise

risk resistant strains)

o Decr pulses suspect compartment syndrome, vascular insufficiency

Escharotomy eschar restricts ventilation

Full thickness burn has no room to expand decompress eschar to

subcutaneous fat immediately b/c can become ischemic as pressure in

compartment rises could be left with non-functional limb

May need to do fasciotomy if muscles are burned

o Ultimate tx = tangential excision of burn wound, then skin grafting (do early!)

A 50 year old male is involved in a high speed motor vehicle accident. EMS transfers the patient to


smells of alcohol. The jugular veins are flat. There is an imprint of the steering wheel on his left anterior

chest. There are multiple left closed rib fractures. There is ecchymosis on the left lateral flank. The left

chest has decreased breath sounds and dullness to percussion. You intubate the patient. You place 2 large

bore peripheral intravenous catheters in the upper extremities and give lactated ringers 2 liters over 10

minutes. You place a foley catheter. You draw laboratory values and order a lateral cervical spine, chest and

pelvis radiographs. The cervical spine and pelvis radiographs reveal no fractures but the chest radiograph

shows multiple rib fractures and the curl of the nasogastric tube in the left chest.

Blunt trauma acute diaphragmatic hernia

Diagnosed in delayed fashion

Dx: Diaphragmatic injury

o Physical findings

decreased breath sounds, dullness to percussion, decreased vocal fremitus, bowel sounds

in chest, most findings on left side, ecchymosis

SOB sm bowel in L chest

o Chest radiographic findings

bowel in left chest, curl of NG tube in chest above diaphragm

Treatment

o 1st time repair- abdominal approach, primary or patch repair of diaphragm

o Recurrent repair-thoracic approach, primary or patch repair


Other notes:

Airway

o Cervical spine stabilization

o Indications to intubate

GCS < 8, abnormal voice, altered mental status, penetrating injuries to neck, expanding

hematoma, chemical or thermal injury to mouth/nares/hypopharynx, extensive

subcutaneous air in neck, complex maxillofacial trauma, airway bleeding

o Airway can be patent, obstructed (by blood/emesis/foreign body), unprotected

Breathing

o Goal: to ensure adequate oxygenation and ventilation

o All trauma pts should get supplemental O2

o All burn pts should get 100% FiO2 b/c of possible CO poisoning (t1/2 of COHb is 4-6 hrs)

o Life threatening ventilation issues: tension pneumo, open pneumo, pulmonary contusions

o Breath sounds can be clear, diminished, absent

Circulation

o Rough first approximation of pts CV status

o Palpate femoral and peripheral pulses, establish IV access, external control of hemorrhage (manual

compression, splints), fluid or blood resuscitation

o Look for palpable pulses, evaluate GCS & BP

o Initial fluid resuscitation

Adult: 1 L LR/NS (never give hypotonic solution or glucose can worsen brain injury);

repeat once prior to administering blood

Children: 20 mL/kg bolus; repeat twice prior to administering blood

o Shock: inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function

Earliest sign of ongoing blood loss = tachycardia

Hypotension, tachypnea, mental status change, diaphoresis, pallor, cool extremities,

diminished capillary refill

Table 6-1 Signs and Symptoms for

Different Classes of Shock

Class I Class II Class III Class IV

Blood loss (mL) Up to 750 7501500 15002000 >2000

Blood loss

(%BV)

Up to 15% 1530% 3040% >40%

Pulse rate 100 >120 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure

(mm Hg)

Normal or

increased

Decreased Decreased Decreased

Respiratory rate 1420 2030 3040 >35

Urine output

(mL/h)

>30 2030 515 Negligible

CNS/mental

status

Slightly

anxious

Mildly

anxious

Anxious and

confused

Confused and

lethargic

DDx of shock in trauma: hemorrhage!!!, septic shock, cardiogenic shock

(pneumothorax, tamponade, MI, air embolus), neurogenic shock (high spinal cord injury,

bradycardia, hypotension)


Pts in which you may not see tachycardia as earliest sign of ongoing blood loss = elderly

on beta blockers, athletes

Other common causes of tachycardia: hypoxia, pain, apprehension, drugs (cocaine,

amphetamines)

Disability

o Neurologic exam: GCS and obvious neurologic deficits

Exposure

o Fully expose pt, warm resuscitation room

Secondary survey

o Head to toe exam for all other injuries

Classic injuries

o Blood at meatus: urethral injury; high-riding prostate, perineal or scrotal hematoma

Dx: RUG, dont place Foley

Tx: Foley to bridge injury or suprapubic tube w later reconstruction by urology

o Battles sign: ecchymosis behind ear and around periorbital region, basilar skull fx, raccoon eyes,

otorrhea, rhinorrhea

Dx: confirm w CT scan, look at nose/ears for CSF leak

Tx: give meningitis antibiotic prophylaxis

Cord syndromes

o Anterior cord syndrome

characterized by injury to the anterior two-thirds of the cord, on the opposite site of spine

injury.

The mechanism of injury is usually a compression or flexion type

Clinically, patients present with complete loss of motor function, sharp pain, and

temperature below the level of injury, but retain proprioception and the ability to sense

vibration and deep pressure.

o Central cord syndrome

Typically results from a hyperextension injury in an older patient with a preexisting

cervical spondylosis.

The injury involves the central portion of the cord.

Clinically, the upper extremities present with more sensory/motor deficit than the lower

extremities, due to the more peripheral positioning of the lower extremity axons within

the spinal cord tracts.

o Brown-Sequard syndrome

This syndrome results from hemitransection of the spinal cord w/unilateral damage to

corticospinal & spinothalamic tracts

Subsequent loss of ipsilateral motor, proprioception, and vibratory sensation

Loss of contralateral pain and temperature sensation.

Penetrating injuries of neck

o Zone III (above angle of mandible)

o Zone II (cricoid to angle of mandible)

o Zone I (between clavicle and cricoids)


Great injuries to great vessels, esophagus, airway r/o and treat b/c lifethreatening

o Zone II if penetrates platysma go to OR

o Above Zone III harder to access; if unstable, actively bleeding go to OR

o Work up zone I & III

Scan for subcutaneous air extravasation of contrast if carotid injury, bronchoscope,

esophageal (EGD, contrast swallow study for extravasation of contrast outside bronchus)

CT angio***

Vascular or aerodigestive injury OR

o Hard findings Airway compromise, shock, or active bleeding, pulsatile hematomas, extensive

subcutaneous emphysema

o Soft findings dysphagia, voice change, hemoptysis, wide mediastinum

Symptomatic but stable must further evaluate

Completely asymptomatic all Zone I injuries should get full evaluation w angiography of great vessels +

soluble contrast

Penetrating wounds DPL

MVC, pelvic fx, hematuria bladder rupture, voiding cystourethrogram

o If residual contrast where bladder was, then implies extravasation, Intraperitoneal injury OR

o Extraperitoneal Foley for 10-14 days, cystogram prior to removal of Foley

Penetrating injury to extremity

o Hard signs (operation mandatory): pulsatile hemorrhage, significant hemorrhage, thrill or bruit,

acute ischemia

o Soft signs (further eval req): proximity, minor hemorrhage, sm hematoma, assoc nerve injury

o Neurovascular exam: palpating all pulses and compare R to L; can Doppler pulses or get systolic

pressures

Significant difference between R & L could have significant arterial injury CT angio

Veins that you MUST repair:

o SVC can result in sudden blindness d/t compression of optic n from venous HTN

o IVC proximal to renal v results in acute renal failure from venous HTN

o Portal vein risk of bowel infarction do second look operation

Abdominal compartment syndrome

o Post-op trauma pt w decreasing UOP, increasing peak inspiratory pressures, hypotension

Dx: bladder pressure > 30 mmHg (clamp off Foley, reflect bag to monitor, get abdominal

pressure)


Absolute # for compartment syndrome > 30 automatic laparotomy to decompress

sterile drapes and dressings

Compartment syndrome of extremity

o Acute increase in pressure in a closed space which impairs blood flow to structures 1st sign =

paresthesias, pain, pallor, poichilothermia, pulselessness is last sign

o Tx: decr pressure in 4 cmpartments

Injury patterns

o Clavicle or first rib fx distal subclavian artery

o Shoulder dislocation or proximal humerus fx axillary artery

o Supracondylar fracture of distal humerus or elbow dislocation brachial artery

o Dislocation of the knee popliteal artery

Documents

Week 1 - Trauma [BB]