absite: trauma/critical care

ABSITE: Trauma/Critical CareKavina Juneja, MD

Trauma & Surgical Critical Care Fellow

University of Alabama at Birmingham

Trauma

▪ ATLS Assessment

▪ Shock and Resuscitation

▪ Trauma by Systems

▪ TBI

▪ SCI

▪ Neck

▪ Thorax

▪ Abdomen

▪ Extremity

▪ Pregnancy

ATLS - Initial Assessment

▪ ABCDEs

▪ Airway

▪ Intubate: GCS<8, certain maxillofacial/neck injuries

▪ Surgical airway: cricothyroidotomy

▪ Breath Sounds

▪ Circulation

▪ Disability

▪ Gross assessment of neuro status & GCS

▪ Exposure

▪ Catalogue injuries

Initial Assessment

▪ ABCDEs

▪ IV access, resuscitation

▪ FAST exam

▪ RUQ, LUQ, supxiphoid, suprapubic

▪ Pleural

▪ Chest/Pelvis XR

▪ Other imaging?

Shock

▪ Shock: end-organ hypoperfusion

▪ Trauma - think hemorrhagic shock till proven otherwise

▪ Hemorrhage

▪ Class I - 0-15% EBL

▪ Class II - 15-30% EBL —> Tachycardia, Narrowed pulse pressure

▪ Class III - 30-40% EBL —> Hypotension

▪ Class IV - >40% EBL

▪ Trauma triad of death: hypothermia, acidosis, coagulopathy

Resuscitation

▪ Minimize crystalloid infusions

▪ Balanced blood product resuscitation

▪ Whole blood

▪ 1:1:1 pRBCs:FFP:Plts

▪ Tranexamic Acid

▪ 2g within 3hours of injury/hemorrhage

▪ Reduces fibrinolysis

▪ No benefit/mortality risk if given >3hours from index event

▪ Goal-directed resuscitation

▪ Permissive hypotension till source control

▪ TEG/ROTEM-guided product resuscitation

Traumatic Brain Injury

▪ Initial assessment based on GCS

▪ 13-15: Mild TBI

▪ 9-12: Moderate TBI

▪ 3-8: Severe TBI

▪ CT imaging

▪ Depressed GCS

▪ Focal neurologic signs

▪ CSF/Blood per nose/ears

▪ AMS/Intoxication

▪ Penetrating trauma

CT findings

▪ Epidural hematoma - head trauma followed by lucid interval, then rapid deterioration -middle meningeal artery bleed

▪ CT: lens-shaped lucency contained by suture lines

▪ Subdural hematoma - bridging veins/venous plexus bleed

▪ CT: crescent-shaped lucency crossing suture lines

▪ Intraparenchymal hemorrhage - MC in trauma

▪ Intraventricular hemorrhage - risk for hydrocephalus

▪ Subarachnoid hemorrhage

▪ Diffuse axonal injury - traumatic shearing forces to axons from acceleration/deceleration injury

▪ MRI: diffuse scattered lesions —> poor prognosis

ICP Monitors & Management

▪ Abnormal Head CT with GCS<9

▪ Normal Head CT with GCS<9 or posturing/hypotension

▪ Ventriculostomy - drain placed in ventricle - able to drain CSF if needed to decrease ICP

▪ Peak ICP ~48-72hours after injury

▪ CPP = MAP - ICP

▪ ICP Management - goal <22mmHg (CPP goal >60)

▪ HOB elevation

▪ Hyperventilation (PaCO2 goal 32-35)

▪ Hypertonic saline bolus (Na goal 140-150)

▪ Mannitol (loading dose 1g/kg, then 0.25g/kg q4h) - can cause hypotension

▪ Sedation

▪ Paralysis

▪ Craniotomy/Craniectomy

TBI Management

▪ Seizure prophylaxis x1week

▪ Correct coagulopathy

▪ Early enteral feeding

Spinal Cord Injury

▪ Neurogenic Shock

▪ Hypotension/Bradycardia

▪ Spinal Shock

▪ No impact on hemodynamics. +Sensory/Motor deficits.

▪ Central cord syndrome - Upper extremity weakness +/- hyperesthesia

▪ Older patient with cervical stenosis

▪ Brown-sequard - Hemi-transection of cord - Ipsilateral motor deficit with contralateral pain/temperature deficit below level of injury

▪ Penetrating injury to back

▪ Anterior cord syndrome - Vascular injury to ASA - Motor deficit below level of injury

Neck Trauma

▪ Penetrating trauma

▪ Zone 1 - clavicles to cricoid cartilage

▪ Bronch, EGD, Esophagram, CTA

▪ Hard sign of vascular injury/hypotension - sternotomy

▪ Zone 2 - cricoid cartilage to angle of mandible

▪ Neck exploration

▪ Zone 3 - angle of mandible to skull base

▪ CTA, laryngoscopy

▪ Guidelines now based on presence of hard signs of bleeding, airway injury esophageal injury (rather than just zones)

Neck Trauma

▪ Esophageal injury

▪ EGD, esophagram

▪ Contained injury: observation

▪ Noncontained injury —> Left neck exploration

▪ Extend myotomy to expose entire mucosal injury —> Repair in 2 layers —> Muscular buttress —> Drain

▪ If extensive or unable to locate —> wide drainage

▪ Tracheal injury —> Cricothyroidotomy or Tracheostomy

▪ Thyroid injury —> Drainage/Observation

Neck Trauma

▪ Blunt Cerebrovascular Injury

▪ Screening CTA

▪ Severe hyperextension/flexion mechanism

▪ Focal neuro deficit - benign head CT or GCS<8

▪ Skull base fractures

▪ LeFort II/III

▪ C-spine fractures (C1-3; transverse foramen)

▪ Treatment: Antiplatelet therapy +/- endovascular intervention

Thoracic Trauma

▪ Indications for OR based on chest tube output

▪ >1500ml upon initial placement

▪ >200ml/hr for 4hours

▪ Instability

▪ Diaphragm injury

▪ More common on left

▪ Air-fluid level in chest seen on CXR

▪ Acute injury: trans-abdominal approach with permanent sutures +/-mesh

Thoracic Trauma

▪ Blunt Aortic Injury

▪ Most common site: proximal descending thoracic aorta just distal to ligamentum arteriosum

▪ Widened mediastinum, apical capping, 1st/2nd rib fx, loss of aortic knob, left hemothorax

▪ Grades

▪ Type 1 - intimal tear

▪ Type 2 - intramural hematoma

▪ Type 3 - pseudoaneurysm

▪ Type 4 - rupture

▪ Management

▪ Impulse control - goal SBP<120

▪ Endovascular repair favored

Thoracic Trauma

▪ Penetrating injuries to the “Box”

▪ Boundaries - sternal notch to xiphoid, medial to bilateral nipples

▪ High risk of cardiac injury

▪ FAST —> +pericardial FAST —> Pericardial window, Sternotomy

▪ Blunt Cardiac Injury

▪ Sternal fracture

▪ Most common EKG changes: sinus tach, PVCs

▪ Most common arrhythmia: SVT

▪ Troponin, EKG —> If abnormal, echo

Thoracic Trauma

▪ Operative approaches

▪ Left thoracotomy

▪ Descending aorta, Left subclavian artery

▪ Distal left mainstem bronchus

▪ Distal esophagus

▪ Right thoracotomy

▪ Trachea, Right mainstem bronchus, Proximal left mainstem bronchus

▪ Upper 2/3 of thoracic esophagus

▪ Median sternotomy

▪ Heart, Ascending aorta, Innominate, Proximal R subclavian, Proximal left common carotid

Abdominal Trauma

▪ Small bowel

▪ Free fluid without solid organ injury, bowel wall thickening, mesenteric stranding/hematoma

▪ Mesenteric hematoma —> explore if expanding

▪ Repair vs. resect

▪ Resect: >50% circumference or reduction of lumen to <1/3 of normal, or devascularized

▪ Resect segment: multiple close lacerations

▪ Colorectal

▪ Resection with anastomosis vs. colostomy depending on shock/resuscitative status

▪ Rectal

▪ Intraperitoneal —> repair/resect, drainage, diverting stony

▪ Extraperitoneal —> diverting ostomy +/- repair

Abdominal Trauma

▪ Liver

▪ Lacerations

▪ Hemodynamically unstable + >4u pRBCs —> failure of conservative management

▪ Active blush/pseudoaneurysm —> angioembolization vs. OR

▪ Operative management of bleeding liver

▪ Packing, hemostatics, sutures, resection

▪ Retrohepatic IVC injury - may need atriocaval shunt

▪ CBD injury

▪ <50% circumference - repair over stent

▪ >50% circumference - choledochojejunostomy

▪ Wide drainage

▪ Portal vein injury

▪ Ligation - 50% mortality

Abdominal Trauma

▪ Spleen

▪ Hemodynamically unstable + >2u pRBCs —> failure of conservative management

▪ Active blush/pseudoaneurysm —> angioembolization vs. OR

▪ Post-splenectomy vaccines - H. Flu, meningococcus, pneumococcus

▪ Duodenum

▪ Hematoma - MC in 3rd portion

▪ SBO symptoms ~12-72hours post injury 2/2 edema

▪ Conservative management with NGT, TPN ~2-3weeks

▪ If in OR, open hematoma if >2cm

▪ Laceration/Perforation - MC in 2nd portion with blunt mechanism

▪ Debridement, Primary closure vs. end-end anastomosis, Drainage

▪ If 2nd portion and close to ampulla —> jejunal serosal patch, pyloric exclusion

Abdominal Trauma

▪ Pancreas

▪ Contusion (no duct injury) - conservative management vs. drain placement if in OR

▪ Distal pancreatic duct injury - distal pancreatectomy

▪ Pancreatic head duct injury - wide drainage, ERCP/stenting, delayed Whipple

▪ RP hematomas - penetrating trauma - always explore

▪ RP hematoma - blunt trauma

▪ Zone 1 - Aorta/IVC - always explore

▪ Zone 2 - Kidneys/Flank - explore if expanding

▪ Zone 3 - Pelvis/Iliac - pack/angioembolization; explore if uncontrolled

Abdominal Trauma

▪ Urologic trauma

▪ Renal

▪ Hematuria —> investigate with CT/delayed phase imaging

▪ Penetrating trauma - always explore

▪ Blunt trauma - explore only if expanding hematoma

▪ Ureteral

▪ Upper 2/3 —> repair over stent vs. nephrostomy

▪ Lower 1/3 —> reimplant onto bladder

▪ Psoas hitch if needed

▪ Wide drainage

▪ Bladder

▪ Extraperitoneal - foley for 1-2 weeks

▪ Intraperitoneal - repair in 2 layers

▪ Urethral

▪ Blood at meatus, scrotal/perineal hematoma, high riding prostate

▪ Retrograde urethrogram

Abdominal Trauma

▪ Pelvic fractures

▪ Open book fractures a/w hypotension —> pelvic binder —> angiography if stable, vs. OR for preperitoneal packing if unstable —> Ortho ex-fix/repair

▪ R/o injuries to adjacent structures - rectum, vagina, bladder, urethra

Penetrating Abdominal Trauma

▪ Abdominal stab wounds

▪ OR if hemodynamically unstable, evisceration, peritonitis

▪ Anterior stab wounds

▪ If anterior rectus sheath violated — CT+Observe with serial exams vs. OR

▪ Flank stab wounds

▪ Risk for retroperitoneal injury

▪ Investigate with triple-phase CT

▪ Thoracoabdominal stab wounds

▪ Need to rule out diaphragm injury —> laparoscopy

Extremity Trauma

▪ Vascular injury

▪ Hard signs: pulsatile bleeding, expanding hematoma, absent pulses, bruit/thrill

▪ Operative exploration

▪ Soft signs: hematoma, diminished pulses (discrepant ABIs)

▪ CT angiogram —> ?OR

▪ Arterial injury - repair with contralateral rSVG

▪ Venous injury - primary repair vs. ligate

▪ Always consider fasciotomies

Trauma in Pregnancy

▪ Prioritize mother first

▪ Can have 1/3 blood loss without any signs

▪ Abdominal trauma

▪ Concern for placental abruption and maternal/fetal hemorrhage

▪ >50% fetal mortality

▪ RhoGAM if mother Rh-

▪ Need fetal monitoring for viable pregnancies —> 24+ weeks GA

▪ Indications for C-section if in OR:

▪ Persistent maternal shock + 34+ weeks GA

▪ DIC

▪ Need to evacuate gravid uterus to assess/repair injuries

Critical Care

▪ Ventilator Management

▪ ARDS

▪ Vasopressors

▪ Cardiovascular Physiology

▪ Pulmonary Embolism

▪ Nutrition

▪ AKI & Hemodialysis

Ventilator Management

▪ Oxygenation - PEEP, FiO2, Mean airway pressure

▪ Excessive PEEP can lead to preload reduction and reduction in CO

▪ FiO2>60%, plateau pressure >30, high PEEP —> free radicals, oxidative damage and barotrauma

▪ Ventilation - RR, Tidal volume

▪ Tidal volume for lung protection: 4-6cc/kg IBW

▪ Extubation Criteria

▪ Follows commands

▪ FiO2<50%

▪ PEEP<10

▪ RSBI (RR/TV) < 100

▪ NIF > 20

Acute Respiratory Distress Syndrome (ARDS)

▪ Within 1 week of insult, CXR with bilateral opacities/whiteout, non-cardiogenic cause

▪ Mild ARDS - P:F ratio <300

▪ Moderate ARDS - P:F ratio <200

▪ Severe ARDS - P:F ratio <100

▪ Permissive hypercapnea to allow for oxygenation (maintain pH>7.2)

▪ Oxygenation strategies

▪ APRV

▪ Inverse I:E ratio with prolonged inhalation and short exhalation

▪ Maintain P(high) with short time releases to P(low)

▪ Patient maintains spontaneous breaths throughout

▪ Proning

▪ Nitrous oxide, Epoprosterenol

▪ Paralysis

Vasopressors

▪ Receptors

▪ Alpha 1&2 —> vascular smooth muscle contraction

▪ Beta 1 —> myocardial contraction, HR

▪ Beta 2 —> vascular smooth muscle dilation

▪ Dopa —> renal/splanchnic smooth muscle dilation

▪ Epinephrine - alpha & beta

▪ Norepinephrine - alpha & some beta1

▪ Phenylephrine - alpha1

▪ Vasopressin - V1

▪ Dopamine - dopa @low dose, beta1 @mod dose, alpha @high dose

▪ Dobutamine - beta1

▪ Milrinone - phosphodiesterase inhibitor

Cardiovascular Physiology

▪ Cardiac Output (CO) = Stroke volume x Heart Rate

▪ Cardiac Index (CI) = CO/TBSA

▪ Oxygen delivery = CO x CaO2 x 10

▪ CaO2 (Arterial O2 Content) = (Hgb x 1.34 x SaO2) + (PaO2 x 0.003)

▪ Main factors are Hgb and SaO2

▪ Shock Parameters

Pulmonary Embolism

▪ Signs/Symptoms - Chest pain, Tachycardia, Tachypnea, Respiratory Alkalosis

▪ EKG findings - Sinus tachycardia

▪ CTA for diagnosis

▪ Treatment

▪ Anticoagulation

▪ Thrombolytics if hemodynamically unstable, right heart strain

▪ Pulmonary embolectomy if lytics contraindicated

Nutrition

▪ Respiratory Quotient = CO2 production / O2 consumption

▪ >1 - overfeeding

▪ 1.0 - carbohydrate

▪ 0.8 - protein

▪ 0.7 - fat

▪ <0.7 - ketosis/starvation

▪ Nitrogen balance

▪ 24hour collection and measurement of urine nitrogen

▪ Nitrogen balance = (Protein intake / 6.25) - (Urine nitrogen + 4)

▪ Negative - catabolic state; Positive - anabolic state

▪ Calorie goals - 25kcal/kg/day

▪ Fats - 9kcal/g

▪ Protein - 4kcal/g

▪ Carbs - 4kcal/g

▪ Colonocytes - short chain fatty acids

▪ Enterocytes - glutamine

AKI and Hemodialysis

▪ Oliguria with bump in creatinine

▪ FeNa <1% - pre-renal

▪ FeNa >1% - intrinsic

▪ FeNa >4% - post-renal

▪ Indications for hemodialysis

▪ Acidosis

▪ Electrolyte abnormalities

▪ Intoxication

▪ Overload

▪ Uremia

Questions

▪ 1. 29yo female presents as a trauma activation following GSW to mouth. She is in distress, gurgling, and unable to phonate. Decision is made to proceed with an emergent surgical airway. Which anatomic landmarks would you place this?

▪ A. Above the thyroid cartilage

▪ B. Below the cricoid cartilage

▪ C. Below the thyroid cartilage

▪ D. Between the tracheal rings

▪ 2. 69yo female with history of Afib on coumadin, presents after a fall with confusion, and flexor posturing. Imaging concerning for subdural hematoma. She is being taken to the OR emergently by Neurosurgery. Which agent do you use to reverse her coagulopathy?

▪ A. Vitamin K

▪ B. Idarucizumab

▪ C. Cryoprecipitate

▪ D. Prothrombin complex concentrate

▪ 3. 20yo male presents after an MVC. Initial workup is concerning for Grade 3 aortic injury of the proximal descending thoracic aorta. He undergoes endovascular repair (TEVAR). POD2, patient is noted to have cool, clammy left hand with motor deficits and decreased pulses. What is the next operative intervention?

▪ A. Relining thoracic aorta with endo-stentgraft for endoleak

▪ B. Carotid-subclavian bypass

▪ C. Open thoracoabdominal aortic repair

▪ D. Brachial embolectomy

▪ 4. 42yo female presents after MVC. She was intubated prior to arrival due to agitation. Upon arrival, patient is hypotensive with SBP60s. Exam notable for scattered abrasions. eFAST exam is negative. Blood product resuscitation is initiated, and patient remains hypotensive. What is the next best step?

▪ A. CT scan of chest/abdomen

▪ B. Repeat FAST

▪ C. Operative exploration of chest

▪ D. Operative exploration of abdomen

▪ 5. 36yo male was discharged from the trauma service after five days hospitalization following MVC. Injuries sustained were femur fracture that was operatively fixed, and Grade IV liver laceration that was conservatively managed. He presents to the ED 1 week later with acute large-volume hematemesis. What is the most likely intervention to treat underlying pathology in an expeditious manner?

▪ A. Endoscopy

▪ B. Angioembolization

▪ C. Gastrectomy

▪ D. Nasogastric decompression

▪ 6. 60% TBSA burn patient in the ICU has developed sepsis, ARDS, and is on multiple pressors. He now has an acute drop in urinary output and increasing peak airway pressures. Which maneuver is most likely to treat underlying pathology?

▪ A. Fluid challenge

▪ B. Addition of another vasopressor

▪ C. Laparotomy

▪ D. Chest tube placement

▪ 7. 32yo male presents after GSW to left thigh, with hypotension to SBP~60s and associated with increasing hematoma and pulsatile bleeding. He is taken for emergent operative exploration. A mid-thigh SFA injury is noted with ~2cm defect between proximal and distal ends. What is the best option to treat this?

▪ A. Primary repair of SFA

▪ B. SFA interposition graft with PTFE

▪ C. SFA interposition graft with rSVG

▪ D. Ligation of SFA

▪ 8. Which of the following parameters is the best predictor of successful extubation attempt?

▪ A. Negative inspiratory force > 20

▪ B. Negative inspiratory force < 20

▪ C. Rapid shallow breathing index > 100

▪ D. Rapid shallow breathing index < 100

▪ 9. 66yo female admitted to the ICU following left hemicolectomy for colon cancer. Hospital course has been complicated by anastomotic leak and acute respiratory failure with prolonged ventilator support and pneumonia. She is newly febrile to 102F, with oliguria, and lactic acidosis. She remains hypotensive after initiation of antibiotics and 2L lactated ringers injection. What is the next best step?

▪ A. Measurement of procalcitonin levels

▪ B. Steroids

▪ C. IV Vitamin C

▪ D. Vasopressor initiation

▪ 10. 18yo male underwent operative fixation of facial fractures and tracheostomy placement two days prior. Nurse notifies physician on-call about 10cc of bright red blood per tracheostomy site. Upon bedside examination, no active bleeding is noted. What is the next best step in evaluation?

▪ A. Observation

▪ B. CT Angiogram

▪ C. Bronchoscopy

▪ D. Tracheostomy in-line suctioning

Thank You

absite: trauma/critical care

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