trauma evaluation and management surgery4.pdf · 2020. 3. 18. · trauma evaluation and management...
TRANSCRIPT
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Trauma Evaluation and
Management
Dr Amr Elheny
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Why is Trauma Care Important?
• Leading cause of death in those <35 yo
• 3rd leading cause of death in all ages
• Significant loss of work force
productivity
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Background
• Trimodal distribution of death
• 50% die at scene
• What do they die of?
• 50% survive to hospital but then die
• 30% die during “golden hour”
• 20% die after prolonged hospital course
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General Approach
• Assume all patients are dying until
proven otherwise
• Plan to operate on everyone and use
diagnostic studies only to convince you
not to
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How do you Triage?
• What if a patient has multiple injuries, all
of which could be life threatening?
• What if multiple patients present, all of
whom are injured?
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Initial Assessment
A AIRWAY
• Can they protect their airway?
B BREATHING
• How can you tell if they are adequately ventilating?
C CIRCULATION
• Are they in shock?
D DISABILITY
• What is their neurologic exam?
E ENVIRONMENT/EXPOSURE
• Fully disrobe but keep them warm
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Primary Survey
• Evaluate ABCs
• Begin resuscitation
• Adjunctive studies:
• Trauma series (CXR, pelvis, lat C-spine)
• Evaluation of abdomen in unstable patients
• Lab work
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Secondary Survey
• Detailed head to toe exam
• Additional diagnostic studies
• Evaluation of the abdomen in stable
patients
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Evaluation of the Abdomen
Who needs objective evaluation of the abdomen after blunt trauma?
• Unstable patients • To identify a source of hemorrhage
• Stable patients with an unreliable exam • Altered mental status
• Major distracting injury
• Need for general anesthesia
• Complaints of abdominal pain
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Evaluation of the Abdomen
• In unstable patients (SBP<90): • Depends on presence or absence of pelvic
fracture
• Diagnostic Peritoneal Lavage (DPL)
• Focused Assessment using Sonography in Trauma (FAST)
• CT contraindicated if unstable
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DPL
• Advantages
• Fast
• Sensitive
• Can be performed while resuscitation ongoing
• Disadvantages
• Invasive
• Learning curve
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FAST
• Advantages
• Fast
• Noninvasive
• Can be performed while resuscitation ongoing
• Can be very sensitive
• Disadvantages
• Operator dependent
• Body habitus may limit quality/sensitivity
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Blunt Abdominal Trauma
The Unstable Patient
Pelvic
Fracture
YES
NO
DPL or
FAST + DPL
- OR ANGIO
+ -
OR Look for other
sources of
hemorrhage
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Evaluation of the Abdomen
• In hemodynamically stable
patients:
• CT
• DPL
• FAST unreliable and insensitive
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DPL
• Advantages
• Fast
• Sensitive
• Can be performed while resuscitation ongoing
• Disadvantages
• Invasive
• Learning curve
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Abdominal CT
• Advantages
• Noninvasive
• Fairly sensitive and specific
• Disadvantages
• Inexperienced radiologist may miss injuries
• A bad place to be if patient “crashes”
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Blunt Abdominal Trauma
The Stable Patient
STABLE
Abdominal
CT
+ -
If negative, admit
for serial
abdominal exams
DPL
If DPL is positive
for blood and pt
remains stable,
then proceed with
abdominal CT.
ADMIT FOR SERIAL
ABDOMINAL EXAMS
Examinable patient
Alert, GCS 15
No evidence of intoxication
No distracting injuries
No need for general
anesthesia in next 6-8 hours.
No abdominal pain
Abdominal CT shows solid
organ injury
Non-operative management
Free fluid without
solid organ injury
Operating Room
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Case #1
• 35 yo F unrestrained driver in high
speed roll-over MVC. Field VS: HR 120,
BP 100/50, RR 30. Patient intubated for
respiratory distress. ER vital signs: HR
120, BP 90/50.
• Is this patient stable or unstable?
• What are the dx options for evaluation of
the abdomen?
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Case #2
• 6 yo M, rear seat passenger in high
speed MVC restrained only with a lap
belt. Field VS: HR 100, BP 95/40, c/o
abdominal pain
• Stable or unstable?
• What are the dx options?
• What pattern of injury is associated with a
seat belt sign?
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Case #3
• 58 yo M, s/p single self-inflicted GSW to
the R chest, just below the nipple. Field
VS: HR 90, BP 130/70, RR 20. Mild
respiratory distress, not intubated. ER
VS: HR 82, BP 140/80.
• Stable or unstable?
• Is the abdomen at risk?
• How should the abdomen be evaluated?
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Penetrating Abdominal Trauma
Penetrating Injury
Unstable
OR
Stable
High Velocity
•Guns
•Rifles
OR
Low Velocity
•Stabs
•Impalements
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Case #4
• 24 yo M s/p single stab wound to the L
flank in the anterior axillary line. Field
VS: HR 90, SBP 120/70. ER VS: HR
85, BP 140/80.
• Is the abdomen at risk?
• How should it be evaluated?
• What if there was omentum coming out of
the wound?
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Penetrating Abdominal Trauma
Local wound exploration
Fascial penetration?
NO
HOME
YES
DPL
+ -
OR Admit and
Observe
Stable Low Velocity
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Penetrating Neck Injury
• 50 yo M, s/p single stab wound to R neck, at level of the larynx, overlying the SCM muscle. VS: HR 110, BP 130/80. No respiratory distress.
• What are the zones of the neck?
• What structures are at risk?
• Who needs a neck exploration?
• If no exploration, what dx studies should be done?
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Thoracic Trauma
• 18 yo M stabbed with a beer bottle in
the 4th intercostal space, just left of the
sternum. Intubated for respiratory
distress. Field VS: HR 130, BP 80/50.
ER VS: HR 140, BP 70/50
• What needs to be done in the ER?
• What is in the differential dx?
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Thoracic Trauma
• How do you diagnose a tension
pneumothorax?
• Remember that it is a clinical diagnosis
• Level of suspicion based on mechanism
needs to be high
• Needs immediate decompression!
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Thoracic Trauma
• How do you diagnose cardiac
tamponade?
• Also a clinical diagnosis but the “classic”
signs may not be present
• Level of suspicion needs to be high based
on mechanism
• Needs immediate pericardial drainage!
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Thoracic Trauma
• 20 yo M s/p multiple stab wounds to the R chest. Field VS: 100/50, HR 110. Intubated, flutter valve in place. ED VS 90/50, HR 120. R chest tube placed with 800cc bloody output. • What should be done now?
• What are the criteria for a 2nd chest tube?
• What are the criteria for exploratory thoracotomy for bleeding?
• If there were wounds below the nipple, how should the abdomen be evaluated?
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Severe Pelvic Fracture
• 50 yo F thrown from her horse and then crushed underneath it. Field VS: HR 120, BP 100/50. ER VS: HR 130, BP 80/40. Pelvis unstable on exam.
• What should be done first?
• How should she be evaluated for bleeding?
• If her pelvis is the source, how should it be treated?
• How can the pelvis be stabilized in the ER?
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Closed Head Injury
• 40 yo M assaulted with a 2x4 to the
head. Patient found unconscious,
unresponsive, GCS=5. Intubated for
airway protection.
• What is the GCS?
• What are the components?
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Glasgow Coma Score
• E=eye opening
• Best score 4
• V=verbal response
• Best score 5
• M=motor response
• Best score 6
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TBI classification
• How is brain injury classified?
• GCS >=13: Mild
• GCS 9-12: Moderate
• GCS <=8: Severe
• All those with GCS 8 or lower need to be intubated for airway protection
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Secondary Brain Injury
• What is secondary brain injury?
• What can be done to prevent it?
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Intracranial hypertension
• What is intracranial hypertension?
• Why does it occur?
• What can be done to decrease the pressure? • Hyperventilation for impending herniation
• Diuretics only if hemodynamically stable
• Keep HOB up
• Keep well sedated
• Ventriculostomy
• Operative decompression
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Closed Head Injury
• 14 yo M tackled during football practice
and had a brief LOC. GCS 15 on medic
arrival and in ER. Hemodynamically
stable.
• Does he need a head CT?
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Crush Injury
• 35 yo F suffers a crush injury to both legs when pinned by a heavy pallet that fell off a forklift. It took 25 minutes to extricate the patient. She is c/o severe pain in her legs. HR 120, BP 150/90.
• How should she be monitored for compartment syndrome?
• What is myoglobinuria and how should it be managed?
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Rhabdomyolysis
• Hydrate, hydrate, hydrate
• Goal UOP about 100 cc/hr
• If poor UOP despite adequate fluid
resuscitation, start diuretics
• Need CVP line to assess preload
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Spinal Cord Injury
• 50 yo F struck by a car and thrown 30 feet.
Found unresponsive with GCS=3, intubated.
BP 90/40, HR 120. Evaluation in the ER
reveals a fracture dislocation at C5/6. DPL
negative, CXR and pelvis XR negative.
• What is the cause of her shock?
• How is neurogenic shock managed?
• Who should receive steroids and why?