TRAUMTRAUMAA(LIFE IN THE ER)(LIFE IN THE ER)

William Beaumont HospitalWilliam Beaumont Hospital

Department of Emergency MedicineDepartment of Emergency Medicine

CASECASE40 y/o male on a MCA, car pulled out to 40 y/o male on a MCA, car pulled out to

turn in front of him, he hit the side of turn in front of him, he hit the side of the car and flew over it landing on his the car and flew over it landing on his face. He is still fully clothed with his face. He is still fully clothed with his leathers on, c-collar, backboard, and leathers on, c-collar, backboard, and splint to LLE. He has obvious facial splint to LLE. He has obvious facial fractures, noisy respirations, and fractures, noisy respirations, and deformity to the LLE extremity. deformity to the LLE extremity.

Where should we begin???Where should we begin???

Where to begin….Where to begin…. A, B, C ‘sA, B, C ‘s O2 – NC, mask, intubationO2 – NC, mask, intubation IV – how many or central line?IV – how many or central line? Monitor – HR, BP, sPO2, RR q15 (min)Monitor – HR, BP, sPO2, RR q15 (min)

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

What is the Golden What is the Golden Hour?Hour?

““Golden Hour”Golden Hour” The idea is to emphasize the importance of The idea is to emphasize the importance of

the initial evaluation and treatment of the the initial evaluation and treatment of the trauma patienttrauma patient

It is our “window of opportunity” to have a It is our “window of opportunity” to have a significant impact on morbidity and significant impact on morbidity and mortalitymortality

One must have a concise, expeditious, well One must have a concise, expeditious, well thought out plan of action for evaluation thought out plan of action for evaluation and treatment of life threatening injuriesand treatment of life threatening injuries

We accomplish this through ATLS guidelines We accomplish this through ATLS guidelines of the Primary and Secondary Surveysof the Primary and Secondary Surveys

Primary Survey: ABCDEsPrimary Survey: ABCDEs

A = airway maintenance with cervical A = airway maintenance with cervical spine protectionspine protection

B = breathing and ventilationB = breathing and ventilation C = circulation and hemorrhage C = circulation and hemorrhage

controlcontrol D = disability and neurological statusD = disability and neurological status E = exposure and environmental E = exposure and environmental

control, undress the pt, log roll the control, undress the pt, log roll the patient and put a blanket on thempatient and put a blanket on them

Primary Survey: ABCDEsPrimary Survey: ABCDEs As you proceed through the list, an As you proceed through the list, an

identified injury should be treated at identified injury should be treated at the time of discoverythe time of discovery

= the airway should be secured before = the airway should be secured before the fracture is stabilizedthe fracture is stabilized

= PTX should be treated before the = PTX should be treated before the patient is completely exposedpatient is completely exposed

A decision about transferring the A decision about transferring the patient should be made before patient should be made before proceeding to the secondary surveyproceeding to the secondary survey

Secondary Survey: head to Secondary Survey: head to toetoe

Complete the history (AMPLE) and Complete the history (AMPLE) and physical examphysical exam

Reassessment of vital signs and Reassessment of vital signs and interventionsinterventions

If GCS not obtained in primary If GCS not obtained in primary survey, now is a good timesurvey, now is a good time

Special procedures (lines), specific x-Special procedures (lines), specific x-rays, and labs are now obtainedrays, and labs are now obtained

Secondary Survey: Rectal Secondary Survey: Rectal ToneTone

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

Check for blood and integrity = tear or Check for blood and integrity = tear or pelvis fracturepelvis fracture

High riding prostate = potential urethral High riding prostate = potential urethral injuryinjury

Tone = brain or spinal injuryTone = brain or spinal injury

Ok, everyone remember our Ok, everyone remember our CASECASE

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

Where should we begin???Where should we begin???

Usually the EC doc goes to the head of the Usually the EC doc goes to the head of the bed to assess A, assume that there are bed to assess A, assume that there are 15 people cutting clothes, starting the 15 people cutting clothes, starting the IVs, and exposing the patient.IVs, and exposing the patient.

Tackling the CASE at handTackling the CASE at hand40 y/o male on a MCA, ... He is still fully clothed with 40 y/o male on a MCA, ... He is still fully clothed with

his leathers on, c-collar, backboard, and splint to his leathers on, c-collar, backboard, and splint to LLE. He has obvious facial fractures, noisy LLE. He has obvious facial fractures, noisy respirations, and deformity to the LLE extremity. respirations, and deformity to the LLE extremity.

Where should we begin???Where should we begin???

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

Tackling the CASE at handTackling the CASE at hand

Where should we begin??? AWhere should we begin??? A Oral intubation of the patient using Oral intubation of the patient using

RSI with in line cervical tractionRSI with in line cervical traction I usually place an orogastric tube I usually place an orogastric tube

at the time of intubation (why not at the time of intubation (why not an NGT in this pt?)an NGT in this pt?)

Tackling the CASE at handTackling the CASE at handA - the pt is intubatedA - the pt is intubated

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

and the pt is difficult to BVMand the pt is difficult to BVM• ? Decreased breath sounds on the R ? Decreased breath sounds on the R

chest and there is crunching under the chest and there is crunching under the bell of your stethoscope, you also bell of your stethoscope, you also imagine that the trachea appears imagine that the trachea appears deviateddeviated

Tackling the CASE at handTackling the CASE at hand

A - the pt is intubatedA - the pt is intubated

What’s next? BWhat’s next? B Needle decompression followed by Needle decompression followed by

tube thoracostomy of the R chesttube thoracostomy of the R chest

Tackling the CASE at handTackling the CASE at handA – pt is intubatedA – pt is intubated

B – surgery is putting in the chest tubeB – surgery is putting in the chest tube

Let’s move to C – BP 90/40, HR 130 Let’s move to C – BP 90/40, HR 130 The nurses have established two 16g IVsThe nurses have established two 16g IVs How about 2L of fluid and a type and How about 2L of fluid and a type and

cross for 4 units of pRBCs (what do you cross for 4 units of pRBCs (what do you give if immediate transfusion is needed?)give if immediate transfusion is needed?)

Tackling the CASE at handTackling the CASE at handA-intubation, B-R CT, C-fluids and bloodA-intubation, B-R CT, C-fluids and blood

What was D? Disability and Neuro examWhat was D? Disability and Neuro exam Our pt is intubated and paralyzed at Our pt is intubated and paralyzed at

this point, but any pt with a GCS of 8 or this point, but any pt with a GCS of 8 or less should be intubated to protect less should be intubated to protect their airwaytheir airway

What is a GCS you ask?What is a GCS you ask?

Tackling the CASE at handTackling the CASE at handA-intubation, B-R CT, C-fluids and blood, A-intubation, B-R CT, C-fluids and blood,

D – neuroD – neuro

E – exposure and environmentalE – exposure and environmental All the clothes are cut off and a All the clothes are cut off and a

warm blanket applied to the ptwarm blanket applied to the pt Deformity to L femur probably from Deformity to L femur probably from

a fracture so the splint is re-applieda fracture so the splint is re-applied

Tackling the CASE at handTackling the CASE at hand

Now that the ABCDE is accomplished, a Now that the ABCDE is accomplished, a more thorough evaluation of the more thorough evaluation of the patient can be performed, orders, patient can be performed, orders, repeat vital signs, FAST exam, and talk repeat vital signs, FAST exam, and talk to EMS for additional information.to EMS for additional information.

What are the usual What are the usual orders?orders?

Or, what would you order for this Or, what would you order for this guy?guy?

LABS AND FILMSLABS AND FILMS Basic: CBC, BMP, PT/PTT, T&S, etoh, B-hcgBasic: CBC, BMP, PT/PTT, T&S, etoh, B-hcg Other labs ordered at the discretion of the practitioner, Other labs ordered at the discretion of the practitioner,

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

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

CT: head and abd/pelvis are usually CT: head and abd/pelvis are usually standardstandard

Chest CT for chest trauma or CXR findingsChest CT for chest trauma or CXR findings Neck CT based upon mechanism, age, injuryNeck CT based upon mechanism, age, injury

What are the 4 views of What are the 4 views of the FAST exam?the FAST exam?

FAST ExamFAST Exam Primary role is detection of Primary role is detection of

hemoperitoneumhemoperitoneum Sensitivity of 75-90% compared to CT Sensitivity of 75-90% compared to CT

(depending on the user and injury)(depending on the user and injury)

Four Views of the FASTFour Views of the FAST Morison’s Pouch = hepatorenalMorison’s Pouch = hepatorenal SplenorenalSplenorenal Rectovesicular = Pouch of DouglasRectovesicular = Pouch of Douglas CardiacCardiac-> some of us also do pleural windows for PTX-> some of us also do pleural windows for PTX

FAST: Normal or Abnormal?FAST: Normal or Abnormal?

FASTFASTNormalNormal

AbnormalAbnormal

FAST: Morison’s PouchFAST: Morison’s PouchNormalNormal

AbnormalAbnormal

FAST: VesicoureteralFAST: Vesicoureteral

NormalNormalAbnormalAbnormal

OOPS!OOPS!

CT vs DPL vs FASTCT vs DPL vs FAST DPL is very sensitive but not specific, invasive, DPL is very sensitive but not specific, invasive,

need NGT/foley placed, good for visceral injuryneed NGT/foley placed, good for visceral injury Unstable trauma where US is unavailable or equivocalUnstable trauma where US is unavailable or equivocal

CT is noninvasive, locates and delineates solid CT is noninvasive, locates and delineates solid organ injury, but is expensive, time consuming, organ injury, but is expensive, time consuming, and located away from the resuscitation bayand located away from the resuscitation bay Pt must be stablePt must be stable

FAST is quick, easy, decent sensitivity and done FAST is quick, easy, decent sensitivity and done at the bedside for unstable ptsat the bedside for unstable pts Not as good for bowel, mesentery, diaphragm, or Not as good for bowel, mesentery, diaphragm, or

pancreatic injuriespancreatic injuries

Any Questions?Any Questions?

Let’s Move on to the Let’s Move on to the Specifics…Specifics…

Head CaseHead Case

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

Head CaseHead Case

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

What is his GCS?What is his GCS?

Head CaseHead CaseOn exam he On exam he

moans, moans,

withdraws to pain, withdraws to pain,

but does not open his but does not open his eyes…eyes…

What is his GCS?What is his GCS?

What should you do What should you do FIRST?FIRST?

Head CaseHead Case

GCS = 7GCS = 7

What should you do first?What should you do first? Intubate the pt using RSI Intubate the pt using RSI (sucs and etomodate)(sucs and etomodate) Brief neuro exam if possible before paralysisBrief neuro exam if possible before paralysis Lidocaine Prophylaxis for Intubation Lidocaine Prophylaxis for Intubation (1.5mg/kg)(1.5mg/kg)

Blunts the cough reflex, hypertensive response, Blunts the cough reflex, hypertensive response, and increased ICP associated with intubationand increased ICP associated with intubation

This is his Head CT…This is his Head CT…What does it show?What does it show?

This is his Head CT…This is his Head CT…Subarachnoid HemorrhageSubarachnoid Hemorrhage

Most common CT Most common CT abnormality in head abnormality in head injuryinjury

Amount of blood Amount of blood correlates directly with correlates directly with outcomeoutcome

Patients c/o HA and Patients c/o HA and photophobiaphotophobia

Nimodipine is used to Nimodipine is used to prevent vasospasm prevent vasospasm which would worsen which would worsen ischemiaischemia

Compare it to theseCompare it to these

Subdural HematomaSubdural Hematoma Epidural HematomaEpidural Hematoma

So what do you do with So what do you do with Head Injured Patients?Head Injured Patients?

Head InjuryHead Injury Complete the primary/secondary surveyComplete the primary/secondary survey Initial goal is to maximize O2 and BP to Initial goal is to maximize O2 and BP to

prevent secondary ischemic brain injuryprevent secondary ischemic brain injury Primary Brain InjuryPrimary Brain Injury = mechanical irreversible = mechanical irreversible

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

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

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

Head Injury: Increased ICPHead Injury: Increased ICP Increased ICP = CSF pressure > 15 mm HgIncreased ICP = CSF pressure > 15 mm Hg The cranium can accommodate about 50-The cranium can accommodate about 50-

100mL of blood before ICP raises100mL of blood before ICP raises CPP = MAP – ICPCPP = MAP – ICP CPP < 40, autoregulation is lostCPP < 40, autoregulation is lost

All you really need to know is that All you really need to know is that CBF depends on the MAP CBF depends on the MAP (=maximize BP)(=maximize BP)

Recognizing Increased ICPRecognizing Increased ICP

What is Cushing’s What is Cushing’s Reflex?Reflex?

Cushing’s ReflexCushing’s Reflex

HypertensionHypertension BradycardiaBradycardia Diminished Respiratory EffortDiminished Respiratory Effort

Indicates that ICP has reached life Indicates that ICP has reached life threatening levelsthreatening levels

Only occurs in 1/3 of casesOnly occurs in 1/3 of cases

Head InjuriesHead InjuriesRecognizing Increased ICP Recognizing Increased ICP

Ipsilateral to Mass LesionIpsilateral to Mass Lesion Anisocoria, ptosis, impaired EOMs, sluggish pupilAnisocoria, ptosis, impaired EOMs, sluggish pupil

Contralateral to Mass LesionContralateral to Mass Lesion HemiparesisHemiparesis Positive BabinskyPositive Babinsky

As ICP continues to increase…As ICP continues to increase… Posturing – decorticate then decerebratePosturing – decorticate then decerebrate Ataxic respiratory patternsAtaxic respiratory patterns Rapid fluctuations in BP and HR, arrhythmiasRapid fluctuations in BP and HR, arrhythmias Lethargy to ComaLethargy to Coma

Methods to Reduce ICPMethods to Reduce ICP Hyperventilation = PCO2 30-35Hyperventilation = PCO2 30-35

Lowering PCO2 by 1mmHg will decrease cerebral Lowering PCO2 by 1mmHg will decrease cerebral vessel diameter 2% which will decrease cerebral vessel diameter 2% which will decrease cerebral blood flow -> good initially but too long will cause blood flow -> good initially but too long will cause reflex vasodilationreflex vasodilation

Diuretics = Mannitol (sometimes lasix)Diuretics = Mannitol (sometimes lasix) Cranial Decompression = trephination, Cranial Decompression = trephination,

ventriculostomy, OR craniotomyventriculostomy, OR craniotomy Seizure Prophylaxis = ativan, dilantin, Seizure Prophylaxis = ativan, dilantin,

pentobarbitalpentobarbital

Head Injury: To CT or not to Head Injury: To CT or not to CTCT

Reasons to CTReasons to CT History of LOC or Amnesia to the EventHistory of LOC or Amnesia to the Event Intoxication: drug and alcoholIntoxication: drug and alcohol Headache, vomiting, focal neuro deficitHeadache, vomiting, focal neuro deficit Moderate (GCS 9-13) and High Risk (GCS<8)Moderate (GCS 9-13) and High Risk (GCS<8) Age > 60 or < 2Age > 60 or < 2 Anti-coagulants – ASA, Plavix, CoumadinAnti-coagulants – ASA, Plavix, Coumadin Posttraumatic SeizurePosttraumatic Seizure Any signs of trauma above the claviclesAny signs of trauma above the clavicles

Not to CT Not to CT (how many people actually meet these criteria)(how many people actually meet these criteria)

Low risk (GCS 14-15) patient who is not Low risk (GCS 14-15) patient who is not intoxicated and fully awake without focal neuro intoxicated and fully awake without focal neuro deficits, no evidence of skull fracture, and who deficits, no evidence of skull fracture, and who can be observed for 12-24 hourscan be observed for 12-24 hours

Back to our Head CaseBack to our Head Case15 y/o boy riding his bike with no helmet tries to jump a 15 y/o boy riding his bike with no helmet tries to jump a

home-made ramp. He went up at good speed, but home-made ramp. He went up at good speed, but goes straight down the back side over his handle bars goes straight down the back side over his handle bars and onto his head. He is unconscious, has a seizure at and onto his head. He is unconscious, has a seizure at the scene, and is missing a piece of scalp from the the scene, and is missing a piece of scalp from the frontal region.frontal region.

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

What does this suggest???What does this suggest???

Basilar Skull FractureBasilar Skull FractureSigns: Signs: blood in the ear canal, rhinorrhea, blood in the ear canal, rhinorrhea,

hemotympanum, otorrhea, battle’s sign, hemotympanum, otorrhea, battle’s sign, raccoon eyes, CN deficits of 3, 4, 5raccoon eyes, CN deficits of 3, 4, 5

These are linear fractures through the base of These are linear fractures through the base of the skull and usually involve the temporal the skull and usually involve the temporal bonebone

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

These pts need a HCT and admissionThese pts need a HCT and admission Most CSF otorrhea and rhinorrhea will resolve Most CSF otorrhea and rhinorrhea will resolve

spontaneously within a weekspontaneously within a week Prophylactic antibiotics are not usually givenProphylactic antibiotics are not usually given

What does this sound like?What does this sound like?

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

Epidural HematomaEpidural Hematoma

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

The classic lucid The classic lucid interval occurs in 30%interval occurs in 30%

Patients needs to go to Patients needs to go to the OR for evacuationthe OR for evacuation

How about this?How about this?

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

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

Subdural HematomaSubdural Hematoma

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

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

Slow bleeding can delay Slow bleeding can delay presentationpresentation

Optimal treatment is Optimal treatment is evacuation in the ORevacuation in the OR

Head InjuriesHead Injuries

ANY ANY QUESTIONS?QUESTIONS?

Next case…Next case…24 y/o male is smacked in the face with a 24 y/o male is smacked in the face with a

whiskey bottle. He is complaining of whiskey bottle. He is complaining of mid facial pain and mal occlusion of his mid facial pain and mal occlusion of his upper teeth.upper teeth.

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

What kind of fracture is this?What kind of fracture is this?

Le Fort FracturesLe Fort Fractures Le Fort ILe Fort I

Transverse fracture Transverse fracture through the maxilla = through the maxilla = upper teeth moveupper teeth move

Le Fort IILe Fort II Fx of the maxilla, nasal Fx of the maxilla, nasal

bridge, lacrimal bones, bridge, lacrimal bones, orbital floor and rim = orbital floor and rim = teeth and nose moveteeth and nose move

Le Fort IIILe Fort III Craniofacial dysjunction Craniofacial dysjunction

= whole face moves= whole face moves

Airway Management in Airway Management in Facial and Neck TraumaFacial and Neck Trauma

Orotracheal intubation: Orotracheal intubation: procedure of choice but procedure of choice but can be difficult with deformity or bleeding, and is can be difficult with deformity or bleeding, and is contraindicated with massive facial trauma or contraindicated with massive facial trauma or suspected laryngeal injurysuspected laryngeal injury

Nasotracheal intubationNasotracheal intubation: contraindicated in apneic : contraindicated in apneic pts and those with facial, skull, or laryngeal fractures pts and those with facial, skull, or laryngeal fractures as you may cause further injuryas you may cause further injury

Cricothyroidotomy:Cricothyroidotomy: indicated when oral intubation indicated when oral intubation fails, when there is severe edema or deformity of the fails, when there is severe edema or deformity of the face and oropharynx, fracture of the larynx, or face and oropharynx, fracture of the larynx, or hemorrhage in the airway. Contraindicated with hemorrhage in the airway. Contraindicated with anterior neck hematoma or laryngeal injury.anterior neck hematoma or laryngeal injury.

Moving on…Moving on…78 y/o lady with a history of heart disease and 78 y/o lady with a history of heart disease and

afib presents after a syncopal episode in her afib presents after a syncopal episode in her yard. She was raking leaves when she felt yard. She was raking leaves when she felt her heart race, passed out, and fell forward her heart race, passed out, and fell forward to hit her head on a bucket.to hit her head on a bucket.

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

What spinal syndrome is this????What spinal syndrome is this????

Central Cord SyndromeCentral Cord Syndrome Most common lesion and often seen in people Most common lesion and often seen in people

with degenerative changes of the C-spine (=old)with degenerative changes of the C-spine (=old) Hyperextension injury that causes the Hyperextension injury that causes the

ligamentum flavum to buckle into the cordligamentum flavum to buckle into the cord Results in concussion or contusion of the central Results in concussion or contusion of the central

portion of the spinal cord -> affects the portion of the spinal cord -> affects the pyramidal and spinothalamic tracts (motor and pyramidal and spinothalamic tracts (motor and sensory)sensory)

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

More than 50% of people recover spontaneouslyMore than 50% of people recover spontaneously

Anterior Cord SyndromeAnterior Cord Syndrome Hyperflexion injury that causes anterior cord Hyperflexion injury that causes anterior cord

contusion through protrusion of a bony contusion through protrusion of a bony fragment or herniated discfragment or herniated disc

Also from laceration or thrombosis of the Also from laceration or thrombosis of the anterior spinal arteryanterior spinal artery

Causes paralysis and hypoalgesia below the Causes paralysis and hypoalgesia below the level of the lesion while preserving posterior level of the lesion while preserving posterior column functions (position,touch,vibration)column functions (position,touch,vibration)

This is a neurosurgical emergency as some This is a neurosurgical emergency as some causes are amendable to surgerycauses are amendable to surgery

Variable degrees of recovery in the first 24 Variable degrees of recovery in the first 24 hourshours

Brown Sequard SyndromeBrown Sequard Syndrome Hemisection of the spinal cordHemisection of the spinal cord Usually from penetrating trauma but can also Usually from penetrating trauma but can also

be from fracture of the lateral mass in the c-be from fracture of the lateral mass in the c-spinespine

Ipsilateral motor and contralateral sensory Ipsilateral motor and contralateral sensory deficits but either can predominate depending deficits but either can predominate depending on the size and location of the injuryon the size and location of the injury

Most maintain bowel and bladder functionMost maintain bowel and bladder function Treatment and prognosis depend on the injuryTreatment and prognosis depend on the injury

Any Questions?Any Questions?

Other c-spine injuries will be Other c-spine injuries will be covered in the ortho lecture.covered in the ortho lecture.

Pedestrian vs MVCPedestrian vs MVC

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

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

Pedestrian vs MVCPedestrian vs MVCIn the trauma bay…In the trauma bay…

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

What should we do first?What should we do first?

Pedestrian vs MVCPedestrian vs MVC

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

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

Now what should we do next???Now what should we do next???

Pedestrian vs MVCPedestrian vs MVCBilateral chest tubes are placed -> surgery Bilateral chest tubes are placed -> surgery

takes one side and the ER takes the other.takes one side and the ER takes the other.

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

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

What does this mean?What does this mean?

Pedestrian vs MVCPedestrian vs MVC

You auscultate the lungs again…You auscultate the lungs again…- on the R, there is improved air exchange - on the R, there is improved air exchange still with crepitus and now you notice still with crepitus and now you notice extensive bruising along the anterolateral CWextensive bruising along the anterolateral CW

- on the L, there is better air exchange, but it - on the L, there is better air exchange, but it is still decreased at the baseis still decreased at the base

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

Pedestrian vs MVCPedestrian vs MVCHere is your portable CXR, Here is your portable CXR,

What do you think?What do you think?

OK, pretend that there are bilateral chest tubes.

Ruptured DiaphragmRuptured Diaphragm Most frequently from penetrating traumaMost frequently from penetrating trauma Rupture due to blunt trauma occurs in less than 5% of pts Rupture due to blunt trauma occurs in less than 5% of pts

hospitalized with chest traumahospitalized with chest trauma If there is fracture of the pelvis, incidence of diaphragm If there is fracture of the pelvis, incidence of diaphragm

rupture increasesrupture increases Incidence of L and R sided rupture about equal, but L side Incidence of L and R sided rupture about equal, but L side

usually symptomatic as R side is protected by the liverusually symptomatic as R side is protected by the liver Clues:Clues:

Respiratory InsufficiencyRespiratory Insufficiency Bowel Sounds in the ChestBowel Sounds in the Chest NGT passes back into chestNGT passes back into chest

Surgery is definitive treatmentSurgery is definitive treatment

Thoracic Trauma: Rib Thoracic Trauma: Rib FracturesFractures

11stst and 2 and 2ndnd rib fractures used to be called rib fractures used to be called the “hallmark of severe chest trauma”the “hallmark of severe chest trauma”

Small, broad, thick bones that take Small, broad, thick bones that take significant force to breaksignificant force to break

Brachial plexus, great vessels, and lungs Brachial plexus, great vessels, and lungs are in close proximity and at great riskare in close proximity and at great risk

Therefore, you should think twice with Therefore, you should think twice with this injury and do a very thorough this injury and do a very thorough neurovascular examneurovascular exam

Thoracic Trauma: Rib Thoracic Trauma: Rib FracturesFractures

Fractures of the 9Fractures of the 9thth, 10, 10thth, and 11, and 11thth ribs suggest ribs suggest an associated intra-abdominal injury: Liver on an associated intra-abdominal injury: Liver on the R, Spleen on the Lthe R, Spleen on the L

Most heal within 3-6 weeksMost heal within 3-6 weeks Other than pain, rib fractures are associated Other than pain, rib fractures are associated

with hemo/pneumothorax, atelectasis, and with hemo/pneumothorax, atelectasis, and pneumoniapneumonia

Each rib fracture can lose 200-300cc of bloodEach rib fracture can lose 200-300cc of blood Patients with displaced rib fractures should Patients with displaced rib fractures should

have a repeat CXR at 3 hours for delayed PTXhave a repeat CXR at 3 hours for delayed PTX Admit vs D/C: depends on the extent of injury, Admit vs D/C: depends on the extent of injury,

age, and ability to breatheage, and ability to breathe

Thoracic Trauma: Flail ChestThoracic Trauma: Flail Chest 2 or more ribs are fractured at two points to 2 or more ribs are fractured at two points to

allow a freely mobile segment of the chest allow a freely mobile segment of the chest wall with inspiration/expiration -> the wall with inspiration/expiration -> the segment moves paradoxical to normal segment moves paradoxical to normal breathingbreathing

Major problems are underlying pulmonary Major problems are underlying pulmonary contusion and chest pain with contusion and chest pain with

splinting that causes atelectasissplinting that causes atelectasis

-> results in major respiratory -> results in major respiratory

insufficiencyinsufficiency

Thoracic Trauma: Sternal Thoracic Trauma: Sternal FractureFracture

Most commonly from anterior chest trauma Most commonly from anterior chest trauma (MVC)(MVC)

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

Older people are more likely to fracture their Older people are more likely to fracture their sternum than younger people (more likely to sternum than younger people (more likely to suffer mediastinal soft tissue injury)suffer mediastinal soft tissue injury)

Intuition would lead you to believe that these Intuition would lead you to believe that these would be life threatening injuries, but again you would be life threatening injuries, but again you must just think about the structures beneath must just think about the structures beneath the sternum and carefully evaluate them the sternum and carefully evaluate them (heart, lungs, and mediastinum)(heart, lungs, and mediastinum)

Thoracic Trauma: Thoracic Trauma: PneumothoraxPneumothorax

Simple PTXSimple PTX: collapse of lung but no communication : collapse of lung but no communication with the atmosphere or shift of the mediastinum or with the atmosphere or shift of the mediastinum or hemidiaphragm; can observe these if <20% and they hemidiaphragm; can observe these if <20% and they are not ventilated, unstable, going to OR, or being are not ventilated, unstable, going to OR, or being transferred to a trauma centertransferred to a trauma center

Tension PTXTension PTX: accumulation of air under pressure : accumulation of air under pressure causes shift of the mediastinum resulting in causes shift of the mediastinum resulting in compression of the contralateral lung and great compression of the contralateral lung and great vessels leading to decreased cardiac output from vessels leading to decreased cardiac output from decreased venous returndecreased venous return

Open PTXOpen PTX: sucking chest wound. Place occlusive : sucking chest wound. Place occlusive dressing – taped on 3 sides only. Place CT at a different dressing – taped on 3 sides only. Place CT at a different site site

DIB and CP are the most common complaintsDIB and CP are the most common complaints Signs and symptoms do not always correlate well with Signs and symptoms do not always correlate well with

the degree of PTXthe degree of PTX

Thoracic Trauma: Thoracic Trauma: PneumothoraxPneumothorax

Tension PTX:Tension PTX: Pts usually develop severe cardiopulmonary collapse Pts usually develop severe cardiopulmonary collapse

within minutes as the mediastinum is crushedwithin minutes as the mediastinum is crushed Classic signs: tachycardia, JVD, absent breath sounds on Classic signs: tachycardia, JVD, absent breath sounds on

the ipsilateral side with trachea deviated awaythe ipsilateral side with trachea deviated away JVD may not be present in a hypovolemic stateJVD may not be present in a hypovolemic state Hypoxia occurs first, then hypotension, then cardiac Hypoxia occurs first, then hypotension, then cardiac

arrest arrest Tension PTX is a clinical (not radiographic) diagnosisTension PTX is a clinical (not radiographic) diagnosis Immediate treatment is needle decompression followed by Immediate treatment is needle decompression followed by

tube thoracostomytube thoracostomy

*At what anatomical location are these procedures *At what anatomical location are these procedures perfomed?perfomed?

What do these films What do these films show?show?

Thoracic Trauma: Thoracic Trauma: HemothoraxHemothorax

Injured lung parenchyma is usually the Injured lung parenchyma is usually the source followed by intercosatal/IMA vessels source followed by intercosatal/IMA vessels then hilar and great vesselsthen hilar and great vessels

Clinically there may be DIB with decreased Clinically there may be DIB with decreased breath sounds on the affected sidebreath sounds on the affected side

CXR – upright may have blunting or CXR – upright may have blunting or obliteration of the diaphragm, supine will obliteration of the diaphragm, supine will have diffuse haziness on the affected sidehave diffuse haziness on the affected side

Rx: Tube thoracostomy if respiratory Rx: Tube thoracostomy if respiratory compromisecompromise 1500mL of blood = OR for thoracotomy1500mL of blood = OR for thoracotomy 200 mL/Hr for 3 hours = OR 200 mL/Hr for 3 hours = OR

What is this?What is this?22 y/o male is stabbed in the epigastrium at a 22 y/o male is stabbed in the epigastrium at a

bar while flirting with another man’s bar while flirting with another man’s girlfriend. He is complaining of abdominal girlfriend. He is complaining of abdominal pain, head pressure, and difficulty breathing. pain, head pressure, and difficulty breathing.

HR 130s BP 80/55 RR 32 sPO2 96HR 130s BP 80/55 RR 32 sPO2 96

Pericardial Effusion or Pericardial Effusion or TamponadeTamponade

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

Tamponade occurs in 2% of pts with Tamponade occurs in 2% of pts with penetrating chest or abdomen trauma and penetrating chest or abdomen trauma and rarely occurs with blunt traumararely occurs with blunt trauma

Rx: initially fluid resuscitation, Rx: initially fluid resuscitation, pericardiocentesis if there is time, ED pericardiocentesis if there is time, ED thoracotomy, or definitive management in thoracotomy, or definitive management in the ORthe OR

Next…Next…17 y/o kid out joy riding on Saturday 17 y/o kid out joy riding on Saturday

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

Joy RideJoy RideHe arrives with c-collar and back board to the He arrives with c-collar and back board to the

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

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

Joy Ride Portable CXRJoy Ride Portable CXRWhat do you think?What do you think?

What do you want to do next?What do you want to do next?

ED Thoracotomy IndicationsED Thoracotomy Indications Penetrating TraumaPenetrating Trauma

Cardiac arrest at any point with initial vitals or Cardiac arrest at any point with initial vitals or signs of life in the fieldsigns of life in the field

Persistent hypotension (SBP<50) despite Persistent hypotension (SBP<50) despite aggressive resuscitationaggressive resuscitation

Severe shock with signs of tamponadeSevere shock with signs of tamponade Blunt TraumaBlunt Trauma

Cardiac arrest in the ECCardiac arrest in the EC

= blunt traumatic arrest in the field is not = blunt traumatic arrest in the field is not an indication for thoracotomyan indication for thoracotomy

Blunt Traumatic Aortic Blunt Traumatic Aortic InjuryInjury

Thoracic aorta is the most common vessel injured by Thoracic aorta is the most common vessel injured by blunt trauma and must be considered in every rapid blunt trauma and must be considered in every rapid deceleration injury (usually MVC)deceleration injury (usually MVC)

80-90% of tears occur just distal to the L subclavian 80-90% of tears occur just distal to the L subclavian artery where the ligamentum arteriosum is located in the artery where the ligamentum arteriosum is located in the descending aorta (aorta is tethered around a fixed point)descending aorta (aorta is tethered around a fixed point)

Patients who suffer an ascending aortic injury usually die Patients who suffer an ascending aortic injury usually die at the sceneat the scene

CXR: mediastinum widening (>8cm on supine), CXR: mediastinum widening (>8cm on supine), obscured aortic knob, loss of the clear space obscured aortic knob, loss of the clear space between the aorta and pulmonary artery, between the aorta and pulmonary artery, displaced NGT, widened paratracheal stripe, displaced NGT, widened paratracheal stripe, trachea deviated to the right, depression left trachea deviated to the right, depression left mainstem bronchusmainstem bronchus

Let’s shift gears and talkLet’s shift gears and talkabout the Belly.about the Belly.

Abdominal TraumaAbdominal TraumaWho do you think is more likely to Who do you think is more likely to

survive?survive?What internal organs are most likely to What internal organs are most likely to

be injured?be injured?

18 y/o kid who…18 y/o kid who…

1.1. Is stabbed in the mid abdomen.Is stabbed in the mid abdomen.

2.2. Falls 12 feet off the roof of a house.Falls 12 feet off the roof of a house.

Abdominal TraumaAbdominal Trauma

Blunt injuries actually carry a greater Blunt injuries actually carry a greater risk of mortality than penetrating risk of mortality than penetrating injuriesinjuries

Blunt injury is more difficult to Blunt injury is more difficult to evaluate and diagnoseevaluate and diagnose

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

Abdominal TraumaAbdominal Trauma Penetrating InjuryPenetrating Injury

Small intestine, colon, and liverSmall intestine, colon, and liver Blunt InjuryBlunt Injury

Spleen>>>>liver, intestineSpleen>>>>liver, intestine

Seat Belt Sign = contusion or abrasion Seat Belt Sign = contusion or abrasion across the lower abdomenacross the lower abdomen Correlates with intraperitoneal lesions or Correlates with intraperitoneal lesions or

lumbar spinal injurylumbar spinal injury

Abdominal Trauma Abdominal Trauma EvaluationEvaluation

Inspect and Palpate most importantlyInspect and Palpate most importantly FAST examFAST exam CT scanCT scan LabsLabs

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

Tox Screen and Ethanol levelTox Screen and Ethanol level

Abdominal Trauma: Abdominal Trauma: TreatmentTreatment

Hemorrhage is the main concern so two Hemorrhage is the main concern so two large bore IVs for fluids followed by blood large bore IVs for fluids followed by blood productsproducts

Antibiotics if concern for bowel injuryAntibiotics if concern for bowel injury Stable – FAST, CT, then OR if necessaryStable – FAST, CT, then OR if necessary Unstable – consider FAST, but really go Unstable – consider FAST, but really go

straight to the OR for ex-lap without delaystraight to the OR for ex-lap without delay Penetrating trauma – determine whether Penetrating trauma – determine whether

or not the peritoneum was violated as this or not the peritoneum was violated as this dictates managementdictates management

Abdominal Trauma: ED Abdominal Trauma: ED standpointstandpoint

2 IVs or a central line for aggressive resuscitation2 IVs or a central line for aggressive resuscitation If the pt is hypotensive/unstable with a high If the pt is hypotensive/unstable with a high

suspicion for intra-abdominal injury -> they need suspicion for intra-abdominal injury -> they need to go for ex-lap not CTto go for ex-lap not CT

If the pt is stable, they can go to CT for evaluation If the pt is stable, they can go to CT for evaluation of the internal organs and management then of the internal organs and management then depends on the findingsdepends on the findings

If the pt is unstable and you are unsure if the If the pt is unstable and you are unsure if the injury is intra-thoracic vs abdominal, a good PE injury is intra-thoracic vs abdominal, a good PE and FAST exam can help the surgeons start and FAST exam can help the surgeons start somewheresomewhere

Trauma: “A Good PE”Trauma: “A Good PE”

Where does blood hide in the body?Where does blood hide in the body?

How much blood do you lose with How much blood do you lose with fractures?fractures?

Where does blood hide in the Where does blood hide in the body?body?

ChestChest AbdomenAbdomen PelvisPelvis FemurFemur

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

Blood Loss with FracturesBlood Loss with Fractures

Pelvis – 1500-3000ccPelvis – 1500-3000cc Femur – 1000ccFemur – 1000cc Ribs – 200-300ccRibs – 200-300cc Tibia/Fibula – 500ccTibia/Fibula – 500cc Humerus – 250ccHumerus – 250cc Radius/Ulna – 150-250ccRadius/Ulna – 150-250cc

Trauma: In the EndTrauma: In the End

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

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

ANY QUESTIONS?ANY QUESTIONS?

THE ENDTHE END