Trauma
“This ain’t ER”
Ben Zarzaur, MD
UNC Department of Surgery
Section of Trauma and Critical Care
What is
trauma?
Real Life & Death
What is
trauma?
Trauma Epidemiology
Years of Potential Life Lost
24.80%
16.40%
18.00%
MMWR 1982;31,599.
40.80%
Injury
Cancer
Heart Disease
All Other Diseases
Mechanisms of Injury:
Blunt Trauma
• MVC
• Pedestrian vs
Vehicle
• Falls
Mechanisms of Injury:
Special Situations
• Explosions
– Blunt + penetrating + burns
•
•
•
•
Burns
Crush injuries
Drowning
Hypothermia/ exposure
Compression injury
• Frontal brain
contusion
• Pneumothorax
• Rupture of Left
hemidiaphragm
• Small bowel
rupture
• Chance fracture
Deceleration Injury
• Aortic tear
– Fixed descending
aorta
– Mobile arch
• Acute subdural
brain hematoma
• Kidney avulsion
• Splenic pedicle
Mechanisms of Injury:
Penetrating Trauma
• Gun shot wounds
• Stab wounds
• Impalement
Gun Shot Wounds: Mechanism
• Energy transfer
– Shape/size of bullet
– Distance to target
• Velocity (most important)
– Kinetic energy = (Mass × Velocity2 )/2
• Surface area distributed
– Tumble and yaw
– Fragmentation
• Anatomy
– Viscoelasticity
• Muscle
• organs
Stab wounds
• Mechanism
– Blunt: Crush injury
– Sharp:Tissue disruption
• Extent of Injury
– Weapon size, length,
sharpness, penetration
• Severe injury
– Chest and abdomen
– 4+ wounds
What happens
when the
patient comes
to a Level I
Trauma Center?
Trauma Team
“Doin it 24/7”
• ED Physicians
• Anesthesiology
• Surgeons
– General and Trauma and Critical Care
– Neurosurgery
– Orthopedics
•
•
•
•
Medical Students
Nurses
Radiology Techs
Radiologists
What happens when
this patient comes to
the ER where you are
moonlighting?
What the heck
do I do now?
Don’t panic!
Trauma is not
rocket science!
•
•
•
•
•
Air goes in & out
Oxygen is good
Blood goes round & round
Stop bleeding
Put things back where and
how they belong
Initial Assessment:
Prerequisites
• Wide-angled view
• Pattern recognition skills
• Ability to triage and set priorities
• Organized structure
Trauma is not
rocket science!
ABCDEF
Initial Assessment:
Primary Survey
• A = Airway
• B = Breathing
• C = Circulation
• D = Disability
• E = Exposure
• F = Fracture
Initial Assessment: Airway
• Clear & establish a
good airway
– Consider intubation
for coma, shock, and
thoracic injuries
• C-spine stabilization
Airway: Cricothyrotomy
Initial Assessment: Breathing
• Chest excursion & breath sounds
– Flail chest
• Pneumothorax
– Open
– Tension
• Massive Hemothorax
Initial Assessment: Circulation
• Perfusion (mental status, skin, pulse)
• Control bleeding with pressure
• Pericardial Tamponade
– Beck’s Triad
• Establish 2 large bore (16G or larger)
IV’s in upper extremity peripheral veins
• Resuscitate with Lactated Ringers
– After 4 L think about resuscitation with
blood
Initial Assessment: Disability
• Neurologic status
– Glasgow Coma Scale
• Eye
• Motor-best predictor of long term
outcome
• Verbal
– Spinal Cord Injury
Initial Assessment: Exposure
• Remove clothes
• Temperature
– warm blankets
• Finger and tube in every orifice
• Maintain full spine precautions
– Log Roll
Initial Assessment: Fracture
• Stabilize Fractures
• Relocate dislocated joints
• Reassess pulses
Secondary Survey
• Patient history
• Head to toe physical exam
• Radiography
– Lateral C-spine, C-xray, pelvis
– One cavity above/below entrance/exit
wounds
– FAST
• Urinary bladder drainage
• NGT
• Blood sampling/monitoring
Does this patient
need to go to the
OR ?
Penetrating Abdominal Trauma
Penetrating Abdominal Trauma
GSW
OR
KSW
HD Unstable
HD Stable/No peritonitis
OR
Peritoneal Penetration
Positive
Negative
OR
Observation
Blunt Abdominal Injuries
Blunt Trauma
Peritonitis
OR
Indeterminate
HD Stable
HD Unstable
CT
FAST/DPL
Positive
Negative
OR
Keep Looking
Liver Injury
Liver Injury
• blunt or penetrating injury
• mortality: 10 - 20%
• may be associated with right lower rib
fracture
• Signs / Symptoms
– RUQ pain abdominal wall spasm ,guarding
hypoactive or absent BS signs of hemorrhage
Liver Injury: Management
Blunt Injury
• ICU monitoring
– For more severe injuries
– Serial HCT
• Floor Monitoring
– Less severe injuries
– Serial HCT
• OR if patient becomes unstable or
requires excessive blood transfusions
Surgical Management
Surgical Management
Surgical Management
Spleen Injury
Splenic Injury
• Blunt or Penetrating
• Signs / Symptoms
– LUQ pain
– Kehr’s sign
– involuntary guarding hypoactive or absent
BS
– signs of hemorrhage
– point tenderness
Splenic Injury Management
• ICU monitoring
– Serial Physical exams
– Serial HCT
• Floor Monitoring
– Not indicated at this time
• Further intervention needed if patient
becomes unstable or requires blood
transfusion
– Embolization vs Splenectomy
Splenectomy
• Complications
– postsplenectomy infection
• Vaccination
– wound infection
– subdiaphragmatic abscess
– pulmonary complications
– hypovolemic shock
Stomach and Small Bowel Injury
• Stomach & Small Bowel
– Blunt vs penetrating
• Diagnosis
– Pneumoperitoneum or free fluid on CT scan
– small bowel injury may be difficult to detect
– Found at laparotomy
• Management
– Primary repair or resection
Colon and Rectal Injury
• Colon
– Diagnosis
• Pneumoperitoneum or free fluid on CT scan
• injury may be difficult to detect
• Found at laparotomy
– Management
• Colostomy vs primary repair
• Rectum
– Intraperitoneal- treat as colon injury
– Extraperitoneal- primary repair with
diversion
• +/- presacral drains
Pancreas & Duodenum
• Diagnosis
– often delayed diagnosis
– frequently seen together
– most often contused due to blunt injury
– Seen on CT Scan or at laparotomy
– intramural hematoma in wall of duodenum
 obstruction bilious vomiting severe
abdominal pain distention
Pancreas Injury
• Management
– if the result of blunt trauma
• nonoperative management NG/OG
decompression serial physical exams
monitoring signs of infection controversial
- 3 weeks of bowel rest with TPN
– Complications of nonoperative care
• pancreatic fistula pseudocyst formation
– Operative management is necessary if:
pain fever ileus elevated serum amylase
Duodenal Injury
• Management
– For hematoma
• NG/OG decompression serial physical
exams monitoring signs of infection
– controversial - 3 weeks of bowel rest with TPN
– For perforation
• Primary repair with duodenal exclusion
• Efferent/Afferent Duodenal tubes
Pelvic Injury
• Introduction
– significant blood loss if bilateral
– may settle in retroperitoneal space
– 3% of all fractures
– mortality 8 - 50%
– 2nd most common cause of traumatic
death
Pelvic Fracture
• Signs & Symptoms
– pelvic instability
– pain (suprapubic also)
– crepitus
– bloody meatus
– neurovascular deficits
Pelvis
• Interventions
– Stable patient
• analgesia
• Repair vs mobilization
– Unstable patient
• Immobilize
• Ex-fix
• Angiography
– embolization