Med 542 Review
Trauma
Ken Stewart MD, FRCSC
Assistant Professor
Division of Thoracic Surgery, University
of Alberta
Trauma
• Precipitous, ubiquitous phenomenon
affecting all ages, races.
– Various forms (blunt, penetrating, burns)
– Disease or process in evolution
– Outcomes based on severity of injury, preexisting conditions, and timing and
appropriateness of treatment.
Objectives
• Describe the
principles of
assessment of the
injured patient
• Describe the
principles of
resuscitation of the
injured or critically-ill
patient
• Describe the
indications for and the
important steps in the
procedure of
emergency
cricothyroidotomy
Objectives --2
• Outline the principles
of assessment and
management of blunt
and penetrating injury
of the chest
• List the indications for
trauma thoracotomy
• List the indications for
tube thoracostomy
• Describe the proper
technique for tube
thoracostomy
• List the indications for
emergency needle
decompression of the
chest
Objectives --3
• Define “shock”, and
list the signs and
symptoms of the
different types of
shock
• Outline the principles
of assessment and
management of blunt
and penetrating injury
of the abdomen
• Describe the
management of the
different types of
shock
• List the indications for
a trauma laparotomy
Internet Resources
American College of Surgeons
– www.FACS.org
– Links to ATLS
Trauma.org
– www.trauma.org
– trauma care website with links to care
related areas
ATLS
Advanced Trauma Life Support
– Program developed by the American
College of Surgeons
– Emerged as a result of experience with
conflict, and health care revision in the US.
– Need for organized approach to
recognition, assessment and treatment of
all types of trauma
ACS outline on ATLS
• Injury is precipitous and indiscriminate･
• The doctor who first attends to the
injured patient has the greatest
opportunity to impact outcome･
• The price of injury is excessive in
dollars as well as human suffering
ATLS--2
• Program:･CME program developed by the
ACS Committee on Trauma･
• One safe, reliable method for assessing and
initially managing the trauma patient･
• Revised every 4 years to keep abreast of
changes
• Audience:･Designed for doctors who care for
injured patients･Standards for successful
completion established for doctors･
• ACS verifies doctors' successful course
completion
ATLS--3
• Benefits:･An organized approach for
evaluation and management of
seriously injured Patients･
• A foundation of common knowledge for
all members of the trauma team
• Applicable in both large urban centers
and small rural emergency departments
ATLS--4
• Objectives:･Assess the patient's condition
rapidly and accurately
• ･Resuscitate and stabilize the patient
according to priority･
• Determine if the patient's needs exceed a
facility's capabilities･
• Arrange appropriately for the patient's
definitive care･
• Ensure that optimum care is provided
ATLS--5
• Trauma Team, and Team Leader
concept
– One person responsible for making
decisions and starting treatment
• Organized into algorithms for the benefit
of systematic recognition and treatment
Assessment and Treatment
• Ongoing assessment from the time of
original notification to response to any
treatment measures.
• Mechanism of injury, timing and preexisting conditions are important
historical features
Systematic Assessment by
“Trauma Team Leader”
Primary Survey
Airway
• Ensure patency
Breathing
• Rule out distress
Circulation
• Provision for large
bore (14-16 gauge) IV
access
• Crossmatch for blood
for severely injured
Secondary Survey
ABC again
Disability
– C-spine precautions and
neuro assessment
Exposure
exam front and back of
patient, then keep warm
Fingers in every orifice
and foley catheter
Assessment Principles
Primary survey
Try to recognize the immediately life-threatening
injuries
1.
2.
3.
4.
5.
Tension Pneumothorax
Massive Hemothorax
Open Pneumothorax
Cardiac Tamponade
Flail Chest
Airway,Breathing,Circulation
Assessment Principles
Secondary Survey
More detailed and complete examination,
aimed at identifying all injuries and
planning further investigation and
treatment.
Airway,Breathing,Circulation, Disability, Exposure, Fingers, Foley
Resuscitation/Treatment
After airway and breathing have been assured, infuse
IV fluids, keep npo and decide on relevant imaging,
and lab testing.
C-spine immobilization and any limb injuries need to be
addressed with dressings, splints and fracture
reduction if vascular or nerve injury apparent.
Decision on where patient should be treated definitively
needs to be determined.
– Consideration of personel and resources.
Airway Assessment
Midline position of trachea
Stridor,presence of hemoptysis
Work of breathing
– Use of accessory muscles
– Respiratory rate
– SaO2 and hypoxemia and hypercapnea on ABG
Level of consciousness
– Depressed GCS--inability to protect the airway
Airway--treatment
Classified as “Simple to Surgical”
Mask, Oropharyngeal airway,
nasopharyngeal airway, laryngeal mask,
endotracheal tube, cricothyrotomy,
tracheostomy
Airways
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Endotracheal intubation
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Endotracheal intubation
Indications
– Hypoxemia
– Hypercapnea
– Impending respiratory
arrest
– Cardiac arrest, multi
trauma
– Readying for OR
Need suction,
Laryngoscope, Muscle
paralysis (?rapid
sequence induction)
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Surgical Airways
Cricothyroidotomy
– Needle
– tube
Quic kTime™ and a
TIFF (Unc ompres sed) dec ompres sor
are needed to see this pic ture.
Tracheostomy
Cricothyroidotomy
Indications
–
–
–
–
Severe facial or nasal injuries (that
do not allow oral or nasal intubation)
Massive midfacial trauma
Anaphylaxis
Chemical inhalation injuries
Contraindications
–
–
–
inability to identify landmarks
(cricothyroid membrane)
Underlying anatomical abnormality
(tumor)
Tracheal transection, acute
laryngeal disease by infection or
trauma
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Cricothyroidotomy
technique
1.With a scalpel, create a 2 cm
horizontal incision through the
cricothyroid membrane
2.Open the hole by rotating the scalpel
90 degrees or by using a clamp
3.Insert a size 6 or 7 endotracheal tube
or tracheostomy tube
4.Inflate the cuff and secure the tube
5.Provide venilation via a bag-valve
device with the highest available
concentration of oxygen
6.Determine if ventilation was
successful (bilateral ausculation and
observing chest rise and fall)
7.No attempt should be made to
remove the endotracheal tube in a
prehospital setting.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Assessment of treatment
Auscultate
CXR
End tidal CO2
SaO2
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Tracheostomy
Definitive surgical
airway
Dedicted appliance or
endotracheal tube
Indications similar for
cricothyroidotomy
QuickTime™ and a
TIFF (Uncomp resse d) de com press or
are nee ded to s ee this picture.
Chest Trauma
Commonest cause of death in blunt and
penetrating trauma
• Immediate causes of death
– Tension pneumothorax, massive hemothorax,
cardiac tamponade, flail, open pneumothorax
• Delayed causes of death
– Pulmonary contusion, cardiac contusion,
pneumothorax, hemothorax, aortic disruption,
tracheobronchial disruption, diaphragmatic
disruption
Chest trauma
• Assessment with physical exam, CXR,
ABGs and SaO2 monitoring
• CT scan
• Echocardiography, ECG
• Serum studies for cardiac injury
(troponin and creatinine kinaseMB
fraction)
Tension Pneumothorax
Typically from penetrating trauma.
– Can be spontaneous
– Bronchopleural fistula from lacerated, or
disrupted lung, open pneumothorax
• Symptoms of dyspnea, syncope, surgical
emphysema, “impending doom”
• Signs of hypotension, tachypnea, tachycardia,
distended neck veins, cyanosis
Hemodynamic mechanism
Axis of the cavae,
point of fixation with
the aorta and great
vessels
Lack of right heart
filling, leading to
shock
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Tension pneumothorax
Treatment
– Suspected: needle
decompression
• 14 gauge angiocath
• Midclavicular line
• Use syringe with
plunger removed
– Leave in place and then
insert standard chest
tube thoracostomy
– What to do if patient is
too thick?
– What if there is no
tension noted with needle
insertion?
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Tension pneumothorax vs
Cardiac tamponade
• In contrast to a pericardial tamponade in
setting of penetrating chest trauma
• Pulse--both elevated
• Percussion-- tympani with tension
• Pulsus paradoxus with tamponade
• Neck veins distended with both
• Trachea shifted with tension
Chest tube thoracostomy
• Indications
– Pneumothorax
– Hemothorax
– Unstable patient
following blunt or
penetrating trauma
– Non trauma
• Pleural effusion,
chylothorax,
empyema,post
operative
– Relative
contraindication=diaphra
gm disruption
• Technique
– Local anesthetic*
– Sterile field*
– Scalpel, kelly or
hemostat forcep
– Chest tube and
pleurevac device
– Securing suture
*if time permits
Chest tube insertion
• Location is typically,
nipple height, midaxilla sparing the
latissimus, and
pectoralis muscle
• No tunnels needed
• CXR post procedure
• Connect to
pleurevac
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Trauma thoracotomy
• Emergency situation
with penetrating
chest injury
– Rarely of benefit in
blunt trauma
– Suspect major
vessel laceration or
cardiac laceration
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Indications
• Penetrating injury to
chest, abdomen or
retroperitoneum
• Signs of life prior to
assessment in ER
then shock
• normothermia
• Clamp aorta
• Defibrillate heart
• Internal cardiac
massage
• Pericardial
decompression
• Repair of lacerated
vessel or heart
Shock
• Hypovolemic
– Following blood loss
– Burns and
hypothermia
• Cardiogenic
– Pump failure
– Ischemia, contusion,
acute valvular
dysfunction
• Distributive
– Sepsis
– Neurogenic
• Obstructive
– Pulmonary embolism
– Tamponade, tension
pneumothorax
• Endocrine
– Manifests like distributive
shock
– Hypothyroidism,
hypoadrenalism
Diagnosis
• Mechanism of injury,
illness
• CXR
• Bloodwork
– ABG, lactate, Hgb,
Creatinine
• Response to trial of
IV fluids
• Monitoring of blood
pressure
• CVP
• SVRI from swan
ganz catheter
measurements
• Response to
vasopressor therapy
Treatment
• Directed at specific
diagnosis
– Fluid resuscitation
• Crystalloid, colloid
• Blood and blood
products
– Vasopressors
• Specific agents for
specific types of
shock
• Definitive treatment
where possible
depending on
etiology.
Blunt Injuries to the
abdomen
• Physical signs
• Distension
• Peritonitis
• Retroperitoneal
bleeding
• Intraabdominal
pressure ( measured
with foley catheter
and tonometer)
• Diagnosis
– Fast scan
(ultrasound)
– CT scan
– Hemodynamic
monitoring
– Diagnostic peritoneal
lavage
Diagnostic peritoneal lavage
• Used to assess need
for laparotomy following
trauma
– Cutdown technique to
midline of abdomen
– Initial aspiration, if
clear…..
– Infusion of one litre of
saline with IV tubing and
then collection
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Diagnostic peritoneal lavage
• Indications for
laparotomy
– GI contents on aspirate
or lavage
• Feces, bile, peas and
corn
– Urine on aspirate
– Blood
• 10 mLs of gross blood
on aspirate
• >100 000 rbc/ mL on
analysis (newspaper
test)
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Role of CT scan
• Use for blunt injury
management
– Assess liver and
spleen injuries
– Presence of
pneumoperitoneum,
free fluid
– Vascular injuries
– Retroperitoneal
injuries
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Indications for laparotomy
following trauma
• Blunt
– Hemodynamic instability
despite resuscitation
– Positive DPL
– Findings on CT scan
• High grade spleen or
liver injury
• Pneumoperitoneum
• Retroperitoneal organ
injury
• Vascular injury
• Penetrating
– Hemodynamic
instability despite
resuscitation
– Evisceration,
pneumoperitoneum
– Positive DPL
– CT scan findings
similar to blunt