COMPLICATIONS OF
TRAUMA
ANN O’ROURKE, MD, MPH
SCRTAC TRAUMA CARE BEYOND THE ED
DECEMBER 4, 2014
Saving Lives By Strengthening Our Region’s Trauma Care System
OUR CASE
• 31 yo man MVC with prolonged extrication
• Presents to ED:
• Confused, HR 120, RR35, BP90/65
• Diminished breath sounds on right with palpable chest
crepitus
• Unequal leg length
• Abdominal bruising
• What are your concerns?
OUR PATIENT
• Right hemopneumothorax-facility placed
28Fr chest tube
• Liver laceration-managed non-operatively
• Right acetabular fracture dislocation with
proximal femur fx-traction with planned
operation
• C3 fracture with small epidural hematomamanaged with PMT collar
POST INJURY DAY 2 OUR PATIENT STILL
COMPLAINS OF DIFFICULTY BREATHING
• What are your concerns?
• Worsening pulmonary contusion
• Pneumothorax
• Hemothorax
• Pain from fractures
• Abdominal fluid/blood
• Pneumonia/pneumonitis
• Pulmonary embolism
RETAINED HEMOTHORAX
• Our chest tube did a
good job of
evacuating air and
most of the blood,
but some clotted
blood remained. This
can lead to:
• Empyema
• Chronic fibrothorax with
trapped lung
RETAINED HEMOTHORAX
Prevention:
• Properly positioned,
LARGE chest tube
(36-42Fr)
• Post placement CXR
• Retained hemothorax post
chest tube placement
independent predictor of
empyema in up to 33% of
patients
RETAINED HEMOTHORAX
Treatment:
•
Operative
• Early VATS (3days) significant reduction
in operative difficulty, contamination/infection of clot, and hospital
length
• After day 5 more likely to need
thoracotomy
•
Fibrinolytic
• VATS is a more effective procedure than
intrapleural streptokinase
• VATS patients having a statistically
significant shorter hospital stay and
decreased need for additional therapy
• Fibrinolytic agents would have to be seen
as a second-line agent behind surgery
when the risks of surgery are too great to
the patient’s overall outcome
EMPYEMA
•
•
Approximately 3% of patients
with chest trauma will develop
a posttraumatic empyema.
Risk factors
• persistent pleural effusion/hemothorax
• duration of a tube
• placement of multiple tubes
•
•
No good evidence for or
against prophylactic abx prior
to chest tube for prevention
As with retained hemothorax,
first line treatment is
operative in patients who will
tolerate
EMPYEMA
PNEUMONIA
• Our patient had difficulty coughing and
clearing secretions
• What risk factors for this?
• Rib fractures with impaired mechanics
• Pulmonary contusion
• Inadequate analgesia
• C-collar impaired swallowing
FROM THE NTDB
ALL AGES
Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25
RIB FRACTURE CORRELATION WITH
MORTALITY
Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25
OUR PATIENT DEVELOPED RLE SWELLING
• What are your
concerns?
• DVT
• Compartment syndrome
• Morel-Lavallée
DVT
• What are his risk
factors for DVT?
• Prolonged extrication
• Immobility
• LE/pelvic fracture
• Holding DVT prophylaxis
WHEN SHOULD WE BEGIN DVT PROPHYLAXIS?
AND WHAT MEDICATION DO WE USE?
• What factors in to the decision for this
patient?
• Solid organ injury (liver)
• Pelvic fracture
• Spinal epidural hematoma
• Other factors:
• Head bleed
• Planned operations
• Epidural catheters
DVT PROPHYLAXIS IN SOLID ORGAN INJURY
• DVT prophylaxis is
safe in patients with
solid organ injury
• BUT timing of
initiation is not
established
• Some retrospective
trials suggest OK to
begin early
DVT PROPHYLAXIS IN TRAUMA
MOREL-LAVALLÉE
OUR PATIENT DEVELOPS ABDOMINAL PAIN,
TACHYCARDIA AND FEVER
• What are your concerns?
• Biloma/bile leak
• Missed bowel injury
• Delayed bleed
• Urinary tract infection
• Hepatic necrosis
• Abscess
• Cholecystitis
DELAYED LIVER COMPLICATIONS
• Delayed bleed 1-6%
severe liver injuries
• Expanding bleed
• Pseudoaneurysm
• Biliary leak 2-7%
• Mean 7-10d post injury
• Most in grade 4-5 injuries
• Treat with drainage and
ERCP and stent
BILIARY COMPLICATIONS
Table 2
Analysis of factors influenced development of complications, including biliary complications in the study group
Complications
No complications
Biliary complications
(n = 22)
(n = 24)
(n = 15)
17
17
13
NS
23.7 ± 11.9
20.6 ± 15
22.5 ± 12.2
NS
ISS (mean ± SD)
36 ± 14
32.6 ± 15
35 ± 15
NS
Grade of liver injury (mean ±
SD)
4 ± 0.6
3.8 ± 0.6
4 ± 0.75
NS
Angioembolization (%)
6 (27.2)
5 (20.8)
5 (33.3)
NS
15 (68.2)*
8 (33.3)
9 (60)
0.038
7 (31.8)
5 (20.8)
5 (33.3)
NS
Male
Age (years)
OR (%)
Penetrating injury (%)
P value
OR - operative group; ISS - Injury severity score; NS - Differences not significant; * - p < 0.05 - complication rate was higher in OR patients.
Bala et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012 20:20 doi:10.1186/1757-7241-20-20
SMALL BOWEL INJURY
MISSED SMALL BOWEL INJURY
OUR PATIENT DEVELOPS MENTAL STATUS
CHANGES
• What are your concerns?
• Hypoxia or hypercarbia
• Sepsis
• Stroke
• Medications
• Drug withdrawal
BLUNT CEREBROVASCULAR INJURY
BCVI
OUR PATIENT IS BACK IN CLINIC WITH SLEEP
DISTURBANCES
• What are your concerns
• Inadequately treated pain
• Medication withdrawal
• Post traumatic stress disorder
• Sleep apnea
• Insomnia related to stroke
PTSD IN CIVILIAN TRAUMA
• More than 20% of
trauma patients have
PTSD at 12 months
following injury
• Risk factors:
• Post-injury emotional
distress
• Pain
• Pre-injury depression
• Benzodiazepine use
Zatzick, et al. Annals of Surgery • Volume 248, Number 3, September 2008
PTSD CRITERIA
• Historically, benzodiazepines were used for
treatment of acute stress and ptsd
• change: use with caution or discourage use
• theoretical, animal, and human evidence to
suggest that benzodiazepines may actually
interfere with the extinction of fear
conditioning or potentiate the acquisition of
fear responses and worsen recovery from
trauma
• Very high co-morbidity of PTSD with alcohol
misuse and substance use disorders
(upwards of 50 percent of co-morbidity) and
potential problems with tolerance and
dependence.
• Once initiated, benzodiazepines can be very
difficult, if not impossible, to discontinue
due to significant withdrawal symptoms
compounded by the underlying PTSD
symptoms.