Case Based Presentation
TRAUMA # 2
Case
• You’re on call on a Saturday in the ICU at
VGH when the head nurse tells you that 2
traumas from an MVA had just come into
the ER. Both the driver and the passenger
were belted when their car lost control and
hit a tree. The trauma team is currently
assessing them and will let you know if they
need any ICU services.
Case
• After speaking to the trauma senior, you
find out that the driver is unstable. A FAST
showed free fluid in the abdomen, and the
patient is now being rushed to the OR for an
exploratory laparotomy. She thinks that the
patient will likely need to come to the ICU
post-operatively.
Question 1
• What are the most common organ injuries
associated with a) blunt and b) penetrating
abdominal trauma? What organ injuries are
associated with deceleration injury? (Yoan)
What are the most common organ injuries
associated with blunt abdominal trauma?
• Liver and spleen : most frequently.
• Small and large intestines : next most
injured.
– Crush, Deceleration, trapped air
• Pancreas (10-12%): in crush injury,
direct blow, seat belt...
• Kidney, bladder
Source: emedicine 2007, Salomone et al
What are the most common organ injuries
associated with penetrating abdominal
trauma ?
• Stab
–
–
–
–
liver (40%)
small bowel (30%)
diaphragm (20%)
colon (15%)
• Gunshot wound
–small bowel (50%)
–colon (40%)
–liver (30%)
–vascular (25%)
• pancreas, duodenum, vascular, gastric,
rectum, porta hepatis, kidneys, ureters
Source: emedicine 2008, Testa et al
What organ injuries are associated with
deceleration injury?
• Classic deceleration injuries include
hepatic tear along the ligamentum teres
and intimal injuries to the renal arteries.
As bowel loops travel from their
mesenteric attachments, thrombosis
and mesenteric tears, with resultant
splanchnic vessel injuries, can result.
Source: emedicine 2007, Salomone et al
Case
• The senior then tells you that the passenger
of the car is currently stable after aggressive
resuscitation. He has a pelvic fracture and is
complaining of chest pain. The CXR shows
a widened mediastinum. The ECG is
unremarkable. A CT chest is ordered and
pending.
Question 2
• Discuss the different types of pelvic
fractures, their associated mechanism of
injury, risk of bleeding, and initial
management
Biomechanics of pelvic
fractures
• Lateral compression injury
– Most common
– Acute shortening of diameter
across pelvis
– Rarely destroy ligamentous
integrity
– Do not typically cause large
blood loss
• Anterior/Posterior Compression
– Force causes pelvic diameter to
widen
– Ligamentous disruption
– Manifest itself as a widened
pubis symphysis and SI joint
– Often associated with
substantial vascular damage:
LS plexus and
common/external iliac artery
• Vertical shear injury
– Fall from a height
– Severe ligamentous injury
– Vascular injury less
severe than AP injuries
Pelvic Fracture Classification
• Tile Classification
– Concentrate on rotational component of
injury to address long-term reconstructive
plans
• Young and Burgess Classification
– Subdivide LC and AP compression injuries
according to increasing level of energy
The American Journal of Surgery 192 (2006) 211ﾐ223
The American Journal of Surgery 192 (2006) 211ﾐ223
Mechanism of injury
Blood loss in pelvic fractures
Initial Management
• ABC’s
• Xmatch and IV access
• Compressive device
– Temporal control of
hemorrhage
– Design to reduce the volume
of the pelvis
– Less useful in LC injuries
Qui ckTime™ and a
TIFF (U ncompr essed) decompressor
are needed to see thi s pi cture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Critical Care2007, 11:204
The American Journal of
Surgery 192 (2006) 211ﾐ223
Indications for Angiography
• 4 U transfused for pelvic bleeding in <24 h
• >6 U transfused for pelvic bleeding in <48 h
• Hemodynamic instability with a negative
FAST or DPL
• Large pelvic hematoma on CT
• Pelvic pseudoaneurysm on helical CT
• Large and/or expanded pelvic hematoma
seen at the time of laparotomy
TRAUMA - 6th Ed. (2008)
External Fixation
• Used as definitive anterior fixation for
open book fracture
• Used if condition does not permit
internal fixation
• Used as a bridge to internal fixation
– “damage control” approach
Question 3
• What associated injuries should you look
for in patients with pelvic fractures?
Which injuries may be associated
with
pelvic
fractures?
UK
So Cal
The Pelvis Doesn’t Fracture
Easily…
• Associated with high energy-transfer
situations…
– Falls
– Crashes
– Assault
– Sports injuries
(including, of course… falls and crashes)
In UK Trauma Audit Research
Network, associated with:
•
•
•
•
•
Chest trauma (21%)
Head trauma (17%)
Hepatic/Splenic injury (8%)
2 or more long bone fractures (8%)
Urogenital (4%) (!?)
But wait… there’s more!
• Longer mean hospital LOS (15 vs 8
days in trauma pts without pelvic
fracture)
• More likely to be admitted to critical care
setting (25% vs 12%)
• 3 month mortality 14% vs 6%.
– Shorter period from injury to death in pelvic
# patients (6 hrs vs 40 hrs)
Trauma Registry at LA County/
USC Trauma Center 1993-2000
Similar to UK data: falls
And crashes!
Associated Injuries
• Intraabominal/urogenital injury:17%
– Bladder/Urethral: 6%
– Solid organ: 12%
• 6% hepatic
– GI perforation: 4%
– Urogential: 6%
• Thoracic Aortic Rupture: 1.4% (vs 0.4% of
trauma pts without pelvic fracture)
• Mortality: 28% (vs 14%)
Case
• The CT chest showed a descending thoracic
aortic dissection with no contrast
extravasation. The patient arrives in the unit
and is hemodynamically stable.
Question 4
• Discuss the diagnosis, the radiographic
features as well as the management of blunt
aortic injury.
• Blunt aortic injury occurs in less than
1% of MVCs but is responsible for 16%
of the deaths
• Up to 80% of patients die before their
arrival at a hospital
• Untreated, approximately 30% of
surviving patients who are admitted to a
hospital will die within the first 24 hours
Mechanism
N Engl J Med 2008;359:1708-16
Diagnosis
• CXR findings
– Wide mediastinum: >8cm on upright,
mediastinal/chest width ratio of >0.38
– obscure or indistinct aortic knob
– depression of the left mainstem bronchus
– deviation of the nasogastric tube
– opacification of the aortopulmonary window
CXR
• Also suggestive
– widened paratracheal and paraspinous
stripes
– apical capping
– 1st and 2nd rib fractures have less an
association
– Between 7.3% and 44% of patients with
blunt aortic injury may have a normal
mediastinum on chest radiography
CT Scan
• Helical CT of the thorax is more
sensitive for blunt aortic injury than
angiography and is estimated to have a
sensitivity of 100%, as compared with
92% for angiography
» Fabian TC, et a l . Ann Surg 1998;227:666-76
CT Scan
• 28% rate of missed diagnoses and
recommend that CT be performed in all
patients with a hx of MVC at a speed of
>15 km/h for unrestrained drivers and
>50 km/h for restrained drivers
» Exadaktylos AK, et al. Cardiovasc J S Afr
2005;16:162-5.
CT vs Angio
Bruckner B. A. et al.; Ann Thorac Surg 2006;81:1339-1346
Copyright ©2006 The Society of Thoracic Surgeons
Other Modalities
• Other options for the diagnosis of BAI
include transesophageal
echocardiography, intravascular
ultrasonography, and magnetic
resonance imaging
Management
• Immediate operative repair used to be
the rule
• Several studies have demonstrated the
relative safety of a delayed approach,
particularly if there are substantial coinjuries, using a regimen of betablockers and antihypertensive agents to
decrease the shear force on the aortic
wall
– Demetriades et al J Trauma 2009, 66:967-973
Medical Mgt
• Fabian et al: a prospective study using
beta-blockers with or without
vasodilators to maintain a systolic blood
pressure of 100 mm Hg (or 110 to 120
mm Hg in older patients) and a pulse
rate of under 100 beats/min
• no patient had an aortic rupture while
awaiting repair.
• Potential problem with severe HI and
SCI
Repair
• There are basically
3 option
– Open “clamp and
sew”
– Open Bypass or
shunt
– Endovascular
repair
Paraplegia
Demetriades et al J Trauma 2009, 66:967-973
•Clamp and sew has an associated mortality of 16%
and a striking 19% incidence of paraplegia
Endovascular Repair
• Majority of the repairs currently
done as seems much safer
especially in multi-trauma patients
• the durability of endografts is
unknown.
• There are questions about longterm device integrity as well as the
natural history of the aorta itself
after this type of injury and repair.
These issues are particularly
important considering the relatively
young age of trauma patients
Case
• Shortly after admitting these 2 patients, the
head nurse tells you another trauma came
into the ER, and was wondering if you were
called about it. The patient is a 19 year-old
man who was also involved in a MVA. On
the scene, the patient was alert and oriented
but unable to move or feel his extremities.
Question 5
• Summarize the clinical findings and
anatomical lesions of the related to the
following clinical syndromes: (Neil)
•
•
•
•
•
Central cord syndrome
Brown-Sequard syndrome
Anterior cord syndrome
Conus medullaris syndrome
Spinal shock.
Anterior
cord
Brown
Sequrd
Pain/Temp
Bilateral
Contralateral Shawl
distribution
Motor
Bilateral
Ipsilateral
Arms>Legs
Ipsilateral
Intact
Vibration/pos Intact
ition
Central
Cord
Conus medullaris
Cauda Equina Syndrome
Location:
L1-L2 vertebral level
Injury to sacral cord (S1-5)
Location:
L2-Sacrum vert level
Injury to lumbosacral roots
Causes:
L1 fracture
Tumors, gliomas
Vascular injury
Spina bifida, tethering of cord
Causes:
L2 or below fracture/disc
Sacral Fractures
Fracture of pelvic ring
Spondylosis
Signs and symptoms
Normal motor function of lower
extremeties,(unless motor S1-S2
involvement)
Saddle anesthesia
No pain
Symmetric abnormalities
Severe bowel, bladder, sexual
dysfunction
BCR may be present
Signs and symptoms
Flacid paralysis of involved lumbar
roots
Areflexic LE
Sensory loss in root distribution
Pain
Asymmetric
High lesions spare bowel and bladder
BCR often absent
EMG Normal
EMG root findings
Spinal Shock
• Concussive injury to spinal cord that
results in complete dysfunction below
level of injury
• Usually lasts <24 hours but can be
days
• Bulbocavernosus reflex is not present
during spinal shock
• Important in prognosis
Case
• In the trauma bay, the patient is hypotensive
and bradycardic. He is on 10 mcg/min of
dopamine. His c-spine films show a
blowout fracture of his C5 vertebra.
Question 6
• What are the cardiovascular complications
of spinal cord injuries and how should you
manage them? (Marios)
Cardiovascular complications
of SCI
•
Occur in patients with cervical or high
thoracic cord injury (T6 or higher).
•
Degree of dysfunction is related to the
location and severity of the injury, and is
manifested by:
1) Low resting blood pressure and orthostatic
hypotension
2) Heart rate abnormalities
3) Autonomic dysreflexia
•
Neurogenic shock typically lasts up to 5
weeks.
Degree of SCI and
cardiovascular dysfunction
Low blood pressure and
orthostatic hypotension
• Hypotension occurs due to the reduced sympathetic
outflow to the cardiovascular system.
• Mechanisms involved in orthostatic hypotension
include:
1) Loss of reflex vasoconstriction caudal to the
injury
2) Lack of muscular effects to counteract venous
pooling
3) Reduced plasma volumes secondary to
hyponatremia
4) Cardiovascular deconditioning secondary to
prolonged bedrest
SBP over time
DBP over time
Heart rate abnormalities
• SCI alters cardiac electrophysiology and increase susceptibility
to arrhythmias such as:
–
–
–
–
–
–
Sinus bradycardia
Repolarization changes
AV blocks
Supraventricular tachycardia
Ventricular tachycardia
Cardiac arrest
• Secondary to a loss of sympathetic tone in the presence of
intact parasympathetic tone.
• The most pronounced changes are seen during the acute phase
post injury (weeks 2 to 6)
Repolarization changes
Heart rate over time
Autonomic dysreflexia
• An increase in SBP of at least 20% associated with a change
in heart rate and accompanied by one of the following signs or
symptoms:
–
–
–
–
–
–
Sweating
Piloerection
Facial flushing
Headache
Blurred vision
Stuffy nose
• Often associated with a triggering factor such as bladder
distension or bowel impaction.
• Relatively common in the chronic phase of SCI, but can also
occur in the acute stage following SCI.
Autonomic dysreflexia
Management
• Hypotension
– R/O other causes of hypotension, including adrenal insufficiency.
– Guidelines recommend the use of fluids +/- vasopressors to
maintain a MAP of 85 mmHg or greater during the first 7 days
following SCI.
– Based on Grade III evidence, this is thought to improve spinal cord
perfusion and therefore possibly neurological outcome.
– High thoracic or cervical cord lesions, where hypotension is often
accompanied by bradycardia should be treated with dopamine or
norepinephrine.
– Lower thoracic cord lesions which are primarily affected by
vasodilation can be treated with phenylephrine.
Management
• Symptomatic bradycardia
– May occur with noxious stimuli such as
suctioning.
– Can be treated with atropine or
vasopressors that have both alpha- and
beta-adrenergic actions such as dopamine,
norepinephrine, and epinephrine.
Management
• Autonomic dysreflexia
1)
2)
3)
4)
If supine  place in sitting position
Loosen constrictive clothing or devices
R/O bladder distention or bowel impaction
If SBP > 150, consider nitroprusside
Question 7
• Is there any evidence for steroids in spinal
cord trauma? (Naisan)
Question 7 - Is there any
evidence for steroids in spinal
cord trauma?
NO…
I think
Clinical Practice Guideline SCI
2008
• No clinical evidence exists to definitively
recommend the use of any
neuroprotective pharmacologic agent,
including steroids, in the treatment of
acute spinal cord injury to
improve functional recovery.
The Studies
• MP has been investigated in three large-scale,
multicenter clinical trials collectively referred to
as NASCIS (National Acute Spinal Cord Injury
Study; Bracken et al.1984, 1990, 1997)
• NASCIS 1 trial compared 2 doses of MP after
traumatic SCI (100mg vs 1000mg for 10 days)
• second clinical trial compared the effects of a
much higher dose of MP (30 mg/kg then
infusion) with those of naloxone and a placebo
• and the third clinical trial evaluated the timing of
initiation and duration of MP treatment following
injury (8 vs 3 hours; 24 vs 48 hrs)
The Outcomes
• NASCIS I: no difference found between
groups
• NASCIS II: if <8hrs, improved motor
function was statistically significant at 6
months and even after 1 year in the MP
group compared with the control group
(17.2 and 12.0 points improvement,
p=.030)
The Results
• NASCIS III: Follow-up after 6 months
revealed no significant difference
between the groups
– At that point, patients were divided into
treatment within 3 hours and after 3 hours
but less than 8 hours after SCI
– After this statistical maneuver, there was a
significant difference in motor score who
received MP for 47 hours compared with
24hrs, in the groups treated between 3 and
8 hours
The Problems
• neither NASCIS II or NASCIS III
addressed some of the potential
confounding variables
• the NASCIS II trial did not include
details about other interventions such
as radiology , surgical manipulations, or
the extent of rehabilitative therapies,
which may have contributed to
improvements or recovery
The Problems
• subsequent post hoc analysis failed to
demonstrate improvement in outcome
measures (motor scores, pinprick
scores,and light-touch scores)
• meaning that improved recovery with
MP may represent random events, thus
weakening the overall study findings
(Coleman et al., 2000; Hurlbert, 2000,
2006; Short et al., 2000).
The Problems
• Only right-sided motor scores were
reported in NASCIS II, but bilateral
sensory scores were reported. Lack of
evidence describing left-sided motor
scores and total body motor scores in
NASCIS II is confusing
• The data were presented as obtained from
the whole study population; however, the
fact is that in the groups that presented
within 8 hours, only 62 patients of the
placebo group and 65 of the MP group
• NASCIS III :Had no difference at one
year in the Functional Independence
Measure (FIM) developed by the
American Spinal Injury Association
• So seems no clinically significant
difference
Side effects
• All studies showed a significant
increase in infection rates,
ICU/Vent times, and GI
bleeding
Question 8
• Discuss DVT prophylaxis in spinal cord
injury. (Todd)
Venous Thromboembolism
Prophylaxis in Spinal Cord Injury
• Spine trauma, immobility and paralysis all
conspire to place SCI pts at risk for VTE.
• Options include:
–
–
–
–
–
Pneumatic calf compression devices
Unfractionated heparin
Low molecular-weight heparin
IVC filters
Screening doppler U/S
• Which is best?
Chest Guidelines 2004
• VTE prophylaxis is recommended for “…all
trauma patients with at least one risk factor.”
Grade 1A.
– Data on pneumatic compression devices is conflicting, but
they may be useful in patients with a contraindication to
anticoagulants.
– IVC filters not recommended as routine treatment unless
absolute contraindication to anticoagulation.
– Not cost-effective to screen with U/S.
– Continue until discharge.
Venous Thromboembolism
Prophylaxis in Spinal Cord Injury
• Low Molecular-Weight Heparin
(LMWH).
– Spine uses it; we use it…and it’s worked
out pretty well so far.
• Low-dose UFH vs LMWH: Geerts, WH, Jay, RM,
Code, KI, et al A comparison of low-dose heparin with
low-molecular-weight heparin as prophylaxis against
venous thromboembolism after major trauma. N
ENGL J MED 1996;335,701-707
• Contraindications:
– Intracranial hemorrhage.
– Active bleeding.
– Uncontrolled coagulopathy.
– Known or suspected perispinal hematoma
(incomplete sci).