Trauma Board ReviewTrauma Board ReviewPart IPart I

Dr. GrumpyDr. Grumpy

DisclosureDisclosure

Drug rep dinnersDrug rep dinners LinezolidLinezolid ErtapenemErtapenem KeppraKeppra LevofloxacinLevofloxacin

STCSTC

Blunt TraumaBlunt Trauma

High speed head-on MVC. 2 cars. 3 High speed head-on MVC. 2 cars. 3 passengers in each car. Front passengers in each car. Front passenger of car #1 pronounced on passenger of car #1 pronounced on scene. The rest are coming to your scene. The rest are coming to your trauma center.trauma center.

Patient #1Patient #1

Driver of car #1. 23yoM. Moaning and Driver of car #1. 23yoM. Moaning and sonorous respirations; will not open his sonorous respirations; will not open his eyes to pain but withdraws to pain. eyes to pain but withdraws to pain. GCS? GCS?

A.A. 44

B.B. 55

C.C. 66

D.D. 77

E.E. 88

GCSGCS

EyesEyes VerbalVerbal MotorMotor

You notice severe midface fractures. You You notice severe midface fractures. You want to intubate patient with RSI. You know want to intubate patient with RSI. You know that:that:

A.A. Thiopental can raise both systemic and Thiopental can raise both systemic and intracerebral blood pressure.intracerebral blood pressure.

B.B. Etomidate is contraindicated.Etomidate is contraindicated.

C.C. Ketamine reduces intracerebral pressure, Ketamine reduces intracerebral pressure, but may cause severe laryngospasm.but may cause severe laryngospasm.

D.D. Pretreatment with lidocaine is not Pretreatment with lidocaine is not indicated.indicated.

E.E. Succinylcholine should be avoided unless Succinylcholine should be avoided unless a defasciculating dose of a a defasciculating dose of a nondepolarizing agent has first been nondepolarizing agent has first been given.given.

Trauma IntubationTrauma Intubation Lidocaine effectively attenuates the cough reflex, Lidocaine effectively attenuates the cough reflex,

hypertensive response, and increased ICP associated hypertensive response, and increased ICP associated with intubation. with intubation.

Thiopental may also be effective but should not be Thiopental may also be effective but should not be used in hypotensive patients (consider it to be a less used in hypotensive patients (consider it to be a less severe form of propofol)severe form of propofol)

If succinylcholine is used, premedication with a If succinylcholine is used, premedication with a subparalytic dose of a nondepolarizing agent should be subparalytic dose of a nondepolarizing agent should be considered if time permits, since fasciculations considered if time permits, since fasciculations produced by succinylcholine may increase ICPproduced by succinylcholine may increase ICP

Blunts ICP and cough response, no evidence for clinical Blunts ICP and cough response, no evidence for clinical differencedifference

Etomidate has beneficial effects on ICP by reducing Etomidate has beneficial effects on ICP by reducing cerebral blood flow and metabolism. cerebral blood flow and metabolism.

Ketamine should be avoided because it increases ICP Ketamine should be avoided because it increases ICP (although studies have bore out no outcome (although studies have bore out no outcome difference)difference)

*Careful intubating peri-hypotensive trauma patients*Careful intubating peri-hypotensive trauma patients

Quick word on EtomidateQuick word on Etomidate

Don’t use itDon’t use it Don’t use itDon’t use it Don’t use itDon’t use it Don’t use itDon’t use it

Contraindications to nasotracheal Contraindications to nasotracheal intubation in a trauma patient intubation in a trauma patient includeinclude

A.A. ApneaApnea

B.B. Cervical spine fractureCervical spine fracture

C.C. Depressed mental statusDepressed mental status

D.D. HypotensionHypotension

E.E. PneumothoraxPneumothorax

Nasotracheal intubationNasotracheal intubation

Must be breathing spontaneouslyMust be breathing spontaneously ContraindicationsContraindications

Apnea, basilar skull fractures (or Apnea, basilar skull fractures (or suspicion)suspicion)

Just don’t do itJust don’t do it

Astutely, you suspect head trauma. Astutely, you suspect head trauma. The most common CT scan The most common CT scan abnormality found after severe abnormality found after severe closed head injury is:closed head injury is:

A.A. cerebral contusioncerebral contusion

B.B. epidural hematomaepidural hematoma

C.C. intracerebral hemorrhageintracerebral hemorrhage

D.D. subdural hematomasubdural hematoma

E.E. traumatic subarachnoid traumatic subarachnoid hemorrhagehemorrhage

Head TraumaHead Trauma

50% (#1) of trauma deaths50% (#1) of trauma deaths Cushing’s (late and unreliable) – htn, Cushing’s (late and unreliable) – htn,

bradycardia, apneabradycardia, apnea

Head TraumaHead Trauma Urgent head CT is indicated if:Urgent head CT is indicated if:

headache headache vomitingvomiting drug or alcohol intoxicationdrug or alcohol intoxication short-term memory deficitsshort-term memory deficits posttraumatic seizureposttraumatic seizure coagulopathycoagulopathy physical evidence of trauma above the claviclephysical evidence of trauma above the clavicle older than 60 yearsolder than 60 years GCS <14 or <15 s/p 2 hoursGCS <14 or <15 s/p 2 hours Amnesia before impact >30minAmnesia before impact >30min Witnessed LOC > 15minWitnessed LOC > 15min Object recall < 3/3Object recall < 3/3 Signs of basilar skull fxSigns of basilar skull fx

Epidural hemorrhageEpidural hemorrhage Arterial bleed (middle Arterial bleed (middle

meningeal artery) meningeal artery) between skull and durabetween skull and dura

““Coup”Coup” Underlying brain injury Underlying brain injury

usually not severeusually not severe PresentationPresentation

LOC then lucid intervalLOC then lucid interval Dilated ipsilateral pupil Dilated ipsilateral pupil

(lateralize if high) and (lateralize if high) and contralateral hemiparesis – contralateral hemiparesis – late findingslate findings

CT: biconcave or lenticularCT: biconcave or lenticular

Subdural HemorrahgeSubdural Hemorrahge

Bridging veins between dura and Bridging veins between dura and ararchnoidararchnoid

““Contracoup”Contracoup” PresentationPresentation

Decreased mental status and LOCDecreased mental status and LOC May have lucid period also?!?!May have lucid period also?!?!

6x more common than epidural6x more common than epidural Higher mortality rate than epiduralsHigher mortality rate than epidurals CT scan: sickle shapedCT scan: sickle shaped

Subarachnoid hemorrhageSubarachnoid hemorrhage Blood within the CSF, caused by Blood within the CSF, caused by

disruption of subarachnoid disruption of subarachnoid vesselsvessels

Most common CT finding in Most common CT finding in mod/severe TBImod/severe TBI

HerniationHerniation TranstentorialTranstentorial

Uncus Uncus → → tentorial tentorial notchnotch

CN III, brainstem CN III, brainstem symptomssymptoms

Ipsilateral pupil fixed Ipsilateral pupil fixed and dilatedand dilated

Respiratory depressionRespiratory depression Tonsillar (Central) Tonsillar (Central)

(rare)(rare) Cerebellar tonsil → Cerebellar tonsil →

foramen magnumforamen magnum Small bilateral pupils, Small bilateral pupils,

posturing, posturing, bradycardia, bradycardia, respiratory arrestrespiratory arrest

Head Injury TidbitsHead Injury Tidbits Isolated linear nondepressed skull fx: no Isolated linear nondepressed skull fx: no

treatmenttreatment Basilar skull fx: temporal bone, Basilar skull fx: temporal bone,

hemotympanum, CSF hemotympanum, CSF otorrhea/rhinorrhea, periorbital otorrhea/rhinorrhea, periorbital ecchymosis, retriauricular ecchymosisecchymosis, retriauricular ecchymosis

Diffuse axonal injury is the most common Diffuse axonal injury is the most common brain injury resulting in coma.brain injury resulting in coma.

Bullet to brainstem/basal ganglia Bullet to brainstem/basal ganglia zero zero survivalsurvival

Increased ICPIncreased ICP- Abnormal > 15, treat > 20Abnormal > 15, treat > 20- CPP = MAP – ICP, keep it >60CPP = MAP – ICP, keep it >60

- Systolic > 90 and goal = 120Systolic > 90 and goal = 120- MAP >85MAP >85- ICP <20ICP <20- Use pressors if needed keep CPP < 70Use pressors if needed keep CPP < 70

- Avoid Sat < 90% or PaO2 < 60Avoid Sat < 90% or PaO2 < 60- PCOPCO22 30-35 (too low 30-35 (too low excessive vasoconstriction) excessive vasoconstriction)

- Hyperventilation only as temporary salvageHyperventilation only as temporary salvage- Mannitol (0.25-1g/kg)Mannitol (0.25-1g/kg)

- ““Restrict mannitol use prior to ICP monitoring to patients with Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurological signs of transtentorial herniation or progressive neurological deterioration not attributable to extracranial causes.”deterioration not attributable to extracranial causes.”

- Dilutes blood and decreases viscosity Dilutes blood and decreases viscosity increased blood flow increased blood flow reactive vasoconstriction and decrease ICP reactive vasoconstriction and decrease ICP

- Replace loss of fluidsReplace loss of fluids- Contraindicated when hypotensiveContraindicated when hypotensive

- HypertonicHypertonic

Pt is intubated. BP 78/48, HR 122, R 16, Pt is intubated. BP 78/48, HR 122, R 16, T 37.5. Neck veins flat. Most likely cause T 37.5. Neck veins flat. Most likely cause of hypotension?of hypotension?

A.A. Cardiac tamponadeCardiac tamponadeB.B. Cardiogenic shockCardiogenic shockC.C. HypovolemiaHypovolemiaD.D. Spinal ShockSpinal ShockE.E. Tension PTXTension PTX

Blunt Traumatic ShockBlunt Traumatic Shock Hemorrhagic shock until proven Hemorrhagic shock until proven

otherwise.otherwise. Spinal Shock – bradycardic, Spinal Shock – bradycardic,

hypotensionhypotension Cardiogenic shock/tamponadeCardiogenic shock/tamponade

FASTFAST Distended neck veinsDistended neck veins

Tension PTX Tension PTX Distended neck veins, tracheal deviation, Distended neck veins, tracheal deviation,

tachypnea, decrease BS on side of PTXtachypnea, decrease BS on side of PTX

After resuscitation, vitals stabilize. After resuscitation, vitals stabilize. CT reveals traumatic rupture of CT reveals traumatic rupture of aorta. Which finding is most aorta. Which finding is most indicative of this entity on the indicative of this entity on the patient’s initial CXR?patient’s initial CXR?

A.A. Deviation of esophagus 1-2cm to the Deviation of esophagus 1-2cm to the rightright

B.B. 11stst and 2 and 2ndnd rib fractures rib fractures

C.C. L clavicle fxL clavicle fx

D.D. Pulmonary contusionPulmonary contusion

E.E. Upward displacement of the L mainstem Upward displacement of the L mainstem bronchus 40bronchus 40oo

Thoracic Aortic DisruptionThoracic Aortic Disruption Rapid deceleration injuries. Rapid deceleration injuries. Most common cause of death in blunt trauma, Most common cause of death in blunt trauma,

80% die at scene, 10-20% die w/in 180% die at scene, 10-20% die w/in 1stst hour. hour. Signs & sx: include chest pain, back pain, Signs & sx: include chest pain, back pain,

dyspnea, intrascapular murmur, and dyspnea, intrascapular murmur, and extremity pain caused by ischemia. extremity pain caused by ischemia.

CXR: widen mediastinum (8 cm) most CXR: widen mediastinum (8 cm) most common. Nl in 2–7% of patients with aortic common. Nl in 2–7% of patients with aortic injury. injury. Aortogram gold standard, but now CTAortogram gold standard, but now CT

False positives with mediastinal hematomaFalse positives with mediastinal hematomaTx: BP management and surgical repair.Tx: BP management and surgical repair.

Aortic Rupture X-rayAortic Rupture X-ray Widened mediastinumWidened mediastinum Obscured aortic knobObscured aortic knob Opacification of the aortic-Opacification of the aortic-

pulmonary window/apical pulmonary window/apical cappingcapping

Widened paratracheal Widened paratracheal stripestripe

Displacement of the Displacement of the esophagus/NG tube to the esophagus/NG tube to the rightright

Inferior displacement of the Inferior displacement of the left mainstem bronchus.left mainstem bronchus.

L hemothorax, 1L hemothorax, 1stst & 2 & 2ndnd rib rib fxfx

Traumatic Aortic TransectionTraumatic Aortic Transection

80-90% tear at isthmus from 80-90% tear at isthmus from deceleration and instant deathdeceleration and instant death

Survivors to ED – tear at ligamentum Survivors to ED – tear at ligamentum arteriosumarteriosum

Retrosternal pain, dyspnea, stridor, Retrosternal pain, dyspnea, stridor, dysphagiadysphagia

Harsh systolic murmurHarsh systolic murmur Pulse difference between upper and Pulse difference between upper and

lower extremitieslower extremities May have delayed presentationMay have delayed presentation

Ruptured DiaphragmRuptured Diaphragm

Left > Right, as liver Left > Right, as liver protects the right sideprotects the right side

Location: 80-90% left Location: 80-90% left posterolateralposterolateral

CXR abnormal in 60%, CXR abnormal in 60%, but often not diagnosticbut often not diagnostic

50% diagnosed at 50% diagnosed at laparotomylaparotomy

Treatment: surgical Treatment: surgical repairrepair

Often missed or Often missed or delayeddelayed

Tracheobronchial InjuryTracheobronchial Injury

Seen with deceleration/shear forcesSeen with deceleration/shear forces Most blunt injury occurs within 2cm Most blunt injury occurs within 2cm

of carinaof carina This is where it is teatheredThis is where it is teathered

Mortality with rupture=30%Mortality with rupture=30% Continuous bubbling in chest tube is Continuous bubbling in chest tube is

a sign of a bronchopleural fistulaa sign of a bronchopleural fistula

Tracheobronchial InjuryTracheobronchial Injury

Signs/symptomsSigns/symptomsChest painChest painDyspneaDyspneaHypoxemiaHypoxemiaHamman’s crunchHamman’s crunchHemoptysisHemoptysisSubcutaneous Subcutaneous emphysemaemphysema

CXR:CXR:PneumothoraxPneumothoraxPneumomediastinuPneumomediastinummTension pneumoTension pneumoRib fractureRib fracture

TreatmentTreatmentOxygenationOxygenationVentilationVentilationChest tubeChest tube

Patient #2Patient #2

50yoM, driver of 250yoM, driver of 2ndnd car, has bruising over his car, has bruising over his sternum. Hit chest against steering wheel. VS sternum. Hit chest against steering wheel. VS unremarkable. Asymptomatic except for anterior unremarkable. Asymptomatic except for anterior chest wall tenderness at site of bruising. CXR and chest wall tenderness at site of bruising. CXR and sternal view reveal sternal fx. EKG is nl. Which of sternal view reveal sternal fx. EKG is nl. Which of the following is the MOST appropriate management the following is the MOST appropriate management plan for this pt?plan for this pt?

A.A. Admit for 24 hr telemetry monitoringAdmit for 24 hr telemetry monitoringB.B. Perform 2 sets of CE and TPN tests, and dc if neg.Perform 2 sets of CE and TPN tests, and dc if neg.C.C. Perform echocardiogram in the ED, and dc if neg.Perform echocardiogram in the ED, and dc if neg.D.D. After a repeat EKG in 6 hrs, dc the pt with pain After a repeat EKG in 6 hrs, dc the pt with pain

medication, without any further testing.medication, without any further testing.

Blunt Myocardial Injury (aka Blunt Myocardial Injury (aka Myocardial Contusion)Myocardial Contusion)

Clinical features: pt in MVA > 35 MPH c/o chest Clinical features: pt in MVA > 35 MPH c/o chest painpain Sternal rub or rib fracture, dyspnea, tachycardia Sternal rub or rib fracture, dyspnea, tachycardia

(70%), S3 gallop, rales, elevated CVP(70%), S3 gallop, rales, elevated CVP CXR greatest value for finding assoc injuries: CXR greatest value for finding assoc injuries:

pulmonary contusion, rib fxpulmonary contusion, rib fx Sternal fx no longer considered important.Sternal fx no longer considered important.

Initial EKG predictive of subsequent clinically Initial EKG predictive of subsequent clinically significant EKG events – recommend initial EKG significant EKG events – recommend initial EKG followed by repeat EKG in 4-6 hrs.followed by repeat EKG in 4-6 hrs. PVCs, 1st degree av block, RBBB (RV closest to PVCs, 1st degree av block, RBBB (RV closest to

anterior chest wall), T wave flattening or elevation, anterior chest wall), T wave flattening or elevation, QTQT

Myocardial contusionMyocardial contusion

Dx: echo (but not as screening), increased Dx: echo (but not as screening), increased CE (poor sensitivity)CE (poor sensitivity)

Most heal without specific treatmentMost heal without specific treatment Complications: effusion, infarction, Complications: effusion, infarction,

dysrhythmia, aneurysm, thrombosis, dysrhythmia, aneurysm, thrombosis, vasospasmsvasospasms

Monitor for 12h Monitor for 12h d/c (not life-threatening) d/c (not life-threatening) If young, ekg and 1 or 2 CE (normal) If young, ekg and 1 or 2 CE (normal) d/c d/c Abnormal Abnormal telemetry telemetry Unstable Unstable echo echo

If decreased CO If decreased CO dobutamine or IABP dobutamine or IABP

Patient #3Patient #3

Complains of tinnitus Complains of tinnitus and headache. and headache. Normal neuro exam. Normal neuro exam. What is the injury?What is the injury?

A.A. Frontal bone fractureFrontal bone fracture

B.B. Parietal contusionParietal contusion

C.C. Subarachnoid Subarachnoid hemorrhagehemorrhage

D.D. Subdural hemorrhageSubdural hemorrhage

E.E. Temporal bone Temporal bone fracture fracture

Basilar Skull FxBasilar Skull Fx Most common fracture involves the petrous Most common fracture involves the petrous

portion of the temporal bone, the external portion of the temporal bone, the external auditory canal, and the tympanic membraneauditory canal, and the tympanic membrane

Fractures Fractures dural tear dural tear communication communication between subarachnoid space, paranasal sinuses, between subarachnoid space, paranasal sinuses, and middle earand middle ear

Compress and entrap cranial nerves passing Compress and entrap cranial nerves passing through basal foraminathrough basal foramina

CSF otorrhea or rhinorrhea, mastoid ecchymosis CSF otorrhea or rhinorrhea, mastoid ecchymosis (Battle sign), periorbital ecchymoses (raccoon (Battle sign), periorbital ecchymoses (raccoon eyes), hemotympanum, vertigo, tinnitus, eyes), hemotympanum, vertigo, tinnitus, decreased hearing, and 7decreased hearing, and 7thth nerve palsy. nerve palsy.

Ring test-halo on sheet-target lesionRing test-halo on sheet-target lesion

Basilar Skull FractureBasilar Skull Fracture

Need thin temporal bone cuts

Battle’s SignBattle’s Sign

Can take 12 hours to show upCan take 12 hours to show up

HEMOTYMPANUMHEMOTYMPANUM

Skull fracturesSkull fractures Abuse=stellate, complex fracturesAbuse=stellate, complex fractures Linear non-depressed does not require Linear non-depressed does not require

treatmenttreatment Temporal skull fracture=middle Temporal skull fracture=middle

menigeal=epidural hematomamenigeal=epidural hematoma Open or depressed skull fracture (one Open or depressed skull fracture (one

bone table width)bone table width)→antibiotics + neurosurgery→antibiotics + neurosurgery At risk for post-traumatic seizuresAt risk for post-traumatic seizures

Occipital skull fracture: SAH, contrecoup Occipital skull fracture: SAH, contrecoup injury, posterior fossa hematoma, cranial injury, posterior fossa hematoma, cranial nerve injurynerve injury

On exam, your abdominal findings are c/w On exam, your abdominal findings are c/w lap belt injury. Compared to other patients lap belt injury. Compared to other patients with blunt abdominal trauma, this patient with blunt abdominal trauma, this patient is at increased risk for injury to which of is at increased risk for injury to which of the following organs?the following organs?

A.A. IntestineIntestine

B.B. KidneyKidney

C.C. LiverLiver

D.D. PancreasPancreas

E.E. SpleenSpleen

ANSWER: AANSWER: A

A.A. intestine. When lap belt bruises are intestine. When lap belt bruises are present, there is a higher incidence of present, there is a higher incidence of intestinal injury. Although seat belt sign intestinal injury. Although seat belt sign is seen in only 1/3 of cases, its presence is seen in only 1/3 of cases, its presence is highly correlated with injury. is highly correlated with injury. Diaphragmatic injury can been seen Diaphragmatic injury can been seen secondary to compressive forces.secondary to compressive forces.

B.B. kidneykidney

C.C. liverliver

D.D. pancreaspancreas

E.E. spleenspleen

Abdominal TraumaAbdominal Trauma

Lap belt injury: hollow viscous Lap belt injury: hollow viscous rupture, mesenteric tear, lumbar rupture, mesenteric tear, lumbar fracture, bladder injury or rupture fracture, bladder injury or rupture (chest seatbelt sign ok)(chest seatbelt sign ok)

Laparotomy indications: evisceration, Laparotomy indications: evisceration, GSW, impalement, gross blood by GSW, impalement, gross blood by NG, rectal, DPLNG, rectal, DPL

Abdominal Trauma ImagingAbdominal Trauma Imaging

CT scan increasingly important in CT scan increasingly important in trauma managementtrauma management Insensitive to hollow organ injury, Insensitive to hollow organ injury,

pancreas, diaphragmpancreas, diaphragm Sensitive to retroperitoneum, solid Sensitive to retroperitoneum, solid

organs, bony structuresorgans, bony structures Role of FASTRole of FAST

Easy to ImageEasy to Image

LiverLiver Most common in penetrating (large)Most common in penetrating (large)

SpleenSpleen Most common in bluntMost common in blunt

Hard to ImageHard to Image PancreasPancreas

Blunt > penetratingBlunt > penetrating Handle bars, steering wheel, think pedsHandle bars, steering wheel, think peds Nonspecific pain due to delayed diagnosisNonspecific pain due to delayed diagnosis DPL may be falsely negative and amylase DPL may be falsely negative and amylase

usually normalusually normal Small intestineSmall intestine

Multiple in penetratingMultiple in penetrating Often delayed symptomsOften delayed symptoms Associated with lap belt injury and lumbar spine Associated with lap belt injury and lumbar spine

fx (chance)fx (chance) ColonColon

Usually transverse (pinned by spine and gas)Usually transverse (pinned by spine and gas)

DPL/DPADPL/DPA Relative contraindications: obesity, pregnancy, Relative contraindications: obesity, pregnancy,

previous abdominal surgery, pelvic fractureprevious abdominal surgery, pelvic fracture False negativeFalse negative

PancreasPancreas BowelBowel RetroperitoneumRetroperitoneum Splenic hematomaSplenic hematoma

False positive: pelvic fractureFalse positive: pelvic fracture Positive lavage:Positive lavage:

10ml gross blood10ml gross blood Blunt > 100,000 RBC/mlBlunt > 100,000 RBC/ml Penetrating > 10,000 RBC/ml (this number a moving target)Penetrating > 10,000 RBC/ml (this number a moving target) WBC > 500/mlWBC > 500/ml Bile, feces, urineBile, feces, urine Increased amylaseIncreased amylase

Too sensitive! Grade I-II liver and spleen lacsToo sensitive! Grade I-II liver and spleen lacs

Abdominal SignsAbdominal Signs Grey Turner’s sign: flank Grey Turner’s sign: flank

discoloration, a late sign of discoloration, a late sign of retroperitoneal hematoma; retroperitoneal hematoma; can be seen with can be seen with hemorrhagic pancreatitishemorrhagic pancreatitis

Kehr’s sign: referred left Kehr’s sign: referred left shoulder pain due to shoulder pain due to subdiaphragmatic subdiaphragmatic irriatation/splenic ruptureirriatation/splenic rupture

Cullen’s sign: periumbilical Cullen’s sign: periumbilical ecchymosis due to ecchymosis due to retroperitoneal bleeding; can retroperitoneal bleeding; can also be see with hemorrhagic also be see with hemorrhagic pancreatitis, ectopic pancreatitis, ectopic pregnancypregnancy

Seat Belt SignSeat Belt Sign Low-lying transverse abdominal Low-lying transverse abdominal

ecchymosis has a strong association with ecchymosis has a strong association with hollow viscus injury and mesenteric tears . hollow viscus injury and mesenteric tears .

Hollow viscus injury often does not Hollow viscus injury often does not produce any pain or tenderness until 6-8 produce any pain or tenderness until 6-8 hours following the traumatic event. hours following the traumatic event.

At minimum, patients with lap-belt At minimum, patients with lap-belt contusions should undergo serial contusions should undergo serial abdominal examinations.abdominal examinations.

Findings of abdominal tenderness should Findings of abdominal tenderness should prompt diagnostic study (e.g., abdominal prompt diagnostic study (e.g., abdominal CT and/or DPL) or laparotomy. CT and/or DPL) or laparotomy.

Still on Patient #4. Blood is noted at Still on Patient #4. Blood is noted at the urethral meatus, and there is the urethral meatus, and there is perineal ecchymosis. Which of the perineal ecchymosis. Which of the following is the next management following is the next management step?step?

A.A. Insertion of a coude catheterInsertion of a coude catheterB.B. IV pyelogramIV pyelogramC.C. Pelvic CT scanPelvic CT scanD.D. Retrograde urethrogramRetrograde urethrogramE.E. Urinalysis with sample obtained Urinalysis with sample obtained

by suprapubic route.by suprapubic route.

GU traumaGU trauma Signs of GU trauma somewhere – hematuriaSigns of GU trauma somewhere – hematuria Urethral injuryUrethral injury

SignsSigns Perineal ecchymosisPerineal ecchymosis Unable to urinateUnable to urinate Blood at meatusBlood at meatus High-riding/absent prostateHigh-riding/absent prostate Blood in scrotum/scrotal hematomaBlood in scrotum/scrotal hematoma Obvious penile traumaObvious penile trauma Pelvic fracturePelvic fracture

DxDx Retrograde urethrogramRetrograde urethrogram Do not blindly put foley (unless you’re really skilled) – partial tear Do not blindly put foley (unless you’re really skilled) – partial tear

into complete disruptioninto complete disruption TxTx

Foley over wire. Foley in for 2 weeks.Foley over wire. Foley in for 2 weeks. Suprapubic catheter placement and surgical repair.Suprapubic catheter placement and surgical repair.

Posterior urethral injury from blunt traumaPosterior urethral injury from blunt trauma

Normal urethrogramNormal urethrogram

Urethral tearUrethral tear

What is the most commonly injured What is the most commonly injured organ of the genitourinary tract?organ of the genitourinary tract?

A.A. UrethraUrethra

B.B. KidneyKidney

C.C. BladderBladder

D.D. UreterUreter

Renal TraumaRenal Trauma Most commonly injured organ of the GU systemMost commonly injured organ of the GU system

Contusions (92%), followed by lacerations, renal pedicle Contusions (92%), followed by lacerations, renal pedicle injuries, and renal ruptures or shattered kidneys; 1-2% injuries, and renal ruptures or shattered kidneys; 1-2% vascularvascular

Diagnosed by CTDiagnosed by CT Rapid deceleration, compression, penetrating traumaRapid deceleration, compression, penetrating trauma Associated with lower rib, L1-2 transverse process Associated with lower rib, L1-2 transverse process

fracturesfractures 25% of vascular injuries have no hematuria (no kidney 25% of vascular injuries have no hematuria (no kidney

perfusion)perfusion) Must revascularize < 12 hoursMust revascularize < 12 hours

IVP indication: gross hematuriaIVP indication: gross hematuria Penetrating injury (15%)Penetrating injury (15%)→IVP and/or CT→IVP and/or CT Most renal injuries are managed conservativelyMost renal injuries are managed conservatively

Rest of GU traumaRest of GU trauma Bladder – 2Bladder – 2ndnd most commonly injured most commonly injured

Assoc with blunt trauma and pelvic fxAssoc with blunt trauma and pelvic fx DxDx

Retrograde cystogram s/p foley or retrograde Retrograde cystogram s/p foley or retrograde cystoscopycystoscopy

Antegrade cystocopy (IV contrast, renal excretion fill Antegrade cystocopy (IV contrast, renal excretion fill bladder) – incomplete and spurious findingsbladder) – incomplete and spurious findings

Ureter – rarestUreter – rarest 90% penetrating trauma 90% penetrating trauma IVP IVP

Testicular traumaTesticular trauma Most common straddle injuryMost common straddle injury Presentation – edema, ecchymosis, tenderness, Presentation – edema, ecchymosis, tenderness,

hematuriahematuria Diagnosis – u/s, nuclear scan, explorationDiagnosis – u/s, nuclear scan, exploration Complications: abscess, hydrocele, infertilityComplications: abscess, hydrocele, infertility

Patient #4Patient #4

76yoF. Respiratory distress on arrival and has 76yoF. Respiratory distress on arrival and has paradoxical movement of R chest during labored paradoxical movement of R chest during labored respirations. 138/76, 118, 28, 88% RA. BS respirations. 138/76, 118, 28, 88% RA. BS auscultated on both sides of chest. Which of the auscultated on both sides of chest. Which of the following is correct?following is correct?

A.A. Can be treated with supplemental oxygen and Can be treated with supplemental oxygen and admission to stepdown unit.admission to stepdown unit.

B.B. Injury mandates early ventilatory support.Injury mandates early ventilatory support.C.C. Most likely cause of hypoxia is splinting from Most likely cause of hypoxia is splinting from

painpainD.D. R chest wall moves outward with inspiration R chest wall moves outward with inspiration

and inward with expiration.and inward with expiration.E.E. Tx involves analgesia and adhesive tap or rib Tx involves analgesia and adhesive tap or rib

belt to stabilize chest.belt to stabilize chest.

ANSWER: BANSWER: BA.A. Can be treated with supplemental oxygen Can be treated with supplemental oxygen

and admission to stepdown unit. and admission to stepdown unit. High High potential for deterioration. Early potential for deterioration. Early ventilatory support and ICU.ventilatory support and ICU.

B.B. Injury mandates early ventilatory support.Injury mandates early ventilatory support.C.C. Most likely cause of hypoxia is splinting Most likely cause of hypoxia is splinting

from pain. from pain. Pulmonary contusion.Pulmonary contusion.D.D. R chest wall moves outward with R chest wall moves outward with

inspiration and inward with expiration. inspiration and inward with expiration. Inward with inspiration and outward with Inward with inspiration and outward with expiration.expiration.

E.E. Tx involves analgesia and adhesive tap or Tx involves analgesia and adhesive tap or rib belt to stabilize chest. rib belt to stabilize chest. Inhibit expansion Inhibit expansion of chest and aggravate atelectasis, of chest and aggravate atelectasis, worsening gas exchange.worsening gas exchange.

Flail ChestFlail Chest

Segmental fracture of Segmental fracture of 3 or more ribs3 or more ribs

Paradoxical chest wall Paradoxical chest wall movementmovement

Decreased ventilation Decreased ventilation and venous returnand venous return

TxTx Intubation, consider Intubation, consider

chest tubechest tube Main cause of Main cause of

hypoxemia=pulmonary hypoxemia=pulmonary contusioncontusion

Flail ChestFlail Chest Initially compensate for reduce TV by Initially compensate for reduce TV by

hyperventilate, when fatigue or underlying hyperventilate, when fatigue or underlying pulmonary injury develops pulmonary injury develops respiratory respiratory failure.failure.

TxTx Supplemental oxygenSupplemental oxygen Pain control – allows pt to fully expand lungs and Pain control – allows pt to fully expand lungs and

improve ventilationimprove ventilation Early intubation consideredEarly intubation consideredExternal chest wall support reduce VC External chest wall support reduce VC worsen respiratory functionworsen respiratory functionIndications for early vent support: shock, Indications for early vent support: shock, three or more associated injuries, severe three or more associated injuries, severe head injury, comorbid pulmonary disease, head injury, comorbid pulmonary disease, fracture of eight or more ribs, or age greater fracture of eight or more ribs, or age greater than 65 years than 65 years

Pulmonary ContusionPulmonary Contusion Interstitial edema, Interstitial edema,

capillary damage, capillary damage, bleedingbleeding

Dec compliance, Dec compliance, hypoxemia, hypoxemia, atelectasisatelectasis

CXR: opacification CXR: opacification (often delayed 6-12 (often delayed 6-12 hours), CT betterhours), CT better

Tx: oxygen, Tx: oxygen, ventilation, PEEP vs. ventilation, PEEP vs. permissive permissive hypercapnea, keep hypercapnea, keep dry if possibledry if possible

This patient also has a clavicle fracture. This patient also has a clavicle fracture. Which of the following statements Which of the following statements regarding clavicle fractures is correct?regarding clavicle fractures is correct?

A.A. 80% involve the distal third of the clavicle80% involve the distal third of the clavicleB.B. Closed reduction alleviates pain and Closed reduction alleviates pain and

allows for improved recoveryallows for improved recoveryC.C. Frequently require surgical intervention to Frequently require surgical intervention to

achieve alignmentachieve alignmentD.D. Most common location is the middle third Most common location is the middle third

of the clavicleof the clavicleE.E. Most common mechanism of injury is Most common mechanism of injury is

forced abduction of the shoulderforced abduction of the shoulder

Clavicle FxClavicle Fx 5% proximal 35% proximal 3rdrd

Usually direct blow to anterior chestUsually direct blow to anterior chest More like complications/other injuries (vasculature)More like complications/other injuries (vasculature) SubclavianSubclavian

80% middle 380% middle 3rdrd

Usually direct force to lateral aspect of shoulder Usually direct force to lateral aspect of shoulder 15% distal 315% distal 3rdrd

Usually direct blow to top of shoulderUsually direct blow to top of shoulder TreatmentTreatment

Most do not need surgeryMost do not need surgery SlingSling Figure-of-eight brace for displaced fxsFigure-of-eight brace for displaced fxs Surgery indicationsSurgery indications

Fracture penetrate skinFracture penetrate skin Nerve/vessel injuriesNerve/vessel injuries

Rib FracturesRib Fractures

Look for ptx, pulmonary Look for ptx, pulmonary contusion, vascular injurycontusion, vascular injury

Multiple rib fracturesMultiple rib fractures Lower ribs: Lower ribs: risk of liver, risk of liver,

renal, spleen injuryrenal, spleen injury Admit: elderly, pre-existing Admit: elderly, pre-existing

pulmonary diseasepulmonary disease TreatmentTreatment

pain control (meds and pain control (meds and nerve block)nerve block)

Bad fracturesBad fractures 11stst & 2 & 2ndnd Ribs Fxs Ribs Fxs

40% have associated occult injury40% have associated occult injury Great force involvedGreat force involved

Well protected, more sturdy ringsWell protected, more sturdy rings Rule outRule out

Myocardial contusionMyocardial contusion Bronchial tearBronchial tear Vascular injury (consider angio)Vascular injury (consider angio)

Scapula FxScapula Fx Associated with occult chest injuryAssociated with occult chest injury

Patient #5 is a 22yoF, 28wks pregnant. Patient #5 is a 22yoF, 28wks pregnant. She denies abdominal pain, contractions, She denies abdominal pain, contractions, and vaginal bleeding. Her PE is and vaginal bleeding. Her PE is unremarkable other than a small unremarkable other than a small contusion to her right flank. Which of the contusion to her right flank. Which of the following is the appropriate following is the appropriate management?management?

A.A. D/c home with precautions and 24-hr D/c home with precautions and 24-hr follow up.follow up.

B.B. External tocodynamics monitoring for External tocodynamics monitoring for 4 hrs4 hrs

C.C. US followed by external tocodynamics US followed by external tocodynamics monitoring for 24 hrsmonitoring for 24 hrs

D.D. US with discharge home if negativeUS with discharge home if negative

Patient #5Patient #523yoF. 28wks pregnant. 110/78, 105, and 23yoF. 28wks pregnant. 110/78, 105, and 25. Which of the following statements 25. Which of the following statements regarding her vital signs is correct?regarding her vital signs is correct?

A.A. Cardiac output is increased in pregnancy, which Cardiac output is increased in pregnancy, which means that she can tolerate larger blood losses means that she can tolerate larger blood losses than a nonpregnant trauma patient canthan a nonpregnant trauma patient can

B.B. Elevation of the diaphragm and reduced functional Elevation of the diaphragm and reduced functional residual capacity are causing the elevated residual capacity are causing the elevated respiratory raterespiratory rate

C.C. Heart rate increases in the second trimester, Heart rate increases in the second trimester, which means that the tachycardia is caused by which means that the tachycardia is caused by pregnancy, not hypovolemiapregnancy, not hypovolemia

D.D. Hypotension might not develop until 35% of her Hypotension might not develop until 35% of her blood volume is lost due to relative hypervolemia blood volume is lost due to relative hypervolemia of pregnancyof pregnancy

E.E. Systolic and diastolic blood pressure decrease in Systolic and diastolic blood pressure decrease in the second trimester, which means that the blood the second trimester, which means that the blood pressure indicates she is not hypovolemic pressure indicates she is not hypovolemic

Pregnancy TraumaPregnancy Trauma

CO inc 40% by 10wks, HR inc 10-15 beats/min; CO inc 40% by 10wks, HR inc 10-15 beats/min; SVR dec, widened pulse pressure, low blood SVR dec, widened pulse pressure, low blood pressurepressure

If hypotensive, roll or move uterus off IVCIf hypotensive, roll or move uterus off IVC Blood volume inc 50% by 28wks; can lose up to Blood volume inc 50% by 28wks; can lose up to

35% without vital signs change (but fetus in 35% without vital signs change (but fetus in trouble)trouble)

MV inc 40%, normal PCOMV inc 40%, normal PCO22 is 30 is 30 High diaphragm High diaphragm dec functional residual dec functional residual

capacitycapacity Chest tube 1-2 ribs higherChest tube 1-2 ribs higher

Pregnancy in TraumaPregnancy in Trauma Pt is at risk for Placental Abruption Pt is at risk for Placental Abruption

although her trauma appears minor.although her trauma appears minor. Major prospective study showed that Major prospective study showed that

minimal of 4 hrs of external tocodynamic minimal of 4 hrs of external tocodynamic monitoring was able to predict immediate monitoring was able to predict immediate adverse pregnancy outcome:adverse pregnancy outcome: < 3 contractions her hour – discharge< 3 contractions her hour – discharge 3-7 C/H: monitor 24 hours3-7 C/H: monitor 24 hours > 8 contractions: higher risk of placental > 8 contractions: higher risk of placental

abruption, none occurred in patients < 8 C/Habruption, none occurred in patients < 8 C/H US is not sensitive to exclude placental US is not sensitive to exclude placental

abruption.abruption.

Traumatic Placental AbruptionTraumatic Placental Abruption Leading cause of fetal loss aside from maternal Leading cause of fetal loss aside from maternal

death is traumatic placental abruption is #1 cause of death is traumatic placental abruption is #1 cause of fetal loss aside from material death. (This is what fetal loss aside from material death. (This is what we have to work-up and why we’re consulting we have to work-up and why we’re consulting ob/gyn.)ob/gyn.)

Shearing and deceleration forces separate placenta Shearing and deceleration forces separate placenta from uterine wallfrom uterine wall Lack of external signs of abdominal trauma means nothingLack of external signs of abdominal trauma means nothing Placental position does not affect incidencePlacental position does not affect incidence Disrupts gas exchange between fetus and mother Disrupts gas exchange between fetus and mother

hypoxia hypoxia fetal distress. fetal distress. In blunt trauma, 50-70% fetal loss result from placental In blunt trauma, 50-70% fetal loss result from placental

abuption.abuption. SignsSigns

Vag bleeding (<40%), abd pain/cramping, amniotic fluid Vag bleeding (<40%), abd pain/cramping, amniotic fluid leakage, uterine tetany(???)leakage, uterine tetany(???)

Fetal distress – cardiotocographic monitoring (>20wk Fetal distress – cardiotocographic monitoring (>20wk gestation)gestation)

U/S < 50% accurateU/S < 50% accurate Placental substances cause coagulopathy (DIC from Placental substances cause coagulopathy (DIC from

high levels of ATP III)high levels of ATP III)

Kleihauer-Betke testKleihauer-Betke test Test for fetomaternal hemorrhage (FMH) (ie, Test for fetomaternal hemorrhage (FMH) (ie,

transplacental bleeding of fetal blood into the transplacental bleeding of fetal blood into the normally separate maternal circulation)normally separate maternal circulation)

ComplicationsComplications Rh sensitization of the motherRh sensitization of the mother Fetal anemia/distress/death from exsanguination.Fetal anemia/distress/death from exsanguination.

Acid elution test on maternal blood to determine Acid elution test on maternal blood to determine ratio of fetal:maternal circulationratio of fetal:maternal circulation

Regardless of result, must get rhogam if mother is Regardless of result, must get rhogam if mother is Rh-Rh-

Used to identify Rh- women at risk of massive FMH Used to identify Rh- women at risk of massive FMH needs more rhogam needs more rhogam

Lecithin-to-sphingomyelin ratio: fetal lung maturityLecithin-to-sphingomyelin ratio: fetal lung maturity Fetal fibronectin test: predicts premature deliveryFetal fibronectin test: predicts premature delivery

Blunt Abd TraumaBlunt Abd Trauma StableStable

Abdominal CTAbdominal CT DPL/DPADPL/DPA

Does not define extent or location of injuryDoes not define extent or location of injury No retroperitonealNo retroperitoneal 1-2% complication rate1-2% complication rate

UnstableUnstable ResuscitateResuscitate Go to OR ifGo to OR if

Positive FAST/DPA or PeritonitisPositive FAST/DPA or Peritonitis ArrestingArresting

Resuscitative ThoracotomyResuscitative Thoracotomy R Chest TubeR Chest Tube

Take a breathTake a breath

Meant for me…not you.Meant for me…not you.

Penetrating TraumaPenetrating Trauma

The bat-phone rings. A fight has The bat-phone rings. A fight has broken out 5 blocks away from broken out 5 blocks away from Elmhurst. Multiple patients coming Elmhurst. Multiple patients coming in.in.

32yoM. Stab in L side of neck with pocket 32yoM. Stab in L side of neck with pocket knife. Injury is inferior to angle of mandible, knife. Injury is inferior to angle of mandible, superior to cricoid cartilage, posterior of superior to cricoid cartilage, posterior of sternocleidomastoid. Penetrates platysma. sternocleidomastoid. Penetrates platysma. No bleeding, no evidence of tracheal No bleeding, no evidence of tracheal deviation or JVD. PE: no carotid bruits, no deviation or JVD. PE: no carotid bruits, no stridor, no SQ emphysema, strong carotid stridor, no SQ emphysema, strong carotid pulses b/l, nl neuro exam. Other than pain to pulses b/l, nl neuro exam. Other than pain to wound area, pt is asymptomatic. 128/82, 86, wound area, pt is asymptomatic. 128/82, 86, 16, 99% on RA. Correct statement?16, 99% on RA. Correct statement?

A.A. Can d/c after neg local wound exploration.Can d/c after neg local wound exploration.B.B. Must get esophagram and esophagoscopyMust get esophagram and esophagoscopyC.C. Must get laryngoscopy and bronchoscopyMust get laryngoscopy and bronchoscopyD.D. Must get local wound exploration in the EDMust get local wound exploration in the EDE.E. Observation alone is appropriate.Observation alone is appropriate.

The platsymaThe platsyma

For STABLE patient only

Zone III-above mandible-Angiograph

-May need esophogram/endoscopy/bronchoscopy

Zone II-between cricoid and mandible-go to OR or…

-Esophagography/esophagoscopy and CT angiography

Zone I-below cricoid,-Angio, esophogram/endoscopy, bronchoscopy

Penetrating Neck InjuryPenetrating Neck InjuryHard SignsHard Signs (with (with instability instability OR) OR)B/P EDB/P EDArterial BleedingArterial BleedingExpand hematomaExpand hematomaDiminished carotid Diminished carotid pulsepulseThrill / bruitThrill / bruitFocal deficitsFocal deficitsHemothorax > 1LHemothorax > 1LBubbling woundsBubbling woundsHemoptysis/Hemoptysis/hematemsishematemsis

Soft SignsSoft SignsStridorStridorHoarsenessHoarsenessVocal cord paralysisVocal cord paralysisSubcut. AirSubcut. AirCN VII injuryCN VII injuryTracheal deviationTracheal deviationNonexpanding Nonexpanding hematomahematomaUnexplained brady Unexplained brady (w/o CNS injury)(w/o CNS injury)

Penetrating Neck InjuryPenetrating Neck Injury

Any wound which violates platysmaAny wound which violates platysma Injuries-most occur in Zone IIInjuries-most occur in Zone II

Vascular > CNSVascular > CNS Peripheral nerve > brachial plexusPeripheral nerve > brachial plexus

Vascular injuries require proximal Vascular injuries require proximal and distal controland distal control

Death=CNS, exsanguination, Death=CNS, exsanguination, airway compromise (intubate early)airway compromise (intubate early)

Blunt Neck traumaBlunt Neck trauma Rare due to protection of head, shoulders and Rare due to protection of head, shoulders and

chestchest Mechanism: steering wheel, dashboard, Mechanism: steering wheel, dashboard,

shoulder belt shearing forces, clothes line shoulder belt shearing forces, clothes line injuriesinjuries

Laryngotracheal and pharyngoesophageal Laryngotracheal and pharyngoesophageal injuries can be subtle require diagnostic imaginginjuries can be subtle require diagnostic imaging

Carotid artery injury: pseudoaneurysm or Carotid artery injury: pseudoaneurysm or dissectiondissection Mechanism: hyperextension, hyperflexion, direct Mechanism: hyperextension, hyperflexion, direct

blow, intra-oral trauma, basilar skull fractureblow, intra-oral trauma, basilar skull fracture Neurologic symptoms may be delayedNeurologic symptoms may be delayed

Strangulation / Blunt Neck InjuriesStrangulation / Blunt Neck Injuries

Soft-tissue neck x-raysSoft-tissue neck x-rays Look for SubQ emphysema (fractured larynx), hyoid bone Look for SubQ emphysema (fractured larynx), hyoid bone

fx, or tracheal deviation because of edema or hematoma.fx, or tracheal deviation because of edema or hematoma. CT of neck structuresCT of neck structures Neck MRINeck MRI

Soft tissueSoft tissue Carotid arteries from aortic arch to circle of Willis, making Carotid arteries from aortic arch to circle of Willis, making

it particularly applicable in the setting of blunt cervical it particularly applicable in the setting of blunt cervical injuries where the level of injury is unknown injuries where the level of injury is unknown

Carotid doppler U/SCarotid doppler U/S Angiography remains the gold standard for diagnosing Angiography remains the gold standard for diagnosing

blunt carotid artery injury blunt carotid artery injury Helical CT scans efficacy unvalidatedHelical CT scans efficacy unvalidated

Laryngosocopy - vocal cord and tracheal evaluationLaryngosocopy - vocal cord and tracheal evaluation Particularly with dyspnea, dysphonia/hoarseness, Particularly with dyspnea, dysphonia/hoarseness,

odynophagia odynophagia

Carotid Artery DissectionCarotid Artery DissectionNeck trauma + TIA/Stroke/Horner’sNeck trauma + TIA/Stroke/Horner’s

Also has GSW through R leg. Which of Also has GSW through R leg. Which of the following findings on PE suggest the following findings on PE suggest the presence of an arterial injury the presence of an arterial injury requiring expeditious angiography or requiring expeditious angiography or surgical intervention?surgical intervention?

A.A. Diminished distal pulsesDiminished distal pulses

B.B. Injury to an anatomically related Injury to an anatomically related nervenerve

C.C. Unexplained hypotensionUnexplained hypotension

D.D. Proximity of the injury to major Proximity of the injury to major vascular structuresvascular structures

Arterial Injury: Penetrating Arterial Injury: Penetrating Extremity TraumaExtremity Trauma

Hard SignsHard Signs Absent/diminished Absent/diminished pulsespulsesObvious arterial Obvious arterial bleedbleedLarge expanding or Large expanding or pulsatile hematomapulsatile hematomaAudible bruitAudible bruitPalpable thrillPalpable thrillDistal ischemiaDistal ischemia

Soft SignsSoft SignsSmall stable Small stable hematomahematomaInjury to Injury to anatomically related anatomically related nervenerveUnexplained Unexplained hypotensionhypotensionh/o hemorrhageh/o hemorrhageProx of injury to Prox of injury to major vascular major vascular structurestructureComplex fractureComplex fracture

Arterial Injury: Penetrating Arterial Injury: Penetrating Extremity TraumaExtremity Trauma

Hard signs: expeditious angiography Hard signs: expeditious angiography and/or surgical interventionand/or surgical intervention

Soft signs: inpatient admission for Soft signs: inpatient admission for observation and repeat examsobservation and repeat exams

No hard or soft: Observe in ED 3-12 hrs, No hard or soft: Observe in ED 3-12 hrs, discharge home with close fu.discharge home with close fu. No signs of arterial bleedNo signs of arterial bleed No bone or nerve injuryNo bone or nerve injury No developing compartment syndromeNo developing compartment syndrome Minimal soft tissue defectMinimal soft tissue defect

Ankle-Brachial IndexAnkle-Brachial Index

1.0 vs. 0.9

Upon ripping his clothes off, you Upon ripping his clothes off, you find a single stab wound to L flank. find a single stab wound to L flank. VS are BP 110/80, HR 90. Which of VS are BP 110/80, HR 90. Which of the following is the most the following is the most appropriate next step in appropriate next step in management of the flank stab management of the flank stab wound?wound?

A.A. DPLDPLB.B. Wound exploration with a cotton Wound exploration with a cotton

swab.swab.C.C. CT with IV contrast.CT with IV contrast.D.D. CT with oral, rectal, and IV CT with oral, rectal, and IV

contrast.contrast.

ANSWER: DANSWER: DA.A. DPL. DPL. In a pt who is hemodynamically In a pt who is hemodynamically

stable after penetrating flank trauma, stable after penetrating flank trauma, DPL would be helpful for intraperitoneal DPL would be helpful for intraperitoneal injury but does not sample the injury but does not sample the retroperitoneal injury (kidney).retroperitoneal injury (kidney).

B.B. Wound exploration with a cotton swab. Wound exploration with a cotton swab. Difficult and limited, esp with deeper Difficult and limited, esp with deeper wounds that extends to muscle layer.wounds that extends to muscle layer.

C.C. CT with IV contrast. CT with IV contrast. D.D. CT with oral, rectal, and IV contrast. Triple CT with oral, rectal, and IV contrast. Triple

contrast should be used to identify rectal contrast should be used to identify rectal and sigmoid injury. Oral contrast may not and sigmoid injury. Oral contrast may not extend down to these areas. Accuracy of extend down to these areas. Accuracy of CT for flank stab wounds approaches CT for flank stab wounds approaches 98%.98%.

Flank or Back WoundFlank or Back Wound Associated with to retroperitoneal injuries Associated with to retroperitoneal injuries

such as the colon, kidney, ureters and such as the colon, kidney, ureters and major vascular structures major vascular structures

Colon is the injury most often missed. If Colon is the injury most often missed. If colon injury is suspected, serial physical colon injury is suspected, serial physical examination is extended to 72 hours, examination is extended to 72 hours, watching for fever or a rise in WBCwatching for fever or a rise in WBC

An alternative is to perform a triple-An alternative is to perform a triple-contrast CT scan. Where the wound track contrast CT scan. Where the wound track extends up to the colon, or there is extends up to the colon, or there is evidence of abnormal bowel wall evidence of abnormal bowel wall thickening, laparotomy is indicated.thickening, laparotomy is indicated.

Another patient rolls in – an anterior Another patient rolls in – an anterior abdominal wall stab wound. What abdominal wall stab wound. What is the likelihood he will need is the likelihood he will need surgery due to this wound?surgery due to this wound?

A.A. 10%10%

B.B. 30%30%

C.C. 50%50%

D.D. 70%70%

E.E. 90%90%

Anterior Abdominal Stab WoundsAnterior Abdominal Stab Wounds 1/3 don’t penetrate peritoneum, 1/3 1/3 don’t penetrate peritoneum, 1/3

penetrate but don’t require laparotomy, penetrate but don’t require laparotomy, 1/3 require laparotomy. 1/3 require laparotomy.

Local wound exploration followed byLocal wound exploration followed by Discharge home if no violation anterior fasciaDischarge home if no violation anterior fascia Admission for observation/serial PE/DPL if Admission for observation/serial PE/DPL if

superficial muscle fascia violated.superficial muscle fascia violated. Indications for exploration: progressive Indications for exploration: progressive

abdominal tenderness, increasing abdominal tenderness, increasing leukocytosis, fever, abdominal distension, leukocytosis, fever, abdominal distension, etc. etc.

If the stab wound was in the LUQ, which If the stab wound was in the LUQ, which of the following is the BEST method for of the following is the BEST method for diagnosing a diaphragmatic injury?diagnosing a diaphragmatic injury?

A.A. Computed tomography.Computed tomography.B.B. Diagnostic peritoneal lavage.Diagnostic peritoneal lavage.C.C. Upper gastrointestinal series.Upper gastrointestinal series.D.D. Laparoscopy.Laparoscopy.

Diaphragmatic InjuriesDiaphragmatic Injuries Majority caused by penetrating trauma.Majority caused by penetrating trauma. Occur predominately on L side b/c liver Occur predominately on L side b/c liver

protects right side. Most likely sight of injury protects right side. Most likely sight of injury posterio-lateral portion of L diaphragmposterio-lateral portion of L diaphragmLaparoscopy. CT misses a lot of penetrating Laparoscopy. CT misses a lot of penetrating injuries.injuries.DPL may be used but must use low cut-off DPL may be used but must use low cut-off (5000 RBCs/ml) as diaphragm bleeds little.(5000 RBCs/ml) as diaphragm bleeds little.NG tube/Upper GI series good for blunt, but NG tube/Upper GI series good for blunt, but not penetrating diaphragmatic injuriesnot penetrating diaphragmatic injuriesDelays in diagnosis lead to increased Delays in diagnosis lead to increased morbidity and mortality. morbidity and mortality.

His CXR comes back with this. His CXR comes back with this. You realized you missed an You realized you missed an axillary injury and pt. has axillary injury and pt. has pneumo/hemothorax. Which of pneumo/hemothorax. Which of the following is true?the following is true?

A.A. Once the blood has been Once the blood has been drained from the chest, clamp drained from the chest, clamp the thoracostomy tube while the the thoracostomy tube while the patient undergoes further patient undergoes further evaluationevaluation

B.B. Perform needle aspiration of the Perform needle aspiration of the hemothorax if the volume is less hemothorax if the volume is less than 300 ccthan 300 cc

C.C. Perform needle decompression Perform needle decompression prior to tube thoracostomyprior to tube thoracostomy

D.D. Place a 28 Fr thoracostomy tube Place a 28 Fr thoracostomy tube directed anteriorly in the right directed anteriorly in the right anterior axillary lineanterior axillary line

E.E. Place a 36 Fr thoracostomy tube Place a 36 Fr thoracostomy tube directed posteriorly in the right directed posteriorly in the right anterior axillary lineanterior axillary line

PneumothoraxPneumothorax

Open pneumothoraxOpen pneumothorax Open >2/3 diam. of trachea (air moves in Open >2/3 diam. of trachea (air moves in

and out of woundand out of wound 3 sided petroleum gauze, one way valve, 3 sided petroleum gauze, one way valve,

chest tubechest tube Dressing can create a tension PTX; remove Dressing can create a tension PTX; remove

dressing if patient has increased SOBdressing if patient has increased SOB

Expiratory chest x-ray is the most Expiratory chest x-ray is the most helpful diagnostic maneuverhelpful diagnostic maneuver

Tension PneumothoraxTension Pneumothorax

Severe dyspnea, ↓ breath sounds, Severe dyspnea, ↓ breath sounds, distended neck veinsdistended neck veins

Classic=tracheal deviation to opposite side, Classic=tracheal deviation to opposite side, hyperresonance, no breath soundshyperresonance, no breath sounds

Decreased venous return, hypoxemia, Decreased venous return, hypoxemia, arrestarrest

Treatment: immediate needle Treatment: immediate needle thoracostomy, chest tubethoracostomy, chest tube

Don’t wait for the x-ray!Don’t wait for the x-ray!

PneumomediastiumPneumomediastium Subcutaneous emphysemaSubcutaneous emphysema Hamman’s sign: crunching during systole (not a Hamman’s sign: crunching during systole (not a

rub)rub) Spontaneous due to increased intrabronhcial Spontaneous due to increased intrabronhcial

pressurepressure Mechanical ventilationMechanical ventilation ValsalvaValsalva SneezingSneezing EmesisEmesis Ruptured blebRuptured bleb Drug useDrug use

Tension pneumomediastinumTension pneumomediastinum Decreased cardiac outputDecreased cardiac output Decompression via neck dissectionDecompression via neck dissection

Cardiac TamponadeCardiac Tamponade

Beck’s triad: hypotension, JVD, muffled heart Beck’s triad: hypotension, JVD, muffled heart tonestones

Pulsus paradoxicus: weaker pulse (lower BP) Pulsus paradoxicus: weaker pulse (lower BP) than usual with inspirationthan usual with inspiration

Electrical alternans: alternating QRS on EKGElectrical alternans: alternating QRS on EKG Diagnosis: EchoDiagnosis: Echo Treatment: pericardiocentesis, thoracotomyTreatment: pericardiocentesis, thoracotomy

If you crack the chest, you MUST skin the heartIf you crack the chest, you MUST skin the heart

Chest tubesChest tubes

Position – 5Position – 5thth interspace, anterior interspace, anterior axillary lineaxillary line No needleNo needle Prevent over-intrusionPrevent over-intrusion Slide along chest wallSlide along chest wall

For blood – large-bore tube (36-40 Fr), For blood – large-bore tube (36-40 Fr), direct posteriorlydirect posteriorly

For pure air – 28 Fr, directed For pure air – 28 Fr, directed anteriorlyanteriorly

Which of the following is an indication Which of the following is an indication for emergency department cesarean for emergency department cesarean delivery after maternal trauma?delivery after maternal trauma?

A. Absence of fetal heart tonesA. Absence of fetal heart tones

B. Fundal height at 19 cmB. Fundal height at 19 cm

C. GSW to uterus with vaginal bleedingC. GSW to uterus with vaginal bleeding

D. Maternal death after 5 minutes of D. Maternal death after 5 minutes of profound shock and a 26-week fetus.profound shock and a 26-week fetus.

E. Solitary GSW to head with stable E. Solitary GSW to head with stable vitals signs of the mother.vitals signs of the mother.

Answer DAnswer D Indications for Perimortem C-section:Indications for Perimortem C-section:

Fetus viable – cardiac activity on USFetus viable – cardiac activity on US Gestational age > 23 weeksGestational age > 23 weeks

Survival from postmortem cesarean Survival from postmortem cesarean delivery unlikely 15 mins after delivery unlikely 15 mins after maternal death.maternal death.

No specific duration of death beyond No specific duration of death beyond which C section is contraindicated.which C section is contraindicated.

GSW to uterus or solitary GSW to GSW to uterus or solitary GSW to head with stable VS are not head with stable VS are not indication for emergency ED C indication for emergency ED C section.section.

What are the 4 accepted What are the 4 accepted indications for ED thoracotomy?indications for ED thoracotomy?

Penetrating thoracic injuryPenetrating thoracic injury Traumatic arrest with previously witnessed Traumatic arrest with previously witnessed

cardiac activity (pre-hospital or in-hospital)cardiac activity (pre-hospital or in-hospital) Unresponsive hypotension (BP < 70mmHg) Unresponsive hypotension (BP < 70mmHg)

Blunt thoracic injuryBlunt thoracic injury Unresponsive hypotension (BP < 70mmHg)Unresponsive hypotension (BP < 70mmHg) Rapid exsanguination from chest tube Rapid exsanguination from chest tube

(>1500ml)(>1500ml)

What are the 4 uses for ED What are the 4 uses for ED Thoracotomy?Thoracotomy?

Relief of tamponadeRelief of tamponade Control hemorrhage from Control hemorrhage from

intrathoracic sourceintrathoracic source Cross clamping of pulmonary hilum Cross clamping of pulmonary hilum

after suspected air embolismafter suspected air embolism Cross clamp aorta with open heart Cross clamp aorta with open heart

massagemassage