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