Module 11 - Trauma

Assessment and Management of the Trauma Patient: Head Trauma - Anatomy - Tentorium Cerebelli

Divides into supratentorial and infratentorial compartments ¥ Supratentorial = anterior and middle fossae ¥ Infratentorial = posterior fossa ¥ Midbrain connects cerebral hemispheres to brain stem through hole in tentorium called tentorial incisura ¥ Temporal lobe herniation results in: - Compression of oculomotor nerve resulting in pupillary change - Medial portion of temporal lobe is the uncus, compression of corticospinal tract in midbrain results in contralateral weakness and ipsilateral pupillary changes (uncal herniation)

Assessment and Management of the Trauma Patient: Abdominal Trauma - Adjuncts to assessment Diagnostic Peritoneal Lavage (DPL)

Diagnostic Peritoneal Lavage (DPL) • Used for the identification of hemorrhage and hollow viscus injury • 98% sensitive for intraperitoneal bleeding • Aspiration of blood, gastrointestinal contents, or bile warrants a laparotomy • If sample not obviously positive, send to lab for microscopic analysis. Positive laboratory sample indicated by >100 k RBCs or 500 WBC/mm3, or +bacteria on gram stain

Assessment and Management of the Trauma Patient: Thoracic Trauma - Initial Assessment and Treatment Goals

Hypoxia is most serious result of chest injury; therefore, early identification and correction is paramount. ¥ Most life-threatening thoracic trauma is treated with airway control and/or placement of a chest tube/needle decompression. ¥ Less than 10% of blunt chest trauma requires thoracotomy. ¥ 15-30% of penetrating chest trauma requires thoracotomy.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Open Pneumothorax

Open Pneumothorax (a.k.a. Sucking Chest Wound) ¥ Pneumothorax with a defect in the chest wall. ¥ If defect is large enough (~⅔ diameter of trachea), results in air preferentially entering through the chest wall instead of trachea. ¥ Results in hypoxia and hypercarbia. ¥ Treatment includes closure of chest defect with a semiocclusive dressing to create a flutter valve (accumulated air in pleural space escapes but cannot return during inhalation). Securing all four sides may result in a tension pneumothorax, becoming a true medical emergency. ¥ Definitive treatment is a chest tube separate from the wound itself, then likely surgical closure of chest wall defect.

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Operative Management: Liver

Operative Management: Liver ¥ Operative management includes suturing, packing, or resection and debridement. ¥ As many as 86% of liver injuries have stopped bleeding by time of operation; as many as 67% of operations for blunt trauma are nontherapeutic.

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Operative Management: Spleen

Operative Management: Spleen ¥ Still the treatment of choice with the highest rate of success. However, splenectomy also introduces lifetime risk to infectious disease. ¥ Repair is often possible.

Assessment and Management of the Trauma Patient: Neck Trauma - Zones of penetrating injury

Penetrating trauma to the neck presents many issues due to the number of crucial anatomical structures confined within a relatively small space. ¥ Dividing the neck into anatomical zones assists in the evaluation of penetrating injury. ◦ Zone 1: the base of the neck, bounded by the thoracic inlet inferiorly and the cricoid cartilage superiorly ◦ Zone 2: the midportion of the neck from the cricoid cartilage to the angle of the mandible ◦ Zone 3: the superior portion of the neck bounded by the angle of the mandible and the base of the skull Mortality ¥ Mortality for penetrating neck injuries, particularly major vascular injuries, may reach 50%. ¥ Delayed complications such as pseudoaneurysms or arteriovenous fistulae can affect long-term outcomes. ¥ For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, operative management is indicated. Penetrating Neck Trauma Guidelines, EAST, 2008

Assessment and Management of the Trauma Patient: Trauma - Mechanism of Injury Penetrating

Penetrating: Low energy—Knives, arrows, most handguns ◦ Injury caused by direct contact with tissues and cavitation High energy—Military or hunting rifles, shrapnel ◦ Injury caused by direct contact, blast wave, and high pressure cavitation

Assessment and Management of the Trauma Patient: Musculoskeletal Trauma - Physical Exam

Physical Exam ¥ Three goals of the exam Identification of life-threatening injuries Identification of limb-threatening injuries Systematic review to avoid missing any other musculoskeletal injury ¥ Four components that must be assessed Skin integrity Neuromuscular function Circulatory status Skeletal and ligamentous integrity

Assessment and Management of the Trauma Patient: Thoracic Trauma - Hemothorax

Hemothorax ¥ Caused by lung laceration or laceration of an intercostal or internal mammary artery. ¥ Penetrating or blunt trauma. ¥ Any hemothorax large enough to appear on CXR should be treated with a large caliber chest tube. ¥ Bleeding usually self-limited and surgical intervention not required unless initial chest tube output >1.5 L, >200 ml/hr for 2-4 hours, or if transfusion is required.

Assessment and Management of the Trauma Patient: Musculoskeletal Trauma - Compartment Syndrome - High risk injuries

High risk injuries include: ¥ Tibial and forearm fractures ¥ Injuries immobilized in tight casts/dressings ¥ Severe crush injury to muscle ¥ Localized and prolonged external pressure on an extremity ¥ Increased capillary permeability due to reperfusion of ischemic muscle ¥ Burns ¥ Excessive exercise

Assessment and Management of the Trauma Patient: Thoracic Trauma - Tracheobronchial Tree Injury

Tracheobronchial Tree Injury ¥ Majority occur within 1 inch of carina. ¥ Most patients with this injury die at the scene from associated injuries. ¥ Patients typically present with hemoptysis, subcutaneous emphysema, and/or tension pneumothorax. (Large persistent air leak from chest tube is highly suggestive.) ¥ Diagnosed by bronchoscopy. ¥ Treatment includes selective lung ventilation and immediate operative intervention for patients with airway compromise/difficult intubation.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Traumatic Aortic Disruption

Traumatic Aortic Disruption ¥ Mechanism of injury should raise suspicions. ¥ Caused by an incomplete tear of aorta at the arteriosum ligamentum with a contained hematoma. ¥ Suggestive signs may be seen on CXR. Chest CT with contrast is more accurate for screening. Transesophageal echo may also be useful. ¥ Thoracic surgical or endovascular repair is required.

Assessment and Management of the Trauma Patient: The Secondary Survey - History

¥ An initial history may be difficult to obtain; the useful mnemonic A-M-P-L-E may be used. ◦ Allergies ◦ Medications ◦ Past illnesses/pregnancy ◦ Last meal ◦ Events/environment related to the injury ¥ Prehospital personnel may be helpful in obtaining information, especially regarding the mechanism of injury.

Assessment and Management of the Trauma Patient: Head Trauma

¥ Anatomy ¥ Classification of head injury ¥ Injuries ¥ Management strategies Scalp: S-C-A-L-P S kin C onnective tissue A poneurosis L oose areolar tissue P ericranium

Assessment and Management of the Trauma Patient: Abdominal Trauma

Abdominal Trauma ¥ Anatomy of the abdomen ¥ Mechanism of injury ¥ Assessment of abdomen ¥ Adjuncts to assessment (FAST, DPL) ¥ Indications for laparotomy ¥ Evaluation and management of solid organ injuries ¥ Evaluation and management of pelvic injuries

Assessment and Management of the Trauma Patient: Abdominal Trauma - Adjuncts to assessment Other

Adjuncts to Assessment of Abdomen ¥ Computed tomography with double or triple contrast ¥ Urethrography, cystography, intravenous pyelogram

Assessment and Management of the Trauma Patient: Trauma - Mechanism of Injury Blunt

** Blunt** - MVC—Impact of individual within the vehicle, angle of impact affects the injuries likely to be seen - Auto vs. pedestrian or cyclist—The unprotected nature of the victim results in multiple traumas, not limited to the point of impact. - Assault - Falls—Injury depends largely upon the height of the fall and the location/surface area of impact. - Blast—Injury sustained by pressure wave that spreads outward at the moment of explosion + Primary—Direct injury from the pressure wave, affects gas-containing organs most. + Secondary—Flying objects strike the individual. + Tertiary—Individual is thrown against an object. + Quaternary—Burns, crush, inhalation, complications of pre-existing conditions. - Crush

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - AAST Hepatic Injury Scale

AAST Hepatic Injury Scale Grade I Injury Type - Hematoma Description - Subcapsular, Grade I Injury Type - Laceration Description - Capsular tear, Grade II Injury Type - Hematoma Description - Subcapsular, Grade II Injury Type - Laceration Description - Capsular tear 1-3 parenchymal depth, Grade III Injury Type - Hematoma Description - Subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding Grade III Injury Type - Laceration Description - >3 cm parenchymal depth Grade IV Injury Type - Laceration Description - Parenchymal disruption involving 25% to 75% hepatic lobe or 1-3 Couinaud's segments Grade V Injury Type - Laceration Description - Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud's segments within a single lobe Grade V Injury Type - Vascular Description - Juxtahepatic venous injuries; i.e., retrohepatic vena cava/central major hepatic veins Grade VI Injury Type - Vascular Description - Hepatic avulsion

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - AAST Splenic Injury Scale

AAST Splenic Injury Scale Grade I Injury Type - Hematoma Description - Subcapsular Grade I Injury Type - Laceration Description - Capsular tear Grade II Injury Type - Hematoma Description - Subcapsular, 10-50% surface area; intraparenchymal Grade II Injury Type - Laceration Description - Capsular tear, 1- to 3-cm parenchymal depth that does not involve a trabecular vessel Grade III Injury Type - Hematoma Description - Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma, intraparenchymal hematoma ≥5 cm or expanding Grade III Injury Type - Laceration Description - >3 cm parenchymal depth or involving trabecular vessels Grade IV Injury Type - Laceration Description - Laceration involving segmental or hilar vessels producing major devascularization (>25%) Grade V Injury Type - Laceration Description - Completely shattered spleen Grade V Injury Type - Vascular Description - Hilar vascular injury with devascularized spleen

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Abdominal Compartment Syndrome

Abdominal Compartment Syndrome ¥ Intra-abdominal hypertension (IAH) results when abdominal contents expand in excess of the capacity of the abdominal cavity. ¥ 68% of patients die from ACS. ¥ Normal intra-abdominal pressure is 0-5 mmHg. ¥ Intra-abdominal pressures >15 mmHg are generally associated with early system pathophysiologic changes. ¥ Multiple body systems can be affected.

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Abdominal Compartment Syndrome Occurrences

Abdominal Compartment Syndrome Occurs in: ¥ Abdominal trauma ¥ Resuscitation edema ¥ Sepsis ¥ Retroperitoneal hematoma ¥ Post-op hemorrhage ¥ Abdominal packing ¥ Intra-abdominal infection ¥ Bowel obstruction ¥ Ileus ¥ Abdominal tumors ¥ Ascites ¥ Ruptured abdominal aortic aneurysm

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Abdominal Compartment Syndrome Patho

Abdominal Compartment Syndrome Pathophysiology ¥ Cardiac ↑ abdominal pressure → pressure on the inferior vena cava and portal vein causing: ↓ cardiac output ↓ venous return ↓ preload ¥ Thoracic ↑ abdominal pressure → the diaphragm rising and reducing lung volumes, causing: ↓ venous return ↓ cardiac function ¥ Renal ↑ abdominal pressure → compression of renal arteries and veins ↓ renal perfusion and the glomerular filtration rate ¥ Neuro ↑ abdominal pressure → impaired jugular venous outflow, causing: Venous congestion

Assessment and Management of the Trauma Patient: Neck Trauma - Management - Adjuncts

Adjuncts to Diagnostic Evaluation of Neck Trauma ¥ Evaluation of hemodynamically stable patients with penetrating neck trauma may include: Endoscopy Lanryngoscopy Esophagoscopy Angiography CT angiography Typically, patients with penetrating neck trauma, blunt force neck trauma, and/or suspected C-spine injury should receive a 4-vessel angiography, which remains the gold standard for investigation of vascular injury.

Assessment and Management of the Trauma Patient: The ABCDEs of Trauma Resuscitation

Adjuncts to the primary survey ¥ Respiratory rate ¥ Pulse oximetry ¥ Arterial blood gas ¥ ECG monitoring ¥ Foley catheter (should be deferred if uretheral/bladder injury suspected) ¥ Gastric catheter (avoid nasogastric route if facial fractures or basilar skull fracture suspected)

Assessment and Management of the Trauma Patient: Thoracic Trauma - Airway compromise

Airway Compromise ¥ Assess for airway patency by listening for air movement at the naso/oropharynx and across all lung fields. ¥ Inspect for naso/oropharynx for foreign-body obstruction. ¥ Assess for laryngeal trauma, listening for stridor. ¥ Assess for posterior dislocation of the clavicular head at the sternoclavicular joint, which may cause airway obstruction as evidenced by stridor or decreased vocal character, and perform an immediate closed reduction.

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey

Airway maintenance (observing cervical spine precautions) Breathing and ventilation Circulation (including hemorrhage control) Disability = Neurologic status Exposure/environmental control (expose the patient while maintaining body temperature)

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Circulation (with hemorrhage control) - Hemorrhage Class I

American College of Surgeons' Classes of Acute Hemorrhage: Class I - Blood Loss mL - Up to 750 Blood Loss % - Up to 15% Pulse Rate Blood Pressure - Normal Pulse Pressure - Normal or increased Respiratory Rate - 14-20 Urine Output - >30 CNS/Mental - Slightly anxious Fluid Replace 3:1 Rule - Crystalloid

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Circulation (with hemorrhage control) - Hemorrhage Class II

American College of Surgeons' Classes of Acute Hemorrhage: Class II - Blood Loss mL - 750 - 1500 Blood Loss % - 15 - 30% Pulse Rate - > 100 Blood Pressure - Normal Pulse Pressure - Decreased Respiratory Rate - 20-30 Urine Output - 20-30 CNS/Mental - Mildly anxious Fluid Replace 3:1 Rule - Crystalloid

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Circulation (with hemorrhage control) - Hemorrhage Class III

American College of Surgeons' Classes of Acute Hemorrhage: Class III - Blood Loss mL - 1500 - 2000 Blood Loss % - 30 - 40% Pulse Rate - > 120 Blood Pressure - Decreased Pulse Pressure - Decreased Respiratory Rate - 30-40 Urine Output - 5-15 CNS/Mental - Anxious/confused Fluid Replace 3:1 Rule - Crystalloid and blood

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Circulation (with hemorrhage control) - Hemorrhage Class IV

American College of Surgeons' Classes of Acute Hemorrhage: Class IV - Blood Loss mL - > 2000 Blood Loss % - > 40% Pulse Rate - > 140 Blood Pressure - Decreased Pulse Pressure - Decreased Respiratory Rate - >40 Urine Output - Negligible CNS/Mental - Confused/lethargic Fluid Replace 3:1 Rule - Crystalloid and blood

Assessment and Management of the Trauma Patient: Abdominal Trauma - Anatomy of the Abdomen

Anatomy of the Abdomen ¥ External: nipple line superiorly to symphysis pubis inferiorly ¥ Internal: three cavities/regions - Peritoneal cavity + Upper: diaphragm, liver, spleen, stomach, transverse colon + Lower: small bowel, ascending and descending colon, sigmoid colon, female reproductive organs - Retroperitoneal space + Located behind peritoneal space. Contains the abdominal aorta, inferior vena cava, most of duodenum, pancreas, kidneys and ureters, posterior aspects of ascending and descending colon, part of pelvic components. - Pelvic cavity + Rectum, bladder, iliac vessels, female reproductive organs

Assessment and Management of the Trauma Patient: Thoracic Trauma - Assess for Circulation Deficit

Assess for Circulation Deficit Physical exam should address: • Pulse quality, rate, regularity • Blood pressure and pulse pressure • Skin color, temperature, and character • Neck veins • Cardiac monitoring, pulse oximetery, EKG Major Injuries That Affect Circulation and Must Be Addressed During the Primary Survey ¥ Massive hemothorax ¥ Cardiac tamponade

Assessment and Management of the Trauma Patient: Thoracic Trauma - Assess for Signs of Chest Injury or Hypoxia

Assess for Signs of Chest Injury or Hypoxia ¥ Tachypnea ¥ Shallow respirations ¥ Cyanosis

Assessment and Management of the Trauma Patient: Abdominal Trauma - Assessment of Abdomen

Assessment of Abdomen ¥ History/mechanism of injury is important for prediction of actual injuries. ◦ MVC info: speed, type of collision, restraints used/air bags ◦ Prehospital treatment ◦ Penetrating trauma: time of injury, weapon type, distance from assailant, estimated number of wounds, amount of bleeding at the scene ◦ Explosion info: type of device, location of patient relative to device, location of device detonation ¥ Initial goal of assessment is to determine if urgent control of hemorrhage is necessary. Physical Examination ¥ Inspection, auscultation, percussion, and palpation ¥ Assessment of pelvic stability ¥ Uretheral, perineal, and rectal exam ¥ Vaginal examination ¥ Gluteal examination

Assessment and Management of the Trauma Patient: Abdominal Trauma - Mechanism of injury

Blunt ¥ Compression and crush injuries to viscera ¥ Shearing injuries (e.g., seat belt worn improperly) ¥ Deceleration injuries (liver and spleen lacerations at their supporting ligaments) ¥ Organs most affected: ◦ Spleen (40-55%) ◦ Liver (35-45%) ◦ Small bowel (5-10%) ◦ Retroperitoneal hematoma (15%) Penetrating ¥ Low velocity: injures by lacerating and cutting tissues - Stab wounds most often involve the liver (40%), small bowel (30%), diaphragm (20%), and colon (15%) ¥ High velocity: injures by same with addition to transfer of high kinetic energy (cavitation) - GSW most often involves small bowel (50%), colon (40%), liver (30%), and vascular structures (25%)

Assessment and Management of the Trauma Patient: Thoracic Trauma - Blunt Cardiac Injury

Blunt Cardiac Injury ¥ Myocardial muscle contusion, cardiac chamber rupture, coronary artery dissection and/or thrombosis, valvular disruption. ¥ Symptoms may include hypotension, dysrhythmias, wall-motion abnormality. ¥ An initial EKG should be obtained. If hemodynamically unstable, an echocardiogram should be included; cardiac enzymes are not useful in identifying those who will develop complications. ¥ Patients with blunt injury are at risk for sudden dysrhythmias and should be monitored for at least 24 hours.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Blunt Esophageal Injury

Blunt Esophageal Injury ¥ Caused by forceful expulsion of gastric contents from a blow to the upper abdomen, producing a linear tear in lower esophagus with leak into the mediastinum. ¥ Results in empyema. ¥ Consider esophageal injury in anyone with a left hemo/pneumothorax, severe blow to lower sternum/upper abdomen with pain/shock out of proportion to apparent injury, particulate matter in the chest tube, mediastinal air. Definitive diagnosis with esophagoscopy and/or contrast studies. Direct surgical repair is treatment of choice, early repair is best.

Assessment and Management of the Trauma Patient: Head Trauma - Anatomy - Brain

Brain ¥ Cerebrum: higher-level functions ◦ Right and left hemispheres ◦ Frontal, temporal, parietal, and occipital lobes ¥ Cerebellum: coordination and balance ¥ Brainstem: autonomic control ¥ Ventricles: CSF-filled spaces within the brain ¥ Right and left lateral, third, and fourth ventricles ¥ Choroid plexus produces 20 ml CSF/hr

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Mechanism

Mechanism ¥ Blunt: an object or force damages brain tissue and meninges without penetrating the dura ¥ Penetrating: brain injured/lacerated by an object such as a projectile or knife

Assessment and Management of the Trauma Patient: Neck Trauma - Types/mechanisms of injury - Fractures

C1 Fractures: Atlas Fractures ¥ ~4% of C-spine injuries ¥ Associated with C7 fractures and C2 pedicle fractures ¥ Jefferson fracture = Burst fracture of C1 C2 Fractures: Axis Fractures ¥ ~6% of C-spine injuries ¥ Associated with C1 fracture 8% ◦ Odontoid fractures (hyperflexion) Type I, II, and III ◦ Hangman's fracture (hyperextension) Bilateral pedicle fracture of C2 Surgery required for Types II and III Odontoid Fracture of the Dens Types I, II, and III ¥ Type II is worst due to difficulty in fixation. Subaxial Fractures ¥ Burst fracture—Comminuted, vertical fracture of the vertebral body from axial loading, often with retropulsion of bone fragments into the cord ◦ Usually results from MVCs and falls ◦ Often with associated injury to the posterior ligaments ¥ Teardrop fracture—Avulsion fracture of the antero/inferior corner of the vertebral body by the anterior ligament ◦ Most severe and unstable injury of the C-spine with highest association of neurologic deficit ◦ May be due to hyperflexion or hyperextension, often at C2 ¥ Clay shoveler's fracture—Avulsion fracture of spinous process of C7 or T1 caused by a sudden load on a flexed spine or due to a rotational injury

Assessment and Management of the Trauma Patient: Neck Trauma - Types/mechanisms of injury

Mechanisms of injury may include one or more of the following: ¥ Axial loading ¥ Flexion ¥ Extension ¥ Rotation ¥ Lateral bending ¥ Distraction

Assessment and Management of the Trauma Patient: Musculoskeletal Trauma - Compartment Syndrome

Compartment Syndrome ¥ Develops when the pressure inside a fascial compartment causes ischemia and eventually necrosis ¥ Can be caused by an increased compartment size (swelling) or decreased compartment size (restriction, as in the case of tight casting) ¥ Can occur anywhere muscle is enclosed in a fascial space ¥ Potential end results include neurologic deficit, muscle necrosis, ischemic contracture, infection, delayed healing of fractures/tissues, and possible amputation

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries

Evaluation and Management of Solid Organ Injuries ¥ Injuries to liver, spleen, or kidney that result in shock, hemodynamic instability, or continued bleeding should have laparotomy. ¥ Abdominal CT is the most reliable method to identify and assess the severity of the injury to the spleen or liver. ¥ Solid organ injury without hemodynamic instability can likely be managed nonoperatively. ¥ The American Association for the Surgery of Trauma (AAST) uses injury-scoring scales to determine extent of organ damage due to trauma.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Flail Chest With Pulmonary Contusion

Flail Chest With Pulmonary Contusion ¥ Associated with two or more fractured ribs in two or more places. ¥ Resulting flail segment disrupts normal chest wall movement, causing paradoxical movement of the flail segment during the respiratory cycle. ¥ Hypoxia may result from underlying lung injury and/or paradoxical and ineffective ventilatory effort; severe pain causing restricted movement of chest wall may exacerbate. ¥ Most severe form of blunt chest wall injury with associated mortality rates of 10-20%. ¥ Treatment includes ensuring adequate oxygenation and ventilation (NIPPV may be considered initially, single lung ventilation may be necessary in the worst cases of unilateral contusion), judicious fluid administration after initial resuscitation, and attention to adequate analgesia (IV narcotics, intercostal nerve blocks, epidural anesthesia).

Assessment and Management of the Trauma Patient: Abdominal Trauma - Adjuncts to assessment Focused Assessment Sonography in Trauma (FAST)

Focused Assessment Sonography in Trauma (FAST) ¥ Used for the identification of hemorrhage and hollow viscus injury ¥ Scans obtained of pericardium, hepatorenal fossa (Morison's pouch), splenorenal fossa, and pelvis (Douglas's pouch) ¥ Sensitivity, specificity, and accuracy similar to that of DPL and abdominal CT ¥ Rapid performance in the trauma resuscitation area, can be repeated frequently if necessary (a "control" scan should be performed 30 minutes after the first to identify progressive hemoperitoneum) ¥ Limited by obesity, presence of subcutaneous air, previous abdominal operations

Assessment and Management of the Trauma Patient: Head Trauma - Management Strategies - Goals of Management of Severe Brain Injury (GCS 3-8)

Goals of Management of Severe Brain Injury (GCS 3-8) ¥ Maintain adequate cerebral perfusion pressure ◦ Cerebral perfusion pressure (CPP) = Mean arterial pressure (MAP) − Intracranial pressure (ICP) ◦ Avoid hypotension, goal SBP >90 ¥ Provide adequate oxygenation ◦ Prevent secondary injury from hypoxia ¥ Maintain normo- to mild hypocapnea ¥ Hyperventilation → ↓ CO2 → Cerebral vasoconstriction → ↓ ICP ¥ Goal PaCO2 (or EtCO2) ~30-35 mmHg

Assessment and Management of the Trauma Patient: Head Trauma - Management Strategies - Adjuncts

ICP monitoring - Anyone with TBI with abnormal CT and GCS - Maintain CPP >70 - Treat for ICP >20 IV fluids to maintain normovolemia Hyperventilation: use only sparingly and for a limited amount of time Mannitol: osmotic diuretic, used to reduce ICP by shrinking healthy brain cells to provide more room for an edematous brain Barbiturates/sedatives Anticonvulsants Maintain normothermia; prophylactic hypothermia has not yet demonstrated a decrease in all-cause mortality

Assessment and Management of the Trauma Patient: Neck Trauma - Imaging/Clearance

Imaging/Clearance ¥ Clinical clearance remains the standard in awake, alert trauma patients without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion. Cervical collars should be removed as soon as feasible. ¥ Computed tomography has supplanted plain radiography as the primary screening modality in those who require imaging. ¥ Flexion/extension films are now used only for patients with persistent neck pain despite a negative CT.

Assessment and Management of the Trauma Patient: Abdominal Trauma - Indications for Laparotomy

Indications for Laparotomy ¥ Blunt abdominal trauma with hypotension and positive FAST or clinical evidence of hemorrhage ¥ Blunt abdominal trauma with positive DPL ¥ Hypotension with penetrating wound ¥ GSW through peritoneal or retroperitoneal cavity ¥ Evisceration ¥ Penetrating trauma with bleeding from stomach, rectum, or urethra ¥ Peritonitis ¥ Pneumoperitoneum, pneumoretroperitoneum, or rupture of the diaphragm from blunt trauma ¥ Ruptured GI tract, intraperitoneal bladder injury, or severe visceral parenchymal injury after blunt or penetrating trauma as seen on contrast CT ATLS Student Course Manual, 8th ed., p. 120

Assessment and Management of the Trauma Patient: Musculoskeletal Trauma - Compartment Syndrome - Pressure readings

Intracompartmental pressure readings may be helpful. Pressures of 30-45 mmHg are suggestive of compartment syndrome. The relationship of systemic blood pressure to intracompartmental pressure is important. If no significant change in symptoms, a fasciotomy is required. Surgical consultation should be requested early.

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Injuries - Intracranial Lesions: Diffuse

Intracranial Lesions: Diffuse ¥ Concussion: transient neurologic disturbance, often with LOC, head CT normal in appearance ¥ Diffuse axonal injury: shearing injury of neurons producing multiple punctate hemorrhages ¥ Severe hypoxic/ischemic: result from prolonged shock or apnea in which the brain may initially appear normal on CT, or manifested as diffuse edema

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Injuries - Intracranial Lesions: Focal

Intracranial Lesions: Focal • Epidural hematoma • Subdural hematoma • Intracerebral hemorrhage

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Airway

Jaw-thrust/chin lift, no head tilt. Maintain C-spine stabilization at all times. Assess for airway obstruction. ◦ Foreign bodies ◦ Fractures ▪ Facial ▪ Mandibular ▪ Tracheal/laryngeal fractures Assume a C-spine injury in any multitrauma patient. Any patient with a GCS of 8 or less should have definitive airway management. Airway adjuncts include ◦ Oro/nasopharyngeal airway ◦ LMA/combitube A definitive airway includes ◦ Oro/nasopharyngeal endotracheal intubation ◦ Cricothyroidotomy → tracheostomy A definitive airway must be established if there is any doubt in the patient's ability to protect his/her own airway. Definitive airway = Cuff in trachea

Assessment and Management of the Trauma Patient: Thoracic Trauma - Breathing and Oxygenation

Major Injuries That Affect Breathing and Oxygenation and Must Be Addressed During the Primary Survey ¥ Tension pneumothorax ¥ Open pneumothorax ¥ Flail chest with pulmonary contusion ¥ Massive hemothorax

Assessment and Management of the Trauma Patient: Neck Trauma - Management

Management Controversy arises over management of the patient without significant symptoms. Management of these patients has been evolving from an era of mandatory exploration, which led to many nontherapeutic explorations, to an era of more selective management based on clinical experience and new imaging capabilities. Penetrating Neck Trauma Guidelines, EAST, 2008

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Abdominal Compartment Syndrome Management

Managing Abdominal Compartment Syndrome ¥ Measure IAP every 2-4 hours if >12 mmHg. ¥ Central lines should be placed above the diaphragm so that IV meds can reach the heart. ¥ Use of reverse Trendelenberg—HOB elevation causes an ↑ intra-abdominal, intrathoracic, and ICP. ¥ Pressure ulcer prevention: Patients are often too hemodynamically unstable to turn. Use pressure-relieving devices. Perform small shifts in weight (reposition without turning). ¥ Continue with sedation vacation, stress ulcer prophylaxis, and DVT prophylaxis.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Massive Hemothorax

Massive Hemothorax ¥ Rapid accumulation of >1.5 L blood in the chest cavity ¥ Most commonly caused by penetrating trauma to systemic or hilar vessels (specifically wounds medial to the nipple anteriorly or medial to the scapula posteriorly) ¥ Signs/symptoms include shock, hypoxia, decreased breath sounds, dullness to percussion to affected side ¥ Treatment involves simultaneous restoration of circulating volume and decompression of the chest cavity. ◦ Large-caliber IV access, rapid crystalloid infusion ◦ Type-specific blood transfusion ◦ Single large chest tube (#38 Fr.) ◦ Autotransfusion set-up for chest drainage ¥ A thoracotomy may be necessary if 1.5 L blood immediately evacuated, bleeding continues at a rate of 200-400 ml/hour for 2-4 hours, or repeated deterioration of patient condition. ¥ Massive hemothorax is complicated by associated hypoxia due to the V/Q mismatch of perfused/nonventilated alveoli, often requiring intubation with mechanical ventilation.

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Morphology/Skull Fractures

Morphology/Skull Fractures Consider the force required to fracture the skull. Vault ◦ Open/closed, depressed/nondepressed, linear/stellate Basilar ◦ With/without CSF leak Otorrhea, rhinorrhea ◦ With/without 7th (facial paralysis) and 8th (hearing loss) nerve palsy ◦ Ecchymosis: Periorbital (raccoon's eyes) or retroauricular (battle sign) ◦ Possible injury of the carotid arteries if basilar skull fracture through carotid canals—consider angiography

Assessment and Management of the Trauma Patient: Musculoskeletal Trauma

Musculoskeletal Trauma ¥ Musculoskeletal injuries occur in 85% of patients with blunt trauma. ¥ Musculoskeletal injuries indicate that the body sustained significant forces. ¥ Long bone and pelvis fractures may be associated with hemorrhage. ¥ Adequate immobilization of fractures may assist with the completion of the primary survey and secondary survey.

Assessment and Management of the Trauma Patient: Neck Trauma - Imaging/Clearance - NEXUS

NEXUS In 2000, the New England Journal of Medicine published the National Emergency X-Radiography Utilization Study (NEXUS). NEXUS was a prospective observational study conducted at over 21 trauma centers across the United States to validate five criteria for a low probability of CS injury. This decision instrument required patients to have: ◦ No midline cervical tenderness ◦ No focal neurologic deficit ◦ Normal alertness ◦ No intoxication ◦ No painful distracting injury

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Circulation (with hemorrhage control) Continued

Name the five places where enough blood can be lost to effect a significant change in H&H 1 Thorax 2 Abdomen 3 Pelvis (including retroperitoneal space) 4 Thighs 5 The Floor (a.k.a. The Street) ¥ Blood volume ◦ 5 liters in the 70-kg adult ◦ 80-90 ml/kg in children ¥ Classification of hemorrhage (% loss) ◦ I: ◦ II: 15-30% ◦ III: 30-40% ◦ IV: >40% ¥ Fluid resuscitation ◦ Initially 2 liters NS/LR for an adult ◦ 20 ml/kg for a child ¥ Aggressive volume resuscitation is not a substitute for hemorrhage control

Assessment and Management of the Trauma Patient: Neck Trauma

Neck Trauma ¥ Types/mechanisms of injury ¥ Imaging/clearance ¥ Zones of penetrating injury ¥ Management

Assessment and Management of the Trauma Patient: Musculoskeletal Trauma - Potentially Life-Threatening Musculoskeletal Injuries

Potentially Life-Threatening Musculoskeletal Injuries ¥ Major pelvic disruption with hemorrhage ◦ Treatment includes either embolization or fixation ¥ Major arterial hemorrhage ◦ Direct or indirect vascular injury ◦ Requires surgical consultation ◦ Treatment includes direct pressure and fluid resuscitation ¥ Crush syndrome (traumatic rhabdomyolysis) ◦ Direct muscle injury ◦ Muscle ischemia ◦ Cell death with release of myoglobin Rhabdomyolysis ranges from asymptomatic to life-threatening AKI and DIC ¥ Open fractures and joint injuries ◦ Communication between bone and the environment ◦ Prone to problems with infection, healing, and function ◦ Requires prompt surgical attention, wound debridement, achievement of hemodynamic stability ¥ Vascular injuries including traumatic amputation ◦ Muscle necrosis occurs after 6 hours of loss of arterial flow ◦ Requires prompt operative revascularization ¥ Neurologic injury secondary to fracture dislocation ◦ Injury potential due to nerve location relative to joint

Assessment and Management of the Trauma Patient: Thoracic Trauma - Pulmonary Contusion

Pulmonary Contusion ¥ Most common potentially lethal injury ¥ May occur with or without rib fractures ¥ Respiratory failure can develop subtly over time ¥ Significant hypoxia requires intubation and mechanical ventilation

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Injuries - Intracranial Lesions: Focal Intracerebral Hemorrhage

Result from tearing or shearing of vessels within the parenchyma

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Severity

Severity ¥ Minor (13-15), moderate (9-12), and severe (3-8) based on GCS If asymmetry is present, use best exam. GCS

Assessment and Management of the Trauma Patient: Musculoskeletal Trauma - Compartment Syndrome - Sign and Symptoms

Signs and symptoms include: ¥ Worsening pain, greater than anticipated intensity, out of proportion to stimulus ¥ Palpable tenseness of the compartment ¥ Asymmetry of the muscle compartments ¥ Pain on passive stretch of the affected muscle ¥ Altered sensation Note that loss of distal pulse is not on the list above. Loss of pulse is rare and should not be used as a marker of the presence of compartment syndrome.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Simple Pneumothorax

Simple Pneumothorax ¥ Air enters the space between the visceral and parietal pleurae ¥ Penetrating or blunt trauma ¥ Creates V/Q mismatch with perfused/nonventilated alveoli ¥ Best treated with a chest tube to negative pressure ¥ Danger, a simple pneumothorax has the potential to convert to a tension pneumothorax, which is a medical emergency!

Assessment and Management of the Trauma Patient: Head Trauma - Anatomy - Skull

Skull Cranial vault (calvaria) ¥ Thin in temporal region, base irregular, floor divided into three regions or fossae Anterior: houses frontal lobes Middle: houses the temporal lobes Posterior: houses the lower brain stem and cerebellum

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Disability

The neurologic evaluation during the primary survey includes level of consciousness, pupillary size and reaction, lateralizing signs, and spinal cord injury level. ¥ Level of consciousness (AVPU) ◦ Alert ◦ Verbal ◦ Pain ◦ Unresponsive ¥ Glasgow Coma Scale ◦ Eye opening ◦ Best verbal response ◦ Best motor response

Assessment and Management of the Trauma Patient: The Secondary Survey - Physical Exam

The physical exam should be conducted in the following order: ¥ Head (including careful examination of the eyes) ¥ Maxillofacial structures ¥ C-spine and neck (Any patient with head and/or maxillofacial injury must be presumed to have a C-spine injury until it can be ruled out.) ¥ Chest ¥ Abdomen ¥ Pelvis/perineum/rectum/vagina ¥ Musculoskeletal system/extremities ¥ Neurologic function (including repeat and periodic GCS evaluation)

Assessment and Management of the Trauma Patient: Thoracic Trauma - Traumatic Diaphragmatic Injury

Traumatic Diaphragmatic Injury ¥ Blunt trauma causes large radial tears, leading to immediate herniation; penetrating trauma may cause smaller holes, which take longer to develop into hernias. ¥ Left side injury easier to diagnose than right side. ¥ May be diagnosed on initial CXR, or by appearance of gastric tube in the thorax, or by additional contrast study. ¥ May require laparoscopic or thorascopic procedure for diagnosis/repair.

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Abdominal Compartment Syndrome Treatment

Treating Abdominal Compartment Syndrome ¥ Surgical decompression is the only definitive treatment for ACS. ¥ If the patient continues to have an ↑ in abdominal pressure, decompression may be required. ¥ The physician may decompress the abdomen in the OR or at the bedside. ¥ After decompression occurs, assess: ◦ Dressing: drainage amount and color ◦ Fluid and electrolyte status ¥ Patients with an "open" abdomen lose a large amount of body heat.

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Circulation (with hemorrhage control)

Vital signs ◦ Central pulse is an easily assessed parameter. ◦ Distal pulse quality gives an indication of volume status. ◦ Blood pressure Signs of perfusion ◦ Level of consciousness ◦ Skin color, temperature, and character Hemorrhage is controlled during the primary survey. ◦ Manual compression/direct pressure ◦ Pneumatic splints ◦ Tourniquets Establish vascular access. ◦ Two large-bore upper extremity PIVs, central vascular access, or intraosseous access Shock associated with traumatic injury is almost always due to hypovolemia. Definitive control may include surgical correction, angio-embolization, stabilization of fractures (pelvis and long bone).

Assessment and Management of the Trauma Patient: Thoracic Trauma - What Secondary Survey Should Include

What Secondary Survey Should Include ¥ More involved physical exam ¥ Upright chest X-ray Widened mediastinum Loss of anatomic detail Boney fracture Shift of midline ¥ ABG and pulse oximetry ¥ ECG monitoring (if not already employed)

Assessment and Management of the Trauma Patient: Head Trauma - Management Strategies - CT Scan

Who Gets a CT Scan? High risk for need for neurosurgical intervention: ¥ Anyone who has a GCS <8? ¥ Clinical suspicion of open or depressed skull fracture ¥ Signs of a basal skull fracture ¥ Two or more episodes of emesis ¥ Anyone >65 years of age Moderate risk for brain injury on CT ¥ Amnesia before impact ¥ Dangerous mechanism (pedestrian vs. vehicle, ejection from vehicle, fall >3 feet)

Assessment and Management of the Trauma Patient: Thoracic Trauma - Tension pneumothorax

¥ "One-way-valve" air leak into the pleural space from the lung ¥ Displaces mediastinum to opposite side, decreases venous return to heart, compresses the opposite lung ¥ Most often caused by positive-pressure ventilation of a patient with a visceral pleural injury ¥ Symptoms include chest pain, air hunger, respiratory distress, tachypnea, tachycardia, hypotension, tracheal deviation, unilateral absence of breath sounds, JVD, cyanosis, hyperresonance over pneumothorax ¥ Medical emergency, requires immediate needle decompression with subsequent placement chest tube

Assessment and Management of the Trauma Patient: Initial Management of Trauma

¥ "Patients are assessed, and their treatment priorities are established, based on their injuries, vital signs, and the injury mechanisms." ¥ Initial management consists of a primary survey, resuscitation, a more detailed secondary survey, and finally the initiation of definitive care. ATLS Student Course Manual, 8th ed., p. 4

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Injuries - Intracranial Lesions: Focal Epidural hematoma

¥ 0.5% of brain injuries but 9% of comatose patients. ¥ Usually located in the temporal or tempoparietal area, between the skull and the dura (epidural space). ¥ Usually the result of a fracture tearing the middle meningeal artery; brisk bleeding can cause rapid expansion of the hematoma with an associated rapid rise in ICP, possibly fatal. ¥ Often presents with a period of lucidity followed by rapid decline in mental status. ¥ If epidural hematoma is suspected, serial head CTs may be required to monitor progress. ¥ Surgical decompression is treatment of choice if epidural hematoma expands.

Assessment and Management of the Trauma Patient: Head Trauma - Classification of Brain Injury Injuries - Intracranial Lesions: Focal Subdural hematoma

¥ 30% of severe brain injuries. ¥ Shearing of surface or bridging veins as they pass from the parenchyma to the sinuses; blood accumulates under the dural layer. ¥ Bleeding appears to follow contours of the brain. ¥ Subacute SDH may have no associated symptoms. ¥ Acute SDH associated with variety of neurologic symptoms as hematoma becomes a space-occupying lesion.

Assessment and Management of the Trauma Patient: The Secondary Survey

¥ A head-to-toe examination of the patient including a history and physical examination. ¥ The secondary survey does not begin until the primary survey is completed and the patient's vital signs are stabilized. ¥ Due to the chaotic nature of a trauma admission, injuries may be missed, or their extent underestimated, unless a thorough repeat survey is performed. ¥ Special tests, radiographic studies, or minor procedures may be performed as needed during the secondary survey.

Assessment and Management of the Trauma Patient: Neck Trauma - Types/mechanisms of injury - Cervical Dislocation/Subluxation

¥ Adjoining vertebrae no longer touch each other. ¥ Subluxation is minor version of dislocation where joints still touch but not in the proper relationship/alignment. ¥ Dislocation often leads to spinal cord damage with possible paralysis or death. ¥ Involves C-spine vertebrae, ligaments, cartilage, the spinal cord, and occasionally nerve roots. ¥ Caused by forceful flexion or extension often by direct trauma or force on the head and/or neck.

Assessment and Management of the Trauma Patient: The Secondary Survey - Adjuncts

¥ Adjuncts to the secondary survey ◦ X-rays ◦ CT scans ◦ Ultrasound ◦ EKG ◦ DPL ◦ Urethrography/cystography ◦ Laboratory studies ¥ Tests and scans should only be undertaken once the primary survey is completed, initial resuscitation is complete, and the patient's vital signs remain stable.

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Breathing/Ventilation

¥ All trauma patients should receive supplemental oxygen, first by non-rebreather, then by whichever method necessary to maintain adequate oxygenation. ¥ Intubation is paramount for patients who have airway compromise from mechanical problems, ventilatory problems, or are unconscious. ¥ Chest decompression should be achieved immediately if tension pneumothorax is suspected. Pulmonary contusions, fractured ribs, hemothorax, and simple pneumothorax can also compromise ventilation.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Cardiac Tamponade

¥ Can be caused by blunt or penetrating trauma. ¥ Pericardium fills with blood from the heart, great vessels, and pericardial vessels restricting the ability of the heart to fill properly. ¥ Signs/symptoms include: - Beck's triad: low arterial pressure, high venous pressure, muffled heart sounds. Neck veins may not be distended if patient is hypovolemic. - Kussmaul's sign: rise in venous pressure with inspiration in the spontaneously breathing patient. ¥ Diagnostics include echocardiogram, FAST study, or echocardiogram. ¥ Treatment involves evacuation of pericardial blood, resuscitation of shock. - Pericardiocentesis can be diagnostic and therapeutic. - Thoracotomy may be necessary for definitive treatment.

Assessment and Management of the Trauma Patient: Head Trauma - Anatomy - Meninges

¥ Dura mater: tough and fibrinous, adheres to internal surface of skull ◦ Splits to enclose the venous drainage from brain (superior sagittal sinus). ◦ Meningeal arteries lie between dura and skull in the epidural space. ¥ Arachnoid mater ◦ Not attached to dura. ◦ Bridging veins travel through the arachnoid to the venous sinuses within the dura. ¥ Pia mater: firmly attached to the surface of the brain, creates watertight space between the brain and the arachnoid (subarachnoid space) ◦ Hemorrhage into this space often occurs with brain contusion or injury to vessels at the base of the brain.

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Pelvic Injuries

¥ Fractured pelvis requires large amount of force; must suspect additional intra/retroperitoneal injury. ¥ Four patterns of injury/force ◦ AP compression ◦ Lateral compression ◦ Vertical shear ◦ Combination ¥ Hemorrhagic shock in the setting of pelvic instability from: ◦ Fractured bone surfaces ◦ Pelvic venous plexus ◦ Pelvic arterial injury ◦ Extrapelvic sources ¥ Assess for leg-length difference, limb rotational defect, motion of pelvis with direct manipulation. ¥ Unstable pelvic fractures must be splinted, reduction of acetabular fracture.

Assessment and Management of the Trauma Patient: Head Trauma - Management Strategies Brain Death Criteria

¥ GCS 3 ¥ Pupils nonreactive ¥ Absence of brain stem reflexes (cough, gag, corneal, oculocephalic) ¥ No activity on electroencephalogram ¥ No cerebral blood flow by study ¥ ICP exceeds MAP for ≥1 hour ¥ Cerebral angiography without flow ¥ Negative cold calorics test ¥ Apnea test

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Abdominal Compartment Syndrome

¥ If left untreated ACS can result in: Hypoxia Anuria Decreased organ perfusion Death ¥ ACS has a wide-ranging effect on many other organ systems.

Assessment and Management of the Trauma Patient: Nine Life-Threatening Conditions That Require Immediate Intervention During ABCDE

¥ Inadequate airway protection ¥ Airway obstruction ¥ Tension pneumothorax ¥ Open pneumothorax ¥ Flail chest (>2 ribs fractured in 2 or more places) with hypoxia ¥ Massive hemothorax (>1500-ml blood) ¥ Cardiac tamponade (Beck's triad = low arterial BP, JVD, and muffled heart sounds) ¥ Severe hypothermia ¥ Severe shock from hemorrhage unresponsive to fluid resuscitation

Assessment and Management of the Trauma Patient: Thoracic Trauma

¥ Initial assessment/management ¥ Major injuries identified in the primary survey and their specific treatment ¥ Major injuries identified in the secondary survey and their specific treatment

Assessment and Management of the Trauma Patient: Thoracic Trauma -

¥ Initial/management ¥ Major injuries identified in the primary survey and their specific treatment ¥ Major injuries identified in the secondary survey and their specific treatment

Assessment and Management of the Trauma Patient: Trauma

¥ Mechanism of injury - Classified as blunt, penetrating. - Subclass of blast and/or thermal. ¥ Injury sustained is an effect of the energy laws. Injury is dependent on the amount and speed of energy transmission, the surface area over which the energy is applied, and the elastic properties of the tissues to which the energy transfer is applied.

Assessment and Management of the Trauma Patient: Initial Management of Trauma - The Primary Survey - Exposure/Environmental Control

¥ Patients must be completely disrobed in order to accomplish a thorough examination. ¥ Logroll the patient to visualize entire body. ¥ Hypothermia can be a potentially lethal complication of trauma. ◦ Patients often arrive hypothermic, or can become hypothermic after being fully exposed. ◦ The temperature of the trauma bay should be increased to prevent loss. Fluids and blood products should be warmed to 39°C prior to administration.

Assessment and Management of the Trauma Patient: Thoracic Trauma - Resuscitative Thoracotomy

¥ Patients with penetrative thoracic injuries who arrive pulseless but with myocardial activity or other signs of life (reactive pupils, spontaneous movement) are candidates. ¥ Patients with blunt thoracic injuries and cardiac arrest are not candidates. ¥ Resuscitative thoracotomy is utilized for: - Evacuation of pericardial tamponade - Direct control of intrathoracic hemorrhage - Open cardiac massage - Cross-clamping of the descending aorta to preferentially shift blood flow to the brain and heart

Assessment and Management of the Trauma Patient: Thoracic Trauma - Initial Assessment and Treatment Goals

¥ Primary assessment ¥ Resuscitation of VS ¥ Focused secondary survey with identification of injuries and immediate correction of major problems ¥ Definitive care

Assessment and Management of the Trauma Patient: 13 Potentially Life-Threatening "Nonobvious" Injuries That Must Be Considered in the Trauma Patient

¥ Simple pneumothorax ¥ Hemothorax ¥ Pulmonary contusion ¥ Tracheo-bronchial injury ¥ Blunt cardiac injury ¥ Traumatic aortic disruption ¥ Any other chest/abdominal/pelvic injuries that may have resulted in organ damage but not in immediate shock ¥ Diaphragmatic rupture ¥ Mediastinal traversing wounds ¥ Blunt esophageal trauma ¥ Sternal/scapular/rib fractures ¥ Ruptured liver or spleen ¥ Rupture of an abdominal or pelvic viscus

Assessment and Management of the Trauma Patient: Abdominal Trauma - Evaluation and Management of Solid Organ Injuries - Blunt Injury to Liver and Spleen

¥ The clinical status of the patient should dictate the frequency of follow-up scans. ¥ Initial CT of the abdomen should be performed with oral and intravenous contrast to facilitate the diagnosis of hollow viscus injuries. ¥ Medical clearance to resume normal activity status should be based on evidence of healing. ¥ Angiographic embolization is an adjunct in the nonoperative management of the hemodynamically stable patient with hepatic and splenic injuries and evidence of ongoing bleeding.

Assessment and Management of the Trauma Patient: Neck Trauma - Imaging/Clearance - Radiographic Evaluation

• All patients with a suspected C-spine injury who cannot be clinically cleared must have radiographic evaluation. This applies to patients with neck pain/tenderness, a neurologic deficit, altered mental status, a distracting injury, and obtunded patients. • The primary screening modality is axial computed tomography (CT) from the occiput to T1 with sagittal and coronal reconstructions. • Plain radiographs contribute no additional information and should not be obtained.