Transcript Trauma, Non Head, Non Spine

Trauma, Non Head, Non
Spine
By
CCM Fellows
UBC
Case
• -19 years old girl, otherwise healthy, was brought
to ER at RCH by EHS after being hit by a freight
train.
• -Earlier, she was partying with her pals, got drunk,
went through a fight with her bf, after which she
decided to walk home alone! At the railway
intersection, she was hit on her left side by the
train, which slowed down coming near the station.
Upon EHS Arrival..
• -When EHS arrived within 2 minutes, she
was conscious but drowsy, GCS E3 M5 (x4)
V2, vomiting, with open wounds on her
posterior scalp, and Lt knee. She was
intubated at the seen and brought to ER.
In ER..
•
•
•
•
A:ETT, C-collar.
B: AC, fiO2 0.5. ABG 7.3/50/19/88/ -6.
C: 110/50 (65), 110 SR, T:34C.
D: PERL 3mm bi, on 3:3 M:M + 100 mcg
of fentanyl given by ER MD when patient
was trying to wake up and bite on the ETT.
• Trauma team are in.
O/E..
• HEENT: 3-cm Laceration wound grade I over the occiput.
• Heart: Normal S1+S2.
• Chest: paradoxical movement of Lt 3-7 ribs chest wall,
with multiple bruises on the Lt side, decreased B/S on the
Lt side.
• Abdomen: multiple bruises on the Lt side, with mildly
distended abdomen. DRE: clear.
• F/C hematuria, 70cc/hr (BWt 90kg).
• Ext: bruises over Lt shoulder posteriorly.
Intact/symmetrical upper pulses/BP. Lt thigh swelling, 15cm Lt knee grade IIIb (at least) laceration with exposed
fractured bone, Lt PT and DP weaker than Rt
FAST..
• No tamponade, “good” LVEF, coarse
spleen, evidence of fluid in the hepatorenal
space and Lt perinephric area.
Labs..
• Hb 60, Plt 80, INR 1.5, PTT 40, Fib 0.9,
WBC 16,
• Cr 80, BUN 7, lytes N, LFE N. LA 4.3,
Trop <0.04,
• U/A RBC 20-50, WBC 5-10.
• ECG: Sinus tachycardia.
Imaging..
• CT head: N. C-spine: N.
• Chest: Lt hemopneumothorax, fractured Lt scapula and
ribs 3-7, Lt lung contusion.
• T-L-S spine: intact.
• Abdomen: Lt diaphragmatic rupture, spleen laceration
grade 4, liver injury grade 1, Lt perinephric hematoma,
evidence of hemoperitoneum.
• Pelvis: Lt pubic ramus fracture.
• Ext: Fracture Lt acetabular and femoral head capitus,
displaced femoral shaft and intercondylar, patella and tibial
plateau, with air tracking from the knee proximally, c/w
open fracture. CTA preliminary report N.
• -Lt chest tube was inserted, drained blood.
Question 1
• Discuss the initial fluid resuscitation in
trauma patient, focusing of monitoring
endpoints (including base deficit),
coagulopathy (including hypothermia), and
massive transfusion protocol (Marios)
Initial trauma fluid
resuscitation
1)
2)
3)
4)
Fluids
Transfusion ratios
Monitoring end-points
Coagulopathy
Initial fluid resuscitation
• A controversial topic with nebulous answers
• Guidelines used to be that you gave 2 or more liters of
crystalloid to any trauma patient you thought was in
shock
• Goal was to rapidly restore circulating volume to
maintain vital organ perfusion.
• There is evidence however that normalizing one’s blood
pressure in the setting of an uncontrollable hemorrhage
may worsen outcome.
• This has led to the concept of “permissive
Initial fluid resuscitation
• Rationale behind permissive hypotension (animal
models)
• Increased blood pressure accelerates bleeding and
dislodges soft early clots (which take 30 min to
harden)
• Dilution of RBC mass by crystalloid or colloid reduces
oxygen delivery despite increasing cardiac output
• Reduced hematocrit and clotting factor concentration
inhibit clot formation
• Resuscitative fluids themselves may have deleterious
properties such as neutrophil activation (RL in
Initial fluid resuscitation
• Human evidence for permissive hypotension
• Houston study (1994)
• Thoraco-abdominal gunshot or stab wounds presenting with
SBP < 90 mmHg
• Patients either treated with “liberal” RL or delayed
resuscitation until OR.
• Patients in the early resuscitation group had a higher
mortality and rate of post-op complications
• Baltimore study (2002)
• Penetrating and blunt trauma patients presenting to the
Shock Trauma Center with SBP < 90 mmHg
• Randomized to a fluid resuscitation strategy targeted to a
lower than normal SBP (> 70 mmHg) or to conventional care
(SBP > 100 mmHg)
• Mortality was identical but fewer complications and a shorter
Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331:1105–1109.
duration
of hemorrhage
were
seen
in the
Dutton RP, Mackenzie CF, Scalea T. Hypotensive resuscitation
during active hemorrhage:
impact on in-hospital mortality.
J Trauma
2002; (52):1141–
1146.low-pressure group
Initial fluid resuscitation
• Who’s practicing permissive
hypotension?
• Current military policy is to resuscitate to
a palpable radial pulse or an SBP of no
more than 90 mmHg.
• This concept has now been adopted
widely, and is reflected in the latest EAST
guidelines.
Dawes R, Thomas GO. Battlefield resuscitation. Curr Opin Crit Care. 2009Dec;15(6):527-35.
Initial fluid resuscitation
• Prehospital resuscitation (EAST guidelines
2009)
• Obtaining IV access in the field has not been
shown to be beneficial, and if anything has
been shown to prolong transport time
• Obtaining IV access en-route to trauma
centre is recommended if wounds more than
superficial.
• IV should be saline-locked if no indication for
fluid therapy is present.
Cotton BA, Jerome R, Collier BR, et al. Eastern Association for the Surgery of Trauma Practice Parameter Workgroup for Prehospital Fluid Resuscitation. Guidelines for prehospital fluid resuscitation in the injured
patient. J Trauma. 2009 Aug;67(2):389-402
Initial fluid resuscitation
• Prehospital resuscitation (EAST guidelines
2009)
• Indications for prehospital fluid administration
(250 cc boluses) in both penetrating and blunt
trauma:
• Patient incoherent
• Non-palpable radial pulse
• Head injury with SBP < 90
• Repeat bolus if no response
• Saline lock of pt responds
Initial fluid resuscitation
• When may fluids be appropriate?
• In traumatic brain injury, where hypotensive
episodes have been associated with worse
outcome
• In severe hypotension where pressors would
otherwise be needed, i.e. MAP < 40 - 50
mmHg
• In hypotensive patients with controllable
bleeding (extremity/superficial bleed)
If you’re going to bolus, bolus
• Theright.
data on whatRight?
type of fluid toBolus
give is worsewith…
than on whether to
give fluid.
• EAST Guidelines states insufficient evidence to make
recommendations.
• Practice therefore depends on opinion:
• RL is liked for its “buffering capacity” but can’t be mixed with blood due to the
calcium
• Plasmalyte doesn’t have calcium but has potassium which can exacerbate
hyperkalemia secondary to tissue injury and massive transfusion
• NS doesn’t have K+ (unless you ask for it), but is more likely to cause a NAGMA
that can theoretically worsen coagulopathy
• Hypertonic saline showed no benefit over isotonic crystalloids
• Early availability of blood and FFP avoids the need for “filler fluids”
Diez C, Varon AJ. Airway management and initial resuscitation of the trauma patient. Curr Opin Crit Care. 2009 Dec;15(6):542-7
Dawes R, Thomas GO. Battlefield resuscitation. Curr Opin Crit Care. 2009Dec;15(6):527-35.
Transfusion ratios
• American and British military practice is to administer warmed
FFP and PRBCs in a 1:1 ratio as soon as possible.
• Others in military have recently suggested modifying this ratio
by further adding platelets, resulting in a ratio of 1:1:1
PRBC:FFP:platelets
• Evidence for benefit based on retrospective trials
• Benefit can therefore be indicative of a survival bias rather
than a true mortality benefit:
• FFP and platelets take longer to receive than pRBCs.
• Possibility that nonsurvivors did not die because they received a
lower FFP : PRBC ratio, but that they received a lower ratio
transfusion because they died.
Dawes R, Thomas GO. Battlefield resuscitation. Curr Opin Crit Care. 2009Dec;15(6):527-35.
Snyder CW, Weinberg JA, McGwin G Jr, et al. The relationship of blood 􏰍􏰍product ratio to mortality: survival benefit or survival bias? J Trauma 2009;66:358–362;
Resuscitation endpoints
• If uncontrolled hemorrhage: permissive
hypotension, maintaining coherence, a
palpable radial pulse, or an SBP > 90 mmHg in
TBI
• Resuscitation effectiveness can be assessed by
standard measures, i.e. lactate clearance and
correction of base deficit.
• Base deficit: Blunt injury patients with
transient field hypotension and a BD > 6 were
found to be more than twice as likely to have
Bilello JF, Davis JW, Lemaster D, et al. Prehospital Hypotension in Blunt Trauma: Identifying the "Crump Factor". J Trauma. 2009 Dec 4
Tisherman SA, et al. Clinical practiceguideline: endpoints of resuscitation. J Trauma. 2004 Oct;57(4):898-912.
Hemorrhagic coagulopathy
• Part of the “lethal triad”
Hemorrhagic coagulopathy
• Impaired hemostasis is often caused by dilution
and consumption of clotting factors and
hyperfibrinolysis.
• However despite replacing FFP, platelets, and
cryoprecipitate, patients may remain
coagulopathic.
• Optimal coagulation requires specific
preconditions concerning acid-base balance,
calcium, hematocrit, and temperature.
• If these preconditions are not fulfilled,
coagulation may remain abnormal despite
Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia onfunctional hemostasis in trauma. J Trauma. 2008
Oct;65(4):951-60.
Hemorrhagic coagulopathy
• Acidosis:
• A notable impairment in hemostasis arises at pH <= 7.1 or a base
deficit of 12.5 or more
• Aggressive resuscitation in OR to reverse acidosis
• Some centres give THAM to raise pH to 7.2 or higher (no outcome
data)
• Hypocalcemia:
• Coagulation defects can be attributed to hypocalcemia if the Cai++
is < 0.6 – 0.7 mmol/L
• Adverse cardiac effects commence at levels at or below 0.8 – 0.9
mmol/L
• Combining these benefits, ionized calcium should be kept above
0.9 mmol/L
Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia onfunctional hemostasis in trauma. J Trauma. 2008
Oct;65(4):951-60.
Hemorrhagic coagulopathy
• Anemia:
• Causes demargination of platelets and decreased adhesion
to endothelial damage (decreases fivefold from HCT of 40%
to 10%)
• Aim is to keep HCT greater or equal to 30%
• Hypothermia
• High risk of persistent coagulopathy at temperatures under
35 deg C
• At temperatures below 33 deg C, hypothermia produces a
coagulopathy that is equivalent to 50% of normal activity at
normothermia
• Should therefore aggressively aim for a Temp > 34 or
Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia onfunctional hemostasis in trauma. J Trauma. 2008
even 36 degrees Celsius
Oct;65(4):951-60.
Dawes R, Thomas GO. Battlefield resuscitation. Curr Opin Crit Care. 2009Dec;15(6):527-35.
Hemorrhagic coagulopathy
• Other measures:
• Hypofibrinogenemia  keep fibrinogen > 1 g/L
• Platelets  keep above 100 x 109
• Tranexamic acid
• At 15 mg/kg, found to reduce blood loss in elective surgical patients by
inhibiting fibrinolysis.
• Results of CRASH II trial are pending (20 000 patients randomized to 1 g of
tranexamic acid followed by 1 g infused over 8 h).
• rFVIIa
• Some evidence that it reduced transfusion requirement in blunt injury but
not in penetrating injury.
• Often used in salvageable patients with continuing haemorrhage that has
failed surgical and nonsurgical methods
Mannucci PM, Levi M. Prevention and treatment of major blood loss. N Engl JMed. 2007 May 31;356(22):2301-11.
Dawes R, Thomas GO. Battlefield resuscitation. Curr Opin Crit Care. 2009Dec;15(6):527-35.
• -After transfusing 4u of PRBCs, 4u FFP,
10u Plt, 4u cryoppt, BP dropped to 80/45,
O2 sat 80%, decreased B/S on Lt, with Lt
CT suddenly draining >1500 ml of blood.
Question 2
• What are the indications and
contraindications for ED thoracotomy?
How to manage lung contusion and flail
chest? What are the complications of lung
contusion? (Erik)
CBP: ED Thoracotomy,
Pulmonary Contusion, & Flail
Chest
Emergency Department
Thoracotomy
• Indications
• Contraindication
s
•
•
Absolute
Relative
Objectives of EDT
• Release of pericardial tamponade.
• Control of intrathoracic vascular or
cardiac bleeding.
• Evacuate obstructive air embolism or
control source of bronchopleural/vascular fistula.
• Perform open cardiac massage.
• Temporarily occlude the descending
thoracic aorta.
Indications for EDT
• Penetrating chest injury in extremis, or
loss of vital signs, within 10 minutes of ED
arrival.
• Limited evidence to support in blunt or
mutli-trauma patients, especially if arrive
in ED with VSA.
• Known tamponade, air embolism.
• Consider in major abdominal vascular
injury (blunt or penetrating) in extremis
or witnessed loss of vital signs.
• Consider in unresponsive hypotension
(SBP < 60mmHg) or chest tube > 1500cc*.
Contraindications
• Severe TBI
• VSA in penetrating injury > 10-15
minutes prior to ED arrival.
• VSA in blunt injury 0-5 minutes prior to
ED arrival.
Pulmonary Contusion & Flail
Chest
• Both PC and FC independently associated
with morbidity.
• Pathophysiology

• Mortality usually resultant
of other injuries sustained
from the [blunt] trauma
(e.g. CNS injury, shock).
Fluid Resuscitation in PC
• Animals models originally suggested that
crystalloid resuscitation had greater impact
versus colloid – but no outcomes were assessed.
• Similarly, observational data from Vietnam War
suggested larger volume resuscitation was
associated with poor outcomes.
• More recently, studies with better (though not
great) methodology show no correlation with
volume of resuscitation with worsening of PC.
• P/F ratio at the time of injury more prognostic.
Ventilation in PC/FC
• Again, animal models with
inappropriate surrogate endpoints are
misleading.
• Current level II evidence supports
intubation and mechanical ventilation
based on standard assessment of
oxygenation/ventilation.
• Advantages of different forms of
mechanical ventilation, including the
use of PEEP, have not been teased out.
Surgical Fixation of FC
• Despite the biological plausibility
supporting the use of ORIF (e.g. Judet
struts), most of the supporting
evidence is derived from Level II and III
studies (i.e. mostly small, single-limb,
observational studies of personal
experience lacking non-surgical
controls).
• “Read about them but never used
them. Thoracics may have applied
Summary: PC and FC
• Respiratory dysfunction after contusion may
relate more to direct traumatic and indirect
biochemical effects of the injury rather than
amounts of fluid administered.
• With respect to ventilation, the bulk of
current evidence favors selective use of
mechanical ventilation, analgesia and
physiotherapy as the preferred initial
strategy.
• Surgical fixation may play a role in select
patients.
• There is no evidence to support the use of
steroids or prophylactic antibiotics in PC.
• -ED thoracotomy was performed,
pulmonary arterial bleeder was clamped. Pt
was urgently taken to the OR and surgical
stabilization of the flial chest using Judet
struts was performed.
Question 3
• How to evaluate blunt abdominal trauma?
How to manage spleen, liver, and
diaphragmatic injuries? Is there a place for
conservative therapy if this was penetrating
abdominal trauma? (Neil)
How to evaluate blunt
abdominal trauma?
•
•
•
•
Physical exam
DPL
CT
FAST
Diagnostic Peritoneal
Lavage
• Positive test
• Fecal contents
• Gross blood
• > 100,000 RBC/mm3
CT
•
•
•
•
•
Hemodynamically stable patient
Sensitvity 92-98%
Specificity 98%
NPV 99.63%
Good for
• Solid organs
• retroperitoneum
• Bad for
• Mesenteric injuries
• Diaphragm
• Hollow viscous
Focused Abdominal Sonography
in Trauma
• 3 views
• Morrison’s pouch
• Spleno-renal
• Suprapubic
• Need 200 cc of fluid for positive.
• Sensitivity 73-88%
• Specificity 98-100%
Focused Abdominal Sonography
in Trauma
Focused Abdominal Sonography
in Trauma
Focused Abdominal Sonography
in Trauma
Focused Abdominal Sonography
in Trauma
EAST Recommendations
• A. Level I
• 1. Exploratory laparotomy is indicated for
patients with a positive DPL.
• 2. CT is recommended for the evaluation of
hemodynamically stable patients with equivocal
findings on physical examination, associated
neurologic injury, or multiple extra-abdominal
injuries. Under these circumstances, patients
with a negative CT should be admitted for
observation.
• 3. CT is the diagnostic modality of choice for
nonoperative management of solid visceral
injuries.
• 4. In hemodynamically stable patients, DPL and
CT are complementary diagnostic modalities.
EAST Recommendations
• B. Level II
• 1. FAST may be considered as the initial diagnostic modality
to exclude hemoperitoneum. In the presence of a negative
or indeterminate FAST result, DPL and CT have
complementary roles.
• 2. When DPL is used, clinical decisions should be based on
the presence of gross blood on initial aspiration (i.e., 10 ml)
or microscopic analysis of lavage effluent.
• 3. In hemodynamically stable patients with a positive DPL,
follow-up CT scan should be considered, especially in the
presence of pelvic fracture or suspected injuries to the
genitourinary tract, diaphragm or pancreas.
• 4. Exploratory laparotomy is indicated in hemodynamically
unstable patients with a positive FAST. In hemodynamically
stable patients with a positive FAST, follow-up CT permits
nonoperative management of select injuries.
• 5. Surveillance studies (i.e., DPL, CT, repeat FAST) are
required in hemodynamically stable patients with
EAST recommendations
• Level III
• 1. Objective diagnostic testing (i.e., FAST, DPL, CT) is
indicated for patient with abnormal mentation, equivocal
findings on physical examination, multiple injuries,
concomitant chest injury or hematuria.
• 2. Patients with seatbelt sign (SBS) should be admitted for
observation and serial physical examination. Detection of
intraperitoneal fluid by FAST or CT in a patient with SBS
mandates either DPL to determine the nature of the fluid or
exploratory laparotomy.
• 3. CT is indicated for the evaluation of suspected renal
injuries.
• 4. A negative FAST should prompt follow-up CT for patients
at high risk for intraabdominal injuries (e.g., multiple
orthopedic injuries, severe chest wall trauma, neurologic
impairment).
• 5. Splanchnic angiography may be considered in patients
who require angiography for the evaluation of other injuries
VGH Protocol
•
How to manage spleen, liver,
and diaphragmatic injuries?
• Nonoperative management of blunt adult and
pediatric hepatic and splenic injuries is the
treatment modality of choice in hemodynamically
stable patients, irrespective of the grade of
injury. It is associated with a low overall
morbidity and mortality and does not result in
increases in length of stay, need for blood
transfusions, bleeding complications, or visceral
associated hollow viscus injuries as compared with
operative management. There is no evidence
supporting routine imaging (CT or US) of the
hospitalized, clinically improving,
hemodynamically stable patient. Nor is there
evidence to support the practice of keeping the
clinically stable patient at bedrest.
• EAST GUIDELINES
Diaphragm injuries
• Often missed and result in delayed
complications
• Investigations/treatment via
laparoscopy/laparotomy
• Repair with non-absorbable sutures
Is there a place for
conservative therapy if this was
penetrating abdominal trauma?
History
• 19th C. - Expectant management
• Blood letting
• Opium
• WWI – manadatory laparotomies
• 1960 – observant and expectant mgmt
• 1990’s – more conservative with SW
and GSW
• Focus on morbidity of non-therapeutic
laparotomy
Recommendations of this
article
Recommendations of this
article
• -In the OR, Lt diaphragmatic repair and
slenectomy were performed.
Question 4
• What are the limb-salvaging reconstruction
strategies? Are there better outcomes vs.
amputation for severe limb-threatening
traumas? What is the best timing for
performing long bones fixations in
polytrauma victims? (Noemie)
Initial treatment
• Neurologic and vascular exam
• Sterile dressing and splint
• Tetanus
• Antibiotics
Approach to Vascular injury
• Arteriography should be done promptly when
hard signs of vascular injury are manifest.
• The interval between injury and reperfusion
should be minimized to less than six hours in
order to maximize limb salvage.
• Restoration of blood flow should always take
priority over skeletal injury management
EAST Guidelines
External vs internal fixation
• Indications for use of external fixation
•
•
•
•
•
•
Open fractures
Severe metaphyseal fractures
Severe intra-articular fractures
Polytrauma
Osteoporotic fractures
Transport
Trauma 2004; 6: 143ｱ 160
Complications of External
fixation
• Pin track infections
• Most common complication: 0 to 60%
• Re-fracture
• If removed too early
• Nonunion
• Malunion
• Pin breakage
Trauma 2004; 6: 143ｱ 160
EAST GUIDELINES
• “External fixation is preferable for the
immediate management of unstable,
displaced, comminuted and open
fractures or dislocations. This is
especially important in those with
severe contamination, extensive soft
tissue injury, or in an unstable patient.
“
NEJM 2002; 347(24):1906-1907
• Are there better outcomes vs. amputation
for severe limb-threatening traumas?
Gustilo Classification
• I Low energy, wound less than 1 cm
• II Wound greater than 1 cm with moderate
soft tissue damage
• III High energy wound greater than 1 cm
with extensive soft tissue damage
• IIIA
• IIIB
• IIIC
Adequate soft tissue cover
Inadequate soft tissue cover
Associated with arterial injury
Factors predicting high rates
of amputation
•
•
•
•
•
•
•
Gustilo III-C injuries
Sciatic or tibial nerve transection
Severe prolonged ischemia
Older age with comorbidity
Multiple long bone fractures
Crush or extensive soft tissue trauma
Severe contamination
Amputation vs
Reconstruction
LEAP Study
• Multicenter observational prospective
trial
• 569 pts
• At 2 years, no difference in outcome
scores or return to work
EAST Guidelines
• “Primary amputation should be considered in
those with tibial or sciatic nerve transection,
prolonged ischemia, massive soft tissue
injury, severe contamination, open
comminuted tib-fib fractures (Gustilo-III), or
life-threatening associated injuries.”
• What is the best timing for performing long
bones fixations in polytrauma victims?
EAST Guidelines
• “Polytrauma patients undergoing long bone
stabilization within 48 hours of injury have no
improvement in survival when compared to those
receiving later stabilization”
• “However, there may be some patients who will
have fewer morbidities”
• “There is no evidence that early stabilization has
any detrimental effect.”
• -Fixation of her fractured Lt femur was
performed.
Question 5
• What are the high risk factors for DVT/PE
in trauma patients? What is the best
prophylaxis? What are the types,
indications, contraindications and
complications of IVC filters? Is it safe and
effective in trauma? (Omar)
High Risk Factors for DVT/PE
• Heterogenous group of patients
• Difficult to prove who is truly at
highest risk
• General consensus of who constitutes high
risk include:
• Advanced age (age at which patients become
high risk is not defined)
• Spinal fractures and cord injuries
• Traumatic brain injury
• Prolonged mechanical ventilation
• Pelvic #’s
• Multiple long bone fractures, esp if
associated with pelvic #
• Venous injuries
• General consensus of who constitutes
high risk include:
• Venous injuries
• Multiple major operative procedures
What is the best
prophylaxis?
• Beats me
• American Surgeon, 2006
What is the best
prophylaxis?
• Low does unfractionated heparin is no
better than no prophylaxis
• LMWH given twice a day offers some
protection
• Mechanical prophylaxis is unproven,
but can be used in patients with high
risk for bleeding
• If high risk for DVT/PE, may use LMWH
and mechanical prophylaxis, but no
proven synergism
What is best prophylaxis?
• Fondaparinux appears to be better
than LMWH in post-op hip # patients
• No studies in multi-trauma patients
Timing
• ASAP
• TBI
• Unclear when to start
• 72 hours post cessation of bleeding
• Splenic or liver lac’n
• 48 hours post cessation of bleeding
• What are the types, indications,
contraindications and complications of
IVC filters? Is it safe and effective in
trauma?
IVC filters: Origins
• Surgical techniques
•
•
•
•
Femoral vein ligation
IVC ligation
IVC occlusion
Partial interruption of IVC
• Plastic clips
• Plication
• Staples
• Surgical technique reduced incidence
of PE significantly
• ….high complication rates and no
decrease in mortality
• 1980’s
• Introduction of first percutaneously
inserted IVC filter
• Mobin-Uddin Umbrella filters
Types
• Permanent
• Temporary
• Retrievable
Permanent
• Birds nest filter (1982)
• Greenfield Filter (1972)
• Has undergone many
revisions/improvements
• Initially introduced via venotomy
• Simon Nitinol Filter
• LGM Venatech
• Trap ease
Permanent
• Different sizes
• Need to determine diameter of IVC before
placement
• Earlier models were incompatible with MRI
and some caused significant scatter
Temporary
• Multiple
• Anchored to skin via wire or catheter
• Risk of infection
• May become irretrievable if clot
entrapped within it
Retrievable
• Most commonly used
• Lowest complication rates
• Require trans-jugular approach for
removal
Complications
• Access site thrombosis
• 1-3%
• Tilting and malposition
• 2%
• Recurrent PE’s
• Up to 4 – 5 %
• IVC thrombosis
• 15% without anticoag
• 7% with anticoag
Complications
• Filter migration
• 1%
• Filter fracture during retrieval with
subsequent embolization of struts
• 1%
• -Post-op, IVC filter was placed in.
• -She was admitted to the ICU, started on
antibiotics for aspiration pneum/Px for
knee/bone with open fracture. She
eventually became septic from both sources,
required aggressive fluid resuscitation and
vasopressors.
• -POD 3, she became oliguric, abdomen
distended, bladder pressure increased from
18 to 20 to 30.
Question 6
• What are the risks/predictors for developing
abdominal compartment syndrome in
trauma patients? What are the
consequences? How to manage traumatic
renal injuries? (Federico)
Emergency Department
Independent Predictors
(< 3 hrs from Hospital
admission)
Predictor
All ACS
Crystalloid > 3L
SBP < 86
Primary ACS
To OR >75 min
Crystalloid > 3L
Secondary ACS
Crystalloid > 3L
No urgent surgery
PRBC > 3 units
ICU independent predictors
(< 6 hrs from hospital
admission)
All ACS
GAP CO”2 >16
Crystalloid >7.5L
UO < 150 ml
HB < 8 g/dl
CI < 2.6 L/min/sm
Primary ACS
Temp < 34 C
GAP CO”2 > 16
Hb < 8g/dl
BD > 12 mEq/L
Secondary ACS
GAP CO”2 > 16
Crystalloid > 7.5L
UO < 150 mL
Outcome
• ACS is a predictor of MOF and mortality
Primary
ACS (n=11)
Secondary
ACS (n=15)
NonACS
(n=162)
MOF (%)
55
53
17
Mortality
(%)
64
53
17
Kidney Injury…
• Blunt trauma: 80-90%
• Rapid deceleration / Direct blow
• MUST be suspected if
• Trauma to back / flank / lower thorax /
upper abdomen
• Flank pain / low rib #
• Hematuria / Ecchymosis over the flanks
• Sudden decelaration / Fall from height.
• Lumbar transverse process #
Classification of Injury
• 5 Classes of Renal Injury :
Organ Injury Scaling
Committee
Moore et al. Organ Injury Scaling: Sleen,
Liver and Kidney, The Journal of Trauma,
29: 1664; 1989.
Grade I
• Hematoma
• Subcapsular
• Non expanding
• Parenchyma N
Grade II
• Hematoma
• Perirenal
• Nonexpanding
• Laceration
• < 1.0 cm
• Renal cortex only
• No urinary
extravasation
Grade III
• Laceration
• > 1.0 cm
• Renal cortex only
• No urinary
extravasation
• Intact collecting
system
Grade IV
• Laceration
• Renal cortex
• Renal medulla
• Collecting system
• Vascular
• Main renal
artery/vein injury
with contained
hemorrage.
Grade V
• Completely
shattered kidney.
• Avulsion of renal
hilum (pedicule)
which
devascularizes
kidney.
Organ Injury Severity
Scale
• Validated lately: Journal of Trauma, 2001
• Predicts the need for surgery
• Need for surgery ; nephrectomy rates:
•
•
•
•
•
Grade
Grade
Grade
Grade
Grade
I: 0 ; 0%
II: 15 ; 0%
III: 76 ; 3%
IV: 78 ; 9%
V: 93 ; 86%
Santucci et al. Validation of the
American Association for the
Surgery of Trauma Organ Injury
Severity Scale for the Kidney. J
Trauma; 50:195-200; 2001.
Management…
• Absolute indication for Surgery:
•
•
•
•
Uncontrollable renal hemorrage
Multiply lacerated, shattered kidney
Grade V
Main renal vessels avulsed
Penetrating injuries usually
• Grade I-II
• conservative
• Grade III-IV
• Conservative if stable hemodynamically vs.
surgery
• Grade V
• Surgery
• -She went to the OR for urgent
decompression.
• -POD 7, she was extubated. POD 9,
discharged to the ward.
The End..