Transcript Trauma – Part I

Trauma – Part I
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45 year old man is involved in a two vehicle
MVC.
He is a single occupant trying to cross a highway
when he is struck on the passenger side.
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When EMS arrives, the patient is unconsciousness and
hypotensive.
He is stabilized on a spine board, extracted from the
car, has an IV inserted, oxygen and transported to the
hospital.
Upon arrival, he has a blood pressure of 89/58, pulse
of 124, respiratory rate of 28, and oxygen saturation of
89%.
His GCS is 6 (Verbal = 2, Motor = 3, Eyes = 1).
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What is your first priority?
Airway: patent
 Breathing: labored, trachea deviated to the left, no
breath sounds on the right
 Circulation: Hypotensive. No external bleeding
found.
 Disability: GCS remains 6 with reactive pupils.
Does not move feet.
 Expose
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Based on the results on the primary survey, what are
the next steps?
After intubation, the patient’ s oxygenation improves to
92% on FiO2 100%.
Two large bore IVs are inserted and 2 litres of Ringer’s
and 2 units of PRBC are given but the blood pressure
only marginally improves.
Is it time for a central line?
A right chest tube is then inserted which results in large
escape of air and improvement in oxygenation and
blood pressure.
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The patient seems to have stabilized somewhat. What
is the next step?
Describe the steps in a secondary survey.
AMPLE history is unremarkable.
Pertinent positive on secondary survey:
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GCS 6 and unchanged
Subcutaneous emphysema on right with chest deformity
Distended and rigid abdomen with left sided bruising
No motor response in legs and no rectal tone
Extensive bruising on right side of body from head to pelvis
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What would you do next?
What is the role for DPL in trauma?
What about ultrasound?
What about CT?
A series of x-rays are taken:
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What are the injuries obvious on the preceding scans?
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Liver laceration with free fluid
Bilateral pneumothoraces with right chest tube (not visible on the
enclosed image)
C spine fracture
After returning from the CT scanner, the patient’s blood
pressure is 84/57, pulse is 112, and saturations 94% on FiO2
100%.
The RT states that the patient is getting harder to bag and the
pressure alarm on the ventilator is ringing. Both
pneumothoraces have been decompressed with chest tubes.
What is going on and what should be done?
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Before we rush off the OR, let’s stop and
consider other issues in abdominal trauma.
What other organs could be injured in this
MVC?
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Consider:
Diaphragmatic rupture
 Splenic laceration
 Renal injury
 Pelvic fracture
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A little segway…
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The radiology resident calls into the trauma
room because the system failed to send some of
the x-rays to the viewer. The problem is now
resolved but she wants to draw your attention to
one film in particular.
What is wrong?
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This patient is unstable and going to the OR for a liver
laceration.
What is the immediate treatment for a pelvic fracture (open and
closed)?
Should we wait for Orthopedics to see and assess?
Let’s assume that there is no liver laceration and no plans to go
to the OR but he is still in the same condition. How would you
manage the patient?
What other problems can arise from a pelvic fracture?
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Consider:
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Massive transfusion from ongoing bleeding
Bladder injuries
Urethral injuries
Continuing our segway…
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Let’s talk about thoracic trauma in more detail.
What are the five conditions that should be immediately
addressed during the primary survey?
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Breathing:
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Circulation:
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Tension pneumothorax
Open pneumothorax
Flail chest
Massive hemothorax
Cardiac tamponade
What is the pathophysiological reason for their lethality?
How do you identify and treat each of these conditions?
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What other thoracic injuries should you look for during
the secondary survey?
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Consider:
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Pulmonary contusion
Tracheobronchial tree injury
Blunt cardiac injury
Aortic disruption
Diaphragmatic injury
How would you identify each of these problems?
How would you treat each of these problems?
Back to the case…
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After bidding the patient farewell at the OR doors, you
go to the call room for a few hours of shut eye. After
all, injuries that severe are going to take hours to repair,
assuming the patient survives.
90 minutes later the ICU charge nurse calls you to take
report from the anesthetist as the patient is in the ICU.
When you arrive, you are told that the patient has been
packed in all four quadrants, all visible bleeding has
been controlled and he lost 5 litres of blood when the
abdomen was opened. Skin is closed but not fascia.
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What happened here? Is the surgeon
incompetent to leave sponge in the belly?
What is this surgical technique called?
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Damage control laparotomy
What is the rationale for this technique?
What are the benefits of this approach?
What are some of the complications?
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The anesthetist tells you that the patient’s blood
pressure has stabilized after being given 9 units of red
cells, 2 pooled platelets, 8 units of FFP and 1 unit of
cyroprecipitate. He has also received 5 litres of
Ringer’s lactate.
The patient’s last ABG is pH 7.19, PCO2 35, PO2 87,
HCO3 15.
Hgb 87, WBC 12.5, Platelets 29
INR 2.1, PTT 49
His vital signs are 109/68, heart rate 93, saturations
99%, temperature 34.7.
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What is the DEADLY TRIAD?
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Hypothermia
Coagulopathy
Acidosis
Why is the deadly triad so deadly?
How is hypothermia in trauma different from primary
hypothermia?
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Secondary hypothermia is a result of diminished heat
production (not just heat loss) due to decreased oxygen
consumption during shock.
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What is the consequence of hypothermia?
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Consider:
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Dysfunctional coagulation proteins
Inhibited platelets
What methods can be used to warm the patient or
prevent hypothermia?
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Consider:
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Passive air warming
Heated inhaled air via ventilator
Pleural and/or peritoneal lavage
Warm IV fluids
CVVHD
Bypass
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What are some of the reasons for the patient’s
deranged coagulation parameters?
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Consider:
Dilution
 Consumption
 DIC
 Fibrinolysis
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How do you treat this coagulopathy?
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What is the cause of the acidosis in the deadly
triad?
What are some of the consequences of acidosis
in trauma?
To be continued….
Questions??