The Multiple Trauma Patient

Shawn Dowling, PGY-2 Preceptor: Rhonda Ness

Objectives

 Will not go over these topics in great detail  Head trauma  C-spine trauma  Chest trauma  Abdo trauma  Pediatric trauma

Why it’s important

 Leading Cause of Death for those aged 1-44yrs (in developed countries)  MVC’s account for most injuries  Followed by assaults, drownings, falls, burns

Distribution of Death

Trimodal Distribution of Deaths # o f d e a t h s 400 350 300 250 200 150 100 50 0 0 2hrs 4hrs 3weeks Death

What is ATLS?

 Structured algorithm designed to prioritize management issues  Designed as a team-based approach  Applicable to both Academic and Rural Settings  It’s useful – take it.

What ATLS isn’t?

 A substitute for clinical acumen – trust your instinct 

Most

up-to-date, most evidence based approach (revised q4yrs, most recently 2004)

Why is the ATLS protocol so nice?

 1.

2.

3.

Overall, the tenets are

Greatest threats to life are identified and treated 1 st Lack of definitive Tx should never impede the application of an indicated Tx Detailed Hx was not essential to begin the evaluation of the acutely injured patient

ATLS overview

 Preparation  Triage  Primary Survey (ABCDE’s)  Resuscitation  Adjuncts to primary survey and Resus  Secondary Survey  Adjuncts to Secondary survey  Continued post-resus monitoring and R/A  Definitive Care

ATLS Overview

Primary Survey Reassess Adjuncts Reassess

CANNOT MOVE ON UNTIL YOU ADDRESS THE PROBLEM!!!

Secondary Survey

ATLS – Primary Survey

 Airway & C-spine Immobilization  Breathing  Circulation  Disability  Exposure/Environmental Control  Full Vital Signs

Case 1

 60ishM  Coming in by STARS, ETA 10 mins  MVC – no more details  Facial fractures, unable to intubate  Significant Chest trauma, hypotense  Great...I’ll just go see this LBP patient and wait till I hear the call to the Trauma Bay

ATLS overview



Preparation

 Triage  Primary Survey (ABCDE’s)  Resuscitation  Adjuncts to primary survey and Resus  Secondary Survey  Adjuncts to Secondary survey  Continued post-resus monitoring and R/A  Definitive Care

Organizing the Trauma Bay

 What do you want?

 Who do you want?

What do you want prepare before he arrives?

1° SURVEY

   

Airway

: Intubation equipment incl difficult airway cart, drugs, +/- anasthesia

Breathing

: RT, bilateral CT set-up

Circulation:

fluids hung, blood ready, level 1 infuser primed, +/- central access 

Adjuncts

X-ray, FAST, B.W., U/S

 What’s the best way to mobilize the right people… a) Soil your scrubs and hope someone notices and calls for help b) Call Trauma Code c) Consult Hospitalist

Who do you want?

 RT, RN’s – 3 ideal, DI techs, U.C.

 ER res/doc  +/- Level 1 Call-out (trauma, gen surg, ICU)  FAST provider – ER IP or Radiology  Others: Ortho, NA, SW,

Trauma Team Activation 6. ER doc discretion

FAST

Muco Man

ER #1 ICU Rez

ER #2/TTL

Organizing the Trauma Bay

 ONE leader:  only leader should be talking and giving orders  FMC ER doc 1 o survey and stabilization THEN trauma junior/ortho/plastics 2 o survey  Small rural centers you’re it  Be decisive  Short window of opportunity for sick patients  Rapid decision making important  Err on the side of being aggressive Thanks Trevor

 Learn names and use them  Be directive  Minimize noise/people in room  Close the Loop  Verbalize your findings and thought process.

 i.e. I think he has a tension PTX – I’m gonna fix it

Now what?

 What do you want to know from EMS?

Important Historical Features



MVC

 Wgt/size vehicle  Speed  Location of pt in veh   ?ejected

Mech’m of accident  Amt of damage (esp windshield, steering wheel)  ?seatbelt (type)  Airbag  ?Other deaths



Motorcycle

 Same + ?helmet



Pedestrian vs MVC

 Speed  Damage to windshield 

Assault

 Weapon used  ?trajectory

 ?sexual assault 

GSW’s

 Type of gun  Handgun: low velocity  Rifles: high velocity  Type of Ammunition  Distance shot from  Route of Entry

Injury Patterns

 Frontal/Side Impact  Side Impact  Rear Impact  MVC versus pedestrian  Adult  Peds

Frontal/Side Impact Rear Impact

 C-spine Injury  Chest: PTX, flail, AoD  Abdo: liver/spleen  PelvisHip/knee #/disloc  C-spine Injury  Soft-Tissue Injury Neck

Ejection MVC versus Pedestrian

No specific pattern, but significant risk of severe injury to all systems Adults triad of  Tib/fib/femur  Truncal injury  Craniofacial injury Peds: tend to be run over

ATLS overview

 Preparation  Triage 

Primary Survey (ABCDE’s)

 Resuscitation  Adjuncts to primary survey and Resus  Secondary Survey  Adjuncts to Secondary survey  Continued post-resus monitoring and R/A  Definitive Care

Airway

LOOK LISTEN I A R W A Y LOC Facial trauma UAW burn Stridor Gurgling Hoarseness FEEL MANAGE Crepitus Tenderness Edema Trachea midline Cervical Collar

Temporize:

Suction Jaw Thrust OP/NP airways Remove FB Prepare and perform ETT: draw meds, start iv, get BP/ tools Thanks Trevor/Rob

B R E A T H I N G LOOK Resp effort Resp rate Cyanosis Chest wall movements Flail segment AE =

Breathing

LISTEN FEEL MANAGE Crepitus Tenderness Chest mvmt 100% oxygen BVM Pulse ox Decompress chest Seal open chest wounds Thanks Trevor/Rob

Circulation

LOOK LISTEN FEEL MANAGE I O N I C R C U L A T Pale Sweaty LOC External Bleeding JVD Heart Sounds Murmur Pulse rate, Quality Quick feel of abdomen, pelvis, femurs Obtain HR, BP Cardiac and BP monitors Two large iv.s

Pressure to external bleeding Bolus crystalloid Blood Consider SOURCE OF BLEEDING Thanks Trevor/Rob

Disability

 GCS  Pupils

Exposure/Environment/Full VS

 Fully Expose patient  Prevent heat loss, warm blankets, warm fluids*

*NABISH II (Pre-hospital Enrolment)

*NABISH II (ED Enrollment)

3. w/i 2 hrs of injury

Goal is moderate hypothermia (32-33°) for 48 hr

ATLS overview

 Preparation  Triage  Primary Survey (ABCDE’s)  Resuscitation 

Adjuncts to primary survey and Resus

 Secondary Survey  Adjuncts to Secondary survey  Continued post-resus monitoring and R/A  Definitive Care

Adjuncts

 X-rays: which ones do you want  Blood Work: which ones do we get routinely  Foley, NG: do we need the NG?

 FAST/ dpl : Who can do it? More to come in the future.

X-rays

 CXR  C-spine(we’ll come back to this)  Pelvis  Do we need to this in every trauma patient?

 Order others you deem necessary (but if unstable prioritize them until after secondary survey)

Routine pelvic radiography in severe blunt trauma: is it necessary?

ALL STUDIES ARE LEVEL II or III, so interpret w/caution…

Civil ID, Ross SE, Botehlo G and Schwab CW. Ann Emerg Med 17(5):488-490. (1988) All patients were classified as unconscious; impaired; awake, alert, and symptomatic; or alert, oriented, and asymptomatic for pelvic fracture on admission. All underwent a plain anterior- posterior radiograph of the pelvis. N=265, 26 pelvic #. 7/26 were unconscious,11/26 were impaired, 8/36 Sx.

No fractures were identified in 110 awake, alert, oriented, and asymptomatic patients (P less than .0001). They conclude that pelvic radiographs are required in unconscious or impaired victims of severe blunt trauma and those with signs or symptoms of pelvic fractures but are not required in the awake, alert, and asymptomatic patient.

CONCLUSION: Err on the Side of Caution

Preserve clot - minimal movement, gentle handling, minimum of rolling.

Punch anyone who tries to 'spring' the pelvis

. Fit pelvic belt (elasticated version of the old 'many-tailed-bandage' with velcro fastening) on basis of mechanism of injury. Minimal iv fluid to preserve systolic of 70 (90 mmHg if associated head injury). Take to a hospital that understands the condition!

Timothy J Coats MD FRCS FFAEM Senior Lecturer in Accident and Emergency/Pre-Hospital Care Royal London Hospital, UK.

Trauma/B.W.

 What blood work do we get when this is ordered?

 If you had only one blood test what would it be Sultana or Heather?

Trauma/B.W.

 What blood work do we get when this is ordered?

 If you had only one blood test what would it be Sultana or Heather?

 T&S, T&C  What’s the diff?

 Unmatched – immediate (F: 0-, M: 0-/+)  T&S – approx 10 min (screens for ABO &Rh)  T&C- approx 30min-1 hr (screens for ABO, Rh, other antibodies)

 Utility of CBC

 Utility of CBC  Hgb – helpful if low, not helpful if N  Initial hgb fxns more as baseline  WBC- who cares  Plts-helpful if low  Coags  Probably useful, some good evidence for HI, ?elderly

 Lytes  913 Trauma pts bw – 54 had clinically significant abN, only 6 changed Tx (all hypokalemia)  authors concluded that a history of hypertension, age older than 50, and a Glasgow Coma Scale (GCS) score less than or equal to 10 appeared to be useful criteria Tortella B, Lavery R, Rekant M. Utility of routine admission serum chemistry panels in adult

trauma

patients.

Acad Emerg Med

1995;2:190-194  Cr/BUN  No evidence but likely worthwhile, esp if potential for CT and contrast  EtOH  Allows you to correlate clinical picture with EtOH

 Amylase    No role Mure A, Josloff R, Rothberg J, et al. Serum amylase determination and blunt abdominal trauma.

Am Surg

1991;57:210-213.

LFT’s  No Role in detecting liver injuries  Lactate/Base Deficit  Multiple studies showing that the higher/more –ve these values are the sicker the patients are and more aggr mngmt is needed – DUHH!

 Trop  No helpful, unless you think it’s the cause of accident  For cardiac contusion – may be a role, but not likely in the ED

?Trops

Case 2

 64M,

Farmer

 Brought in by STARS  Bucked off horse, c/o of mild lower abdo/pelvis pain, walked to his house to get help  What do you want to do?

 What do you think is going on?

 Airway/Breathing N  Circulation: BP140/50, HR 80  Disability: GCS- 14, PERLA  Exposure - N  Rest of vitals N  Now what?

What films?

 CXR – Yes  Pelvis – Yes (symptomatic)  Can you clear his C-spines clinically?

 According to CCR?

 According to NEXUS?

Canadian C-spine Rule

Stiell. NEJM Dec 2003; 349:2519-8.

S P I N E

NEXUS

ensorium altered ain the the midline njury that is distracting eurologic deficits tOH, Rx

Hoffman et al. NEJM 2000

Minor Trauma

Who should get "routine" CT neck?

Moderate Trauma (GCS 9-14, not poly) Polytrauma (intubated) Plain films CT if plain films abn, inadequate, or high suspicion Not going for CT head Going for CT head CT SB - T4 in all Start with plain films then CT prn Routine CT SB-T4

Missed C-spine #’s

ATLS overview

 Preparation  Triage  Primary Survey (ABCDE’s)  Resuscitation  Adjuncts to primary survey and Resus 

Secondary Survey

 Adjuncts to Secondary survey  Continued post-resus monitoring and R/A  Definitive Care

Secondary Survey

•Look, listen and feel when possible •Finger (only one)/tubes in every orifice •AMPLE Hx: •Systematic: head to toe

HEENT Abdomen + GU Maxillofacial Pelvis Neuro (incl CNS/PNS, CN, M/S/R) Chest Vertebral Column (C/T/L) Back CVS Extremeties

Back to the Case

 The trauma jr asks the nurse to put a foley in and she notes  Scrotal hematoma  Blood at meatus  Perineal Ecchymosis  Rectal N (and I’ve got short fingers)  What do you want to do?

Retrograde Urethrogram

 What is it?

 Retrograde injection of contrast urethral integrity and x-ray  How do you do it?

 Plain KUB 1st  OR Sterile, insert foley 1-2cm, inflate baloon w/2-4cc H 2 0  Insert 60cc syringe with x-mas tree adaptor  Slowly inject 60cc of radio opaque dye (avoid forceful inj)  Ensure not to spill any (spurious results)  Two x-rays, one AP, one lateral/oblique when 10cc left to inject

 Partial tear  +/- talk to urology, attempt to pass 12-14F foley  If resistance/difficulties, speak to urology – may need suprapubic catheter  Complete tear  Talk to urology (actually, page them, wait 6 hours and then talk to them) and they’ll likely need a suprapubic catheter

Retrograde Cystogram

 KUB  Foley  Gravity fill bladder with 400cc of contrast (age + 2) x 30 for peds  AP and Oblique/Lateral x-rays  Then AP post-evacuation X-ray

Case #

 18M, Story from EMS  Brought in from Coventry Hills by STARS who “Scooped and Ran” with him  Hx: MVC (car vs cement abutment), prolonged extrication (>1hr), hwy speeds, couldn’t intubate  P/E: hypotense, pale, concerned about chest/abdo, bilateral femur #, L humerus

What do you want to do?

 Airway:  Do you want to do anything?

 How, ?Rx

 Breathing:  Post-intubation  a/e @ L  DDx:  Intervention  What if the CXR is N, can they still have a PTX

 103 PTX, 57 (55%) were not seen on AP CXR  Likely of little significance in the non-ventilated pt  But for those who are intubated or going to OR- thought that they may progress  One small study, RCT of CT or nothing for oPTX (ventilated and non-ventilated) – NO difference 

J Trauma. 1999 Jun;46(6):987-90

Primary Survey

What are six(seven) life-threatening injuries you need to identify and Tx in the primary survey?

Primary Survey

What are six(seven) life-threatening injuries you need to identify and Tx in the primary survey?

 Airway: Obstruction  Breathing:  Tension PTX  Open PTx  Massive Hemothorax  +/-Flail  Circulation  Cardiac Tamponade (?Beck’s)  Life-Threatening Bleeds

 Circulation  BP - unable to measure  But palpable radials – what’s his BP?, Only Femorals, Only Carotid?

 Where’s he bleeding from?

 What are the three big areas you can bleed into?

 How about kids?

Fluid Resus

 Crystalloids 2 L then blood  Level 1 infuser  Goal is sBP 90ish  What do you want to do know?

 RA



Summarizing

 Intubated, needle thoracostomy, no CT yet  L humerus, bilateral femurs, VS pelvic #  FAST –ve  Gross blood from Foley  BP still very tenuous  What next?

 Let the TTL decide - OR

What about the kidneys?

 When do you worry enough about renal injuries to image the kidneys?

 Nicholaisen G, McAninch J, Marshall G, et al. Renal

trauma

: Re-evaluation of the indications for radiographic assessment.

J Urol

1985;133:183-187.

CT Renal

What Grade of Renal Injury?



Renal Injury Classification

Grade 1

: subcapsular hematoma – non-operative 

Grade 2

: superficial renal laceration with perirenal hemorrhage – non-operative 

Grade 3

: deep laceration w/o extension into the collecting system of the kidney – serial exams, usu non-op 

Grade 4

: parenchymal injury: deep laceration that extends into collecting system, – serial exams, usu non-op, +/- embolization/OR 

Grade 5

: parenchymal injury: multiple deep lacerations that result in a shattered kidney OR Renal Artery Avulsion - OR Harris A., Zwirewich C

CT Findings in Blunt Renal Trauma

, Radiographics, 2001

CT Chest

Case #3

 27M  Transferred from 8 th and 8 th –  Single stab wound to the right chest.

 Chest had been needle decompressed  Intubated in ED for hypotension  Chest Tube on R side.

 After chest tube (which is not draining any blood) and intubation, his vitals are…  BP80/40, HR 120, Sats 100% on vent  What do you want to do?

 Move onto your secondary survey?

 CT scanner?

 CANNOT MOVE ONTO THE NEXT STEP UNTIL YOU’VE DEALT WITH ALL THE ISSUES.

 WHAT ABOUT LOG ROLLING?

Case # 4

 23F, 28wks pregnant  Brought into trauma bay pt begins to c/o of severe cramping  VS – 70/30,HR-100, RR-12, sats 94%, c/s-N  What do you want to do?

 Supine Hypotension Syndrome  IVC compression  May have vasovagal bradycardia  90% of term pregnant women have COMPLETE obstruction of IVC when supine  Mx: tilt spine board, towel roll under on hip, manually displace uterus

Thanks Rob

PEARL

 Pregnant patient may lose up to 40% of blood volume before manifesting typical signs of shock. The fetus is compromised before signs of shock.

 So you put her into the LLD position and she goes into asystolic arrest.

 What do you do?

Perimortem C-section Indications

 Gestation must be at least 24-26 wks  - progress if fundal hgt  25wks  ?Less if doing for mom  CPR w/no response to other Tx modalities (LLD, fluids, needle chest, ACLS Tx, ) w/i four minutes  Ideal, start by four minutes/finish 5 minutes  Mother hemodynamics improve considerably

Procedure

 Do not stop CPR  Don’t prep/drape  Vertical incision from epigastrium to pubis right through peritoneum  Scapel to upper uterus, extend with scissors  Deliver baby  NRP for baby

Perimortem C-Section Results

 Katz VL. Obstet Gynecol. 1986.

 61 cases b/w 1900-85 that survived  TIME NUMBER NORMAL NEUROSQL  <5 42 42 0  6-10 8 7 1  11-15 7 6 1  16-20 1 0 1  >21 3 1 2

Case #5

 69F  MVC, restrained driver, hwy speeds  PMHx – o  Stable, A & O x 3, ++ agitated

When to order CT abdo?

      Abnormal vitals Abdominal pain/tender Unreliable physical examination (EtOH, Rx, HI, SCI, sedated). Inability to do serial examinations Dangerous mechanism of injury Gross Hematuria   Stable: CT abdomen +/ FAST Unstable: FAST or DPL

What Injuries does CT abdo miss?

 Diaphragmatic  Pancreatic  Bowel  Should we add Telebrex then?

Oral Contrast in Trauma CT

Case #6

 57M, working in the Foothills Industrial Area  Working inside a metal structure welding, when a explosion occurred  Pt was found unresponsive inside  EMS has intubated the patient (for GCS of 3)

Blast Injuries

 What injury patterns are seen in Blasts?

 What bodily structures would you expect to be involved?

 What do you want to know about accident scene?

Incidence

 In NA tend to be industry related, accidental (fireworks), bombings/Sept.11

 1 ° blast injury is caused solely by the direct effect of blast overpressure on tissue. Air is easily compressible, unlike water. As a result, a primary blast injury almost always affects air-filled structures  2 ° blast injury is caused by flying objects that strike people.

 3 ° blast injuries occurs when people fly through the air and strike other objects.  Miscellaneous blast-related injuries encompass all other injuries caused by explosions, i.e. fires

Location is important

 An explosion that occurs in an enclosed space tends to cause more serious injury.

 Intensity of an explosion pressure wave declines increasing distance from the explosion.  Blast waves are reflected by solid surfaces; thus, a person standing next to a wall may suffer increased primary blast injury .

Complications

 Barotrauma  TM’s: perforation, hemotympanum, ossicle #  Lungs: PTX, contusion, ARDS  GI: pneumoperitoneum, hemotoma, solid organ damage  Acute Gas embolism - ?Tx

 DIC  Injuries from projectile objects,  Injuries from being thrown (MSK, CNS)  Inhalational, Burns, Toxins (CN, CO)

Work-Up

 Look at their TM’s  B.w. – CO/CN if explosion/fire and entrapped, lytes,  CXR (PA and Lat) preferred)  Urine  Serial Abdo Exams or  AXR/CT abdo if abdo pain  Other tests PRN – CT head as PRN CT head rule

Management

 TM’s – avoid putting stuff in their ears,  Lung – manage PTX as per N  If PTX, probably worth monitoring to ensure no contusion develops  Belly: high index of suspicion for bowel hematoma – may need to be Admitted for serial exams  AGE – LL decubitus, 100% O2, hyperbaric 02, ASA

PEA/Asystole

 75M  MVC, prolonged extrication  Lost vitals en route  EMS Unable to intubate  What do you want to do?

 What’s you Ddx for PEA/Asystole?

 What can we reverse?

 Intubate  Bilateral CT  2L wide open  FAST  ABG – correct lytes  CXR  Then decide whether to continue

Suicide/Jump from a building

 38F  Attempted suicide by jumping off a local seven story downtown building, landed feet first.

 Brought in by EMS  Combative, hypotense, c/o pain at lower extremeties

 What injury patterns do you look for in this situation?

 What x-rays do you want to order?

 What’s the likelihood of dying from a 4 story fall? 7 story fall? If feet first.

 Now what?  Any other films to order?

 Where do you usually see spinal #’s  What other films?

Why is she hypotense

 Neurologic shock – but she’s moving here legs  Belly – her abdo FAST is –ve, where else could the blood be  Heart – Autopsy study: 33/61 had cardiac injuries and in 16/33, the heart was felt to be cause of death – pericardial /transmural tears, epicardial tears   SO, WE SHOULD AT THE HEART w/FAST

Blunt Cardiac Trauma Caused by Fatal Falls From Height: An Autopsy-Based Assessment of the Injury Pattern.

Journal of Trauma-Injury Infection & Critical Care. 57(2):301-304, August 2004.

Turk, E E. MD; Tsokos, M MD

Missed injuries



Important because…

 Long-term disability (i.e. scaphoids)  Litigation  Overshadow our heroic measures, “sure they saved my life, but they missed my sprained ankle” 

Missed cuz…

 Tx life-threatening stuff 1 st  Altered sensorium  Distracting injuries  Inadequate p/e  Misinterpretation of investigations

 MI defined as injury detected >24hrs after A or missed by 3° survey 

Intervention

: 3° form required to be filled out for ever patient admitted to the TICU or trauma service 

Results:

significant decrease in MI’s post intervention

Results

Missed Injuries

 Unavoidable to some extent  To prevent…  Think of MOI  3° Exam – no studies in ED, but makes sense  D/c instructions  Interpret your x-rays  If they’re not going to trauma – ENSURE NOTHING ELSE IS GOING ON