Transcript Review of the C-Spine Assessment in Stable ER Patients

Trauma Case Based
Presentation
S. Mountain
Adult Critical Care Fellow
Feb. 14, 2008
The Case (A True Story)

It’s 0200, and you are on call.
Thankfully, you have managed to
make it home, and are in your
warm bed, fast asleep, when your
pager goes off. You wake up with
your usual instant alertness, and
call the number back.
The Case

It’s the trauma surgeon on call. He
says he is calling to give you a heads up
on a case that is just coming out of the
O.R. “You better come in,” he says.
“This is a young guy who had the worst
liver smash I have ever seen in anyone
who survived. He has required a
massive transfusion, and is going to
need significant ongoing support.”
The Case

You leap into your scrubs and head
in to the unit. You get there a few
minutes after the patient has
arrived in the unit. The on call
resident is going through the
chart, and tells you the story.
The Case

The patient is a 22 year-old previously healthy
man, visiting Whistler from Spain. He was in the
bike park today, and took a jump, landing badly on
his handle bars. He was wearing a helmet, and
didn’t hit his head, or suffer any loss of
consciousness. Nevertheless, he required
ambulance evacuation from the bike park to the
Whistler clinic, where he received 8 units of
PRBCs and 2 units of crystalloid for hypotension
and anemia, and transport was initiated due to a
grossly positive FAST.
The Case
He was transported by helicopter
to VGH. On his arrival he was very
pale, but his GCS was 15, and he
denied neck pain, but complained
of abdominal pain.
 After initial assessment and central
line placement, he was taken
rapidly to the O.R.

The Case
On opening his abdomen in the O.R. a
massive hemoperitoneum was
evacuated, most of it into the Cell
Saver.
 The O.R. was long and complicated,
with initial hemostasis and exposure
being achieved with a Pringle maneuver,
a Katell maneuver, and a Kocher
maneuver.

Question 1

Naisan – what are Pringle, Katell, and
Kocher’s maneuvers?
Pringle Maneuver

Pringle Maneuver.ram
Kocher Maneuver

Kocher Maneuver.ram
The Case

Ongoing hemodynamic instability and massive
transfusion required further exploration, and a
period of veno-venous bypass. Eventually
reasonable hemostasis was achieved after packing
of the abdomen, and the patient was transferred to
the ICU with an open abdomen and 3 hemovacs.
Injuries identified intraoperatively were a Grade 5
hepatic injury, controlled with packing and a right
hepatectomy, and a hemorrhagic duodenum,
possibly secondary to manipulation.
Grading Liver Injuries
The Case
At this point, you are getting tired
of listening to the history, and
want to get a look at the patient.
 Question 2 – Steve - What is your
initial approach to assessing the trauma
patient transferred to the ICU? Does it
differ from the initial assessment of a
trauma patient in emerg? If so, how?

Initial approach to the trauma patient being
transferred to the ICU

Initial management of the trauma patient. Richards CF; Mayberry JC Crit Care
Clin 2004 Jan;20(1):1-11.
ATLS for Doctors Student Course Manual, 1997, pp23-44

Primary Survey (ABCDE)

– Airway - including assessment of level of consciousness. RSI w/ C-spine
–
–
–
–
–
stabiization.
Breathing - needle thoracostomy prn at this stage.
Circulation - assess volume status, obtain vascular access, compress
external bleeding, resuscitate, search for hidden bleeding.
Disability - GCS prior to sedation if possible, cerebro-protective measures
if necessary.
Exposure, environment - search for secondary injuries, warm.
Initial radiographs and procedures - C-spine, chest, chest tubes, FAST.
Initial approach to the trauma patient being
transferred to the ICU

Secondary survey
– Repeat exam; “tubes and fingers in every orifice”
– Get more history, including collateral, mechanism,
energy transfer.
– Further imaging if stable.

Tertiary survey
–
–
–
–
Repeat exam.
Reassess resuscitation.
Review imaging, labs, add on and repeat as necessary.
Monitor for compartment syndromes associated with
resuscitation, hypothermia and coagulopathy.
The Case
After your initial assessment, you ask the resident
to evaluate the patient for other injuries, while
you review the history. He replies “I can just get
the list of other injuries from the trauma team
records. They do such a complete assessment
anyway, it is redundant for us to go over
everything again.”
 Question 3 – Steve – Is the resident right, or is
there evidence to support the value of a tertiary
survey in the ICU?

What is the evidence to support the value of a tertiary
survey?

Implementation of a tertiary trauma survey decreases missed injuries. Biffl WL;
Harrington DT; Cioffi WG J Trauma 2003 Jan;54(1):38-43.

~ 7,000 trauma patients, pre and post TS implementation.
MIs decreased from 2.4% to 1.5% overall, and from 5.7% to 3.4% in
TICU patients, after TS implementation. Patients with MIs were
slightly older (49 vs. 45 years; > 0.05) and had higher Injury Severity
Scores (21 vs. 10; < 0.05) than patients without MIs. Sixty percent of
MI patients had brain injuries, 56% were admitted to the TICU, and
26% went directly from the emergency department to the operating
room. The large majority of MIs in the POST period were detected in
patients not undergoing timely TS.
CONCLUSION: ICU patients-particularly brain injury victims and those
undergoing emergent surgical procedures-appear to be at highest risk
for MI. Implementation of a standardized TS decreased MIs by 36% in
our Level I trauma center, and more timely TS would likely have
further reduced MIs. A TS should be routine in trauma centers.


The Case

You leave the room and sit down to
examine the anesthesia record, confident
that this is where the best information will
be recorded. You are a bit shocked by the
number of blood bank stickers on the
records, and start to add up the transfusions.
The grand total when you’re done is:
The Case
25 litres of crystalloid
 45 units of PRBCs
 41 units of platelets
 20 units of FFP
 8 liters of fluid through the Cell
Saver

The Case
You cleverly deduce that this patient
has required a significant resuscitation,
and is very likely to need more. You
glance up at the hemovacs, and indeed
notice that they are all filling up with
blood fairly quickly.
 Question 4 – Dave - What is your approach to
massive transfusion for the trauma patient? In
what order and what proportions do you use blood
products and adjunctive treatments?

The Case
You then notice that there is blood in
the foley catheter. The post-op INR
comes back at 2.1. You turn your
attention to correcting the obvious
coagulopathy.
 Question 6 – Yoan – What are the
main causes of coagulopathy in the
multiply injured patient?

Coagulation defects
Coagulation Defects: Etiologies
Question 7

Question 7 – Yoan – What is the “lethal
triad”? Draw the “bloody vicious cycle”.
The Lethal Triad/Bloody Vicious Cycle
Question 8

Naisan - Is there any evidence
demonstrating benefit to active internal
rewarming in trauma models? Are the
authors trustworthy enough to consider the
evidence valid?
The Case
Further review of the anesthetic record
reveals that the patient received two
separate dose of Factor VIIa
intraoperatively; first 4.8 mg, then 2.4
mg later in the case.
 Question 9 – Yoan - How does rFVIIa work? Is
there evidence to support its use in trauma
patients?

RFVIIa Mechanism

At pharmacological doses, rFVIIa binds
to the surface oflocally activated
platelets following vascular injury,
directly activating factor X,and thereby
enhancing localized thrombin
generation and formation of a stable
fibrin clot only at the site of vascular
injury.
RFVIIa evidence
R FVIIa evidence
RFVIIa evidence
RFVIIa evidence
Rfactor VIIa
RFVIIa evidence
The Case

With the above measures, you
start to catch up with the ongoing
bleeding, and things slow down for
a bit. The resident comes out of
the room and asks you why the
surgeons didn’t just finish the job
while they were in the O.R.,
instead of exposing the patient to
the risk of a second operation.
Question 10

Gord - Describe the concepts underlying
“damage control surgery (DCS).” What
are the key issues for early ICU
management?
Damage Control
American Naval term applied to ship’s absorbing
injury and continued integrity of mission:
 “The damaged ship undergoes rapid assessment
and adequate repair to allow a return to the
controlled environment of port”


Goal: Interruption of the Lethal Triad
 Variable indications… pH 7.2, Temp <34, 4L
EBL, 10L resusc fluid, onset of coagulopathy
Damage Control
Damage control surgery
Question 11

Gord - What are some predictable
complications in DCS patients, and what
can be done to prevent them?
Complications in DCS patients
Preventing complications in DCS patients
The Case

With your ongoing resuscitative measures, the
patient finally starts to stabilize. You grab
breakfast and a coffee, and start to do rounds with
the team. When you arrive at the bedside of the
trauma patient, the nurse asks if they can
discontinue cervical spine precautions, since the
patient’s GCS was 15 on arrival in the E.R., and
they did not complain of neck pain. The patient is
now fully sedated.
Question 12

Naisan – Can you D/C precautions based
on the documented findings in emerg?
What is your current approach to removal
of C-spine precautions in the obtunded
trauma patient? What is the evidence to
support your approach?
C-spine injuries in blunt
trauma

2-4% of blunt trauma injuries have
associated C-spine injuries.
 Missed or delayed diagnosis occurs in 4-8%
of patients, 70% of whom have altered
LOC.
C-spine Clearance
C-spine Clearance

The most common etiology of neurologic
deterioration due to missed spinal injury
was insufficient imaging studies (14/24). (ie
had another study been added, the injury
would not have been missed).
 Other studies found 19-25% of C-spine
injuries were missed by CT scan alone.
C-spine Clearance
C-spine clearance




Previous guidelines (EAST) seem appropriate for bony
clearance, but may not be adequate for ligamentous injury
in the obtunded patient.
Recent reviews recommend MRI for evaluation of
potential ligamentous injuries in patients who are at high
risk based on mechanism, and who will remain obtunded
for > 48 hrs. Not cost effective for all patients.
CT alone can miss a significant number of ligamentous
injuries.
Studies of multislice CT vs. MRI need to be done.