Transcript Complications of Traumatic Injuries

COMPLICATIONS OF
TRAUMA
ANN O’ROURKE, MD, MPH
SCRTAC TRAUMA CARE BEYOND THE ED
DECEMBER 4, 2014
Saving Lives By Strengthening Our Region’s Trauma Care System
OUR CASE
• 31 yo man MVC with prolonged extrication
• Presents to ED:
• Confused, HR 120, RR35, BP90/65
• Diminished breath sounds on right with palpable chest
crepitus
• Unequal leg length
• Abdominal bruising
• What are your concerns?
OUR PATIENT
• Right hemopneumothorax-facility placed
28Fr chest tube
• Liver laceration-managed non-operatively
• Right acetabular fracture dislocation with
proximal femur fx-traction with planned
operation
• C3 fracture with small epidural hematomamanaged with PMT collar
POST INJURY DAY 2 OUR PATIENT STILL
COMPLAINS OF DIFFICULTY BREATHING
• What are your concerns?
• Worsening pulmonary contusion
• Pneumothorax
• Hemothorax
• Pain from fractures
• Abdominal fluid/blood
• Pneumonia/pneumonitis
• Pulmonary embolism
RETAINED HEMOTHORAX
• Our chest tube did a
good job of
evacuating air and
most of the blood,
but some clotted
blood remained. This
can lead to:
• Empyema
• Chronic fibrothorax with
trapped lung
RETAINED HEMOTHORAX
Prevention:
• Properly positioned,
LARGE chest tube
(36-42Fr)
• Post placement CXR
• Retained hemothorax post
chest tube placement
independent predictor of
empyema in up to 33% of
patients
RETAINED HEMOTHORAX
Treatment:
•
Operative
• Early VATS (3days) significant reduction
in operative difficulty, contamination/infection of clot, and hospital
length
• After day 5 more likely to need
thoracotomy
•
Fibrinolytic
• VATS is a more effective procedure than
intrapleural streptokinase
• VATS patients having a statistically
significant shorter hospital stay and
decreased need for additional therapy
• Fibrinolytic agents would have to be seen
as a second-line agent behind surgery
when the risks of surgery are too great to
the patient’s overall outcome
EMPYEMA
•
•
Approximately 3% of patients
with chest trauma will develop
a posttraumatic empyema.
Risk factors
• persistent pleural effusion/hemothorax
• duration of a tube
• placement of multiple tubes
•
•
No good evidence for or
against prophylactic abx prior
to chest tube for prevention
As with retained hemothorax,
first line treatment is
operative in patients who will
tolerate
EMPYEMA
PNEUMONIA
• Our patient had difficulty coughing and
clearing secretions
• What risk factors for this?
• Rib fractures with impaired mechanics
• Pulmonary contusion
• Inadequate analgesia
• C-collar impaired swallowing
FROM THE NTDB
ALL AGES
Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25
RIB FRACTURE CORRELATION WITH
MORTALITY
Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25
OUR PATIENT DEVELOPED RLE SWELLING
• What are your
concerns?
• DVT
• Compartment syndrome
• Morel-Lavallée
DVT
• What are his risk
factors for DVT?
• Prolonged extrication
• Immobility
• LE/pelvic fracture
• Holding DVT prophylaxis
WHEN SHOULD WE BEGIN DVT PROPHYLAXIS?
AND WHAT MEDICATION DO WE USE?
• What factors in to the decision for this
patient?
• Solid organ injury (liver)
• Pelvic fracture
• Spinal epidural hematoma
• Other factors:
• Head bleed
• Planned operations
• Epidural catheters
DVT PROPHYLAXIS IN SOLID ORGAN INJURY
• DVT prophylaxis is
safe in patients with
solid organ injury
• BUT timing of
initiation is not
established
• Some retrospective
trials suggest OK to
begin early
DVT PROPHYLAXIS IN TRAUMA
MOREL-LAVALLÉE
OUR PATIENT DEVELOPS ABDOMINAL PAIN,
TACHYCARDIA AND FEVER
• What are your concerns?
• Biloma/bile leak
• Missed bowel injury
• Delayed bleed
• Urinary tract infection
• Hepatic necrosis
• Abscess
• Cholecystitis
DELAYED LIVER COMPLICATIONS
• Delayed bleed 1-6%
severe liver injuries
• Expanding bleed
• Pseudoaneurysm
• Biliary leak 2-7%
• Mean 7-10d post injury
• Most in grade 4-5 injuries
• Treat with drainage and
ERCP and stent
BILIARY COMPLICATIONS
Table 2
Analysis of factors influenced development of complications, including biliary complications in the study group
Complications
No complications
Biliary complications
(n = 22)
(n = 24)
(n = 15)
17
17
13
NS
23.7 ± 11.9
20.6 ± 15
22.5 ± 12.2
NS
ISS (mean ± SD)
36 ± 14
32.6 ± 15
35 ± 15
NS
Grade of liver injury (mean ±
SD)
4 ± 0.6
3.8 ± 0.6
4 ± 0.75
NS
Angioembolization (%)
6 (27.2)
5 (20.8)
5 (33.3)
NS
15 (68.2)*
8 (33.3)
9 (60)
0.038
7 (31.8)
5 (20.8)
5 (33.3)
NS
Male
Age (years)
OR (%)
Penetrating injury (%)
P value
OR - operative group; ISS - Injury severity score; NS - Differences not significant; * - p < 0.05 - complication rate was higher in OR patients.
Bala et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012 20:20 doi:10.1186/1757-7241-20-20
SMALL BOWEL INJURY
MISSED SMALL BOWEL INJURY
OUR PATIENT DEVELOPS MENTAL STATUS
CHANGES
• What are your concerns?
• Hypoxia or hypercarbia
• Sepsis
• Stroke
• Medications
• Drug withdrawal
BLUNT CEREBROVASCULAR INJURY
BCVI
OUR PATIENT IS BACK IN CLINIC WITH SLEEP
DISTURBANCES
• What are your concerns
• Inadequately treated pain
• Medication withdrawal
• Post traumatic stress disorder
• Sleep apnea
• Insomnia related to stroke
PTSD IN CIVILIAN TRAUMA
• More than 20% of
trauma patients have
PTSD at 12 months
following injury
• Risk factors:
• Post-injury emotional
distress
• Pain
• Pre-injury depression
• Benzodiazepine use
Zatzick, et al. Annals of Surgery • Volume 248, Number 3, September 2008
PTSD CRITERIA
• Historically, benzodiazepines were used for
treatment of acute stress and ptsd
• change: use with caution or discourage use
• theoretical, animal, and human evidence to
suggest that benzodiazepines may actually
interfere with the extinction of fear
conditioning or potentiate the acquisition of
fear responses and worsen recovery from
trauma
• Very high co-morbidity of PTSD with alcohol
misuse and substance use disorders
(upwards of 50 percent of co-morbidity) and
potential problems with tolerance and
dependence.
• Once initiated, benzodiazepines can be very
difficult, if not impossible, to discontinue
due to significant withdrawal symptoms
compounded by the underlying PTSD
symptoms.