Foundations 3 Trauma - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries General Approach - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls General Approach
#1 cause of death ages 1 —> 44y/o General Approach
#1 cause of death ages 1 —> 44y/o Timing of death:
Immediate - Massive head inj - High C-spine inj - Cardiac lac - Aortic rupture - Great vessel lac - Airway obstruct General Approach
#1 cause of death ages 1 —> 44y/o Timing of death:
Immediate Golden Hour - Massive head inj - SDH, EDH - High C-spine inj - Splenic/Liver lac - Cardiac lac - Multiple injuries - Aortic rupture —> shock - Great vessel lac - Pelvic Fx - Airway obstruct - Long bone Fxs - TnPTX - HTX - Tamponade - Aortic Dissection General Approach
#1 cause of death ages 1 —> 44y/o Timing of death:
Immediate Golden Hour Delayed - Massive head inj - SDH, EDH - MOF - Sepsis - High C-spine inj - Splenic/Liver lac - Cardiac lac - Multiple injuries - ARDS - Aortic rupture —> shock - Great vessel lac - Pelvic Fx - Airway obstruct - Long bone Fxs - TnPTX - HTX - Tamponade - Aortic Dissection General Approach
Can they talk? 1st: chin lift/head tilt No gag/pooled secretions? —> intubate Severe mid-face injuries —> Cric Kids: Needle cric w/ jet ventilation Confirm tube: EtC02, see tube pass cords MAINTAIN C-SPINE!!! A Kids: may used cuffed tube now General Approach
Probably OK to blast O2 Low Tidal volumes (compress IVC) Look for and correct chest injury: Needle thoracostomy for TnPTX B Seal sucking chest wound (3-side tape) General Approach
2 large-bore IVs (16g) 1st: Compress external bleeding 1st: Wrap unstable pelvis 2nd: 1-2L warm IVF 3rd: Blood (1:1:1) 3rd: TXA C 4th: No pulse+cardiac motion = Thoracot General Approach
Pupil size/reactivity D GCS: GCS < 8 —> intubate General Approach
Expose patient (fully undressed) Environmental control (gasoline, etc.) E Keep them warm General Approach
“AMPLE” history Complete physical exam “Finger or tube in every orifice” Rectal for blood and high-riding prostate Rainbow labs CXR, PXR EFAST exam CT (may do selective scanning if pt alert) 2 Tdap, Ancef - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Hemorrhagic Shock - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Hemorrhagic Shock
Earliest sign: Tachycardia Hemorrhagic Shock
Earliest sign: Tachycardia
Class 1: 10% blood loss ; HR<100
Class 2: 20% blood loss ; HR<120
Class 3: 30% blood loss ; HR~130 ; Low BP
Class 4: 40% blood loss ; HR>140 ; Shock/AMS Hemorrhagic Shock
Earliest sign: Tachycardia
Class 1: 10% blood loss ; HR<100
Class 2: 20% blood loss ; HR<120
Class 3: 30% blood loss ; HR~130 ; Low BP
Class 4: 40% blood loss ; HR>140 ; Shock/AMS
Human = 5L blood - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Head Injury - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Head Injury Pearls
#1 cause of death and disability in trauma cases
End-mechanism of death = elevated ICP
ALL head injury has C-spine injury til disproved
ALL altered pts have head injury til disproved
TBI doesn’t cause hypotension Epidemiology
Falls Epidemiology
Falls Epidemiology
Falls Epidemiology
Falls Epidemiology
Falls Epidemiology
Transportation Epidemiology
Transportation Epidemiology
Transportation Epidemiology
Firearms Epidemiology Sports Cerebral Contusion
Look for “coupe” / “counter-coupe” injury May have delayed bleed/edema/complication IntraParenchymal Hemorrhage Subdural Hematoma
Concave (“moon-shaped”) - crosses suture lines Acute=hyper-dense ; Subacute (~2w)=Iso-dense ; Chronic=Hypo-dense Epidural Hematoma
Middle Meningeal Artery. “Lens-shaped” LOC —> Lucent period —> Fixed pupil ipsilateral SubArachnoid Hemorrhage
Look around suprasellar cistern AND around peripheral sulci No Nimodipine Diffuse Axonal Injury
Small “petechial hemorrhages” Shearing force (i.e. deceleration) —> Profound obtundation Treatment Pearls
Head of Bed 30 degrees!
? Mannitol or Hypertonic Saline
? Hyperventilate —> temporary
? Antiepileptics
NuSu consultation early Skull Fractures
No Tx Surgery Surgery Abx Abx Skull Fractures
+ = Skull Fractures
+ =
ABUSE - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Facial Injury - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Orbital Blow-out Fxs ? Orbital Blow-out Fxs
Right Orbital Floor Blow-out Fx Orbital Blow-out Fxs Orbital Blow-out Fxs Pearls
Can’t look UP —> inferior wall blowout
Can’t look LATERAL —> media wall blowout
R/o Globe rupture
R/o Hyphema
Decongestants ; Antibiotics (Augmentin) LeFort Fxs LeFort Fxs
“One in your gums, Two to the top, Three you can’t see” - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Neck/Back Injury - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Unstable C-Spine Injuries Unstable C-Spine Injuries Jefferson’s Unstable C-Spine Injuries Jefferson’s Unstable C-Spine Injuries Bilateral Facet Dislocation Unstable C-Spine Injuries Bilateral Facet Dislocation Unstable C-Spine Injuries Odontoid Unstable C-Spine Injuries Odontoid Unstable C-Spine Injuries Avulsion of the Anterior Axis Unstable C-Spine Injuries Avulsion of the Anterior Axis Unstable C-Spine Injuries Hangman’s Unstable C-Spine Injuries Hangman’s Unstable C-Spine Injuries Hangman’s Unstable C-Spine Injuries Teardrop Unstable C-Spine Injuries Teardrop Unstable C-Spine Injuries Teardrop The Serious The Bullsh*t The In-Between The In-Between - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Thoracic Trauma - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Tension PTX
CLINICAL DIAGNOSIS Hypotension, trachea away from lesion, JVD Needle decompression Tension PTX
CLINICAL DIAGNOSIS Hypotension, trachea away from lesion, JVD Needle decompression Regular PTX
Dx: US or expiratory CXR Chest tube Regular PTX
Dx: US or expiratory CXR Chest tube Open PTX (“Sucking Chest Wound”)
PTX + Open wound >2/3 size of trachea Sterile occlusive derisive (petroluem gauze/ plastic), tape on 3 edges, chest tube @ away site Pneumothoraces Pulmonary Contusion
“PNA of blood” Most common potentially lethal chest injury ARDS = delayed vs PC = immediate findings Most common, and worst complication? Pulmonary Contusion
“PNA of blood” #1 common potentially lethal chest injury ARDS = delayed vs PC = immediate findings Most common, and worst complication? PNA! Pulmonary Contusion
1 lung/small
- O2 - Pain meds Pulmonary Contusion
1 lung/small 1 lung/big ; both lungs
- Intubate - O2 - Low TV, high PEEP - Pain meds - Good lung down Pulmonary Contusion
1 lung/small 1 lung/big ; both lungs
- Intubate - O2 - Low TV, high PEEP - Pain meds - Good lung down Hemothorax
Trauma + Effusion = Hemothorax
>???cc Hemothorax
Trauma + Effusion = Hemothorax
>200cc Hemothorax
Trauma + Effusion = Hemothorax
>200cc
Initial ????+cc Continuous ???+cc/h Hemothorax
Trauma + Effusion = Hemothorax
>200cc
Initial 1500+cc Continuous 200+cc/h Cardiac Contusion Cardiac Contusion
Right Ventricle!
Suspicion/Mechanism >>> EKG/Trop/Echo
EKG: poor sens/spec… but seeing something ?bad
EKG: most common=Sinus tach (poor specificity)
Echo: RV hypokinesia Cardiac Contusion
No Sx + Low Risk + (N) initial EKG —> Dispo
+Sx + Low Risk + (N) serial EKGs —> ED Obs
+Sx + Mod Risk + (N) serial EKGs —> Echo/Obs
High risk or bad EKG or bad Echo —> Tele/CCU Tamponade
IVF
? Pericardiocentesis
Thoracotomy ?Cardiac Lac
IVF
? Pericardiocentesis
Thoracotomy Aortic Rupture
Ligamentum Arteriosum Widened high mediastinum (>8mm) - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Abdominal Trauma - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Ab Trauma
20% have benign initial exam
FAST test of choice…miss diaphragm/bowel/pancreas
CT after FAST for HD-stable pts. May miss same
DPL + if >100,000 RBCs in lavage. Miss RP injury
Spleen #1 injured organ in blunt ab trauma - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Pelvic Injuries - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Pelvic Injuries
“Open Book” Fx “Vertical Shear Fx” “Straddle Fx”
Can bleed out in the pelvis (~6L) Bind unstable pelvis Pelvic Injuries - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Extremity Injuries - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Extremity Injuries
1) Exsanguination —> Tamponade/tourniquet 2) Deformed Fx/Dslc —> Reduce immediately 3) Compartment Synd —> (delayed). “Pain” 1st - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries BONUS!!! - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Bonus
Q: What cause of trauma has the highest mortality rate? Bonus A: “MACHINE GUN” SHAY - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Drowning - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Drowning
#3 cause accidental death; M>F; Fresh > Salt water
?C-spine? ?Hypothermia? ?Underlying medical/tox/psych cause?
Most reliable predictor of outcome: duration under Asymptomatic —> ED obs x6h Symptoms/Hypoxic —> Admit - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Electrical Shock - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Electrical Shock Electrical Shock
Arrhythmias
- V. Fib Electrical Shock
Arrhythmias Tissue Damage
- V. Fib - Rhabdo
“More like a crush injury than a thermal burn” Electrical Shock
Arrhythmias Tissue Damage Blunt Trauma
- V. Fib - Rhabdo - P. Shoulder dslc Electrical Shock
Arrhythmias Tissue Damage Blunt Trauma
- V. Fib - Rhabdo - P. Shoulder dslc
Tdap? Exit wound? Compartment syndrome? Low Voltage, No Sx, (N) EKG, no Rhabdo —> ED obs Electrical Shock
Delayed bleed 3-14d post-injury. Labial art. - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Rhabdo - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Rhabdo
“I Love Bananas!” Rhabdo
HYPER K+ (HYPO Ca++) Rhabdo
HYPER K+ (HYPO Ca++)
1) IVF (UO=2cc/h)
2) Lasix (2mg/kg)
3) Bicarb (1amp/L NS)
“I Love Bananas!” - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Burns - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Thermal Burns
AIRWAY/BREATH: Soot in nares, intubate early
CIRCULATION: 4cc/kg/BSA
2NDARY SURVEY: ?trauma/tox? - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Pregnant Patient - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Trauma in Pregnancy - Pearls 1
#1 cause non-obstetric maternal death
Place chest tubes higher (3rd-4th IC space)
Blood volume higher —> Shock presents later (30+%)
Left Lateral decub (partial), even on backboard! Trauma in Pregnancy - Pearls 2
#1 cause fetal death in trauma? Abruption
FHR <120 or >160 BAD
Uterine rupture?
Rhogam (50mcg <12w, 300mcg >12w) - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Penetrating Trauma - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Penetrating Injury
Velocity counts
vs Penetrating Injury
GSW to ab —> Ex-lap
Stab to ab —> selective management - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Pediatric Spine - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Pediatric Spine Pediatric Spine
Very young have higher c-spine injuries (big head)
SCIWORA? - General approach - Hemorrhagic shock - Head injury - Neck/back injury - Thoracic trauma - Abdominal trauma - Pelvic injuries Pearls - Extremity injuries - Drowning - Electrical shock - Rhabdo - Thermal burns - Pregnant patients - Penetrating trauma - Pediatric spine - Trauma Pearls Pearls
Q: Most commonly injured organ in blunt ab trauma? Pearls
Q: Most commonly injured organ in blunt ab trauma?
Spleen Pearls
Q: Most commonly injured organ in penetrating ab trauma? Pearls
Q: Most commonly injured organ in penetrating ab trauma?
Liver (bowel) Pearls
Q: Most common cause of sudden death from MVA or high fall? Pearls
Q: Most common cause of sudden death from MVA or high fall?
Aortic rupture Pearls
Q: Subtle but ominous Fx on CXR? Pearls
Q: Subtle but ominous Fx on CXR?
Sternal Fx Pearls
Q: Ab injury most likely to present late? Pearls
Q: Ab injury most likely to present late?
Bowel Pearls
Q: Knee dislocation? Pearls
Q: Knee dislocation?
Angio Pearls
Q: Best thing to do for any trauma patient while still in the ED? Pearls
Q: Best thing to do for any trauma patient while still in the ED?
Re-evaluate The End
Seeya Trauma