Management of in the Trauma Patient Ellianne M. Nasser, DPM, CWS, FACFAS • Associate, Podiatry – Geisinger Health System • Assistant Program Director, Podiatric Medicine and Surgery Residency - Geisinger Community Medical Center Emergency Care • US ED 12.2 million patients/year • Most frequently performed procedure second to IV insertion

| 2 Malpractice Issues and Emergency Wounds

• Wound care – 5-20% of all emergency medicine malpractice claims and 3-11% dollars paid out • Most common reasons for litigation: – Failure to diagnose foreign bodies – Wound infections – Failure to detect underlying • Standard of care? – 92’ board certified ER physicians – 38% soak, 67% scrub, 27% irrigate with “other than recommended irrigation”, and 76% never practice DPC Basic Principles

• Thorough irrigation • Assess for tendon injury • X-rays • Tetanus • Antibiotics? • Fixation? Ex-Fix? • WOUND CARE! • Wound vac • Primary repair? • OR?

| 4 Lacerations

• Avg laceration in ER 1-3cm • 13% lacerations in ER “significantly contaminated” • 3.5-6.3% of lacerations  infection • Assess for other !!

| 5 | 6

| 7 Bite Wounds

• 2 mil/yr in US • 3.6-23% human bite wounds • Irrigation/debridement

| 8 Puncture Wounds

• Tetanus!! • Antibiotics • Imaging • Retained foreign body? • Tendon injury?

| 9 | 10 Open Fractures

• 6 hour window? • Antibiotics!!! • Abx duration? • Antibiotic beads? • Washout? • Close or keep open? • Fixation?

| 11 | 12

• Watch for ! • Imaging • Soft tissue damage

| 13 Degloving Injury

• Limb salvage • Multiple washouts • Multi-team approach • WOUND VAC!

| 14 Hyperbaric Oxygen Therapy

• Angiogenesis • Fibroblast growth • Collagen production • Improved osteoclast function • Inhibits α –toxin production in clostridial myonecrosis • Improves leukocyte killing • Decreases neutrophil adherence to capillary walls • Edema reduction

| 15 HBO in the Trauma Patient

• Crush • Open fractures • Compartment Syndrome • Thermal burns • “Acute Traumatic Peripheral Ischemia” • Triad of tissue ischemia, hypoxia, and edema • Gradient of tissue injury • Capacity of injury to become self-perpetuating

| 16 HBO in the Trauma Patient: What does the Literature Say? Bouachour et al 1996 • Only RCT • 36 pts with crush injury • 18 HBO • 18 Placebo • Gustilo II or III • Surgical management within 6 hours

| 17 HBO in the Trauma Patient: What does the Literature Say? Yamada et al 2014 crush injuries and open fractures Gustilo class IIIA

| 18 Garcia- Covarrubias et al 2005

| 19 HBO in the Trauma Patient: What does the Literature Say?

Eskes et al Cochrane Review 2010 • HBO for acute surgical and traumatic wounds • 3 trials met inclusion criteria • Insufficient data to support or refute effectiveness

| 20 • Acute open tibial fracture GA Grade III • Minimal age 18 • Enrollment within 48h of injury

| 21 Case Presentation 1: Puncture Injury

| 22 Case Presentation 1: Puncture Injury

| 23 Case Presentation 1: Puncture Injury

| 24 Case Presentation 1: Puncture Injury

Plan •Tetanus booster given in ED •Antibiotics given in ED •Patient taken emergently for removal FB/I&D •Discharged POD#1 on Clinda/Cipro x 5 days

| 25 Case Presentation 2: Traumatic Hematoma

CC: traumatic hematoma left foot HPI: 53yo female presents to ED with left foot bleeding, swelling, pain. 3 weeks prior hit her foot off wooden bedpost. Patient was in ED 3 times as well as outpatient office over the course of the 3 weeks. Compression dressing/splint applied after negative x-rays, patient told to ice and elevate.

PMH: Hepatitis C, Alcoholic Liver Cirrhosis, Alcohol Dependence (remission for 9 days at time of presentation), thrombocytopenia, coagulopathy SH: current smoker 1.5 PPD for 20 years, alcohol dependence

| 26 | 27 | 28 Labs

Ref. Range 7/12/2015 16:21 7/13/2015 12:31 7/13/2015 14:49

WBC Latest Range: 4.00- 4.97 3.74 (L) 4.15 10.80 K/uL

RBC Latest Range: 3.85- 3.29 (L) 3.06 (L) 2.87 (L) 5.15 M/uL

HGB Latest Range: 12.0- 11.0 (L) 10.1 (L) 9.4 (L) 15.3 g/dL

HCT Latest Range: 36.0- 32.0 (L) 29.8 (L) 27.7 (L) 45.2 %

PLATELET COUNT Latest Range: 140- 56 (L) 35 (LL) 46 (LL) 400 K/uL

Ref. Range 7/12/2015 17:46 7/13/2015 12:31 7/13/2015 20:20

PT/INR-PT Latest Range: 11.5- 22.2 (H) 17.9 (H) 18.8 (H) 14.6 seconds

PT/INR-INR Latest Range: 0.85- 2.01 (H) 1.52 (H) 1.62 (H) 1.16

| 29 Surgical Plan

• 4U FFP • Platelets • Vanc/Zosyn • ID Consult • OR for evacuation hematoma/debridement

| 30 Hospital Course

• Infectious Disease: Unasyn as inpatient • Gastroenterology : Trental, will f/u as outpatient for management of cirrhosis, portal HT and hepatitis C • Hematology: • bleeding tendency due to combination of abnormal coags due to liver disease and thrombocytopenia - probably due to ETOH/Hep C/cirrhosis vs ITP • F/U Abdominal imaging results for any splenomegaly/ fibrinogen and PTT levels • Will give cryoppt if fibrinogen is low preoperatively • FFP as needed if PTT/INR is elevated • Repeat washout/debridement/wound vac • Discharged with wound vac and home health

| 31 F/u in Wound Care Center

| 32 2 months following initial I&D

| 33 Case Presentation 3: Crush Injury/Compartment Syndrome

CC: Right foot pain/crush injury HPI: 50yo male presents with right foot pain. He states that he was at work earlier today (works for PennDot) and was operating a road milling machine when both of his feet became stuck under the machine. He was able to get his left foot out from under the machine after a brief period of time; however, his right foot remained under the machine for 45 minutes. The part of the machine that his foot was caught under had a sharp metal portion that was on top of his foot. After his foot was removed form the machine he was brought to the ED immediately.

PMH (+) obesity, HTN, (+) EtOh use

| 34 | 35 Case Presentation 3: Crush Injury/Compartment Syndrome

- Tetanus booster, Ancef administered in ER - Emergent fasciotomy - Monitor for – CPK total q6h

| 36 Case Presentation 3: Crush Injury/Compartment Syndrome

| 37 | 38 Case Presentation 3: Crush Injury/Compartment Syndrome

1 week postop

| 39 Case Presentation 3: Crush Injury/Compartment Syndrome

• 1 month postop • Scheduled for debridement, Integra/wound vac in OR

| 40 | 41 -fracture healed uneventfully -wound healed 4 months after initial injury

5 weeks after Integra

| 42 | 43 Case Presentation 4: Motorcycle Accident

CC: degloving injury HPI: 27yo male presented to Trauma Bay following motorcycle crash. Pt unhelmeted, motorcycle struck by SUV.

He suffered multiple injuries including: – Left degloving foot wound, left 2nd met midshaft open fx, left 4th and 5th digit open fx. – Left open midshaft tibial fracture and fibular shaft fracture – Left closed displaced midshaft femoral fracture – Right intra-articular comminuted distal femur fracture.

No PMH, former smoker

| 44 | 45 | 46 | 47 | 48 HBO Consult HBO Day 2

HBO Day 3

HBO Day 1

| 49 Case Presentation 5: Degloving Injury

CC: mangled foot HPI: 33yo female presented to Trauma Bay after being struck by a vehicle. Pt relates that her foot was stuck between the car and the curb.

PMH: Hepatitis C SH: current smoker, 1PPD, IVDA

| 50 | 50 | 51 | 52 | 53 | 54 Case Presentation : Degloving Injury

Surgical Plan: • Patient refuses any further • I&D • Ex-Fix 1st Ray • ORIF 4th Metatarsal • Wound Vac

| 55 | 56 | 57 | 58 Repeat Washout/Wound Vac Change in OR

| 59 Repeat Washout/Wound Vac Change in OR

| 60 Repeat Washout/Wound Vac Change in OR

| 61 Repeat Washout/Wound Vac Change in OR

| 62 Repeat Washout/Wound Vac Change in OR

| 63 Repeat Washout/Wound Vac Change in OR

| 64 TMA with Wound Vac Application

| 65 TMA with Wound Vac Application

| 66 TMA with Wound Vac Application

| 67 | 68 | 69 Conclusions

• Common in emergency medicine • Basic wound care tenets • Refer quickly to specialist • Multiple team approach!! • Consider HBO • Each case unique, no single way to treat

| 70 References:

• Ball V, Younggren BN. Emergency management of difficult wounds: part I. Emerg Med Clin N Am. 25:101-121, 2007. • Bouachour C, Cronier P, Gpuello J, et al. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double blind placebo controlled clinical trial. J Trauma Inj Infect Crit Care. 42(2):333-339, 1996. • Bowersox J, Strauss M, Hart G. Clinical experiences with hyperbaric oxygen therapy in the salvage of ischemic skin grafts and flaps. J Hyperb Med. 1:141-149, 1986. • Buettner MF, Wolkenhauer D. Hyperbaric oxygen therapy in the treatment of open fractures and crush injuries. Emerg Med Clin N Am. 25:177- 188, 2007. • Dougherty, JE. The role of hyperbaric oxygen therapy in crush injuries. Crit Care Nurs Q. 36(3):299-309, 2013. • Eskes A, Ubbink D, Lubbers M, et al. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. Cochrane Database Syst Rev. 10, 2010. • Foong DP, Evriviades D, Jeffery SL. Integra permits early durable coverage of improvised amputation device (IED) amputation stumps. J Plast Reconstr Aesthet Surg. 66(12): 1717-24, 2013. • Garcia-Covarrubias L, McSwain NE, Van Meter K, Bell RM. Adjuvant hyperbaric oxygen therapy in the management of crush injury and traumatic ischemia: an evidence-based approach. The American Surgeon. 71:144-151, 2005. • Greensmithy JE. Hyperbaric oxygen therapy in extremity trauma. JAAOS. 12(6): 376- 384, 2004. • Millar IL, McGinnes RA, Williamson O et al. Hyperbaric Oxygen in Lower Limb Trauma (HOLLT); protocol for a randomised controlled trial. BMJ Open. 1-10, 2015. • Helgeson MD, Potter BK, Evans KN, Shawen SB. Bioartificial dermal substitute: a preliminary report on its use for the management of complex combat-related soft tissue wounds. J Orthop Trauma. 21(6): 349-9, 2007. • Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period. J Trauma. 67(4): 752-7, 2009. • Pfaff JA, Moore GP. Reducing risk in emergency department wound management. Emerg Med Clin N Am. 25:189-201. 2007. • Sheean A, Tintle SM, Rhee PC. Soft tissue and wound management of blast injuries. Curr Rev Musculoskelet Med. 8:265-271, 2015. • Stefanidou S, Kotsiou M, Mesimeris T. Severe lower limb crush injury and the role of hyperbaric oxygen treatment: a case report. Diving and Hyperbaric Medicine. 44(4): 243-245, 2014. • Tintle SM, Gwinn DE, Anderson RC et al. Soft tissue coverage of combat wounds. J Surg Orthop Adv Spring. 19 (1): 29-34, 2010. • Trott A. Wounds and Lacerations: Emergency Care and Closure. March 2012, Saunders. • Yamada N, Toyada I, Doi T et al. Hyperbaric oxygen therapy for crush injuries reduces risk of complications: research report. UHM 41(4): 283-289, 2-14. • Younggren BN, Denny M. Emergency management of difficult wounds: part II. Emerg Med Clin N Am. 25:123-134, 2007. | 71