10/17/2019

Trauma Killers

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Objectives

• Recognize components of the • Identify interventions to manage life threatening conditions • Relate mechanisms of to types of sustained in trauma • State the goal of post care • Identify post resuscitative care of the trauma patient • Articulate benefits of a tertiary exam • Understand the psychosocial impact of trauma

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Case‐SCH ETC

First Peak Third Peak • Seconds to minutes of injury • Days to months after injury – Irreversible brain injury – Why? – Exsanguination • Very few of these patients can be salvaged due to extent of injury

Second Peak • Minutes to hours after injury ‐ Trauma Care focuses primarily on this peak – Major internal hemorrhages of head, resp. system, or Abd organs – Multiple minor injuries resulting in severe loss

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Trauma Triad of Death

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Hemorrhage

• Blood on the floor x 4 more – Obvious – Chest • Holds up to 3L – Pelvis/Retro‐ peritoneum • 2.5 L – Thigh • 1‐2 L – Abdomen

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Hypothermia

• Body Temp of <95 F (35 C) • Approximately 2/3 of all bleeding trauma patients arrive in the emergency room with a core temp <96.8 F(36 C) • Affects every organ system

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Hypothermia: Contributing Factors

• Environment – Outside temperature, prolonged extrication times, skin exposure, air movement, wet clothing • Extremes of Age – Very young or elderly • Drug/Alcohol Use • Injuries Sustained – Hemorrhage, TBI, • Pre‐existing conditions – Hypoglycemia, hypothyroidism, diabetic neuropathy, Peripheral vascular disease, anorexia • Treatments – Exposure to ambient temperature – Fluid and/or blood administration – Immobilization – Medications (Narcotics, sedatives, etc.) – Open Cavity procedures

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Hypothermia: Prevention

• Warm the environment • Remove wet clothing or linens • Warm anything that touches the patient – Warm linens – Warm Fluids • Monitor temperature

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Coagulopathy‐ A loss of Cohesiveness

• Causes in Trauma – Hemorrhage • Clotting cascade becomes abnormally activated excessive clot formation and subsequent breakdown (fibrinolysis)inability to effectively clot – Platelet dysfunction secondary to hypothermia and • Slowed clotting • Decreased production of clotting factors – Dilutional from Fluid Resuscitation and uncontrolled hemorrhage

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Coagulopathy: Identification and Prevention Identification Prevention • Recognize the source of occult • Careful fluid and blood hemorrhage. replacement • Observe for signs of bleeding • Keep your patients warm from , bladder, GI • STOP THE BLEEDING! tract, and brain. – Quickly identify source • Abnormal petechiae and – Direct Pressure bruising. – Tourniquets • Lab tests – OR to control bleeding – Platelet Count – Damage Control – aPTT and PT • Administer TXA as directed – INR

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Acidosis: Risky Numbers game

• Acidosis pH < 7.35 (Normal 7.35‐7.45) • Inadequate tissue perfusion • Causes of shock in trauma – Hypovolemic Shock: Hemorrhage – Obstructive Shock: Tension or – Cardiogenic Shock: (Rarely from trauma)MI, arrythmia – Distributive Shock: Neurogenic Shock from SCI • Some evidence that Fluid resuscitation also risk of acidosis (pH of NS is 5.5)

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Acidosis: Identification and Prevention Identification Prevention • ABGs • Provide adequate • ventilation • Base Deficit • Avoid hypothermia • Identify WHY acidosis is happening‐TREAT IT! • Monitor labs • Monitor UOP

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Head Trauma

• Blunt or Penetrating MOI • Risk Factors • • Primary vs Secondary Injury

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SDH‐ Causes and Presentation

• Acceleration/Deceleration Injuries – Shearing of bridging veins • Acute vs Chronic • Blood accumulates below the dura • Presentation: – Could have delayed Sx presentation (Acute: up to 72o, Chronic: Up to 2 weeks after injury) – HA – Altered LOC – Seizures – Unilateral fixed and dilated pupils – Aphasia • Special considerations‐ – Peds patients: consider child abuse (shaken baby syndrome) • High Risk: – Patients taking anticoagulant medications (delayed clotting times) – The older adult – Chronic alcohol users

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SDH‐ Treatment and Ongoing Assessement Treatment • Observation if <1 cm, and neurologically stable • Craniotomy if unstable or bleed is large

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EDH‐ Causes and Presentation

• Direct (typically to temporal bone) • Blood accumulates between the skull and the dura • Rapid accumulation of blood – Middle Meningeal Artery • Presentation/Assessment: – Transient loss of consciousness with lucid period – Headache – Nausea and vomiting – Dizziness – Contralateral hemiparesis or hemiplegia – Unilateral fixed and dilated pupil – Rapid neurologic deterioration

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EDH‐ Treatment • Observation if less than 1 cm and neurologically stable • Craniotomy if unstable or bleed is large

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SAH

Causes and Treatment Presentation • Medical Management • Surgical intervention to stop • Traumatic and Non‐ bleeding and lower ICP Traumatic (Aneurysm and AVM) • Presentation – Neuro Deficits – “Worst HA of my life”

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Cerebral Contusion: Causes and Presentation • Blunt Trauma • Typically in frontal or temporal lobes • Can be present on initial scan – Progress with time (peaks 18‐36)

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Cerebral Contusions

• Close Neuro observation • Repeat head CTs • Craniectomy if needed

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Traumatic Brain Injury

• TBI Classified by GCS assessment – Mild – Moderate – Severe • Second Impact Syndrome • Post‐concussive Syndrome assessment findings – Persistent headache – Nausea – Dizziness – Memory impairment – Difficulty concentrating – Attention deficit – Irritability – Insomnia – Anxiety – Depression

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Penetrating Head Trauma

• Cerebral contusions, lacerations, intracranial • Extremely high mortality • Stabilize protruding objects • Surgical emergency

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Cerebral Blood Flow

Cerebral Perfusion Pressure Autoregulation • CPP=MAP‐ICP • Primary regulator: CO2 • One episode of systolic BP – Hypercapnia: Vasodilation < 90 mm Hg can be – Hypocapnia: Vasoconstriction

detrimental • Normalize PaCO2 ASAP • Brain autoregulates blood • Hypoxia flow to brain based on – One episode of PaO2 < 60mm CPP (60‐160mm Hg Hg can be detrimental • As ICP rises, CPP decreases

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Head Trauma Post Resuscitative Care • Serial Neuros (GCS, Pupil exam, etc) • ICP Monitoring • VS Monitoring • Position head midline • Elevate HOB (if cleared) • Meds: – Mannitol – Hypertonic Saline – Anticonvulsants – Others?

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Chest and Neck Trauma

• Contains , great vessels, respiratory system • Blunt Trauma to chest – MVCs, MCCs, ped vs auto account for > 50% of blunt chest trauma • to neck/chest – Commonly assaults with firearms and stabbings in adults – Peds‐ falling on objects or MVCs

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Aortic Injuries

• Penetrating or Blunt Trauma • 80‐90% of Aortic injuries are fatal on scene • Descending aorta most common site of injury • 50% of patients with aortic injury die prior to repair • 30% mortality rate in those who receive surgical intervention

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Aortic Injuries: Presentation and Identification • Presentation: – Interscapular pain – Dyspnea – Hypotension – Asymmetrical pulses or BPs – Paraplegia – Signs of shock – to chest with significant penetration • Identification – Mediastinal widening on CXR – CT Scan

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Aortic Injuries: Treatment

• Transfer out‐QUICKLY • Surgical Repair • Hemodynamic Support – MTP

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Pneumothorax

• Blunt Trauma – Air escapes from injured to pleural space  negative intrapleural pressure is lost  collapse of lung • Spontaneous (atraumatic) • Common missed injury • Presentation: – Dyspnea, tachypnea – Tachycardia – Decreased/absent breath sounds on injured side – Chest Pain • Identification: – CXR or Chest CT

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Pneumothorax‐Treatment

• Small PTX and stable pt – Observe • Unstable pt, large PTX, likely to deteriorate, air transport –

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Pneumothorax‐ Post Resuscitative Care • Breathing Assessments – LS – Rate/Quality/Depth of Resp • Chest Tube – FOCA • Vented Patients – Watch them closely!

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Tension Pneumothorax

• Untreated/Undiagnosed pneumothorax • Mediastinal shift occurs‐ compresses heart, great vessels, and eventually opposite lung • LIFE THREATENING • Presentation: – Severe respiratory distress – Diminished breath sounds on the affected side – Hypotension – Distended neck veins – Tracheal Deviation – Anxiousness/ restlessness • Identification: – Patient Status!!

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Tension Pneumothorax: Treatment

Immediate Treatment Definitive Treatment Needle Decompression Chest Tube Placement (Needle Thoracostomy)

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Open Pneumothorax

• Open wound to chest wall (, , impalement) • Air enters intrapleural space via open wound during inspiration and becomes trapped • Presentation – Same as pneumothorax – Chest wound that makes sucking sound on inspiration – • Treatment – Immediate: 3 sided occlusive dressing – Definitive: Chest Tube, Wound closure

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Hemothorax

• Blood accumulates in intrapleural space • Causes‐ blunt or penetrating trauma with injury to: – – Costal blood vessels – Great vessels – Liver or spleen with diaphragm injury • Common missed injury • Presentation – Anxiety – Dyspnea, tachypnea – Chest pain – Signs of shock – Decreased breath sounds on injured side • Identification: CXR, CT • Treatment – Chest Tube – Open Thoracotomy

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Hemothorax‐Ongoing Assessment

• Chest Tube – FOCA • Contact Provider if: – Initial output > 500ml – Output > 200ml per hour x2‐4 hours • Resp effort • VS

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Rib Fractures

• Causes: Blunt Trauma – Most frequent injury with chest trauma • Presentation: – Pain – Dyspnea – Chest wall contusions – Bony Crepitus • Identification: – CXR – CT Scan

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Rib Fractures

• Up to 54% missed on plain CXR • Significant pain • High risk for: – Pneumonia – Increased mortality – Ineffective ventilation • Special considerations: – Pediatrics‐low incidence • See with high energy MOI and child abuse – Geriatrics‐high incidence, low energy MOI, higher mortality rates • 19% increased mortality per rib fx in geriatric patients • 27% increase in chance of pneumonia per rib fx

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Rib Fractures‐

• 2 fxs in at least 3 consecutive ribs • Presentation – Dyspnea, tachypnea – Decreased or absent breath sounds on injured side – Chest Pain – Paradoxical chest wall movement • Flail segment will sink in with inspiration and bulge with expiration • Patient will most likely need intubation and vent support

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Rib Fractures: Treatment • Observation • Pain Control • Pulmonary Hygeine • Symptomatic Treatments • Rib Fixation

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Pulmonary Contusion

• Blunt chest trauma • Most common potentially lethal • Resp insufficiency develops over time • Can occur concomitantly with rib fxs – Peds: May be missing rib fxs but still have significant pulmonary contusions • Develops 6‐12 hours after injury • Peaks about 72 hours after injury • May change over time • High risk for: – ARDS – Pneumonia – Resp Insufficiency

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Imaging‐

http://www.trauma.org/index.php/main/article/398/

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Pulmonary Contusion‐ Ongoing Assessment

• Signs and Symptoms: (may not be seen in ED) – Dyspnea – Increased WOB – Hypoxia – Chest Pain – Hemoptysis – Hypercarbia – Course LS – Wheezing

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Pulmonary Contusion‐ Treatment

• Judicious IVF replacement • Close monitoring • IS • Pulmonary toilet • Intubation • PEEP

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Abdominal and Pelvic Trauma

• Mortality rate 10%–30% • Pelvic fractures common after a fall – 20% mortality – Stable vs Unstable • Blunt trauma – Solid organs lacerate – Hollow organs rupture – Tearing or shearing • Penetrating – GSW/SW/blast • Common missed injuries – – Intestinal injuries – Renal injuries

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Asessment

• Serial abd assessment – Inspect: • Seatbelt sign • Cullen’s sign – Auscultate: • BS – Palpate: • Tenderness • Rebound pain • Firmness/distention

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Liver Injury

• Blunt or penetrating trauma to RUQ • Most frequently injured organ from blunt and penetrating trauma combined • Presentation – Trauma to RUQ (ecchymosis, abrasions, etc.) – R Lower Rib Fxs – Tenderness to RUQ – S/S of hemodynamic instability – Elevated LFTs – Cullen’s Sign – Abnormal Abd assessment

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Liver Injury‐Identification

• Identification: – FAST Scan (indicates blood in the Abd, not liver injury specifically) – CT Scan • grading based on location and depth of laceration or injury

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Liver Injury‐Treatment

• Conservative management – Observation (serial Abd exams, VS monitoring, etc.) • Embolization • Surgical Intervention – Packing – Mesh

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Spleen Injury

• Most commonly injured organ from blunt trauma – Highly elastic and flexible – High Vascularity • Presentation – Trauma to LUQ – Abnormal Abd assessment (distention, asymmetry, tightness, tenderness, etc.) – L Shoulder pain – S/S of hemodynamic instability

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Spleen Injury‐Identification and Grading • Identification: – FAST Scan (indicates blood in Abd, not specifically) – CT Scan • Graded based on location and depth of injury

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Spleen Injury‐Treatment

• Observation (serial Abd exams, VS monitoring, etc.) • Embolization • Surgical Intervention – Mesh – Packing – Partial or Total Splenectomy • Can be dysfunctional even if salvaged – Ensure proper vaccinations

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SCH Solid Organ Injury Protocol

Floor ICU • Hemoglobin on admission • Hemoglobin on admission • Hemoglobin q AM and q 8 hours • VS every 2 hours x4, then every 4 hours x24, then per • Continuous monitoring of unit standard VS • Abd exam every 4 hours x3 • Abd exam every 4 hours and prior to discharge • Call provider for SBP less • Call provider for SBP less than than 90, HR greater than 90, HR greater than 120, or significant changes in Abd 120, or any changes in exam. Abd exam. • Regular Diet • Regular Diet • Activity as tolerated • Activity: Up ad lib

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Pelvis Injury

• Presentation: – Shortening or external rotation of LE – Blood at urinary meatus or hematuria – Pelvic Pain – S/S of hemodynamic instability • Identification: – PXR or CT • Stable or Unstable: – Stable Fx: Does not involve pelvic ring, minimal displacement of pelvic ring – Unstable Fx: Two or more fxs of pelvic ring, open posterior pelvis

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Stable or Unstable

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Stable or Unstable?

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Stable or Unstable?

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Pelvis Injury‐ Treatment

• Pelvic Stabilization – Pelvic Binder – External Fixation – Internal Fixation • Hemodynamic Stabilization – Blood Products – Angiography (embolization and or vascular repair) – Surgical Packing (Ex Lap) • Observation/Medical Management if stable pelvis and stable patient

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Musculoskeletal Injury‐ • Pressure in osteofascial compartment increases causes and potentially necrosis • High Risk Injuries: – Tibial and forearm fractures – Injuries immobilized in tight dressings or casts – Severe crush injuries – Burns http://orthotips.com/223-compartment-syndrome

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Musculoskeletal Injury‐ Compartment Syndrome • Presentation: (6 Ps) – Pain out of proportion for injury (Pain) – Tight/tense limb upon palpation (Pressure) – Poor skin color and temp (Pallor) – Weak or absent pulses (late sign) (Pulse) – Numbness, tingling, loss of sensation (Parasthesias) – Paralysis • Management/Treatment: – Remove casts/splints/dressings if present – Avoid ice – Elevate limb to level of heart (not above) – Prepare for intracompartmental pressure measurements – Prepare for fasciotomy

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Post Resuscitation Care

• “Goal of trauma care for the trauma patient is to return the patient to his or her full potential within the community, and trauma care continues until that goal is reached.” 2014. Emergency Nurses Association (ENA). Trauma Nursing Core Course Provider Manual, Seventh Edition. 24: 331 • Post‐Resuscitation care happens in many environments – ED – Rehab – ICU – Home – Med/Surg – Clinic – OR • Continued organized, systematic approach

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Trauma Tertiary Exam

• Completed 24‐48o after injury/admission – May have to delay or repeat due to patient status – Distracting injuries less of a distraction • Subjective interview with patient • Objective thorough head to toe exam • Review of ALL imaging studies again – Overreads – Missed interpretations – Missed injuries • Catch missed or delayed diagnoses

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DVT and PE DVT PE • 50% higher risk in • Pleuritic chest pain trauma • Dyspnea/Orthopnea • Classic triad • Hypoxemia – Stasis – Endothelial damage • Cough/Hemoptysis – Hypercoagulability • Decreased lung sounds • Goal of treatment • Hypotension – Limit clot development • JVD – Prevent PE

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Psychosocial Post Resuscitative Care‐ Alcohol Withdrawal • 30‐50% of trauma patients ingested some kind of intoxicant prior to injury • 1 in 4‐5 patients have some degree of alcohol abuse • Sx develop within 6 hours after last drink or can take days • Assessment findings: – Autonomic hyperactivity – Tremors – N/V – Agitation – Anxiety/restlessness – Insomnia – Hallucinations – Seizures

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Psychosocial Post Resuscitative Care‐ Alcohol Withdrawal • Treatment – Fluids/electrolytes – Thiamine – Glucose – Vitamins – Benzodiazepines – Phenobarbital

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Psychosocial Post Resuscitative Care‐ Mental Health • 20‐40% of injured trauma patients report PTSD and/or depression • Contributing factors – Poor pain control – Loss of function – Injury type and severity – Previous mental health history • High long term societal costs if left untreated or under treated

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Psychosocial Post Resuscitative Care‐ Mental Health • Screening process • Watch for early signs and symptoms – Palpitations – Repetitive questions – Tachypnea – Hyper‐alertness – Hyperventilation – Silence – HA – Tearfulness – N/V – Anger • Early identification and intervention is key in long term treatment

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