TheThe SecondarySecondary SurveySurvey

Clay Cothren Burlew, MD FACS

Director, Surgical Intensive Care Unit Attending Surgeon, Denver Health Medical Center Associate Professor of Surgery, University of Colorado OutliningOutlining thethe ResuscitationResuscitation

•• ABCsABCs CompletedCompleted –– adjunctsadjuncts toto thethe 11°° surveysurvey –– startstart 22°° surveysurvey

•• History/MechanismsHistory/Mechanisms ofof InjuryInjury •• Examination:Examination: • injury identification • intervention and treatment • management pitfalls •• TakeTake HomeHome PointsPoints OutliningOutlining thethe ResuscitationResuscitation

Resuscitation

Primary Survey Secondary Survey Definitive Treatment

Reassessment PITFALLPITFALL

BeBe warywary ofof thethe transienttransient responderresponder…….... AdjunctsAdjuncts toto thethe ABCsABCs

•• ECGECG monitoringmonitoring –– tachycardiatachycardia –– dysrhythmiasdysrhythmias –– STST segmentsegment changeschanges

•• FetalFetal monitoringmonitoring •• >> 2626 weeksweeks •• highhigh--riskrisk forfor 2424°° AdjunctsAdjuncts toto thethe ABCsABCs

•• CathetersCatheters –– foleyfoley –– NGNG tubetube PITFALLPITFALL •• SuspectSuspect urethralurethral injuryinjury •• bloodblood atat meatusmeatus •• perinealperineal bruisingbruising foleyfoley •• highhigh--ridingriding prostateprostate •• pelvispelvis fracturefracture PITFALLPITFALL

•• AppropriateAppropriate NGNG tubetube use:use: •• maymay precipitateprecipitate gagginggagging •• emesis/aspirationemesis/aspiration •• avoidavoid nasalnasal routeroute inin patientspatients withwith facialfacial fxfx AdjunctsAdjuncts toto thethe ABCsABCs

•• PortablePortable XX--rays:rays: –– bluntblunt traumatrauma == ““BigBig 33”” •• APAP chestchest •• APAP pelvispelvis •• laterallateral cc--spinespine AdjunctsAdjuncts toto thethe ABCsABCs

•• PortablePortable XX--rays:rays: –– penetratingpenetrating == ““injuredinjured spacespace plusplus 11 above/belowabove/below”” AdjunctsAdjuncts toto thethe ABCsABCs

•• FASTFAST exam:exam: –– 44 viewsviews ofof abdomenabdomen –– >200cc>200cc ofof fluidfluid

LIVER

CARDIAC CHAMBERS

Right Upper Quadrant Left Upper Quadrant Pericardial Pelvis PITFALLPITFALL

IfIf persistentpersistent oror recurrentrecurrent hypotension,hypotension, rememberremember FASTFAST isnisn’’tt 100%100% accurate!accurate! SecondarySecondary Survey:Survey: HistoryHistory

•• AA == AAllergiesllergies

•• MM == MMedicationsedications

•• PP == PPastast illnesses/illnesses/PPregnancyregnancy

•• LL == LLastast mealmeal

•• EE == EEventsvents aroundaround injuryinjury

SecondarySecondary Survey:Survey: HistoryHistory

•• PrenatalPrenatal history:history: •• PIH,PIH, DM,DM, CHDCHD •• pretermpreterm laborlabor •• placentalplacental abruption/previaabruption/previa •• fetalfetal movementmovement

•• FundalFundal heightheight  fetalfetal ageage SecondarySecondary Survey:Survey: HistoryHistory

•• BluntBlunt Mechanisms:Mechanisms: –– seatseat belt/helmetbelt/helmet useuse –– vehiclevehicle damagedamage –– steeringsteering wheelwheel deformationdeformation –– impactimpact directiondirection –– passengerpassenger ejectionejection –– deathsdeaths atat thethe scenescene SecondarySecondary Survey:Survey: MechanismMechanism

•• FrontFront impact:impact: –– CC--spsp fx,fx, ribrib fxfx  PTX,PTX, liver/spleenliver/spleen lacs,lacs, postpost hiphip dislocationdislocation •• SideSide impact:impact: ••CC--spsp fx,fx, ribrib fxfx  PTX,PTX, diaphragmdiaphragm rupture,rupture, pelvispelvis fxfx •• Ejection:Ejection: ••increasedincreased riskrisk SecondarySecondary Survey:Survey: MechanismMechanism

•• PenetratingPenetrating trauma:trauma: –– bodybody regionregion –– GSW:GSW: distancedistance fromfrom weaponweapon toto wound,wound, velocity,velocity, caliber,caliber, presumedpresumed pathpath –– SW:SW: lengthlength ofof object,object, impactimpact directiondirection –– associatedassociated bluntblunt trauma?trauma? PITFALLPITFALL

IfIf thethe weaponweapon isis inin thethe patient,patient, allowallow thethe surgeonsurgeon toto removeremove itit underunder controlledcontrolled conditions!conditions! SecondarySecondary Survey:Survey: ExamExam

HeadHead toto ToeToe

““EveryEvery NookNook andand CrannyCranny”” Exam:Exam: HEENTHEENT

•• Head:Head: –– scalpscalp lacerationslacerations oror contusionscontusions –– skullskull fracturesfractures Exam:Exam: HEENTHEENT

•• Eye:Eye: –– pupilpupil examexam –– globeglobe intact?intact? –– visualvisual acuity?acuity?

•• Ears:Ears: –– blood?blood? CSFCSF leak?leak? –– intact?intact? Exam:Exam: HEENTHEENT

•• Nose/Mouth/Throat:Nose/Mouth/Throat: –– airwayairway issuesissues paramountparamount –– bonybony stepstep--offoff –– bitebite feelsfeels normal?normal? –– bleedingbleeding fromfrom nose/mouthnose/mouth PenetratingPenetrating NeckNeck InjuriesInjuries

Hemodynamically Unstable Uncontrolled Hemorrhage

CT CT CTA + Zone I neck/ esophagram bronchoscopy chest Hemodynamically Stable Operative PENETRATING Zone II Symptomatic** Exploration NECK INJURY Zone III Angio + IR embo

CT CT CTA + Zone I neck/ esophagram bronchoscopy chest

Transcervical GSW Asymptomatic Zone II Asymptomatic All Others Observe ** symptoms = expanding hematoma Zone III airway compromise dysphagia subcutaneous emphysema hoarseness Exam:Exam: HEENTHEENT

•• TheThe Brain!Brain! –– evaluationevaluation partpart ofof ABCABCDDEsEs –– calculatecalculate GCSGCS •• GCSGCS << 88 severesevere headhead injury/comainjury/coma –– DxDx == CTCT scan,scan, ICPICP monitormonitor Exam:Exam: SpineSpine

•• Cervical/Thoracic/Lumbar:Cervical/Thoracic/Lumbar: –– alwaysalways protectprotect thethe spinespine –– safelysafely offoff thethe backboardbackboard •• ifif oneone fx,fx, looklook forfor another!another! •• sensory/motorsensory/motor lossloss == injuryinjury •• rememberremember steroidssteroids •• complicationcomplication == neurogenicneurogenic shockshock Exam:Exam: ThoracicThoracic InjuriesInjuries

•• 88 LethalLethal Injuries:Injuries: •• pneumothoraxpneumothorax •• hemothoraxhemothorax •• pulmonarypulmonary contusioncontusion •• bluntblunt cardiaccardiac injuryinjury •• aorticaortic disruptiondisruption •• diaphragmdiaphragm rupturerupture •• tracheobronchialtracheobronchial injuryinjury •• traversingtraversing mediastinalmediastinal woundswounds Exam:Exam: ThoracicThoracic InjuriesInjuries

•• SimpleSimple pneumothoraxpneumothorax •• penetratingpenetrating andand bluntblunt •• lunglung lacerationlaceration withwith airair leakageleakage •• ↓↓ breathbreath soundssounds •• hyperresonancehyperresonance

•• TxTx == chestchest tubetube Exam:Exam: ThoracicThoracic InjuriesInjuries

•• HemothoraxHemothorax •• lunglung lacerationlaceration oror lacerationlaceration ofof intercostalintercostal vesselvessel •• bleedingbleeding selfself--limitedlimited before chest tube •• <10%<10% requirerequire thoracotomythoracotomy

•• TxTx == chestchest tubetube •• IfIf >> 1500cc1500cc outout initiallyinitially  thoracotomythoracotomy after chest tube PITFALLPITFALL

MakeMake suresure bloodblood isis evacuatedevacuated –– R/OR/O cakedcaked hemothorax.hemothorax. Exam:Exam: ThoracicThoracic InjuriesInjuries

•• PulmonaryPulmonary contusioncontusion •• mostmost commoncommon injuryinjury •• developsdevelops overover timetime •• presentpresent withoutwithout ribrib fxfx inin childrenchildren admit

•• TxTx == intubationintubation ifif significantsignificant hypoxiahypoxia

12 hrs Exam:Exam: ThoracicThoracic InjuriesInjuries

•• BluntBlunt cardiaccardiac injuryinjury •• contusioncontusion toto anyany chamberchamber •• occasionaloccasional rupturerupture •• clinicalclinical symptoms:symptoms: • tachycardia • arrhythmias • abnormal ECHO •• TxTx == 2424˚˚ ofof TelemetryTelemetry SwanSwan ifif ECHOECHO abnormal,abnormal, patientpatient unstableunstable Exam:Exam: ThoracicThoracic InjuriesInjuries

•• AorticAortic disruptiondisruption •• completecomplete transectiontransection –– typicallytypically DOADOA •• incompleteincomplete teartear –– potentiallypotentially salvageablesalvageable •• injuryinjury nearnear ligamentumligamentum arteriosumarteriosum •• containedcontained hematomahematoma Exam:Exam: ThoracicThoracic InjuriesInjuries

•• AorticAortic disruptiondisruption •• fewfew symptomssymptoms •• XX--rayray findings:findings: • wide mediastinum • obliterated aortic knob • deviation of trachea • depressed left bronchus • deviation of esophagus • apical capping Exam:Exam: ThoracicThoracic InjuriesInjuries

•• AorticAortic disruptiondisruption •• empiricempiric treatmenttreatment inin traumatrauma baybay • esmolol SBP < 100, HR < 100 •• screeningscreening helicalhelical CTCT scanscan •• angiographyangiography isis thethe goldgold standardstandard

•• TxTx == operativeoperative repairrepair vs.vs. stentstent graftgraft Exam:Exam: ThoracicThoracic InjuriesInjuries

•• DiaphragmDiaphragm rupturerupture •• moremore commoncommon onon leftleft •• bluntblunt == radialradial teartear •• penetratingpenetrating == linearlinear laclac

left diaphragm rupture •• DiagnosisDiagnosis •• gastricgastric bubblebubble inin chestchest •• liverliver inin thethe chestchest •• NGTNGT coiledcoiled inin chestchest

right diaphragm rupture Exam:Exam: ThoracicThoracic InjuriesInjuries

•• DxDx == CTCT scanscan cancan bebe confirmatoryconfirmatory •• TxTx == operativeoperative repairrepair viavia thethe abdomenabdomen Exam:Exam: ThoracicThoracic InjuriesInjuries

•• TracheobronchialTracheobronchial InjuryInjury •• withinwithin 11 inchinch ofof carinacarina •• oftenoften lethallethal •• hemoptysis,hemoptysis, subQsubQ emphysema,emphysema, tensiontension pneumothoraxpneumothorax •• persistentpersistent airair leakleak •• bronchoscopybronchoscopy

•• TxTx == watchwatch vs.vs. glueglue vs.vs. operateoperate Exam:Exam: ThoracicThoracic InjuriesInjuries

•• TransmediastinalTransmediastinal WoundsWounds •• externalexternal woundswounds ++ XrayXray

•• TxTx == determineddetermined byby hemodynamicshemodynamics •• stablestable –– CT,CT, tripletriple evaleval •• unstableunstable –– OROR

•• MortalityMortality >> 2020--40%40% KEYKEY POINTPOINT

RuleRule outout thethe 88 lethallethal chestchest injuries.injuries. Exam:Exam: AbdominalAbdominal InjuriesInjuries

•• BluntBlunt traumatrauma == crushingcrushing injuryinjury •• PenetratingPenetrating == lacerationlaceration •• OrganOrgan injuriesinjuries •• bluntblunt == spleenspleen  liverliver  bowelbowel •• SWSW == liverliver  bowelbowel  diaphragmdiaphragm •• GSWGSW == bowelbowel  coloncolon  liverliver Exam:Exam: AbdominalAbdominal InjuriesInjuries

•• DiagnosticDiagnostic tools:tools: •• FASTFAST examexam  bloodblood inin thethe abdomen?abdomen? •• PlainPlain filmfilm  retainedretained bullet?bullet? •• DPA/DPLDPA/DPL  blood?blood? bowelbowel contents?contents? •• CTCT scanscan  specificspecific injury?injury? BluntBlunt AbdominalAbdominal TraumaTrauma

Hemodynamically Stable

No Yes

FAST + Peritonitis?

Yes Yes No Equivocal

+ DPA LAPAROTOMY FAST +

Yes No

Abdominal CT Yes Indications for CT: No Repeat FAST -Altered mental status in 30 minutes -Confounding injury -Gross hematuria -Pelvic fracture -Abdominal tenderness -Unexplained Hct<35% PenetratingPenetrating AbdominalAbdominal TraumaTrauma

Hemodynamically Unstable

Anterior Penetrating Abdomen Abdominal GSW RUQ Trauma Tangential Back/Flank CT CT + Scan Operating Hemodynamically Room Stable

Back/Flank

SW + AASW Serial with Exams + LWE Exam:Exam: AbdominalAbdominal InjuriesInjuries

BluntBlunt liverliver injury:injury:

PenetratingPenetrating liverliver injury:injury: Exam:Exam: AbdominalAbdominal InjuriesInjuries

BluntBlunt spleenspleen injury:injury: Exam:Exam: AbdominalAbdominal InjuriesInjuries

BluntBlunt pancreatic/duodenalpancreatic/duodenal injury:injury: Exam:Exam: AbdominalAbdominal InjuriesInjuries

BluntBlunt bowelbowel injury:injury: Exam:Exam: AbdominalAbdominal InjuriesInjuries

PenetratingPenetrating vascularvascular injury:injury:

SW to inferior vena cava GSW to left external iliac artery Exam:Exam: PelvicPelvic InjuriesInjuries

•• ExamExam •• stablestable pelvicpelvic ring?ring?

•• PelvisPelvis filmfilm •• intactintact circle?circle? •• ramirami intact?intact? •• acetabulumacetabulum smooth?smooth? Exam:Exam: PelvicPelvic InjuriesInjuries

•• IfIf patientpatient hashas aa pelvicpelvic fracturefracture •• rectalrectal examexam  bonybony fragments?fragments? •• vaginalvaginal examexam  lacerations?lacerations? •• GUGU examexam  bladder/urethralbladder/urethral injury?injury? •• perinealperineal examexam  degloving?degloving? PelvicPelvic FractureFracture KCPKCP

FAST Exam

Positive Negative

Operating Room 2 units PRBCs/ED trauma bay

HD Unstable Laparotomy, Pelvic Fixation, HD Stable Pelvic Packing

Operating Room Hemodynamically Stable? Yes No SICU +/- CT scans** Pelvic Fixation and Pelvic Packing

Angiography Ongoing Transfusion Requirements?

Yes SICU No ** normalize coagulation status, Angiography abdominal CT scan if no laparotomy done. SICU Exam:Exam: ExtremityExtremity InjuriesInjuries

•• ExamExam •• deformity?deformity? •• openopen fracture?fracture? •• intactintact motor/sensorymotor/sensory exam?exam? •• pulses?pulses?

•• StopStop bleedingbleeding withwith pressurepressure •• MeasureMeasure AA--AA gradientgradient •• Traction/splintsTraction/splints 22ºº SurveySurvey:: TakeTake HomeHome PointsPoints

•• SystematicSystematic evaluationevaluation •• RecognizeRecognize andand treattreat lifelife threateningthreatening injuriesinjuries •• OngoingOngoing resuscitationresuscitation •• DiagnosticDiagnostic teststests •• WatchWatch forfor pitfallspitfalls TheThe SecondarySecondary SurveySurvey

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