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Home , Abdominal trauma, Stabbing, Stab wound, Wound

Trauma case reviews Lisa Yosten MD, FACEP Assistant Medical Director, Director of EMS Case #1

 EMS bringing “stab ” to , 2 am  “10 inch knife”  Full trauma alert activated  25 y/o hispanic male stabbed left lower flank and left upper quadrant, intoxicated  GCS 14, verbalizing, not cooperative.  VS: 90, 140/80, 26, 95% RA  Physical exam: 2 lacerations, 4-5 cm each, oozing  mid axillary line, 9-10th intercostal space  Left upper quadrant Case #1

 Physical exam  slightly diminished on left  2+ pulses in extremities  Abdomen: tense, firm, difficult to determine tenderness due to patient’s intoxication  Back: no evidence of  Treatment  IV’s placed, NS bolus started  FAST exam (focused abdominal sonography in trauma) performed by ER physician: questionable for fluid around to abdomen

Stab wound to abdomen

 Vitals stable after primary, secondary survey, airway intact  Portable chest x-ray: small on left with small pleural effusion  CT scan chest/abdomen/pelvis: 9th left , and 20% left pneumothorax, perforation of colon, , hemoperitoneum  Labs: Bicarbonate 21, glucose 108, creatinine 1.3, EtOH 148, HGB 12.6, UA neg, drug screen neg. INR normal.  Decision to proceed to OR

Stab wound to abdomen OR management

 Left chest tube placement for hemo/pneumothorax

 Exploratory  Stab wound through transverse colon-partial colectomy with anastamosis  Control of mesenteric vascular  Repair of left hemidiaphragm laceration

 Patient stabilized

 Post operative complication:  in pleural fluid (empyema)  Leaking from colon anastomosis  Back to OR for iliostomy  Requiring TPN  Massive transfusion ATLS: stab to abdomen

 Most commonly affected organs  Liver (40%)  Small bowel (30%)  Diaphragm (30%)  Colon (15%)

 Most commonly affected organs with GSW to abdomen  Small bowel (50%)  Colon (40%)  Liver (30%)  Abdominal vascular structures (25%)

OR or not??

 History, knife length?  Exam: signs of ?  Vitals: Hypotensive?  FAST exam positive?  DPL (diagnostic peritoneal lavage) positive?  Stable patient, CT findings?  to back/flank less likely to have to go to OR due to deep muscle presence. OR guidelines

 98% of GSW to abdomen require laparotomy

 60% of stab wounds that penetrate anterior have hypotension, peritonitis, or evisceration of omentum and/or small bowel that would necessitate going to OR for exploratory laparotomy. Evisceration : OR guidelines

 Blunt abdominal trauma with hypotension and positive FAST with evidence of intraperitoneal bleeding  Blunt or penetrating abdominal trauma with positive DPL  Hypotension with penetrating abdominal wound  GSW transectiong or visceral/vascular retroperitoneum  Evisceration  Bleeding from , rectum or GU tract from Abdominal trauma: OR guidelines

 Peritonitis

 Free air, rupture of hemidiaphragm

 CT positive for ruptured GI tract, intraperitoneal bladder injury, renal pedicle injury, or severe solid injury

Case #2

 27 y/o male transferred from critical access by Life net with left hand  Right hand dominant  Amputation at wrist by wood cutter  PMH/PSH: none. SH: positive for smoking  VS : 151/98, 98.7, 94, 22, 96% on 2 liters nasal cannula  IV present in right arm: 300 mcg Fentanyl, 4mg IV Zofran, 2 grams IV Ancef, Versed, 1 liter NS bolus  Tetanus up to date  Tourniquet removed in ER: no active bleeding  Hand consult: To OR Hand amputation OR

 Reimplantation of hand  Proximal row carpectomy  Fasciotomies  Reattachments of tendons, nerves, vessels

 Back to OR following day for left ulnar thrombosis.

 Hospitalized for 2 weeks

Amputations

 If transferring a patient with amputated part  Stop bleeding  Direct pressure is favored over tourniquet  IV for pain control,  Tetanus updated if needed  Judicious IVF (more IVF, more bleeding)  Make NPO  Send the detached part wrapped in gauze and “on ice”, not “in ice”  Tissue survival time 6 hours if not cooled, 12 hours if cooled Reattachment procedures

 Factors favoring successful reattachment  Multiple fingers involved and/or thumb of dominant hand  Younger patient without co-morbidities  Nonsmoker  Clean severed amputated part vs. tearing or crushed tissue Steps in Reattachment

 X-raying and cleaning amputated part  Debriding dead tissue  Tagging nerves, blood vessels, and tendons with special surgical clips  Trimming bone from amputated part, fixing it with K-wires, and stabilizing it to extremity  Repair flexor and extensor tendons  Repair lacerated , veins and nerves  Use of vein grafts for blood vessels that cannot be reattached  Splint the extremity and elevate

Following reattachment

 Constant monitoring of tissue perfusion  may be used to increase blood flow, reduce anxiety, and for anti-coagulation  Long term PT/OT  Success  Good nerve recovery  >50% ROM of joint  Acceptable cosmetic results  Most likely will have cold intolerance in extremity

Complications

 Poor perfusion to reattached part

 Infection

 Need for further due to adhesions, scarring, infection, poor circulation

Case #3

 31 y/o male transferred after fall from zip line, 41 feet into 6 feet of water, landing on buttocks. No LOC. Pt c/o left hand, wrist and buttock pain  BLS transport with cervical and T/L/S immobilization  PMH: Lumbar fracture with after MVC rollover  Lawnmower injury with traumatic right great toe amputation  SH: positive for alcohol (8 beers) Fall from height Case #3

 ED arrival 1730  128/90, 89, 16, 95% on RA  GCS 15, Awake, Oriented x 3  Fully immobilized on backboard with cervical collar  Chest wall abrasions on exam and pelvic tenderness but no instability  Normal neurological and vascular exam  No abdominal tenderness, FAST exam negative  No cervical, TLS tenderness Case #3

 IVF, Morphine 4mg IV x 4, Fentanyl 100mcg, Zofran 4mg IV, tetanus updated, Rocephin 1 grams

 Xrays  Left hand/wrist: positive for angulated and shortened distal radius fracture, comminuted distal phalanyx 4th finger  Pelvis: superior right pubic rami fracture extending into right acetabulum  Chest: patchy opacities middle lobe and left base  Cervical/TLS spines: negative

Acetabular fracture Distal radius/ulna fracture Case #3

 CT abdomen/pelvis: inferior left laceration with surrounding, pubic rami fractures with adjacent , right medial acetabular fracture, fracture and left SI joint involving the lateral sacrum medial ilium

 CT chest: pulmonary contusions

 CT head: mildly displaced fracture inferolateral wall left maxillary sinus

 CT cervical: negative for fracture

Case #3

 Left wrist fracture splinted  1900 decision to transfer to UNMC for trauma  Life net unable to fly  Ground transport arranged  Ground transport cancelled as UNMC Life Net to fly  2015 Life net lands and pt transferred to UNMC  (2 hours 45 minutes in ER)  Decision to transfer  Acetabular fracture  Multi-organ system trauma Repair of acetabular fracture Case #3

 UNMC follow up  Pt went to surgery for ORIF of wrist fracture  Admitted five days, discharged home  Pelvic fractures non-operative  Non-weight bearing right lower extremity and weight bearing as tolerated for left lower extremities for transfers only  Wheelchair  Also found to have Grade 1 spleen and liver lacerations managed non-operatively

Pelvic Fractures

 Types  Closed fracture  Lateral compression 60-70% frequency  MVC  Falls  Internal rotation of involved hemipelvis  Pelvic volume decreased so life-threatening hemorrhage not common  Open book fracture  Anterior-Posterior compression (15-20%)  Auto-pedestrian collision  Motorcycle crash  Direct to pelvis  Fall from > 12 feet

Pelvic fractures

 Open book pelvic fracture  Disruption of symphysis pubis, tearing of posterior ligaments represented by sacroiliac fracture  Opening of ring can lead to hemorrhage from pelvic venous complex and/or internal iliac artery  Sheet or pelvic binder recommended for unstable pelvis fracture  Vertical shear fracture  5-15% frequency  High energy force in vertical plane  Major pelvic instability  Most likely from fall from significant height Anatomy of pelvic bones Closed pelvic fracture Open book pelvic fracture Open book pelvic fracture Vertical shear Decision tree

Embolization of pelvic vessels Embolization of pelvic vessels

 Overall, 7-11% of pelvic fractures will require embolization

 Lateral compression fractures  2% need embolization due to arterial injury

 Open book (anterior-posterior compression), vertical shear or combined fractures  20% require embolization Transfer to trauma hospital

 Significant resources required to care for patients with severe pelvic fractures

 Early consideration of transfer to is essential  Trauma orthopedics  Interventional  Multi-specialty as high likelihood of other Case #4

 87 y/o female, chief complaint “weakness” brought to ER by family  Symptoms x 3 days.  Initially strained hip getting into car, left hip/leg pain  Today, fell forward from swivel chair, caught arms and landed prone. No LOC  Feels dizzy and weak since, questionable syncope for several seconds at home today  Difficulty with speech, slurred and expressive aphasia  PMH: chronic atrial fibrillation, , HTN remote breast cancer

Case #4

 Medications  Coumadin among many others

 ER  130/66, 98, 70, 20, 100% RA  c/o 10/10 hip/leg pain

 Exam  No obvious head injury  No cervical spine or TLS tenderness  Lungs clear  irregular rhythm, rate normal 70, no murmur  Extremities: mild left ankle tenderness, no swelling; left hip tender and pain with ROM of leg. No pain with internal/external rotation. Normal pulses

Case #4

 Neurological: Awake and alert, sleepy but would wake easily  Rectal: grossly guaiac positive  Labs  Hgb 8.8, Creat 1.6, Gluc 380, LFT’s 2-3 x normal, INR no clot detected (INR > 18)  X-ray pelvis and left hip: normal  X-ray left ankle: avulsion fracture off medial malleolus  CT head: large left subdural hematoma with midline shift

Subdural Hematomas Ipsilateral dilated pupil: herniation Case #4

 IV Morphine 2mg, Zofran 4mg given

 Pt with slurred speech, more sedate

 INR > 18, hgb 8.8 and grossly guaic pos stool (GI bleeding)

 Vitamin K 10mg IV

 FFP 4 units

 Transfer to neurosurgical center: UNMC Burr Hole for evacuation Burr Hole for evacuation Craniotomy Indications for Head CT in trauma

 Altered level of consciousness

 Neurological signs  Severe headache, persistent , numbness, weakness on one side, slurred speech, facial droop

 Mental status difficult to evaluate  , drug and alcohol intoxication, young children

 Low index of suspicion in elderly patients with minimal trauma and on anticoagulants

FRHS warfarin reversal protocol

 INR 5-9 without bleeding  Vitamin K (Mephyton) 2.5mg PO once  INR > 9 without bleeding  Vitamin K (Mephyton) 5mg PO once  Perioperative Non-Urgent  Vitamin K 10mg IV once  Life Threatening bleeding, add Kcentra  INR 2 -<4: Kcentra (prothrombin complex concentrate) 25 units/kg IV once  INR 4-6: Kcentra 35 units/kg IV once  INR >6: Kcentra 50 units/kg IV once KCentra

 Contains Vitamin K dependent coagulation factors II, VII, IX, and X (prothrombin complex) and the antithrombotic Protein C and Protein S.

 Made specifically to reverse warfarin in patient with acute major bleeding

 FDA approval randomized controlled trial  FFP and Vitamin K  Kcentra and Vitamin K KCentra

 More likely to stop acute bleeding at 24 hour endpoint (72.4% of Kcentra vs 65% FFP)  Faster reduction of INR (down 1.3 in 30 minutes in 62% of patients vs. 9.6% of FFP patients)  Kcentra infusion produced a rapid and sustained increase in plasma levels of clotting factors within 30 minutes post treatment with 87% less volume than FFP.  Common reactions: Headache, /vomiting, arthralgia, hypotension. Most severe is thrombotic events (CVA,PE,DVT) Case #4 outcome

 Transfer UNMC  Neurosurgery consulted  Reversal of warfarin coagulopathy  Non-operative management of SDH  MRI brain showed midbrain CVA  Orthopedics  Ankle fracture nonoperative  GI consulted due to high bilirubin  CT abdomen showed pancreatic mass, ERCP performed, biopsy done and stent placed  Patient discharged to skilled nursing facility

Case #5

 40 y/o female pedestrian struck

 Walking on side of county road, arguing with significant other. S.O. had parked car in middle of road. Car coming up behind them swerved to miss head on collision with parked car and hit patient. Pt was pinned under front passenger tire, laying prone. Right front tire was between her legs and left leg under engine block. Chest/abdomen was pinned under bumper. + LOC. Life net unable to fly to scene. BLS tiered with NFD ALS service.

Case #5

 C-collar, backboard  IV placed. Fentanyl given prehospital.  VS: 122/76, 98, 23, 95% on RA  Pt awake and alert, mildly confused. GCS 14  Exam:  HEENT: no scalp swelling, laceration. Left periorbital bruising. PERRLA 3mm bilaterally. Airway intact. Teeth decayed  Neck : in collar. NO c-spine tenderness Case #5

 Respiratory: lungs clear

 CV: RRR, Lungs clear bilaterally

 Abdomen: diffusely tender, no rebound/guarding

 Rectal: decreased tone, no blood

 MS: Midline and paraspinal lumbar tenderness, over lumbar spine. No pelvic tenderness

: 2cm left arm laceration, linear. 3rd degree linear on left lower extremity (2% BSA)

 Neuro: GCS 14. Alert. Disoriented to time. Short term memory loss. Both legs flaccid. Absent DTR’s patella. Sensory deficit to umbilicus. Pedestrian Struck

 IVF, Fentanyl, zofran, tetanus, monitor

 FAST exam negative in ER

 Labs: drug screen pos meth, HGB normal

 X-ray  C-spine lateral: neg to C7. posterior emphysema in neck  Pelvis: no fracture  Chest: Extensive emphysema in superior , neck, chest wall bilaterally. No PTX appreciated  Lumbar (one view, cross table lateral): no fracture

Pedestrian struck

 Consult to trauma center  Suspected pulmonary contusions vs. pneumothorax  Suspected  Suspected head injury  Multi-organ system trauma plus third degree burn

 Patient transferred by Life Net to UNMC Dermatomes: Spinal Cord Full thickness burn Pedestrian struck

 Transfer to UNMC  Findings:  T 10/11 dislocation resulting in paraplegia  Taken to OR for T8-L1 spinal fusion and open reduction of T 10/11 dislocation  Bilateral rib fractures and pneumothoraces requiring chest tube placement  4th degree to left leg requiring debridement  To follow up later regarding  Grade 1 thoracic aortic injury  Nonoperative

Pedestrian struck

 Multiple facial fractures  Nonoperative  Left posterior acetabular fracture  Nonoperative due to paralysis and non weight bearing  Grade II spleen laceration and Grade III liver laceration, bilateral renal infarcts and adrenal hemorrhage  Received multiple blood transfusions but remained stable thus nonoperative Pedestrian struck

 Admitted 5/28-6/26/14

 Transferred to Madonna for acute rehab Thoracic aortic injury

 Rapid deceleration by history

 Complete aortic transection = at scene

 Partial transections  Control blood pressure  Identify other causes of hypotension/bleeding  Surgical repair if actively bleeding Chest x-ray findings

 Wide mediastinum (> 8 cm at aortic arch)  Obliteration of aortic knob  Deviation of trachea to right  Depression of left mainstem bronchus  Deviation of esophagus to right  Left apical/ pleural cap  Left hemothorax  Fractures of 1st or 2nd rib or scapula Normal chest x-ray Suspicious for aortic injury Aortic injury

 Chest x-ray findings  40-60% sensitive and specific

 Chest CT  97-100% sensitive  83-99% specific Chest CT Types of injury Management

 Full thickness tear and are hemodynamically unstable  Chest tube placement with large volume blood loss  Over 1500 cc initially or 200 cc/hour x 2 hours of ongoing loss  Indication for thoracotomy  Evaluation for other injuries causing blood loss  Abdominal or pelvic trauma

 Partial thickness tear  Minor injuries such as small intimal flaps or small pseudoaneurysms are managed nonoperatively  Blood pressure control < 120 systolic

References

 Encyclopedia of Surgery. Finger Reattachment. Web site

 Trauma.org: Permissive Hypotension. Barry Armstrong. 10/02

 Trauma.org: Chest Trauma: Traumatic Aortic injury

 Advanced Trauma Life Support. American College of . 9th edition. 2012