IDENTIFYING LIFE THREATENING INTERNAL INJURIES ON THE FIELD JARON SANTELLI, MD PRIMARY CARE SPORTS MEDICINE FELLOW EMERGENCY MEDICINE PHYSICIAN UNIVERSITY OF MARYLAND/MEDSTAR DISCLOSURES No financial disclosures GOALS: • Identifying tools at your disposal both on the field and in the training room • Discuss the primary and secondary survey • Identifying a handful of cardiac, pulmonary and gastrointestinal life threatening injuries • Identify possible life-saving interventions WHAT ARE THE BASIC ASSESSMENT TOOLS THAT YOU HAVE? OBJECTIVE INFORMATION • General Appearance • Vitals • Exam: Primary and Secondary Survey • Supplemental Tools VITALS • Heart Rate • Blood Pressure: BP cuff • Respiratory Rate • Oxygen Saturation • Temperature: Oral or Rectal EXAM A: Airway If they are talking to you this is intact B: Breathing Auscultation, watch for chest rise, equal bilateral C: Circulation Auscultate, assess pulses, especially at site of injury, bleeding D: Disability GCS, spine board, obvious trauma E: Environment PrimarySurvey Assess for safety, temperature EXAM HEENT: Oropharynx, bleeding, foreign body CV: Heart sounds quieter then normal? Fast or slow, regular or irregular, murmur? Are pulses equal left and right? PULM: Do you hear breath sounds bilaterally, are they equal? Labored, fast or slow, wheezing/crackles/rhonchi? GI/GU: External injuries or bruising? Tenderness/guarding/mass/rigidity? GU Inspection? SecondarySurvey* *Limited to scope of lecture SUPPLEMENTAL TOOLS • Blood Glucose • Urine: gross and dip stick • Basic Chemistry • Ultrasound THE MEET AND POTATOES RECOGNIZING EMERGENCT CONDITIONS EMERGENT CONDITIONS 1. Identify sick or not sick 2. Identify potential life threatening situations 3. Identify trends 4. RE-EVALUATE CARDIOVASCULAR PROBLEMS • Cardiac Arrest/Commotio Cordis1: • V fib/sudden death after blunt chest trauma • TX: CPR, defibrillate • Transfer to ED • Prevention: not realistic presently http://lifeinthefastlane.com/commotio-cordis/ CARDIOVASCULAR PROBLEMS • Hemorrhagic Shock: http://lifeinthefastlane.com/ccc/major-haemorrhage-in-trauma/ CARDIOVASCULAR PROBLEMS • Hemorrhagic Shock, con’t • If you suspect shock there is blood loss. FIND IT! • “Blood on the floor and 4 more” o Abdomen, Chest, Pelvis, Thigh • Treatment includes o Pressure to slow bleeding o IV fluids • Cardiac Tamponade • Bleeding into the sac around the heart • Beck’s Triad: o Decreased/quiet heart sounds o Hypotension o Distended neck veins • Treatment includes o BP support with fluids o Pericardiocentesis GI PROBLEMS Think SPLEEN and LIVER GI PROBLEMS In general think about • Mechanism, Inspection, Palpation, Auscultation • Direct impact • Crush injury/ compression • Deform solid/ hollow organs • Deceleration • Shear injury All can lead to life threatening internal injuries GI PROBLEMS • Blunt Abdominal Trauma • Vitals: Tachycardia, Hypotension stages of shock • Inspection: o Gray-Turner’s and Cullen’s Sign are late findings (>12 hours) o Kerh’s Sign: referred pain to the shoulder from ANY diaphragm irritation o Left shoulder is affected in splenic injuries classically o Seagasser’s Sign: neck pain referred from phrenic nerve pressure o Hematuria or Hematochezia CULLEN’S & GREY-TURNER’S SIGN Canadian Medical Association Journal Photo GI PROBLEMS • Blunt Abdominal Trauma, con’t • Palpation: o Local and generalized rebound tenderness, rigidity o Dullness to percussion of flank that is not affected by position; Ballance’s Sign (uncommon) o Palpable mass • Auscultation o Markedly decreased bowel sounds (subacute) • Treatment includes o 2 large bore IV’s o Fluids o Transfer to ED PULMONARY PROBLEMS • Pulmonary Arrest • Per BLS, support with O2, Definitive Airway • Pneumothorax/Tension Pneumothorax • Part or all of lung has collapsed spontaneously or with trauma • Complaints: chest pain, dyspnea • Vitals: hypoxia, tachypnea, tachycardia, normal BP hypotension (with tension pneumo) • PE: o Labored breathing, dyspnea o Auscultation: decreased breath sounds on the affected side o Tracheal deviation away from affected side (tension pneumo) • TX: o O2, needle decompression, ED TENSION PNEUMOTHORAX http://www.fprmed.com/Pages/Trauma/Tension_Pneumothorax.html TENSION PNEUMO: XRAY http://regionstraumapro.com/post/457670048 NEEDLE DECOMPRESSION: TENSION PNEUMO http://www.emsworld.com/article/12041960/whats-the-best-site-for-needle-decompression WHAT’S NEXT….. ULTRASOUND • E-FAST • No literature looking into the role of ultrasound on the sideline or in the training room (OPURTUNITY!!) • Barriers to use • Cost of machine • Training/user dependent • Power • Benefits • Immediate identification of life threatening internal injuries • Procedural Assistance EFAST: MORRISON’S POUCH, RUQ The positive exam (red arrows) indicates hemoperitoneum in the setting of trauma. A B E-FAST: PNEUMOTHORAX Looking for lung sliding and “sandy beach pattern” to indicate a normal exam (A) Rib Rib E-FAST: PNEUMOTHORAX Comet Tails, normal lung. Loss of these indicates loss of pleural sliding/pneumo. REFERENCES 1. Maron, B. & Estes, M. (2010). Commotio Cordis. The New England Journal of Medicine. 362(10), 917-927. 2. Stevens RL, et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care, 2009 Jan-Mar; 13(1): 14–7. 3. Rawlins R, et al. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J, 2003 Jul; 20(4): 383–4. 4. Montoya J, Stawicki SP, Evans DC, Bahner DP, Sparks S, Sharpe RP, et al. From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment. Eur J Trauma Emerg Surg. 2015 Mar 14. 5. http://lifeinthefastlane.com 6. http://www.emsworld.com .