10/17/2019 Trauma Killers 1 Objectives • Recognize components of the trauma triad of death • Identify interventions to manage life threatening conditions • Relate mechanisms of injury to types of injuries sustained in trauma • State the goal of post resuscitation care • Identify post resuscitative care of the trauma patient • Articulate benefits of a tertiary exam • Understand the psychosocial impact of trauma 2 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 blood loss 3 1 10/17/2019 Trauma Triad of Death 4 Hemorrhage • Blood on the floor x 4 more – Obvious Bleeding – Chest • Holds up to 3L – Pelvis/Retro‐ peritoneum • 2.5 L – Thigh • 1‐2 L – Abdomen 5 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 6 2 10/17/2019 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, Burns • 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 7 Hypothermia: Prevention • Warm the environment • Remove wet clothing or linens • Warm anything that touches the patient – Warm linens – Warm Fluids • Monitor temperature 8 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 acidosis • Slowed clotting • Decreased production of clotting factors – Dilutional Coagulopathy from Fluid Resuscitation and uncontrolled hemorrhage 9 3 10/17/2019 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 wounds, 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 surgery – aPTT and PT • Administer TXA as directed – INR 10 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 Pneumothorax or Cardiac Tamponade – 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) 11 Acidosis: Identification and Prevention Identification Prevention • ABGs • Provide adequate • Lactic Acid ventilation • Base Deficit • Avoid hypothermia • Identify WHY acidosis is happening‐TREAT IT! • Monitor labs • Monitor UOP 12 4 10/17/2019 Head Trauma • Blunt or Penetrating MOI • Risk Factors • Facial Trauma • Primary vs Secondary Injury 13 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 14 SDH‐ Treatment and Ongoing Assessement Treatment • Observation if <1 cm, and neurologically stable • Craniotomy if unstable or bleed is large 15 5 10/17/2019 EDH‐ Causes and Presentation • Direct blunt trauma (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 16 EDH‐ Treatment • Observation if less than 1 cm and neurologically stable • Craniotomy if unstable or bleed is large 17 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” 18 6 10/17/2019 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) 19 Cerebral Contusions • Close Neuro observation • Repeat head CTs • Craniectomy if needed 20 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 21 7 10/17/2019 Penetrating Head Trauma • Cerebral contusions, lacerations, intracranial hematomas • Extremely high mortality • Stabilize protruding objects • Surgical emergency 22 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 23 Head Trauma Post Resuscitative Care • Serial Neuros (GCS, Pupil exam, etc) • ICP Monitoring • VS Monitoring • Position head midline • Elevate HOB (if spinal precautions cleared) • Meds: – Mannitol – Hypertonic Saline – Anticonvulsants – Others? 24 8 10/17/2019 Chest and Neck Trauma • Contains heart, great vessels, respiratory system • Blunt Trauma to chest – MVCs, MCCs, ped vs auto account for > 50% of blunt chest trauma • Penetrating Trauma to neck/chest – Commonly assaults with firearms and stabbings in adults – Peds‐ falling on objects or MVCs 25 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 26 Aortic Injuries: Presentation and Identification • Presentation: – Interscapular pain – Dyspnea – Hypotension – Asymmetrical pulses or BPs – Paraplegia – Signs of shock – Wound to chest with significant penetration • Identification – Mediastinal widening on CXR – CT Scan 27 9 10/17/2019 Aortic Injuries: Treatment • Transfer out‐QUICKLY • Surgical Repair • Hemodynamic Support – MTP 28 Pneumothorax • Blunt Trauma – Air escapes from injured lung 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 29 Pneumothorax‐Treatment • Small PTX and stable pt – Observe • Unstable pt, large PTX, likely to deteriorate, air transport – Chest tube 30 10 10/17/2019 Pneumothorax‐ Post Resuscitative Care • Breathing Assessments – LS – Rate/Quality/Depth of Resp • Chest Tube – FOCA • Vented Patients – Watch them closely! 31 32 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!! 33 11 10/17/2019 Tension Pneumothorax: Treatment Immediate Treatment Definitive Treatment Needle Decompression Chest Tube Placement (Needle Thoracostomy) 34 Open Pneumothorax • Open wound to chest wall (stab wound, gunshot wound, 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 – Subcutaneous emphysema • Treatment – Immediate: 3 sided occlusive dressing – Definitive: Chest Tube, Wound closure 35 Hemothorax • Blood accumulates in intrapleural space • Causes‐ blunt or penetrating trauma with injury to: – Lungs – 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 36 12 10/17/2019 Hemothorax‐Ongoing Assessment • Chest Tube – FOCA • Contact Provider if: – Initial output > 500ml – Output > 200ml per hour x2‐4