High Yield Topics of the ABSITE: Trauma/Critical Care

Jacob D. Edwards, MD

PGY-6

East Carolina University

Vidant Medical Center

Outline• Trauma

• Head• Neck• Chest• Abdominal• Retroperitoneal• Pelvic• Extremity• Pregnacy

• Critical Care• Ventilator management• ARDS• Hemodynamic monitoring and

parameters• Shock• Cardiovascular Pharmacology• Nutrition• AKI/ARF• Indications for hemodialysis

Trauma

Head Trauma

• GCS calculation

• Indications for Head CT• Penetrating trauma

• CSF from Nose or Ears

• Hemotympanum

• EtOH/Drugs

• AMS or depressed GCS

• Focal Neurologic signs

Feature Response Score

Motor Follows Commands 6

Localizes to pain 5

Withdraws to pain 4

Flexion w/ pain (decort) 3

Extension w/ Pain (decer) 2

No response 1

Verbal Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

No response 1

Eye opening

Spontaneous 4

Open to command 3

Open to pain 2

No response 1

Head Trauma

• Epidural hematomaMiddle meningeal artery• LOClucid perioddeterioration

• Operate for MLS>5mm

• Subdural Hematomabridging veins/venous plexus• Operate for MLS >1cm

• Intraventricular hemorrhage• Cause Hydrcephalusventriculostomy

• DAI• MRI>CT

• If elevated ICPcraniectomy

Photo credit: Medscape.com

Head Trauma• ICP Monitors

• Brain trauma foundation• GCS <9 w/ abnormal CT• Normal CT w/ GCS <9 and >40 yo or posturing or hypotensive

• Peak ICP 48-72hrs after injury

• CPP = MAP – ICP

• ICP management >20mmHg (newer guidelines >22mmHg)• Goal to obtained CPP >60• Raise HOB• Relative Hyperventilation• Hypertonic Saline bolus: Na goal 140-150, Osm 295-310• Mannitol (loading dose 1g/kg, then 0.25g/kg q4H)• Sedation• Paralysis• Barbiturate coma• Craniotomy/Craniectomy

Head Trauma

• Common Associations• Basilar Skull fxraccoon eyes/Battle’s sign (facial nerve injury)

• Temporal Skull FxCN VII (geniculate ganglion) and VIII

• Brain injuryincrease tissue factor releasecoagulopahtic

Neck Trauma

• C-spine• C1 burst fx = Jefferson Fracture TX: rigid collar• C2 Hangmans TX: traction/halo• C2 odontoid fx

• Type 1 = above the base (stable)

• Type 2 = at the base (unstable) Tx: Fusion/halo• Type 3 = extension in to body (unstable) Tx: Fusion/halo

• Facet fxcord injury w/ ligamentous disruption

• MRI to eval cord/ligamentous injury

• Surgical decompression of cord if progressing neuro symptoms or open fractures

Neck Trauma

• Historically based on zone of injury• Zone 1 (Clavicle to cricoid) = CTA, Bronch, EGD, Barium Swallow (if operative,

then sternotomy)

• Zone 2 (cricoid to angle of mandible) = Neck exploration in OR

• Zone 3 (angle of mandible to skull base) = CTA, laryngoscopy (if operative, may have to sublux mandible and dived the digastric and SCM)

• Now based on hard signs of bleeding, airway injury, or esophageal injury• Shock, arterial bleeding, expanding hematoma, subq air, stridor, dysphagia,

hemoptysis , neuro deficit

Neck Trauma

• Esophageal Injury (hard to find/diagnosis)• EGD, Barium swallow (get both)

• Contained Injuries can be observed

• Noncontained Injuries• Primary closuresmall and minimal contamination

• Wide drainage (Cervical esophagus) extensive injury or contamination (Left Side approach)

Neck Trauma

• Tracheal or Laryngeal injury• Secure airway (cric)

• Take to OR—convert cric to trach

• Thyroid injury• NO thyroidectomy, just drain

Chest Trauma

• Chest tube—When to go to the OR• >1500ml initially

• >250ml/h for 3 hours

• >2500ml/24hr

• Instability

• Drainage after 48hours increase risk of:• Fibrothorax

• Entrapment

• Infected hematoma

Chest Trauma

• Tracheobronchial injuries• Worse oxygenation after placement of chest tube, may need to clamp chest

tube

• Right side more common

• Consider mainstem ventilation

• Dx: Bronch

• Tx: immediate repair if large air leak or respiratory compromise, OR if persistent air leak for 2 weeks

Chest Trauma

• Diaphragm• Left most common

• Air-fluid level in chest from herniated stomach (CXR)

• Operative approach• <1 weektransabdominal

• >1 weekTransthoracic

• Depending on size may need mesh repair

Chest Trauma

• Aortic Transection• Widen mediastinum, 1st/2nd rib fx, apical capping, loss of the aortic knob, left

hemothorax, tracheal deviation to right

• Location: ligamentum arteriosum, aortic root, diaphragmatic hiatus

• Dx: CTA chest

• OR: left thoracotomy with partial left heart bypass or if distal injuryendograft

• Treat other life-threatening injuries first (i.e. if +fast and hypotensive gets ex lap first)

Chest Trauma

• Penetrating “Box” injuries• Dx: pericardial window/FAST, bronchoscopy,

esophagoscopy, barium swallow

• +pericardial FASTPericardial window if bloodSternotomy

• Penetrating Thoracoabdominal injuries • Laparotomy/laparoscopy

Chest Trauma

• Operative Approcaches

• Right Thoracotomy• Right mainstem bronchus• Trachea• Proximal left mainstem bronchus• Upper 2/3 of the esophagus• Right hemidiaphragm

• Left Thoractomy• Distal left mainstem bronchus• Descending Aorta• Lower 1/3 of the esophagus• Left subclavian artery

• Median Sternotomy• Ascending Aorta• Innominate Artery/Vein• Proximal Right Subclavian• Proximal Left Common Carotid• Heart

• Midclavicular incision w/ resection of medial clavical• Distal right subclavian artery

Abdominal Trauma

• Small Bowel (Most common hollow viscus injury with penetrating)• CT scan: free fluid with no solid organ injury, bowel wall thickening,

mesenteric stranding/hematoma

• If no peritonitis: serial exams, +/- repeat CT in 8-12 hours

• Repair Rules• >50% of circumference or reduction of luminal diameter to <1/3 normal Resection

• Multiple close lacerationsresection of segment

• Mesenteric hematoma• Explore if expanding or if >2cm

Abdominal Trauma

• Colorectal• Right colon and Transverse colon primary repair or resection with

anastomosis

• Left colonprimary repair or resection • If in shock or has extensive gross contamination temporize with end colostomy/mucus

fistula or diverting loop ileostomy

• High rectal• Intraperitonealrepair defect and diverting ileostomy

• Extraperitoneal general not accessablediverting ileostomy

• Low rectal• Repair transanally

Abdominal Trauma

• Liver • If need Common hepatic artery can be ligated

• Collateral supply via the GDA

• Okay to temporize with packing and temporary abdominal closure to allow time for resuscitation

• Retrohepatic IVC injury may need atriocaval shunt

• Lacerations• Failure of conservative management if:

• Unstable vitals despite resuscitation including >4 units PRBC

• Active blush/pseudoaneurysm on CT

• Posteriorangio

• AnteriorOR

Abdominal Trauma

• CBD injury• <50% circumference repair over stent

• >50% circumference choledochojejunostomy

• Leave drains

• Portal Vein Injury• Okay to transect pancreas to access the injury (later will need distal

pancreatectomy)

• Ligation of portal vein = 50% mortality

Abdominal Trauma

• Spleen• Failure of conservative management

• Unstable despite resuscitation including >2 units of PRBC

• Post splenectomy sepsis up to 2 years after splenectomy

• Post splenectomy vaccines• H.flu, meningococcal, pneumococcal

Retroperitoneal Trauma

• Duodenum• Blunt mechanism, 2nd portion near ampulla or near ligament of Treitz

• Morbidity: Fistula

• Hematoma most common in 3rd portion—if in OR open it if >2cm

• Hematoma on CT (commonly missed/delayed presentation)• SBO symptoms 12-72 hours post injury

• UGI series shows “stack of coins”

• Tx: NGT, TPN for 2-3 weeks

• Operative Management• Debridement and primary closure, wide drainage, okay

to resect with end-to-end anastomosis, except for the 2nd

portion

• 2nd portionjejunal serosal patch, pyloric exclusion, GJ

Feeding, wide drainage, NGT

Retroperitoneal Trauma• Pancreas

• CT: edema or necrosis of peripancreatic fat

• Contusion: if already in OR leave drain

• Distal pancreatic duct injurydistal pancreatectomy

• Pancreatic head duct injury• Wide drainage

• Delayed Whipple or ERCP for stenting

• Hematomas (Blunt mechanism)• Zone 1—Aorta/IVC—always explore

• Zone 2—Kidneys/Flank—explore if expanding

• Zone 3—Pelvic—explore if expanding

Retroperitoneal Trauma• Renal

• Hematuria CT with delayed phase imaging

• Anatomy VAP (vein, artery, pelvis)

• If already in OR• Blunt mechanism hematoma—explore

only if expanding

• Penetrating mechanism hematoma—explore all

• Ureteral• >2 cm injury Upper 2/3 temporize

with nephrostomy, tie off ureteral ends

• >2cm injury Lower 1/3 reimplant onto bladder (Psoas Hitch/Boari Flap)

• <2cm mobilize and primary anastomosis over stent

• Leave drains

• Blood supply• Upper 2/3 = medial

• Lower 1/3 = lateral

• Bladder• Extraperitonealfoley 7-14 days

• IntraperitonealOR 2 layer closure, foley

Extremity trauma

Trauma in Pregnancy

• Mother first

• 1/3 volume loss without any signs

• Placental abruption>50% fetal mortality• Kleihaur-Betke test—test for fetal blood in maternal circulation

• Uterine ruptureposterior fundus• Fluid resuscitation only, let the uterus contract down after delivery

• Indications for C-section if in OR already• Persistent maternal shock, GA >34 weeks• DIC• Unable to access life threatening injury due to gravid urterus

Critical Care

Pulmonary• Compliance

• Decreased with: ARDS, fibrotic lung disease, pulmonary edema, atelectasis

• PEEP (affects oxygenation)• Alveolar recruitmentimproves FRC• Excessive PEEPpreload reduction and reduction in CO

• Rate and Volume affect CO2 (ventilation)• 6cc/kg of IBW = set TV for lung protective strategy

• FiO2 <60% to reduce free radicals • Barotraumaplateau pressure >30, peak pressures >50• Dead Spacelow CO, PE, pulm HTN, ARDS• ARDS

• Due to PMNs *Berlin Criteria: Timing w/in 1 week, CXR-bilat • Increased A-a gradient whiteout, cardiogenic cause r/o, PF ratio <300• Pulmonary shunting <300 = mild; <200 = mod; <100 = severe

Pulmonary

• Aspiration• pH<2.5

• Medelson’s syndromechemical pneumonitis

• Pulmonary vasoconstriction• Hypoxia, Acidosis, TXA2

• Pulmonary vasodilation• PGE1, Prostacylcin, bradykinin, alkalosis

Pulmonary Function

FRC is decreased by reduction in compliance-ARDS-Atelectasis-contusions

Restrictive Lung Disease--Low TV--Low RV--Low FVC--Normal FEV1

Obstructive Lung Disease--high TV--High RV--normal FVC--Low FEV1

Cardiovascular• Shock

• Normal Parameters• CO = 4-8

• CI = 2.5-4

• SVR = 800-1400

• PCWP = 7-15

• CVP = 5-9

• PAP = 20-30/10

• SvO2 = 70-80

• Increase SvO2 shunting, sepsis, cirrhosis, cyanide toxicity

• Decrease SvO2 low hemoglobin, cardiogenic shock

Cardiovascular

• Oxygen Delivery• CO x CaO2 x 10

• CaO2 (arterial O2 content)• Hgb x 1.34 x O2 sat + (PaO2 x0.003)

• Hemoglobin most important factor

• Oxyhemoglobin dissociation Curve• Right shift (unloading)

• Hypercarbia, fever, 2,3-DGP, acidosis

Cardiovascular

• Receptors (all g-protein coupled)• Alpha 1&2vascular smooth muscle contraction

• Beta 1myocardial contraction, HR

• Beta 2relaxes vascular smooth muscle

• Doparelax renal and splanchnic smooth muscle

• Drugs• Dopalow dose dopa, mod dose Beta, high dose alpha

• DobutamineBeta-1

• PhenylephrineAlpha-1

• Norepi/EpiBeta 1, Alpha 1&2

GI/Nutrition

• Respiratory Quotient• >1.0overfeeding• 1.0 carbohydrate oxidation• 0.8protein oxidation• 0.7fat oxidation• <0.7starvation (ketosis)

• Calories• Goal 25 kcal/kg/day• Fats 9kcal/g• Protein 4kcal/g• Carbs4kcal/g• Dextrose3.4kcal/g

• ColonocytesSCFA (acetate/butyrate)

• Enterocytesglutamine

• Chyle leakMCFA diet

• Essential FAalpha linolenic and linolenic (omega 3 and 6)

• Fat Soluble VitADKE

• Refeeding• EtOH, Malnutrished, Starved• Hypophosphatemialow ATPRespiratory

distress

Renal

• AKI w/ oliguria• FeNA <1% pre renal; >3% renal

• Indications for HD• Acidosis, Electrolyte abnormalities, Intoxication, Fluid overload, Uremic

encephalopathy

• Renal toxic drugs• Aminoglycosides

• Myoglobin (alkalinize the urine)

• Vancomycin

• Contrast dyes

Thank you!