Trauma – Part ITrauma – Part I

45 year old man is involved in a two 45 year old man is involved in a two vehicle MVC.vehicle MVC.

He is a single occupant trying to He is a single occupant trying to cross a highway when he is struck cross a highway when he is struck on the passenger side.on the passenger side.

When EMS arrives, the patient is When EMS arrives, the patient is unconsciousness and hypotensive.unconsciousness and hypotensive.

He is stabilized on a spine board, He is stabilized on a spine board, extracted from the car, has an IV inserted, extracted from the car, has an IV inserted, oxygen and transported to the hospital.oxygen and transported to the hospital.

Upon arrival, he has a blood pressure of Upon arrival, he has a blood pressure of 89/58, pulse of 124, respiratory rate of 28, 89/58, pulse of 124, respiratory rate of 28, and oxygen saturation of 89%.and oxygen saturation of 89%.

His GCS is 6 (Verbal = 2, Motor = 3, Eyes His GCS is 6 (Verbal = 2, Motor = 3, Eyes = 1).= 1).

What is your first priority?What is your first priority? Airway: patentAirway: patent Breathing: labored, trachea deviated to Breathing: labored, trachea deviated to

the left, no breath sounds on the rightthe left, no breath sounds on the right Circulation: Hypotensive. No external Circulation: Hypotensive. No external

bleeding found.bleeding found. Disability: GCS remains 6 with reactive Disability: GCS remains 6 with reactive

pupils. Does not move feet.pupils. Does not move feet. ExposeExpose

Based on the results on the primary survey, Based on the results on the primary survey, what are the next steps?what are the next steps?

After intubation, the patient’ s oxygenation After intubation, the patient’ s oxygenation improves to 92% on FiO2 100%.improves to 92% on FiO2 100%.

Two large bore IVs are inserted and 2 litres Two large bore IVs are inserted and 2 litres of Ringer’s and 2 units of PRBC are given of Ringer’s and 2 units of PRBC are given but the blood pressure only marginally but the blood pressure only marginally improves.improves.

Is it time for a central line?Is it time for a central line? A right chest tube is then inserted which A right chest tube is then inserted which

results in large escape of air and results in large escape of air and improvement in oxygenation and blood improvement in oxygenation and blood pressure.pressure.

The patient seems to have stabilized The patient seems to have stabilized somewhat. What is the next step?somewhat. What is the next step?

Describe the steps in a secondary survey.Describe the steps in a secondary survey. AMPLE history is unremarkable.AMPLE history is unremarkable. Pertinent positive on secondary survey:Pertinent positive on secondary survey:

GCS 6 and unchangedGCS 6 and unchanged Subcutaneous emphysema on right with chest Subcutaneous emphysema on right with chest

deformitydeformity Distended and rigid abdomen with left sided Distended and rigid abdomen with left sided

bruisingbruising No motor response in legs and no rectal toneNo motor response in legs and no rectal tone Extensive bruising on right side of body from Extensive bruising on right side of body from

head to pelvishead to pelvis

What would you do next?What would you do next? What is the role for DPL in trauma?What is the role for DPL in trauma? What about ultrasound?What about ultrasound? What about CT?What about CT? A series of x-rays are taken:A series of x-rays are taken:

What are the injuries obvious on the preceding What are the injuries obvious on the preceding scans?scans? Liver laceration with free fluidLiver laceration with free fluid Bilateral pneumothoraces with right chest tube (not visible Bilateral pneumothoraces with right chest tube (not visible

on the enclosed image)on the enclosed image) C spine fractureC spine fracture

After returning from the CT scanner, the patient’s After returning from the CT scanner, the patient’s blood pressure is 84/57, pulse is 112, and blood pressure is 84/57, pulse is 112, and saturations 94% on FiO2 100%.saturations 94% on FiO2 100%.

The RT states that the patient is getting harder to The RT states that the patient is getting harder to bag and the pressure alarm on the ventilator is bag and the pressure alarm on the ventilator is ringing. Both pneumothoraces have been ringing. Both pneumothoraces have been decompressed with chest tubes.decompressed with chest tubes.

What is going on and what should be done?What is going on and what should be done?

Before we rush off the OR, let’s stop Before we rush off the OR, let’s stop and consider other issues in and consider other issues in abdominal trauma.abdominal trauma.

What other organs could be injured What other organs could be injured in this MVC?in this MVC? Consider:Consider:

Diaphragmatic ruptureDiaphragmatic rupture Splenic lacerationSplenic laceration Renal injuryRenal injury Pelvic fracturePelvic fracture

A little segway…A little segway…

The radiology resident calls into the The radiology resident calls into the trauma room because the system trauma room because the system failed to send some of the x-rays to failed to send some of the x-rays to the viewer. The problem is now the viewer. The problem is now resolved but she wants to draw your resolved but she wants to draw your attention to one film in particular.attention to one film in particular.

What is wrong?What is wrong?

This patient is unstable and going to the OR for a This patient is unstable and going to the OR for a liver laceration.liver laceration.

What is the immediate treatment for a pelvic What is the immediate treatment for a pelvic fracture (open and closed)?fracture (open and closed)?

Should we wait for Orthopedics to see and assess?Should we wait for Orthopedics to see and assess? Let’s assume that there is no liver laceration and Let’s assume that there is no liver laceration and

no plans to go to the OR but he is still in the same no plans to go to the OR but he is still in the same condition. How would you manage the patient?condition. How would you manage the patient?

What other problems can arise from a pelvic What other problems can arise from a pelvic fracture?fracture? Consider:Consider:

Massive transfusion from ongoing bleedingMassive transfusion from ongoing bleeding Bladder injuriesBladder injuries Urethral injuriesUrethral injuries

Continuing our segway…Continuing our segway… Let’s talk about thoracic trauma in more detail.Let’s talk about thoracic trauma in more detail. What are the five conditions that should be What are the five conditions that should be

immediately addressed during the primary survey?immediately addressed during the primary survey? Breathing:Breathing:

Tension pneumothoraxTension pneumothorax Open pneumothoraxOpen pneumothorax Flail chestFlail chest

Circulation:Circulation: Massive hemothoraxMassive hemothorax Cardiac tamponadeCardiac tamponade

What is the pathophysiological reason for their What is the pathophysiological reason for their lethality?lethality?

How do you identify and treat each of these How do you identify and treat each of these conditions?conditions?

What other thoracic injuries should you look What other thoracic injuries should you look for during the secondary survey?for during the secondary survey? Consider:Consider:

Pulmonary contusionPulmonary contusion Tracheobronchial tree injuryTracheobronchial tree injury Blunt cardiac injury Blunt cardiac injury Aortic disruptionAortic disruption Diaphragmatic injuryDiaphragmatic injury

How would you identify each of these How would you identify each of these problems?problems?

How would you treat each of these problems?How would you treat each of these problems?

Back to the case…Back to the case…

After bidding the patient farewell at the OR After bidding the patient farewell at the OR doors, you go to the call room for a few hours doors, you go to the call room for a few hours of shut eye. After all, injuries that severe are of shut eye. After all, injuries that severe are going to take hours to repair, assuming the going to take hours to repair, assuming the patient survives.patient survives.

90 minutes later the ICU charge nurse calls 90 minutes later the ICU charge nurse calls you to take report from the anesthetist as the you to take report from the anesthetist as the patient is in the ICU.patient is in the ICU.

When you arrive, you are told that the patient When you arrive, you are told that the patient has been packed in all four quadrants, all has been packed in all four quadrants, all visible bleeding has been controlled and he lost visible bleeding has been controlled and he lost 5 litres of blood when the abdomen was 5 litres of blood when the abdomen was opened. Skin is closed but not fascia.opened. Skin is closed but not fascia.

What happened here? Is the surgeon What happened here? Is the surgeon incompetent to leave sponge in the belly?incompetent to leave sponge in the belly?

What is this surgical technique called?What is this surgical technique called? Damage control laparotomyDamage control laparotomy

What is the rationale for this technique?What is the rationale for this technique? What are the benefits of this approach?What are the benefits of this approach? What are some of the complications?What are some of the complications?

The anesthetist tells you that the patient’s The anesthetist tells you that the patient’s blood pressure has stabilized after being blood pressure has stabilized after being given 9 units of red cells, 2 pooled given 9 units of red cells, 2 pooled platelets, 8 units of FFP and 1 unit of platelets, 8 units of FFP and 1 unit of cyroprecipitate. He has also received 5 cyroprecipitate. He has also received 5 litres of Ringer’s lactate.litres of Ringer’s lactate.

The patient’s last ABG is pH 7.19, PCO2 The patient’s last ABG is pH 7.19, PCO2 35, PO2 87, HCO3 15.35, PO2 87, HCO3 15.

Hgb 87, WBC 12.5, Platelets 29Hgb 87, WBC 12.5, Platelets 29 INR 2.1, PTT 49INR 2.1, PTT 49 His vital signs are 109/68, heart rate 93, His vital signs are 109/68, heart rate 93,

saturations 99%, temperature 34.7.saturations 99%, temperature 34.7.

What is the DEADLY TRIAD?What is the DEADLY TRIAD? HypothermiaHypothermia CoagulopathyCoagulopathy AcidosisAcidosis

Why is the deadly triad so deadly?Why is the deadly triad so deadly? How is hypothermia in trauma different How is hypothermia in trauma different

from primary hypothermia?from primary hypothermia? Secondary hypothermia is a result of diminished Secondary hypothermia is a result of diminished

heat production (not just heat loss) due to heat production (not just heat loss) due to decreased oxygen consumption during shock.decreased oxygen consumption during shock.

What is the consequence of hypothermia?What is the consequence of hypothermia? Consider:Consider:

Dysfunctional coagulation proteinsDysfunctional coagulation proteins Inhibited plateletsInhibited platelets

What methods can be used to warm the What methods can be used to warm the patient or prevent hypothermia?patient or prevent hypothermia? Consider:Consider:

Passive air warmingPassive air warming Heated inhaled air via ventilatorHeated inhaled air via ventilator Pleural and/or peritoneal lavagePleural and/or peritoneal lavage Warm IV fluidsWarm IV fluids CVVHDCVVHD BypassBypass

What are some of the reasons for the What are some of the reasons for the patient’s deranged coagulation patient’s deranged coagulation parameters?parameters? Consider:Consider:

DilutionDilution ConsumptionConsumption DICDIC FibrinolysisFibrinolysis

How do you treat this coagulopathy?How do you treat this coagulopathy?

What is the cause of the acidosis in What is the cause of the acidosis in the deadly triad?the deadly triad?

What are some of the consequences What are some of the consequences of acidosis in trauma?of acidosis in trauma?

To be To be continued….continued….

Questions??Questions??