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Trauma

Trauma: Basic science for general surgical residents.
More on Schwartz's Principle of Surgery and ATLS 10th ed
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Trauma

  1. 1. TRAUMA Facebook: Happy Friday Knight July, 10th, 2015 Department of Surgery Thailand
  2. 2. INTRODUCTION
  3. 3. • Trauma/ injury = cellular disruption caused by an exchange with environmental energy that beyond body’s resilience • = cell death due to ischemia or reperfusion • Most common cause of death between age 1- 44 years • Third most common cause of death regardless of age • Causes 110,000 deaths per year, 40% from motor vehicle collisions
  4. 4. INITIAL EVALUATION AND RESUSCITATION OF THE INJURED PATIENT
  5. 5. Preparation • Prehospital phase: – EMS – Should be set up to notify the receiving hospital before personnel transport from the scene • Hospital phase: primary survey
  6. 6. • Emphasis on: – Airway maintenance – Control of external bleeding and shock – Immobilization – Immediate transport to the nearest hospital
  7. 7. Triage: sorting the patients based on their needs for treatment and the resource available to provide that treatment http://www.cdc.gov/mmwr/previe w/mmwrhtml/rr6101a1.htm. CDC, January 13th, 2012
  8. 8. • Multiple Casualties: – the number and severity of patients do not exceed capability of the facility – Patients with life-threatening conditions and multiple system injuries are treated first • Mass Casualties – Exceed – Patient with greatest chance of survival and requiring expenditure of time, equipment, supplies, and personnel, are treated first
  9. 9. Primary Survey • ATLS: ABCDEs and adjuncts • 10-second assessment: What’s your name? What happen? • Life-threatening injuries must be identified and treated before distracted by secondary survey
  10. 10. Airway Management with Cervical Spine protection • First Priority • Conscious, normal voice without tachypnea  should be OK but repeat assessment is essential • Exceptions: penetrating neck injury, complex maxillofacial trauma, inhalation injury • Require further evaluation: abnormal voice or breathing sound, tachypnea, altered mental status
  11. 11. • Predicting difficult airway: LEMON • Maintaining airway maneuvers: chin lift, jaw thrust, pharyngeal airway, LMA etc • Definitive airway: a tube placed in trachea with: – Cuff inflated below vocal cord – Connected to oxygen-enriched assisted ventilation – Secured in place with tape Airway Management with Cervical Spine protection
  12. 12. Airway Management with Cervical Spine protection • Surgical Airway: – Cricothyroidotomy – Emergency tracheostomy http://www.surgeryencyclopedia.com/Ce- Fi/Cricothyroidotomy.html. Advanmeg, 2015
  13. 13. Airway Management with Cervical Spine protection • Don’t forget c-spine!!!! • Apply hard collar or sandbags to all patients who are suspected c-spine injury, blunt trauma, and altered mental status • Soft collar shows no benefit
  14. 14. Breathing with Ventilation • Life-threatening conditions: open, tension pneumothorax, massive air leak, severe flail chest • Look for indication to ICD
  15. 15. Circulation with Hemorrhagic Control • Palpable pulse: – Carotid = 60 mmHg – Femoral = 70 mmHg – Radial = 80 mmHg • Any episode of hypotension is assumed to be caused by HEMORRHAGE until proven otherwise
  16. 16. • IV access for fluid resuscitation: – 2 peripheral catheter, 16 gauge or larger – If difficult: IO (<6yrs), saphenous cutdown, femoral or subclavian vein insertion • 5 potential area: chest, abdomen, pelvis, long bone, external • External Control of visible hemorrhage: – Simultaneous with fluid resuscitation – Manual compression – Avoid blind clamping Circulation with Hemorrhagic Control
  17. 17. • Tourniquet can cause tissue necrosis but may be essential to save life (in case of direct pressure failure) • Open fractures: reduction and immobilization • Scalp laceration deep to galea: skin staples, continuous suture to stop bleeding Circulation with Hemorrhagic Control
  18. 18. • FAST • Massive Hemothorax – >1500ml from ICD – > 25% of blood volume in children – Usually from multiple rib fractures, occasionally from lung laceration – Suspected great vessels or pulmonary hilar vessels injury – Indication for operative intervention Circulation with Hemorrhagic Control
  19. 19. • Cardiac tamponade – Beck’s triad – FAST – most common cause: penetrating chest injury – < 100 ml – RV output – Initial Treatment: fluid resuscitation and pericardiocentesis (80% success) – SBP< 60 mmHg: resuscitative thoracotomy Circulation with Hemorrhagic Control
  20. 20. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 167
  21. 21. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 168
  22. 22. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 169
  23. 23. Shock Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 171
  24. 24. Shock • = inadequate tissue perfusion • In trauma, always HEMORRHAGIC until proven otherwise • The goal of fluid resuscitation is to re-establish tissue perfusion • 2 L in adult, 20 ml/kg in child IV bolus, usually warm Ringer’s lactate
  25. 25. Shock • Goal: return of perfusion => urine output – Adult > 0.5 ml/kg – Child > 1 ml/kg – Infant < 1 yr > 2 ml/kg • Initial response: responders, transient responders, nonresponders
  26. 26. Shock: Persistent Hypotension • Either transient or nonresponders • Consider categories of shock: hemorrhagic, cardiogenic, neurogenic, septic • FAST helps • CVP may guide: > 15 cmH2O: cardiogenic, < 5 cmH2O: hypovolemic • Other monitor: urine output, oxygen saturation, base deficit, lactate
  27. 27. • DDx of cardiogenic shock in trauma: – Tension pneumothorax (most common) – Cardiac tamponade – Blunt cardiac injury – Bronchovenous air embolism • In blunt cardiac injury: – EKG and TropT help – ECHO is performed – Most common finding is RV dyskinesia due to orientation – AMI may be the cause of accidents in older patients Shock: Persistent Hypotension
  28. 28. • Air embolism – Air from injured bronchus entered injured pulmonary vein and returns air to left heart, resulting in impeded diastolic filling – And during systole, air is pumped into coronary arteries – Treatment: Trendelenburg position and emergency thoracotomy to cross-clamping to prevent further embolism, air aspiration, and controlling the injury Shock: Persistent Hypotension
  29. 29. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 172
  30. 30. Shock • If persistent hypotension with negative FAST and no obvious source  DPL • Hypotensive resuscitation, permissive hypotension, balanced resuscitation, controlled resuscitation: keep BP 90/60 mmHg • Fracture-related blood loss: – Each rib fracture: 100-200 ml – Tibia: 300-500 ml – Femur: 800-1,000 ml – Pelvic: > 2000 ml
  31. 31. Disability and Exposure • D: Pupil and GCS • Exposure: keep warm, PR, log roll
  32. 32. Adjuncts to Primary Survey • Monitor: BP, oxygen saturation, EKG, ABG • Catheter: NG, Foley cath • Investigation: FAST & film (CXR, pelvis AP)
  33. 33. Secondary Survey • Head-to-toe examination • AMPLE
  34. 34. Special Diagnostic Tests • Head: CT brain (non-contrast), facial bone reconstruction, c-spine Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 175
  35. 35. • Neck: – In blunt injury: cervical spine injury has to be ruled out – Observe expanding hematoma, airway obstruction, aerodigestive injuries Special Diagnostic Tests
  36. 36. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 415.
  37. 37. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 176
  38. 38. • Chest: – Most injuries can be evaluated by PE and CXR – CXR is needed after ETT, ICD, central line insertion – Persistent pneumothorax should undergo fiberoptic bronchoscopy to exclude tracheobronchial injury – CXR after ICD is required to document complete evacuation; if persistent  thoracotomy Special Diagnostic Tests
  39. 39. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 178
  40. 40. • Abdomen: – Blunt or penetrating – If penetrating: stab wound or GSW – FAST will be positive when free fluid > 250 ml – Anterior abdominal SW: explore under LA to determine if fascia is injured – For GSW: >90% have internal abdominal injuries Special Diagnostic Tests
  41. 41. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 180
  42. 42. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 181
  43. 43. • Pelvis: – Foley catheter in one attempt – Film pelvis AP – CT pelvis to evaluate precise geometry – CT cystograms – Urethrograms – CT angiogram Special Diagnostic Tests
  44. 44. • Extremities: – Film – Vascular injuries: hard and soft signs – Doppler u/s – CT angiogram Special Diagnostic Tests
  45. 45. GENERAL PRINCIPLES OF MANAGEMENT
  46. 46. Transfusion • ATLS says massive transfusion = PRC > 10 U in first 24 hr • ATLS says PRC : FFP : PC = 1:1:1 • Types of blood component – Complete typing and crossmatching: 45min- 1hr – Type-specific: 10 min – O-negative, O-low titer: should be ready
  47. 47. Prophylactic Measures • Antibiotics • Tetanus prophylaxis • VTE prophylaxis – LMWH – Compression stocking • Thermal protection: passive and active rewarming
  48. 48. Damage Control Surgery • The purpose is to limit operative time and return patient to ICU from physiologic restoration • The goal is to control surgical bleeding and limit GI contamination and definitive repair of injuries delayed until patient is physiologically replete
  49. 49. • bloody vicious cycle (lethal triad) • Hypothermia, coagulopathy, metabolic acidosis • Indications to institute DCS technique – BT < 35oC – Profound acidosis  ABG pH < 7.2, base deficit > 15 mmol/l – Refractory coagulopathy Damage Control Surgery
  50. 50. • Arterial injuries: – Ligation tolerable: Rt/Lt hepatic, celiac • Venous injuries: ligation except suprarenal IVC and popliteal • Solid organ injuries: – Spleen/kidney: Excision > repair – Hepatic injuries: packing, foley cath ballooning for GSW Damage Control Surgery
  51. 51. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 189
  52. 52. • Lung injuries: open parenchymal tract by TA stapler, access to injured vessels and bronchi, and ligate by PDS 3-0, and the tract left opened • Cardiac injuries: temporarily controlled with 3-0 polypropylene, running Damage Control Surgery
  53. 53. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 195
  54. 54. • GI contamination: – Small injuries: repair using 2-0 polypropylene – Complete transection: GIA stapler to resect damage segment and open end may be ligated by umbilical tape • Pancreatic injuries: pack and evaluate duct later • Urologic injuries: catheter diversion Damage Control Surgery
  55. 55. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 196
  56. 56. TREATMENT OF SPECIFIC INJURIES
  57. 57. Head Injuries • Intracranial injuries: – CT brain NC – Penetrating injuries: require operation to bleeding control, evacuate clot, skull fx fixation, debridement – Patient with diffuse cerebral edema with elevated ICP: decompressive craniectomy – In open or depressed skull fracture: assess underlying brain, look for visible brain, CSF leakage, dural laceration
  58. 58. • Intracranial injuries: – Closed head injuries: • GCS<8 should be monitor ICP • Treatment start at ICP > 20 mmHg • Indications for intervention: clot volume, midline shift, location of clot, GCS, ICP Head Injuries
  59. 59. • Intracranial injuries: – Postinjury care: • SBP > 100 mmHg • Avoid hypoxia: PO2 < 60mmHg, O2sat < 90% • CPP > 50 mmHg • PCO2 35-40 mmHg, <30 mmHg for acute management of hypertension • BT 32-33oC • Anticonvulsant: dilantin Head Injuries
  60. 60. Head Injuries • Maxillofacial: – Most common scenario which can be life- threatening: bleeding from facial fracture – Don’t forget to protect the airway! – Contraindication of NG – Fractures of tooth-bearing bone = open fractures
  61. 61. American College of Surgeons ACS Committee of Trauma. ATLS Student Course Manual. 8th ed. Chicago: American College of Surgeons, 2008. page 59
  62. 62. Cervical Injuries • Spine: – At ER: Immobilization and CT C-spine – Treatment based on: • Level • Stability • Presence of subluxation • Extent of angulation • Level of neurologic deficit – Treatment: • axial traction via cerival tong > halo vest
  63. 63. Cervical tong http://www0.sun.ac.za/ortho/webct- ortho/general/trac/trac-3.html Halo vest http://borsodib.hu/2012/index.php/hirek/140-halo- vest-a-nyakcsigolyatores-gyogyeszkoze
  64. 64. • Spine: – Treatment: • Surgical fusion in pt with neurodeficit or remain unstable after halo placement • Methylprednisolone (30 mg/kg IV bolus, then 5.4mg/kg in 23 hr) • Urgent surgical decompression: may be done in patients with incomplete tetraplegia or neurologic deterioration Cervical Injuries
  65. 65. • Vascular: – Penetrating injuries: neck exploration to repair – All carotid injuries should be repaired except in patients who present in coma with a delay in transport – Blunt injuries: • May cause dissection, thrombosis, pseudoaneurysm • Patients treated with antithrombotic agent have a stroke rate < 1% compared with 20% in untreated patients Cervical Injuries
  66. 66. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 199
  67. 67. Cervical Injuries • Aerodigestive – sign: subcutaneous emphysema – CT usually repaired – Common: thyroid cartilage fractures, thyroepiglottic ligament rupture, vocal cord tears,cricoid fractures – Tracheal injuries: debridement and end-to-end repair with single layer, interrupted, absorbable suture – Esophageal rupture: debridement, repair, and interposition of SCM or strap muscles to prevent fistulas
  68. 68. Chest Injuries • Most common injuries are hemothorax and pneumothorax • 85% can be definitively treated with ICD • Even initial chest tube output is 1.5L, if the output ceases, lung re-expanded, and hemodynamically stable, it can be nonoperatively managed
  69. 69. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 462.
  70. 70. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 463.
  71. 71. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 464.
  72. 72. Chest Injuries • Great vessels: – >90% are penetrating – Blunt injuries to innominate, subclavian, or descending aorta may cause pseudoaneurysm or frank rupture – Simple laceration of aortic arch: lateral aortorrhapy – To prevent aortic rupture: esmolol, keep SBP < 100 mmHg, HR < 100/min
  73. 73. Chest Injuries • Heart – Before repair, bleeding should be controlled – Temporary control: skin staples for LV laceration – Definitive repair: running 3-0 polypropylene, or interrupted pledgeted 2-0 polypropylene suture in RV to prevent sutures from pulling through the thinner myocardium – ECHO may be done – No pathognomonic signs on EKG and TropT doesn’t tell risk of complications
  74. 74. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 201
  75. 75. Chest Injuries • Trachea, Bronchi, and Lung Parenchyma: – ICD: pneumothorax – Same as injuries at neck – Bronchial injuries less than 1/3 circumference of airway and no persistent air leak can be expectantly managed – Bronchoscope with direct fibrin glue may be useful – Most complication after injury: empyema • PCD • Decortication with VATS • Antibiotics (cover MRSA in ICU)
  76. 76. Chest Injuries • Esophagus – Often occurs with tracheobronchial injuries, in penetrating trauma – Same as injuries at neck +- gastrostomy
  77. 77. • Chest wall and diaphragm – Rib fractures: pain control + ventilation support – Diaphragmatic injury: • Blunt: large radial tear • Penetrating: variable size • Develop diaphragmatic hernia • Treatment: direct repair by running 1 prolene or mesh Chest Injuries
  78. 78. http://www.mactheknife.org/Cases_trauma/Paralysed_diaphragm.html
  79. 79. Abdominal Injuries • Blunt injuries – most frequently injured: 1. Spleen (40-55%) 2. Liver (35-45%) 3. Small bowel (5-10%) • Penetrating injuries: – SW: liver (40%), small bowel (30%), diaphragm (20%), colon (15%) – GSW: small bowel (50%), colon (40%), liver (30%), vessels (25%) (reference: ATLS, page 125)
  80. 80. • Liver and extrahepatic biliary tract – In liver injury without peritonitis or unstable hemodynamic, nonoperative management with serial examination in ICU is OK – Angiogram and angioembolization: indication • PRC > 4U in 6hr • PRC > 6U in 24 hr • Hemodynamic stable – Indication for surgery is hemodynamic instability Abdominal Injuries
  81. 81. • Liver and biliary tract – Surgery: • Initial control of hemorrhage is best by perihepatic packing and manual compression and remove packing at 24 hr • Pringle maneuver: clamping across portal triad bleeding should be stopped if injuries are at hepatic artery or portal vein  bleeding from hepatic vein and retroperitoneum IVC will continue • Gastroduodenal a. injury: ligation • Proper hepatic a. should be repaired Abdominal Injuries
  82. 82. http://myhomeimprovement.org/home-remodel/celiac-axis-diagram
  83. 83. • Liver and biliary tract: surgery – Hepatic parenchymal hemorrhage • Minor laceration: manual compression • Topical hemostatic techniques: argon beam, microcrystalline collagen, thrombin-soaked gelatin foam sponge, fibrin glue, BioGlue, and blunt tipped 0 chromic suture or liver suture – Complication: liver necrosis, bilomas, arterial pseudoaneurysm, biliovenous fistula Abdominal Injuries
  84. 84. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 183
  85. 85. • Spleen – Extravasation risks for nonoperative management failure – Angioembolization – Surgery: • Splenectomy: hilar inj, grade II, completely destroyed • Partial splenectomy: pole • Splenorrhaphy with pledgated suture: cut edge Abdominal Injuries
  86. 86. • Stomach and Small Bowel – Single layer suture Abdominal Injuries
  87. 87. • Duodenum and Pancreas – Suture if perforation – Duodenal hematoma  observe – Pancreas: determine parenchymal and damage – Proximal (Rt to SMA) pancreatic injuries: closed suction drainage – Distal injuries: distal pancreatectomy – CBD injury: Roux-en-Y choledochojejunostomy Abdominal Injuries
  88. 88. • Colon and Rectum – Treatment: primary repair, end colostomy, and primary repair with diverting ileostomy – All suturing and anastomoses are performed using a running single-layer technique – Complications: IAA, fecal fistula, wound infection, stomal complications (necrosis, stenosis, obstruction, prolapse) Abdominal Injuries
  89. 89. • Genitourinary Tract – Explore all penetrating wounds to kidneys when undergoing laparotomy and treat same as liver and spleen – >90% of blunt renal injuries are treated nonoperatively – Hematuria will resolve in 2-3 days, but persistent gross hematuria may require embolization Abdominal Injuries
  90. 90. • Genitourinary Tract – Bladder injuries: intraperitoneal  suture, extra  bladder decompression for 2 wks – Urethral inj: bridging the defect with foley – Pelvic fracture penetrating to vagina = open fracture Abdominal Injuries
  91. 91. Pelvic Fracture Hemorrhage Control • 85% of bleeding is from venous or bony in origin • Pelvic packing: 6-8 cm midline incision and packing each side of bladder and preperitoneal space • Open pelvic fracture: – High risk for pelvic sepsis and osteomyelitis – Recommendation: divesting sigmoid colostomy and debridement
  92. 92. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 213
  93. 93. SPECIAL POPULATIONS
  94. 94. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 220
  95. 95. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 220
  96. 96. References Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. American College of Surgeons ACS Committee of Trauma. ATLS Student Course Manual. 9th ed. Chicago: American College of Surgeons, 2012. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. Kaiser LR et al. Mastery of Cardiothoracic Surgery. 3rd ed. Philadelphia: Lippincott Wiliams & Wilkins, 2014.

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