02.sabtu pagi, chapter06-08, continous presentation
TRANSCRIPT
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Initial Assessment and Management
Committee on Trauma Presents
Head
Trauma
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Case Scenario
58-year-old male fell from a roof in asmall rural town
Initial GCS score = 12
On admission after 2-hour transfer,GCS score is 6
What in jur ies would you suspect?
What are your p r ior i t ies in m anaging th is
pat ient?
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Objectives
Describe basic intracranial anatomy and
physiology.
Explain the importance of limitingsecondary brain injury.
Describe the classification of head injuries.
Describe proper stabilization of the patientand arrangements for definitive care.
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Anatomy and Physiology
What are the un ique
features o f b rain
anatomy and
phys io logy, and howdo they affect patterns
of brain in jury?
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Anatomy and Physiology
Rigid, nonexpansile skull filled with
brain, CSF, and blood
Cerebral blood flow (CBF) usually
autoregulated
Autoregulatory compensation
disrupted by brain injury Mass effect of intracranial hemorrhage
Effects
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Monro-Kellie Doctrine
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Volume-Pressure Curve
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Intracranial Pressure (ICP)
Sustained increased ICP leads to decreasedbrain function and poor outcome
Hypotension and low saturation adverselyaffect outcome
10 mm Hg = Normal
>20 mm Hg = Abnormal>40 mm Hg = Severe
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Cerebral Perfusion Pressure
Normal 90 10 80
Cushings
Response100 20 80
Hypotension 50 20 30
MAP ICP = CPP
CPP Cerebral Blood FlowCaution
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Classifications of Head Injury
Blunt
High and lowvelocity
By Mechanism of Injury
Penetrating
GSW andother
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Classifications of Head Injury
Focal
Epidural (extradural)
Subdural
Intracerebral
By Morphology Brain Injuries
Diffuse
Concussion
Multiple contusions
Hypoxic / ischemic injury
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Epidural Hematoma
Associated with skull fracture
Classic: middle meningeal artery tear
Lenticular / biconvex
Lucid interval
Can be rapidly fatal
Early evacuation essential
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Epidural Hematoma
Temporal Epidural Hematoma
Uncal herniation
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Subdural Hematoma
Venous tear / brain laceration
Covers cerebral surface
Morbidity / mortality due tounderlying brain injury
Rapid surgical evacuation
recommended, especially if > 5 mm
shift of midline
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Subdural Hematoma
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Intracerebral Hematoma / Contusion
Coup / contracoup injuries
Most common: frontal / temporal lobes
CT changes usually progressive
Most conscious patients: no operation
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Intracerebral Hematoma / Contusion
Large Frontal Contusion with Shift
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Diffuse Brain Injury
Normal CT Diffuse Injury
Range from mild concussion to severe
ischemic insult
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Classifications of Head Injury
Mild
Moderate
Severe
By Severity of Injury Based on GCS Score
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Mild Brain Injury
GCS score = 13 15
History
Exclude systemic injuries
Neurologic exam
X-rays as indicated
Alcohol / drug screens as indicated
Liberal use of head CT
Observe or discharge based on findings
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Moderate Brain Injury
GCS score = 9 12
Initial evaluation same as for mild injury
CT scan for all Admit and observe
Frequent neurologic exams
Repeat CT scan
Deterioration: Manage as severe head
injury
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Severe Brain Injury
GCS score = 3 8
Evaluate and resuscitate
Intubate for airway protection
Focused neurologic exam
Frequent reevaluation
Identify associated injuries
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Indications for CT Scan
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Indications for CT Scan
GCS score still < 15 two hours after injury
Neurologic deficit
Open skull fracture
Sign of basal skull fracture
Extremes of age
High Risk
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Indications for CT Scan
Dangerous mechanism
Retrograde amnesia > 30 minutes induration
Severe headache
Vomiting > 2 episodes
Moderate Risk
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Management
Priorities
ABCDE
Minimize secondary brain injury
Administer oxygen
Maintain adequate ventilation
Maintain blood pressure(systolic > 90 mm Hg)
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Management
Focused Neurological Exam
GCS score
Pupils
Lateralizing signs
Consult
neurosurgeon
early
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Management
Medical
Controlled ventilation
Goal: Paco2 at 35 mm Hg
Intravenous fluids
Euvolemia
Isotonic
Consult with neurosurgeon
Mannitol
Use with signs of tentorial herniation
Dose: 0.25 to 1.0 g / kg IV bolus
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Management
Medical
Other medications
Anticonvulsants
Sedation
Paralytics
Neurological examination before
prolonged sedation / paralysis
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Management
Surgical
Scalp Wounds
Possible site of major blood loss
Direct pressure to control bleeding
Occasional temporary closure
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Management
Surgical
Intracranial Mass Lesion
Can be life-threatening if expanding rapidly
Immediateneurosurgical consult
Hyperventilation / mannitol
Damage control craniotomy: transfer toneurosurgeon (rural / austere areas)
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Summary
Ensure adequate oxygenation
Maintain Paco2 near / at 35 mm Hg
Maintain mean BP > 90 mm Hg
Frequent neurologic assessment
Liberal use of CT
Earlyneurosurgical consult
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Initial Assessment and Management
Committee on Trauma Presents
Spine andSpinal Cord
Trauma
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Case Scenario
38-year-old male is pulled from a
swimming pool.
BP: 80/62; Pulse: 58; RR: 28
GCS score: 15
Breathing is shallow.
He is not moving his arms or legs.
Discuss the patients diagnosis
and management.
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Objectives
Describe the evaluation of a patient with
suspected spinal injury.
Explain the appropriate management ofspinal injury.
Discuss appropriate patient disposition.
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Spinal Injury
When should you suspect a spine in jury?
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Spinal Injury
Mechanism of injury
Unconscious patient Neurologic deficit
Spine pain / tenderness
When should you suspect a spine in jury?
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Spinal Injury
How do I protect the spine dur ing evaluat ion
and transpo rt?
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Spinal Injury
Immobilize entirepatient on long spineboard with properpadding.
Apply semirigid collar.
How do I protect the spine dur ing evaluat ion
and transpo rt?
Protection is priority;
detection is secondary.
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Drugs, alcohol, and other
injuries can mask spinal injury.
Spinal Injury Screening
Clinical
Normal neurologic exam and
Absence of spinal pain and tenderness
Caution
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Spinal Injury Screening
If patient is
Conscious
Cooperative
Able to concentrate on c-spine
Ifnoneck or spine pain or tenderness
If still nopain or tenderness with
voluntary movement
No further evaluation or x-ray necessary
Clear spine and remove cervical co l lar.
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Spinal Injury Screening
Radiographic visualization of entire
spine Plain films
CT scan of suspicious or poorly
visualized areas
Altered Consciousness or Symptoms
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Spinal Injury Screening
How do I conf i rm a spine in jury?
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Spinal Injury Screening
Clinical signs of neurological deficit
Radiological investigations Plain X-ray / CT / MRI
Identify bony fracture / subluxation
Presume spinal instability
Early spine service consult
How do I conf i rm a spine in jury?
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Cervical Spine X-rays
Crosstable lateral film excludes 85% of
fractures
Addition of AP and odontoid viewsexcludes most fractures
Also may require
Swimmers view
CT scan for bony detail
MRI
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Cervical Spine X-rays
10% of patients with a c-spine fracture have
a second, associated noncontiguous
vertebral column fracture
Identify one abnormality? Look for another !
Radiographic screening of entire spine
required in this situation
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Spinal evaluation complicated by altered
sensorium Remove spine board as soon as possible and
logroll patient
Pressure sores occur early in unconscious
or paralyzed patients
Pitfalls
Pitfalls
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Caution
At least 5% of patients with
spinal cord injuries worsen
neurologically at the hospital.
Caution
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Neurologic Status
How do I assess the patients neurologic status?
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Neurologic Status
Neurologic level
Most caudal level of motor / sensory function Motor and sensory may not be the same
Sensory can vary on each side
Bony level
Site of vertebral column damage
How do I assess the patients neurologic status?
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Neurologic Status
Complete Injury
No motor or sensory function below
injury level
Incomplete Injury
Any motor or sensory preservation
below injury level Sacral sparing may be only residual
function
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Effects of Spinal Cord Injury
Neurogenic shock
Spinal shock
Other consequences
Fasciculus cuneatus
Dorsal columnFasciculus gracilis
Lateral corticospinal tract
Spinothalamic
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Effects of Spinal Cord Injury
Cardiovascular phenomenon due toloss of sympathetic tone
Associated with cervical / high thoracicspine injury
Hypotension and slow heart rate
Treatment includes fluid resuscitationand occasional atropine andvasopressors
Neurogenic Shock Direct Effects
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Effects of Spinal Cord Injury
Neurologic, not hemodynamicphenomenon
Occurs shortly after cord injury
Variable duration
Flaccidity and loss of reflexes
Spinal Shock Direct Effects
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Management
How do I manage pat ients w i th spinal cord
in jury and l im i t secondary in jury?
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Management
Ensure adequate ventilation and
oxygenation
Maintain blood pressure
Maintain perfusion of spinal cord
How do I manage pat ients w i th spinal cord
in jury and l im i t secondary in jury?
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Management
Assess for associated bleeding
Consider neurogenic shock
Monitor urinary output
Management of Hypotension
Stop
the
bleeding!
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Management
Unstable fractures
Neurologic deficit
Whom do I trans fer?
Avoid transfer delay!
Caution
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Management
Provide respiratory
support as needed Exclude other life-
threatening injury
Properly immobilize
entire patient
Avoid hypothermia
Management of Patients Requiring Transfer
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Summary
Treat life-threatening injuries first
Properly immobilize entire patient
Obtain appropriate spine films
Document examination
Obtain neurosurgical / orthopaedic consult
Transfer unstable fracture / cord injury
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Initial Assessment and Management
Committee on Trauma Presents
Musculoskeletal
Trauma
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Case Scenario
A wall collapses on a 44-year-old
male worker
BP: 130/75; Pulse: 110; RR: 22
GCS score: 15
Painful, bruised, deformed right leg
What are your pr io r i t ies?
Is th is l i fe- or l imb-threatening?
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Objectives
Describe the principles for assessing patients
with musculoskeletal injuries.
Identify treatment priorities.
Explain the importance of musculoskeletal
injuries in multiply injured patients.
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Primary Survey
What are my pr ior i t ies and m anagement p r incip les?
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Primary Survey
Stop the bleeding! (pressure / tourniquet)
Splint the extremity
Stabilize the pelvis
During the Primary SurveyThe 3 Ss
What are my pr ior i t ies and m anagement p r incip les?
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Primary Survey
Stabilization
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Secondary Survey
Look
Listen
Feel
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Secondary Survey
Look
Deformity Pain
Tenderness
Wound(s)
Rationale for Splinting
Listen
Dopplersignals
Bruit
Feel
Crepitus Skin flaps
Neurologicdeficit
Pulses
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Secondary Survey
Preinjury status and predisposing factors
Mechanism of injury
Time of injury
Associated factors (eg, environment)
Prehospital observations and care
Key Information
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Secondary Survey
Vascular compromise
Open fractures
Early Concerns
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Secondary Survey
Reduce fracture(s)
Splint fracture(s)
Assess by Doppler
Obtain surgical consult
Time is critical!
Consider angiography
Assess and Manage Vascular Compromise
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Secondary Survey
Apply appropriate splint
Cleanse / debride(now or later)
Consider time factor
Obtain orthopedic consult
Antibiotic / tetanus status
Managing Open Fractures
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Secondary Survey
What x-rays do I need?
Any suspected area One joint above and below
When do I obtain them?
Patient is hemodynamically
normal
X-Ray Studies
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Secondary Survey
When should I delay getting
x-rays?
If life-threatening injuries take
priority
If patient transfer will be
delayed
X-Ray Studies
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Compartment Syndrome
What in jur ies can cause compartment synd rome?
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Compartment Syndrome
What in jur ies can cause compartment synd rome?
Tibia and forearm fractures
Vascular and bony injuries
Injuries immobilized in tight
dressings or casts
Severe crush injuries to muscle
Burns
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Compartment Syndrome
How do I recogn ize com partment syndrom e?
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Compartment Syndrome
Pain
Disproportionate Passive stretch
Tense compartments
Asymmetry
Paresthesia
Tissue pressures > 35 to 45 mm Hg
How do I recogn ize com partment syndrom e?
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Altered sensation
Compartment syndrome
Vascular injury
Crush injuries / myoglobinuria
Occult fractures / soft tissue injuries
Coagulation disorders
Pitfalls
Pitfalls
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Summary
Manage life-threatening injuries first
Stop the bleeding!
Reduce and immobilize fractures and
dislocations
Recognize vascular compromise
Consider compartment syndrome
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