day 2 | cme- trauma symposium | master trauma panel perspective

Top Ten TopicsPanel Discussion

Top Ten Topics

1. Appropriateness of helicopter transport

Top Ten Topics

2. Surgeons won’t come in to see trauma patients in rural hospitals (?EMTALA considerations)

Top Ten Topics

3. Massive transfusion protocols – transfusion ratio

FFP : RBC Ratio / 6 Hr – Civilian Experience

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1:1 1:2 1:3 1:4 ≥1:5

Pre

dic

te

d P

ro

ba

bil

ity

FFP:RBC at 6 hrs

Upper Quartile

Trendline

Lower Quartile

AAST / J Trauma 2008

J Trauma Acute Care Surg. 2012;72: 106–111

Objective : To characterize changes in resuscitation which have occurred over time in a cohort of severely injured patients requiring MT.

Glue Grant:BluntBD <6

J Trauma Acute Care Surg. 2012;72:106–111.

FFP : RBC Transfusion Ratios over Time

J Trauma Acute Care Surg. 2012;72:106–111.

Sub-MT = 7 – 10 RBC

PLT : RBC Ratios for Sub-MT Patients Across Time Periods

FFP and PLT Transfusion in First 6, 12, 24 Hr Post-injury

Top Ten Topics

 4. Volume resuscitation in trauma: penetrating vs blunt

Top Ten Topics

5. Blunt neck trauma – who needs a workup and what should it be?

OHSU NeurotraumaResearch Group

UW/HMC NeurotraumaResearch Group

Clearing the C Spine

The rule on our wall in the ED is:

INDICATIONS FOR SCREENING CT OF THE CERVICAL SPINE

In patients receiving initial HMC CT head:Screening cervical spine CT used in those patients considered to be at "high-risk (pre-test

probability of > 5%)Includes:

1. High speed collisions (MVC > 35 mph combined impact.)2. Crash with death at the scene3. Patients with an acute myelopathy or radiculopathy4. Falls > 10 feet.5. Patients with known or strongly suspected pelvic or multiple extremity fractures.6. Patients with significant closed head injury (intra-cranial blood.)

Since we use the same inclusion criteria, all you need to include is something like "Initial spine imaging according to HMC ED protocols.”

• I think radiology would all be happy with that

Clinical Decision Rules

• Canadian Spine Rules• Nexus Low Risk Criteria• Both meant to select patients who don’t need C-spine imaging in the Emergency Department

Canadian C-spine Rules

Nexus Exclusionary Rules

OHSU NeurotraumaResearch Group

UW/HMC NeurotraumaResearch Group

Spine is CLEARED1 - Remove cervical collar2 - Mobilize as tolerated

Trauma admission:FULL SPINE precautions

FULL SPINE PRECAUTIONS.Consult Spine Service

PARTIAL SPINE precautions

ALERT TRAUMA PATIENT

Primary serviceexamines

patient

Spine is TREATED1 - Maintain cervical collar

2 - Review supine films again for possible missed injury3 - F/U in spine clinic in 2-3 wks for flex-ex images

Supine Imaging Studies

Is there a fracture,ligamentous injury,

orneurologic deficit?

Neck painor

tenderness?

Yes

Yes

No

No

OHSU NeurotraumaResearch Group

UW/HMC NeurotraumaResearch Group

TRAUMA PATIENTWith ALTERED LEVEL of CONSCIOUSNESS

Trauma admission:FULL SPINE precautions

C Spine CT

Is there a fracture or

ligamentous injury documented by final radiology

report?

FULL SPINE PRECAUTIONS.Consult Spine Service

Is a gross motor exam possible? (No

neuromuscular blockade, extreme

sedation/analgesia, or hypotension)

Primary serviceexamines

patient

Does pt have neurologic examsuspicious for

SCI?

PARTIAL SPINE PRECAUTIONS.Maintain cervical collar pending

motor exam

Spine is CLEARED1 - Remove cervical collar2 - Mobilize as tolerated

Yes

No

FULL SPINE PRECAUTIONS.Consult Spine Service

e.g. Motor asymmetry not attributable to other causes

Old CVANew brain

injury

Initial spine imaging according to HMC ED

protocols

No

No

Yes

Yes

Missing C Spine Injuries

• 1985-1991• 740 c-spine injuries in San Diego Trauma Centers• 34 delayed or missed diagnosis (4.6%)• 10 of 34 (29%) with permanent sequelae of missed

injury• Delayed diagnosis could have been avoided in 31 of

34 patients by appropriate use of a standard three-view C-spine series.

Jim et al later go on to tell us: • Ah, yes, but don’t do flex-extension views to clear the

spine• Too rare (0.02%) and some danger of quadriplegia(J Trauma 2001)

OHSU NeurotraumaResearch Group

UW/HMC NeurotraumaResearch Group

Spine Clearance Form

Purpose• Clarify understanding of relationship

between status of diagnosis and clearance of spine

Spine “A” Clearance: Evaluation Complete

Spine “B” Clearance: Injury Present or Probably

Spine “C” Clearance: C-Spine Cleared Clinically or Radiographically

BCVI: Mechanism of Injury

• 3 Fundamental Mechanisms:

– direct blow to the neck

– laceration by adjacent fractures of sphenoid/petrous bones

– hyperextension with contralateral rotation

Seat belt sign?

Drawing from Curr Prob Surg

Crissey et al., Surgery 1974Biffl et al., Curr Probl Surg 1999

BCVI: Mechanism of Injury

Hyperextension with contralateral rotation causing a stretch injury

BCVI: Stroke Rate

I 3% 6%

II 14% 38%

III 26% 27%

IV 50% 28%

V 100% 100%

VAIsCAIs

Injury Grade

Biffl et al., Annals 2002

BCVI: Denver Series

15,767 Admissions

727 Angiograms

screening

244 BCVI

diagnosis

21 symptomatic pts

Gender 68% men

Age 35 ± 3.7 years

ISS 28 ± 3.81.5% + rate

BCVI: Denver Series

48 no therapy

10 strokes (21%)

244 asymptomatic BCVI pts

187 antithrombotics• Heparin – 117• Antiplatelet – 59• LMWH – 11

1 stroke (0.5%)

Cothren et al., Am J Surg 2005 In press.

Seattle BCVI High Risk

Imaging Indication Definite BCVI

Number of patients

%

Midface fracture 4 20 20.0%

Mandible fracture 2 24 8.3%

Skull base fx 16 79 20.3%

Cspine trans. for. Fx 15 66 22.7%

C1,C2,C3 fx 2 11 18.2%

Seatbelt sign 0 26 0.0%

Hanging/strang. 1 21 4.8%

Clinical stroke 1 6 16.7%

Infarct 0 1 0.0%

Other/Unknown 8 53 15.1%

Total 49 307 16.0%

Harborview BCVI High Risk Screening

Midface fracture (Lefort II or III) Skull base fracture C-spinse transverse foramen fracture C1, C2, or C3 fracture High energy or bilateral mandible

fracture Unexplained stroke/neuroexam Hanging or strangulation

Top Ten Topics

6. Pelvic fracture management

32 y.o. : injury to you: x? hours

Relevant Imaging

Pelvic Fractures & Mortality

Source of mortality:

Head Injury31%

Bleeding39%

MOF30%

Scalea et al. J Trauma 2003

Pelvic Fracture Bleeding

mechanical stabilization resuscitation

Close down the pelvic volume.

Mechanical Stabilization

• Pros: Quick. Easy.• Goals: Splint bone, tissue.

Decrease, stabilize pelvic volume.

“pelvic sheeting” pelvic binder C-clamp

Trauma Ultrasound• FAST: Focused Abdominal Sonography in Trauma

– portable, rapid, repeatable– noninvasive– no contraindications– 3 views of abdomen

SPLEENKIDNEY

RUQ LUQ pelvis

PITFALL

If persistent or recurrent hypotension, remember FAST isn’t

100% accurate!(as much as 30% false negative)

Diagnostic Peritoneal Aspirate

• Catheter placed at umbilicus• “Positive” aspirate = 10cc of blood,

enteric contents

Gross Hemoperitoneum by CT, US, or DPA

OR?Angio?

Pelvis Fx + HD Unstable

resuscitation mechanical stabilization embolization

Importance of management protocols: 20% decrease in mortality

Biffl et al. Ann Surg 2001

Current management: USA

Pelvis Fx + HD Unstable

• Described in Europe– rapid transport to OR

– external bony fixation

– packing of retroperitoneum

Pelvic Packing

Pohlemann et al. OTA Ann Mtg 2000 Ertel et al. J Orthop Trauma 2001

• Rationale:– addresses venous/bony bleeding

– additional procedures as indicated

Pelvic fixation first:– C-clamp application

– External fixator

Pelvic Packing

Modified European technique:– 6-8 cm suprapubic incision

– divide midline fascia

Pelvic Packing

Smith et al. J Trauma 2005Cothren et al. J Trauma 2007

KEY POINT

Incision should be away from a laparotomy incision – keep the spaces separate!

You will encounter the hematoma!

Pelvic Packing

Packing the pelvis:– 3 lap pads on either side of bladder– 1st one is all the way down to presacral space

Pelvic Packing

Typically 6 packs for adults, 4 for children

Pelvic Packing

Suprapubic catheters

Pelvic Packing

Close fascia and skin

Pelvic Packing

• 5½ years – 1245 pelvic fx patients

• Pelvic fx classification: APC III (17) LC II (12) LC III (11) APC II (11) LC I (10) APC I (4) vertical shear (10)

• 75 patients underwent PPP/EF75% men Age = 42 ± 2 yrs ISS = 52 ± 2

• ED vitals: SBP 76 ± 2 HR 119 ± 2 BD 12 ± 1

Packing: Hemorrhage Control

• Time to OR: 66 ± 7 minutes • RBCs: 4 ± 0.4 units in ED

• Pre-SICU vs. subsequent 24˚

10 ± 0.8 units vs. 4 ± 0.5 units

• FFP:RBC ratio was 1:2

Packing and Concurrent Procedures

• 87% of pts underwent 3 ± 0.3 procedures– External fixation of long bone fractures = 44 – I&D wounds/fasciotomy = 43 – Laparotomy = 34 – Urologic procedures = 15 – Extremity vascular = 4 – Neurosurgical/spine = 4 – Thoracotomy = 2

Angiography After Packing

• 10 (13%) patients underwent AE

• Time to angio = 10 hours(range 1-38 hours)

pelvic packs

• Fx classification:LC I (3) LC II (2)APC III (2) APC II (1) LC III (1) VS (1)

Who Needs Angiography?

• Can’t predict by: age, ISS, presenting SBP, presenting base

deficit, ED blood tx, or fracture pattern

• Patients with AE after packing: lower HR (105 8 vs 121

3) more RBC pre-SICU (15 3 vs 9 1)

more FFP pre-SICU (9 2 vs 4 1)more RBC in subseq 24˚ (7 2 vs 3

1) more FFP in subseq 24˚ (6 2 vs 2 0.4)

Operation

Top Ten Topics

7. Termination of resuscitation; when to stop (adults vs kids)

Top Ten Topics

8. When to return to sports and play in minor TBI (football, soccer, basketball, is there a difference?)

Top Ten Topics

9 . Current indications for an ED thoracotomy

Patient in Extremis

– Undergoing

CPRPenetrating

Trauma

EDT

ECG: Any Rhythm?

Yes

CPR < 5 min

Blunt Trauma

DeadNo

Yes

Yes

No

Cardiac Rhythm?

NoTamponade?

No

Repair Heart

SBP > 70 mmHg?

Yes

ORYes

No

Thoracic Hemorrhage

Air Emboli

Tamponade

Extrathoracic Hemorrhage Aortic X-clamp

Hilar X-clamp

Control

CPR < 15 min

CPR < 5 minNon-torso

Torso No

No

Yes

Top Ten Topics

10. What is the minimum workup needed in the multiply injured patient who needs to be transferred to a higher level of care?

Top Ten Topics

• 1. Appropriateness of helicopter transport

• 2. Surgeons won’t come in to see trauma patients

• 3. Massive transfusion protocols – transfusion ratio  

• 4. Volume resuscitation in trauma penetrating vs blunt  

• 5. Blunt neck trauma

• 6. Pelvic fracture management  

• 7. Termination of resuscitation; when to stop

• 8. When to return to sports and play in minor TBI

• 9 . Current indications for an ED thoracotomy

• 10. What is the minimum workup needed in patient who

needs to be transferred