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