the secondary survey - anschutz medical campus
TRANSCRIPT
The Secondary SurveyThe Secondary Survey
Clay Cothren Burlew, MD FACS
Director, Surgical Intensive Care Unit
Attending Surgeon, Denver Health Medical Center
Associate Professor of Surgery, University of Colorado
Outlining the ResuscitationOutlining the Resuscitation•• ABCs Completed ABCs Completed
–– adjuncts to the 1adjuncts to the 1°°
surveysurvey–– start 2start 2°°
surveysurvey
•• History/Mechanisms of InjuryHistory/Mechanisms of Injury
•• Examination:Examination:•• injury identificationinjury identification•• intervention and treatmentintervention and treatment•• management pitfallsmanagement pitfalls
•• Take Home PointsTake Home Points
Outlining the ResuscitationOutlining the Resuscitation
Primary Survey Secondary Survey Definitive Treatment
Resuscitation
Reassessment
PITFALLPITFALL
Be wary of the Be wary of the transient respondertransient responder……....
Adjuncts to the ABCsAdjuncts to the ABCs
•• ECG monitoringECG monitoring–– tachycardiatachycardia–– dysrhythmiasdysrhythmias–– ST segment changesST segment changes
•• Fetal monitoringFetal monitoring•• > 26 weeks> 26 weeks•• highhigh--risk for 24risk for 24°°
Adjuncts to the ABCsAdjuncts to the ABCs
•• CathetersCatheters–– foleyfoley–– NG tubeNG tube
PITFALLPITFALL•• Suspect urethral injurySuspect urethral injury
•• blood at meatusblood at meatus•• perineal bruisingperineal bruising•• highhigh--riding prostateriding prostate•• pelvis fracturepelvis fracture
foleyfoley
PITFALLPITFALL•• Appropriate NG tube use:Appropriate NG tube use:
•• may precipitate gaggingmay precipitate gagging•• emesis/aspirationemesis/aspiration•• avoid nasal route in avoid nasal route in
patients with facial fxpatients with facial fx
Adjuncts to the ABCsAdjuncts to the ABCs•• Portable XPortable X--rays:rays:
–– blunt trauma = blunt trauma = ““Big 3Big 3””•• AP chestAP chest•• AP pelvisAP pelvis•• lateral clateral c--spinespine
Adjuncts to the ABCsAdjuncts to the ABCs
•• Portable XPortable X--rays:rays:–– penetrating = penetrating = ““injured space plus 1 injured space plus 1
above/belowabove/below””
Adjuncts to the ABCsAdjuncts to the ABCs
•• FAST exam:FAST exam:–– 4 views of abdomen4 views of abdomen–– >200cc of fluid >200cc of fluid
Right Upper Quadrant Left Upper Quadrant Right Upper Quadrant Left Upper Quadrant Pericardial Pericardial PelvisPelvis
CARDIAC CHAMBERSCARDIAC CHAMBERS
LIVERLIVER
PITFALLPITFALL
If persistent or If persistent or recurrent hypotension, recurrent hypotension, remember FAST isnremember FAST isn’’t t
100% accurate! 100% accurate!
Secondary Survey: HistorySecondary Survey: History
•• AA
= = AAllergiesllergies
•• MM
= = MMedicationsedications
•• PP
= = PPast illnesses/ast illnesses/PPregnancyregnancy
•• LL
= = LLast mealast meal
•• EE
= = EEvents around injuryvents around injury
Secondary Survey: HistorySecondary Survey: History
•• Prenatal history:Prenatal history:•• PIH, DM, CHDPIH, DM, CHD•• preterm laborpreterm labor•• placental abruption/previaplacental abruption/previa•• fetal movementfetal movement
•• Fundal height Fundal height fetal agefetal age
Secondary Survey: HistorySecondary Survey: History
•• Blunt Mechanisms:Blunt Mechanisms:–– seat belt/helmet useseat belt/helmet use–– vehicle damagevehicle damage–– steering wheel deformationsteering wheel deformation–– impact directionimpact direction–– passenger ejectionpassenger ejection–– deaths at the scenedeaths at the scene
Secondary Survey: MechanismSecondary Survey: Mechanism
•• Front impact:Front impact:–– CC--sp fx, rib fx sp fx, rib fx
PTX, liver/spleen lacs, PTX, liver/spleen lacs,
post hip dislocationpost hip dislocation
•• Side impact:Side impact:••CC--sp fx, rib fx sp fx, rib fx
PTX, diaphragm PTX, diaphragm
rupture, pelvis fxrupture, pelvis fx
•• Ejection:Ejection:••increased riskincreased risk
Secondary Survey: MechanismSecondary Survey: Mechanism
•• Penetrating trauma:Penetrating trauma:–– body regionbody region
–– GSW: distance from weapon GSW: distance from weapon to wound, velocity, caliber, to wound, velocity, caliber, presumed pathpresumed path
–– SW: length of object, impact SW: length of object, impact directiondirection
–– associated blunt trauma?associated blunt trauma?
PITFALLPITFALL
If the weapon is in the patient, If the weapon is in the patient, allow the surgeon to remove it allow the surgeon to remove it under controlled conditions!under controlled conditions!
Secondary Survey: ExamSecondary Survey: Exam
Head to ToeHead to Toe
““Every Nook and Every Nook and CrannyCranny””
Exam: HEENTExam: HEENT
•• Head:Head:–– scalp lacerations or contusionsscalp lacerations or contusions–– skull fracturesskull fractures
Exam: HEENTExam: HEENT
•• Eye:Eye:–– pupil exampupil exam–– globe intact?globe intact?–– visual acuity?visual acuity?
•• Ears:Ears:–– blood? CSF leak?blood? CSF leak?–– intact?intact?
Exam: HEENTExam: HEENT
•• Nose/Mouth/Throat:Nose/Mouth/Throat:–– airway issues paramountairway issues paramount–– bony stepbony step--offoff–– bite feels normal?bite feels normal?–– bleeding from nose/mouthbleeding from nose/mouth
PENETRATINGPENETRATINGNECK INJURYNECK INJURY
Hemodynamically UnstableHemodynamically UnstableUncontrolled HemorrhageUncontrolled Hemorrhage
Operative Operative ExplorationExploration
ObserveObserve
Hemodynamically StableHemodynamically StableSymptomatic**Symptomatic**
** symptoms = expanding hematoma** symptoms = expanding hematomaairway compromiseairway compromisedysphagiadysphagiasubcutaneous emphysemasubcutaneous emphysemahoarsenesshoarseness
AsymptomaticAsymptomatic
Zone IZone I
Zone IIZone IIZone IIIZone III AngioAngio
IR emboIR embo++
Zone IZone I
Zone IIZone II
Zone IIIZone III
Transcervical GSWTranscervical GSWAll OthersAll Others
Penetrating Neck InjuriesPenetrating Neck Injuries
CT CT neck/neck/chestchest
++CTA CTA esophagramesophagram
bronchoscopybronchoscopy
CT CT neck/neck/chestchest
++CTA CTA esophagramesophagram
bronchoscopybronchoscopy
Exam: HEENTExam: HEENT
•• The Brain!The Brain!–– evaluation part of ABCevaluation part of ABCDDEsEs–– calculate GCS calculate GCS
•• GCS < 8 severe head injury/comaGCS < 8 severe head injury/coma
–– Dx = CT scan, ICP monitorDx = CT scan, ICP monitor
Exam: SpineExam: Spine
•• Cervical/Thoracic/Lumbar:Cervical/Thoracic/Lumbar:–– always protect the spinealways protect the spine–– safely off the backboardsafely off the backboard
•• if one fx, look for another!if one fx, look for another!•• sensory/motor loss = injurysensory/motor loss = injury•• remember steroidsremember steroids•• complication = neurogenic shockcomplication = neurogenic shock
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• 8 Lethal Injuries:8 Lethal Injuries:•• pneumothoraxpneumothorax•• hemothoraxhemothorax•• pulmonary contusionpulmonary contusion•• blunt cardiac injuryblunt cardiac injury•• aortic disruptionaortic disruption•• diaphragm rupturediaphragm rupture•• tracheobronchial injurytracheobronchial injury•• traversing mediastinal woundstraversing mediastinal wounds
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Simple pneumothoraxSimple pneumothorax•• penetrating and bluntpenetrating and blunt•• lung laceration with air leakagelung laceration with air leakage•• ↓↓
breath soundsbreath sounds
•• hyperresonancehyperresonance
•• Tx = chest tubeTx = chest tube
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• HemothoraxHemothorax•• lung laceration or laceration lung laceration or laceration
of intercostal vesselof intercostal vessel•• bleeding selfbleeding self--limitedlimited•• <10% require thoracotomy<10% require thoracotomy before chest tubebefore chest tube
after chest tubeafter chest tube
•• Tx = chest tubeTx = chest tube•• If > 1500cc out initially If > 1500cc out initially
thoracotomythoracotomy
PITFALLPITFALL
Make sure blood is evacuated Make sure blood is evacuated –– R/O caked hemothorax. R/O caked hemothorax.
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Pulmonary contusionPulmonary contusion•• most common injurymost common injury•• develops over timedevelops over time•• present without rib fx in present without rib fx in
childrenchildren admitadmit
12 hrs12 hrs
•• Tx = intubation ifTx = intubation ifsignificant hypoxiasignificant hypoxia
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Blunt cardiac injuryBlunt cardiac injury•• contusion to any chambercontusion to any chamber•• occasional ruptureoccasional rupture•• clinical symptoms:clinical symptoms:
•• tachycardiatachycardia•• arrhythmiasarrhythmias•• abnormal ECHOabnormal ECHO
•• Tx = 24Tx = 24˚̊
of Telemetryof TelemetrySwan if ECHO abnormal, patient unstableSwan if ECHO abnormal, patient unstable
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Aortic disruptionAortic disruption•• complete transection complete transection ––
typically DOAtypically DOA
•• incomplete tear incomplete tear ––
potentially salvageablepotentially salvageable•• injury near ligamentum arteriosuminjury near ligamentum arteriosum•• contained hematomacontained hematoma
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Aortic disruptionAortic disruption•• few symptomsfew symptoms•• XX--ray findings:ray findings:
•• wide mediastinumwide mediastinum•• obliterated aortic knobobliterated aortic knob•• deviation of tracheadeviation of trachea•• depressed left bronchusdepressed left bronchus•• deviation of esophagusdeviation of esophagus•• apical cappingapical capping
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Aortic disruptionAortic disruption•• empiric treatment in trauma empiric treatment in trauma
baybay•• esmolol SBP < 100, HR < 100esmolol SBP < 100, HR < 100
•• screening helical CT scanscreening helical CT scan•• angiography is the gold angiography is the gold
standardstandard
•• Tx = operative repair Tx = operative repair vs.vs.stent graftstent graft
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Diaphragm ruptureDiaphragm rupture•• more common on leftmore common on left•• blunt = radial tear blunt = radial tear •• penetrating = linear lacpenetrating = linear lac
left diaphragm ruptureleft diaphragm rupture
right diaphragm ruptureright diaphragm rupture
•• DiagnosisDiagnosis•• gastric bubble in chestgastric bubble in chest•• liver in the chestliver in the chest•• NGT coiled in chestNGT coiled in chest
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Dx = CT scan can be Dx = CT scan can be confirmatoryconfirmatory
•• Tx = operative repair via Tx = operative repair via the abdomenthe abdomen
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Tracheobronchial InjuryTracheobronchial Injury•• within 1 inch of carinawithin 1 inch of carina•• often lethaloften lethal•• hemoptysis, subQ emphysema, hemoptysis, subQ emphysema,
tension pneumothoraxtension pneumothorax•• persistent air leakpersistent air leak•• bronchoscopybronchoscopy
•• Tx = watch Tx = watch vs.vs. glue glue vs.vs. operateoperate
Exam: Thoracic InjuriesExam: Thoracic Injuries
•• Transmediastinal WoundsTransmediastinal Wounds•• external wounds + Xray external wounds + Xray
•• Tx = determined by hemodynamicsTx = determined by hemodynamics•• stable stable ––
CT, triple evalCT, triple eval
•• unstable unstable ––
OROR
•• Mortality > 20Mortality > 20--40%40%
KEY POINTKEY POINT
Rule out the Rule out the 8 lethal 8 lethal
chest injuries.chest injuries.
Exam: Abdominal InjuriesExam: Abdominal Injuries
•• Blunt trauma = crushing injuryBlunt trauma = crushing injury•• Penetrating = lacerationPenetrating = laceration•• Organ injuriesOrgan injuries
•• blunt = spleen blunt = spleen liver liver bowelbowel•• SW = liver SW = liver bowel bowel diaphragmdiaphragm•• GSW = bowel GSW = bowel colon colon liverliver
Exam: Abdominal InjuriesExam: Abdominal Injuries
•• Diagnostic tools:Diagnostic tools:•• FAST exam FAST exam blood in the abdomen?blood in the abdomen?•• Plain film Plain film retained bullet?retained bullet?
•• CT scan CT scan specific injury?specific injury?•• DPA/DPL DPA/DPL blood? bowel contents?blood? bowel contents?
Hemodynamically Stable
Peritonitis?
FAST +
Indications for CT:-Altered mental status-Confounding injury-Gross hematuria-Pelvic fracture-Abdominal tenderness-Unexplained Hct<35%
Repeat FASTin 30 minutes
FAST +
LAPAROTOMY
Abdominal CT
Yes
Yes
Yes
Yes
Yes No
No
No
DPA
Equivocal
+
No
Blunt Abdominal TraumaBlunt Abdominal Trauma
PenetratingPenetratingAbdominalAbdominal
TraumaTrauma
HemodynamicallyHemodynamicallyUnstableUnstable
HemodynamicallyHemodynamicallyStableStable
Operating Operating RoomRoom
GSWGSW
SWSW
AnteriorAnteriorAbdomenAbdomen
RUQRUQ
Tangential Tangential Back/FlankBack/Flank CTCT
Scan Scan
AASWAASWwithwith
+ LWE + LWE
Back/FlankBack/Flank
SerialSerialExamsExams
++
++
Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Exam: Abdominal InjuriesExam: Abdominal Injuries
Blunt liver injury:Blunt liver injury:
Penetrating liver injury:Penetrating liver injury:
Exam: Abdominal InjuriesExam: Abdominal Injuries
Blunt spleen injury:Blunt spleen injury:
Exam: Abdominal InjuriesExam: Abdominal Injuries
Blunt pancreatic/duodenal injury:Blunt pancreatic/duodenal injury:
Exam: Abdominal InjuriesExam: Abdominal Injuries
Blunt bowel injury:Blunt bowel injury:
Exam: Abdominal InjuriesExam: Abdominal Injuries
Penetrating vascular injury:Penetrating vascular injury:
SW to inferior vena cavaSW to inferior vena cava
GSW to left externalGSW to left externaliliac arteryiliac artery
Exam: Pelvic InjuriesExam: Pelvic Injuries
•• ExamExam•• stable pelvic ring? stable pelvic ring?
•• Pelvis filmPelvis film•• intact circle?intact circle?•• rami intact?rami intact?•• acetabulum smooth?acetabulum smooth?
Exam: Pelvic InjuriesExam: Pelvic Injuries
•• If patient has a pelvic fractureIf patient has a pelvic fracture•• rectal exam rectal exam bony fragments?bony fragments?•• vaginal exam vaginal exam lacerations?lacerations?•• GU exam GU exam bladder/urethral injury?bladder/urethral injury?•• perineal exam perineal exam degloving?degloving?
Pelvic Fracture KCPPelvic Fracture KCP
FAST ExamFAST Exam
PositivePositive NegativeNegative
2 units PRBCs/ED trauma bay2 units PRBCs/ED trauma bay
HD StableHD Stable
SICU +/SICU +/--
CT scans**CT scans**
Laparotomy, Pelvic Fixation,Laparotomy, Pelvic Fixation,Pelvic PackingPelvic Packing
Operating RoomOperating Room
Hemodynamically Stable?Hemodynamically Stable?
YesYes
AngiographyAngiography
SICUSICU
Pelvic Fixation and Pelvic PackingPelvic Fixation and Pelvic Packing
HD UnstableHD Unstable
Operating RoomOperating Room
Ongoing Transfusion Requirements?Ongoing Transfusion Requirements?
NoNo
AngiographyAngiography
SICUSICU
YesYes
NoNo
** normalize coagulation status,** normalize coagulation status,abdominal CT scan if no laparotomy done.abdominal CT scan if no laparotomy done.
Exam: Extremity InjuriesExam: Extremity Injuries
•• ExamExam•• deformity?deformity?•• open fracture?open fracture?•• intact motor/sensory exam?intact motor/sensory exam?•• pulses? pulses?
•• Stop bleeding with pressureStop bleeding with pressure•• Measure AMeasure A--A gradientA gradient•• Traction/splintsTraction/splints
22ºº
SurveySurvey: Take Home Points: Take Home Points
•• Systematic evaluationSystematic evaluation
•• Recognize and treat life threatening Recognize and treat life threatening injuriesinjuries
•• Ongoing resuscitationOngoing resuscitation
•• Diagnostic testsDiagnostic tests
•• Watch for pitfallsWatch for pitfalls
The Secondary SurveyThe Secondary Survey
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