trauma updates 2012
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Trauma Updates 2012. Douglas S. Ander, MD Professor of Emergency Medicine Emory University School of Medicine. Disclosure. I have no actual or potential conflict of interest in relation to this program/presentation. Case #1. - PowerPoint PPT PresentationTRANSCRIPT
Douglas S. Ander, MDProfessor of Emergency
MedicineEmory University School of
Medicine
DisclosureI have no actual or potential conflict of
interest in relation to this program/presentation
Case #124 year old female single
car MVC. She lost control on a patch of ice and struck a tree. Significant front end damage. Older model car with no airbag.
She was restrained with 3-point restraint.
Primary survey normal.Secondary survey
significant for abrasion and slight swelling to neck.
Blunt Neck InjuryIncidence: 1% of blunt trauma admissionsIncidence of stroke amongst 27 patients with
CAI was 33%48 untreated BCVI patients, 10(21%) had an
adverse neurologic eventsEstimated that 32 asymptomatic patients
averted strokes with appropriate treatment
Cothren CC et al. Amer J Surg 2005;190:849-854Miller et al. Ann Surgery 2002;236:386-395.
Signs/Symptoms of BCVIArterial hemorrhage from neck/nose/mouthExpanding cervical hematomaCervical bruit in pt < 50 yrs oldFocal neurologic defect: TIA, hemiparesis,
vertebrovasilar symptoms, Horner’s Syndrome
Stroke on CT or MRINeurologic deficit inconsistent with head CT
Horner’s Syndrome
Risk Factors for BCVIHigh energy transfer mechanism associated with
Displaced mid-face fracture (LeFort II or III)Basilar skull fracture with carotid canal involvementCHI consistent with DAI and GCS < 6Cervical vertebral body or transverse foramen
fracture, subluxation, or ligamentous injury at any level; any fracture at C1-C3
Near hanging with anoxiaClothesline type injury or seat belt abrasion
with significant swelling, pain or altered mental status
EvaluationAngiography
Gold StandardInvasive and resource intensive
Duplex UltrasonographySensitivity 38.5% Specificity 100%
CTA (16 slice or higher)Current recommendation for suspected BCVI
with angiography for negative CTA with high suspicion
TreatmentInjury Grade Description
I Luminal irregularity or dissection <25% luminal narrowing
II Dissection or intramural hematoma with >25% luminal narrowing, intraluminal thrombus, or raised intimal flap
III Pseudoaneuryms
IV Occlusion
V Transection with free extravasation
Grades 1-4Heparin
Grade 5 Surgical
repair
Case #238 year old male
restrained driver head on collision. Airbags deployed. Significant front end damage. 20 minute extrication from the vehicle.
Case #358 year old female, restrained rear passenger
in an MVC. Rollover at highway speeds. Airbags deployed. No LOC. Self extricated and was ambulatory at the scene. Complains of neck pain and was immobilized by EMS. Upon arrival to ED was hemodynamically stable, had some mild neck tenderness around C4, no obvious injuries, abd was soft and nontender.
Whole Body CT (Pan) ScanDefinition
CT Head and Cervical Spine without IV contrast Followed by
CT Chest, Abdomen, and Pelvis with IV contrastOral contrast case dependent
Whole Body CT for Blunt Trauma
Of 143 patients with at least one unsupported scan an injury would have been missed in 53 (36%)
Abnormal CT Scans by Indication
UnsupportedN(%) EM
Head 5/62 (8)
Neck 2/50 (4)
Chest 33/116 (28)
Abd/Pelvis
12/83 (14)
TOTAL 52/311 (17)
Tillou et al. J Trauma 2009;67:779-787. UCLA Medical Center
Whole Body CTTrauma patients with no signs injury1000 patients over 18 monthsClinically significant abnormalities found in:
3.5% of Head CTs5.1% of Cervical CTs19.6% of Chest CTs7.1% of Abdominal CTs
Salim A et al. Arch Surg 2006;141:468-475
Change in treatment for the 592 patients who had a CT for mechanism is 120 (20.3%)
Whole Body CT
Change in Treatment Based on CT Findings for the 592 Patients Evaluated for Mechanism Only
No. (%)
Abdominal CT Results
Changed (n=120)
Unchanged (n=472)
Abnormal 24 (57.1) 18 (42.9)
Normal 96 (17.5) 454 (82.5)
Whole Body CT and SurvivalRetrospective multicenter studyData from German Trauma Society registry1494 (32%) of 4621 patients received a whole body
CTRelative reduction in mortality based on Trauma
and Injury Severity Score was 25% (14-37)and 13% (4-23) based on Revised Injury Severity Score
Multivariate analysis confirmed that whole body CT is an independent predictor of survival (p<0.002)
Number needed to scan was 17 and 32 respectively based on TRISS and RISC calculation
Humber-Wagner S et al. Lancet 2009;373:1455-1461
Whole Body CT600 patients underwent pan-scanEmergency physicians and trauma surgeons
documented whether pan-scan was necessaryOf the 992 scans that one or both physicians
indicated could be omitted, 102 (10%) were abnormal
3 (0.3%) led to a critical actionT8 burst fracture to ORSAH – empiric platelets for aspirin use (OR for
femur fx)Rib fxs, pulmonary contusion and lung lac – ICU
admit Gupta M et al. Ann Emerg Med 2011;58:407-416
Whole Body CT ConclusionNo clear guidelinesCurrent studies provide no definitive answer
due to study limitationsClinical judgment based on history, physical,
initial studies and ultrasoundHigh risk criteria:
MVC >35 mphFalls >15 ftPed vs auto with ped thrown >10 ftAssaulted with depressed level of consciousness
Case #417 year old male presents with a stab wound
to his left chest. EMS initially reported vital signs but as they arrive to the resuscitation room with CPR in progress state that he lost vitals as they pulled up to the ambulance ramp.
RationalePhysiologic Rationale for ED Thoracotomy
Release of pericardial tamponade
Control of intrathoracic vascular or cardiac hemorrhage
Permit open cardiac massage
Occlusion of descending aorta (cross-clamping)
Control of massive air embolism or bronchopleural fistula
Blunt TraumaVery low survival rate and poor neurologic
outcomePatients presenting pulseless even with
myocardial electrical activity are not candidates for emergency thoracotomy
Penetrating traumaPatients who arrive pulseless but with
myocardial electrical activity may be candidates for thoracotomy
Time frame of CPR??15 minute
Other considerationsAgePre-existing conditionsAvailability and accessibility of specialist
personnelProximity to appropriate operating facilities
and equipmentExperience of the unit carrying out the
procedure
Fluid Resuscitation“Controlled”, “Balanced”, “Hypotensive”,
“Permissive”Goal is balance, not the hypotensionBridge to definitive surgical control of
bleeding
Hypotensive ResuscitationRandomized trialTwo groups: Target SBP >100 mmHg or SBP of
70 mmHgEqual survival rates, 92.7%
Dutton et al. J Trauma 2002;52:1141-1146
Delayed Fluid ResuscitationRandomized trialTwo groups: immediate and delayed resuscitation
in patients with penetrating torso trauma and BP<90 mmHgVariable Immediate
Resuscitation
Delayed Resuscitation
P Value
Survival to discharge
62% 70% 0.04
Length of hospital stay (days)
14 + 24 11 + 19 0.006
Length of ICU stay (days)
8 + 16 7 + 11 0.30
Patients with > 1 complication
30% 23% 0.08Bickell et al. NEJM 1994;331:1105-1109.
Other ATLS update highlightsDigital rectal examination selective prior to
placement of foleyLMA plays a role in the “cannot intubate,
cannot ventilate” scenarioMethylprednisolone in spinal cord injuries
No evidence exists to support routine use
Trauma in pregnancyRetrospective chart review271 patientsRisk factors of fetal death
Maternal HR > 110Injury Severity Score > 9Evidence of placental
abruptionFetal heart rate > 160 or <
120Ejection from motor vehicleMotorcycle or pedestrian
collisions
>20-24 week gestationNo risk factors
6 hours monitoringRisk factors
24 hours monitoring
Curet et al. J Trauma 2000;49:18-24
Airway updatesAssess for difficult airway, LEMON mnemonic
Look externallyEvaluate using the 3-3-2 rule, Mallampati,
Obstruction, and neck mobility
Pelvis Fracture
Minor Head Injury (GCS 13-15)Witness LOC, amnesia, or witnessed
disorientationHigh risk
GCS < 15 at two hours after injurySuspected open or depressed skull fractureAny sign of basal skull fractureVomiting (> 2 episodes)Age > 65 years
Moderate riskAmnesia before impact (>30 minutes)Dangerous mechanism
Other ATLS update highlightsWarmed isotonic solutions (LR or NS)Tamponade best managed by thoracotomy
Pericardiocentesis is temporizingBase deficit and/or lactate play a role in
determining presence and severity of shock