Trauma

Primary Survey

• ABCDE
  
  • Airway
    
  • Breathing
    
  • Circulation
    
  • Disability
    
  • Exposure

Airway

• –If trauma patient comes in unconscious: Intubate!
• –If GCS < 8: Intubate!
• –If guy stung by a bee, developing stridor and tripod posturing: Intubate!
• –If guy stabbed in the neck, GCS = 15, expanding mass in lateral neck: Intubate!
• –If guy stabbed in the neck, crackly sounds w/ palpating anterior neck tissues: fiberoptic bronchoscope 
• –If huge facial trauma, blood obscures oral and nasal airway, & GCS of 7: cricothyroidotomy

Breathing

• –After Intubating a patient, next best step: Check bilateral breath sounds
• –If decr on the left: Means you intubated the right mainstem bronchus
• –What to do: Pull back your ET tube
• –Next step: Check pulse ox, keep it >90%

Secondary Survey

• full exam after determining pt is stable

5 Thoracic causes of immediate death

1. tension pneumothorax
   
2. cardiac tamponade
   
3. open pneumothorax
   
4. massive hemothorax
   
5. airway obstruction

Cardiac Tamponade

Hemoperitoneum

Isotonic Fluids

Head Trauma

• GCS -> eyes 4, motor 6, verbal 5
• Hematoma, edema, tumor can cause increased ICP
• Symptoms: Headache, vomiting, altered mental status
• Treatment: Elevate HOB, hyperventilate to pCO2 28-32, give mannitol (watch renal fxn)
• Surgical intervention: Ventriculostomy

Epidural Hemorrhage

• Def:
  • Collection of blood between dura and skull caused by arterial hemorrhage
  • -An epidural hematoma may appear to cross the brain midline on CT; subdural hematomas do not.
• MC Cause:
  • damage to the middle meningeal artery from blunt trauma.
• Presentation:
  • 1. (immediate or slow) loss of consciousness followed by a lucid interval (minutes to hours).
    
  • 2. Uncal herniation leads to coma with a “blown pupil” (fixed and dilated ipsilateral pupil)
    
  • 3. ultimately ipsilateral hemiparesis
  • Note: Mental status changes associated with an expanding epidural hematoma occur within minutes to hours and classically have a lucid
    interval.
• Diagnosis:
  • Radiology = CT without contrast shows convex hyperdensity compressing the brain at site of injury, adjacent skull fracture may be apparent in traumatic cases.
• Treatment:
  
  • 1. emergent drainage of hematoma either under radiographic guidance or by surgical burr hole
    
  • 2. stabilization of ICP and blood pressure
• Complications:
  • permanent neurologic injury or death usually results without prompt treatment

James Heilman, MD / CC BY-SA

Subdural Hemorrhage

• Def:
  • Collection of blood between the dura and arachnoid meningeal layers caused by rupture of bridging veins following trauma
• Cause: 
  • -Typically occurs following head trauma (usually falls or assaults), leading to rupture of bridging veins and accumulation of blood between the dura and arachnoid membranes.
    -Common in the elderly and alcoholics.
• Types: Acute and Chronic
• Presentation:
  • 1. (Slowly/Quickly) progressive headache (days to weeks)
    2. Change in mental status (occur within days
    to weeks)
    3. Contralateral hemiparesis
    4. increased deep tendon reflexes (DTRs)
    b. Large hematomas can cause transtentorial herniation with decreased consciousness and pupil abnormalities.
  • Notes:
    • With mental status changes seen in an elderly patient with a history of falls, perform a workup for subdural hematoma
    • Do not perform an LP in patients with subdural hematoma because of increased risk of herniation.
• Diagnosis:
  • CT without contrast shows concave hyperdensity compressing the brain that does not cross midline
• Treatment:
  • surgical drainage or supportive therapy, depending on size of bleed and extent of neurologic deficits

Glitzy queen00 at English Wikipedia / Public domain

Neck Trauma (penetrating)

• Penetrating Trauma -> GSW or stab wound
  • Zone 3 = ↑ angle of mandible
    • w/u: Aortography and triple endoscopy.
  • Zone 2 = angle of mandible-cricoid
    • w/u: 2D doppler +/-exploratory surgery.
  • Zone 1 = ↓ cricoid
    • w/u: Aortography
• Work-up:
  • 1) intubate early
  • 2) immediate surgical exploration is mandatory for pts w/ shock and active ongoing hemorrhage from neck wounds
    
    • – all wounds that violate the platysma are considered true penetrating neck trauma.
    • – assess based on neck zones (3)
      
      • —1) above angle of mandible
      • —2) between angle of mandible and cricoid
      • —3) below cricoid
  • 3) Continue dx work-up w/ appropriate tests
    
    • – angiography or aorta
    • – carotid/cerebral arteries
    • – CT scan of the neck w/ or w/o CT angiography
    • – Doppler U/S
    • – contrast esophagography/esophagoscopy
    • – bronchoscopy

Injuries

Contaminated wounds

Penetrating Abdominal Trauma

• If GSW to the abdomen: Ex-lap. (plus tetanus prophylaxis)
• If stab wound & pt is unstable, with rebound tenderness & rigidity, or w/ evisceration: Ex-lap. (plus tetanus prophylaxis)
• If stab wound but pt is stable: FAST exam. DPL if FAST is equivocal.
  Ex-lap if either are positive.
• If blunt abdominal trauma pt with hypotension/tachycardia:If you see this? Do not pass go, go directly to exploratory laparotomy. Ex-lap. (plus tetanus prophylaxis) Ex-lap. (plus tetanus prophylaxis) Ex-lap.
• If Air under the diaphragm: Do not pass go, go directly to exploratory laparotomy.

Blunt Abdominal Trauma

• If unstable: Ex-lap.
• If stable: Abdominal CT
  • –If lower rib fx plus bleeding into abdomen: Spleen or liver lac.
  • –If lower rib fx plus hematuria: Kidney lac.
  • –If Kehr sign & viscera in thorax on CXR: Diaphragm rupture.
  • –If handlebar sign: Pancreatic rupture.
  • –If stable w/ epigastric pain?
    • Best test: Abdominal CT.
    • If the retroperitoneal fluid is found? Consider duodenal rupture.

Pelvic Trauma

• If hypotensive, tachycardic -> FAST and DPL to r/o bleeding in the abdominal cavity.
• Can bleed out into pelvis -> stop bleeding by fixing fx -> internal if stable, external if not.
• If blood at the urethral meatus and a high riding prostate: Consider pelvic fracture w/ urethral or bladder injury.
• Next best test: Retrograde urethrogram (NOT FOLEY!)
• If normal: Retrograde cystogram to evaluate bladder
• What are you looking for: Check for extravasation of dye. Take 2 views to ID trigone injury.
  • If extraperitoneal extravasation: Bed rest + foley
  • If intraperitoneal extravasation: Ex-lap and surgical repair

Ortho Trauma

• Fractures that go to the OR:
  • –Depressed skull fx
  • –Severely displaced or angulated fx
  • –Any open fx (sticking out bone needs cleaning)
  • –Femoral neck or intertrochanteric fx

Anterior Shoulder dislocation

• –Arm outwardly rotated, & numbness over deltoid

Posterior Shoulder dislocation

• –Shoulder pain s/p seizure or electrical shock

Boxers fracture

• –Punching a wall: Metacarpal neck fracture “Boxer’s fracture”. May need K wire

Clavicle fracture

• –Clavicle is most commonly broken where: Between middle and distal 1/3s. Need figure of 8 device

Colles fracture

• –old lady FOOSH, distal radius displaced

Depressed skull fracture

Femoral Neck fracture

Intertrochanteric fracture

Scaphoid fracture

• –young person FOOSH, anatomic snuffbox tender

Child Abuse

Procedures

EM Notes

• leave any impaled object in the chest in place until pt is taken to the OR, as such objects may tamponade further blood loss

References

1. Blausen.com staff (2014). &quot;Medical gallery of Blausen Medical 2014&quot;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. / CC BY