Trauma Overview David B. Reedy, M.D., FACEP 4/15/2017 Trauma Overview David B. Reedy, M.D., FACEP Contra Costa Regional Medical Center Assistant Clinical Professor UCSF/SFGH

Trauma is an injury caused by a physical force 4/15/2017 Trauma is an injury caused by a physical force Motor vehicle collisions Falls Gun shot Stabbing Burns Blunt assault

Advanced Trauma Life Support 4/15/2017 Advanced Trauma Life Support American College of Surgeons Provides a framework for the management of the injured patient Intended to allow the single doctor in a rural hospital to assess and manage trauma patients

4/15/2017 ATLS Origins Nebraska, 1976 Plane crash in a Nebraska field changed the face of trauma care throughout the world Medical, EMS, and Nursing groups began to collate protocols for trauma management ACS publishes ATLS in 1980

4/15/2017 Blunt Thoracic Trauma

Blunt Thoracic Trauma Airway Look for associated injuries 4/15/2017 Blunt Thoracic Trauma Airway Look for associated injuries Remember c-spine

Blunt Thoracic Trauma Breathing Respiratory rate Paradoxical motion 4/15/2017 Blunt Thoracic Trauma Breathing Respiratory rate Paradoxical motion Crepitus Subcutaneous air Auscultation

Blunt Thoracic Trauma CXR-pneumothorax 4/15/2017 Blunt Thoracic Trauma CXR-pneumothorax Tracheal deviation, hypotension, hypoxemia

Blunt Thoracic Trauma Circulation Hypotension Hypovolemia Pneumothorax 4/15/2017 Blunt Thoracic Trauma Circulation Hypotension Hypovolemia Pneumothorax Cardiac tamponade Aortic Injury Blunt cardiac injury Arrhythmia NSR

4/15/2017 Blunt Thoracic Trauma CXR-widened mediastinum

Blunt Thoracic Trauma Aortic injury 4/15/2017 Blunt Thoracic Trauma Aortic injury 80-90% of patients with thoracic aortic rupture die in the pre-hospital setting Those who survive may have minimal initial symptoms CXR may be first clue

Penetrating Thoracic Trauma 4/15/2017 Penetrating Thoracic Trauma Emergency Department Thoracotomy “The surgeon who should attempt to suture a wound of the heart would lose the respect of his surgical colleagues” - Theodore Bilroth, 1882

Penetrating Thoracic Trauma 4/15/2017 Penetrating Thoracic Trauma Emergency Department Thoracotomy

Penetrating Thoracic Trauma 4/15/2017 Penetrating Thoracic Trauma Emergency Department Thoracotomy Indications Penetrating thoracic traumatic arrest with previously witnessed cardiac activity Penetrating thoracic unresponsive hypotension

Penetrating Thoracic Trauma 4/15/2017 Emergency Department Thoracotomy

Penetrating Thoracic Trauma 4/15/2017 Penetrating Thoracic Trauma Emergency Department Thoracotomy Contraindications Blunt thoracic injuries with no witnessed cardiac activity Multiple blunt trauma Severe head injury

Penetrating Thoracic Trauma 4/15/2017 Penetrating Thoracic Trauma Emergency Department Thoracotomy ACLS algorithms do NOT apply to traumatic arrest

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography The FAST Exam

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography Focused Assessment with Sonography for Trauma (FAST) Limited ultrasound exam Directed solely at identifying the presence of free intraperitoneal or pericardial fluid Free fluid is usually due to hemorrhage Helps determine the need for OR, CT, or angiography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography FAST examines four areas for free fluid

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography Low Frequency Probe 2.5 - 5.0 MHz Tissue Penetration

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography Perihepatic and hepato-renal

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonograpy 4/15/2017 Trauma Ultrasonograpy Spleno-renal

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography Pelvis

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography Pericardium

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography Blunt Abdominal Trauma Not for bowel injury, solid organ injury, or retroperitoneal injury Detection of free intraperitoneal or pericardial fluid

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Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography EFast Exam Extended Fast Exam Anterior lung apices for pneumothorax Lung bases for pleural fluid

Trauma Ultrasonography 4/15/2017

Trauma Ultrasonography 4/15/2017

Trauma Ultrasonography 4/15/2017 Trauma Ultrasonography Conclusions Clinician based ultrasound has changed the way trauma care is practiced and is rapidly becoming standard of care Noninvasive, straightforward, relatively short training period Multiple training courses exist Focused exam, goal specific

ATLS 8th Edition, 2008 30 year anniversary 4/15/2017 ATLS 8th Edition, 2008 30 year anniversary “Best evidence” based (i.e. spinal steroids) Revised pediatric guidelines Disaster management

4/15/2017 The Knife and Gun Club