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Published byTheresa Rodgers Modified over 9 years ago
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UNC Department of Surgery Section of Trauma and Critical Care
Trauma “This ain’t ER” Ben Zarzaur, MD UNC Department of Surgery Section of Trauma and Critical Care
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What is trauma?
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Real Life & Death
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What is trauma?
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Trauma Epidemiology
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Years of Potential Life Lost
MMWR 1982;31,599.
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Mechanisms of Injury: Blunt Trauma
MVC Pedestrian vs Vehicle Falls
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Mechanisms of Injury: Special Situations
Explosions Blunt + penetrating + burns Burns Crush injuries Drowning Hypothermia/ exposure
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Compression injury Frontal brain contusion Pneumothorax
Rupture of Left hemidiaphragm Small bowel rupture Chance fracture
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Deceleration Injury Aortic tear Acute subdural brain hematoma
Fixed descending aorta Mobile arch Acute subdural brain hematoma Kidney avulsion Splenic pedicle
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Mechanisms of Injury: Penetrating Trauma
Gun shot wounds Stab wounds Impalement
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Gun Shot Wounds: Mechanism
Energy transfer Shape/size of bullet Distance to target Velocity (most important) Kinetic energy = (Mass × Velocity2 )/2 Surface area distributed Tumble and yaw Fragmentation Anatomy Viscoelasticity Muscle organs
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Stab wounds Mechanism Extent of Injury Severe injury
Blunt: Crush injury Sharp:Tissue disruption Extent of Injury Weapon size, length, sharpness, penetration Severe injury Chest and abdomen 4+ wounds
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What happens when the patient comes to a Level I Trauma Center?
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Trauma Team “Doin it 24/7” ED Physicians Anesthesiology Surgeons
General and Trauma and Critical Care Neurosurgery Orthopedics Medical Students Nurses Radiology Techs Radiologists
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What happens when this patient comes to the ER where you are moonlighting?
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What the heck do I do now?
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Don’t panic!
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Trauma is not rocket science!
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Air goes in & out Oxygen is good Blood goes round & round Stop bleeding Put things back where and how they belong
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Initial Assessment: Prerequisites
Wide-angled view Pattern recognition skills Ability to triage and set priorities Organized structure
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Trauma is not rocket science!
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ABCDEF
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Initial Assessment: Primary Survey
A = Airway B = Breathing C = Circulation D = Disability E = Exposure F = Fracture
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Initial Assessment: Airway
Clear & establish a good airway Consider intubation for coma, shock, and thoracic injuries C-spine stabilization
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Airway: Cricothyrotomy
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Initial Assessment: Breathing
Chest excursion & breath sounds Flail chest Pneumothorax Open Tension Massive Hemothorax
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Initial Assessment: Circulation
Perfusion (mental status, skin, pulse) Control bleeding with pressure Pericardial Tamponade Beck’s Triad Establish 2 large bore (16G or larger) IV’s in upper extremity peripheral veins Resuscitate with Lactated Ringers After 4 L think about resuscitation with blood
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Initial Assessment: Disability
Neurologic status Glasgow Coma Scale Eye Motor-best predictor of long term outcome Verbal Spinal Cord Injury
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Initial Assessment: Exposure
Remove clothes Temperature warm blankets Finger and tube in every orifice Maintain full spine precautions Log Roll
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Initial Assessment: Fracture
Stabilize Fractures Relocate dislocated joints Reassess pulses
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Secondary Survey Patient history Head to toe physical exam Radiography
Lateral C-spine, C-xray, pelvis One cavity above/below entrance/exit wounds FAST Urinary bladder drainage NGT Blood sampling/monitoring
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Does this patient need to go to the OR ?
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Penetrating Abdominal Trauma
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Blunt Abdominal Injuries
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Liver Injury
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Liver Injury blunt or penetrating injury mortality: 10 - 20%
may be associated with right lower rib fracture Signs / Symptoms RUQ pain abdominal wall spasm ,guarding hypoactive or absent BS signs of hemorrhage
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Liver Injury: Management Blunt Injury
ICU monitoring For more severe injuries Serial HCT Floor Monitoring Less severe injuries OR if patient becomes unstable or requires excessive blood transfusions
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Surgical Management
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Surgical Management
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Surgical Management
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Spleen Injury
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Splenic Injury Blunt or Penetrating Signs / Symptoms LUQ pain
Kehr’s sign involuntary guarding hypoactive or absent BS signs of hemorrhage point tenderness
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Splenic Injury Management
ICU monitoring Serial Physical exams Serial HCT Floor Monitoring Not indicated at this time Further intervention needed if patient becomes unstable or requires blood transfusion Embolization vs Splenectomy
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Splenectomy Complications postsplenectomy infection wound infection
Vaccination wound infection subdiaphragmatic abscess pulmonary complications hypovolemic shock
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Stomach and Small Bowel Injury
Stomach & Small Bowel Blunt vs penetrating Diagnosis Pneumoperitoneum or free fluid on CT scan small bowel injury may be difficult to detect Found at laparotomy Management Primary repair or resection
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Colon and Rectal Injury
Diagnosis Pneumoperitoneum or free fluid on CT scan injury may be difficult to detect Found at laparotomy Management Colostomy vs primary repair Rectum Intraperitoneal- treat as colon injury Extraperitoneal- primary repair with diversion +/- presacral drains
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Pancreas & Duodenum Diagnosis often delayed diagnosis
frequently seen together most often contused due to blunt injury Seen on CT Scan or at laparotomy intramural hematoma in wall of duodenum obstruction bilious vomiting severe abdominal pain distention
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Pancreas Injury Management if the result of blunt trauma
nonoperative management NG/OG decompression serial physical exams monitoring signs of infection controversial - 3 weeks of bowel rest with TPN Complications of nonoperative care pancreatic fistula pseudocyst formation Operative management is necessary if: pain fever ileus elevated serum amylase
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Duodenal Injury Management For hematoma For perforation
NG/OG decompression serial physical exams monitoring signs of infection controversial - 3 weeks of bowel rest with TPN For perforation Primary repair with duodenal exclusion Efferent/Afferent Duodenal tubes
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Pelvic Injury Introduction significant blood loss if bilateral
may settle in retroperitoneal space 3% of all fractures mortality % 2nd most common cause of traumatic death
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Pelvic Fracture Signs & Symptoms pelvic instability
pain (suprapubic also) crepitus bloody meatus neurovascular deficits
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Pelvis Interventions Stable patient Unstable patient analgesia
Repair vs mobilization Unstable patient Immobilize Ex-fix Angiography embolization
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