1. 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

2. What is trauma?

4. Real Life & Death

5. What is trauma?

6. Trauma Epidemiology

7. Years of Potential Life Lost
MMWR 1982;31,599.

8. Mechanisms of Injury: Blunt Trauma
MVC
Pedestrian vs Vehicle
Falls

9. Mechanisms of Injury: Special Situations
Explosions
Blunt + penetrating + burns
Burns
Crush injuries
Drowning
Hypothermia/ exposure

10. Compression injury Frontal brain contusion Pneumothorax
Rupture of Left hemidiaphragm
Small bowel rupture
Chance fracture

11. Deceleration Injury Aortic tear Acute subdural brain hematoma
Fixed descending aorta
Mobile arch
Acute subdural brain hematoma
Kidney avulsion
Splenic pedicle

12. Mechanisms of Injury: Penetrating Trauma
Gun shot wounds
Stab wounds
Impalement

13. 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

14. 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

16. What happens when the patient comes to a Level I Trauma Center?

17. Trauma Team “Doin it 24/7” ED Physicians Anesthesiology Surgeons
General and Trauma and Critical Care
Neurosurgery
Orthopedics
Medical Students
Nurses
Radiology Techs
Radiologists

19. What happens when this patient comes to the ER where you are moonlighting?

21. What the heck do I do now?

22. Don’t panic!

23. Trauma is not rocket science!

24. Air goes in & out
Oxygen is good
Blood goes round & round
Stop bleeding
Put things back where and how they belong

25. Initial Assessment: Prerequisites
Wide-angled view
Pattern recognition skills
Ability to triage and set priorities
Organized structure

26. Trauma is not rocket science!

27. ABCDEF

28. Initial Assessment: Primary Survey
A = Airway
B = Breathing
C = Circulation
D = Disability
E = Exposure
F = Fracture

29. Initial Assessment: Airway
Clear & establish a good airway
Consider intubation for coma, shock, and thoracic injuries
C-spine stabilization

31. Airway: Cricothyrotomy

32. Initial Assessment: Breathing
Chest excursion & breath sounds
Flail chest
Pneumothorax
Open
Tension
Massive Hemothorax

35. 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

36. Initial Assessment: Disability
Neurologic status
Glasgow Coma Scale
Eye
Motor-best predictor of long term outcome
Verbal
Spinal Cord Injury

37. Initial Assessment: Exposure
Remove clothes
Temperature
warm blankets
Finger and tube in every orifice
Maintain full spine precautions
Log Roll

38. Initial Assessment: Fracture
Stabilize Fractures
Relocate dislocated joints
Reassess pulses

39. 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

40. Does this patient need to go to the OR ?

42. Penetrating Abdominal Trauma

43. Blunt Abdominal Injuries

44. Liver Injury

45. 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

47. 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

48. Surgical Management

49. Surgical Management

50. Surgical Management

51. Spleen Injury

52. Splenic Injury Blunt or Penetrating Signs / Symptoms LUQ pain
Kehr’s sign
involuntary guarding hypoactive or absent BS
signs of hemorrhage
point tenderness

54. 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

61. Splenectomy Complications postsplenectomy infection wound infection
Vaccination
wound infection
subdiaphragmatic abscess
pulmonary complications
hypovolemic shock

62. 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

63. 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

64. 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

66. 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

67. 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

68. 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

70. Pelvic Fracture Signs & Symptoms pelvic instability
pain (suprapubic also)
crepitus
bloody meatus
neurovascular deficits

71. Pelvis Interventions Stable patient Unstable patient analgesia
Repair vs mobilization
Unstable patient
Immobilize
Ex-fix
Angiography
embolization