1. 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

2. Trauma is an injury caused by a physical force
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Trauma is an injury caused by a physical force
Motor vehicle collisions
Falls
Gun shot
Stabbing
Burns
Blunt assault

3. Advanced Trauma Life Support
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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

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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

5. 4/15/2017
Blunt Thoracic Trauma

6. Blunt Thoracic Trauma Airway Look for associated injuries
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Blunt Thoracic Trauma
Airway
Look for associated injuries
Remember c-spine

7. Blunt Thoracic Trauma Breathing Respiratory rate Paradoxical motion
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Blunt Thoracic Trauma
Breathing
Respiratory rate
Paradoxical motion
Crepitus
Subcutaneous air
Auscultation

8. Blunt Thoracic Trauma CXR-pneumothorax
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Blunt Thoracic Trauma
CXR-pneumothorax
Tracheal deviation, hypotension, hypoxemia

9. Blunt Thoracic Trauma Circulation Hypotension Hypovolemia Pneumothorax
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Blunt Thoracic Trauma
Circulation
Hypotension
Hypovolemia
Pneumothorax
Cardiac tamponade
Aortic Injury
Blunt cardiac injury
Arrhythmia
NSR

10. 4/15/2017
Blunt Thoracic Trauma
CXR-widened mediastinum

11. Blunt Thoracic Trauma Aortic injury
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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

12. Penetrating Thoracic Trauma
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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

13. Penetrating Thoracic Trauma
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Penetrating Thoracic Trauma
Emergency Department Thoracotomy

14. Penetrating Thoracic Trauma
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Penetrating Thoracic Trauma
Emergency Department Thoracotomy
Indications
Penetrating thoracic traumatic arrest with previously witnessed cardiac activity
Penetrating thoracic unresponsive hypotension

15. Penetrating Thoracic Trauma
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Emergency Department Thoracotomy

16. Penetrating Thoracic Trauma
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Penetrating Thoracic Trauma
Emergency Department Thoracotomy
Contraindications
Blunt thoracic injuries with no witnessed cardiac activity
Multiple blunt trauma
Severe head injury

17. Penetrating Thoracic Trauma
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Penetrating Thoracic Trauma
Emergency Department Thoracotomy
ACLS algorithms do NOT apply to traumatic arrest

18. Trauma Ultrasonography
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Trauma Ultrasonography
The FAST Exam

19. Trauma Ultrasonography
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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

20. Trauma Ultrasonography
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Trauma Ultrasonography
FAST examines four areas for free fluid

21. Trauma Ultrasonography
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Trauma Ultrasonography
Low Frequency Probe
MHz
Tissue Penetration

22. Trauma Ultrasonography
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Trauma Ultrasonography
Perihepatic and hepato-renal

23. Trauma Ultrasonography
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Trauma Ultrasonography

24. Trauma Ultrasonography
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Trauma Ultrasonography

25. Trauma Ultrasonography
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Trauma Ultrasonography

26. Trauma Ultrasonography
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Trauma Ultrasonography

27. Trauma Ultrasonograpy
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Trauma Ultrasonograpy
Spleno-renal

28. Trauma Ultrasonography
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Trauma Ultrasonography

29. Trauma Ultrasonography
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Trauma Ultrasonography

30. Trauma Ultrasonography
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Trauma Ultrasonography
Pelvis

31. Trauma Ultrasonography
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Trauma Ultrasonography

32. Trauma Ultrasonography
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Trauma Ultrasonography

33. Trauma Ultrasonography
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Trauma Ultrasonography
Pericardium

34. Trauma Ultrasonography
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Trauma Ultrasonography

35. Trauma Ultrasonography
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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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38. Trauma Ultrasonography
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Trauma Ultrasonography
EFast Exam
Extended Fast Exam
Anterior lung apices for pneumothorax
Lung bases for pleural fluid

39. Trauma Ultrasonography
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40. Trauma Ultrasonography
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41. Trauma Ultrasonography
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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

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

43. 4/15/2017
The Knife and Gun Club