1. Douglas S. Ander, MD Professor of Emergency Medicine Emory University School of Medicine

2. Disclosure I have no actual or potential conflict of interest in relation to this program/presentation

3. Case #1 24 year old female single car MVC. She lost control on a patch of ice and struck a tree. Significant front end damage. Older model car with no airbag. She was restrained with 3-point restraint. Primary survey normal. Secondary survey significant for abrasion and slight swelling to neck.

4. Blunt Neck Injury Incidence: 1% of blunt trauma admissions Incidence of stroke amongst 27 patients with CAI was 33% 48 untreated BCVI patients, 10(21%) had an adverse neurologic events Estimated that 32 asymptomatic patients averted strokes with appropriate treatment Cothren CC et al. Amer J Surg 2005;190:849-854 Miller et al. Ann Surgery 2002;236:386-395.

5. Signs/Symptoms of BCVI Arterial hemorrhage from neck/nose/mouth Expanding cervical hematoma Cervical bruit in pt < 50 yrs old Focal neurologic defect: TIA, hemiparesis, vertebrovasilar symptoms, Horner’s SyndromeHorner’s Syndrome Stroke on CT or MRI Neurologic deficit inconsistent with head CT

6. Horner’s Syndrome

7. Risk Factors for BCVI High energy transfer mechanism associated with Displaced mid-face fracture (LeFort II or III) Basilar skull fracture with carotid canal involvement CHI consistent with DAI and GCS < 6 Cervical vertebral body or transverse foramen fracture, subluxation, or ligamentous injury at any level; any fracture at C1-C3 Near hanging with anoxia Clothesline type injury or seat belt abrasion with significant swelling, pain or altered mental status

8. Evaluation Angiography Gold Standard Invasive and resource intensive Duplex Ultrasonography Sensitivity 38.5% Specificity 100% CTA (16 slice or higher) Current recommendation for suspected BCVI with angiography for negative CTA with high suspicion

9. Treatment Injury GradeDescription ILuminal irregularity or dissection <25% luminal narrowing IIDissection or intramural hematoma with >25% luminal narrowing, intraluminal thrombus, or raised intimal flap IIIPseudoaneuryms IVOcclusion VTransection with free extravasation Grades 1-4 Heparin Grade 5 Surgical repair

10. Case #2 38 year old male restrained driver head on collision. Airbags deployed. Significant front end damage. 20 minute extrication from the vehicle.

11. Case #3 58 year old female, restrained rear passenger in an MVC. Rollover at highway speeds. Airbags deployed. No LOC. Self extricated and was ambulatory at the scene. Complains of neck pain and was immobilized by EMS. Upon arrival to ED was hemodynamically stable, had some mild neck tenderness around C4, no obvious injuries, abd was soft and nontender.

12. Whole Body CT (Pan) Scan Definition CT Head and Cervical Spine without IV contrast Followed by CT Chest, Abdomen, and Pelvis with IV contrast Oral contrast case dependent

13. Whole Body CT for Blunt Trauma Of 143 patients with at least one unsupported scan an injury would have been missed in 53 (36%) Abnormal CT Scans by Indication Unsupported N(%) EM Head5/62 (8) Neck2/50 (4) Chest33/116 (28) Abd/Pelvis12/83 (14) TOTAL52/311 (17) Tillou et al. J Trauma 2009;67:779-787. UCLA Medical Center

14. Whole Body CT Trauma patients with no signs injury 1000 patients over 18 months Clinically significant abnormalities found in: 3.5% of Head CTs 5.1% of Cervical CTs 19.6% of Chest CTs 7.1% of Abdominal CTs Salim A et al. Arch Surg 2006;141:468-475

15. Change in treatment for the 592 patients who had a CT for mechanism is 120 (20.3%) Whole Body CT Change in Treatment Based on CT Findings for the 592 Patients Evaluated for Mechanism Only No. (%) Abdominal CT ResultsChanged (n=120)Unchanged (n=472) Abnormal24 (57.1)18 (42.9) Normal96 (17.5)454 (82.5)

16. Whole Body CT and Survival Retrospective multicenter study Data from German Trauma Society registry 1494 (32%) of 4621 patients received a whole body CT Relative reduction in mortality based on Trauma and Injury Severity Score was 25% (14-37)and 13% (4-23) based on Revised Injury Severity Score Multivariate analysis confirmed that whole body CT is an independent predictor of survival (p<0.002) Number needed to scan was 17 and 32 respectively based on TRISS and RISC calculation Humber-Wagner S et al. Lancet 2009;373:1455-1461

17. Whole Body CT 600 patients underwent pan-scan Emergency physicians and trauma surgeons documented whether pan-scan was necessary Of the 992 scans that one or both physicians indicated could be omitted, 102 (10%) were abnormal 3 (0.3%) led to a critical action T8 burst fracture to OR SAH – empiric platelets for aspirin use (OR for femur fx) Rib fxs, pulmonary contusion and lung lac – ICU admit Gupta M et al. Ann Emerg Med 2011;58:407-416

18. Whole Body CT Conclusion No clear guidelines Current studies provide no definitive answer due to study limitations Clinical judgment based on history, physical, initial studies and ultrasound High risk criteria: MVC >35 mph Falls >15 ft Ped vs auto with ped thrown >10 ft Assaulted with depressed level of consciousness

19. Case #4 17 year old male presents with a stab wound to his left chest. EMS initially reported vital signs but as they arrive to the resuscitation room with CPR in progress state that he lost vitals as they pulled up to the ambulance ramp.

20. Emergency Thoracotomy

21. Rationale Physiologic Rationale for ED Thoracotomy Release of pericardial tamponade Control of intrathoracic vascular or cardiac hemorrhage Permit open cardiac massage Occlusion of descending aorta (cross-clamping) Control of massive air embolism or bronchopleural fistula

22. Blunt Trauma Very low survival rate and poor neurologic outcome Patients presenting pulseless even with myocardial electrical activity are not candidates for emergency thoracotomy

23. Penetrating trauma Patients who arrive pulseless but with myocardial electrical activity may be candidates for thoracotomy Time frame of CPR?? 15 minute

24. Other considerations Age Pre-existing conditions Availability and accessibility of specialist personnel Proximity to appropriate operating facilities and equipment Experience of the unit carrying out the procedure

25. Fluid Resuscitation “Controlled”, “Balanced”, “Hypotensive”, “Permissive” Goal is balance, not the hypotension Bridge to definitive surgical control of bleeding

26. Hypotensive Resuscitation Randomized trial Two groups: Target SBP >100 mmHg or SBP of 70 mmHg Equal survival rates, 92.7% Dutton et al. J Trauma 2002;52:1141-1146

27. Delayed Fluid Resuscitation Randomized trial Two groups: immediate and delayed resuscitation in patients with penetrating torso trauma and BP<90 mmHg VariableImmediate Resuscitatio n Delayed Resuscitation P Value Survival to discharge 62%70%0.04 Length of hospital stay (days) 14 + 2411 + 190.006 Length of ICU stay (days) 8 + 167 + 110.30 Patients with > 1 complication 30%23%0.08 Bickell et al. NEJM 1994;331:1105-1109.

28. Other ATLS update highlights Digital rectal examination selective prior to placement of foley LMA plays a role in the “cannot intubate, cannot ventilate” scenario Methylprednisolone in spinal cord injuries No evidence exists to support routine use

29. Trauma in pregnancy Retrospective chart review 271 patients Risk factors of fetal death Maternal HR > 110 Injury Severity Score > 9 Evidence of placental abruption Fetal heart rate > 160 or < 120 Ejection from motor vehicle Motorcycle or pedestrian collisions >20-24 week gestation No risk factors 6 hours monitoring Risk factors 24 hours monitoring Curet et al. J Trauma 2000;49:18-24

30. Airway updates Assess for difficult airway, LEMON mnemonic Look externally Evaluate using the 3-3-2 rule, Mallampati, Obstruction, and neck mobility

31. Pelvis Fracture

32. Minor Head Injury (GCS 13-15) Witness LOC, amnesia, or witnessed disorientation High risk GCS < 15 at two hours after injury Suspected open or depressed skull fracture Any sign of basal skull fracture Vomiting (> 2 episodes) Age > 65 years Moderate risk Amnesia before impact (>30 minutes) Dangerous mechanism

33. Other ATLS update highlights Warmed isotonic solutions (LR or NS) Tamponade best managed by thoracotomy Pericardiocentesis is temporizing Base deficit and/or lactate play a role in determining presence and severity of shock

34. Your Questions