1. Trauma – Part I

2. 45 year old man is involved in a two vehicle MVC. 45 year old man is involved in a two vehicle MVC. He is a single occupant trying to cross a highway when he is struck on the passenger side. He is a single occupant trying to cross a highway when he is struck on the passenger side.

6. When EMS arrives, the patient is unconsciousness and hypotensive. When EMS arrives, the patient is unconsciousness and hypotensive. He is stabilized on a spine board, extracted from the car, has an IV inserted, oxygen and transported to the hospital. He is stabilized on a spine board, extracted from the car, has an IV inserted, oxygen and transported to the hospital. Upon arrival, he has a blood pressure of 89/58, pulse of 124, respiratory rate of 28, and oxygen saturation of 89%. Upon arrival, he has a blood pressure of 89/58, pulse of 124, respiratory rate of 28, and oxygen saturation of 89%. His GCS is 6 (Verbal = 2, Motor = 3, Eyes = 1). His GCS is 6 (Verbal = 2, Motor = 3, Eyes = 1).

7. What is your first priority? What is your first priority? Airway: patent Airway: patent Breathing: labored, trachea deviated to the left, no breath sounds on the right Breathing: labored, trachea deviated to the left, no breath sounds on the right Circulation: Hypotensive. No external bleeding found. Circulation: Hypotensive. No external bleeding found. Disability: GCS remains 6 with reactive pupils. Does not move feet. Disability: GCS remains 6 with reactive pupils. Does not move feet. Expose Expose

8. Based on the results on the primary survey, what are the next steps? Based on the results on the primary survey, what are the next steps? After intubation, the patient’ s oxygenation improves to 92% on FiO2 100%. After intubation, the patient’ s oxygenation improves to 92% on FiO2 100%. Two large bore IVs are inserted and 2 litres of Ringer’s and 2 units of PRBC are given but the blood pressure only marginally improves. Two large bore IVs are inserted and 2 litres of Ringer’s and 2 units of PRBC are given but the blood pressure only marginally improves. Is it time for a central line? Is it time for a central line? A right chest tube is then inserted which results in large escape of air and improvement in oxygenation and blood pressure. A right chest tube is then inserted which results in large escape of air and improvement in oxygenation and blood pressure.

9. The patient seems to have stabilized somewhat. What is the next step? The patient seems to have stabilized somewhat. What is the next step? Describe the steps in a secondary survey. Describe the steps in a secondary survey. AMPLE history is unremarkable. AMPLE history is unremarkable. Pertinent positive on secondary survey: Pertinent positive on secondary survey: GCS 6 and unchanged GCS 6 and unchanged Subcutaneous emphysema on right with chest deformity Subcutaneous emphysema on right with chest deformity Distended and rigid abdomen with left sided bruising Distended and rigid abdomen with left sided bruising No motor response in legs and no rectal tone No motor response in legs and no rectal tone Extensive bruising on right side of body from head to pelvis Extensive bruising on right side of body from head to pelvis

10. What would you do next? What would you do next? What is the role for DPL in trauma? What is the role for DPL in trauma? What about ultrasound? What about ultrasound? What about CT? What about CT? A series of x-rays are taken: A series of x-rays are taken:

14. What are the injuries obvious on the preceding scans? What are the injuries obvious on the preceding scans? Liver laceration with free fluid Liver laceration with free fluid Bilateral pneumothoraces with right chest tube (not visible on the enclosed image) Bilateral pneumothoraces with right chest tube (not visible on the enclosed image) C spine fracture C spine fracture After returning from the CT scanner, the patient’s blood pressure is 84/57, pulse is 112, and saturations 94% on FiO2 100%. After returning from the CT scanner, the patient’s blood pressure is 84/57, pulse is 112, and saturations 94% on FiO2 100%. The RT states that the patient is getting harder to bag and the pressure alarm on the ventilator is ringing. Both pneumothoraces have been decompressed with chest tubes. The RT states that the patient is getting harder to bag and the pressure alarm on the ventilator is ringing. Both pneumothoraces have been decompressed with chest tubes. What is going on and what should be done? What is going on and what should be done?

15. Before we rush off the OR, let’s stop and consider other issues in abdominal trauma. Before we rush off the OR, let’s stop and consider other issues in abdominal trauma. What other organs could be injured in this MVC? What other organs could be injured in this MVC? Consider: Consider: Diaphragmatic rupture Diaphragmatic rupture Splenic laceration Splenic laceration Renal injury Renal injury Pelvic fracture Pelvic fracture

16. A little segway… The radiology resident calls into the trauma room because the system failed to send some of the x-rays to the viewer. The problem is now resolved but she wants to draw your attention to one film in particular. The radiology resident calls into the trauma room because the system failed to send some of the x-rays to the viewer. The problem is now resolved but she wants to draw your attention to one film in particular. What is wrong? What is wrong?

18. This patient is unstable and going to the OR for a liver laceration. This patient is unstable and going to the OR for a liver laceration. What is the immediate treatment for a pelvic fracture (open and closed)? What is the immediate treatment for a pelvic fracture (open and closed)? Should we wait for Orthopedics to see and assess? Should we wait for Orthopedics to see and assess? Let’s assume that there is no liver laceration and no plans to go to the OR but he is still in the same condition. How would you manage the patient? Let’s assume that there is no liver laceration and no plans to go to the OR but he is still in the same condition. How would you manage the patient? What other problems can arise from a pelvic fracture? What other problems can arise from a pelvic fracture? Consider: Consider: Massive transfusion from ongoing bleeding Massive transfusion from ongoing bleeding Bladder injuries Bladder injuries Urethral injuries Urethral injuries

19. Continuing our segway… Let’s talk about thoracic trauma in more detail. Let’s talk about thoracic trauma in more detail. What are the five conditions that should be immediately addressed during the primary survey? What are the five conditions that should be immediately addressed during the primary survey? Breathing: Breathing: Tension pneumothorax Tension pneumothorax Open pneumothorax Open pneumothorax Flail chest Flail chest Circulation: Circulation: Massive hemothorax Massive hemothorax Cardiac tamponade Cardiac tamponade What is the pathophysiological reason for their lethality? What is the pathophysiological reason for their lethality? How do you identify and treat each of these conditions? How do you identify and treat each of these conditions?

20. What other thoracic injuries should you look for during the secondary survey? What other thoracic injuries should you look for during the secondary survey? Consider: Consider: Pulmonary contusion Pulmonary contusion Tracheobronchial tree injury Tracheobronchial tree injury Blunt cardiac injury Blunt cardiac injury Aortic disruption Aortic disruption Diaphragmatic injury Diaphragmatic injury How would you identify each of these problems? How would you identify each of these problems? How would you treat each of these problems? How would you treat each of these problems?

21. Back to the case… After bidding the patient farewell at the OR doors, you go to the call room for a few hours of shut eye. After all, injuries that severe are going to take hours to repair, assuming the patient survives. After bidding the patient farewell at the OR doors, you go to the call room for a few hours of shut eye. After all, injuries that severe are going to take hours to repair, assuming the patient survives. 90 minutes later the ICU charge nurse calls you to take report from the anesthetist as the patient is in the ICU. 90 minutes later the ICU charge nurse calls you to take report from the anesthetist as the patient is in the ICU. When you arrive, you are told that the patient has been packed in all four quadrants, all visible bleeding has been controlled and he lost 5 litres of blood when the abdomen was opened. Skin is closed but not fascia. When you arrive, you are told that the patient has been packed in all four quadrants, all visible bleeding has been controlled and he lost 5 litres of blood when the abdomen was opened. Skin is closed but not fascia.

22. What happened here? Is the surgeon incompetent to leave sponge in the belly? What happened here? Is the surgeon incompetent to leave sponge in the belly? What is this surgical technique called? What is this surgical technique called? Damage control laparotomy Damage control laparotomy What is the rationale for this technique? What is the rationale for this technique? What are the benefits of this approach? What are the benefits of this approach? What are some of the complications? What are some of the complications?

23. The anesthetist tells you that the patient’s blood pressure has stabilized after being given 9 units of red cells, 2 pooled platelets, 8 units of FFP and 1 unit of cyroprecipitate. He has also received 5 litres of Ringer’s lactate. The anesthetist tells you that the patient’s blood pressure has stabilized after being given 9 units of red cells, 2 pooled platelets, 8 units of FFP and 1 unit of cyroprecipitate. He has also received 5 litres of Ringer’s lactate. The patient’s last ABG is pH 7.19, PCO2 35, PO2 87, HCO3 15. The patient’s last ABG is pH 7.19, PCO2 35, PO2 87, HCO3 15. Hgb 87, WBC 12.5, Platelets 29 Hgb 87, WBC 12.5, Platelets 29 INR 2.1, PTT 49 INR 2.1, PTT 49 His vital signs are 109/68, heart rate 93, saturations 99%, temperature 34.7. His vital signs are 109/68, heart rate 93, saturations 99%, temperature 34.7.

24. What is the DEADLY TRIAD? What is the DEADLY TRIAD? Hypothermia Hypothermia Coagulopathy Coagulopathy Acidosis Acidosis Why is the deadly triad so deadly? Why is the deadly triad so deadly? How is hypothermia in trauma different from primary hypothermia? How is hypothermia in trauma different from primary hypothermia? Secondary hypothermia is a result of diminished heat production (not just heat loss) due to decreased oxygen consumption during shock. Secondary hypothermia is a result of diminished heat production (not just heat loss) due to decreased oxygen consumption during shock.

25. What is the consequence of hypothermia? What is the consequence of hypothermia? Consider: Consider: Dysfunctional coagulation proteins Dysfunctional coagulation proteins Inhibited platelets Inhibited platelets What methods can be used to warm the patient or prevent hypothermia? What methods can be used to warm the patient or prevent hypothermia? Consider: Consider: Passive air warming Passive air warming Heated inhaled air via ventilator Heated inhaled air via ventilator Pleural and/or peritoneal lavage Pleural and/or peritoneal lavage Warm IV fluids Warm IV fluids CVVHD CVVHD Bypass Bypass

26. What are some of the reasons for the patient’s deranged coagulation parameters? What are some of the reasons for the patient’s deranged coagulation parameters? Consider: Consider: Dilution Dilution Consumption Consumption DIC DIC Fibrinolysis Fibrinolysis How do you treat this coagulopathy? How do you treat this coagulopathy?

27. What is the cause of the acidosis in the deadly triad? What is the cause of the acidosis in the deadly triad? What are some of the consequences of acidosis in trauma? What are some of the consequences of acidosis in trauma?

28. To be continued…. Questions??