Lecture 10, trauma management Flashcards
1
Q
Trauma
A
- A wound or an injury
- Blunt/penetrating
- May occur secondary to several events
- Severity can range from undetectable to fatal
- May affect one or multiple organ systems
- Initial approach often makes the difference in the eventual outcome
- Primary survey
- Secondary survey
2
Q
Primary and secondary survey
A
- Without excess time-wasting
- Primary survey
1) Assessment of the respiratory and cardiovascular systems
2) Assessment of the central nervous system and urinary track system - Secondary survey
3) Assessment of all other systems once the immediately life-threatening problems (identified during primary survey) are dealt
with
3
Q
Critically ill trauma patient (primary survey)
A
- Airways
- Patent airway – intubation if
necessary
- Patent airway – intubation if
- Breathing
-RR, pattern, auscultation, imaging
– thoracocentesis if necessary
(before imaging!)- Oxygen support!!
- Circulation
- Mucous membranes, CRT, HR
(auscultation) + pulse,
hemorrhage? (imaging), IV
catheter (+ blood sample), BP - IV fluids!! (treatment of shock)
- Mucous membranes, CRT, HR
- Disability (neurologic evaluation)
- Consciousness, MGCS, voluntary
motor function, reflexes, deep
pain etc.
- Consciousness, MGCS, voluntary
4
Q
After primary survey and initial stabilization
A
- Continued monitoring and systemic treatment! (analgesia!)
- Full medical history including:
- Time of traumatic event
- Specific signs of illness after trauma (and progression!)
- Current medications
- Allergies to foods or medications
- Previous history of blood transfusion
- Secondary survey
- Complete physical examination
- Identification of all trauma-associated injuries
5
Q
Further diagnostics and treatment
A
- Preferrably once the patient is stable
- In case the patient is deteriorating
- Clinical examination!
- Diagnostic imaging
- Symptomatic/specific treatment
- Each case is different
6
Q
Trauma-associated thoracic injury
A
Blunt thoracic trauma
- Vehicular trauma (most common)
- Animal-animal and human-animal
interactions
- Falls from a height
- Most managed conservatively (blunt)
- Penetrating thoracic trauma (less common)
- Animal-animal interactions
- Projectile injuries, impalements
- Surgical emergencies after medical stabilization (penetrating)
7
Q
Assessment
A
- Most serious thoracic injuries suspected or identified during primary survey
- Thorough observation of RR and character
- Auscultation
- Trauma-associated thoracic injuries (often several at a time):
- Pulmonary injuries
- Thoracic wall injuries
- Cardiac injuries
- Mediastinal injuries
- Pleural space injuries
8
Q
Clinical signs of respiratory compromise
A
- Increased respiratory rate and effort (also sounds)
- Restlessness
- Extended head and neck
- Abducted elbows
- Paradoxic movement of the chest and abdominal walls
- Unwillingness to lie down/on one side
9
Q
Trauma-associated pulmonary injuries
A
- Pulmonary contusion – lesion of the lung after compression - decompression injury leading to alveolar collapse and lung
consolidation due to hemorrhage and edema - Diagnosis: physical examination + confirmed by radiography
- Treatment: oxygen! (signs may worsen over the initial 24h)
- Blebs – small pockets of air within the visceral pleura (damage of
alveoli and leakage of air) and bullae – similar to a bleb, but
associated with the pulmonary parenchyma - Diagnosis: radiography, CT
- Treatment: indicated if pneumothorax occurs (by rupture of bullae or blebs)
10
Q
Trauma-associated thoracic wall injuries
A
- Rib fractures
- Risk of pneumo- or hemothorax
- Diagnosis: physical examination, radiographs
- Treatment: pain control, surgery at times
- Flail chest – ‘’paradoxical“ movement of a floating thoracic segment
- Diagnosis: physical examination
- Treatment: mostly conservative, surgery sometimes indicated
- Penetrating thoracic injury
- Diagnosis: physical examination, imaging, surgical wound exploration
- Treatment: stabilization, AB, surgical closure, drainage
11
Q
Trauma-associated cardiac injuries
A
- Cardiac arrhythmias
- Diagnostics: auscultation, ECG
- Treatment: dependant on the case; ventricular arrhythmias: lidocaine, procainamide
- Pericardial effusion (rarely traumatic) – accumulation of fluid in the pericardial space
- Diagnostics: auscultation, echocardiography, ECG
- Treatment: pericardiocentesis
12
Q
Trauma-associated mediastinal injuries
A
- Tracheal avulsion – traumatic disruption of the trachea between the tracheal rings
- Diagnosis: radiography, tracheoscopy
- Treatment: surgical (tracheal resection and anastomosis)
- Mainstem bronchial rupture
- Diagnosis and treatment similar to tracheal avulsion
- Pneumomediastinum – accumulation of air in the mediastinal place (may occur secondary to a variety of injuries)
- Diagnosis: radiography + search for an underlying cause
- Treatment: does not require specific treatment (treat underlying disease!), but can progress to pneumothorax
13
Q
Trauma-associated pleural space injuries
A
- Pneumothorax
- Hemothorax
- Chylothorax
- Diaphragmatic hernia
- Pleural effusion – a buildup of fluid in the pleural space (many causes; in case of blood or chyle –
possibly caused by trauma)
14
Q
Pneumothorax
A
- Accumulation of air in the pleural space
- One of the most common trauma-associated thoracic injuries
- Open/closed (closed more common)
- Diagnosis: clinical examination/auscultation → thoracocentesis (U/S?)
- Radiography contraindicated in clinically significant cases!
- Treatment: thoracocentesis, oxygen!, AB (open), thoracostomy tube placement if necessary, surgery (open/recurrent pneumothorax 3-4 days or suspected tracheal avulsion/rupture)
15
Q
Hemothorax
A
- The accumulation of blood within the pleural space, results from
disruption of vasculature of the chest wall, lungs, or mediastinal
structures including the great vessels - Uncommonly clinically significant
- Diagnosis: clinical examination/auscultation → thoracocentesis only if
necessary (guided by U/S if possible) - Radiography contraindicated in clinically significant cases!
- Treatment: thoracocentesis, oxygen!, analgesia, thoracostomy tube placement if necessary, possible blood transfusion, surgery
(persistent ongoing hemorrhage or penetrating injury)
16
Q
Chylothorax
A
- Chyle is composed of lymph and chylomicrons (triglycerids)
- Traumatic (rare) chylothorax may occur secondary to rupture of the
thoracic duct (uncommon) - Not a peracute manifestation of thoracic trauma but is usually noted
within days of the traumatic event - Diagnosis: examination/auscultation → thoracocentesis
- Radiography contraindicated in clinically significant cases!
- Treatment: thoracocentesis, oxygen!, thoracostomy tube placement if necessary, surgery usually not necessary (performed if
fails to resolve over 2 weeks)
17
Q
Thoracocentesis
A
Equipments:
* Syringe, 3-way stopcock, IV extension tubing
* 19-21 g butterfly needle or 18-22 g needle (18-22 g catheter)
- Sternal recumbency
- Clip and prepare area (often bilateral), use aseptic technique
- Insert needle dorsally for pneumothorax, ventrally for effusion
- Stay close to the cranial edge of the rib while advancing though the skin (pneumothorax – 9th-11th intercostal space, hemothorax – 5th-8th space)
- Guided by ultrasound if possible
- Aspirate
- Effusion – collect fluid (assess clotting first – should not clot) for analysis
18
Q
Diaphragmatic hernia
A
- Movement of abdominal viscera through the diaphragm into the
pleural space (not always traumatic – can be congenital) - Most common organs herniated into the thorax: liver, small bowel,
stomach, spleen, omentum, large bowel, gall bladder, pancreas - Diagnosis: anamnesis, physical examination, diagnostic imaging
- Treatment (acute cases): oxygen!, thoracocentesis (in case of
concurrent fluid or air in the thoracic cavity), surgical intervention after initial stabilization!
19
Q
Tracheostomy
A
Creation of a temporary or permanent opening into the trachea to facilitate airflow
- Temporary tracheostomy is performed to provide an alternate airflow route during surgery or as an emergency procedure in severely dyspneic patients (upper respiratory tract problem)
- Ventral midline incision from the cricoid cartilage extending 2 to 3 cm
caudally → separate sternohyoid muscles, make a transverse
tracheotomy through the annular ligament → place cartilage-encircling sutures around adjacent cartilages to separate the edges
and allow for tube insertion → secure the tube, close the wound as
much as possible
20
Q
Abdominal trauma
A
Surgery indicated in case:
- Evidence of septic peritonitis
- Any form of penetrating injury
- Evidence of unremitting intraperitoneal hemorrhage
- Any evidence of a traumatic body wall hernia that contains herniated
abdominal viscera
- In all cases, thorough exploratory laparotomy necessary
- Decision to operate: after stabilization/deteriorating patient
21
Q
Trauma-associated urinary tract injury
A
- Blunt/penetrating
- Trauma to the urinary tract often goes undetected (initially)
- Uroperitoneum
- Retroperitoneal injuries (kidney, ureter)
- Bladder injuries (rupture)
- Urethral injuries (rupture)
22
Q
Uroperitoneum
A
- Uroperitoneum – urine in the peritoneal cavity
- Occurs secondary to urine leakage from the urethra, bladder, ureter
or kidney - Diagnosis: anamnesis, examination, hematology, biochemistry, ECG,
abdominocentesis + fluid analysis, diagnostic imaging - Treatment: stabilization (life-threatening hyperkalemia!, abdominal
drainage), definitive treatment variable, surgery often necessary
23
Q
Trauma-associated abdominal parenchymal organ injury
A
- Common, hemorrhage the most common complication (injury to the
liver, spleen, kidneys) - Diagnosis: examination, imaging, bloodwork, monitoring (BP, ECG),
abdominocentesis - Most animals with blunt abdominal parenchymal organ injury and hemoabdomen can be managed conservatively whilst others may require emergent surgery
- Following cardiovascular stabilization, animals with penetrating abdominal injury require immediate surgery (potential bowel perforation etc.)
24
Q
Trauma-associated biliary tract injury
A
- Traumatic injury to the extra-hepatic biliary tract uncommon in dogs and rare in cats
- Difficult to diagnose
- Challenging to treat successfully
- Spillage of bile can lead to generalized peritonitis
- Diagnosis: blood sample, imaging, abdominocentesis + fluid analysis,
exploratory laparotomy - Treatment: surgical (treatment of defect, peritoneal lavage, ongoing
drainage)
25
Q
Trauma-associated body wall and torso injury
A
- Abdominal wall herniation - a protrusion of the abdominal contents through an acquired/congenital area of weakness or defect in the wall
- Can occur at multiple sites
- Diagnosis: physical examination, diagnostic imaging
- Treatment: surgical once the patient is stable
- In case of strangulation – emergency surgery
- Evisceration – extrusion of viscera outside the body through a wound
or a surgical incision - Treatment: protection of organs (contamination), stabilization,
bacterial culture, AB, surgical closure (thorough lavage; drain?)
26
Q
Trauma-associated gastrointestinal injury
A
- Primary gastrointestinal injuries can include:
- Minor bowel contusions/hematomas
- Mesenteric tears
- Vascular compromise/avulsion
- Penetrating wounds resulting in septic peritonitis
Diagnosis: clinical examination, imaging (contrast radiography: iodine not barium if suspected perforation!), abdominocentesis (in case of ascites) + fluid analysis, bloodwork
- Treatment: surgery often indicated
27
Q
Abdominocentesis
A
- Ascites – abnormal accumulation of fluid (trauma-associated:
blood/septic exudate/urine/bile/chyle) in the peritoneal cavity - Abdominocentesis may be performed with or without (blind)
ultrasound guidance in case of ascites - Ultrasound guidance usually the preferred option – only confirmed
fluid pockets are punctured - Open/closed technique, similar equipment as for thoracocentesis
- Fluid always collected and analyzed!
28
Q
Blind abdominocentesis
A
- To avoid splenic injury, abdominocentesis is most commonly performed in left lateral recumbency
- Using an aseptic technique, an over-the needle catheter, butterfly
catheter, or hypodermic needle is introduced 1–3 cm caudal to the
umbilicus and just to the left of midline - A single negative abdominocentesis mandates a four-quadrant peritoneal tap when paired with high clinical suspicion of abdominal effusion
