Lecture 10, trauma management

Question 1

Trauma

Answer 1

• 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

Question 2

Primary and secondary survey

Answer 2

• 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

Question 3

Critically ill trauma patient (primary survey)

Answer 3

• Airways
  
  • Patent airway – intubation if
    necessary
• 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)
• Disability (neurologic evaluation)
  
  • Consciousness, MGCS, voluntary
    motor function, reflexes, deep
    pain etc.

Question 4

After primary survey and initial stabilization

Answer 4

• 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

Question 5

Further diagnostics and treatment

Answer 5

• Preferrably once the patient is stable
• In case the patient is deteriorating
• Clinical examination!
• Diagnostic imaging
• Symptomatic/specific treatment
• Each case is different

Question 6

Trauma-associated thoracic injury

Answer 6

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)

Question 7

Assessment

Answer 7

• 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

Question 8

Clinical signs of respiratory compromise

Answer 8

• 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

Question 9

Trauma-associated pulmonary injuries

Answer 9

• 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)

Question 10

Trauma-associated thoracic wall injuries

Answer 10

• 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

Question 11

Trauma-associated cardiac injuries

Answer 11

• 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

Question 12

Trauma-associated mediastinal injuries

Answer 12

• 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

Question 13

Trauma-associated pleural space injuries

Answer 13

• 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)

Question 14

Pneumothorax

Answer 14

• 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)

Question 15

Hemothorax

Answer 15

• 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)

Question 16

Chylothorax

Answer 16

• 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)

Question 17

Thoracocentesis

Answer 17

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

Question 18

Diaphragmatic hernia

Answer 18

• 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!

Question 19

Tracheostomy

Answer 19

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

Question 20

Abdominal trauma

Answer 20

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

Question 21

Trauma-associated urinary tract injury

Answer 21

• Blunt/penetrating
• Trauma to the urinary tract often goes undetected (initially)
• Uroperitoneum
• Retroperitoneal injuries (kidney, ureter)
• Bladder injuries (rupture)
• Urethral injuries (rupture)

Question 22

Uroperitoneum

Answer 22

• 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

Question 23

Trauma-associated abdominal parenchymal organ injury

Answer 23

• 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.)

Question 24

Trauma-associated biliary tract injury

Answer 24

• 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)

Question 25

Trauma-associated body wall and torso injury

Answer 25

• 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?)

Question 26

Trauma-associated gastrointestinal injury

Answer 26

• 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

Question 27

Abdominocentesis

Answer 27

• 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!

Question 28

Blind abdominocentesis

Answer 28

• 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