Trauma: ATLS and Blunt vs Penetrating Trauma

Question 1

Why does Acute trauma management present unique challenges?

Answer 1

-Time is a luxury and often a scarce resource
-In many instances, it warrants immediate surgical intervention.
-Mechanism of action, multisystem injury, patient medical Hx unknown/incomplete, acute intoxication
-Every attempt should be made to ascertain a thorough history, but it should not delay care.

Question 2

How has modern trauma care evolved?

Answer 2

-Historically, management of trauma occurred at the municipal level between EMS and Community hospitals.
-Evolved now to integrate prehospital, tertiary care providers, and public policy in the effort to direct trauma care.
-It has resulted in significant improvement in patient outcomes.

Question 3

Who developed standards to which all trauma systems must adhere to become accredited?

Answer 3

The American College of Surgeons (ACS) Committee on Trauma

Question 4

What is a Level 1 Trauma Center?

Answer 4

A tertiary care center that can provide the total spectrum of trauma care immediately.

Question 5

What is a Level 2 Trauma Center?

Answer 5

A 24 hour in-house general surgeon is present.
-Specialty access is available to support
-Able to initiate definitive care

Question 6

What is a Level 3 Trauma Center?

Answer 6

Has a 24 hour in-house ED physician.
-Specialty access is available to support (general surgery/anesthesia)
-Transfer agreements to a higher-level trauma center
-Provides stabilizing care

Question 7

What is a Level 4 Trauma Center?

Answer 7

Basic emergency department with the ability to provide ATLS support
-Transfer agreements to a higher-level trauma center

Question 8

ATLS Care targets patients in which level of the trimodal death distribution?

Answer 8

The Second Peak (Early) deaths.
-Occur minutes to hours following injury
-Due to inadequate tissue perfusion from secondary injury (hypoxia, hemorrhage)
-Can possibly be saved by ATLS

Question 9

What is the Golden Hour?

Answer 9

The “Golden Hour” was initially modeled from data collected from young, healthy males in military service during the Vietnam War. It represents a period of time (60 minutes) in which selected patients will likely survive hemorrhagic shock if perfusion is restored.

Question 10

What are the 4 principles of Advanced Trauma Life Support (ATLS)?

Answer 10

1) Prehospital
2) Hemorrhage
3) Primary Survey
4) Secondary Survey

Question 11

What are the Prehospital goals of ATLS?

Answer 11

-ABCs: Ensure a patent airway, Adequate ventilation, Control external bleeding
-Airway + Adequate oxygenation. Patients should arrive at hospital with supplemental O2

Question 12

What are the immediate, late, and post-discharge causes of trauma related death?

Answer 12

Immediate: Brain injury and hemorrhage!!!

Late: Infection, Multisystem organ failure, Brain injury and Hemorrhage

Post-Discharge: CV event, second major trauma, neuro injury, and malignancy

Question 13

What are the 5 major spaces that hemorrhage or blood leaving the circulatory system can spill into?

Answer 13

1) Thorax
2) Peritoneum/abdomen
3) Retroperitoneum or the pelvis
4) Fascial planes of long bones
5) The environment (i.e., the street).

Question 14

How was hemorrhage classically managed?

Answer 14

Large bore intravenous (IV) access and volume resuscitation in the prehospital setting.

Question 15

Why is hemorrhage no longer classically managed?

Answer 15

Early fluid resuscitation in the absence of surgical hemostasis may not be beneficial because it will likely increase bleeding, coagulopathy through dilution of factors and ultimately worsen patient outcome.
-Without hemostasis, mortality increases.

Question 16

What is the “Injury First” Model?

Answer 16

ABCs are now CABC = catastrophic bleeding–airway–breathing–circulation.
-If bleeding is not controlled, the patient will face certain death.
-Immediate application of direct pressure, tourniquets, hemostatic agents to control exsanguinating hemorrhage

Question 17

What is the Primary Survey?

Answer 17

A irway
B reathing
C irculation
D isability (neurologic status)
E nvironment/Exposure (undress the patient to fully assess) and roll patient to assess the back/spine

Question 18

What is the goal of the Primary Survey?

Answer 18

To identify and rapidly manage life-threatening conditions and injuries.
-Rapid assessment using physical examination and standard monitors
-Ultrasound and Radiography
-IV access and blood samples
-All aspects of the primary survey are performed simultaneously
-Provides enough information to stabilize and/or prepare for transfer to a higher level of care

Question 19

What is the Secondary Survey?

Answer 19

Begins after the completion of the primary survey and when resuscitative and stabilization efforts have been initiated.
-A complete head to toe assessment (includes neuro eval)
-Determines any injuries missed during primary survey
-Vigilance!

Question 20

What is Blunt Trauma?

Answer 20

Direct impact, deceleration, continuous pressure, shearing and rotary forces associated with high levels of energy.
-Motor vehicle collisions (MVC) and falls from substantial heights

Question 21

What is Newton’s First Law?

Answer 21

An object tends to remain in motion until it is affected by an outside force.

Question 22

How does Newton’s First Law apply to Blunt Trauma?

Answer 22

-Abrupt deceleration creates negative gravitational forces.
-The outside “shell” of the human body decelerates abruptly.
-The internal organs continue forward at original velocity and are torn from attachments by rotary and shearing forces.
-Disruption of connective tissue, blood vessels and nerves.

Question 23

What are the 5 Classifications of MVCs?

Answer 23

1) Head on
2) Rear Impact
3) Side Impact
4) Rotational Impact
5) Rollover

Question 24

How are injuries above the waist different from those below the waist?

Answer 24

Above the waist: may collide with the dashboard / steering wheel / windshield
-Injuries of the head, neck, chest, abdomen, and upper extremities

Below the waist: may contact the dashboard / vehicle
-Injuries to knees, femurs, and acetabular fractures (acetabular fx are result of tensing leg during brace for impact)

Question 25

T/F: Blunt Trauma occurs in isolated body systems.

Answer 25

False. Blunt trauma produce effects body wide, rarely in isolated systems

Question 26

_____ _____ injury should be suspected and treated as if unstable until proven otherwise with blunt trauma.

Answer 26

Cervical spine injury (!!) should be suspected and treated as if unstable until proven otherwise with blunt trauma.

Question 27

What is Blunt Chest Trauma?

Answer 27

-The 3rd leading result of injury (following TBI and extremity trauma)
-Penetrating and blunt trauma to the chest may injure the chest wall, the lungs and airways, the heart and pericardium, and the great vessels of the thorax which may compromise optimal resuscitation and anesthesia care affecting gas exchange and cardiac output.
-Accounts for 20-25% of all deaths
-Contributor in 50% trauma related deaths
-Associated with MVCs (drivers not wearing a seatbelt who impact the steering wheel)

Question 28

What is important to know regarding Pneumothoraces and Blunt Thoracic Injury?

Answer 28

-Pneumothoraces are present in as many as 40% of all blunt thoracic injuries.
-The size and location of the pneumothorax may vary throughout the lung field.
-It is estimated that as many as 50% of pneumothoraces are not detected on initial radiography.
-This occurrence presents several clinical intraoperative issues and may alter an anesthetic plan (Nitrous oxide should be avoided in patients with suspected thoracic trauma)
-There is a role for POCUS.

Question 29

What are life-threatening emergencies that require immediate intervention in patients with thoracic/chest trauma?

Answer 29

-Tension pneumothorax
-Pericardial tamponade
-Massive hemothorax
-Cardiac rupture
-Traumatic aortic rupture

Question 30

How does a Tension Pneumothorax develop?

Answer 30

When the lung is punctured within the thoracic cavity, creating a one-way valve that traps air between the layers of the pleura.
-With each breath, more and more air becomes trapped in this space.
-The enlarging pleural cavity then collapses the ipsilateral lung and shifts structures of the mediastinum (e.g., trachea, great vessels, and heart) into the opposite hemithorax, thereby compressing the contralateral lung.
-The size of a pneumothorax will rapidly increase during positive-pressure ventilation, especially if nitrous oxide is used!!

Question 31

What are the S/Sx associated with a Tension Pneumothorax?

Answer 31

Hypotension
Hypoxemia
Tachycardia
SubQ emphysema of the neck/chest
Unilateral (!) decrease in breath sounds
Asymmetric chest wall motion
Distended neck veins
Tracheal shift

Massive pneumothorax can result in decreased CO and CV collapse.

Hyperlucency on CXR on ipsilateral side.

Question 32

What is the treatment for a Tension Pneumothorax?

Answer 32

-Needle decompression (large bore IV catheter is inserted into the 2nd ICS, just above the 3rd rib along midclav line to release pressure)
-Chest Tube Thoracostomy

Question 33

What is bad about Pericardial Tamponade?

Answer 33

Tamponade restricts filling of the cardiac chambers during diastole and produces a fixed low CO.
-If fluid accumulates rapidly, may result in CV collapse
-Life-threatening emergency that requires immediate correction with pericardiocentesis.

Question 34

What are the S/Sx of Pericardial Tamponade?

Answer 34

-Cardiac Distress
-Beck’s Triad: Hypotension, JVD, and muffled heart sounds (!)
-Pulsus paradoxus: exaggerated decrease in SBP with inspiration

Question 35

What is Beck’s Triad?

Answer 35

Hypotension, JVD, and muffled heart sounds.
-Jugular venous distention occurs because of decreased forward blood flow through the heart

Question 36

What is Pulsus Paradoxus?

Answer 36

An exaggerated (i.e., greater than 10 mm Hg) decrease in systolic blood pressure that normally occurs with inspiration.

Question 37

How do you diagnose Pericardial Tamponade?

Answer 37

-Echocardiography is most sensitive, noninvasive method for detection of pericardial effusion and exclusion of tamponade
-CXR: enlarged cardiac silhouette
-POCUS

Question 38

What is the treatment of Pericardial Tamponade?

Answer 38

Pericardiocentesis, performed either percutaneously by needle decompression, through a subxiphoid incision, or via thoracotomy or video-assisted thorascopic surgery to create a pericardial window.

Question 39

What drug is recommended for the induction of anesthesia with Pericardial Tamponade?

Answer 39

Ketamine

Question 40

How does Pericardial Tamponade occur?

Answer 40

-Impairment of diastolic filling of the heart due to continual increases in intrapericardial pressure.
-Slow accumulation of fluid in the pericardial space initially causes minute increases in intrapericardial pressure. This occurs as a result of the pericardium’s ability to stretch to accommodate an increased volume.
-If the pericardial fluid accumulates rapidly, the presence of a few hundred milliliters may cause a significant increase in intrapericardial pressure that may result in cardiovascular collapse.
-Cardiac tamponade that results in shock is also known as cardiac compressive shock and can result in inadequate peripheral perfusion, acidosis, and death.

Question 41

What are the Hemodynamic goals for management of cardiac tamponade?

Answer 41

PL: Maintain or Inc
AL: Maintain
Contractility: Maintain or Inc
HR: Maintain
Rhythm: NSR

Question 42

What is the cause of a Hemothorax?

Answer 42

Bleeding from the heart and great vessels.
-Occurs after rib fracture
-Can occur with penetrating injury

Question 43

What is the Tx of a Hemothorax?

Answer 43

-Fluid resuscitation BEFORE thoracostomy/chest tube (because they can lead to more extensive bleeding and further hypotension)
-Airway mgmt if needed
-Restoration of circulating blood volume
-Evacuation of the accumulated blood

Question 44

When is Thoracostomy/chest tube indicated for a Hemothorax?

Answer 44

Allows for drainage of blood from the pleural cavity.
-indicated if the initial bleeding rate is greater than 20 mL/kg per hr.

If bleeding subsides but remains greater than 7 mL/kg per hr, if chest radiograph worsens, or if hypotension persists after initial blood replacement and decompression, thoracostomy is indicated.

Question 45

What are the S/Sx of Cardiac Rupture?

Answer 45

May present with a variety of symptoms related to the extent of cardiac injury.
-S/Sx: same as cardiac tamponade
-Most patients die pre-hospital
-Need efficient & rapid prehospital transportation, high index of suspicion, and immediate surgical intervention to survive.

Question 46

What is a traumatic aortic rupture?

Answer 46

If complete, is usually fatal, but with an intimal tear with a dissecting aneurysm the patient can be saved if the diagnosis and repair are performed promptly with concurrent well-managed fluid resuscitation, surgical and anesthesia care.
-Surgical: Non-operative (watch in ICU), Open, or Endovascular repair
-Anesthesia: Large bore IV access, keep BP around 100 mmHg SBP to not worsen dissection

Question 47

Describe tracheal injuries after thoracic trauma.

Answer 47

Airway injuries represent a devastating and potentially lethal event after blunt thoracic trauma.
-These are relatively rare, 0.5% to 2% rate among blunt trauma patients and 3% to 8% for those with penetrating cervical trauma.
-There is high victim mortality at the scene of injury.
-Majority are located below the carina, visible only during bronchoscopy or CT examination.
-Partial or total disruption

Question 48

Describe management of a Partial disruption of the trachea or major bronchi

Answer 48

Managed through securing of the airway (by intubation or tracheostomy) and surgical correction.

Question 49

Describe management of a Total disruption of the trachea

Answer 49

Often fatal unless rapid surgical retrieval of the distal disrupted airway segment is accomplished to allow lifesaving mechanical ventilation.

Question 50

Damage from Penetrating Injuries depends on what 3 Factors?

Answer 50

1) Type of wounding instrument (knife, bullet, fragment)
2) Velocity of projectile at time of impact
3) Characteristics of tissue through which it passes (e.g., bone, muscle, fat, blood vessels, nervous tissues, and organs)

Question 51

How do Lower-Velocity wounds inflict injury?

Answer 51

Lower-velocity wounds (i.e., stab wound) inflict injury by lacerating and cutting tissue.

Question 52

How do Moderate-High Velocity wounds inflict injury?

Answer 52

Ex: Penetrating bullet wounds
-Occur as a result of the deceleration of the object as it passes through tissues, causing kinetic energy to transfer to the surrounding tissue.

Question 53

What is the most significant determinant of wound potential?

Answer 53

Velocity of the projectile is the most significant determinant of wound potential!!!
-Either situation, low- or high-velocity penetration, ultimately results in disruption of normal anatomy and physiology.