Trauma management Flashcards
Define and describe trauma (as in the physical injury, not psychological).
- 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 of trauma patients.
What is meant by “Primary and secondary survey”?
First-pass assessment of a trauma patient, emphasis on “A-B-C-s” (airway, breathing/oxygenation and circulation).
Assessment of all other systems once the immediately life-threatening problems (identified during primary survey) are dealt
with so after initial stabilization.
Describe what assessment’s primary & secondary surveys include.
Primary survey:
A(irway) B(reathing) C(irculation)’s
1) Assessment of the respiratory and cardiovascular systems.
Secondary survey:
2) Assessment of the central nervous system and urinary track system.
3) Assessment of all other systems once the immediately life-threatening problems (identified during primary survey) are dealt
with.
Critically ill trauma patient and primary survey. Describe the steps more specifically.
Airways
* Ensure patent airway – intubation if necessary.
Breathing
* RR, pattern, auscultation, imaging – thoracocentesis if necessary.
Chest tap if breathing sounds & heart are muffled - do it before imaging because imaging can kill a compromised patient!
- Oxygen support!!
Circulation
* Mucous membranes, CRT, HR (auscultation) + pulse, hemorrhage? (imaging, T/A-FAST), IV catheter (+ blood sample), BP.
- IV fluids!! (treatment of shock)
Disability (or neurologic evaluation)
* Consciousness, MGCS, voluntary motor function, reflexes, deep pain etc.
MGCS =
modified Glasgow coma scale
PLR = Pupillary light response
TFAST =
AFAST =
Thoracic Focused Assessment With Sonography in Trauma
Abdominal Focused Assessment With Sonography in Trauma
= constitute limited ultrasound examinations that focus on identifying the presence of fluid within the peritoneal, pleural, and pericardial spaces.
After primary survey and initial stabilization: (3)
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.
Describe further diagnostics and treatment of a trauma patient.
- Preferably once the patient is stable.
- However, in case the patient is deteriorating then do them.
- Clinical examination!
- Diagnostic imaging
- Symptomatic/specific treatment
- Each case is different
Describe trauma-associated thoracic injury.
Blunt thoracic trauma
* Vehicular trauma (most common)
* Animal-animal and human-animal interactions.
* Falls from a height
Most are managed conservatively (blunt).
Penetrating thoracic trauma (less common)
* Animal-animal interactions
* Projectile injuries, impalements
Are surgical emergencies after medical
stabilization (penetrating).
Assessment of Trauma-associated thoracic injury.
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) may include:
* Pulmonary injuries
* Thoracic wall injuries
* Cardiac injuries
* Mediastinal injuries
* Pleural space injuries
Clinical signs of respiratory compromise.
- 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.
Review this flowchart on the assessment of respiratory compromise.
- characterize lung sounds as increased or decreased.
- If lung sounds decreased suspect pleural space injury. If sounds are increased suspect pulmonary injury.
- Each of the above take a different path - see flowchart.
Trauma-associated pulmonary injuries. (3)
Pulmonary contusion is a 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 are small pockets of air within the visceral pleura (damage of alveoli and leakage of air).
Bullae are similar to a bleb, but associated with the pulmonary parenchyma.
- Diagnosis: radiography, CT
- Treatment: indicated if pneumothorax occurs (by rupture of bullae or blebs).
Trauma-associated thoracic wall injuries. (3)
Rib fractures
* Risk of pneumo- or hemothorax
* Diagnosis: physical examination, radiographs.
* Treatment: pain control, surgery sometimes.
Flail chest = ‘’paradoxical“ movement of a floating thoracic segment (which would include 2 or more broken ribs (in order to produce an independently moving segment of chest wall)).
- Diagnosis: physical examination
- Treatment: mostly conservative, surgery sometimes, if indicated.
Penetrating thoracic injury
* Diagnosis: physical examination, imaging, surgical wound exploration.
* Treatment: stabilization, AB, surgical closure, drainage.
Trauma-associated cardiac injuries. (2)
Cardiac arrhythmias
* Diagnostics: auscultation, ECG
* Treatment: dependent on the case; ventricular arrhythmias: lidocaine,
procainamide.
Pericardial effusion (rarely traumatic) – accumulation of fluid in the pericardial space.
* Diagnostics: auscultation, echocardiography, ECG
* Treatment: pericardiocentesis
Trauma-associated mediastinal injuries. (3)
Tracheal avulsion is the 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 is the 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.
Trauma-associated pleural space injuries. (5)
- Pneumothorax
- Hemothorax
- Chylothorax
- Diaphragmatic hernia
- Pleural effusion is a buildup of fluid in the pleural space (many causes; in case of blood or chyle –possibly caused by trauma).
Describe pneumothorax.
Pneumothorax
* Accumulation of air in the pleural space
* One of the most common trauma-associated thoracic injuries.
- Can be open/closed (closed is more common).
- Diagnosis: clinical examination/ auscultation → thoracocentesis (U/S?).
- Radiography contraindicated in clinically significant cases!
- Treatment: thoracocentesis, oxygen!, AB (in open cases), thoracostomy tube placement if necessary, surgery (open/ recurrent pneumothorax 3-4 days or suspected tracheal avulsion/rupture).
Describe hemothorax.
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 (remove blood until signs resolve so some may remain), oxygen!, analgesia, thoracostomy tube placement if necessary, possible blood transfusion, surgery (persistent ongoing hemorrhage or penetrating injury).
Describe chylothorax.
- Chyle is composed of lymph and chylomicrons (triglycerides).
- 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).
Equipment needed for thoracocentesis?
Explain the steps as well.
Equipment:
* Syringe, 3-way stopcock, IV extension tubing
* 19-21 g butterfly needle or 18-22 g needle (18-22 g catheter)
Patient in sternal recumbency or even standing.
- Clip and prepare area (often bilaterally), use aseptic technique (if time - if acutely emergent then straight through the animal’s coat).
- Insert needle dorsally for pneumothorax, ventrally for pleural effusion. You decide this based on auscultation of lung sounds.
- 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 and collect fluid. Measure!
- In effusions, collect fluid for analysis.(Assess clotting first – should not clot, if it clots it may indicate you are in the heart or a vessel that you should not be poked into during thoracocentesis.)
Pleural effusion differentials based on fluid type.
After thoracocentesis, analyze the effusion fluid collected to establish differential diagnoses.
Describe Diaphragmatic hernias.
- IS the displacement of abdominal viscera through the diaphragm into the pleural space (not always traumatic – can be congenital).
- Most common organs to be herniated into the thorax: liver, small bowel, stomach, spleen, omentum, large bowel, gall bladder, pancreas.
- Diagnosis: anamnesis, physical exam, diagnostic imaging.
- Treatment (acute cases): oxygen!, thoracocentesis (in case of concurrent fluid or air in the thoracic cavity), surgical intervention after initial stabilization!
Describe Tracheostomies.
The 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.
Abdominal trauma assessment flowchart.
Exploratory laparotomy is not uncommon for traumatic abdominal injuries.
Note that air in the abdominal cavity concurrent with intact abdominal wall , this could indicate intestinal perforation so air from GI tract gets into abdo cavity.
Treatment of Abdominal trauma.
Surgery is indicated in case of:
* 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.
Trauma-associated urinary tract injury.
- Blunt/penetrating
- Trauma to the urinary tract often goes undetected (initially).
- Uroperitoneum
- Retroperitoneal injuries (kidney, ureter)
- Bladder injuries (rupture)
- Urethral injuries (rupture)
Suspected uroabdomen. What analysis do you run on the collected fluid to decide whether it is urine or not?
Measure creatinine from the collected fluid as well as from the blood plasma.
If the creatinine is 2 x greater in the abdo fluid than in the blood plasma, this indicates most likely uroabdomen.
Describe Uroperitoneum.
Otherwise known as uroabdomen - free urine in the peritoneal cavity.
- Occurs secondary to urine leakage from the urethra, bladder, ureter or kidney (trauma, neoplasia etc.).
- Diagnosis: anamnesis, examination, hematology, biochemistry, ECG,
abdominocentesis + fluid analysis, diagnostic imaging. - Treatment: stabilization (life-threatening hyperkalemia can occur!, abdominal drainage), definitive treatment variable, surgery often necessary.
What’s this?
contrast urography to check for urinary tract patency
Trauma-associated abdominal parenchymal
organ injury.
Common; hemorrhage is 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 to stim the bleed. - Following cardiovascular stabilization, animals with penetrating abdominal injury require immediate surgery (potential bowel
perforation etc.) (note: can be some rare exceptions in which the penetration injury is very small and can resolve conservatively).
Trauma-associated biliary tract injury.
Traumatic injury to the extra-hepatic biliary tract is 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).
Trauma-associated body wall and torso injury.
Abdominal wall herniation is a protrusion of the abdominal contents through an acquired/congenital area of weakness or defect in the wall.
- Can occur at multiple sites simultaneously.
- Diagnosis: physical examination, diagnostic imaging.
- Treatment: surgical once the patient is stable.
- In case of strangulation – emergency surgery.
Evisceration is the extrusion of viscera outside the body through a wound
or a surgical incision.
- Treatment: protection of organs (from contamination and desiccation), stabilization,
bacterial culture, AB, surgical closure (thorough lavage; drain?).
Trauma-associated gastrointestinal injury.
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.
Describe abdominocentesis.
- Ascites is the abnormal accumulation of fluid (trauma-associated can be: 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!
Describe blind abdominocentesis.
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.
SBS =
Short-bowel syndrome (SBS) is a clinical syndrome characterized by severe weight loss secondary to a malabsorptive diarrhea from a markedly shortened small intestine. SBS may be congenital or acquired.
E.g. after abdominal trauma and surgical correction which requires removal of a large portion of bowel.
