Traumatology Flashcards
leading cause of death in patients <45 yr
trauma
Trimodal distribution of death in trauma
■ minutes: death usually at the scene from lethal injuries
■ early: death within 4-6 h – “golden hour” (decreased mortality with trauma care)
■ days-weeks: death from multiple organ dysfunction, sepsis, etc
Categories of trauma injuries
■ blunt (most common): MVC, pedestrian-automobile impact, motorcycle collision, fall, assault, sports
■ penetrating (increasing in incidence): gunshot wound, stabbing, impalement
Considerations for traumatic injury
- important to know the mechanism of injury to anticipate traumatic injuries
- always look for an underlying cause (alcohol, medications, illicit substances, seizure, suicide attempt, medical problem)
- always inquire about HI, loss of consciousness, amnesia, vomiting, headache, and seizure activity
What is the cardiac box
sternal notch, nipples, and xiphoid process; injuries inside this area should increase suspicion of cardiac injury
High risk injuries
- MVC at high speed, resulting in ejection from vehicle
- Motorcycle collisions
- Vehicle vs. pedestrian crashes
- Fall from height >12 ft (3.6 m)
What is Waddle’s triad
Vehicle vs. Pedestrian Crash
In adults look for triad of injuries (Waddle’s triad)
- Tibia-fibula or femur fracture
- Truncal injury
- Craniofacial injury
MVC special considerations
Vehicle(s) involved: weight, size, speed, damage
Location of patient in vehicle
Use and type of seatbelt
Ejection of patient from vehicle
Entrapment of patient under vehicle
Airbag deployment
Helmet use in motorcycle collision
MVC associated injuries
Head-on collision: head/facial, thoracic (aortic), lower extremity
Lateral/T-bone collision: head, C-spine, thoracic, abdominal, pelvic and lower extremity
Rear-end collision: hyper-extension of C-spine (whiplash injury)
Rollover
Pedestrian-automobile impact special considerations
High morbidity and mortality
Vehicle speed is an important factor
Site of impact on car
Pedestrian-automobile impact associated injuries
Children at increased risk of being run over
(multisystem injuries)
Adults tend to be struck in lower legs (lower extremity injuries), impacted against car (truncal injuries), and thrown to ground (HI)
Falls special considerations
1 storey = 12 ft = 3.6 m
Distance of fall: 50% mortality at 4 storeys and 95% mortality at 7 storeys
Landing position (vertical vs. horizontal)
Falls associated injuries
Vertical: lower extremity, pelvic, and spine fractures; HI
Horizontal: facial, upper extremity, and rib fractures; abdominal, thoracic, and HI
60% of MVC related deaths are due to
HI
Signs of basal skull fracture
- Battle’s sign (bruised mastoid process)
- Hemotympanum
- Raccoon eyes (periorbital bruising)
- CSF rhinorrhea/otorrhea
How to diagnose head fracture
non-contrast head CT
physical exam
Types of skull fractures
■ vault fractures
linear, non-depressed
– most common – typically occur over temporal bone, in area of middle meningeal artery (commonest cause of epidural hematoma)
◆ depressed
– open (associated overlying scalp laceration and torn dura, skull fracture disrupting paranasal sinuses or middle ear) vs. closed
■ basal skull fractures
◆ typically occur through floor of anterior cranial fossa (longitudinal more common than transverse)
◆ clinical diagnosis superior as poorly visualized on CT
Types of facial fractures
■ neuronal injury
■ beware of open fracture or sinus fractures (risk of infection)
■ severe facial fractures may pose risk to airway from profuse bleeding
Scalp laceration management
■ can be a source of significant bleeding
■ achieve hemostasis, inspect and palpate for skull bone defects ± CT head (rule-out skull fracture)
Types of neuronal injury
A. diffuse
■ mild TBI = concussion
◆ transient alteration in mental status that may involve loss of consciousness
◆ hallmarks of concussion: confusion and amnesia, which may occur immediately after the trauma or minutes later
◆ loss of consciousness (if present) must be less than 30 min, initial GCS must be between 13-15, and post-traumatic amnesia must be less than 24 h
■ diffuse axonal injury
◆ mild: coma 6-24 h, possibly lasting deficit
◆ moderate: coma >24 h, little or no signs of brainstem dysfunction
◆ severe: coma >24 h, frequent signs of brainstem dysfunction
B. focal injuries
■ contusions
■ intracranial hemorrhage (epidural, subdural, intracerebral)
Warning signs of severe head injury
- GCS <8
- Deteriorating GCS
- Unequal pupils
- Lateralizing signs
N.B. Altered LOC is a hallmark of brain injury
Assessment of brain injury physical exam
• assume C-spine injury until ruled out
• vital signs
■ shock (not likely due to isolated brain injury, except in infants)
■ Cushing’s response to increasing ICP (bradycardia, HTN, irregular respirations)
• severity of injury determined by
1. LOC
◆ GCS ≤8 intubate, any change in score of 3 or more = serious injury
◆ mild TBI = 13-15, moderate = 9-12, severe = 3-8
2. pupils: size anisocoria >1 mm (in patient with altered LOC), response to light
3. lateralizing signs (motor/sensory)
◆ may become subtler with increasing severity of injury
• reassess frequently
Assessment of brain injury investigations
- labs: CBC, electrolytes, PT/PTT or INR/PTT, glucose, toxicology screen
- CT scan head and neck (non-contrast) to exclude intracranial hemorrhage/hematoma
- C-spine imaging
Canadian CT head rule
CT Head is only required for patients with minor HI with any one of the following
High Risk (for neurological intervention)
• GCS score <15 at 2 h after injury
• Vomiting ≥2 episodes
• Age ≥65 yr
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (hemotympanum, “raccoon” eyes, CSF otorrhea/rhinorrhea, Battle’s sign)
Medium Risk (for brain injury on CT) • Amnesia before impact >30 min (i.e. cannot recall events just before impact) • Dangerous mechanism (pedestrian struck by MVC, occupant ejected from motor vehicle, fall from height >3 ft or five stairs)
Minor HI is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patient with a GCS score of 13-15.
NB: Canadian CT Head Rule does not apply for nontrauma cases, for GCS<13, age <16, for patients on Coumadin® and/or having a bleeding disorder, or having an obvious open skull fracture.
Brain injury management
• goal in ED: reduce secondary injury by avoiding hypoxia, ischemia, decreased CPP, seizure
• general ■ ABCs ■ ensure oxygen delivery to brain through intubation and prevent hypercarbia ■ maintain BP (sBP >90) ■ treat other injuries
• early neurosurgical consultation for acute and subsequent patient management
• seizure treatment/prophylaxis
■ benzodiazepines, phenytoin, phenobarbital
■ steroids are of no proven value
• treat suspected raised ICP, consider if HI with signs of increased ICP:
■ intubate
■ calm (sedate) if risk for high airway pressures or agitation
■ paralyze if agitated
■ hyperventilate (100% O2) to a pCO2 of 30-35 mmHg
■ elevate head of bed to 20º
■ adequate BP to ensure good cerebral perfusion
■ diurese with mannitol 1g/kg infused rapidly (contraindicated in shock/renal failure)
Head injury disposition
- neurosurgical ICU admission for severe HI
- in hemodynamically unstable patient with other injuries, prioritize most life-threatening injuries and maintain cerebral perfusion
- for minor HI not requiring admission, provide 24 h HI protocol to competent caregiver, follow-up with neurology as even seemingly minor HI may cause lasting deficits
Mild traumatic brain injury severity correlate
Extent of retrograde amnesia correlates with severity of injury
Mild traumatic brain injury clinical features
- somatic: headache, sleep disturbance, N/V, blurred vision
- cognitive dysfunction: attentional impairment, reduced processing speed, drowsiness, amnesia
- emotion and behaviour: impulsivity, irritability, depression
- severe concussion: may precipitate seizure, bradycardia, hypotension, sluggish pupils
Mild traumatic brain injury investigations
- neurological exam
- concussion recognition tool (see thinkfirst.ca)
- imaging – CT as per Canadian CT Head Rules, or MRI if worsening symptoms despite normal CT
Mild traumatic brain injury management
- close observation and follow-up; for patients at risk of intracranial complications, give appropriate discharge instructions to patient and family; watch for changes to clinical features above, and if change, return to ED
- hospitalization with normal CT (GCS <15, seizures, bleeding diathesis), or with abnormal CT
- early rehabilitation to maximize outcomes
- pharmacological management of pain, depression, headache
- follow Return to Play guidelines
Mild traumatic brain injury prognosis
• most recover with minimal treatment
■ athletes with previous concussion are at increased risk of cumulative brain injury
• repeat TBI can lead to life-threatening cerebral edema or permanent impairment
Every Patient with One or More of the Following Signs or Symptoms should be Placed in a C-Spine Collar
- Midline tenderness
- Neurological symptoms or signs
- Significant distracting injuries
- HI
- Intoxication
- Dangerous mechanism
- History of altered LOC
Spine trauma most important film
the lateral C-spine x-ray is the single most important film; 95% of radiologically visible abnormalities are found on this film
Cauda Equina Syndrome cause and presentation
Cauda Equina Syndrome can occur with any spinal cord injury below T10 vertebrae. Look for incontinence, anterior thigh pain, quadriceps weakness, abnormal sacral sensation, decreased rectal tone, and variable reflexes
Spinal trauma physical exam
- ABCs
- abdominal: ecchymosis, tenderness
- neurological: complete exam, including mental status
• spine: maintain neutral position, palpate C-spine; log roll, then palpate T-spine and L-spine, assess rectal tone
■ when palpating, assess for tenderness, muscle spasm, bony deformities, step-off, and spinous process malalignment
• extremities: check capillary refill, suspect thoracolumbar injury with calcaneal fractures
assume cord injury with
significant falls (>12 ft), deceleration injuries, blunt trauma to head, neck, or back
when to maintain spinal immobilization until
until spinal injury has been ruled out
does a normal neuro exam exclude spinal injury
vertebral injuries may be present without spinal cord injury; normal neurologic exam does not exclude spinal injury
can you injury cord despite normal c spine xray
cord may be injured despite normal C-spine x-ray (spinal cord injury without radiologic abnormality)
types of spinal cord injuries
complete/incomplete transection
cord edema
spinal shock
spinal trauma investigations
• bloodwork: CBC, electrolytes Cr, glucose, coagulation profile, cross and type, toxicology screen
• imaging
■ full C-spine x-ray series for trauma (AP, lateral, odontoid)
• thoracolumbar x-rays
■ AP and lateral views
thoracolumbar xrays indications
◆ C-spine injury
◆ unconscious patients (with appropriate mechanism of injury)
◆ neurological symptoms or findings
◆ deformities that are palpable when patient is log rolled
◆ back pain
◆ bilateral calcaneal fractures (due to fall from height) – concurrent burst fractures of the lumbar or thoracic spine in 10% (T11-L2)
◆ consider CT (for subtle bony injuries), MRI (for soft tissue injuries) if appropriate
The Canadian C-Spine Rule
For Alert GCS=15 and Stable Trauma Patients where C-Spine injury is a concern
- Any high -risk factor that mandates radiography
Dangerous Mechanism or Age 65+ or Paresthesias in extremities
If yes then radiography
If no the go to 2
- Any low-risk factors that allows safe assessment of ROM?
Simple rear end MVC or No midline C-spine tenderness or Ambulatory at any time or Delayed onset of neck pain or Sitting position in ED
If no then radiography
If yes then go to 3
- Able to actively rotate neck >45o left and right?
Unable then radiography
Able then no radiography
Dangerous mechanism: Fall from 1 m/5 stairs + Axial load to head (ex. diving) MVC high speed (>100 km/h), rollover, ejection Motorized recreational vehicles Bicycle collision
Simple rear end MVC excludes Pushed into oncoming traffic Hit by bus/large truck Rollover Hit by high speed vehicle
When to complete CT for C spine
- Inadequate plain film survey
- Suspicious plain film findings
- To better delineate injuries seen on plain films
- Any clinical suspicion of atlanto-axial subluxation
- High clinical suspicion of injury despite normal x-ray
- To include C1-C3 when head CT is indicated in head trauma
Clearing C-spine
- oriented to person, place, time, and event
- no evidence of intoxication
- no posterior midline cervical tenderness
- no focal neurological deficits
- no painful distracting injuries (e.g. long bone fracture)
Normal films ->
Neck pain ->
Normal flexion/extension films = cleared
Normal films ->
Abnormal neuro exam ->
Normal MRI = cleared
If abnormal flexion/extension films or MRI then remain immobilized and consult spine service
Management of cord injury
• immobilize
• evaluate ABCs
• treat neurogenic shock (maintain sBP >100 mmHg)
• insert NG and Foley catheter
• high dose steroids: methylprednisolone 30 mg/kg bolus, then 5.4 mg/kg/h drip, start within 6-8 h of injury (controversial and recently has less support)
• complete imaging of spine and consult spine service if available
• continually reassess high cord injuries as edema can travel up cord
• if cervical cord lesion, watch for respiratory insufficiency
■ low cervical transection (C5-T1) produces abdominal breathing (phrenic innervation of diaphragm still intact but loss of innervation of intercostals and other accessory muscles of breathing)
■ high cervical cord injury (above C4) may require intubation and ventilation
• treatment: warm blanket, Trendelenburg position (occasionally), volume infusion, consider vasopressors
Lines of contour on lateral c-spine x-ray
- Anterior vertebral line
- Posterior vertebral line (anterior margin of spinal canal)
- Posterior border of facets
- Laminar fusion line (posterior margin of spinal canal)
- Posterior spinous line (along tips of spinous processes)
Sensitivity of prevertebral soft tissue selling for injury
49%
Approach to C-spine x-rays
• 3-view C-spine series is the screening modality of choice
- lateral C1-T1 ± swimmer’s view
◆ lateral view is best, identifies 90-95% of injuries - odontoid view (open mouth or oblique submental view)
◆ examine the dens for fractures – if unable to rule out fracture, repeat view or consider CT or plain film tomography
◆ examine lateral aspects of C1 and spacing relative to C2 - AP view
◆ alignment of spinous processes in the midline
◆ spacing of spinous processes should be equal
◆ check vertebral bodies and facet dislocations
Interpretation of lateral c-spine xray
A Adequacy and Alignment
Must see C1 to C7-T1 junction; if not, downward traction of shoulders, swimmer’s view, bilateral supine obliques, or CT scan needed
Lines of contour in children <8 yr of age, can see physiologic subluxation of C2 on C3, and C3 on C4, but the spino-laminal line is maintained
Fanning of spinous processes suggests posterior ligamentous disruption
Widening of facet joints
Check atlanto-occipital joint
Line extending inferiorly from clivus should transect odontoid
Atlanto-axial articulation, widening of predental space (normal: <3 mm in adults, <5 mm in children) indicates injury of C1 or C2
B Bones
Height, width, and shape of each vertebral body
Pedicles, facets, and laminae should appear as one – doubling suggests rotation
C Ca tilage
Intervertebral disc spaces – wedging anteriorly or posteriorly suggests vertebral compression
S Soft Tissues
Widening of retropharyngeal (normal: <7 mm at C1-4, may be wide in children <2 yr on expiration) or
retrotracheal spaces (normal: <22 mm at C6-T1, <14 mm in children <5 yr)
Acute phase of spinal cord injury
■ spinal shock: absence of all voluntary and reflex activity below level of injury
◆ decreased reflexes, no sensation, flaccid paralysis below level of injury, lasting days to months
■ neurogenic shock: loss of vasomotor tone, SNS tone
◆ watch for: hypotension (lacking SNS), bradycardia (unopposed PNS), poikilothermia (lacking SNS so no shunting of blood from extremities to core)
◆ occurs within 30 min of SCI at level T6 or above, lasting up to 6 wk
◆ provide airway support, fluids, atropine (for bradycardia), vasopressors for BP support
Chronic phase of Spinal cord injury
■ autonomic dysreflexia: in patients with an SCI at level T6 or above
◆ signs and symptoms: pounding headache, nasal congestion, feeling of apprehension or anxiety, visual changes, dangerously increased sBP and dBP
◆ common triggers – GU causes: bladder distention urinary tract infection, and kidney stones – GI causes: fecal impaction or bowel distension
◆ treatment: monitoring and controlling BP, prior to addressing causative issue
Utility of supine oblique views of the c spine
- Rarely used
- Beter visualization of posterior element fractures (lamina, pedicle, facet joint)
- Good to assess patency of neural foramina
- Can be used to visualize the C7-T1 junction
what needs to be r/o before proceeding to OR for C-spine fracture
20% of C-spine fractures are accompanied by other spinal fractures, so ensure thoracic and lumbar spine x-rays are normal befo e proceeding to OR
What account for 50% of all trauma deaths
chest trauma
Airway obstruction physical exam
Anxiety Stridor Hoarseness Altered mental status Apnea Cyanosis
Airway obstruction investigations
Do not wait for ABG to intubate
Airway obstruction management
Definitive airway management
intubate early
remove foreign body if visible with laryngoscope prior to intubation
Tension pneumothorax how to diagnose
clinical diagnosis
tension pneumothorax pathophysiology
one way valve causing accumulation of air in pleural space
tension pneumothorax physical exam
Respiratory distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion
Tracheal deviation away from pneumothorax
Percussion hyperresonance
Unilateral absence of breath sounds
tension pneumothorax investigations
Non-radiographic diagnosis
tension pneumothorax management
Needle thoracostomy – large bore needle, 2nd ICS mid clavicular line, followed by chest tube in 5th ICS, anterior axillary line
open pneumothorax pathophysiology
air entering chest from wound rather than trachea
open pneumothorax physical exam
wound (hole >2/3 tracheal diameter) ± exit wound
Unequal breath sound
open pneumothorax investigations
ABG: decreased pO2
open pneumothorax management
Air-tight dressing sealed on 3 sides (prevents tension pneumo)
Chest tube
Surgery
Pulsus paradoxus
a drop in BP of >10 mmHg with inspiration. Recall that BP normally drops with inspiration, but what’s “paradoxical” about this is that it drops more than it should
Massive hemothorax definition
> 1,500 cc blood loss in chest cavity
Massive hemothorax physical exam
Pallor, flat neck veins, shock
Unilateral dullness
Absent breath sounds, hypotension
Massive hemothorax investigations
Usually only able to do supine CXR – entire lung appears radioopaque as blood spreads out over posterior thoracic cavity
Massive hemothorax management
Restore blood volume
Chest tube
Thoracotomy if:
>1,500 cc total blood loss
≥200 cc/h continued drainage
Flail chest definition and common associated diagnosis
Free-floating segment of chest wall due to >2 rib fractures, each at 2 sites
Underlying lung contusion (cause of morbidity and mortality)
Flail chest physical exam
Paradoxical movement of flail segment
Palpable crepitus of ribs
Decreased air entry on affected side
Flail chest investigations
ABG: decreased pO2, increased pCO2
CXR: rib fractures, lung contusion
Flail chest management
O2 + fluid therapy + pain control
Judicious fluid therapy in absence of systemic hypotension
Positive pressure ventilation ± intubation and ventilation
Cardiac tamponade diagnosis
clinical
Cardiac tamponade pathophysiology
Pericardial fluid accumulation impairing ventricular function
Cardiac tamponade physical exam
Penetrating wound (usually)
Beck’s triad: hypotension, distended neck veins, muffled heart sounds
Tachycardia, tachypnea Pulsus paradoxus Kussmaul’s sign (increased JVP with inspiration)
Cardiac tamponade investigations
Echo
FAST
Cardiac tamponade management
IV fluids
Pericardiocentesis
Open thoracotomy
Ruptured diaphragm more commonly diagnosed what side
Ruptured diaphragm is more often diagnosed on the left side, as liver conceals right side defect
Pulmonary contusion physical exam
Blunt trauma to chest
Interstitial edema impairs compliance and gas exchange
Pulmonary contusion investigations
CXR: areas of opacification of lung within 6h of trauma
Pulmonary contusion management
Maintain adequate ventilation
Monitor with ABG, pulse oximeter, and ECG
Chest physiotherapy
Positive pressure ventilation if severe
Ruptured diaphragm physical exam
Blunt trauma to chest or abdomen (e.g. high lap belt in MVC)
Ruptured diaphragm investigations
CXR: abnormality of diaph agm/lower lung fields/ NG tube placement
CT scan and endoscopy: sometimes helpful for diagnosis
Ruptured diaphragm management
Laparotomy for diaphragm repair and associated intra-abdominal injuries
Esophageal injury physical exam
Usually penetrating trauma (pain out of proportion to degree of injury)
Esophageal injury investigations
CXR: mediastinal air (not always)
Esophagram (Gastrograffin®)
Flexible esophagoscopy
Esophageal injury management
Early repair (within 24 h) improves outcome but all require repair
Aortic tear location and prognosis
90% tear at subclavian (near ligamentum arteriosum), most die at scene
Salvageable if diagnosis made rapidly
Aortic tear physical exam
Sudden high speed deceleration (e.g MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent)
Decreased femoral pulses, differential arm BP (arch tear)
Aortic tear investigations
CXR, CT scan, transesophageal echo, aortography (gold standard)
Aortic tear management
Thoracotomy (may treat other severe injuries first)
Blunt Myocardial Injury (rare) physical exam
Blunt trauma to chest (usually in setting of multi-system trauma and therefore difficult to diagnose)
Physical exam: overlying injury, e.g. fractures, chest wall contusion
Blunt Myocardial Injury (rare) investigations
ECG: dysrhythmias, ST changes
Patients with a normal ECG and normal hemodynamics never get dysrhythmias
Blunt Myocardial Injury (rare) management
O2
Antidysrhythmic agents
Analgesia
Aortic tear xray features
ABC WHITE
X-ray features of Aortic tear
Depressed left mainstem Bronchus
pleural Cap
Wide mediastinum (most consistent) Hemothorax Indistinct aortic knuckle Tracheal deviation to right side Esophagus (NG tube) deviated to right (Note: present in 85% of cases, but cannot rule out)
Penetrating neck trauma management
management: injuries deep to platysma require further evaluation by angiography, contrast CT, or surgery
• do not explore penetrating neck wounds except in the OR
If penetrating neck trauma present DON’T
- Clamp structures (can damage nerves)
- Probe
- Insert NG tube (leads to bleeding)
- Remove weapon/impaled object
3 zones of neck
Zone 1: Base of neck (thoracic inlet to cricoid cartilage)
Zone II: Midportion of neck (cricoid to angle of the mandible)
Zone III: Superior aspect of neck
Larynx injury history
strangulation, direct blow, blunt trauma, any penetrating injury involving platysma
Larynx injury triad and other symptoms
hoarseness, subcutaneous emphysema, palpable fracture
hemoptysis, dyspnea, dysphonia
Larynx injury investigations
CXR, CT scan, arteriography (if penetrating)
Larynx injury management
◆ airway: manage early because of edema
◆ C-spine may also be injured, consider mechanism of injury
◆ surgical: tracheotomy vs. repair
Trachea/bronchus injury history
deceleration, penetration, increased intra-thoracic pressure, complaints of dyspnea, hemoptysis
Trachea/bronchus injury examination
Subcutaneous air
Hamman’s sign (crunching sound synchronous with heart beat)
Trachea/bronchus injury CXR
Mediastinal air
Persistent pneumothorax or persistent air leak after chest tube inserted for pneumothorax
Trachea/bronchus injury management
Surgical repair if >1/3 circumference
Seatbelt injuries may cause what
- Retroperitoneal duodenal trauma
- Intraperitoneal bowel transection
- Mesenteric injury
- Lspine injury
Indications for foley and NG tube in abdominal trauma
Foley catheter: unconscious or patient with multiple injuries who cannot void spontaneously or is unconscious
NG tube: used to decompress the stomach and proximal small bowel. Contraindicated if suspected facial or basal skull fractures
Types of abdominal trauma and common organ injury that they cause
■ blunt: usually causes solid organ injury (spleen = most common, liver = 2nd)
■ penetrating: usually causes hollow organ injury or liver injury (most common)
Blunt trauma results in what two types of hemorrhage
Intra-abdominal
Retroperitoneal
Abdominal trauma physical exam
• often unreliable in multi-system trauma, wide spectrum of presentations
■ slow blood loss not immediately apparent
■ tachycardia, tachypnea, oliguria, febrile, hypotension
■ other injuries may mask symptoms
■ serial examinations are required
• abdomen
■ inspect: contusions, abrasions, seat-belt sign, distention
■ auscultate: bruits, bowel sounds
■ palpate: tenderness, rebound tenderness, rigidity, guarding
■ DRE: rectal tone, blood, bone fragments, prostate location
■ placement of NG, Foley catheter should be considered part of the abdominal exam
• other systems to assess: cardiovascular, respiratory (possibility of diaphragm rupture), genitourinary, pelvis, back/neurological
Abdominal trauma investigations
labs: CBC, electrolytes, coagulation, cross and type, glucose, Cr, CK, lipase, amylase, liver enzymes, ABG, blood EtOH, β-hCG, U/A, toxicology screen
Xray in abdominal trauma strengths and limitations
Chest (looking for free air under diaphragm, diaphragmatic hernia, air-flud levels), pelvis, cervical, thoracic, lumbar spines
Soft tissue not well visualized
CT scan in abdominal trauma strengths and limitations
Most specific test
Radiation exposure 20x more than x-ray Cannot use if hemodynamic instability
Diagnostic peritoneal lavage (rarely used) in abdominal trauma strengths and limitations
Most sensitive test
Tests for intra-peritoneal bleed
Cannot test for retroperitoneal bleed or diaphragmatic rupture
Cannot distinguish lethal from trivial bleed
Results can take up to 1 h
Ultrasound FAST in abdominal trauma strengths and limitations
Identifies presence/absence of free fluid in peritoneal cavity
RAPID exam: less than 5 min
Can also examine pericardium and pleural cavities
NOT used to identify specific organ injuries
If patient has ascites, FAST will be falsely positive
Criteria for positive lavage
- > 10 cc gross blood
- Bile, bacteria, foreign material
- RBC count >100000 x 106/L
- WBC >500 x 106/L,
- Amylase >175 IU
When must imaging be completed in abdominal trauma
■ equivocal abdominal examination, altered sensorium, or distracting injuries (e.g. head trauma, spinal cord injury resulting in abdominal anesthesia)
■ unexplained shock/hypotension
■ patients have multiple traumas and must undergo general anesthesia for orthopedic, neurosurgical, or other injuries
■ fractures of lower ribs, pelvis, spine
■ positive FAST
Laparotomy is mandatory if penetrating trauma and
- Shock
- Peritonitis
- Evisceration
- Free air in abdomen
- Blood in NG tube, Foley catheter, or on DRE
Abdominal trauma management
- general: ABCs, fluid resuscitation, and stabilization
- surgical: watchful waiting vs. laparotomy
- solid organ injuries: decision based on hemodynamic stability, not the specific injuries
- hemodynamically unstable or persistently high transfusion requirements: laparotomy
- hollow organ injuries: laparotomy
- even if low suspicion of injury: admit and observe for 24 h
Penetrating trauma high risk of what
gastrointestinal perforation and sepsis
Penetrating trauma history
size of blade, calibre/distance from gun, route of entry
How to rule out peritoneal penetration
local wound exploration under direct vision may determine lack of peritoneal penetration (not reliable in inexperienced hands) with the following exceptions:
• thoracoabdominal region (may cause pneumothorax)
• back or flanks (muscles too thick)
Rule of thirds for stab wounds
- 1/3 do not penetrate peritoneal cavity
- 1/3 penetrate but are harmless
- 1/3 cause injury requiring surgery
Penetrating trauma management
- general: ABCs, fluid resuscitation, and stabilization
* gunshot wounds always require laparotomy
GU tract injuries etiology
• blunt trauma: often associated with pelvic fractures
■ upper tract
◆ renal – contusions (minor injury – parenchymal ecchymoses with intact renal capsule) – parenchymal tears/laceration: non-communicating (hematoma) vs. communicating (urine extravasation, hematuria)
◆ ureter: rare, at uretero-pelvic junction
■ lower tract
◆ bladder – extraperitoneal rupture of bladder from pelvic fracture fragments – intraperitoneal rupture of bladder from trauma and full bladder
◆ urethra – posterior urethral injuries: MVCs, falls, pelvic fractures – anterior urethral injuries: blunt trauma to perineum, straddle injuries/direct strikes
■ external genitalia
• penetrating trauma
■ damage to: kidney, bladder, ureter (rare), external genitalia
• acceleration/deceleration injury
■ renal pedicle injury: high mortality rate (laceration and thrombosis of renal artery, renal vein, and their branches)
• iatrogenic
■ ureter and urethra (from instrumentation)
GU tract injuries history
- mechanism of injury
- hematuria (microscopic or gross), blood on underwear
- dysuria, urinary retention
- history of hypotension
GU tract injuries physical exam
- abdominal pain, flank pain, CVA tenderness, upper quadrant mass, perineal lacerations
- DRE: sphincter tone, position of prostate, presence of blood
- scrotum: ecchymoses, lacerations, testicular disruption, hematomas
- bimanual exam, speculum exam
- extraperitoneal bladder rupture: pelvic instability, suprapubic tenderness from mass of urine or extravasated blood
- intraperitoneal bladder rupture: acute abdomen
- urethral injury: perineal ecchymosis, scrotal hematoma, blood at penile meatus, high riding prostate, pelvic fractures
GU tract injuries investigations
- urethra: retrograde urethrography
- bladder: U/A, CT scan, urethrogram ± retrograde cystoscopy ± cystogram (distended bladder + postvoid)
- ureter: retrograde ureterogram
- renal: CT scan (best, if hemodynamically stable), intravenous pyelogram
GU tract injuries management
• urology consult
• renal
■ minor injuries: conservative management
◆ bedrest, hydration, analgesia, antibiotics
■ major injuries: admit
◆ conservative management with frequent reassessments, serial U/A ± re-imaging
◆ surgical repair (exploration, nephrectomy): hemodynamically unstable or continuing to bleed >48 h, major urine extravasation, renal pedicle injury, all penetrating wounds and major lacerations, infections, renal artery thrombosis
• ureter
■ ureterouretostomy
• bladder ■ extraperitoneal ◆ minor rupture: Foley drainage x 10-14 d ◆ major rupture: surgical repair ■ intraperitoneal ◆ drain abdomen and surgical repair
• urethra
■ anterior: conservative, if cannot void, Foley or suprapubic cystostomy and antibiotics
■ posterior: suprapubic cystostomy (avoid catheterization) ± surgical repair
Gross hematuria suggests what GU tract injury
Bladder injury
In the case of gross hematuria the GU system is investigated in what order
distal to proximal (ie urethrogram, cystogram, etc)
Description of fractures
SOLARTAT
Site Open vs. closed Length Articular Rotation Translation Alignment/Angulation Type e.g. Salter-Harris, etc.
Fracture physical exam
- look (inspection): “SEADS” swelling, erythema, atrophy, deformity, and skin changes (e.g. bruises)
- feel (palpation): all joints/bones for local tenderness, swelling, warmth, crepitus, joint effusions, and subtle deformity
- move: joints affected plus those above and below injury – active ROM preferred to passive
- neurovascular status: distal to injury (before and after reduction)
Life threatening orthopedic injuries
Major pelvic fractures
Traumatic amputations
Massive long bone injuries and associated fat emboli syndrome
Vascular injury proximal to knee/elbow
Limb threatening orthopedic injuries
Fracture/dislocation of ankle (talar AVN)
Crush injuries
Compartment syndrome
Open fractures
Dislocations of knee/hip
Fractures above knee/elbow
Open fractures increase risk of what complication
osteomyelitis
Open fracture management
- remove gross debris, irrigate cover with sterile dressing – formal irrigation and debridement often done in the OR
- control bleeding with pressure (no clamping)
- splint
- antibiotics (1st generation cephalosporin and aminoglycoside) and tetanus prophylaxis
- standard of care is to secure definitive surgical management within 6 h, time to surgery may vary from case-to-case
Remember “STAND” Splint Tetanus prophylaxis Antibiotics Neurovascular status (before and after) Dressings (to cover wound)
How to manage orthopedic injuries with vascular injuries associated
- realign limb/apply longitudinal traction and reassess pulses (e.g Doppler probe)
- surgical consult
- direct pressure if external bleeding
Compartment syndrome pathophysiology
when the intracompartmental pressure within an anatomical area (e.g. forearm or lower leg) exceeds the capillary perfusion pressure, eventually leading to muscle/nerve necrosis
Compartment syndrome diagnosis and clinical presentation
clinical diagnosis: maintain a high index of suspicion
■ pain out of proportion to the injury
■ pain worse with passive stretch
■ tense compartment
■ look for “the 6 Ps” (note radial pulse pressure is 120/80 mmHg while capillary perfusion pressure is 30 mmHg, seeing any of the 6ps indicates advanced compartment syndrome, therefore do not wait for these signs to diagnose and treat)
Pulse discrepancies
Pallor
Paresthesia/hypoesthesia
Paralysis
Pain (especially when refractory to usual analgesics)
Polar (cold)
Compartment syndrome management
requires prompt decompression: remove constrictive casts, dressing ; emergent fasciotomy may be needed
Nerves at risk with anterior shoulder dislocation
axillary nerve (lateral aspect of shoulder) and musculocutaneous nerve (extensor aspect of forearm) at risk
What should be ruled out with forceful anterior shoulder dislocation
fracture
Anterior shoulder dislocation management
reduce (traction, scapular manipulation), immobilize in internal rotation, repeat x-ray, out-patient follow-up with orthopedics
Colles’ fracture description
distal radius fracture with dorsal displacement from “Fall on Outstretched Hand” (FOOSH)
Colles’ fracture plain film
■ AP film: shortening, radial deviation, radial displacement
■ lateral film: dorsal displacement, volar angulation
1. Dorsal tit 2 Dorsal displacement 3. Ulnar styloid fracture 4. Radial displacement 5. Radial tilt 6. Shortening
Colles’ fracture management
■ reduce, immobilize with splint, out-patient follow-up with orthopedics or immediate orthopedic referral if complicated fracture
■ if involvement of articular surface, emergent orthopedic referral
Scaphoid fracture presentation
tenderness in anatomical snuff box, pain on scaphoid tubercle, pain on axial loading of thumb
Scaphoid fracture management
negative x-ray: thumb spica splint, repeat x-ray in 1 wk ± CT scan/bone scan
positive x-ray: thumb spica splint x 6-8 wk, repeat x-ray in 2 wk
■ outpatient orthopedics follow-up
Scaphoid fracture risk if no immobilization
■ risk of AVN of scaphoid if not immobilized
Mechanism of avulsion of base of 5th metatarsal
occurs with inversion injury
avulsion of base of 5th metatarsal management
supportive tensor or below knee walking cast for 3 weeks
calcaneal fracture history
fall from height
calcaneal fracture associated injuries
may involve ankles, knees, hips, pelvis, lumbar spine
Ottawa Knee Rules
A knee xray examination is required only for acute injury patients with one or more of:
Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex to 90o
Inability to weight bear both immediately and in the ED (four steps)
Ottawa ankle and foot rules
An ankle radiographic series is required only if there is any pain in malleolar zone and any of these findings
- Bony tenderness at posterior edge or tip of lateral malleolus
- Bony tenderness at posterior edge or tip of medial malleolus
- Inability to bear weight both immediately and in ED (four steps)
A radiographic series is required only if there is any pain in midfoot zone and any of these findings:
- Bony tenderness at base of 5th metatarsal
- Bony tenderness at navicular
- Inability to bear weight both immediately and in ED (four steps)
Acute treatment of contusions
RICE Rest Ice Compression Elevation
Tetanus prophylaxis in pregnancy
Both tetanus toxoid (Td) and immunoglobulin (TIG) are safe in pregnancy
High risk factors for infection
Wound Factors • Puncture wounds • Crush injuries • Wounds >12 h old • Hand or foot wounds
Patient Factors
• Age >50 yr
• Prosthetic joints or valves (risk of endocarditis)
• Immunocompromised
Guidelines for tetanus prophylaxis for wounds
Unknown or fewer than 3 doses vaccination history
with Tdap or Td
with clean minor wounds
YES
Unknown or fewer than 3 doses vaccination history
with TIG
with clean minor wounds
NO
Unknown or fewer than 3 doses vaccination history
with Tdap or Td
with not clean, minor wounds
YES
Unknown or fewer than 3 doses vaccination history
with TIG
with not clean, minor wounds
YES
Vaccination history of 3+ doses with Tdap or Td with clean, minor wounds NO Yes if more than 10 years since the last tetanus toxoid-containing vaccine dose
Vaccination history of 3+ doses
with TIG
with clean, minor wounds
NO
Vaccination history of 3+ doses with Tdap or Td with non clean, minor wounds NO Yes if more than 5 years since the last tetanus toxoid-containing vaccine dose
Vaccination history of 3+ doses
with TIG
with non clean, minor wounds
NO
- note that non clean, minor wounds include contaminated with dirt, feces, coil and saliva, puncture wounds, avulsions, wounds resulting from missiles, crushing, burns and frostbite
Tetanus vaccination options
Tdap is preferred to Td for adults who have never received Tdap.
Single antigen tetanus toxoid (TT) is no longer available in the United States
Types of bruises and things to check for
- non-palpable = ecchymosis
- palpable collection (not swelling) = hematoma following blunt trauma
- assess for coagulopathy (e.g. liver disease), anticoagulant use
Abrasion management
■ clean thoroughly with brush to prevent foreign body impregnation ± local anesthetic antiseptic ointment (Polysporin® or Vaseline®) for 7 d for facial and complex abrasions
■ tetanus prophylaxis
Suture to face type and duration
Close with Nylon or Other Non-absorbable Suture 6-0
5 days
Suture to not joint type and duration
Close with Nylon or Other Non-absorbable Suture 4-0
7 days
Suture to joint type and duration
Close with Nylon or Other Non-absorbable Suture 3-0
10 days
Suture to scalp type and duration
Close with Nylon or Other Non-absorbable Suture 4-0
7 days
Suture to mucous membrane type and duration
Absorbable (vicryl)
N/A duration
Who may require sutures for longer than standard periods of time
Patients on steroid therapy
Lacerations physical exam
■ think about underlying anatomy
■ examine tendon function actively against resistance and neurovascular status distally
■ clean and explore under local anesthetic; look for partial tendon injuries
Lacerations imaging
■ x-ray or U/S wounds if a foreign body is suspected (e.g. shattered glass) and not found when exploring wound (remember: not all foreign bodies are radioopaque), or if suspect intra-articular involvement
Lacerations management
■ disinfect skin/use sterile techniques
■ irrigate copiously with normal saline
■ analgesia ± anesthesia
■ maximum dose of lidocaine
◆ 7 mg/kg with epinephrine
◆ 5 mg/kg without epinephrine
- evacuate hematomas, debride non-viable tissue, remove hair and foreign bodies
- ± prophylactic antibiotics (consider for animal/human bites, intra-oral lesion, or puncture wounds to the foot)
- suture unless: delayed presentation (>6-8 h), puncture wound, mammalian bite, crush injury, or retained foreign body
- take into account patient and wound factors when considering suturing
- advise patient when to have sutures remove
What are the most important factors in decreasing infection risk in lacerations
Early wound irrigation and debridement are the most important factors in decreasing infection risk
Agents for sedation and amnesia in children
in children, topical anesthetics such as LET (lidocaine, epinephrine, and tetracaine), and in selected cases a short-acting benzodiazepine (midazolam or other agents) for sedation and amnesia are useful
Alternatives to sutures
tissue glue
steristrips
staples
