OUTLINE

• PEARLS AND PITFALLS OF MANAGING THE MANY DETAILS INVOLVED IN THIS

TRAUMA PATIENTS WITH MULTI-SYSTEM INJURIES
• ISSUES OF CONCERN BEFORE LEAVING THE TRAUMA BAY
• ICU IMPLICATIONS
• TRAUMA PATIENTS ON THE FLOOR
ISSUES IN THE TRAUMA BAY
• AIRWAY
• BREATHING
• CIRCULATION
• DISABILITY (NEUROLOGIC EVALUATION)

• SECONDARY EVALUATION
• MANY INJURIES ARE EVIDENT
• TBI, PENETRATING TRAUMA, LONG BONE FRACTURES
• OTHERS ARE MORE DIFFICULT TO DIAGNOSE
• ABDOMINAL HEMORRHAGE, PELVIC FRACTURES, ETC.
ABDOMINAL EVALUATION
• INTRAABDOMINAL HEMORRHAGE IS MOST COMMON PREVENTABLE CAUSE OF DEATH IN BLUNT TRAUMA
INJURIES (16-25% )
• DIFFICULT DIAGNOSIS: PERITONEAL COMPARTMENT CAN HOLD SIGNIFICANT FLUID W/O EVIDENCE OF
DISTENTION
• THREE COMMON TESTS
• DIAGNOSTIC PERITONEAL LAVAGE
• FOCUSED ABDOMINAL SONOGRAPHY FOR TRAUMA
• COMPUTED TOMOGRAPHY SCANNING
DIAGNOSTIC PERITONEAL LAVAGE
• PERITONEAL DIALYSIS CATHETER DIRECTED TO THE PELVIC SPACE OF THE PERITONEAL COMPARTMENT
VIA A DIRECT APPROACH
• GREATER THAN 10 ML OF ASPIRATED BLOOD BEING CONSIDERED A POSITIVE RESULT
• DIRECT ASPIRATION IS NEGATIVE, 1 L OF CRYSTALLOID SOLUTION IS INFUSED VIA THE CATHETER
• FRANKLY SANGUINEOUS FLUID OR A LABORATORY COUNT OF GREATER THAN 105 RBC/ML3 IS
CONSIDERED A POSITIVE TEST
• EXPLORATORY LAPAROTOMY INDICATED
DIAGNOSTIC PERITONEAL LAVAGE
DPL RISKS AND SHORTCOMINGS

• SEMI-INVASIVE AND TECHNIQUE SENSITIVE

• OVERLY SENSITIVE LEADING TO RATE OF UP TO 40% FOR NON-THERAPEUTIC LAPRAROTOMY
• BUT, IT REQUIRES THE LEAST HIGH TECH EQUIPMENT OUT OF ALL OPTIONS
FOCUSED ABDOMINAL SONOGRAPHY
• FAST EXAMINATION (FOCUSED ASSESSMENT WITH SONOGRAPHY IN TRAUMA)
• SUBXIPHOID TO EVALUATE THE CARDIAC SILHOUETTE AND THE PRESENCE OF CARDIAC TAMPONADE
• THE RIGHT UPPER QUADRANT OR MORISON’S POUCH TO DETECT BLOOD IN THE HEPATORENAL FOSSA
• LEFT UPPER QUADRANT TO DETECT BLOOD IN THE SPLENORENAL SPACE
• A PELVIC VIEW TO DETECT BLOOD IN THE POUCH OF DOUGLAS (BEHIND THE BLADDER AND ANTERIOR TO THE
RECTUM)
FAST EXAMINATION
• 85-90 % SENSITIVITY IN DETECTION MORE THAN 200 ML OF BLOOD IN ABDOMEN
• RAPID AND NON-INVASIVE
• CAN BE PERFORMED CONCURRENTLY WITH RESUSCITATIVE CARE
• REQUIRE EQUIPMENT AND TRAINED INDIVIDUAL
• CAN BE IMPEDED BY MORBIDLY OBESE PATIENTS OR PRESENCE WITH SUBCUTANEOUS AIR
COMPUTED TOMOGRAPHY SCANNING

• GIVES SIGNIFICANT ANATOMIC DETAIL

• LIABILITY: PATIENT MUST BE MOVED AND PLACED IN SCANNER REMOVED FROM CARE TEAM
• EACH CT SCAN GIVES MORE DETAIL, BUT TAKES MORE TIME (45 MIN OR MORE)
• THE COST/BENEFIT OF AN ADDITIONAL MUST BE WEIGHED
• “BLUSH”
BLUSH
• FOCAL INTENSE CONTRAST, INDICATING POOLING/ EXTRAVASCULAR ACCUMULATION OF CONTRAST
AGENT
BLUSH
• HELP IN DIAGNOSIS HEMORRHAGIC SHOCK
• AID IN OTHER THERAPY
• EX: BLUSH IN FRACTURED PELVIS SUGGESTS URGENT NEED FOR PELVIC ANGIOGRAPHY IN ADDITION TO
HEMODYNAMIC AND ORTHOPEDIC STABILIZATION

• IF BLUSH IS SEEN ON FIRST CT, PATIENT IS RESCANNED TO SHOW TEMPORAL DATA ON BLEEDING PATTERN
CONSIDERATIONS BEFORE PATIENT LEAVES
ED

• OCCULT PNEUMOTHORAX
• COMPLEX PELVIC INJURIES
• GREAT VESSEL INJURIES
OCCULT PNEUMOTHORAX
• UP TO 40% OF TRAUMATIC PNEUMOTHORAX ARE MISSED ON INITIAL AP RADIOGRAPH (SUPINE)
• IF SUSPECTED, UPRIGHT PA RADIOGRAPH SHOULD BE CONSIDERED
OCCULT PNEUMOTHORAX
• CT would give most diagnostic detail

✓ Traumatic pneumothorax of >5-10% is

indication for chest tube placement prior to
GA or intubation w/ mechanical ventilation
COMPLEX PELVIC INJURIES
• CLASSIFICATION SCHEME
• MOST POPULAR IS BASED OFF TRANSMISSION OF FORCE RESPONSIBLE FOR THE INJURY

• LATERAL COMPRESSION
• ANTERIOR COMPRESSION
• VERTICAL SHEAR
• STRADDLE INJURIES (MOTORCYCLE) AND FALLS FROM HEIGHTS
• INCREASED RISK FOR RETROPERITONEAL HEMORRHAGE AND HEMODYNAMIC INSTABILITY
• EVALUATE FOR BLUSH ON CT

• MUST HAVE CT PRIOR TO LEAVING ED IF FRACTURE IS SEVERE

• LOOK FOR BLUSH
• MAY NEED ANGIOGRAPHY/EMBOLIZATION OR EXTERNAL FIXATION
COMPLEX PELVIC INJURIES
OCCULT VASCULAR INJURIES
• CAROTID OR VERTEBRAL ARTERY INJURY ARE UNCOMMON (0.5-1.5%) BUT DEVASTATING
• CLASSIC DESCRIPTION IS STRETCHING OF CAROTID OVER TRANSVERSE PROCESS OF UPPER CERVICAL
VERTEBRAE
• OFTEN DISRUPTS INTIMA, LEAVING MEDIA AND ADVENTITIA INTACT
• IRREGULARITY CAN LEAD TO THROMBUS AND SUBSEQUENT EMBOLIZATION
• CAN ALSO LEAD TO DISSECTION OF BLOOD MIDDLE LAYERS CAUSING THROMBOSIS OF LUMEN
• 70% LEAD TO STROKE IF UNDIAGNOSED
OCCULT VASCULAR INJURIES
• DIAGNOSED BY CEREBRAL ANGIOGRAM
• STROKE RISK OF 1-3%
• RESOURCE INTENSIVE
• MULTI-SLICE CT SCANNERS WHEN AVAILABLE
• AUTHORS BELIEVE WITHIN NEXT 10 YEARS, THIS MODALITY WILL REPLACE TRADITIONAL VASCULAR ANGIOGRAPHY
• MAGNETIC RESONANCE ANGIOGRAPHY
• NOT POSSIBLE IN MANY PATIENTS DUE TO LOGISTICAL CONSTRAINTS
WHEN TO SUSPECT OCCULT VASCULAR
INJURY
• PATIENTS WITH BASILAR SKULL FRACTURES, ESPECIALLY IF THE FRACTURE PATTERN EXTENDS TO, OR
THROUGH, THE CAROTID CANAL
• PATIENTS WITH CERVICAL TRANSVERSE PROCESS FRACTURES EXTENDING TO OR INTO THE FORAMEN
TRANSVERSARIUM
• PATIENTS WITH COMBINED THORACIC AND HEAD INJURIES WITH AN ABBREVIATED INJURY SCALE (AIS)
SCORE GREATER THAN 3 IN EACH OF THESE REGIONS
• PATIENTS WITH UNEXPLAINED LATERALIZING NEUROLOGIC DEFICITS
• CERVICAL SPINE FRACTURES
 ICU CONSIDERATIONS
• SHOCK
• PULSE, BLOOD PRESSURE, URINARY OUTPUT
• ONLY RELIABLY ABNORMAL IN SEVERE HEMORRHAGIC SHOCK
• OTHER POSSIBLE PARAMETERS
• BASE DEFICIT, LACTATE LEVELS, AND MIXED VENOUS OXYGEN SATURATION

• TEMPERATURE
• HYPOTHERMIA → COAGULATION DISORDERS

• VENTILATOR-ASSOCIATED PNEUMONIA
• TRACHEOSTOMY
• SINUSITIS
• FEEDING TUBES
SHOCK
• INADEQUATE CELLULAR DELIVERY OF OXYGEN
• ANAEROBIC CELLULAR METABOLISM LEADS TO LACTATE PRODUCTION
• INCREASED LACTATE LEVELS ARE CORRELATED WITH INCREASED MORTALITY
• LACTATE LEVELS WERE NOT AN IDEAL TO MEASURE HISTORICALLY
• SERUM MUST BE KEPT ON ICE
• TESTING PROCESS IS TIME CONSUMING
• TECHNOLOGICAL ADVANCES HAVE EASED THIS PROCESS
SHOCK
• INSTEAD USE BASE DEFICIT
• DERIVED FROM ARTERIAL BLOOD GAS (ABG)
• DESCRIBES THE AMOUNT OF BUFFER THAT WOULD BE REQUIRED TO NEUTRALIZE THE OBSERVED SERUM TO A PH OF 7.40
• DURING ACUTE HEMORRHAGIC SHOCK; AS LACTATE LEVELS RISE, BASE DEFICIT BECOMES MORE NEGATIVE
• OBTAIN ABG IN EARLY PHASES OF RESUSCITATION IN TRAUMA BAY
• PATIENTS WITH A BASE DEFICIT GREATER THAN -6 OR A SERUM LACTATE LEVEL GREATER THAN 4 ARE AT
INCREASED RISK FOR COMPLICATIONS→ EVALUATE AND MOVE TO ICU
SHOCK
• PULMONARY ARTERY CATHETER
• HX OF CARDIAC OR MEDICAL COMORBIDITIES (DIABETES, ATHEROSCLEROSIS)
• MORE PRECISE ESTIMATION OF CARDIAC PRELOAD AND CARDIAC PERFORMANCE
• CAN MONITOR MIXED VENOUS SATURATION
• REPRESENTS GLOBAL ADEQUACY OF OXYGEN DELIVERY
• 70-75% IS NORMAL
• <60%→INCREASED COMPLICATION RISK
TEMPERATURE
• CHEMICAL PARALYTICS TO SECURE THE AIRWAY ABLATES THE ONLY PROTECTIVE MECHANISM FOR THERMAL GENERATION
(SHIVERING)
• PATIENT IS OFTEN IN COLD ROOMS, EX. CT ROOM (KEEPS EQUIPMENT FUNCTIONAL)
• HYPOTHERMIA BLOCKS EFFECTIVE COAGULATION BY SLOWING THE RATE OF ENZYMATIC PATHWAYS
• EACH DROP OF TEMPERATURE BELOW 98° F IS ASSOCIATED WITH A DEMONSTRABLE AND PROGRESSIVELY EXPONENTIAL
LOSS OF ENZYMATIC FUNCTION.
• AT 92°F, NORMAL BLOOD WILL NOT BE ABLE TO CLOT BECAUSE OF THE DERANGEMENTS OF ENZYMATIC FUNCTION
• UTILIZE WARMING BLANKETS, OVERHEAD HEATING LIGHTS, AND ACTIVE AIR-WARMING DEVICES
VENTILATOR-ASSOCIATED PNEUMONIA
• ENDOTRACHEAL INTUBATION CARRIES A RISK OF VAP OF APPROXIMATELY 3% PER INTUBATED DAY
• PARENTERAL ANTIBIOTIC WILL ALTER THE MICROBIAL FLORA OF THE PATIENT AND HIS OR HER LUNGS AND
WILL ALSO EXERT SELECTION PRESSURE FAVORING THE EMERGENCE OF DRUG- RESISTANT ORGANISMS.
• CAREFULLY WEIGH THE EVIDENCE-BASED SUPPORT FOR THE USE OF PROPHYLACTIC ANTIBIOTICS IN THE
SETTING OF FACIAL FRACTURES.
TRACHEOSTOMY

• MAY BE REQUIRED IN CASES WITH MAXILLARY/MANDIBULAR FIXATION

• FAVORED IF GLASGOW COMA SCALE (GCS) SCORE OF LESS THAN 8 BY THE FOURTH DAY OF
HOSPITALIZATION
• EARLY TRACHEOSTOMY IN THE HEAD-INJURED PATIENT
• SHORTED ICU STAY AND LESS DAYS ON VENTILATOR
SINUSITIS
• NASOTRACHEAL INTUBATION, NASOGASTRIC DRAINAGE TUBE, NASOENTERIC FEEDING TUBES CAN CAUSE
LOCAL TRAUMA LEADING TO CLOSED SPACE INFECTIONS
• ORAL GASTRIC DRAINAGE TUBES OR FEEDING TUBES SHOULD BE CONSIDERED IN SOME CASES
• OCCULT SINUSITIS MAY BE RESPONSIBLE FOR, OR CONTRIBUTORY TO, AS MANY AS 25% OF ALL FEVERS
OF UNKNOWN ORIGIN IN THE ICU
• SINUS DECONGESTANTS, EARLY REMOVAL OF NASAL TUBES, APPROPRIATE IMAGING STUDIES TO
EVALUATE THE SINUS SPACES, AND APPROPRIATE SURGICAL DRAINAGE WILL MINIMIZE COMPLICATIONS
FEEDING TUBES
• EARLY ENTERAL NUTRITION ENSURES ADEQUATE NUTRITION TO PROMOTES WOUND HEALING.
• ALSO MAINTAINS IMMUNOLOGIC COMPETENCY OF GUT
• PATIENTS WITH SIGNIFICANT TRAUMATIC BRAIN INJURY (GCS < 8 AT DAY 4) OFTEN REQUIRE PLACEMENT
OF SECURED LONG-TERM ACCESS, SUCH AS A PERCUTANEOUS GASTROSTOMY TUBE (PEG)
• PRIOR TO MMF, PEG TUBE MAY BE REQUIRED
• CANNOT BE DONE AFTER MMF BECAUSE ENDOSCOPE IS REQUIRED
PEG TUBE
STEROIDS IN ICU?

• INTUBATED WITH MECHANICAL VENTILATION

• ADVISE AGAINST
• CAN LEAD TO MULTIDRUG RESISTANT ORGANISMS AND VAP
• AUTHOR ADVISES AGAINST IN CRITICAL ICU PATIENTS
TRAUMA PATIENT ON THE FLOOR

• TERTIARY EXAMINATION
• DVT PROPHYLAXIS
• DISCONTINUATION OF ANTIBIOTICS
• PREPARATION FOR REHABILITATION
TERTIARY EXAMINATION

• THOROUGH REPEAT EXAMINATION FROM THE CROWN OF THE HEAD TO THE BASE OF THE FEET IN THE
ATTEMPT TO ELICIT NEW FINDINGS THAT MAY HAVE BEEN OVERLOOKED
DVT PROPHYLAXIS
• INCREASED RISK FOR VENOUS THROMBOSIS AND SUBSEQUENT COMPLICATIONS SUCH AS PULMONARY EMBOLISM.
• HYPERCOAGULABILITY AS A RESULT OF AN ACUTE ALTERATIONS OF THE RELATIVE CONCENTRATIONS OF THE COMPONENTS
OF THE CLOTTING CASCADE
• THE USE OF VENOUS ACCESS DEVICES SUCH AS FEMORAL VEIN CATHETERS IS INCREASINGLY COMMONPLACE AND THEIR
USE PROVIDES THE INTIMAL INJURY
• DUPLEX SCANNING MAY BE EFFECTIVE IN DIAGNOSIS, BUT IS CONTROVERSIAL
• WITHHOLDING OF DVT PROPHYLAXIS MUST ALSO BE COORDINATED WITH RESPECT TO THE TIMING OF FURTHER SURGICAL
PROCEDURES
• SETTING OF TRAUMATIC BRAIN INJURY AND/OR SOLID ORGAN INJURY (SPLEEN OR LIVER)
DISCONTINUATION OF ANTIBIOTICS
• THE IMPLEMENTATION OF PARENTERAL ANTIBIOTICS MUST BE EVIDENCE BASED AND/OR THE RESULT OF
OBJECTIVE CULTURE DATA.
• NARROWEST SPECTRUM THAT WILL APPROPRIATELY ERADICATE THE IDENTIFIED PATHOGEN
• THE TIME COURSE OF USE OF ANTIBIOTICS SHOULD BE LIMITED TO THE PERIOD OF EVIDENCE OF ACTIVE
INFECTION (NOT A SET TIME PERIOD)
• A MORE APPROPRIATE COURSE OF ACTION IS TO CONTINUE USE OF ANTIBIOTICS UNTIL THE WHITE
BLOOD CELL COUNT NORMALIZES (<12,000 CELLS/MM3) AND UNTIL EVIDENCE OF FEBRILE RESPONSE IS
ELIMINATED FOR AT LEAST 24 HOURS.
PREPARATION FOR REHABILITATION (PMR
TEAM)
• THE EARLY EVALUATION OF THE TRAUMA PATIENT BY MEMBERS OF THE PHYSICAL MEDICINE AND
REHABILITATION SERVICE (PMR) IS A KEY COMPONENT TO A MULTI-DISCIPLINARY TEAM
• EARLY COORDINATION OF ITEMS SUCH AS A SPEECH AND SWALLOWING EVALUATION
• HELPS COORDINATE THE TIMING AND PLACEMENT OF FEEDING ADJUNCTS
• BED ELEVATION GREATER THAN 45 DEGREES DECREASES THE RISK OF ASPIRATION
• PROMOTES RESOLUTION OF FACIAL EDEMA
THANK YOU