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Trauma “This ain’t ER”

Trauma “This ain’t ER”

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Trauma “This ain’t ER”

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  1. Trauma“This ain’t ER” Ben Zarzaur, MD UNC Department of Surgery Section of Trauma and Critical Care

  2. What is trauma?

  3. Real Life & Death

  4. What is trauma?

  5. Trauma Epidemiology

  6. Years of Potential Life Lost MMWR 1982;31,599.

  7. Mechanisms of Injury: Blunt Trauma • MVC • Pedestrian vs Vehicle • Falls

  8. Mechanisms of Injury:Special Situations • Explosions • Blunt + penetrating + burns • Burns • Crush injuries • Drowning • Hypothermia/ exposure

  9. Compression injury • Frontal brain contusion • Pneumothorax • Rupture of Left hemidiaphragm • Small bowel rupture • Chance fracture

  10. Deceleration Injury • Aortic tear • Fixed descending aorta • Mobile arch • Acute subdural brain hematoma • Kidney avulsion • Splenic pedicle

  11. Mechanisms of Injury: Penetrating Trauma • Gun shot wounds • Stab wounds • Impalement

  12. Gun Shot Wounds: Mechanism • Energy transfer • Shape/size of bullet • Distance to target • Velocity (most important) • Kinetic energy = (Mass × Velocity2 )/2 • Surface area distributed • Tumble and yaw • Fragmentation • Anatomy • Viscoelasticity • Muscle • organs

  13. Stab wounds • Mechanism • Blunt: Crush injury • Sharp:Tissue disruption • Extent of Injury • Weapon size, length, sharpness, penetration • Severe injury • Chest and abdomen • 4+ wounds

  14. What happens when the patient comes to a Level I Trauma Center?

  15. Trauma Team“Doin it 24/7” • ED Physicians • Anesthesiology • Surgeons • General and Trauma and Critical Care • Neurosurgery • Orthopedics • Medical Students • Nurses • Radiology Techs • Radiologists

  16. What happens when this patient comes to the ER where you are moonlighting?

  17. What the heck do I do now?

  18. Don’t panic!

  19. Trauma is not rocket science!

  20. Air goes in & out • Oxygen is good • Blood goes round & round • Stop bleeding • Put things back where and how they belong

  21. Initial Assessment: Prerequisites • Wide-angled view • Pattern recognition skills • Ability to triage and set priorities • Organized structure

  22. Trauma is not rocket science!

  23. ABCDEF

  24. Initial Assessment: Primary Survey • A = Airway • B = Breathing • C = Circulation • D = Disability • E = Exposure • F = Fracture

  25. Initial Assessment: Airway • Clear & establish a good airway • Consider intubation for coma, shock, and thoracic injuries • C-spine stabilization

  26. Airway: Cricothyrotomy

  27. Initial Assessment: Breathing • Chest excursion & breath sounds • Flail chest • Pneumothorax • Open • Tension • Massive Hemothorax

  28. Initial Assessment: Circulation • Perfusion (mental status, skin, pulse) • Control bleeding with pressure • Pericardial Tamponade • Beck’s Triad • Establish 2 large bore (16G or larger) IV’s in upper extremity peripheral veins • Resuscitate with Lactated Ringers • After 4 L think about resuscitation with blood

  29. Initial Assessment: Disability • Neurologic status • Glasgow Coma Scale • Eye • Motor-best predictor of long term outcome • Verbal • Spinal Cord Injury

  30. Initial Assessment: Exposure • Remove clothes • Temperature • warm blankets • Finger and tube in every orifice • Maintain full spine precautions • Log Roll

  31. Initial Assessment: Fracture • Stabilize Fractures • Relocate dislocated joints • Reassess pulses

  32. Secondary Survey • Patient history • Head to toe physical exam • Radiography • Lateral C-spine, C-xray, pelvis • One cavity above/below entrance/exit wounds • FAST • Urinary bladder drainage • NGT • Blood sampling/monitoring

  33. Does this patient need to go to the OR ?

  34. Penetrating Abdominal Trauma

  35. Blunt Abdominal Injuries

  36. Liver Injury

  37. Liver Injury • blunt or penetrating injury • mortality: 10 - 20% • may be associated with right lower rib fracture • Signs / Symptoms • RUQ pain abdominal wall spasm ,guarding hypoactive or absent BS signs of hemorrhage

  38. Liver Injury: ManagementBlunt Injury • ICU monitoring • For more severe injuries • Serial HCT • Floor Monitoring • Less severe injuries • Serial HCT • OR if patient becomes unstable or requires excessive blood transfusions

  39. Surgical Management

  40. Surgical Management

  41. Surgical Management