EM - Trauma pt. 1

Golden hour conditions

Sub/epidural bleeds, HTX/PTX, Spleen/liver lac

Primary survey

ABCDEF

(airway, breathing, circulation, disability, exposure, full VS)

Airway red flags

Abnormal Voice

Bleeding/secretions

Facial burns/swelling

Stridor

AMS

Hypoxia

Absent Gag reflex

When is nasotracheal intubation contraindicated?

basilar skull fracture, apnea, facial trauma

Rapid Sequence Intubation (RSI)

Short active sedatives: Etomidate, Propofol

Neuromuscular blocking agents: succynolcholine, rocuronium

What should you do if concerned for tension pneumothorax

Needle decompression THEN tube thoracostomy

Breathing red flags

Tracheal deviation

Decreased breath sounds

Crepitus

Abnormal chest movement

Multiple rib fx

Open chest wounds

AMS

open PTX tx

3 sided dressing

Hemothorax tx

chest tube

Pt has tachycardia, hypotension or obvious blood loss. How do you manage this pt?

Stop bleed, emergent transfusion, consider early OR

Circulation red flags

Bleeding

Decreased/absent pulses

Tachycardia

Narrow pulse pressure

Hypotension

Poor perfusion

Abnormal heart sounds

Class 1 blood loss

Up to 15%

Class 2 blood loss

15-30%

Class 3 blood loss

30-40%

*hypotension

Class 4 blood loss

> 40%

How to access consciousness

Pupils, GCS, CT without contrast if head injury concern

Disability red flags

Focal neuro deficits

Abnormal pupils

Posturing

GCS eye opening

4 - spontaneous

3 - to voice

2 - to pain

1 - none

GCS verbal response

5-Oriented

4-Confused conversation

3-Inappropriate words

2-Incomprehensible sounds

1-None

GCS motor response

6- obeys commands

5- moves to localized pain

4- flex to withdraw from pain

3- abnormal flexion (decorticate)

2- extension response (decerebrate)

1- none

Cushing reflex

HTN, bradycardia, and respiratory depression (BP, brady, breathing)

Exposure and Environment red flags

FBs

Penetrating injuries

Burns

What should you perform immediately following primary survey?

FAST exam

Secondary survey

AMPLE Hx: allergies, meds, PMH/pregnancy, last meal, events

Visualize everything, palpate, imaging

Which pt would you send to the Operating Room vs. Observation

OR: unstable, ongoing bleeding

Observation (ER/Inpatient): blunt abdominal trauma, head, chest injuries

How are TBIs classified?

GCS

Mild: > 14

Moderate: 9-13

Severe: < 9

TOC for head injuries

CT scan

Basilar skull fracture sx/red flags

raccoon eyes, battle sign, CSF leak, hemotympanum

Pt comes in following blunt force trauma to the head. They have a lucid interval -> decompensation; fixed and dilated pupil on side of injury, opposite side paresis. What is suspected Dx?

Epidural hematoma

*biconvex, MC MMA involved

Injury resulting from tears of bridging veins following acceleration-deceleration injury

Subdural hematoma

You suspect patient has a SAH, what LP finding would confirm this suspicion?

Xanthochromia -> yellowish appearance of CSF

Pt comes in with blown pupil; what is this finding indicative of?

Same side elevated brain pressure

Canadian head rules

High risk if:

GCS < 15 2 hrs post-injury

Suspected open/depressed skull fracture

Sx of basilar skull fx

2 or more episodes of vomiting

Age > 65

Retrograde amnesia > 30 min

Dangerous mechanism

PECARN criteria (younger than 2 yrs)

AMS or GCS < 15 or Palpable skull fx -> CT head

PECARN criteria

AMS or GCS < 15 or sx of basilar skull fx -> CT head

Head trauma management

Maintain cerebral perfusion

- fluid and pressors

Keep sats > 90%

Treat elevated ICP

- mannitol 1 g, HOB > 30, 3% hypertonic saline 250 cc bolus (refer to specialist for mannitol/hypertonic saline), intubated goal pCO2 30-35 mmHg

Treat hyperglycemia

Seizure prophylaxis

- antiepileptic if GCS < 10

Keep body temp 36C-38.3C

Reverse coagulapothy

Indications for intubation after trauma

Burns to airway

Rapidly expanding hematoma

GCS < 8

Facial trauma imaging

CT maxillofacial without contrast

Common indications for ABX following facial trauma

Sinus fx, open fx

Key facial injuries

Frontal bone - fractures of INTERNAL frontal sinus wall

Blowout fractures w entrapment of extra-ocular muscles

Septal hematoma

Zygomaticomaxillary complex fx

Le fort fractures (upper jaw)

Open fractures/intraoral laceration (lower jaw)

*look for septal hematoma and CSF leaks

Le Fort 1

Transverse fracture through lower maxilla, above roots of teeth

*palate mobile, stable fx

Le Fort II

Pyramidal fx from central maxilla through orbital rim, nasal bridge, and hard palate

*nose and maxilla mobile

Le Fort III/IV

Fx through frontozygomatic sutures, orbits, nose, and ethmoids (+ frontal bone = IV)

*entire face mobile, unstable, +/- CSF leak (cribiform plate)

Admit + IV ABX

Le Fort 1/2 management

ENT or facial surgery consult

*EARLY intubation, avoid paralytics, consider awake intubation

Le Fort III and IV management

Admission and IV ABX

EARLY intubation, avoid paralytics, consider awake intubation

Pt presents w malocclusion, trismus, lower lip paresthesia. What should you consider?

Mandibular fx

*consider bilateral and open until proven otherwise

Mandibular fx DX/TX [open vs closed]

CT, intraoral exam

Open: admit, IV ABX, OR

Closed: Barton bandage f/u OMFS

Blunt Neck Trauma red flags

Seatbelt sign

Clothesline injury

Steering wheel/dashboard to the neck

*neuro sx may be delayed

Blunt neck trauma imaging

CTA

Blunt neck trauma tx

Unstable -> intubate, ENT consult

Penetrating neck trauma

Injury through platysma muscle

Zone 2 penetrating neck trauma

MC; cricoid to angle of mandible

Hard signs of penetrating neck trauma

HARD Bruit

Hemoptysis/hematemesis/hypotension

Arterial bleeding

Rapidly expanding hematoma

Deficit (neurologic/pulse)

Bruit

Soft signs of penetrating neck trauma

Hoarseness, SQ air, vocal cord paralysis, facial nerve injury, nonexpanding hematoma

Management for penetrating neck trauma w hard signs

OR or Angio

Management for penetrating neck trauma w soft signs (hoarseness, CN 7 injury, SQ air, vocal cord paralysis)

CTA

Unstable cervical spine fractures

Jefferson

Bilateral facet dislocation

Odontoid

Atlanto-occipital dislocation

Hangman

Teardrop

Jefferson fracture

Burst fracture @C1, due to axial loading

Key imaging for Jefferson fracture

Odontoid view, CT

Hangman's fracture

Fracture of posterior elements of C2, due to hyperextension-compression

Teardrop fracture

Antero-inferior cervical vertebral body fx