Trauma 2007: An Update

Basic Principles in the Treatment of the Multitrauma Patient

Jeffrey M. Nicastro, MD, FACS Director of Trauma and Surgical Critical Care Staten Island University Hospital

Department of Surgery: SIUH

Objectives
Magnitude of trauma as a health issue Current and future prehospital care Emergent assessment Current resuscitation issues Evolution of approach to TBI Current controversies in evaluation Illustrative case presentation

Department of Surgery: SIUH 2

Current Statistics*

2.7 million Americans are injured annually 146,000 deaths Trauma is the 3rd leading cause of death for all ages in the U.S. Most common cause age-group 1-44
35% 30% 25% 20% 15% 10% 5% 0% MVC Suicide Homicide Other 28% 21% 18% 34%

Department of Surgery: SIUH

*Data from CDC and National Center for Injury Prevention

Prehospital Care:
EMS is the tip of the spear

Principle of scoop and run has been firmly established for the trauma patient
save as much of the golden hour as possible

In-route interventions are controversial

airway management Access (if possible)/volume (No)

Technology should decrease event-arrival time

Automatic Crash Notification technology GPS-based location/guidance systems

Department of Surgery: SIUH

Emergency Room Assessment Guided by Advanced Trauma Life Support

Primary Survey
Airway (c-spine precautions), Breathing, Circulation, Disability, and Exposure (avoid hypothermia) Life-saving interventions carried out

Secondary Survey:
Rapid, complete head to toe evaluation - finger and/or tube in every orifice Diagnostic studies obtained

Definitive Treatment or Transfer

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Department of Surgery: SIUH

Issues in Initial Resuscitation

When Should We Resuscitate? How Should We Resuscitate? What Constitutes Successful resuscitation?

Department of Surgery: SIUH

When Should We Resuscitate?

Conflicting Data

ATLS teaches immediate attempts at normalization of vital signs 1917 Cannon questions resuscitation prior to control of hemorrhage. Prehospital data suggests transport more important than resuscitation attempts Emerging data again raise the issue of resuscitation prior to definitive control of hemorrhage.

Department of Surgery: SIUH

How Should We Resuscitate?

Blood, colloid, crystalloid

Shires work in 1960s and 70s

Blood plus crystalloid more effective than blood alone

Volume replacement with non-blood colloid not superior to crystalloid

Dextran, Hetastarch, Albumin

Hypertonic Saline
Mixed results from recent studies Hypertonic saline should be considered in head injury

Blood Substitutes
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Department of Surgery: SIUH

Iraq

IEDs (improvised explosive devices)

Delayed resuscitation Aggressive resuscitation of the coagulation system Minimize extraction definitive care Acitvated clotting factors

Department of Surgery: SIUH

Endpoints of Resuscitation
How do we know what is enough?

Traditional Clinical Parameters

Vital Signs, Urine Output, Mental Status

Invasive Hemodynamic Parameters:

CVP, Pulmonary Artery Pressures, Wedge Cardiac Index, O2 Delivery and Consumption

Metabolic Parameters - global perfusion

Base deficit and serum lactate

Organ Specific Parameters

Gastric and rectal tonometry

Department of Surgery: SIUH

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Resuscitation Summary

Ongoing controversies:
blood substitutes Activated clotting factor hypertonic saline delayed resuscitation permissive hypothermia optimal endpoints organ-specific resuscitation

Current Practice:
Prompt resuscitation Combination of crystalloid/blood Utilize combination of vital signs, interventional metabolic, and organ perfusion parameters to establish endpoints

Department of Surgery: SIUH

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Traumatic Brain Injury (TBI)

Shifting paradigms TBI accounts for the vast majority of blunt trauma mortality in the US The human, economic, and productivity costs are staggering Traditional approach focused on ICP Current thinking:

10 vs. 20 injury Balance between lowering ICP and maintaining perfusion (CPP)
Department of Surgery: SIUH 12

Current Approach to Emergent Management of TBI

10 concern ABCs Early CT scanning to delineate injury Prompt operative intervention Liberal use of ICP monitoring devices Maintain overall perfusion while minimizing ICP (CPP helpful) Hyperventilation only to avoid herniation no steroids

Department of Surgery: SIUH 13

Rapid Evaluation of the Abdomen in Blunt Trauma

Focused Abdominal Sonography in Trauma, FAST CT Scans (multidetector, helical) Diagnostic Peritoneal Lavage

Department of Surgery: SIUH

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FAST Technique
Focused Abdominal Sonography in Trauma

Rapidly evaluate for blood in RUQ, LUQ, pelvis, and pericardium Immediate, low cost Operator dependent Questionable accuracy Training and credentialing issues

Department of Surgery: SIUH

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Computed Tomography

Excellent accuracy for solid organ injury and free fluid in abdomen Images the retroperitoneum well Allows accurate serial exams

Costly Requires use of IV contrast material Usually involves patient transport Time consuming (Multi-detector?) Requires stability

Department of Surgery: SIUH

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Diagnostic Peritoneal Lavage

Is it an anarchonism?

Highly sensitive for Intra-abdominal pathology Relatively rapid Immediately available

Too sensitive? Invasive potential for iatrogenic injury Does not evaluate retroperitoneum

Department of Surgery: SIUH

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Blunt Abdominal Trauma

Peritoneal signs
No/unknown yes

O.R.
1

Stable CT or observation

Marginal Resuscitate?

Unstable
2

Resuscitate? FAST/DPL +

CT

Stable

Marginal

CT/Angio/Ex-fix

Department of Surgery: SIUH

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Rapid Assessment of Traumatic Aortic Injury (TAI)

When suspicion of TAI exists, diagnostic modalities include:

Aortogram Transesophageal echocardiography Helical (dynamic) ct scanning

Department of Surgery: SIUH

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TEE, CT, or Angio in TAI?

Aortography: Most studied

Best specificity, excellent sensitivity Most cost, most time, most contrast Helical CT: Well studied Best sensitivity, good specificity Mid-cost, mid-time (?), mid-contrast TEE: Least studied Mid-sensitivity, excellent specificity Lower cost, fast, no contrast, esophageal intubation
Department of Surgery: SIUH 20

One Approach to TAI

Suspicious Mechanism CXR No suspicious findings At least one finding or very suggestive mechanism Not going to OR Aortogram Department of Surgery: SIUH

Going to OR TEE

Chest CT No aortic injury

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Extremity Vascular Injury (EVI)

Injuries to the peripheral arterial system are relatively common

Blunt and penetrating mechanisms Time sensitive delay can lead to limb loss

Diagnosis & Management have evolved significantly

Mandatory exploration prevailed until 1970s Angiography for equivocal or soft signs 1980 More recently proximity questioned as indication for angiography Most recently, color flow doppler/duplex exams substitute for arteriography and stenting injuries is on the immediate horizon.

Department of Surgery: SIUH

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One Algorithm for EVI

Patient w/potential vascular injury: resuscitate and evaluate

Soft signs +/- proximity Hard Signs Duplex + or API <0.9 Duplex - or API > 0.9

Proximity

Arteriogram
If + If -

Operative Exploration
Department of Surgery: SIUH

Observation

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Case Presentation
38 year old man pinned under a steel I-beam that fell on his lower abdomen from a 10ft height. Patient presented somewhat confused with a SBP of 90 mildly tachycardic. He became oriented and blood pressure improved with 2L crystalloid resuscitation. His 20 survey revealed a clinically unstable pelvis which pelvic films subsequently confirmed as open book fracture. His abdomen was distended and mildly tender. Immediate FAST evaluation revealed the presence of free fluid. He was taken to the operating room where a large segment of small bowel was resected as well as the sigmoid colon. A large pelvic hematoma was identified and external fixation of the pelvis carried out.
Department of Surgery: SIUH 24

Case presentation continued.

He was subsequently taken from the OR to angiography where embolization of a number of hypogastric branches on the right side was carried out. The patient went on to make a rapid recovery. He subsequently underwent a complex pelvic reconstruction and a colostomy closure.

Department of Surgery: SIUH

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Questions

Department of Surgery: SIUH

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