1st peak for trauma deaths (0–30 minutes) – deaths due to lacerations of heart, aorta, brain, brainstem, or spinal cord; cannot really save these patients; death is too quick

  2nd peak for trauma deaths (30 minutes–4 hours) – deaths due to head injury (#1) and hemorrhage (#2); these patients can be saved with rapid assessment (golden hour)

  3rd peak for trauma deaths (days to weeks) – deaths due to multisystem organ failure and sepsis

  Blunt injury – 80% of all trauma; liver most commonly injured (some texts say spleen)

•  Kinetic energy = ½ MV², where M = mass, V = velocity

•  Falls – age and body orientation biggest predictors of survival. LD₅₀ is 4 stories

  Penetrating injury – small bowel most commonly injured (some texts say liver)

  Hemorrhage – most common cause of death in 1st hour

•  Blood pressure is usually OK until 30% of total blood volume is lost

•  Resuscitate with 2 L Lactated Ringers, then switch to blood

  Head injury – most common cause of death after reaching the ER alive

  Infection – most common cause of death in the long term

  Tongue – most common cause of upper airway obstruction → perform jaw thrust

  Seat belts – small bowel perforations, lumbar spine fractures, sternal fractures

  Saphenous vein at ankle – best site for cutdown for venous access

  Diagnostic peritoneal lavage (DPL)

•  Used in hypotensive patients with blunt trauma

•  Positive if > 10 cc blood, > 100,000 RBCs/cc, food particles, bile, bacteria, > 500 WBC/cc

•  Need laparotomy if DPL is positive

•  DPL needs to be supraumbilical if pelvic fracture present

•  DPL misses – retroperitoneal bleeds, contained hematomas

  FAST scan (focused abdominal sonography for trauma)

•  Ultrasound scan used in lieu of DPL

•  Checks for blood in perihepatic fossa, perisplenic fossa, pelvis, and pericardium

•  Examiner dependent

•  Obesity can obstruct view

•  May not detect free fluid < 50–80 mL

•  Need laparotomy if FAST scan is positive

•  FAST scan misses – retroperitoneal bleeding, hollow viscous injury

  In hypotensive patients with a negative FAST scan (or negative DPL) you need to find the source of bleeding (pelvic fracture, chest, or extremity)

  Need a CT scan following blunt trauma in patients with abdominal pain, need for general anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, or hematuria

•  Patients requiring DPL that turned out negative will need an abdominal CT scan

•  CT scan misses – hollow viscous injury, diaphragm injury

  Need laparotomy with peritonitis, evisceration, positive DPL, uncontrolled visceral hemorrhage, free air, diaphragm injury, intraperitoneal bladder injury, contrast extravasation from hollow viscus, specific renal, pancreas, and biliary tract injuries

  Penetrating abdominal injury (eg GSW) – generally need laparotomy

  Possible penetrating abdominal injuries (knife or low-velocity injuries) – local exploration and observation if fascia not violated

  Abdominal compartment syndrome

•  Occurs after massive fluid resuscitation, trauma, or abdominal surgery

•  Bladder pressure > 25–30 suggests compartment syndrome

•  IVC compression is the final common pathway for decreased cardiac output

•  Low cardiac output causes visceral and renal malperfusion (↓ urine output)

•  Upward displacement of diaphragm affects ventilation

•  Tx: decompressive laparotomy

  Pneumatic antishock garment – controversial; use in patients with SBP < 50 and no thoracic injury. Release compartments one at a time after reaching ER

  ER thoracotomy

•  Blunt trauma – use only if pressure/pulse lost in ER

•  Penetrating trauma – use only if pressure/pulse lost on way to ER or in ER

•  Thoracotomy – open pericardium anterior to the phrenic nerve, cross-clamp the aorta, watch for the esophagus (anterior to the aorta)

  Catecholamines – peak 24–48 hours after injury

  ADH, ACTH, and glucagon – also ↑ after trauma (fight or flight response)

BLOOD TRANSFUSION

  Type O blood (universal donor) – contains no A or B antigens; males can receive Rh-positive blood; females who are prepubescent or of childbearing age should receive Rh-negative blood

  Type-specific blood (nonscreened, non–cross-matched) – can be administered relatively safely, but there may be effects from antibodies to HLA minor antigens in the donated blood

HEAD INJURY

  Glasgow Coma Scale (GCS)

•  Motor

•  6 – follows commands

•  5 – localizes pain

•  4 – withdraws from pain

•  3 – flexion with pain (decorticate)

•  2 – extension with pain (decerebrate)

•  1 – no response

•  Verbal

•  5 – oriented

•  4 – confused

•  3 – inappropriate words

•  2 – incomprehensible sounds

•  1 – no response

•  Eye opening

•  4 – spontaneous opening

•  3 – opens to command

•  2 – opens to pain

•  1 – no response

  GCS score – ≤ 14: head CT; ≤ 10: intubation; ≤ 8: ICP monitor

  Epidural hematoma – most commonly due to arterial bleeding from the middle meningeal artery

•  Head CT – shows lenticular (lens-shaped) deformity

•  Patients often have loss of consciousness (LOC) → then lucid interval → then sudden deterioration (vomiting, restlessness, LOC)

•  Operate for significant neurologic degeneration or significant mass effect (shift > 5 mm)

  Subdural hematoma – most commonly from tearing of venous plexus (bridging veins) that cross between the dura and arachnoid

•  Head CT – shows crescent-shaped deformity

•  Operate for significant neurologic degeneration or mass effect (> 1 cm)

•  Chronic subdural hematomas – usually in elderly after minor fall

  Intracerebral hematoma – usually frontal or temporal

•  Can cause significant mass effect requiring operation

  Cerebral contusions – can be coup or contrecoup

  Traumatic intraventricular hemorrhage – need ventriculostomy if causing hydrocephalus

  Diffuse axonal injury – shows up better on MRI than CT scan

•  Tx: supportive; may need craniectomy if ICP elevated

•  Very poor prognosis

  Cerebral perfusion pressure (CPP = MAP − ICP)

•  CPP = mean arterial pressure (MAP) minus intracranial pressure (ICP)

•  Signs of elevated ICP – ↓ ventricular size, loss of sulci, loss of cisterns

•  ICP monitors – indicated for GCS ≤ 8, suspected ↑ ICP, or patient with moderate to severe head injury and inability to follow clinical exam (eg is intubated)

•  Supportive treatment for elevated ICP

•  Normal ICP is 10; > 20 needs treatment

•  Want CPP > 60

• Sedation and paralysis

• Raise head of bed

• Relative hyperventilation for modest cerebral vasoconstriction (CO₂ 30–35); do not want to over-hyperventilate and cause cerebral ischemia from too much vasoconstriction

• Keep Na 140–150, serum Osm 295–310 – may need to use hypertonic saline at times (draws fluid out of brain)

• Mannitol – load 1 g/kg, give 0.25 mg/kg q4h after that (draws fluid from brain)

• Barbiturate coma – consider if above not working

• Ventriculostomy w/ CSF drainage (keep ICP < 20)

• Craniotomy decompression – if not able to get ICP down medically (can also perform Burr hole)

• Fosphenytoin or Keppra – can be given prophylactically to prevent seizures with moderate to severe head injury

• Peak ICP – occurs 48–72 hours after injury

• Dilated pupil – temporal pressure on the same side (CN III, oculomotor, compression)

  Basal skull fractures

•  Raccoon eyes (peri-orbital ecchymosis) – anterior fossa fracture

•  Battle’s sign (mastoid ecchymosis) – middle fossa fracture; can injure facial nerve (CN VII)

•  If acute facial nerve injury, need exploration and repair

•  If delayed, likely secondary to edema and exploration not needed

•  Can also have hemotympanum and CSF rhinorrhea/otorrhea with basal skull fractures

  Temporal skull fractures – can injure CN VII and VIII (vestibulocochlear nerve)

•  Most common site of facial nerve injury – geniculate ganglion

•  Temporal skull fractures most commonly associated with lateral skull or orbital blows

  Most skull fractures do not require surgical treatment

•  Operate if significantly depressed (> 1 cm), contaminated, or persistent CSF leak not responding to conservative therapy

  CSF leaks after skull fracture – treat expectantly; can use lumbar CSF drainage if persistent

  Coagulopathy with traumatic brain injury – due to release of tissue factor

SPINE TRAUMA

  Cervical spine

•  C-1 burst (Jefferson fracture) – caused by axial loading

•  Tx: rigid collar

•  C-2 hangman’s fracture – caused by distraction and extension

•  Tx: traction and halo

•  C-2 odontoid fracture

•  Type I – above base, stable

•  Type II – at base, unstable (will need fusion or halo)

•  Type III – extends into vertebral body (will need fusion or halo)

•  Facet fractures or dislocations – can cause cord injury; usually associated with hyperextension and rotation with ligamentous disruption

  Thoracolumbar spine

•  3 columns of the thoracolumbar spine:

•  Anterior – anterior longitudinal ligament and anterior ½ of the vertebral body

•  Middle – posterior ½ of the vertebral body and posterior longitudinal ligament

•  Posterior – facet joints, lamina, spinous processes, interspinous ligament

•  If more than 1 column is disrupted, the spine is considered unstable

•  Compression (wedge) fractures usually involve the anterior column only and are considered stable

•  Burst fractures are considered unstable (> 1 column) and require spinal fusion

•  Upright fall – at risk for calcaneus, lumbar, and wrist/forearm fractures

  Need MRI for neurologic deficits without bony injury to check for ligamentous injury

  Indications for emergent surgical spine decompression

•  Fracture or dislocation not reducible with distraction

•  Open fractures

•  Soft tissue or bony compression of the cord

•  Progressive neurologic dysfunction

MAXILLOFACIAL TRAUMA

  Fracture of temporal bone is the most common cause of facial nerve injury

  Try to preserve skin and not trim edges with facial lacerations

  Nasoethmoidal orbital fractures – 70% have a CSF leak

•  Conservative therapy for up to 2 weeks

•  Can try epidural catheter to ↓ CSF pressure and help it close CSF leak

•  May need surgical closure of dura to stop leak

  Nosebleeds

•  Anterior – packing

•  Posterior – can be hard to deal with; try balloon tamponade 1st

•  May need angioembolization of internal maxillary artery or ethmoidal artery

  Orbital blowout fractures – patients with impaired upward gaze or diplopia with upward vision need repair; perform restoration of orbital floor with bone fragments or bone graft

  Mandibular injury – malocclusion #1 indicator of injury

•  Diagnosis – fine-cut facial CT scans with reconstruction to assess injury

•  Most repaired with IMF (metal arch bars to upper and lower dental arches, 6–8 weeks) or open reduction and internal fixation (ORIF)

  Tripod fracture (zygomatic bone) – ORIF for cosmesis

  Patients w/ maxillofacial fractures are at high risk for cervical spine injuries

NECK TRAUMA

  Asymptomatic blunt – neck CT scan

  Asymptomatic penetrating – controversial; most common method below

  Symptomatic blunt or penetrating neck trauma – shock, bleeding, expanding hematoma, losing or lost airway, subcutaneous air, stridor, dysphagia, hemoptysis, neurologic deficit → all need neck exploration

  Esophageal injury

•  Hardest neck injury to find

•  Esophagoscopy and esophagogram – best combined modality (find essentially 95% of injuries when using both methods)

•  Contained injuries – can be observed

•  Noncontained injuries:

•  If small injury and minimal contamination → primary closure

•  If extensive injury or contamination →

Neck esophageal injuries – just place drains (will heal)

Chest esophageal injuries – chest tubes to drain injury and place spit fistula in neck (will eventually need esophagectomy)

•  Always drain esophageal and hypopharyngeal repairs – 20% leak rate

•  Approach to esophageal injuries

•  Neck – left side

•  Upper ⅔ of thoracic esophagus – right thoracotomy

•  Lower ⅓ of thoracic esophagus – left thoracotomy

  Laryngeal fracture and tracheal injuries

•  These are airway emergencies

•  Symptoms: crepitus, stridor, respiratory compromise

•  Need to secure airway emergently in ER (cricothyroidotomy usual)

•  Tx: primary repair, can use strap muscle for airway support; tracheostomy necessary for most to allow edema to subside and to check for stricture (need to convert cricothyroidotomy to tracheostomy)

  Thyroid gland injuries – control bleeding and drain (not thyroidectomy)

  Recurrent laryngeal nerve injury – can try to repair or can reimplant in cricoarytenoid muscle (Sx – hoarseness)

  Shotgun injures to neck – need angiogram and neck CT; esophagus/trachea evaluation

  Vertebral artery bleeds – can embolize or ligate without sequela in majority

  Common carotid bleeds – ligation will cause stroke in 20%

CHEST TRAUMA

  Chest tube

•  > 1,500 cc after initial insertion, > 250 cc/h for 3 hours, > 2,500 cc/24 h, or bleeding with instability → all relative indications for thoracotomy in OR

•  Need to drain all of the blood (in < 48 hours) to prevent fibrothorax, pulmonary entrapment, infected hemothorax

•  Unresolved hemothorax after 2 well-placed chest tubes → thoracoscopic drainage

  Sucking chest wound (open pneumothorax)

•  Needs to be at least ^⅔ the diameter of the trachea to be significant

•  Cover wound with dressing that has tape on three sides → prevents development of tension pneumothorax while allowing lung to expand with inspiration

  Tracheobronchial injury

•  Patient may have worse oxygenation after chest tube placement

•  One of the very few indications in which clamping the chest tube may be indicated

•  Bronchus injuries are more common on the right

•  May need to mainstem intubate patient on unaffected side

•  Dx: bronchoscopy

•  Tx: repair if large air leak and respiratory compromise or after 2 weeks of persistent air leak

•  Right thoracotomy for right mainstem, trachea, and proximal left mainstem injuries (avoids the aorta)

•  Left thoracotomy for distal left mainstem injuries

  Esophageal injury – see section “Neck Trauma”

  Diaphragm

•  Injuries are more likely to be found on left and to result from blunt trauma

•  CXR – see air–fluid level in chest from stomach herniation through hole (diagnosis can be made essentially with CXR)

•  Transabdominal approach if < 1 week

•  Chest approach if > 1 week (need to take down adhesions in the chest)

•  May need mesh

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