CHAPTER 21
Trauma
Test Taking Tips
• Historically, there is always a question that tests your priorities in caring for the trauma patient. Do not get sidetracked! It is always primary survey with airway, breathing, and circulation.
• Know how to calculate the Glasgow coma scale (GCS) score.
INITIAL MANAGEMENT
When does the first mortality peak for trauma occur?
Within seconds to minutes after injury
The trauma system and acute patient care has the greatest impact on patients in which mortality peak for trauma?
Second mortality peak (golden hour)
Most of the deaths during the second mortality peak for trauma occur from?
Hemorrhage, central nervous system injuries
When does the third mortality peak for trauma occur?
24 hours after injury, from multisystem organ failure and sepsis
How long should the primary survey in the initial evaluation of a trauma patient take?
No more than 5 minutes, unless an intervention is needed.
What mnemonic is used to conduct the primary survey?
ABCDE: Airway, Breathing, Circulation, Disability, Exposure
What are the goals during airway assessment?
Secure the airway, protect the spinal cord
What is required for spinal immobilization?
A rigid cervical collar, use of a full backboard
Contraindications to nasotracheal intubation:
Apnea, maxillofacial fracture
What is the quickest way to test for an adequate airway in an awake, alert patient?
Ask a question, if the patient is able to speak the airway is intact.
Indications for a surgical airway:
Anatomic distortion as a result of neck injury, massive maxillofacial trauma, inability to visualize the vocal cords (blood, secretions, airway edema)
What are the goals during the breathing assessment?
Secure oxygenation and ventilation; treat life-threatening thoracic injuries
What should be done on physical examination to adequately assess breathing?
Inspection (air movement, cyanosis, tracheal shift, JVD, respiratory rate, asymmetric chest expansion, open chest wounds, use of accessory muscles of respiration)
Auscultation/percussion (hyperresonance or dullness over lung fields)
Palpation (flail segments, subcutaneous emphysema)
What life-threatening conditions must be treated during the breathing assessment if encountered?
Open pneumothorax, tension pneumothorax, massive hemothorax
What is the most common cause for upper airway obstruction?
The tongue
What is the preferred emergency airway procedure?
Cricothyroidotomy
In a patient with poor peripheral upper extremity access, what alternative routes can be considered for intravenous access?
Femoral vein at the groin, venous cutdown on greater saphenous vein at the ankle, subclavian vein, IJ
What are the goals of the circulation assessment?
Treatment of bleeding, assuring adequate tissue perfusion
What is the initial test for adequate circulation?
Palpation of pulses
What systolic blood pressure are you expecting with a palpable radial pulse?
80 mm Hg
What systolic blood pressure are you expecting with a palpable femoral/carotid pulse?
At least 60 mm Hg
What should be done of physical examination to adequately assess circulation?
Obtain heart rate and blood pressure; check peripheral perfusion and capillary refill, mental status; examine the skin
Which patients may not demonstrate tachycardia with hypovolemic shock?
Patients on beta-blockers, well-conditioned athletes, patients with concomitant spinal cord injury
During femoral catheter placement, what is the pneumonic used to remember the anatomy of the groin?
NAVEL (from lateral to medial): Nerve, Artery, Vein, Extralymphatic space, Lymphatics
What is the preferred alternative route if intravenous access cannot be obtained on a small child?
Intraosseous tibial plateau
What are the goals of the disability assessment?
Determination of neurologic injury
What should be performed during the physical examination for an adequate assessment of disability?
Mental status (GCS), pupils for size, appearance, and reactivity, motor/sensory examination for lateralizing extremity movement and sensory deficits
What are the goals during the exposure portion of the primary survey?
Completely disrobe patient and thoroughly inspect and evaluate the patient; keep patient in warm environment.
What 3 elements are measured with the GCS?
Eye opening, best verbal response, best motor response
What does a GCS score with a T signify?
Patient is intubated
What is the highest GCS an intubated patient can have?
4 (eye) + 1 (verbal) + 6 (movement) = 11, GCS 11t
What is the secondary survey?
A complete physical examination, obtain labs and x-rays, place additional lines, tube (foley, ngt), and monitoring devices
When should the tertiary examination be performed?
Another complete head-to-toe physical examination should be performed 12 to 24 hours after the initial trauma and should be aimed at identifying injuries missed during the primary and secondary surveys.
NEURO/SPINE
What are the typical signs of a basilar skull fracture?
Raccoon eyes, Battle sign, clear otorrhea or rhinorrhea, hemotympanum
What is the “halo” sign?
A halo of clear fluid around drainage from nose and ears, representing basilar skull fracture with CSF leakage.
What conditions must be present before a cervical spine can be cleared by physical examination?
No neck pain on palpation or full range of motion without neurologic injury, no ethanol/drug intoxication, no distracting injury, no pain medications
What vertebral bodies must be seen on lateral cervical spine film for adequate evaluation?
C1 to T1
What view on x-ray can help visualize C7 to T1?
Swimmer view
What imaging studies evaluate cervical spine ligamentous injury?
Lateral flexion and extension c-spine films, MRI of c-spine
What is primary brain injury?
Anatomic and physiologic disruption that occurs as a direct result of external trauma
Hypotension and hypoxemia, which can lead to secondary brain injury
What is the Monro-Kellie doctrine?
The doctrine states that the volume inside the cranium is a fixed volume and that the cranial compartment is incompressible.
Blood, CSF, and brain are in a state of volume equilibrium and any increase in volume of one of the cranial constituents is compensated for by a decrease in the volume of another.
How do you calculate the cerebral perfusion pressure (CPP)?
Mean arterial pressure (MAP)—Intracranial pressure (ICP)
What signs of elevated ICP can be seen on imaging studies?
Decrease in ventricular size, loss of sulci, loss of cisterns, midline shift, herniation
Indications for ICP monitoring:
GCS <8
Patient with moderate to severe head injury and inability to follow clinical examination
Suspicion of elevated ICP
What is the normal ICP?
10
What ICP requires treatment?
20
What CPP is desired in a head injured patient?
CPP >60
How is serum osmolarity adjusted in head injured patients?
3% NSS or Mannitol
When do the peak ICPs occur after injury?
48 to 72 hours after injury
What does a unilateral dilated pupil in a head injured patient signify?
Uncal herniation with compression of cranial nerve III
What GCS score indicates moderate head injury?
9> GCS <12
What GCS score indicates severe head injury?
GCS <8
Which component of the GCS is the most predictive of serious anatomic injury to the brain and correlates most strongly with outcome?
The motor component
What does a score of 0 on assessment of motor strength signify?
No contraction of muscle
What does a score of 1 on assessment of motor strength signify?
Palpable muscle contraction without limb movement
What does a score of 2 on assessment of motor strength signify?
Able to move in a gravity-neutral plane
What does a score of 3 on assessment of motor strength signify?
Able to move against gravity
What does a score of 4 on assessment of motor strength signify?
Diminished strength
What does a score of 5 on assessment of motor strength signify?
Normal strength
Table 21-1 Motor Examination
What artery is usually responsible for an epidural hematoma?
Middle meningeal artery
What kind of deformity is seen on CT head with an epidural hematoma?
Lenticular (lens-shaped) deformity
What kind of head injury is associated with a lucid interval?
Epidural hematoma
How many mm of shift on CT head is considered significant mass effect?
5 mm
How does a subdural hematoma most commonly occur?
Bridging veins between the dura and arachnoid are torn
What kind of deformity is seen on CT head with a subdural hematoma?
Crescent-shaped deformity
What are indications for drainage of a chronic subdural hematoma?
Significant symptoms, large size
Where do intracerebral hematomas usually occur?
Frontal or temporal lobes
What is the most common site of facial nerve injury with a temporal skull fracture?
Geniculate ganglion
Indications for operative intervention in a patient with skull fracture:
Significant depression (8–10 mm), contaminated, persistent CSF leak not responding to conservative management
What is central cord syndrome?
Hyperflexion or hyperextension of the neck leads to interference with blood flow in the spinal arteries leading to motor weakness and sensory loss primarily affecting the distal muscles of the upper extremities.
What is Brown-Séquard syndrome?
Partial transection of the spinal cord, which results in loss of ipsilateral motor function and loss of contralateral sensory function.
What are the 3 columns of the spinal column?
Anterior spinal ligament/anterior walls of the vertebral bodies, posterior spinal ligament/posterior walls of the vertebral bodies, posterior elements of the vertebral column (facet joints, lamina, spinous processes, interspinous ligaments)
How many columns need to be involved for a spinal column injury to be considered unstable?
≥2 columns
How are stable spinal column injuries treated?
Immobilization (collar for cervical spine, molded jacket for thoracic and lumbar spine)
How are unstable spinal column injuries treated?
Surgical stabilization (placement of hardware posteriorly, use of hardware and bone grafting anteriorly, both techniques simultaneously (3-column injury)
If within a few hours of injury: bolus with 30 mg/kg of methylprednisolone over a 1-hour period, followed by 5.4 mg/kg/h for next 23 hours.
If injury is greater than 3 hours old but less than 8 hours old continue the steroids for a total of 48 hours—controversial and no longer recommended by ATLS.
What is the eponym for a C1 burst fracture?
Jefferson fracture
What is a type I odontoid fracture?
A stable fracture that occurs above the base
What is a type II odontoid fracture?
An unstable fracture that involves the base that is treated with immobilization or fusion
What is a type III odontoid fracture?
Fracture extends into the vertebral body that is treated with immobilization or fusion
What is known as SCIWORA?
Spinal Cord Injury Without Radiologic Abnormality—usually transient motor/sensory symptoms attributable to spinal cord distribution but without injury noted by x-ray, CT scan, or MRI.
What study should be obtained in patients without bony injury to the spine with neurologic deficits?
MRI, look for ligamentous injury
HEAD AND NECK
What is the #1 indicator of mandibular injury?
Malocclusion
What injury is not to be missed during examination of nose?
Septal hematoma
Where are the major vascular and aerodigestive structures in the neck, in the anterior triangle or the posterior triangle?
Anterior triangle
Which zone of the neck extends from the sternal notch to the cricoid cartilage?
Zone I
Which zone of the neck extends from the cricoid cartilage to the angle of the mandible?
Zone II
Which zone of the neck extends from the angle of the mandible to the base of the skull?
Zone III
What are the clinical indications for neck exploration with neck trauma?
Airway: dysphonia/voice changes, hemoptysis, hoarseness, stridor, subcutaneous air
Digestive tract: blood in oropharynx, dysphagia/odynophagia, subcutaneous air
Neurologic: altered state of consciousness not caused by head injury, lateralized neurologic deficit consistent with injury
Vascular: diminished carotid pulse, expanding hematoma, external hemorrhage
FIGURE 21-1. Anatomic zones of the neck: anterior view. (Reproduced from Feliciano DV, Mattox KL, Moore EE. Trauma. 6th ed. http://accesssurgery.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
What is the most commonly injured vascular structure in the neck?
Internal jugular vein
How should you treat an actively bleeding unstable patient with a penetrating neck injury?
Take immediately to operating room for neck exploration
How would you manage an asymptomatic patient with a penetrating injury to the base of the neck (zone I)?
CT neck/chest or 4-vessel arch angiography; bronchoscopy; rigid esophagoscopy; barium swallow
How would you manage an asymptomatic patient with a penetrating midcervical injury (zone II)?
Neck exploration
An acceptable alternative is 4-vessel angiography, bronchoscopy, esophagoscopy, and barium swallow.
How would you manage an asymptomatic patient with a penetrating injury above the angle of the mandible (zone III)?
CT neck, 4-vessel arch angiography, laryngoscopy, rigid esophagoscopy, barium swallow
In a patient with an expanding neck hematoma, how do you perform a safe exploration of an anatomically hostile neck?
Follow the “trail of safety”: make a standard cervical incision along the anterior border of the sternocleidomastoid muscle, divide the platysma, identify the anterior border of the sternocleidomastoid muscle (first key structure), dissect and identify the internal jugular vein (second key structure), dissect along the anterior border of the internal jugular vein until you find the facial vein (marks the carotid bifurcation), ligate and divide the facial vein to gain access to the carotid bifurcation.
During a neck exploration for neck trauma, you encounter an injury to the internal carotid artery, how would you repair the artery?
Debridement and primary repair if possible.
If primary repair not possible because of loss of length perform a bypass with a short interposition graft (PTFE).
Ligate the common carotid artery (same goes for internal carotid and external carotid arteries), approximately 50% stroke rate, high mortality.
What methods have been described to control bleeding from the distal stump of an injured internal carotid artery at the base of the neck?
Interventional angiography, place balloon catheter through the missile tract and tamponade bleeding, ligate and divide the internal carotid artery at the carotid bifurcation, and remove the balloon 3 days later, insert a balloon catheter into the distal stump of the internal carotid, and clip and cut the catheter, leaving the balloon inside the artery.
What would you do if during a neck exploration for trauma, you encountered hemorrhage emanating from a hole between the transverse processes of the cervical vertebrae, posterolateral to the carotid sheath?
Tightly fill the bleeding hole in the transverse process with bone wax.
What are the typical mechanisms for blunt traumatic injury to the carotid/vertebral arteries?
Direct blow to neck, hyperextension with contralateral neck rotation
What is the clinical hallmark of blunt carotid artery injury?
Hemispheric neurologic deficit that is incompatible with CT findings
What is the treatment of blunt carotid/vertebral artery injury?
Antiplatelet agents for low-grade injuries.
Systemic anticoagulation for higher-grade injuries (if not prohibited by associated injuries).
Consider endovascular techniques for inaccessible pseudoaneurysm or hemodynamically significant dissection or inaccessible pseudoaneurysm but controversial.
What percentage of asymptomatic minimal arterial injuries (small false aneurysms, and small arteriovenous fistulas, nonocclusive intimal flaps, segmental arterial narrowing) progress to require surgical or endovascular repair?
~10%
How should initial control of hemorrhage be obtained?
Direct pressure over bleeding site with digital or manual compression
Under what 3 clinical situations can a temporary intraluminal shunt be used to maintain distal perfusion through an injured artery?
Situations where skeletal alignment is accomplished before vascular repair in an ischemic limb in a patient with combined vascular and orthopedic extremity injuries.
Transport of a patient from the field/remote facility with a peripheral arterial injury for vascular reconstruction at a trauma center.
Damage control technique in a critically injured patient unlikely to survive a complex repair because of exhausted physiologic reserve.
Using damage control techniques for vascular injuries, how is hemorrhage control and distal perfusion maintained?
Hemorrhage is controlled with balloon tamponade or ligation.
Distal perfusion is maintained with temporary intra-arterial shunt.
FIGURE 21-2. LeFort classification of maxillary fractures. (Reproduced from Feliciano DV, Mattox KL, Moore EE. Trauma. 6th ed. http://accesssurgery.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
How would you repair a simple laceration to the trachea?
Debridement and primary repair with absorbable suture.
If loss of more than 2 tracheal rings, may require tracheostomy/complex reconstructive procedures.
How would you repair a laryngeal injury?
Closure of mucosal lacerations and reduction of cartilaginous fractures
How would you manage a facial fracture with significant hemorrhage?
Secure the airway, obtain initial control with anterior and posterior nasal packing and direct packing of the oropharynx, then proceed to angiography and selective embolization versus ligation of external carotid artery.
When should sutures be removed from the face to prevent cross-hatching of the scar?
~3 days
What elements should be obtained with a functional eye examination?
Visual acuity; pupillary response; assessment of extraocular eye movements, globe pressure (palpation or tonopen)
What procedure is performed if high intraocular pressure due to retrobulbar hematoma?
Lateral canthotomy
CHEST
What is the major morbidity and mortality associated with esophageal injuries?
Delay in diagnosis
Describe how you would repair a traumatic esophageal perforation found in the upper two-thirds of the esophagus <24 hours old?
Perform right thoracotomy, debride nonviable tissue, perform myotomy to define extent of mucosal injury, close in 2 layers over a nasogastric tube, cover repair with tissue flap (pleural/pericardial/intercostal muscle), place a chest tube (consider J tube), keep patient NPO and on TPN or feeds through J tube, and on IV antibiotics.
Describe how you would repair a traumatic esophageal perforation found in the lower one-third of the esophagus <24 hours old?
Perform left thoracotomy, debride nonviable tissue, perform myotomy to define extent of mucosal injury, close in 2 layers over a nasogastric tube, cover repair with Thal patch/diaphragm/or fundoplication, place a chest tube (consider J tube), keep patient NPO and on TPN or feeds through J tube, and on IV antibiotics.
How you would manage a traumatic esophageal perforation in an unstable patient >24 hours old?
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