LECTURE SCRIPT

TRAUMA
Captain L. Albert Villarin, Jr, MD, US Army
Darnall Army Community Hospital


Trauma by definition is the damage of the human body by external means. In this lecture, I will discuss the major points of this important facet of knowledge for emergency physicians.

As with any initial evaluation of a patient one must assess whether the airway is intact. This must be performed while maintaining c-spine immobilization to prevent cervical injury. A speaking patient tells you that the airway is patent and the patient is awake. If the contrary is the case, then perform a chin lift and jaw thrust. Immediate visualization by laryngoscope for foreign body or body fluids must be performed. One must assume c-spine injury If there is any supraclavicular trauma. Application of a c-collar should be completed by EMS or as soon as possible in the ED.

Trauma to the cervical spine manifests itself in several forms. Depending upon the direction of force upon the head, one may determine the classification of cervical spine fracture. There are seven specific types of force. Flexion forces, which cause anterior subluxation, bilateral interfacetal, simple wedge(compression), clay-shoveler and teardrop fractures are associated with anterior compression vertebral laminar injuries. Flexion-rotation forces cause unilateral interfacetal dislocations. Extension-rotation create pillar fractures. Vertical (Axial) forces produce atlas (Jefferson) burst fractures. Hyperextension forces produce dislocations, avulsions, teardrops, and traumatic spondylolisthesis (hangman's fx). Uncinate process fractures are caused by lateral flexion forces.

Shows a scale of stability cervical fractures. Note that the more common fractures are also the more stable.

Depicts the important parameters to remember when reviewing a cervical spine film. Prevertebral soft tissue at the level of C3 to C4 should be less than 5mm, otherwise it indicates hematoma caused by a possible fracture. Check lordotic alignment of anterior and posterior margins of vertebral bodies, spinolaminal line and the tips of the spinous processes. Each of these measurements should be performed on all cervical spine films and committed to memory.

A complete neurological exam will assist in determining the possible spinal lesion. Anterior compression of cord or spinal artery produces complete motor paralysis, loss of pain and temperature sensation distal to the lesion. Hyperextension injury causes a central lesion with weakness greater in the arms than legs because the upper extremity motor fibers are carried in the central segments of the spinal cord. Brown-Sequard injury to one side of the cord causes paralysis and loss of gross proprioception and vibratory sensation ipsilateral to the lesion. Contralaterally there is a loss of pain and temperature sensation. Post-traumatic syringomyelia are neurodeficits distant from the level of injury usually seen during recuperation several hours post-injury.

The sensory level of innervation and motor level of function also assists in determining the level of spinal cord lesion. These levels and deep tendon reflex arcs should also be committed to memory.

Indications for intubation include apnea, airway obstruction, class III-IV hemorrhage, loss of gag reflex, pulmonary contusion, PaO2 <55mmHg or <70mmHg on 100% face mask or PaCO2 > 55mmHg.
If you are unable to intubate or if the patient has severe maxillofacial injuries then cricothyroidotomy is indicated.

In neck trauma there are several means of evaluation. Radiographically these include c-spine series, soft tissue lateral (airway), CXR (pneumothorax, pneumomediastinum, or hemothorax), gastrograffin swallow for esophageal injury. Interventional fiberoptic esophagoscopy or bronchoscopy for evaluation of anatomy. Arteriography should be used to evaluate injury depending on the zone of trauma. Zone I consists of the upper mediastinum to cricoid cartilage = highest mortality. Penetrating trauma occurs most commonly in Zone II - between cricoid cartilage and the angle of the mandible. Zone III, above the mandible, contains the major vascular, aerodigestive, and salivary organs.

The next two slides shows the manifestations of circulation and pertinent knowledge for evaluation and treatment of the cardiovascularly compromised patient. In major trauma, these are the primary laboratory tests necessary for rapid assessment. CBC - looks for any infections, blood loss (may not be true Hematocrit initially, may need to be repeated 1 - 2 hours later). Chem7 - probably not abnormal initially in trauma, but a good baseline for future changes. Type and Cross - depending on the type of injury, Hematocrit, blood pressure class, and obvious bleeding site, one would determine transfusion priority. Immediate blood would be Type O negative 2 to 4 Units, then typed specific as necessary. PT/PTT also a measure of coagulation and indicates need for Vit.K or coagulation factors - Fresh Frozen Plasma. Drug/Toxicologic/ETOH screen is information obtained for medicolegal reasons, but may influence care if any of the classical toxidromes are involved.
The hemorrhage classes are a gross evaluation of the severity of blood loss and appropriate therapeutic crystalloid/colloid management.

Clinical manifestations of shock and possible severe causes which must be rapidly assessed. Of trauma victims, hemorrhagic shock is, by far, the most common, with cardiogenic shock as a factor in blunt or penetrating chest trauma. Neurogenic cause must be considered in any patient who may have cervical cord injury.

Indications for mast trousers. These are an excellent way to stabilize pelvic or lower extremity bone fracture and maintain venous return in the hypotensive patient. Important to remember when removing MAST trousers to deflate proximal (Abdomen) segments to distal and slow enough to maintain systemic blood pressure. Significant contraindications are determined by thoracic organ dysfunction which may worsen pulmonary edema or increase blood loss, as well as pregnancy and evisceration.

Usual ATLS appropriate resuscitation fluids for adults and pediatrics

Disability is a rapid assessment of mental status and neurologic function. The Glasgow Coma scale evaluates spontaneity of eye opening, and best motor/verbal response to verbal and tactile stimulation. A GCS of greater than 8 usually indicates a good chance of survival from injury with poor prognosis if GCS is below 7.

Full exposure of the patient is critical for complete clinical evaluation. By physical exam, these are some possible findings in thoracic trauma. Becoming efficient and complete with your physical exam enables you to effectively assess most thoracic trauma by auscultation, percussion (hemo/pneumothorax) and palpation(subcutaneous emphysema). Neck exam with distended veins is a fine indication of cardiac failure or pulmonary dysfunction. Abdomen exam depicts possible bleeding if rigid or scaffoid indicating thoracic herniation.
Radiologic evaluations of thoracic trauma progress in urgency of technique. Immediate assessment necessitates rapid CXR to denote pneumothorax, foreign body or widened mediastinum, indicating great vessel injury. CT scan is good utility but is rarely immediate. The gold standard for evaluation of vascular injury is arteriogram. If a trauma patient survives thoracic injury, without acute aortic dissection, then most will be stable for arteriogram evaluation.

As depicted by this slide, there are several CXR findings indicative of aortic trauma.

A rare but very invasive procedure performed as a final attempt to stabilize a intrathoracic bleed such as aortic dissection, cardiac tamponade, or coronary artery bleeding is the thoracotomy. Indications are usually loss of vital signs in transit or within the emergency department.

Rapid invasive life-saving measures for most results of thoracic trauma are depicted here. Most important is the fast assessment of these injuries and evacuation of air or blood from pleural or pericardic spaces.

Abdominal trauma is difficult especially if the patient is unconscious. A deep peritoneal lavage is for the purpose of establishing the presence of blood in the abdominal cavity. The indications are presented here with results for positive findings.

Exploratory laparotomy, an obvious surgical procedure, will be indicated by your evaluation and interventions early in the trauma resuscitation. If there is another life threatening injury, closed head or thoracic injury, rapid determination of abdominal bleeding will be invaluable for the surgeon.

There are four classifications of pelvic fractures each with increasing number of pelvic ring fractures. Type I - fracture of iliac spines, pubis, ischium, sacrum or ilium. Type II - single ring fracture with pubis subluxation or sacro-iliac joint fracture. Type III - double ring fracture with double vertical fracture of the ring (Malgaigne). Type IV - acetabular fracture - displaced or undisplaced.

Genitourinary evaluation is necessary to determine urethra, bladder or nephro-ureteral injury. Indications are any obvious signs of trauma (pelvic fracture or gross/microscopic hematuria).

Depicts an algorithm for evaluation and further radiologic intervention for determination of genitourinary injury. Note that when performing a cystogram, the bottle of contrast should not be raised greater than 2 feet above the patient to avoid further bladder rupture. After cystogram an AP Pelvis view should be performed with and without dye (washout).

Three classifications of burns. First degree is much like a severe sunburn with painful erythema. Second degree burn extends the damage to blistering and edema fluid production. Third degree burn is a painless full thickness burn with dark leathery or waxy white tissue. Because of the large amount of edema fluid lost in severe burns, replacement is necessary and may be calculated by the Parkland formula depicted here. Note that 50% is infused over the first 8 hours then the rest over the next 16 hours.

Indications for endoscopy for evaluation If any airway edema or compromise is noted on exam or by subjective patient complaint then immediate intubation is indicated.

Rules of Nines are a rapid estimation of percent body surface are burned. These percentages are different for infants and children due to the larger head proportion to body size.

The American Burn Association criteria for burn center referral are dependent on the degree of burn and percent body surface area.