General Trauma Care
- Thromboelastogram result interpretation:
- CTin = elevated with heparin or intrinsic coagulation defect
- CTex= elevated with extrinsic coagulation defect
- A10in,ex= lowered with weak clot (platelet, fibrinogen or factor XIII)
- MCFin,ex= lowered with weak clot (platelet, fibrinogen or factor XIII)
- MCFfib= lowered with poor fibrin
- MLin,ex,fib > 15%= fibrinolysis
- Endpoints for transfusion from ACS TQIP:
- FFP for either
- CT exTEM>100s or
- CT inTEM>230s
- cryo or FFP for MCF fibTEM<8mm
- platelets for both:
- MCF exTEM<45mm and
- MCF fibTEM>10mm
- antifibrinolytic (TAA) for ML exTEM>15%
Rapid shallow breathing index (RSBI)= RR / Tv. Want < 105 for extubation; although <65 is ideal.
Negative inspiratory force (NIF)= want < -20 for extubation.
Tidal volume (Tv)= want 5ml/kg for extubation.
Vital capacity= want 15ml/kg for extubation.
Adrenal Insufficency is treated with steroids emperically, but can do ACTH stimulation test.
Check cortisol level. If serum cortisol is < 20mcg/dl this suggests adrenal insufficency. Then, administer ACTH 250mcg IV push (time zero). Next, check serum cortisol at 30min and 60min. If the cortisol increase is < 9mcg/dl this is diagnostic for adrenal insufficency.
Dexamethasone does not interfere with ACTH stimulation test.
Prednisone 5mg = Cortisone 25mg = Dexamethasone 0.75mg = hydrocortisone 20mg
Postop Hypotension is from: MI, CHF, PE, bleeding, coagulopathy, sepsis, medication induced, malignant hyperthermia, blood transfusion reaction.
Workup: foley, cxr, ekg, cbc, cmp, pt/ptt/inr, Echo, cardiac enzymes.
Management: fluid challange with 1L saline, give blood if suspect anemia. Manage cause.
MI suggested with elevated wedge, elevated PAP, EKG changes, elevated enzymes --> cardiology consult, B-blocker, ASA, morphine, O2, heparin of tolerate, cardiac cath, IABP
- Fever --> malignant hyperthermia, transfusion rxn, adrenal insufficency
- Transient responder or non-responder needs OR exploration for bleeding or sepsis (if not MI/CHF/PE)
- GCS score= glascow coma score. < 8 consider ICP monitoring. <13 consider intubation.
- 1= closed
- 2= opens to pain
- 3= opens to voice
- 4= open
- 1= no sound
- 2= makes sounds
- 3= makes words
- 4= disoriented
- 5= oriented
- 1= no movement
- 2= decerebrate (extensor posturing)
- 3= decorticate (flexor posturing)
- 4= withdraws from pain
- 5= localizes pain
- 6= follows commands
- Epidural hematoma= from injury to the middle meningeal artery. Can see pupil dilated on ipsilateral side. There is often a lucid interval. Can see contralateral posturing
- Subdural hematoma= injury to bridging veins
- Brainstem herniation= dilation of both pupils, must rule out pharmacologic effect
Pediatric head trauma=
- Do not need head ct if: <2yr, GCS 15, no depressed skull fxr. (PECARN criteria). If >2yo can avoid if no worsening HA, vomiting, or LOC.
- Consider CT or 6hr obs if: nonfrontal scalp hematoma, loc> 5 sec, not acting right, severe mechanism, <3mo, vomiting, worsening headache
Acute Management of TBI
- Cerebral perfusion pressure is the most important for management of TBI.
- want ICP < 20-25mmHg
- want SBP > 100 mmHg
- want MAP > 80mmHg before ICP monitor inserted
- want PC02 35-45mmHg
- want PaO2 > 100
- want pH 7.35-7.45
- want temp 36-38C
- want Glucose 80-180 mg/dl
- want serum sodium 135-145
- want INR < 1.4
- want Platelet > 75k
- want Hb > 7
- CPP = MAP - ICP
- want CPP > 60 mmHg
- Mannitol can acutely decrease ICP (30min) and increase blood volume (cerebral blood flow) given as 20% mannitol 0.25 to 1g/kg, then 0.25g/kg q4hrs
- goal serum Osm 315-320 mOsm.
- do not want serum osm > 320mOsm.
- Hypertonic saline (3% NaCl) may be superior to mannitol as a 250ml Bolus, then 40ml/hr.
- goal CPP > 60-70 mmHg
- goal ICP 20-25 mmHg
- goal PaCO2 30-35 mmHg
- serum osm 315-320 mOsm.
- serum Na 145-155 mmol/L
- Drain ventriculostomy up to 10-20ml/hr
- Additional military protocols are available.
- Diabetes insipidus is the decreased secretion of ADH (central) or resistance to ADH (nephrogenic). Central DI can be seen in TBI.
- Dx with urine specific gravity of < 1.005, urine osm < 200mOsm/kg, plasma osm > 287 mOsm/kg, and > 3L urine per day.
- Tx goal is to reduce serum sodium 0.5mmol per hour.
- hypo-osmolar fluid replacement orally or IV
- ddAVP 1-2 mcg IV BID
- Brain Death
- Family must be notified
- Exclusion: hypotension (BP >100), hypoxia hypoglycemia, Extreme I/o imbalances, locked in state (no paralytics, cannot move eyes to command), cspine/facial trauma, hypothermia (<36), intoxications, metabolic abnormalities
- Must show irriversible:
- GCS 3
- Areflexia (but ensure DTR present and not paralized)--> pupils 3-8mm and fixed, no ocular movements (oculocaloric or oculocephalic), no corneal, no cough
- Apnea Test, repeat after ~6hrs
- Apnea test:
- Baseline ABG PCO2 40+5
- Oxygenate to PO2 200
- Temp >36deg
- Keep SBP >90mmHg
- Disconnect vent and uncover patient
- Provide 100% O2 (red rubber to level of carina)
- Observe respiratory movements
- ABG 7-10min to see if CO2 increases by 20 or pH < 7.24
- Confirmatory test: not required but used if missing 1-2 parts of prior requirements or indeterminate apnea test. Especially with CO2 retainer, CHF, hemodynamic instability, severe obesity.
- cerebral angiogram
- Brain scan (doesn't image posterior circulation
- Transcranial doppler
- Cardiopulmonary death:
- Warm >90 degF
- Brief neuro exam: GCS3, pupillary reflex, corneal reflex
- Cardiac: 2min no pulse or 3min asystole (EKG, a-line)
- Plum: 2min no breathing
Zones of the neck
- Zone 1= clavicals to the cricoids cartilage (inferior trachea, esophagus, brachiocephalic trunk, subclavian arteries, common carotids, thyrocervical trunk, thoraci duct, thyroid, spinal cord)
- Zone 2= cricoid cartilage to the angle of the mandible (common carotids, internal/external carotids, IJ veins, larynx, hypopharynx, cranial nerves 10, 11, 12, spinal cord)
- Zone 3= angle of the mandible to the base of the skull (carotids, vertebral arteries, IJ veins, pharynx, cranial nerves, spinal cord)
- Zone 1
- left--> left anterior thoracotomy, can use left posterolateral thoracotomy to better expose arch, proximal left subclavian, left common carotid.
- right--> sternotomy
- proximal vertibral artery can be reached with transverse supraclavicular incision
- Zone 2 --> parallel to SCM
- Zone 3--> parallel to SCM, may require mandibular subluxation to reach distal ICA
- Evaluation of esophagus/larynx --> barium swallow, intraoperative DL and esophagoscopy, intraoperative methylene blue into esophagus
- injury above arytenoids--> abx and NPO for 7d
- below arytenoids--> 2 layer repair
- unable to repair--> T-tube or spit exteriorization
- 2 layer repair
- inner layer with vicryl to mucosa
- outer layer with prolene to cartilage
- keep intubated 3d
Thoracic trauma and Pulmonary Care
- Zone 1= Central
- penetrating --> open all
- blunt --> open all
- Zone 2= Lateral
- penetrating --> open unless 1) preop ct allows staging of renal parenchymal injury or 2) stable retrohepatic
- blunt --> open unless preop CT shows the hematoma is around a reasonably intact kidney; do not open stable retrohepatic
- Zone 3= Pelvic
- penetrating --> open all
- blunt --> do not open if pelvic fxr, intact pulses, no expansion
Smal bowel Injuries
Renal vascular trauma
Venous avulsion - nephrectomy if have 2 kidneys; repair versus nephrectomy if have 1 kidney. Left renal vein can be ligated proximal to gonadal/adrenal; right renal vein ligation means nephrectomy
Arterial thrombosis - observe if have 2 kidneys; thrombectomy if have 1 kidney.
Vascular and Extremity trauma
- Veins that should be repaired:
- Popliteal vein- 50% risk of edema if ligated, may need fasciotomy; high risk of limb ischemia with concomitant popliteal artery injury
- Femoral/iliac veins are ok to ligate, use leg wraps.
- Arteries that should be repaired:
- Internal carotid artery- 10-20% stroke with ligation
- External iliac artery
- Common femoral artery
- Superficial femoral artery
- Superior mesenteric
- Inferior mesenteric
- Hard signs- go to OR
- Arterial bleeding
- Rapidly expanding hematoma
- Thrill or bruit
- Arterial occlusion= pain, pallor poikilothermia, pulseless, paresthesia, paralysis
- Soft signs- Angio, serial exam, duplex
- History of bleeding
- Decreased distal unilateral pulse
- Neuro deficit
- Diminished duplex wave form
- ABI < 0.9
Rattle Snake Bite
Coagulopathy and bleeding
Swelling, pain, and ecchymosis adjacent to the bite site
Normal coagulation parameters•; no bleeding
Swelling, pain, and ecchymosis less than full extremity or less than 50 cm if bite on head, neck, or trunk
Present but not life-threatening (eg, nausea, vomiting, diarrhea, oral paresthesia, unusual tastes, tachycardia, tachypnea, mild hypotension [systolic BP >90 mmHg in an adult])
Abnormal coagulation parameters•; no bleeding or minor hematuria, gum bleeding, and/or epistaxis
Swelling, pain, ecchymosis involving more than the entire extremity; greater than 50 cm if bite on head, neck, or trunk; threatens the airway; OR signs of compartment syndrome
Present and life-threatening (eg, respiratory insufficiency, marked tachycardia for age with severe hypotension, obtundation, seizures)
Markedly abnormal coagulation parameters• with serious bleeding
- Treatment: based on severity of bite, not species identification.
- CroFab 4-6 vials over 30-60min for mild envenemation. Can repeat if sx's don't improve.
- TetTox; abx only for signs of infection.
- Observe for worsening sx's.
- Coagulopathy --> treat with CroFab.
- Rhabdomyolysis --> treat with fluid and electrolyte support.
- Elevated compartment pressures --> CroFab and elevation; may need fasciotomy for true compartment syndrome.
- 30mmHg is recommended as a critical point for fasciotomy
- Measuring compartment pressures: Technique
- abdominal compartment syndrome suggested at > 25mmHg and diagnosed at >30mmHg.
- Burn Depth
- Superficial partial-thickness burn- pink, moist, easily blanch, hair follicles and papillary dermis intact
- Deep partial-thickness burns- extend into reticular dermis, dry, eschar, slow capillary refill
- Full thickness- dark, dry, leathery, insensate
- Burn management
- >20% BSA 2nd degree needs burn resuscitation
- Tetanus toxoid if not within 12mo
- Inhalation injury= suspected with unconscious, enclosed room, blister/soot in hypopharynx (not singed nasal hairs), carbonaceous sputum
- Get COHb, ABG, lactate, cxr
- Incubate early
- American burn association transfer
- Hydroflouric acid- treat with topical, local, and arterial Ca gluconate; can get hypoCa, hypoMg, HyperK
- Chemical burn- initial tx with water irrigation to pH7
- Carbon monoxide (CO) toxicity
- Sx: flu like, delirium, MI, sz cva
- Dx: COHb serum levels >5% no smoker or >13% smoker, pulse Co-oximetry
- Tx: O2, consider hyperbaric O2
- Cyanide (CN) exposure
- Sx: n/v, dizziness, htn, shock
- Dx: lactate>8 in non smoke exposure or >10 in smoke exposure
- Tx: hydroxycobalamine, sodium thiosulfate
- Dx: Start with ABC's, electrolytes, cardiac enzymes, UA/micro, urine myoglobin.
- Check extremities for compartment syndrome
- Opthalmologic exam in tertiary survey
- < 0.5 ng/ml --> systemic infection not likely
- 0.5-2 ng/ml --> systemic infection possible, reassess PCT in 6-24hrs
- >2 ng/ml --> sepsis likely
- > 10n ng/ml --> almost exclusively due to sepsis
- SIRS criteria > 2:
- Temp > 38 or < 36 C; >100.4 or < 96.8F
- HR > 90
- RR > 20 or PaCO2 < 32mmHg
- WBC > 12, < 4, or bands > 10% bands
- Vecuronium- induction with 100mcg/kg x1 = 10mg; intermittent paralysis with 10-15mcg/kg q15min= 1mg
- RSI: Induce with etomidate 0.5mg/kg ; Paralyze with succinylcholine 1mg/kg; Contraindicated with difficult ariway, arrest, obstruction.
- Flumazenil- 0.2mg qmin for benzo overdose max 5 doses
- Naloxone- 0.4-2mg q2min for opioid overdose
- Coumadin reversal protocol
- Platelet transfusion triggers:
- < 100 for head trauma
- < 50 for major surgery or massive transfusion
- < 20 for LP