3/21/16 Trauma Conference, Las Vegas
-whole
body CT scanning may have increased survival in trauma pts.
Subclavian
injury:
·
OR for hard signs (hemothorax,
pulsetile bleeding, large hematoma, loss of pulse)
·
CTA for soft signs
Tx:
·
Clavicular incision: only incision
needed for R or L
·
anterior scalene m overlies subclavian,
phrenic n is on medial aspect of this (preserve)
·
can do delto
pectoral extension
·
can do sternotomy extension= opens
medial extension
·
just over
clavicle, remove soft tissue attachments, remove clavicle from sternum with gigli saw (minimal functional deficit), or can just cut
medial end and move.
·
PTFE often used
·
venous injury can be ligated
Concussion:
·
=occures immeditely, transient, causes disturbance of function but
not structure, LOC not needed
·
there is no grading
·
SCAT3 is a cuncussion
assessment tool
·
types of concussion: cognitive,
vestibular, affective, somatic
Tx:
·
no return to play if symptomatic
·
gradual return
·
no brain rest
-vascular
injuries below knee or shoulder should be repaired with venous grafts
Esophageal
perforation
-eval with swallow study, CT, endoscopy
-explore
cervical esophagus, even if only for drainage
-Criteria
for nonop management of esophageal perforation:
Well
contained/ localized
Contrast
drains back into esophagus
Minimal
sx, no sepsis
Cervical
or thoracic esophagus
No
maligancy
No
distal esophageal obstruction
Detected
early, or late with minimal sx
Aortic
root injuries:
-R
coronary comes off directly anterior
Blunt:
usually need bypass, have time.
Access:
-midline,
median sternotomy
Colonic
Surgical Emergencies:
-primary
anastamosis has ok outcome than for diverticulitis
(MAY have improved morbidity/mortality over hartman's)
-Diverticulitis
laparoscopic lavage has 2% conversion, 10% Morbidity. Not yet indicated for feculant or purulant peritonitis
Transition
zone challenges:
Neck
·
-SCM incision initially
·
-Zone 3: detach scm,
digastric, sternohyoid & styloid m devision
·
-beware of facial n posterior to
mandible , inferior alveolar n anterior to mandible
·
-vertibral a
travels in canal C6-C2
Thoracoabdominal
·
-suprahepatc
vena cava can be accessed through central tendon via abdomen (like a
pericardial window)
·
-diaphragm can be taken down radially
laterally (preserves innervation of diaphram which
comes centrally)
Popliteal
·
-usually accesed
with incision parallel to sartorius m., divide gracilis, semimembranous, semitendinous, and medial head of gastrocnemius.
Residual
Hemothorax:
·
= retained blood > 300-500ml
(blunted costophrenic angle)
·
large size tube not found to help decrease
·
<300ml usually resorbed
spontaneously
·
Large residual hemothorax
can worsen resp function, risk empyema (27%
incidence), entrap lung
·
Risk for empyema: no abx at time of insertion, penetrating trauma, duration of
chest tube, multiple chest tubes.
Tx:
·
replace tubes (not recommended)
·
percutaneous drain: for encased
collections
·
thrombolysis: TPA
25mg or Urokinas 100,000 U in 50ml NS via chest tube.
Clamp. Walk for 4hrs. Unclamp. Repeat for 3d. After trauma, usually wait 3-5d;
longer for head injury.
·
VATS- good for < 10d. lat decubitus; dbl lumen tube;
two ports, 6th intercostal ant/post axillary lines; 3rd in mid axillary 4th
intercostal
·
thoracotomy- for > 10d
Biliary
Bailouts
·
Dome down is an option
·
subtotal
cholecystectomy= GB drained, opened, evacuated, anterior wall excised, back
wall may be left on; mucosa may be obliterated; cystic duct can be left open or
closed with suture/endoloop/clips; drained.
o For
severe cholecystitis preventing safe dissection; cirrhosis (bleeding during
dissection)
o 18% bile
leak, usually resolves spontaneously; may need ERCP/stent; 2% need re-operation
·
Cholecystostomy hasn’t
been shown to lower conversion rate of lap chole.;
good for poor surgical candidates
Necrotizing
pancreatits
·
Nasogastric feeds may be ok
·
Wait 5-7d before starting TPN (enteral
better than tpN)
·
Infected pacreatic
necrosis= Air in retroperitoneum, bacteria in necrotic fluid
o Tx: abx, necrosectomy
o Open:
debride, can pack or drain.
o Step up:
IR drainage, if doesn't improve after a few days (try ~4wks from initial
pancreatitis) --> do cutdown on drain, 10mm scope
to access retroperitoneum, can debride with yankaur
and ring forcepts; has lower DM, hernia, pancreatic insufficency, death.
Ostomies
in obese pts
·
Preoperative stoma siting= 5cm of flat
skin despite position changes; ostomy triangle is umbilius,
ASUS, pubic symphisis
o Obese pts
may need higher on abdomen
o
Avoid
prior radiation fields
·
Intraabdominal
options
o
Clamp
IMA to ensure blood flow is preserved
o
Don't
dissect close to mesentary
o
Mobilize
flexures
o Make a
large trephine (hole for bowel to go through ab wall)
o
Pseudo
loop end colostomy
o
Pie
crusting= cut mesentery perpendicular to vessel to gain length
·
Abdominal
wall options:
o Siting
o Contouring,
take subcutaneous fat
o Can use Alexis
Wound retractor to allow bowel to slide into site easier
3/22/16
EFAST
(Extended focused assessment for trauma)
·
FAST (detects 200ml fluid, 80%
sensitive, 100% specific for free fluid) + thoracic views
o 25-50%
false negative for solid organ injury
o Pediatric
fast is < 50% sensitive
o Doesn't eval retroperitoneum
·
Thoracic views detect pleura-pleura
apposition and movement.
o Comet
tail= normal finding (no ptx)
o HTX can
be seen just above diaphram on liver/splene views
o Pleura
not moving with respiration (no moving comet tail) is ptx
IVC
filters
·
TID heparin is comparable to lovenox for DVT prophylaxis
·
PE is #1 delayed death following trauma
·
Guidelines:
o Known
DVT/PE and can't anticoagulate
o GCS <
8 tbi, spinal chord with plegia, complex pelvic/long bone -- little/no clinical
evidence
o PE while
adequately anticoagulated
o Too sick
to tolerate a second PE
·
In general: Above knee DVT --> anticoagulate; if high risk/bleeding place a filter
·
About 20% PE's are actually primary
pulmonary thrombosis
·
If unable to give DVT prophylaxis, can
do surveillance US for DVT (weekly or biweekly)
·
Only 21% of retrievable filters are
retrieved
·
Recommendations by Dr. Sise:
o Filter
for DVT/PE when can't anticoagulate
o PE
despite anticoagulation
o Consider
if unable to tolerate 2nd PE due to cardio/pulmonary instability
o No role
for SVC filters for upper extremity clot -- unless this caused a PE
o No
prophylactic IVC filter, do surveillance
Fibrinogen=
Normal rxn to trauma is to increase; low (<230) in
trauma is associated with bleeding and death. Early cryo
may help, but doesn't effect mortality.
·
Should keep level > 200
Open
Abdomen
·
Use: packing, bowel edema, ACS,
sepsis/ischemic bowel
o Diffuse
non-surgical bleeding
o hypothermia
< 34C
o acidosis
< 7.3
o volume
overload > 7
o bowel edema
·
Risk:
o 15% EC
fistula
o Protein
loss
o Hernia
·
Recommend:
o Bowel anastamosed in 24hrs to prevent SBO
o 34% of
pts are able to be closed 1st take back and can decrease
infection/complications
o Leaving
abdomen open for sepsis has increased morbidity, fistulas, hernias,
inflammatory response = don't do serial washouts for sepsis. Do re-exploration
on demand.
o Ischemic
bowel only 20% need further resection for ischemia
TBI
Management
·
ICP monitor does not effect outcome (NEJM Dec 27, 2012)
·
Decompressive craniectomy
in diffuse TBI has worse outcome (NEJM 4/21/11)
·
Rescue craniectomy
o Leaving
bone flap off has complication of new surgery
o Replacing
bone flap has rick of inc ICP and needing removal
·
Targeted temperature measurement only
indicated in neonates (hypothermia)
·
Mannitol v. HTS - no clear preference
for eaither over the other
ABCDEF
Initiative = ICU care
·
A= assess pain
o Use
scoring
o Treat in
30min
o Pain
control before procedure/dressing change
·
B= spontaneous awake/breath trial
o Decrease
time in ICU, vent, mortality, delerium
o Use RAS
or SAS
o Hold
sedation until open eyes, squeeze, follow commands; then restart 50% of dose
·
C= choice of analgesia/sedation
o Benzo's
are bad
o Analgesias first
o Precedex has
lower delerium than propofol
lower than benzo
·
D= delerium
assess
o Can be
hyper/hypo active or mixed
o Delerium has 1%
increased 1yr mortality for every day deleriuc
o CAM-ICU
is scoring system (poor for TBI)
o Modifiable
factors: sleep, choice of home meds, procedures, mobilization, pain
·
E= early mobility
o Decreased
incidence and duration of delerium
o Avoid
bedrest
·
F= family engagement
o Presence
in unit, in rounds (open ICU policy), shared decision making, ICU diaries
o Decreases
falls, agitation, cardiac complications
ECMO
·
Passive venous drainage, oxygenation,
then pump blood back (to vein VV or artery VA, only VA is good for cardiac
support as well)
·
Increased survival for H1N1 flu in 2009
·
40% survival in cardiac shock
·
Indications
o Respiratory
failure with > 50% expected mortality done within 7d
o Failed
Prone positioning, APRV, inhaled NO
·
1 additional survivor for 6 treated
Antibiotics
in Acute Care Surgery
·
Intraabdoinal
infection
o No flouroquinolone for ecoli
o Mefoxin for
moderate perfoated
o Primaxin, zosyn, cef/flag for severe infection,
immunocompromised, extremes of age
·
Trauma laparotomy
o Single
dose broad spectrum (mefoxin, GN and anaerobe)
o 24hrs for
hollow viscus injury
·
VAP
o Late=
after 4 d
o Fluroquinolones are 100%
penetration
o B lactams
low penetration
o Ex: zosyn 1st, imipenem for escalation
o 7-10d
duration
o Use singe
drug for single bug
o CIPS:
temp, wbc, trach secretio,
oxygenation, cxr, tracheal aspirate cx
·
Cdiff
o Most
common healthcare infection
o Metronidazle,
vancomycin, fidoxamicin
o Tx: Vanc 500mg/500cc q6hr per rectal lavage in addition to oral
vanc and IV flag
Fluids
in the ICU
·
Albumin may have increased mortality in
TBI (SAFE trial), but is safe in sepsis
·
HES starches increase renal failure,
not for acute resuscitation
·
Use lactate or base deficit, CVP 8-12,
MAP > 65, SVO2 70%, UOP > 0.5 cc/kg/hr as endpoints for resuscitation
Anticoagulation
in TBI
·
Prophylaxis decreases DVT, not PE or
death
·
Neurocritical Care
Society guidelines:
o Mechanical
prophylaxis early
o Add LMWH
24-48hrs if bleeding is stable on CT
·
Chemoprophylaxis and SCD reduce dvt risk
·
Chemo is better then
mechanical prophylaxis
·
Lovenox is
better than heparin to prevent DVT
·
Heparin can increase bleeding in the
brain more
Lung
Protection Strategies
·
Use
PEEP/FiO2 table
·
Prone
ventiolation trial 4-6hrs for ARDS (PF<200)
o
Works
best in the first 5d
·
Ventilator
strategies
·
NM
blockade
o Helps
with pt-vent dissynchrony
o Can have
increased survival with PF<150
·
NO
o Transient
improvement in oxygenation
o
No
survival advantage
·
Can
trend SVO2 to identify limitation in oxygen delivery
o Best ways
to improve O2 delivery are Hb and CO
o
Increasing
PaO2 only helps up to about 90% O2 sat
o
Ensure
O2 demand is lessened (pain, sedation)
ICU
nutrition
·
NPO better than TPN for normal Pt
·
TPN
o Uses
·
Short gut
·
Preoperative malnourished pts without
oral intake
·
Complicated or unusable GI tract (not
open abdomen)
o Complications:
·
Cholecystitis
·
Line complications
·
Liver dz
·
infection
·
Postpyloric feeds
decrease PNA
TXA
·
Contraindicated with active clotting
and acquired defective color vision
·
Must be given within 3 hrs of bleeding
Pain Control
·
Can judge opiod
use with MME.
·
NSAIDS increase fracture non-union
·
Ketamine reduces pain severity,
continuous or intermittent.
·
Alpha agonists (clonidine, Precedex) work
Addicted patient
·
Replacement therapy (methadone, buporphenone)
o
Can morphine titrate
o
Need to cover withdraw and pain control
o
Local/regional pain control,
paracetamol
o
Careful with PCA
·
Drug addiction
o
Try to avoid opioids
·
1mg Oral morphine = 3mg IV morphine =
2mg oxycodone = 7.5mg hydromorphone = 1/6mg codein =
1/5mg tramadol
Cervical Spine imaging
·
Who to image (Nexus criteria):
o
Not alert
o
Intoxicated
o
Distracting injury
o
Midline c-spine tenderness
o
Neuro deficit
·
Unevaluable pt
can consider remove collar based on CT alone (high NPV to exclude unstable
injury)
·
Midline tenderness 100%
sensitivity/specificity of CT (Jama 2014)
·
In adequate CT, can likely clear with
CT unless there are neurodeficits
Death and dying in ICU
·
Advanced directive= written expression
of how a pt would want to be treated in medical
circumstances
·
DNR= MD order limiting medical
treatment
o
Pts can suspend DNR perioperatively
·
Medical futility
o
Quantitative= when tx
has minimal probability of success
o
Qualitative= perceived benefit is
exceedingly poor
o
TX and CA has futility policy, MD can
decide, must let family know, ethics, allow time to transfer
Delerium Tremens
(DTs)
·
Mortality of 5-15%
·
15-30% of trauma pts go into alcohol
withdraw
·
Older and higher BAL have higher risk
of withdraw
·
Stages of AWS
o
1- 24hrs, anxiety, tachycardia, HTN
o
2- after 24hrs hallucinations,
irritability
o
3- 3d, sz,
hallucinations
o
4- 3-5d, adrenergic crisis, HTN, fever,
cerebral edema (DTs)
·
Symptom triggered benzo tx is best; can use CIWA scale
·
Tx:
o
Benzo- 1st line
o
Precedex- adds
alpha agonist
Hartford Consensus= group of experts on
how to improve survival with active shooter
Brachial Plexus injuries
· Erb’s palsy=
C5,6, upper arm with waiters tip deformity
o
From overheas
stretch
· Klumpke’s palsy=
C5-T, hand with claw hand
· Penetrating
injurà explore and repair
· Blunt
o
Avulsion (no nerve root remaining)-
can’t repair
o
Rupture- needs surgical repair
o
Axonotemesis- stretch
injury, regenerates in 4-6wk
o
Neuropraxia-
reverses rapidly
o
Dx:
§ Shoulder/arm
film
§ CXR
§ Electrophysiology
§ MRI/CT
myelogram to eval root avulsion
o
Tx:
§ OT,
splints
§ Follow
for 3mo
Pediatric Trauma
·
Airway
o
ETT size= (age+4)/4; nailbed width
o
Bradycardia with RSI= atropine
0.02mg/kg
o
Surgical airway= Avoid in kids due to
subglottic stenosis
·
Breating
o
Similar to adults
o
Look at trachea on xray,
more likely to shift in kids
·
Circulation
o
Blood volume of 80cc/kg
o
10cc/kg PRBC or FFP
o
20cc/kg crystalloid per ATLS
o
MTP started at 40cc/kg, hypotension
o
Use 1:1:1 ratio
o
Hyperkalemia is risk from blood through
small IV’s
o
Bleeding in kids has higher mortality
than in adults
Hernia Repair in contaminated field
·
30% laparotomies have incisional hernia
·
STITCH trial= Small biles
5mmx5mm with 2-0PDS reduce recurrence; excluded morbidly obese.
·
Lap v open repair
o
No clear defined difference
o
Lower wound infection
o
Increased enterotomies
o
Less hospital stay
o
Maybe < 3cm should not be lap,
>10 should not be lap
·
PRIMA trial will address prophylactic
mesh
Surgical Soul
·
Vascular structures
o
Deep= cava, kidney, IVC; Compress
o
Middle= mesenteric, portal; do double pringle
o
Superficial= pancreatico-duodenal
arcade, need Kocher to find
o
Tx:
§ Wide kocher, Cattell Braasch, R kidney
mobilization
§ Portal v-
repair; ligate if dying and hepatic a intact
§ Hepatic
a- repair
§ Bile
duct- deal with later
§ SMV-
transect head of pancreas
§ Proximal
SMA- repair
§ SMV-
repair, ligate in extremis
§ IVC-
compress with sponge sticks; statinsky clamp, repair;
ligate in extremis
§ Superficial
vessels @ head of pancreas- ligate, pack
·
Pancreas
o
Consider bailout
o
Tx:
§ Drain!!
§ Whipple-
only when injury already did the resection
·
Bile duct
o
Prijmary repair
o
Consider T-tube through a separate area
o
Can leave GB to leave as a conduit
(roux limb)
·
Duodenum
o
Primary repair, tenuous suture line
o
Pyloric exclusion after repair (open
antrum, oversew pyloris,
loop gastro J)
Recurrant Adhesive
Small bowel Obstruction
·
49% of sbo
·
5% of prior surgery will develop SBO
due to adhesions
·
Recurrence rate increases after
recurrence
·
Dx: Hx, px
o
SB > 3cm dilation
·
Tx:
o
Urgent surgery after resuscitation for
complete SBO if no evidence of adhesions
o
Use lactate as an endpoint for
resuscitation
o
Gastrograffin SBFT
done after resuscitation and NG decompression
§ Reduces
need for surgery
§ Reduces
time for resolution
§ Reduce
hospital stay
§ Failure
of passage at 8hrs may need surgery; however, contrast in colon at 24hrs will
likely resolve
o
PSBO resolves 55-75%
o
Complete SBO resolves ~35%
o
Fluorescein dye 1 ampule and Woods lamp
to eval vascular compromise
·
Small bowel syndrome= <200cm SB
·
Hyaluronic acid/carboxymethylcellulose
– reduces severity of obstruction
·
Icodextrin 4%
irrigation solution reduces adhesions and SBO
Unnecessary
transfers
·
Inappropriate: closed distal radius, fami, closed anle, femur, tib/fib, clavicle, elbow dislocation, proximal humerus, felon, closed midshaft
radius/ulna, closed metacarpal, femoral neck, intertrochanteric, patella,
fibula, metatarsal
·
But accept.
Air
ambulances
·
Has a role in long distance, hostile
environment, difficult geography
·
No proven benefit for urban environment
EMTALA
·
Pt in emergency department must be
evaluated and astabilized
·
On call physician availability
o
Each hospital must maintain community
need on-call list
o
Coverage within reason depending on
number of MDs
o
ER MD determins
if on call MD must come in
o
Cannot refer to office unless it is in
the hospital (rather than come in)
o
Simultaneous call is ok (unless
critical access hospital)
o
Physician extender is ok unless ER MD
says they want the MD
·
EMTALA does not apply to in-patients
·
EMTALA can get waived during certain
emergency cirucmstances
Antibiotics
Only for Acute Appendicitis
·
APPAC trial: RCT
o
Uncomplicated appendicitis
o
27% abx only
failure rate over a 1yr
§
Still only7% complication versus 21%
complication with immediate OR
o
Lower complications
o
Better pain and recovery
o
Protocol
§
3d IV abx (irtapenem)
§
OR group was open appy
·
NOTA study: prospective study
o
Brief course of abx
o
14% failure rate (66% still only
managed with abx)
·
ABx only
safe for kids as well
o
76% success at 1 yr
(JAMA 2015)
·
10-20% complication rate with surgery
·
Choose surgery:
o
More certainty for future
o
High risk occupation or remote travel
·
Very low perforation rate from time of
diagnosis
·
Protocol by Dr Martin:
o
Immunocompetent adult, no perforation,
no abscess, no fecolith, no peritonitis, reliable pt
o
Initial IV abx
o
Can immediately convert to PO if
tolerating PO
o
Admission if fever, worsening pain,
abnormal vitals, not tolerating PO
o
F/u within 72hrs: pain, PO tolerance,
bowel function, other complaints, vital signs
o
Appendectomy for worsening status,
failure to improve, patient preference.
o
f/u imaging
or endoscopy for suspicion of mass.
Organ
donation
·
as of 2006, OPO (organ procurement
organization) authorization on license is legally binding (Uniform Anatomical
Gift Act)
·
Donation after circulatory death (DCD)
starts ~1hr after pronounced death
5/1/17 TOPIC course