Transcript for:
Key Principles of Trauma Surgery

guy is actually one of the original authors I think of atls um so he's a he's a world renowned trauma surge so he just made a video so what did you what was bad about that huh team wasn't ready no roles no roles were assigned what else priorities were completely out of order what else control the bleeding like oh man this's bleeding what else not enough people no cloes communication yeah they want to send them a CT and they still unstable they didn't even didn't really do much they definitely didn't check the interventions what else he wasn't tra naked he wasn't inated they completely missed the airway so that dude was toast right and then they were like oh I don't think you have p and then the compressions were terrible so yeah you got the point right so I'm going to show you a quick video we're not g to watch the whole thing but I'm going show you what right looks like how was that compared to the the first video we watched course sounds better right so good communication closed loop he's going in order prioritize the airway identified the need to evaluate for massive hemorr genene um identified the need for blood early uh and the list goes on and on right had traction spint immediately on assessing distal pulses uh so that was that was a lot better wasn't it all right that's how um you should expect a trauma to go usually you're going to have more people so he still didn't have everything he needed uh but he did vocalize when he needed help for somebody to come in pick up the slack and they did so he did a pretty good job there on that version of the trauma that came in all right so we're going to talk about the secondary survey uh these are the objectives and then let's get into it so the secondary survey happens after the primary so the primary the priorities are xabcde so we're going to control massive hemr we're going to assess Airway breathing circulation disability and expose the patient um we're going to intervene on things that are immediately life-threatening as we do that right likewise in the secondary survey we're doing the same thing it's just going to be more detailed going to go ahead the toe and as we find things that need to be immediately intervene on we're going to do that all right and the idea is to simultaneously be intervening on these injuries and potentially stabilizing the patient to buy us more time potentially stabilizing the patient and allowing us to get even more information through additional ancillary testing by the time the primary and secondary survey are done done what two ancillary tests we say need to be definitely part of your uh service chess xand to fast plus or minus that pelvic x-ray right we'll talk about that here in a second uh because that could be the third site where we bleed a lot right in trauma so we said there's three places we Le from where is it chest AB pelvis especially true in blunt trauma um you know extremity hemorr can be a concern as well U since most of our mechanisms are BL civilian sector we kind of think the chest abdomen and pelvis kind of the big places where we B doesn't mean we disregard extremity H all right so we're going to do uh systematic head to toe we're going to get additional history and physical examination the history is pretty important when that EMS comes in and they give that handoff hopefully they've had somebody on the scene that knew the the casualty that's going to give us some of that information on their previous medical history previous conditioning medications those kinds of things sometimes we can't get that information we don't know it patient give it to us because they're unconscious or unable to tell us uh and or there wasn't any anybody present that can give us that information so as much of that information as we can get we get uh otherwise we move on and that includes things like their tent status um the allergies medications past illness last meal and then events leading up to the injury so we call that the ample hisory so when we talked about triage and and determining whether somebody was immediate or delayed we said we consider the vitals we consider the mechanism the the anatomy of the injury and then special considerations uh during the secondary survey that becomes even more important right because mechanism and the anatomy specifically are going to clue Us in to what exactly could be happening with that patient all right tells us what potential injuries they might have we generally think about injuries as two broad categories they're either penetrating or they're blunt training injuries typically have a more localized trauma so think of a stao there's a track and everything along that track could be injured right it's very localized to that that stab versus in Blunt mechanisms blunt mechanisms that cause significant trauma imply that there's a lot of kinetic energy behind blunt mechanism so that means is when blunt injuries come in there is a likelihood that there are other things injured more than what we're seeing on the surface right you see a bruise on the belly that can mean a bunch of stuff see a seat belt sign it can mean maybe the spleen is injured maybe there's a chance fracture in the Lo elpine or you know the list goes on and on maybe there's a hollow viscous injury right so there's a bunch of stuff that can happen so we need to kind of approach patient that way and if we can subcategorize them between penetrating and blunt we can kind of narrow down our differentials out front all right life threatening injuries we said need to be addressed first so as we we do our evaluation we're going to identify those and as we identify those we kind of stop per second and ask ourselves does this need to be intervened on now yes or no can I intervene on it yes or no and stabilize it or do or does this patient need to go to the O for the intervention or they die those are kind of the questions you ask yourself as you go through and identify those injuries if you spend too much time in the Ed doing the treasure hunt of all the injuries you could be neglecting an injury that's the compensating the patient and so it's a little bit of balance right you want to spend the time in the Ed that you need to stabilize the patient as much as possible simultaneously if you need to make a critical decision because you ran into an injury that needs immediate operative intervention you need to be able to pull the trigger on that and go to the O all right and sometimes you have conflicting or conflicting priorities right you have somebody like this they like they were in a motor vehicle accident they have this really impressive facial trauma am I get neur neurosurgery now do I get imag they have a felt sign and they got a positive fast I know I need to go to the O so what do I do what's the priority I got to do all of these things for this patient eventually but which one's more important which one's more important is the thing that's going to kill them first what did we say patients and Trauma die from first hypmic shock right and so when there are conflicting priorities the best and safest thing to do is to take the patient up to the O and we can manage that in the O right it's not uncommon to have a patient like this be bleeding in the belly we need to get in you need to do an exploratory laparotomy and simultaneously do an interoperative neurosurgery consult to have them come in and do the cranc right that happens all the time or you know Ortho comes in because there's also a crazy femur fracture with compromised glimp right so that's kind of how that works it's a little bit of chaos especially when you have polyon patients so here's a question for you you are working in a rural Ed and get a call that the volunteer fire service is bringing an unresponsive adult male patient stat post DC patient arrives on backboard with the c collar which of the following components of patient evaluation is most likely to be performed during the secondary survey so if the primary survey is X a b CDE e what is part of the primary survey if we know that it is a head to toe assessment is it check your pulses that's part of circulation that's part of the primary mobilize the sepine no that's part it's part of the primary blunt mechanisms right we have to always have sepine considerations glassco scale it's part of disability primary evaluation abdominal exam yes yeah that's where we kind of stop we're going to look for seat Bel sign kind of do a little bit more of a close exam during the secondary survey we might put our ears on the belly we might palpate check for um you know bruising like Cullen sign that kind of thing and then unclo the patient that's the E and ABCDE e right so that's part of the primary as well so secondary survey most appropriate exams during secondary surveys is theom exam all right so we said penetrating and blunt mechanisms so we're going to start with the penetrating okay forget about blunt for a second we're just going to go down the down the list on penetrating and we're going to kind of go head to toe we're going to skip the head because penetrating injuri is to the Noggin those are pretty catastrophic right not a whole lot to do other than call neurosurgery and hope for the best so we'll have a whole lecture on head injuries um it's more focused on closed head injuries which are the ones that patients tend to survive uh and that required a lot of intervention and really fine-tuning in their management so in the penetrating uh mechanisms we're going to start with talking uh just generalities here all right so priorities we already talked about this is to identify the wounds de decide whether the wound needs an urgent operation and then if it doesn't determine whether the wound needs additional testing so you see up here uh is a picture of somebody who got a gunshot wound to the left external iliac artery and vein and it was repaired with a segment uh with a 8 mm poly tetral ethylene graph basically connect the vessels uh and then a Venus an asmosis anend an asmosis all right when this came in it was probably just a bleeding hole right so primary survey secondary survey they were like cool pack it stuff it stop it try to get in stasis check thisal pulses and as they further evaluated that wound what they actually found was that there was a continuity in one of the vessels right which probably triggered them to then take them in for a more definitive um procedure which in this case was to do a graph and then to an asmosis all right so the decision making uh for this is going to really be dependent on the anatomy of the injury and then the hemodynamic stability of patient hemodynamic stability probably being the most important thing if you have hemodynamic stability it means you have more time to figure things out if you have H Dynamic instability you don't have that time and that's going to make you pull the trigger lower the threshold um for doing something operative and do an intraoperative exploration of whatever injury we're dealing with whether it be the belly whether it be a vessel whether it be in the chest all right so the efforts in resuscitating a patient should be uh to get adequate IV access initiate blood initiate blood products and then transport the patient into to the or if they don't respond to the resuscitated process it is not to resuscitate to stability we talked about that yesterday right we're not resuscitating until they get to 120 systolic and they techic cardio goes away right we're we're resuscitating to see if they respond to it to give us more time to get more information to make a better decision and if we can't get that then we're left with having to make an interoperative decision to explore inter operatively and that's not ideal but sometimes necessary does that make sense okay so we'll start with the neck so depending on where in the neck the patient is experiencing a penetran trauma kind of Drive certain decisions okay but the big takeaway here is that what we're looking for because in that contains a lot of vessels is we're looking for hard signs injuries of hard signs of injury of the neck so those hard signs are very similar to the hard signs of vascular trauma that we talked about in vascular so expanding hematoma in this case because there's also the trachea and the esophagus crepitus forcus bloody cough saliva drool strier dysphasia excessive bleeding hypotension those are all signs of hard signs of injury in the neck and so in those cases we assume that the platisa muscle here that separates the compartment that goes into the neck we assume that's violated and these people need management that that is surgical so in the emergency department really all you're doing for these patients is going to be get the airway if they're bleeding they have an expanding hematoma get compression on that try to control it as much as possible get IV access so you can resuscitate them maybe a chest x-ray because that's part of your primary survey maybe a fast because that's part of your primary survey then need to get to the O hard signs neck injury o good right a neuro exam is important to do if you can get it right especially if if you can get that information from EMS from paramedics ahead of them arriving to you uh because why why is that important your exam for neck injury I think that can like lead to a stroke or something like that yeah it can it can involve vessels that might under profuse the brain so you could get a schic brain injury as a result of neck trauma penetrating neck trauma otherwise if they're hemodynamically stable without obvious injuries meaning it's not obvious that the platisa has been violated then you basically have time to further assess and the CTA the angiography of the neck is the best one to rule out any vascular injury or aerody digestive structures being injured all right the zones that you see up there are kind of right but we'll talk about it here for a sec so again the point of the slide is penetrating neck injury hard signs go to the O hemodynamically stable not obvious that the pisma has been violated we have time to get the CTA okay in the zone what we do is depending on the Zone because the zones contain different structures Zone one starts at the the thyroid um it's the hyoid actually and goes all the way or the clavicles to the hyid and then zone two is from the the CID all the way up to the angle mandible and zone three is from angle mandible up all right those different zones contain different structures that require different operative approaches to be able to get to them if we have to repair all right so in the Hemo dynamically unstable patient with hard signs zones don't matter you're going to explore that surgeon is going to make an incision from a along sternomastoid and they're going to enter the neck and they're going to figure out what they what they need to chase if they have to go into zone three sometimes they have to dislocate the manable to be able to get to the structures there all right so point is though if you got hard signs you're going to the O if you don't have hard signs you're stable depending on the Zone all of them are going to get the CTA but if you're in zone three for example it's pretty important get a CT head right got trauma up here is a really good chance that you might have trauma in the brain Le gossip is going to be really important in zone one for example an EGD and the Bron is going to be important because there can be ins sop deal injury or tracha okay not so important that you memorize that about the zones again the point is hard signs you go to the or no hard signs you got time get the CTA penetrating that get okay any questions on that so for the chest uh unstable patients with thoracic injuries there's a low threshold to put in the chest Tu all right because we assume there could be some tension physiology that's causing that whether it's caused by air or sufficient if you have a sufficiently large Horax that can also cause it chest radiograph is a really good initial test to kind of give us more clues if we're unsure um and then sometimes because the hearts in chest we got to be worried about that depending on the mechanism so a cardiac wound uh if suspected can be best evaluated by ultrasound at the bedside and that's part of the fast isn't it right all right so if they're persistently unstable without evidence of intrathoracic bleeding or paracardial tonon especially if injuries occur below the nipples in the penetrating variant we need to be suspicious that there could be an abdominal injury that looks like a chest injury right if you have an abdominal injury or a chest injury below the nipple line going this way in this trajectory it can actually violate diaphragm and then cause bleeding inter abdominally right and so we should keep that as a suspicion after all we know that patients bleed where chest abdomen all right good so in blood mechanisms thoracic spinal cord injury can cause autonomic dyslexia and lead to neurogenic shock that kind of picture but we already established that patients are dying from what first hypmic shock then then yeah nice got better at this all right um the good thing about chest trauma in general whether it's penetrating or blunt is the overwhelming majority of chest traumas managed nonoperative that's great news that means that patients who are pretty sick from chest trauma are actually going to respond they're very likely to respond to a for C to right to test you and so you could do a little bit of volume resuscitation right give them some blood if they're losing blood uh and put a chest tube in there and a lot of times that's going to take care of it a lot of those bleeds in the chest are self-limited meaning they're going to stop on their own and that you'll achieve hemostasis so what you got to do is remove the blood that could be potentially causing you know shifting of structures and if left behind are going to cause things like impas because it's in the plal space right so we got to just get that stuff out and then patients tend to do okay but there are times where that chest tube that D cosom tube has to be converted to a doroty we actually have to uh deliberately open the chest and go in there and take care of something because mostly because the bleed didn't stop there are cases where the bleeding is not self-limited the chest tube is insufficient to uh definitively address the problem and so we have to do a th urgent thoracotomy okay that thoracotomy happens in O that's different from an Ed thoron we'll talk about that during the the chest trauma lecture and we'll preview it here today all right so the reasons to convert a chest tube to deliberate thoracotomy in the O is if that initial chest tube output when you put in that chest tube is greater than 1500 CC I pre previewed this with you guys during our lab and talked about the pleurovac and where that fluid line um can get up to and if that initial output is rated 1500 this is a big bleed this bleed is not going to stop on its own with the chest so we got to take that guy to the o make sense the other one is if they have a persistent Le right we put in the chest tube looks good maybe they're hemodynamically staish and we admit them to the ICU but the tube keeps putting out 200 CC's per hour for the first three hours of blood right that means that that's a moderate that's a modest bleed that is not stopping and it won't be sufficient for the chest to stop it we got to go to the O and we got to fix that then there's a a chance that you continue to bleed should what you should expect is when you remove the blood in the hemothorax that there's no more bleeding happening and that makes us happy right we can then eventually remove the chest tube and assuming that the patient is hematic we can do nothing else sometimes it doesn't meet those two previous thresholds I talked about and there's just a small persistent bleed despite us putting you know two chest tubes and you know repeating physical exams on this patient so if there's a small persistent bleed then we also need to take him into the O eventually for Thor the other one is if you have a major tracheal bronchial injury right meaning the trachea or the bronchus right any of those branches that that are big enough usually I think they say if it's bigger than a centimeter or something hole like that you're going to get a persistent uh air leak and that's unlikely to heal on its own if it's small enough you can you can get away with leaving it alone so that's why I say major tracheobronchial injury and how are you going to identify major bronal injury in a patient on physical exam who has a chest tube in talk about it in the lab okay so yeah you you could see subcutaneous osma but you could see that in numor as well and it can potentially resolve on its own so it doesn't it's not confirmatory or even makes us super suspicious that there's a major traal bronchial injury huh so in that florac that three chamber system we talked about there's one little system that's the water seal the blue water bubbles right when we put a tube in there and there's a numo we expect the air to come out of the plural space and so that air is going to come into the water seal and it's going to create bubbles yes if all the air is removed from the plural space and we have a closed system what should happen to those bubbles they should stop what if they don't stop and it continues continues to vigorously bubble and you've checked your equipment and everything's still good is the leak it's in the patient and they might have a major tracho Bron okay persistent air leak in your plur and what happens if you put that chest tube in the patient and what you get out of the chest tube is a bunch of gastric contents you send it out because you're like I don't even know what that is and the lab comes back and they're like there's a bunch of amas in there where does amas live panc the pancreas but where else does it liveo which means it lives in what two esophagus right so if you have a major esophageal injury if it's big enough that needs to be operatively repaired you can't just take care of that with test so major Sage injury can be a reason to Urgent Dy as well that's all different than an emergency or emergent thorocotomy and Ed thorocotomy okay Ed thorocotomy is a last last Stitch effort to revive a patient that's bleeding from an unknown place okay that's all is we're opening the chest we're cross-clamping the aorta we're shutting everything off with the exception of the heart and the brain so that we can buy ourselves time and go find the bleed and get Source control all right so basically the indication to do that is when a patient loses Vital Signs just before or just after arriving to the Ed we do that in the Ed B okay we'll get to that and and um show you how that's done and and when to do it and all that when we get to the chest trauma lecture okay I just want you to make sure that there's a difference right thoracotomy doesn't mean I'm doing an Eed thoracotomy thoracotomy just means I'm making uh opening into the chest to get into the chest got it and that's different from aor okay so read your questions carefully all right penetrating trauma to the abdomen the abdomen is tough um especially in the blunt mechanisms we'll get to that in a second with penetrating mechanisms uh we really can't assess very well what's happening uh in terms of like what's exactly what's injured so in these cases we want to as much as possible be able to get Imaging to kind of figure that out but at the very least get Baner abdominal radio graphs to figure out what the trajectory is of of the thing that's penetrating and there is a difference between low kinetic and high kinetic penetrating trol right if I have a low kinetic Stab Wound that's shallow to the abdomen I might not need to do anything about that right I could have an HB positive patient you're syon when we do that and that might just mean the local wound exploration and see you later you're good to go if I have a high kinetic gunshot wound to the abdomen that changes the map right now you're violating the fascia you're in the perum and God knows what that bullets doing it could be tumbling it could be damaging all kinds of structures so all bets are off there all right so typically if the patient comes in with a penetrating abdominal trauma and they're unstable they're going to the o that's usually the case Okay stable patients with t training abdominal trauma really depends right because I said the kinetic energy matters so it really depends on the patient uh a laparotomy is usually reserved for patients with penetrating wounds that violate the paral cavity okay in most cases if it's penetrating the paranal cavity and it's causing major bleeding or ruptures a hollow viscous organ that's going to almost immediately cause a peritonitis and we've said already in Block one somebody with a distended diffusely distended abdomen that's rigid that W move in their bed because it's so tender is what par that's a surgical belly that's an acute surgery belly that's an acute AB all right so most of the times the penetrating injuries happening in the anterior abdominal wall it violates the fascia and it's in the paria most of the time you're going to go to surgery there's exceptions to that we're going to get to that when we talk about the abdominal trauma lure but going back to the shallow injury you could have shallow injury that penetrates peritoneum or penetrates fascia goes into peritoneum and hits a solid organ IE the liver it's very shallow it's isolated it's a singular injury we said penetrating traumas are localized a lot more than blunt so in those cases that's a rare exception where we can actually get away with not necessarily doing a major surgery and potentially non-operatively managing that all right again we're going to revisit that when we get back to the abdomen the abdomen is tricky sometimes too we can get tangential injuries so a high kinetic gunshot wound while we would expect if it violates the anterior abine fashion and goes into the parum it's going to mess all kinds of stuff up right but sometimes it can you could get a mere fleshman and it hits the periphery of the the ab right and it stays in the soft tissue like this picture I'm showing you here so it's tangential tangential meaning it's right off off of the side of the peral cavity also known as luckiest man on earth right but the mechanism makes us concerned because just by looking at it do you know that the vi the perum has been violated or not no you don't but they're totally stable and clinically they're they're fine so a lot of the times what we can do is a laparoscopy so we take the the little incisions we make holes we go in with our uh laparoscopy approach and we have the little camera and we can actually look around and see if the perum has been violated yeah so if you send a tube into the hole what what are you going to get out of that potentially so you're kind of talking about almost like a lavage yeah you could uh but a laparoscopy is going to give you better definitive answer on that because all the lavage or a tube is going to do is tell you if stuff's bleeding there yeah so the and we'll talk about why the lavage has has come out a favor mostly it's because of the fast because the lavage and the fast is going to identify int peronal fluid we're getting ahead a little bit here but that's okay it's going to identify int peronal fluid tube is not going to identify whether the perum is violated elsewhere so the whole idea of the laparoscopic thing is that we can look and if there is no violation of the peritoneum we know that the Imaging tells us it's tangential then we don't have to do a highly invasive unnecessarily unnecessarily highly morbid surgery that's an exploratory laboratory because that makes it saves the patient this major operation that was unnecessary because we because we took the camera and looked around and confirm that this was in fact tangential and only tangential does that make sense all right these are kind of foundational Concepts all right good so some stab wounds if they're shallow and patient's completely uh stable um you can have just straight soft tissue injury right somebody like gets stabbed with box cutter they're like cutting a box of then stab themselves in the Aben and I taking them to the o no that doesn't even make sense right they're going to show up to the O and like I cut my belly right like the insulin injectors right do they they put the little insulin needle on the belly and give themselves insulin are we concerned that they violated the fashion and they like got a needle in their parum and potentially cause a hollow viscous or injury no right and so like very shallow superficial uh penetrating trauma can be managed uh with local wound exploration we can just make sure door kind of open up that incision go down to the fat and make sure the fat is intact FAS is intact that's confirmatory that it's not in the parum as long as they're hemodynamically stable we can actually even send them home that same night we've done that before um so a story comes to mind I was on the shift one night and this um dude came in and he was running his mouth at a bar and got stabbed like three times and he got stabbed with a shallow object which he actually brought him uh so he was able to like grab the guy after the third time stabbed him and the guy like just ran off and left the knife so he brought it in it was pretty shallow and so the trauma surge at the time I was like well he's got stabbed he's stable but he's going to the CT send him the CT and in my head I was like we're going to go do at least a laparoscopy and the surgeon came over to the bedside and he was like now I'm just going to do this wound exploration at the bedside and want to go and I was like whatever I like that's weird and he did and then basically he was like yeah he's good want to sew that up and then you know just leave them to the Ed to discharge so we told the guy we're like hey you're good you're going to you're going to go home tonight and then he was like pissed he was like I just got stabbed what do you mean I'm not gonna die I like no you're good stop running your mouth um so yeah so you can do that uh retr parital structures that's where it gets a little tricky right so anterior abdomen is one thing retrop peronal penetrating injuries is different because they're notoriously difficult to identify right um and the retr peronal structures are pretty critical so what's in the retrop parum that would be super concerning yeah kidneys is probably the most common organ that's injured solid organ but but these giant tubes and a pancreas oh that's right so large vessels exist back there and so um and the belly can hold a ton of blood before they start manifesting symp symptomatically right so up to like three liters or maybe more um so if they're unstable they come in unstable with a retrop Partin Neal injury that's almost always an indication to do an immediate lap we're not going to mess around it could be an IVC injury or something like that we need to go in there and fix it they're stable we have time but it's really hard to figure out what's going on so we're going to get Imaging and all that we're going to do more testing especially like digital rectal exams so if we see blood on the rectal exam that's an indication that there could be like a sigmoid injury or something like that all right gross Huma probably the biggest indicator of a bladder or kidney injury or kidney injuries basically you see humu in a patient you assume they have a kidney injury right that's a proven otherwise and then you could do double or triple contrast CTS or CT tractography for penetrating trauma tractography is putting D into the track of the injury to see if you can follow it to the site of the suspected injury all right so most uh retrop peronal colon injuries are identified on the basis of extraluminal gas or or basically extravasation gas and fluid from the contrast and yeah and if you have a suspected rectal injury It's always important to do a signal right so if they're stable it's difficult to evaluate sometimes they don't declare themselves until a few days later it's also important to understand that these people should get serial abdominal examinations and you shouldn't necessarily let them go when it's retr paranal you probably need to watch these people for a little bit before to go okay make sense all right so that's we did Ne chest abdomen now let's talk about extremities um really the the big thing with the extremities is is the hard signs we want to know if the the extremity is a threatened limb if it is a threatened limb that's a trigger to jump to an operate procedure right especially if there's paresthesia neurological deficits or absence of pulse those are reasons to get vascular involved immediately if it's a concominant bone fracture like a femur fracture then Oro needs to be involved sometimes both all right so it's important to get IV access but not on the injured limb right that's kind of obvious what we shouldn't try to do is the blackhaw down blind clamping a vascular structures right especially arteries because arteries tend to clamp down and they tend to run away from you um if if vessels are injured uh It's always important to remember that if there's going to be some kind of vascular repair that that can a reperfusion injury after the repair because we have to get proximal distal control of the vessel and so that whole area of the body is going to be esic for period of time while the vessel's being repaired and that can cause um reperfusion injury and that's why a lot of these patients will get prophylactic fascio especially in the extremities okay so search for those hard signs of arterial injury again those are external bleeding like massive external bleeding absence of pulse or even diminish p palpable Thrills and audible brewey um that's it if there aren any signs of distal esmia you have time okay you can get more imaging so the CT is going to be in the cards for this patient as long as they're stable if they do have signs of D esmia then they need to go straight to the o or potentially to angiography with Interventional Ral sometimes you have a vessel injury like let's say yeah sometimes you can have a vessel injury that has collaterals it's bleeding it's not stopped but it's not necessar something you have to primarily repair and you can angio embolize that vessel so that's why you can do some of this stuff in in the angiography suite okay on time so fasciotomies um remember vascular injuries reperfusion uh injury as a result of vascular repair and so fashion alies are commonly done in those situations they're also done uh with major fractures like the classic is like the tip FIB fracture that's really bad and a lot of swelling it impedes uh Venus return Burns snake bites can also be reasons to do fasciotomies so uh in those cases it's more of a result of that compartment syndrome so the compartment pressures increase um and and you get the six PS right pain wmia parathesis paralysis pul power this is not a benign procedure okay so it's a pretty morbid procedure it takes somebody with a lot of experience to be able to do it correctly um but usually you're going to in a trauma patient you're going to think about fasciotomies and Vascular injuries usually if there's a com combined arterial and Venus injury that's almost guaranteed you're going to need bad massive soft tissue injuries so think think of crush injuries uh delays of repair for injuries that needed it so like a tip FIB that wasn't repaired for a long time prolonged hypotension and an excessive swelling leading to high pressures in the compartments all right question for you 18-year-old man is minute in the Intensive Care Unit following multiple blunt injuries approximately 12 hours ago he reportedly fell from 40t and subsequently landed first feet first his injuries included bilateral FEMA fractures he's not noted to be confused and appears to have difficulty catch his breath his pulseox is 89% uh despite administration of 100% Oxygen by face mask his lungs are clear to alation bilaterally his chest x-ray reveals clear lung field Bilal and a normal cardiac which the F his best explanation for does this is Flashback yeah who says pulmonary contusion ult pumo IC psychosis fat ulis all right Adis yeah F good job okay let's do a couple slides and then we'll take a break all right so now we're going to talk about blunt trauma all right so super common in the civilian sector uh everything from Falls from standing motor vehicle accidents motorcycle crashes assaults closed head injuries common with blunt mechanisms extremity fractor are common chest trauma abdominal G trauma is still also common okay so the initial screening for blunt mechanisms because we said in Blunt mechanisms there's more damage right when somebody is hurt sufficiently to get brought to a hospital due to blunt mechanism there is significant kinetic energy behind that and so we expect there to be surrounding structures to be injured uh beyond what we initially see right especially in the belly so the focus is really to figure out figuring out who needs to go to the O immediately so who's unstable stability of the patient is the most important thing in Blunt mechanisms so um initial screening is directed to identify the El completing that necessitates immediate intervention and screening is going to be again chest abdomin pelv right because that's where patients bleed from so the test radiograph is super important to do on blunt mechanisms because it's going to give you evidence of in thoracic bleeding uh it can also help you confirm the location of the tubes you might put into to that patient and then Central Venus C catheters if you put those in as well it will give you P fluid line show you num thorax all that stuff okay Hemes we said need to be drained promptly with thomy tubes or chest tube uh and then hopefully we can put that in an auto transfusion canister and potentially give that blood back to the patient if possible all right and then continued bleeding needs to be monitored carefully sometimes we got to convert that thoracostomy to a thoracotomy just the same as with the penetrating trauma for the same reasons if you have a persistent bleed a bleed that initially gives you 1500 cc's or more out of that chest tube or you have 200 CC's for the first three hours all right so that's chest it's kind of more or less the same as penetr it's this one that really is your money maker okay so this is where where and why the fast is so important what does the fast do in the belly it identifies free fluid right doesn't identify air very well doesn't identify discus injury it doesn't really identify even solid uh organ injury it simply is kind of a binary hey is there free fluid in the abdomen or not okay and if if there is in the setting of a hemodynamically unstable patient that came in as a result of a blunt mechanism that is an immediate ticket to the O you stop everything you're doing you're go into the O for an exploratory laborant that make sense I'm gonna say that again right so somebody who has a blunt abdominal trauma they're hemodynamically stable unresponsive to your resuscitated process I giving them the stuff they need and they're the same or worse and they have a positive fast they're going to the O got it unstable positive F I think I want to double check I think said human human dynamically stable unstable unable sorry if I said stable I didn't mean to say stable I unstable hemodynamically unstable positive fast go to the O okay so what if I have somebody who's hemodynamically unstable or you know uh blunt mechanism positive fast but they respond to my resuscitative process blood pressure comes up the tactic cardia goes down send to the O I hear side chatter do I have time did I buy myself time with that patient yes because not all bleeding in the belly is as bad as you think in fact as we'll learn in the abdominal trauma section solid organs that exist in the belly the liver the spleen are managed nonoperatively the overwhelming majority of them will you get a positive fast if you have a bleeding liver yes yeah that doesn't necessarily mean you need to go to the O right so if you're stable enough to get the CT you get the CT okay but if you're hemodynamically unstable positive fast and you're staying hemodynamically unstable we go to the O make sense all right and what that does is it buys a patient time you you're getting that patient immediate treatment that they need now and not wasting time doing more resuscitation hoping for the best and trying to get the image right you could see 20 30 40 minutes get burned trying to do that I've seen it in real life like experienced surgeons messing around with cardiogenic shock reasons for the patient being sick and the whole time they had a positive fast right and you're and you're missing the thing that's killing the patient so those are precious minutes you don't want to waste okay so um the belly is tough in all injuries because it Harbors a bunch of blood it can sequester about three liters before they start becoming symptomatic and then add to that a drunk patient right like drunk driers are and or other injuries distracting injuries like a femur fracture and all of a sudden the belly exams pretty unreliable right so that's why the the hemodynamic status that fast becomes really important um so yeah that's what a fast looks like we're going to show you a video of what that looks like um when we get to the belly uh lecture and then have you guys done that you guys haven't started your eem that ultrasound stuff right and you're going to get a bunch of reps and you're going to get to see you know the structures that way as well all right let's take a break let's come back uh say let's just come back at 5 after tunnel VIs [Music] over up iard somebody Jun talking I would take our Junior we had a good Junior like knowing like this yeah I like with sheet like she has what I would call be like don't know what that means got go back I used her sheets and I just compared it to the slides and then stud the slides good sem just Str okay you you already take home no just got wait on that want yo Andy what was the spot in um in Austin that you said that like not the young cats hang out but all most of the older people uh rainy Street Rain Street rainy how youg that it's his name there's only so much R man there's only so much that this thing can it's your name rolling makes sound like machine oh yeah what is that like trying to kind of yeah you want to say small there two more I grew up in Texas I played against see Irish need to it's IR we'll blind you in the sunlight Nathan had his appointment and apparently they brought one of those cometer that his appointment yeah that's a chill pediatrician I mean you like kid playing or kid playing to little to do anything else you know they over there they can ask questions doesn't have but she'll just grab like whatever be like oh or she'll like grab always does she know in school but out right now back they got one point so they have to play can't but it's still like just like right your scrolling through [Music] what get They're Not Afraid just making sure all right so we left off with abdominal trauma so we said chest AB we're on the blunt mechanisms and now we're at the P part of the primary survey or sorry secondary survey is to do a really quick pelvic examination want check the pelvic pelvic instability there's pelvic instability in hemodynamically unstable patient there should be concern that there're bleeding in the pelvis okay difficulty becomes distinguishing whether the bleeding is happening in the abdomen or it's happening in the pelvis right so the the fast again is why it's so important question if the perum is violated so if the sack is otherwise no but if there's like a penetrating me yeah and so that's why you're like oh which one is it right so theoretically though if it's just a pelvic fror you should have a negative f in right and so if you're hemodynamically unstable chest is good belly is good then the bleeding is happening in pelvis especially if it's unstable on your exam do that make sense so the pelvis can hold a lot of fluid as well um so what we try to do with the pelvis is to reduce the volume in which vessels can bleed into so we put a pelvic binder on right we do that for all pelvic injuries now I know that there are some pelvic injuries and if you bind them it can make the injury worse got it but initially during this acute period we were're more concerned about the bleed than making the fracture worse so we're going to put that on out of a abundance of precaution for the bleed concern does that make sense okay awesome um when the pelvis bleeds it's usually going to be if the posterior elements are involved so the pelvis deres stability from the posterior sacral iliac joint um from the posterior Columns of the pelvis so we'll talk about pelvic cers here in the next lecture and usually if you have a vertical mechanism a vertical Vector for the for the pelvis so the mechanism matters that's where you're concerned for bleeds happening bleeds in the pelvis are usually Venus and that's good news because Venus bleeds are less concerning than material beds right and so we can find a pelvis or potentially xfix a pelvis if the anterior Venus bleed is the is the cause and then stabilize bleed that way when it's arterial all bets are off you have a bleeding artery you got to get in there and stop the bleed and so if there's no evidence of abdominal bleeding they're unstable it's coming from the pelvis these people and they have an arterial bleed they need to have things like external pelvic fixation uh or paranal pelvic packing pelvic fixation better for Venus bleeds um arterial prepar to neop pelvic packing in the O you just have to pack the space and hopefully try to Tamp no that off while you can isolate the bleed and then get that okay had a uh isn't here but he he probably remembers him one of our our Ranger buddies had a mishap um in in the parachute malfunction and landed on his butt uh and had an open book pelvis fracture and he transected both of his iliacs his internal iliacs so we were a able to get into the uh hospital um Andrew emation wasn't even an option he was so unstable so I was able to scrub in and go in there with Trump surgeon and clamped off the comment uh at that time he bled out so much he was he was kind of toast but it gave us enough time to keep them alive to bring the family down basically say goodbye but when you have an Archer Ro lead it's super tough because you have a bony structure here you got to get in you can prepare to meil pack all you want but you got to definitively get to those to the bleeding Source um and those are pretty big pipes so they can bleed out pretty quick all right brain um so blood trauma in the head again we we talked about in Block one how that third uh peak of deaths happen in the ICU usually from complications of multi-organ damage or multi-organ system failure and then uh sepsis and then uh uncontrolled or untreated ICP in cranial pressure so Clos head injury is really important Clos head injuries have been become kind of the Forefront uh for additional Management in the last Wars that we're involved in right a lot of iids closed head injuries uh so there's a lot a lot coming out on things that we can do at the non- neurosurgery level that we can do to manage that we're going to have a whole elect Dr all right but 20% of blun trauma patients are going to come in with a significant TV die um so the key with these is they can be a distractor because we said people die from bleeding then cardiogenic shocks then neurogenic shock right so they can be a distractor it's not that it's not important and that we don't need to address it it's that we need to address the other stuff first okay but the big thing that we're trying to identify in a patient with a tvi and a blood mechanism is whether they will benefit from early intracranial monitoring of the pressure we'll talk about what that is in the head lecture and then those who need need emergency neurosurgery so who of these patients do we need to call neurosurgery for there's actually a laundry list of criteria we call if anybody's over a big two criteria you don't need to worry about that that's usually when we call neurosurgery because it's not something that we can manage even as even a trauma surgeon it requires a specific neurosurgeon to go in there and do their thing all right but it is super important to know what the initial uh GCS is so that initial GCS in the field is critical and and then usually if somebody has a GCS less than nine or they have been lateralizing signs or neurod deficits then this usually Clues Us in that this is somebody who could potentially need an emergency promy all right CT head of of the head is the most uh useful test to do non-contrast to identify those bleeds in patients who are stable enough to undergo CT okay so we'll talk about what we do for these um a little later so there it is CT is the initial diagnostic tool of choice uh Clos head trauma is rarely the cause for hypertension so we talked about that hyperic shock cardiogenic shock then neogenic shock or TBI so we talked about competing um injuries and what's what could be the priority you could have somebody who has such a significant brain injury and increased in ICP that they are showing evidence of that they have the neurological def they have a GCS less than nine and you're you're waiting on neurosurgery and they're also having you know a parenetic abdomen and all of a sudden they start posturing and you're like what's going to kill them first the herniation or the bleeding in the belly right you're like what do I do what do I do what do I do what we said was Whenever there is uh concerns of the priorities the best and safest place to take the patient is okay so in inter cranial pressure in can be important for in certain cases and decompressive craniac can be important for people who are demonstrating significant ICP increases um there was something I wanted to emphasize here look my not oh yeah so there are things that that we do right it doesn't mean we do we don't do anything somebody has a TBI if they have other injuries at the very least you can do certain things to manage the ICP right things as simple as elevating the head of the bed to 30° right help gravity kind of reduce some of the ICP pressure and we'll talk about other treatment modalities when we get to the specific head pressure okay things like hyperonic saline manol all those things most common injuries that you'll see or findings you'll see in the head C are these it's going to be your epidural your subdural and your subarachnoid again we're going to review these at length when we get to the Head Trum lecture but the epidural um hematoma I always think of when I look at that image it looks like a convex kind of caved in you know uh defect so I think of like if I were to punch the brain here I would leave a dent in that direction right that's epidural subdural is more Crescent shape some moon shape uh and then subarachnoid is in the subarachnoid space so it's going to look more like that and what's usually the cause of an epidural bleed what uh what artery uh middle menal middle menal and then this is the one that has like a lucid interval right yeah what about the sub old people yeah exactly and then what about the well the subid is in that's self-explanatory the other thing that you can see and we'll talk about during the head lecture is you'll see a lot of um contusions in the brain so you can see like these little punct tap contusions around the brain um um and that can also be a clue to uh brain damage you also see a lot of gray white matter differentiation that is lost so you'll see basically like a more homogeneous appearance of the brain um and again we'll review that in detail at a later time Blood traumas also should make us concerned especially things like motor vehicle accidents should make us concerned for cerebral vascular injuries so the vessels around the neck leading to the brain all right we used to think that incidence was as low as 0.1% problem is when they did present they all presented symptomatically and when they presented symptomatically it was in a delayed fashion meaning in reality we were missing the injuries and they were just presenting later and when they did present they had really bad morbidity outcomes so as high as 50% so then we started to change our management of this right and if certain people had certain mechanisms and certain signs and symptoms we added to the pan CT scan specifically the CT of the neck the CT Angel of the neck to evaluate for cerebrovascular injuries or bcvis and what we found was there was about a tenfold increase and probably more in incidence to bcvis depending on the mechanism and the overall incidence is actually between 1 to 1.6% so still low meaning we don't have to do screening on everybody but it is a lot higher than we thought previously all right and this can kill people right it can make them stroke out so CTA of the neck is considered the gold standard for that so quick story and I'll move on um one of our Rangers jumps out of the plane somehow gets the the static line get catches him and he gets dragged on the side of the plane right um they pull him back in he comes to see me to see me the next morning I didn't even know it happened which is not a good thing right and he's got this giant like freaking bruise across his neck and immediately I was like hey you feeling good he's like yes I'm doing a neuro exam and he's having like some difficult of moving his neck or whatever um and I couldn't really tell if he was having a neural deficit or not but um I was like hey I saw this in a book somewhere I think you might be at risk for bcvi so let's get you an image this isn't him but we got him an image and he had like a very subtle Lumen uh uh on a lucency but also a Lumin narrowing and I think it was his external kateed uh so it was enough for us to put him on like a blood thinner for a little while right but in major trauma this is what you're trying to catch okay because this could lead to an es schema event of the brain or potentially cause a clot to form there that breaks off and then causes a stroke in the patient all right so what do we do how do we decide who to get a bcv screening on is we use there's a couple we could use the Denver criteria or the Memphis criteria the other one you don't need to memorize this please don't memorize this I'm not making you memorize this all right what I'm highlighting here is the things that are clinically that clinically make sense to make you want to do this High kinetic energy causing things like a massive soft neck injury like a seat belt sign around the neck expanding hematoma hard sign of the neck in a blunt mechanism right basically it's the same as with the penetrating but blunt if you see hard signs of neck injury in a blunt mechanism that's a concern for bcvi make sense don't memorize this chart please all right for the chest we kind of already talked about that with the chest really we're looking out for Major things like rib fractures pulmonary contusions that are going to cause breathing problems uh major cardiac injuries to include cardiac vestil right ventricles usually the most commonly part commonly injured part of the heart and the blunt mechanism just because of the anatomical location and then the big vessels right things we've talked about already like uh dissections or transsection transsection and otherwise people are probably more common a major blunt chest traa so before we get into that let's talk let's do a question so you have 43y old man that was involved in motor vehicle crash actually motorcycle crash when the bike slipped on the wet pavement and hit a tree Emergency Center is noted uh he is noted to have multiple rib fractures a right tibial fracture and a left forarm fracture during monitoring in the Ed he is found to have a brief period about 3 minutes of super ventricular Tech of cardio that resoled spontaneously which of the following is most likely ideology of this Rhythm abnormality is it anxiety fat ulis blood cardiac injury caffeine induced arhythmia or pain pain C cardiac blunt cardiac injury right you have to assume that he's had a major trauma to the chest that cause myosite insult that is causing an arhm okay then you can blame it on the other stuff have all that stuff checked out all right so rib fractur is really really common rib fractur not that big of a deal as long as they are not excessively distracted angulated right um they are very painful though and so the thing that we worry about with red fractur is that people don't take sufficient breaths they don't inflate their lungs sufficiently they don't take enough title volume and they take their breaths and that leads to collapse of the avoli that leads to adasis that can lead to pneumonia that can lead to all other kinds of pulmonary complications so that's really what we're concerned about the other special consideration is a patients have high rib fractures so that first rib fracture can be associated with blunt cardiac injury and major vessel injury so look out for that have a low index of Suspicion for that when you see rib number one being fractured what am i showing you in picture B that guy just lazy or tired you can't really see it but he's got myosis he's got Tois he's got hor syndome I thought you said Horner syndrome was only for cancer did I say that no it's not anything that Pines on that game going now is going to cause that same manifestation Corner syndrome right so if you have a first RI fractor and you have like a hematoma or some kind of laceration happening at that level that affects that sympathetic inovation then you can have burner syndrome all right flail chest is the other thing it's like basically a really bad rib fracture but it's in two ribs in at least two different areas creating a free segment and what you'll see that as on on exam is a paradoxical breathing of the patient so when they breathe in it depresses and when they breath out breathe out does the other or breathe in yeah it depresses breathe out does the other so you should also expect that there's a lot of high kinetic energy behind that thing that that mechanism that caused the flail chest and you should expect to see a pulmonary contusion directly behind that flil chest if it doesn't present immediately it could present in a delayed fashion so you always keep that index of Suspicion high in those cases because these patients have a lot of pain it's like a really bad R fractor because it's multiple in one in two separate areas and they're going to need respiratory support big time they're going to need epidurals for pain uh and they're going to need to need some help with keeping their lungs inflated if you have a bad enough uh flail chest um or you have a reason to go into the chest for another reason you could do this stuff right here down here which is rib plating okay but rib plating is basically it's just internal fixation of a rib fracture rib plating is rarely done it probably needs to be done more a lot of the literature is suggesting that patients could potentially benefit from early rib fixating but right now we don't necessarily fixate the ribs in the flail chest we still give them a chance and if if need be we could potentially do this okay the rib plating when we get to the chest traa lecture is really more when these ribs are really really separated and angulated and you kind of have to go in there and basically repair the chest wall and this case you're repairing the ribs the bones as well numores we've beat this dead horse so you tell me about numores so simple pumos they're usually going to be a patient that doesn't have really all that much of a concerning physical manifestation so if they're really small we don't need to do anything about that if they're greater than 20% collapse we're going to do chest tube uh sometimes you can have oul pumora pneumothorax that you won't necessarily appreciate on a chess x-ray or on exam and it shows up on a CT does it change your management nah okay uh we do need to be concerned for tension physiology because that can be an obstructive process that causes a cardiogenic shock picture in the patient so those ones we need to treat immediately with a chest tube if we have it if we don't we can do a medal chest tube compression if we don't have that we can do a finger thoc costum that's what we said in the last in the last class ultimately though it still needs a two for a [ __ ] for a chest all right question for you 33y old woman is brought to the emergency center after high-speed head-on collision with another car traveling in the opposite direction she's noted to be hemodynamically stable with tenderness over the anterior chest chess x-ray is normal she under go a CT scan evaluation with the brain chest abdomen pelvis where a 10% left in thorax is observed after C te she remains comfortable with respiration rates of 24 NO2 stats of 97% on Mo air what do you want to do a yeah leave it alone give her supplemental oxygen continue observation good job all right pericardial T nods is is on the differential for cardiogenic shock reasons for patients to die in trauma and so we need to quickly identify those because they can deteriorate pretty fast especially if you have a tampon and a fusion that causes tampon that's a reason to actually take them to uh surgery so the way we identify these we said if WEP Ed blunt cardiac trauma involved during the secondary survey that fast exam is going to be pretty important and we're going to take that ultrasound and check the heart okay if the heart identifies hemopericardium or identifies fluid around the pericardium that's evidence of of a tampon and that person just proceed to the O the procedure of choice is a sternotomy and repair of the injury all right the effusion that you're seeing why do the he here here's a question for you let's see if you can critically think through this hemopericardium happens why yeah blood but where's the blood coming from coming from wherever the injury is Right could be a a the heart itself or it could be a vessel right the point is it's bleeding into that paracardial sack so that's a concern for a major heart injury right so that's why the sternotomy in emergency medicine I think a lot of it kind of stops at the paric cardiio cesis right which which is true pericardiocentesis is going to get the fluid out so you remove the tampon effect but the underlying injury is still there right hopefully that underlying injury is self-limited and it stops bleeding and removing the fluid the affusion could be sufficient that informs why we do this other stuff so if you have uh a paric Cardon confirm on the ultrasound but you don't have a surgeon you don't have surgical capability in your facility or they're not immediately available then you can do the pericardio synthesis pericardio synthesis is to tampon but the needle chesty compression is to num tensions does that make sense yes okay so it is not definitive temporizing persistent signs of pericardio so you can have a patient that is Tech cardic they got distended neck veins but they have a normal sonogram right you don't see the affusion there uh they still need to be transported to the or clinically percing with tonot effect you just might not have a sufficient amount of infusion to detect it on the ultrasound or there is not an infusion and the reason and for that reason we take them to the O and what we do is we create a subid pericardio window so we go subsid we access the paric cardium and we put a little chest dbe in paracardial space and what that does for us is hey if there was an infusion forming because they clinically presented like they did we're going to get it and it's not going to kill them right and then that's going to trigger us to potentially go back in and figure out if we need to get Source control if we need to do a stonom but if if it was then we got it if it wasn't then fine we put a paracardial window there and we can just take it out we they can heal up really nicely you don't have to do anything else so this is kind of like the laparoscopy of the EXP exploratory lapara it helps avoid a major morbid surgery which is a sternotomy where we're opening across the chest and going to the heart does that make sense cool all right and then you could always get somebody who has a tampon and they they just tank right you didn't get to it in time you didn't get the paric Cardis or the sternotomy and they tank and then they need a resuscitated Ed thoracotomy so basically you're going to have to open the chest and we'll talk about that when we get to the chest tra blood trauma to the aortic artery or to the aorta um um so rapid deceleration and blunt mechanisms is kind of the culprate here 80% of these people die at the scene the most common site where the transsection happens is at the ismith called what all right that's where it tears okay and if you have a transsection um typically what you're going to see on that initial chess ACC during the primary survey is they wiing the assum assum is widen and above 8 centimeters that is highly suspicious for a blunt aortic injury B AI okay um or you might see obscurement of the Apex of chest known as an apical cap which you've probably learned that already in Radiology if that is present or the injury is suspected the way we really Define that injury is through the CT angio we talked about that already in Block two and these people are going to need anti- impulse control right so we're going to try to blockade them with a beta block or optimize your blood pressure so that that left ventricular outflow track is not worsening iny right so we want to get their T cardia down we want to get their their blood pressure down to a level that still allows them to produ but not further their injury more than than necessary now again most of these these people don't survive uh if they do survive it's because something held up what is it I love it all right diaphragmatic injuries are also a concern you know even though the diaphragm obviously separates the chest compartment from the abdomen compartment they can be involved both compartments can be involved by virtue of the of the diaphragm being ruptured both in penetrating and in Blunt okay in Blunt mechanisms we say that most of the tears are going to be left-sided left diaphragm versus right diaphragm anybody want to take a guess why the liver is there it's a big cushion right so we'll see we'll talk more about that during the abdomen lecture all right but we can see this as easily with uh as getting a chest extra right if you see bowel in the chest that's path demonic if you're onshore you put an NG tube down that patient and it coils up in the chest stomach's in the chest that's pathon all right and it's also going to give them some symptomatic relief all right that always requires operative intervention or operative okay almost done um Hol viscus injury can present in a delayed fashion notoriously difficult to assess especially in the blunt mechanisms um um and the penetrating mechanism is a little easier right you got a gunshot wound and it goes through the tummy and then the bowel like the large bowel and the small bowel you're going to get immediate succus immediate air that's being released into the perenium and so that's going to cause peritonitis that patient needs and that's spory laparo in a blood mechanism it's pretty rare for hollow viscus to actually rupture right but it can happen and so it can also happen in a delayed fashion you can have like a small rupture and then you're just getting a small leak happening and then eventually the patient starts to manifest with symptoms um so a lot of times what you get is a CT that doesn't really show you much it might show you a little bit of free fluid mesic or bowel wall thickening sugges suggesting that the bowel is injured but not necessarily that the bowel is spilling all right so these patients you need to be really careful with and you got to do these serial abdominal examinations just like we talked about for people with retrop peronal abdominal injuries right we just keep a high threshold that something could be threshold that something could be going on uh concerning for an hbii we Trend their H&H we do serial abdominal exam until they have stabilized demonstrated to us that there is no significant injury here okay blood trauma uh for solid organs it's pretty easy solid organs are pretty resilient so we don't do much for it we just watch it most of the time really depends on the grade of the injury high grade injuries might require angioembolization it might require surgery but most of the times we can safely observe these injuries and call day so that's why the fast is really important uh and the stability of the patient is really important they're unstable with the Positive fast not responding to the resuscitated process where do they go no if they're stable and they have blood abdominal trauma where do they go you got time you go to the CT very good so mostly we manage nonoperatively we may or may not need anization and in rare cases in high grade injuries we might need actual surgery renal trauma most commonly uh genital urinary organ that is injured in blunt trauma usually manifests it will usually manifest as humeral okay um CT is the first line Imaging that we do for that so that's a pretty terrible kidney injury but it is still a solid organ right so what did we say about solid organs and how we manage those a lot of them we do not non operably this is like a super high grade injury that probably needs surgery right um but for the non-operative guys gals uh we're going to do strict bed rest this is really really important it's a kidney right so what do you want to do to kidneys when they're injured same thing you would do for an Aki lot of water right so you're GNA give them a lot of fluids and put a fol in you're going to need to monitor their UOP and you're going to do that until they clear all the human turb basically until they Avid clear earing all right uh and then you can do a followup CT 48 to 72 hours for those with clinical signs and pendant complications right they continue to have pain or they start to become emically unstable other genital Ur urinary injuries are including rethal injuries especially common with pelvic fractures the pelvis contains a lot of that visc of the GU system um so we can suspect these when you have a pelvic fracture in the setting of a high R and prostate with blood present at the urethal metis and before we catheterize those patients we want to do a rug or retrograde rogram to make sure that a the paint C of the urethra is intact and that there is no damage then we can catheterize if it is damaged there is urethal injury then we have to do something else right we have to repair that and we would have to get um you know catheterization another way we can go super pubic there's other things that we can do but it's super important to identify that injury of you know catheterizing a patient bladder injuries also suspicious when you have a pelvic fracture and bladder injuries are best identified with IV contrast CT of the ab in pelvis and you can even do a CT syst okay which of the following radio graph abnormality seen on chest x-ray is most likely to suggest traumatic rupture of the aorta TR which is a transsection it say a b c d D is the correct answer good job all right so blood trauma it's all kind of a crapshoot really depends on the injury this chemodynamic stability of the patient what injury what organ is injured and then what are images say right to include chess x-ray abdomen and pelvis uh images hopefully they can respond to our primary survey resuscitated process secondary survey process and stabilize and bias enough time to then take them to a CT to further find injuries and we can make decisions from there so ultimately just like we said in the last lecture these patients are going to be dispositioned either in the ER if they're stable or they go to the O if they need an operative intervention think uh hemodynamically unstable patient with blood abdominal trauma right if they have uh stability or they've been stabilized they've been resuscitated adequately that doesn't mean they get to go home they can end up in the ICU uh the step down unit which is also known as Telemetry or the medical for okay so they can land anywhere along the hospital depending on their injuries and the minor patients the ones that are are minor injuries that are non concerning they can say in the Ed they could be dispositioned and released from there all right so a little bit on the icus and the different WS that patients can go so ICU think of like the highest level that you need to go to right you have to have all the services available that patient might need respiratory therapy and physical therapy and nutrition and you and nursing and all of it right so usually um this is the highest level Specialty Care in a hospital they're going to have everything from ventilators to ECMO to Telemetry uh they'll have one to one with the nurse so you have dedicated nurse that one individual patient especially if they have like you know a lot of these trauma patients are going to be alcoholics so if they have a need for uh watching the patient for withdrawal symptoms that becomes very helpful uh and it's usually multi-disciplinary appro so you have all those services available for the patient these are your really really sick patients your sick patients but maybe not so so so bad maybe they have like multiple fractures uh they just got done with a exploratory surgery but they were completely stabilized they might go to a Telemetry Flor right to uh step down and here you're going to have constant cardiac monitoring so think of somebody who had like a blunt cardiac iny uh they didn't do anything operative for them but you still need to watch them they can go here they're going to have one to three or four nursing ratio to Patient ratio and then they need usually vitals every four hours and ICU vitals are every hour that's their capability and then the medical floor it's like hey there's a guy that had a a you know numo after his car accident wasn't that bad ripped fracture needed a chest tube that's it so we're just G to watch him we're make sure that pumo resolves we'll take it out eventually let him go he's going to go to the floor gets one to six or to eight uh nursing the patient ratio and by those Q4 hours that's it guys so that's a really kind of broad overview of all of the secondary survey stuff right I know I threw a lot at you but I'm doing it early and during the secondary survey because when we start breaking down the different parts of the body and different injuries that we see you're going to see that there's a lot of overlap there's a lot of repetition in this block and that's the point the way you learn this is by things over and over and over all right so if you feel like I'm beating the dead horse on the numo thorax good that's what I'm trying to do all right uh if you have any questions I'll hang back otherwise group we start up in 5 minutes at 2:45 oh man take a Sol hour I I was going to get that that one scared me everybody's yeah I mean I list no no no get EX were you leaving ter youan you don't want to be was second here for the same reason could barely say what is it gr I had to I had to throw that there growing I've been practicing than you guys made me so conscious self-conscious just kidding I don't have feelings suckers all right um I do have feelings but they're not important what is important is talking about black three so what uh what questions do you guys have tracking so far feel like it's a lot there's like 30 different things that can be happening at the same time with patient right we haven't even started talking about complications and all that so uh really the focus is going to be here on doing like the secondary survey part of what we talked about today right so there will be a little bit of overlap with the primary survey stuff we talked about yesterday all right so you get a patient they come in um this is a 23y old dude that was hanging out and uh I'm actually going to give you a real life story so this guy was was um working for HB in the docks you know unloading stuff and throwing them in the cargo um trucks or taking them off the cargo trucks and he was like unloading a box and this is at night time and some guy comes up behind him and freaking stabs him in the throat stabs him in the neck like four times uh and leave him there ble out so he's like holding pressure on himself you know paramedics come up and gets called up and they bring this guy to FY the initial call is that there's this know 20-some year old gentleman uh with multiple stab wounds to the neck impossible to the thorax he is currently a ds14 went off for confusion he was hemodynamically stable with a blood pressure in 11s over let's say 80 and he was Tac cardic in the 120s uh spo2 is 95% on room air and they're bringing him time now they've given him a WID of pine 25 micrograms and he's otherwise doing um well all right so what are we doing you got that call what's next team yeah prep your team so you go to the eBay say hey heard what's coming in let's get everybody set up so what do you do okay sign somebody to the airway sign somebody to the left and right of the body of the patient somebody's going to be scribing all that stuff great so the patient shows up you see him unload being unloaded in the ambulance he's on the gurnie you walk up to him you immediately put your hand on his wrist and you start talking to him to assess how he looks right if he's if he's stable or not if he has at least an adequate blood pressure for profusion he's controlling and protecting his Airway he did get stabbed in the throat or in the neck and he's just kind of has some bandages there that EMS put on there he looks really nervous he's kind of breathing fast he tells you more or less what happened with broken up words and he's got a radio pulse right he goes into the eday he's getting transferred to the Ed bed and EMS starts to give report they give the same report you heard over the phone and you are ready to initiate the primary survey so started primary survey and what's happening what are the priorities okay massive exanguination so what you see is a bandaid with lots of red stuff right he's breathing on his own so his Airway is good breathing right are you concerned for breathing no if he has a Zone one injury you have a numo right you're in zone one you have to load the CL okay so maybe so but you listen to the chest chest is good uh circulation has got good pulses throughout and and disability itility is a gcs1 14 and then exposure right have you exposed them completely yet so expose them you expose the wound and what you see is four lacerations in the neck okay and you see that there is a lot of blood there's a lot of blood on the bandage it looks red kind of dark kind of bright can't really tell and when you look at the wound there's one wound that demonstrates uh like a mass that's kind of growing expanding hematoma so Drago says he's going to put some pressure on that bad boy I would agree with him um okay somebody said hard sign so that's a hard sign a vascular injury so what do we do yeah this person needs to go to the or to have a heart right that was the question question was which of the following is an absolute indication for surgical me exploration is it Venus fusing is it non-pulsatile hematoma expanding hematoma peripheral nerve deficit or history of hemor theine expanding H right what are other hard signs that might make you want to take this person to crepitus heness drooling Strider right so priorities in this case is secure that Airway which he was protecting his own own Airway and then get the pressure on the bleed to take them to the for definitive management nice job yes sir so blood product sending away yeah how does that yes and yes if if you think you need blood prodcts you call the or that's a whole dance right somebody while somebody's doing all this assessment and treatment somebody else one of the residents or something is calling up to the o to give a heads up to anesthesia and to the O uh charge nurse that you got a patient coming up to the trauma or and that we're going to need blood products we're going to need and then you tell them everything that you need and that usually is pretty quick process right yeah I mean not necessarily I'll just ask all right so got somebody holding G pressure not going to take time it pressure all the Y and then they're just to stand there while scrubs in and take over yep it's just like if you open the chest in the Ed and you're massaging it massaging the heart you're going to keep doing that all the way up to the O and probably stay there while they do the exploratory labant and you're going to be like Yep this is my life all right okay okay uh next question you have an 18-year-old man that arrives through the emergency department shortly after being involved in an automobile accident in a coma got GCS is seven all right his pulse is barely palpable at a rate of 140 uh his BP is 60 over pal breathing is rapid and shallow aing both lungs his abdomen is moderately distended with no audible peristalsis okay there are obvious anatomic deformities to the right forearm and the left lower leg uh rapid IV Administration to whole blood it's given and his pulse is 140 now and BP is still 60 overow so no change the patients write up a quadrant fast demonstrate free fluid in Morrison's pouch okay uh which so what do you think of that okay so it could be liver liver injury but is hemodynamically stable or unstable unstable did he respond to his primary resuscitative interventions no so positive fast unstable patient where do they go okay good the question wasn't that the question is which of the following findings observed in this patient is the best indication for an emergent laparotomy so is it because of the GCS of7 is it because of the lack of audible peristalsis is it because of the obvious anatomic deformities of the extremities is it because of the rapid and shallow rig or is it because of the lack of response to the initial fluid Rec excellent after the primary what do you do you stop and and check and look at the monitors and look at the patient and see how they respond and then if they're good move on to the secondary survey but this guy's unstable belly trauma positive fast not responding goes to the got it nice job okay last one any questions so far all right last one you have a 49y old man that was the restrained driver in motor vehicle collision he decelerated rapidly in order to avoid hitting another car and then swerved into a ditch he complains of chest pain which of the following okay let's stop there he complains of chest pain so voided the car turns hit in the ditch let's say let's let's ask you a few questions what do you want to know from the MS about this patient was he wearing a seat Bel initial vitals huh yeah did the airbags go off did the steering wheel hit his chess chess anything else about that initial GCS y did anybody die in the in the vehicle how fast was it going all these things right intrusion to the vehicle all of those things okay so EMS says yeah freaking air bags deployed uh he was wearing seat belt somebody died the passenger died in the car he was driving uh he was not ambulatory had scen GCS was a 13 and um his initial vitals were tachicardia and 130s and a BP of 100 so let's formulate our differentials you did your primary survey your secondary survey you identified a positive seat belt sign across the belly and across the chest you have actually some bruising on the neck you have uh deformities to the right lower extremity you have a deformity to the left upper extremity you have a massive laceration to the scalp posteriorly at the ox what's your concern what do you want to do huh concern inj aortic injury is your concern okay fine so part of your primary is that chess x-ray in the fast your fast is negative your chess x-ray because of your concern what are you looking out for in the chess x-ray wi in Med sign and that was the question question was which of the following findings on chess radio graph would be most likely to indicate an aortic injury and the question the answers were multiple right sided rip fractures that's a good distractor somebody's going to fall for that right you we fractur that means probably wind the center no no no rip fractures what would you expect behind rip fractur potential contusion right numo media Signum no a left pumo thorax no left pulmonary contusion no if you're concerned about aortic injury the wide media assignment is going to give you that suspicion right how wide is that me assignment going to be for you to be really really concerned than also second what do you guys think do you want a CTA of the neck in the SP because of the bruising on his neck mechanism fits yeah be absolutely um so long as they can go to the CT scanner because at this point they're Hally unstable so you would need to resuscitate concern here is the the the thing with the chest do you need to do impulse control on this patient your CICS were 100 you don't want to drop that syic too much right we're at where we want to be now if he was they came in and their systolic were like in the 140s you want to drop that yeah you want to drop okay uh very good that's all I got sir any questions is that helpful okay