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use full body ct scout as lodox for bullet location
LD90 for fall=7 stories
The median lethal dose (LD50) for falls is 4 stories, or 48
ft, and the lethal does for 90% (LD90) of test subjects is 7 stories, or 84 ft.
Reference: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th
ed. Mosby-Year Book, Inc; 1998:352.
Prognostic factors are height, impact surface, and the body part which first hits the ground (Crit Care Med 2005;33:1239)
Over 50% in autopsy study had cardiac trauma (in half of these, it was the cause of death), consider thoracotomy (J Trauma 2004;57:301)
ABCs in trauma room often stand for Accuse, Blame, and Criticize, Deny, Exaggerate
Anaesthetic ABCD:
Avoid
Block
Cancel
Defer
Consultant
> A appear
> B blame
> C
criticize
> D disappear
power vacuum needs to be filled
Airway-Ask patient to take deep breath (Gives A,B, and LOC)
Breathing
Circulation Search For Bleeding
Disability (pupils/moves extremities)
Expose and then cover (Strip, Flip, Touch, and Smell)
Finger (rectal)/FAST Exam/Foley
Glucose/Girl (pregnancy test)
Hang Antibiotics
Inject (tetanus)
Primary Survey
Secondary Survey
Tertiary Exam
The tertiary exam was first introduced in 1993 by Enderson et al to assist with
the diagnosis of any injuries that were not identified during the primary and
secondary survey. The tertiary survey involved repetition of the primary and
secondary surveys, meticulous physical examination, repetition of the history of
the trauma history, and review of all laboratory and radiographic studies. These
authors’ use of this tertiary survey resulting in diagnosis of missed injuries
in 36 of 399 patients (9%). The most common reason for injuries to be missed was
altered level of consciousness. None of the missed injuries resulted in death,
but one missed injury resulted in disability and seven required operative
intervention. In a second large series, a tertiary trauma survey detected 56% of
the injuries missed during the initial assessment within 24 hours of admission.
Military is switching to <C>ABC for catastrophic hemorrhage to urge immediate use of tourniquets, dressings, and hemostatic agents
BATLS
(Emerg Med J 2006;23:745)
Consider an A-line if they need blood or pressors for hypotension
Lactate/Base Deficit probably more useful then serial crits
Study of serial crits (Injury 2006;37:46)
Delta crit @ 4 hours had only 40% sensitivity, specificity of 95%. LR- 0.64 LR+ 7.1
Sodium azide is contained in airbags, shot c spark causing huge gas expansion and releasing talc, if airbag doesn’t properly deploy, then can get NaOH (sodium hydroxide,) which can give contact dermatitis
Use fentanyl 1-2 ug/kg instead of morphine
Consider SQ Ketamine .25 mg/kg then .1 mg/kg/hr. Use 26 gauge cannula in the SubQ space on the
anterior abd wall. Avoid if possibility
of head injury
delayed fluid resuscitation in penetrating torso injuries resulted in shorter hospitalization and less complications (NEJM 331:17; 1105-1109 Oct 1994)
Blood: external chest abd retroperitoneal pelvis long bone
Non-Blood: pneumo tamponade myocardial contusion spinal shock
do not assume aortic injury is the cause of shock
"janitorial injuries"
Best article on traumatic aortic disruption Fabian J Trauma 1997 42:374
new strategy of delayed aortic repair with BP/HR monitoring and control
Brain injury article J Trauma 1993 34:216
Mannitol has to be given by bolus not continuous infusion to be beneficial
pelvis injuries
lateral compression horizontal fracture of the anterior ring look at the sacrum's arcuate lines
vertical shear, tape the feet together
hemoperitoneum goes to the OR first, otherwise to angio suite
put pinky in sternal notch, index finger will be in the cricothyroid
Not true 80/70/60 pulse rule, but they will disappear in the predictable manner (Deakin et al BMJ Sept 2000)
do not need plain films after getting ct abd/pelvis, just reformat (J Trauma 55(4):665, October 2003)
Levels of Trauma Center Shitstorm
SNAFU
FUBAR
AMF YoYo
Farming-manure to vegetables
Scalea TM et al: Central venous
blood oxygen saturation: an early, accurate measurement of volume during
hemorrhage. J Trauma 28:725, 1988;
"Rookies talk tactics, experts discuss logistics"
Tactics/Strategy/Team
General Operative Management
for abd, prep knee to chin
for ext, prep entire ext and 1 unaffect lower ext
neck, prep entire chest
Lethal triad of hypothermia, coagulopathy, and acidosis
always choose the repair option which fails best
figure of eight, first bite to lift the tissue, 2nd bite to get the bleeder
(Peterson J Traum Volume 58(5).May 2005.1078-1 81)
Do not use bovine fibrin glue anymore, it may sensitize to ATIII
Bradycardia actually incredibly common and predicts bad outcome in some groups (J Trauma 2009;67:1051)
Bradycardia may be present very often in hypovolemic/hemorrhagic shock. There is a biphasic response, the first and the one we commonly think of is catecholamine surge with resulting tachycardia and increased card output. Later on, there is actually a cardiac vagal response resulting in bradycardia. This may be present in up to 1/3 of hypovolemic patients (BMJ 2004;328:451-453 (21 February))
bradycardia is more common than tachycardia in acute blood
loss (9.
McGee S, Abernathy WB, Simel DL. Is this patient hypovolemic? JAMA
1999; 281:1022–1029)
Bezold-Jarisch
Bradycardia may be present very often in hypovolemic/hemorrhagic shock. There is a biphasic response, the first and the one we commonly think of is catecholamine surge with resulting tachycardia and increased card output. Later on, there is actually a cardiac vagal response resulting in bradycardia. This may be present in up to 1/3 of hypovolemic patients (BMJ 2004;328:451-453 (21 February))
retrospective prehospital study. DNR if apneic and pulseless on arrival or asystolic or PEA with rate<40 (J AM Coll Surg 2004;198:227)
Another study shows prognosis in traumatic arrest is the same as medical (Crit Care Med 2007;35:2251)
Reasons to Omit Digital Rectal Exam in Trauma Patients: No Fingers, No Rectum, No Useful Additional Information (J Trauma 2005;59(6):1314)
Level I has only limited air elimination abilities (J Clin Anesthesia 1997;9:233)
Study objective: Most injured
patients taken by ambulance to hospital
emergency departments do
not require emergency surgery, yet most US trauma centers require a
surgeon to be present on their
arrival. If a clinical decision rule could be developed to accurately
identify which injured patients
require emergency operative intervention, then such "secondary
triage"
criteria could permit a trauma
center to more efficiently use their surgeons' time.
Methods: We analyzed 7.5 years of data (8,289 consecutive trauma
activations) in our prospectively
maintained Level I trauma center registry. We used classification and
regression tree analyses to
generate clinical decision rules using standard out-of-hospital
variables to identify emergency
operative intervention (within 1 hour) by a general surgeon (for
adults) or a pediatric surgeon (if _14
years).
Results: Emergency operative intervention occurred in 3.0% of adults
and 0.35% of children. For
adults, summoning a surgeon for any one of 3 criteria (penetrating
mechanism, systolic blood
pressure _96 mm Hg, pulse rate _104 beats/min) could reduce surgeon
calls by 51.2% while
failing to identify emergency operative intervention in only 0.08%
(rule sensitivity 97.2% and
specificity 48.6%). For children, no rule at all (ie, never
automatically summoning a surgeon) would
fail to identify emergency operative intervention in only 0.35% of
patients, and use of a single
criterion (penetrating mechanism) would reduce surgeon calls by 96.2%
while failing to identify
emergency operative intervention in only 0.09% (rule sensitivity 75.0%
and specificity 96.5%).
Conclusion: We have derived simple decision rules for trauma centers
that, if validated, could
substantially reduce the need for routine surgeon presence on trauma
patient arrival. These rules
demonstrate low false-negative rates. [Ann Emerg Med.
2006;47:135-145.]
article discussing the evidence (Annals of EM 2006;47(5):405)
Damage Control
Scalea [19] has condensed the principles of damage control: only blood loss kills early; gastrointestinal injury causes problems later; everything takes longer than you think; an injury may be missed during hurried laparotomy in an unstable patient; hypothermia, acidosis, and coagulopathy lead to more of the same; the best setting for a critically ill patient is the intensive care unit.
Damage control Review article by Feliciano
Low iCal at arrival is associated with bad outcome (J Trauma Volume 61(4), October 2006, pp 774-779)
Cochrane Database Syst Rev.
2004;(3):CD004173. Links
Advanced trauma life support training for hospital staff.Shakiba H, Dinesh S,
Anne MK.
BACKGROUND: Injury is responsible for an increasing global burden of death and
disability. As a result, new models of trauma care have been developed. Many of
these, though initially developed in high-income countries, are now being
adopted in low and middle-income countries (LMICs). One such trauma care model
is advanced trauma life support (ATLS) training in hospitals, which is being
promoted in LMICs as a strategy for improving outcomes for victims of trauma.
However, the evidence of effectiveness for this health service intervention, in
either HIC or LMIC settings, has not been rigorously tested using methodology
such as a systematic review. OBJECTIVES: To quantify the effectiveness of
hospitals with an ATLS-trained trauma response system versus hospitals without
such a response system in reducing mortality and morbidity following trauma.
SEARCH STRATEGY: We searched the Cochrane Injuries Group Specialised Register (CIGSR),
the Cochrane Controlled Trials Register (CCTR), MEDLINE & PubMed, EMBASE, CINAHL,
Science Citation Index, National Research Register, and web-based trials
databases such as Current Controlled Trials. We checked references of background
papers and contacted authors to identify additional published or unpublished
data. SELECTION CRITERIA: Randomised controlled trials, controlled trials,
controlled before- and- after studies comparing effectiveness of hospitals with
an ATLS-trained trauma response system versus hospitals without such a response
system in reducing mortality and morbidity following trauma. DATA COLLECTION AND
ANALYSIS: Two reviewers independently applied eligibility criteria to trial
reports for inclusion and to extract data. MAIN RESULTS: There is a limited
literature relating to this topic but none of the studies identified met the
inclusion criteria for this review. REVIEWERS' CONCLUSIONS: There is no clear
evidence that ATLS training (or similar) impacts on the outcome for victims of
trauma, although there is some evidence that educational initiatives improve
knowledge of what to do in emergency situations. Further, there is no evidence
that trauma management systems incorporating ATLS training impact positively on
outcome. Future research should concentrate on the evaluation of trauma systems
incorporating ATLS, both within hospitals and at the health system level, by
using rigorous research designs.
Resus from Severe Hemorrhage (Crit Care Med 1996;24(2):12S)
mention the Bickell Study (NEJM 1994;331:1105) delayed till operating room vs. immediate.
give fluids when inducing or pericode
Hypertonic Saline (Trauma Resus update Lancet 2004;363:1988)
J Trauma, Volume 62(5).May 2007.1310-1312
Trauma & Motorcyclists (Injury 2007;38:1131)
Pull helmet edges in the lateral direction
Journal of Emergency Medicine
Volume 34, Issue 3, April 2008, Pages 319-320
how to properly apply direct pressure
INJURY
Volume 39, Issue 11, Pages 1229-1308 (November 2008)
Interventional Radiology in Trauma Care
Edited by S.J.A. Sclafani and I.D.S. Civil
Just under the skin, and residing in a pressure area where the bullet is painful when the patient sits or lies down.
Visibly bulging beneath the skin and causing cosmetic distress.
In a joint space
In the globe of the eye.
In a vessel lumen causing ischaemia or with the risk of embolisation to the heart, lungs or peripheral vessles.
Impinging on a nerve or nerve root and causing pain.
Localised abscess formation (usually due to dirt or clothing fragments entrained by the bullet).
Required for forensic investigation and the patient and surgeon are in full agreement that the removal will not result in increased pain, suffering, complications or injury and both agree to the removal.
Documented elevated lead levels, usually in a child and occurring several months after injury (extremely rare)
Vasopressors kill trauma patients, don't do it (J Trauma 2008;64:9)
Balloon Pump to Stop Abd/Pelvis Bleeding
(J Trauma 2010;68(4):942)
Assar AN, Zarins CK. Endovascular proximal control of ruptured abdominal
aortic aneurysms: the internal aortic clamp. J Cardiovasc Surg (Torino).
2009;50:381–385.
Mount Sinai Serials
Bibliographic Links
[Context Link]
Gupta BK, Khaneja SC, Flores L, Eastlick L, Longmore
W, Shaftan GW. The role of intra-aortic balloon occlusion in penetrating
abdominal trauma. J Trauma. 1989;29:861–865.
Ovid Full Text
Mount Sinai Serials
Request Permissions
Bibliographic Links
[Context Link]
Karkos CD, Bruce IA, Lambert ME. Use of the
intra-aortic balloon pump to stop gastrointestinal bleeding. Ann Emerg Med.
2001;38:328–331.
Ovid Full Text
Mount Sinai Serials
Bibliographic Links
[Context Link]
Harma M, Harma M, Kunt AS, Andac MH, Demir N. Balloon
occlusion of the descending aorta in the treatment of severe post-partum
haemorrhage. Aust N Z J Obstet Gynaecol. 2004;44:170–171.
Mount Sinai Serials
Bibliographic Links
[Context Link]
Rieger J, Linsenmaier U, Euler E, Rock C, Pfeifer KJ.
[Temporary balloon occlusion as therapy of uncontrollable arterial hemorrhage in
multiple trauma patients]. Rofo. 1999;170:80–83.
Mount Sinai Serials
Bibliographic Links
[Context Link]
10 F sheath
20-mm berenstein balloon introduced to 50 cm
slowly inflate dwith saline until friction is felt against wall
eventually placed in infrarenal aorta
identify absent femoral pulses
Mikey likes it
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Journal of Trauma: Injury, Infection, and Critical Care 68(5), May
2010, pp 1172-1177
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1 amp of 44.6 bicarb in 500 ml of NS
makes 550 of total volume=
Na
121.6
Cl 77
Bicarb 44.6
to extend to 1 liter
Na 217
Cl 138.6
BiCarb 80
1.3% Saline solution
can be used to close organs
We are very poor at predicting prognosis in the trauma ICU ((J Trauma. 2010;68: 1279–1288)
Even a single drop < 105 SBP associated with severe injuries (J Trauma. 2010 Jun;68(6):1289-94; discussion 1294-1295.)
each hour of delay is associated with an almost ~50% increase in mortality in a J trauma retropsective study ( J Trauma 2010;68:1296)
Lancet 2010
1g tranexamic acid over 10 minutes followed by infusion of 1 g over 8 hours
within 8 hours of injury
sig hemorrhage or predicted sig. hemorrhage (SBP < 90 or HR > 110)
1.5% reduction in mortality (all-cause)
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