trauma overview david b. reedy, m.d., facep contra costa regional medical center assistant clinical...
TRANSCRIPT
Trauma Overview
David B. Reedy, M.D., FACEP
Contra Costa Regional Medical Center
Assistant Clinical Professor UCSF/SFGH
Trauma is an injury caused by a physical force Motor vehicle collisions Falls Gun shot Stabbing Burns Blunt assault
Advanced Trauma Life Support American College of Surgeons Provides a framework for the
management of the injured patient Intended to allow the single doctor
in a rural hospital to assess and manage trauma patients
ATLS Origins
Nebraska, 1976 Plane crash in a Nebraska field
changed the face of trauma care throughout the world
Medical, EMS, and Nursing groups began to collate protocols for trauma management
ACS publishes ATLS in 1980
Blunt Thoracic Trauma
Blunt Thoracic Trauma Airway
Look for associated injuries
Remember c-spine
Blunt Thoracic Trauma Breathing
Respiratory rate Paradoxical motion Crepitus Subcutaneous air Auscultation
Blunt Thoracic Trauma CXR-pneumothorax
Tracheal deviation, hypotension, hypoxemia
Blunt Thoracic Trauma Circulation
Hypotension Hypovolemia Pneumothorax Cardiac tamponade Aortic Injury Blunt cardiac injury
• Arrhythmia• NSR
Blunt Thoracic Trauma CXR-widened mediastinum
Blunt Thoracic Trauma Aortic injury
80-90% of patients with thoracic aortic rupture die in the pre-hospital setting
Those who survive may have minimal initial symptoms
CXR may be first clue
Penetrating Thoracic Trauma Emergency Department
Thoracotomy “The surgeon who should attempt
to suture a wound of the heart would lose the respect of his surgical colleagues” - Theodore Bilroth, 1882
Penetrating Thoracic Trauma Emergency Department
Thoracotomy
Penetrating Thoracic Trauma Emergency Department
Thoracotomy Indications
Penetrating thoracic traumatic arrest with previously witnessed cardiac activity
Penetrating thoracic unresponsive hypotension
Penetrating Thoracic Trauma
Emergency Department Thoracotomy
Penetrating Thoracic Trauma Emergency Department
Thoracotomy Contraindications
Blunt thoracic injuries with no witnessed cardiac activity
Multiple blunt trauma Severe head injury
Penetrating Thoracic Trauma Emergency Department
Thoracotomy ACLS algorithms do NOT apply to
traumatic arrest
Trauma Ultrasonography The FAST Exam
Trauma Ultrasonography
Focused Assessment with Sonography for Trauma (FAST) Limited ultrasound exam Directed solely at identifying the presence of free intraperitoneal or pericardial fluid Free fluid is usually due to hemorrhage Helps determine the need for OR, CT, or angiography
Trauma Ultrasonography FAST examines four areas for free
fluid
Low Frequency Probe 2.5 - 5.0 MHz
Tissue Penetration
Trauma Ultrasonography
Trauma Ultrasonography Perihepatic and hepato-renal
Trauma Ultrasonography
Trauma Ultrasonography
Trauma Ultrasonography
Trauma Ultrasonography
Trauma Ultrasonograpy Spleno-renal
Trauma Ultrasonography
Trauma Ultrasonography
Trauma Ultrasonography Pelvis
Trauma Ultrasonography
Trauma Ultrasonography
Trauma Ultrasonography Pericardium
Trauma Ultrasonography
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Trauma Ultrasonography
Blunt Abdominal Trauma Not for bowel injury, solid organ
injury, or retroperitoneal injury Detection of free intraperitoneal or
pericardial fluid
Trauma Ultrasonography
EFast Exam Extended Fast Exam
Anterior lung apices for pneumothorax Lung bases for pleural fluid
Trauma Ultrasonography
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Trauma Ultrasonography
QuickTime™ and aSorenson Video decompressorare needed to see this picture.
Trauma Ultrasonography Conclusions
Clinician based ultrasound has changed the way trauma care is practiced and is rapidly becoming standard of care
Noninvasive, straightforward, relatively short training period
Multiple training courses exist Focused exam, goal specific
ATLS 8th Edition, 2008
30 year anniversary
“Best evidence” based (i.e. spinal steroids)
Revised pediatric guidelines
Disaster management
The Knife and Gun Club