Trauma, Non Head, Non Spine

1
Trauma, Non Head, Non Spine

• By
• CCM Fellows
• UBC

2
Case

• -19 years old girl, otherwise healthy, was
  brought to ER at RCH by EHS after being hit by a
  freight train.
• -Earlier, she was partying with her pals, got
  drunk, went through a fight with her bf, after
  which she decided to walk home alone! At the
  railway intersection, she was hit on her left
  side by the train, which slowed down coming near
  the station.

3
Upon EHS Arrival..

• -When EHS arrived within 2 minutes, she was
  conscious but drowsy, GCS E3 M5 (x4) V2,
  vomiting, with open wounds on her posterior
  scalp, and Lt knee. She was intubated at the seen
  and brought to ER.

4
In ER..

• AETT, C-collar.
• B AC, fiO2 0.5. ABG 7.3/50/19/88/ -6.
• C 110/50 (65), 110 SR, T34C.
• D PERL 3mm bi, on 33 MM 100 mcg of fentanyl
  given by ER MD when patient was trying to wake up
  and bite on the ETT.
• Trauma team are in.

5
O/E..

• HEENT 3-cm Laceration wound grade I over the
  occiput.
• Heart Normal S1S2.
• Chest paradoxical movement of Lt 3-7 ribs chest
  wall, with multiple bruises on the Lt side,
  decreased B/S on the Lt side.
• Abdomen multiple bruises on the Lt side, with
  mildly distended abdomen. DRE clear.
• F/C hematuria, 70cc/hr (BWt 90kg).
• Ext bruises over Lt shoulder posteriorly.
  Intact/symmetrical upper pulses/BP. Lt thigh
  swelling, 15-cm Lt knee grade IIIb (at least)
  laceration with exposed fractured bone, Lt PT and
  DP weaker than Rt

6
FAST..

• No tamponade, good LVEF, coarse spleen,
  evidence of fluid in the hepatorenal space and Lt
  perinephric area.

7
Labs..

• Hb 60, Plt 80, INR 1.5, PTT 40, Fib 0.9, WBC 16,
• Cr 80, BUN 7, lytes N, LFE N. LA 4.3, Trop lt0.04,
  
• U/A RBC 20-50, WBC 5-10.
• ECG Sinus tachycardia.

8
Imaging..

• CT head N. C-spine N.
• Chest Lt hemopneumothorax, fractured Lt scapula
  and ribs 3-7, Lt lung contusion.
• T-L-S spine intact.
• Abdomen Lt diaphragmatic rupture, spleen
  laceration grade 4, liver injury grade 1, Lt
  perinephric hematoma, evidence of hemoperitoneum.
  
• Pelvis Lt pubic ramus fracture.
• Ext Fracture Lt acetabular and femoral head
  capitus, displaced femoral shaft and
  intercondylar, patella and tibial plateau, with
  air tracking from the knee proximally, c/w open
  fracture. CTA preliminary report N.
• -Lt chest tube was inserted, drained blood.

9
Question 1

• Discuss the initial fluid resuscitation in trauma
  patient, focusing of monitoring endpoints
  (including base deficit), coagulopathy (including
  hypothermia), and massive transfusion protocol
  (Marios)

10
Initial trauma fluid resuscitation

1. Fluids
2. Transfusion ratios
3. Monitoring end-points
4. Coagulopathy

11
Initial fluid resuscitation

• A controversial topic with nebulous answers
• Guidelines used to be that you gave 2 or more
  liters of crystalloid to any trauma patient you
  thought was in shock
• Goal was to rapidly restore circulating volume to
  maintain vital organ perfusion.
• There is evidence however that normalizing ones
  blood pressure in the setting of an
  uncontrollable hemorrhage may worsen outcome.
• This has led to the concept of permissive
  hypotension/hypotensive resuscitation

12
Initial fluid resuscitation

• Rationale behind permissive hypotension (animal
  models)
• Increased blood pressure accelerates bleeding and
  dislodges soft early clots (which take 30 min to
  harden)
• Dilution of RBC mass by crystalloid or colloid
  reduces oxygen delivery despite increasing
  cardiac output
• Reduced hematocrit and clotting factor
  concentration inhibit clot formation
• Resuscitative fluids themselves may have
  deleterious properties such as neutrophil
  activation (RL in hemorrhagic shock 1998)

13
Initial fluid resuscitation

• Human evidence for permissive hypotension
• Houston study (1994)
• Thoraco-abdominal gunshot or stab wounds
  presenting with SBP lt 90 mmHg
• Patients either treated with liberal RL or
  delayed resuscitation until OR.
• Patients in the early resuscitation group had a
  higher mortality and rate of post-op
  complications
• Baltimore study (2002)
• Penetrating and blunt trauma patients presenting
  to the Shock Trauma Center with SBP lt 90 mmHg
• Randomized to a fluid resuscitation strategy
  targeted to a lower than normal SBP (gt 70 mmHg)
  or to conventional care (SBP gt 100 mmHg)
• Mortality was identical but fewer complications
  and a shorter duration of hemorrhage were seen in
  the low-pressure group

Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate
versus delayed fluid resuscitation for
hypotensive patients with penetrating torso
injuries. N Engl J Med 1994 33111051109.
Dutton RP, Mackenzie CF, Scalea T. Hypotensive
resuscitation during active hemorrhage impact on
in-hospital mortality. J Trauma 2002 (52)1141
1146.
14
Initial fluid resuscitation

• Whos practicing permissive hypotension?
• Current military policy is to resuscitate to a
  palpable radial pulse or an SBP of no more than
  90 mmHg.
• This concept has now been adopted widely, and is
  reflected in the latest EAST guidelines.

Dawes R, Thomas GO. Battlefield resuscitation.
Curr Opin Crit Care. 2009Dec15(6)527-35.
15
Initial fluid resuscitation

• Prehospital resuscitation (EAST guidelines 2009)
• Obtaining IV access in the field has not been
  shown to be beneficial, and if anything has been
  shown to prolong transport time
• Obtaining IV access en-route to trauma centre is
  recommended if wounds more than superficial.
• IV should be saline-locked if no indication for
  fluid therapy is present.

Cotton BA, Jerome R, Collier BR, et al. Eastern
Association for the Surgery of Trauma Practice
Parameter Workgroup for Prehospital Fluid
Resuscitation. Guidelines for prehospital fluid
resuscitation in the injured patient. J Trauma.
2009 Aug67(2)389-402
16
Initial fluid resuscitation

• Prehospital resuscitation (EAST guidelines 2009)
• Indications for prehospital fluid administration
  (250 cc boluses) in both penetrating and blunt
  trauma
• Patient incoherent
• Non-palpable radial pulse
• Head injury with SBP lt 90
• Repeat bolus if no response
• Saline lock of pt responds

17
Initial fluid resuscitation

• When may fluids be appropriate?
• In traumatic brain injury, where hypotensive
  episodes have been associated with worse outcome
• In severe hypotension where pressors would
  otherwise be needed, i.e. MAP lt 40 - 50 mmHg
• In hypotensive patients with controllable
  bleeding (extremity/superficial bleed)

18
If youre going to bolus, bolus right. Right?
Bolus with

• The data on what type of fluid to give is worse
  than on whether to give fluid.
• EAST Guidelines states insufficient evidence to
  make recommendations.
• Practice therefore depends on opinion
• RL is liked for its buffering capacity but
  cant be mixed with blood due to the calcium
• Plasmalyte doesnt have calcium but has potassium
  which can exacerbate hyperkalemia secondary to
  tissue injury and massive transfusion
• NS doesnt have K (unless you ask for it), but
  is more likely to cause a NAGMA that can
  theoretically worsen coagulopathy
• Hypertonic saline showed no benefit over isotonic
  crystalloids
• Early availability of blood and FFP avoids the
  need for filler fluids

Diez C, Varon AJ. Airway management and initial
resuscitation of the trauma patient. Curr Opin
Crit Care. 2009 Dec15(6)542-7 Dawes R, Thomas
GO. Battlefield resuscitation. Curr Opin Crit
Care. 2009Dec15(6)527-35.
19
Transfusion ratios

• American and British military practice is to
  administer warmed FFP and PRBCs in a 11 ratio as
  soon as possible.
• Others in military have recently suggested
  modifying this ratio by further adding platelets,
  resulting in a ratio of 111 PRBCFFPplatelets
  
• Evidence for benefit based on retrospective
  trials
• Benefit can therefore be indicative of a survival
  bias rather than a true mortality benefit
• FFP and platelets take longer to receive than
  pRBCs.
• Possibility that nonsurvivors did not die because
  they received a lower FFP PRBC ratio, but that
  they received a lower ratio transfusion because
  they died.

Dawes R, Thomas GO. Battlefield resuscitation.
Curr Opin Crit Care. 2009Dec15(6)527-35. Snyder
CW, Weinberg JA, McGwin G Jr, et al. The
relationship of blood ????product ratio to
mortality survival benefit or survival bias? J
Trauma 200966358362
20
Resuscitation endpoints

• If uncontrolled hemorrhage permissive
  hypotension, maintaining coherence, a palpable
  radial pulse, or an SBP gt 90 mmHg in TBI
• Resuscitation effectiveness can be assessed by
  standard measures, i.e. lactate clearance and
  correction of base deficit.
• Base deficit Blunt injury patients with
  transient field hypotension and a BD gt 6 were
  found to be more than twice as likely to have
  repeat hypotension (crump).

Bilello JF, Davis JW, Lemaster D, et al.
Prehospital Hypotension in Blunt Trauma
Identifying the "Crump Factor". J Trauma. 2009
Dec 4 Tisherman SA, et al. Clinical
practiceguideline endpoints of resuscitation. J
Trauma. 2004 Oct57(4)898-912.
21
Hemorrhagic coagulopathy

• Part of the lethal triad

22
Hemorrhagic coagulopathy

• Impaired hemostasis is often caused by dilution
  and consumption of clotting factors and
  hyperfibrinolysis.
• However despite replacing FFP, platelets, and
  cryoprecipitate, patients may remain
  coagulopathic.
• Optimal coagulation requires specific
  preconditions concerning acid-base balance,
  calcium, hematocrit, and temperature.
• If these preconditions are not fulfilled,
  coagulation may remain abnormal despite
  replacement of products.

Lier H, Krep H, Schroeder S, Stuber F.
Preconditions of hemostasis in trauma a review.
The influence of acidosis, hypocalcemia, anemia,
and hypothermia onfunctional hemostasis in
trauma. J Trauma. 2008 Oct65(4)951-60.
23
Hemorrhagic coagulopathy

• Acidosis
• A notable impairment in hemostasis arises at pH
  lt 7.1 or a base deficit of 12.5 or more
• Aggressive resuscitation in OR to reverse
  acidosis
• Some centres give THAM to raise pH to 7.2 or
  higher (no outcome data)
• Hypocalcemia
• Coagulation defects can be attributed to
  hypocalcemia if the Cai is lt 0.6 0.7 mmol/L
• Adverse cardiac effects commence at levels at or
  below 0.8 0.9 mmol/L
• Combining these benefits, ionized calcium should
  be kept above 0.9 mmol/L

Lier H, Krep H, Schroeder S, Stuber F.
Preconditions of hemostasis in trauma a review.
The influence of acidosis, hypocalcemia, anemia,
and hypothermia onfunctional hemostasis in
trauma. J Trauma. 2008 Oct65(4)951-60.
24
Hemorrhagic coagulopathy

• Anemia
• Causes demargination of platelets and decreased
  adhesion to endothelial damage (decreases
  fivefold from HCT of 40 to 10)
• Aim is to keep HCT greater or equal to 30
• Hypothermia
• High risk of persistent coagulopathy at
  temperatures under 35 deg C
• At temperatures below 33 deg C, hypothermia
  produces a coagulopathy that is equivalent to 50
  of normal activity at normothermia
• Should therefore aggressively aim for a Temp gt 34
  or even 36 degrees Celsius

Lier H, Krep H, Schroeder S, Stuber F.
Preconditions of hemostasis in trauma a review.
The influence of acidosis, hypocalcemia, anemia,
and hypothermia onfunctional hemostasis in
trauma. J Trauma. 2008 Oct65(4)951-60. Dawes R,
Thomas GO. Battlefield resuscitation. Curr Opin
Crit Care. 2009Dec15(6)527-35.
25
Hemorrhagic coagulopathy

• Other measures
• Hypofibrinogenemia ? keep fibrinogen gt 1 g/L
• Platelets ? keep above 100 x 109
• Tranexamic acid
• At 15 mg/kg, found to reduce blood loss in
  elective surgical patients by inhibiting
  fibrinolysis.
• Results of CRASH II trial are pending (20 000
  patients randomized to 1 g of tranexamic acid
  followed by 1 g infused over 8 h).
• rFVIIa
• Some evidence that it reduced transfusion
  requirement in blunt injury but not in
  penetrating injury.
• Often used in salvageable patients with
  continuing haemorrhage that has failed surgical
  and nonsurgical methods

Mannucci PM, Levi M. Prevention and treatment of
major blood loss. N Engl JMed. 2007 May
31356(22)2301-11. Dawes R, Thomas GO.
Battlefield resuscitation. Curr Opin Crit Care.
2009Dec15(6)527-35.
26

• -After transfusing 4u of PRBCs, 4u FFP, 10u Plt,
  4u cryoppt, BP dropped to 80/45, O2 sat 80,
  decreased B/S on Lt, with Lt CT suddenly draining
  gt1500 ml of blood.

27
Question 2

• What are the indications and contraindications
  for ED thoracotomy? How to manage lung contusion
  and flail chest? What are the complications of
  lung contusion? (Erik)

28
CBP ED Thoracotomy, Pulmonary Contusion, Flail
Chest
29
Emergency Department Thoracotomy

• Indications
• Contraindications
• Absolute
• Relative

30
Objectives of EDT

• Release of pericardial tamponade.
• Control of intrathoracic vascular or cardiac
  bleeding.
• Evacuate obstructive air embolism or control
  source of broncho-pleural/vascular fistula.
• Perform open cardiac massage.
• Temporarily occlude the descending thoracic aorta.

31
Indications for EDT

• Penetrating chest injury in extremis, or loss of
  vital signs, within 10 minutes of ED arrival.
• Limited evidence to support in blunt or
  mutli-trauma patients, especially if arrive in ED
  with VSA.
• Known tamponade, air embolism.
• Consider in major abdominal vascular injury
  (blunt or penetrating) in extremis or witnessed
  loss of vital signs.
• Consider in unresponsive hypotension (SBP lt
  60mmHg) or chest tube gt 1500cc.

32
Contraindications

• Severe TBI
• VSA in penetrating injury gt 10-15 minutes prior
  to ED arrival.
• VSA in blunt injury 0-5 minutes prior to ED
  arrival.

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34
Pulmonary Contusion Flail Chest

• Both PC and FC independently associated with
  morbidity.
• Pathophysiology ?
• Mortality usually resultant
• of other injuries sustained
• from the blunt trauma
• (e.g. CNS injury, shock).

35
Fluid Resuscitation in PC

• Animals models originally suggested that
  crystalloid resuscitation had greater impact
  versus colloid but no outcomes were assessed.
• Similarly, observational data from Vietnam War
  suggested larger volume resuscitation was
  associated with poor outcomes.
• More recently, studies with better (though not
  great) methodology show no correlation with
  volume of resuscitation with worsening of PC.
• P/F ratio at the time of injury more prognostic.

36
Ventilation in PC/FC

• Again, animal models with inappropriate surrogate
  endpoints are misleading.
• Current level II evidence supports intubation and
  mechanical ventilation based on standard
  assessment of oxygenation/ventilation.
• Advantages of different forms of mechanical
  ventilation, including the use of PEEP, have not
  been teased out.

37
Surgical Fixation of FC

• Despite the biological plausibility supporting
  the use of ORIF (e.g. Judet struts), most of the
  supporting evidence is derived from Level II and
  III studies (i.e. mostly small, single-limb,
  observational studies of personal experience
  lacking non-surgical controls).
• Read about them but never used them.  Thoracics
  may have applied them once to my knowledge.

38
Summary PC and FC

• Respiratory dysfunction after contusion may
  relate more to direct traumatic and indirect
  biochemical effects of the injury rather than
  amounts of fluid administered.
• With respect to ventilation, the bulk of current
  evidence favors selective use of mechanical
  ventilation, analgesia and physiotherapy as the
  preferred initial strategy.
• Surgical fixation may play a role in select
  patients.
• There is no evidence to support the use of
  steroids or prophylactic antibiotics in PC.

39

• -ED thoracotomy was performed, pulmonary arterial
  bleeder was clamped. Pt was urgently taken to the
  OR and surgical stabilization of the flial chest
  using Judet struts was performed.

40
Question 3

• How to evaluate blunt abdominal trauma? How to
  manage spleen, liver, and diaphragmatic injuries?
  Is there a place for conservative therapy if this
  was penetrating abdominal trauma? (Neil)

41
How to evaluate blunt abdominal trauma?

• Physical exam
• DPL
• CT
• FAST

42
Diagnostic Peritoneal Lavage

• Positive test
• Fecal contents
• Gross blood
• gt 100,000 RBC/mm3

43
CT

• Hemodynamically stable patient
• Sensitvity 92-98
• Specificity 98
• NPV 99.63
• Good for
• Solid organs
• retroperitoneum
• Bad for
• Mesenteric injuries
• Diaphragm
• Hollow viscous

44
Focused Abdominal Sonography in Trauma

• 3 views
• Morrisons pouch
• Spleno-renal
• Suprapubic
• Need 200 cc of fluid for positive.
• Sensitivity 73-88
• Specificity 98-100

45
Focused Abdominal Sonography in Trauma
46
Focused Abdominal Sonography in Trauma
47
Focused Abdominal Sonography in Trauma
48
Focused Abdominal Sonography in Trauma
49
EAST Recommendations

• A. Level I
• 1. Exploratory laparotomy is indicated for
  patients with a positive DPL.
• 2. CT is recommended for the evaluation of
  hemodynamically stable patients with equivocal
  findings on physical examination, associated
  neurologic injury, or multiple extra-abdominal
  injuries. Under these circumstances, patients
  with a negative CT should be admitted for
  observation.
• 3. CT is the diagnostic modality of choice for
  nonoperative management of solid visceral
  injuries.
• 4. In hemodynamically stable patients, DPL and
  CT are complementary diagnostic modalities.

50
EAST Recommendations

• B. Level II
• 1. FAST may be considered as the initial
  diagnostic modality to exclude hemoperitoneum.
  In the presence of a negative or indeterminate
  FAST result, DPL and CT have complementary roles.
• 2. When DPL is used, clinical decisions should
  be based on the presence of gross blood on
  initial aspiration (i.e., 10 ml) or microscopic
  analysis of lavage effluent.
• 3. In hemodynamically stable patients with a
  positive DPL, follow-up CT scan should be
  considered, especially in the presence of pelvic
  fracture or suspected injuries to the
  genitourinary tract, diaphragm or pancreas.
• 4. Exploratory laparotomy is indicated in
  hemodynamically unstable patients with a positive
  FAST. In hemodynamically stable patients with a
  positive FAST, follow-up CT permits nonoperative
  management of select injuries.
• 5. Surveillance studies (i.e., DPL, CT, repeat
  FAST) are required in hemodynamically stable
  patients with indeterminate FAST results.

51
EAST recommendations

• Level III
• 1. Objective diagnostic testing (i.e., FAST,
  DPL, CT) is indicated for patient with abnormal
  mentation, equivocal findings on physical
  examination, multiple injuries, concomitant chest
  injury or hematuria.
• 2. Patients with seatbelt sign (SBS) should be
  admitted for observation and serial physical
  examination. Detection of intraperitoneal fluid
  by FAST or CT in a patient with SBS mandates
  either DPL to determine the nature of the fluid
  or exploratory laparotomy.
• 3. CT is indicated for the evaluation of
  suspected renal injuries.
• 4. A negative FAST should prompt follow-up CT for
  patients at high risk for intraabdominal injuries
  (e.g., multiple orthopedic injuries, severe chest
  wall trauma, neurologic impairment).
• 5. Splanchnic angiography may be considered in
  patients who require angiography for the
  evaluation of other injuries (e.g., thoracic
  aortic injury, pelvic fracture).

52
VGH Protocol

53
How to manage spleen, liver, and diaphragmatic
injuries?

• Nonoperative management of blunt adult and
  pediatric hepatic and splenic injuries is the
  treatment modality of choice in hemodynamically
  stable patients, irrespective of the grade of
  injury. It is associated with a low overall
  morbidity and mortality and does not result in
  increases in length of stay, need for blood
  transfusions, bleeding complications, or visceral
  associated hollow viscus injuries as compared
  with operative management. There is no evidence
  supporting routine imaging (CT or US) of the
  hospitalized, clinically improving,
  hemodynamically stable patient. Nor is there
  evidence to support the practice of keeping the
  clinically stable patient at bedrest.
• EAST GUIDELINES

54
Diaphragm injuries

• Often missed and result in delayed complications
• Investigations/treatment via laparoscopy/laparotom
  y
• Repair with non-absorbable sutures

55
Is there a place for conservative therapy if this
was penetrating abdominal trauma?
56
History

• 19th C. - Expectant management
• Blood letting
• Opium
• WWI manadatory laparotomies
• 1960 observant and expectant mgmt
• 1990s more conservative with SW and GSW
• Focus on morbidity of non-therapeutic laparotomy

57
Recommendations of this article
58
Recommendations of this article
59

• -In the OR, Lt diaphragmatic repair and
  slenectomy were performed.

60
Question 4

• What are the limb-salvaging reconstruction
  strategies? Are there better outcomes vs.
  amputation for severe limb-threatening traumas?
  What is the best timing for performing long bones
  fixations in polytrauma victims? (Noemie)

61
Initial treatment

• Neurologic and vascular exam
• Sterile dressing and splint
• Tetanus
• Antibiotics

62
Approach to Vascular injury

• Arteriography should be done promptly when hard
  signs of vascular injury are manifest.
• The interval between injury and reperfusion
  should be minimized to less than six hours in
  order to maximize limb salvage.
• Restoration of blood flow should always take
  priority over skeletal injury management

EAST Guidelines
63
External vs internal fixation

• Indications for use of external fixation
• Open fractures
• Severe metaphyseal fractures
• Severe intra-articular fractures
• Polytrauma
• Osteoporotic fractures
• Transport

Trauma 2004 6 143? 160
64
Complications of External fixation

• Pin track infections
• Most common complication 0 to 60
• Re-fracture
• If removed too early
• Nonunion
• Malunion
• Pin breakage

Trauma 2004 6 143? 160
65
EAST GUIDELINES

• External fixation is preferable for the
  immediate management of unstable, displaced,
  comminuted and open fractures or dislocations.
  This is especially important in those with severe
  contamination, extensive soft tissue injury, or
  in an unstable patient.

66
NEJM 2002 347(24)1906-1907
67

• Are there better outcomes vs. amputation for
  severe limb-threatening traumas?

68
Gustilo Classification

• I Low energy, wound less than 1 cm
• II Wound greater than 1 cm with moderate soft
  tissue damage
• III High energy wound greater than 1 cm with
  extensive soft tissue damage
• IIIA Adequate soft tissue cover
• IIIB Inadequate soft tissue cover
• IIIC Associated with arterial injury

69
Factors predicting high rates of amputation

• Gustilo III-C injuries
• Sciatic or tibial nerve transection
• Severe prolonged ischemia
• Older age with comorbidity
• Multiple long bone fractures
• Crush or extensive soft tissue trauma
• Severe contamination

70
Amputation vs Reconstruction
71
LEAP Study

• Multicenter observational prospective trial
• 569 pts
• At 2 years, no difference in outcome scores or
  return to work

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EAST Guidelines

• Primary amputation should be considered in those
  with tibial or sciatic nerve transection,
  prolonged ischemia, massive soft tissue injury,
  severe contamination, open comminuted tib-fib
  fractures (Gustilo-III), or life-threatening
  associated injuries.

75

• What is the best timing for performing long bones
  fixations in polytrauma victims?

76
EAST Guidelines

• Polytrauma patients undergoing long bone
  stabilization within 48 hours of injury have no
  improvement in survival when compared to those
  receiving later stabilization
• However, there may be some patients who will
  have fewer morbidities
• There is no evidence that early stabilization
  has any detrimental effect.

77

• -Fixation of her fractured Lt femur was performed.

78
Question 5

• What are the high risk factors for DVT/PE in
  trauma patients? What is the best prophylaxis?
  What are the types, indications,
  contraindications and complications of IVC
  filters? Is it safe and effective in trauma?
  (Omar)

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80
High Risk Factors for DVT/PE

• Heterogenous group of patients
• Difficult to prove who is truly at highest risk

81

• General consensus of who constitutes high risk
  include
• Advanced age (age at which patients become high
  risk is not defined)
• Spinal fractures and cord injuries
• Traumatic brain injury
• Prolonged mechanical ventilation
• Pelvic s
• Multiple long bone fractures, esp if associated
  with pelvic
• Venous injuries

82

• General consensus of who constitutes high risk
  include
• Venous injuries
• Multiple major operative procedures

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84
What is the best prophylaxis?

• Beats me

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86

• American Surgeon, 2006

87
What is the best prophylaxis?

• Low does unfractionated heparin is no better than
  no prophylaxis
• LMWH given twice a day offers some protection
• Mechanical prophylaxis is unproven, but can be
  used in patients with high risk for bleeding
• If high risk for DVT/PE, may use LMWH and
  mechanical prophylaxis, but no proven synergism

88
What is best prophylaxis?

• Fondaparinux appears to be better than LMWH in
  post-op hip patients
• No studies in multi-trauma patients

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90
Timing

• ASAP
• TBI
• Unclear when to start
• 72 hours post cessation of bleeding
• Splenic or liver lacn
• 48 hours post cessation of bleeding

91

• What are the types, indications,
  contraindications and complications of IVC
  filters? Is it safe and effective in trauma?

92
IVC filters Origins

• Surgical techniques
• Femoral vein ligation
• IVC ligation
• IVC occlusion
• Partial interruption of IVC
• Plastic clips
• Plication
• Staples

93

• Surgical technique reduced incidence of PE
  significantly
• .high complication rates and no decrease in
  mortality

94

• 1980s
• Introduction of first percutaneously inserted IVC
  filter
• Mobin-Uddin Umbrella filters

95
Types

• Permanent
• Temporary
• Retrievable

96
Permanent

• Birds nest filter (1982)
• Greenfield Filter (1972)
• Has undergone many revisions/improvements
• Initially introduced via venotomy
• Simon Nitinol Filter
• LGM Venatech
• Trap ease

97
Permanent

• Different sizes
• Need to determine diameter of IVC before
  placement
• Earlier models were incompatible with MRI and
  some caused significant scatter

98
Temporary

• Multiple
• Anchored to skin via wire or catheter
• Risk of infection
• May become irretrievable if clot entrapped within
  it

99
Retrievable

• Most commonly used
• Lowest complication rates
• Require trans-jugular approach for removal

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102
Complications

• Access site thrombosis
• 1-3
• Tilting and malposition
• 2
• Recurrent PEs
• Up to 4 5
• IVC thrombosis
• 15 without anticoag
• 7 with anticoag

103
Complications

• Filter migration
• 1
• Filter fracture during retrieval with subsequent
  embolization of struts
• 1

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• -Post-op, IVC filter was placed in.
• -She was admitted to the ICU, started on
  antibiotics for aspiration pneum/Px for knee/bone
  with open fracture. She eventually became septic
  from both sources, required aggressive fluid
  resuscitation and vasopressors.

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• -POD 3, she became oliguric, abdomen distended,
  bladder pressure increased from 18 to 20 to 30.

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Question 6

• What are the risks/predictors for developing
  abdominal compartment syndrome in trauma
  patients? What are the consequences? How to
  manage traumatic renal injuries? (Federico)

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Emergency Department Independent Predictors(lt 3
hrs from Hospital admission)
Predictor
All ACS Crystalloid gt 3L SBP lt 86
Primary ACS To OR gt75 min Crystalloid gt 3L
Secondary ACS Crystalloid gt 3L No urgent surgery PRBC gt 3 units
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ICU independent predictors (lt 6 hrs from
hospital admission)

All ACS GAP CO2 gt16 Crystalloid gt7.5L UO lt 150 ml HB lt 8 g/dl CI lt 2.6 L/min/sm
Primary ACS Temp lt 34 C GAP CO2 gt 16 Hb lt 8g/dl BD gt 12 mEq/L
Secondary ACS GAP CO2 gt 16 Crystalloid gt 7.5L UO lt 150 mL
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Outcome

• ACS is a predictor of MOF and mortality

Primary ACS (n11) Secondary ACS (n15) NonACS (n162)
MOF () 55 53 17
Mortality () 64 53 17
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Kidney Injury

• Blunt trauma 80-90
• Rapid deceleration / Direct blow
• MUST be suspected if
• Trauma to back / flank / lower thorax / upper
  abdomen
• Flank pain / low rib
• Hematuria / Ecchymosis over the flanks
• Sudden decelaration / Fall from height.
• Lumbar transverse process

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Classification of Injury

• 5 Classes of Renal Injury

Organ Injury Scaling Committee Moore et al. Organ
Injury Scaling Sleen, Liver and Kidney, The
Journal of Trauma, 29 1664 1989.
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Grade I

• Hematoma
• Subcapsular
• Non expanding
• Parenchyma N

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Grade II

• Hematoma
• Perirenal
• Nonexpanding
• Laceration
• lt 1.0 cm
• Renal cortex only
• No urinary extravasation

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Grade III

• Laceration
• gt 1.0 cm
• Renal cortex only
• No urinary extravasation
• Intact collecting system

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Grade IV

• Laceration
• Renal cortex
• Renal medulla
• Collecting system
• Vascular
• Main renal artery/vein injury with contained
  hemorrage.

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Grade V

• Completely shattered kidney.
• Avulsion of renal hilum (pedicule) which
  devascularizes kidney.

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Organ Injury Severity Scale

• Validated lately Journal of Trauma, 2001
• Predicts the need for surgery
• Need for surgery nephrectomy rates
• Grade I 0 0
• Grade II 15 0
• Grade III 76 3
• Grade IV 78 9
• Grade V 93 86

Santucci et al. Validation of the American
Association for the Surgery of Trauma Organ
Injury Severity Scale for the Kidney. J Trauma
50195-200 2001.
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Management

• Absolute indication for Surgery
• Uncontrollable renal hemorrage
• Multiply lacerated, shattered kidney
• Main renal vessels avulsed
• Penetrating injuries usually
• Grade I-II
• conservative
• Grade III-IV
• Conservative if stable hemodynamically vs.
  surgery
• Grade V
• Surgery

Grade V
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• -She went to the OR for urgent decompression.
• -POD 7, she was extubated. POD 9, discharged to
  the ward.

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The End..