A. Head Trauma

Algorithm for management of head injury patient is found in Part 3.

Head injury is common and is frequently one of several injuries. Head injury is a part of ‘D’, and as such A, B and C injuries take priority. Once initial stabilisation has been undertaken patients with GCS < 14 will require neurosurgical assessment including CT scanning at some stage (Figure 1).

Basic neurological examination should include assessment of the Glasgow Coma Scale noting not only the best response but also any lateralising signs (i.e. also the worst response).

It should be remembered that hypoxaemia, shock, alcohol and other drugs all depress the level of consciousness and worsen the neurological signs. Analgesic and anaesthetic drugs and muscle relaxants also interfere with neurological assessment.

Glasgow Coma Scale

  Response Score

Eye opening

Spontaneous
To voice *
To pain
Nil

4
3
2
1

Best verbal response Oriented
Confused
** Inappropriate
Incomprehensible
None
5
4
3
2
1
Best motor response Obeying
Localising
Withdrawal
Abnormal Flexion
Extension
None
6
5
4
3
2
1

 

B. Prevention of Secondary Brain Injury

Algorithm for management of head injured patients is found in Part 3.

  • Adequate Oxygenation
  • Prevent Hypercarbia and Hypocarbia (Hypoventilation and Hyperventilation)
  • Adequate Perfusion
  • Pressure Prevention of Hypoglycaemia
  • Reduce agitation
  • Early decompression when indicated
  • Use of:
    • Mannitol
    • 4 Molar salt
    • Hyperventilation

C. Spinal Cord Trauma

Algorithm for management of cervical spine injury is found in Part 3.

Physical signs of spinal cord trauma include:

  • No movement of arms and/or legs
  • Abnormal peripheral vasodilatation
  • Lax anal sphincter tone
  • Contusions/tenderness/deformity/crepitus on clinical examination of the spine during the logroll
  • Subjective and objective sensory changes

The only cervical spine view indicated in the emergency room is the lateral view. The cervical spine must remain protected until the patient is stable enough to undergo the 3 film cervical series, performed either in the radiology suite or in DCCM. “Clearance” of the cervical spine is undertaken according to the guidelines in Figure 2 (Appendix).

Any patient who has a cervical spine injury or severe blunt trauma requiring admission to DCCM should have screening AP and Lateral x-rays of the entire thoracic and lumbar spine. Patients with clinical signs of thoracic or lumbar spine injury similarly require radiologic evaluation.

Presently at ACH steroids are not used in the acute management of cord injuries.

Any patient with isolated spinal cord impairment, refer to the Supra-Regional Spinal Cord Injury Guidelines. These patients are transferred as soon as possible to Middlemore Hospital.

D. Chest Trauma

Algorithms for management of blunt and penetrating chest trauma are found in Part 3.

Injuries that immediately compromise ventilation and oxygenation should be identi ed during the initial assessment of the trauma patient and treated appropriately. Examples include pneumothorax and haemothorax. These patients are always admitted.

Some injuries result in severe respiratory compromise hours or even days after injury. Minor injuries can be a marker

for more severe injuries. The Trauma Service has a liberal admission policy for patients with seemingly minimal chest trauma.

Patients with the following conditions will be admitted:

  1. Sternal fractures
  2. Any 1st, 2nd or 3rd rib fractures
  3. More than 1 rib fracture in any region (We might not admit an otherwise t and healthy patient on the basis of a single rib fracture)
  4. Pulmonary contusion
  5. Subcutaneous emphysema
  6. Traumatic asphyxia
  7. Flail segment
  8. Chest trauma associated with an arrhythmia or other evidence of myocardial injury.

Co-morbid (e.g. CORD, warfarin etc.) and elderly patients may be admitted following any chest trauma.

Patients with chest injuries are admitted under general surgery unless they require admission for another injury requiring surgery i.e. orthopaedic/neurosurgical. They can be referred to the Trauma Service for continuing care as a ward referral. Chest injury patients should not be admitted under medical service due to pain service availability and differing nursing skills. All should receive supplemental oxygen as needed, chest physiotherapy, and adequate analgesia. Consultation with the Pain Service on the day following injury should be considered.

Indications for tube thoracostomy

Tube thoracostomy (chest tube insertion) is indicated in the following circumstances.

  1. Haemothorax on chest x-ray
  2. Signi cant pneumothorax (>20% loss of diameter on chest x-ray)
  3. Severe lung injury or any pneumothorax, no matter how small on chest x-ray, in a patient who is to be transported by ground or air, or is to undergo GA or positive pressure ventilation
  4. As a diagnostic / therapeutic procedure in the unstable multi-trauma patient with suspected internal haemorrhage into the chest
  5. Small pneumothorax or surgical emphysema if patient is to undergo positive pressure ventilation.

E. Aortic Injury

All trauma patients with an “appropriate mechanism of injury” (total body acceleration/deceleration e.g. road crashes [incl. pedestrians and cyclists] and falls >1 storey) are at risk for thoracic great vessel injury. Concerns must be discussed with consultants.

Suspicious clinical signs include:

  • neck haematoma
  • unilateral diminution or loss of pulse, asymmetric BP • radiofemoral delay (pseudocoarctation)
  • severe searing transthoracic pain

AP chest x-ray signs include:

  • Widened mediastinum >8cm
  • Loss of normal aortic contour
  • Opaci cation of aorta-pulmonary window
  • Apical capping
  • Displacement of main stem bronchi (left down, right up), NG tube to the right
  • Fracture of rst rib, scapula

The widened mediastinum requires further investigation, most commonly with CT aortogram.

A widened mediastinum does not necessarily mean an abnormal mediastinum and an abnormal mediastinum may not necessarily be widened.

The investigations for great vessel injury are:

CTA Chest
  • Can be helpful in resolving the diagnosis of abnormal mediastinum
  • Requires the appropriate CT protocol (thoracic aorta dissection protocol)
  • Can identify injuries that may otherwise be missed on plain lms
  • Is not useful for mediastinal haematoma if anatomical boundaries are obliterated by undrained haemothorax etc.

In general, the investigation and the treatment of aortic rupture should follow treatment of expanding intracranial haemorrhage or active chest, abdominal, or pelvic bleeding.

F. Penetrating Chest Trauma

Algorithms for management penetrating chest trauma are found in Part 3.

Penetrating wounds to the chest are relatively uncommon presentations to Auckland City Hospital. Many will cause pneumothorax or haemothorax and require chest drain. Occasionally mediastinal or cardiac injuries occur. Penetrating cardiac injuries have a high mortality and only 25% (2 or 3 each year) survive to reach our hospital. Diagnosis before tamponade is associated with better outcomes than waiting for cardiac arrest.

Any patient who is haemodynamically unstable after a stab wound to the chest needs the cause established as soon

as possible. Finger thoracostomy and tube or chest drains will identify tension pneumothorax or massive haemothorax. Undertake a FAST scan to assess bleeding into the abdomen or pericardium.

In stable patients, clinical examination combined with chest x-ray can be used to evaluate the lungs and pleural cavities but these modalities are insensitive for cardiac injury. When patients have been stabbed in “the box” the possibility of cardiac injury exists. (“The box” is that part of the anterior chest and abdomen bounded by the clavicles superiorly,

the mid-clavicular lines laterally, and the costal margin in the mid-clavicular line.)

Cardiac injury can be identi ed by: FAST scan, echocardiography, pericardial window or thoracotomy. All of these are operator and skill dependent. Get consultant input immediately for suspected cardiac injury.

Thoracotomy procedure

Emergency Department Thoracotomy

This procedure is a desperate measure performed to try and save “agonal” patients. Most patients will die (70 to 90%). In blunt trauma 99% will die.

Indications: A penetrating injury to the chest, where the patient is dying in front of you and will not survive the trip to theatre, and vital signs were present either on arrival in the ED or within the previous 15 minutes but are now absent. Vital signs include a palpable pulse, electrical cardiac activity on an ECG monitor, spontaneous respiration, or reactive pupils.

Procedure:

Tell the consultant surgeon on call this is happening.

The airway doctor advances the ET tube into the right main bronchus. The operating doctor makes a long left thoracotomy incision (5th space). Extend across the sternum if required. Use the Finochietto retractor. Have good access before proceeding.

Then (dependent upon findings):

Pericardial tamponade
  • Identify the phrenic nerve. Open the pericardium anterior to the phrenic nerve. Evacuate the clot. Plug the hole in the heart ( finger, IDC, suture, skin stapler).

G. Abdominal Trauma

Algorithm for evaluation of the abdomen is found in Part 3.

Refer to Appendix I: Evaluation of abdomen in the blunt trauma patient

Injuries may be identi ed in the primary survey (breathing: diaphragmatic hernia, circulation: blood loss). Decisions for laparotomy may be based on history and exam ndings or via the primary survey adjuncts (FAST scan).

The FAST scan should take between 1-5 minutes and has the advantage that it is repeatable and non-invasive. The FAST operator should document the ndings in the notes. When

a credentialed operator is present, this investigation has acceptable sensitivity to exclude haemoperitoneum, cardiac tamponade and pleural uid or blood.

The history of abdominal pain, may be all that points to signi cant intra abdominal injury. Signs may include the ‘seat belt’ sign, abrasion or bruising, and/or abdominal tenderness and/or gross haematuria. Abdominal CT may identify occult injuries in stable patients.

Patients with altered GCS or who are or will be intubated cannot be reliably assessed for these ndings, or monitored for evolving peritonitis. Abdominal CT scan can be used to ‘screen’ these patients for occult injury.

Abdominal CT reports should include: organ injuries (or absence of), free uid, air or contrast and fractures identified.

Blunt Splenic Trauma

Imaging will be performed as detailed below* on blunt trauma patients who do not have immediate indications for theatre i.e. peritonitis, hypotension.

Evidence of splenic trauma with contrast extravasation, false aneurysm, and/or arteriovenous stula will proceed directly to angiography from emergency department. This will be organised by phone call from the most senior surgical registrar/ consultant available to the interventional consultant.

Any grade 3+ splenic injury without the above ndings will prompt a phone call from the surgical consultant to the interventional consultant. If the surgical consultant is not available within 20 minutes to make this call, the most senior surgical fellow/registrar will initiate the communication.

Factors that may prompt angiography in the absence of contrast extravasation, false aneurysm, and/or arteriovenous stula include but are not limited to:

  • Significant hemoperitoneum
  • Clinical findings concerning for impending instability
    • Haemoglobin drop
    • Tachycardia
    • Hypotension
    • Fluid requirement >1L or blood product requirement
  • Patients who are higher risk for complications from hypotension and/or laparotomy
    • TBI
    • Elderly/comorbid

If it is decided that the patient not require immediate angiography, a plan will be put in place to allow for prompt reconsideration should the patient’s condition change. Ideally the patient will be admitted to a monitored setting i.e. HDU.

*Imaging (pertains only to those patients who do not require a chest CT; these patients will continue as before)

  • Dual phase abdominal CT (arterial upper abdomen, portal venous abdo and pelvis)
    • Resus patients coming through as a trauma call
    • Non resus patients with positive FAST
  • Dual phase abdominal CT including pelvis (arterial abdo and pelvis, portal venous abdo and pelvis):
    • Patients with unstable pelvic fractures.
  • Single phase abdominal CT (portal venous phase abdo and pelvis)

H. Penetrating Abdominal Trauma

Algorithm for management of penetrating lower chest or abdomen stab wound is found in Part 3.

Because the diaphragm reaches the level of the fourth intercostal space on full expiration, any penetrating wound below the nipples anteriorly or tips of the scapulae posteriorly are considered potentially abdominal. Gunshot wounds mandate laparotomy.

I. Pelvic Trauma

Algorithm for management of fractured pelvis is found in Part 3.

The pelvis should be assessed clinically as part of the Secondary Survey. Be gentle when examining the patient

  1. Look
  • Abrasion or bruising over bony prominences.
  • Scrotal or perineal haematoma.
  • Blood at the urethral meatus.
  • Leg length discrepancy
  • Feel/move
    • Posterior compression of iliac wings
    • Medial compression of iliac wings
    • Compression of pubic symphysis
    • Hip flexion and rotation
  • Rectal examination
  • All “impaired” patients and any patient with signs or symptoms of pelvic injury should have a plain AP x-ray of the pelvis. When fractures are identi ed, orthopaedic consultation is necessary.

    If a patient with a pelvic fracture is haemodynamically unstable a FAST scan is required:

    • If grossly positive, the patient must go to the OR for a laparotomy.
    • If grossly negative then pelvic angiography and embolisation of arterial bleeders is next step.

    In major pelvic injury, stressing the pelvis should be avoided as it may dislodge vital clot.

    • Orthopaedic stabilisation of mechanically unstable pelvic fractures follows laparotomy or angiography to reduce venous loss.
    • Intensivist, orthopaedic and trauma specialists should be involved early.

    J. Genitourinary Injuries

    Anterior pelvic fractures are associated with a high rate of bladder and urethral injuries.

    Cystogram can be used to investigate these injuries. Gross haematuria with anterior pelvic fractures will likely have bladder rupture as a cause.

    An alternative to cystography in the screening room is a CT cystogram. (The bladder is lled with 300 ml of contrast prior to obtaining a CT ‘run’ through the pelvis. Post-drainage views of the bladder are then taken).

    Retrograde urethrogram is required for the patient with: blood at the urethral meatus, scrotal bruising, high-riding prostate on PR or the stable patient with multiple grossly displaced superior and inferior pubic rami fractures.

    An IDC may still be passed with gentle advancement but any resistance should stop procedure and alternate bladder drainage sought.

    K. Extremity Trauma

    Look for deformity or bruising, feel for pain and listen for bruits over haematomas.

    Do a neurovascular exam.

    X-ray suspicious areas, including the joint either side. A common missed injury is the fracture distal to a fracture in the same limb.

    Wounds should be accurately described, so subsequent examinations are not required. Repeated examination of wounds that are under sterile dressings is counterproductive.

    After splinting or traction the neurovascular state of the limb is reassessed.

    Femur fractures should be immobilised and femoral nerve blocks done.

    Dislocated joints (except native hip joints) and fractures should primarily be managed with relocation within resus rst prior to OT or other de nitive treatment.

    Native hip joint dislocations should go to OR for proper assessment. Always come if intubated and ventilated already. Check with Ortho.

    L. External Trauma

    Make sure you have seen the entire patient.

    External injuries are rarely life-threatening, however active bleeding should be stopped.

    In penetrating injury the most obvious injury may well not be the most important injury.

    Multiple injuries are common.

    In blunt injury, external signs often provide clues to other more serious but less obvious injuries. Clinical rib fractures and the seat-belt sign are good examples.