POTD: Trauma Tuesday. Blunt Abdominal Trauma: What's the injury?

Let’s start with a case:

19 year-old Male presents after MVC as unrestrained driver in head on collision. He appears tachypneic and is noted to have decreased breath sounds on his left side. Just as the Trauma Team is prepping for a chest tube, POCUS shows +lung sliding at the apex and something that looks strange at the bases…

potd diaph.png

What does this patient have?

·      Diaphragmatic rupture with herniation of the abdominal contents into the thoracic cavity

·      Pathophysiology? Blunt trauma causes compression of the abdominal cavity and the pressure gradient between the thoracic and abdominal cavities

o   Previously thought to be more common on left side due to absence of liver

  • No longer true! more or less the same frequency

  • Right sided injury with greater mortality

    • d/t force required for injury is higher

    • more delay in diagnosis

o   Proceed cautiously if considering chest tube placement in these patients to avoid visceral injury from the chest tube

  • Keep in mind that ptx is more common

·      Can lead to respiratory distress and the degree of his respiratory distress is related:

  • o    size of the diaphragmatic tear

  • o   amount of abdominal viscera that is herniated

·      The mortality rate higher with blunt trauma than penetrating trauma because blunt diaphragmatic injury tends to lead to larger defects.

·      If the injury is large enough, it can be detected on cxr

·      CT scan can help identify these injuries when they are not visible on chest xray

·      Small injuries are notoriously very difficulty to detect

  • Patients can even present from weeks to months to years later with symptoms from a previously undiagnosed injury

·      Complications

o   tension gastrothorax, visceral ischemia, perforated viscus

 

Sources:

ACEP Clinical Policy on acute blunt abdominal trauma

Tintinellis

Peer IX

Cxr from: https://www.semanticscholar.org/paper/Blunt-diaphragmatic-rupture%3A-four-year%E2%80%99s-experience-Matsevych/35f84bfd12f4633dcb29539464a67e9cca51bd29/figure/3

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POTD: Tongue Blade Test in Minor Mandibular Blunt Trauma

Minor trauma with mild swelling and want to avoid imaging the patient?

Tongue blade test:

How is it done? Have the patient attempt to "clamp down on” a tongue blade between the teeth with enough force that the examiner is unable to pull it out from the teeth.

When the examiner twists the blade, a patient should be able to generate enough force to break or crack the blade.

A positive test: if the patient cannot clench the tongue blade between the teeth or if the examiner cannot break the blade while it is held in the patient’s bite. If the test is positive, imaging is indicated.  

A negative test: If the blade can be gripped by the patient and be broken by the examiner, fracture of the mandible is much less likely, and additional imaging is likely not needed. In a prospective series of 110 patients with suspected mandible fracture, the test was found to be approximately 96% sensitive and 65% specific.

Who is not likely to benefit from this test? Major trauma that would indicate further imaging, signs of mandibular fracture such as: intraoral bleeding, tooth malocclusion, trismus, ecchymosis, and intraoral swelling.

Sources: https://www.aliem.com/2010/07/trick-of-trade-tongue-blade-is-as/

^ Check out this awesome aliem post and especially for the video demonstration

Alonso L, Purcell T. Accuracy of the tongue blade test in patients with suspected mandibular fracture. J Emerg Med. 1995;13(3):297-304. [PubMed]

Peer IX

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POTD: Trauma Tuesday: Lateral Canthotomy

When to perform it?

·      To release orbital compression syndrome, most commonly due to retrobulbar hematoma.

·      IOP > 40, the pressure that indicated that you need to cut and release the compartment syndrome.

·      Without decompression, irreversible vision loss due to increasing orbital pressure may occur in as little as 90-120 minutes.

Clinical situation: trauma to the head/face.

Physical exam:

https://www.emra.org/emresident/article/emergency-department-evaluation-of-blunt-orbital-trauma/

https://www.emra.org/emresident/article/emergency-department-evaluation-of-blunt-orbital-trauma/

CT head and face

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familiarize yourself with the anatomy

potd anatomy eye.png

Before starting, highly consider sedation.

Steps:

1)    Generously inject 1% Lidocaine with epi to numb that lateral canthus to the orbital rim.

  • Do this by directing the needle away from the globe itself

  • Helps with bleeding and with pain.

2)    Using the needle driver as your hemostat, advance from the lateral canthus to outer orbit rim. Clamp down and hold for 1- 2 minutes.

3)    Using your small scissors, cut the lateral canthus to the orbital rim.

4)    Then cut inferiorly to cut the inferior crus of the lateral canthus (you may need to probe around to feel the structures)

5)    Repeat IOP. If the IOP is not immediately lower, then cut the superior crus of the lateral canthus and recheck pressure.

Pearls:

·      There is a lot of swelling. It can be hard to fit your hemostat in place and to feel your landmarks. Use you instruments to feel/probe around.

·      Also, do not worry about cutting too much. You are doing this to save this patient’s vision. After discussing this with optho, these are repaired quite easily days/weeks later. For example, Dr. Tome Levy performed this once on a patient that I later followed up with in split flow about 2 weeks later. There was no physical evidence on physical exam that this had ever happened. At first I thought I had the wrong patient in front of me… but the patient confirmed that a week and half ago he had in fact had the optho plastic surgery to repair it.  

Sources:

https://emedicine.medscape.com/article/82812-overview

http://www.tamingthesru.com/blog/annals-of-b-pod/ocular-emergency

This is an excellent emrap video that reviews the procedure: https://www.youtube.com/watch?v=tgQaKVGynFA

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POTD Trauma Tuesday: Name that fracture!

A 36-year-old man presents by ambulance following a motorcycle crash. He told the EMTs that he lost control and fell sideways, bracing his fall with his outstretched right hand. His R arm looks deformed but is neurovascularly intact. An xray is obtained.

xray potd.png



What’s the name of this one again?!

Galeazzi fracture! Named after an Italian surgeon from Milan.

What is it? a fracture-dislocation of the distal third of the radius associated with dislocation-subluxation of the distal radial ulnar joint, or DRUJ.

Why do we care? With Galeazzi fractures, there is a high risk of malunion, loss of function, infection, and chronic pain in adult patients. For this reason, surgical management with internal fixation and possible open reduction is required. The repair should occur promptly, so the emergency physician or another clinician should contact the orthopedic consultant emergently to coordinate care.

What about in peds? Emergent orthopedic consultation is still required but interestingly, in children, some Galeazzi fractures are treated conservatively with closed reduction by an orthopedic surgeon. Disruption of the DRUJ can be subtle, so a high suspicion should be maintained when a patient presents with a fracture of the distal third of the radius.

Pearls of the Peal:

* Look for fracture-dislocation of the distal radius and ulna after a fall onto an outstretched arm. This injury can’t be missed: it requires immediate orthopedic involvement.

* Skin tenting associated with the Galeazzi fracture-dislocation puts the patient at risk for skin necrosis and conversion to an open fracture.

Wasn’t there some way to remember this compared to other one?? Why, yes! See below:


mugger.png

Sources:

Comic: Medcomic.com

Xray and clinical information: PEER IX

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POTD: Trauma Tuesdays. Le Forte Fractures

Inservice is over but let’s keep the review of Le Forte Fractures going strong!

Interesting historical fact: Named after French Surgeon Rene Le Forte. He described fracture classifications are based on experiments conducted in 1900 by dropping bricks on cadavers and observing the pattern of fractures.

I included the words for description of the fractures but pictures are truly best.

·       Le Fort I: the gist: palate. across both maxillae above the dentition.

o   More wordy: The fracture extends through the piriform aperture superior to the maxillary alveolar ridge, then propagating through the anterior, medial, and posterolateral maxillary sinus walls.

·       Le Fort II: the gist: nose + palate. starts in the maxilla laterally but extends more superiorly into the orbital floor.

o   More wordy: The fracture involves the posterolateral maxillary sinus wall and anterior maxillary wall, extending through the inferior orbital rim into the orbital floor, medial orbital wall, and the region of the nasofrontal suture.

·       Le Fort III: The gist: craniofacial separation. completely separates the facial bones from the skull. Transverses zygomatic arches laterally. Buzz word: CSF rhinorrhea.

o   More wordy: The fractures extend through the nasal bridge, medial orbital wall, posterior orbital floor, and lateral orbital wall near the frontozygomatic suture. The zygomatic arch is always fractured as well.

In general: All of these patients are going to have severe swelling, possible airway obstruction. All will need OMFS consult, IV abx, surgical management and admission.

Sources:

LIFL: https://litfl.com/le-fort-facial-fractures-eponymictionary/

ENT trauma handbook published 2017 written by the American Academy of Otolyngology- Head and Neck surgery

Photo: https://emedicine.medscape.com/article/434875-overview

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POTD: Trauma Tuesdays - Concussions

Clinical scenario:

A 16-year-old boy presents after hitting his head in a collision with another player during a soccer game. He denies loss of consciousness but complains of a moderate headache, nausea, and difficulty concentrating. 

Which of the following represents appropriate next steps in management?

A. Admit the patient to the hospital for overnight observation

B. Clear the patient to play after 48 hours if his symptoms resolve

C. Discharge with instructions to get follow-up care and not return to play

D. Order a head CT to rule out the presence of an intracranial bleed or swelling

The correct answer is C. 

Concussions

What is a concussion?

The term "concussion" is often used in the medical literature as a synonym for mild TBI but more specifically describes a pathophysiological state that results in the characteristic symptoms and signs that individuals may experience after a mild TBI. 

Symptoms

Rapid-onset short-lived neurologic function impairment that resolves on its own. These symptoms reflect functional disturbance rather than structural injury.

concussion symptoms.png

Diagnosis

If one or more of the following:

  • Symptoms, including somatic (headache, nausea, off balance), cognitive (“ in a fog,” slow), or emotional (rapidly changing)

  • Physical signs, such as loss of consciousness, amnesia, although LOC is not required

  • Behavior changes, such as irritability

  • Cognitive impairment, such as slowed reaction times

  • Sleep disturbance, such as insomnia

Evaluation

  • Concussion is a clinical diagnosis, and there are a variety of sideline assessment tools (that are outside the scope of the ED) that include measurements of orientation, symptoms, gross cognition, and physical examination findings (e.g. Standardized Assessment of Concussion (SAC)Balance Error Scoring System (BESS), computerized neurocognitive testing, and the Sport Concussion Assessment Tool version 5 (SCAT5 or Child-SCAT5)).

  • Physical exam should include: 

    • assessment of the cervical spine (+/- immobilization with c-collar if cervical spine injury suspected)

    • detailed neurologic assessment (including mental status, cognitive functioning, and gait/balance)

    • structural brain imaging (i.e. CT scan or MRI) if concern for structural injury (e.g. acute brain bleed)

Discharge Precautions

This is arguably the most important part of your role in the concussed patient. Thankfully, the CDC has a ton of great literature on the subject.

Pediatric Care Packets:

  1. Pediatric Discharge Instructions

  2. Symptom-Based Recovery Tips

  3. Pediatric Care Plan

Adult Care Packets:

  1. Adult Concussion Fact Sheet

  2. Adult Concussion Brochure

  3. Adult Care Plan

References:

PEER IX

http://www.emdocs.net/concussion-update/?fbclid=IwAR3KSyGMyb-55DTXUWRkTXRLBurnrvULl2zPhZb4xIyiJH8_idVktsaDTJA

https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-adults?search=concussion&sectionRank=3&usage_type=default&anchor=H25&source=machineLearning&selectedTitle=1~79&display_rank=1#H25

https://www.cdc.gov/HeadsUp/

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Blunt Cardiac Injury Guidelines

To trop or not to trop? Here's a brief review of the 2012 EAST trauma guidelines for BCI. 

What is BCI, anyway?

Describes a range of injuries due to blunt thoracic trauma: wall motion abnormalities, myocardial contusion, valve injuries, focal wall dilation, coronary injury, pericardial rupture, wall rupture

Right heart most commonly affected as it is most anterior.

Who to work up?

According to 2012 East guidelines: “patients with any significant blunt trauma toanterior chest should be screened.”

Also consider BCI in patients with persistent unexplained tachycardia, cardiogenic shock, or hypotension not explained by other injuries.

Now that I suspect BCI, what should I do?

Screening:

Screening consists of an EKG (Level 1 evidence) and a troponin (Level 3 evidence). Early studies suggested that EKG alone is sufficient to diagnose BCI, however multiple studies since then show that such an approach does not capture the small percentage of BCI patients that present with normal initial EKG and positive troponin. 

A normal EKG and troponin rules out BCI (even in the setting of a sternal fracture, which is not predictive of BCI). Several studies show that the addition of troponin raises the NPV to 100%. Same screening approach is supported for pediatric pts.

Management & Disposition: 

Management is supportive; severe trauma may require surgical repair. 

Patients who have a new abnormality on EKG (arrhythmias, ST changes, heart block, PACs or PVCs, ischemic changes, etc) must be admitted to a telemetry floor for continuous monitoring. 

A new dysrhythmia or hemodynamic instability warrants an echo, preferably TEE over TTE.

Note that degree or persistence of elevation of troponin does not correlate with prognosis.

The chicken or the egg…did an MI precede the MVA or is it BCI?

It is important to differentiate which patients need cath with anticoagulation and which patients would be harmed from it. Can be differentiated via ekg-gated CT angiocoronaries.

Read more at:
http://www.aast.org/blunt-cardiac-injury
https://www.east.org/mobile/practice-management-guideline/96

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Traumatic Hemothorax

Case: 18 y/o M is wheeled in with a stab wound to the left chest. VS: HR 130, BP 95/45, RR 30, SpO2 92% on 15L NRB. Pt is maintaining airway, no tracheal deviation, diminished BS on the left, strong distal pulses. You place a left-sided 36F chest tube with immediate blood return. 

What are the possible etiologies of traumatic hemothorax?

Laceration/injury to the heart, major vessels, intercostal vessels, mammary arteries, thoracic spine, diaphragm or lung parenchyma. 

How reliable is the FAST exam in diagnosing a hemothorax?

Sensitivity is 92-96% however bear in mind that the presence of subcutaneous air or concomitant PTX may obscure the underlying blood.

How much blood must be present to diagnose a hemothorax on CXR?
For upright CXRs, 150-300mL of blood causes blunting of the costophrenic angle. However, most trauma will have their CXR done in a supine position, which has a low sensitivity 35-60%. It may take 1L of blood distributed throughout a supine hemithorax to develop haziness on a supine film!

What defines a massive hemothorax?
Traditionally:

-Immediate drainage of 1.5L (or 15mL/kg) or 1/3 of blood volume
-Drainage of 200mL/h (or 3mL/kg/h) x 2-4 hours plus persistent need for blood products

Other definitions:

Screen Shot 2018-12-12 at 9.39.07 AM.png

How to manage a massive hemothorax post thoracentesis?

Address hypoxia by keeping patient on oxygen and may attempt to position so that affected lung is down (if permitted by lack of other injuries). Resuscitate with 1:1:1 blood products. These patients benefit from thoracotomy in the OR as soon as possible. 

What are the long-term complications of not adequately draining a hemothorax?

Retained hemothorax consisting of clotted blood can form, which is not easily drainable by a chest tube. A traumatic hemothorax is also a nidus of infection; these patients are at risk of developing empyemas.

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More pressure more problems

High Pressure Injection Injury Occurs when fluid is expelled at least 100 pounds per square inch.  The fluid punctures skin and can dissect up along facial plains, neurovascular bundles, and tendons.   This can easily cause compartment syndrome, deep infections, and debilitating fibrosis.  Extremity necrosis can develop within 12 hours.  Even with expeditious OR debridement and washout there is a 38% risk of amputation and with caustics or higher pressure the risk is up to 80%.  Those that keep their limb lose a great deal of functionality.

Demographic:

  • Young adult typically male injured non-dominant hand

  • Inexperienced operator of equipment

  • exposure material is paint, grease, water, oil, diesel, paint thinner,

Acute phase

  • onset within 4-6 hours

  • paresthesias, pain, swelling,

  • vascular compromise

  • compartment syndrome

  • injury site may have no skin perforation or small subtle pinhole

ED steps:

  1. Recognize this minuscule puncture site is a huge life changing problem

  2. Broad spectrum antibiotics

  3. Tetanus

  4. Hand consultation for OR wash out/debridement

  5. X-ray--> lead base paint is radio opaque but may appear like calcifications. Other paints will show sub-cutaneous emphysema. Grease will appear as a lucency.

  6. analgesia

  7. council patient of detriment to extremity function

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Arterial Pressure Index

TRAUMA TUESDAY POD- ARTERIAL PRESSURE INDEX

INDICATIONS

  • Severe extremity injury with...

  • Proximity of injury to vascular structures

  • Major single nerve deficit

  • Reduced pulses

  • Posterior knee or anterior elbow dislocation

  • Hypotension or moderate blood loss at scene

  • Concern for vascular injury

CONTRAINDICATIONS

  • Unable to place BP Cuff around ankle or arm due to injury

EQUIPMENT

  • Manual BP Cuff

  • Handheld Doppler Instrument

  • Ultrasound Gel

PROCEDURE

  1. Measure systolic pressure in injured extremity distal to the injury (may measure radial, ulnar, brachial, dorsalis pedis, posterior tibial)

  2. Measure systolic pressure in uninjured brachial artery

  3. Perform Calculation: Injured extremity SBP/ Uninjured brachial SBP

INTERPRETATION

  • API >0.9: Vascular injury very unlikely, CT angio unnecessary

  • API <0.9: Possible vascular injury, CT angio is indicated

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Trauma Tuesday POD- Hare Traction Splint

traction-splint.jpg

What is a Hare Traction Splint?

When to Use a Hare Traction Splint?—Midshaft femur fracture when there is no evidence of pelvic or lower leg injury.

How to apply a Hare Traction Splint?

  1. Expose the injured limb.

  2. Measure distance of splint on uninjured leg- Should be 6-8inches past ankle.

    1. Measure on opposite leg of fracture as femur fracture side can be shortened

    2. Apply ankle hitch

    3. Slide splint under injured leg.

    4. Fasten the ischial strap.

    5. Connect loop of ankle hitch to splint

    6. Tighten the ratchet so the splint holds the traction

    7. Apply the rest of the straps- avoiding the fracture site.

    8. Assess neurovascular function

Here is a link to a video to see how it is applied!

https://youtu.be/498SydRP4jg

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Trauma Tuesday POD- BOWING FRACTURE

bowing-fracture.jpg

BOWING FRACTURES  

What is it?

  • Incomplete fracture of tubular long bones pediatric patients.

    • Commonly radius and ulna

Presentation:

  • Fall on outstretched hand. Child presenting with pain and swelling of forearm

How does it happen?

  • Pediatric bones bend because the cortex is thinner than adult bones.

Management

  • Depends on degree of angulation

    • <20degrees= splint

    • >20 degrees= reduction of bowing (call orthopedics)

      • during the reduction they are very prone to fracturing

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Pulmonary Contusion

History:

  • Symptoms include SOB and chest pain.

    • Remember this may manifest as back pain depending on mechanism.

    • Look for in high impact injuries to chest (MVC, fall, pedestrian struck, trampled by livestock, etc)

    • MOA being compression-decompression.

Exam:

  • Flail chest or crackles (however unlikely unable to auscultate in ED).

  • Observe for crepitus for possible pneumothorax.

  • Seatbelt sign.

Diagnosis:

  • CXR or CT chest

  • Extent of injury not apparent on CXR for 24-48 hours

  • Areas of lung opacification within 6 hours diagnostic of pulmonary contusion.

  • There are NEXUS chest guidelines (yes, chest!) for patients>14 to omit any imaging in chest trauma (see appendix below) - 98.8% sensitive.

  • Look for homogenous focal or diffuse opacity that may cross typical anatomical landmarks (i.e. lobes).

pulm-contusion.jpeg

Treatment:

  • Primarily supportive. Watch for delayed presentation!

  • Consider Bipap; pain control with intercostal block or epidural inpatient. Avoid unnecessary fluids.

  • Up to 40-60% will require mechanical ventilation. Also may be necessary to sedate for pain control.

  • Place good lung in dependent position to improve V/Q mismatch 50% go on to develop ARDS (blood in alveoli activates inflammatory cascade).

  • If not improving - ECMO (V-V) is a possibility.

Bottom line:

  • Monitor patients suspicious for pulmonary contusion - if they have signs of CXR there is a good chance they may need more invasive support (e.g. intubation).

  • Have low suspicion for concurrent injuries including mediastinal and vascular injuries, diaphragmatic rupture, and cardiac contusion.

  • Be aware of patient fluid status and try not to overload patient.

Table-3_-NEXUS-Chest-Decision-Instrument.jpg

Keywords:  Pulmonary Contusion NEXUS Chest Radiography Chest Trauma

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Trauma Tuesday: Handlebar Injuries

oldbike.gif

Case: Pediatric patient arrives after being overzealous on his bicycle with the following wound.

The first thing you do is recognize the sign. The second thing you do is ask to look at a video of what happened.

What we see above is the handlebar sign. It can present either as a longitudinal pattern of the bicycle handlebars strike the abdomen in collision or it may be a circular wound from the end of the handlebar impaling the abdomen.

Management:

An estimated 10% of bicycle injuries are related to contact with handlebars. Hemodynamically unstable patients should raise consideration for injury to the IVC or other abdominal vascular structures.

Your trauma survey places a lot of importance on the chest xray which can show diaphragmatic rupture or significant viscous perforation early on. Early laparotomy should occur in unstable patients, patients with significant peritonitis, or free air on x-ray.

Patients with isolated injuries to the abdomen, a negative FAST, normal labs (including LFTs/lipase/UA), and clinical improvement over 24 hours are safe for discharge.

Persistent LUQ pain that radiates to left shoulder during serial exams will generally require further investigation including advanced imaging like CT with IV contrast. If bilious vomiting ensues 24-48 hours after injury, consider a duodenal hematoma as hollow viscous injuries are rarely seen on CT scans.

Splenic injuries require serial hemoglobin/hematocrits, serial abdominal exams, and bed rest. Grades 1-4 are non-operative per American Pediatric Surgical Association. Splenectomy is rarely required though vaccination for encapsulated bacteria should be performed in the setting of severe injuries.

Read More: Gutierrez IM, Ben-Ishay O, Mooney DP. Pediatric thoracic and abdominal trauma. Minerva Chir 2013;68:263-274.

Puskarich MA, Marx JA: Abdominal Trauma, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 46:p 459-478,

Teisch LF, Allen CJ, Tashiro J, et al. Injury patterns and outcomes following pediatric bicycle accidents. Pediatr Surg Int 2015;31:1021-1025.