17 ABSITE Trauma 1_Edited

Welcome back. It's Patrick and Kevin, and we are talking trauma. As always, you want to start with the trauma survey with your primary survey. A lot of the questions on the app site just want you to be able to prioritize. So remember your primary survey, airway, breathing, circulation, disability, and exposure.

You can then move on to your secondary survey, which includes a systematic head to toe physical exam. And if your patient's able to give one a history, of course, we also have adjuncts we can use to help evaluate our trauma patients, including vital signs, EKG labs. x ray, fast exam and the truth machine, the CT scanner.

So Kevin, starting with airway, what does it mean when a patient's protecting their airway? What does that mean to you? So we want to make sure that they can cough clear secretions and swallow. Airway compromise is secondary to airway obstruction or altered mental status. Yeah. And that can be due the, you mentioned airway obstruction, due to something like a direct injury.

A trauma to the neck where I'd be swelling in that area or even

bleeding. You also mentioned altered mental status, right? So altered mental status, that's what we're talking about. Your head here, head injury, drug overdose, et cetera. But if your head is so messed up that you can't coordinate all those activities like coughing, clearing and swallowing, you are in fact not protecting your airways.

What are some tips to manage airway compromise? Yes. You can start with the chin lift and the chin tilt. Definitely have the suction ready to go. And then of course we have our oropharyngeal and nasopharyngeal airways. Yeah. So lots of tips and tricks. And this is of course made harder by the presence of a C collar and our blunt injured patients.

Moving on to more definitive airways, you can certainly intubate the patient if you cannot intubate or ventilate that patient and you move on to a cricothyrotomy. Now, some patients will arrive with a king supraglottic airway. This is not considered a definitive airway and should be exchanged for an endotracheal tube when appropriate.

So, Kevin, you may get a question on the exam about rapid sequence intubation. What kind of meds would you use for induction and what's your favorite med

for paralysis? Yeah, for the RSI generally for the induction, you're going to start with the tomidate or ketamine as these are least likely to cause hypotension.

And then for the paralysis, succinylcholine is the best one to use as the shortest half life. It's safest when obtaining a difficult airway. Yeah. And that succinylcholine has that short half life. So if you run into problems with the airway, then you can you know, within five minutes or so, get them back, potentially even breathing spontaneously again.

And really more commonly, it's about that neuro status, right? So we want to be able to reevaluate and do a thorough neuro exam. And that short acting succinylcholine is ideal for that situation. So Kevin, I mentioned cricothyrotomy. Those are scary situations. Can't intubate, can't ventilate. What are you actually cutting through?

What's the piece of anatomy you're cutting through to place that emergency airway? So it's the cricothyroid membrane. Yeah, and the cricothyroid membrane right between the thyroid cartilage and the cricoid cartilage. And that's the most prominent part of your neck, and that's why we're aiming

for that as opposed to the tracheostomy, which is deeper and more posterior, harder to get to.

So in an emergency situation, We're shooting for the crico thyroid membrane. Again, the most prominent part of the neck, easiest way to get an emergency airway in. I bet everyone out there is actually feeling it right now on themselves. That's what I do every time I think about it. Just take a little feel.

All right, moving on to breathing. How do you evaluate for breathing, Kevin? So, pretty basic stuff. You auscultate, you check for the chest rise and fall, and then you feel for crepitus. And if you have concern for hemo or pneumothorax, you're in place, a chest tube. What are some of the. Kind of basic pointers when it comes to chest tubes, Kevin.

Yeah, so you want to consider it in the fifth intercostal space generally identified at the intersection of the anterior axillary line and nipple and males or inframammary fold in females. It's really easy to go too low, so you really want to be high kind of at that nipple line in males or the inframammary fold in females.

So generally you're going to place a relatively small bore chest tube, something around 28 French and these are preferred over the large chest tubes, like the 36 French for both hemo and

pneumothoraces. And then classically, if you get greater than 1500 cc's of blood out of the chest tube, this warrants a trip to the operating room.

However, it also depends on if the patient continues to bleed and if they require ongoing transfusions. Yeah, we're going to jump into a little bit more about the indications for thoracotomy later in the episode. You're right, Kevin. This question about small versus large bortez chest tubes. So, you know, 28 French is not that small, but the main studies show that 28 to 32 French are as good as anything over 36 French.

So you don't need to put it in that big quote unquote, you know, historical trauma tube. And then not sure if it's fair game yet, but pigtail catheters, right? These are typically around 14 French catheters. They have been shown to be effective for pneumothorax. Absolutely. and hemothorax too. And so, that's also less painful for the patient.

And so that, that may be something that comes up on the exam. It may not. Probably fair game at this point because they are used quite frequently and have been proven. Alright, let's move on to circulation. So, as

part of the primary survey, you're going to check the circulation with a limited pulse exam.

Really, you're just feeling for a pulse. Typically, the femoral artery is your best shot. You can also use the radials, usually the neck. The carotids are covered by The C collar or folks working up top there. Take note that as the true, the true primary survey is just feeling for a pulse. It's not blood pressure.

Certainly we can use blood pressure as an adjunct when we think about circulation, but the actual part of the primary survey is that pulse check. Kevin, what is shock index? Yeah, so this is a quick way to help determine quickly if a patient has shocks. It's the heart rate divided by the systolic blood pressure.

If it's greater than one, this suggests shock. And in the trauma patient, you assume it's hemorrhagic shock. Yeah, hemorrhagic shock, number one. Number two is hemorrhagic shock. Number three is hemorrhagic shock. These are trauma patients, remember. And so, big picture, we want to obtain source control as rapidly as possible.

And typically that means getting to the operating room or interventional radiology suite. Without delay, but we're also going to do a few things at the same time. We want to obtain

vascular access so we can start resuscitation. You have a few options for that. Multiple peripheral IVs are wonderful.

They're working well. Ideally you want a relatively quote unquote large bore. Kevin, what is large bore? Yeah, generally 16 or 18 gauge. Yeah. And you can use a central line. Typically there's subclavian or femoral a cortis resuscitation type catheter. And or intraosseous catheters if you can't get a line.

There's some controversy about that being a go to option or whether it's just more of an adjunct. And really, it's more of an adjunct at this point. What are we going to give our trauma patients, Kevin? Yeah, so nowadays we resuscitate with blood, not crystalloid. Whole blood is best, and if using component therapy, you want to try and administer it at the 1 ratio.

Yeah, crystalloids for cooking pasta, they say. And again, this is hugely important. So, if you have the option for whole blood, that is actually the best. 1. Otherwise, you'll almost certainly get a question about that type of ratio in terms of transfusion. The other thing is practically, you want to start massive transfusion protocol early.

Another app site favorite are the classes of hemorrhagic shock, right? There's class one through four, and this describes the percent blood lost. And this is the classic description of the tennis score, right? So class one, less than 15%. blood loss or total volume, blood loss, class two, 15 to 30 percent class three, 30 to 40 percent and class four greater than 40.

So you have a zero 1530 and then 40. So Kevin for class one, that's a little more subtle, right? What is, what is the, the changes that we might see or something you could pick up on a question stem that would describe class one shock? Yeah. So I think the, the thing on the question sim would probably be the heart rate and the pulse pressure are really the only.

Things that you're going to see change in class one shock. Right, right. That's exactly right. And moving on to class three shock what's the big difference there? What's the change that again may pop up in a question stem? Yeah, this is the first time you actually see the blood pressure drop. Right.

Important classification. In class three and class four

shock, do patients start becoming more anxious, confused, etc.? This mental status changes. All right, let's move on to disability. So Kevin, what are the two key components to the disability exam as part of the trauma primary survey? Yeah, you need to calculate a GCS and look at their pupillary exam.

And knowing how to calculate a GCS score is something you just need to learn how to do. So you got to check out the table, familiarize yourself with these numbers. It can be a bit confusing, but stare at it long enough and you may put it in that brain of yours. What component of the GCS score Kevin has the most?

in terms of prognosis. It's actually the motor score. That's right. And what cutoff when it comes to GCS suggest you might want to intubate the patient. So GC less than eight intubate. That's right. All right. We are cranking through let's get to E exposure. You're going to cut off the patient's clothes and expose the patient's entire body.

Check for wounds, especially penetrating injuries. It's of critical importance that you find all of those penetrating injuries, especially when it comes to gunshot wounds.

So you got to check in all the crevices, all the deep and hard to reach places. You're going to log roll the patient to examine their back and remember once finished with the full exam that you cover the patient in warm blankets.

So one of the key adjuncts that we use in the trauma bay is the FAST exam or focused assessment with sonography for trauma. And we use the FAST exam to try to identify fluid. In different spaces within the body Kevin, right? So what are the four windows for a fast exam? Yeah. So you have your pericardial window, your right upper quadrant also known as the pad or renal window.

You have your left upper quadrant also known as the splenorenal and your super pubic. And what about an E FAST or extended FAST? What does that add on? So this adds an anterior view and the bilateral hemithoracies to detect a pneumothorax. Okay. Let's say I have a positive FAST and the patient's unstable.

Straight to the operating room. Yeah, easy, right? How about I have a positive FAST and a stable patient? So this, you generally would get further imaging with a CT scan. Right. Lots more information from the truth

machine. And you can repeat a fast, right? That's a ultrasound test. It's easy to do and it's actually something that can be quite helpful, especially in patients where their clinical status is changing.

It's also important to note that there's some limitations that come with a fast that can lead to. for instance, false negative results. I think the biggest point here is that the FAST exam will not see what's inside the retroperitoneum and the retroperitoneum is attached essentially to the pelvis. So if you have a bad pelvic fracture, bad pelvic bleeding and bad retroperitoneal hematoma, your FAST exam is not going to be able to identify that.

So that's critically important. All right. Another hot topic in trauma is the resuscitative thoracotomy. Kevin, what are some of the main considerations that go through your mind when you're trying to decide Whether or not to cut open a patient's chest. Yeah, you want to know the mechanism of the injury.

Kind of blunt versus penetrating. You want to know the location of the injury. And you want to know the duration of the cardiac arrest. And if they have any signs of life. Right, and signs of life include pupillary reflex,

spontaneous ventilation, carotid pulse, measurable blood pressure, extremity movement, and cardiac electrical activity.

So there are two primary guidelines that we use in the trauma community. One from the Western Trauma Association. The other from the Eastern Association for the Surgery of Trauma. And they kind of clash a little bit. And so this makes this topic a bit more controversial, a little more nuanced. When it comes to the Western Trauma Association guidelines, they are referring to patients who are pulseless and have no signs of life.

So if the patient has a penetrating injury, you can consider going ahead with recessive thoracotomy if they've had less than 15 minutes of CPR. Whereas if they've had a blunt injury, you can consider recessive thoracotomy if they've had less than 10 minutes of CPR. So again, 15 minutes for penetrating, 10 minutes for blunt.

They also have a category for patients who are quote unquote in profound refractory. Shock. Now compare this to the Eastern Association for the Surgery of Trauma Guidelines, which are a little bit of a

mouthful. So I'm just going to go ahead and read them. So for penetrating thoracic injury, resuscitative thoracotomy is strongly recommended for pulseless patients with signs of life, and is conditionally recommended for pulseless patients without signs of life.

For penetrating extra thoracic injury, resuscitative thoracotomy is conditionally recommended for pulseless patients with signs of life. And without signs of life and for blunt injury, recessive thoracotomy is conditionally recommended for pulses patients with signs of life and is not recommended for patients without signs of life.

So again, there's a lot there. I'm not sure exactly how that would come across on the ab site. It may be a bit too nuanced, but you have all the information there that you need. Now, Kevin, if you remove aortic occlusion, for instance, after a recessive thoracotomy, or maybe you used a roboa. What are some of the physiologic changes that the body might experience?

Yeah, it can be quite dramatic. So now you have a substantial drop in your aortic afterload and you have a washout of ischemic

metabolites from dilated distal vasculature. So paradoxically restoration of blood flow causes further tissue injury. Yeah. Yeah. Patients can get even sicker on you. All right, let's talk about damage control laparotomy.

So what are the two main goals of damage control surgery? Stop the bleeding and limit the contamination. Yeah. And so you do that because you want to get out of the OR quick, right? These patients are really sick. They're on the oftentimes getting sicker right in front of your eyes. And so take care of those things.

Stop the bleeding, limit contamination, keep going through resuscitation, get to the ICU, and then you can come back to the operating room. Once all the physiologic derangements have been. All right, with that, let's move on to damage control resuscitation. And so this is essentially permissive hypotension, right?

Kevin, you're given. Enough blood pressure to maintain a perfusion to key organs. And how do we measure what's enough when it comes to damage control resuscitation? Generally, you want the patient meditating and to have a radial pulse. Right. And a radial pulse roughly correlates to a

systolic blood pressure of around 90.

And we're trying to avoid this idea of, of quote unquote blowing the clot, right? So we're giving enough blood pressure, but not too much. And we're going to limit the use of crystalloids, as we mentioned earlier, and we're going to transfuse blood products, right? Whole blood is best, but we also talked about this balanced resuscitation.

What is that exactly? So it's the one to one to one we talk about, which is platelets to packed red cells to FFP in a ratio that gets close to being like whole blood. Yeah, yeah. So for every bag of pack cells you see going into the patient, that needs to be matched with a bag of FFP. The tricky part about this, though, is that for every five bags of pack cells and FFP, you're actually going to give one bag of platelets.

It's because those are either five or six packs of pooled platelets. So again, sometimes if you're in a real gnarly trauma case and... The bags are piling up on the ground. You're going to see, hopefully, equal stacks of Paxil bags and FFP bags, with fewer of those platelet bags. So, again, those are five or six packs in that single

bag.

Kevin, what about TXA? What's the indication for TXA from the CRASH 2 trial? So, we give TXA. Generally, one gram within three hours of injury, with a subsequent one gram over the next eight hours. Yeah, and what's the mechanism by which we think TSA, TXA may be helping us in the trauma setting? It helps decrease the fibrinolysis.

Yeah, that's exactly right. Let's move on to thromboelastography or TEG, which is the most commonly used commercial product. This looks at the whole of clotting from a given blood sample and you should definitely check out our figure in our book. It's pretty phenomenal. It gives you all the information you need.

And it's colorful too, which is kind of nice. So there are a number of different pieces of information that you can get from a tag. And I think at this point, it's certainly fair game on the app site. And that includes asking specific questions about given features like the R time, for instance, and what you might give.

So let's go through each of those one by one, Kevin. So starting with

time or the R time or reaction time. If that's prolonged, what do we want to give? So in that situation, you want to give FFP. That's right, because this is measuring how long it takes to start the clot in terms of getting it formed. Next, we want to talk about the angle, which shows how quickly the clot is forming.

Kevin, if we have a low angle, what's indicated? In this situation, you give cryoprecipitate. Awesome. And then the amplitude, or the MA, the maximum amplitude, measures the strength of the clot. If this is low, what do we give? Platelets. And finally, the LY30, or the lysis, at 30 minutes, if lysis is high, what can we give?

TXA. Right, for the same reasons that we mentioned earlier. Alright, we are cruising along. Let's talk about head trauma. This is a favorite topic on the ab site, and one that's a little bit jerky, because it's not something we deal with. Every day. So let's talk some talk about different types of intracranial bleeds.

Kevin, how do you describe an epidural hematoma? Yeah, so this is a very characteristic lens shaped

collection of blood that's contained by the suture lines on the head CT. Yeah, what's the classic presentation for these patients? Yeah, so it's generally someone like a bat to the head and then they'll have a lucid interval, and then they'll have a rapid deterioration.

Right, and compare and contrast that to a subdural hemorrhage, so what does that look like on CT? Yeah, so that's more of a crescent shaped collection of blood because it's crossing the suture lines on the head CT. Right, and management for both of these? Management for both of these is an immediate surgical evaluation and determining if they need to have a decompression.

Yeah. Compare and contrast, that's an intraparenchymal bleeds. These are, you know, located within the brain parenchyma itself, most common after blunt injury. May require surgical intervention, but less frequently and last would be the subarachnoid hemorrhage Kevin So this is what's the classic presentation for this is the classic ruptured brain aneurysm the worst headache of your life Yeah, and it can be spontaneous or or traumatic now.

This is also a question That's a bit nuanced, you know who needs an ICP monitor.

What's the easy answer? The easy answer is a patient with a GCS less than eight with an abnormal head CT. Yeah. Now there's more that goes into it than that, but that's your absolute answer. GCS less than eight. And there's two different kinds of types, right?

Of, of monitors. And what are the big, the big categories? Right. You have the ventriculostomy and you have the bolt. Right. And that ventriculostomy goes into the ventral itself, right? So it can measure pressure, but it can also drain off. CSF, whereas the bolt is placed into the parenchyma itself, barely into the parenchyma and will measure a pressure within the parenchyma itself.

And so, when it comes to treating patients with head trauma, we're really intent on reducing one. We want to reduce secondary injury, and we do this by avoiding hypotension and hypoxia. That's right. What about Cushing's reflex? This is often tested. What is that or what is Cushing's reflex? Yeah, this is always one that I had a hard time memorizing for whatever reason, but it's...

When they have bradycardia and hypertension with altered respirations. Yeah, what does that indicate? That indicates that they have compression of their, their brain.

Yeah and then, you know, could mean that the patient's gonna herniate. Either already has herniated or is herniating. And so... When it comes to management of elevated ICP, what are some of the things that we can do?

Yeah, so start with the easiest thing. Elevate the head of the bed. You can also drive down their CO2 to 35. You can use mannitol or hypertonic saline. And then of course sedation and paralyzation. An emergent surgical evaluation, right? If these patients, certainly if they're deteriorating. What about cerebral perfusion pressure?

What's the formula for that? Yeah, so we like to talk about this in vascular for protecting the spine. It's the same for the brain. It's your MAP minus your ICP. Right, and this is a surrogate for cerebral blood flow. And what's the number we want to keep CPP above? Greater than 60. Exactly. And in traumatic brain injury, one of the issues with blood flow to the brain is that the auto regulation function of your brain is actually lost or it can be dysregulated and that can lead to the CPP being really

affected by your MAP, by your blood pressure in general.

So that's why we care. So, a few other things that you want to consider when managing patients with head injury. You want to avoid, as we mentioned, hypoxia and hypotension. That is first and foremost. Ideally, the patient should not be febrile. They should have normal temperature and blood glucose as well.

In general, seizure prophylaxis is recommended. You want to maintain a low threshold as well to obtain an EEG if you have concern for subclinical seizures following traumatic brain injury. And if the patient has any coagulopathy, you want to address that. And so that's a good segue, Kevin, into talking about our oral anticoagulants and how they might be reversed.

So let's start with warfarin. What is the mechanism of action of warfarin? So Warfarin, kind of the oldest one out there, this inhibits vitamin K dependent synthesis of clotting factors such as 10, and protein CNS. Okay, how do we reverse it? So, we're going to go from fastest to slowest, PCC,

prothiamine complex is the fastest, then you have FFP, and then the slowest way is vitamin K.

Great. PCC, FFP, vitamin K. Dabigatran or Pradaxa, what's the mechanism of action there? So this is a direct thrombin inhibitor. Right, and very specific reversal agent. Praxbind. Yeah. Alright, and the most common agents we see essentially on a daily basis at this point are Rivaroxaban or Xarelto, and Apixaban or Eliquis.

What is the mechanism of action here? These are factor Xa inhibitors. Right, and reversal options for us? So to reverse this we generally give PCC. But now there's a specific reversal agent called indexa that's very expensive, but is actually binds directly to the, and reverses these. Great. And actually forgot to mention this earlier.

Do you give steroids for head injury? There's been a lot of studies into this and the conclusion is no benefit and they may potentially harm the patient. Great. Let's talk spinal cord injuries. So some

specific spinal cord injury syndromes. Let's start with central cord. How does that present? So this.

presents as upper extremity weakness. Yeah. The old cape and gloves generally seen in elderly patients with spinal stenosis. How about brown saccade or like the hemitrans section of the spinal cord? Yes. This is where you have the kind of differing symptoms. You'll have ipsilateral motor deficit. And then contralateral pain and temperature deficit below the level of the injury.

Yeah, this would have to be a very specific type of trauma, like a spinal cord, like a stab to the spinal cord that only goes through half the cord. How about anterior cord syndrome? So this is what you see, when you have a, in vascular, when you do a T bar and they lose their motor in their legs, you get a motor deficit below the level of the injury.

Right, and that's from the anterior injury to the anterior spinal artery. And how about this Seawara, spinal cord injury without radiographic abnormality. So the what populations are usually presented? Yeah, it's really limited to just the pediatric

population. Right, so you have a clinical findings of spinal cord injury without anything on imaging.

Now something that's, that's quite confusing is this idea of neurogenic shock versus spinal shock. So neurogenic shock affects the hemodynamics, right? And this is hypotension that occurs due to loss of vascular tone. And it can also occur if there's bradycardia when the injury is high enough to impact the sympathetic input to the heart, which is T1 through T4.

So, Kevin, how do we treat neurogenic shock? So for this, you just resuscitate and use vasopressors, and it typically improves within one to two weeks of the injury. That's right. So again, neurogenic shock, think hemodynamics, versus spinal shock, which has nothing to do with hemodynamics. So, spinal shock refers to the immediate loss of spinal cord function below the level.

of the injury, and this includes spinal cord reflexes. And so the motor and sensory deficits may or may not be permanent, depending on the type of injury. But when the spinal

cord reflexes return, this indicates the resolution of spinal shock. Remember that you're always going to have those spinal cord reflexes, even if it's below the level of injury.

And so if you have reflexes present, After a spinal cord injury, then you know that any residual or existing deficits at that time are likely permanent. And the way to really test this is the bulbal cavernosus reflex, which is when you actually pinch the glans penis or the clitoris or you tug up on the foley catheter.

And a normal response, a normal reflex would be contraction of the anus in that setting. So Kevin, with spinal cord injuries, what are some of the keys to management? Yeah. So first you have to determine if it's a stable versus unstable injury. Kind of one way to help determine this is if there's. Two of three columns disrupted of the spine then it's unstable and requires operative fixation You also want to remember that we don't use steroids for spinal injuries And then

some providers recommend elevated maps for a week or so after the injury to ensure spinal cord perfusion Although this is somewhat controversial.

Okay, let's move on to neck trauma. So Kevin, what is what are the zones in the neck? Let's start with zone one. So zone one is from the clavicles to the cricoid cartilage and zone two That's from the cricoid cartilage all the way up to the angle of the mandible and zone three So this is from the angle of the mandible to the skull base Let's go in reverse zone three angle of the mandible to the skull base zone two Cricoid cartilage to the angle of the mandible zone one clavicles to the cricoid cartilage.

Yeah. All right So on the app site you get a patient who has a penetrating injury to the neck who is hypotensive. What do you do? Straight to the operating room. Yeah, or let's say they have hard signs of vascular injury. Straight to the operating room. Great. And what are those hard signs of vascular injury?

So, pulsatile bleeding, expanding hematoma, distal ischemia, brewery, or arterial thrill. Right. And if

we don't have hypotension or hard signs, where are we going? This is where we get our CTA of the neck. Yeah, super, super useful. All right, Kevin. Let's say we have a vascular injury. to zone. Yeah. So zone three is best approach through kind of endovascular interventions.

Yeah. And what about zone one? Same thing. Yeah. Same thing or a sternotomy, right? So, vascular or IR colleagues aren't available. A sternotomy is the best approach to that zone one injury. Now, zone two, what's the surgical incision for that? Yeah, this is kind of the most fun one. It's you get to do the incision along the anterior border of the sternocleidomastoid.

Yeah. And what are the steps to getting into the neck and onto the vessels? Just like if you're doing a carotid enderectomy. You do a divide the platysma and you move the SCM laterally. You identify the medial border of the internal jugular and then identify the facial vein and ligate it. And then you move the IJ laterally and now you're at your carotid artery.

That's right. Alright, so how about

esophageal injuries? Let's talk about those. What are some signs of esophageal injury? Yeah, so hard signs of injury that would prompt immediate evaluation is massive hemoptysis or hematemesis, respiratory stress or air bubbling from the wound. Yeah, and how are you going to diagnose a esophageal injury?

So, an upper GI study with water soluble contrast. Yeah, what if that's negative but you still have a high concern for esophageal injury? And then I'd upgrade it to dilute barium in esophagoscopy. Yeah, so at any point you can put a scope down as well and try to even directly visualize an injury. How are we going to treat patients who come in with a very recent injury, let's say it's an hour or two old?

So, if it's very recent, we can repair it immediately. Yeah, and you're going to debride that devitalized tissue. Definitely drain widely if given the option. You want to buttress the repair. What's a good piece of muscle to use for... Yeah, strap muscle. Yeah, right from the neck anteriorly there. And you want to keep the patient's MPO.

You

want to think also in these circumstances, obviously, about feeding access. So get a tube past that repair so you can feed after the fact. What are some of the surgical principles when it comes to esophageal repair? We know the esophagus has no serosa, right? So it can be a bit of a bear to deal with.

So what are some of these principles? Yeah. So generally you want to extend the myotomy to see the full extent of the mucosal injury, and then you're going to repair in two layers, and then buttress it with a muscle flap, hopefully, and then drain it. Kevin, what if you're in the neck, you're looking around, and you can't find any injury?

Then you can perform an EGD. That's right. And we didn't mention anything about tracheal injuries, but you want to use laryngoscopy and or bronchoscopy to evaluate a tracheal injury. If it is around any of the important structures in the vocal cords, you want to bring in your ENT colleagues.

These injuries can also be repaired with interrupted absorbable suture as well. Moving on to blunt cerebrovascular. injury. When do we screen these patients? That's a really good question because that's also somewhat

nuanced. Some folks at this point in time are recommending universal screening for trauma patients while others use a certain criteria, the most common being the Denver or Memphis criteria.

So what are these guidelines? These screening guidelines rely on Kevin? Yeah. So they rely on symptoms like focal neurologic deficit or neck hematoma. And then mechanism of injury such as a high speed crash or hanging and then associated injuries such as including face fractures, severe TBI and chest trauma.

Right, and what's the most common actual mechanism that leads to a blunt cerebrovascular injury? That's hyperextension. Yeah, and what's the actual injury to the vessel? So it's an intimal tear is the most common. Yeah, and there's a BCVI grading scale goes 1 through 5. Number 1 is the least severe, a mild injury or irregularity in the intima.

Grade 2 is dissection with a raised intimal flap. or intramural hematoma with luminal narrowing that is greater than 25 percent and or intraluminal

thrombosis. Grade 3 is a pseudoaneurysm. Grade 4 is vessel occlusion or thrombosis. Grade 5 is vessel transection with active extravasation. So in general Kevin, how do we treat...

Blood cerebrovascular injuries. So for the one and two grades where you have patent flow with some sort of intimal injury, you can use antithrombotic medications such as anti platelets. Once you get to three, four, five, that's when you're going to have to intervene on the pseudo aneurysm or potentially the vessel occlusion that gets a little controversial depending on what the symptoms are.

And then obviously a grade five needs immediate surgery, right? And remember that zone one and zone three are difficult to access. Surgically, and that's when you might consider things like stenting. All right, Kev, how are you feeling? Yeah, this is great. Yeah, we're cooking. We're cooking with gas here now.

Let's keep going to thoracic trauma. So, Kevin, what are the indications to take a patient to the OR based on bloody chest tube output?

So if you have 1, 500 milliliters out after the initial placement, that alone is an indication. Or if you have 200 milliliters per hour over four hours. Or, of course, if you have an unstable patient despite blood product resuscitation.

Right, and so it is patient specific, but those are good numbers to know for the exam. Kevin, how do you define flail truss? So this is when you have three consecutive rib fractures in two locations. Right, and this can be associated with some pretty bad pulmonary contusions. Patients may be quite hypoxic.

We manage flail chest with multimodal pain control, with pulmonary toilet even epidurals and positive pressure ventilation like CPAP or BiPAP. And this is a one true proven indication for rib plating. So if you have a patient who has flail chest, who's not doing well from a pain or respiratory standpoint, randomized controlled data supports rib plating in this patient population.

Great. Let's talk about blunt cardiac injury. What are some of the things that you associate with blunt cardiac injury, Kevin? So high speed

mechanisms, thoracic trauma and chest pain. Yeah, and if you get an EKG or if you get, you know, the EKG result on the test and it shows normal sinus rhythm. That patient is highly unlikely to have blunt cardiac injury, but any other dysrhythmia, including sinus tachycardia, warrants a farther evaluation.

What's the next test you're going to order to evaluate this patient? A troponin. Right. And if it's elevated? Then we should closely monitor them and get an echocardiogram. Alright, now while unlikely, you may be asked a question or two about the surgical management of penetrating cardiac injury. A few key points, sternotomy is the preferred approach.

Remember that when opening the pericardium, you want to avoid injury to the phrenic nerve, which runs laterally. To get quick control of bleeding from the heart, you can put your finger over the injury. And you can repair with 3 0 permanent monofilament suture. Oftentimes we will use pledges to help reinforce that repair.

Great, Kevin, we get to now talk about one of your favorite topics, blunt aortic

injury. So what's the most common site of injury to the aorta? So it generally happens at the ligamentum arteriosum. And this happens just distal to the subclavian arteries where you see these injuries. Yeah, what are some other, you know, possible sites of, of injury as well?

So you can see that the aortic root or the diaphragmatic hiatus. Yeah. And to diagnose a aortic injury, we need that CTA. And so what are the types of injury, the grading scheme? Yeah, so there's kind of varying levels of injury similar to many of the vascular criteria. So you have a type one, which is just an intimal tear.

You have a type two, which is an intramural hematoma. Type three is when we start getting excited about surgery and that's going to be the pseudoaneurysm where you have an external contour abnormality of the actual aorta and then type four is a rupture. Right. And so this is where the money's at on the test is the management of blunt aortic injuries.

So what are some of the keys in terms of especially the medical management? Yeah. So you, you gotta get these patients blood pressures controlled immediately. So generally we put them

on a Esmolil short acting beta blocker and try and keep their systolic blood pressure less than 120. Right. And this day and age, most of these folks are getting repaired with an endovascular approach.

Is that right? Yeah, definitely. A T Var. And how about a patient who develops left hand ischemia following repair? So, yeah, so there's times when we're doing the T Var. And so, just to clarify, it's only when we are treating type 3 or type 4 do we use a T Var. Most of the other injuries will heal over time and we just get repeat imaging.

If you have left hand ischemia because you had to cover the left subclavian artery with your tvar, then you need to do a carotid subclavian bypass. Okay, moving down to the belly. Kevin, what's the most common injury after blunt abdominal trauma? Generally, it's solid organ injury. Yeah, and the most commonly injured organ is the liver.

What's the most common missed injury? So, it'll be a hollow viscous or a pancreatic injury. Yeah, and a commonly tested area is a patient who comes in

with an abdominal seatbelt sign and that should prompt concern for bowel injury and or pancreatic injury. Kevin, what if we have a patient with a CT scan who has free fluid, but no solid organ injury visible?

So now you're concerned that there's a hollow viscous injury that is not visualized. Right, and so that patient needs to be taken to the O. R. for exploration. What if a patient has solid organ injury and they are hemodynamically unstable? Easy. O. R. Great, hemodynamically stable. CT scan, right? With a blush angio embolization of IR.

Great. And what if they don't have a blush, but have an injury? I'll say it's a grade three spleen. So these patients you can closely monitor and do serial abdominal exam in labs, right? And the key here is to, is recognizing failure, right? So recognizing failure of non operative or non interventional management and some of the common things you might see would be hemodynamic instability, obviously ongoing transfusion requirements.

Down trending hemoglobin and certainly worsening pain on exam. And these patients need to be taken to the O. R. immediately. So don't get

stuck going the CT scan or other things like that. Take them to the O. R. In real life and on the test. And for the hollow viscous injuries, are you generally doing a, if you're concerned, are you starting laparoscopic?

Yeah. So I think that's absolutely something that would be warranted if the patient's hemodynamically stable, starting with a laparoscopic. Intervention it would be a totally reasonable thing to say in the test. I'm not sure how they would cover that, you know, exactly versus open. But if your skill set allows by all means, all right, Kevin, here's a high yield topic abdominal stab wounds.

So if the patient's human amicably unstable or they have a visceration or peritonitis on exam, that's easy. They're going to go to the operating room, but what about local wound exploration? Let's say you're looking at the wound. What finding mandates a trip to the operating room either with diagnostic laparoscopy or exploratory laparotomy?

So you're going to look for a violation of the anterior rectus sheath. Right. If that's equivocal, you can't really tell, what would be the next step in the workup? In that situation, you get a CT scan or monitor them

serially with exams and labs. Right. Flank stab wounds are a special category because this raises concern for retroperitoneal injury.

If the patient's otherwise well, you can get a CT scan with triple contrast, which would add a rectal contrast and can help identify an injury to the colon. With thoracoabdominal stab wounds, you're going to have concern for a diaphragm injury. These can be difficult to see on the CT scan. So if you got a kind of funny question stem and things aren't quite adding up or they're showing you x rays and it looks kind of funny, you're going to want to take the patient to the operating room for diagnostic laparoscopy so you can take a direct look at the, at the diaphragm and that can be repaired with permanent suture and interrupted or running fashion.

All right, last but not least, retroperitoneal injury. Remember that zone one is central and contains the aorta and IVC. Zone two lateral contains the kidneys and zone three is below the aortic bifurcation. This can be a little bit

confusing. We'll try to simplify it. So if you have a penetrating injury, you should explore The entire trajectory of the injury does not matter which zone you are in.

It's a little more confusing with blunt injury. And so here's some general recommendations. If you have blunt injury with retroperitoneal bleeding or hematoma in zone one, that should be explored. Ideally, you want to get proximal and distal control before diving in. If you have a zone two injury, again, blunt, you should explore only if you have expanding or pulsatile hematoma.

And for zone three, in general, you don't want to go digging around down there. In this case, you'd want to pack and take the patient to IR. However, if there is concern for arterial injury, then exploration would definitely be warranted. All right, we did it. We covered a whole bunch. That's part one of two in trauma.

We hope you enjoyed it. Take it away, Jason and John.