Master trauma panel perspective

1. Top Ten Topics
Panel Discussion

2. Top Ten Topics
1. Appropriateness of helicopter
transport

3. Top Ten Topics
2. Surgeons won’t come in to
see trauma patients in rural
hospitals (?EMTALA
considerations)

4. Top Ten Topics
3. Massive transfusion protocols
– transfusion ratio

5. FFP : RBC Ratio / 6 Hr – Civilian Experience
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1:1 1:2 1:3 1:4 ≥1:5
PredictedProbability
FFP:RBC at 6 hrs
Upper
Quartile
Trendline
Lower
Quartile
AAST / J Trauma 2008

6. J Trauma Acute Care Surg. 2012;72: 106–111
Objective : To characterize changes in resuscitation which
have occurred over time in a cohort of severely injured
patients requiring MT.
Glue Grant:
Blunt
BD <6

7. J Trauma Acute Care Surg. 2012;72:106–111.
FFP : RBC Transfusion Ratios over Time

8. J Trauma Acute Care Surg. 2012;72:106–111.
Sub-MT = 7 – 10 RBC
PLT : RBC Ratios for Sub-MT
Patients Across Time Periods
FFP and PLT Transfusion in First
6, 12, 24 Hr Post-injury

9. Top Ten Topics
4. Volume resuscitation in
trauma: penetrating vs blunt

10. Top Ten Topics
5. Blunt neck trauma – who
needs a workup and what
should it be?

11. OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
Clearing the C Spine
The rule on our wall in the ED is:
INDICATIONS FOR SCREENING CT OF THE CERVICAL SPINE
In patients receiving initial HMC CT head:
Screening cervical spine CT used in those patients considered to be at "high-risk (pre-test
probability of > 5%)
Includes:
1. High speed collisions (MVC > 35 mph combined impact.)
2. Crash with death at the scene
3. Patients with an acute myelopathy or radiculopathy
4. Falls > 10 feet.
5. Patients with known or strongly suspected pelvic or multiple extremity fractures.
6. Patients with significant closed head injury (intra-cranial blood.)
Since we use the same inclusion criteria, all you need to include is something like "Initial spine
imaging according to HMC ED protocols.”
• I think radiology would all be happy with that

12. Clinical Decision Rules
• Canadian Spine Rules
• Nexus Low Risk Criteria
• Both meant to select patients who
don’t need C-spine imaging in the
Emergency Department

13. Canadian C-spine Rules

14. No
Algorithm_CSpine Evaluation_FINAL_11-20-2012
Clinical Decision Rules
Reproduced from Stiell I. et al. “The Canadian C-spine Rule versus the NEXUS Low Risk Criteria in patients with trauma” NEJM 2003;349:2510-8
Table 1. The NEXUS Low-Risk Criteria. *
*Criteria are from Hoffman and colleagues.
26
† Midline posterior bony cervical-spine tenderness is present if the patient
reports pain on palpation of the posterior midline neck from the
nuchal ridge to the prominence of the first thoracic vertebra, or the
patient evinces pain with direct palpation of any cervical spinous
process.
‡ Patients should be considered intoxicated if they have either of the
following:
A recent history provided by the patient or an observer of intoxication or
intoxicating ingestion, or evidence of intoxication on physical
examination such as an odor of alcohol, slurred speech, ataxia,
dysmetria, or other cerebellar findings, or any behavior consistent with
intoxication. Patients may also be considered to be intoxicated if tests
of bodily secretions are positive for alcohol or drugs that affect the level
of alertness.
§ An altered level of alertness can include and of the following: a
Glasgow Coma Scale score of 14 or less; disorientation to person ,
place, time, or events; an inability to remember three objects at five
minutes; a delayed or inappropriate response to external stimuli; or
other findings.
¶ A focal neurologic deficit is any focal neurologic finding on motor or
sensory examination.
║ No precise definition of a painful distracting injury is possible. This
category includes any condition thought by the clinician to be producing
pain sufficient to distract the patient from a second (neck) injury. Such
injuries may include, but are not limited to, any long bone fracture; a
visceral injury requiring surgical consultation; a large laceration,
degloving injury or crush injury; large burns; or any other injury causing
acute functional impairment. Physicians may also classify any injury as
distracting if it is thought to have the potential to impair the patient’s
ability to appreciate other injuries.
Cervical-spine radiography is indicated for patients with trauma unless they meet
all of the following criteria;
No posterior midline cervical-spine tenderness, †
No evidence of intoxication, ‡
A normal level of alertness, §
No focal neurological deficit, ¶ and
No painful distracting injuries. ║
Figure 1. The Canadian C-Spine Rule
Any high-risk factor that mandates radiography?
Age > 65 or dangerous mechanism or paraesthesias in
extremities
Able to rotate neck actively?
45
o
left and right
For patients with trauma who are alert (as indicated by a score of 15 on the Glasgow
Coma Scale) and in stable condition and in whom cervical-spine injury is a concern, the
determination of the risk factors guides the use of cervical-spine radiography. A
dangerous mechanism is considered to a fall from an elevation of >= 3 ft. or 5 stairs; an
axial load to the head (e.g. diving); a motor vehicle collision at high speed (>100 km/hr.)
or rollover or ejection; a collision involving a motorized recreations vehicle; or a bicycle
collision. A simple rear-end motor vehicle collision excludes being pushed into
oncoming traffic, being hit by a bus or large truck, a rollover, and being hit by a high
speed vehicle
Any low-risk factor that allows safe
assessment of range of motion ?
Simple rear end MVC or sitting position in the
emergency department or ambulatory at any time or
delayed (not immediate) onset of neck pain or absence
of midline cervical-spine tenderness
Radiography
No Radiography
No
Yes
Unable
Yes
Yes

15. Nexus Exclusionary Rules

16. OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
Spine is CLEARED
1 - Remove cervical collar
2 - Mobilize as tolerated
Trauma admission:
FULL SPINE precautions
FULL SPINE PRECAUTIONS.
Consult Spine Service
PARTIAL SPINE precautions
ALERT
TRAUMA PATIENT
Primary service
examines
patient
Spine is TREATED
1 - Maintain cervical collar
2 - Review supine films again for possible missed injury
3 - F/U in spine clinic in 2-3 wks for flex-ex images
Supine Imaging
Studies
Is there a fracture,
ligamentous injury,
or
neurologic deficit?
Neck pain
or
tenderness?
Yes
Yes
N
o
N
o

17. OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
TRAUMA PATIENT
With ALTERED LEVEL of CONSCIOUSNESS
Trauma admission:
FULL SPINE precautions
C Spine
CT
Is there a fracture
or
ligamentous injury
documented by
final radiology
report?
FULL SPINE PRECAUTIONS.
Consult Spine Service
Is a gross motor exam
possible? (No
neuromuscular blockade,
extreme
sedation/analgesia,
or hypotension)
Primary service
examines
patient
Does pt have
neurologic exam
suspicious for
SCI?
PARTIAL SPINE PRECAUTIONS.
Maintain cervical collar pending
motor exam
Spine is CLEARED
1 - Remove cervical collar
2 - Mobilize as tolerated
Yes
N
o
FULL SPINE PRECAUTIONS.
Consult Spine Service
e.g. Motor asymmetry not
attributable to other causes
Old CVA
New brain
injury
Initial spine imaging
according to HMC ED
protocols
N
o
No
Yes
Yes

18. Missing C Spine Injuries
• 1985-1991
• 740 c-spine injuries in San Diego Trauma Centers
• 34 delayed or missed diagnosis (4.6%)
• 10 of 34 (29%) with permanent sequelae of missed
injury
• Delayed diagnosis could have been avoided in 31 of
34 patients by appropriate use of a standard three-
view C-spine series.
Jim et al later go on to tell us:
• Ah, yes, but don’t do flex-extension views to clear the
spine
• Too rare (0.02%) and some danger of quadriplegia
(J Trauma 2001)

19. OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
Spine Clearance Form
Purpose
• Clarify understanding of relationship
between status of diagnosis and clearance
of spine

20. Suspected Cervical Spine Injury
· Apply C-collar
· Assess using Clinical Decision
Rules if able to communicate and
age 3 or older.
Collar Off
Cleared C-Spine
Clinical Decision Rules
Clear
Algorithm_CSpine Evaluation_FINAL_11-20-2012
Cervical Spine Injury Algorithm Pediatric (age 0-10)
If Head CT is obtained, tailored CT
will be extended to include skull
base through C2 and Xrays of
the rest of the C-spine should be
performed
Imaging
Clinically Clear by Palpation
and Range of Motion? YES
NO
Clinical Decision Rules NOT Clear, or
under 3 or unable to communicate
Imaging Normal, and no
neurologic abnormality
Imaging Abnormal, or persistent
neurologic abnormality
Maintain full spine
precautions, consult
Spine service
Collar off
Cleared C-spine
If head CT is not obtained, spine
Xrays should be used as a first line
imaging tool with follow up CT
cervical spine if necessary

21. Suspected Cervical Spine Injury
· Apply C-collar
· Assess using Clinical Decision
Rules Criteria.
Collar Off
Cleared C-Spine
Clinical Decision Rules
Clear
Cervical Spine Injury Algorithm Adult (age 11-64)
CT of C-Spine
NO
Clinically Clear by
Palpation and
Range of Motion?
YES
Clinical Decision Rules
NOT Clear
Meets Criteria for Xrays? **
YES
Normal
C-Spine Xrays
Abnormal, Inadequate or Can’t
clear Clinically after normal film.
CT suggests
acute injury, or
persistent
neurologic
abnormality
CT with no acute
injury and Patient
obtunded / intubated
Refer to
Inpatient
C Spine
clearance
protocol
Full spine
precautions
Spine Consult
in ED
** X rays if all of the following:
· No head CT is required.
· No h/o DJD or C-spine hardware.
· Able to cooperate.
· No known TLS spine injury.
· Does Not meet HMC High Risk Criteria.
HMC High Risk Criteria
Presence of any of the following criteria indicates a patient
at high risk (>5%) for C- Spine injury and should warrant
imaging with CT.
1. High energy mechanism (high speed > 35 mph MVC or
MCC, MVC with death at scene, fall from > 10ft.)
2. High risk clinical parameter (significant head injury,
unconscious in ED, focal neurologic symptoms referable
to cervical spine, pelvic or multiple extremity fractures.
CT Normal or non-
acute findings, unable
to clear clinically
Use Clinical Judgment to
clear pt., or if concerned,
consider leaving collar on
and evaluate as INPATIENT
(Spine consult, +/- MRI) or
OUTPATIENT (flex/ex Xrays
in 7-10 days
CT with no
acute injury,
and no
neurologic
abnormality
Collar Off
Cleared
C-Spine
Algorithm_CSpine Evaluation_FINAL_11-20-2012
NO

22. Suspected Cervical Spine Inj.
· Apply C-collar
Algorithm_CSpine Evaluation_FINAL_11-20-2012
Cervical Spine Injury Algorithm Adult (age 65 and up)
CT with no
acute injury,
and no
neurologic
abnormality
CT with no acute injury or non-acute
findings, unable to clear clinically
CT with no acute
injury and Patient
obtunded / intubated
Collar Off
Cleared C-Spine
Use Clinical Judgment to clear pt., or if
concerned, consider leaving collar on
and evaluate as INPATIENT
(Spine consult, +/- MRI) or
OUTPATIENT (flex/ex Xrays in 7-10
days
Full spine
precautions
Spine Consult
in ED
CT of Cervical Spine is the recommended imaging test of choice for the elderly
CT suggests
acute injury, or
persistent
neurologic
abnormality
Refer to
Inpatient
C Spine
clearance
protocol

25. Spine “A” Clearance: Evaluation Complete

26. Spine “B” Clearance: Injury Present or Probably

27. Spine “C” Clearance: C-Spine Cleared Clinically or Radiographically

28. BCVI: Mechanism of Injury
• 3 Fundamental
Mechanisms:
– direct blow to the neck
– laceration by adjacent
fractures of
sphenoid/petrous bones
– hyperextension with
contralateral rotation
Seat belt sign?
Drawing from
Curr Prob Surg
Crissey et al., Surgery 1974
Biffl et al., Curr Probl Surg 1999

29. BCVI: Mechanism of Injury
Hyperextension with contralateral
rotation causing a stretch injury

30. BCVI: Stroke Rate
I 3% 6%
II 14% 38%
III 26% 27%
IV 50% 28%
V 100% 100%
VAIsCAIs
Injury
Grade
Biffl et al., Annals
2002

31. BCVI: Denver Series
15,767 Admissions
727 Angiograms
screening
244 BCVI
diagnosis
21 symptomatic pts
Gender 68% men
Age 35 ± 3.7 years
ISS 28 ± 3.8
1.5% + rate

32. BCVI: Denver Series
48 no therapy
10 strokes (21%)
244 asymptomatic BCVI pts
187 antithrombotics
• Heparin – 117
• Antiplatelet – 59
• LMWH – 11
1 stroke (0.5%)
Cothren et al., Am J Surg 2005 In
press.

33. Seattle BCVI High Risk
Imaging Indication Definite
BCVI
Number of
patients
%
Midface fracture 4 20 20.0%
Mandible fracture 2 24 8.3%
Skull base fx 16 79 20.3%
Cspine trans. for. Fx 15 66 22.7%
C1,C2,C3 fx 2 11 18.2%
Seatbelt sign 0 26 0.0%
Hanging/strang. 1 21 4.8%
Clinical stroke 1 6 16.7%
Infarct 0 1 0.0%
Other/Unknown 8 53 15.1%
Total 49 307 16.0%

34. Harborview BCVI High Risk
Screening
l Midface fracture (Lefort II or III)
l Skull base fracture
l C-spinse transverse foramen fracture
l C1, C2, or C3 fracture
l High energy or bilateral mandible
fracture
l Unexplained stroke/neuroexam
l Hanging or strangulation

35. Top Ten Topics
6. Pelvic fracture management

36. 32 y.o. : injury to you: x? hours

37. Relevant Imaging

38. Pelvic Fractures & Mortality
Source of mortality:
Head
Injury
31%
Bleeding
39%
MOF
30%
Scalea et al. J Trauma
2003

39. Pelvic Fracture Bleeding
mechanical stabilization
resuscitation
Close down the pelvic volume.

40. Mechanical Stabilization
• Pros: Quick. Easy.
• Goals: Splint bone, tissue.
Decrease, stabilize pelvic volume.
“pelvic sheeting” pelvic binder C-clamp

41. Trauma Ultrasound
• FAST: Focused Abdominal Sonography in Trauma
– portable, rapid, repeatable
– noninvasive
– no contraindications
– 3 views of abdomen
SPLEEN
KIDNEY
RUQ LUQ pelvis

42. PITFALL
If persistent or
recurrent hypotension,
remember FAST isn’t
100% accurate!
(as much as 30% false negative)

43. Diagnostic Peritoneal Aspirate
• Catheter placed at umbilicus
• “Positive” aspirate = 10cc of blood,
enteric contents

44. Gross Hemoperitoneum by CT, US, or DPA
OR?
Angio?
Pelvis Fx + HD Unstable

45. resuscitation mechanical stabilization embolization
Importance of management protocols:
20% decrease in mortality
Biffl et al. Ann Surg 2001
Current management: USA
Pelvis Fx + HD Unstable

46. • Described in Europe
– rapid transport to OR
– external bony fixation
– packing of retroperitoneum
Pelvic Packing
Pohlemann et al. OTA Ann Mtg
2000
• Rationale:
– addresses venous/bony bleeding
– additional procedures as indicated

47. Pelvic fixation first:
– C-clamp application
– External fixator
Pelvic Packing

48. Modified European technique:
– 6-8 cm suprapubic incision
– divide midline fascia
Pelvic Packing
Smith et al. J Trauma 2005
Cothren et al. J Trauma 2007

49. KEY POINT
Incision should be away from a laparotomy
incision – keep the spaces separate!

50. You will encounter the hematoma!
Pelvic Packing

51. Packing the pelvis:
– 3 lap pads on either side of bladder
– 1st one is all the way down to presacral space
Pelvic Packing

52. Typically 6 packs for adults, 4 for children
Pelvic Packing

53. Suprapubic catheters
Pelvic Packing
Close fascia
and skin

54. Pelvic Packing
• 5½ years – 1245 pelvic fx patients
• Pelvic fx classification:
APC III (17) LC II (12) LC III (11)
APC II (11) LC I (10) APC I (4)
vertical shear (10)
• 75 patients underwent PPP/EF
75% men Age = 42 ± 2 yrs ISS = 52 ± 2
• ED vitals: SBP 76 ± 2 HR 119 ± 2 BD 12 ± 1

55. Packing: Hemorrhage Control
• Time to OR: 66 ± 7 minutes
• RBCs: 4 ± 0.4 units in ED
• Pre-SICU vs. subsequent 24˚
10 ± 0.8 units vs. 4 ± 0.5 units
• FFP:RBC ratio was 1:2

56. Packing and Concurrent Procedures
• 87% of pts underwent 3 ± 0.3 procedures
– External fixation of long bone fractures = 44
– I&D wounds/fasciotomy = 43
– Laparotomy = 34
– Urologic procedures = 15
– Extremity vascular = 4
– Neurosurgical/spine = 4
– Thoracotomy = 2

57. Angiography After Packing
• 10 (13%) patients underwent AE
• Time to angio = 10 hours
(range 1-38 hours)
pelvic
packs
• Fx classification:
LC I (3) LC II (2)
APC III (2) APC II (1)
LC III (1) VS (1)

58. Who Needs Angiography?
• Can’t predict by:
age, ISS, presenting SBP, presenting base
deficit, ED blood tx, or fracture pattern
• Patients with AE after packing:
lower HR (105  8 vs 121  3)
more RBC pre-SICU (15  3 vs 9  1)
more FFP pre-SICU (9  2 vs 4  1)
more RBC in subseq 24˚ (7  2 vs 3  1)
more FFP in subseq 24˚ (6  2 vs 2  0.4)

59. Operation

60. Top Ten Topics
7. Termination of resuscitation;
when to stop (adults vs kids)

61. Top Ten Topics
8. When to return to sports and
play in minor TBI
(football, soccer, basketball, is
there a difference?)

62. Top Ten Topics
9 . Current indications for an ED
thoracotomy

63. Patient
in Extremis
–
Undergoing
CPR
Penetrating
Trauma
EDT
ECG: Any
Rhythm?
Yes
CPR < 5 min
Blunt
Trauma
Dead
No
Yes
Yes
No
Cardiac
Rhythm?
No
Tamponade?
No
Repair Heart
SBP > 70
mmHg?
Yes
OR
Yes
No
Thoracic
Hemorrhage
Air Emboli
Tamponade
Extrathoracic
Hemorrhage Aortic X-clamp
Hilar X-clamp
Control
CPR < 15 min
CPR < 5 minNon-torso
Torso No
No
Yes

64. Top Ten Topics
10. What is the minimum
workup needed in the
multiply injured patient who
needs to be transferred to a
higher level of care?

65. Top Ten Topics
• 1. Appropriateness of helicopter transport
• 2. Surgeons won’t come in to see trauma patients
• 3. Massive transfusion protocols – transfusion ratio
• 4. Volume resuscitation in trauma penetrating vs blunt
• 5. Blunt neck trauma
• 6. Pelvic fracture management
• 7. Termination of resuscitation; when to stop
• 8. When to return to sports and play in minor TBI
• 9 . Current indications for an ED thoracotomy
• 10. What is the minimum workup needed in patient who
needs to be transferred