Post on 03-Oct-2021
IDENTIFYING LIFE THREATENING INTERNAL INJURIES ON THE FIELD
JARON SANTELLI, MD PRIMARY CARE SPORTS MEDICINE FELLOW EMERGENCY MEDICINE PHYSICIAN UNIVERSITY OF MARYLAND/MEDSTAR
DISCLOSURES No financial disclosures
GOALS:
• Identifying tools at your disposal both on the field and in the training room
• Discuss the primary and secondary survey • Identifying a handful of cardiac, pulmonary and
gastrointestinal life threatening injuries • Identify possible life-saving interventions
WHAT ARE THE BASIC ASSESSMENT TOOLS THAT
YOU HAVE?
OBJECTIVE INFORMATION
• General Appearance • Vitals • Exam: Primary and Secondary Survey
• Supplemental Tools
VITALS
• Heart Rate • Blood Pressure: BP cuff • Respiratory Rate • Oxygen Saturation • Temperature: Oral or Rectal
EXAM
Prim
ary
Sur
vey
A: Airway If they are talking to you
this is intact
B: Breathing Auscultation, watch for
chest rise, equal bilateral
C: Circulation Auscultate, assess pulses, especially at site of injury,
bleeding
D: Disability GCS, spine board, obvious
trauma
E: Environment Assess for safety,
temperature
EXAM
Sec
onda
ry S
urve
y*
HEENT: Oropharynx, bleeding, foreign body
CV: Heart sounds quieter then normal?
Fast or slow, regular or irregular, murmur? Are pulses equal left and right?
PULM: Do you hear breath sounds bilaterally, are they
equal? Labored, fast or slow, wheezing/crackles/rhonchi?
GI/GU: External injuries or bruising?
Tenderness/guarding/mass/rigidity? GU Inspection?
*Limited to scope of lecture
SUPPLEMENTAL TOOLS
• Blood Glucose • Urine: gross and dip stick • Basic Chemistry • Ultrasound
RECOGNIZING EMERGENCT CONDITIONS
THE MEET AND POTATOES
EMERGENT CONDITIONS
1. Identify sick or not sick 2. Identify potential life threatening situations 3. Identify trends 4. RE-EVALUATE
CARDIOVASCULAR PROBLEMS
• Cardiac Arrest/Commotio Cordis1: • V fib/sudden death
after blunt chest trauma
• TX: CPR, defibrillate • Transfer to ED • Prevention: not
realistic presently
http://lifeinthefastlane.com/commotio-cordis/
CARDIOVASCULAR PROBLEMS
http://lifeinthefastlane.com/ccc/major-haemorrhage-in-trauma/
• Hemorrhagic Shock:
CARDIOVASCULAR PROBLEMS • Hemorrhagic Shock, con’t
• If you suspect shock there is blood loss. FIND IT! • “Blood on the floor and 4 more”
o Abdomen, Chest, Pelvis, Thigh • Treatment includes
o Pressure to slow bleeding o IV fluids
• Cardiac Tamponade • Bleeding into the sac around the heart • Beck’s Triad:
o Decreased/quiet heart sounds o Hypotension o Distended neck veins
• Treatment includes o BP support with fluids o Pericardiocentesis
GI PROBLEMS Think SPLEEN and LIVER
GI PROBLEMS In general think about • Mechanism, Inspection, Palpation, Auscultation • Direct impact
• Crush injury/ compression • Deform solid/ hollow organs
• Deceleration • Shear injury
All can lead to life threatening internal injuries
GI PROBLEMS • Blunt Abdominal Trauma
• Vitals: Tachycardia, Hypotension stages of shock
• Inspection: o Gray-Turner’s and Cullen’s Sign are late
findings (>12 hours) o Kerh’s Sign: referred pain to the shoulder from
ANY diaphragm irritation o Left shoulder is affected in splenic injuries
classically o Seagasser’s Sign: neck pain referred from
phrenic nerve pressure o Hematuria or Hematochezia
CULLEN’S & GREY-TURNER’S SIGN Canadian Medical Association Journal Photo
GI PROBLEMS • Blunt Abdominal Trauma, con’t
• Palpation: o Local and generalized rebound tenderness, rigidity o Dullness to percussion of flank that is not affected by
position; Ballance’s Sign (uncommon) o Palpable mass
• Auscultation o Markedly decreased bowel sounds (subacute)
• Treatment includes o 2 large bore IV’s o Fluids o Transfer to ED
PULMONARY PROBLEMS • Pulmonary Arrest
• Per BLS, support with O2, Definitive Airway • Pneumothorax/Tension Pneumothorax
• Part or all of lung has collapsed spontaneously or with trauma • Complaints: chest pain, dyspnea • Vitals: hypoxia, tachypnea, tachycardia, normal BP
hypotension (with tension pneumo) • PE:
o Labored breathing, dyspnea o Auscultation: decreased breath sounds on the affected side o Tracheal deviation away from affected side (tension pneumo)
• TX: o O2, needle decompression, ED
TENSION PNEUMOTHORAX
http://www.fprmed.com/Pages/Trauma/Tension_Pneumothorax.html
http://regionstraumapro.com/post/457670048
TENSION PNEUMO: XRAY
http://www.emsworld.com/article/12041960/whats-the-best-site-for-needle-decompression
NEEDLE DECOMPRESSION: TENSION PNEUMO
WHAT’S NEXT….. ULTRASOUND • E-FAST
• No literature looking into the role of ultrasound on the sideline or in the training room (OPURTUNITY!!)
• Barriers to use
• Cost of machine • Training/user dependent • Power
• Benefits • Immediate identification of life threatening internal injuries • Procedural Assistance
The positive exam (red arrows) indicates hemoperitoneum in the setting of trauma.
EFAST: MORRISON’S POUCH, RUQ
Looking for lung sliding and “sandy beach pattern” to indicate a normal exam (A)
E-FAST: PNEUMOTHORAX A B
Comet Tails, normal lung. Loss of these indicates loss of pleural sliding/pneumo.
E-FAST: PNEUMOTHORAX
Rib Rib
REFERENCES 1. Maron, B. & Estes, M. (2010). Commotio Cordis. The New
England Journal of Medicine. 362(10), 917-927. 2. Stevens RL, et al. Needle thoracostomy for tension
pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care, 2009 Jan-Mar; 13(1): 14–7.
3. Rawlins R, et al. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J, 2003 Jul; 20(4): 383–4.
4. Montoya J, Stawicki SP, Evans DC, Bahner DP, Sparks S, Sharpe RP, et al. From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment. Eur J Trauma Emerg Surg. 2015 Mar 14.
5. http://lifeinthefastlane.com 6. http://www.emsworld.com