COOKCOUNTYTRAUMAUNIT

Protocols

TraumaProtocols

HEAD– PENETRATING• Allpenetratinginjuries(gunshot,stab,bbetc)involvingthecraniumgetaCTheadregardlessofmentalstatus.

HEAD– BLUNT• AnyonewithaperiodofLOC,seizures,ornotneurologicallyintactshouldhaveanon-contrastCThead.HistoryofamnesiaorunknownLOCequalsLOCandshouldhaveaCThead.

• Patientswithsuspecteddepressedskullfractures(byhistoryorphysicalexam)shouldalsohaveaCThead.

• Allpatientswithbluntheadtraumaonanticoagulationorantiplatelet(ASA,Plavix,etc.)agentsshouldhaveaCTheadregardlessofLOC.• 24hourCT ifpatientonanticoagulation(Coumadin,NOAC’setc).Canconsider24hourwhenon,PlavixorASA.• PatientswhohavehadbluntheadtraumawithLOCandwhohaveanegativeheadCT,neurologicallyintact,notintoxicated,notanticoagulated,notonantiplatelettherapy,andhavenootherinjurieswhichrequireadmissionmaybedischargedhomewithfamilyandheadinjuryinstructions.Allothersshouldbeadmittedfor23hourobservation.

• LOCthatistheresultofasyncopal episodeshouldgetaCThead,andusuallyanEKGandamedicineconsultforasyncopeworkupinadditiontotheremainderoftheirsymptombasedtraumaworkup.

NECK– PENETRATING• Anteriorneckisdefinedasabovetheclaviclesandanteriortotheposteriorborderofthesternocleidomastoidmuscle.

• TheanteriorneckisdividedintoZONESI,IIandIII.ZoneIisthethoracicinlettothecricoid cartilage.ZoneIIisthecricoid cartilagetotheangleofthemandible.ZoneIIIisabovetheangleofthemandible.

• Allpenetratinginjuriesthatdonotpenetratetheplatysmaarelacerationsanddonotrequirefurtherworkup.PatientswhohaveapenetratinginjurytotheneckandwhoareUNSTABLEorhaveHARDSIGNSofvascularinjuryrequiresurgicalorproceduralintervention.Otherwise,workupis:

• 1.ZoneI• a.CTAarchandneck• b.EvaluationofesophaguswithEGDandesophagram• c.Considerevaluationoftracheawithbronchoscopy

• 2.ZoneII• a.CTAneck• b.EvaluationofesophaguswithEGDandesophagram• c.Considerevaluationoftracheawithbronchoscopy

• 3.ZoneIII• a.CTAneckandsofttissues• b.Visualinspectionoforopharynx

• PenetratinginjuriestotheposteriorneckinproximitytothevertebralarteriesshouldhaveaCTAnecktoevaluatethevertebralarteries.

NECK– BLUNT

• Patientswithblunttraumamayhavetheircervicalspinesclearedclinicallyiftheymeetthefollowingcriteria:• 1.Notclinicallyintoxicated(abletodiscriminate2pointtactilesensationandpain)

• 2.AwakeandalertwithaGCSof15• 3.Noneckpainortendernessonexamormotionofneck• 4.Noneurologicalfindings• 5.Nodistractingpain

• Iftheabovecriteriacannotbemet,thentheC-spinemustbeclearedwithaCTC-spine.IftheCTC-spineisnegativeforfracture,thentheC-spineshouldbeclinicallyreevaluated.IfthepatientisthenclinicallysoberwithanormalGCSandnolongerhasneckpainortenderness,theC-spinecanbeclearedclinically.

• IfthepatientcontinuestohaveneckpainortendernessandthepatientisclinicallysoberwithanormalGCS:

• -Theligamentscanbeclearedwithaflexion/extensionx-ray[thisisreciprocaltoMRIneckforevaluationofligamentous injury].

• -Theflexion/extensionx-raymustimagetheareaofpainortendernessandhaveadequateflexionandextension(15degreeseachdirection).

• -Ifaflexion/extensionx-rayisinadequateorcannotbeperformed,thenanMRIofC-spineisthefinalmethodforclearingaC-spineinanawakepatient.

• -Ifapatienthaspersistentmidlinec-spinepainwithanegativeCTc-spineandnegativeflex/ex(withadequatevisualizationoftenderareaandflexion)thenthec-spineiscleared.ThepatientdoesnotrequireaMiamiJcollar/neurosurgeryfollow-up.

• IfaC-spineisunabletobeclearedinanobtundedpatient,thenaMiami

• JcollarwillremaininplaceandaCTC-spinecanberepeatedonhospitalday5to7.Ifthisisnegativeforinjury,thentheC-collarcanberemoved.

THORACIC/LUMARSPINE– BLUNT• PatientswiththoracicorlumbarspinepainortendernessorneurologicdeficitsshouldhaveaCTThoracicorLumbarspine.IfthepatientisalsogettingaCTarchoraCTabdomen/pelvis,thespinecanbereconstructedfromtheseimages.

THORAX-PENETRATING• Thechestconsistsofseveralcompartmentsdividedbyanatomicboundaries.Theyare:• 1.chest• 2.cardiacbox• 3.posteriorbox• 4.thoraco-abdomen

• 1.Chest:• Allareassupportedwithintheribcages,are,bydefinition,the“chest”.Allpenetratingwoundstothechestthatcannotbedeterminedconclusivelytobeextra-thoracicshouldhaveanadmissionCXR.• Allpneumothoraces oreffusionsshouldbetreatedwithachesttube.IftheinitialCXRisnormal,arepeatinspiration/expirationCXRshouldbedone6hoursafterthefirstCXR.

THORAX-PENETRATINGcont’d• 2.Cardiacbox:• Thecardiacboxisarectangleboundby:• Superior– theangleofLouis=manubriosternaljunction• Laterally– mid-clavicularlines• Inferior– alinedrawnbetweenthecostalmarginatthelevelofthemid- clavicularlineswhichincludedtheupperepigastrium

• Penetratinginjuriesinthisareaareatriskforinjurytotheheart.AnECHOshouldbedoneemergentlytoevaluateforpericardialfluid–cardiologyfellowoncallimmediatelyconsulted.AnyfluidseenonECHOorasuboptimalstudymandatesapericardialwindow.

THORAX-PENETRATINGcont’d4.Posteriorbox:• Injuriestothisareaputposteriormediastinalstructures(aorta,esophagusandtrachea)atrisk• Superior– scapularspine(topofscapula)• Lateral– medialbordersofscapulae• Inferior– costalmargin

• Workup:

1.Gunshotinjuries• a.CXR• b.CTarch• c.EsophagramandEGD• d.Considerevaluationoftracheawithbronchoscopy2.Stabwounds• LesslikelythanGSWtoproduceinjuryduetoprotectivemuscles• a.CXR• b.IFCXRiscompletelynormal,workupiscompletedexceptforarepeatCXRin6hours• c.IfPTXoreffusion,achesttubeisplaced.Ifnoparticulatematterisrecovered,followpatientasindicated• d.Ifmediastinal air,consideresophagealinjury• e.Ifmediastinal widening,consideringaorticinjury

• THORAX-PENETRATINGcont’d

• 4.Thoracoabdomen:

• Woundsoriginatingfromthethoracoabdomenareatriskforcausingdiaphragmaticinjuries• 1.Superiormargin

• a.Anterior– nipples• b.Posterior– tipsofscapula

• 2.Inferiormargin– costalmarginsWorkupincludes:• 1.CXR• 2.DPL• a.PositiveDPL>10,000RBC• IfaDPLcannotbedone,considerdiagnosticlaparoscopyorlaparotomytoevaluatefordiaphragminjury.• CTscanisnotsensitivefordiaphragminjuryhowevercanbeconsideredatthediscretionoftheattendingoncallasasub-optimaltesttoriskstratifythepatient.

Chesttubemanagement

• Chesttubesareplacedforpneumo- andhemothoraces.• Onceachesttubeisplaced,itisconnectedtoapleuravac andplacedtowallsuction.

• Thechesttubestaystowallsuctionuntilthereisnoairleakandnopneumothorax onCXR.Oncethesecriteriahavebeenmet,regardlessofoutputamount,thechesttubeisthenplacedtowatersealandaCXRisdone.IftheCXRdemonstratesapneumothorax,thechesttubeisplacedbacktowallsuctionfor48hours.

• Thechesttubeisreadytoberemovedonce:• 1.Itisonwaterseal• 2.Theprevious24houroutputislessthanorequalto100mL

THORAX-BLUNT• Bluntchesttraumaputsmultiplestructuresatrisk.Ribfractures,pulmonarycontusion,pneumo/hemothoraces arecommon.TheseshouldbeevaluatedwithaCXR.

• Bluntaorticinjuryriskfactors:

• 1.Accelerating/deceleratinginjuries>30MPH,falls>30feet,orsuddencompressionofchest(ie,carfallingoffjack)• 2.Physicalexamfindings– abrasionsortendernessofchestwall• 3.AbnormalitiesonCXR

• Ifapatienthasanappropriatemechanism(riskfactor1)PLUS oneoftheotherfactors– imagingorphysicalexamfindings,thenthepatientshouldhaveaCTofthechestwith“archprotocol”toevaluatetheiraorta.TheCTarchmustbereadbytheattendingradiologistoncall.IftheCTarchisabnormal,cardiac/vascularsurgeryisconsulted.

Bluntcardiacinjury• Triggerissamemechanismsofinjuryasinbluntaorticinjurywithorwithoutchesttenderness.

• AninitialEKGandtroponin Iisobtained.IfthetroponinIleveliselevated,oranyofthefollowingEKGfindingsexist,thenthepatientisadmittedtotraumaobs forserialEKGs(totalof4,Q8hoursapart)for24hoursandtelemetrymonitoring.• SerialtroponinsarenotrequiredforBCI

• EKGfindingsofBCI:• 1.AbnormalEKG=STchanges,bundle-branchblocks,changesfrompreviousEKGs

• 2.Dysrhythmiasonmonitor• 3.Cardiogenic shock

• *Note– sinustachycardiaisnotsuggestiveofBCI(mostpatientstothetraumaunithavesinustachycardia)• IfBOTHinitialEKGandtroponin Iarenegative,BCIisruledout.

ABDOMEN-PENETRATING• Indicationsforoperation:• 1.Locationofbulletpathway/trajectory• 2.Unstablepatient• 3.Evisceration• 4.Retainedstabbingimplement• 5.Grossbloodperorifice• 6.Peritonitis• 7.Pneumoperitoneum• 8.PositiveDPL

• a.GSW>10,000RBC• b.Anteriorabdomenstabwound>100,000RBC• c.Thoracoabdomen orback/flankstabwounds>10,000RBC

• GUNSHOTWOUNDS• Allgunshotwoundsthatpenetratingtheperitonealcavityrequireanoperationas>98%willhaveaninjurythatrequiresrepair.“Tangential”gunshotwoundsmayhaveaDPLwhichisconsideredpositiveandrequiresoperativeexplorationif>10,000RBC.• ANTERIORSTABWOUNDS• Only50%penetratetheperitonealcavity.Ofthose,only50%willcauseaninjurythatrequiresrepair.InjurymaybediagnosedwithaDPL.ApositiveDPLrequiringoperativeexplorationis>100,000RBC.Localwoundexplorationsareunreliableandpronetocomplications.

ABDOMEN- BLUNT• Patientswithblunttraumatotheabdomenshouldhaveanevaluationforintra-abdominalinjuries.Methodsofevaluationare:• 1.CTabdomen/pelvis

• aStablepatient• bGoodforevaluationofsolidorganinjury

• 2.FAST• Foruseinunstablebluntabdominalpatientstoidentifycavitywithhemorrhage

• 3.DPL• c.RBC>100,000ispositive

• 4.Serialabdominalexamination• a.Mustbedonefrequentlyandbythesameexaminer• b.Onlyinstablepatients

BACKANDFLANK– PENETRATING

• Penetratinginjuriesoriginatingfromthisregionputretroperitonealstructuresatriskwithoutnecessarilyinjuringintra-abdominalorgansBackandflankborders:

• 1.Anterior– midaxillary lines• 2.Superior– tipofthescapula• 3.Inferior– iliaccrests

• Workup

• 1.Triplecontrast(oral,rectalandIVcontrast)CTscan• 2.DPL>10,000indicatespenetratingintotheperitonealcavityandmandatesoperativeexplorationforbothGSWandstabwounds• 3.IfCTscanisentirelynegativeandshowstheentiretrackoftheknifeorbullet,thentheDPLmaybeavoided.

PELVIS– PENETRATING• Allpenetratinginjuriesthataretrans-pelvicputtheabdominalvisceraandpelvic

• “outflowtracts”atrisk.• Workup:• 1.Rigidproctosigmoidoscopy• 2.Retrogradeurethrogramandcystogram• 3.Females– vaginalspeculumexam• 4.CTApelvicvessels• 5.DPLifintra-abdominalpenetratingcannotberuledout• 6.TriplecontrastCTifretroperitonealinjuryispossible

• Discusswiththeattendingoncalltheorderoftestsrequired.TheRUG/cysto canusuallybedonequickly.TheCTscanprovidesconsiderableusefulinformationontrajectoryandstructuresatrisk.ConsiderdelayedCTfordistaluretericworkupifindicated.

PELVIS– BLUNT• Mostoftheadversesequelae ofbluntpelvictraumaresultsfrompelvicfractures.Hemorrhageisthemostimmediatelylife-threateningconcern.• Workup:• 1.Ruleoutintra-abdominalinjury• a. IfneedDPL,useopensupra-umbilicaltechnique

• 2.RUGandcystogram for• a.Allfracturesofanteriorpelvis• b.Bloodatmeatus,perineal orscrotalhematoma,orhigh-ridingprostate

• 3.Rigidproctosigmoidoscopy• a.Ifgrossrectalblood• 4.Vaginalspeculumexam• a.Allopenpelvicfractures

VASCULARINJURIES

• Hardsignsofvascularinjury:• 1.Absentpulse• 2.Activehemorrhage• 3.Expandinghematoma• 4.BruitorthrillInjurieswithhardsignsgenerallyrequireoperativeintervention.

• Softsignsofvascularinjury:• 1.Unequalordecreasedpulse• 2.Nonexpandinghematoma• 3.H/olargebloodlossatthescene• 4.Neurologicdeficit

• PenetratinginjuriestotheextremitiesINPROXIMITYTOAMAJORBLOODVESSELPLUSSOFTSIGNSonphysicalexamshouldundergoaCTAofthatextremity.

• Consideraformalangiograminpatientswitharetainedmissileormultiplemetallicfragmentsinproximitytotheareaofconcern.Formalangiogramsdoneforproximityaloneinacompressable (extremity)vesselcanbedoneinthemorning.

• Penetratinginjuriesinproximityalonetothesubclavian/axillary vesselsshouldundergoCTAimagingoraformalangiogramimmediately.