Evaluation and emergency management of the trauma patient.pdf

Evaluation and Emergency Management of the Trauma Patient Thoracic trauma Carlos Pizarro Ldo. Vet., MSc, PGCAP University Clinician in Small Animal Emergency and Critical Care CP3.14.18 Supporting the Patient Carlos Pizarro 2023 1 Intended Learning Outcomes (ILOs) Year ILOs CP3005: Perform and...

Evaluation and Emergency Management of the Trauma Patient Thoracic trauma Carlos Pizarro Ldo. Vet., MSc, PGCAP University Clinician in Small Animal Emergency and Critical Care CP3.14.18 Supporting the Patient Carlos Pizarro 2023 1 Intended Learning Outcomes (ILOs) Year ILOs CP3005: Perform and interpret a clinical examination, including a pain assessment, in a veterinary patient that requires emergency treatment. CP30011: Explain the aetiology, pathophysiology & epidemiology of conditions of veterinary interest that require emergency treatment including pain, shock, trauma & poisoning CP30017: Select and explain appropriate diagnostic techniques to investigate common veterinary emergencies, including problems arising under anaesthesia, and interpret the findings of these techniques. CP3024b: Formulate a therapeutic plan to treat/manage common veterinary emergencies including complications arising under anaesthesia, demonstrating an understanding of the underpinning science principles. 2 2 Intended Learning Outcomes (ILOs) Lecture ILOs Thoracic Trauma • • • Describe the major causes of hypoxaemia following an RTA Outline the various options for management of pneumothorax Select an appropriate method of providing supplemental oxygen Traumatic Brain Injury • • Recognize the clinical manifestations of traumatic brain injury and raised ICP Understand the principles governing the medical management of TBI 3 3 Evaluation and Emergency Management of the Trauma Patient 1. Trauma 1. 2. 3. 4. Relevance Definition and classification Consequences Evaluation 1. 2. 3. 4. 5. 6. Overview Triage and Primary survey Thoracic trauma Head trauma / Traumatic Brain Injury (TBI) Skeletal trauma Abdominal Trauma … to be continued… 2. Clinical Scenario 4 4 1.1 Trauma Relevance • • • • 10% hospital admissions 35% Serious/grave injuries 10% mortality Common Causes: Road traffic accident (RTA) fall from a height animalanimal interaction animalhuman interaction fire exposure 5 5 1.2 Definition and Classification 6 6 1.3 Consequences of trauma Hypovolaemic Haemorrhage Shock Hypoxic SIRS Inflammatory Distributive ARDS Infection Sepsis TAC (Trauma Associated Coagulopathy) Coagulopathy DIC (Disseminated Intravascular Coagulopathy) 7 7 1.4 Evaluation • Triage • Primary Survey • Scoring systems – ATT (Animal Trauma Triage) score – mGCS (modified Glasgow Coma Scale) • Secondary Survey Rockar RA, Drobatz KS, Shofer FS. Development Of A Scoring System For The Veterinary Trauma Patient. J Vet Emerg Crit Care. 1994;4(2):77–83. 8 8 Evaluation and Emergency Management of the Trauma Patient 1. Trauma 1. 2. 3. 4. Relevance Definition and classification Consequences Evaluation 1. 2. 3. 4. 5. 6. Overview Triage and Primary survey Thoracic trauma Head trauma / Traumatic Brain Injury (TBI) Skeletal trauma Abdominal Trauma 2. Clinical Scenario 9 9 Trauma: Setting the Scene… 6-month old Springer Spaniel, Tess, has just been hit by a car. She appeared to lose consciousness briefly and now is dazed and breathing rapidly. Bring Tess straight into the practice! I’ll be prepared for her arrival. In the next 45 minutes we’re going to use Tess to illustrate the various aspects of the initial evaluation and management of the (poly)trauma patient. There are 3 CDMs to complement this lecture. 10 A client phones into the practice to say that their 6-month old Springer Spaniel, Tess, has just been hit by a car. She appeared to lose consciousness briefly and now is dazed and breathing rapidly. You advise the client to bring Tess straight into the practice and prepare for her arrival. 10 2.1 Trauma: Overview superficial wounds CNS / Head injury Abdominal trauma skeletal injuries Road traffic accident Thoracic trauma 11 11 2.1 Trauma: Overview Soft Tissue injuries Lacerations, abrasions, degloving Fractures 81-90% TBI 25% Thoracic injury Contusions Hindlimb Head injury 17-36% Forelimb 12-15% Spinal 9-10% Skull 5-11% Pelvic/sacral Head trauma superficial wounds Pneumothorax skeletal injuries Haemothorax CNS / 21-39% Road injury Abdominal Rib fractures 44-88% 7-47% 3-18% 9-14% traffic Haemoperitoneum accident Abdominal hernia 23-38% Diaphragmatic hernia 2-6% 5% Flail Chest Uroperitoneum 2-3% Abdominal trauma 2% Thoracic trauma 12 12 2.1 Trauma: Overview  Death tends to be associated with… Thoracic trauma Abdominal trauma CNS trauma 13 13 2.2 Trauma: Triage and Primary Survey Triage: RANK and MANAGE injuries based on their THREAT TO LIFE 14 14 2.2 Trauma: Triage and Primary Survey 15 15 Trauma: Tess, 6 mo FE Springer Spaniel 16 16 Trauma: Tess, 6 mo FE Springer Spaniel A/B • RR 104 breaths/minute • Rapid shallow breathing • Thoracic trauma? C • HR 180 bpm • Pale pink mucous membranes • CRT 2 sec • Fair femoral pulse quality • Shock? • Abdominal trauma? D • Obtunded • Responsive to voice • Mid-range pupils with direct and consensual PLRs • Head trauma? • Shock? 17 17 Trauma: Tess, 6 mo FE Springer Spaniel Supplemental Oxygen Assessment of pulse quality ECG to Assess Cardiac Rhythm Intravenous Access & Fluid Therapy What Next? 18 18 Evaluation and Emergency Management of the Trauma Patient 1. Trauma 1. 2. 3. 4. Relevance Definition and classification Consequences Evaluation 1. 2. 3. 4. 5. 6. Overview Triage and Primary survey Thoracic trauma Head trauma / Traumatic Brain Injury (TBI) Skeletal trauma Abdominal Trauma 2. Clinical Scenario 19 19 2.3 Thoracic Trauma Blunt Thoracic trauma Pulmonary Contusions Haemothorax Pneumothorax Diaphragmatic hernia/rupture Pneumomediastinum Flail chest Rib Fractures Myocardial injury Traqueal tear/rupture Penetrating 20 20 2.3 Thoracic Trauma • Pulmonary contusions (44-88% of trauma events) – Compression/Decompression injury following blunt trauma – Pulmonary interstitial & alveolar haemorrhage/oedema – Ventilation/Perfusion (V/Q) mismatch / hypoxaemia • Progressive deterioration over several hours – 34-57% dogs / 17% cats in RTA • High index of suspicion in trauma patients • Concomitant injuries 21 21 • Pulmonary Contusions – Assessment POCUS ×ôô↓ô borderBoxgroupChrmsSubSupgroupChrPrmcPrvalal B-lines (image B, right) C-lines: irregular pulmonary-pleural line and indicate the presence of lung consolidation 22 22 • Pulmonary Contusions – Assessment POCUS vs Rx vs CT Dicker SA, et al. Diagnosis of pulmonary contusions with point-of-care lung ultrasonography and thoracic radiography compared to thoracic computed tomography in dogs with motor vehicle trauma: 29 cases (2017-2018). J Vet Emerg Crit Care. 2020;30(6):638–46. 23 Top: Images from a 1-year-old male Chihuahua mix that was positive for PC on LUS and TCT, but not on TXR. (a) Lung ultrasound image at the right Cd Vet BLUE acoustic window with >3 B-lines. (b) Ventrodorsal thoracic radiograph with no evidence of PC. The black circle indicates where the ultrasound probe would contact the thorax at the right Cd Vet BLUE acoustic window. (c) Thoracic CT image of PC (solid arrows) in the right caudal lung lobe that touch the pulmonary-pleural surface (dashed arrow). Total PC scores for this patient were LUS 4, TXR 0, and TCT 1 Bottom: Images from a 2-year-old male neutered Chihuahua mix that was positive for PC on all imaging modalities. (a) Lung ultrasound image at the rightMd Vet BLUE acoustic window with C-lines (dashed arrows) and confluent B-lines originating from the pulmonary-parietal pleural interface (solid arrows). (b) Ventrodorsal thoracic radiograph (combined with lateral radiographs, not shown) scored as positive for PC with an interstitial pattern in the left Cd and right Md sites as well as an alveolar pattern in the left Md site (black circle). (c) Thoracic CT image of PC in both the left and right lungs. Certain PC (solid arrows) touch the pulmonary-parietal pleural surface and other PC are more central (dashed arrows); the latter are not visible with LUS. Total PC scores for this patient were LUS 24, TXR 4, and TCT 12 Lung ultrasound had a high sensitivity when compared to the gold standard CT for diagnosis of pulmonary contusions providing a reliable diagnosis after trauma. 23 2.3 Thoracic Trauma • Pneumothorax (7-47% of trauma events) – Accumulation of air within the pleural space • Atelectasis of lungs • No participation in gas exchange – Open • E.g. Rib fractures, penetrating injuries – Closed • E.g. ruptures alveolus, bronchus, trachea, oesophagus… 24 24 25 25 2.3 Thoracic Trauma • Tension Pneumothorax – The site of air-leakage acts as a one-way valve – Pleural pressure ↑ during each inspira on until is is greater than Patm – Atelectasis ➜ life-threatening hypoxaemia – Poor venous return ↴ – Cardiovascular collapse – Shock ↵ 26 26 2.3 Thoracic Trauma • Diaphragmatic hernia/Rupture (26%) – Often concurrently with trauma caudal to the diaphragm • Sudden ↑ in abdominal pressure with an open glottis is thought to result in a tear to the diaphragm – Herniated organs within the pleural space contributes to hypoxaemia – Reduced venous return may contribute to cardiovascular signs. 27 27 2.3 Thoracic Trauma • Fractured ribs (9-14% of trauma events) – Often associated with pulmonary contusions & pleural space disease – Pain associated hypoventilation – “Flail chest” • Rarely as a result of RTA • Fracture (dorsally and ventrally) of 2 or more adjacent rib segments • Paradoxical chest motion 28 28 2.3 Thoracic Trauma - Assessment • Assessment of thoracic trauma – Physical Examination • Breathing pattern • Auscultation • Percussion 29 29 2.3 Thoracic Trauma – Assessment PE Pneumothorax • High index of suspicion based on dull dorsal lung sounds and hyperresonance of the chest on percussion • Look out for the “barrel-chest” as an indicator of tension pneumothorax in severely dyspnoeic/cyanotic patients Diaphragmatic Hernia • Lung sounds may be dull ventrally or you may hear borborygmi on auscultation of the thorax Traumatic haemothorax / chylothorax • Lung sounds may be dull ventrally 30 30 2.3 Thoracic Trauma - Advanced Assessment • Assessment of thoracic trauma – Physical Examination • Breathing pattern • Auscultation • Percussion – Advanced assessment • • • • Point of Care Ultrasound (POCUS) Diagnostic/Therapeutic thoracocentesis Thoracic Imaging: radiography vs. CT ECG 31 31 2.3 Thoracic Trauma - Advanced Assessment • POCUS – T-FAST (Focused Assessment by Sonography for Trauma) • 5-point exam – VetBLUE (Bedside Lung US Exam) • 9-point exam 32 32 Trauma: Tess, 6 mo FE Springer Spaniel What’s your diagnosis? 33 33 Trauma: Tess, 6 mo FE Springer Spaniel What’s your diagnosis? What action are you going to take? 34 34 2.3 Thoracic Trauma – Management • Pneumothorax – Goal • Re-expansion of the collapsed lung • Improvement in venous return & cardiac output Needle thoracocentesis – Thoracocentesis / Thoracostomy tube placement • Intermittent or continuous pleural drainage may be required • Consider induction-intubation in rapidly deteriorating patients and commence IPPV • Potential need for exploratory thoracotomy if ongoing/unresolved pneumothorax Tube thoracostomy (closed): Seldinger or Trochar technique 35 35 Trauma: Tess, 6 mo FE Springer Spaniel Case Update • Pneumothorax recurs after needle thoracocentesis on 2 occasions • A small-bore chest drain is placed under local anaesthetic • Tess remains dyspnoeic after draining air from the pleural space • Using a pulseoximeter Tess has an SpO2 of 89% 36 36 Trauma: Tess, 6 mo FE Springer Spaniel Time to review the diagnosis (Secondary Survey) • Suspicion of concurrent pulmonary contusions on initial thoracic radiographs • Confirmed on repeat thoracic radiography 37 37 2.3 Thoracic Trauma – Management • Pulmonary contusions – Supportive management – O2 supplementation • Intubation and ventilation may be indicated in severe cases – Avoiding over-zealous fluid therapy – Lesions typically worsen over 2448h and improve over 3-10 days 38 38 Trauma: Introduction to Lecture-Based Problems Formative CDM Question Practice  RR 104 breaths/minute, rapid shallow breathing: explained by pneumothorax & pulmonary contusions For more details on the management of pneumothorax and decision-making regarding oxygen therapy in this case take a look at the lecture-based problem in the Formative CDM Question Practice 39 39 2.3 Thoracic Trauma - Management Management of Diaphragmatic Hernia/Rupture • Surgical correction • Factors influencing the timing of surgical intervention include – Patient stability – The nature of the herniated contents – If the contents are significantly compromising respiratory function Management of diaphragmatic hernia/rupture will be covered in the Alimentary Module Clinical Reasoning Workshops under “Hernias and Ruptures” Fractured Ribs • Management of pain-associated hypoventilation – Consider local blocks (lidocaine or bupivacaine) – Systemic analgesics Pleural/Pericardial Effusions • Drainage where effusion is having a clinical impact 40 40 Trauma: Introduction to Lecture-Based Problems Formative CDM Question Practice  RR 104 breaths/minute, rapid shallow breathing: explained by pneumothorax & pulmonary contusions  HR 180bpm, oral mm pale pink, CRT approx 2 seconds, femoral pulse quality fair  Neurological assessment; obtunded, responsive to voice, midrange pupils, with direct and consensual PLRs 41 41 Trauma: Introduction to Lecture-Based Problems Formative CDM Question Practice  HR 180bpm, oral mm pale pink, CRT approx 2 seconds, femoral pulse quality fair Based on what you know about this case so far, can you explain Tess’s initial cardiovascular parameters? Are there any special considerations for support of the cardiovascular system in this case? Take a look at the lecture-based problem in the Formative CDM Questions Practice 42 42 Trauma: Tess, 6 mo FE Springer Spaniel Neurological assessment; obtunded, responsive to voice, mid-range pupils, with direct and consensual PLRs Question: Is Tess’s reduced level of consciousness due to Traumatic Brain Injury (TBI) or secondary to shock/hypoxaemia? 43 2.1 Trauma: Overview superficial wounds CNS / Head injury Abdominal trauma skeletal injuries Road traffic accident Thoracic trauma 44 44 2.4 Head trauma / Traumatic Brain Injury (TBI) • Injury to the CNS is common following RTA – Traumatic Brain Injury (TBI) • 25% of dogs involved in RTA • Spinal Cord Injury (SCI) – May have concurrent skeletal and soft tissue trauma affecting the head • Fractured mandible • Orbital fractures • Soft palate trauma 45 45 2.4 Head trauma / Traumatic Brain Injury (TBI) • Primary injury: immediate • Secondary injury: hours to days after the initial trauma Chai O, et al. Computed tomographic findings in dogs with head trauma and development of a novel prognostic computed tomography-based scoring system. Am J Vet Res. 2017;78(9):1085–90. Transverse unenhanced CT images of the head of an 11-year-old sexually intact male mixed-breed dog following head trauma. A—At the level of the optic canal, a focal hyperattenuating lesion (arrowhead) surrounded by a larger hypoattenuated area (thin arrow), consistent with acute intraparenchymal hemorrhage, and surrounding brain edema are visible. Rightward deviation of the falx cerebri (thick arrow) and mild subcutaneous gas are also evident. B—A more rostral (8 mm), wide-windowed image at the level of the frontal lobes shows fractures of the left wing of the basisphenoid bone, with large intracranially depressed fragments (arrows) and mild subcutaneous gas 46 2.4 Head trauma / Traumatic Brain Injury (TBI) • Primary Injury: immediate • Concussion (no histologic lesion) • Contusion (parenchymal haemorrhage & oedema) • • “coup” or “contrecoup” injury Laceration resulting in haematoma formation & brain compression • Axial (within the brain parenchyma) • Extra-axial (epidural, subdural, subarachnoid) Extra-axial Haemorrhage/Haematoma Axial Intracranial Haemorrhage/Haematoma Concussion is characterized by a brief loss of consciousnes and it is not associated with an underlying histopathologic lesion. Brain contusion consists of parenchymal hemorrhage and edema, clinical signs can range from mild to severe. Contusions can occur in the brain directly under the site of impact (“coup” lesions), in the opposite hemisphere (“contrecoup” lesions), or both, as a result of displacement of the brain within the skull. 47 2.4 Head trauma / Traumatic Brain Injury (TBI) • Secondary injury (hours to days after trauma) – Combination of intracranial and systemic insults leading to neuronal cell death Systemic insults • Hypotension and Hypoxia • Systemic inflammation (secondary to trauma) • Hypercapnia ( PCO2) or hypocapnia ( PCO2) • Hyperglycaemia, electrolyte imbalances, acid-base disturbances Intracranial insults • Increased intracranial pressure (ICP) • Compromise of blood brain barrier • Cerebral oedema • Seizures 48 48 2.4 Head trauma / Traumatic Brain Injury (TBI) Raised Intracranial Pressure (ICP)   The volume of the intracranial contents exceeds compensatory mechanisms Consider ICH (Intracranial Hypertension) if you observe deterioration in neurological function  Deterioration in mentation, brainstem function, postural changes (decerebrate rigidity) Results in brain herniation if not identified and treated  Transtentorial (cerebrum herniating caudally)  Development of abnormal respiratory patterns  Transforaminal (cerebellum herniates caudally through the foramen magnum)  Systemic hypertension and bradycardia: “Cushing reflex” 49 2.4 Head trauma / Traumatic Brain Injury (TBI) • ASSESSMENT of severity of TBI – Glasgow Coma Scale (modified) mGCS • • • • • Level of consciousness Brain-stem reflexes (pupil size, PLRs and eye movement) Limb movements Respiratory pattern Blood pressure and heart rate 50 50 Patients are allocated a score between 3 and 18 3 is indicative of severe neurological dysfunction 18 is indicative of normal or nearnormal CNS function Score of 8 is associated with 50% chance of survival Ref: Platt SR, Radaelli ST, McDonnell JJ. The prognostic value of the modified Glasgow Coma Scale in head trauma in dogs. JVIM (2001) Nov-Dec;15(6):581-4 51 2.4 Head trauma / Traumatic Brain Injury (TBI) • Management/Therapy – Goals • Ensure adequate oxygenation • Avoid and/or correct factors that predispose to secondary brain injury • Address raised ICP – Patients at risk of developing ICH • Prevent hypercapnia by controlling PaCO2 between 30-35 mmHg – Mechanical ventilation • Maintain PaO2 > 80 mmHg • Elevate the head to 30o and prevent jugular compression • Remove causes of increased intrathoracic pressure 52 52 2.4 Head trauma / Traumatic Brain Injury (TBI) • Management/Therapy – If Clinical evidence of ICH • Reduce cerebral oedema with • Ensure adequate oxygenation hyperosmolar therapy • Avoid and/or correct factors – Goals that predispose to secondary brain injury • Address raised ICP – Mannitol (0.5-1 g/kg IV over 20. minutes) – Hypertonic saline (NaCl 7.5%)(2-4 ml/kg IV over 10 minutes) • Reduce Cerebral Metabolic rate – Anaesthesia, barbiturate therapy, hypothermia 53 53 2.5 Skeletal Trauma • • Mandibular symphyseal fractures are relatively common in cats following RTA – Consider the nutritional management in these cases particularly as concurrent facial and nasal trauma frequently affects appetite in cats – Consider placement of an oesophagostomy tube Decision making regarding the timing of fracture repair should take into account the clinical status of the patient 54 2.6 Abdominal trauma • To be continued… 55 55 Trauma Summary  Polytrauma is common following RTA  Poor outcome is associated with intra-thoracic, intra-abdominal and CNS trauma  The extent of intra-thoracic and intra-abdominal trauma is not always immediately apparent  Prioritise patient management so that life-threatening injuries are addressed first  Frequent re-assessment of RTA patients is essential for optimising treatment and for early detection of clinical deterioration 56 Questions? [email protected] 57 57