TRIPASS XR تري باس

 

Inspect the perineum for lacerations, contusions, and

hematomas. Perform vaginal and rectal examinations to

assess for gross blood or mucosal trauma. Note the rectal tone

and check the prostate for signs of displacement. Findings

CHAPTER 84

consistent with urethral injury include scrotal hematomas,

blood at the urethral meatus, and a high-riding prostate.

Look for any signs of blunt or penetrating trauma to the

extremities. Document any open wounds, point tenderness,

or obvious deformities. Range all joints, looking for abnormal

movement. Palpate all muscle compartments to detect any

signs of developing tension. Roll the patient and palpate the

entire spine, noting any point tenderness or bony step-offs.

Assess the pulses in all 4 extremities. In penetrating

trauma, the "hard" signs of arterial injury include absent

distal pulses, pulsatile bleeding, expanding hematomas,

and the presence of bruits or thrills. The "soft" signs of

arterial injury include diminished distal pulses, visible

hematomas, corresponding peripheral nerve deficits, or

delayed capillary refill. Patients with soft signs for arterial

injury require the measurement of the arterial pressure

index (API). The API can be calculated by dividing the

systolic pressure of the affected extremity by the systolic

pressure of the contralateral unaffected limb. An API <0.9

is considered abnormal and suggestive of arterial injury.

Finally, perform a comprehensive motor and sensory

examination, reevaluate the pupils and mental status, and

recalculate the GCS.

DIAGNOSTIC STUDIES

� Laboratory

Check a STAT bedside capillary blood glucose level in all

patients with an abnormal mental status as hypoglycemia

can mimic a traumatic brain injury. Check a complete

blood count to assess an initial hematocrit and follow

serially to assess for occult hemorrhage and responsiveness

to therapy. If available, obtain a bedside serum base deficit

and lactate level and follow serially to gauge responsiveness

to therapy. Send a type and screen on all trauma patients

and crossmatch blood as necessary for patients likely to

require transfusions or operative intervention. Obtain a

urinalysis to rule out gross hematuria, a bedside urine

pregnancy test in all female patients of childbearing age,

and a urine toxicology screen in patients with an abnormal

level of consciousness. Check coagulation studies in all

patients with a clotting disorder (eg, patients on warfarin).

� Imaging

Portable plain radiography is readily available at most

institutions for the rapid bedside evaluation of trauma

patients. Plain films are useful for diagnosing bony

fractures including unstable pelvic and spinal injuries;

determining the trajectory of penetrating projectiles;

identifying HTX, PTX, or an abnormal mediastinum; and

detecting the presence of intraperitoneal free air.

Bedside ultrasonography provides a quick, highly sensitive,

noninvasive, and readily repeatable modality to detect occult

hemorrhage. Perform a FAST exam to look for signs of pericardia! tamponade, PTX/HTX, and intraperitoneal bleeding

(see Chapter 88 for further details).

Computed tomography ( CT) imaging has revolutionized

the care of trauma patients. That said, this modality does

expose the patient to increased health care costs, potential

contrast reactions, and harmful ionizing radiation, so every

effort should be made to limit its use to patients whose condition truly warrants it. Furthermore, CT imaging should be

pursued only in patients who are stable enough to safely

leave the resuscitation area for an extended period of time.

CT imaging of the head has become invaluable for the

evaluation and treatment of patients with traumatic brain

injury. CT imaging of the chest is now the preferred modality to evaluate patients with potential intrathoracic vascular

emergencies ( eg, TAl) and evolving pulmonary contusions.

CT of the abdomen and pelvis can simultaneously detect

solid viscus injury (eg, liver and spleen) and intraperitoneal

hemorrhage and determine the severity of pelvic injuries.

Finally, CT angiography has rapidly become the preferred

means to exclude vascular injuries in patients whose c ondition warrants some form of radiographic imaging (eg,

patients with "soft signs" for arterial injury).

Magnetic resonance imaging is useful for the evaluation

of patients with potential spinal cord injury and to further

delineate the severity of traumatic brain injury. That said, its

use should be limited only to stable patients who can afford

prolonged excursions outside of a resuscitation arena.

PROCEDURES

The coordinated resuscitation of a critically ill trauma patient

may require a multitude of simultaneous interventions. The

following procedures are described in detail in the corresponding chapters: central line placement and volume

resuscitation (Chapter 3), needle thoracostomy and

chest tube insertion (Chapter 7), emergent airway management (Chapter 1 1), pericardiocentesis and ED thoracotomy

(Chapter 8 7), and diagnostic peritoneal lavage (Chapter 88).

Perform a retrograde urethrogram and cystogram in

all patients with suspected urethral and bladder injuries.

Indications include straddle injuries, pelvic fractures,

scrotal hematomas, high-riding prostates, and blood at the

urethral meatus. A urethrogram is performed by injecting

intravenous (IV) dye into the urethral meatus while

simultaneously capturing a pelvic radiograph to detect any

signs of urethral disruption (ie, contrast extravasation).

Avoid the insertion of a Foley catheter into any patient with

a demonstrated urethral injury without GU consultation.

For patients with an intact urethra, insert a catheter and

distend the bladder with up to 300 mL of diluted IV contrast while simultaneously capturing a pelvic radiograph

(cystogram) to detect any evidence of bladder rupture.

MEDICAL DECISION MAKING

Obtain a complete set of vital signs and note any

abnormalities. Hemodynamic instability in the setting of

trauma is hemorrhagic shock until proven otherwise.

Initiate aggressive volume resuscitation in said patients.

TRAUMA PRINCIPLES

Primary survey

Identify and treat

emergent life threats

Discharge home Admit for observation and

serial testing Operative intervention

Figure 84-1. Trauma principles diagnostic a lgorithm. OR, operating room.

Perform an immediate primary survey and address any

emergent life threats including airway obstruction,

tension or open PTX, massive HTX, and pericardia!

tamponade. Use your laboratory and imaging studies as

necessary to determine the presence and severity of

injury. Following patient stabilization, perform a

comprehensive secondary survey and treat all encountered

injuries (Figure 84- 1).

..... Treatment

Evaluation and treatment should coincide during the

primary survey. All life-threatening conditions must be

stabilized before further evaluation. Secure the airway in

any patient with signs of impending compromise.

Patients with a GCS �8 require endotracheal intubation

to guard against obstruction and/or aspiration. Examine

the thoracic wall to identify any open PTX and cover

with a 3-sided occlusive dressing to restore normal respiratory mechanics. Perform immediate needle thoracos ­

to my in all patients with signs of tension PTX, and place

a chest tube in all patients with evidence of traumatic

PTX or HTX.

Patients with evidence of impaired circulation require

large-bore IV access and aggressive volume resuscitation

(Lactated Ringer's or normal saline) . Attempt to

determine the class of hypovolemic shock to guide fluid

resuscitation and identify the need for packed red blood

cell transfusion (Table 84- 1). Concurrently attempt to

identify the source of hemorrhage to determine the need

for surgical intervention. Unstable patients with either

clinical evidence (hypotension, distant heart sounds,

jugular venous distention) or ultrasonographic

confirmation of pericardia! tamponade require emergent

pericardiocentesis.

Provide sufficient analgesia to ensure patient comfort

and facilitate further evaluation. Small boluses of IV

fentanyl are ideal because of its short duration of activity

and minimal hemodynamic side effects. Ketarnine can be

used both as an analgesic and sedative agent in lower than

normal "subdissociative" doses without concern for

respiratory or cardiovascular depression. Ondansetron can

Table 84-1. Cl asses of hypovolemic shock .

Class I Class II Class Ill Class IV

Blood loss Up to 750 750-1,500 1 ,SOD--2,000 >2,000

(mL)

Blood loss Up to 15% 1 5-30% 30-40% >40%

(% blood

volume)

Pulse rate <100 >100 >120 >140

(beats/

min)

BP Normal Normal Decreased Decreased

Pulse pres· Normal or Decreased Decreased Decreased

sure (mm increased

Hg)

RR (breaths/ 1 4-20 20-30 30-40 >35

min)

Urine output >30 20-30 5-15 Negligible

(mL/hr)

CNS/mental Slightly Mildly Anxious, Confused,

status anxious anxious confused lethargic

Fluid repla£e· Crystalloid Crystalloid Crystalloid Crystalloid

ment (3:1 and and

rule)* blood blood

,.,Fluid replacement should be 3x the estimated blood loss.

CHAPTER 84

be given to reduce nausea and vomiting, and haloperidol

may be necessary to sedate agitated patients.

DISPOSITION

..... Admission

The majority of blunt trauma victims require admission for

observation to rule out occult injuries not detected on

either the primary and secondary surveys or CT imaging.

Hemodynamically unstable patients with positive focused

assessment with sonography for trauma (FAST) or CT

imaging typically require operative intervention. Victims of

penetrating trauma generally require admission and

operative intervention when the implements clearly violate

significant body cavities or injure vital anatomical

structures.

..... Discharge

Blunt trauma patients with minor injuries who remain

hemodynamically stable on serial assessments can be

safely discharged. Penetrating trauma patients may be

discharged provided that the path of the implement

clearly does not violate any significant body cavities nor

approach any vital anatomical structures. Always ensure

that the patient is able to ambulate and tolerate oral intake

before discharge.

SUGGESTED READINGS

Bailitz J, et al. Emergent Management of Trauma. 3rd ed.

Chapter 3. Patient Evaluation. New York, NY: McGraw Hill,

20 1 1.

Bonatti H, Calland J. Trauma. Emerg Med Clin North Am.

2008;26:625--648.

Brunett PH, Cameron PA. Trauma in adults. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20 11.

Initial assessment and management. ATLS Student Course

Manual. 9th ed. Chapter 1. Chicago, IL: American College of

Surgeons, 2012, 2-28.

Head Inj u ries

Katie L. Tata ris, MD

Key Points

• Traumatic brain injury can be classified by severity into

mild (Glasgow coma Sca le [GCS] <::1 4), moderate (GCS

9-1 3), and severe (GCS ::::: 8) categories.

• An emergent noninfused head computed tomography is

the imaging modal ity of choice in patients with cranial

trauma.

INTRODUCTION

Between 1.2 and 2 million patients sustain some form of

traumatic brain injury (TBI) in the United States every

year. Fortunately the majority of cases ( -80%) are mild,

as moderate and severe TBI is associated with significant

long-term disability and death. In fact, head injuries are

the leading cause of traumatic death in all patients

younger than 25 years. Currently more than 50,000

deaths and 370,000 hospitalizations are attributable to

TBI on an annual basis. The associated costs of caring for

patients with acute and chronic TBI are astronomical,

exceeding $4 billion per year. TBI occurs as the normal

physiologic function of the brain is disrupted by either

direct (object striking the cranium) or indirect (acceleration/deceleration) forces. Patterns of injury can be classified as either primary (occur at the time of impact) or

secondary (develop over time owing to neurochemical

and inflammatory responses). Patients with TBI can be

further stratified by their Glasgow Coma Scores (GCS)

into mild (GCS ;:::14), moderate (GCS 9-13), and severe

(GCS �8) categories (Table 85-1).