Trauma in 2009

Educational Objectives

The goal of this program is to improve the management of simple wounds, resuscitation and management of victims of combat trauma, and hemorrhage control. After hearing and assimilating this program, the clinician will be better able to:

1.   Utilize appropriate methods for cleansing and closure of wounds.

2.   Recognize when to utilize prophylactic antimicro-bials.

3.   Choose the appropriate fluid replacement solution for resuscitation.

4.   Describe the new techniques and products available for hemorrhage control.

5.   Determine when it is appropriate to use recombinant factor VIIa.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose. In his lecture, Dr. Kaufmann presents information that is related to off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Chisholm was recorded at 15th Annual Scientific Assembly, held March 2-4, 2009, in Phoenix, AZ, and spon­sored by the American Academy of Emergency Medicine. Dr. Kaufmann was recorded at 26th Annual Northwest Winter Conference in Emergency Medicine, held January 25-28, 2009, in Sunriver, OR, and sponsored by the Ore­gon Chapter of the American College of Emergency Physicians. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Am I Treating Simple Wounds Correctly?

Carey D. Chisholm, MD, Professor of Emergency Medicine, and Director, Emergency Medicine Residency, Indi­ana University School of Medicine, Indianapolis

Wound management: few good studies; most randomized controlled trials underpowered and not helpful; 5 steps for appropriate wound care  —  1) determine situation; obtain appropriate hemostasis; if anatomically appropriate, perform downstream neurologic examination to ascertain whether nerves damaged; 2) make patient more com­fortable; decide whether and what type of anesthesia to use; perform exploration of wound; 3) decide what cleansing, if any, to perform, how much, and with what; 4), decide on method to close wound; 5) aftercare and expectations (most critical in preventing medicolegal problems)

Anesthesia: ropivacaine  —  safer form of bupivacaine; avoid epinephrine in elderly person with atherosclerotic heart disease and large laceration; long duration of action; no black box warning like bupivacaine (potential for cardiovascular side effects); selective use in high-risk patients

Wound in knee: most likely to become infected after closure in emergency department (ED); likely due to tension placed on suture line; speaker recommends brief period of immobilization (crutches for few days); describe signs of infection to patient and ensure that patient understands need to look for these signs

Cleansing of wound: tap water  —  considered first-line option; as effective as normal saline; commercial devices at­tached to tap allow for irrigation of wounds in torso and lower extremities; soaking no longer used; avoid detergents and hydrogen peroxide; normal saline appropriate alternative; 1% povidone iodine  —  consider in high-risk wounds; used as irrigant or cleaning agent at end of cleansing process; doing nothing acceptable option for most scalp and face lacerations

Closure of wounds: monofilament sutures  —  if wound gaping (>5 mm), should buttress with absorbable sutures, except if wound on palm of hand or sole of foot (associated with dramatic increase in infection rate); fast-absorbing catgut  —  for facial and scalp lacerations in children; staples  —  in cosmetically unimportant areas; not comfortable in pressure surfaces; tissue adhesive  —  ideal closure method for selected wounds;  »50% of hand lacerations in ED good candi­dates; wounds must be linear and small (less than 2-2.5 cm); effective and ideal for most finger lacerations; loose ap­proximation of wound edges  —  not acceptable in ED wound management; delayed primary closure  —  disadvantages of primary closure present in risk for infection and introduction of foreign body (FB) without advantages (no occlusive bond of dermis and epidermis); performed in areas where wounds do not heal rapidly (not for scalp, face, or neck); perform all steps in wound management up to point of closure, but instead, place fine mesh gauze onto wound with occlusive dressing; patient asked to return in 48 to 72 hr for reassessment; if healthy granulation tissue present, wound cleansed and closed; if cellulitis or purulent drainage present (infected), allow to heal by secondary intention and give antibiotic of choice; eventual healing with bigger scar seen; ensure that patient understands, and write detailed instruc­tions for patient to take to primary care physician

Prophylactic antimicrobials: consider age of wound, location, and patient choice; age of wound  —  increased amount of bacteria seen over 6 to 24 hr; if patient or mechanism of injury not high-risk, decision not to close wound because of age of wound alone not appropriate, especially in cosmetically important area with low risk for infec­tion; wounds one of top 5 reasons for successful lawsuits against ED physicians; consider FBs and deep structures involved (eg, nerve, tendon); also infection, failure to align expectations, and high-risk wounds

Foreign bodies: most problematic those not seen on x-ray (glass and rock seen on x-ray); should not tell patient that no FB present in wound; instead, state that, to best of your ability, not able to detect FB by x-ray and exploration, but one still possibly present to cause infection and complications; deep structures  —  understand functional anat­omy (know nerves, vessels, tendons, or joint under area of laceration) and ascertain involvement

Realigning patient expectations: patient needs to hear 3 times that scar will develop from laceration; if patient wants plastic surgeon in ED, provide scripted response that plastic surgeon not available and offer services; plantar punc­ture wounds  —  most patients present few days after injury because of pain; make patient understand that serious complication possible; risk for complication not reduced by probing, antibiotics, or irrigation

Organisms in wounds: Pasteurella multocida  —  causes rapid disseminated infection after injury (<24 hr); usual source cats; may result in lymphangitis or bacteremia; treat with antibiotics; also consider that cat’s tooth can break off in wound; Capnocytophaga canimorsus  —  consider in asplenic individuals or patient with liver disease and dog bite (or history of licking by dog); present with picture of overwhelming sepsis 3 to 4 days after injury or contami­nation; counsel patient to return to ED immediately if flu-like symptoms develop and document; unknown whether prophylaxis with penicillin (drug of choice) effective, but advocated in high-risk host with dog bite; fish tank granuloma  —  due to Mycobacterium marinum; patient presents with granuloma or plaques; due to handling of fish; fight bites  —  most patients with fist injury do not present until few days later due to infection with Eikenella; ensure that joint capsule not violated and that extensor tendon not involved (may require extension of laceration); antimi­crobials required; aggressive treatment necessary; Vibrio  —potentially life-threatening infection; associated with minor lacerations, breaches in skin, or just contact with water; hemorrhagic cellulitis, bullae, and overwhelming sepsis seen; in patient with liver disease, can be caused by eating raw oysters; finning injuries  —  due to cuts from spine when handling fish

Aftercare of wounds: occlusive dressing preferred for most lacerations; instruct patient on care of suture line, ie, cot­ton-tipped swab with hydrogen peroxide rolled up and down over developing scab, followed by application of layer of petroleum jelly or topical antibiotic ointment; instruct patient when to return for suture removal, about signs of infection, and about activities to be restricted and allowed (eg, when patient can bathe)

Lessons Learned from Military Conflicts and How They Apply to Your ED

Christoph Kaufmann, MD, MPH, Professor of Surgery, Uniformed Services University, Bethesda, MD

Triage: recent experiences in military show that most experienced surgeon one who best understands big picture in triage; occurs at many levels; initially, triage officer in military least valuable medical officer (often dentist) and given training in advanced trauma life support (ATLS); involves doing most good for greatest number of individu­als; continuous and repetitive (not one-time decision) until all patients managed; previously expectant patient can become emergent or vice versa; ATLS shows that airway, breathing, and circulation (ABC) effective way to make triage decisions; airway problem kills patient faster than breathing problem, which kills patient faster than circula­tion problem; despite practice and rehearsal, perfection not achieved; important part of triage to make decision and move ahead

Controlled hypotensive resuscitation: if necessary to give fluids, give early and aggressively, but must have end point; otherwise, result might be tissue edema, bowel edema, acute respiratory distress syndrome, abdominal compartment syndrome, and multiple organ failure; crystalloids  —inefficient; proinflammatory; prime immune system; increase neutrophil sequestration and cytokine release; no difference in physiologic response to lactated Ringer’s solution (LRS) and normal saline; ideal resuscitation fluid for military efficient and lightweight; hypertonic saline  —  used by military; not proinflammatory; avoids margination of white blood cells stuck to vessel wall seen with LRS; combat ca­sualty optimal resuscitation  —control bleeding; consider tourniquet; transport to higher level of care; if patient has ac­ceptable vital signs, not necessary to give extra fluids (oral fluids sometimes adequate); permissive hypotension  —  avoid vigorous resuscitation before hemorrhage control; adverse effects seen with overresuscitation; significant bleed­ing does not necessarily require significant pressure (fingers better than stack of gauze to stop bleeding)

Hospital care: in many cases, hemorrhage control begins at ED; perform trauma work-up, check ABCs, stop bleed­ing, and provide large-bore intravenous access; concern with ischemic injury to extremities if patient has signs of vascular injury

Avoiding pitfalls: resuscitation masks quiescent hemorrhage sites (eg, arteries deep in soft tissue may start bleeding, transected vessels in spasm may rebleed [especially in elderly], limbs with tourniquet or hemostatic dressings may rebleed); hemostatic resuscitation  —  begins in earnest once surgeon in position to control hemorrhage; should not resuscitate beyond blood pressure (BP) value needed for mentation, maintenance of radial pulse, and adequate urine output; fresh blood and hemostatic products  —  aim for 1:1 ratio of fresh frozen plasma (FFP) to red blood cells (RBCs); expanded to 1:1:1 (FFP, packed RBCs, and platelets) to 1:1:1:1 (FFP, packed RBCs, platelets, and cryoprecipitates); reconstituting whole blood appropriate; operating room (OR) resuscitation  —  most severely in­jured patients (eg, BP <90 mm Hg, penetrating trunk trauma) sent directly from ambulance to OR; pitfalls  —  prehospital pitfalls reduced with rigorous training and constant surveillance of wound; resuscitation may cause re­bleeding; if operative findings in body cavities do not explain shock, look for other sources of bleeding

New techniques: one-handed combat tourniquet; tourniquets  —effective, but not perfect; must be above arterial pressure; pitfalls include being too tight or too loose; once above arterial pressure, no need to tighten more (causes muscle necrosis and injury); surgical clamps  —  use in bleeding extremity discouraged if not in OR; management of chest wound  —  in ten­sion pneumothorax, needle thoracentesis performed with 3.5-in 14-gauge needle; requires “hole” in chest; in sucking chest wound, apply occlusive dressing and tape on 4 sides; fresh whole blood  —  highly effective; drawbacks of concept of “walking blood bank” include possibility of wrong blood type shown on dog tag and transmission of infectious diseases; in patients with low ratio of packed RBCs to FFP, mortality »65% (reduced to 19% with 1:1 ratio)

Initial resuscitation management: be prepared for patient; “quick” procedures take much longer than previously thought; patients in extremis usually die on induction of anesthesia; pitfalls  —  in military, “code red” previously meant 4 units of packed RBCs and 2 units of FFP; presently, means 4 units of packed RBCs, 4 units of FFP, and 4 6-packs of platelets for each mangled or amputated extremity; previous ratio of 1 unit of FFP to 2 packs of RBCs needs change to 1:1 ratio

Damage-control resuscitation: standard; Pringle maneuver  —clamping with finger under portal triad to stop bleeding of portal vein and hepatic artery and then packing liver; performed when patient acidemic, hypothermic, and coagulopathic; definitive management in calculated stepwise fashion based on patient’s physiologic tolerance; initial procedure, subse­quent resuscitation, and planned definitive reoperation; as ED lengths of stay increase, damage control concepts may ap­ply

Recombinant factor VIIa: study showed that small dose of factor VIIa corrected coagulopathy quickly in patients on anticoagulants who presented with subdural hemorrhage; monitored by prothrombin time; should not use if pH <7.2; »10% as active at pH 7.2 as it is at pH 7.4; if patient highly acidemic, increase dose or attempt to correct acidosis with bicarbonate (unproven); in coagulopathic patients, helpful and “miraculous” on occasion, but does not stop surgical bleeding; given in patient with subdural hematoma if on warfarin (Coumadin) or if international normalized ratio ³2

Hemostatic dressings: gauze and Surgicel (oxidized cellulose) not as effective; active bandages include Quick Clot and HemCon; Quick Clot  —  zeolite; absorbs water, concentrates clotting factors, and exothermic (causes burns); HemCon  —  made of shrimp shells; does not burn; disadvantages of Quick Clot  —  washed away by spurting blood if pressure not applied; burns medical worker’s eyes and hands if aerosolized; clot formed can fracture and cause re­bleeding when patient transported or moved; burns tissues; both bandages undergoing reformulation and provide advantage over regular gauze; pitfalls in hemorrhage control  —  easy to “chase” wrong bleeding source in patient with multiple penetrating injuries; may require >1 person

Transport of patient: understand evacuation platform and its capabilities and limitations; critical care air transport team  —  “flying intensive care unit” (physician, nurse, and respiratory therapist); does not include helicopters (noisy, challenging, and difficult); in military, most dangerous part of patient’s care usually 30-min flight from for­ward surgical team or battalion aide station to combat support hospital; advisable for patient to stay longer before transport; preventable trauma mortality  —  concept of joint theater trauma system developed using civilian princi­ples

Suggested Reading

Brummel-Ziedins K et al: The resuscitative fluid you choose may potentiate bleeding. J Trauma 61:1350, 2006; Ciesla DJ et al: Secondary overtriage: a consequence of an immature trauma system. J Am Coll Surg 206:131, 2008; Duchesne JC et al: Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy. J Trauma 67:33, 2009; Fox CJ et al: Effect of recombinant factor VIIa as an adjunctive therapy in damage control for wartime vascu­lar injuries: a case control study. J Trauma 66:S112, 2009; Harrington DT et al: Transfer times to definitive care facilities are too long: a consequence of an immature trauma system. Ann Surg 241:961, 2005; Hashiguchi N et al: Hypertonic sa­line resuscitation: efficacy may require early treatment in severely injured patients. J Trauma 62:299, 2007; Lapid O: An improvised wound closure system. J Trauma 60:910, 2006; Melis P et al: Long-term results of wounds closed under a sig­nificant amount of tension. Plast Reconstr Surg 117:259, 2006; Moore FA et al: StO2 Study Group. Is there a role for ag­gressive use of fresh frozen plasma in massive transfusion of civilian trauma patients? Am J Surg. 196:948, 2008; Shaz BH et al: Transfusion management of trauma patients. Anesth Analg 108:1760, 2009; Snyder CW et al: The relationship of blood product ratio to mortality: survival benefit or survival bias? J Trauma 66:358, 2009; Wareham DW et al: The dan­gers of dog bites. J Clin Pathol 60:328, 2007.