CHALLENGES IN TRAUMA
Selections from the California Trauma Conference, presented January 26-28, 2006
| CERVICAL SPINE CLEARANCE —James W. Davis, MD, Associate Professor of Clinical Surgery, University of California,
San Francisco, School of Medicine, and Chief of Trauma, University Medical Center, Fresno, CA
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| Cervical spine evaluation standards: Eastern Association for the Surgery of Trauma (EAST)—20-yr literature
review; of 961 citations, 62 well conducted; National Emergency X-Radiography Utilization Study (NEXUS)
Group—prospective study of 34,000 patients, producing multiple publications; American Association of Neurologic
Surgery (AANS)—published March 2002; based on independent Medline analysis; reviewed EAST and NEXUS; emphasis
on Class I data
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| Cervical spine evaluation guidelines
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 | Awake alert patients with normal mentation: if patient not intoxicated and has no neck pain, distracting injuries, or neurologic
deficits, cervical spine series may not be necessary; if clinical examination reveals no tenderness and full range of
motion, cervical spine can be cleared and x-ray not required; supported by EAST, NEXUS, and AANS
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| Patients requiring radiographic evaluation: if patient not alert, intoxicated, in pain, or has neurologic deficit, perform
minimum of 3-view series; axial computed tomography (CT) with sagittal reconstruction indicated for any area of
questionable injury or if C7-T1 not seen clearly; supported by EAST, NEXUS, and AANS
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| Patients complaining of neck pain: normal 3-view series indicated; can do extreme flexion-extension views (patient must
actively position); if patient unable to perform flexion-extension, magnetic resonance imaging (MRI) or stiff collar for
2 wk indicated
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| Patients with neurologic deficit: CT or MRI indicated; perform MRI as soon as possible; body of recent evidence suggests
CT better than plain films
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| Unconscious or obtunded patients in intensive care unit (ICU): can use 3-view series or fine-cut CT; evaluating
stability—MRI or dynamic flexion-extension; dynamic fluoroscopy involving passive flexion-extension described by
EAST as “reasonable thing to do”, and according to AANS, “may be performed for clearance” (not used by speaker)
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| MRI to evaluate instability: Richards (2005)—all patients should receive MRI; NEXUS Group—MRI better for
soft tissue, CT better for bones; study—patients with normal multi-detector row CT and no neurologic deficit do not
need MRI
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| Pediatric cervical spine evaluation: incidence—2% to 3% of all cervical spine injuries; 1 per yr over 15 yr at children’s
hospitals; clinical clearance—x-rays not required if child awake, alert, and conversant, has no neurologic deficit,
tenderness, painful or distracting injuries, and not intoxicated; radiographic clearance—for patients not alert with neurologic
deficit or pain, options include 2-view series with optional odontoid, 3-view series, and CT
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| Treatment of secondary injuries
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| Steroids: National Acute Spinal Cord Injury Studies (NASCIS) II and III—if steroid therapy initiated within 3 hr,
continue for 24 hr; if initiated within 3 to 8 hr, continue for 48 hr; became medicolegal standard of care; however,
study largely discounted due to flaws; penetrating trauma—no benefit; may impair recovery; consequences—may
increase risk for pneumonia and days on ventilator and in ICU; Systematic Review (Spinal Cord, 2000)—evidence
does not support use to improve neurologic recovery
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| GM1 ganglioside: shown to enhance functional recovery of damaged neurons in animal studies; study—in 37 patients,
enhanced recovery of some muscle (primarily for bowel and bladder control); prospective randomized controlled
trial—in 797 patients (all received methylprednisolone before ganglioside), improvement associated with ganglioside
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| THE EVIDENCE OF FAST EXAMINATION IN PENETRATING TRAUMA —M. Margaret Knudson, MD, Professor of
Surgery, University of California, San Francisco, School of Medicine
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| Echocardiography for assessment of pericardium: patients with cardiac injuries occasionally present with normal
vital signs; multicenter prospective study—261 patients underwent cardiac echocardiography performed primarily
by surgeons; 29 true positives; 7 false positives (mostly older patients with benign pericardial effusions); no false negatives
(sensitivity 100%); time to perform examination 1 min; time from presentation to operating room (OR) 11 min;
speaker estimates cost savings with ultrasonography (US) of $2800 per patient
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| US for assessment of pleural effusions: Emory University study—in 360 patients, 40 cases of pleural effusion
identified, of which 39 identified by US and 37 by chest x-ray; US result obtained in 1 min, chest x-ray result obtained in
14 min; speaker does not believe this precludes use of chest x-ray
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| US for assessment of pneumothorax: use linear probe and higher-frequency (7.5 MHz) probe than for normal Focused
Assessment with Sonography for Trauma (FAST) exam; useful when patients deteriorate in OR and time not available
to get chest x-ray, or patients in ICU develop tension pneumothorax
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| Assessment of patients with penetrating abdominal trauma
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| Indications for surgery: stab wounds with evisceration; hypotensive patients with positive FAST exam; most gunshot
wounds if peritoneal penetration demonstrated or suspected; patients with peritonitis, free air, or known diaphragmatic
tear; complications—Emory University study demonstrated complication rate of 20% for negative laparotomy
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| University of Southern California study: of 1900 patients with gunshot wounds, 800 managed initially without operation, and
of these, 80 underwent subsequent operation (5 complications related to delay); CT not used (speaker believes CT should
be used to assess path of bullet in nonoperative management)
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| Speaker’s comments: most gunshots to abdomen still require surgery; if penetration unclear, perform x-ray; some isolated
liver injuries do not need laparotomy but should be followed carefully
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| Local wound exploration: if mandatory laparotomy performed for all stab wounds, 70% of operations nontherapeutic; speaker
believes local wound exploration unreliable
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| US: positive results helpful in deciding how to proceed; not helpful for bowel; sensitivity 70%; fairly high specificity
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| Laparoscopy: requires general anesthesia; associated with trocar-insertion complications; insufflation can cause instability,
especially if patient has pneumothorax; limited ability to repair injuries
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| Summary: diagnostic peritoneal lavage (DPL)—very sensitive but not very specific; CT—very specific but not very
sensitive; US—fairly sensitive and fairly specific; laparoscopy—very sensitive and fairly specific but very expensive
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| FREE FLUID WITHOUT SOLID ORGAN INJURY ON ABDOMINAL CT—Andrew B. Peitzman, Professor of Surgery,
University of Pittsburgh Medical Center, Pittsburgh, PA
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| Evaluation of abdomen: determine whether abdominal injury present and whether operation required; CT—sensitive;
specific; accuracy 98%; can quantify amount of blood present and help grade solid organ injuries; intravenous contrast
carries risk, eg, anaphylaxis; misses 15% of hollow viscus injuries and may miss acute pancreatic injuries
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| Nonoperative management: in children and adults, majority of injuries to liver and spleen managed nonoperatively;
liver and spleen heal within 8 to 12 wk, and risk of missing hollow viscus injury <0.3%; factors increasing risk for hollow
viscus injury—Chance fractures of lumbar spine; lap seat belt mark
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| EAST study: in 250,000 blunt trauma patients, incidence of hollow viscus injury 0.3%; no diagnostic test reliable; CT
missed 13% of bowel injuries; for patients treated within 8 hr, mortality 2%; when treatment delayed by 8%, mortality
9%; if patient not treated for >24 hr, mortality 31%; lap seat belt mark associated with 2.4-fold increased risk; US—used
in 30% of patients; for diagnosis of small bowel (SB) injury, positive predictive value 38%; DPL—used in 14% of patients;
all patients with white blood cell (WBC) count >500/mm3 had SB injury, but 5% of patients with SB injury had
WBC count <500/mm3 ; CT—majority of patients underwent CT; 13% of patients with SB injury had normal CT;
conclusion—alone or in combination, current diagnostic modalities lack sensitivity for diagnosis of SB injury
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| Reasons for delay in diagnosis and treatment: not understanding mechanism of injury; not interpreting physical
findings appropriately; failure to interpret radiographic tests appropriately (more commonly false negative); SB injuries
can be difficult to see on CT; unstable patients with multiple injuries
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| Mesenteric hemorrhage: not life-threatening; can cause bleeding and SB obstruction; imaging studies reveal blood in
leaflets of mesentery and contrast extravasation from active bleeding
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| Brasel et al: in 1100 abdominal CT studies for blunt trauma, free fluid associated with organ injury in 77% of cases; only
3% of patients with free fluid did not have solid organ injury; of laparotomies performed on 13 of 34 patients with free
fluid alone, 6 SB injuries and 1 diaphragm injury diagnosed (therapeutic laparotomy rate 54%); conclusion—
misinterpretation of true positive CT more common than true false-negative study; trace amount of intraperitoneal
fluid not associated with abdominal or viscus injury; patients with moderate-to-large amounts of intraperitoneal free
fluid without solid organ injury should be considered for laparotomy
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| Levine et al: 60 patients with CT findings of free fluid without solid organ injury; no operations required for 44 patients
with small amount of fluid; of 11 patients with intermediate amount of fluid, 3 underwent laparotomy (1 jejunal perforation,
2 mesenteric lacerations); 2 of 5 patients with large amount of fluid underwent laparotomy; conclusion—
patients with small amount of intraperitoneal fluid do not require laparotomy, with exception of fluid in mesentery
(suggests mesenteric injury); DPL recommended for patients with intermediate or large amount of fluid
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| Rodriguez et al: analysis of 10 articles and 16,000 patients; therapeutic laparotomy performed in 27% of patients;
conclusion—more fluid increases likelihood of intestinal injury; physical findings do not predict abnormal CT; free
fluid alone does not mandate laparotomy
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| Diagnostic algorithm: stable patients with blunt trauma and small amount of fluid—small likelihood of injury, observation
indicated (lap seat belt marks and other risk factors may change management); alert patients with moderate-
to-large amount of fluid—if physical examination negative, observation probably sufficient; if physical examination
positive, laparotomy or laparoscopy indicated; if no physical examination, intervention depends on level of suspicion
and comfort level with diagnostic tests
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| DAMAGE CONTROL REVISTED: WHEN TO BAIL OUT —David A. Spain, MD, Professor of Surgery, Chief of
Trauma, Stanford University School of Medicine, Stanford, CA
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| Damage control surgery: should be active decision, not default thought process; abbreviated operation can sometimes
be predicted based on injury patterns or patient characteristics; intraoperative events can also lead to decision to abbreviate
operation
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| Objectives: hemorrhage control, eg, packing, ligation; repair of essential vascular structures (can be temporary [eg,
shunt] or definitive); stop gastrointestinal contamination, eg, staple or tie off colon injuries
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| Outcomes: Rotondo et al—maximum injury subset defined as patients with transabdominal or transpelvic gunshot
wounds, both of which likely involve multiple organ injuries; in maximum injury subset patients undergoing damage
control surgery, survival 77%; in patients undergoing definitive surgery, survival 11%; Carrillo et al—1 of 11 patients
who underwent damage control surgery died, compared to 5 of 13 who underwent definitive surgery
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| Liver injuries: 80% of liver injuries managed nonoperatively; only unstable patients with large injuries undergo surgery;
packing—in past, patients packed late (eg, after receiving 20 U of blood), often resulting in death; patients have better outcome
if packed earlier, ie, mortality reduced to 30% from 60%; can increase survival in patients with known venous injury
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| Preoperative indicators: study—70 patients requiring packing to control hemorrhage (liver injuries, vascular injuries,
retroperitoneal injuries); initial pH 7.1 for nonsurvivors and 7.3 for survivors; nonsurvivors thrombocytopenic and
coagulopathic, and often arrive at emergency department (ED) after long prehospital time and prolonged period of hypotension
(indicates abbreviated operation likely necessary)
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| Intraoperative indications: coagulopathy, hypothermia, and acidosis (“triangle of death”); transfusion of ≥8 U total
blood volume (speaker has packed patients after 2-4 U); unstable patients with multiple injuries; patients may have other
issues that obligate abbreviated abdominal or thoracic operation, eg, aortic transection, severe closed head injury, pulmonary
contusions
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| Survival after damage control surgery: study—if pH <7.2 in ICU after leaving OR, 14 of 14 patients died; if pH
>7.33, 12.5% of patients died; of patients with mild acidosis, coagulopathy, and partial thromboplastin time (PTT) >80
sec, all died; patients with mild acidosis and mild coagulopathy had fairly good outcome
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| Summary: important to identify patients early; consider abbreviated operation as option on way to OR; pack patients dependent
on type and severity of injury rather than number of transfusions; important to have team game plan
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Educational Objectives
| The goal of this program is to educate the listener on management of trauma patients. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Evaluate trauma patients.
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| 2. Diagnose and manage cervical spine injuries.
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| 3. Review the use of ultrasonography for evaluating patients with penetrating abdominal trauma.
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| 4. Use computed tomography to evaluate patients with blunt trauma.
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| 5. Review indications for damage control surgery.
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Suggested Reading
Barba CA et al: A new cervical spine clearance protocol using computed tomography. J Trauma 51:652, 2001;
Barrett TW et al: Injuries missed by limited computed tomographic imaging of patients with cervical spine injuries.
Ann Emerg Med 47:129, 2006; Cunningham J et al: Enhanced recognition of "lung sliding" with power color
Doppler imaging in the diagnosis of pneumothorax. J Trauma 52:769, 2002; Davis JW et al: Routine evaluation of
the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma 50:1044, 2001; Fakhry
SM et al: Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury:
analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma 54:295, 2003;
Gale SC et al: The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma
59:1121, 2005; Ghanta MK et al: An analysis of Eastern Association for the Surgery of Trauma practice guidelines
for cervical spine evaluation in a series of patients with multiple imaging techniques. Am Surg 68:563, 2002;
Hanks PW, Brody JM: Blunt injury to mesentery and small bowel: CT evaluation. Radiol Clin North Am
41:1171, 2003; Killeen KL et al: Imaging of traumatic diaphragmatic injuries. Semin Ultrasound CT MR 23:184,
2002; Kirkpatrick AW et al: Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the
Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma 57:288, 2004; Knudtson JL et
al: Surgeon-performed ultrasound for pneumothorax in the trauma suite. J Trauma 56:527, 2004; Mower WR,
Hoffman J: Comparison of the Canadian C-Spine rule and NEXUS decision instrument in evaluating blunt trauma
patients for cervical spine injury. Ann Emerg Med 43:515, 2004; Poletti PA et al: Blunt abdominal trauma patients:
can organ injury be excluded without performing computed tomography? J Trauma 57:1072, 2004; Rotondo MF,
Bard MR: Damage control surgery for thoracic injuries. Injury 35:649, 2004; Soffer D et al: A prospective evaluation
of ultrasonography for the diagnosis of penetrating torso injury. J Trauma 56:953, 2004; Stassen NA et al:
Abdominal seat belt marks in the era of focused abdominal sonography for trauma. Arch Surg 137:718, 2002; Stassen
NA et al: Examination of the role of abdominal computed tomography in the evaluation of victims of trauma
with increased aspartate aminotransferase in the era of focused abdominal sonography for trauma. Surgery 132:642,
2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Davis, Knudson, Peitzman, and Spain addressed the California Trauma Conference, presented January 26-28,
2006, in San Diego, CA, and sponsored by the University of California Schools of Medicine at San Diego, Los Angeles,
Davis, San Francisco, and Fresno, as well as Scripps Mercy, Scripps Memorial, and Sharp Memorial Hospitals.
The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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