TRAUMA
| VASCULAR TRAUMA —Michael J. Sise, MD, Clinical Professor of Surgery, University of California, San
Diego, School of Medicine, and Trauma Medical Director, Scripps Mercy Hospital, San Diego, CA
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| Cerebrovascular injury after blunt trauma: routinely missed, yet incidence increasing due to greater use
of passenger restraints and changes in automotive engineering (greater survival, but with higher rates of carotid
and vertebral artery tears); patients deserve computed tomography (CT) of chest, head, neck, abdomen,
pelvis, and thoracolumbar spine (CHNAPTL), face and mandible, plus CT angiography of neck;
carotid or vertebral artery injury may occur in ≈1% of patients with blunt trauma; successful management
based on early diagnosis and prompt treatment
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 | Mechanism: points of greatest stress are transverse processes at T6 and T2, where vertebral artery exits canal and
enters brain, and where carotid artery crosses skull base; tears occur due to rotation and crunching of second
transverse process at base of skull, hyperextension and crunching of carotid, or rotational effect on vertebral artery
at C1 and C2; 50% of these injuries result from high-speed trauma, eg, motor vehicle or motorcycle
crashes; 15% result from pedestrian-automobile trauma; 15% from falls; 20% due to other mechanisms; early
diagnosis critical, yet early findings rare
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| Associated injuries: head injury; facial or mandibular fractures; cervical spine fractures; torso trauma; however,
no findings in 20% of patients
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| Diagnosis: catheter angiography gold standard, however, radiologist usually not present during night to perform;
for practical purposes, 16-array or 64-array CT just as good, but trauma surgeons must learn to interpret
cross-sectional images to make diagnosis
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| Treatment options: surgery dangerous; stents unproven; anticoagulation treatment of first choice, but cannot
be used in most trauma patients because of associated injuries; antiplatelet therapy second option
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| Screening criteria: hyperflexion or extension injury; facial fractures; near-hanging; physical signs include
seatbelt sign, neck swelling, and altered mental status, but absent in 20% of patients; basilar skull fractures,
especially near carotid canal; any major fracture of cervical spine indication for CT angiography
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| Take-home message: these injuries relatively rare but may be deadly; screen early and often; make aggressive
use of CT and CT angiography
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| Clinical presentation of vascular injury: trauma surgeons seeing more people with penetrating injuries because
of regionalization of trauma care and rapid transport of patients
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| Diagnosis: broad application of CT now permits early identification and diagnosis of vascular injury; scanning
protocols crucial; time administration of contrast so patients can undergo CT angiography of neck simultaneously
with CT of cervical spine and torso, followed by chest, abdomen, and pelvis; 64-array CT
will redefine patient work-up
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| Management: case 1—man, 22 yr of age, stabbing victim; chest CT shows pneumothorax, fracture at T11 and
aortic pseudoaneurysm at point of body fracture; small lacerations of liver and spleen; head CT normal;
right tube thoracostomy performed; stent graft required in thoracic aorta; patient transferred to tertiary care
hospital after 31 days; case showed comprehensive imaging “way to go”; case 2—man, 20 yr of age, shot
through left cheek; sustained left hemiparesis; intubated immediately; arteriography reveals internal carotid
artery laceration at base of skull; initial pH 6.9; surgery in this area difficult; interventional radiologist inserted
covered stent; patient alive but has high risk for infection; hemiparesis resolved quickly; patient had
major problems with swallowing but gradually recovered; case 3—patient in high-speed motorcycle crash;
chest and pelvic x-rays negative; CT showed torn thoracic aorta; patient went directly to surgery without
angiography (CT alone sufficient for diagnosing torn aorta; skipping angiography saves time); stent graft
placed (off-label use)
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| Lessons learned: tourniquets have place in trauma care, especially in combat injuries; shunts and vein grafts
also invaluable; if patient talking and has pulse, hold fluid to avoid dislodging blood clot; actively bleeding
patients belong in operating room (OR) or angiography suite; moving towards OR endovascular suite;
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| Crisis in trauma surgery: trauma surgeons at risk of becoming subordinate to vascular, orthopedic, or neurosurgeons;
trauma surgeons should be trained in vascular repair; need for trauma/critical care surgeons growing
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| PREHOSPITAL PROCEDURES FOR TRAUMA: SAVING LIVES OR WASTING TIME ?—Stuart P.
Swadron, MD, Program Director, Residency in Emergency Medicine, Los Angeles County/University of
Southern California Medical Center
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| Current thinking on prehospital interventions: few good studies in this area until recently (difficult to obtain
informed consent from critically ill patients); one observational study showed better survival when patients
transported via private automobile rather than by ambulance
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| Survey of nearly 200 trauma surgeons: most would intubate patients with head trauma in field, especially if
transport time long (difficult to extrapolate results of studies in urban setting to rural setting, and vice versa);
only ≈ 50% of surgeons with >20 yr experience favored repeated attempts at intubation; most respondents
supported use of paralytic agents in intubation
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| Management of gunshot wound to torso with no neural deficit: most surgeons favored administration of some
fluids (but not too much; maintenance of hypotension), regardless of transport time; majority of surgeons
think normal saline or lactated Ringer’s solution acceptable; two thirds would not immobilize spine; 52%
would use military antishock trousers (“MAST pants”) if transport time >20 min; many would also use
them not only in pelvic fractures, but also in blunt trauma and shock
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| Evaluating evidence: consider whether situation experimental, and whether outcomes patient-oriented; studies
in Canada and Scotland show mortality worse in patients who received more sophisticated prehospital care,
presumably because of increased time at scene, ie, better survival with basic rather than advanced life support
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| Intubation of patients with head injuries: 5 large studies arrived at widely varying conclusions (all observational
and involved bias); esophageal intubation in field common (shows difficulty of intubation in field;
supports giving paramedics paralytic agents); in study conducted in San Diego, patients given paralytics
and intubated in field spent more time at scene and were more likely to die than those receiving bag-valve-
mask (BVM) ventilation
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| Pediatric airway management: children intubated in field did worse than those taken straight to hospital
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| Fluid management: at least one study has shown that patients with penetrating torso injuries do better when
fluids withheld until resuscitation in OR; in more recent study, hypertonic saline of no value in patients with
head trauma and shock
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| Prehospital chest decompression: Dutch authors reported good results with prehospital chest tube thoracostomy,
but study had many flaws and may not hold up in long run
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| Focused abdominal sonography for trauma (FAST): study in Germany found prehospital FAST examination
helpful for diagnosis and triage of patients with blunt abdominal trauma, but results variable and should
be confirmed; good methodology important
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| Conclusions supported by good evidence: field use of paralytics for intubation in large urban setting does not
improve outcomes; field intubation of children does not improve outcomes; delaying fluid administration to patients
with penetrating torso injuries does improve outcomes in urban setting (short transport time); prehospital administration
of hypertonic saline does not improve outcomes
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| PREHOSPITAL TRAUMATIC ARRESTS: SHOULD THEY BE DECLARED IN THE FIELD ?—Dr. Sise
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| Factors to consider: blunt vs penetrating injury; duration of cardiopulmonary resuscitation (CPR); accuracy
of diagnosis; severity of injury
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| Special considerations: emotional and psychologic needs of family, colleagues, community (examples—
promising student gunned down in drive-by shooting; widely respected police officer [known to emergency
personnel] injured in automobile accident; fellow officers present in emergency department);
conclusion—sometimes compassion dictates heroic measures, even in hopeless situations
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| Guidelines developed by National Association of Emergency Medical Services Physicians and American
College of Surgeons: stop resuscitation early in cases of blunt trauma and pulseless electrical activity
(PEA); if injury penetrating, look for signs of life; stop if significant time has elapsed or in presence of
clear signs patient has expired; if transport time >15 min, consider it carefully, especially if trauma blunt;
tailor approach to system
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| Special considerations: drowning, lightning strikes, extreme cold (patient may appear to have PEA but could
be salvageable)
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| Medical control of stopping: allow physician to determine whether resuscitation efforts should be stopped
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| Continuous quality improvement: essential
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| Testing of guidelines: in one prospective study, of 184 patients who met criteria to be declared dead in field,
28.6 survived (16%); suggests that emergency personnel need broad discretion for determining when to
resuscitate
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| Other factors: trauma surgeons must maintain good working relationship and communication with paramedics;
“when in doubt, transport;” ask paramedics what they saw at scene that led them to transport patient
(never criticize their decision); pulseless asystolic blunt-trauma patients should probably be declared dead
(similar situation with penetrating trauma also “pretty much hopeless”)
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| SIMULATION IN TRAUMA: IS IT FINALLY READY ?—M. Margaret Knudsen, MD, Professor of Surgery,
University of California, San Francisco, School of Medicine, and Attending Surgeon, San Francisco General
Hospital
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| Reasons for using simulators: reduction in residents’ work hours means less time available for one-on-one
instruction and to spend with patients; growing focus on patient safety; medicine learning from aviation,
which emphasizes simulator training; helps surgeons fulfill board-mandated competency criteria
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| Working with simulators: some models cost as much as $250,000 and come equipped with computer chips, so
“patient” responds appropriately to certain drugs, examinations, and interventions; vital signs displayed continuously
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| Comparison with moulage: in study of 60 interns, half trained on simulator, half with traditional moulage;
scenario same for all students (patient with multiple injuries, including fractured leg, who deteriorated
abruptly during resuscitation); all cases videotaped; interns trained on simulator did better, especially when
recognizing deterioration event
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| Follow-up study: hypothesis—surgical residents trained in program that incorporates simulation have better
nontechnical as well as technical skills than residents receiving only didactic training plus 2 hr/wk “face
time” with instructor; 5 scenarios—shock and blunt trauma; stab wound in heart with tamponade; simultaneous
head and pelvic injury; burn and inhalation injuries in pregnant woman; multisystem trauma in geriatric
patient; all based on actual cases; evaluation—learning objectives test given to determine abilities at baseline;
performance taped during simulation; grading done by judges blinded to training method; scoring system
grades technical and behavioral performance (eg, leadership, task management); results—18 mid-level residents
have participated so far; on objective examination, both groups have similar scores, but preliminary
findings suggest that residents trained on simulator have better behavioral skills
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Educational Objectives
| The goal of this program is to review current thinking on several important issues in trauma care. After hearing
and assimilating this program, the listener will be better able to:
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| 1. Diagnose and manage vascular injuries resulting from trauma.
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| 2. Explain the importance of screening for traumatic vascular injuries.
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| 3. List the prehospital trauma interventions whose use is supported by good evidence.
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| 4. Consider all the factors involved when determining whether to declare a patient dead at the scene.
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| 5. Cite research demonstrating the value of training residents on a patient simulator.
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Suggested Reading
American College of Emergency Physicians: Emergency ultrasound imaging criteria compendium. Ann
Emerg Med 48:487, 2006; Berne JD, Reuland KS, Villareal DH et al: Sixteen-slice multi-detector computed
tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury. J Trauma
60:1204, 2006; Bochicchio GV, Scalea TM: Is field intubation useful? Curr Opin Crit Care 9:524, 2003; Bub
LD, Hollingworth W, Jarvik JG et al: Screening for blunt cerebrovascular injury: evaluating the accuracy
of multidetector computed tomographic angiography. J Trauma 59:691, 2005; Gausche M, Lewis RJ, Stratton
SJ et al: Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcomes:
a controlled clinical trial. JAMA 283:783, 2000; Goaley TJ, Dente CJ, Feliciano DV: Torso vascular trauma
at an urban level I trauma center. Perspect Vasc Surg Endovasc Ther 18:102, 2006; Knudson MM, Sisley AC:
Training residents using simlation technology: experience with ultrasound for trauma. J Trauma 48:659, 2000;
Lee SK, Pardo M, Gaba D et al: Trauma assessment training with a patient simulator: a prospective, randomized
study. J Trauma 55:651, 2003; McGuffie AC, Graham CA, Beard D et al: Scottish urban versus
rural trauma outcome study. J Trauma 59:632, 2005; Meier AH, Rawn CL, Krummel TM: Virtual reality:
surgical application—challenge for the new millennium. J Am Coll Surg 192:372, 2001; Spanjersberg WR,
Ringburg AN, Bergs EA et al: Prehosital chest tube thoracostomy: effective treatment or additional trauma?
J Trauma 59:96, 2005; Sukumaran S, Henry JM, Beard D et al: Prehospital trauma management: a national
study of paramedic activities. Emerg Med J 22:60, 2005; Walcher F, Weinlich M, Conrad G et al: Prehospital
ultrasound imaging improves management of abdominal trauma. Br J Surg 93:238, 2006; Winchell RJ,
Hoyt DB: Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma
Research and Education Foundation of San Diego. Arch Surg 132:592, 1997.
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.
Dr. Sise spoke at the 2006 California Trauma Conference, held January 26-28, 2006, in San Diego, CA, and
sponsored by the University of California, San Diego, School of Medicine. Dr. Swadron and Dr. Knudson were
recorded at the Annual USC Trauma/Critical Care Symposium, held May 22-23, 2006, in Pasadena, CA, and
sponsored by the Division of Trauma/Critical Care and the Office of Continuing Medical Education at the Keck
School of Medicine, University of Southern California, and the Institute for Continuing Education for Nurses,
Department of Nursing, Los Angeles County-USC Medical Center. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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