Tuesday, March 23, 2021

The Patient with Blunt Trauma Case File

Posted By: Medical Group - 3/23/2021 Post Author : Medical Group Post Date : Tuesday, March 23, 2021 Post Time : 3/23/2021
The Patient with Blunt Trauma Case File
Lydia Conlay, MD, PhD, MBA, Julia Pollock, MD, Mary Ann Vann, MD, Sheela Pai, MD, Eugene C. Toy, MD

Case 44
A 50-year-old man is brought to the emergency room from the scene of a 2-car motor vehicle accident. He was the restrained driver of one of the vehicles involved. He is slightly anxious and complaining of a headache, neck pain, and abdominal pain, but does not recall ever losing consciousness. His past medical history is significant only for recurring sinusitis, for which he receives antibiotics. He is not allergic to any medications.

On physical examination the patient is a thin but well-nourished middle-aged male with no obvious bruises or wounds on his body. His blood pressure is 98/31 mm Hg, heart rate is 107 beats/minute, respirations are 16 breaths/minute, and his temperature is 36.2°C (97.2°F). He has no gross neurological deficits, although he had a neck collar on. He has two large-bore peripheral intravenous cannulae in place through which fluid were being infused.

Laboratory findings include a hemoglobin level of 10.2 g/dL, a normal chest roentgenogram, and electrocardiogram. A whole body CT scan was performed to rule out aerodigestive abnormalities, major vascular injuries, and long bone fractures. A diagnostic peritoneal lavage was done at bedside and yielded aspiration of approximately 25 mL of gross blood. The patient was scheduled for an emergency exploratory laparotomy. A urethral catheter was placed and a blood sample was sent for typing and cross-matching.

➤ What are the anesthetic concerns for this patient?

➤ What are the associated injuries one should look for?

➤ What is the anesthetic plan?


ANSWERS TO CASE 44:
The Patient with Blunt Trauma
Summary: A 50-year-old man was involved in a motor vehicle accident and shows signs of hemodynamic instability (hypotension and tachycardia), and a peritoneal lavage positive for frank blood.

Anesthetic concerns: Possibility of neck injury requiring cervical immobilization, degree of hypovolemia, and presence of associated injuries and timing of last meal.

Associated injuries: Pericardial injury, tamponade, aortic dissection, aortichematoma, rib fractures, and myocardial injury.

Anesthetic plan: General anesthesia with rapid-sequence induction with cricoid pressure and intubation is the only option since this patient needs emergency surgery.


ANALYSIS
Objectives
1. Appreciate the diverse nature of injuries in blunt trauma.
2. Understand some of the different approaches to the administration of anesthesia in the presence or absence of certain injuries.


Considerations
This patient requires emergent surgery, and general anesthesia with rapidsequence induction. While standard monitors are applied (pulse oximetry, 5-lead ECG, noninvasive blood pressure), intravascular volume repletion is continued through the existing large-bore intravenous access sites. He is asked to inspire 100% oxygen by face mask, using a few vital capacity breaths to ensure alveolar de-nitrogenation.

Since the patient is hypotensive, etomidate is chosen for induction, and succinylcholine is administered in quick succession as cricoid pressure is applied by an assistant. Laryngoscopy and endotracheal intubation are performed while a second assistant maintains stabilization of the neck. Once the endotracheal tube is secured, and its position confirmed by auscultation and capnography, the surgery may proceed.

Given the severity of the accident and possibility of associated major injuries, an arterial catheter is placed in right radial artery to achieve beat-tobeat arterial blood pressure monitoring as well as access for blood draws for continuous assessment of hemoglobin values. However, given the patient’s intra-abdominal bleeding, the laparotomy is not delayed to allow placement
of this line.

Once surgical exploration is begun and findings are clear, there might be a need for blood and blood product transfusion to help control surgical bleeding. A bronchoscopy and an esophagoscopy performed at the end of the procedure were negative for tracheobronchial and esophageal injuries.


APPROACH TO
The Patient with Blunt Trauma

CLINICAL APPROACH
The three-point lap-shoulder seat belt is reported to reduce the risk of death or serious injury for front-seat occupants by approximately 45%. In frontal MVAs, air bags provide a reduce risk of fatality by approximately 30%. In all crashes, the reduction in the risk of death with use of seat belts has been estimated at 11%. But as the death rate declines, the number of survivors increases. Thus serious injuries following blunt trauma are on the rise. The primary survey of the Acute Trauma Life Support (ATLS) course concentrates on six immediately life-threatening injuries to the airway and the chest. The secondary survey detects another six potentially life-threatening injuries that scan the spectrum of thoracic injuries (see Table 44–1).

Many of the injuries of the thorax and abdomen result from the rapid acceleration toward the seat belt followed by subsequent, sudden deceleration. Thoracic cavity injuries occur when differential movement occurs

Table 44–1 THORACIC INJURIES IN BLUNT TRAUMA

IMMEDIATELY LIFE THREATENING

INJURIES

POTENTIALLY LIFE-THREATENING

INJURIES

Airway obstruction

Simple pneumo/hemothorax

Tension pneumothorax

Aortic rupture

Open pneumothorax

Tracheobronchial rupture

Massive hemothorax

Pulmonary contusion

Flail chest

Blunt cardiac injury

Cardiac tamponade

Diaphragmatic rupture


between adjacent structures; for example the distal aorta is anchored to the thoracic spine and decelerates much more quickly than the relatively mobile aortic arch. Shear forces are generated in the aorta by the continued forward motion of the arch with respect to the distal thoracic aorta. Similar situations occur at the renal pedicles, at the junction of the cervical and thoracic spine, and also between the white and grey matter within the brain. These injuries are obviously not visible to the naked eye. Diagnostic aids include: diagnostic peritoneal lavage (DPL); focused abdominal sonography for trauma (FAST); and abdominal and pelvic computed tomography (CT). CT scans are the most useful in terms of specificity and sensitivity to aid in diagnosis.

Occult bleeding can accumulate in a closed space, since the bleeding tamponades. However, on incision, the tamponade may be suddenly relieved and hypovolemia revealed. Intraperitoneal bleeding is a common cause of hemorrhage, and most commonly results from a splenic injury. Pericardial bleeding may also manifest in hemodynamic instability. Severe pelvic fractures can also present as hypovolemic shock in the patient with blunt trauma. Repleting intravascular volume (blood and/or crystalloid) and oxygen-carrying capacity (blood) is a priority even as preparations for emergency surgery are underway. Large-bore peripheral intravenous access is required for fluid administration. The presence of a CVP line aids in both fluid resuscitation and administration of vasoactive drugs.

The presence or possibility of cervical instability precludes the routine induction of general anesthesia. If there is a high cervical vertebral fracture, awake fiberoptic intubation is indicated to prevent neurological injury from displacement of the fracture. If the stability of the neck is unclear, the neck may be immobilized during induction of general anesthesia and intubation using direct laryngoscopy.

One of the most devastating and silent injuries of the head and neck is the fracture of the larynx. Perhaps presenting only as hoarseness in the emergency room, this complication may be noted first during rapid-sequence induction. If diagnosed prior to surgery, it is, of course, an indication for an awake bronchoscopy and intubation.

Blunt trauma is associated with pneumomediastinum in approximately 10% of cases. Pneumomediastinum is usually be identified by CT scans, however in equivocal cases, bronchoscopy and esophagoscopy may be indicated. The spectrum of injuries extending into the mediastinum can range from tracheal and laryngeal displacement, to esophageal tears. The treatment depends upon extent of injury. Pneumothorax is also common in trauma patients. Positive pressure ventilation expands a pneumothorax, which will further reduce venous return and precipitate end organ hypoperfusion.

Thoracic aortic injuries are usually diagnosed by CT scan. Blood in the pericardium is suggested by nonspecific abnormalities on the ECG, and requires further evaluation such as echocardiography. The presence of a thoracic aortic dissection is obviously a surgical emergency, usually involving the cardiothoracic surgery team and perfusionists. Morbidity and mortality increase significantly if the repair of a thoracic dissection is delayed beyond 6 hours of presentation. However, approximately 85% of thoracic trauma can be managed without surgical intervention. The mainstays of management are supplemental oxygen, intercostal drainage, good physiotherapy, and pain control.

Diaphragmatic injury should be suspected in any patient who has suffered blunt trauma and is short of breath. It is diagnosed on chest x-ray by evidence of stomach herniation or misplaced nasogastric tube.

Deceleration injuries like motor vehicle accidents may be associated with hollow viscus rupture, resulting from deceleration which causes compression of gas-filled viscus. Hollow viscus rupture may be difficult to diagnose by routine tests such as DPL and CT scans. Misdiagnosed viscus injuries significantly increase the morbidity and mortality associated with blunt trauma. A high index of suspicion for hollow viscus injury should be maintained in the presence of other multiple organ injuries and in the presence of pancreatic injury with solid organ injury. An exploratory laparotomy in the face of suspected viscus injury is not unreasonable.

Spinal cord injury occurs from traction and compression of the spinal cord. Inflammatory mediators released after the injury are attributed to the phenomenon of spinal shock. Spinal cord injury is mostly managed conservatively with measures to reduce secondary injury. Steroids administered in the first 8 hours after cord injury decrease cord edema significantly. Operative intervention is reserved for cases of canal entrapment.


Comprehension Questions

44.1. A 24-year-old man is involved in a motor vehicle accident in which he veered off the road and hit a tree. In his evaluation, there are no overt bleeding sites. Which of the following findings is most likely associated with bleeding?
A. Hypertension
B. Tachycardia
C. Polyuria
D. Elevated INR

44.2. A 38-year-old man falls off a platform while cleaning a window on the second floor of building. He is suspected of having a ruptured spleen with intra-abdominal bleeding. During this surgical procedure, the surgeon notes that the abdomen is somewhat tense. He incises the peritoneum and about 750 mL of blood is rapidly suctioned from the peritoneal cavity. What else might the anesthesiologist predict to occur within that time frame?
A. Reduced anesthetic level
B. Hypercapnia
C. Hypotension
D. Hypertension

44.3. A 41-year-old woman is involved in a “head on” motor vehicle accident. She was wearing a seat belt, and the air bags deployed. An ECG is performed revealing nonspecific ST-T wave changes. Which of the following should be considered?
A. Pericarditis
B. Myocardial infarction
C. Heart failure
D. Aortic injury


ANSWERS
44.1. B. Tachycardia. The triad of hypotension, tachycardia, and oliguria should always evoke the suspicion of bleeding; if none is visible, occult bleeding should be high on the differential diagnosis list.

44.2. C. Sudden relief of tamponade is associated with hypotension secondary to hypovolemia, which is unmasked on relief of the hemoperitoneum. An appropriate action might be to reduce the level of the anesthetic.

44.3. D. A restrained motor vehicle accident causes acceleration and sudden deceleration which can rip the arch of the aorta from the descending portion of the aorta, causing an aortic dissection. CT angiography, transesophageal echocardiography are the diagnostic modalities of choice if there is a suspicion of aortic injuries.


Clinical Pearls
➤ Blunt trauma to the neck can rapidly become life-threatening due to airway compromise from a rapidly expanding hematoma or from direct disruption of the trachea or larynx. Securing an artificial airway becomes emergent in such cases.
➤ Pneumothorax, rib fractures (with or without flail chest), pericardial tamponade, aortic rupture, and diaphragmatic injuries are examples of devastating injuries that may result from blunt trauma.
➤ A low threshold for the diagnosis of pneumothorax and a chest tube or needle thoracostomy should be performed promptly.
➤ Blunt abdominal trauma may cause splenic and/or hepatic injury resulting in massive hemorrhage and hemoperitoneum.Hollow viscus injury should be suspected in the presence of multiple organ injury, and presence of pancreatic injury.

References

Crosby E. Considerations for airway management for cervical spine surgery in adults. Anesthesiol Clin. 2007;25:3. 

Donaldson VP, Heil BV, Donaldson VP, et al. The effect of airway maneuvers on the unstable C1-C2 segment. Spine. 1997;22(11):1215-1218. 

Isenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin North Am. 2007;25:3.

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