Saturday, May 1, 2021

Blunt Trauma Case File

Posted By: Medical Group - 5/01/2021 Post Author : Medical Group Post Date : Saturday, May 1, 2021 Post Time : 5/01/2021
Blunt Trauma Case File
Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 28
A 48-year-old man was an unrestrained driver who fell asleep at the wheel while driving on a  highway. His car struck the highway divider resulting in a  vehicle rollover, and he was ejected from the vehicle. He was evaluated in the emergency department (ED), and the following injuries were  identified by CT  imaging: bi-frontal cerebral contusions, facial fractures, left-sided rib fractures, a left pulmonary  contusion, a nondisplaced bilateral pubic rami fracture, a left mid-shaft femur fracture, and a  grade 2 splenic laceration. In the ED, the patient received 2 L  of crystalloid and had a blood pressure of 100/80 mm Hg, pulse of 98 beats/minute, respiratory rate of 24 breaths/minute, and GCS of 13.  He is transferred to the ICU for monitoring and further care.

 How should this patient be monitored? 
 What are the priorities in the management of this patient?


ANSWER TO CASE: 28

Blunt Trauma

Summary: A 48-year-old man has been in a high-speed motor vehicle collision sustaining blunt mechanism polytrauma. His injuries include: brain injury, pulmonary contusion with multiple rib fractures, pelvic fracture, grade 2 splenic laceration, and a femur fracture. He is hemodynamically stable with a GCS of 13 and is now in the ICU. 
  • Monitoring: This patient will need to be monitored for signs of deterioration in his pulmonary status, hemodynamic status, and neurological status. Pulse oximetry will be helpful for continuous monitoring of oxygenation. Respiratory rate and respiratory efforts are important to monitor given his pulmonary contusion and chest wall injuries. Hemodynamic monitoring with CVP catheters and/or intra-arterial pressure monitors should be considered for close monitoring for possible continued blood loss from his multiple injured sources. Close follow-up of his neurological functions with serial GCS evaluation will be important to monitor his intracranial injury. Often a repeat brain CT 8 to 12 hours following the initial CT can be helpful. 
  • Priority in management: 1) Breathing concerns (chest wall and lungs) first, 2) bleeding sources (spleen and pelvis) are next, followed by 3) brain injury, and lastly 4) non-life-threatening orthopedic injuries.

ANALYSIS

Objectives
  1. To learn common injuries produced by blunt trauma.
  2. To learn to prioritize and coordinate the management of patients with multiple inj uries including intra-abdominal injuries, blunt chest injuries, orthopedic injuries, and brain injuries.
  3. To learn the criteria for the selection of nonoperative management of solid organ intra-abdominal injuries.
Considerations
The patient is a 48-year-old man who has been in a high-energy mechanism motor vehicle crash. This represents significant mechanism for major injuries. He has undergone radiographic imaging and his identified injuries include a brain injury, thoracic injuries, pelvic fracture, splenic laceration and a femur fracture. He is currently in the ICU for observation of his head injury, optimization of his pulmonary status, and for monitoring of potential bleeding from his splenic laceration and pelvic fracture. He is at risk for deterioration of his mental status secondary to his brain injury or from developing shock due to splenic or pelvic hemorrhage. Additionally, his respiratory status may deteriorate requiring potential intubation to maintain adequate oxygenation and ventilation. Two factors have been consistently identified as leading to worse outcomes in head- injured patients: hypotension, and hypoxemia. These complications should be prevented and/or addressed aggressively in this patient.

Approach To:
Blunt Trauma

CLINICAL APPROACH

Common Injuries Produced by Blunt Injury
Blunt trauma is the most common mechanism causing injury in trauma patients. However, different types of blunt mechanisms produce different types of injuries. For example high-speed motor vehicle crash, fall from a roof, and fall from standing all produce different injury patterns. Blunt trauma patients are often quite challenging to treat due to the fact that with a severe mechanism multiple organ systems may be involved. In these patients, the prioritization of care is important to optimize outcomes.

Commonly affected organ systems include the central nervous system (skull, brain, and spine), respiratory system (chest wall and lung), solid intra-abdominal organs (liver and spleen), gastrointestinal system (intestines and the mesentery), urologic system (kidneys and bladder), and musculoskeletal system (long bone and pelvis fractures).

Central nervous system injuries will include skull fractures and brain injuries. The main issue with skull fractures is that there is often underlying associated brain injury. Brain injuries include cerebral contusions, epidural hematoma, subdural hematoma, and subarachnoid hemorrhage. These injuries are clinically manifested as altered mental status, or depressed level of consciousness as reflected in a decreased Glasgow coma scale score. A brain injury or skull fracture mandates neurosurgical consultation, although the majority of these injuries are treated by observation and serial neurological examinations.

Respiratory system injuries include rib fractures, pulmonary contusion, pneumothorax, and hemothorax. Rib fractures contribute to significant morbidity and even mortality particularly in patients over the age of 45. Rib fractures cause significant pain which can lead to splinted respiration and poor inspiratory effort. The sequelae of this may be pneumonia and respiratory failure requiring mechanical ventilatory support, which carries its own set of complications. Pulmonary contusions are believed to be due to direct impact of pulmonary parenchyma against the chest wall as a result of significant deceleration force. Clinically, they result in decreased oxygenation as there is a physiologic shunt of damaged lung which may not exchange gas effectively while being perfused. Unfortunately, pulmonary contusions often worsen post injury as intravenous fluids may sequester within the injured lung parenchyma.

Pneumothorax may occur as a result of a bone fragment from a broken rib lacerating the pulmonary parenchyma, causing air to accumulate in the pleural space. At its extreme it may lead to enough air occupying the thorax to cause the mediastinum to shift and impede venous return t o the heart. This may result in circulatory collapse and is termed tension pneumothorax. Prompt recognition and treatment with tube thoracostomy is a life-saving procedure in these patients. Hemothorax is the result of bleeding into the pleural space, most often from the thoracic cage. Besides the risk of exsanguination, accumulated blood in the thorax may lead to infection, resulting in an empyema and sepsis. This would require operative drainage.

Solid abdominal organ injury (liver and spleen) manifests as hemorrhage during the initial hours or 1 to 2 days following injuries. Intervention in the form of operation or angiography/embolization may be necessary to control hemorrhage. Most clinically significant bleeding will be manifested as drop in blood pressure or hemoglobin and hematocrit within the first 24 hours following the injury. Patients with severe liver injuries may develop bile leaks; these patients may present with bile peritonitis. Treatment options include nonoperative methods such as CT guided drain placement and biliary decompression by ERCP with endoscopic stent placement.

Hollow viscus injury may result in the development of peritonitis if enteric contents irritate the peritoneal cavity. Clinically, the patients will often exhibit a hyperdynamic picture associated with leukocytosis. This will result in a profound inflammatory/septic response and requires operation and possible bowel resection for therapy. Mesenteric injuries may result in exsanguinating hemorrhage or bowel ischemia with delayed presentation of peritonitis. These injuries are best treated operatively.

Renal injuries from a blunt mechanism may result in parenchymal laceration or in renovascular injuries. Renal lacerations result in hemorrhage and perinephric hematoma. In extremely rare circumstances, particularly if the renal pelvis is involved, these injuries may result in the development of a urinoma and sepsis which would require drainage either operatively or percutaneously. Renovascular injuries occur as a result of the kidney's retroperitoneal location. The forces involved in a high-energy mechanism in effect cause a "stretch" of the renal artery from its origin at the aorta. This causes an intimal injury to the renal artery which will lead to renal artery thrombosis and renal ischemia. Unfortunately, success with revascularization of the kidney following blunt traumatic injury has been dismal. An ischemic kidney may result in the development of persistent hypertension or chronic flank pain requiring nephrectomy.

Pelvic fractures can result in life-threatening hemorrhage. The pelvis can be thought of as a "ring." When this ring is disrupted by fracture, two potential problems may develop: bleeding and internal injury. The pelvis is well vascularized so hemorrhage from veins and arteries may develop. Additionally, the disrupted "ring" leads to an expanded pelvic volume. As a consequence, greater blood loss occurs due to the larger capacity, and absence of tamponade effect which normally would exerted from an intact pelvic bony ring. Additionally, bone fragments from the pelvis may lacerate pelvic organs such as the rectum, the vagina, and the urethra. Pelvic fractures in and of themselves may be fatal, and unfortunately they are frequently associated with other life-threatening injuries.

Prioritizing and Coordinating the Blunt Trauma Management
Patients often have multiple injuries such as involving intra,abdominal, chest, orthopedic, and brain structures. 

Mortality from trauma demonstrates a temporal relationship. Immediate deaths occur from devastating brain injury or massive exsanguination on scene from aortic ruptures. Fatality that occurs in minutes may be a result of airway issues, overwhelming brain injury, or hemorrhage. Fatality that occurs from a few hours up to the first 2 days after injury is often caused by hemorrhage or injury to the brain. Mortality that occurs subsequent to this time period is usually due to multi-system organ dysfunction or sepsis/infection. As a result, the key to triaging injury is recognizing this temporal pattern of mortality. These principles guide the Advanced Trauma Life Support guidelines for resuscitation. In brief, these principles are:

A-Airway
B- Breathing
C-Circulation
D-Disability
E-Exposure/Environment

Inability to maintain an airway leads to the rapid demise of the patient. Airway problems are most often due to the patient's inability to protect his airway secondary to diminished level of consciousness caused by brain injury or shock. If a patient is not alert or responsive, it is critical that the airway is secured, ideally via orotracheal intubation. This is the first priority in trauma patients with a blunt mechanism. In the scenario described, the patient has a GCS of 13 which implies adequate mentation/sensorium to protect his airway. As a result, he does not require emergent intubation in the ER or in the ICU. If, however his condition deteriorates, there should be no hesitation in establishing a definitive airway. A GCS of 8 or less is defined as coma and would mandate intubation for securing airway.

With a GCS of 13, it would be appropriate to monitor this patient in the ICU with frequent neuro/mental status checks. If the patient's mental status degrades as represented by a decrease in GCS, it would be appropriate to notify the neurosurgical consultant and obtain a repeat head CT to evaluate for progression of head injury. Additionally, if the GCS drops significantly, it would be prudent to intubate the patient urgently in order to prevent hypoxia from an inability to maintain an airway secondary to diminished consciousness.

If, on presentation, the patient's GCS was 8 or less, a Level II recommendation from the American Association of Neurological Surgeons suggests that intracranial pressure monitoring is warranted. This requires an invasive procedure performed by a neurosurgeon but may be done at the patient's bedside (Figure 28-1 ).

Patients with multiple rib fractures and pulmonary contusion need to undergo close observation, preferably with cardiac monitoring and pulse oximetry. Management of patients with significant pulmonary contusion and other hemorrhagic injuries is challenging; the fluid and blood products used to resuscitate the patient from hemorrhagic shock can aggravate the pulmonary contusion-related oxygenation defects. The process can be even further complicated if the patient also has a severe brain injury, because any further hypoxic and hypotensive insult will cause secondary brain injuries and worsen the neurologic outcome.

Blunt Trauma Case File

Splenic injuries cause concerns for further bleeding. A computed tomography (CT) scan for grading splenic injuries has been developed:

The majority of splenic injuries may be observed. Those that are prone to failure of nonoperative management include:
  1. Lower hematocrit at admission
  2. Lower blood pressure at admission
  3. Higher CT grade of injury
  4. Higher Injury Severity Score
  5. Lower Glasgow coma scale
  6. Larger volume of hemoperitoneum
brain CT demonstrates

Figure 28-1. This brain CT demonstrates a subdural hemorrhage of the right side with midline shift. Hemorrhage on a noncontrast head CT is demonstrated by white density. (Courtesy of J  Sadjadi, MD.)

pelvic fracture with disruption

Figure 28-2. The image demonstrates an "open book" pelvic fracture with disruption of the pubic symphysis. This injury is prone to bleeding and requires a binder to be placed. (Courtesy of J  Sadjadi, MD.)

Data from retrospective reviews has suggested that the addition of angioembolization
may lead to increased rates of successful nonoperative management of spleen
injuries.

Pelvic fractures may also lead to clinically significant hemorrhage. The disruption of the bony ring causes injury to the venous plexus of pelvis and also to branches of the internal iliac artery. Additionally, bleeding from the fractured bone edges themselves occurs. Bleeding is most pronounced in pubic rami and symphysis fractures. Acetabular and iliac wing fractures tend not to bleed, but may result in early onset osteoarthritis. Pelvic hemorrhage can often be controlled by placing a pelvic binder, which reduces the potential volume of hemorrhage and can assist in tamponade of pelvic bleeding. If a binder does not control the hemorrhage, angiography with embolization or preperitoneal pelvic packing performed in the operating room are options (Figure 28-2 ) .

Femur fractures may result in bleeding of up t o 1 L within the thigh. However, it may be unwise to perform definitive operative fixation of this patient's femur at this time as it is unclear whether this patient's head injury or splenic injury is going to progress. An operation for his femur at the time of admission may mask worsening of his other injuries while he is under general anesthesia for his orthopedic injury. This has lead to the development of the concept of damage control orthopedic surgery. It is possible to realign this patient's femur and control hemorrhage and potentially reduce pulmonary complications by placing a Steinman pin at the bedside. This weighted traction would reduce his femur fracture to length until his physiologic status is optimized prior to undergoing definitive operative femur fixation.

In summary, patients with multiple blunt traumatic injuries from high-energy mechanisms are best managed by being monitored in the ICU. Prioritization of the management of the various injuries is essential to optimize outcome. The intensive care provider must communicate and coordinate care for these patients to optimize outcome.

Criteria for the Selection of Nonoperative Management of Solid Organ Intra-abdomina/ Injuries
The management of spleen and liver injuries in blunt trauma patients has shifted toward a nonoperative paradigm. The Focused Abdominal Sonogram for Trauma (FAST) has changed the method of diagnosis of intraperitoneal hemorrhage following blunt trauma. Traditionally, physical examination and the invasive adjunct of diagnostic peritoneal lavage were the main tools used to diagnose intra-abdominal hemorrhage. However, the FAST examination is noninvasive and rapid and can readily identify intra-abdominal free fluid which in a hemodynamically unstable patient is presumed to be blood and mandates an operative exploration.

However, if the patient is hemodynamically stable, the next step even with a positive FAST examination is CT of the abdomen/pelvis. This allows the physician to identify injuries and plan therapy.

A large multicenter database review identified several risk factors for failed nonoperative spleen injury management. These risk factors were:
  1. Increased age
  2. Increased injury severity score
  3. Decreased hematocrit
  4. Increased grade of injury
  5. Increased amount of hemoperitoneum
Additionally, the study delineated the percentage chance of splenectomy by grade of injury:

Blunt Trauma Case

Any development of hemodynamic instability mandates exploration and likely splenectomy.

Liver lacerations behave somewhat differently then spleen lacerations. Patients who present with a blunt hepatic injury but are hemodynamically stable and undergo a CT scan rarely require operation. The necessity of operation for blunt liver injury is dictated by clinical findings, not radiographic findings (Figure 28-3).

Grade IV spleen injury

Figure 28-3. The image demonstrates a Grade IV spleen injury with 2 large fractures affecting the splenic hilum with a small vascular blush and some hemoperitoneum. This patient was successfully treated nonoperatively with angioembolization. (Courtesy of J  Sadjadi, MD.)

CLINICAL CASE CORRELATION
  • See also Case 27 (Traumatic Brain  Injury), Case 33 (Multiorgan Dysfunction), and Case 34 (Endocrinopathies).

COMPREHENSION QUESTIONS

28.1 Which of the following patients may benefit from placement of an intracranial pressure monitor?
A. A 24year-old man who fell from 10 ft and presented with a GCS of 7 but a normal head CT scan.
B. A 28-year-old man involved in a high-speed motor vehicle collision with a GCS of 8 who is receiving propofol and has a right-sided subdural hematoma.
C. A 1 9-year-old woman who has fallen from standing and has a witnessed seizure but has a GCS of 9 and a small subarachnoid hemorrhage.
D. An 82-year-old man who fell from his bed, is confused, and cannot move his left side.
E. A 17-year-old man with an epidural hematoma based on CT and GCS of 15.

28.2 A 35 -year-old woman is in a high-speed motor vehicle crash. On presentation, she is complaining of abdominal pain. Her pulse is 136, blood pressure is 76/40, and she is confused. A FAST examination is positive for fluid. The best next step is:
A. Intubation
B. CT scan of the abdomen/pelvis
C. Exploratory laparotomy
D. Admission to the intensive care unit
E. Mesenteric angiography and embolization of bleeding vessels

28.3 A 23-year-old man is involved in a 10-ft fall from a ladder. He complains of pelvic pain. On arrival his heart rate is 120 beats/minute and his blood pressure is 90/65 mm Hg. On examination he has ecchymoses of his buttocks. X-rays identify pelvic fracture with a widened pubic symphysis. FAST examination is normal. The best next step is:
A. Placement of pelvic binder in emergency room
B. Angiography
C. Exploratory laparotomy
D. CT of the abdomen/pelvis
E. Open reduction and internal fixation of the pelvis


ANSWERS TO QUESTIONS

28.1  B. Although there are insufficient data to make Level I recommendations, patient B does fulfill the criteria of the American Association of Neurological Surgeons for possible intracranial pressure monitoring. These criteria are: CT confirmed intracranial hemorrhage, GCS of 8 or less, and receiving sedation.

28.2  C. This scenario describes a patient who was involved in a high-speed motor vehicle collision and is hemodynamically unstable. Her FAST examination is positive suggesting intra-abdominal hemorrhage. She requires exploratory laparotomy. Bleeding takes priority in this instance, since without control of hemorrhage she is likely to die; she is already hemodynamically unstable, suggesting that she is in Class IV shock. Angiography and embolization are options for relatively stable patients with solid organ injuries, and reasoning behind embolization is that early embolization can help avoid surgical interventions in some of the patients. If this patient stabilizes with resuscitation and a CT demonstrates such injuries, then angiography and embolization can be viable options.

28.3  A . This patient has a pelvic fracture with a pattern known to result i n bleeding. Additionally, he is hemodynamically unstable. A normal FAST examination has ruled out intra-abdominal hemorrhage. It must be assumed that his hemodynamic instability is secondary to bleeding from his pelvic fracture. The first step is to place a pelvic binder to reduce the potential pelvic space where bleeding can occur. If his hemodynamic status improves, he would not need angiography. If he continues to deteriorate despite placement of the binder and transfusion, he would require angiography and possible embolization of branches of the internal iliac artery which may be bleeding.


CLINICAL PEARLS
 Patients who have suffered blunt  poly  trauma can  have multiple poten­tially  lethal  injuries. It is the physician's responsibility to triage the patient's injuries. 
 The great majority of mild head injuries (GCS 13-15) can be monitored and do not require intervention. 
 A positive FAST examination in a hypotensive patient mandates exploration. 
 Several  radiographic findings can  help predict success of nonoperative management of spleen injuries. 
 Liver injury  management (operative vs nonoperative) is dictated by the patient's clinical status. 

References

Bratton SL, Carney NA. Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring.] Neurotrauma. 2007;24(Suppl1):S37 -S44. 

Moore EE, Cogbill TH, Jurkovich OJ, et al. Organ injury scaling: spleen and liver (1994 revision). ] Tr auma. 1995;38:323-324. 

Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma.] Trauma. 2000;49:177-189.

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