Credit Lisa Yosten, M.D

1. Trauma case reviews
Lisa Yosten MD, FACEP
Assistant Medical Director, Emergency Department
Director of EMS

2. Case #1
 EMS bringing “stab wound” to abdomen, 2 am
 “10 inch knife”
 Full trauma alert activated
 25 y/o hispanic male stabbed left lower flank and left upper
quadrant, intoxicated
 GCS 14, verbalizing, not cooperative.
 VS: 90, 140/80, 26, 95% RA
 Physical exam: 2 lacerations, 4-5 cm each, oozing
 mid axillary line, 9-10th intercostal space
 Left upper quadrant

3. Case #1
 Physical exam
 Lungs slightly diminished on left
 2+ pulses in extremities
 Abdomen: tense, firm, difficult to determine
tenderness due to patient’s intoxication
 Back: no evidence of injury
 Treatment
 IV’s placed, NS bolus started
 FAST exam (focused abdominal sonography in
trauma) performed by ER physician: questionable for
fluid around liver

4. Stab wound to abdomen

6. Stab wound to abdomen
 Vitals stable after primary, secondary survey, airway
intact
 Portable chest x-ray: small pneumothorax on left with
small pleural effusion
 CT scan chest/abdomen/pelvis: 9th left rib fracture,
hemothorax and 20% left pneumothorax, perforation of
colon, pneumoperitoneum, hemoperitoneum
 Labs: Bicarbonate 21, glucose 108, creatinine 1.3, EtOH
148, HGB 12.6, UA neg, drug screen neg. INR normal.
 Decision to proceed to OR

7. Stab wound to abdomen

8. OR management
 Left chest tube placement for hemo/pneumothorax
 Exploratory laparotomy
 Stab wound through transverse colon-partial colectomy with anastamosis
 Control of mesenteric vascular bleeding
 Repair of left hemidiaphragm laceration
 Patient stabilized
 Post operative complication:
 Infection in pleural fluid (empyema)
 Leaking from colon anastomosis
 Back to OR for iliostomy
 Requiring TPN
 Massive transfusion

9. ATLS: stab wounds to
abdomen
 Most commonly affected organs
 Liver (40%)
 Small bowel (30%)
 Diaphragm (30%)
 Colon (15%)
 Most commonly affected organs with GSW to abdomen
 Small bowel (50%)
 Colon (40%)
 Liver (30%)
 Abdominal vascular structures (25%)

10. OR or not??
 History, knife length?
 Exam: signs of peritonitis?
 Vitals: Hypotensive?
 FAST exam positive?
 DPL (diagnostic peritoneal lavage) positive?
 Stable patient, CT findings?
 Stabbing to back/flank less likely to have to go to OR
due to deep muscle presence.

11. OR guidelines
 98% of GSW to abdomen require laparotomy
 60% of stab wounds that penetrate anterior
peritoneum have hypotension, peritonitis, or
evisceration of omentum and/or small bowel that
would necessitate going to OR for exploratory
laparotomy.

12. Evisceration

13. Abdominal trauma: OR
guidelines
 Blunt abdominal trauma with hypotension and positive
FAST with evidence of intraperitoneal bleeding
 Blunt or penetrating abdominal trauma with positive
DPL
 Hypotension with penetrating abdominal wound
 GSW transectiong peritoneal cavity or visceral/vascular
retroperitoneum
 Evisceration
 Bleeding from stomach, rectum or GU tract from
penetrating trauma

14. Abdominal trauma: OR
guidelines
 Peritonitis
 Free air, rupture of hemidiaphragm
 CT positive for ruptured GI tract, intraperitoneal
bladder injury, renal pedicle injury, or severe solid
organ injury

15. Case #2
 27 y/o male transferred from critical access hospital by
Life net with left hand amputation
 Right hand dominant
 Amputation at wrist by wood cutter
 PMH/PSH: none. SH: positive for smoking
 VS : 151/98, 98.7, 94, 22, 96% on 2 liters nasal cannula
 IV present in right arm: 300 mcg Fentanyl, 4mg IV Zofran, 2
grams IV Ancef, Versed, 1 liter NS bolus
 Tetanus up to date
 Tourniquet removed in ER: no active bleeding
 Hand surgeon consult: To OR

16. Hand amputation

17. OR
 Reimplantation of hand
 Proximal row carpectomy
 Fasciotomies
 Reattachments of tendons, nerves, blood vessels
 Back to OR following day for left ulnar artery
thrombosis.
 Hospitalized for 2 weeks

19. Amputations
 If transferring a patient with amputated part
 Stop bleeding
 Direct pressure is favored over tourniquet
 IV for pain control, antibiotics
 Tetanus updated if needed
 Judicious IVF (more IVF, more bleeding)
 Make NPO
 Send the detached part wrapped in gauze and “on
ice”, not “in ice”
 Tissue survival time 6 hours if not cooled, 12 hours if
cooled

20. Reattachment procedures
 Factors favoring successful reattachment
 Multiple fingers involved and/or thumb of dominant
hand
 Younger patient without co-morbidities
 Nonsmoker
 Clean severed amputated part vs. tearing or crushed
tissue

21. Steps in Reattachment
 X-raying and cleaning amputated part
 Debriding dead tissue
 Tagging nerves, blood vessels, and tendons with special
surgical clips
 Trimming bone from amputated part, fixing it with K-wires,
and stabilizing it to extremity
 Repair flexor and extensor tendons
 Repair lacerated arteries, veins and nerves
 Use of vein grafts for blood vessels that cannot be reattached
 Splint the extremity and elevate

22. Following reattachment
 Constant monitoring of tissue perfusion
 Medications may be used to increase blood flow, reduce
anxiety, and for anti-coagulation
 Long term PT/OT
 Success
 Good nerve recovery
 >50% ROM of joint
 Acceptable cosmetic results
 Most likely will have cold intolerance in extremity

23. Complications
 Poor perfusion to reattached part
 Infection
 Need for further surgeries due to adhesions,
scarring, infection, poor circulation

25. Case #3
 31 y/o male transferred after fall from zip line, 41
feet into 6 feet of water, landing on buttocks. No
LOC. Pt c/o left hand, wrist and buttock pain
 BLS transport with cervical and T/L/S
immobilization
 PMH: Lumbar fracture with surgery after MVC
rollover
 Lawnmower injury with traumatic right great toe
amputation
 SH: positive for alcohol (8 beers)

26. Fall from height

27. Case #3
 ED arrival 1730
 128/90, 89, 16, 95% on RA
 GCS 15, Awake, Oriented x 3
 Fully immobilized on backboard with cervical collar
 Chest wall abrasions on exam and pelvic tenderness
but no instability
 Normal neurological and vascular exam
 No abdominal tenderness, FAST exam negative
 No cervical, TLS tenderness

28. Case #3
 IVF, Morphine 4mg IV x 4, Fentanyl 100mcg, Zofran
4mg IV, tetanus updated, Rocephin 1 grams
 Xrays
 Left hand/wrist: positive for angulated and
shortened distal radius fracture, comminuted distal
phalanyx 4th finger
 Pelvis: superior right pubic rami fracture extending
into right acetabulum
 Chest: patchy opacities middle lobe and left lung base
 Cervical/TLS spines: negative

29. Acetabular fracture

30. Distal radius/ulna fracture

31. Case #3
 CT abdomen/pelvis: inferior left kidney laceration
with hematoma surrounding, pubic rami fractures
with adjacent hematomas, right medial acetabular
fracture, fracture and left SI joint involving the
lateral sacrum medial ilium
 CT chest: pulmonary contusions
 CT head: mildly displaced fracture inferolateral
wall left maxillary sinus
 CT cervical: negative for fracture

33. Case #3
 Left wrist fracture splinted
 1900 decision to transfer to UNMC for trauma
 Life net unable to fly
 Ground transport arranged
 Ground transport cancelled as UNMC Life Net to fly
 2015 Life net lands and pt transferred to UNMC
 (2 hours 45 minutes in ER)
 Decision to transfer
 Acetabular fracture
 Multi-organ system trauma

34. Repair of acetabular
fracture

35. Case #3
 UNMC follow up
 Pt went to surgery for ORIF of wrist fracture
 Admitted five days, discharged home
 Pelvic fractures non-operative
 Non-weight bearing right lower extremity and weight
bearing as tolerated for left lower extremities for
transfers only
 Wheelchair
 Also found to have Grade 1 spleen and liver
lacerations managed non-operatively

36. Pelvic Fractures
 Types
 Closed fracture
 Lateral compression 60-70% frequency
 MVC
 Falls
 Internal rotation of involved hemipelvis
 Pelvic volume decreased so life-threatening hemorrhage not
common
 Open book fracture
 Anterior-Posterior compression (15-20%)
 Auto-pedestrian collision
 Motorcycle crash
 Direct crush injury to pelvis
 Fall from > 12 feet

37. Pelvic fractures
 Open book pelvic fracture
 Disruption of symphysis pubis, tearing of posterior
ligaments represented by sacroiliac fracture
 Opening of ring can lead to hemorrhage from pelvic venous
complex and/or internal iliac artery
 Sheet or pelvic binder recommended for unstable pelvis
fracture
 Vertical shear fracture
 5-15% frequency
 High energy force in vertical plane
 Major pelvic instability
 Most likely from fall from significant height

38. Anatomy of pelvic bones

39. Closed pelvic fracture

40. Open book pelvic fracture

41. Open book pelvic fracture

42. Vertical shear

43. Decision tree

44. Embolization of pelvic
vessels

45. Embolization of pelvic
vessels
 Overall, 7-11% of pelvic fractures will require
embolization
 Lateral compression fractures
 2% need embolization due to arterial injury
 Open book (anterior-posterior compression),
vertical shear or combined fractures
 20% require embolization

46. Transfer to trauma hospital
 Significant resources required to care for patients
with severe pelvic fractures
 Early consideration of transfer to trauma center is
essential
 Trauma orthopedics
 Interventional radiology
 Multi-specialty as high likelihood of other injuries

47. Case #4
 87 y/o female, chief complaint “weakness” brought
to ER by family
 Symptoms x 3 days.
 Initially strained hip getting into car, left hip/leg pain
 Today, fell forward from swivel chair, caught arms
and landed prone. No head injury LOC
 Feels dizzy and weak since, questionable syncope for
several seconds at home today
 Difficulty with speech, slurred and expressive aphasia
 PMH: chronic atrial fibrillation, diabetes, HTN remote
breast cancer

48. Case #4
 Medications
 Coumadin among many others
 ER
 130/66, 98, 70, 20, 100% RA
 c/o 10/10 hip/leg pain
 Exam
 No obvious head injury
 No cervical spine or TLS tenderness
 Lungs clear
 Heart irregular rhythm, rate normal 70, no murmur
 Extremities: mild left ankle tenderness, no swelling; left hip tender
and pain with ROM of leg. No pain with internal/external rotation.
Normal pulses

49. Case #4
 Neurological: Awake and alert, sleepy but would
wake easily
 Rectal: grossly guaiac positive
 Labs
 Hgb 8.8, Creat 1.6, Gluc 380, LFT’s 2-3 x normal, INR
no clot detected (INR > 18)
 X-ray pelvis and left hip: normal
 X-ray left ankle: avulsion fracture off medial
malleolus
 CT head: large left subdural hematoma with midline
shift

50. Subdural Hematomas

51. Ipsilateral dilated pupil:
herniation

52. Case #4
 IV Morphine 2mg, Zofran 4mg given
 Pt with slurred speech, more sedate
 INR > 18, hgb 8.8 and grossly guaic pos stool (GI
bleeding)
 Vitamin K 10mg IV
 FFP 4 units
 Transfer to neurosurgical center: UNMC

53. Burr Hole for evacuation

54. Burr Hole for evacuation

55. Craniotomy

56. Indications for Head CT in
trauma
 Altered level of consciousness
 Neurological signs
 Severe headache, persistent vomiting, numbness,
weakness on one side, slurred speech, facial droop
 Mental status difficult to evaluate
 Anesthesia, drug and alcohol intoxication, young
children
 Low index of suspicion in elderly patients with
minimal trauma and on anticoagulants

58. FRHS warfarin reversal
protocol
 INR 5-9 without bleeding
 Vitamin K (Mephyton) 2.5mg PO once
 INR > 9 without bleeding
 Vitamin K (Mephyton) 5mg PO once
 Perioperative Non-Urgent
 Vitamin K 10mg IV once
 Life Threatening bleeding, add Kcentra
 INR 2 -<4: Kcentra (prothrombin complex concentrate) 25
units/kg IV once
 INR 4-6: Kcentra 35 units/kg IV once
 INR >6: Kcentra 50 units/kg IV once

59. KCentra
 Contains Vitamin K dependent coagulation factors
II, VII, IX, and X (prothrombin complex) and the
antithrombotic Protein C and Protein S.
 Made specifically to reverse warfarin in patient with
acute major bleeding
 FDA approval randomized controlled trial
 FFP and Vitamin K
 Kcentra and Vitamin K

60. KCentra
 More likely to stop acute bleeding at 24 hour endpoint
(72.4% of Kcentra vs 65% FFP)
 Faster reduction of INR (down 1.3 in 30 minutes in 62%
of patients vs. 9.6% of FFP patients)
 Kcentra infusion produced a rapid and sustained
increase in plasma levels of clotting factors within 30
minutes post treatment with 87% less volume than FFP.
 Common reactions: Headache, nausea/vomiting,
arthralgia, hypotension. Most severe is thrombotic
events (CVA,PE,DVT)

61. Case #4 outcome
 Transfer UNMC
 Neurosurgery consulted
 Reversal of warfarin coagulopathy
 Non-operative management of SDH
 MRI brain showed midbrain CVA
 Orthopedics
 Ankle fracture nonoperative
 GI consulted due to high bilirubin
 CT abdomen showed pancreatic mass, ERCP performed,
biopsy done and stent placed
 Patient discharged to skilled nursing facility

63. Case #5
 40 y/o female pedestrian struck
 Walking on side of county road, arguing with
significant other. S.O. had parked car in middle of
road. Car coming up behind them swerved to miss
head on collision with parked car and hit patient. Pt
was pinned under front passenger tire, laying
prone. Right front tire was between her legs and
left leg under engine block. Chest/abdomen was
pinned under bumper. + LOC. Life net unable to
fly to scene. BLS tiered with NFD ALS service.

64. Case #5
 C-collar, backboard
 IV placed. Fentanyl given prehospital.
 VS: 122/76, 98, 23, 95% on RA
 Pt awake and alert, mildly confused. GCS 14
 Exam:
 HEENT: no scalp swelling, laceration. Left
periorbital bruising. PERRLA 3mm bilaterally.
Airway intact. Teeth decayed
 Neck : in collar. NO c-spine tenderness

65. Case #5
 Respiratory: lungs clear
 CV: RRR, Lungs clear bilaterally
 Abdomen: diffusely tender, no rebound/guarding
 Rectal: decreased tone, no blood
 MS: Midline and paraspinal lumbar tenderness, abrasion over
lumbar spine. No pelvic tenderness
 Skin: 2cm left arm laceration, linear. 3rd degree linear burn on left
lower extremity (2% BSA)
 Neuro: GCS 14. Alert. Disoriented to time. Short term memory
loss. Both legs flaccid. Absent DTR’s patella. Sensory deficit to
umbilicus.

66. Pedestrian Struck
 IVF, Fentanyl, zofran, tetanus, monitor
 FAST exam negative in ER
 Labs: drug screen pos meth, HGB normal
 X-ray
 C-spine lateral: neg to C7. posterior emphysema in neck
 Pelvis: no fracture
 Chest: Extensive emphysema in superior mediastinum,
neck, chest wall bilaterally. No PTX appreciated
 Lumbar (one view, cross table lateral): no fracture

67. Pedestrian struck
 Consult to trauma center
 Suspected pulmonary contusions vs. pneumothorax
 Suspected spinal cord injury
 Suspected head injury
 Multi-organ system trauma plus third degree burn
 Patient transferred by Life Net to UNMC

68. Subcutaneous emphysema

69. Dermatomes: Spinal Cord

70. Full thickness burn

71. Pedestrian struck
 Transfer to UNMC
 Findings:
 T 10/11 dislocation resulting in paraplegia
 Taken to OR for T8-L1 spinal fusion and open reduction
of T 10/11 dislocation
 Bilateral rib fractures and pneumothoraces requiring
chest tube placement
 4th degree burns to left leg requiring debridement
 To follow up later regarding skin grafting
 Grade 1 thoracic aortic injury
 Nonoperative

72. Pedestrian struck
 Multiple facial fractures
 Nonoperative
 Left posterior acetabular fracture
 Nonoperative due to paralysis and non weight
bearing
 Grade II spleen laceration and Grade III liver
laceration, bilateral renal infarcts and adrenal
hemorrhage
 Received multiple blood transfusions but remained
stable thus nonoperative

73. Pedestrian struck
 Admitted 5/28-6/26/14
 Transferred to Madonna for acute rehab

74. Thoracic aortic injury
 Blunt trauma
 Rapid deceleration by history
 Complete aortic transection = death at scene
 Partial transections
 Control blood pressure
 Identify other causes of hypotension/bleeding
 Surgical repair if actively bleeding

75. Chest x-ray findings
 Wide mediastinum (> 8 cm at aortic arch)
 Obliteration of aortic knob
 Deviation of trachea to right
 Depression of left mainstem bronchus
 Deviation of esophagus to right
 Left apical/ pleural cap
 Left hemothorax
 Fractures of 1st or 2nd rib or scapula

76. Normal chest x-ray

77. Suspicious for aortic injury

78. Aortic injury
 Chest x-ray findings
 40-60% sensitive and specific
 Chest CT
 97-100% sensitive
 83-99% specific

79. Chest CT

80. Types of injury

81. Management
 Full thickness tear and are hemodynamically unstable
 Chest tube placement with large volume blood loss
 Over 1500 cc initially or 200 cc/hour x 2 hours of ongoing loss
 Indication for thoracotomy
 Evaluation for other injuries causing blood loss
 Abdominal or pelvic trauma
 Partial thickness tear
 Minor injuries such as small intimal flaps or small
pseudoaneurysms are managed nonoperatively
 Blood pressure control < 120 systolic

83. References
 Encyclopedia of Surgery. Finger Reattachment.
Web site
 Trauma.org: Permissive Hypotension. Barry
Armstrong. 10/02
 Trauma.org: Chest Trauma: Traumatic Aortic
injury
 Advanced Trauma Life Support. American College
of Surgeons. 9th edition. 2012