A Dangerous Safety Measure<br />Alireza Haghshenass<br />
Seatbelts<br />
Injury<br />34 Year-Old Female <br />Mechanism<br />Brought in by helicopter retrieval team<br />Restrained back-seat pass...
Injury<br />Scene:<br />Sweaty & Diaphoretic<br />BP: 90/50<br />HR: 115 / min<br />O2 Sat: 92% on Air<br />GCS : 15/15<br...
Emergency<br />AMPL: No significant finding, mother of 1.5 year-old child also injured in the accident and was transferred...
Adjuncts<br />Chest X-Ray<br />Multiple left sided lateral rib #s<br />Minor lucency seen at the lower chest wall laterall...
Adjuncts<br />ECG : Sinus Tachcardia, Normal Axis<br />U/A : Blood ++ / Protein +<br />FAST : Not Done<br />
Secondary Survey<br />Head : NAD<br />Face : NAD<br />C-Spine : Collar In Situ, Mid-Cervical Spine Tenderness<br />Chest :...
Secondary Survey<br />Abdomen : <br />Generalized tenderness with guarding<br />Large tender lower abdominal abrasion (Lap...
Blood Test Results<br />FBC : 131, 26.8 , 260<br />INR : 1.2 <br />EUC : 138, 3.4, 6.2 , 68<br />CMP : 2.05, 0.82, 1.25<br...
CT-Scan<br />
CT-Scan<br />
CT-Scan<br />
CT-Scan<br />Report:<br />Sternal fracture with retrosternal haematoma<br />Multiple left sided rib fractures with a small...
Lower Limb X-Rays<br />Report:<br />Transverse fractures through the mid shaft of both tibia and fibula noted.  Alignment ...
Surgical Team Plan<br />?<br />
Surgical Team Plan<br />Major Trauma Call activated<br />NBM, IVF, DVT Prophylaxis<br />ABx<br />ADT<br />For laparotomy ±...
Repeat Bloods<br />FBC : 93, 15.7, 138<br />EUC : 136, 3.4, 4.9, 64<br />INR : 1.5 <br />ABG : <br />pH : 7.28<br />pO2 : ...
OT<br />Midline Laparotomy<br />Haemoperitoneum<br />Lesser Sac Opened : <br />D3 Longitudinal 2 cm Serosal Tear<br />Prox...
Repeat Bloods<br />ABG : <br />pH : 7.26<br />pO2 : 208<br />pCO2 :41<br />BE : -8<br />HCO3 : 18<br />Lactate :  1.3<br />
OT<br />D3 Serosal Tear Repaired Longitudinally<br />Jejunum Resection X 2<br />Right Hemicolectomy<br />Decision was made...
ICU<br />Treatment Commenced:<br />2 U Pack Cells	<br />2 U FFP<br />4 U Cryoprecipitate<br />After 1 hour:<br />Improving...
ICU<br />4 hours after admission:<br />ABG:<br />pH : 7.37<br />pO2 : 181<br />pCO2:36<br />BE : -4<br />Lactate :  2.7<br...
ICU<br />36 hours:<br />FBC : 85, 7.6, 11<br />INR : 1.6<br />4 U FFP Transfused<br />Improvement in all markers then onwa...
ICU<br />
Timeline<br />D2:<br />ICU : Commence TPN<br />General Surgery:<br />No contamination<br />No active bleeding<br />Anastom...
Timeline<br />D3: ICC was removed<br />D4 : Extubated<br />D9 : <br />Development of abdominal sepsis found on CT<br />Com...
Timeline<br />D16 : <br />ABx Stopped <br />OT : Fixation of Tibia<br />D19 : VAC Dressing of abdominal wound<br />D23 : R...
Damage Control Laparotomy<br />
Damage Control<br />
Damage Control<br />Term used in the Merchant Marine, maritime industry and navies for the emergency control of situations...
History of DCL<br />Was first described by John H. Pringle in 1908<br />Used to suture over gauze packing to control porta...
History of DCL<br />In 1913 William Stewart Halsted modified the Pringle’s technique and laid a rubber sheath between the ...
History of DCL<br />Progress over decades and with the contribution of surgeons such as Kenneth Mattox the concept of abbr...
History of DCL<br />The term “Damage Control Laparotomy” was coined by Rotondo et al. in 1992<br />In this landmark report...
Bloody Vicious Cycle<br />Hypothermia:<br />Evaporative and Conductive heat loss<br />Diminished heat production<br />Meta...
DCS<br />Indication to limit the operation time and proceed with DCS:<br />T < 35° <br />pH < 7.2<br />Base Deficit <15 or...
Control of Haemorrhage<br />
Abdominal Closure<br />
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Seatbelt Injury Trauma Presentation

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Seatbelt Injury Trauma Presentation

  1. 1. A Dangerous Safety Measure<br />Alireza Haghshenass<br />
  2. 2. Seatbelts<br />
  3. 3. Injury<br />34 Year-Old Female <br />Mechanism<br />Brought in by helicopter retrieval team<br />Restrained back-seat passenger (driver side) of a high-speed MVA (combined speed of 140 Km/h)<br />Major deformity to the car<br />Extricated by the retrieval team on to a spinal board<br />Injuries:<br />Severe Neck, Chest, Abdomen, and Left Lower Limb Pain (Obvious Closed #)<br />
  4. 4. Injury<br />Scene:<br />Sweaty & Diaphoretic<br />BP: 90/50<br />HR: 115 / min<br />O2 Sat: 92% on Air<br />GCS : 15/15<br />Treatment:<br />IVC 18 G Left Forearm<br />C-Spine Collar<br />Spinal Board<br />Morphine 10 mg<br />Ketamine 20 mg<br />Midazolam 1 mg<br />Transfer to hospital as patient appeared stable <br />
  5. 5. Emergency<br />AMPL: No significant finding, mother of 1.5 year-old child also injured in the accident and was transferred to Westmead Children at the same time. Last meal : 6 hours ago and since then just a few cups of water and soft drink.<br />Primary:<br />A : Patent, C-Spine Collar In Situ, Talking<br />B : Bilateral air entry tender to touch on left side, no subcutaneous emphysema O2 Sat 95% RA, RR 20 / min<br />C : Warm, Well-perfused, capillary return < 2”, no obvious source of bleeding HR 120/min, BP 100/70<br />D : GCS 15/15, Pupils 2 mm bilateral sluggish reaction to light <br />
  6. 6. Adjuncts<br />Chest X-Ray<br />Multiple left sided lateral rib #s<br />Minor lucency seen at the lower chest wall laterally over the left hemidiaphragm, ? small pneumothorax<br />
  7. 7. Adjuncts<br />ECG : Sinus Tachcardia, Normal Axis<br />U/A : Blood ++ / Protein +<br />FAST : Not Done<br />
  8. 8. Secondary Survey<br />Head : NAD<br />Face : NAD<br />C-Spine : Collar In Situ, Mid-Cervical Spine Tenderness<br />Chest : <br />Paradoxical Chest wall movement on left side<br />Abrasion, bruising, and tenderness obliquely across right clavicle, sternum, left breast, left lower chest wall<br />Sash bruising all across the chest from the right base of the neck to the left lower abdomen<br />
  9. 9. Secondary Survey<br />Abdomen : <br />Generalized tenderness with guarding<br />Large tender lower abdominal abrasion (Lap bruising)<br />Pelvis : tenderness over the left hipin continuation of the seatbelt bruising<br />Upper Limbs : NAD<br />Lower Limbs :<br />Left leg deformity, tenderness, and bruising<br />Abrasion right above the left knee<br />Back : <br />Tenderness around T3-4 level, no other spinal tenderness, anal tone good<br />
  10. 10. Blood Test Results<br />FBC : 131, 26.8 , 260<br />INR : 1.2 <br />EUC : 138, 3.4, 6.2 , 68<br />CMP : 2.05, 0.82, 1.25<br />Lipase : 522<br />LFTs:<br />Bili 14<br />ALT 77<br />AST 133<br />GGT 11<br />ALP 55<br />
  11. 11. CT-Scan<br />
  12. 12. CT-Scan<br />
  13. 13. CT-Scan<br />
  14. 14. CT-Scan<br />Report:<br />Sternal fracture with retrosternal haematoma<br />Multiple left sided rib fractures with a small flail segment<br />Left 5th - 9th Rib #s<br />7th – 8th Rib #s in 2 Segments<br />Fracture of the T2 spinous process, likely resulting from significant flexion. No definite cervical spine fracture is identified. however ligamentous injury is not excluded.<br />Superior endplate depression fracture of T10 without extension into the posterior elements. <br />High grade injury to the third part of the duodenum, with evidence of perforation and retroperitoneal haematoma. There is suggestion of active haemorrhage within this haematoma.<br />While the haematoma extends to the right renal hilum, no definate renal injury is identified, however delayed renal excretory phase CT is required to exclude a ureteric injury.<br />Evidence of bowel injury, with thickening of a few mid abdominal jejunal loops, and marked thickening of the caecum. Haemorrhage is noted along the right paracolicgutter.<br />
  15. 15. Lower Limb X-Rays<br />Report:<br />Transverse fractures through the mid shaft of both tibia and fibula noted. Alignment is near anatomical. No unusual features are noted. The visualised portions of the ankle and knee joints appear within normal limits. <br /> <br />
  16. 16. Surgical Team Plan<br />?<br />
  17. 17. Surgical Team Plan<br />Major Trauma Call activated<br />NBM, IVF, DVT Prophylaxis<br />ABx<br />ADT<br />For laparotomy ± small bowel resection ± Whipple’s<br />Left ICC with the view of PPV<br />
  18. 18. Repeat Bloods<br />FBC : 93, 15.7, 138<br />EUC : 136, 3.4, 4.9, 64<br />INR : 1.5 <br />ABG : <br />pH : 7.28<br />pO2 : 504<br />pCO2 :42<br />BE : -7<br />HCO3 : 19<br />Lactate : 1.2<br />
  19. 19. OT<br />Midline Laparotomy<br />Haemoperitoneum<br />Lesser Sac Opened : <br />D3 Longitudinal 2 cm Serosal Tear<br />Proximal Jejunum Perforation<br />Distal Jejunum Mesenteric Tear<br />Caecum and Transverse Colon Mesenteric Tear with Ischaemic Changes<br />Expanding Right Retroperitoneal Collection<br />
  20. 20. Repeat Bloods<br />ABG : <br />pH : 7.26<br />pO2 : 208<br />pCO2 :41<br />BE : -8<br />HCO3 : 18<br />Lactate : 1.3<br />
  21. 21. OT<br />D3 Serosal Tear Repaired Longitudinally<br />Jejunum Resection X 2<br />Right Hemicolectomy<br />Decision was made to abbreviate the laparotomy as the patient:<br />More acidotic<br />Increasing INR<br />Expanding Retroperitoneal Collection was explored<br />
  22. 22. ICU<br />Treatment Commenced:<br />2 U Pack Cells <br />2 U FFP<br />4 U Cryoprecipitate<br />After 1 hour:<br />Improving blood gases with:<br />Increasing pH : 7.29<br />Dropping BE : -6<br />HCO3 : 20<br />Repeat <br />FBC : 109, 14.4, 142<br />INR : 1.2<br />EUC : 139, 4.4, 4, 62<br />LFTs : Unchanged<br />CMP : 1.71, 0.7, 0.81<br />
  23. 23. ICU<br />4 hours after admission:<br />ABG:<br />pH : 7.37<br />pO2 : 181<br />pCO2:36<br />BE : -4<br />Lactate : 2.7<br />12 hours after admission:<br />FBC : 74, 6.2, 99<br />EUC : 139, 4.1, 4.4, 62<br />CMP : 1.85, 1.04, 1.17<br />INR : 1.5<br />Drain in right retroperitoneum : Cr : 1,378<br />
  24. 24. ICU<br />36 hours:<br />FBC : 85, 7.6, 11<br />INR : 1.6<br />4 U FFP Transfused<br />Improvement in all markers then onwards<br />
  25. 25. ICU<br />
  26. 26. Timeline<br />D2:<br />ICU : Commence TPN<br />General Surgery:<br />No contamination<br />No active bleeding<br />Anastomosis<br />Urology:<br />Complete transection at the level of the lower pole<br />Primary repair over 6Fr Stent<br />
  27. 27. Timeline<br />D3: ICC was removed<br />D4 : Extubated<br />D9 : <br />Development of abdominal sepsis found on CT<br />Commencement of Timentin and Clindamycin<br />D11 : TPN was weaned off<br />D12 : <br />Abdominal wound collection<br />Openned and Packed<br />
  28. 28. Timeline<br />D16 : <br />ABx Stopped <br />OT : Fixation of Tibia<br />D19 : VAC Dressing of abdominal wound<br />D23 : Rehab<br />D33 : D/C<br />
  29. 29. Damage Control Laparotomy<br />
  30. 30. Damage Control<br />
  31. 31. Damage Control<br />Term used in the Merchant Marine, maritime industry and navies for the emergency control of situations that may hazard the sinking of a ship<br />
  32. 32. History of DCL<br />Was first described by John H. Pringle in 1908<br />Used to suture over gauze packing to control portal venous haemorrhage caused by trauma<br />
  33. 33. History of DCL<br />In 1913 William Stewart Halsted modified the Pringle’s technique and laid a rubber sheath between the gauze and the liver to protect the liver parenchyma<br />
  34. 34. History of DCL<br />Progress over decades and with the contribution of surgeons such as Kenneth Mattox the concept of abbreviated laparotomy prevailed.<br />
  35. 35. History of DCL<br />The term “Damage Control Laparotomy” was coined by Rotondo et al. in 1992<br />In this landmark report they explained the 3 phases of DCL:<br />Expeditious surgical control of haemorrhage with temporary abdominal closure<br />Rewarming and resuscitation in the ICU<br />Definitive Surgical Repair<br />
  36. 36. Bloody Vicious Cycle<br />Hypothermia:<br />Evaporative and Conductive heat loss<br />Diminished heat production<br />Metabolic Acidosis:<br />Exacerbated by aortic clamping<br />Vasopressors<br />Massive transfusion<br />Impaired myocardial performance<br />Coagulopathy:<br />Dilution<br />Hypothermia<br />Acidosis<br />
  37. 37. DCS<br />Indication to limit the operation time and proceed with DCS:<br />T < 35° <br />pH < 7.2<br />Base Deficit <15 or < 6 if > 55 Years<br />INR/aPTT > 50% Normal<br />The Goal:<br />Limit haemorrhage without causing ischaemia<br />Limit GI Spillage<br />Small GI Injuries: a rapid whipstitch 2.0 nonabsorbable<br />Complete transection or segmental damage: GIA stapler<br />Pancreatic injury: packed and assessment of duct integrity is postponed<br />
  38. 38. Control of Haemorrhage<br />
  39. 39. Abdominal Closure<br />

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