Case Files Surgery, (LANGE Case Files) 4th Ed.

SECTION II. Clinical Cases

CASE 40

A 23-year-old man was the restrained driver of an automobile involved in a highspeed head-on collision with an 18-wheeler that drifted across the highway divider. According to the paramedics, the front-seat occupant in the patient’s automobile was found dead at the scene. Extrication of the patient required approximately 30 minutes. His vital signs at the scene were pulse rate 110 beats/min, blood pressure 90/60 mm Hg, respiratory rate 14 breaths/min, and Glasgow Coma Score (GCS) 6. The paramedics performed endotracheal intubation, placed a peripheral intravenous line and initiated ventilation, and administered intravenous fluids during transportation to your trauma center. His vital signs on arrival at the emergency department are temperature 36.2°C (97.2°F), pulse 112 beats/min, blood pressure 88/70 mm Hg, assisted respiratory rate 20 breaths/min, and GCS 6 (M4 + V1T + E1). A forehead hematoma, multiple facial lacerations and abrasions, and a bony deformity of the left cheek are present. The breath sounds are diminished on the left, with soft tissue crepitation in the left anterior chest wall. The abdomen is distended, with diminished bowel sounds. The bony pelvis is stable to palpation. Examination of the extremities reveals a markedly swollen, tender left thigh with a 10-cm laceration over the left knee. The peripheral pulses are present in all the extremities. No spontaneous movements in the lower extremities are identified.

Images What should be the next steps in this patient’s treatment?

Images What are the most likely mechanisms causing the patient’s current clinical picture?

ANSWERS TO CASE 40: Blunt Trauma (Multiple)

Summary: A 23-year-old restrained driver is involved in a high-speed motor vehicle crash (MVC). He presents with tachycardia, hypotension, and a GCS of 6. The patient’s initial assessment suggests the following injuries: closed-head injury, left pneumothorax, possible intra-abdominal injury, and left femur fracture. The exact cause of the hypotension is undetermined at this time.

• Next steps: Placement of a left chest tube (tube thoracostomy) should be performed to treat the suspected left pneumothorax, which should improve his breathing and address a potential cause of the hemodynamic instability.

• Responsible mechanisms: The possible causes of the tachycardia, hypotension, and unresponsiveness in this patient include hemorrhagic shock and left tension pneumothorax; less likely causes are neurogenic shock, primary cardiac dysfunction, and severe closed head injury.

ANALYSIS

Objectives

1. Learn the priorities and principles in treating patients with multiple injuries, including blunt chest injury, blunt abdominal injury, closed-head injury, orthopedic injury, and spinal cord injury.

2. Learn to recognize the causes of hemodynamic instability in a trauma patient and learn the methods of diagnosis for these problems.

Considerations

A young man is injured in a high-speed MVC and presents with tachycardia, hypotension, a GCS of 6 (see Table 12–1 Glasgow Coma Scale), clinically suspicious left pneumothorax, and a left femur fracture. It is vital to approach any patient with multiple injuries or the potential for multiple injuries systematically to ensure that serious injuries are identified and treated timely and in the most appropriate sequence. The evaluation begins by learning the details of collision from the patient, eyewitnesses, or paramedics to gain insight into the injury mechanisms and severity. With an initial GCS of 6, severe closed-head injury should be strongly suspected, and therefore early airway control is essential for oxygenation, ventilation, and minimizing the effects of secondary brain injury.

The primary survey should begin with reassessment of the airway to make certain the endotracheal tube has been secured in the correct position. The presence of left chest wall crepitation, diminished breath sounds, and hypotension is highly suggestive of pneumothorax or possibly tension pneumothorax; therefore, a left chest tube should be placed even prior to confirmation by chest radiography or ultrasonography. If the patient remains hemodynamically unstable following chest tube insertion, the cause of the hypotension is most likely hemorrhage. Treatment should then be directed toward restoring intravascular volume, and simultaneous attempts should be made to identify the source of blood loss. It is important to recognize that other causes of hypotension in the acute traumatic setting are possible but less likely, and these include cardiac dysfunction, cardiac tamponade, and neurogenic shock. Because these other causes of shock are far less common than hemorrhagic shock, hypotension in a polytrauma patient should be presumed to be the result of hemorrhage until bleeding from all possible sources can be ruled out. The potential locations of major blood loss to be considered include external, pleural space, intraperitoneal, retroperitoneal, pelvic, and soft tissue. A survey of the patient’s body for open wounds and clothing for blood is usually helpful in identifying external blood loss. A chest radiograph or empiric bilateral chest tubes are useful in locating pleural space blood loss. A pelvic radiograph can identify bony fractures and/or dislocations, which are the primary cause of extra-peritoneal pelvic blood loss.

Intraperitoneal bleeding can be readily identified by focused abdominal sonography for trauma (FAST) or diagnostic peritoneal lavage (DPL) performed during the secondary survey of unstable patients. Major long bone fractures are the result of large kinetic energy transfers and are associated with destruction and bleeding from the surrounding soft tissue; this type of bleeding is generally identified by physical examination and radiography. Retroperitoneal blood loss without pelvic fracture occurs rarely and can be identified by FAST. Injuries to the cervical or upper thoracic spinal cord can disrupt sympathetic functions and lead to neurogenic shock. The majority of spinal cord injuries occur in the presence of bony fractures and/or dislocations; therefore, plain radiographs of the spine can be used to screen for these injuries. Rarely, cardiac dysfunction can result from blunt injury, which is generally recognized by echocardiography or elevated right heart filling pressures measured through central venous catheters or pulmonary artery catheters. In a hemodynamically unstable patient, it is important to identify life-threatening problems in a timely fashion without having to transport the patient to the radiology suite. Therefore, the use of a CT scan is not indicated in the evaluation of unstable trauma patients.

APPROACH TO: Multiple Trauma

DEFINITIONS

FOCUSED ABDOMINAL SONOGRAPHY FOR TRAUMA (FAST): A quick ultrasound examination performed during the secondary survey. The four views examined are subxiphoid, right and left upper quadrant, and pelvic. The FAST procedure is sensitive in identifying intraperitoneal fluid and pericardial fluid, and it is most useful for the rapid assessment of unstable patients.

DIAGNOSTIC PERITONEAL LAVAGE (DPL): A bedside invasive diagnostic procedure performed during the secondary survey in unstable patients. This study is highly sensitive in identifying intraperitoneal blood. Positive results are defined as 10 mL of gross blood or enteric content aspirate or a red blood cell (RBC) count of more than 100,000/mL or a WBC count of more than 500/mL. The primary limitation of DPL is its lack of specificity. In hemodynamically stable patients, laparotomies performed on the basis of microscopically positive DPL result in non-therapeutic laparotomies in up to 30% of patients. In most practice settings, the FAST has replaced DPL as the diagnostic procedure of choice for the evaluation of hypotensive blunt trauma patients.

ABDOMINAL CT SCANS: A sensitive, specific diagnostic modality for solid-organ injuries, retroperitoneal injuries, and peritoneal fluid in the blunt trauma setting. Because of the time required for completion and the need to transport patients to an uncontrolled environment, CT imaging is contraindicated for unstable patients.

CLINICAL APPROACH

The initial treatment begins with a primary survey consisting of airway (A), breathing (B), and circulation (C) assessment and optimization, commonly referred to as the ABCs. The primary survey focuses on immediate life-threatening problems, which should be promptly treated. Once the ABCs are addressed satisfactorily, a secondary survey is conducted via a thorough head-to-toe examination and an inventory of all possible injuries. Plain nasogastric tubes and urinary catheters are placed as needed. After completion of the primary and secondary surveys, the next step in treating the patient can generally be determined. If the patient is stable, additional radiographic studies can be completed in the radiology suite as indicated. It is important to remember that whenever a patient develops any significant change in clinical condition, a thorough reevaluation beginning with the ABCs should be performed immediately. For patients with identifiable bleeding, neurosurgical injuries, and orthopedic injuries, the problem of ongoing bleeding should be addressed first if it causes hemodynamic instability. Damage control operations are abbreviated surgeries to control bleeding and may be useful to allow timely management of severe neurosurgical injuries. Generally, the treatment of major orthopedic injuries not associated with significant bleeding can be delayed until after an initial period of stabilization (>24-48 hours). Many hemodynamically stable patients with hemoperitoneum, liver, spleen, or kidney injuries can be successfully managed nonoperatively with close monitoring; therefore, an initial nonoperative approach is appropriate.

COMPREHENSION QUESTIONS

40.1 A 73-year-old man is seen after falling down a flight of stairs. He arrives on a backboard with a C-collar in place. His initial pulse rate is 70 beats/min, blood pressure 160/80 mm Hg, respiratory rate 10 breaths/min, and GCS 6. He has a large scalp hematoma, a dilated, nonreactive left pupil, and a large bruise over his left flank. Which of the following is the most appropriate treatment?

A. Provide an O2 face mask and intravenous (IV) fluids, obtain a head and abdomen CT scan, and request a neurosurgical consultation.

B. Perform endotracheal intubation, provide IV fluids, obtain an abdomen CT scan, and request a neurosurgical consultation.

C. Perform endotracheal intubation, provide IV fluids, perform a FAST examination, request a neurosurgical consultation, and perform a bedside decompressive craniectomy.

D. Perform endotracheal intubation, request a neurosurgical consultation, and transfer the patient to the operating room for a decompressive craniectomy.

E. Perform endotracheal intubation, provide IV fluids, perform a FAST examination, obtain a head CT scan, and request a neurosurgical consultation.

40.2 A 34-year-old man, who is an unrestrained passenger, underwent a high-speed motor vehicle accident and sustains a fractured femur as well as blunt abdominal trauma. After stabilization of the patient, the ED physician orders a CT scan of the abdomen. Which of the following statements is most accurate regarding abdominal CT scan for blunt trauma patient?

A. Costly and time consuming and thus should not be used when the FAST or DPL is available

B. Highly sensitive and specific for solid-organ injuries but lacks sensitivity for retroperitoneal and hollow viscus injuries

C. Highly sensitive and specific for solid-organ injuries but lacks sensitivity for hollow viscus injuries

D. Highly sensitive and specific for solid-organ injuries and intraperitoneal blood and useful for both stable and hypotensive patients

E. CT not indicated when patients have no abnormalities on abdominal physical examination

40.3 A 40-year-old unrestrained man was the driver of a car that crashed into a tree when his car apparently veered off the road. He was brought to the emergency department, and after his initial resuscitation and evaluation, he is found to have multiple superficial scalp lacerations, a left subdural hematoma with no associated midline ship and with a GCS of 14, a 60% left pneumothorax, and left tibia and fibular fractures that are associated with diminished pedal pulses. Which of the following is the most appropriate sequence of prioritization for this patient’s injuries?

A. Brain injury, pneumothorax, lower extremity injuries, and facial lacerations

B. Pneumothorax, lower extremity injuries, facial lacerations, and brain injury

C. Pneumothorax, lower extremity injuries, brain injuries, and facial lacerations

D. Brain injury, lower extremity injuries, pneumothorax, and facial lacerations

E. Pneumothorax, brain injury, lower extremity injuries, and facial lacerations

40.4 A 32-year-old man is brought to the emergency center after having been struck by a large branch that broke off a tree and struck the patient on the side of his head and right chest area. He is brought to the emergency center with a large right parietal scalp hematoma, right cheek deformity, and right chest wall deformity associated with diminished left breath sounds. His pulse rate is 110 beats/min, blood pressure is 110/60 mm Hg, respiratory rate is 30 breaths/min, and GCS is 13. Which of the following is the most appropriate next step?

A. Endotracheal intubation

B. Right chest tube placement

C. CT scan of the brain

D. FAST

E. Repair of the scalp laceration

40.5 Which of the following factors is most likely to contribute to a worse outcome in a patient with a left subdural hematoma associated with a GCS of 9?

A. Blood pressure of 70/50 mm Hg recorded for approximately 10 minutes prior to arrival to the hospital

B. Epidural hematoma

C. Depressed skull fracture

D. Pelvic fracture

E. A 10% left pneumothorax

ANSWERS

40.1 E. In a hemodynamically stable patient with signs of severe closed-head injury with a left hemispheric mass effect as demonstrated by the nonreactive and dilated left pupil, immediate airway management with controlled ventilation is essential to minimize secondary brain injury. A CT scan of the head is vital to help the neurosurgeon define the problem so the appropriate surgical intervention can be performed. A blindly performed craniectomy is never indicated.

40.2 C. A CT scan of the abdomen is very accurate in identifying solid-organ and retroperitoneal injuries, but it lacks sensitivity for hollow viscus injuries. Fortunately, hollow viscus injuries are unusual following blunt trauma and occur in only 1% to 5% of cases. The abdominal physical examination lacks sensitivity or specificity for the identification of intra-abdominal blunt injuries.

40.3 E. The treatment prioritization for patients with multiple injuries should always consider life-threatening injuries before injuries that may compromise qualities of life and are non–life-threatening. In this patient, the pneumothorax needs to be addressed as part of the ABCs. The subdural hematoma is potentially life threatening, but with the patient’s initial GCS of 14 this is not likely to pose a threat to his life at this time. The lower extremity fractures are serious and may be compromising his lower extremity circulation, but this poses no threat to his life. Similarly, the facial laceration repair has the lowest priority among all his injuries.

40.4 B. Right chest tube placement is the most important initial intervention in this patient with chest wall deformity and diminished breath sounds. Endotracheal intubation does not appear necessary at this time in this individual with probable facial fracture but satisfactory airway.

40.5 A. Hypotension alone is associated with a 30% to 60% increase in the mortality associated with brain injury, and this is due to secondary brain injury that occurs as the result of reduced cerebral perfusion. A 10% pneumothorax may not cause hypoxemia, and therefore may not contribute to secondary brain injury.

CLINICAL PEARLS

Images Airway, breathing, and circulation should be reassessed whenever clinical deterioration develops in a trauma patient.

Images Obtaining a detailed description of the traumatic event helps identify the injury mechanisms and direct the evaluation process.

Images A closed-head injury is rarely the cause of hemodynamic instability in a trauma patient; therefore, the evaluation should be directed toward identification of the bleeding source.

Images A low GCS score in a patient with profound shock may result from inadequate brain perfusion, and the usual sequence of approach should not be altered.

REFERENCES

Committee on Trauma of the American College of Surgeons. Initial assessment and management. In: Advanced Trauma Life Support Program for Doctors. 7th ed. Chicago, IL: Committee on Trauma of the American College of Surgeons; 2004.

Cothren CC, Biffl WL, Moore EE. Trauma. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Mathews JB, Pollock RE, Eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010:135-195.

McSwain NE. Initial assessment and resuscitation of trauma patients: a practical, efficient, and evidence-based medicine approach. In: Cameron JL, ed. Current Surgical Therapy. 9th ed. Philadelphia, PA: Mosby Elsevier; 2008:930-936.