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JURSI AHD - Approach to Trauma and Trauma Xrays

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Janet Ferguson

on 4 December 2013

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Transcript of JURSI AHD - Approach to Trauma and Trauma Xrays

JURSI Academic Halfday, January 22, 2013 Janet Ferguson, PGYII FRCPC-EM OBJECTIVES ATLS Approach:
Primary SURVEY
would be important? AIRWAY Why do we care so much about the airway? Normal radius approx 1cm Area is 3.14cm2 If we decrease the radius to 0.5cm the new area is 0.785cm2 3.14 VS 0.785 What are we actually looking for? Q:What can we do about it? What about the C-Spine Collar? What if we cannot get a patent airway
and the patient cannot be ventilated or
"can't intubate, can't ventilate" BREATHING What constitutes normal breathing? Q: How do we assess breathing? RR SpO2 No Ox or Vent? Tension Pneumothorax Q: How Will this Present??? Q: What is a Flail Chest? Possibly Mechanical Ventilation Possibly Surgery Bleeding...Anywhere Hemothorax ED Thoracotomy CIRCULATION We are dealing with SHOCK here Definition? How do we assess for S/S of Shock? HR
Capillary refill
Level of consciousness
Signs of end organ dysfunction

Look for bleeding Chest Scalp Cardiac tamponade Abdomen Pelvis and Longbones Pressure or Embolization Massive Transfusion Protocol Packed RBCs
Fresh Frozen Plasma
Cryoprecipitate DISABILITY How do we classify hemorrhagic shock? GCS 40 yo male
Opens eyes to command
Disoriented, talking in sentences
Localizes pain 12 38 yo female
Does not open eyes
Incomprehensible sounds
Decorticate posturing 6 Decorticate VS Decerebrate Monroe Kelly Secondary injury prevention Q: How can we Alleviate Pressure? Raise the Head of Bed
Ensure C-Spine Collar not too restrictive
Mannitol or Hypertonic Saline
Extraventricular Drain
Craniectomy EXPOSURE The purpose of exposure? Temperature
Look for Hidden Injuries How do we do exposure? TESTS to ORDER Blood Work (CBC, Lytes, Urea, Cr, LFTs, VBG, BhCG, EtOH)
Type and Screen
Portable Xrays
SURVEY Purpose of the Secondary Survery? Disposition of the Patient EMS is arriving with 30yo M involved in MVC Q: What information do you think is important
to get from EMS on arrival? Crash Intubation
Rapid Sequence Intubation
Difficult Airway Ah...the first time Q: Questions?? Q: What are the signs and symptoms of
Respiratory Distress? Q: Tests to Order? Q: Who needs to get intubated? Questions about the AIRWAY? Induction Agents Paralyzing Agents Sucking Chest Wound/Open Pneumothorax Q: What traumatic injuries can interfere
with breathing? Need for Thoracotomy Don't forget the tricky places! Q: Which forms of shock occur most often in trauma? To Surgery or Not to Surgery (Yet)? IV ACCESS
Central Line ACCESS FLUIDS Vasopressors Treating Shock Q: Do fluids flow faster from a peripheral IV line or a central line? Poiseuille's Law Develop an approach to the management of trauma patients
Learn the basics of the primary and secondary survey
Understand the use of an AMPLE history
Learn the adjuncts which are important in managing trauma patients
Develop an approach to the interpretation of basic trauma imaging After the break... Trauma Imaging TRAUMA XRAYS What Xray's are included in the typical primary series? Which ones are actually useful? What other imaging modalities can we use for trauma patients? Learning Radiology PACS PACS Emergency Radiology TIME TO PRACTICE! PACS Tintinalli Medscape Medscape PACS C2 - Hangman fracture ("traumatic spondylolisthesis”) - bilateral posterior arch fractures Classic Injuries – Eponyms Dens 
Type I – rare, fracture of tip of dens from alar ligament avulsion
Type II—"high" (through base of dens) (common)
Type III—"low" (into C2 vertebral body) Classic Injuries – Eponyms AP view Medscape C = Cartilage Spaces Name
Must visualize the cervico-thoracic junction at C7/T1
No rotation Approach to C-spine Interpretation Sensitivity, specificity, and negative predictive value of the NLC were calculated and were respectively found to be 99.6, 12.9, and 99.8%
Sensitivity, specificity, and negative predictive values of the CCR were respectively 99.4, 45.1, and 100%
Lateral is the most useful (but should never be used alone) How accurate are C-spine films at detecting an injury? Odontoid
(open and closed mouth views) Oblique

Swimmer’s AP

Lateral Anatomy
Lower Cervical Vertebrae (C3-C7) Canadian C-Spine Rule Nexus Low-Risk Criteria (NLC)
Cervical spine radiography can be omitted when a patient exhibits all of the following: 
1. No posterior midline cervical tenderness
2. Normal level of alertness
3. No evidence of intoxication
4. No focal neurologic deficit
5. No painful distracting injuries NEXUS
National Emergency X-ray Utilization Study Group How do you “clear” someone’s C-spine? Why is this important? Review Decision Rules
Review Anatomy
Approach to Interpretation
Review Classic C-spine Injuries (eponyms)
PRACTICE C-spine X-rays Emergency Radiology Compression Fracture
Teardrop Fracture (flexion or extension) Classic Injuries - Eponyms C6/C7 - Clay-shoveler’s fracture – tip of spinous process Classic Injuries - Eponyms C1 -Jefferson burst fracture—axial compression, forces the lateral masses apart Classic Injuries – Eponyms Wheeless’ Textbook Orthopedics Odontoid View “<7 mm in front of C2
<22 mm in front of C7” Emergency Radiology S = Soft tissues Medscape B = Bones A = Alignment A = Alignment

B = Bones

C = Cartilage Spaces

S = Soft Tissues “ABC’S” of the Lateral Film Approach to Interpretation Anatomy
Cervicocranium (C1 and C2) CHEST What should you pick up on primary survey? THREATS TO LIFE! CERVICAL SPINE GCS less than 8?
2) Central
3) Cingulate
4) Transcalvarial 5) Upward
6) Tonsillar Types of Chest Trauma Chest wall injuries:
-open chest wound
-flail chest
-rib fractures PELVIS Lung injuries:
-pneumothorax (tension or simple)
-pulmonary contusion
-tracheobronchial tree injuries Diaphragmatic injuries:
-penetrating or blunt injury to diaphragm (results in a portion of the GI tract herniating into chest cavity) Cardiac injuries:
-penetrating injury (often the RV)
-blunt cardiac injury (cardiac contusion, myocardial rupture)
-coronary artery dissection or thrombus
-pericardial effusion/cardiac tamponade Esophageal injuries:
-penetrating or blunt aortic injury Injuries to the great vessels:
-penetrating or blunt aortic injury (90% will die on scene) How can you tell clinically if your patient has a pelvic injury? Types of Pelvic Injuries Burgess and Young
divided by the mechanism of injury into four subtypes:
(1) lateral compression (LC)
(2) anteroposterior compression (APC; open-book injury)
(3) vertical shear (VS)
(4) a combined mechanism (CM) Pelvic Xrays AP is the only view we get initially in trauma patients! Practice! Approach to Reading Chest Xrays (Note - before doing this, always first go through the initial steps. i.e. - patient name, date, view, rotation, # of ribs on inspiration, spinous processes visible)

A = Airway (midline, patent)

B = Bones (fractures, lytic lesions)

C = Cardiac Silhouette size (should be less than 50%)

D = Diaphragm (flat or elevated hemidiaphragm?)

E = Edges (borders) of heart

F = Fields (lung fields well inflated; no effusions, infiltrates, or nodules noted)

G = Gastric Bubble

H = Hilum (nodes, masses)

I = Instrumentation Practice! Why are pelvic injuries important in major trauma? Because they are associated with:
High energy mechanisms
Major hemmorhage
Other major organ injuries
High morbidity Approach to Interpretation Emergency Department Echosonography (EDE) Basics:
Fluid (BLOOD) appears black on the images
Visceral and parietal pleura covering the lungs move against each other in normal respiration causing the normal lung slide and "comet tail artifacts" F
T Why is it so good? What is the eFAST? What can't it do? 1. Injuries that do not cause free fluid

2. Injuries causing retroperitoneal free fluid

3. Injuries that cause <300 cc intraperitoneal free fluid (the lower the fluid amount the more likely to miss)

4. Injuries causing free fluid where the FAST scan is done too early in free fluid accumulation, and, therefore, will not detect it Free fluid, Pericarial effusion, Pneumothorax/Hemothorax Time to desaturation... What can help? Questions about trauma imaging? KEY POINTS:

Have a systematic approach when managing trauma patients (it's really easy...ABC)
Primary Survey (looking for immediate life threats!)
Intervene as you find injuries in the primary survey
AMPLE History
Adjuncts (Labs, ECG, Imaging)
Secondary Survey

In a trauma patient the only xray you get every time is a chest xray, use your judgment with pelvic xrays, almost ZERO utility for a single lateral C-spine
Be systematic when looking at imaging
Know the rules in clearing a patient's C-spine (or at least where to look them up!)
Start learning about ultrasound or EDE, it will replace our stethoscopes someday Questions about anything? THANKS!
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