Volume 1 Issue 5 September 1996

Contents:

• Introduction
• Case of the Month
• What is new in trauma
• Points from Trauma Audit Meetings
• Letters to the Editor

Introduction:

In South West Sydney the current epidemic of trauma continues. Our eighteen month registry report, which is available on request from Erica Caldwell (98283929), indicates that our trauma admissions have increased by 30% in the last six months. Trauma constitutes one of the major reasons for admission to hospital in South West Sydney, approaching 2,000 cases per annum. We have now expanded our communication systems to include E-mail and have opened up a Web Page on the Internet.

M.Sugrue@unsw.edu.au
http://www.med.unsw.edu.au./livtrauma

Finally, please remember if you feel that your trauma patient may need Intensive Care or High Dependency care when transferring trauma patients to Liverpool Hospital use the dedicated Trauma Hotline. The new number for the Hotline is 98283666.

Michael Sugrue
Director, Department of Trauma Services

CASE OF THE MONTH:

Pre-Hospital:

1. Intact
2. Respiratory rate 24/m, shallow, clinically fractured ribs on right
3. P120/m BP 105/60mmHg
4. GCS - 14

The patient was transported to Liverpool Hospital, arriving 32 minutes after the initial call.

Resuscitation Room:

1. Airway intact. O2 mask changed for a non-rebreathing mask with a flow rate of 15L/m. The head and neck were stabilised manually.
2. Breathing was shallow, RR 24/m. There was poor chest expansion with no paradoxical movement. Air entry was reduced on the right side and dull to percussion. Saturation was 98%. There was a suggestion from a team member to insert a right sided chest drain. The team leader stated that the primary survey would continue and that the radiographer should be ready to perform an erect chest x-ray.

   Questions:
   

   1. Would you have inserted the chest drain before or after the CXR?
   2. When should one perform an erect chest x-ray in a trauma patient?
   3. Should the c-spine x-ray have been performed before the chest x-ray?
3. Circulation, a right cubital fossa 14 G cannula was inserted and ten minutes after arrival the total fluid administration was 700mls (1200mls since accident).

   Current Obs: Pulse 135/m Blood Pressure 100/60mmHg
   Poor capillary refill >2 seconds.
   
   

4. He was alert. Pupils equal.
   

Questions:

1. Would you have been happy to wait nearly 30 minutes from admission to commence blood transfusion in this patient?
2. Would you have ordered group specific blood?
3. What are your indications for a thoracotomy?

Question:

1. Why did this blood not come out the first chest tube?
2. Should the patient have gone to theatre after the first 900mls of blood was drained?
3. What would you do next?

What should you have done?- a review of last month's case.

To recap, the case discussed was that of a female security guard stabbed in the epigastrium with haemodynamic instability at the scene who was scooped and run by the Paramedics. On primary survey airway was intact, breathing revealed a mild tachypnoea. Blood pressure was normal but the patient had a tachycardia of 130/m

An erect chest x-ray was performed because of the possibility of chest penetration and in the process of sitting the patient up she collapsed with an unrecordable blood pressure.

The questions were:

1. Should the patient have had a thoracotomy?

   Generally for penetrating abdominal trauma the initial priority would have been to perform an urgent laparotomy (in the Operating Theatre). The indication to do a thoracotomy would have been a very high suspicion of pericardial tamponade or multiple previous abdominal incisions which may lead to dense adhesions. The presence of dense adhesions in the abdomen in an exsanguinating patient is an indication for initial thoracotomy and aortic cross clamping. This however is very rare. A thoracotomy is best avoided in a patient unless there is some contra- indication to entering the abdomen in major abdominal trauma.

2. Should the patient have had a major transfusion in the Resuscitation Room to restore the blood pressure?

   The vital step is arrest of haemorrhage by surgical means rather than trying to keep up with ongoing bleeding. In addition in a situation less critical than that described with hypotension rather than collapse resuscitation may aggravate haemorrhage and may increase post operative complications and multi organ failure. Increasing evidence from the United States shows that patients who undergo urgent surgery without pre-operative fluid resuscitation generally do better than those who are aggressively resuscitated. It is important to realise that the pre-hospital times in these U.S. studies are very short and that at present they only apply to penetrating trauma.

3. Should the patient have had an Emergency Room thoracotomy?

   No, the patient should be transported to the Operating theatre where better assistance and equipment will increase the chances of arresting haemorrhage. Emergency Room thoracotomy should be reserved for the collapsed patient with no recordable blood pressure who has a suspicion of a pericardial tamponade or aortic rupture. Prolonged attempts at fluid resuscitation while there is ongoing major vessel bleeding, will have a negative effect on patient outcome.

Progress Report on the Case:

The young lady was rushed to the Operating Theatre where a midline laparotomy revealed a massive haemoperitoneum with frank bleeding from the aorta below the level of the renal artery. In addition there was transection of the portal vein, splenic vein, pancreas and mesentery. Initial control was difficult and supracoeliac aortic clamping was performed. The right and the left colon were mobilised (rapidly) exposing the right and left side of the aorta. The aortic laceration was repaired under direct vision, the portal vein was repaired, the splenic vein was oversewn and the pancreatic laceration was left with a drain in place. The patient at this stage had a massive transfusion but was normothermic (a credit to the Anaesthetic Team). The patient's abdomen was packed in a damage control manoeuvre and returned to Intensive Care. After a series of further operations, mainly involving removal of abdominal packs and control of other areas of minor bleeding points the patient made a recovery and was discharged some five weeks later.

Comment

Where major haemorrhage has occurred from a damaged major vessel early surgery by an experienced operator, working with an aggressive anaesthetic team and good post-operative ICU care are required to salvage the patient.

What's new in Trauma?

Editorial Comments:

In the last four years we have seen a number of carotid cavernous fistulae and a number of internal carotid dissections from blunt trauma. It is important to think of this in patients with head injuries and sudden deceleration injuries. Dr. Jahangir Janjua, our current Trauma Fellow has recently reported a similar case in the Journal of Trauma. Where arterial injury is suspected duplex scanning and arteriography should be considered at an early stage. Internal flaps following trauma are not uncommon in the renal and mesenteric artery and pose a difficult diagnostic dilemma. Failure to diagnose a renal artery intimal flap will lead to loss of renal function within four hours. Often in renal infarction there is no haematuria.

INTERNET WEB PAGE:

Points from the Trauma Audit:

Over the years we have heard presentations at the Trauma Audit where patients are deemed "haemodynamically stable". It is vital to realise that, especially in young males, that significant blood loss can occur before there are any changes in the patient's observations. In the presence of a normal blood pressure and pulse you may still have significant haemodynamic instability with tissue hypoperfusion and potential multi organ failure at a later stage. A 100kg male has a blood volume approaching 7 litres and will require blood losses approaching 2-3 litres before significant hypotension occurs.

Evaluation of Haemodynamic Instability:

In general terms in polytrauma patients, major blood loss, is pre-empted by either hypotension at the scene, or excessive fluid requirements in the early stages of resuscitation in the Resuscitation Room. It is vital that the potential sites of major haemorrhage are ruled out quickly. Inspection will reveal external bleeding; chest x-ray - haemothorax; pelvic x-ray; potential for pelvic haematoma and a DPL - intra-abdominal bleeding. If the patient is unstable (BP 80-100mm/Hg) then one should obtain frank blood on insertion of DPL catheter. This does not take long (3 minutes) to do. It is important to consider DPL early (after primary survey) in a borderline or unstable patient, otherwise the patient is exposed to risks of ongoing haemorrhage.

Tips to rapidly locate source of bleeding:

• Inspection - reveals external blood
• CXR - haemothorax
• Pelvic x-ray - pelvic haematoma
• DPL - intraabdominal bleeding

BRADYCARDIA IN TRAUMA:

1. Hypoxia
2. Raised ICP
3. Myocardial contusion
4. Electromechanical dissociation
5. Spinal injury
6. Drugs
7. Fit young patients

BRADYCARDIA ALGORITHM

1. RULE OUT HYPOXIA
   • ->Check ventilator
   • ->end-Tidal CO2
   • ->O2
   • ->Check Position Of ET Tube
2. ASSESS FOR SPINAL INJURY
3. ASSESS FOR RISK OF CONING

LETTERS TO THE EDITOR:

I distributed the Trauma Grapevine to several places in the hospital and county including the resuscitation room nursing staff, San Diego Trauma Co-ordinators, and the Trauma Research and Education Foundation. I am hoping that the Foundation will revive their newsletter for our region based on some enthusiasm from having read yours. If it is possible, would you continue to send these to me and I will distribute them. Again, thank you for the copy of the Trauma Grapevine which I enjoyed very much.

Sincerely,

Peggy Hollingsworth-Fridlund, R.N
Trauma Co-ordinator,
UCSD Medical Centre,
200 West Arbor Drive
San Diego CA 92103-8896

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