Joint EM/Surgery Trauma Conference July 2019

August 27, 2019

Joint EM/Surgery Trauma Conference July 2019

Case 1

Moped accident with decreased GCS requiring intubation.

  • 100% of trauma patients should receive supplemental oxygen in the bay.
  • Somnolence means hypercarbia, agitation means hypoxia until proven otherwise.
  • Nasopharyngeal airways are generally well-tolerated but should not be used in patients with facial injuries.
  • Oropharyngeal airways are an effective adjunct to BVM but will cause gagging in patients with intact reflexes.
  • A definitive airway is defined as a cuffed tube in the airway below the vocal cords.
  • Apneic oxygenation with nasal cannula 15L/min during intubation buys you (and the patient) an additional 2 minutes before desaturation.  

Ramachandran, S.K. et al. Apneic oxygenation during prolonged laryngoscopy in obese patients. JClinAnesth. 2010; 22: 164–168

Case 2

MVC intubated in the field with multiple rib fractures and liver/spleen lacerations with hemoperitoneum, SIRS response HD 2.

  • Do not blame altered mental status on drug use as this is a diagnosis of exclusion.
  • Tachycardia is often the first sign of decompensation.
  • Bandemia of 10% or greater is a SIRS criteria, always look for bands even in patients with normal WBC - the differential typically results after the WBC has returned.
  • Active extravasation of solid organs is often treated with embolization in Interventional Radiology.
  • Splenic injuries are graded from Grade 1 (<3cm laceration) to Grade 5 (hilar injury with devascularization).
  • Perforated viscus is not well-visualized on CT imaging - maintain a high index of suspicion and consider serial exams.
  • XR has a sensitivity of 50-70% for pneumoperitoneum.
  • Distal perforation peritonitis is more commonly bacterial (stool), proximal is chemical (gastric contents) - mortality can be as high as 30-50%.
  • Perform a thorough secondary survey, especially in patients who are intubated - retained tampons can lead to toxic shock and DIC.

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