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.
