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Welcome back to Behind the Knife. This is Patrick Georgiouf, trauma surgeon at Duke University. And today we have another installment of the Big T Trauma Series. So the Big T Trauma Series offers clinically oriented material that focuses on how bad... to care for traumatically injured and critically ill patients. We've had a number of really fantastic episodes, up to 20 now. Past topics include transfusion medicine for the trauma surgeon. We've covered gun violence, rib fractures.
specific injuries like neck trauma, a whole lot more as well. And so this series gets its name from the University of Texas in Houston at Memorial Hermann Red Duke Trauma Institute, which is one of the busiest trauma centers in the country. And that's where I trained. with my co-hosts, Dr. Teddy Puzio, who's currently on faculty at UT Houston, and Dr. Jason Brill, Trauma Medical Director for the U.S. Indo-Pacific Command.
the big man on campus and today i'm thrilled to have dr tyler simpson who's currently one of our fellows at duke tyler welcome we're happy to have you Thank you. All right. So Teddy, what are the Big T episodes all about? So we compiled a list of scenarios that we would consider common pitfalls and trauma. And in these cases, I think pitfalls are good learning opportunities.
One of my favorite quotes from training that I repeat very often to the residents is the eyes do not see what the mind does not know. And when you step back and you think about it, that's, that's really how we learn, right? Like you're never gonna.
see something if you don't know to look for it. And this is one of the principles that's the core to all of our training and really the basis for these episodes. It's important to learn about things so you can know when to look for them and how to recognize them. Of all of the episodes aired in the Big T Trauma series, the pitfalls seem to be a fan favorite. So we have compiled a list.
of slightly more complicated, perhaps not so obvious scenarios that we all have experienced. And we think that the wider BTK community would benefit from hearing about. Yeah, so this is the fourth pitfall episode. So if you haven't heard the previous ones, take a look. You can easily search for them and find them on the website. And let's get on to our first scenario.
Tyler, you have a 55-year-old male who was involved in a single vehicle MVC where the driver smashed into a telephone pole while traveling approximately 55 miles per hour. There was reportedly loss of consciousness, and he arrives to the trauma bay with a GCS of 5. Heart rate is 68. Blood pressure is 90 over 60. Respiratory rate is 12.
End tidal CO2 is 45, and SATs are 91%. For the complete primary and secondary survey, you do it so rapidly and efficiently with a well-oiled trauma team, and those primary and secondary surveys are unremarkable. He is intubated in the bay given his decreased GCS, and he is resuscitated with two units of whole blood.
without significant change in his vital signs. You get a chest x-ray, pelvic x-ray, and fast exam, all unremarkable. The patient goes on to get pan scanned. He has no injuries. So, Tyler, what's going on here? Well, to summarize, we've got a middle-aged male, and he was involved in MVC with no injuries detected on his CT. His mental status is altered, but he's non-responsive to blood product resuscitation.
So at this point, I'm concerned about potentially non-traumatic causes of his altered mental status. And I would begin by revisiting his disability in our ABCTEs. Yeah. So what are we looking for when we assess for disability, specifically trauma? I mentioned the GCS. Is there anything else you want to know? Of course. In all traumas, we should perform a rapid abbreviated neuro exam, and that's to establish their level of consciousness using the GCF.
and we should also assess their pupillary size and reactivity to light, and then try to identify any gross neurological deficits. We can do this by asking the patient to follow simple commands like squeezing our hands or wriggling their toes. and then test their response to pain if they're uptunded. Yeah, sure. So let's rewind the scenario. So we expand our disability exam during the primary survey and find that the pupils are three millimeters.
bilaterally and minimally reactive. And, drumroll please, you can look into the future, you know that his drug screen ends up being positive for opioids, but we should note that EMS did not give him any opioids. Yeah, so I think that's the key to this pitfall, the failure to perform an adequate neurological exam and recognize non-traumatic causes of altered male status in the trauma patient.
Definitely one of those Monday morning quarterback scenarios where you are hanging your head when you're describing the scenario the next day. Right. Very easy. A little bit of shame. Yeah. Easy to pick up in hindsight, but of course, not readily apparent in the trauma bay when you...
hear this horrible story and paramedic shows you a photo of the car completely wrapped around this telephone pole. And there's all this stuff going on in the background. People are really excited because man, this is going to be a great blunt trauma. And then as it turns out, somehow, you know, this ragdoll of a person didn't have any injuries and was just intoxicated with a substance. And I think that's why it's so important to approach every trauma systematically.
Details matter. So Tyler, what else on exam might clue us into an opioid intoxication? Well, decreased respiratory rate, myiac pupils, and altered mental status are the hallmarks of opioid intoxication, but heart rate, blood pressure, and temperature can all also be decreased. Whenever you see bradycardia in a trauma patient, you need to think about neurologic shock. Medication use like beta blockers.
And as we see in this scenario, opioid intoxication. Yeah, that relative bradycardia always piques my interest, especially if they're not an older patient. So we also mentioned end tidal CO2. So what's the role of end tidal CO2 in trauma patients, Tyler? Well, it's a useful adjunct in the setting of trauma. Entitle can be used to confirm airway placement and detect problems with ventilation like we have in this patient because they're hypoventilating from opioid overdose.
However, I would say that you most often hear about entitled CO2 being talked about in the saying of trauma as a way to detect shock. And low end-tidal CO2 levels correlate with poor perfusion. And in fact, some studies have shown that an end-tidal CO2 of less than 25 or so is associated with higher mortality.
All right, Tyler, so you and I jump in a time machine. We travel back in time together. We complete the patient's trauma evaluation. Once again, no injuries are found. But this time, we slip him a dose of naloxone before we go wheels up to the CT scanner. And he... wide-eyed, clears day, asks if Behind the Knife still has free apps for iOS and Android. You confirm that we actually do. And it's just the bed. And so with that, let's wrap up with a quick review of Naloxone.
Sir, so naloxone is a short-acting opioid antagonist that's used as anecdotal therapy for opioid intoxication. And this is key. The goal of naloxone administration is not to achieve a normal level of consciousness, but rather to achieve adequate ventilation. So patients with spontaneous ventilation should receive an initial dose of 0.04 milligrams, and that dose can be titrated up every few minutes until the respiratory rate is greater than 12.
Now, patients with apnea or impending respiratory arrests are going to require initially higher doses, and typically those are on the order of 0.2 milligrams to 1 milligram IV. I remember as a resident, this is one of the drugs that I...
saved in my phone as a dosage thing, right? Because this is like an emergency use drug. So when you're like a junior resident and you may be the only person that shows up to a code and you can't remember this, I would add this drug dosing and you can start adding drugs like... Flumazenil. When I was a fellow, I put RSI drugs just so you have a source to rapidly look at them in an emergency. Papinephrine. Yeah.
Yeah, I was going to also note and add in there that it's not just the dose. You also need to know the how. And this is another potential pitfall. The half-life of naloxone is often less than the opioid ingested. So you really do need to be careful about monitoring and setting up repeat doses because most of the time these patients... especially if they've done something other than fentanyl, they're going to be sleepy and start decreasing their GCS here within a couple of hours.
Okay, well that wraps up another trauma pitfall. Don't forget about opioid intoxication as a potential ideology of altered mental status and trauma. Patrick, what's our next case? I'm ready. Okay. 25-year-old male, multiple gunshot wounds, who arrives to the trombone bay, clearly in hemorrhagic shock, tachycardic, hypotensive, has peridonitis.
This patient is taken immediately to the operating room and exploratory laparotomy is performed. And on laparotomy, you're able to obtain hemorrhage control by ligating the common iliac vein. And there's a liver injury too. That's past.
There's also numerous injuries to the small bowel and a transgastric injury. And despite really balanced and appropriate resuscitation with blood products and warming calcium, etc. He's currently on a norepinephrine infusion, and the patient has a persistent lactic acidosis.
He's also hypothermic with a core body temperature of 35.2 degrees. And the gastric injuries are pretty rapidly repaired. And two separate small bowel resections with anastomosis are also performed. And at that time, when we're wrapping up and performing those anastomosis, there's... Notice that there's oozing from the peritoneum, from the laparotomy incision, from the patient's IVs.
etc. And a temporary abdominal closure is done. He's taken back to the ICU where he ultimately requires MTP. He keeps bleeding. So he ends up going to the IR for hepatic angioembolization. Goes back to the OR 24 hours later, gets closed. And unfortunately, seven days later, there's a leak.
There's a lot of information there. This is a really sick patient who bled and had some physiologic derangements in the OR. Now we're dealing with this leak. So Tyler, what's the simple answer here about the pitfall? Maybe quite obvious. Well, there's a couple of things, but for starters, we stayed in the operating room too long. And as trauma surgeons, we have to be able to recognize when we should bail for the sake of the patient.
Exactly. This patient is sick as snot. So Patrick, you mentioned that the patient was starting to bleed from any manipulated tissue, and that is consistent with trauma-induced coagulopathy, which is... Defined by abnormal coagulation that's attributable to trauma. Goes by a few names, but TIC is what we use here. Typically characterized by early hypocoagulation. followed by hyper-coagulability in later stages.
Tissue injury and shock synergistically promote this endothelial immune system platelet and clotting activation. which are really accentuated by a lethal triad, which hopefully a few of our listeners have heard of, which is coagulopathy, hypothermia. Yeah. I think the bottom line is trauma-induced coagulopathy is frightening. So the patients start oozing from everywhere. It's not just cut tissue, but also IV sites, Foley catheters, their nose, their mouth. And here's the thing.
you as a trauma surgeon, or really any surgeon for that matter, right? Other surgeons can see this as well. If you start to visualize this type of bleeding with your own eyes, then it's often very late in the game. Yeah, if you see it, it's too late. And this is why we chose this pitfall, because it takes experience to recognize which patients are at risk of developing trauma-induced coagulopathy.
And you have to have the wherewithal to get out of dodge quick. You got to finish that case as soon as possible by performing a true damage control surgery. And this patient, as presented in the case, very clearly is too sick. They are physiologically deranged, cold, acidotic, etc. And we're messing around doing bowel anastomosis. Like, absolutely not. That's not a good move. And there's an interest in preventing open abdomens.
This is the perfect case for an open abdomen. This is when you get that amp there out and temporarily dress the abdomen and live to fight another day. As you mentioned, Teddy, if you see trauma-induced coagulopathy, you've waited too long. You're too late.
Knowing when to get out of Dodge really does take experience, though. There are a few things we can talk about in terms of predictors, but really, I think... experience is the key here so it can be out of your control right so it could be the patient's physiology is just that poor to begin with But there are also a number of things that you could do to speed up what you are doing and really stick to damage control. And I would imagine that everyone on this podcast is at some point.
stayed and played just a bit too long and not been watching the clock. And then lo and behold, you're watching TIC develop in front of your eyes. And like, like Teddy mentioned, it's not something you forget. So Tyler, how can we prevent you? Generally speaking, balanced resuscitation with warm blood products, avoiding hypothermia, and most importantly, obtaining control of bleeding as quickly as possible. Yeah, that's right. And Tyler, for the sake of completeness, what is damage control?
Damage control surgery is an approach that's designed to prioritize the immediate control of life-threatening conditions, such as... hemorrhage, and contamination over the definitive surgical repair in the critically injured or unstable trauma patient. So the primary goal is to stabilize the patient physiologically and prevent the lethal triad of hypothermia, acidosis, and choagulopathy, which are exacerbated by prolonged surgical procedures.
Important to note here, though, here's another pitfall, that temporary abdominal closure does not equal DCS like in this patient. So we stayed and played doing definitive repairs. That's not damage control surgery. The goal is restored physiology, not restored anatomy. So the correct approach, going back in Patrick's time machine here, would have been iliac ligation.
hepatic packing, and whatever the minimum resection or quick whip stitching would have been needed to prevent further contamination from the bowel injuries. You get that done as quickly as possible. And then you do your temporary abdominal closure and get out of there. Yeah. To hammer the point home, do you have specific numbers? that you might want to follow when it comes to thinking about damage control surgery. Now, these are going to vary a little bit depending on what you read.
But the most commonly cited indications for damage control surgery are a systolic blood pressure less than 90, a pH less than 7.2, a temperature less than 34 degrees Celsius. an INR or PTT 1.5 times greater than normal, a base deficit greater than 14, estimated blood loss greater than 4 liters, and transfusion of 10 or more units of packed red blood cells. Essentially, it's any patients with unresolved metabolic failure after operative hemorrhage control.
And trends are important too. So patients that have increasing lactate or falling temperature should undergo damage control surgery before these classic thresholds are reached. Yeah, totally agree. Trends. Absolutely. Trends. The trends go both ways too, right? Like I think if you're... trending in a better direction and you're making that it's like i've had times where i'm like oh we're going to do a damage control operation and then things turn around and you're trending in the right direction
You don't necessarily have to. So it's good to have the data as you go along through the case. Right. All right. That's a good discussion. So that wraps up pitfall number two. Perform a damage control operation. Get out of the OR as fast as you can when dealing with a truly sick patient. So this is a nice segue into our next case.
in which an adult female is involved in an MVC and sustains polytrauma, including full thickness disruption of the rectus muscle from a seatbelt injury, a grade 2 liver lach. small bowel injury, ascending colon injury, and echemosis of the anterior sigmoid colon. So the index operation. She undergoes small bowel resection, right colectomy, and hepatic packing. She gets 11 units of pack cells, 10 of FFP, and 2 of platelets.
Now, using the knowledge that you gained from our prior discussions, this patient is placed in temporary abdominal closure device, and she's hustled back to the ICU in discontinuity where she's resuscitated. for a second look back to the or and she's doing better overall at this point but it's still on low dose norepinephrine and her lactate is just hanging right around three
Now, at this operation, the second one, that dusky anterior colon that you saw at the initial injury is now, frankly, dead. And you perform a sigmoid activity. And there's also one of the small bowel staple lines is actually, frankly, ischemic appearing, and that's re-resected as well. So an apthera goes back on and the patient returns to the ICU. It's now post-injury day number four. She's off all pressers. Lactate is completely normalized. Wakes up when you turn down the sedation.
And she goes back to the OR and gets the following. There's one small bowel anastomosis, an ileocolonic anastomosis, and a colorectal anastomosis. ilio to transverse colon, and sigmoid to sigmoid anastomosis. Now, I think you guys probably know what's coming here. It's day 12 following injury. The writing is on the wall, Patrick. We got to make these obvious to some degree, but now she's going to suck. We're all sad. Nothing even happened yet. I know. You saw it coming. A mile away.
so their suck is draining now from the midline and cross-sectional energy reveals not one but multiple anastomotic Tyler? Yeah, so the pitfall here is failure to perform fecal diversion at the time of a delayed colon or rectal anastomal. I like to call this the surgical Shakespeare question. So to divert or not, that is the question. And so how do you decide?
Yeah, this is another one of those not-so-straightforward pitfalls. How to put Humpty Dumpty back together again. This patient was badly broken. We've gotten her through a difficult... collection of injuries and we've got to decide what to do with her bow.
Again, you can take a look at data like temperature and heart rate and lactate and press requirements. But for this type of patient, you really got to step back and take a look at the big picture. This is a very sick patient recovering from a massive insult. And they're not going to heal. And another big hit, like the one you get from intra-abdominal sepsis, can really threaten this patient's recovery. I hate ostomies just as much as anyone else, and I wouldn't want one.
Yeah, I always plan on failing well. Yeah, fail well, maybe not even fail at all. But this is where I also tend to think of difficult trauma and EGS patients really as like a flavor. of patient or brand of patient. And I know that this flavor of patient, regardless of if they are off pressers on their third take back.
is prone to leaks and other really nasty post-operative complications. Again, ask me, ask us how you know, right? I want to avoid that urge and I want to keep it simple. Keep it simple, stupid, make the ostomy, don't roll the dice. This patient can be reversed in the future. Yeah, I agree. Once she's recovered, ostomy takedowns, while they can be frustrating sometimes, they're not the end of the world for most patients.
So let her recover, and then we can put her back to the other again. And overall, it will be very likely to be a less copy. Yeah, I've seen some surgeons using their emergency general surgery experience. dealing with diverticulitis to inform decisions on these complex trauma patients. And typically, this experience is used to avoid ostomy creation. But this type of thinking can be dangerous, right?
Exactly. All right, that wraps up pitfall number three, divert the super sick blunt trauma patient and avoid. intra-abdominal disaster whenever you can. So next up, we have a 17-year-old male who was transferred to your facility following an unhelmeted ATV accident with rollover. He has a large scalp black that was addressed with gauze and coban.
There's some bleeding noted through the gauze. He's all through with a GCS of 9, and his initial values are notable for heart rate of 130 and blood pressure of 100 over 80. Chest x-rays normal. Pelvic x-ray shows an open book fracture and a pelvic binder is appropriately applied. FAST is negative. He has a Foley catheter with no urine or blood in the bag. Labs are pending, but ETOH is positive.
He got one liter of crystalloid in root, and he goes on to get a CT scan, which demonstrates the pelvic fracture, which is known, and a moderate pelvic hematoma without active extravasation. And he returns to the trauma bay where a few minutes later, he arrests. So this is more subtle, but we've got a pitfall in mind. So Tyler, what did we miss here? What's the pitfall we're going to get after?
Yeah, it could be a lot of things, but let's go ahead and share this pitfall up front for the sake of discussion. This patient was in unrecognized hemorrhagic shock. What about his... Presentation suggests a cult shock. Well, Teddy, for one, the patient was 17 years old and they had a high-risk injury mechanism. He was initially taken to an outside hospital for evaluation. And prior to the transfer, we don't really know exactly what happened there.
He's tachycardic, he's got a narrowed pulse pressure, and he's got relative hypotension. His mental status is altered, his urine output's low. All of these are consistent with at least class 3 hemorrhagic shock. Well, I think I have a question that our audience may have for the sake of discussion. What if he is in hemorrhagic shock, but what's the source?
I thought the CT only showed a moderate-sized pelvic hematoma, and there wasn't even any active extravasation on the CT. So where did the blood loss go? That's true. Now, remember, the main sites for acute blood loss and trauma are the chest, the abdomen, the pelvis, and the retroperitoneum, long bones, and lastly, external or the street.
Given his imaging findings, the most likely explanation is his large scalp lack, or the street, especially combined with the other sites of stabilized blood loss. Yeah. Good job, Tyler. How can we clue ourselves into external bleeding as a source of this possible hemorrhagic shock earlier in this scenario? We'll begin by paying close attention to the EMS handoffs to clue into the amount of blood loss at the scene, although even these descriptions should be taken with a grain of salt.
And the patient was seen at another hospital first. So who knows how long that scalp was left to bleed before it was addressed. Remember that hypotension does not occur until class 3 hemorrhagic shock after 1.5 to 2 liters of blood loss, but narrowed pulse pressure, tachycardia, and mental status changes can occur earlier. Or if this patient was 67 instead of 17, maybe with some baseline cardiac dysfunction and on a beta blocker, even minimal blood loss could induce shock.
Yeah. So what about objective findings? Any objective findings that can aid with detecting shock earlier? Yeah, first up is our physical exam. The patient will be cool and clamped down. Labs oftentimes show elevated lactate and normal hemoglobin. Remember, trauma patients bleed whole blood. Also, end-tidal CO2 can be helpful. Low end-tidal CO2, 25 or less, suggests poor perfusion.
Yeah, these can be tough to identify. And it's a scary scenario because it would be... hard to catch this before really a devastating collapse, especially in young patients. who will just keep compensating with heart rate and supplementing their cardiac output that way until they fall off of the cliff. And we have definitely all seen that, unfortunately. So remember to listen to your pre-hospital team. And if they told you the patient lost a lot of blood, just believe them and act like that.
And even if they didn't, let's say they weren't the primary team responding or... Maybe the patient was moved from their pool of blood or who knows what the circumstances are. Even if EMS doesn't tell you about massive blood loss on the scene, I would still suspect it for any open wound. even if it's hemostatic by the time you are looking. And those trauma transfers, this goes back to that earlier pitfall. Watch out.
Any open wound can be a source of significant bleeding, even something that looks really minor now that just has a bandaid on it. You have no idea how much blood coming out of that wound before the patient got to you. Not every trauma patient bleeds out into their belly or their chest or their retroperineum. So let's move on to our last trauma pitfall. So the case is a 70-year-old male who experienced a mechanical fall with mildly displaced left rib fractures, three through nine specifically.
The test x-ray shows a moderate left pneumothorax and a small left pleural fusion. A pigtail is placed in the ED and he's admitted a step down for rib fracture protocol. Chest x-ray on hospital day number two shows a persistent small left lower lung opacity that's stable on day three, at which time the pigtail is removed.
and everything is kosher. You are working with case management, trying to get this patient to a skilled nursing facility. It's now day six because discharge was delayed. The patient has a pretty mean fever that's persisted. So Tyler, what's on the differential for this patient's fever? So persistent opacity on a chest x-ray in a patient with blunt chest trauma. This is concerning for atelectasis, pulmonary contusion, pneumonia, or my favorite, retained hemothorax.
If it's retained hemothorax and it's now infected, it could also be the beginning of an empyema. I think this is something that we see all the time, right? An abnormal chest X-ray. It really doesn't tell you much. It could be a lot of different things that you just covered. So Tyler, what is the next step with this opacity?
Yeah, this patient needs to be imaged with the CT chest as a chest x-ray will not allow us to differentiate between a process in the lung parenchyma versus one in the pleural space. Yeah. So unfortunately, the CT scan demonstrates a loculated rim-enhancing pleural fluid collection. The lung is actually trapped. They require a VATS that's ultimately converted to an open decortication, and the patient hangs out for a while longer, and they're actually discharged on hospital day 22 to an LTAP.
where they actually have to wean from the vent. Anything that we could have done differently for this patient. There's definitely a few opportunities for improvement here. For starters, a single dose of an antibiotic like ANCEF before or during chest tube placement may reduce some infectious complications. But more importantly, early vats within 72 hours. of injury results in decreased operative difficulty, decreased contamination or infection of the clot, and decreased hospital lengths of stay.
So anytime a patient, trauma patient specifically, has a pleural fusion in the center of rib fractures, our suspicion for developing hemothorax should be quite high. And any patient with significant rib fracture burden should ideally get daily chest x-rays for at least the first few days of their admission. And if there's persistent or worsening or pacification of the pleural space, then they should be evaluated with the CT scan, as Tyler mentioned.
If they don't have a chest tube already, this would be a time to place one, again, with a dose of antibiotics. I think that's something that we easily forget. In fact, when I started placing chest tubes, I never gave antibiotics. It's now part of the standard protocols and recommendations and guidelines that a single dose, at the very least, will prevent infections like an empyema.
or at least decrease them and if they already have a chest tube in place studies show that early vats in patients who are good operative candidates is absolutely superior to placement of another chest tube or a prolonged treatment with fibrinolib. Yeah, I agree. Some centers have even implemented pleural lavage or thoracic irrigation protocols at the time of tube thoracostomy, and the early data do look promising.
I'm sure there's more to come on this in the future. But for now, the key is to look for retained hemothorax. You have to know that it exists so that you can look for it. And any remaining pleural effusion on that chest X-ray, even if you don't think that it looks very impressive, might actually turn out to be very significant on CT, depending on your patient positioning and the quality of the X-ray.
So I have a very low threshold to get an early non-con CT on these patients to decide whether they need something further. Yeah. Teddy, you do non-con or contract? Yeah, I was going to make a comment on that. I actually changed practice. And if there's not a concentration to getting contrast, I almost always get a contrasted CT of the chest because I think it gives you...
The ability to see the difference between the lung parenchyma, you can have consolidated lung parenchyma, and sometimes that... It gives you contrast between that and the effusion to see which is which. Yeah. That's a good point, Teddy. I use an IV contrast. It's can as well. If there's not a contraindication, it was like Teddy. Fantastic. That wraps up our last pitfall. Don't miss a retained team of Thorax and the opportunity to treat it before it becomes an Empyema.
Thanks to everyone for another amazing Big T pitfalls episode. Remember, the eyes do not see what the mind does not know. So now you know, right? And until next time, Tyler, be sure to... Dominate the day. That's right. This episode of Big T Trauma was sponsored by Teleflex, a global provider of medical devices. Learn more at teleflex.com.
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