PROFESSOR

CONFERENCE
TRAUMA SERVICE
3/5/2015
RYAN JEFFERSON
DENISE LIU

ATTENTION ALL PERSONNEL, TRAUMA

ALERT ER, LEVEL 1
21yom restrained right rear passenger in an MVA
T-boned on right by pickup truck going at 50-60mph
LOC+
Airbag status unknown
What do you do next? Tick tock tick tock

ORGANIZED CHAOS
GCS 15
FAST +

Blood in Morisons pouch (hepatorenal recess) b/w liver & Rt kidney

Suprapubic (-)

Left side (-)

Subxyphoid (-)

IV access: L groin Cordis (femoral v)

Monitor: VS 97F88HR

12RR

120/82BP

Foley: minimal blood tinged urine

CXR: Right PTX!
Pelvic Xray NL
Now WHAT?

100%RA

STILL IN THE TRAUMA BAY

Emergent thoracostomy tube (chest tube) placed
Checked ABC: intact
Inspection: Bloody face (Rt>Lf), multiple facial lacerations, Lf chest deformity, 4-5
small abrasions RLE
Tenderness with spinal palpation around C5-6

Whats next?

CT SCAN OF?
FINDINGS:
Head

Rt eye globe fracture

Facial

Rt LeFort III

Neck

Lf LeFort II

Chest

Minimally displaced nasal bone fracture

Abdomen

Grade 2 splenic rupture

Pelvis

Grade 4 liver laceration w/hemoperitoneum

Small hemothorax

Xrays:
Rt knee, ankle, tib-fib
(general RLE pain)

Rt proximal fibular fx with 1.5cm posterior displacement

LABS
8.4
135

102

108
7.3

3.5

26

0.7
9

121

7.9
24.
1

Mg 1.4
Phos 2.3

WHO TO CONSULT?

www.google.com/images/corneallaceration

Ophthalmology

Plastics/OMFS

Orthopaedics

SURGERIES
2/27
Ophth: Rt orbital exploration with watertight restorationfor future
reconstruction
2/28
fixation

OMFS: Close reduction of Rt LeFort III, ORIF ZMC fx, intermaxillary

2/28

Ortho: Splint RLE; No surgeries at the moment

BASIC PRINCIPLES OF TRAUMA

Important to be aware. Why?
The leading cause of death in people < 44 y.o.
> 2,000,000 years of potential life lost per year
Increased survival over last decades due to:

Regionalization

Diagnostic modalitiesCT and U/S

Damage Control Surgery

INITIAL ASSESSMENT
Purpose: Identify and treat life threatening, potentially life threatening, and life
altering conditions
In that order!
Four phases
1. Primary Survey
2. Resuscitation
3. Secondary Survey
4. Definitive Care

PRIMARY SURVEY: ABCDE

AIRWAY

BREATHING

CIRCULATION

Must Be Patent and

Protected: establish
if needed

To be determined
after establishment
of an airway

Concern: SHOCK vs. No

Shock

Assessment

Assessment

Compromised

Tension
Pneumothorax

BE CAREFUL WITH
THE CERVICAL
SPINE!!!
Options

Identify and
resuscitate
(faster=better)
Symptoms
#1 cause of shock in
trauma patient
Tx: Lactated Ringers or
Normal Saline;
Transfusion if needed

PRIMARY SURVEY: ABCDE

DISABILITY
Neurologic state
Assessed via the
Glasgow Coma Scale
(GCS)

Max: 15, Min: 3

Eye opening

Verbal

Motor

WHY?

PRIMARY SURVEY: ABCDE

EXPOSURE
Remove clothing for
complete exam
Remove toxins and wet
clothes
Keep patient warm

hypothermia can lead to

acidosis and coagulopathy
and increases demand on
patient

SECONDARY SURVEYAMPLE
Purpose: identify and treat injuries not found during primary. Usually less urgent
A- Allergies
M- Medications
P- Past Medical and Surgical History
L- Last Meal
E- Events leading up to the Trauma
2 Survey also includes a COMPLETE head to toe physical exam

FURTHER STUDIES
Primary and Secondary Survey determine what to do next
UTMC: everyone gets a FAST scan
CT Pan-Scan

Head

Neck

Chest

Abdomen/Pelvis

Facial bones if needed

DEFINITIVE CARE
This is the overarching goal of the trauma assessment
Sometimes surgical, sometimes medical
Surgery is not always urgent
Multidisciplinary treatment: consults are common

LEFORT FRACTURES
Named after Rene Le Fort in early 1900's
Occur secondary to high energy blunt force
to the face
Three Classes

LeFort I, II, III

LEFORT I
Horizontal
Force directed low to the alveolar rim in an
inferior direction
Nasal septum and along the top of the
teeth
Below the zygomaticomaxillary junction
Interrupts pterygoid plates

LEFORT II
Pyramidal shaped
Force directed at the lower/mid maxilla
Nasal bridge inferolaterally down the
maxilla
Under that zygomatic
Interrupts pterygoid plates

LEFORT III
Transverse- Crainiofacial dissociation
Nasofrontal through medial wall of orbit
Along the floor of the orbit through the
zygomaticofrontal junction and zygomatic
arch
Through the pterygoid to the base of
sphenoid

TREATMENT
ABCDE's
Goal is to restore anatomical
relationships
Fix loose structure to fixed ones

TREATMENT

LeFort I

LeFort II

LeFort III

THANK YOU!
ANY QUESTIONS?