Early Management of Specific Injuries

Head Injury. Approximately 40% of deaths from trauma are caused by head injury, and even a moderate brain injury may increase the mortality rate of patients with other injuries. Of all the possible secondary insults to the injured brain, decreased oxygen delivery as a result of hypotension and hypoxia has the greatest detrimental impact.
1. Diagnosis. If consciousness remains depressed despite ventilation and fluid replacement, a head injury is assumed to be present, and the patient is managed accordingly.
  1. Every effort should be made to support the blood pressure with fluids and vasopressors (preferably phenylephrine, which does not constrict cerebral vessels).
  2. A baseline neurologic examination should be performed after initial resuscitation but before any sedative or muscle relaxant agents are administered and should be repeated at frequent intervals because the patient's condition may change rapidly (Table 52-4: Two-Level Initial Evaluation of Consciousness).
  3. Dilatation and sluggish response of the pupil is a sign of compression of the oculomotor nerve by the medial portion of the temporal lobe (uncus). A maximally dilated and unresponsive “blown” pupil suggests uncal herniation under the falx cerebri.
  4. CT scanning is used for the diagnosis of most acute head injuries (midline shift, distortion of the ventricles and cisterns, effacement of the sulci in the uninjured hemisphere, and the presence of a hematoma at any location in the cranial vault). Patients in severe coma (Glasgow Coma Scale [GCS] score <8) have a 40% likelihood of an intracranial hematoma.
2. Management. The most important therapeutic maneuvers in these patients are aimed at normalizing ICP, cerebral perfusion pressure (CPP), and oxygen delivery. Primary therapy includes normalization of the systemic blood pressure (mean blood pressure >80 mm Hg) and maintaining the PaO₂ >95, the ICP <20 to 25 mm Hg, and the CPP at 50 to 70 mm Hg.
  1. The patient is kept at 30 degrees of head elevation; sedation and paralysis are given as necessary; and cerebrospinal fluid is drained through a ventriculostomy catheter, if available.
  2. Rapid and adequate restoration of the intravascular volume with isotonic crystalloid and, if necessary, with colloid solutions should be aimed at maintaining the CPP between 50 and 70 mm Hg.
  3. To minimize edema formation, it is wise to monitor serum osmolality and to replace LRS with isotonic normal saline. (If serum osmolality cannot be measured, this change can be made empirically after 3 L of LRS.)
  4. Patients with a GCS score ≤8 in whom endotracheal intubation was attempted at the accident site have a higher mortality rate than those who were not intubated until arrival at the emergency department; this may reflect physiological insults during intubation.
  5. Normalization of the ICP has been shown to reduce the mortality rate. If the ICP remains elevated despite all measures, pentobarbital may be required. High-dose barbiturates are of no value in the routine therapy of patients with head injuries and should be used only for refractory ICP elevation.
  6. Current recommendations are to maintain glucose levels of 110 to 180 mg/dL.
Spine and Spinal Cord Injury
1. Initial Evaluation. The objective in the evaluation of spinal trauma is to diagnose instability of the spine and the extent of neurologic involvement. (Not stabilizing the spine in the first hours after a major accident until a definitive diagnosis is established carries the risk of converting a neurologically intact patient into a para- or quadriplegic.)
2. Initial Management. The spinal cord, a microcosm of the brain, is also vulnerable to a secondary injury process that may be a product of hypotension and hypoxia.
  1. Immobilization and Intubation. If a C-spine fracture is suspected, immobilization or MILS of the neck is necessary before the patient is moved.
  2. Steroids. Most centers have abandoned the use of steroids in patients with spinal cord injuries.
3. Respiratory Complications. Injuries at C5 or lower are usually associated with normal tidal volumes because the function of the diaphragm is intact; patients with levels at C4 or above may require permanent ventilatory assistance.
  1. Pulmonary edema is a significant cause of respiratory dysfunction. (Severe catecholamine surge follows acute trauma to the spinal cord.) Overzealous fluid therapy to treat the patient's initial hypotension may lead to acute pulmonary edema when the sympathetic activity returns approximately 3 to 5 days after the injury.
  2. In contrast to other diseases that produce respiratory insufficiency, the supine position improves respiration in persons with quadriplegia.
4. Hemodynamic Management
  1. Hypotension despite adequate fluid infusion, acidosis, or low mixed venous Po ₂ requires treatment with inotropes such as dopamine.
  2. These patients frequently experience deep vein thrombosis (DVT).
5. Anesthetic Considerations. Although succinylcholine is probably safe during the first 4 to 7 days after injury, it is probably best to avoid it altogether in the paraplegic patient and to use rapid-onset nondepolarizing agents such as rocuronium when a rapid-sequence induction is required.
Neck Injury
1. Decreased or absent upper extremity or distal carotid pulses, as well as carotid bruit or thrill, are pathognomonic for cervical arterial injury.
2. Dysphagia, odynophagia, hematemesis, subcutaneous crepitus, prevertebral air on a lateral cervical radiograph, and major concomitant injuries to other cervical structures suggest an esophageal injury.
Chest Injury
1. Chest Wall Injury. Effective pain relief, preferably with continuous thoracic epidural anesthesia, or paravertebral or intercostal block is central to management.
2. Pleural Injury
  1. Closed pneumothorax is easy to miss in major trauma. The presence of subcutaneous emphysema, pulmonary contusion, and rib fractures should draw suspicion of coexisting pneumothorax.
  2. Patients with tension pneumothorax involving >50% of a hemithorax present with dyspnea, tachycardia, cyanosis, agitation, diaphoresis, neck vein distention, tracheal deviation, and displacement of the maximal cardiac impulse to the contralateral side.
  3. Although an upright plain chest radiograph provides the best opportunity for detection of pneumothorax, this position may be impossible or contraindicated in patients who are experiencing major hemorrhage and those with suspected spine injury. Transthoracic ultrasound may be used for the emergency diagnosis of pneumothorax. After diagnosis, a traumatic pneumothorax, no matter how small, should be treated with thoracostomy drainage before tracheal intubation and positive-pressure ventilation.
  4. Bleeding intercostal vessels are responsible for most hemothoraces. Treatment is chest tube drainage and initial drainage of 1,000 mL of blood or collection of >200 mL/hr for several hours is an indication for thoracotomy.
3. Penetrating Cardiac Injury. Pericardial tamponade, cardiac chamber perforation, and fistula formation between the cardiac chambers and the great vessels are the consequences of penetrating cardiac injury. Emergency cardiopulmonary bypass may be needed.
  1. Pericardial Tamponade. The classic findings of pericardial tamponade (tachycardia, hypotension, distant heart sounds, distended neck veins, pulsus paradoxus, or pulsus alternans) are difficult to appreciate or may be absent in a hypovolemic trauma patient. TEE can demonstrate blood in the pericardial sac and the presence of ventricular “diastolic collapse,” which indicates at least a 20% reduction in cardiac output.
4. Blunt Cardiac Injury. This term has replaced “myocardial contusion” and encompasses varying degrees of myocardial damage; coronary artery injury; and rupture of the cardiac free wall, septum, or a valve following blunt trauma.
  1. Clinical findings are angina, sometimes responding to nitroglycerin, dyspnea, chest wall ecchymosis and/or fractures; dysrhythmias of any type; and right- or left-sided congestive heart failure.
  2. The diagnosis is based on the 12-lead electrocardiogram (ECG) (which is sensitive but not specific), troponin I level, and echocardiography. Common ECG abnormalities include almost any type of arrhythmia, ST or T-wave changes, and conduction delays.
5. Thoracic Aortic Injury. Blunt trauma most commonly causes damage at the isthmus, the junction between the free and fixed portions of the descending aorta, which is just distal to the origin of the left subclavian artery (Table 52-5: Common Clinical, Radiographic, and Ultrasound Features of Thoracic Aortic Injuries).
6. Diaphragmatic Injury. Injury to the diaphragm may permit migration of abdominal contents into the chest, where they may compress the lung, producing abnormalities of gas exchange, or the heart, resulting in dysrhythmias and/or hypotension. Diagnosis of a diaphragmatic hernia can be made by laparoscopy. Noting that the end of a nasogastric tube is above the diaphragm on the chest radiograph is a certain sign that the stomach is displaced into the chest.
Abdominal and Pelvic Injuries (Table 52-6: Diagnostic Tools in Abdominal Trauma: Strengths and Weaknesses). Pelvic fractures result in major hemorrhage in about 25% of patients, and exsanguination occurs in 1%. Large retroperitoneal hematomas may also cause respiratory difficulty because of pressure on the diaphragm. CT examination is a key diagnostic measure.
Extremity Injuries. Surgical repair of extremity fractures, whether open or closed, should be performed as soon as possible. (Delayed fracture repair is associated with an increased risk of DVT, pneumonia, sepsis, and the pulmonary and cerebral complications of fat embolism.) Wounds left unrepaired for more than 6 hours are likely to become septic.
1. Compartment syndrome, which is characterized by severe pain in the affected extremity, should be recognized early so that emergency fasciotomy can be effective in preventing irreversible muscle and nerve damage.
  1. The definitive diagnosis is made by measuring compartment pressures using a transducer attached to a fluid-filled extension tube and a needle inserted into the various compartments of the extremity. A pressure exceeding 40 cm H₂O is an indication for immediate surgery.
  2. Caution must be exercised when using epidural or nerve block analgesia for perioperative pain relief in the presence of extremity fractures. Absence of pain can delay the diagnosis of compartment syndrome.

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