Whenever the patient’s status changes in a trauma, start over with primary survey.
TRAUMATIC AORTIC RUPTURE
Thoracic aortic rupture – rare, but a common cause of death from blunt MVC trauma. Many die before arrival at the hospital.
– two stages of injury: injury to intima and media, followed by adventitia rupture second to years later
– causes a diastolic murmur
– X-ray findings: mediastinal widening, L apical pleural cap, blurring or enlargement of aortic knob, tracheal deviation to R (usually bleeding on the L pushing things to the R)
Grade 1: intimal tear
Grade 2: intramural hematoma
Grade 3: pseudoaneurysm
Grade 4: aortic rupture
– permissive hypotension – keep SBP near 100, HR < 100/min
– IV esmolol is ideal first-line agent
– CCB can be used as second-line agent
– IV nitroglycerin or nitroprusside can be used
Endovascular v Open Repair:
– open: may need systemic anticoagulation, risk of spinal ischemia due to aortic cross-clamping; 17% complication rate
– endovascular: stents are designed more for older patients with aneurysms; 13-14% complication rate
Basically, if they survive to the ED, you can stay calm and address their trauma.
Ionizing radiation: X-rays, gamma rays, etc.
Tobacco becomes radioactive via absorbing radium through soil – radon decays to polonium, which can give heavy smoker the radiation exposure equivalent to 100 CXR/year!
CXR = 10 millirems, vs a body CT (low end) is 1000 millirems. Head CTs can be 4000-6000 millirems.
Pregnancy: recommended radiation not to exceed 50 mrem/mo – one CXR is about 10 mrem.
Effects of exposure vary according to dose and radiosensitivity of the tissues: rapidly replicating cells (GI, marrow, gonads) are more sensitive to radiation damage.
Acute radiation syndrome: 0-48 h – vomiting, abdominal pain, diarrhea (time of onset of vomiting is prognostically important); 1-60 days, multiple organ involvement, sepsis, death. If exposure >5-12 Gy, can cause death of GI crypt stem cells, which means no regeneration, which means death. There are also CNS and pulmonary syndromes.
Radiation skin ulcers: early telangiectasias, followed by skin and SQ fat atrophy, followed by tissue loss. Late malignant transformation.
Cataracts can occur with as little as 0.2 Gy, and may be delayed by 5+ years – wear eye protection!
Who to call for help: Poison Control, Radiation Safety Office (or Security after hours).
ACUTE COMPARTMENT SYNDROME
An acute surgical emergency, must be recognized early!
Can lead to flexion contractures, rhabdomyelitis, sepsis, etc.
Volkman’s Ischemic Contracture – flexed elbow, forearm pronation, wrist flexion, MP extension.
What’s a compartment: an enclosed anatomic space usually bounded by relatively inflexible fascial planes, and with individual neurovascular supply.
Etiologies: circumferential burns, arterial injury, snake envenomations, spider bites, intrauterine cord strangulation of a fetal limb, revascularization, prolonged immobilization.
Most common: after long bone fractures, most commonly the tibial diaphysis fracture (1-10% of these).
Compartments: forearm volar compartment most at risk with radial fractures; hand has 10 small compartments; 3 gluteal compartments; proximal lower extremity (thigh) – less at risk for compartment syndrome that lower leg; lower leg: anterior > deep posterior compartment. Foot compartments – most often seen in the pediatric population.
Sxs: intense pain, out of proportion to the exam. The five Ps: pain, parasthesias, pallor, paralysis, pulselessness (don’t wait to get to pulselessness!). So, it’s possible to have compartment syndrome in a normal-looking limb with preserved pulses!
Exam: swelling, tenseness, “wood-like” feeling.
Measuring intracompartmental pressures: Stryker handheld intracompartmental pressure monitor, needle manometer, Wick catheter. Should always take several readings to ensure accurate results.
Pressure 30+ is bad – needs immediate surgical treatment
Pressure 20+ should probably be urgently addressed
Pressure 10-15 – frequent re-checks
Pressure < 10 – okay (if no symptoms or signs)
– from lecture by Drs Eric Frankel and Saba Rivzi, 2016