COMPLICATIONS OF TRAUMA ANN O’ROURKE, MD, MPH SCRTAC TRAUMA CARE BEYOND THE ED DECEMBER 4, 2014 Saving Lives By Strengthening Our Region’s Trauma Care System OUR CASE • 31 yo man MVC with prolonged extrication • Presents to ED: • Confused, HR 120, RR35, BP90/65 • Diminished breath sounds on right with palpable chest crepitus • Unequal leg length • Abdominal bruising • What are your concerns? OUR PATIENT • Right hemopneumothorax-facility placed 28Fr chest tube • Liver laceration-managed non-operatively • Right acetabular fracture dislocation with proximal femur fx-traction with planned operation • C3 fracture with small epidural hematomamanaged with PMT collar POST INJURY DAY 2 OUR PATIENT STILL COMPLAINS OF DIFFICULTY BREATHING • What are your concerns? • Worsening pulmonary contusion • Pneumothorax • Hemothorax • Pain from fractures • Abdominal fluid/blood • Pneumonia/pneumonitis • Pulmonary embolism RETAINED HEMOTHORAX • Our chest tube did a good job of evacuating air and most of the blood, but some clotted blood remained. This can lead to: • Empyema • Chronic fibrothorax with trapped lung RETAINED HEMOTHORAX Prevention: • Properly positioned, LARGE chest tube (36-42Fr) • Post placement CXR • Retained hemothorax post chest tube placement independent predictor of empyema in up to 33% of patients RETAINED HEMOTHORAX Treatment: • Operative • Early VATS (3days) signiﬁcant reduction in operative difﬁculty, contamination/infection of clot, and hospital length • After day 5 more likely to need thoracotomy • Fibrinolytic • VATS is a more effective procedure than intrapleural streptokinase • VATS patients having a statistically signiﬁcant shorter hospital stay and decreased need for additional therapy • Fibrinolytic agents would have to be seen as a second-line agent behind surgery when the risks of surgery are too great to the patient’s overall outcome EMPYEMA • • Approximately 3% of patients with chest trauma will develop a posttraumatic empyema. Risk factors • persistent pleural effusion/hemothorax • duration of a tube • placement of multiple tubes • • No good evidence for or against prophylactic abx prior to chest tube for prevention As with retained hemothorax, first line treatment is operative in patients who will tolerate EMPYEMA PNEUMONIA • Our patient had difficulty coughing and clearing secretions • What risk factors for this? • Rib fractures with impaired mechanics • Pulmonary contusion • Inadequate analgesia • C-collar impaired swallowing FROM THE NTDB ALL AGES Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25 RIB FRACTURE CORRELATION WITH MORTALITY Half-a-dozen ribs: The breakpoint for mortality. Flagel, et al. Surgery 2005;138:717-25 OUR PATIENT DEVELOPED RLE SWELLING • What are your concerns? • DVT • Compartment syndrome • Morel-Lavallée DVT • What are his risk factors for DVT? • Prolonged extrication • Immobility • LE/pelvic fracture • Holding DVT prophylaxis WHEN SHOULD WE BEGIN DVT PROPHYLAXIS? AND WHAT MEDICATION DO WE USE? • What factors in to the decision for this patient? • Solid organ injury (liver) • Pelvic fracture • Spinal epidural hematoma • Other factors: • Head bleed • Planned operations • Epidural catheters DVT PROPHYLAXIS IN SOLID ORGAN INJURY • DVT prophylaxis is safe in patients with solid organ injury • BUT timing of initiation is not established • Some retrospective trials suggest OK to begin early DVT PROPHYLAXIS IN TRAUMA MOREL-LAVALLÉE OUR PATIENT DEVELOPS ABDOMINAL PAIN, TACHYCARDIA AND FEVER • What are your concerns? • Biloma/bile leak • Missed bowel injury • Delayed bleed • Urinary tract infection • Hepatic necrosis • Abscess • Cholecystitis DELAYED LIVER COMPLICATIONS • Delayed bleed 1-6% severe liver injuries • Expanding bleed • Pseudoaneurysm • Biliary leak 2-7% • Mean 7-10d post injury • Most in grade 4-5 injuries • Treat with drainage and ERCP and stent BILIARY COMPLICATIONS Table 2 Analysis of factors influenced development of complications, including biliary complications in the study group Complications No complications Biliary complications (n = 22) (n = 24) (n = 15) 17 17 13 NS 23.7 ± 11.9 20.6 ± 15 22.5 ± 12.2 NS ISS (mean ± SD) 36 ± 14 32.6 ± 15 35 ± 15 NS Grade of liver injury (mean ± SD) 4 ± 0.6 3.8 ± 0.6 4 ± 0.75 NS Angioembolization (%) 6 (27.2) 5 (20.8) 5 (33.3) NS 15 (68.2)* 8 (33.3) 9 (60) 0.038 7 (31.8) 5 (20.8) 5 (33.3) NS Male Age (years) OR (%) Penetrating injury (%) P value OR - operative group; ISS - Injury severity score; NS - Differences not significant; * - p < 0.05 - complication rate was higher in OR patients. Bala et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012 20:20 doi:10.1186/1757-7241-20-20 SMALL BOWEL INJURY MISSED SMALL BOWEL INJURY OUR PATIENT DEVELOPS MENTAL STATUS CHANGES • What are your concerns? • Hypoxia or hypercarbia • Sepsis • Stroke • Medications • Drug withdrawal BLUNT CEREBROVASCULAR INJURY BCVI OUR PATIENT IS BACK IN CLINIC WITH SLEEP DISTURBANCES • What are your concerns • Inadequately treated pain • Medication withdrawal • Post traumatic stress disorder • Sleep apnea • Insomnia related to stroke PTSD IN CIVILIAN TRAUMA • More than 20% of trauma patients have PTSD at 12 months following injury • Risk factors: • Post-injury emotional distress • Pain • Pre-injury depression • Benzodiazepine use Zatzick, et al. Annals of Surgery • Volume 248, Number 3, September 2008 PTSD CRITERIA • Historically, benzodiazepines were used for treatment of acute stress and ptsd • change: use with caution or discourage use • theoretical, animal, and human evidence to suggest that benzodiazepines may actually interfere with the extinction of fear conditioning or potentiate the acquisition of fear responses and worsen recovery from trauma • Very high co-morbidity of PTSD with alcohol misuse and substance use disorders (upwards of 50 percent of co-morbidity) and potential problems with tolerance and dependence. • Once initiated, benzodiazepines can be very difficult, if not impossible, to discontinue due to significant withdrawal symptoms compounded by the underlying PTSD symptoms.