IDENTIFYING LIFE THREATENING INTERNAL INJURIES ON THE FIELD

JARON SANTELLI, MD PRIMARY CARE SPORTS MEDICINE FELLOW EMERGENCY MEDICINE PHYSICIAN UNIVERSITY OF MARYLAND/MEDSTAR

DISCLOSURES No financial disclosures

GOALS:

• Identifying tools at your disposal both on the field and in the training room

• Discuss the primary and secondary survey • Identifying a handful of cardiac, pulmonary and

gastrointestinal life threatening injuries • Identify possible life-saving interventions

WHAT ARE THE BASIC ASSESSMENT TOOLS THAT

YOU HAVE?

OBJECTIVE INFORMATION

• General Appearance • Vitals • Exam: Primary and Secondary Survey

• Supplemental Tools

VITALS

• Heart Rate • Blood Pressure: BP cuff • Respiratory Rate • Oxygen Saturation • Temperature: Oral or Rectal

EXAM

Prim

ary

Sur

vey

A: Airway If they are talking to you

this is intact

B: Breathing Auscultation, watch for

chest rise, equal bilateral

C: Circulation Auscultate, assess pulses, especially at site of injury,

bleeding

D: Disability GCS, spine board, obvious

trauma

E: Environment Assess for safety,

temperature

EXAM

Sec

onda

ry S

urve

y*

HEENT: Oropharynx, bleeding, foreign body

CV: Heart sounds quieter then normal?

Fast or slow, regular or irregular, murmur? Are pulses equal left and right?

PULM: Do you hear breath sounds bilaterally, are they

equal? Labored, fast or slow, wheezing/crackles/rhonchi?

GI/GU: External injuries or bruising?

Tenderness/guarding/mass/rigidity? GU Inspection?

*Limited to scope of lecture

SUPPLEMENTAL TOOLS

• Blood Glucose • Urine: gross and dip stick • Basic Chemistry • Ultrasound

RECOGNIZING EMERGENCT CONDITIONS

THE MEET AND POTATOES

EMERGENT CONDITIONS

1. Identify sick or not sick 2. Identify potential life threatening situations 3. Identify trends 4. RE-EVALUATE

CARDIOVASCULAR PROBLEMS

• Cardiac Arrest/Commotio Cordis1: • V fib/sudden death

after blunt chest trauma

• TX: CPR, defibrillate • Transfer to ED • Prevention: not

realistic presently

http://lifeinthefastlane.com/commotio-cordis/

CARDIOVASCULAR PROBLEMS

http://lifeinthefastlane.com/ccc/major-haemorrhage-in-trauma/

• Hemorrhagic Shock:

CARDIOVASCULAR PROBLEMS • Hemorrhagic Shock, con’t

• If you suspect shock there is blood loss. FIND IT! • “Blood on the floor and 4 more”

o Abdomen, Chest, Pelvis, Thigh • Treatment includes

o Pressure to slow bleeding o IV fluids

• Cardiac Tamponade • Bleeding into the sac around the heart • Beck’s Triad:

o Decreased/quiet heart sounds o Hypotension o Distended neck veins

• Treatment includes o BP support with fluids o Pericardiocentesis

GI PROBLEMS Think SPLEEN and LIVER

GI PROBLEMS In general think about • Mechanism, Inspection, Palpation, Auscultation • Direct impact

• Crush injury/ compression • Deform solid/ hollow organs

• Deceleration • Shear injury

All can lead to life threatening internal injuries

GI PROBLEMS • Blunt Abdominal Trauma

• Vitals: Tachycardia, Hypotension stages of shock

• Inspection: o Gray-Turner’s and Cullen’s Sign are late

findings (>12 hours) o Kerh’s Sign: referred pain to the shoulder from

ANY diaphragm irritation o Left shoulder is affected in splenic injuries

classically o Seagasser’s Sign: neck pain referred from

phrenic nerve pressure o Hematuria or Hematochezia

CULLEN’S & GREY-TURNER’S SIGN Canadian Medical Association Journal Photo

GI PROBLEMS • Blunt Abdominal Trauma, con’t

• Palpation: o Local and generalized rebound tenderness, rigidity o Dullness to percussion of flank that is not affected by

position; Ballance’s Sign (uncommon) o Palpable mass

• Auscultation o Markedly decreased bowel sounds (subacute)

• Treatment includes o 2 large bore IV’s o Fluids o Transfer to ED

PULMONARY PROBLEMS • Pulmonary Arrest

• Per BLS, support with O2, Definitive Airway • Pneumothorax/Tension Pneumothorax

• Part or all of lung has collapsed spontaneously or with trauma • Complaints: chest pain, dyspnea • Vitals: hypoxia, tachypnea, tachycardia, normal BP

hypotension (with tension pneumo) • PE:

o Labored breathing, dyspnea o Auscultation: decreased breath sounds on the affected side o Tracheal deviation away from affected side (tension pneumo)

• TX: o O2, needle decompression, ED

TENSION PNEUMOTHORAX

http://www.fprmed.com/Pages/Trauma/Tension_Pneumothorax.html

http://regionstraumapro.com/post/457670048

TENSION PNEUMO: XRAY

http://www.emsworld.com/article/12041960/whats-the-best-site-for-needle-decompression

NEEDLE DECOMPRESSION: TENSION PNEUMO

WHAT’S NEXT….. ULTRASOUND • E-FAST

• No literature looking into the role of ultrasound on the sideline or in the training room (OPURTUNITY!!)

• Barriers to use

• Cost of machine • Training/user dependent • Power

• Benefits • Immediate identification of life threatening internal injuries • Procedural Assistance

The positive exam (red arrows) indicates hemoperitoneum in the setting of trauma.

EFAST: MORRISON’S POUCH, RUQ

Looking for lung sliding and “sandy beach pattern” to indicate a normal exam (A)

E-FAST: PNEUMOTHORAX A B

Comet Tails, normal lung. Loss of these indicates loss of pleural sliding/pneumo.

E-FAST: PNEUMOTHORAX

Rib Rib

REFERENCES 1. Maron, B. & Estes, M. (2010). Commotio Cordis. The New

England Journal of Medicine. 362(10), 917-927. 2. Stevens RL, et al. Needle thoracostomy for tension

pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care, 2009 Jan-Mar; 13(1): 14–7.

3. Rawlins R, et al. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J, 2003 Jul; 20(4): 383–4.

4. Montoya J, Stawicki SP, Evans DC, Bahner DP, Sparks S, Sharpe RP, et al. From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment. Eur J Trauma Emerg Surg. 2015 Mar 14.

5. http://lifeinthefastlane.com 6. http://www.emsworld.com