07.31.19 Conference Summary

Morbidity and Mortality - Dr. Nik Sekoulopoulos

Case #1

  • Cervical Fractures

    • Hangman Fx

      • Traumatic anterior spondylolisthesis of the axis

      • Bilateral fracture of the pars interarticularis

      • hyperextension with secondary flexion

      • Typically, no spinal cord injury (30% risk of other associated cervical fractures)

    • Teardrop Fracture

      • Hyperextension injury with avulsion of the vertebral body

      • Disruption of the anterior longitudinal ligament

      • Associated with central cord syndrome

      • Typically no spinal cord injury but is also associated with other associated cervical fractures

    • Neurogenic shock

      • Decrease in sympathetic tone to the vasculature with decrease in oxygen delivery and decrease in cardiac output

      • Hypotension with relative bradycardia

      • What is the incidence of neurogenic shock in isolated spinal cord injury?

        • <20%

      • What is the best practice for treatment?

        • Levophed

        • MAP goal >85 to perfuse the spinal cord

      • How do you determine brain death?

        • Medical

          • Attending physician with expertise in brain death evaluation (usually neurologist, neurosurgeon, intensivist)

          • Rule out reversible causes such as hypoxemia, hypercapnea, acidosis, hypotension, etc.

          • Coma

          • Absent brain reflexes

          • Apnea test

            • If failed, there is supplemental testing

        • Legal

          • Laws vary by state

Case #2

  • Massive transfusion

    • Replacing entire blood volume in <24 hr or >4 units in 2 hours

  • PROMMTT

    • Triggers for MTP. The more you have, the more likely you are to require MTP

      • INR >1.5

      • Initial SBP <90

      • Hgb <11

      • + FAST

      • HR >120

      • Base deficit >6

Case #3

  • VP shunts

    • Relieves pressures caused by hydrocephalus

    • Tip is in the ventricle, valve behind ear, drain in peritoneum

    • Ventriculitis can progress to meningitis and vice versa

  • What does a VP shunt infection look like?

    • Headache, AMS, lethargy

    • Tenderness and erythema over the shunt tubing

    • Abdominal pain, peritonitis

    • Fever is less specific

  • What lab findings are more suggestive of VP shunt infections?

    • CSF Culture (an initial negative culture does NOT rule out infection)

    • Elevated CSF lactate

    • CSF Cell count, glucose, protein abnormalities may or may not be indicative of infection vs inflammatory changes from recent surgery, ect

    • WBC, ANC, inflammatory markers like CRP are weak markers

  • What imaging in recommended?

    • MRI w/wout contrast

    • CT abdomen and pelvis

  • What is the best treatment?

    • Source control

    • Vancomycin and Zosyn/Cefepime

    • Intraventricular antibiotics are recommended via EVD if there is not appropriate response to IV antibiotics

    • Duration?

      • 10-14 days after the first negative culture

    • Does complete removal of an infected CSF shunt and replacement with an EVD need to occur emergently?

      • No, but within 48 hours

    • Shunt can be replaced after cultures are negative at the end of the antibiotic course


Blunt Abdominal Trauma - Dr. Andrew Loudon

  • Injury related to deceleration and entire body is potentially injured

  • More difficult to identify source of bleeding compared to penetrating trauma

  • Unstable Trauma Patient

    • Identify source of bleeding -> OR

    • Find the blood, stop the bleeding, give blood

      • Physical exam

      • CXR

      • Pelvic X-ray

        • Widening of pubic symphysis or SI joints is associated with hemorrhage

      • FAST exam

  • Stable Trauma Patient

    • Blunt Liver Trauma

      • Grade 1-3: Non-operative

        • Outcomes can worsen based on how close is the laceration to a major hepatic vein

      • Grade 4-5

        • Risk of hemorrhagic shock and long term complications increases

        • Look for a “blush” or extravasation of IV contrast into the abdomen into an area outside of a named blood vessel, concerning for active bleed and an indication for immediate IR intervention vs operative management

        • Long term complications:

          • Bile leak

          • Hemobilia

            • Fistula between biliary system and arterial system

            • Presents as hemoptysis

      • Grade 6: Hepatic Avulsion

        • Almost universally fatal because you usually can’t get a liver transplant fast enough

        • The entire liver is disrupted from your portal triad

    • Blunt Splenic Trauma

      • Grade 1-2

        • Observation

      • Grade 3-4

        • IR intervention in any laceration with a blush

        • May require surgery if the patient is unstable

      • Grade 5: “shattered spleen”

        • Splenectomy

    • Blunt Renal Injury

      • Grade 1

        • Observation

        • Patient may have hematuria/pain

      • Grade 2-3

        • Not involving the main blood supply or collecting system

      • Grade 4

        • Extends to the renal cortex

        • Urine leaks

        • Renal artery thrombosis

      • Grade 5: Shattered kidney

        • Nephrectomy

    • Blunt diaphragm rupture

      • L>R

      • Diagnosed with NG tube coiled in L chest on x-ray

      • Usually contains stomach; may contain colon

      • Management considerations:

        • NG tube? Yes - decompressing the stomach will give the lung more space to inflate

        • Chest tube? No, this may be tempting in a hypoxemic patient in the trauma bay but you are at risk of perforating the bowel

        • Directly to OR? No, take to CT scan first if stable

    • Blunt Pancreatic Injury

      • Usually overlying spine

      • Mechanism: seatbelt or bike handle

      • Associated with duodenal/splenic/hepatic injury

      • Management considerations:

        • Observation vs OR? Observation, unless you have a complete transection of your pancreas causing pancreatic fluid leaking into the abdomen

          • Consider MRCP to evaluate the integrity of your pancreatic duct

    • Blunt intestine/colonic injury

      • Mechanism: Seatbelt/bike handle

      • Can present with perforated bowel: free air and acute abdomen

      • Associated with Chance fracture of the spine

      • Management Considerations:

        • Observation

        • OR if peritoneal abdomen

        • Rescan in 48 hours

    • Bladder injury

      • Mechanism: Usually due to seat belt compression on a full bladder (EtOH)

      • A/w Chance and pelvic fractures

      • Low grade: Observation

      • High grade: OR

Julieta Lacey