Critical Care Scenarios
Episode 35: When to operate in trauma with Dennis Kim
Looking at trauma from the perspective of a surgeon, with a focus on the perennial dilemma of when a patient needs surgery. Our guest is trauma surgeon Dr. Dennis Kim (@traumaicurounds), associate professor of Clinical Surgery at UCLA and medical director of the Harbor-UCLA Medical Center SICU, as well as host of the Trauma ICU Rounds podcast.
* Trauma patients who are hypotensive or otherwise unstable should be assumed to be bleeding, bleeding, bleeding until proven otherwise, and should have a very low threshold to proceed directly to the operating room for exploration.* Airway is not the first priority in most trauma patients and can often wait until a patient is resuscitated—in many hemorrhaging patients, it can wait until the OR. Likewise, many penetrating injury patients with palpable pulses can wait for further resuscitation (whether blood or anything else) until surgery. The treatment for bleeding is hemostasis.* The exception is patients with concomitant brain injury, in whom permissive hypotension should not be allowed. However, don’t delay the unstable patient from the OR by getting a CT of the head.* Don’t forget examination of the back, and hair-bearing areas like the axillae and groin, which can easily hide penetrating wounds.* Consider using the shock index, the heart rate/SBP, to detect underlying shock. Over .8 or 1 is highly suspicious.* Operative prep for exploratory laparotomy is usually from the chin to the knees. Although a midline laparotomy incision is the typical starting point, injuries can track more widely than you expect, and there should be the ability to open the chest or access the groin (for femoral exploration, conduits, etc) without repositioning or re-prepping.* Damage control surgery involves evacuating hematoma, packing to provide initial hemostasis, then securing bleeding (by coagulation, suturing, packing, etc), resecting or reperfusing ischemic tissue, and securing injured bowel. In patients with continued metabolic or coagulopathic instability, surgery typically stops there with the abdomen left open and a wound vac (e.g. Abthera) placed. More stable patients may tolerate more extensive initial repairs.* The most expeditious repair for open bowel injury is simply stapling the bowel shut in discontinuity. However, there are some arguments for repairing it early (by anastamosis/stoma creation), as discontinuous bowel becomes edematous, becomes an obstacle to later closure, and may be difficult to eventually reconnect.* Orthopedic injuries should be manually reduced and perfusion ensured, splinted (e.g. pneumatically), then definitively addressed by Orthopedics at their convenience. Traction splinting is usually not done in the ED. In patients planned to receive a contrast CT, perfusion to a threatened limb can often be easily evaluated by simply adding an arterial study (extremity run-off) to your pan-scan.* Ultrasound (eFAST) and plain x-rays (chest and pelvis) are useful tools for rapid evaluation in the ED. Although not as definitive as CT, they are safer and quicker, and can rapidly rule-in many problems needing immediate intervention.* Instead of giving TXA as the CRASH dose of 1 g up front plus a 1 g drip, give 2 g upfront. The drip tends to get forgotten.* Bowel edema noted on CT should raise suspicion for occult bowel perforation, which is very difficult to primarily visualize on CT.* Serial abdominal exams are a valid way to follow a questionable abdomen. These should ideally be repeatedly done by the same person, looking for worsening tenderness, pain, or rigidity, and combined with lab trends (e.g. trending a CBC every 4–8 hours to follow the leukocytosis).* The lungs mirror the abdomen! Worsening respiratory status should raise suspicion for a worsening abdominal process,