A  24-year-old   male   mountain  bike   rider  crashes   into   a   tree,  resulting  in   a   severe hyperextension neck injury, and fractured lower left ribs.  He now presents to hospital  with shock and a painful distending  abdomen.

He returns from the operating theatre after a splenectomy.   He is haemodynamically stable,  but  little  is known  of his other injuries.   What  is your plan  for the  next  24 hours?

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College Answer

At this stage stability must be confirmed in other areas as well as haemo-dynamic. Blood pressure goals should consider spinal perfusion pressure if spinal injury is suspected (may be unable to achieve target “normal” MAP in presence of high spinal injury), steroids should be considered in the first 8 hours following injury (“NASCIS II”).

Now is the time to ensure that oxygenation and ventilation are stable; coagulation should be assessed and corrected if abnormal; and temperature should be in target range.

Secondary survey should be completed, including detailed neurologic examination (eg. in an attempt to exclude spinal injury). Spinal precautions should be continued for the interim. The primary X rays should be obtained (CXR, pelvic X-ray, lateral cervical spine) but now additional
X-rays should be obtained as indicated (repeat CXR, spinal series ± CTs eg. of head, cervical spine, chest, abdomen). Long bone injuries should be sought and excluded (or treated).

Other specialists should be asked to review patient as indicated (eg. cardiothoracic, spinal). Antibiotics and tetanus prophylaxis should be prescribed if indicated.
Anti-ulcer prophylaxis should be instituted, and as should pharmacological prophylaxis for DVTs when contraindications subside. Enteral feeding should be started as soon as practical, and glycaemic control should be implemented.

Discussion

This question is about the management of a trauma patient who returns from theare following damage control surgery. It seems some definitive management (splenectomy) has already taken place.

The college mention the use of corticosteroids in spinal cord injury; this is not something we do any more. In fact, there is no strong evidence behind any of the pharmacologial measures. However, the idea of "spinal perfusion pressure" is interesting. The current guidelines are not so bold as to suggest a MAP of 85, but they do recommend the systolic not be allowed to drop below 90, which is slightly contrary to the doctrine of permissive hypotension in damage control resuscitation.

Anyway, the college baits us with the words "little is known of his other injuries".

A secondary survey must take place, including the following:

  • Coags, troponin, CK, EUC FBC and LFTs
  • ECG
  • Repeat CXR
  • Xrays of the long bones
  • CT trauma series, including fine slice through the C spine

A systematic, boring response to the question of supportive management would resemble the following:

A) - Airway control and adequate secretion clearance with suctioning, given the increased risk of pneumonia

B) - Adequate ventilation and oxygenation, with sufficient PEEP to splint the rib fractures and prevent left-sided atelectasis

C) - Haemodynamic control, with less conservative MAP targets - maintaining a MAP >65 mmHg, and SBP >90mmHg.

D) - Attention to spinal precautions, and deescalation of hard collar as soon as the spine is cleared. Adequate analgesia.

E) - Control of electrlytes, paying attention to the calcium

F) Adequate fluid resuscitation, aiming for a high normal urine output given the tendency of these patients to dveelop ATN due to haemoglobinuria and rhabdomyolysis

G) Reassessment of the abdomen to exclude ongoing bleeding.

Insertion of an NG tube if permitted by facial injuries, and commencement of enteral feeding, with the aim to supply a daily minimum of 2g protein per kg of body mass.

Ulcer prophylaxis with PPI may not be necessary of the enteral nutrition is well tolerated.

Glucose control should be established with insulin as needed.

H) Corection of anaemia and dilutional coagulopathy;

Attention to thromboprophylaxis, given that trauma (and especially spinal trauma) patients have the highest likelihood of developing DVTs.

I) No indication for antibiotics at this stage. An ADT should be given IM if it was omitted in ED.

References