Although none of the editors of InsideSurgery.com participated in his care, we have noted the news reports that California Angels baseball pitcher Nick Adenhart died after undergoing surgery at UC Irvine medical center early this morning after the car he was riding in was struck by a minivan that reportedly ran a red light.
Adenhart was killed from injuries suffered in the motor vehicle accident that occurred around 12:23 am. The car he was riding in reportedly was struck by the minivan and then crashed into a utility pole. Two of the occupants were dead at the scene and one is in critical condition
It was not clear from reports as to whether Adenhart had been wearing his seatbelt. Almost universally, patients in motor vehicle crashes have a higher survival rate if they are wearing a seatbelt, even if the the vehicular damage is severe.
What happens to a patient when they are in a devastating motor vehicle accident?
The first step in the care of the patient is to get them extracted from the vehichle as quickly as possible. Often this can take up to an hour, depending on how severely the vehicle is deformed.
A prolonged extrication of a patient with serious injuries worsens outcomes as the placing of a breathing tube and gaining intravenous access and starting fluid resuscitation is delayed. The extrication time is always reported to the trauma surgeon by the prehospital team.
On the way to the trauma bay, the prehospital team would attempt to stabilize the patient. This includes intubation (placing a breathing tube in the trachea), inserting large bore intravenous lines, and starting fluid resuscitation with normal saline or lactated Ringer’s solution or blood.
The classic teaching for trauma surgeons upon arrival of a patient in the trauma bay is evaluating a patient using the protocol is known as the ABC’s – an acronym for airway, breathing, and circulation.
A patent (open) airway is needed for the patient to be ventilated and oxygenated. In a situation like Adenhart’s with such devastating injuries, if the airway had not been placed in the field, it would be done immediately either by intubation or cricothyroidotomy.
The assessment of breathing is an assessment of the function of the lungs. This is done by auscultating (listening to) the lung fields with a stethoscope to evaluate whether the breath sounds are heard on inspiration.
Loss of lung sounds in one or both lungs is a sign of pneumothorax, hemothorax, tension pneumothorax, or malposition of the endotracheal tube in one of the main stem bronchi.
In blunt trauma such as Adenhart’s a chest radiography (X-ray) would also be done shortly after arrival to check for pneumothorax or hemothorax.
Circulation is assessed by the heart rate of the patient and the systolic and diastolic blood pressure. The heart rate is usually evaluated by placing monitor leads on the patients chest that send electrical signals similar to a continuous electrocardiogram. The blood pressure is taken initially manually by sphygomanometer (blood pressure cuff), with many trauma programs requiring the first three blood pressure recordings to be manual recordings.
If not already placed in the field, large bore intravenous lines in the antecubital space would be placed. If the patient was hypotensive (low blood pressure) central venous catheters would also likely be placed in the subclavian vein or femoral vein or both.
The traditional teaching is that there needs to be large bore access both above and below the diaphragm.
A blood draw for laboratory tests and blood typing would be done through one of these lines when it is being placed.
If the patient is hypotensive, an immediate search must begin for the source after resuscitation is started.
Most causes of hypotension in the blunt trauma patient are from massive bleeding.
The teaching in trauma states that there are five compartments where a patient can bleed to death from; the chest cavity, the abdominal cavity, the pelvis, the femur, and “on the pavement.”
Bleeding into the chest cavity can occur because of broken ribs lacerating intercostal arteries and veins and tears in the pulmonary arteries and veins, aorta, subclavian vein and arteries, and lung tissue.
Generally, bleeding into the chest cavity is picked up by loss of breath sounds on the side with the blood and/or blood seen in the chest cavity on radiograph. Not all blood in the chest cavity is a cause for operative intervention.
A tube thoracostomy (chest tube placement) is done at bedside in the trauma bay. If there is an initial return of 800cc – 1000 cc of blood operative intervention is warranted.
Bleeding in the abdominal cavity is diagnosed by physical exam (a distended abdomen) and one of several radiology tests. Massive blood loss in the abdomen generally is from fracture of the spleen or liver.
If the patient is stable (systolic blood pressure > 90 mmHg) computed tomography with intravenous contrast dye can be done to image the abdomen. Generally, if this test is done the chest and pelvis are also included.
If the patient is unstable, a FAST (focused abdominal sonogram in trauma) exam would be performed at the bedside in the trauma bay. This is an ultrasound exam that images four areas of the body; the pericaridal space, the liver, the spleen, and the bladder.
It is relatively easy to detect free fluid (presumably blood) in the abdominal cavity with this technique. A patient who is hypotensive with a positive FAST exam is taken emergently to the operating room (see below for an explanation of what happens).
Bleeding into the pelvis that causes hypotension is a condition dreaded by all trauma surgeons. It occurs secondary to fracture of the pelvic bones that tear the nearby arteries and veins.
Pelvic fractures can be diagnosed on examination by gross deformity of the position of the limbs or an unstable pelvis when the pelvis is rocked. A pelvic radiograph is usually obtained very early in the resuscitation (usually at the same time as the chest radiograph).
If the pelvic fracture is of the “open book” type where the bones are splayed apart, an attempt is made to manually reduce the pelvic ring by using a pelvic binder. This sometimes will tamponade the bleeding enough to allow more definitive treatment of pelvic bleeding.
If an experienced trauma orthopedic team is available, an external fixator device can be placed in the trauma bay. This is a series of metal bars that are placed into the pelvic bones and then connected to each other on outside of the patient to hold the fractured bone segments in place
Although not as common as the causes listed above, patients can bleed to death from fractures of the femur if the bone edges lacerate the femoral artery or vein. Usually this cause can be seen on physical exam by a greatly enlarged, deformed leg. Immediate care is to reduce (realign) the fracture and to replace the blood loss.
What happens to a patient when they are taken emergently to the operating room for massive abdominal bleeding?
The patient is placed supine (face up) on the operating room table. The abdominal cavity is opened by making a midline incision from the tip of the sternum to the pubic bone (trauma laparotomy).
If there is a blood return, all four quadrants are packed. This means that laparotomy sponges (similar to dishtowels) are placed throughout the abdomen; next to the liver and spleen and throughout the pelvis.
This universally used maneuver is intended to stop or slow the bleeding and to stabilize the patient’s vital signs. In addition, this will “buy some minutes” to allow for the nursing and anesthesia team to “catch up” on important task such as retrieving blood from the blood bank, getting needed equipment from the stock room, and calling for additional help.
Assuming the packing worked and after the anesthesia and nursing teams are ready, the packs are removed sequentially, with the area of least likely bleeding removed first. This allows the trauma surgeons to decrease blood loss from areas most easily controlled.
Most massive abdominal bleeding that is life-threatening comes from fractures of the spleen or liver. The spleen is the most commonly injured abdominal organ on blunt trauma.
However, if a patient’s life-threatening hemorrhage is from splenic bleeding and they survive to the operating room, death does not usually result. This is because the spleen is relatively easy for an experienced trauma surgeon to remove in just a few seconds, thus eliminating the source of bleeding.
Far more serious to control is a severely damaged liver. Liver injuries are graded on a scale of 1-5, with grades 4 and 5 having a high fatality.
Bleeding from liver parenchyma on the posterior side is often is difficult to control, particularly if the first attempts are not successful and the clotting mechanisms of the body become impaired because of the use of large amounts of blood products or hypothermia (reduced body temperature). This is referred to in trauma as having a surgical bleed become a medical bleed.
To avoid this and in an attempt to improve outcomes, the concept of the damage control laparotomy has emerged. This uses the strategy that on initial surgery the minimum needed to save the patient’s life should be done. The liberal use of packs in the liver if it controls bleeding is encouraged to get the patient into and out the operating room alive and to the intensive care unit where the patient can be warmed and further resuscitation performed.
The difficult situation arises when the bleeding in the liver can not be controlled and the patient remains alive only through massive transfusion. Generally, the patient is then resuscitated sufficiently so they can be moved to the intensive care unit to allow family and friends to visit before the patient dies.
This is a demoralizing and disheartening for the entire trauma team. Universally, it is difficult for trauma surgeons to watch a patient exsanguinate and particularly so when they can not save the life of a patient injured by a drunk driver.