TRAUMA TALK NEWSLETTER TRAUMA TALK WINTER 2016 NEWSLETTER E D I T O R : R O O K I E S T E V E N S - NP- C

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1 TRAUMA TALK WINTER 2016 To transfer a trauma patient to St. Joseph s Hospital and Medical Center: Call BEDS (2337) St. Joseph s Hospital Faculty Surgeon s Medical Group Trauma/General Surgery: Dr. Thomas Gillespie Dr. Jordan Jacobs Dr. James Mankin Dr. Kevin McGeever Dr. Scott Petersen Dr. James Russell Dr. Raymond Shamos Dr. Jordan Weinberg Colorectal Surgery: Dr. Ronald Gagliano Dr. David Row ENT Surgery: Dr. Don Headley TRAUMA TALK NEWSLETTER NEWSLETTER EDITOR: WROOKIE I N T E R STEVENS, NP-C E D I T O R : R O O K I E S T E V E N S - NP- C Continuing Education FEBRUARY IN PHOENIX TRAUMA SYMPOSIUM February 9 th and 10 th 2017 Black Canyon Conference Center Phoenix, AZ For registration and payment by credit card, please call ResourceLink Information and Referrals Or visit dignityhealth.org/stjosephs/classes-and-events. Trauma Grand Rounds: Every Tuesday morning, EXCEPT the first Tuesday of the month. Trauma Grand Rounds are held in the El Dorado Conference Room located on the 6th floor of the Neuroscience building. Anyone is invited to attend. The conference takes place from 7:30 to 8:30 am. ATLS Instructor Course: Jan 11-12, 2017 Endocrine Surgery: Dr. Katie Coen Main office: IN THIS ISSUE 01 [Continuing Education] 02 [New Employees] 03 [Hangings] 04 [Holiday Safety] ATLS Provider classes 2017: May 3-4 Aug Dec 6-7 To register, or for any questions regarding ATLS, please Contact Dana Stout, RN at ATCN Courses 2017: May 3-4 Aug Dec 6-7 For any questions regarding ATCN, please contact Tracy Thomas, RN at For your trauma-related educational needs, please contact Dana Stout, RN, Trauma Services Supervisor at Dignity Health Newsletter 5

2 TRAUMA ADMINISTRATION MOVING! The offices for Trauma Administration will be moving sometime in December. Trauma Administration will move to an area within the Emergency Department. The General Surgery offices will be relocated to an area near the PACU across from the Pinnacle Peak elevators. Shane Mangelsdorf, AG-ACNP -BC WELCOME NEW EMPLOYEES Please welcome Shane Mangelsdorf to the Trauma and General Surgery Service. Shane received his nursing degree in He went on to obtain his Master s degree from Grand Canyon University and graduated in Shane has been with St. Joseph s Hospital since June of He has worked in the ICUs and as a SWAT nurse. Upon completing his MSN and NP degree he has moved into his new role as a mid-level provider. Most recently he has worked in the Norton Thoracic Institute. Claire Mankiewicz, PA-C Please welcome Claire Mankiewicz to the Trauma and General Surgery Service. Claire is originally from Colorado but came to Arizona to study Physiology and Spanish at the University of Arizona. After completing her Master's degree at Midwestern University in 2012, she began working with a neurocritical care and stroke practice, where she developed an interest to work with the trauma and critically ill patient population. He has been a great resource within the hospital and we are lucky to have him continue his career with our trauma and general surgery service. Shane loves to snow ski and listens to Texas Country but he mostly enjoys having fun and hanging out with his family. In her free time, she searches for adventure in the outdoors with her husband and two dogs.

3 CASE #1: HANGINGS CASE REVIEWS A 35 year old female was found hanging from the neck from a second floor balcony. She had been hanging for an unknown length of time. She was cut down by neighbors who found her and she fell approximately seven to ten feet from where she was hanging. EMS on scene reported blood pressure of 106/75, heart rate of 80, respiratory rate of 14 and her left pupil was fixed. EMS placed her in cervical spine precautions, started an IV, inserted an OPA and started 100% oxygen. They transported her to the trauma center and reported that her vital signs were stable in route. Upon arrival to the trauma room she had ligature marks around her neck, her GCS was 9 and pupils were reactive bilaterally. She was given sedation, intubated and placed on mechanical ventilation. Her blood pressure was labile for about an hour after presenting to the trauma center. She was admitted to the ICU. CT scans of the cervical spine, thoracic and lumbar spines were obtained and were all negative for fractures, and CT of the head was negative for acute intracranial abnormality, CT angio of the neck showed no obvious vascular injury and no stenosis. There were TMJ degenerative changes on the left with anterior subluxation. X-rays of her lower extremities and pelvis were negative for fractures. Her toxicology screen was negative for alcohol but positive for amphetamines. Appropriate psychiatric and neurology consults were obtained. The next day she was agitated but able to follow commands and could open her eyes. She was extubated on post injury day two and transferred to a floor monitoring unit the next day. She did not have any memory of the events. She continued to improve over the next few days with mild cognitive deficits and was able to be transferred to a psychiatric facility. CASE #2: A 38 year old male was found hanging by a family member. The family had cut him down and upon arrival of EMS he was found to be unresponsive and in asystole with ligature signs around his neck. CPR was started and he was given three rounds of CPR and epinephrine with return of spontaneous circulation. He was transported to the trauma center and upon arrival to the hospital his blood pressure was 66/34, heart rate of 109, respiratory rate of 14 and oxygen saturations of 98%. His GCS was 3 with bilateral fixed and dilated pupils, and he still had no spontaneous movement. He was admitted to the ICU. CT scan of the cervical spine was negative for fractures, CT angio of the neck was negative for vascular or other injury, and CT angio of the head showed no acute intracranial abnormality. An MRI of the brain was obtained on injury day two and findings were compatible with diffuse anoxic injury. There was bilateral uncal herniation and inferior herniation of the brainstem and cerebellum with obliteration of the foramen magnum. His GCS remained at 3 and he was declared to be brain dead on injury day 3. The family requested the patient to be made an organ donor. (Pisanello, Wikipedia.org/wiki/Hanging)

4 Hangings: Hanging is defined as suspension of a person by a noose or ligature around the neck.(4) Hanging has been a common method of capital punishment since medieval times; and still is an official method of execution in numerous countries.(4) Hanging is the second most common type of suicide in the U.S after firearms. Out of 34,500 suicides occurring in 2007, 23% were hangings.(5) Hanging can be classified as complete or incomplete and also as intentional or accidental. In a complete hanging the person has a drop equal to or greater than their own height. The cervical spine fractures and the spinal cord is transected with the drop and the body is suspended off the floor.(3) This usually results in instant death.(3) An incomplete hanging occurs when the person does not experience a high enough drop and a portion of the body is touching the floor.(3) The full weight of the victim is not fully supported by the neck.(1) (epmonthly.com/article/clincal-focus) Intentional hanging is the second most common suicide method among men.(3) Accidental hanging occurs in younger children when they become entangled in crib slats, hanging ropes, drawstrings, drapery cords or other hanging objects.(3) There has been an increase in adolescent accidental hangings from strangulation due to the Choking Game.(1) The Choking Game, also known as Flatline, Space Monkey and Suffocation Roulette, involves voluntary near-strangulation in order to enjoy the altered mental state and physical sensations.(1) In young adults, autoerotic accidents, assault and suicidal depression are common causes.(1) Almost all autoerotic deaths involve men and women are more often victims of strangulation assault then men. (1) Pathophysiology: In complete hangings there is decapitation that occurs with distraction of the head from the neck and torso, fracture of the upper cervical spine, the classic Hangman s Fracture of C2, and transection of the spinal cord. In other methods of mechanical strangulation, such as manual choking, application of a ligature, or postural asphyxiation such as the child whose neck is caught in the slats of a crib; venous and arterial obstruction of flow and decreased cerebral perfusion and hypoxia ensues.(1,3) Vagal collapse secondary to pressure on the carotid sinuses and increased parasympathetic tone results in bradycardia and hypotension.(3,1) Assessment: Physical signs are dependent on how the person was strangled and may include :(1) Neck abrasions, lacerations, contusions, or edema Skin and subconjunctival petechiae above the site of choking Severe pain of the larynx may indicate a laryngeal fracture Mild cough Stridor Muffled voice Respiratory distress Hypoxia (a late finding) Mental status changes (epmonthly.com/article/clincal-focus) Prehospital care includes c-spine stabilization and immediate assessment of the airway.

5 Endotracheal intubation in the field should not be attempted unless the airway is acutely compromised. If respiratory failure or airway obstruction is present, intubation should be performed.(1) Once the patient arrives at a definitive care center assessment and treatment of the airway is of utmost importance. Judicious fluid resuscitation must be considered as these patients are at risk for ARDS and cerebral edema.(1) Monitor for cardiac arrhythmias and consider consultation with ENT, neurology and/or psychiatry in cases of suicide.(1) Complications: Outcomes: Respiratory complications such as ARDS, pneumonia and aspiration Tracheal stenosis Scarring of neck tissue Neurologic issues such as muscle spasms, transient hemiplegia, central cord syndrome and seizures. With spinal cord involvement long-term paraplegia or quadriplegia and short-term autonomic dysfunction may be seen. Psychiatric disturbances such as psychosis, Korsakoff syndrome, amnesia and progressive dementia. Outcomes for those that survive hanging and strangulation depends on the severity of the injury and associated complications.(3) Martin, Weng, Demetriades, et al, queried patients with a diagnosis of hanging injury from the National Trauma Data Bank (NTDB). (7) Demographics, injury patterns and disability at discharge was reviewed using the Functional Independence Measure (FIM) scores for feeding, mobility, and expression.(7) They reviewed 655 patients with mean age of 30 years, and mean injury severity score (ISS) of 9.(7) There were 92 deaths in the emergency department(ed) (14%) and 119 (18%) deaths after admission. Survivors had significantly higher GCS at the scene and in the ED, a lower ED base deficit, and lower ISS compared with non-survivors. Emergency Department GCS < 15 was the strongest independent predictor of hospital mortality.(7) The group of patients who survived to discharge, 84% were functionally independent (FIM = 12), and 10% had severe functional disabilities in feeding, expression, or mobility (FIM < 3).(7) The patients with severe disabilities had a higher incidence of intracranial and chest injuries, however surprisingly demonstrated equal rates of vascular and spinal injury compared to those patient without severe disability. (7) Salim, Martin, Sangthong, et al., looked at a group of near-hanging injuries admitted to a level I trauma center.(6) During this 10 year time period 63 patient were admitted. A total of 12 patients had 17 injuries. Cervical spine injury occurred in about 5% of the patients.(6) They identified four factors that were found to be significantly associated with poor outcome.(6) Systolic blood pressure < 90 GCS < or equal to 8 Anoxic brain injury on CT scan Injury severity score > 15 Interestingly, logistic regression analysis found only anoxia on CT scan to be independently associated with poor outcome. (6) References: 1. Ernoehazy, W., Mills, RJ., et al. Hanging Injuries and Strangulation Clinical Presentation. Jan 19, Rao, D. Hanging. Forensic Pathology (2013) Mansfield, M., McGinty, Joseph. Responding to hanging injuries. Nursing Volume 38(5), May 2008, pp 56cc1, 56cc3. 4. Wikipedia. Hanging. Dec 5, Menne, A., Pryor, P. Clinical Focus: Strangulation and Hanging Injuries. Emergency Physicians Monthly Salim, A., Martin, M., Sangthong, B., et al. Near-hanging injuries: a 10-year experience. Injury May;37(5): Epub 2006 Feb Martin, MJ., Weng, J., Demetriades, D, Salim, A. Patterns of injury and functional outcome after hanging: analysis of the National Trauma Data Bank. Am J Surg Dec; 190(6):

6 (with permission from ESFI.org)