Download Initial assessment of trauma.

Trauma
Why trauma is important
• Death
– Leading cause for first four decades of life.
• Disability
– For every death - two survivors with significant
disability.
• Trauma deaths in Scotland higher than rest of
the UK
Local significance
• Road deaths by council 2014
No of deaths
Council
25
Aberdeenshire
19
Highland
13
Perth and Kinross
12
Lanarkshire and Fyfe
Prevention is better than cure!
Trauma care is not new.
• WW1
– Thomas splint introduced.
– Mortality rate in femoral fractures 80% - 8%.
– Still used today.
• WW2
– Several studies about risk of too much clear fluid and
ongoing haemorrhage.
Conflict often leads to advances in trauma care.
But we are still not getting it right!
Trauma “Who Cares”
• National confidential enquiry into patient
outcome and death (NCEPOD) 2007.
• Report revealed significant deficiencies.
• Up to 30% of deaths potentially avoidable
– Compared to 75/300 unexpected survivors 2006-2008
in Afghanistan.
Trauma “Who cares?”
• What we need to do
– Improve prehospital care
– Use ATLS principles – (Caution!)
– Integration of trauma services - Trauma Networks
– Invest in rehabilitation
– Clinical audit and research
Benefits of improving trauma care?
• Because trauma care involves
– multiple specialities
– Several imaging modalities
– is time critical
It is a good test of a healthcare system as a whole.
• Good trauma systems improve care for non
trauma serious illness.
Advances in trauma care
• Advanced Trauma Life Support (ATLS)
– Structured guidelines to direct initial trauma care.
• BATLS
– ATLS adjusted for the military (battlefield).
• Helicopter Emergency Medical Services
(HEMS/MERT)
– Prehospital care
– Senior doctor led
– With advanced skills, equipment and blood products.
ATLS
• 1976 James Styner (Ortho surgeon) crashed a
light aircraft.
• Wife was killed.
• 3 of his 4 children had critical injuries.
• He triaged and flagged down a car to transport to
the local hospital – closed.
• Dr was called in but the care was variable.
• He developed the ATLS course to standardise
initial trauma care.
ATLS
• Started in the UK in 1988
• In 2007 had
– 16,000 providers
– 1,500 instructors
– 103 centres running 237 courses/year
Further advances in Trauma Care
• What we do is still based on ATLS.
• We have made some changes based on new
knowledge, some from recent conflicts.
• BASICS Responders and Pre-hospital team.
• Major Trauma Network in Scotland.
Things to help us improve
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Standard operating procedures (SOPs)
Checklists
Simulation
Study days
Debrief
Documentation
Audit
– STAG (Scottish Trauma Audit Group)
– TARN (The Trauma Audit and Research Network)
So
• That is the background to why we do it.
• Next is what we actually do.
Trauma management
• Should start from time of injury.
• Golden hour/platinum ten minutes
– Good early care prevents early and late deaths.
– If you get to hospital odds of survival are good.
– Good early care prevents secondary injury and
reduces disability.
– Trauma care should be proactive not reactive.
Pre-hospital
Time of injury
Mechanism of injury
Speed/forces involved
Ejection/pedestrian
Likely serious injuries
Vital signs
Interventions carried out
Pre hospital
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Appropriate tasking
(trauma desk)
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Using most appropriate
resource
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Critical care skills Doctor
if required and available.
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Going to most
appropriate centre.
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Standby call to centre.
Pre Arrival
• Trauma is a team sport
• A Trauma call pre-alerts the
trauma team of a patient.
• Team is made up of ED,
anaesthetics, radiology, ICU
and surgical specialities.
• Equipment and drug set up
takes place prior to arrival.
• An ABC approach for this
helps.
Trauma assessment
• Primary survey
– ABC, detects and treats immediate threats to life.
• Secondary survey
– Identification of all injuries and planned
management.
• Damage control resuscitation and surgery
– Minimise blood loss, maximise tissue oxygenation.
Primary survey
• ATLS
• BATLS
• “ABC” approach
• “<C> ABC”
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• Catastrophic
haemorrhage control
Airway with C-spine control
Breathing with O2
Circ. with haemorrhage control
Disability
Expose and environment
Primary survey
• Although priorities are in a set order in reality
a team approach is used.
• Allows collateral activity.
• Team leadership and communication is vital.
• Good non-technical skills are essential.
• Team need to train together.
Catastrophic haemorrhage control
• Haemorrhage leading cause of death in
military trauma. (ballistic/explosive)
• Delays in treating haemorrhage while
assessing A and B led to deterioration.
• Novel ways of stopping/reducing haemorrhage
led to large increase in survival.
Catastrophic haemorrhage.
(external)
Airway and C-spine control
• Assessment
– Noises
• Speech
• Gurgling
• Stridor
– Visual
• Swelling/deformity
• Vomit/blood/debris
• Airway management
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Manoeuvres
Suction
Adjuncts
Advanced procedures
• RSI
• Surgical Airway
Airway assessment
C-spine
• Assume injury in
– Major trauma
– Reduced conscious level
– Dangerous mechanism
– Injury above clavicles
– Neurological signs
– If distracting injury(s) care in clinical assessment
Breathing and oxygen
• Expose the chest
– Look
• Work of breathing
• Expansion
• Effort
– Feel
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Palpate
Percuss
– Auscultate
ATOMFC
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Airway Obstruction
Tension Pneumothorax
Open Pneumothorax
Massive Haemothorax
Flail Chest
Cardiac Tamponade
Tension Pneumothorax
Circulation - assessment
• Clinical
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Heart rate
Palpable radial pulse
CRT
BP
Pulse pressure narrows
Urine output
Confusion
• Blood tests
– HB
– Lactate
• Imaging
– Ultrasound
– CT
Circulation
• Sites for blood loss – 5 sites
– Chest
– Abdomen
– Pelvis
– Long bones
– Floor
C - Haemorrhage control.
Circulation
Volume replacement
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IV access
IO access
Type of fluid
Amount of fluid
Massive transfusion protocols
Circulation
• Monitoring volume replacement
– Vital signs
– Urine output
– Lactate
• Lethal triad
– Coagulopathy
– Acidosis
– Hypothermia
Disability
• Neurological examination
– AVPU
– GCS
– Pupils
– Tone and reflexes
– Moving all 4 limbs to command?
Expose and Environment
• Expose to allow full examination
• Then cover and keep warm.
DEFG
• Don’t ever forget glucose
Bed side tests
• ECG – Not always requires in the immediate
phase – Stabilise ABC first!
• Arterial blood gas -Ventilatory Failure?
• Urine dip – Gross Renal Injury?
Investigations and Secondary
survey
Traditionally
Primary survey x-rays
• C-spine
• Chest
• Pelvis
Secondary survey
• Meticulous head to toe
• Log roll
• “Spring the pelvis - NO”
• Check all orifices – PR etc.
Modern approach
Ultrasound
• Pneumothorax
• Fast scan
Minimal handling
• Possibly no log roll
CT secondary survey
• NNtB 17
Ultrasound and CT
Transfer and further management
• Theatre
– Operative management (DCS)
• Interventional radiology
– Control of bleeding
• ITU
– ICP monitoring
In summary
• Trauma is the major cause of death in young
people.
• A standardised ABC (CABC) approach identifies
life threatening emergencies.
• A well practiced trauma team is vital.
• Good trauma care depends on multiple hospital
systems.
Silver Trauma
Silver Trauma
Overview:
- Elderly population is expanding (>65 years old)
- Accounts for 20-30% of all major trauma in the
UK
- Almost 50% of injuries occur indoors
- Number one cause of elderly trauma is falls
- Mortality is higher in the elderly (double) even if
the injury is relatively of low severity
- Longer hospital stay: complications & cost
Silver Trauma
Types of trauma in the elderly:
1. Falls: fracture NOF, Colles’ fracture and head
injuries
1. Motor-vehicle Collisions: Increased risk of chest
injuries compared to younger patients
1. Thermal Injuries: Inhalation, scalding and
electrical injuries
Silver ABCDE
A:
Reduced airway clearance due to poor cough and
reduced mucociliary clearance with age
B:
Higher risk of aspiration and infection, reduced
chest compliance, stiffening of chest wall,
declining strength of chest muscles and kyphosis
Reduced ventilation capacity and decreased
response to hypercapnia: respiratory acidosis
Silver ABCDE
C:
- Ischaemic Heart Disease IHD
- Atherosclerosis and high BP
- Cardiac medications: B blockers and warfarin
D:
- Brain shrinks with age: risk of subdural
haematoma
- Altered mental status: acute vs chronic (Senile
Dementia)
Silver ABCDE
E: Thermo-regulation in the elderly trauma victim
- Hypothermia:
Due to temperature control impairment and
reduced subcutaneous tissue
- Infection in the absence of fever: normal or low
temperature
Silver Trauma and Medications
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Anticoagulants
Beta Blockers
Antihypertensives
Opiates
Nephrotoxic medications
Pitfalls in Managing Silver Trauma
• Silver trauma is under-recognised:
**Elderly pts DIE from LESS severe injuries**
• May not report symptoms: higher pain
threshold
• Communication issues: dentures, dementia or
delirium
• Be aware of chronic comorbidities: what
precipitated the trauma?
Pitfalls in Managing Silver Trauma
• Many layers of clothing:
Do not take shortcuts, expose pt adequately to allow full
assessment
• Collateral history is essential to ascertain MOI and need
for further imaging or observation
• Signs of violence or neglect: Is your patient a
*vulnerable adult*
• Be aware of chronic comorbidities: what precipitated
the trauma? Syncope? Melaena?
• Risk of fluid overload: Judicious iv fluid administration
with frequent pulmonary assessment
Warfaranised Head Injury
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Primary Survey: AcBCDE (obtain iv access)
Secondary Survey: full Neurology exam
Analgesia and wound management
Document collateral Hx, GCS and AMT
Check INR
To CT or not to CT?
To admit or not to admit?
Warfaranised HI - CT
CT Head – Indications: NICE 2014
Within 1 hour:
1. GCS <13 on initial assessment
2. GCS <15 at 2 hours
3. Suspected open or depressed skull fracture
4. Signs of basal skull fracture
5. Post traumatic seizure
6. Focal neurological deficit
7. >1 episode of vomiting
Warfaranised HI – CT
CT Head within 8 hours: NICE guidelines 2014
Hx of LOC and/or amnesia and one of the followings:
1. Age >= 65 (silver trauma)
2. Bleeding/clotting disease/on anticoagulants
3. Dangerous MOI (Collateral Hx!)
4. More than 30 min retrograde amnesia
Head Injury on warfarin when to
discharge?
Patient can be discharged home following discussion
with senior Registrar/Consultant if:
1. Completely asymptomatic
2. Normal Neurological examination
3. Normal CT scan
4. INR < 3
5. Has a reliable adult staying with them
6. Head injury advice given (written and verbal)
7. Distance from hospital is reasonable
Take-home message..
• Trauma kills the elderly more than the young
• Elderly patient might conceal a significant
injury – Reassess, reassess, reassess
• Comorbidities and poly-pharmacy complicate
the picture
• Be careful with iv fluids
• Collateral Hx is crucial
• NICE Guidelines: indications for head CT
• When to discharge pts with warfarnised HI
Questions?