Download Primary Survey - BHS Education Resource

Major Trauma
A standard approach
Ballarat Health Services
Emergency Medicine Training Hub
Learning objectives
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To be familiar with BHS protocols for trauma including trauma teams
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Management of suspected cervical spine injuries
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To understand the Victorian State Trauma System and the role of Ballarat
Health Services in that system.
Pre reading
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Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester,
West Sussex, UK : John Wiley & Sons, 2011. Chapter 8 Trauma; primary
survey. Chapter 9 Trauma; secondary survey. Chapter 10 Major head and neck
injury. Chapter 11 Minor head & neck injury
Refer to ED lecture series and self directed workbooks
Other learning resources
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http://www.health.vic.gov.au/trauma/links.htm
http://www.health.vic.gov.au/trauma/triage.htm
Relevant guidelines for Ballarat Health Services
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Trauma – General Approach
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BHS Intranet Link
http://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-31766~intranet-search
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Trauma Team Activation
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BHS Intranet Link
http://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-32235~intranet-search
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Cervical spine
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BHS Intranet Link
http://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-32499~intranet-search
All available via http://bhsnet/gov-doc-search
Introduction
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Trauma leading cause death 1-40yo
Peak age 15-30
Cost in A$ 11 billion
Up to 40% trauma deaths preventable
Improvements largely due to social education
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Seat belts
Speed limits
Drink driving
Helmets
For each death estimated to be 10 serious
non-fatal injuries
Essence of Trauma Care
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Right patient to the right resources as soon
as possible
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Achieved by:
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Integrated system - ‘Trauma Network’
Seniority or experience of providers
Decision Pathways and education
Trauma Network
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Ministerial Taskforce on Trauma and
Emergency Services - 1997
Victoria State Trauma Network – 1998
ROTES report (Trauma deficiencies) – 1999
Ongoing governance
The Trauma Approach
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Standardisation of approach has helped improve
outcomes
Concept of “Golden Hour”
 50% deaths <1/24 due to major vessel, CNS, spinal
injury
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30% deaths patients major truncal injuries causing
respiratory & circulatory compromise
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benefit from prevention
benefit from prevention and timely intervention
20% die from sepsis, organ failure etc.
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benefit from prevention, timely intervention and possibly from
integrated approach to recovery
Phases of care
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Pre-hospital
Triage
Primary survey
Secondary survey
Disposition
Pre-hospital
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Very little evidence to support major interventions in
the field
Oxygenation
Immobilisation cervical spine
Ventilation (unproven)
Fluids (unproven)
Lights and sirens (increases mortality and
community risk)
Triage to trauma centre
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Physiological
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Pre-hospital treatment requirement
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Anatomical injury/deficits
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Mechanism (high ‘false alarm’ rate)
Triage to trauma centre
Increased risk of death:
 Demographics
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Vital signs
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Age <5 >55
Known chronic (e.g. cardiac/respiratory) disease
BP <90
RR <10 >29
GCS < 13
Trauma score >14
Under-triage (transport to non-trauma centers) more likely if:
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Falls
female gender
age greater than 65 years
Triage to trauma centre
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Injuries
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Penetrating injury to chest, abdomen,
head, neck or groin
Significant injuries to two or more body
regions
Severe injury to head, neck or trunk
Two or more proximal long bone fractures
Burns >15% or involving face or airway
Triage to trauma centre
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Mechanism (high ‘false alarm’ rate)
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High speed >60 kph*
Fall > 6m*
>50 cm intrusion into vehicle
Ejection from vehicle*
Death of other occupant
Rollover*
Pedestrian*
Trauma reception
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Prior warning
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Preparation
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Staff
Area
Paramedical services
Trauma teams
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Team leader
 Overview
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Airway team
 Assess and secure airway
 Control cervical spine
 Ventilation
 NGT
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Scribe
Scout
Radiographers
Resus
Assessment
Communication
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Internal & external
• Assessment
• primary
• secondary surveys
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Procedure team
 IV access & bloods
 IDC
 ICC
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Handover
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Patient should transferred to trauma trolley
prior to hand over
Parallel processing
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Airway and procedure teams commence
assessment
leader receives handover (silent team handover)
Assume the worst & protect against
unforeseen injuries do not focus on obvious
injuries – protocol of ATLS
Primary Survey
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Ac
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B
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C
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D
Primary Survey
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Ac – Airway Assessment (with C-Spine
immobilsation)
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B - Breathing
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C - Cardiovascular
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D – Disability (GCS and don’t ever forget the
glucose)
XRs
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Primary survey
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Airway & cervical spine
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Assess & secure airway
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Patency
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Jaw trust (no chin lift as cervical spine uncleared)
Oropharyngeal airway, nasopharyngeal airway?
RSI
Maintain cervical protection until spine cleared
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Look, listen, feel
In-line immobilization
Consider NGT
Primary survey
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Ventilation/Breathing
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Oxygen is the most important drug in the trauma
room
Ensure adequate ventilation
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Assess adequacy
Exclude pneumothorax, haemothorax
Bag/mask, ETT if required to maintain ventilation
Aim for normocarbia
CXR
Intervention may precede investigation if
required
Primary survey
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Circulation
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Assess adequacy & effect of blood loss
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Conscious state
Pallor
Capillary return
BP
HR
visual estimation of blood loss unreliable
FAST scan – ‘rule in’ test
Primary survey
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Circulation
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Control haemorrhage
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pressure dressings
Tourniquets
Haemostatic dressings
Splinting
Thoracotomy (Cardiac manoeuvres/Aortic
compression)
Theatre
Primary survey
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Haemorrhage classification
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Class
Loss BP HR
RR
CRT UFR CS
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Class I <15%
N/+
N
N/+
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Class 2 <30% N
+
+
+
anx
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Class 3 <40%
++
++
++
leth
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Class 4 >40%
+/-
+/-
++
coma
N
N
N
Primary survey
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Circulation
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Access 2x >16G peripheral IV’s
Fluids initially crystalloid 20mlkg (repeat if
required) warmed
Crystalloid vs colloid (no proven benefit)
Blood O negative
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Class III/IV haemorrhage
Continuing need for crystalloid
Consider need for clotting factors and plateletes ‘1:1:1’
Hypotensive resuscitation
Primary survey
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Disability
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Level of consciousness
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AVPU
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ALERT
VOICE
PAIN
UNCONSCIOUS
GCS – E4M6V5
Pupil response
Don’t ever forget the glucose
Primary survey
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Exposure
Remove
 Clothes
 Jewellery
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Avoid hypothermia
Primary survey
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Monitoring
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Analgesia
Radiology
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ECG, BP, SaO2, GCS +/- ventilator obs
CXR, Cx spine, AP pelvis
IDC traditionally part of 1° survey but
usually done later
Secondary survey
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AMPLE history
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Allergy
Medications
Past history
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Last food
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Event
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Secondary survey
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Head to toe examination – ‘all over and all
holes’
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Look, feel, move, listen
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Log roll
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PR examination
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Consider
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Tetanus toxoid
Antibiotic prophylaxis
Review
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Constantly reassess and review
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Any change repeat 1° survey
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After any corrective procedure repeat 1°
survey
Disposition
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Parallel thinking from before patients arrival
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Direct to appropriate services
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Definitive care made aware of patient
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Discharge with appropriate support
Questions?
Summary
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You are all part of a trauma network
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Education saves lives
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Reassess, reassess, and reassess again
(and intervene if required of course . . .)
Thankyou
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Go and get coffee
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See you in 20mins
Major Trauma
Scenarios
Ballarat Health Services
Emergency Medicine Training Hub
Trauma Scenario 1
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You receive a phone call from the ambulance
service. They have a 27 yr old male involved
in a MCA, he is conscious alert, the car has
rolled he has been ejected from the vehicle.
He has a probable # femur and compound
# tib/fib
How are you going to prepare?
Trauma preparation
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Trauma call
personnel
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trauma team
radiology
pathology
department
equipment
Trauma Scenario 1
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Arrival
history as above
patient conscious, alert,
orientated
HR145 BP100/50 RR30
complaining of severe pain in
R leg
Deformity upper leg and
obvious compound R tib/fib
What is your approach?
Trauma Scenario 1
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Primary survey
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Airway intact
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Breathing decreased air entry L hemi-thorax
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What else would you look for?
Assessment of pneumothorax
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Tension pneumothorax
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RR30
BP100/50
HR145
tracheal deviation
decreased chest movement
venous engorgement
What are you going to do now?
Management tension
pneumothorax
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Needle decompression
Then ICC
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CXR
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re-check ABC
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Trauma Scenario 1
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Once AB stable
re-check C continued hypotension N saline
bolus
D
E
rest of trauma series radiology
analgesia femoral N block + iv analgesia
head to toe examination
Questions?
next case . . .
Trauma Scenario 2
Trauma Scenario 2
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A patient presents following a MCA, the other
driver was killed, she left the scene and
brought herself to hospital. She is
complaining of abdominal discomfort and
back pain.
What is you approach?
Approach to trauma
• Primary survey
• AcBC
• CXR, C-Spine, Pelvis XRs
• Secondary survey
• head to toe
• include log roll (if not already done)
• IDC
• NGT
Primary survey
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primary survey
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Airway normal
Cervical collar applied and immobilised
Breathing RR35, otherwise normal
Circulation HR140 BP100/45
Describe your subsequent management
Hypotensive trauma
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Resuscitate circulation
Hypotensive trauma
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Resuscitate circulation
Analgesia
Hypotensive trauma
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Resuscitate circulation
Analgesia
Exposure of abdomen in 1° survey
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marked seat belt bruising over mid/lower
abdomen
abdomen tender generalised guarding
log roll
 Thoraco-lumbar junction tender with bruising
 PR NAD
Hypotensive Abdominal
trauma
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Surgical registrar review asks for:
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CXR
Lateral lumbar spine
what other injuries are likely?
what further investigations do you require?
What does the patient need?
Reproduced from http://www.radiologyassistant.nl
Hypotensive Abdominal
trauma
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Surgical registrar review asks for:
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What other injuries are likely?
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CXR
Lateral lumbar spine
Upper abdominal visceral injury
What further investigations do you require?
What does the patient need?
Hypotensive Abdominal
trauma
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Surgical registrar review asks for:
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What other injuries are likely?
What further investigations do you require?
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CXR
Lateral lumbar spine
CT
What does the patient need?
Hypotensive Abdominal
trauma
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Surgical registrar review asks for:
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CXR
Lateral lumbar spine
What other injuries are likely?
What further investigations do you require?
What does the patient need?
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Adequate fluid resuscitation – Crystalloid and
Blood
Theatre?
Chance fracture
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Fracture of L1 hyperflexion
Transverse fracture through posterior
elements +/- body
Associated injury to
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pancreas
duodenum 4th part
kidney
liver/spleen
retroperitoneal haemorrage
Hypotensive Abdominal
trauma
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Investigation
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Additional treatment
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CT abdomen dual contrast
NGT, IDC
Tetanus toxoid/Antibiotics if required
police bloods
next of kin
Disposition
Questions?
next case . . .
Trauma scenario 3
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A 20 yr old presents via ambulance after
falling from his motorcycle. He is conscious,
complains of neck discomfort and shortness
of breath.
What is your approach?
Approach to trauma
• Primary survey
• AcBC
• CXR, C-Spine, Pelvis XRs
• Secondary survey
• head to toe
• include log roll (if not already done)
• IDC
• NGT
Primary survey
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Airway - intact
Cervical collar and sand bags
Breathing - limited chest expansion but equal
air entry
Circulation
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HR 70 BP90/50 RR 30
What is the likely cause of this patient’s
hypotension?
Hypotensive trauma
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Loss-haemorrhage
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Redistribution
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eg vasodilatation 2° spinal shock
Pump failure
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internal/external
cardiac contusion
loss cardio-accelerator
Substance use/abuse
Hypotensive trauma response
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Exclude obstruction to venous return
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Fluid bolus
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CXR normal
What now?
Hypotensive trauma
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Repeat fluid bolus if no response
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Debility
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Re-do 1° survey, include ‘D’ in assessment of ‘C’
GCS 15/15
flaccid paralysis of both legs
sensory level at level of upper chest
Priapism
BP 100/50 HR 80
What do you do next?
Hypotensive trauma
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Trauma series X-rays?
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Cervical spine
CXR
Pelvis
Hypotensive trauma
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Trauma series X-rays?
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Cervical spine
CXR
Pelvis
CX spine/CT shows # dislocation at C6/7
Reproduced from JBJS Journal of Bone and Joint Surgery Br June 2006 vol 88-B No.6 771-775
Franz T et al. Br J Sports Med 2008;42:55-58
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
Hypotensive trauma
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Trauma series X-rays?
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Cervical spine
CXR
Pelvis
CX spine/CT shows # dislocation at C6/7
What are the priorities with this patient?
Spinal trauma
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Treatment priorities
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breathing loss of intercostals exhaustion
spinal shock
temperature control
fluid balance important risk of over-filling
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Steroids
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IDC important
controversial increases morbidity
Referral to specialist unit
Referral
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Be familiar with specialist unit provision
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Consider moving to Major Trauma Service
provider early
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Engage retrieval service early with
appropriate detail
Reproduced from Radiopaeia.org
Reproduced from JBJS Journal of Bone and Joint Surgery Br June 2006 vol 88-B No.6 771-775
Questions?
Summary

You are all part of a trauma network

Education saves lives

Reassess, reassess, and reassess again
(and intervene if required of course . . .
And then reassess)
Further reading
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More cases
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http://lifeinthefastlane.com/tag/trauma-tribulation/
Online education resource
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http://www.surgicaltutor.org.uk/defaulthome.htm?core/trauma/spinal.htm~rig
ht
Thankyou
End
Trauma scenario 4
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47 yr old woman presents via ambulance she
was trapped between her car and a car that
reversed into her in the supermarket car park.
She is conscious but confused, complaining
of pain in her “tummy”.
What is your approach?
Primary survey
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ABCx normal
C HR120 BP 80/60 RR 32
Approach to hypotension?
Hypotensive trauma
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Fluid bolus
CXR & CX spine normal
Pelvic Xray shows
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# body pubis with separation anteriorly
# through sacrum
no response to initial fluid bolus
What is the cause of the hypotension?
What is your assessment & management?
Pelvic Fracture
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Open book AP compression pelvic fracture
Hypotension due to haemorrhage
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pelvic veins
other abdominal injury
Approach to pelvic fracture
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secondary survey
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Including AMPLE history
abdominal examination
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tender and guarding lower abdomen
PV blood at meatus
IDC blood
Log roll sacral pain and tender
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approach ?
Pelvic # and Hypotension
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Call orthopaedic Reg ASAP
Repeat fluid bolus +/- blood
close #
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MAST suit
wrap
“C” clamp
Exclude other abdominal organ injury
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CT abdomen dual contrast
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US “FAST”
Image gallery – e.g radiology
First slide with image /question
Image gallery
2nd slide with answer
Summary of learning