Download 05-Trauma

Trauma Care
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Importance of Trauma Care
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Principles of primary and secondary
assessments.
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Establish management priorities.
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ATLS is primarily directed at providing initial care during the
“Golden Hour.”
This is the window of opportunity for the physician to have
the greatest impact on morbidity and mortality of the trauma
patient.
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The leading cause of death in the first four
decades of life. The only way to decrease the
number of death by car accidents is by
prevention.
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More than 5 million trauma-related deaths each
year worldwide.
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Motor vehicle crashes cause over 1 million deaths
per year.
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Injury accounts for 12% of the world’s burden of
Trimodal Death Distribution
• There are three peaks of death from trauma.
• First peak: Immediate – unsurvivable injuries,
impacted by trauma prevention.
• Second peak: Early – golden hour of care,
impacted by early hospital care.
• Third peak: Late – caused by sepsis and
multiple organ dysfunction syndrome
(MODS), impacted by optimal early care and
trauma center management.
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ABCDE approach to evaluation and treatment
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Treat greatest threat to life first before even identifying the
cause or taking history and examination, immediately start
managing.
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Definitive diagnosis not immediately important
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Time is of the essence. Golden hour and this hour is what
predicts the survival of the patient.
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Do no further harm
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ABCDE is the universal language for the
primary exam.
ABCDE is the order in which the injuries will
kill patients.
Definitive diagnosis and an in-depth history
are not required initially.
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation: stop the bleeding!
Disability / neurological status and not orthopedic
status.
Expose from head to toe to look for any other sites
of injuries but be careful of hypothermia /
Environment / body temperature
Injury
Transfer
Primary Survey
Adjuncts
Resuscitation
Optimize
patient status
Reevaluation
Reevaluation
Detailed
Secondary Survey
Adjuncts
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ABCDE is the primary survey, you do not
move to the next step until stabilizing the
step before (step-wise manner).
This should be done by any primary care
physician.
Its better to do everything at the same time
but if you cant prioritize your steps.
As you are resuscitating you reevaluate.
After you reevaluate you move to secondary
survey.
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24-year-old male involved in a motorcycle crash in
to a truck
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Not wearing a helmet
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Arrives at hospital with the red crescent
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BP 80/40, P140, RR 33, and central cyanosis
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C-collar, Oxygen at 8L/min, Dressing to forehead
& thigh soaked in blood
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Has a wrist splint & is on a spinal board
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Apply principles of primary and secondary surveys
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Identify management priorities
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Institute appropriate resuscitation and
monitoring procedures
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Recognize the value of the patient history and
biomechanics of injury
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Anticipate and manage pitfalls
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Cap
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Gown
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Gloves
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Mask
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Shoe covers
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Goggles / face shield
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Note: the first thing to do is
protecting yourself from fluid
splash and needle pricking….
1-4 Standard Precautions
 Standard precautions are one component
of preparing for the patient in the hospital.
 You may query what items are needed to
protect the patient and the trauma team
members.
 Emphasize the need to protect the patient
and trauma team members from
communicable diseases.
Primary survey and
resuscitation of vital
functions are done
simultaneously using
a team approach.
1-5
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Initial Assessment
We recognize that, when a team is
present, many individuals accomplish
disparate tasks simultaneously.
The ABCDE format is somewhat artificial,
but it serves the purpose of establishing
priorities and helping the student to return
to “A” (home base) whenever the
patient’s condition worsens or the patient
does not respond as anticipated during the
initial assessment process.
Primary Survey
Adjuncts
Definitive Care
Resuscitation
Reevaluation
Reevaluation
Detailed
Secondary Survey
Adjuncts
What is a quick, simple way
to assess a patient in 10 seconds?
What is a quick, simple way to assess a
patient in 10 seconds?
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Identify yourself
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Ask the patient his or her name
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Ask the patient what happened
Note: the best way to assess the patient initially is talking to the
patient and asking him about place time and person. If he can talk clearly
that means airway is patent, oxygenation is enough to maintain speaking
and enough blood is going to the brain to maintain its function. If he is
not talking clearly then ABCDE.
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A
Patent airway
B
Sufficient air reserve to permit speech
C
Sufficient perfusion to permit cerebration
D
Clear sensorium
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NOTE:Appropriate Response Confirms….
The patient who fails this simple test needs immediate attention.
Airway with c-spine protection
Breathing with adequate oxygenation
Circulation with hemorrhage control
Disability
Exposure / Environment
The priorities are the
same for all patients.
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ATLS is intended to guide the assessment
and resuscitation of injured patients.
Judgment is required to determine what
procedures are necessary, because not all
patients require all procedures.
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Trauma in the elderly
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Pediatric trauma
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Trauma in pregnancy
Airway
Establish patent airway and protect c-spine
Pitfalls
Occult airway injury
Progressive loss of airway
Equipment failure
Inability to intubate
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Primary Survey: Establish patent airway and protect cspine
Emphasize the need to protect the c-spine during airway
management, especially avoiding the ACLS head-tilt
maneuver.
Cervical collar doesn’t prevent movement, its only there to
remind you and the patient not to move the neck to prevent
spine injury.
Head tilt should not be preformed even if a cervical collar is
there.
Basic Airway Techniques
Chin-lift Maneuver
Without head tilt because its
trauma in which you always
consider the patient having
cervical spine injury until
proven otherwise.
Basic Airway Techniques
Jaw-thrust Maneuver
Preferred because it moves the
jaw and tongue anterioraly
without tilting the head
Advanced Airway Techniques
Orotracheal intubation: tube from the mouth to
the trachea, and it’s a definitive treatment.
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Indications for endo-tracheal intubation:
Airway obstruction by tongue, blood and
secretion.
Unconscious patient.
Glasgow coma scale less than 8.
Breathing
Assess and ensure adequate
oxygenation and ventilation
● Respiratory rate
● Chest movement brief chest
examination.
● Air entry
● Oxygen saturation the most
important i.e. oxygenation is the
most important thing
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Primary Survey: Assess and ensure
adequate oxygenation and ventilation
Attend an adequate oxygenation and
ventilation in the injured patient.
If the patient is receiving high-flow oxygen,
adequate oxygenation is no guarantee of
adequate ventilation.
Breathing
Pitfalls
Airway versus ventilation problem?
latrogenic pneumothorax
or
tension pneumothorax?
Breathing
The Immediate life threatening injuries (must be
ruled out)
● Laryngeotracheal injury / Airway obstruction
● Tension-massive pneumothorax
● Open pneumothorax
● Flail chest and pulmonary contusion
● Massive hemothorax
● Cardiac tamponade
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Laryngeal and major right or left bronchial
injury is more severe than lung injury because
air will go to the least resistant pathway and
will lead to massive pneumothorax.
Diagnosed by putting a chest tube: a lot of air
will come out.
Tension pneumothorax
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When normal physiology is disrupted leading to tracheal shift and
hemodynamic instability.
Its clinically diagnosed: hyper-resonance, decreased chest
expansion,tracheal shift and absent breath sounds.
its not diagnosed by chest x-ray, the x-ray is only used to check if the
tube is in the right position. Another indicator is hearing air entry.
Treatment: needle (12-16G)aka thoracocentesis in the 2nd intercostal
space mid-clavicular line. Always Followed by a chest tube (32-36 “the
larger the number the larger the tube unlike the needle the smaller the
number the bigger the tube) placed in the 5th or 6th intercostal space
anterior or mid axillary line.
Intubation is not used in the treatment because it will make it worse.
Open pneumothorax
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It’s a two way valve communicating to the
outside unlike tension pneumothorax which
is a one way valve in which air comes in and
doesn’t go out.
Air will go in through the wound until the
pressure is equal in and out so no more air
movement will be there.
Treatment is chest tube and dressing the
wound.
Flail chest
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3 broken ribs that are disconnected from the
rest of the chest, with negative pressure
(during inspiration) they get sucked in with
+ve pressure (expiration) they are pushed out.
It affects breathing mechanics, its very
painful, injures the lung causing pulmonary
edema (main problem) worsening hypoxia.
Massive hemothorax
1.2-1.5 L of blood comes out when you put a chest
tube, or 200 cc of blood per hour over 6 hours.
 Treatment: chest tube or surgical intervention but
never conservatively.
 In trauma any fluid is considered blood.
 Cardiac temponade: its an extreme emergency
because the heart is injured. Its treated surgically by
opening the pericardium and looking for the site of
injury. If not treated will lead to shock and cardiac
arrest.
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Functions of
Circulation
Assess for organ perfusion
● Level of consciousness
● Skin color and temperature
● Pulse rate and character (we don’t depend on peripheral pulses.
Note: assess clinically the signs of inadequate tissue
perfusion and do a cardiac examination, examine the
central vessels (carotid, coronaries) instead of focusing
on the patient’s blood pressure.
Circulatory Management
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Control hemorrhage or stop bleeding.
This might be achieved in severe
cases by operative manegement. The
most important. By finding the site of
bleeding.
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Restore volume by giving fluid
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Reassess patient response to
treatment
Elderly
Children
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Lethal triad: hypothermia, acidosis,
coaglopathy.
Athletes
1st priority detect site of bleeding , 2nd
priority stop bleeding , 3rd priority
restore blood volume .
Pitfalls
Medications
Patient may lose blood:
Peritoneal.
Retro-peritoneal.
On the floor- open injury.
Chest
Pelvis (different than the abdomen have a
separate management)
6. Femur (2L of blood will be lost from one femur if
both are injured then 4L (80% of the blood
volume-5L)
7. We don’t lose blood intracranially because small
bleeds will lead to death.
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We rule out bleeding in the abdomen by diagnostic peritoneal lavage,
but this method is time consuming, requires an incision in the abdomen
and needs expertise therefore its replaced by FAST- (used for both
abdomen and chest)
FAST: focal assessment with sonography in trauma. In this method you
look between the liver and the kidney in the right side and between the
spleen and the kidney in the left side.
To rule out chest bleeding you do a thoracocentesis or FAST.
To ruleout pelvic bleeding by examining the pelvis first (if it moves and its
painful indicating a fracture which might lead to large bleeding due to
the presence of large vessels) or by x-ray.
To replace the volume we need 2 large bore I.V
access (12-16G), the bigger the better (12 is the
best).
 The peripheral line is better than the central line (it
has lumen and its very long therefore high
resistance).
 We give 2 L of crystelloids (RL or NS) over 2 mins, if
the patient remains hypotensive you give blood or if
he initially presented with massive blood loss or
blood is available from the beginning.
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Disability
● Baseline neurologic
evaluation
● Glasgow Coma Scale
score
Note: identify neurological
injury using the tools of GCS
score and pupil response
early in order to avoid
secondary brain injury,
identify surgically
correctable lesions rapidly,
and provide a baseline GCS
score to identify trends and
changes.
Disability
● Baseline neurologic
evaluation
● Glasgow Coma Scale
score
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Pupillary response
Disability
Observe for
neurologic
deterioration
● Baseline neurologic evaluation
Glasgow Coma Scale score to check for
consciousness and severity of head injury. (score
range 3-15)
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Pupillary response bilaterally. (reactive, equal and
papilledema). If pupil is non reactive in one side and
unequal in size that’s the lateralization sign meaning
that the patient is bleeding intracranially and
compressing the brain. It starts in one side then
becomes bilateral due to herniation and it’s a surgical
emergency.
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Exposure / Environment
Completely undress the patient and examine the entire
body
(chest, abdomen, limbs…etc) cover the
patient with
Prevent
blankets
hypothermia
to prevent hypothermia
Pitfalls
Missed
injuries
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Log roll is to move the patient as one unit: one person fixes
the head and 2 persons hold the trunk and one for each limb
and one examines the back.
After primary survey, you have to investigate the paint
(imaging, labs)
Cervical spine injury is missed in 50% of the cases on x-ray so
CT is better , x-ray for chest and pelvis ( no x-ray for
abdomen instead FAST or by Diagnostic Peritoneal
Lavage=DPL)
● Protect and secure airway
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Ventilate and oxygenate
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Stop the bleeding!
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Vigorous shock therapy
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Protect from hypothermia
Note: the treatment is administered at the time the life threatening
problem is identified. assessment and treatment during the primary
survey and resuscitation phases of the initial assessment process
often are done simultaneously.
Vital signs
ABGs
ECG
PRIMARY SURVEY
Urinary
output
Urinary / gastric catheters
unless contraindicated
Pulse
oximeter
and CO2
Diagnostic Tools
● FAST
● DPL
Consider Early Transfer
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Use time before transfer
for resuscitation
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Do not delay transfer for
diagnostic tests
The complete
history and
physical
examination
When do I start the secondary survey?
After
● Primary survey is completed
● ABCDEs are reassessed
● Vital functions are returning to normal
What are the components of the
secondary survey?
● History
● Physical exam: Head to toe (regardless
the symptoms), joint by joint because it
might be injured but the patient isn’t
complaining of pain because he is
unconscious.
● Complete neurologic exam
● Special diagnostic tests
● Reevaluation
History
Allergies
Medications
Past illnesses
Last meal
Events / Environment / Mechanism
Mechanisms of Injury
Head
● External exam
● Scalp palpation
● Comprehensive
eye and ear exam
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Including visual
acuity
Pitfalls
Unconsciousness
Periorbital edema
Occluded auditory canal
Maxillofacial
● Bony crepitus
● Deformity
● Malocclusion
Pitfalls
Potential airway obstruction
Cribriform plate fracture
Frequently missed
Neck (Soft Tissues)
Mechanism:
Blunt vs penetrating
Symptoms:
Airway obstruction, hoarseness
Findings:
Crepitus, hematoma, stridor, bruit
Pitfalls
Delayed symptoms and signs
Progressive airway obstruction
Occult injuries
Chest
● Inspect
● Palpate
● Percuss
● Auscultate
● X-rays
Chest
The Potential life threatening injuries
● Blunt cardiac injury
● Traumatic aortic disruption
● Blunt esophageal rupture
● Traumatic diaphragmatic injury
Abdomen
● Inspect / Auscultate
● Palpate / Percuss
● Reevaluate
● Special studies
Pitfalls
Hollow viscous injury
Retroperitoneal injury
Indications for Laparotomy – Blunt Trauma
● Hemodynamically abnormal with
suspected abdominal injury (DPL /
FAST)
● Free air
● Diaphragmatic rupture
● Peritonitis
● Positive CT
Indications for Laparotomy – Penetrating Trauma
● Hemodynamically abnormal
● Peritonitis
● Evisceration
● Positive DPL, FAST, or CT
Perineum
Contusions, hematomas, lacerations, urethral blood
Rectum
Sphincter tone, high-riding prostate, pelvic fracture,
rectal wall integrity, blood
Vagina
Blood, lacerations
Pitfalls
Urethral injury
Pregnancy
Pelvis
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Pain on palpation
Leg length unequal
Instability
X-rays as needed
Pitfalls
Excessive pelvic manipulation
Underestimating pelvic blood loss
Extremities
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Contusion, deformity
Pain
Perfusion
Peripheral
neurovascular status
X-rays as needed
Musculoskeletal
Pitfalls
Potential blood loss
Missed fractures
Soft tissue or ligamentous injury
Compartment syndrome (especially with
altered sensorium / hypotension)
Neurologic: Brain
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GCS
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Pupil size and reaction
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Lateralizing signs
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Frequent reevaluation
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Prevent secondary brain
injury
Early
neurosurgical
consult
Neurologic: Spinal Assessment
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Whole spine
Tenderness and swelling
Complete motor and sensory exams
Reflexes
Imaging studies
Pitfalls
Altered sensorium
Inability to cooperate with
clinical exam
Neurologic: Spine and Cord
Conduct an in-depth evaluation of the
patient’s spine and spinal cord
Early neurosurgical /
orthopedic consult
Special Diagnostic Tests as Indicated
Pitfalls
Patient
deterioration
Delay of transfer
Deterioration
during transfer
Poor
communication
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Tertiary survey: after the patient is fully fine
to identify any small problems that might
have been missed as neck ligament injuries or
MCP joints.
Massive blood transfusion might lead to
massive immunological reaction.
How do I minimize missed injuries?
● High index of
suspicion
● Frequent reevaluation
and monitoring
● Relief of pain / anxiety
as appropriate
● Administer
intravenously
● Careful monitoring is
essential
Which patients do I transfer to
a higher level of care?
Which patients do I transfer to
a higher level of care?
Those whose injuries exceed institutional
capabilities:
● Multisystem or complex injuries
● Patients with comorbidity or age extremes
When should the transfer occur?
Which patients do I transfer to
a higher level of care?
As soon as possible after stabilization:
● Airway and ventilatory control
● Hemorrhage control
Local facility
Transfer agreements
Local resources
Trauma
center
Specialty
facility
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Rapid accurate assessment
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Resuscitate and stabilize by priority
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Determine needs and capabilities
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Arrange for transfer to definitive care
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Ensure optimum care
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ABCDE approach to trauma care
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Do no further harm
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Treat the greatest threat to life first
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One safe way
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A common language
Primary Survey
Adjuncts
Definitive Care
Resuscitation
Reevaluation
Reevaluation
Detailed
Secondary Survey
Adjuncts
Questions