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Management of the trauma
patient
Dr. Zoltan Peto
2010.
The Need
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Trauma is the leading cause of death in the first
4 decades of life in most developed countries.
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3.8 million deaths / year worldwide
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312 million injured / year worldwide
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3 patients permanently disabled / death
ACS
Trimodal Death Distribution
ATLS Concept
● ABCDE approach to evaluation and
treatment
● Treat greatest threat to life first
● Definitive diagnosis not immediately
important
● Time is of the essence
● Do no further harm
● Good recordkeeping is paramonunt!
ATLS Concept
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation: stop the bleeding!
Disability / neurological status
Expose / Environment / body temperature
Initial Assessment /
Management
Injury
Transfer
Primary Survey
Adjuncts
Resuscitation
Optimize
patient status
Reevaluation
Reevaluation
Detailed
Secondary Survey
Adjuncts
Standard Precautions
●
Cap
●
Gown
●
Gloves
●
Mask
●
Shoe covers
●
Goggles / face shield
Initial Assessment
Primary survey and
resuscitation of vital
functions are done
simultaneously using a
team approach.
Concepts of Initial Assessment
Primary Survey
Adjuncts
Definitive Care
Resuscitation
Reevaluation
Reevaluation
Detailed
Secondary Survey
Adjuncts
Quick Assessment
What is a quick, simple way
to assess a patient in 10 seconds?
●
Identify yourself
●
Ask the patient his or her name
●
Ask the patient what happened
Primary Survey
Airway with c-spine protection
Breathing with adequate oxygenation
Circulation with hemorrhage control
Disability
Exposure / Environment
The priorities are the same for all patients.
Primary Survey
Exposure / Environment
Completely undress the patient
Caution
Prevent
hypothermia
Pitfalls
Missed
injuries
Resuscitation
● Protect and secure airway
● Ventilate and oxygenate
● Stop the bleeding!
● Vigorous shock therapy
● Protect from hypothermia
Adjuncts to Primary Survey
Vital signs
ABGs
ECG
PRIMARY SURVEY
Urinary
output
Urinary / gastric catheters
unless contraindicated
Pulse
oximeter
and CO2
Adjuncts to Primary Survey
Diagnostic Tools
Adjuncts to Primary
Survey
Diagnostic Tools
● FAST
● DPL
Adjuncts to Primary
Survey
Consider Early Transfer
● Use time before
transfer for
resuscitation
● Do not delay transfer
for diagnostic tests
What is the secondary
survey?
The complete
history and
physical
examination
Airway
and
Ventilatory
Management
Airway Assessment
Signs and symptoms of airway compromise
High index of suspicion
Change in voice / sore throat
Noisy breathing (snoring and stridor)
Dyspnea and agitation
Tachypnea
Abnormal breathing pattern
Low oxygen saturation (late sign)
Airway Assessment
When to intervene when the airway is patent
● Inability to protect the airway
● Impending airway compromise
● Need for ventilation
Airway Assessment
Impending Airway Obstruction
Airway Management
●
Supplemental oxygen
●
Basic techniques
●
Basic adjuncts
●
Definitive airway
●
●
●
Cuffed tube in the trachea
Rapid sequence induction with C-spine
protection!
Difficult airway adjuncts:
Unexpected/Predicted difficult airway
Airway Management
Definitive Airway
● Surgical airway
● Cricothyroidotomy
Needle
Surgical
Airway Decision
Scheme
What is shock?
Generalized State of Hypoperfusion
Inadequate oxygen delivery
Catecholamines and other responses
Anaerobic metabolism
Cellular dysfunction
Cell death
Signs of shock
● Alteration in level of consciousness, anxiety
● Cold, diaphoretic skin
● Tachycardia
● Tachypnea, shallow respirations
● Hypotension
● Decreased urinary output
Shock
Hypovolemic
● Blood loss
● Fluid loss
vs
Nonhemorrhagic
● Tension
pneumothorax
● Cardiac tamponade
● Cardiogenic
● Septic
● Neurogenic
Interventions
What can I do about it?
Direct pressure /
tourniquet
Reduce
pelvic
volume
Angioembolization
STOP
the
bleeding!
Splint
fractures
Operation
Interventions
What can I do about it?
● Fluid resuscitation
● Vascular access?
● Type?
● Volume?
● Monitor response
● Prevent hypothermia!
Class I Hemorrhage
750 mL BVL (15%)
● Slightly anxious
● Normal blood pressure
● Heart rate < 100 / min
● Respirations 14-20 / min
● Urinary output 30 mL / hour
Crystalloid
Class II Hemorrhage
750-1500 mL BVL (15-30%)
● Anxious
● Normal blood pressure
● Heart rate > 100 / min
● Decreased pulse pressure
● Respirations 20-30 / min
● Urinary output 20-30 mL / hour
Crystalloid,
? blood
Class III Hemorrhage
1500-2000 mL BVL (30-40%)
● Confused, anxious
● Decreased blood pressure
● Heart rate > 120 / min
● Decreased pulse pressure
● Respirations 30-40 / min
● Urinary output 5-15 mL / hour
Crystalloid,
blood
components,
operation
Class IV Hemorrhage
>2000 mL BVL (>40%)
● Confused, lethargic
● Hypotension
● Heart rate > 140 / min
● Decreased pulse pressure
● Respirations >35 / min
● Urinary output negligible
Definitive control,
blood
components
Abdominal Injury
When should you suspect abdominal injury?
Blunt
Penetrating
● Speed
● Weapon
● Point of impact
● Distance
● Intrusion
● Number and location
of wounds
● Safety devices
● Position
● Ejection
Abdominal Injury
Assessment: Physical Exam
● Inspection
● Auscultation
● Percussion
● Palpation
Abdominal Injury
Factors that Compromise the Exam
● Alcohol and other drugs
● Injury to brain, spinal cord
● Injury to ribs, spine, pelvis
Caution
A missed abdominal
injury can cause a
preventable death.
Adjuncts
X-ray Studies
● Blunt: AP chest and pelvis
● Penetrating: AP chest and abdomen with
markers (if hemodynamically normal)
Adjuncts
Contrast Studies
● Abdominal CT
● Urethrogram
● Cystogram
● IVP
● GI studies
Caution
Don’t delay definitive care!
Laparotomy
Indications for Laparotomy – Blunt Trauma
● Hemodynamically abnormal with
suspected abdominal injury
(DPL / FAST)
● Free air
● Diaphragmatic rupture
● Peritonitis
● Positive CT
Laparotomy
Indications for Laparotomy – Penetrating Trauma
● Hemodynamically abnormal
● Peritonitis
● Evisceration
● Positive DPL, FAST, or CT
Early operation is usually the
best strategy for GSW
Pelvic Fractures
Assessment of Pelvic Fractures
● Inspection
● Leg-length discrepancy, external rotation
●
Open or closed
● Palpation of pelvic ring, stability
● Rectal / GU / vaginal exam
● Open or closed? Palpate prostate
Thoracic Trauma
● Significant cause of mortality
● Blunt: < 10% require operation
● Penetrating: 15-30% require operation
● Majority: Require simple procedures
● Most life-threatening injuries are
identified during the primary survey
Thoracic Trauma
What are the immediately life-threatening
chest injuries?
● Laryngeotracheal injury / Airway
obstruction
● Tension pneumothorax
● Open pneumothorax
● Flail chest and pulmonary contusion
● Massive hemothorax
● Cardiac tamponade
Thoracic Trauma
What are the pathophysiologic
consequences of these chest injuries?
● Hypoxia
● Hypoventilation
● Acidosis
● Respiratory
● Metabolic
● Inadequate tissue
perfusion
Manage in
the primary
survey as
identified
Tension Pneumothorax
● Clinical diagnosis,
not by x-ray
● Immediate
decompression
● Needle
● Chest tube
Open Pneumothorax
● 3-sided cover over
defect
● Chest tube
● Definitive operation
Flail Chest and Pulmonary
Contusion
Massive Hemothorax
● Systemic / pulmonary
vessel disruption
● > 1500 mL blood loss
● Flat vs. distended
neck veins
● Shock with no breath
sounds and/or
percussion dullness
Cardiac Tamponade
● Decreased arterial
pressure
● Distended neck veins
● Muffled heart sounds
● Pulseless electrical
activity
Radio antenna
Cardiac Tamponade
A
Secure airway
B
Ventilate and oxygenate
C
Volume resuscitation
FAST, operation
Resuscitative Thoracotomy
When should I consider resuscitative
thoracotomy?
● Patients with penetrating thoracic injury
arriving with PEA may be a candidate
● When a surgeon with appropriate skills
is present
● ED thoracotomy not indicated in blunt
trauma with PEA
Head injury
Monro-Kellie Doctrine
Volume-Pressure Curve
Autoregulation
●
If autoregulation is intact, CBF is
maintained constant between a mean BP of
50 to 160 mm Hg.
●
In moderate or severe brain injury,
autoregulation is impaired so CBF varies
with mean BP.
●
The injured brain is more vulnerable to
episodes of hypotension, causing
secondary brain injury.
Mild Brain Injury
●
●
●
●
●
●
●
GCS score = 13 – 15
History
Exclude systemic injuries
Neurologic exam
X-rays as indicated
Alcohol / drug screens as indicated
Liberal use of head CT
Observe or discharge based on findings
Moderate Brain Injury
●
GCS score = 9 – 12
●
Initial evaluation same as for mild
injury
●
CT scan for all
●
Admit and observe
●
●
Frequent neurologic exams
●
Repeat CT scan
Deterioration: Manage as severe head
injury
Severe Brain Injury
●
GCS score = 3 – 8
●
Evaluate and resuscitate
●
Intubate for airway protection
●
Focused neurologic exam
●
Frequent reevaluation
●
Identify associated injuries
Indications for CT Scan
High Risk
● GCS score still < 15 two hours after injury
● Neurologic deficit
● Open skull fracture
● Sign of basal skull fracture
● Extremes of age
Indications for CT Scan
Moderate Risk
● “Dangerous mechanism”
● Retrograde amnesia > 30 minutes in
duration
● Severe headache
● Vomiting > 2 episodes
Management
Priorities
● ABCDE
● Minimize secondary brain injury
● Administer oxygen
● Maintain adequate ventilation
● Maintain blood pressure
(systolic > 90 mm Hg)
Management
Focused Neurological Exam
● GCS score
● Pupils
● Lateralizing signs
Consult
neurosurgeon
early
Management
Medical
● Controlled ventilation
● Goal: Paco2 at 35 mm Hg
● Intravenous fluids
● Euvolemia
● Isotonic
● Consult with neurosurgeon
● Mannitol
● Use with signs of tentorial herniation
● Dose: 0.25 to 1.0 g / kg IV bolus
Management
Medical
● Other medications
● Anticonvulsants
● Sedation
● Paralytics
Neurological examination before
prolonged sedation / paralysis
Management
Surgical
● Scalp Wounds
● Possible site of major blood loss
● Direct pressure to control bleeding
● Occasional temporary closure
Management
Surgical
Scalp Wounds: Possible site of major blood loss
Direct pressure to control bleeding
● Intracranial Mass Lesion
● Can be life-threatening if expanding rapidly
● Immediate neurosurgical consult
● Hyperventilation / mannitol
● Damage control craniotomy: transfer to
neurosurgeon (rural / austere areas)
Anaesthesia of the trauma patient
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Continue ABCDE in the theatre
Apply monitoring: IABP, ECG, SatO2,
Temperarure, UOP, Airway gases, etc.
Beware of hypovolaemia – reduced amount of
drugs needed
Beware of reduced amount of drugs – awareness
Beware of hypothermia
Intensive care after operation
Good recordkeeping is paramonunt!
Intensive care
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Standard intensive care monitoring
Abdominal pressure monitoring
Fracture site/wound awareness
ABCDE to be continued
Weaning starts with the ventilation
Early tracheostomy if needed
Respiratory / circulatory / renal support
Fluid replacement / blood products therapy
Stabilisation on ICU might be the step before
operation
Intensive care
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Proper pain relief to be given (opioids)
Proper sedation to be given (short acting drugs)
Pressure sore prevention
Gastric ulcer prevention
Thrombosis prophylaxis (LMWH)
Antibiotics if indicated
Early feeding (preferably enteral feeding)
Relatives to be kept informed
Good recordkeeping is paramount!
©ACS