The Management of Trauma. Trauma. Ways of Trauma Management. Why it s important 08/06/2012. RTC s account for most injuries. Injury is a disease
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1 The Management of Trauma RTC s account for most injuries Followed by assaults, drownings, falls, burns Injury is a disease Trauma Trimodal Distribution of Death Laceration : Brain Brainstem Aorta Heart Host = patient Vector of transmission (motor vehicle, firearm, etc) Haemopneumothorax Epidural Subdural Long bone injuries Abdominal injuries Death 0 0 2hrs 4hrs 3weeks Why it s important Ways of Trauma Management Leading Cause of Death for those aged 1 44yrs (in developed countries) 1 million deaths worldwide / year 3% are fatal 6% are permanently disabling ATLS (Advanced Trauma Life Support) EMST (Early Management of Severe Trauma) ETC (European Trauma Course) ATACC (Anaesthesia Trauma and Critical Care) EMSB (Emergency Management of Severe Burns) 1
2 Trauma Rule #1 Anxiety provokes memory loss; so learn a system and stick to it Why? When the chips are down, you may only have your own experience to rely on. When your experience is limited, you need sometime easy to remember and apply Why is ATLS all about? Overall, the tenets are 1. Treat the greatest threat to life first 2. Lack of definitive diagnosis should never impede the application of an indicated treatment for life threatening injury 3. Detailed history is not essential to begin the evaluation of the acutely injured patient What is ATLS? How do we approach major trauma? Structured algorithm designed to prioritise management issues Accepted as the standard of care for initial treatment and management in trauma centers Applicable to both Academic and Rural Settings Preparation Triage Primary Survey (ABCDE s) Resuscitation Adjuncts to primary survey and Resus Secondary Survey Adjuncts to Secondary survey Continued post resus monitoring and R/A Definitive Care A substitute for clinical acumen trust your instinct Most up to date, most evidence based approach (revised q4yrs, most recently 2008) What ATLS isn t? ATLS Overview Primary Survey Reassess Adjuncts Reassess Secondary Survey DO NOT MOVE ON UNTIL YOU ADDRESS THE PROBLEM!!! 2
3 ATLS Primary Survey Airway & C spine Immobilization Breathing Circulation Disability Exposure/Environmental Control Full Vital Signs What do you want prepare before he arrives? 1 SURVEY Airway: Intubation equipment inc. difficult airway cart, drugs, +/ anaesthesia Breathing: RT, bilateral Chest tube set up Circulation: fluids hung, blood ready, level 1 infuser primed, +/ central access, +/ EZIO Adjuncts X ray, FAST, Level 1, Prewarn CT How do we approach major trauma? Preparation Triage Primary Survey (ABCDE s) Resuscitation Adjuncts to primary survey and Resus Secondary Survey Adjuncts to Secondary survey Continued post resus monitoring and R/A Definitive Care SN s 3 ideal ER SpR/Cons +/ Level 1 Call out (T+O, Gen Surg, ITU) FAST provider ED or Radiology Others: CT, OMFS, ENT, etc Who do you want? Trauma Team Activation 6. ER doc discretion Organizing the Trauma Bay What s the best way to mobilise the right people a) Soil your scrubs and hope someone notices and calls for help b) Activate Trauma Callout c) Bleep the speciality ONE leader: only leader should be talking and giving orders ED doc 1 o survey and stabilization THEN trauma junior/ortho/plastics 2 o survey In a small DGH you re it Be decisive Short window of opportunity for sick patients Rapid decision making important Err on the side of being aggressive 3
4 Injury Patterns Learn names and use them Be directive Minimize noise/people in room Close the Loop Verbalise your findings and thought process. i.e. I think he has a tension PTX I m gonna fix it Frontal/Side Impact Side Impact Rear Impact RTC versus pedestrian Adult Paeds RTC Important Historical Features Wt/size vehicle(s) Speed Location of pt in vehicle?ejected Mechanism of accident Amount of damage (esp windshield, steering wheel)?seatbelt (type) Airbag?Other deaths Frontal/Side Impact Rear Impact C spine Injury Chest: PTX, flail, AoDiss Abdo: liver/spleen PelvisHip/knee #/disloc C spine Injury Soft Tissue Injury Neck Motorcycle Same +?helmet Pedestrian vs MVC Speed Damage to windshield Assault Weapon used?trajectory?sexual assault GSW s Type of gun Handgun: low velocity Rifles: high velocity Type of Ammunition Distance shot from Route of Entry Ejection MVC versus Pedestrian No specific pattern, but significant risk of severe injury to all systems Adults triad of Tib/fib/femur Truncal injury Craniofacial injury Peads: tend to be run over 4
5 How do we approach major trauma? Airway Maintenance with Cervical Spine Protection. Preparation Triage Primary Survey (ABCDE s) Resuscitation Adjuncts to primary survey and Resus Secondary Survey Adjuncts to Secondary survey Continued post resus monitoring and R/A Definitive Care * GCS score of 8 or less require the placement of definite airway. *Protection of the spine & spinal cord is an important management principle, but the airway is more important than the cervical spine *Neurological exam alone does not exclude a cervical spine injury. *Always assume a cervical spine injury in any pt with multi system trauma, especially with an altered level of consciousness or blunt injury above the clavicle Primary Survey Easy as ABC A = Airway (with Cervical Spine Control) B = Breathing C = Circulation B R E A T H I N G Breathing LOOK LISTEN FEEL MANAGE Resp effort Resp rate Cyanosis Chest wall movements Flail segment AE = Compare Crepitus Tenderness Chest mvmt 100% oxygen BVM Pulse oximetry Decompress chest Seal open chest wounds Airway LOOK LISTEN FEEL MANAGE Circulation LOOK LISTEN FEEL MANAGE A I R W A Y LOC Facial trauma Upper airway burn Stridor Gurgling Hoarseness Crepitus Tenderness Oedema Trachea midline Cervical Collar Temporise: Suction Jaw Thrust OP/NP airways Remove FB Prepare and perform ETT: draw meds, start iv, get BP/ tools C I R C U L A T I O N Pale Sweaty LOC External Bleeding CRT Raised JV Heart Sounds Murmur Pulse rate, Quality Quick feel of abdomen, pelvis, femurs Obtain HR, BP Cardiac and BP monitors Two large iv.s Pressure to external bleeding Bolus crystalloid Blood Consider SOURCE OF BLEEDING 5
6 Rule 17 : Short and thick does the trick Flow = P π r⁴ 8 η L P = pressure difference r = radius of cannula η = viscosity of the liquid L = length of cannula Pupils Disability GCS E V M AVPU A : Alert V : Responds to Vocal stimuli P : Responds to Painful stimuli U : Unresponsive to all stimuli C = circulation Hemorrhage Classification : Exposure/Environment/Full Vital Signs Class I Hemorrhage : up to 15% loss Class II Hemorrhage : 15 30% loss Class III Hemorrhage : 30 40% loss Class IV Hemorrhage : >40% loss Fully Expose patient Prevent heat loss, warm blankets, warm fluids Normal Blood Amount: Normal adult blood volume : 7% of body weight Normal blood volume for child : 8 9% of body weight How much fluid? Crystalloid (Hartmans / Ringers Lactate ideally warmed) 1 2 L Then blood products Massive transfusion protocols? Preparation Triage Primary Survey (ABCDE s) Resuscitation Adjuncts to primary survey and Resus ATLS overview Secondary Survey Adjuncts to Secondary survey Continued post resus monitoring and R/A Definitive Care Packed cells : FFP : LR 1:1:1 6
7 Adjuncts X rays: which ones do you want CT Blood Work: which ones do we get routinely Foley, NG: do we need the NG? FAST/dpl: Who can do it? More to come in the future. Primary Survey What are six(seven) life threatening injuries you need to identify and Rx in the primary survey? Airway: Obstruction Breathing: Tension PTX Open PTx Massive Hemothorax +/ Flail Circulation Cardiac Tamponade (?Beck s) Life Threatening Bleeds CXR X rays C spine(we ll come back to this)? Pelvis Do we need to this in every trauma patient? Order others you deem necessary (but if unstable prioritize them until after secondary survey) Secondary Survey Does not begin until the primary survey (ABCDEs) is completed, resuscitative effort are well established and the pt is demonstrating normalisation of vital sign. Head to Toe evaluation & reassessment of all vital signs Utility of FBC Pathology Hb helpful if low, not helpful if normal Initial Hb functions more as baseline WBC who cares Plts helpful if low Coags Probably useful, some good evidence for HI,?elderly PHYSICAL EXAMINATION 1. Head Visual acuity Pupillary size Hemorrhage of conjunctiva and fundi Penetrating injury Contact lenses(remove before edema occurs) Dislocation of lens Ocular movement 7
8 2. Maxillofacial Injury no NG tube, definite airway? 3. Cervical Spine & Neck *Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine. 4. Chest *elderly pt are not tolerant of even relatively minor chest injury. *Children often sustain significant injury to the intrathoracic structure without evidence of thoracic skeletal trauma. 1/ Abdomen *excessive manipulation of the pelvic should be avoided. 6. Perineum/rectum/vagina 7. Musculoskeletal 8. Neurologic * Protection of spinal cord is required at all times until a spine injury excluded, especially when the pt is transfer. 8
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Kinetic Energy Energy in Motion KE = Mass (weight) X Velocity (speed)² 2 Double Weight = Energy Double Speed = Energy IS THE GREATEST DETERMINANT
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55-year-old male with 2nd and 3rd degree burns to face, chest, and arms on 25% of the body Respirations: 34 Pulse: 120 Mental Status: moans to painful stimulus Mucous membranes charred Stridor 10 cm scalp
Chapter 29 - Chest Injuries
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