APPROACH TO TRAUMA. Dr E.Memary Anesthesiologist Assistant Professor of SBMU
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1 APPROACH TO TRAUMA Dr E.Memary Anesthesiologist Assistant Professor of SBMU
2 Objectives Describe the initial approach to the injured patient, including the primary and secondary surveys. Identify the types and clinical presentations of shock. Identify the classes (I, II, III, IV) of hemorrhagic shock. Understand basic principles of initial trauma resuscitation. Understand the aspects of airway management that are unique to the trauma patient. Describe the indications for cervical radiography in the trauma patient. Describe the clinical presentation and initial treatment measures for life threatening injuries.
3 ATLS Trimodal death distribution First peak instantly (brain, heart, large vessel injury) Second peak minutes to hours Third peak days to weeks (sepsis, MSOF)
4 ATLS ATLS focuses on the second peak..deaths from: TBI, EDH, SDH Basilar skull fractures, orbital fractures Penetrating neck injuries Spinal cord syndromes Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries Bladder rupture, renal contusion, renal laceration, urethral injury Pelvic fractures, femur fractures, humerus fracture
5 Concepts of ATLS Treat the greatest threat to life first The lack of a definitive diagnosis should never impede the application of an indicated treatment A detailed history is not essential to begin the evaluation ABCDE approach
6 Trauma Team
7 Primary Survey Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms ABCDEs of trauma care A Airway and c-spine protection B Breathing and ventilation C Circulation with hemorrhage control D Disability/Neurologic status E Exposure/Environmental control
8 A- Airway Airway should be assessed for patency Is the patient able to communicate verbally? Inspect for any foreign bodies Examine for stridor, hoarseness, pooled secretions or blood Assume c-spine injury in patients with multisystem trauma C-spine clearance is both clinical and radiographic C-collar should remain in place until patient can cooperate with clinical exam
9 Airway Interventions Supplemental oxygen Suction Chin lift/jaw thrust Oral/nasal airways Definitive airways RSI for agitated patients with c-spine immobilization
10 Difficult Airway
11 B- Breathing Airway patency alone does not ensure adequate ventilation Inspect, palpate, and auscultate Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds CXR to evaluate lung fields
12 Flail Chest
13 Subcutaneous Emphysema
14 Simple Pneumothorax
15 Breathing Interventions Ventilate with 100% oxygen Needle decompression if tension pneumothorax suspected Chest tubes for pneumothorax / hemothorax Occlusive dressing to sucking chest wound If intubated, evaluate ETT position
16 C- Circulation Hemorrhagic shock should be assumed in any hypotensive trauma patient Rapid assessment of hemodynamic status
17 Primary Survey - Circulation Table Estimated Fluid and Blood Losses Based on Patient's Initial Presentation Class I Class II Class III Class IV Blood loss (ml)* Up to >2000 Blood loss (percent blood volume) Up to Pulse rate < >140 Blood pressure Normal Normal Decreased Decreased Pulse pressure (mm Hg) Normal or increased Decreased Decreased Decreased *Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.
18 Circulation Interventions Cardiac monitor Apply pressure to sites of external hemorrhage Establish IV access 2 large bore IVs Central lines if indicated Cardiac tamponade decompression if indicated Volume resuscitation
19 Resuscitative strategies in traumatic hemorrhagic shock Adrien Bouglé, Anatole Harrois, and Jacques Duranteau.. Annals of Intensive Care 2013,
20
21 D- Disability Abbreviated neurological exam Level of consciousness Pupil size and reactivity Motor function GCS» Utilized to determine severity of injury» Guide for urgency of head CT and ICP monitoring
22 GCS EYE VERBAL MOTOR Spontaneous 4 Oriented 5 Obeys 6 Verbal 3 Confused 4 Localizes 5 Pain 2 Words 3 Flexion 4 None 1 Sounds 2 Decorticate 3 None 1 Decerebrate 2 None 1
23 Disability Interventions Spinal cord injury High dose steroids if within 8 hours ICP monitor- Neurosurgical consultation Elevated ICP Head of bed elevated Mannitol Hyperventilation Emergent decompression
24 E- Exposure Complete disrobing of patient Logroll to inspect back Rectal temperature Warm blankets/external warming device to prevent hypothermia
25 Always Inspect the Back
26 Secondary Survey AMPLE history Allergies, medications, PMH, last meal, events Physical exam from head to toe, including rectal exam Frequent reassessment of vitals Diagnostic studies at this time simultaneously X-rays, lab work, CT orders if indicated FAST exam
27 Diagnostic Aids Standard trauma labs CBC, K, Cr, PTT, Utox, EtOH, ABG Standard trauma radiographs CXR, pelvis, lateral C-spine (traditionally) CT/FAST scans Pt must be monitored in radiology Pt should only go to radiology if stable
28 Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption What should this injury make you worry about?
29 Airway Management Control of Hemorrhage Exploratory: thoracotomy or laparotomy, Pelvic external fixation,neck Exploration Intracranial Mass Excision: EDH,SDH with mass effect Threatened Limb or Eyesight Traumatic near amputation Peripheral vascular Trauma Compartment Syndrome Open globe injury High risk of sepsis Perforated Stomach or bowel Massive soft tissue infection Control of ongoing Hemorrhage Exploratory thoracotomy or laparotomy Wound Early mobilization Closed long bone fixation Spinal fixation Better cosmetic Outcome Facial fracture repair Soft tissue closure
30 Priorities in Orthopedia Life threatening Limb threatening Function threatening
31 Priorities Life threatening - pelvic hemorrhage Limb threatening Function threatening - vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture - distal extremity fx
32 Patients can be generally divided into 4 groups: stable : can be treated with immediate fixation unstable, and in extreme: should be treated with damage control
33 Borderline: most difficult one to define and identify. decision regarding the optimal course of action is most critical complications of the "incorrect" decision are profound.
34 Borderline: In general, the borderline patient has multiple thoracic and abdominal injuries and is suffering from hemorrhagic shock or it s sequel Early total care of major bone fractures in theses patients may be potentially harmful Such patient is probably best treated with damage control
35 damage control emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered
36 A few scenarios deserve special mention
37 femoral fracture external fixation, for reduce the "second hit" injury especially in the setting of bilateral femur fx in the multiply injured patient pelvic ring fx & hemorrhage appropriate skeletal and/or hemodynamic stabilization procedure(s): pelvic binder/external fix, to therapeutic angiography, to emergent open pelvic packing.
38 damage control The timing of definitive fixation of secondary injuries or is also a crucial decision. Most patients treated can be definitively stabilized within one week, but this may depend on the overall physiologic state of the patient. Days 2-4 following the injury have been defined as the time of greatest systemic inflammation and any additional unnecessary surgery should be avoided during this period.
39 What to do? Clinical status? stable borderline unstable resuscitate reevaluate stabilized uncertain ETC?DCO
40 Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics J Trauma Nov;67(5): O'Toole RV, O'Brien M, Scalea TM, Habashi N, Pollak AN, Turen CH.
41 Summary Trauma is best managed by a team approach (there s no I in trauma) A thorough primary and secondary survey is key to identify life threatening injuries Once a life threatening injury is discovered, intervention should not be delayed Decision is determined by the patient s condition as well as available resources.
42 References ATLS Student Course Manuel, 6 th edition. Rosen s Emergency Medicine Concepts and Clinical Practice, 5 th edition. Emergency Medicine A Comprehensive Study Guide, 5 th edition. Resuscitative strategies in traumatic hemorrhagic shock Annals of Intensive Care 2013, 3:1.Adrien Bouglé, Anatole Harrois and Jacques Duranteau
43 References The right team at the right time: Multidisciplinary approach to multi-trauma patient with orthopedic injuries. OPUS 12 Scientist 2012 Vol. 6, No. 1. John A et al.
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