A Good Trauma Examination Gives Your Patient Increased Odds for a Good Outcome druffol@lumc.edu 708.216.4541 Lets Get it Right Trauma is a Disease Importance of Trauma Care and the trauma provider role Apply principles of primary and secondary assessments. Identify management priorities Institute appropriate resuscitation and monitoring procedures Anticipate and manage pitfalls Overview of emerging trends The leading cause of death in the first four decades of life. More than 5 million trauma-related deaths each year worldwide. Motor vehicle crashes cause over 1 million deaths per year. Injury accounts for 12% of the world s burden of disease. 1/3 of trauma deaths are related to blood loss What about this slope? 1
When I can provide better care in the field with limited resources than what my children and I received at the primary care facility there is something wrong with the system, and the system has to be changed. James Styner, MD, FACS 1977 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 Airway with c-spine protection (<C>ABC) Injury Transfer as needed Breathing / ventilation / oxygenation Circulation: stop the bleeding! Primary Survey Resuscitation Adjuncts Optimize patient status Disability / neurological status Expose / Environment / body temperature Reevaluation Detailed Secondary Survey Reevaluation Adjuncts Primary survey and resuscitation of vital functions are done simultaneously using a team approach. 2
TALK TO THEM! 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 A Patent airway Airway Establish patent airway and protect c-spine B Sufficient air reserve to permit speech C Sufficient perfusion to permit cerebration D Clear sensorium Occult airway injury Progressive loss of airway Equipment failure Inability to intubate Aspiration Failure to ventilate Airway should be assessed for patency Is the patient able to communicate verbally? Inspect for any foreign bodies Loss of facial bone buttresses, tracheal deviation Examine for stridor, hoarseness, gurgling, pooled secretions or blood, sub q air Obdundation (CO2)/agitation (PaO2) 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 or cleared radiographically (Hot Area of Nursing Litigation in Trauma Care) Supplemental oxygen Suction Positioning (RT/tracheal fracture) Chin lift/jaw thrust Oral/nasal airways Definitive airways RSI for agitated patients with c-spine immobilization (Caution with SUX) ETI for comatose patients (GCS<8) 3
Advanced Airway Techniques Tracheal intubation LEMON Law Mallampati Classification < 3 has a 95% first try success *WHEN IN DOUBT INTUBATE* *< 8 intubate* Cricothyroidotomy Levels of training are important for determination of the type of airway. Larygneal Mask Airway (LMA) -- better then BVM but not the same as ETT --has a large cuffed cup --cannot slip into the trachea or the esophagus --blindly inserted Requires no laryngoscope There are risks of aspiration Positive pressure ventilation C-spine must be guarded closely Where We See Them Ease to place when patients pinned Flying Doctors have utilized them for years Some hospitals utilize them on their crash carts Videolaryngoscopy Pros: Minimizes neck movement Good at visualizing glottis when neck unable to be moved or mouth unable to be opened wide Cons: Difficult to pass tube Availability 4
Pros: Good visualization Minimal neck motion Cons: Availability Operator dependent Relatively slow The verification is more important then the intubation itself. Direct visualization-- I saw the cords Auscultation-- ~75% accuracy CXR-- time-limiting Pulse oximetry some limitations End-tidal CO2-GOLD STANDARD Patients Should Die With An Airway Surgical airway: The patients physiology is compromised --hypertension/hypotension --bradycardia --hypoxia --hypercarbia --IICP Can they be bagged? Caution with kids < 10 Have they been given short acting medications? Occurs ~ 3% NEAR 2013 Breathing Assess and ensure adequate oxygenation and ventilation LOOK--- LISTEN ---FEEL Respiratory rate Chest movement Air entry Oxygen saturation Breathing Airway versus ventilation problem? Laryngeotracheal injury / Airway obstruction Tension pneumothorax Open pneumothorax Flail chest and pulmonary contusion Massive hemothorax Cardiac tamponade 5
Airway patency alone does not ensure adequate ventilation Inspect, palpate, and auscultate Tachypnea,deviated trachea, flail chest, sucking chest wound, absence of breath sounds Look/feel for symmetry of the chest excursion Look for any defects in the chest wall Palpate for crepitus, sub q air Pulse oximetry (indirect measurement with some limitations) CXR/US to evaluate lung fields Ventilate with 100% oxygen Needle decompression if tension pneumothorax suspected One way valve dressing to sucking chest wound Chest tubes for pneumothorax / hemothorax Evaluate airway again and again Circulation Assess Goal is for Optimization organ perfusion of Tissue Perfusion Level of consciousness Skin color and temperature Pulse rate and character Circulatory Management Control hemorrhage Restore volume Reassess patient Lethal triad Challenging population-meds Fluid resuscitation Massive hemothorax Massive hemoperitoneum Vascular injury Unstable pelvic fracture Look Skin Color (knees please) Listen BP Late sign Level of Consciousness Feel Pulse Perfusion Fractures: Rib Femur Pelvis 100-200 cc 800-1200 cc > 1500 cc Chest cavity: > 1500 cc Retroperitoneum >1500 cc Peds small margin of error: 1 year old child loses 3/4 cup of blood is 25% blood loss classii/iii shock 6
Cardiac monitor Apply pressure to sites of external hemorrhage Establish IV access 2 large bore IVs Central lines if indicated Volume resuscitation Continue to assess the patient for changes in status! Shock should be considered on every Trauma patient- vital signs can be deceiving Types of shock: Hypovolemic loss of blood or plasma *** Cardiogenic The heart is less able to pump blood (tamponade/contusion) Obstructive Physical obstruction reduces cardiac output (tension pneumo) Distributive Disruption to vasomotor tone (SCI) Class I Class II Class III Class IV Blood Loss ml Up to 750 750-1500 1500-2000 >2000 Blood Loss % Up to 15% 15-30% 30-40% >40% Pulse rate <100 >100 >120 >140 Systolic blood pressure Normal Normal Decreased Decreased Pulse pressure Normal Decreased Decreased Decreased Diagnostic Tools FAST DPL/DPA Respiratory rate 14-20 20-30 30-40 >35 Urine output >30 20-30 5-15 Negligible Mental status Fluid (3:1 rule) Slightly anxious Mildly anxious Anxious, confused Crystalloid Crystalloid Crystalloid and blood Confused, lethargic Crystalloid and blood Indications: are likely similar to the indications for DPL. Its major role may be in the rapid diagnosis of hemoperitoneum. Contraindications: to the use of ultrasound are an obvious need for laparotomy and inadequate training or experience of the trauma team member performing the examination. Can anyone identify the following equation? V = 4/3 Π r³ Accuracy: Reports of sensitivity (>90%) and specificity vary. 7
Controversy over use Three advantages Reduce pelvic volume Immobilizes fracture Reduce displacement Indicated in long transport times when exfix not available Institution dependent Inflation pressure < MAP Latin to reanimate or revive Refers to the diagnostic and therapeutic maneuvers used to treat trauma patients Defines restoration of physiologic parameters Reversal of shock Restore volume Improve DO2 Improve microcirculation????? Despite the recent evidence, the American College of Surgeons recommendations for trauma resuscitation still maintain that an initial infusion of LR or NS is the standard of care for the initial treatment of hemorrhagic shock Disability Baseline neurologic evaluation Glasgow Coma Scale score FOUR Score for "Full Outline of UnResponsiveness. Pupillary response Disability Baseline neurologic evaluation-unconscious patient has head injury until proven otherwise Caution Observe for neurologic deterioration-2 nd hit Agitation is not ALWAYS impairment Reassess neuro state after any movement or intervention Pupillary response can change without notice 8
Exposure / Environment Completely undress the patient Caution Prevent hypothermia Missed injuries *Fluid warmers *Ambient temperature *Convection warmers *Head covers *Warmed blankets *Off wet sheets ECG Vital signs ABGs/lactate Consider Early Transfer Urinary output PRIMARY SURVEY Urinary / gastric catheters unless contraindicated Pulse oximeter and EtCO 2 Use time before transfer for resuscitation Do not delay transfer for diagnostic tests Control external hemorrhage with manual pressure, obtain vascular access, and begin volume resuscitation with crystalloids +/- blood Identify source of hemorrhage: ongoing blood loss causing hypotension can usually be found in the chest, abdomen, or retroperitoneum Always protect the C-spine; obtain X-rays once stable Keep them warm Monitor and inform about how much fluid/blood has gone in and what has been lost Look, listen and feel again and again and again Communicate findings and procedures to the scribe clearly Urine is your friend TALK to the PATIENT Get the family in there if possible DOCUMENT DOCUMENT DOCUMENT 9
When do I start the secondary survey? The complete history and physical examination 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 Complete neurologic exam Special diagnostic tests Laboratory studies Re-evaluation History- from patient or others Allergies Medications Past illnesses Last meal Events / Environment / Mechanism Head Maxillofacial External exam Scalp palpation Comprehensive eye and ear exam Including visual acuity Contacts Periorbital edema Unconsciousness Hyphema Optic nerve injury Posterior scalp laceration Occluded auditory canal Bony crepitus Deformity Malocclusion Potential airway obstruction Cribriform plate fracture Cervical spine injury Exsanguinating midface fracture Lacrimal duct lacerations Facial nerve injuries 10
Neurologic: Brain GCS Pupil size and reaction Lateralizing signs Frequent reevaluation Prevent secondary brain injury Early neurosurgical consult Increased intracranial pressure Subdural hematoma Epidural hematoma Depressed skull fracture Spine injury Beware of unconscious patient even if transient! Neck-COLLAR!!!! Mechanism: Symptoms: Findings: Blunt vs penetrating Airway obstruction, hoarseness Crepitus, hematoma, stridor, bruit Esophageal injury Progressive airway obstruction Delayed symptoms and signs Tracheal or laryngeal injury Carotid injury (blunt or penetrating) 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 Hollow viscous injury Retroperitoneal injury 11
Abd Trauma is a common source of traumatic injury Mechanism is important High suspicion with tachycardia, hypotension, and abdominal tenderness Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis Be suspicious of free fluid without evidence of solid organ injury Can be asymptomatic early on FAST exam can be repeated a ANY time 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 Pelvis Pain on palpation Leg length unequal Instability X-rays as needed Vagina Blood, lacerations-tampons Urethral injury****** Pregnancy Excessive pelvic manipulation Underestimating pelvic blood loss 12
Neurologic: Spine and Cord Conduct an in-depth evaluation of the patient s spine and spinal cord Early neurosurgical / orthopedic consult Neurologic: Spinal Assessment Whole spine Tenderness and swelling Complete motor and sensory exams Reflexes-rectal exam Imaging studies Altered sensorium Inability to cooperate with clinical exam Extremities Musculoskeletal Contusion, deformity Pain Perfusion Peripheral neurovascular status** X-rays as needed Potential blood loss Missed fractures Soft tissue or ligamentous injury Compartment syndrome (especially with altered sensorium / hypotension) How Do I Minimize Missed Injuries? Special Diagnostic Tests as Indicated High index of suspicion Patient deterioration Delay of transfer Deterioration during transfer Poor communication Frequent reevaluation and monitoring Think ENERGYmost people are not that lucky! Tertiary Survey 13
Relief of pain / anxiety as appropriate Administer intravenously Careful monitoring is essential but pain must be addressed ABCDE approach to trauma care Do no further harm Treat the greatest threat to life first One safe way A common language 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 Disposition is determined by the patient s condition as well as available resources. (ATLS/ACLS/FCCS) 14