Trauma – initial assessement and

management.

Paweł Grala

Klinika Chirurgii Urazowej, Leczenia Oparzeń, Chirurgii Plastycznej AM w PoznaniuKierownik Kliniki: Prof. dr hab. med. Krzysztof Słowiński

“Trauma” - expression comprising a

spectrum of severity of mechanical violation of tissues, from a little scratch to a multiply

injured patient. - also surgical intervention.

seconds to minutes

minutes to hours GOLDEN HOUR

several days or weeks

Trauma - the leading cause of death in the first four decades of life

Death from trauma has a trimodal distribution:within

•Prehospital – control airway, external hemorrhage, rapid transport

•Primary survey - initial assesement and resuscitation of vital functions, prioritization (based on ABCDEFG)

An organized consistent approach to the trauma patient optimal outcome.

The Advanced Trauma Life Support (ATLS) adopted by the American College of

Surgeons in 1979.

The primary focus of ATLS is on the first hour of trauma management - rapid

assessment and resuscitation THE GOLDEN HOUR

The primary survey –life threatening conditions are identified and management is

begun simultaneously!

• A - Airway maintenance with cervical spine control

• B - Breathing and ventilation • C - Circulation with hemorrhage control • D - Disability: neurological status • E - Exposure: completely undress the patient

Airway / BreathingAll patients should be

transported/treated initially with supplemental oxygen.

• immobilization of the C-spine

• combination of a hard collar and sandbags on opposite sides of the head

Airway / Breathing

• establishing verbal contact with the patient - clear phonation by the patient establishes that the airway is patent.

• further intervention depends on: - neurologic stability - adequacy of gas exchange and the potential for

airway compromise

Neurological Stability • decreased level of consciousness is considered to be

intracranial pathology until proven otherwise (drugs, alkohol)

• brief neuro exam (done during the primary survey): A - Alert V - responds to Verbal stimuli P - responds to Painful stimuli U - Unresponsive • Glasgow Coma Scale (GCS):GCS < 8 requires definite airway intervention to prevent

aspiration pneumonitis, to insure adequate oxygen delivery and to avoid hypercarbia.

If a patient is responding only to painful stimuli or is unresponsive/unconscious, the GCS is or has a high likelihood of being less than 8.

Adequacy of Gas Exchange

• airway patency does not insure adequate ventilation

LOOK• nature of the injury: maxillofacial

trauma/airway burns - potential for airway compromise, obvious airway or chest trauma (sucking chest wounds, flail segments), cyanosis

• tachypnea, use of accessory muscles of respiration or evidence of tracheal shift

Adequacy of Gas Exchange

LISTEN

• stridor upper airway compromise.

• hyperresonance to percussion/lack of air entry pneumothorax

• dullness to percussion/lack of air entry hemothorax.

• bowel sounds in the chest ruptured diaphragm.

Adequacy of Gas Exchange FEEL

• hand over the mouth - feel for air exchange. • Insertion of a finger - sweep to clear the mouth of any

foreign bodies (especially dislodged teeth) and to evaluate for evidence of maxillofacial trauma.

LAB• pulse oximetry - haemoglobin saturation; immediate

feedback pitfalls - motion, peripheral vasoconstriction,

carboxy/methaemoglobinemia. • ABG`s - more complete picture of the patient; feedback on

oxygenation, ventilation and tissue perfusionpitfalls - a defined waiting period (institution dependent)..

Securing the Airway - endotracheal intubation (inspection of th airway, suction of

blood and secretions, bag mask ventillation)- possible spinal cord or direct traumatic tracheal injuries

surgical airway - translaryngeal intubation • Immediate - apnea• Emergent - hypoventilation, significant head

injury, cyanosis• Urgent - burns, maxillofacial injury and cervical

hematomas will likely require a secure airway to prevent upper airway obstruction; chest wall and pulmonary injuries are usually initially well compensated but may eventually require mechanical ventilation

there is often time for a history, appropriate physical exam and cervical radiographs

Securing the Airway

Blind nasotracheal intubation vs direct orotracheal intubation

Determined by the experience of the physician Blind nasotracheal intubation: requires a spontaneously breathing unconscious

or cooperative conscious patient, unacceptable failure rate (35%) - requires 3.7 vs. 1.3 oral attempts, contraindicated if basal skull or mid-face fracture.

can precipitate epistaxis (may interfere with subsequent alternative attempts at intubation if unsuccessful).

high incidence of sinusitis if a tube is left in place greater than 72 hours.

Assume the cervical spine to be unstable until proven otherwise

• up to 50% of patients sustaining C-spine trauma develop neurologic abnormalities (nerve root compression and weakness to quadri- plegia and death).

• 10% of patients with C-spine injury are initially neurologically intact, but develop deficits during the course of emergency care

• risks of airway management

C-spine evaluation

• bone and soft tissue• X-ray exam: „one view is no view”, L-all 7C+Th1

(30% inj.C7Th1), AP-vertical alignment of the spinous and articular process and abnormalities in joint and disc spaces, open mouth view - integrity of the atlanto-occipital and atlanto-axial joints, the odontoid process, oblique – intervert. foramina

• CT• lateral cervical spine - sensitivity of about 85% 92% in a three view series 100% when selective CT scanning is employed

Circulation

• BP• HR Alghevar scheme - quantification of shock: SBP / HR

>1 no or minor clinical symptoms <1 major shock• Pulses• Indirect signs: UA, skin, tachypnoe, altered

consciousness, „empty” periferal veins Large bore IV lines

Circulation

• warmed intravenous infusions

Control: • external hemorrhage• internal hemorrhage:

MAST (PASG) suit

Pelvic binders

Surgery stabilisation secondary survey

Initial assessement

• Chest and abd. PE

• Orthopaedic PE

• Periferial Neurologic PE

• Labs

• X-rays, US, CT

tertiary trauma survey

• ACS definition - a patient evaluation that identifies and catalogues all injuries after the initial resuscitation and operative intervention

• 2 - 50% of combined life threatening and non-life threatening injuries are missed during primary and secondary surveys

• timing is institution specific (typically occurs within 24 h after admission and is repeated when the patient is awake, responsive, and able to communicate any complaints).

• is a comprehensive review of the medical record with emphasis on the mechanism of injury and pertinent co-morbid factors such as age, includes the repetition of the primary and secondary surveys, a review of all laboratory data, and a review of radiographic studies with an attending radiologist