health-process evidence-based clinical practice guidelines for trauma john lloyd fonte md, alma...

Health-ProcessEvidence-Based

Clinical Practice Guidelinesfor Trauma

John Lloyd Fonte MD, Alma Jawali MD, Robelle PeraltaMDLevel I- Surgery Resident

Michelle N. Galang MD, Jonathan Malabanan MDLevel II- Surgery Resident

Ospital ng Maynila Medical CenterDeparment of Surgery

Clinical Questions

1. What is the operational concept of Trauma?

Trauma -bodily injury severe enough to pose a threat to life or limb

Clinical Questions

2. What are the common causes of trauma?• Motor vehicle crashes • Falls • Burn and fire-related injuries • Intentional trauma (includes all aspects of

violence: homicides, nonfatal assaults, and suicides)

Clinical Questions

3. What are the Classification of Trauma?

–Category 1: major trauma patients–Category 2: significant mechanism of

injury–Category 3: everything else

Clinical Questions

4. What is Category 1 of trauma ?• Does not follow commands – (GCS Motor ≤5)

• Hypotension, even single episode– Systolic <90 in adults of <70 in children

• Penetrating injury to head, neck, torso and proximal to elbows/knees

• Chest injuries with respiratory difficulty

Category 1 of Trauma cont’d

• Two or more femur/humerus fractures• Pelvic fractures• Paralysis, weakness, sensory deficit from

spinal cord injury• Amputation above wrist/ankle

5. What is Category 2 of Trauma?• Death of another occupant in same vehicle• Auto vs. pedestrian/bicycle injury with

significant impact • Pedestrian thrown/run over• Extrication time >20 minutes

Clinical Questions

Category 2 (cont’d)

• Falls > 20 feet• Ejection from vehicle• Vehicle rollover• High-energy crash• Motorcycle crash with separation

Category 2 (cont’d)

• Rigid, tender abdomen• Age <5 or >55 years old• Combination of trauma and burns• Known heart disease, CHF or COPD• Bleeding disorder or taking Coumadin or Heparin• Pregnancy >20 weeks• Amputation of fingers with possibility of

reattachment

Clinical Questions

6. What is Category 3 of Trauma ?

Any patient that does NOT meet criteria for Category 1 or 2

Clinical Questions

7. What are the goals of treatment on patients with trauma?

• Ensure an adequate airway• Adequate oxygenation and ventilation• Monitor for ongoing bleeding

• What are the major components of the initial assemment o a trauma patient?– Primary Survey– Resuscitation– Secondary Survey– Re-evaluation– Definitive care

Clinical Questions

• What is the purpose of a Primary Survey?

– To define life-threatening injuries in a prioritized time frame.

Clinical Questions

• What are the components of a primary survey?

• A Airway control with cervical spine (C-spine) protection

• B Breathing with oxygenation and ventilation• C Circulation with hemorrhage control• D Disability or neurologic status• E Exposure of patient with temperature control

Clinical Questions

• What are the adjuncts to the primary survey?

All trauma patients should receive high-flow supplemental oxygen by nasal cannula or facemask.

Continuous monitoring should include pulse oximetry, cardiac ECG monitor, and a cycled blood pressure cuff.

Two large-bore IV lines are placed as blood is drawn for screening tests, including blood type and crossmatch.

Clinical Questions

Adjuncts to primary survey cont’d

Nasogastric or orogastric tubes are placed for gastric decompression and to prevent aspiration.

A Foley catheter is inserted to assess urine flow and character of urine.

Radiographs should include the "big three" for major trauma "mechanism": cervical spine, chest x-ray, and pelvic x-ray.

• What can prevent unexpected acute deterioration of the trauma patient during initial assessment?

Re-evaluation

Clinical Questions

• How is the airway assessed?Ask the patient a question.

A response in a normal voice suggests that the airway is not in immediate danger.

A hoarse, weak, or stridorous response may imply airway compromise.

Clinical Questions

Airway assemment cont’d

An agitated or combative response indicates hypoxia (agitation or confusion in any surgical patient always means hypoxia)-until proved otherwise.

No response indicates the need for a "definitive airway"(a cuffed tube in the trachea).

• What are the most common causes of upper airway obstruction in the trauma patient?

The tongue, followed by blood, loose teeth or dentures, vomit, and soft tissue edema.

Clinical Questions

• What are the initial maneuvers used to restore an open airway?

• The chin lift and jaw thrust physically displace the mandible and the tongue anteriorly to open the airway, and manual clearance of debris and suctioning of the oropharynx optimize patency.

• Oropharyngeal and nasopharyngeal airways (trumpets) are useful adjuncts in maintaining an open airway in obtunded patients.

Clinical Questions

Clinical Question

• What are the indications for a definitive airway?

• Apnea, inability to maintain or protect the airway (compromised consciousness), inability to maintain oxygenation, hemodynamic instability, need for muscle relaxation or sedation, and need for hyperventilation.

Clinical Question

• What are the types of definitive airway ?

• Orotracheal intubation• Nasotracheal intubation• Surgical airway (cricothyroidotomy or

tracheostomy)

• When should a surgical airway be performed?

In any circumstance in which the patient requires a definitive airway but neither orotracheal nor nasotracheal intubation can be accomplished safely, such as in patients with extensive maxillofacial trauma or high-risk anterior neck trauma.

Cricothyroidotomy should not be performed in patients with direct laryngeal trauma, patients with tracheal disruption, or patients < 12 years old. Tracheostomy and transtracheal ventilation are the preferred alternatives under these circumstances.

Clinical Question

• How does one "clear the C-spine"?

• Alert patients without other significant injuries may be moved without x-rays if they are asymptomatic and have no cervical spine tenderness to direct palpation.

• Patients with symptoms or other major (distracting) injury require a three-view cervical spine series (anteroposterior, lateral, and odontoid) to evaluate the cervical spine.

Clinical Question

• What type of cervical spine collars can adequately immobilize the cervical spine?

• A semirigid (Philadelphia) collar allows 30% normal flexion and extension, > 40% normal rotation, and > 60% lateral movement.

Clinical Question

Clinical Question

• What are the nonairway conditions that pose an immediate threat to breathing?

Tension pneumothorax Open pneumothorax Flail chest

Clinical Question

• What are the key elements in assessing hemodynamic stability?

• Mental status (alert, verbal, pain, and unresponsive),

• Skin perfusion (pink/warm versus pale/cool), and

• hemodynamic parameters (blood pressure, heart rate, respiratory rate).

Clinical Question

• What are the three components to the minineurologic examination during the primary survey?

• Mental status (when you look the patient in the eye, does he look back?),

• pupillary status, and• best motor activity.

Clinical Question

• What is the goal of initial fluid resuscitation?

• The goal of fluid resuscitation is to re-establish tissue perfusion.

Clinical Question

• What are the preferred sites of emergent IV access?

• Peripheral venous access in the upper extremities (i.e., antecubital fossa) with a large-bore 14G or 16G catheter.

Clinical Question

• What fluids should be used for initial resuscitation?

• The mainstay of fluid resuscitation is rapid crystalloid infusion (lactated Ringer's or normal saline).

Clinical Question

• What are the signs and symptoms of shock?

• Tachycardia, hypotension, tachypnea, mental status changes, diaphoresis, and pallor.

Clinical QuestionWhat are the classes of shock and their signs and symptoms?

Clinical Question

• What are the categories of Hypovelemic injured patient based on their response to initial fluid resuscitation?

• Responders• Transient responders• Nonresponders

Clinical Question

• What are “Responder” patients?

Individuals who are stable as evidenced by normalization of their vital signs, mental status, and urine output

Clinical Question

• What are “Transient Responder” patient?

• Patients who regain normal vital signs and then deteriorate.

• Comprise the most complex group with regard to decision making.

Clinical Question

• What are “Non-responder “ patients?

• Individuals who are persistently hypotensive despite adequate fluid resuscitation

• Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma. 2001; 50(2):201-5 (ISSN: 0022-5282)

• Penumothorax Tension and Traumatic; Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Department of Emergency Medicine, Mercy Springfield Hospital ( Medline)

• Traumatic Pneumothorax Detection with Thoracic US: Correlation with Chest Radiography and CT—Initial Experience1 Kevin R. Rowan, MD, Andrew W. Kirkpatrick, MD, FRCSC, David Liu, MD, Kevin E. Forkheim, MD, John R. Mayo, MD and Savvas Nicolaou, MD, FRCPC

• Emanuel, LL, von Gunten, CF, Ferris, FF (eds.). “Module 11: Withholding and Withdrawing Therapy,” The EPEC Curriculum: Education for Physicians on End-of-Life Care. www.EPEC.net: The EPEC Project, 1999. Principles and practice of withdrawing life-sustaining treatment in the ICU. Reubenfeld GD and Crawford SW, in Managing death in the Intensive Care Unit. Curtis JR and Reubenfeld GD (eds) Oxford University Press, 2001 pgs: 127-147.

• Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. Mar 1974;14(3):187-96. [Medline].

• Balogh Z, Offner PJ, Moore EE, Biffl WL. NISS predicts postinjury multiple organ failure better than the ISS. J Trauma. Apr 2000;48(4):624-7; discussion 627-8. [Medline]

• Champion HR, Copes WS, Sacco WJ, Frey CF, Holcroft JW, Hoyt DB, et al. Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation [see comments]. J Trauma. Jan 1996;40(1):42-8; discussion 48-9. [Medline].

• Champion HR, Copes WS, Sacco WJ, Lawnick MM, Bain LW, Gann DS, et al. A new characterization of injury severity. J Trauma. May 1990;30(5):539-45; discussion 545-6. [Medline].

• Champion HR, Sacco WJ, Copes WS. A revision of the Trauma Score. J Trauma. May 1989;29(5):623-9. [Medline].