trauma
TRANSCRIPT
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TRAUMAPRIMARY AND SECONDARY SURVEY
+CASE:A 25 year old is brought to casualty with history of fall from a height of 20 feet. He landed on a pile of bricks. Fortunately there was no head injury. He is complaining of severe abdominal pain. On examination he is conscious; his pulse is 110/minute, BP 90/60 mmHg. There is no external wound. However has abrasions in left upper quadrant and left lower chest.
+MECHANISMS OF TRAUMA Trauma can be classified in type by causation and by effect
Blunt , e.g. car bonnet
Penetrating , e.g. Knife
Blast , e.g. Bomb
Crush , e.g. building collapse
Thermal
+Deaths from trauma show three peaks:
Immediate death :
o Occurs within seconds
o Cause : head injury , heart injury or aortic injury
o These deaths are not preventable
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Early death:
o Begins an hour or two after injury
o Cause: subdural and epidural hematomas , hemo or pneumothorax , organ rupture or blood loss
o Often preventable
o This period is called the GOLDEN HOUR during which prompt intervention can save a life
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Late death:
o Occurs many days after injury
o Cause: sepsis or multi-organ failure
o Prompt treatment of shock and hypoxemia during GOLDEN HOUR can reduce these deaths
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STEPS IN ADVANCED TRAUMA LIFE SUPPORT:
Prehospital care
Primary survey with simultaneous resuscitation: identify and treat what is killing the patient
Secondary survey : proceed to identify all other injuries
Definitive care: develop a definitive management plan
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PREHOSPITAL CARE
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Airway maintenance Control of external bleeding & shock Immobilization of the patient Communication with receiving hospital & immediate transport to the closest, appropriate facility History taking
+Prior to arrival: Ensure senior emergency medical and nursing staff are aware of
all available details of the case.
Call Trauma Team (Trauma surgeon , Anaesthetist , Nurses , Emergency physician , Respiratory therapist , Radiologist , Surgical subspecialists)
Delegate specific tasks to appropriate individuals.
Check the resuscitation equipment and prepare intravenous lines and fluids.
If possible, estimate the patient's weight using the formula (Age + 4) x 2 (or 3 x Age for those over 9 years) and calculate:
1) The amount of fluid bolus at 20 ml/kg
2)The endotracheal tube size (age/ 4) + 4
3)Any other drugs likely to be needed
+On arrival:
Immediately perform a primary survey by assessing and managing the patient's airway, with cervical spine stabilisation, breathing and circulation.
Obtain a history, if possible, from the attendents or ambulance officers e.g. type of trauma, speed of the vehicle, height of the fall, restraints or safety equipment used, whether other people were injured.
Obtain information regarding any treatment or interventions to date.
+PRIMARY SURVEY
+Identified the life-threatening conditions and simultaneously manage:
A: Airway maintenance with cervical spine protection
B: Breathing and ventilation
C: Circulation with hemorrhage control
D: Disability ( Neurologic status )
E: Exposure / Environmental control: Undress the patient & prevent hypothermia
+A : Airway and C- spine
A patient who can speak clearly must have a clear airway
Unconscious patient may require airway and ventilatory assistance.
The cervical spine must be protected during endotracheal intubation if a head, neck or chest injury is suspected.
Airway obstruction is most commonly due to obstruction by the tongue in the unconscious patient.
Hoarsness or pain with speaking indicate
laryngeal injury.
* Talk to the patient
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The signs of airway obstruction may include:
snoring or gurgling ( foreign body , aspiration )
stridor or abnormal breath sounds
agitation (hypoxia)
using the accessory muscles of ventilation/paradoxical chest movements
cyanosis.
* Assess airway
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Indications for advanced airway management techniques for securing the airway include:
o persisting airway obstruction
o penetrating neck trauma with haematoma (expanding)
o Apnoea
o Hypoxia
o severe head injury
o chest trauma
o maxillofacial injury
* Consider need for advanced airway management
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Advanced airway management: * * If obstruction persists: - Chin lift and Jaw thrust - Consider C-spine injury in every patient until proven otherwise
•Endotracheal intubation if:- above don’t help - unconscious patient - airway swelling or burns -GCS less than 8
* Surgical Cricothyrotomy (if there is severe facial or neck injury)
+B: Breathing and ventilation
Cyanosis
penetrating injury
presence of flail chest
sucking chest wounds
use of accessory muscles
* Inspection (LOOK) of respiratory rate is essential. Are any of the following present
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tracheal shift
broken ribs
subcutaneous emphysema
percussion is useful for diagnosis of haemothorax (dull) and tension pneumothorax (hyper-resonant)
* Palpation (FEEL) for
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pneumothorax (decreased breath sounds on site of injury)
Detection of abnormal sounds in the chest.
Give 100% oxygen (if available, via self-inflating bag or mask) injury that may acutely impair ventilation
1. Tension pneumothorax 2. Flail chest with pulmonary contusion 3. Massive haemothorax 4. Open pneumothorax
* Auscultation (LISTEN) for
+ Tension pneumothorax
* Respiratory distress
* Over inflated hemithorax and visibly splayed ribs
* Ipsilateral Hyperresonant percussion note
* Ipsilateral reduce or absent breath sounds
* Treacheal deviation
* Distended neck veins
Management: Immediate needle decompression in second Intercostal space midclavicular line
+Open pneumothorax
* Ipsilateral reduced breath sounds
* Ipsilateral resonant percussion note
* Decreased expansion
* Penetrating chest wall injury
Management:
Cover defect - Sterile waterproof three sided dressing secured on two sides to act as a flutter valve.
Intercostal drain placed away from open wound.
Surgical debridement and closure later.
+Massive Hemothorax
* Hypotension due to blood loss
* Ipsilateral dullness to percussion note
* Ipsilateral absent or reduced breath sounds
* Ipsilateral decreased chest movements
Management:
Infusion of fluids through large bore IV cannula before draining
Large bore intercostal drain for adults
+Flial Chest
* Segment of chest looses bony continuity with thoracic cage
* Moves paradoxically with respiration and reduces tidal volume
Management: Analgesia for pain
Fluid management
Ventilatory support
+C: Circulation and hemorrhagic control
Direct pressure for external hemorrhage
No tourniquet unless other methods are not effective in controlling bleeding
Long bones splinted with external fixation
Pelvic binding or pneumatic anti-shock garment
Watch out for hypothermia, acidosis and coagulopathy
* Hemorrhagic control
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Check skin: color , clamminess and capillary refill time
Heart rate
Blood pressure
Pulse pressure
Conscious level
Connect an automatic BP recorder and ECG
Hypovolaemia is the commonest cause of shock in trauma patients
* Assessment for hypovolaemia
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Two Large bore IV cannulas: peripheral i.e. Femoral Vein
Central – Subclavian or Internal Jugular
Intraosseous in children
Draw 20ml blood for grouping and cross matching , analysis of electrolytes and full blood count
*Vascular cannulization
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Bolus of warm crystalloids
Surgical control of hemorrhage is better than aggressive fluid resuscitation
Fluid resuscitation inhibits platelet aggregation , dilutes clotting factors and raises BP
Altered cardiovascular response to hemorrhage in trauma pts
Enough warm crystalloids to maintain a radial pulse
Blood may also be required
* Fluid resuscitation
+D : Disability
Glasgow Coma Scale
Pupilary reflexes
Monitor frequently to detect deterioration
Common causes for deterioration
Hypoxia
Hypovolaemia
Hypoglycemia
Raised intracranial pressure
+E : Exposure
Clothes should be cut to remove
Pt kept warm and covered with blankets
Log roll
Assess spine from base of skull to coccyx
Examine back for any signs of injury
Digital Rectal Examination:
Boney fragments
Rectal wall
Bleeding Prostate
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SECONDARY SURVEY
+ HISTORY
A. Allergies
M. Medications currently used + tetanus status
P. Past illness / pregnancy
L. Last meal / LMP
E. Events / Environment related to injury
+HISTORY : MECHANISM OF INJURY Blunt
Automobile collisions Seat belt usage Steering wheel deformation Direction of impact Ejection of passenger form the vehicle
Burns and Cold injury Inhalation injury and CO. intoxication in fire field
Hazardous environment
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Penetrating Anatomy factors Energy transfer factor
Velocity and caliber of bullet Trajectory Distance
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PHYSICAL EXAMINATION
+HEAD Scalp: lacerations, bruising, depressions or irregularities
in the skull, Battles sign (bruising behind the ear indicative of a base of skull fracture).
Mouth: lacerations to the lips, gums, tongue or palate.
Teeth: subluxed, loose, missing or fractured.
Nose: deformities, bleeding, nasal septal haematoma, CSF leak
Ears: bleeding, blood behind tympanic membrane.
Eyes: foreign body, subconjunctival haemmorhage, hyphaema, irregular iris, penetrating injury, contact lenses.
Jaw: pain, trismus, malocclusion.
+NECK
Cervical spine: pain, tenderness, deformity, inability to move neck;
Soft tissues: bruising, pain and tenderness;
Trachea: deviation, crepitus;
Neck veins: distention.
+CHEST
Chest wall: bruising, lacerations, penetrating injury, tenderness, flail segment.
Lung fields: percussion note, lack of breath sounds, wheezing, crepitations.
Heart: Apex beat, presence and quality of heart sounds.
+ABDOMEN
Abdo wall: bruising, lacerations, penetrating injury, tenderness.
Viscera: splenic, hepatic or renal tenderness, bladder tenderness or enlargement.
Bowel: abdominal tenderness or rebound, absent bowel sounds.
Pelvis: pain on springing.
+LIMBS
Soft tissues: bruising, lacerations, muscle, nerve or tendon damage.
Bones: tenderness, deformities, open fractures.
Joints: penetrating injuries, ligament injuries.
+BACK
Soft tissues: bruising, lacerations
Bones: tenderness, space between vertebrae.
+BUTTOCKS AND PERINIEUM
Soft tissues: bruising, lacerations.
+GENITALIA
Soft tissues: bruising, lacerations.
Urethra: bleeding.
Introitus: bleeding.
+NEUROLOGIC
Determine GCS scoreRe-evaluate pupilsSensory / motor evaluation Maintain immobilizationPrevent secondary CNS injury ( keep stable vital
signs, avoid increased ICP and treat IICP )Early neurosurgical consultation
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INVESTIGATIONS
CBC
Urine output
Urinanalysis
Xray
CT
MRI
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