MANAGEMENT OF TRAUMA

GOLDLIN BEAULAH.ACLINICAL INSTRUCTOR -ED

TODAYS DISCUSSION…….• Definition of trauma• Trimodal distribution of trauma death• Mechanism of injury• Initial assessment and management of trauma

ARE YOU AWARE?• Every day 16,000 people die from trauma• Trauma accounts for 16% of global burden of disease.• It also accounts for 2.7 million hospital admissions per

year in US • WHO predicts by 2020, RTA will be second leading

cause of death

ARE YOU AWARE? • 5.8 MILLION DEATHS PER YEAR

• 3.2% MORE DEATHS THAN HIV ,TB , MALARIA COMBINED

WHAT IS TRAUMA?????• THE TERM DERIVED FROM THE GREEK FOR WOUND• IT REFERS TO ANY BODILY INJURY• IT DEFINED AS TISSUE INJURY DUE TO DIRECT EFFECTS

OF EXTERNALLY APPLIED ENERGY,ENERGY MAY BE MECHANICAL,THERMAL,ELECTRICAL,ELECTROMAGNETIC OR NUCLEAR

• INCLUDED:BURNS,DROWNING,SMOKE INHALATION,SLIP & FALL.

• EXCLUDED:POISONING/TOXIC INGESTION

TRIMODAL DISTRIBUTION OF TRAUMA DEATH• FIRST PEAK :SECONDS-MINUTES HEART,BRAIN,LARGE VESSEL &SPINAL CORD INJURY BEST TREATED BY PREVENTION• SECOND PEAK:MINUTES-HOURS EPI/SUB DURAL HEMATOMA,HEMO/PNEUMO

THORAX,SPLEEN/LIVER INJURY BEST TREATED BY APPLYING PRINCIPLES OF ATLS• THIRD PEAK:DAYS-WEEKS SEPSIS,MSOF DIRECTLY CORRELATED TO EARLIER TREATMENT

MECHANISM OF INJURY• BLUNT TRAUMAINJURIES IN WICH TISSUES ARE NOT PENETRATED BY EXTERNAL OBJECT

• FALLS FROM HEIGHT SEVERITY OF INJURIES IMPACTED BYo HEIGHTo POSITIONo SURFACEo PHYSICAL CONDITION

• PENETRATING TRAUMA INVOLVES DISRUPTION OF SKIN AND TISSUES IN A FOCUSED

AREA

• GUNSHOT WOUNDS• SEVERITY DEPENDS ON DISTANCE OF VICTIME TYPES OF TISSUE STRUCK

• MOTOR VEHICLE CRASHES

• IMPACT PATTERNS FRONTAL OR HEAD ON IMPACTS

LATERAL OR SIDE IMPACTS

ROLLOVERS

• PEDESTRIAN INJURIES

WHAT CAN BE DONE ABOUT THESE DEATHS?

• MOST OF THE TRAUMA RELATED DEATHS ARE PREVENTABLE AND ITS HIGH TIME TO REALISE THIS FACT

INITIAL ASSESSMENT AND MANAGEMENT

• 1. Preparation• 2. Triage• 3. Primary Survey (ABCDEs)• 4. Resuscitation • 5. Adjuncts to primary survey & resuscitation• 6. Secondary Survey (head to toe evaluation & history)• 7. Adjuncts to secondary survey• 8. Continued post-resuscitation monitoring & re-evaluation• 9. Definite care.

1.PREPARATION• Pre hospital phase• Notify receiving hospital• Send to the closest, appropriate facility• In hospital phase• Team assembly• Equipment's made readily available• Ancillary departments informed• Hospital personal protection

PRE HOSPITAL INFORMATION &HAND OVER• M-I-S-T• MECHANISM OF INJURY• INJURIES SUSTAINED OR SUSPECTED• SIGNS- VITALS ON SCENE AND DURING TRANSPORT• TREATMENT INITIATED

PREPARATION FOR PATIENT ARRIVALAIRWAY DOCTOR

CIRCULATION NURSE

AIRWAY NURSE

CIRCULATION DOCTOR

ORTHO REGISTRAR

SOCIAL WORKER

TEAM LEADER

SCRIBE NURSE

RADIOGRAPHER

TEAM LEADER CHECKLIST• TRAUMA TEAM ACTIVATION PRIOR TO

ARRIVAL• UNIVERSAL PRECAUTION IN PLACE• LEAD GOWNS IN PLACE• WARMED IV FLUID HANGING• O-VE BLOOD READY,BLOOD WARMER

&RAPID INFUSER READY• OR NOTIFIED• RADIOLOGY NOTIFIED

PRINCIPLES OF INITIAL ASSESSMENTAPPLY

APPROPRIATE MONITORING

DEVICES

OBTAIN HISTORY A-M-P-L-E

&TETANUS STATUS

RAPID PRIMARY SURVEYSIMULTANEOUS

MANAGEMENT OF LIFE THREATENING INJURIES

AMPLEALLERGY

MEDICATIONPAST HISTORY

LAST FOODEVENTS

PERFORM DETAILED

SECONDARY SURVEY(HEA

D-TOE)

TRANSFER FOR DEFINITIVE

CARE

2.TRIAGE• Sort patients by level of acuity (CTAS)

3.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

DON’T GET DISTRACTED WITH UGLY “INJURIES”

SPECIAL GROUPS1. PEDIATRICS• Same Priorities and Approach• Need for different amounts of fluids and medications• Need for equipment of varying sizes2.PREGNANT WOMEN• Same Priorities and approach• Anatomic and physiologic changes• Potential two patients not one• “TREAT THE MOTHER TO TREAT THE FETUS”

3.ELDERLY• Diminished physiologic reserve• Comorbidities• Heart disease, Diabetes, lung disease• Multiple medication use• Increased risk of death for any given

injury compared to younger patient

AIRWAY ASSESSMENT AND C-SIPNE CONTROL

• Airway should be assessed for patency• Is the patient able to communicate verbally?• Inspect for any foreign bodies• Examine for stridor, hoarseness, gurgling, pooled secretions or

blood • Assume c-spine injury in patients with multisystem trauma• THE MANTRA BEING”AIRWAY MANAGEMENT WITH CERVICAL SPINE

STABILISATION”

MILS- MANUAL IN LINE STABILISATION• INDEX FINGERS IN THE

EXTERNAL AUDITORY CANAL

• PALMS ON THE PARIETAL BONE

• THUMBS ON THE FORE HEAD

• REMAINING FINGERS UNDER THE MASTOID PROCESSES

• WITHOUT APPLYING AXIAL TRACTION

PATIENT CONSCIOUS ORIENTED

FAILS TO RESPOND APPROPRIATELY(DROWSY OR UNCONSCIOUS)

THREATENED AIRWAY

MANDATORY INTUBATION

1. GCS<92. SEVERE FACIAL

INJURY OR BLEED3. SEVERE FACIAL

OR NECK BURNS

CONSIDER INTUBATION1. COMBATIVE

PATIENTS2. GCS -9-123. FACIAL OR NECK

INJURY WITH IMPENDING AIRWAY COMPROMISE(PENETRATING INJURY)

YES (VOCALISES NORMALLY)

ASK TO TAKE DEEP BREATHSASSESS UPPER AIRWAY,

CHEST EXPANSION

SUPPLEMENTAL O2

CERVICAL COLLAR

• PRE-INTUBATION-• SUPPLEMENT OXYGEN• OROPHARYNGEAL SUCTION• JAW THRUST• ORO-PHARYNGEAL AIRWAY

• RAPID SEQUENCE INDUCTION AND ENDO-TRACHEAL INTUBATION

• DIFFICULT AIRWAY ANTICIPATED-• AIRWAY INJURY• HEAD AND NECK INJURY• SHORT NECK• REDUCED MOUTH OPENING

• SURGICAL AIRWAY• CAN’T INTUBATE• DISTORTED ANATOMY

• IN FAILED INTUBATION – LMA AS BRIDGE

• ADVANCED AIRWAY TECNIQUES-• FOB• specialized laryngoscopes• Bougies• double lumen tubes• Laryngeal injury-immediate tracheostomy• At least 3 assistants required FOR INTUBATION-• MILS• cricoid pressure• DRUGS

BREATHING AND VENTILATION• Do not confuse airway problem for ventilation problem• Patent airway does not equal adequate ventilation.• Need good gas exchange• Oxygen in• CO2 out• Rapid assessment of• RR• SPO2• TRACHEA• CHEST EXPANSION• PERCUSSION• AUSCULTATION

BREATHING WITH SUPPLEMENTAL OXYGEN• INSPECT:Equal chest rise, paradoxical chest movements,sucking chest wound, distended neck veins

• AUSCULTATE: equal breath sounds, absence of breath sounds

• PALPATE:Trachea,chest wall tenderness, subcutaneous emphysema, sternal and rib fracture

• PERCUSS:dullness,hyperresonance• If you think about giving oxygen, GIVE IT!!!!!

TENSION PNEUMOTHORAX• RESPIRATORY DISTRESS• HYPERINFLATED CHEST• DEVIATED TRACHEA• DECREASED MOVEMENT• DECREASED BREATHSOUND• TACHYCARDIANEEDLE THORACOSTOMY VIA 2ND ICS IN MCL FOLLOWED BY DEFINITIVE CHEST TUBE (4TH- 5TH ICS JUST ANTERIOR TO MAL CONNECTED TO WATER UNDER SEAL DRAIN)

MASSIVE HEMOTHORAX• SIGNS SIMILAR TO TENSION

PNEUMOTHORAX EXCEPT DULLNESS ON PERCUSSION

• SHOCK• T/T- TUBE THORACOSTOMY• THORACOTOMY IN• >1500ml DRAIN IMMEDIATELY• >200ml/hr FOR 4 HOURS• CONTACT CTVS EARLY.

FLAIL CHEST• >2 RIB FRACTURESIN 2 OR MORE PLACES• PARADOXICAL CHESTWALL MOVEMENT• ADEQUATE VENTILATION• REEXPAND LUNGS: INTUBATION, IPPV,

CTVS CONSULTATION

CIRCULATION AND HEMORRHAGE CONTROL• ASSESS-• PULSE RATE AND CHARACTER• SKIN COLOUR AND TEMPERATURE• CONSCIOUS LEVEL(GCS)• CAPILLARY REFILL TIME• DECREASED URINE OUTPUT• HYPOTENSION-A LATE SIGN WHEN≥ 30% BLOOD VOLUME

LOST.

• Stopping the bleeding: most important priority

IDENTIFY• External hemorrhage• Apply direct pressure• Be aware of possible sources of

internal bleeding both from blunt and penetrating trauma

Primary Survey - Circulation

MANAGEMENT OF CIRCULATION• Control bleeding with direct

pressure • Splint limb fractures• Insert 2 large bore IV cannulas

in adults • Send off blood-cross match,

coagulation screen,Hb, hct,biochemistry,blood alcohol level if req

• Intraosseous needle in children up to 10 yrs.

• Fluid replacement: adults up to 2-3 lt crystalloid/colloid,

• Children 20 ml/kg• Blood replacement• O neg,group specific or fully cross

matched packed cells• Remember other blood product

requirements: ffp, cryoppt, platelets

DISABILITY AND NEUROLOGIC STATUS• DISABILITY assessed by AVPU scale• A. Alert i.e. Obeys commands• V. vocalizes-inappropriate or incomprehensible• P. Responds to pain• U. Unresponsive• NEUROLOGIC ASSESSMENT-GCS SCALE, pupil reaction to light, limb

movement

Consider possible injuries-depressed skull fractures, SDH, SAH, DAI, spinal injury

Clearing the cervical spine-no spinal tenderness, normal conscious state, normal neurological examination, no major distracting injury,. Collar may be removed and no further investigation required

GLASGOW COMA SCALE Variables Score Eye opening Spontaneous To speech To pain None

4321

Verbal response Oriented Confused Inappropriate words Incomprehensible sounds None

54321

Best motor responsObeyscommands Localizes pain Normal flexion abnormal flexion Extension None

654321

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

E- Exposure• You can’t treat what you don’t find!• If you don’t look, you won’t see!• Logroll the patient to examine patient’s back• Maintain cervical spinal immobilization• Palpate along thoracic and lumbar spine• Minimum of 3 people, often more providers required• Avoid hypothermia• Apply warm blankets after removing clothes• Hypothermia = Coagulopathy• Increases risk of hemorrhage

Always Inspect the Back

Trauma Logroll• One person = Cervical spine• Two people = Roll main body• One person = Inspect back and

palpate spine

3.RESUSCITATION• Protect/Secure airway & protect C-spine • Breathing/Ventilation/Oxygenation• Vigorous shock therapy• At least two large - caliber IV line• Crystalloid solution ( Ringer’s lactate 2~3 litter)• Type-specific blood• surgical intervention• Protect from Hypothermia : 39oC warm IV fluid• Urinary/gastric catheters unless contraindication

4.PRIMARY SURVEY ADJUNCTS:- MONITOR• VITALS• ECG• FOLEY’S CATHETER• GASTRIC TUBE• ABG• PULSE OXIMETER• URINE OUTPUT

Apply appropriate monitoring device

GASTRIC TUBE• RELIEVE GASTRIC DILATATION• DECOMPRESS STOMACH BEFORE DPL• REDUCE RISK OF ASPIRATION• N.G TUBE – C.I. IN BASILAR SKULL #

DIAGNOSTIC PROCEDURES

CASE STUDY• A PATIENT BROUGHT TO E.D.

WITH• M- CAR DRIVER HIT TREE ON

ROAD SIDE(UNDER INFLUENCE OF ALCOHOL)

• I- HEAD AND CHEST• S- PR- 100/MIN; BP-90/60mm Hg;

RR- 30/ min• T- 20 Gz i.v. line- 2 pints NS; O2

inhalation

• ON PRIMARY SURVEY• AIRWAY- CLEAR• GCS- 7/15• BREATHING-RR- 30/min, DECRASED BREATH

SOUNDS ON LEFT LUNG FIELD, HYPER-RESONANT• SpO2- 84%• CXR- LEFT PNEUMOTHORAX

CIRCULATION-MEANWHILE BP IS 84/62mm Hg DESPITE 1.5 L FLUID• NO VISIBLE SOURCE OF BLOOD LOSS • P/A RIGIDITY MORE IN RUQ, ABDOMINAL

DISTENSION, B.S.- PRESENT.

INTUBATE WITH MILS

ICTD- 5TH ICS

• X-RAY PELVIS- NAD• FAST- COLLECTION IN ALL QUADRANTS• OR NOTIFIED FOR URGENT LAPAROTOMY• DISABILITY- GCS- 7/15, • EXPOSURE PRIOR TO OR- RULE-OUT HIDDEN

INJURIES• DAMAGE CONTROL LAPAROTOMY• PATIENT SHIFTED TO ICU FOR OBSERVATION

AND FURTHER MANAGEMENT.

5.SECONDARY SURVEY• History• Physical exam: head to toe• “Tubes OR fingers in every orifice”• Complete neurological exam• Special diagnosis tests• Re-evaluation

SECONDARY SURVEY• History • “AMPLE”• A:Allergies• M:Medication currently being taken by the patient• P:Past illness and operations, pregnancy• L:Last meal• E:Event/Environment related to the injury

• HEAD• Signs of skull base fracture • Pupillary size • Hemorrhages of

conjunctiva/fundi • Visual acuity• Penetrating injury

• Contact lens • Dislocation of lens • Ocular movement• Posterior scalp laceration

• MAXILLOFACIAL• Associated with airway obstruction or major bleeding• Fracture • No NG tube [performed oral route]

• NECK• Cervical tenderness, subcutaneous emphysema • Esophageal injury • Tracheal/laryngeal injury • Carotid injury (penetrating/blunt)

• CHEST• Inspect• Palpate• Percuss• Auscultate• Obtain x-rays

• ABDOMEN• Inspect• Auscultate• Palpate• Percuss• Reevaluate• Special studies

• Musculoskeletal• Contusion, deformity• Pain• Perfusion• Peripheral neurovascular status• X-ray

6.ADJUNCTS TO SECONDARY SURVEY• Special diagnostic tests as indicate• CT• Contrast x-ray studies• Extremity x-ray• Endoscopy• Ultrasound

7.DEFINITIVE CARE• OR• ICU • Refer

8.DAMAGE CONTROL• Multi trauma pt. triad of

coagulopathy,hypothermia,metabolic acidosis-interfernce with surgical mgt

• Goal- 1.control hmg• 2. prevent contamination • 3. protect pt. from further • injury• Proceed to definitive surgery once pt

stabilizes• Clear communication between surgeon,

anesthesiologist and intensivist

PAIN CONTROL• Relief of pain is an important part of the management of the

trauma patient• Titrate IV opiates and anxiolytics• Be aware that these agents can cause hypotension and

respiratory depression

TO SUMMARISE• Organized team approach• Priorities in management and resuscitation• Rule out more serious injuries• Through examination• Frequent reassessment• Monitoring

REFERENCE• emedicine.medscape.com/article/434707-• www.uptodate.com/contents/initial-management-of-trauma-in

-adults• lifeinthefastlane.com › Education• www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central

(PMC)• www.trauma.org/archive/anaesthesia/initialassess.html