partners in global health education 1 of 43 1.how to use this module 2.learning outcomes...

Partners in Global Health Education

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1. How to use this module

2. Learning outcomes

3. Introduction4. Burden of trauma5. Pathophysiology6. Triage7. Management8. Airway9. Breathing10. Circulation11. Disability12. Exposure13. Secondary survey14. Transition to

definitive care15. Authors and

reviewers

Introduction 1

Primary Trauma Care

For more information about the authors and reviewers of this module, click here

Welcome to the Primary Trauma Care module!

Worldwide, trauma is a leading cause of death especially in young adults.

In developing nations, it is the second leading cause of death among all ages and leading cause in the third and fourth decades.

Simple and timely initial management can save lives and greatly improve outcomes for trauma victims.

Urbanisation and industrialisation have led to an increase in trauma-related deaths globally Source: Environment, Nigeria Oct 2007


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Primary Trauma Care

How to use this module

• This self-directed learning (SDL) module has been designed for all staff who deal with the acutely injured patient.

• We suggest that you start with the learning objectives and try to keep these in mind as you go through the module at your own pace.

• Print-out the question & answer sheets. Write your answers to the questions on the mark sheet as best you can at the end of each section before looking at the answers.

• Repeat the module until you have achieved a mark of > 80%.

• You should research any issues that you are unsure about. Look in your textbooks, access the on-line resources indicated at the end of the module and discuss with your peers and teachers.

• Finally, enjoy your learning! We hope that this module will be enjoyable to study and complement your learning about trauma management from other sources.


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Introduction 2

By the end of the module, you would be expected to be able to:

• Discuss the burden of trauma

• Describe the concept of triage

• Identify common life-threatening injuries

• Adequately resuscitate and re-evaluate the trauma patient

• Manage common life-threatening injuries effectively

• Perform a secondary survey to plan the next stage of care

Primary Trauma Care

Learning Outcomes


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Introduction 1

• There are notable disparities in the outcome of trauma care around the world.

• 60% of preventable trauma associated deaths occur in the first 24 hours.

• Difficulties facing trauma care in developing countries include manpower development, infrastructure, availability of equipment and organization.

• Much of the improvement in trauma care has resulted from better organization of trauma care services.

• The main focus of this module is appropriate life-saving management in the first few hours following trauma.

Primary Trauma Care

Introduction


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Primary Trauma Care

The burden of trauma

This can be divided into:

• The “direct” health burden: morbidity and mortality

• The “indirect” burden: impaired human and economic development

Click on the boxes to find out more

Direct burden

Indirect burden


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Trauma-related death has a trimodal distribution:

A. Immediate deaths due to fatal injuries

B. Early deaths occur within a few hours of the accident and are largely preventable

C. Late deaths occurring days and weeks after the injury are usually due to sepsis and other sequelae of trauma

Causes of trauma-related deaths according to time after injury; MOF- multiple organ failure

Primary Trauma Care

Distribution of trauma-related deaths


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Introduction 2

Various mechanisms act in concert in major trauma. Hypotension and hypoxia lead to ischemia and tissue death.

Appropriate, timely intervention leads to reperfusion and reoxygenation of ischaemic cells and restores cell integrity.

Undue delay in reversing these pathophysiological changes associated with trauma leads to the activation of systemic inflammatory responses. Together, these changes may ultimately culminate in the death of the patient. Early intervention saves lives.

Primary Trauma Care

Pathophysiology

HYPOTENSION

HYPOXIA

ISCHEMIA

Take home message!Like many diseases, adverse outcomes after trauma can be prevented

Tissue death


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Primary Trauma Care

Triage in the emergency room

TRIAGE - “to sort or sieve”• Triage is employed to ensure optimal medical assistance to save lives and

prevent morbidity

• Triage involves using systematic scoring systems which identify those patients who need urgent medical attention

Take home messages!Triage must be simple and swift but reproducible and reliable.

Triage should be done by the most experienced staff available.

Current systems involve measuring key physiological variables in the brief initial assessment:• Level of consciousness• Airway • Vital signs


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Primary Trauma Care

Triage scenarios

Four accident victims are brought in a police truck to the emergency room. You are the only doctor who is readily available.

Which TWO of these patients are most likely to die without early intervention? Click on the boxes to find the answers.

• The first is quiet and appears calm and still

• The second is in excruciating pain from an obvious femoral fracture

with the foot twisted in the opposite direction

• The third patient is screaming at the site of his clothes soaked with blood from an extensive scalp laceration

• The fourth patient walks-in complaining of right sided chest pain and difficulty with breathing

D

C

B

A


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End of Section 1

Well done!You have come to the end of the first section.

We suggest that you answer Question 1 to assess your learning so far. Please remember to write your answers on the mark sheet before looking at the correct answers!

Click here for Question 1


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Primary Trauma Care

Managing the severely injured patient

Initial management (resuscitation) must be prioritised according to the physiological needs for survival. In the ‘A,B,C,D,E’ of resuscitation, the ‘A’ comes before the ‘B’, the ‘B’ before ‘C’ and so on. A problem identified at any step must be corrected immediately before moving to the next step.

Please note that there is an exception to this rule (see next slide)

A A patent Airway

B Effective Breathing / Ventilation

C Adequate Circulation and haemorrhage control

D Neurological Disability

E Adequate Exposure to search for other injuries

Take home message!

Making a definitive diagnosis is the least important issue at this stage


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Primary Trauma Care

Catastrophic heamorrhage: the exception to “A,B,C,D,E”

• This is life threatening haemorrhage, often due to traumatic amputation or crush injury to the limbs. Bleeding is usually massive and the patient may be on the point of exsanguination.

• It is necessary to rapidly control the haemorrhage before assessing the airway.

• The bleeding vessel may be ligated if it can be identified. If not, this may be one of the exceptional cases when a tourniquet may be used. However, the duration of application must be noted.

• Remember that in patients with sickle cell disease a tourniquet may precipitate a sequestration crisis.

Remember! Once the bleeding is temporarily controlled, complete the ‘ABCDE’.


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Primary Trauma Care

Airway management: The conscious patient

• Speak to the patient. • Does he respond? If he responds in a normal voice giving a

logical answer then he most probably can control his airway. • However, cervical spine injury (CSI) may be present. First, inspect

the neck meticulously for wounds and other abnormalities. Click here for a list of important clinical signs.

• Cover any penetrating wounds with clean gauze and plaster. • Then, immobilise the cervical spine using one of these methods:

MILS (Manual in-line stabilisation)

Cervical collar

Spinal board, head blocks, sandbags See next slide


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Primary Trauma Care

Cervical spine stabilisation

Improvised cervical collar using flip-flop slippers (Alonge et al.)

Rigid cervical collar


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Primary Trauma Care

Airway management : The unconscious patient

Assess the airway and breathing

• Check the mouth for foreign matter; if present remove by suction or Magill's forceps.

• If obstruction persists, perform a jaw thrust without tilting the head (this may exacerbate cervical spine injury).

• Should obstruction persists, insert an oropharyngeal or nasopharyngeal airway.

Click picture for larger view

Take home message!

Always give supplementary oxygen

If obstruction persists despite these manoeuvres, consider more advanced airway management such as orotracheal or nasotracheal intubation.


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Primary Trauma Care

Managing the severely injured patient

Case Scenario A 30 year old man is brought unconscious to the emergency room

after a motor vehicle accident. His clothes are soaked in blood from a scalp laceration. There is an obvious fracture of the left forearm. What is the first step of your management?

(Click on the boxes for the answers)

• Immediately suture the bleeding scalp laceration

• Splint the forearm fracture to reduce pain

• Ensure there is no foreign body obstructing the airway and the tongue is not falling back

• Give oxygen immediately

Case Scenario A 30 year old man is brought unconscious to the emergency room

after a motor vehicle accident. His clothes are soaked in blood from a scalp laceration. There is an obvious fracture of the left forearm. What is the first step of your management?

(Click on the boxes for the answers)

• Immediately suture the bleeding scalp laceration

• Splint the forearm fracture to reduce pain

• Ensure there is no foreign body obstructing the airway and the tongue is not falling back

• Give oxygen immediately D

C

B

A


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End of Section 2

Well done!You have come to the end of the second section.

We suggest that you answer Question 2 to assess your learning so far. Please remember to write your answers on the mark

sheet before looking at the correct answers!



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Primary Trauma Care

Breathing (Ventilation 1)

Take home message!The respiratory rate and effort are sensitive indicators of chest trauma. They should be monitored and recorded at frequent intervals.

• Observe the respiratory rate and effort of the patient. Assess the use of accessory respiratory muscles.

• Palpate the neck carefully for tracheal deviation.• Identify emphysema (air in the subcutaneous tissue) by palpating

the chest wall for crepitation (a crackling feeling)• Place your hands in the patient’s axillae and gently compress the

chest. Tenderness and emphysema suggest chest trauma.• Auscultate the lung fields in the axillae and compare both sides. No

air entry to both sides occurs in:– an inadequately patent upper airway– massive tension pneumothorax– tracheal laceration


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Primary Trauma Care

Breathing (Ventilation 2)

• When assessing the trauma patient’s chest in the primary survey, expose the patient adequately without causing hypothermia

• Certain immediate life-threatening conditions must be considered

Life-threatening chest conditions in trauma patients

• Tension pneumothorax

• Open pneumothorax

• Massive haemothorax

• Flail chest

• Cardiac tamponade

Click

Click

Click

Click

Click


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End of Section 3

Well done!You have come to the end of the third section.





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Primary Trauma Care

Circulation: assessment

Assess the 5 features of hypovolemia• Cold, clammy extremities• poor capillary refill• tachycardia (>120 beats / minute)• low blood pressure (systolic blood pressure <80mmHg)• altered consciousness (hypovolemia alone can cause decreased conscious level)

Quickly re-check airway patency, breathing and oxygen supply before assessing circulation.

Take home message! Hypoperfusion causes acidosis.


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Primary Trauma Care

Circulation: management

Stop external haemorrhage. • Direct pressure is the preferred method• Fractured long bones must be splinted• If possible, avoid tourniquets as they increase distal ischeamia. If they must be used, the duration of application must be monitored.

Volume replacement • Establish 2 large bore IV lines (14G or 16G cannulae)• Obtain blood samples for CBC, urea & electrolytes and cross match • Administer IV fluids (warm crystalloids: normal saline or Ringers lactate). In young adults, 2 liters of IV fluid can safely be given in the first hour.

Click here for the exception

Take home message!Consider a venous cut down or intraosseous needle if peripheral

lines are not accessible

Stop external haemorrhage. • Direct pressure is the preferred method• Fractured long bones must be splinted• If possible, avoid tourniquets as they increase distal ischeamia. If they must be used, the duration of application must be monitored.

Volume replacement • Establish 2 large bore IV lines (14G or 16G cannulae)• Obtain blood samples for CBC, urea & electrolytes and cross match • Administer IV fluids (warm crystalloids: normal saline or Ringers lactate). In young adults, 2 liters of IV fluid can safely be given in the first hour.

Click here for the exception


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Primary Trauma Care

Disability

• This is a rapid neurological assessment

• Assessing AVPU is quick and easy to do

• It is a baseline for more detailed neurological examination carried out in the secondary survey

• A

• V

• P

• U

ALERT GCS 14-15

VERBAL STIMULATION RESPONSEGCS 9 - 13

UNRESPONSIVEGCS 3

RESPONDS TO PAIN ONLYGCS 4 - 8

Click to see GCS


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Primary Trauma Care

Exposure and environmental control

• Fully expose the patient whilst assuming that other injuries are present

• Prevent hypothermia by controlling room temperature or covering the patient with blankets immediately after examination. Hypothermia may be a cause of coagulopathy; both hypothermia and coagulopathy are components of the lethal triad (see later).

• To expose the patient, use scissors to cut along the seams of clothes to avoid worsening any injury and ensure minimal movement of the patient.

• Do not forget to do a rectal examination whilst log rolling the patient

Take home message! You may miss injuries if you do not fully expose the patient

Click to read rectal findings


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LETHAL TRIAD

Primary Trauma Care Three components of the lethal triad

COAGULOPATHY

ACIDOSIS HYPOTHERMIA


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Primary Trauma Care

At the end of the primary survey what next? • Is the airway patent and secure?

• Is the patient receiving high flow oxygen?

• Is the cervical collar in place?

• Are all the tubes in place? i.e. urinary catheter, nasogastric tube and intravenous lines

• Have blood samples been sent to appropriate laboratories?

• Are the vitals signs being recorded every 5 minutes?

• Have the X-ray forms been filled?

Only then can you consider a secondary survey


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Primary Trauma Care

Some notes of caution

• If there is bleeding from the ears and nostrils– pass the nasogastric tube carefully– make sure it is not coiled in the cranial fossa

• Bleeding from the penile meatus may be suggestive of urethral injury which is a relative contraindication to urethral catheterisation

• If the patient vomits while lying flat, in the absence of a suctioning machine, roll him/her to one side keeping the nose and the umbilicus in line all the time.


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End of Section 4

Well done!You have come to the end of the fourth section.





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Primary Trauma Care

Radiological Investigations

• A multiply injured patient requires X-rays in the resuscitation room

– Cervical X-ray (recent modifications now tend to move this to the secondary survey because of the associated time delay)

– Chest X-ray

– Pelvic X-ray

Further radiological investigation should be taken at the end of the secondary survey.


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Primary Trauma Care

Secondary survey

• Once the immediate life-threatening conditions have been managed or excluded, the patient should be completely re-examined

• If the patient deteriorates at any stage, the airway, breathing and circulatory systems must be re-examined as discussed previously for the primary survey

• The secondary survey is a head-to-toe, front-to-back assessment along with a detailed medical history and appropriate investigations


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Primary Trauma Care

Secondary survey: History

Remember “AMPLE”

A Allergies

M Medications

P Previous medical/ surgical history

L Last meal (Time)

E Events / Exact circumstances


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Primary Trauma Care

Secondary survey: Examination

Has Head/Skull

My Maxillofacial

Critical Cervical spine

Care Chest

Assessed Abdomen

Patients Pelvis

Priorities Perineum

Or Orifices (PR/PV)

Next Neurological

Management Musculoskeletal

Decision? Diagnostic tests/ definitive care

Source: Hughes S C A, ATLS secondary survey mnemonic: Has My Critical Care Assessed Patient ’s Priorities Or Next Management Decision? Emergency Medicine Journal 2006; 23:661-662.


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Primary Trauma Care

Transition to definitive care

Once the patient has been adequately assessed and resuscitated, definitive care can start. This may require surgery and/or intensive care

Factors which determine priority of treatment:• Are the injuries immediately life-threatening?• Are the injuries potentially life-threatening?• Are the injuries limb-threatening?• What is the physiological state of the patient?• What resources are available in the hospital?• Will the patient require transfer for further specialist care?


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End of Section 5

You have come a long way!This is the end of the last section.

For the section just ended, you should be able to answer Question 5 to assess what you have learnt. It is still required

that you put down your answers on the mark sheet before looking at the right answer!

Click here forQuestion 5


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Primary Trauma Care

References

1. Trauma care manual. Oxford University Press Inc., New York 2002

2. Basic Trauma Care. Temitope Alonge 3nity Concepts. Ibadan Nigeria 2007

3. Guidelines for essential trauma care WHO / International association for the surgery of trauma and surgical intensive care( IATSIC) 2004


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Primary Trauma Care

Authors and reviewers

Authors:

Dr. Oludolapo Afuwape Consultant General

Surgeon/Lecturer, College of Medicine, University of Ibadan/ University College Hospital Ibadan, Nigeria.

Dr. Stephen Allen Reader in Paediatrics and

Honorary Consultant Paediatrician, The School of Medicine, Swansea University, Swansea, UK

Mrs. Abiodun Alao, Senior System Analyst, University of Ibadan/ College of Medicine, Ibadan, Nigeria.

Expert reviewers:

Mr Ian PallisterReader in Trauma & OrthopaedicsThe School of Medicine, Swansea University,

Swansea, UK

Mr Temitope Alonge FRCS MD LeicesterSenior Lecturer / Consultant Surgeon

Orhtorpeadics and Trauma, College of Medicine, University of Ibadan /

University College Hospital Ibadan, Nigeria.

Permissions:

Please note that verbal permission was granted from patient and relations to use the images in this module for teaching purposes only. The images should not be used for any other purpose.

Back


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Sources of information and further reading

http://www.emedicine.com/med/topic3221.htm1. Initial evaluation of the trauma patient

2. Sabiston Textbook of Surgery, 17th ed., Copyright © 2004 Elsevier

3. Trauma Care Manual Second Edition

http://www.trauma.myzen.co.uk/trauma_care_manual.pdf

partners in global health education 1 of 43 1.how to use this module 2.learning outcomes...

Documents

primary trauma care

trauma management

burden of trauma

reviewers primary trauma

trauma patient

trauma victims

reviewers introduction

definitive care