ABC’s of Multi ABC’s of Multi System TraumaSystem Trauma

Christopher Freeman M.D.Christopher Freeman M.D.

Multi system traumaMulti system trauma Invention of Invention of

Motor Motor VehiclesVehicles

High ForcesHigh Forces

Multiple Multiple InjuriesInjuries

Multi system traumaMulti system trauma TheThe most dramatic most dramatic

injury usually is injury usually is NOTNOT the most dangerousthe most dangerous

Primary SurveyPrimary Survey Secondary SurveySecondary Survey Re-evaluationRe-evaluation

Initial ManagementInitial Management AirwayAirway BreathingBreathing CirculationCirculation DisabilityDisability ExposureExposure

Correct problem before moving onCorrect problem before moving on

AirwayAirway Assess for PatencyAssess for Patency LookLook

FB in AirwayFB in Airway Blood/Vomit/SecretionsBlood/Vomit/Secretions

ListenListen Noisy Breathing = Obstructed BreathingNoisy Breathing = Obstructed Breathing Normal speech = No ObstructionNormal speech = No Obstruction

FeelFeel Tracheal Location and Midline ShiftTracheal Location and Midline Shift

Airway ObstructionAirway Obstruction Be Vigilant withBe Vigilant with

Maxillofacial TraumaMaxillofacial Trauma Neck TraumaNeck Trauma Laryngeal TraumaLaryngeal Trauma Nonverbal PatientsNonverbal Patients

Airway InterventionsAirway Interventions Remove FB/Secretions/EmesisRemove FB/Secretions/Emesis Chin lift/Jaw ThrustChin lift/Jaw Thrust Oral/Nasopharyngeal airwaysOral/Nasopharyngeal airways

Reassess after interventionsReassess after interventions

Maintain C spine precautionsMaintain C spine precautions

BreathingBreathing Open airway = VentilationOpen airway = Ventilation LookLook

Chest rise/Symmetric movementChest rise/Symmetric movement ListenListen

Symmetric and adequate BS/Adequate Symmetric and adequate BS/Adequate raterate

FeelFeel CrepitusCrepitus

BreathingBreathing Danger SignsDanger Signs

Respirations <10Respirations <10 Respirations >24Respirations >24 Poor Chest RisePoor Chest Rise Labored breathingLabored breathing CrepitusCrepitus

BreathingBreathing If inadequate ventilation/airwayIf inadequate ventilation/airway

BVMBVM 2>1 2>1 LMALMA CombitubeCombitube ET intubationET intubation

BreathingBreathing Remember:Remember: If Adequate BVM +/- IntubatingIf Adequate BVM +/- Intubating All trauma patient deserve OxygenAll trauma patient deserve Oxygen

Face mask is bestFace mask is best Protect the SpineProtect the Spine

CirculationCirculation LookLook

Skin ColorSkin Color Listen Listen

BPBP Late sign Late sign Level of ConsciousnessLevel of Consciousness

FeelFeel PulsePulse PerfusionPerfusion

CirculationCirculation InterventionsInterventions

IVIV Fluids Fluids Control HemorrhageControl Hemorrhage

TourniquetTourniquet uncontrolled bleeding uncontrolled bleeding in unstable patientin unstable patient

Reassess after interventionsReassess after interventions

DisabilityDisability GCSGCS

APVUAPVU

ExposureExposure Remove from toxic exposuresRemove from toxic exposures

Remove wet clothingRemove wet clothing

Prevent hypothermiaPrevent hypothermia

Expose for examExpose for exam

Secondary SurveySecondary Survey After primary After primary If stable If stable

No Secondary No Secondary No problem No problem

Multiple TraumaMultiple Trauma Goal Goal Stabilize patient and Stabilize patient and

transport to definitive caretransport to definitive care Definitive Care unstable patient Definitive Care unstable patient

OROR Minimum time on sceneMinimum time on scene Maximum treatment in routeMaximum treatment in route Continue reassessment Continue reassessment ABC’s ABC’s

Case 1Case 1 20’s y/o M, 20’s y/o M,

single car MVA single car MVA into tree, into tree, ejected, found ejected, found on ground, on ground, unresponsiveunresponsive

AirwayAirway LookLook

Blood in airwayBlood in airway ListenListen

GurglingGurgling FeelFeel

Midline tracheaMidline trachea

Airway InterventionAirway Intervention SuctionSuction Jaw thrust/Chin liftJaw thrust/Chin lift

ReassessmentReassessment Clear respirations, No FB present in Clear respirations, No FB present in

airwayairway

BreathingBreathing LookLook

Symmetric, adequate chest rise, no Symmetric, adequate chest rise, no paradoxical movementparadoxical movement

ListenListen Rate 20, equal BS B/LRate 20, equal BS B/L

FeelFeel Crepitus over L chest WallCrepitus over L chest Wall

Breathing InterventionBreathing Intervention ?????? Crepitus Crepitus No respiratory distress No respiratory distress

CirculationCirculation LookLook

Pale, no obvious bleedingPale, no obvious bleeding Listen Listen

100/60, Arousable to stimuli100/60, Arousable to stimuli FeelFeel

HR 130’s, Cool to touchHR 130’s, Cool to touch

Circulation InterventionCirculation Intervention Place 2 Large bore IVPlace 2 Large bore IV Bolus 2 L NSBolus 2 L NS

Reassess VitalsReassess Vitals

DisabilityDisability GCS GCS

Eyes 2Eyes 2 Verbal 3Verbal 3 Motor 5Motor 5 Total 10Total 10

ExposureExposure Wet clothes removedWet clothes removed No obvious limb injuryNo obvious limb injury Blanket appliedBlanket applied

ReassessmentReassessment AirwayAirway

GurglingGurgling Suction with improvement Suction with improvement BreathingBreathing

RR 34, Decreased BS on L, L sided RR 34, Decreased BS on L, L sided Crepitus…Crepitus…

DiagnosisDiagnosis Tension PneumothoraxTension Pneumothorax

Breathing InterventionBreathing Intervention Needle Decompression L chest WallNeedle Decompression L chest Wall

ReassessmentReassessment AirwayAirway

Clear, no gurgling, trachea midlineClear, no gurgling, trachea midline BreathingBreathing

RR 20, Equal chest expansion, good chest RR 20, Equal chest expansion, good chest wall risewall rise

Needle 2Needle 2ndnd intercostal space midclavicular intercostal space midclavicular lineline

CirculationCirculation HR 110, BP 110/70, Skin Warm/Well HR 110, BP 110/70, Skin Warm/Well

perfusedperfused

Secondary SurveySecondary Survey Blah, Blah, BlahBlah, Blah, Blah

DispositionDisposition To ED, Stable To ED, Stable AdmittedAdmitted ConcussionConcussion R CT, PTX/HTXR CT, PTX/HTX Grade 3 liver lacerationGrade 3 liver laceration D/c from hospital 1 week laterD/c from hospital 1 week later

Case 2Case 2 27 Y/O MCA into Car27 Y/O MCA into Car Unhelmeted, thrown from Unhelmeted, thrown from

vehiclevehicle Found on groundFound on ground Bystander called EMSBystander called EMS

AirwayAirway LookLook

Blood in airwayBlood in airway ListenListen

Gurgling respirationGurgling respiration FeelFeel

Midline tracheaMidline trachea

Airway InterventionAirway Intervention SuctionSuction Jaw thrust/Chin liftJaw thrust/Chin lift Oropharengeal Airway placedOropharengeal Airway placed

ReassessmentReassessment Quiet, No FB present in airwayQuiet, No FB present in airway

BreathingBreathing LookLook

Symmetric, Poor chest rise, no Symmetric, Poor chest rise, no paradoxical movementparadoxical movement

ListenListen Rate 6, diminished BS B/LRate 6, diminished BS B/L

FeelFeel Crepitus over B/L chest WallCrepitus over B/L chest Wall

Breathing InterventionBreathing Intervention BVMBVM

Breathing ReassessmentBreathing Reassessment LookLook

Symmetric, Poor chest rise, no Symmetric, Poor chest rise, no paradoxical movementparadoxical movement

ListenListen Rate 18 by BVM, diminished BS B/LRate 18 by BVM, diminished BS B/L

FeelFeel Crepitus over B/L chest WallCrepitus over B/L chest Wall

Breathing InterventionBreathing Intervention B/L Needle DecompressionB/L Needle Decompression

Breathing ReassessmentBreathing Reassessment LookLook

Symmetric, Adequate chest rise, no Symmetric, Adequate chest rise, no paradoxical movementparadoxical movement

ListenListen Rate 20 by BVM, equal BS B/LRate 20 by BVM, equal BS B/L

FeelFeel Crepitus over B/L chest WallCrepitus over B/L chest Wall

CirculationCirculation LookLook

Pale, Bleeding from LLE, LUEPale, Bleeding from LLE, LUE Listen Listen

80/50, unconscious, unarousable80/50, unconscious, unarousable FeelFeel

HR 140’s, Cool to touchHR 140’s, Cool to touch

Circulation InterventionCirculation Intervention Place 2 Large bore IVPlace 2 Large bore IV Bolus 2 L NSBolus 2 L NS Pressure on bleeding sitesPressure on bleeding sites

Reassess VitalsReassess Vitals

Circulation Circulation ReassessmentReassessment

LookLook Pale, Persistent bleeding LLE, Bleeding Pale, Persistent bleeding LLE, Bleeding

controlled LUEcontrolled LUE Listen Listen

80/50, unconscious, unarousable80/50, unconscious, unarousable FeelFeel

HR 150’s, Cool to touchHR 150’s, Cool to touch

Circulation InterventionCirculation Intervention Tourniquet to LLETourniquet to LLE

DisabilityDisability GCS GCS

Eyes 1Eyes 1 Verbal 2Verbal 2 Motor 4Motor 4 Total 7Total 7

ExposureExposure Wet clothes removedWet clothes removed Limb deformity, Bleeding LUE, LLELimb deformity, Bleeding LUE, LLE Blanket appliedBlanket applied

ReassessmentReassessment AirwayAirway

Oropharngeal Airway in place, No FBOropharngeal Airway in place, No FB BreathingBreathing

RR 20, Decreased BS on B/L, Increased RR 20, Decreased BS on B/L, Increased Airway resistanceAirway resistance

InterventionIntervention Chin Lift/ Jaw ThrustChin Lift/ Jaw Thrust Oral SuctionOral Suction Needle decompressionNeedle decompression

ReassessmentReassessment AirwayAirway

Oropharngeal Airway in place, No FBOropharngeal Airway in place, No FB BreathingBreathing

RR 20, Equal BS on B/L, Normal RR 20, Equal BS on B/L, Normal resistanceresistance

CirculationCirculation HR 120’s, BP 90/50, Bleeding controlled HR 120’s, BP 90/50, Bleeding controlled

with tourniquetwith tourniquet

Secondary SurveySecondary Survey Not Done prior to arrivalNot Done prior to arrival

DispositionDisposition To ED, UnstableTo ED, Unstable Arrest In EDArrest In ED ED Thoracotomy ED Thoracotomy Unsuccessful Unsuccessful

SummarySummary Keep it SimpleKeep it Simple

ABC’sABC’s

Airway Management = IntubationAirway Management = Intubation

Minimize time to Definitive Minimize time to Definitive treatment treatment OR OR

Questions?Questions?