Trauma

transcript

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

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

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

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

PREHOSPITAL CARE

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

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

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

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

tracheal shift

broken ribs

subcutaneous emphysema

percussion is useful for diagnosis of haemothorax (dull) and tension pneumothorax (hyper-resonant)

* Palpation (FEEL) for

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

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

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

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

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

Penetrating Anatomy factors Energy transfer factor

Velocity and caliber of bullet Trajectory Distance

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.

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.

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

INVESTIGATIONS

Urine output

Urinanalysis

Trauma

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