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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?