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Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division...

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Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care
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Page 1: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Management of the Trauma Patient

Hieu Ton-That, MD, FACSLoyola University Medical Center

Division of Burns, Trauma and Surgical Critical Care

Page 2: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Trauma in the United States

• 2.7 million hospital admissions per year

• Leading cause of death for ages 1-44 years

• 100,000 deaths per year from traumatic injuries– Half die before they reach medical care

• Hemorrhage is second-leading cause of death in trauma

Page 3: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Figure 6A: Number of Incidents by Age

Number of Incidents by Age

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106

Age (years)

Nu

mb

er o

f In

cid

ents

Page 4: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Figure 7A: Number of Incidents by Age and Gender

Number of Incidents by Age and Gender

0

5,000

10,000

15,000

20,000

25,000

30,000

0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 102

Age (years)

Nu

mb

er o

f In

cid

ents

Males

Females

Page 5: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Figure 8A: Case Fatality Rate by Age

Case Fatality Rate by Age

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

0 10 20 30 40 50 60 70 80

Age (years)

Ca

se

Fa

talit

y R

ate

Page 6: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Figure 10A: Number of Incidents by Mechanism of Injury

Number of Incidents by Mechanism of Injury

0

100,000

200,000

300,000

400,000

500,000

600,000

Mot

or ve

hicle

traffic Fall

Struck

by,

again

st

Trans

port,

othe

r

Firearm

Cut/pier

ce

Other

spec

ified an

d cla

ssifia

ble

Pedal

cycli

st, o

ther

Fire/b

urn

Mac

hiner

y

Mechanism of Injury

Nu

mb

er o

f In

cid

ents

Page 7: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Primary Survey

• Advanced Trauma Life Support• Assess and address life threatening

injuries in order• “ABCDE of trauma”

– Airway– Breathing– Circulation– Neurologic “deficit”– Exposure of patient

Page 8: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Airway

– Identify airway obstruction– Maintain cervical spine immobilization– May require definitive airway

• Orotracheal intubation• Blind nasotracheal intubation• Cricothyroidotomy• Tracheotomy

Page 9: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Breathing

– Identify life threatening deficits in breathing mechanism

• Simple pneumothorax• Tension pneumothorax• Massive hemothorax• Open pneumothorax (“sucking chest wound”)• Flail chest

Page 10: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.
Page 11: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Circulation

• Or, identification of shockDefinition of shock – inadequate organ

perfusion• Causes of shock

– Hemorrhage/hypovolemia– Compressive– Cardiogenic– Neurogenic– Sepsis

Page 12: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Class I Class II Class III Class IVBlood Loss mL Up to 750 750-1500 1500-2000 >2000

Blood Loss

%

Up to 15% 15-30% 30-40% >40%

Pulse rate <100 >100 >120 >140

Systolic blood pressure

Normal Normal Decreased Decreased

Pulse pressure Normal Decreased Decreased Decreased

Respiratory rate 14-20 20-30 30-40 >35

Urine output >30 20-30 5-15 Negligible

Mental status Slightly anxious

Mildly anxious

Anxious, confused

Confused, lethargic

Fluid

(3:1 rule)

Crystalloid Crystalloid Crystalloid and blood

Crystalloid and blood

Page 13: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Circulation

• Treatment of shock

• Direct pressure on external bleeding

• Initial 2 liter bolus of crystalloid fluid– Responders– Non-responders– Transient responders

• Definitive management for ongoing hemorrhage

Page 14: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Neurologic “deficit”

• Rapid assessment of neurologic status to identify life-threatening injury– Pupil size and response– Mental status (Glascow coma scale)– Motor and sensory exam

Page 15: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Glascow Coma Scale

• 3 – 15 point scale to assess mental status only

• Best observed response

• Modified scale for children

• GCS ≤ 8 is a “coma” and requires intubation for airway protesction

Page 16: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Eye opening» None = 1» To painful stimuli only = 2» To voice only = 3» Spontaneously open = 4

Verbal response» None = 1» Incomprehensible sounds = 2» Incomprehensible words = 3» Confused = 4» Oriented = 5

Motor response» None = 1» Decerebrate (extension) posturing = 2» Decorticate (flexion) posturing = 3» Withdraws to pain = 4» Localizes pain = 5» Follows commands = 6

Page 17: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Exposure

Head to toe examination of the patient for injury

• Pitfalls– Maintenance of spine precautions– Prevention of heat loss– Under cervical collar– Back and flanks

Page 18: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Adjuncts to the Primary Survey

• Exams during or after primary survey to aid in identifying life-threatening injuries– Chest x-ray– Pelvis x-ray– Focused abdominal sonogram for trauma

(FAST)– Diagnostic peritoneal lavage (DPL)

Page 19: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.
Page 20: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Secondary Surveyand Definitive Treatment

• The secondary survey is a complete head to toe evaluation of the patient

• Adjuncts to the secondary survey include CT’s, plain radiographs, blood tests

• Treatment plans, especially for multiple injuries, based on clinical status and specific injuries

Page 21: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Resuscitation

• Restoring organ perfusion• How much is enough? What are the endpoints of

resuscitation?– Heart rate, blood pressure, urine output

• May lead to “compensated shock”

– Organ-specific indicators of perfusion• ie gastric tonometry

– Global indicators of perfusion• Lactic acid, base deficit• Cardiac output, oxygen delivery, oxygen consumption• Mixed venous O2 saturation (SvO2)

Page 22: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Lactic acid and base deficit

• Initial BD and serum LA are reliable indicators of the need for ongoing resuscitation

• Time to normalization of LA and BD are predictive of MSOF and mortality

Page 23: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Damage-control laparotomy

• A shift from definitive management of abdominal injuries to stabilizing the patient for resuscitation

• Goals– Stop bleeding– Control contamination– Temporary abdominal closure

Page 24: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.
Page 25: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.
Page 26: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Critical care and rehabilitation

Page 27: Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care.

Questions?


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