Principles of Trauma Simon Albert Mar10

8/8/2019 Principles of Trauma Simon Albert Mar10

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Principles of

Resuscitation in TraumaDr Simon Albert

Clinical FellowEmergency Medicine

St Thomas Hospital


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Contents

Advanced Trauma Life Support

Tension Pneumothorax

Head Injuries & Glasgow Coma Score

Burns


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Advanced Trauma Life

Support Standardised framework for the

management of trauma

Treat the greatest threat first

Injury kills in a predictable timeframe

ABCDE


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Primary Survey

AAirway + C-spine control

BBreathing + oxygen

CCirculation + haemorrhage and iv access

DDisability

EExposure without hypothermia


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Airway & C-spine control Look & Listen for signs of obstruction

Beware of facial fractures, foreignbodies, GCS


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Airways and Ventillation

Oxygen mask

Manoevres

Oropharyngeal airway Nasopharyngeal airway

Bag-valve-mask

Endotracheal tube Cricothyroidotomy


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Breathingand VentilationAssessment of ventilation

Chest wall excursion/inspection/palpation

Percussion

Auscultation

End tidal CO2

ABG

Level of consciousness


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Life threatening ConditionsLife threatening Conditions

Airway obstruction

Tension pneumothorax

Open pneumothorax

Massive haemothorax

Flail chest Cardiac tamponade


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Circulation with external

haemorrhage control Control external bleeding with direct

pressure

IV access 2 x 16G minimum + bloods

Flow is proportional radius 4


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SHOCKCLASS I II III IV

Blood loss ml 2000

% 40%

Pulse 100 >120 >140

BP normal normal low Low

Pulse pressure Normal/incr decrease decrease Decrease

RR 14-20 20-30 30-40 >35

Urine O/P >30 20-30 5-15 NegligibleCNS Slight anxious Mildly anxiousconfused Confused

lethargic

Fluid Hartmans Hartmans Hartmans + blood Hartmans + blood


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Disability - neurological

AVPU or GCS

AVPU

Alert

Verbal

Pain

Unresponsive

GCS


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Exposure & Environmental

Control Patient should be exposed fully

Dignity Maintained

Kept warm

Log roll


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Why we Logroll


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Adjuncts to the Primary Survey

Monitoring ECG, SpO2, P/BP, ABG

NGT/OGT, Urinary catheter

Imaging

C-spine, chest and pelvis x-rays

FAST scan

CT

DPL


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Secondary survey

Ample history

Top to toe physical examination

Head and faceNeck

Chest

Abdomen & Perineum

Musculoskeletal & log roll

Neurological

tubes and fingers in every orifice


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ATLS Summary

ABCDE

Primary survey must be repeated often and

with any change in the patients condition Secondary survey may not be completed in

the Emergency department

A normal C-spine XR does not exclude afracture


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Life threatening emergency

Air progressively enters the pleuralspace but is unable to leave

Separation of the pleura and collapseof the affected lung leading tomediastinal shift to the opposite side

Kinking of SVC/IVC giving decreasevenous return and cardiac outputleading to circulatory collapse


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Diagnosis

Symptoms

History, dyspnoea, tachypnoea, distress

Signs

External examination, tracheal deviation,breath sounds, resonance, tachycardia,

hypotension, distended neck veins,unconscious, high ventilator pressures.


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Head Injuries and GCS


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Head Injuries AMPLE history

Time of injury & Mechanism

Loss of consciousness

Amnesia anterograde/retrograde Headache

Diplopia

Nausea or vomiting Anti-coagulants

Alcohol consumption


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Examination

AVPU / Glasgow Coma Score

Vital signs + BSL

Area of impacthaematoma/laceration/bony tenderness or step

CNS exam with Pupil size and reactivity

Nose - rhinorrhea / rhinorrhagia

Ears - otorrhea / otorragia

Signs of base of skull fracture

PNS

C-Spine


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Basal Skull Fractures

Indicated by CSF / ecchymosis / anosmia / ear ornasal csf / blood

Periorbital ecchymosis Raccoon eyes

Retroauricular ecchymosis Battle sign Haemotympanum

Subconjuntival haemorrage (no posterior margin)

No antibiotics

Meningitis & head injury advice CT


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GCS

Best Eyes Response4 Eyes open spontaneously

3 Eyes open to speech

2 Eyes open to pain

1 Eyes dont open


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GCS

Best Verbal Response5 Normal speech

4 Confused

3 Words

2 Sounds

1 None


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GCS

Best Motor Response6 Obeys commands

5 Localises to pain

4 Normal flexion/withdraw

3 Abnormal flexion (decorticate)

2 Extension (decerebrate)

1 No movement


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GCS

Best eyes response 4

Best verbal response 5

Best motor response 6

3-15 / 153-15 / 15


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Burns

Thermal

ChemicalRadiation

Electrical


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Burns Management

ABCDE + Analgesia

Airway hoarseness, stridor, facialburn, singed nasal hair, soot in nose ormouth. Early intubation

Smoke inhalation

Measurement of surface area

Assessment of burn thickness

Escharotomy chest/limbs


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Measurement of Body Surface

Area


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Superficial Erythema

Pain

Absence of blisters


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Partial thickness

Red or mottled

Blistered, broken

epidermis, swelling Weeping, wet

surfaces

Painful

Sensitive to air


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Full thickness

Pale, white, charredleatheryappearance.

Damage to all skinlayers, nerveendings, and evensubcutaneoustissues.

Dry surface,Painless, insensate


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Burns: iv fluid calculation

ParklandParkland formula (Hartmans)

4 x weight x % burn = 24hr fluids

Half given in first 8 hrs.

Timed from burn not arrival


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Criteria for transfer

Partial thickness >10%

Full thickness

Face, hands, feet, genitalia, perineumor major joints

Paediatric

Inhalation injury


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Summary

ATLS framework ABCDE

Diagnosis and management of Tension

Pneumothorax Assessment and classification of head

injuries, GCS, AVPU

Burns measurement, management andreferral


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Any Questions?

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Principles of Trauma Simon Albert Mar10

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