Initial Evaluation and Treatment of the Multiple Trauma Victim
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Initial Evaluation and Treatment of the Multiple Trauma Victim
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EpidemiologyTrauma is a disease of the young, and is the leading cause of death in patients between the ages of 1-44. In 2001 there were 38,000 traffic fatalities, 39% were alcohol related.In 1999 28,000 deaths from firearms, 115,000 injuries annuallyFatalities represent only a fraction of all patients that suffer from traumatic injuries.
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Mechanism of InjuryKnowledge of the mechanism of injury can alert one to specific injuries.Auto crashes: Broken windshield, bent steering wheel, knees to dashboard, restraint type, type of accident, speed of accident, extrication time.Penetrating injuriesGSW’sFalls : LD50 for falls is 4 stories (48 ft)Strangulation
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Initial Triage of the Trauma Patient
Assess Vital Signs and LOC: SBP<90, RR<10 or >29, GCS <14, or RTS
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Initial Triage of the Trauma Patient
Assess Injury: Penetrating injuries, flail chest, trauma with burns, two or more proximal long bone injuries, pelvic fx, paralysis, amputations.Assess Mechanism: Ejected, death in same accident, long extrication time, fall >20 ft, rollover, high speeds, intrusion, major auto damage, motorcycle crash >20 mph, auto-ped or auto-bicycle over 5 mphConsideration of Other factors: extremes of age, pregnancy, bleeding d/o, serious underlying diseases like cardiac or pulmonary disease, diabetes, cirrhosis, etc.
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Initial ApproachTeam approach with team leader directing care is optimal, may vary with institution. Assume the most serious injury is presentTreatment based on limited assessment, before diagnosis.Start with brief initial survey, followed by resuscitation, then secondary survey as patient is stabilized.Frequent reassessment and constant monitoring.
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Primary Survey
A: Airway with c-spine control
B : Breathing
C : Circulation -control external bleeding.
D : Disability-neurological status
E : Exposure (undress patient)/Environment (Warmed fluids/blankets)
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Initial Stabilization
ABC’s- initial assessment of airway and ventilation.
Assess airway: look for obstruction with debris, blood, teeth, etc. vs. obstruction from displaced anatomical structures.
Assess ventilation: look at the rate and quality of respirations. Ventilation may be compromised by decreased LOC, flail segments, penetrating wounds, look for tracheal deviation, distended neck veins.
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Airway Maintenance with Cervical Spine Protection.
GCS score of 8 or less require the placement of definite airway.Spinal precautions must be maintained during airway manipulation.A normal neurological exam alone does not exclude a cervical spine injury.Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or distracting injury.
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CirculationLook for signs of shock by assessing
LOCskin colorpulseurine output
Control bleedingDirect pressureLimited use for tourniquets, MAST
Establish IV access
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CirculationInitial Fluid with crystalloid
Blood loss replaced with 2-3x volume in crystalloidHypertonic saline
Indications for TransfusionPatient clinically unstable after 2-3 Liters or 40-50 ml/kg crystalloid Type O uncrossmatched blood/type specific bloodOn-going blood loss usually located in one of the three body cavities: chest, abdomen, retroperitoneum.
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Disability ( Neurological Evaluation)
Assess Patient’s level of consciousnessA : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
P: Assess pupils
Assess patient for signs of impending herniation
Keep patient in full spinal precautions until full evaluation is complete
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Exposure / Environmental Control
Completely undress patient,
Warm ambient temperature, warmed blankets to decrease heat loss
All fluids/blood products should be warmed
Early control of hemorrhage.
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Initial EvaluationMultiple trauma patients should have constant cardiac monitoring, continuous pulse ox, and initial set of vitals upon arrival. Vitals should be reassessed frequently to determine response to initial resuscitationOxygen should be routinely administered.In patients who do not need immediate intervention based on primary survey should have initial radiological evaluation including a chest and pelvis.
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Secondary SurveyAMPLE history Physical consists of a head to toe evaluation of patient.Thorough evaluation of neurological status, and complete exam of cardiac, abdominal, musculoskeletal and soft tissue systems.Reassess vitals/EKGPlacement of NG tube/ Foley after evaluation for contraindications
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Secondary Exam: Neurological Evaluation
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Secondary Exam - Neuro
Complete Neuro exam should include evaluation of level of consciousness, pupil responses, careful cranial inspection, and evaluation for spinal tenderness and spinal and peripheral nerve function, including rectal tone
Head injury Classification:Mild : GCS 14-15
Moderate : GCS 9-13
Severe : GCS 3-8
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Secondary Exam- Neuro
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Intracranial NG Tube Placement
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Incomplete Cord Syndromes
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Secondary Exam :Lethal Thoracic Injuries
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Lethal Thoracic Injuries
Tension pneumothorax
Hemothorax
Pulmonary contusion
Tracheobronchial-bronchial tree injury
Cardiac contusion/tamponade
Traumatic aortic disruption
Traumatic diaphragmatic injury
Mediastinal traversing wounds.
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Secondary Exam: Abdominal Evaluation
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Secondary Exam- Abdominal Evaluation
Initial stabilization of vital signs with fluid/blood.
Any patient with altered mental status, or distracting injuries requires an objective evaluation of the abdomen via DPL, CAT scan, or Ultrasound.
CAT scan is noninvasive, and sensitive. Also allows evaluation of the retroperitoneum. Limited use in patients who are unstable and do not respond to initial resuscitation.
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Secondary Exam- Abdominal Evaluation
Ultrasound is noninvasive and can be used at bedside to detect hemoperitoneum.
Useful in unstable patients
FAST exam evaluates the RUQ (Morison’s pouch), LUQ(splenorenal recess), pericardium, and pouch of Douglas in less than 5 minutes.
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FAST Exam
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Secondary Exam- Abdominal Evaluation
Unstable patients with decreased level of consciousness and + DPL or U/S needs urgent laparotomy; head CT should not be performed unless there is lateralizing neurological findings.
Unstable patients with a wide mediastinum and + DPL or U/S; laparotomy is recommended before arch aortography