RESUSCITATION & TRANSPORTATION OF TRAUMA

PATIENTSMODERATORS :DR.VIJAY KUMAR

DR.CHIRANTH

SPEAKER: DR.SHANKAR.K

Epidemiology

Golden Hour = 80% of trauma deaths in first hour after injury

Rapid trauma care has greatest level of impact in these patients

2

Immediately Hours Days/Weeks

50%

30%20%

Trimodal Distribution of Trauma Deaths

THE GOLDEN HOUR

• originated by R Adams Cowley.• first sixty minutes after the occurrence of multisystem trauma.• victim's chances of survival are greatest if they receive definitive care in the OR within the first hour after a severe injury. 2nd and 3rd peak in tri-modal distribution of death can be reduced if definitive care is received with in 1 hr.

SYSTEMATIC APPROACH1] Preparation2] Primary survey (ABCDE) and Management3] Secondary survey and Management4] Tertiary survey

DETERMINING THE NEED FOR PATIENT TRANSFER

RAPID PRIMARY SURVEY

• IDENTIFY LIFE THREATENING INJURIES in orderly manner based on effect of injury on patients physiology and life

• INITIATE LIFE PRESERVING THERAPIES • In settings with limited resources, the primary survey simplifies

priorities and any problems identified should be managed immediately, in the order they are detected, before moving on to the next step of the survey.

• However, at major trauma centers, many capable clinicians may be present, allowing the team to address multiple problems simultaneously.

The primary survey consists of the following steps:●Airway assessment and protection (maintain cervical spine stabilization when appropriate)●Breathing and ventilation assessment (maintain adequate oxygenation)●Circulation assessment (control hemorrhage and maintain adequate end-organ perfusion)●Disability assessment (perform basic neurologic evaluation)●Exposure, with environmental control (undress patient and search everywhere for possible injury, while preventing hypothermia)

PROTECTION OF C- SPINE

RECOGNITION OF AIRWAY COMPROMISE• Maxillofacial Trauma• Neck Trauma• Laryngeal Trauma Agitation,obtundation Cyanosis indicates hypoxemia. However, cyanosis is a late finding of hypoxia. Pulse oximetry is used early in the airway assessment to detect inadequate oxygenation prior to the development of cyanosis. LOOK FOR retractions, use of accessory muscles LISTEN FOR abnormal sounds. Noisy breathing,Snoring, gurgling, and stridor FEEL FOR the location of the trachea.

PREDICTING DIFFICULT AIRWAYS

The LEMON© approach to difficult airway assessment• - L: Look externally• - E: Evaluate (3-3-2 rule)• - M: Mallampati score• - O: Obstruction/Obesity• - N: Neck mobilityDifficult bag-mask ventilationDifficult crico-thyrotomyDifficult supra-glottic airway placement

AIRWAY EQUIPMENTS AT BED SIDE SuctionBag-valve mask attached to high flow oxygenOral and nasal airwaysRescue airways (eg, Combitube™, Laryngeal mask airway)Endotracheal tubes in a range of sizesStyletsEndotracheal tube introducer (ie gum elastic bougie)LaryngoscopesLighted and optical stylets, Video laryngoscope, flexible endoscopes if availableSurgical airway devices

AIRWAY MAINTENANCE TECHNIQUES1] CLEAR AIRWAYS FROM SECRETIONS, VOMITUS, BLOOD etc BY THOROUGH SUCTIONING OF AIRWAYS.2] Chin lift 3] Jaw thrust4] Insertion of Airway

Indications for Definitive AirwayNEED FOR AIRWAY PROTECTION NEED FOR VENTILATION OR OXYGENATIONSevere maxillofacial fractures Inadequate respiratory efforts

• Tachypnea• Hypoxia• Hypercarbia• Cyanosis

Risk for obstruction• Neck hematoma• Laryngeal or trachealinjury• Stridor

Massive blood loss and need forvolume resuscitation

Risk for aspiration• Bleeding• Vomiting

Severe closed head injury withneed for brief hyperventilationif acute neurologic deteriorationoccurs

Unconscious Apnea• Neuromuscular paralysis• Unconscious

RAPID SEQUENCE INTUBATION• Pre-oxygenation• Pre-treatment• Paralysis with induction• - Induction agents• - Neuromuscular blocking agents• Protection (cricoid pressure) and positioning• Placement with proof• Post-intubation management

SURGICAL AIRWAYS• CRICOTHYROIDOTOMY (NEEDLE or SURGICAL)• TRACHEOSTOMY ( SURGICAL)

B: Breathing and Ventilation

• Tension pneumothorax• Open pneumothorax• Massive hemothorax• Flail chestNEEDS TO BE IDENTIFIED AT THIS STAGE OF PRIMARY SURVEY

• Ventilation requires functioning lungs, chest wall, diaphragm.

• Tachypnea can indicate respiratory distress

• Patients chest to be exposed to assess chest wall excursion.

• Palpate to detect chest wall injuries that compromise ventilation.

• Percuss to demonstrate air or blood.

RECOGNITION OF BREATHING COMPROMISE1] Ventilation can be compromised by airway obstruction, altered ventilatory mechanics, and/or central nervous system (CNS) depression. If a patient’s breathing is not improved by clearing the airway, other causes of the problem must be found and managed.

2] Direct trauma to the chest, especially with rib fractures,

3] Intracranial injury 4] Cervical spinal cord injury

OXYGENATION IS IT ADEQUATE?

Pulse oximetry is useful, as the continuous monitoring of oxygen saturation provides an immediate assessment of therapeutic interventions.• Oxygenated inspired air is best provided via a tightfitting oxygen

reservoir face mask with a flow rate of at least 11 L/min. Other methods (e.g., nasal catheter, nasal cannula, and nonrebreather mask) can improve inspired oxygen concentration

Circulation with hemorrhage control

• First step is to identify the presence of shock.• The second step in the initial management of shock is to identify the

probable cause of the shock state

ESTIMATED BLOOD LOSS BASED ON INITIAL PRESENTATIONBlood loss (mL) Up to 750 750–1500 1500–2000 >2000Blood loss (% blood volume)

Up to 15% 15%–30% 30%–40% >40%

Pulse rate (BPM) <100 100-120 120-140 >140Systolic b pressure Normal Normal decreased decreasedPulse pressure (mm Hg)

normal narrow narrow narrow

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

Urine output (mL/hr)

>30 20–30 5–15 Negligible

CNS/mental status Slightly anxious Mild anxious confused confusedInitial fluid replacement

crystalloid crystalloid Blood and crystalloid

Blood and crystalloid

Obvious and immediately detectable manifestations of the shock state include:• Tachycardia• Hypotension• Cool extremities• Weak peripheral pulses• Prolonged capillary refill (>2 seconds)• Narrowing of the pulse pressure (<25 mmHg)• Altered mental status not due to head injury• DIAGNOSTIC STUDIES HELP IN IDENTIFYING SOURCE OF

HAEMORRAGE AT EARLY STAGE

LETHAL TRIAD

COAGULOPATHY, ACIDOSIS, HYPOTHERMIADue to activation of protein C as a result of tissue hypo-perfusion. Protein C inactivates Factor V, V111…Haemorrhage result in the consumption of coagulation factors and early coagulopathy.Tissue hypoperfusion leads to inadequate oxygen delivery, switch over to anaerobic metabolism lactate production and ACIDOSIS.Anaerobic metabolism limits endogenous heat production exacerbating hypothermia caused by injudicious cold fluid and blood administration.

DAMAGE CONTROL RESUSCITATION• PERMISSIVE HYPOTENSION • HEMOSTATIC RESUSCITATION• DAMAGE CONTROL SURGERY

PERMISSIVE HYPOTENSION• Target SBP of 70-90 mm hg [ palpable radial pulse]• BY RESTRICTED OR DELAYED APPROACH TO FLUID ADMINISTRATION.• Aggressive fluid administration as ineffective and potentially harmful.• Controlled hypotension may be beneficial in patients with

hemorrhagic shock. However, it may be detrimental to blunt trauma patients with brain injury, as hypotension reduces cerebral perfusion and increases mortality.

• The rationale for improved outcomes with delayed fluid resuscitation is that aggressive fluid administration might, via augmentation of blood pressure, dilution of clotting factors, and production of hypothermia, disrupt thrombus formation and enhance bleeding.

INITIAL MANAGEMENT OF HEMORRHAGIC SHOCKThe initial treatment of shock is directed toward restoring cellular and organ perfusion with adequately oxygenated blood.• Definitive control of hemorrhage and restoration of adequate

circulating volume are the goals of treatment of hemorrhagic shock.• External haemorrhage is identified and controlled in primary survey(MANUAL COMPRESSION, SPLINTS, ELASTIC BANDAGE, TORNIQUET)• Vasopressors are contraindicated for the treatment of hemorrhagic

shock because they worsen tissue perfusion.

• Short, large-caliber peripheral intravenous lines are preferred• The most desirable sites for peripheral, percutaneous intravenous

lines in adults are the forearms and antecubital vein• If circumstances prevent the use of peripheral veins, large-caliber,

central venous (i.e., femoral, jugular, or subclavian vein. • In children younger than 6 years, the placement of an intraosseous

needle should be attempted before inserting a central line.

INITIAL FLUID THERAPY• An initial, warmed fluid bolus is given. The usual dose is 1 to 2 L for

adults and 20 mL/kg for pediatric patients.• ISOTONIC CRYSTALLOIDS(NS,RL,plasmalyte-A ), Hypertonic saline,

COLLOIDS• RESTRICTIVE VS LIBERAL FLUID ADMINISTRATIONExcessive fluid administration can exacerbate the LETHAL TRIAD of coagulopathy, acidosis, and hypothermia with activation of the inflammatory cascade.

ISOTONIC CRYSTALLOIDS

ADVANTAGES• INEXPENSIVE• READILY AVAILABLE• NON-ALLERGENIC• NON-INFECTIOUS• RESTORES TOTAL BODY FLUID• EASY TO STORE AND ADMINISTER• CAN BE RAPIDLY WARMED TO

BODY TEMP

DISADVANTAGES LACK OF O2 CARRING CAPACITY LACK OF COAGULATION LIMITED INTRAVASCULAR LIFE RECENT DATA SHOWS IT AS A TRIGGER OF CELLULAR APOPTOSIS

HYPERTONIC SALINE

• Enhanced ability to restore intravascular volume in contrast to equivalent isotonic crystalloids

• Studies involving polytrauma patients with both hemorrhage and TBI showed improved neurological status and recovery from shock.

so, most commonly used as an osmotic agent in TBI and increased ICP

• ADVANTAGES• RAPID INTRAVASCULAR VOLUME

RESTORATION AT A LWER VOLUME• READILY AVAILABLE• EASILY STORED AND

ADMINISTERED• RELATIVELY INEXPENSIVE

• DISADVANTAGES

LACK OF O2 CARRING CAPACITY LACK OF COAGULATION

SYSTEMATIC REVIEWS CONTINUE TO SHOW NO BENEFIT OF COLLOIDS OVER CRYSTALLOIDS

COLLOIDS

RESTRICTIVE VS LIBERAL FLUID ADMINISTRATION

•  Aggressive fluid administration via augmentation of blood pressure, dilution of clotting factors, and production of hypothermia, disrupt thrombus formation and enhance bleeding.

• Patient’s mental status and likelihood of intracranial injury, type of injury, severity of injury (eg, ongoing hemorrhage), and proximity to a trauma center to be considered.

• Aggressive fluid administration as ineffective and potentially harmful. and limited volume replacement that maintains minimally adequate organ perfusion improve outcomes. This strategy is often referred to as delayed fluid resuscitation or controlled hypotension, an approach which targets early fluid resuscitation only to a systolic blood pressure of 70 – 90 mmHg.[ palpable radial pulse]

HEMOSTATIC RESUSCITATION1] Early use of blood and blood products as primary resuscitation fluids to treat ATC and prevent development of dilutional coagulopathy.2] Aggressive hemostatic resuscitation to be equally combined with aggressive control of bleeding.3] Transexamic acid 1g over 10 min f/b 1g over 8hours when given within 1 hr for uncontrollable bleeding who required blood transfusion were benefited. As per CRASH2 trial in 2010 transexaemic acid significantly reduced mortality due to haemorrhage without any increase of Thrombo-embolic complications. 4] factor7,prothrombin complex, fibrinogen concentrates also play a role in hemostatic resuscitation.

BLOOD TRANSFUSION• The decision to initiate blood transfusion is based on the patient’s response, as

described in the previous section. • Patients who are transient responders or nonresponders—those with Class III or

Class IV hemorrhage—will need pRBCs and blood products as an early part of their resuscitation.

• CROSSMATCHED, TYPE-SPECIFIC, AND TYPE O BLOOD• Fully crossmatched blood is preferable. However,the complete crossmatching

process requires approximately 1 hour in most blood banks. • Type-specific blood can be provided by most blood banks within 10 minutes. Such

blood is compatible with ABO and Rh blood types, but incompatibilities of other antibodies may exist.

• If type-specific blood is unavailable, type O negative packed cells are indicated for patients with exsanguinating hemorrhage.

RBC:PLATELET:FFP------1:1:1 or 2:1:1 ?

• PROPPR trial and PROMMTT study showed that early use of higher amounts of plasma and platelets was associated with improved survival during first 6 hours after admission.

• Early availability of blood products administerd within minutes of arrival using transfusion ratio of 1:1:1 was associated with better hemostasis ad decreased hemorrhage related death.

DAMAGE CONTROL SURGERY• Concept in which initial surgery becomes a part of resuscitation

process rather than curative process.• Aimed at restoring normal physiology rather than anatomical integrity• 3parts initial abbreviated laparotomy, ICU resuscitation, and

subsequent reoperation for definitive resuscitation.• Only when patient is physiologically stable final therapeutic surgery is

carried out.

Disability and neurologic evaluation

Glasgow Coma Scale (GCS) score Assessments of pupillary size and reactivity Gross motor function, and sensation

Exposure and environmental controlCompletely undressed and entire body is examined for signs of injury during the primary survey Missed injuries pose a grave threat Regions often neglected include the scalp, axillary folds, perineum, gluteal folds and in obese patients, abdominal folds. • While maintaining cervical spine precautions, examine the patient's back.• Hypothermia should be prevented if possible and treated immediately once

identified.• department (ED) and operating room (OR) temperatures of at least 29.4°C

(85°F) during the treatment of these patients• Make liberal use of warm blankets and active external warming devices.

Warm IV fluids and blood

DIAGNOSTIC STUDIES• Portable x-rays• Ultrasound (FAST exam) & Extended FAST (E-FAST)• Diagnostic peritoneal tap or lavage• Electrocardiogram• Laboratory tests

X-rays

• Screening x-rays should be obtained, either in the emergency department (ED) or the operating room (OR), even in hemodynamically compromised patients who are sent directly to the OR during or after their primary survey.

• Prompt imaging of the lateral cervical spine, chest, and pelvis can detect life threatening injuries that might otherwise be missed.

• A plain radiograph of the chest should be obtained in patients with penetrating injuries of the chest, back, or abdomen regardless of the need for CT. Plain films may reveal sub-diaphragmatic free air, a foreign body, or a pneumothorax or haemothorax

FAST• Primarily to detect pericardial and intra-peritoneal bleed.• Reliably identifies 200-250ml of intra-peritoneal fluid Sensitivity/specificity: 75%/98% Performed using a curvilinear 2.5 or 3.5 MHz probe• Cardiac: parasternal or sub-xiphoid, hepato-cardiac interface, pericardial space. RUQ: hepato-renal interface (Morrison’s Pouch), diaphragm, inferior pole of kidney.LUQ: spleno-renal interface, diaphragm, inferior pole of kidney, inferior tip of spleen.Suprapubic: outline of bladder, silhouette of uterus (females).Cannot reliably evaluate retro-peritoneal structure/hollow viscous injury/ pelvic bleeding[cannot differentiate urine or blood]

• Unstable patient: FAST >>>>>>>> OR. Stable : abdominal CT is gold standard

Diagnostic Peritoneal Lavage (DPL)• Open or closed (Seldinger) approach • It can be performed to detect intra-peritoneal blood when FAST is

unavailable, to determine the type of intra-peritoneal fluid when it is important to do so (eg, blood vs urine in the setting of a pelvic fracture)

• Highly accurate for hemo-peritoneum (Sn = 95%, Sp = 99%)• Laparotomy when:

• 10 cc gross blood• Enteric contents• 1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3

• High Sn for hollow viscous injuries [More so than CT]• Retro-peritoneum can’t be assessed • High false positive DPL with pelvic fracture• A negative aspirate in an unstable patient with a pelvic fracture suggests

retroperitoneal hemorrhage, and angiography with possible embolization should ensue

Computerized Tomography• It is a time-consuming procedure that should be used only in hemodynamically normal

patients.• Sn = 92-97%, Sp = 99% for bleeding• Only modality to directly detect retroperitoneal injury

• CT scanning's benefits include: Detects not only the presence but the source and amount of hemo-peritoneum Active bleeding often detectable Retro-peritoneum and vertebral column can be assessed

• CT scanning's disadvantages include: Suboptimal sensitivity for pancreatic, diaphragmatic, bowel, and mesentery injury. Can be unobtainable or harmful to obtain in unstable patients

SECONDARY SURVEY• A secondary survey is performed in all trauma patients determined to be

stable upon completion of the primary survey. The secondary survey includes a

Detailed history[ AMPLE],Detailed Head to Toe examination, Targeted diagnostic studies plays a crucial role in avoiding missed injuriesTERTIARY SURVEY < 24 hours & prior to discharge.• Identifies and catalogues all injuries after the initial resuscitation and

operative intervention . The timing of this survey typically occurs within twenty four hours after admission and is repeated when the patient is awake, responsive, and able to communicate any complaints & prior to discharge.

DRUG HISTORY

1] Ask for co-morbid illness2] Beta blockers- can maintain normal heart rate in hypovolemia.3] Psychiatric medications-injuries can be self inflicting4] ANTI-PLATELET AND ANTI-COAGULANTS esp in TBI Warfarin– Suggestive reversalsVitamin K (10mg IV);FFP; rFVIIa; Transexamic Acid. Unfractionated Heparin (UHF) Reversal agent = Protamine Low Molecular Weight Heparin No proven antidote, Protamine is suggested but it may only neutralize 60% of the anti-factor Xa activity in LMWH

Antiplatelet Agents Platelet transfusion may be useful; DDAVP can be considered

Fondaparinux, • Apixaban and Rivaroxaban No specific antidote

Direct Thrombin Inhibitors Argatroban and Bivalirudin No specific antidote Rapidly eliminated upon cessation of the therapy Dabigatran NO REVERSAL Hemodialysis, – PCC’s or activated PCCs?, FFP?, rFVIIa?

HEAD INJURY• The primary goal of treatment for patients with suspected traumatic

brain injury (TBI) is to prevent secondary brain injury.

• Secondary injury may occur due to hypotension, hypoxia, hypercapnia, and iatrogenic hypocapnia.

Severity Minor Moderate Severe

• GCS Score 13–15• GCS Score 9–12• GCS Score 3–8

Morphology • Skull fractures • Vault Linear vs stellate Depressed/non-depressed Open/closed

• Basilar With/without CSF leak With/without nerve palsy

• Intracranial lesions

• Focal Epidural Subdural Intra-cerebral • Diffuse Concussion Multiple contusions Hypoxic/ischemic injury Axonal injury

MANAGEMENT OF HEAD INJURIES 1] Adequate oxygenation (PaO2 >60 mmHg) and blood pressure support (systolic BP >90 mmHg) Isotonic fluids (normal saline) should be used to maintain euvolemia. A subgroup analysis in the large SAFE study found that for patients with TBI, fluid resuscitation with albumin was associated with a higher mortality as compared with normal saline (33 versus 20 percent); this risk was even more pronounced in those with severe TBI (42 versus 22 percent)

2] Early endotracheal intubation is generally recommended for patients with a Glasgow coma scale score of 8 or less3] Management of raised ICP ventriculostomy placement with ICP monitoring in patients with severe TBI and an abnormal CT scan showing evidence of mass effect from lesions such as hematomas, contusions or swelling

4] CPP target is 60 mmHg, avoiding CPP >70 mmHg and <50 mmHg, which should be achieved by optimizing ICP first and then MAP (with volume expansion, vasopressors) second5] Short-term (one week) use of antiepileptic drugs ( phenytoin , valproate ) for the prevention of early seizures 6] fever and hyperglycemia be avoided for their potential to exacerbate secondary neurologic injury. Coagulopathy should be corrected to maintain an INR < 1.4 and a platelet count > 75,000/mm 3 . 7] SURGICAL TREATMENT OF INTRA CRANIAL HAEMORRAGES PENETRATING INJURIES, SKULL FRACTURES, DECOMPRESSIVE CRANIECTOMY

THREE TIERED APPROACH FOR INCREASED ICP TIER 1 TIER 21] Head elevation to 30 degree 1] Hyperosmolar therapy2] Neck in neutral position 2] PaCO2 of 30-35mmhg 3] Sedation, analgesia if intubated 3] Neuromuscular paralysis 4] Ventricular drainage intermittently if persistent increased ICP5] Rpt CT, neurological examination 4] Repeat CT, neurological examTo R/O mass lesionIF ICP REMAINS 20-25mmhg TIER 2 IF ICP REMAINS 20-25mmhg TIER3

TIER 31] Decompressive craniectomy2] Neuromuscular paralysis via continuous infusion to maintain alteast 2 twitches in TOF3] Barbiturate Coma4] Hypothermia as a rescue or salvage therapy

Mannitol· Use with signs of tentorial herniation· Dose: 0.25-1.0 g / kg IV bolus• Consult with neurosurgeon first• Mannitol should not be given to patients with hypotension, because

mannitol does not lower ICP in hypovolemia and is a potent osmotic diuretic. This can further exacerbate hypotension and cerebral ischemia.

Hypertonic saline 2-6ml/kg bolus is also used to reduce elevated ICP.Concentrations of 3% to 23.4% are used, and this may be the preferable agent to use in patients with hypotension, as it does not act as a diuretic. However, thereis no difference between mannitol and hypertonic salinein lowering ICP

•Hyperventilation should be used only in moderation and for as limited a period as possible

• hypercarbia (PCO2 > 45mm Hg) will promote vasodilation and increase intracranial pressure, and thus it should be avoided.

• Hyperventilation will lower ICP in a deteriorating patient with expanding intracranial hematoma until emergent craniotomy

• Aggressive and prolonged hyperventilation may promote cerebral ischemia in the already injured brain by causing severe cerebral vasoconstriction and thus impaired cerebral perfusion. This is particularly true if the PaCO2 is allowed to fall below 30 mm Hg

Indications for CT Scan?

1] ALL PATIENTS WITH MODERATE AND SEVERE BRAIN INJURY

NEW ORLEANS CRITERIA HeadacheVomitingAge over 60 years,Drug or alcohol intoxication,Deficits in short-term memory, Physical evidence of trauma above the clavicles, and seizure.

CANADIAN CT HEAD RULE in MTBI• GCS score less than 15 at 2 hours after injury• Suspected open or depressed skull fracture• Any sign of basilar skull fracture (e.g., hemotympanum,raccoon eyes, CSF otorrhea or rhinorrhea, Battle’s sign)• Vomiting (more than two episodes)• Age more than 65 years

2]Indications for CT Scanning in MTBI

MODERATE RISK FOR BRAIN INJURY ON CT• Loss of consciousness (more than 5 minutes)• Amnesia before impact (more than 30 minutes)• Dangerous mechanism (e.g., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height more than 3 feet or five stairs

SPINAL SHOCK

• Spinal shock refers to the flaccidity (loss of muscle tone) and loss of reflexes seen after spinal cord injury.

• The “shock” to the injured cord may make it appear completely nonfunctional, although the cord may not necessarily be destroyed.

• The duration of this state is variable.

• LEVEL• SEVERITY• SPINAL CORD SYNDROMES• MORPHOLOGY

RADIOGRAPHIC IMAGING

NEXUS -The National Emergency X- Radiograph Utilization Study

• Prospective study to validate a rule for the decision to obtain cervical spine x- ray in trauma patients

• Hoffman, N Engl J Med 2000; 343:94-99 Canadian C-Spine rules

• Prospective study whereby patients were evaluated for 20 standardized clinical findings as a basis for formulating a decision as to the need for subsequent cervical spine radiography

• Stiell I. JAMA. 2001; 286:1841-1846

NEXUS Criteria1. Absence of tenderness in the posterior midline2. Absence of a neurological deficit3. Normal level of alertness (GCS score = 15)4. No evidence of intoxication (drugs or alcohol)

5. No distracting injury/pain • Patient who fulfilled all 5 of the criteria were considered low risk for

C-spine injury No need C-spine X-ray

• For patients who had any of the 5 criteria radiographic imaging was indicated ( AP, lateral and open mouth views

Canadian Cervical Spine Rule for stable and alert patients where cervical spine injury is a concern

1. High risk factors that require imaging

• Age ≥65 yo• Dangerous mechanism of

injury• Fall from 1m (5 stairs)• Axial load to the head (eg.

Diving)• MVA- high speed (>100kph,

rollover, ejection)• Motorised recreational

vehicles• Bicycle collision

• Paraesthesia in extremities

2. Low risk factors that allow safe assesment of range of motion

• Sitting position in the emergency department or

• Simple rear end MVA or• Ambulatory at any one time

or• Delayed onset of neck pain

or• Absence of midline C-spine

tenderness

Immobilization Cervical spine injury requires continuous immobilization of the entire patient with a semi-rigid cervical collar, head immobilization,backboard, tape, and straps before and after transfer toa definitive-care facility

Four-Person Logroll. Logrolling a patient to remove a spine board and/or examinethe back (A) One person stands at the patient’s head to control the head and c-spine, and two are along the patient’s sides to control the body and extremities. (B) As the patient is rolled, three people maintain alignment of the spine, while(C) the fourth person removes the board and examines the back. (D) Once the board is removed,the patient is returned to the supine position, while maintaining alignment of the spine

INTRAVENOUS FLUIDS in spinal trauma 1] Intravenous fluids are administered as they would usually be for resuscitation of trauma patients. 2] If active hemorrhage is not detected or suspected, persistent hypotension should raise the suspicion of neurogenicshock. 3] Patients with hypovolemic shock usually have tachycardia, whereas those with neurogenic shock classically have bradycardia. If the blood pressure does not improve after a fluid challenge, use of DOPAMINE is usually the vasopressor of choice.

THORACIC INJURIES

B-Identify and initiate treatment of the following potentially life-threatening injuries assessed during the secondary survey:

1.Pulmonary contusion 2.Aortic disruption 3.Tracheobronchial disruption 4.Esophageal disruption 5.Traumatic diaphragmatic hernia 6.Myocardial contusion

CARDIAC TAMPONADE DIAGNOSED BY : Beck’s triad, FAST scan, suspected if not responding to resuscitation of haemorrhagic shock TREATED BY : Surgical evacuation of pericardial blood.

MASSIVE HAEMOTHORAXDIAGNOSED BY : Clinically, radiologically, suspected if not responding to resuscitation of haemorrhagic shock.TREATED BY : Simultaneous restoration of blood volume. Decompression by chest tube insertion Thoracotomy[ if >1500ml bleed or persistent bleed]

Chest pain ■ Respiratory distress■ Tachycardia ■ Hypotension■ Tracheal deviation away from the side ofinjury■ Unilateral absence of breath sounds■ Neck vein distention■ Cyanosis (late manifestation)

Definitive treatment: insertion of a chest tube into the 5th ICS.

. Immediate covering of defect. Chest tube. Definitive operation

Open Pneumothorax--->

Tension Pneumothorax--^

FLAIL CHEST Paradoxical motion of the chest wall during inspiration and expiration. If the injury to the underlying lung is significant, serious hypoxia can result

Ensure adequate oxygenation Provide analgesia to improve ventilation [NSAIDS,OPIOIDS,EPIDURAL, INTERCOSTAL BLOCK]Intubation and mechanical ventilation is rarely indicated for chest wall injury alone. Where ventilation is necessary it is usually for hypoxia due to underlying pulmonary contusions.

Resuscitative Thoracotomy The therapeutic maneuvers that can be effectively accomplished with a resuscitative thoracotomy are:1] Evacuation of pericardial blood causing tamponade2] Direct control of exsanguinating intrathoracic hemorrhage3] Open cardiac massage4] Cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart.

Abdominal and Pelvic Trauma

ASSESMENT AND MANAGEMENT1] Inspect the abdomen and flanks for lacerations, contusions and ecchymosis; palpate for tenderness and rigidity. The presence of a seat belt sign, rebound tenderness, abdominal distension, or guarding all suggest intra-abdominal injury.2] Rectum and genitourinary — Inspect the perineum of all patients for signs of injury3] DRE is warranted in cases where urethral injury or penetrating rectal injury is suspected. If the examination is performed, check for the presence of gross blood (sign of bowel injury), a high-riding prostate (sign of urethral injury), abnormal sphincter tone (sign of spinal cord injury), and bone fragments (sign of pelvic fracture).

Indications for Laparotomy1] Blunt abdominal trauma with hypotension with a positive FAST or clinical evidence ofIntra-peritoneal bleeding2] Blunt or penetrating abdominal trauma with a positive DPL3] Hypotension with a penetrating abdominalwound4] Gunshot wounds traversing the peritonealcavity or visceral/vascular retro-peritoneum5] Evisceration

6] Bleeding from the stomach, rectum, or genitourinary tract from penetrating trauma7] Peritonitis8] Free air, retroperitoneal air, or rupture of the hemi-diaphragm9] Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intra-peritoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma

Musculoskeletal Trauma

ASSESS AND MANAGE Major arterial hemorrhage Vascular compromise Open fractures, Pelvic fractures Crush syndrome Compartment syndrome

MEASURES IN MUSCULOSKELETAL TRAUMA

• Reduce fracture, Stabilize pelvis• Splint fracture

• Application of direct pressure [if bleeding]

• Use of a tourniquet may be helpful and lifesaving [ severe bleed]• Appropriate fluid resuscitation [ prevents crush syndrome]

• All constrictive dressings, casts, and splints applied over the affected extremity must be released[ in compartment syndrome]

If no significant changes occur, fasciotomy is required

TRANSFER OF TRAUMA PATIENTS

Determining the Need for Patient Transfer It is essential that clinicians assess their own capabilities and limitations, as well as those of their institution, to allow for early differentiation between patients who may be safely cared for in the local hospital and those who require transfer for definitive care.

TIMELINESS OF TRANSFER When should I transport the patient?

Patient outcome is directly related to the time elapsed between injury and properly delivered definitive care. In institutions in which there is no full-time, in-house emergency department (ED) coverage, the timeliness of transfer is partly dependent on the how quickly the doctor on call can reach the ED. In addition, the attending doctor must be committed to respond to the ED prior to the arrival of critically injured patients.

WHOM DO I TRANSFER?CATEGORY SPECIFIC INJURY &OTHER FACTORS

CNS – Penetrating injury or depressed skull fracture – Open injury with or without cerebrospinal fluid (CSF) leak – GCS score <15 or neurologically abnormal – Lateralizing signs• Spinal cord injury or major vertebral injury

CHEST • Widened mediastinum or signs suggesting great vessel injury• Major chest wall injury or pulmonary contusion• Cardiac injury• Patients who may require prolonged ventilation

PELVIS/ABDOMEN • Unstable pelvic-ring disruption• Pelvic-ring disruption with shock and evidence of continuing hemorrhage• Open pelvic injury• Solid organ injury

EXTREMITIES • Severe open fractures• Traumatic amputation with potential for replantation• Complex articular fractures• Major crush injury• Ischemia

MULTI SYSTEM INJURIES • Head injury with face, chest, abdominal, or pelvic injury• Injury to more than two body regions• Major burns or burns with associated injuries• Multiple, proximal long-bone fractures

SECONDARY DETERIORATION Mechanical ventilation required• Sepsis• Single or multiple organ system failure (deterioration in central nervous, cardiac, pulmonary, hepatic, renal, or coagulation systems)• Major tissue necrosis

CO MORBID FACTORS ELDERLY, CHILD<5, DM, CARDIC DISEASE, RESPIRATORY DISEASE, PREGNANCY, MORBID OBESITY, IMMUNOSUPPRESSION

Patients with evidence of shock, Significant physiologic deterioration, or progressiveDeterioration in neurologic status require the highestLevel of care and will likely benefit from timely transfer

The inter-hospital transfer of a critically injured patient is potentially hazardous unless the patient’s condition is optimally stabilized before transport, transfer personnel are properly trained, and provision has been made for managing unexpectedcrises during transport.

TREATMENT PRIOR TO TRANSFER

• Patients should be resuscitated and attempts made to stabilize their conditions as completely as possible based on the following suggested outline:

• 1. Airwaya. Insert an airway or endotracheal tube, if needed.b. Provide suction.c. Insert a gastric tube to reduce the risk of aspiration.• 2. Breathinga. Determine rate and administer supplementary oxygen.b. Provide mechanical ventilation when needed.c. Insert a chest tube if needed.• 3. Circulationa. Control external bleeding.b. Establish two large-caliber intravenous lines and begin crystalloid solution infusion.c. Restore blood volume losses with crystalloid fluids or blood and continue replacement during transfer.d. Insert an indwelling catheter to monitor urinary output.e. Monitor the patient’s cardiac rhythm and rate.

4. Central nervous system a. Assist respiration in unconscious patients. b. Administer mannitol, if needed.

c. Immobilize any head, neck, thoracic, and lumbar spine injuries. 5.Diagnostic studies When indicated; obtaining these studies should not delay transfer

6. Wounds Performing these procedures should not delay transfer.

7. Fractures Apply appropriate splinting and traction.

TREATMENT DURING TRANSPORT• The appropriate personnel should transfer the patient, based on

the patient’s condition and potential problems.• Treatment during transport typically includes: 1.Monitoring vital signs and pulse-oximetry2.Continued support of cardio-vascular system3.Continued blood-volume replacement4.Use of appropriate medications as ordered by a doctor or as allowed by written protocol5.Maintenance of communication with a doctor or institution during transfer6.Maintenance of accurate records during transfer

PITFALL: ET tubes, IV cannulas may get dislodged during transport. Necessary equipments to be ready for the procedure.

 Establishment of transfer agreements provide for the consistent and efficient movement of patients between institutions, and enhance the efficiency and quality of the patient’s treatment during transfer.

Transfer responsibilities are held by both referring and receiving doctor

• REFERRING DOCTORThe referring doctor is responsible for initiating transfer of the patient to the receiving institution and selecting the appropriate mode of transportation and level of care required for optimal treatment of the patient

• Stabilizing the patient’s condition before transfer to another facility is the responsibility of the referring doctor, within the capabilities of his or her institution.

• Initiation of the transfer process should begin while resuscitative efforts are in progress.

• Transfer agreements must be established to provide for the consistent and efficient movement of patients between institutions.

• PITFALLInappropriate communication b/w Referring and accepting care providers resulting in loss of information critical to the patient’s care.

RECEIVING DOCTOR1.The receiving doctor must be consulted with regard to the transfer of a trauma patient.2.The receiving doctor should assist the referring doctor in making arrangements for the appropriate mode and level of care during transport.3. If the proposed receiving doctor and facility are unable to accept the patient, they should assist in finding an alternative placement for the patient.4. Only by direct communication between the referring and receiving doctors can the details of patient transfer be clearly delineated. 5.If adequately trained emergency medical personnel are not available, a nurse or doctor should accompany the patient. 6.All monitoring and management rendered en route should be documented.

MODES OF TRANSPORTATION• Do no further harm is the most important principle when choosing

the mode of patient transportation. • Ground, water, and air transportation can be safe and effective in

fulfilling this principle, and no one form is intrinsically superior to the others.

• Local factors such as availability , geography, cost, and weather are the main determining factors as to which to use in a given circumstance.

• PITFALLfailure to anticipate deterioration in the patient’s neurologic condition or hemodynamic status during transport

REFERENCES• ADVANCED TRAUMA LIFE SUPPORT 9TH EDITION• MILLERS ANAESTHESIA 8TH EDITION• WASHINGTON MANUAL OF CRITICAL CARE 2ND EDITION• JOURNAL OF ANAESTHESIOLOGY CLINICAL PHARMACOLOGY: Fluid

management in trauma patients Restrictive vs Liberal approach• INDIAN JOURNAL OF ANAESTHESIA: Transfusion practice in Trauma.• JAMA CARDIOLOGY: Transfusion of plasma platelet RBC in 1:1:1 vs

1:1:2• BRITISH JOURNAL OF ANAESTHESIA: Damage control surgery in the

era of damage control resuscitation

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