Trauma Care

● Importance of Trauma Care

● Principles of primary and secondary assessments.

● Establish management priorities.• ATLS is primarily directed at providing initial care

during the “Golden Hour.”• This is the window of opportunity for the physician

to have the greatest impact on morbidity and mortality of the trauma patient.

● The leading cause of death in the first four decades of life. The only way to decrease the number of death by car accidents is by prevention.

● More than 5 million trauma-related deaths each year worldwide.

● Motor vehicle crashes cause over 1 million deaths per year.

● Injury accounts for 12% of the world’s burden of disease.

Trimodal Death Distribution• There are three peaks of death from

trauma. • First peak: Immediate – unsurvivable

injuries, impacted by trauma prevention. • Second peak: Early – golden hour of care,

impacted by early hospital care. • Third peak: Late – caused by sepsis and

multiple organ dysfunction syndrome (MODS), impacted by optimal early care and trauma center management.

● ABCDE approach to evaluation and treatment

● Treat greatest threat to life first before even

identifying the cause or taking history and

examination, immediately start managing.

● Definitive diagnosis not immediately important

● Time is of the essence. Golden hour and this hour

is what predicts the survival of the patient.

● Do no further harm

• ABCDE is the universal language for the primary exam.

• ABCDE is the order in which the injuries will kill patients.

• Definitive diagnosis and an in-depth history are not required initially.

Airway with c-spine protection

Breathing / ventilation / oxygenation

Circulation: stop the bleeding!

Disability / neurological status and not orthopedic status.

Expose from head to toe to look for any other sites of injuries but be careful of hypothermia / Environment / body temperature

Transfer

Reevaluation

Adjuncts

Adjuncts

Primary Survey

Resuscitation

Reevaluation

DetailedSecondary

Survey

Injury

Optimize patient status

ABCDE is the primary survey, you do not move to the next step until stabilizing the step before (step-wise manner).

This should be done by any primary care physician.

Its better to do everything at the same time but if you cant prioritize your steps.

As you are resuscitating you reevaluate. After you reevaluate you move to

secondary survey.

● 24-year-old male involved in a motorcycle crash in to a truck

● Not wearing a helmet

● Arrives at hospital with the red crescent

● BP 80/40, P140, RR 33, and central cyanosis

● C-collar, Oxygen at 8L/min, Dressing to forehead & thigh soaked in blood

● Has a wrist splint & is on a spinal board

● Apply principles of primary and secondary surveys

● Identify management priorities

● Institute appropriate resuscitation and monitoring procedures

● Recognize the value of the patient history and biomechanics of injury

● Anticipate and manage pitfalls

● Cap● Gown● Gloves● Mask● Shoe covers● Goggles / face

shield● Note: the first thing to do is

protecting yourself from fluid splash and needle pricking….

1-4 Standard PrecautionsStandard precautions are one

component of preparing for the patient in the hospital.

You may query what items are needed to protect the patient and the trauma team members.

Emphasize the need to protect the patient and trauma team members from communicable diseases.

Primary survey and resuscitation of vital functions are done simultaneously using a team approach.

1-5 Initial Assessment

• We recognize that, when a team is present, many individuals accomplish disparate tasks simultaneously.

• The ABCDE format is somewhat artificial, but it serves the purpose of establishing priorities and helping the student to return to “A” (home base) whenever the patient’s condition worsens or the patient does not respond as anticipated during the initial assessment process.

Definitive Care

Reevaluation

Adjuncts

Adjuncts

Primary Survey

Resuscitation

Reevaluation

DetailedSecondary

Survey

What is a quick, simple wayto assess a patient in 10

seconds?

What is a quick, simple way to assess a patient in 10 seconds?

● Identify yourself

● Ask the patient his or her name

● Ask the patient what happened

● Note: the best way to assess the patient initially is talking to the patient and asking him about place time and person. If he can talk clearly that means airway is patent, oxygenation is enough to maintain speaking and enough blood is going to the brain to maintain its function. If he is not talking clearly then ABCDE.

A Patent airway

B Sufficient air reserve to permit speech

C Sufficient perfusion to permit cerebration

D Clear sensorium NOTE:Appropriate Response Confirms…. • The patient who fails this simple test needs immediate attention.

Airway with c-spine protection

Breathing with adequate

oxygenation

Circulation with hemorrhage control

Disability

Exposure / Environment

The priorities are the same for all patients.

ATLS is intended to guide the assessment and resuscitation of injured patients. Judgment is required to determine what procedures are necessary, because not all patients require all procedures.

● Trauma in the elderly

● Pediatric trauma

● Trauma in pregnancy

Establish patent airway and protect c-spine

Occult airway injury

Progressive loss of airway

Equipment failure

Inability to intubate

Pitfalls

Airway

Primary Survey: Establish patent airway and protect c-spine

• Emphasize the need to protect the c-spine during airway management, especially avoiding the ACLS head-tilt maneuver.

• Cervical collar doesn’t prevent movement, its only there to remind you and the patient not to move the neck to prevent spine injury.

• Head tilt should not be preformed even if a cervical collar is there.

Basic Airway TechniquesChin-lift Maneuver

Without head tilt because its trauma in which you always consider the patient having cervical spine injury until proven otherwise.

Basic Airway TechniquesJaw-thrust Maneuver

Preferred because it moves the jaw and tongue anterioraly without tilting the head

Advanced Airway TechniquesOrotracheal intubation: tube from the

mouth to the trachea, and it’s a definitive treatment.

Indications for endo-tracheal intubation:

Airway obstruction by tongue, blood and secretion.

Unconscious patient.Glasgow coma scale less than 8.

Assess and ensure adequate oxygenation and ventilation

● Respiratory rate

● Chest movement brief chest examination.

● Air entry

● Oxygen saturation the most important i.e. oxygenation is the most important thing

Breathing

Primary Survey: Assess and ensure adequate oxygenation and ventilation

• Attend an adequate oxygenation and ventilation in the injured patient.

• If the patient is receiving high-flow oxygen, adequate oxygenation is no guarantee of adequate ventilation.

Breathing

Airway versus ventilation problem?

latrogenic pneumothoraxor

tension pneumothorax?

Pitfalls

BreathingThe Immediate life threatening injuries

(must be ruled out)

● Laryngeotracheal injury / Airway obstruction

● Tension-massive pneumothorax

● Open pneumothorax

● Flail chest and pulmonary contusion

● Massive hemothorax

● Cardiac tamponade

Laryngeal and major right or left bronchial injury is more severe than lung injury because air will go to the least resistant pathway and will lead to massive pneumothorax.

Diagnosed by putting a chest tube: a lot of air will come out.

Tension pneumothorax

When normal physiology is disrupted leading to tracheal shift and hemodynamic instability.

Its clinically diagnosed: hyper-resonance, decreased chest expansion,tracheal shift and absent breath sounds.

its not diagnosed by chest x-ray, the x-ray is only used to check if the tube is in the right position. Another indicator is hearing air entry.

Treatment: needle (12-16G)aka thoracocentesis in the 2nd intercostal space mid-clavicular line. Always Followed by a chest tube (32-36 “the larger the number the larger the tube unlike the needle the smaller the number the bigger the tube) placed in the 5th or 6th intercostal space anterior or mid axillary line.

Intubation is not used in the treatment because it will make it worse.

Open pneumothorax

It’s a two way valve communicating to the outside unlike tension pneumothorax which is a one way valve in which air comes in and doesn’t go out.

Air will go in through the wound until the pressure is equal in and out so no more air movement will be there.

Treatment is chest tube and dressing the wound.

Flail chest

3 broken ribs that are disconnected from the rest of the chest, with negative pressure (during inspiration) they get sucked in with +ve pressure (expiration) they are pushed out.

It affects breathing mechanics, its very painful, injures the lung causing pulmonary edema (main problem) worsening hypoxia.

Massive hemothorax

1.2-1.5 L of blood comes out when you put a chest tube, or 200 cc of blood per hour over 6 hours.

Treatment: chest tube or surgical intervention but never conservatively.

In trauma any fluid is considered blood. Cardiac temponade: its an extreme

emergency because the heart is injured. Its treated surgically by opening the pericardium and looking for the site of injury. If not treated will lead to shock and cardiac arrest.

● Level of consciousness

● Skin color and temperature

● Pulse rate and character (we don’t depend on peripheral pulses.

Assess for organ perfusion

Functions of Circulation

Note: assess clinically the signs of inadequate tissue perfusion and do a cardiac examination, examine the central vessels (carotid, coronaries) instead of focusing on the patient’s blood

pressure.

● Control hemorrhage or stop bleeding. This might be achieved in severe cases by operative manegement. The most important. By finding the site of bleeding.

● Restore volume by giving fluid

● Reassess patient response to treatment

● Lethal triad: hypothermia, acidosis, coaglopathy.

1st priority detect site of bleeding , 2nd priority stop bleeding , 3rd priority restore blood volume .

Elderly

Children

Athletes

Medications

Circulatory Management

Pitfalls

Patient may lose blood:1.Peritoneal.2.Retro-peritoneal.3.On the floor- open injury.4.Chest5.Pelvis (different than the abdomen have a

separate management)6.Femur (2L of blood will be lost from one

femur if both are injured then 4L (80% of the blood volume-5L)

7.We don’t lose blood intracranially because small bleeds will lead to death.

We rule out bleeding in the abdomen by diagnostic peritoneal lavage, but this method is time consuming, requires an incision in the abdomen and needs expertise therefore its replaced by FAST- (used for both abdomen and chest)

FAST: focal assessment with sonography in trauma. In this method you look between the liver and the kidney in the right side and between the spleen and the kidney in the left side.

To rule out chest bleeding you do a thoracocentesis or FAST.

To ruleout pelvic bleeding by examining the pelvis first (if it moves and its painful indicating a fracture which might lead to large bleeding due to the presence of large vessels) or by x-ray.

To replace the volume we need 2 large bore I.V access (12-16G), the bigger the better (12 is the best).

The peripheral line is better than the central line (it has lumen and its very long therefore high resistance).

We give 2 L of crystelloids (RL or NS) over 2 mins, if the patient remains hypotensive you give blood or if he initially presented with massive blood loss or blood is available from the beginning.

Disability● Baseline neurologic evaluation

● Glasgow Coma Scale score

Note: identify neurological injury using the tools of GCS score and pupil response early in order to avoid secondary brain injury, identify surgically correctable lesions rapidly, and provide a baseline GCS score to identify trends and changes.

Disability

● Baseline neurologic evaluation

● Glasgow Coma Scale score

● Pupillary response

Disability

● Baseline neurologic evaluation● Glasgow Coma Scale score to check for consciousness and severity of head injury. (score range 3-15)

● Pupillary response bilaterally. (reactive, equal and papilledema). If pupil is non reactive in one side and unequal in size that’s the lateralization sign meaning that the patient is bleeding intracranially and compressing the brain. It starts in one side then becomes bilateral due to herniation and it’s a surgical emergency.

Observe for neurologic

deterioration

Prevent hypothermia

Exposure / Environment

Completely undress the patient and examine the entire body (chest, abdomen, limbs…etc) cover the patient with blankets to prevent hypothermia

Missed injuries

Pitfalls

Log roll is to move the patient as one unit: one person fixes the head and 2 persons hold the trunk and one for each limb and one examines the back.

After primary survey, you have to investigate the paint (imaging, labs)

Cervical spine injury is missed in 50% of the cases on x-ray so CT is better , x-ray for chest and pelvis ( no x-ray for abdomen instead FAST or by Diagnostic Peritoneal Lavage=DPL)

● Protect and secure airway

● Ventilate and oxygenate

● Stop the bleeding!

● Vigorous shock therapy

● Protect from hypothermia

Note: the treatment is administered at the time the life threatening problem is identified. assessment and treatment during the primary survey and resuscitation phases of the initial assessment process often are done simultaneously.

PRIMARY SURVEY

PRIMARY SURVEY

Vital signsABGs

Pulseoximeterand CO2

Urinary / gastric cathetersunless contraindicated

Urinaryoutput

ECG

Diagnostic Tools

● FAST

● DPL

Consider Early Transfer

● Use time before transfer for resuscitation

● Do not delay transfer for diagnostic tests

The completehistory and

physicalexamination

After● Primary survey is completed

● ABCDEs are reassessed

● Vital functions are returning to normal

When do I start the secondary survey?

● History

● Physical exam: Head to toe (regardless the symptoms), joint by joint because it might be injured but the patient isn’t complaining of pain because he is unconscious.

● Complete neurologic exam

● Special diagnostic tests

● Reevaluation

What are the components of the secondary survey?

History

Allergies

Medications

Past illnesses

Last meal

Events / Environment / Mechanism

Mechanisms of Injury

Unconsciousness

Periorbital edema

Occluded auditory canal

Head

Pitfalls

● External exam

● Scalp palpation

● Comprehensive eye and ear

exam

● Including visual acuity

● Bony crepitus

● Deformity

● Malocclusion

Maxillofacial

Potential airway obstruction

Cribriform plate fracture

Frequently missed

Pitfalls

Mechanism: Blunt vs penetrating

Symptoms: Airway obstruction, hoarseness

Findings: Crepitus, hematoma, stridor, bruit

Neck (Soft Tissues)

Delayed symptoms and signs

Progressive airway obstruction

Occult injuries

Pitfalls

● Inspect

● Palpate

● Percuss

● Auscultate

● X-rays

Chest

The Potential life threatening injuries● Blunt cardiac injury

● Traumatic aortic disruption

● Blunt esophageal rupture

● Traumatic diaphragmatic injury

Chest

● Inspect / Auscultate

● Palpate / Percuss

● Reevaluate

● Special studies

Abdomen

Hollow viscous injury

Retroperitoneal injury

Pitfalls

● Hemodynamically abnormal with suspected abdominal injury (DPL / FAST)

● Free air

● Diaphragmatic rupture

● Peritonitis

● Positive CT

Indications for Laparotomy – Blunt Trauma

● Hemodynamically abnormal

● Peritonitis

● Evisceration

● Positive DPL, FAST, or CT

Indications for Laparotomy – Penetrating Trauma

Perineum Contusions, hematomas, lacerations, urethral blood

Rectum Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood

VaginaBlood, lacerations

Urethral injury

Pregnancy

Pitfalls

● Pain on palpation● Leg length unequal● Instability● X-rays as needed

Pelvis

Excessive pelvic manipulation

Underestimating pelvic blood loss

Pitfalls

● Contusion, deformity

● Pain● Perfusion● Peripheral

neurovascular status

● X-rays as needed

Extremities

Potential blood lossMissed fractures

Soft tissue or ligamentous injuryCompartment syndrome (especially

with altered sensorium / hypotension)

Musculoskeletal

Pitfalls

● GCS ● Pupil size and reaction● Lateralizing signs● Frequent reevaluation● Prevent secondary

brain injury

Earlyneurosurgical

consult

Neurologic: Brain

Altered sensorium

Inability to cooperate with clinical exam

● Whole spine● Tenderness and swelling● Complete motor and sensory exams● Reflexes● Imaging studies

Neurologic: Spinal Assessment

Pitfalls

Early neurosurgical /

orthopedic consult

Neurologic: Spine and CordConduct an in-depth evaluation of the patient’s spine and spinal cord

Special Diagnostic Tests as Indicated

Patient deterioration

Delay of transfer

Deterioration during transfer

Poor communication

Pitfalls

Tertiary survey: after the patient is fully fine to identify any small problems that might have been missed as neck ligament injuries or MCP joints.

Massive blood transfusion might lead to massive immunological reaction.

● High index of suspicion

● Frequent reevaluation and monitoring

How do I minimize missed injuries?

● Relief of pain / anxiety as appropriate

● Administer intravenously

● Careful monitoring is essential

Which patients do I transfer to a higher level of care?

Which patients do I transfer to a higher level of care?

Those whose injuries exceed institutional capabilities:

● Multisystem or complex injuries

● Patients with comorbidity or age extremes

When should the transfer occur?

Which patients do I transfer to a higher level of care?

As soon as possible after stabilization:

● Airway and ventilatory control

● Hemorrhage control

Transfer agreements

Local resources

Trauma center

Specialtyfacility

Local facility

● Rapid accurate assessment

● Resuscitate and stabilize by priority

● Determine needs and capabilities

● Arrange for transfer to definitive

care

● Ensure optimum care

● ABCDE approach to trauma care

● Do no further harm

● Treat the greatest threat to life first

● One safe way

● A common language

Definitive Care

Reevaluation

Adjuncts

Adjuncts

Primary Survey

Resuscitation

Reevaluation

DetailedSecondary

Survey

Questions