trauma management over view

8/4/2019 trauma management over view

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TRAUMA

Surgical unit II

Tuesday, 4rth Oct 2011

9:30-11:30 AM


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The Scheme Recitation

How it started Why is it important for US

Primary Trauma Approach (Triage, BLS, ATLS)

Dr Shafiq Chughtai, PGT 4

Deadly dozen

Dr Asif Reza, PGT 4

Cases

Dr Sundas

Dr Hena

Mortality

Dr Shafiq Chughtai, PGT 4

Discussion/Questions


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Recitation


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How it started


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ATLS has its origins in the United States in1976, whenJames K. Styner, an orthopedicsurgeon piloting a light aircraft, crashed his

plane into a field in Nebraska.

His wife was killed instantly and three of hisfour children sustained critical injuries
http://en.wikipedia.org/wiki/James_K._Stynerhttp://en.wikipedia.org/wiki/Orthopedic_surgeryhttp://en.wikipedia.org/wiki/Orthopedic_surgeryhttp://en.wikipedia.org/wiki/Nebraskahttp://en.wikipedia.org/wiki/Nebraskahttp://en.wikipedia.org/wiki/Orthopedic_surgeryhttp://en.wikipedia.org/wiki/Orthopedic_surgeryhttp://en.wikipedia.org/wiki/James_K._Styner


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He carried out the initial triage of his children at

the crash site. Dr. Styner had to flag down a carto transport him to the nearest hospital; uponarrival, he found it closed.
http://en.wikipedia.org/wiki/Triagehttp://en.wikipedia.org/wiki/Triage


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Even once the hospital was opened and a doctorcalled in, he found that the emergency careprovided at the small regional hospital where

they were treated was inadequate andinappropriate.

Upon returning to work, he set aboutdeveloping a system for saving lives in medicaltrauma situations.


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First ATLS course which was held in 1978.

1980, American College of Surgeons committeeon Trauma adopted ATLS.

Styner himself recently recertified as an ATLSinstructor, teaching his Instructor Candidatecourse in the UK and then in the Netherlands.


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Why is it important for US


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Approximately twenty million people are killedor injured every year due to the road trafficaccidents.

1.66 million deaths were attributed to violence inthe year 2000.


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The situation in Pakistan is worse because

There is an ever increasing number of traumavictims due to road traffic accidents.

Increasing violence.

There is lack of timely provision of appropriate prehospital/ hospital based medical care.


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A study from Karachi reported that 58% of thevictims of violence died before they could reachthe hospital.

National road safety secretariat estimated thatabout two million accidents occurred in Pakistanin year 2006 and 0.418 million were of seriousnature


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Increase of 55% was noted in homicidal attacksduring a ten year period (1985-1994) in one

study.

Another study estimated the loss of 31.94

healthy life years per 1000 population inPakistan due to injuries in 1990.

Today with worst law and order situation andviolence, the situation has aggravatedconsiderably in Pakistan.


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It has been clearly proved in a study, that themortality rates for seriously injured victims weresix times more in the under developed countries

than at the level 1 trauma centre in US.

Most of these deaths occurred in the early hours

after trauma and were attributed to (A) airwaycompromise (B) respiratory failure and (C)uncontrolled haemorrhage.


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The Aim Today Is

To inculcate basic knowledge and approach in you so thatwe can bring a change and save more precious lives ..


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Approach To Trauma

Triage BLS ATLS

Primary Survey Secondary Survey


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TriageThe greatest good for the greatest number.


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Segregate & Priorities casualties into different groupson the basis of there injuries.

Used since Neopolianic wars.

Studies show 10-15% casualties are serious enough!

Patient status is dynamic and therefore, triage is done in

Field, Before evacuation

At hospital.


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Basic Life Support


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Head tilt & Chin Lift


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Ventilation

In patient with compromised breathing / apnea,there is need to take control of the airway.

Mouth to mouth/ mouth to nose ventilation.

Bag Valve Mask Ventilation (BVMV)

Endotracheal Intubation


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Mouth to mouth ventilation is proven to be of valuebut considerable hesitancy exist leading to the tendencyof not doing cpr in victims.

Provision of chest compression without mouth-to-mouth

ventilation is far better than not attempting resuscitation at all.

Reference

Van Hoeyweghen RJ, Bossaert LL, Mullie A, Calle P, Martens P, Buylaert WA, Delooz H, Belgian CerebralResuscitation Study Group. Quality and efficiency of bystander CPR. Resuscitation.. 1993;26:47-52.[Medline][Order article via Infotrieve]
http://circ.ahajournals.org/cgi/external_ref?access_num=8210731&link_type=MEDhttp://circ.ahajournals.org/cgi/external_ref?access_num=8210731&displayid=7382&link_type=INFOTRIEVEhttp://circ.ahajournals.org/cgi/external_ref?access_num=8210731&displayid=7382&link_type=INFOTRIEVEhttp://circ.ahajournals.org/cgi/external_ref?access_num=8210731&link_type=MED


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BVM-Ventilation


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BVM ventilation is absolutely contraindicated inthe presence of complete upper airwayobstruction.

BVM ventilation is relatively contraindicatedafter paralysis and induction (because of theincreased risk of aspiration).

BVM-V, Indications &

Contraindications


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Technique of BVM-V

One hand C & E Technique

Two hand technique


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One hand, C & E Technique


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Two Hand Techniques

A B


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Provide a volume of 6-7 mL/kg per breath(approximately 500 mL for an average adult.

During cardiopulmonary resuscitation (CPR),give 2 breaths after each series of 30 chest

compressions until an advanced airway is placed.Then ventilate at a rate of 8-10 breaths perminute.


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Endotracheal Intubation

Patient dies from lack of O2, not lack of ETT!

Pre oxygenation. 8 deep breaths in 60

seconds. Apneia time increases to 8 minutes.

Confirm that balloon of tube is functional.

Rough guide to size of tube is little fingerdiameter.


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Hold your breath while passing tube, when ufeel uncomfortable, stop and start ventilating

patient.

ETT requires considerable practice.


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Cardiac Arrest


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Advanced Trauma Life Support


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Primary Survey


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Primary Survey

AAirway and C Spine

Protection

B

Breathing & Ventilation

C

Circulation

D

Disability

E

Exposure


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The Golden Hour Concept

"There is a golden hour between life and death. If youare critically injured you have less than 60 minutes tosurvive. You might not die right then; it may be threedays or two weeks later -- but something has happenedin your body that is irreparable.

Dr Cowley

University of Maryland

USA


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Airway & C Spine

Protection


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1. Look, listen feel for air movement and chest wallmovement.

2. Look for direct injury to airway, presence of edema,FBs and secretions.

3. Listen for stridor.

4. Can the patient protect his airway.


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Immobilize C-spine in all till

Chin lift, jaw thrust, suction.

Open mouth , inspect for secretions , FBs ,broken teeth . Finger swap.remove FBs.


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Intubate if

apnea

gcs < 8

respiratory distress


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Emergency cricothyrotomy if:

Oral/nasal attempts fail

Significant maxillofacial trauma

There is little role of emergency tracheostomy.


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Children

Shorter anterior lyranx.

Floppy epiglottis,

Short & small trachea

Large tongue.


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Airway insertion only in unconscious child , onlyin oro-phyranx

Vomiting risk reduced. Minimize iatrogenic injury to soft palate.

Surgical cricothyroidiotomy is contraindicated inless than 12 yrs. Cricothyroid membrane is notdeveloped.


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Breathing & Ventilation


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Assess chest for defects, instablity and

asymmetry.

Assess respiratory rate, depth and chracter of

respiration.

Percuss the chest.

Listen for breath sound.


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Evaluate for

Neck distended veins

Trachea central vs deviated.

Chest wall open sucking wounds, Symetry,

paradoxical movementcerpetus, emphysema.


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Lung percuss and ascultate.

Back don t forget it.

Diaphram rises to nipple level, do not forgetabdomen.


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Oxygenate with FiO2 -85%.

Ventilate with Bag valve mask.

Seal an open pneumothorax.

Emergent chest tube for tension pneumothoraxor large heamothorax.


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Hypoxic patient get very irritable. They pull andpush and fight with health care workers.

Sedation might be required. Midazolam(dormicum) 1-2.5mg diluted iv push may work.

RR of children is 20/min and infants are 40-60/min.


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Assess

Pulses, hr, rhythm,

Blood pressure, heart sounds,

Neck veins, skin color, temperature.

Sources of bleeding:

Chest, abdomen , Open Extremity Wounds


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Direct pressure to external bleed.

Insert two large bore IV catheters

Rapidly infuse Lactated Ringers.

Start blood if hypotension does not respond tocrystalloids


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Resuscitation and intervention goes side by side!!

If iv access has failed twice, IO access should betried specially in less than 6 yrs old.

Pulse is an unreliable indicator in elderly.


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Disablity


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What is patients response?

A Alert

V responds to Verbal

P responds to Pain

U Unresponsive

Assess pupils size, equality, reaction to light.

ENT bleed/ CSF.
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Protect from secondary injury:

Avoid hypothermia,

Hypoxemia, hypercapnea,

Hypotension, hypoglycemia,

Volume excess.

Urgent neuro consult for signs of increased ICPor SCI.

Presume SCI in all patients.
http://www.google.com.pk/imgres?imgurl=http://trialx.com/curetalk/wp-content/blogs.dir/7/files/2011/05/diseases/Extradural_Hemorrhage-3.jpg&imgrefurl=http://trialx.com/curebyte/2011/08/28/images-related-to-extradural-hemorrhage/&usg=__5sxb6gzzksqQwPEZKPiWr5ZhBB8=&h=525&w=450&sz=35&hl=en&start=6&zoom=1&itbs=1&tbnid=JHCvfUgZaEaqUM:&tbnh=132&tbnw=113&prev=/search%3Fq%3Dextradural%2Bhematoma%26hl%3Den%26sa%3DG%26gbv%3D2%26biw%3D1366%26bih%3D561%26tbm%3Disch&ei=CEmHTsCeKc_s-gaj2Zg0


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Exclude

Hypoglycemia, Alcohol, drugs.

Children

Blunt head injury has the worst prognosis in this agegroup.

Elderly

Brain atrophy in this age group has protection fromcontusion.

Large amount of blood can collect around the brainwithout overt symptoms.


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Exposure


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Remove all of pts clothing.

Fully exposed front and back via log roll via in

line traction

All orifices, haired areas, axilla, perineum etc.

Assess for hypothermia.


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Detect easily missed injuries.

Re warm with blankets, air devices, reflectiveshield, warm IV fluids.


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IMPORTANT

Most trauma surgeons do primary survey twicebefore embarking on secondary survey.

Patients status changes rapidly, re evaluation isof critical importance from time to time.


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Inx and Mx at a glance

O2 inhalation , May need Pulse Oximeter

Ecg Monitor.

Double iv access 16/14 G, take grouping and crossmatch at the same time, ringer lactate / normal saline /

RCC.

IV antibiotics, Tetnus, good pain killer.


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ER profile if time permits.

Xray

skull , c spine, chest , pelvis , limbs if indicated.

FAST DPL


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Foleys catheter (blood at urethreal meatus is a contraindication)

Adults 0.5 ml/kg/hr.

Infants 2ml/kg/hr.

1-5 yrs 1.5ml/kg/hr.

6-16yrs 1 ml/kg/hr.
http://www.google.com.pk/imgres?imgurl=http://images.allegrocentral.com/02/35/Silicone-Coated-Latex-Foley-Catheter-175723-BIG_IMAGE.jpg&imgrefurl=http://www.allegromedical.com/browse/ViewProductLargeImage.do%3FproductId%3D8ab281020bb66dff010bb6731a447dc3&usg=__UXqotp2-12jg0B5LCh7zhJngsro=&h=500&w=500&sz=14&hl=en&start=13&zoom=1&itbs=1&tbnid=4Lrt2LKk35BhVM:&tbnh=130&tbnw=130&prev=/search%3Fq%3Dfoleys%2Bcatheter%26hl%3Den%26gbv%3D2%26biw%3D1366%26bih%3D561%26tbm%3Disch&ei=z0mHTp2oK8qM-wbthoQ1


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IMPORTANT

Once the primary survey along with all theinvestigations and appropriate intervention isdone , then one embarks on secondary survey.


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Secondary Survey


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This is the through head to toe examination.

AMPLE

Palpate Head, orbital margins, zygomatic arches, nose and

ears,

Cervical spine and neck, anteriorly and posteriorly

for crepitus, heamatoma, tenderness


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Assess throughly

Chest Abdomen

CNS Extremities

REEVALUATION can not be stressed enough.

Injuries to the Abdomen , back , perineum , hands andfeet and even dislocations are picked up late if this stepis missed!


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Trauma management

at SU 2The Trauma Scoring System


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The Deadly Dozen

Dr Asif Reza

PGT 4


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Case 1

Dr Sundas

House Surgeon


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Case 2

Dr Hena

House Surgeon


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Mortality

Dr Shafiq Chughtai

PGT 4


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Ambreen

18/ f, unmarried

Resident of Mandra

Victim of FAI while traveling in bus on whichunidentified men opened fire


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Referred from local health care facility aftertaking first AID and brought by relatives, 2 hrs

after the initial event.

Arrival at emergency department at 1215 hrs.

At Pr nt ti n


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At Presentation

Airway Intact, pt was able to talk in complete sentences

Breathing 20/min, regular, no cyanosis, trachea central, breath sound

decreased left lower zone

Circulation Radial not palpable, carotid 120/min, blood pressure

90/60mm Hg

Disability E3M5V6 14/15, PEARL, complete sensory and motor deficit

in both lower limbs


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Exposure


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Management In Er Room


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Management In Er Room

Oxygen via air mask

Double iv access, transfusion of heamacel and

ringer lactate (2 Ltrs).

Grouping x match

Tetnus prophylaxis and injection dicloran

Secondary Survey


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Secondary Survey

Chest. Decreased breath sounds left side of chest.Trachea

was central.

Abdomen. Unremarkable

CNS.

Flaccid lower limbs, power 0/5 in both limbs, nosensory perception to painful stimuli.

Impression


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Impression

Shock due to external bleed.

Left haemo thorax.

Plan


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Plan

X ray chest ------- proceed to tube thoracostomyif indicated **

X ray skull

X ray pelvis

FAST.

1230 hrs


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1230 hrs

CXR

Shows complete haziness in left hemi thorax.No gas

under diaphragm.

Pulse was 110/ min, BP 100/60 mmHg after 2 ltrs

of haemacel and ringer lactate combined.

Shifted to OT for tube thoracostomy.

1235 hrs


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1235 hrs

Patient on OT table. Stats were P 110/min, BP 110/60 mm Hg

No respiratory distress

Left shoulder wound started bleeding.

I closed it with silk sutures as significant oozewas coming out of it and patient had been inshock.

1240 hrs 1005 hrs


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1240 hrs1005 hrs

Patient started bleeding from the back wound.

When I turned the patient on the right because

there was blood on the OT table and floor, therewas gush of blood as if it was coming fromsome cavity, almost 200ml.

I packed the wound, BP dropped to 90/60 mmHg.


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After 30 seconds I removed the pressure, againthere was a gush of blood from the woundalmost 300 cc.

Patient blood pressure dropped to 80/60mmHgand she became unresponsive.

I removed the stitches and inspected the wound.


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On Inspection, there was shattered vertebraebeneath but there was no cavity or track.

I applied pressure for 5 minutes and infused500 cc of R/L. Her BP climbed to 100/60 mmHg and there were some sounds made by the

patients as well.


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I approximated the muscles in an attempt tocontrol bleeding.

It took me 2 minutes and bleeding stopped.


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Once I was done with the posterior wound,patient BP dropped to 58/40 mmHg.

I turned the patient on her back, put in chesttube in 5th ICS left side.

Immediately 50 ml blood came.


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During the initial attempts to take control ofposterior bleed, I lost left sided iv access. Patienthad one iv access on right side from which we

pushed in blood which we had arranged by thenon non donor basis.

Afterwards, BP became nil & she became apnic.


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At the same time, patient was intubated,attached to ventilator and ventilated.

Carotids were impalpable and CPR startedimmediately.

Multiple attempts and cannulations and anemergency cut down was attempted in leftinguinal region to get an iv access which failed.


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During the next 20 min, 900 cc blood came in

chest tube.

0115 hrs


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0115 hrs

CPR done for 20 minutes. Patient did notrespond. Patient died at 0115 hrs.

Relatives were explained while the resuscitationwas in progress about the critical condition ofthe patient. There were almost 50 people with

her and whole the ER was filled with them.However, no unpleasant event took place.

My Assessment


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My Assessment

Cause of death Hypovolemic Shock

Haemo thorax with Lung contusion

Spinal shock T12 level

External bleed

Intra abdominal bleed?

Patient was in shock when she came due toe ternal bleed as ell as haemothora


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external bleed as well as haemothorax.

Initially due to low blood pressure, the bleedwas contained. Due to fluid resuscitation, herblood pressure elevated and she started bleeding

from the back wound which was incommunication with thorax.

The bleeding was rapid and patient wascompromised already so she went in irreversibleshock.

Looking back


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Looking back

Immediate tube thoracostomy and thoracotomy/ laprotomy.


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trauma management over view

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