Trauma management

1. Trauma management

2. Trauma Management Zohair Alaseri, MD FRCPc, Emergency Medicine FRCPc, Critical Care Medicine Intensivest and Emergency Medicine Consultant King Saud University Medical City Chairman National Emergency Medicine Development Committee

3. 1-What is the leading cause of preventable death from trauma? • A. multi-organ failure • B. sepsis • C. hemorrhage • D. respiratory arrest

4. 2-Which injuries are particularly prone to develop coagulopathy? • A. brain injury and long bone fractures • B. hepatic and splenic injuries • C. intestinal and renal injuries • D. pulmonary and cardiac injuries

5. 3..36 years old male, involved in MVC brought to Emergency Department (ED), unconscious with BP-70/40mmhg, HR-52, O2Sat is 90% and RR-10. What is the most appropriate immediate intervention you should do? • Take Further quick history from paramedic • Give atropine 1mg to increase the heart rate which will increase blood pressure. • Insert central line and start aggressive fluid resuscitation. • Insert peripheral line and start 1L normal saline.

6. 4. A 20-years-old man was involved in a MVC and is found to be in respiratory distress. In the ER he is intubated and is on bag valve mask. The anaesthetist tells you that he has to use a lot of force to ventilate the patient. On auscultation there is reduced air entry on the left side of the chest, trachea is deviated to the right. What is the most appropriate management option for this patient? • An urgent Chest XR. • Take him to do immediate CT thorax. • Decompression using large bored cannula on the left 2nd intercostal space. • Decompression using large bored cannula on the right 2nd inter costal space

7. 5..The EMS brought unconscious patient to you in ED. He is middle aged patient involved in MVA, he has two (2) IV line started by paramedics. When two (2) liters of crystalloid finished his vital sign as follow; HR – 130, BP – 80/53, RR – 10, O2Sat. is 75% with 100% non rebreathing mask. What is your next step? • Change IV Crystalloid to albumin. • Insert new IV line. • Intubate this patient. • Circulation is still a priority, you should continue fluid resuscitation and delay intubation.

8. These patients benefit from skillful resuscitation; they are healthy, young individuals who, if salvaged, have a normal life expectancy. Trauma Management Introduction

9. a disease of the youth leading cause of death in those 1 to 37 years old. majority of trauma deaths occur either before reaching the hospital or within four hours of arrival. Trauma Introduction

10. Trauma Management Introduction Blunt trauma patient + Hypotension + Altered mental status = Diagnostic and Therapeutic Dilemma

11. broad knowledge sound judgment technical skill leadership capabilities. Trauma Management Requirements NO MORE ONE MAN SHOW Often what happens in the initial phase of resuscitation period often determines the outcome of care

12. Assessment and resuscitation should be performed simultaneously. Initial evaluation to diagnose and address life-threatening. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT Primary Survey

13. Includes 5 components A. Airway Maintenance with Cervical Spine Protection B. Breathing and Ventilation C. Circulation and Hemorrhage Control including FAST D. Disability/Neurological Status E. Exposure/Environmental Control INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT Primary Survey

14. F. Foley Catheter G. Gastric Tube H. Hertz - Imaging INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT After the 5 main, continue with F,G,H if needed:

15. A. Airway 1. Clear the oropharynx of blood, mucus and foreign bodies. 2. Jaw thrust. (Don't overextend the neck; the patient might have a spinal injury!). INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

16. No oropharyngealtubes in patients with gag reflexes. Why? Induce vomiting Oropharyngealtubes have limited use! Size… Distance between the angle of the mouth and the earlobe. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

17. If the patient is unconscious (GCS=<8) What to do now? Endotracheal intubation. (Size 8 for adult males, size 7 for females, or the size of the patient's small finger irrespective of age). INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

18. Make sure ETT in correct place by checking for EtCO2 listening for bilateral breath sounds obtaining a chest x-ray INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

19. If intubation is impossible In emergencies there is no place for tracheostomy. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT LMA impossible cricothyroidotomy

20. High index of suspicion depending on the history of the accident: (MVC, falls, certain sports). Avoid rough manipulation of the head and neck. Use hard collars to immobilize the neck. Immobilize the whole body on a long spinal board. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT Cervical Spine Protection

21. Obtain appropriate radiological evaluation. Radiological evaluation should be done only after the patient has been stabilized. Clearance of the cervical spine is NOT an emergency! INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT Cervical Spine Protection

22. Inspect for symmetrical chest movements. Auscultatefor breath sounds bilaterally. Palpate the trachea for deviation Palpate chest wall for fractures or emphysema. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT Breathing and Ventilation

23. Life-threatening problems to be identified during primary survey: 1-Flail chest: Monitor pulse oximetry Intubateif there is hypoxia or respiratory distress Consider early intubation in elderly or severe multitrauma patients. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

24. Life-threatening problems to be identified during primary survey: 2. Open, sucking/blowing wound in the chest wall: Do not suture or pack before thoracostomy tube insertion. Danger of tension pneumothorax! A Square gauze taped on only 3 sides can be applied while preparing for chest tube insertion. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

25. 3. Tension pneumothorax: Initial decompression with needle insertion through the 2nd or 3rd intercostal space anteriorly, mid-clavicularline Thoracostomytube. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

26. C. CIRCULATION AND HEMORRHAGE CONTROL 1. Assess BP, heart rate and evidence of bleeding. 2. Control any external bleeding by direct pressure. 3. In penetrating injuries of the neck, put the patient in the Trendelenberg position, (head down) to prevent air embolism. 4. If there is shock, insert one or two large intravenous lines and start fluid resuscitation. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT FAST

27. 1--HypovolemicShock The most common cause of post-traumatic Hypotension. due to external or internal blood loss. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock: FAST

28. Hypovolemic Shock Vascular access with two or more large bore IV. In patients with neck or arm injuries, line should be inserted on the opposite side to avoid extravasation. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock: FAST

29. Hypovolemic Shock Consider intra-osseous infusion, if a peripheral vein is not available. The infusion rate depends on the length and diameter of the catheter and NOT on the size of the vein. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock: FAST

30. Hypovolemic Shock Give a fluid challenge of 2 liters of Ringer's Lactate (or 20 ml/kg for children). If more fluids are needed, consider blood transfusion. For clear indication for surgery no time should be wasted for fluid resuscitation! INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock: FAST

31. Hypovolemic Shock There is evidence that in penetrating trauma with active bleeding some degree of mild hypotension until the bleeding is surgically controlled may be beneficial! INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock:

32. Blood Rh negative: No need for typing or cross matching. For life threatening blood loss only. Should be Available in refrigerator in the Emergency & OR. Typing but no cross matching. ("Type specific blood") Ready in about 10 minutes. Fully typed and cross-matched. Ready in about 30 minutes. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

33. Blood Always use blood warmers. Hypothermia may aggravate acidosis, induce arrhythmias, shift the oxyhemoglobin dissociation curve to the left, and impair platelet function. In severe hypovolemia use Level I rapid infusion blood warmers. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

34. 2--CardiogenicShock Suspected in trauma pts with shock in the absence of blood loss. Low BP and distended neck and veins. (although not always) INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock:

35. 2--CardiogenicShock Possible associated conditions with cardiogenic shock: cardiac tamponade myocardial contusion tension pneumothorax air embolism myocardial infarction.. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock:

36. Cardiogenic Shock Air Embolism may follow injuries to major veins, lungs, or the low-pressure cardiac chambers. Occasionally it may be iatrogenic, during insertion of a central venous line. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock:

37. Cardiogenic Shock Myocardial infarction should be suspected in elderly patients presenting in cardiogenic shock. ECG and Troponin level should be performed routinely Cardiac Arrest: There is no place for external massage (except in head injuries). INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock:

38. 3--NeurogenicShock This is the result of loss of vascular tone following cervical cord or upper thoracic spinal cord injury. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT In trauma there are 3 conditions, can cause shock: TTT with fluid and vasopressor

39. D. DISABILITY (NEURO EVALUATION AND MANAGEMENT) 1. Assess level of consciousness (Glasgow Coma Scale). 2. Assess pupils (size, reactivity). INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

40. E. EXPOSURE/ENVIRONMENT CONTROL 1. Undress the patient completely for thorough examination. 2. Avoid hypothermia by using warm blankets and IV fluids if needed. INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

41. E. EXPOSURE/ENVIRONMENT CONTROL Trauma patients become hypothermic very quickly. Risk for hypothermia: Severe blood loss Elderly patients Pediatric INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT

42. The secondary survey is done only after the primary survey is completed and resuscitation is initiated. Sometimes the secondary survey is performed after operation for life-threatening injuries. Complete examination from head to toe (head and neck, chest, abdomen, back,, and musculoskeletal). SECONDARY SURVEY

43. A tertiary survey should always be performed semi-electively. The purpose of this survey is to diagnose any occult or minor injuries! TERTIARY SURVEY

44. 1. Examination of the trauma patient: Undress the patient completely Always examine the back. Serious injuries may otherwise be missed. Cover the patient with warm blankets to prevent hypothermia. The presence of an obvious wound should not distract from another less obvious but more dangerous injury. EXPERT COMMENTS

45. 2. Head Injury: Correct any condition, which aggravates an existing brain injury (e.g. shock or hypoxia). Cervical spine injury is a commonly associated problem. Apply a semi-rigid collar, keep the head and neck in a neutral position, and apply precautions during transportation, until a cervical injury has been excluded. The cervical spine clearance is not an emergency as long as protection is maintained. EXPERT COMMENTS

46. 2. Head Injury: Closed head injuries alone rarely produce hypotension, except in the terminal stages or in neonates. If the patient is in shock, look for a source of bleeding, cardiogenic shock or associated cervical spine injury. Scalp lacerations can bleed profusely and may cause hypotension. EXPERT COMMENTS

47. 3. Fractures: EXPERT COMMENTS Immobilize all severe fractures at an early stage, before moving the patient to CT scan or other investigations. minimize neurovascular damage decrease bleeding reduce fat embolism reduce pain

48. 3. Fractures: Fractures of the pelvis or the femur may be associated with significant blood loss. Early operative fixation of major fractures decreases morbidity, mortality, and hospitalization. In the presence of severe associated head or chest trauma, prior stabilization of the patient is advisable. EXPERT COMMENTS

49. 4. Common mistakes: Insertion of an oropharyngeal airway in the presence of brisk gag reflexes. Problem: Vomiting and aspiration! Tracheostomy in emergency situations. Problem: It takes a few minutes even in the hands of experienced surgeons! Procedure of choice: Cricothyroidotomy. EXPERT COMMENTS

50. External cardiac massage in traumatic cardiac arrest due to blood loss or cardiac tamponade. Procedure of choice is the resuscitative thoracotomy and internal cardiac massage. EXPERT COMMENTS Common mistakes