Trauma – initial assessement and management.

Trauma – initial assessement and management. Paweł Grala Klinika Chirurgii Urazowej, Leczenia Oparzeń, Chirurgii Plastycznej AM w Poznaniu Kierownik Kliniki: Prof. dr hab. med. Krzysztof Słowiński

“Trauma” - expression comprising a spectrum of severity of mechanical violation of tissues, from a little scratch to a multiply injured patient. - also surgical intervention.

seconds to minutesminutes to hours GOLDEN HOURseveral days or weeks Trauma - the leading cause of death in the first four decades of life Death from trauma has a trimodal distribution: within

Prehospital – control airway, external hemorrhage, rapid transport • Primary survey - initial assesement and resuscitation of vital functions, prioritization (based on ABCDEFG)

An organized consistent approach to the trauma patient  optimal outcome. The Advanced Trauma Life Support (ATLS) adopted by the American College of Surgeons in 1979. The primary focus of ATLS is on the first hour of trauma management - rapid assessment and resuscitation THE GOLDEN HOUR

The primary survey –life threatening conditions are identified and management is begun simultaneously! • A - Airway maintenance with cervical spine control • B - Breathing and ventilation • C - Circulation with hemorrhage control • D - Disability: neurological status • E - Exposure: completely undress the patient

Airway / BreathingAll patients should be transported/treated initially with supplemental oxygen. • immobilization of the C-spine • combination of a hard collar and sandbags on opposite sides of the head

Airway / Breathing • establishing verbal contact with the patient - clear phonation by the patient establishes that the airway is patent. • further intervention depends on: - neurologic stability - adequacy of gas exchange and the potential for airway compromise

Neurological Stability • decreased level of consciousness is considered to be intracranial pathology until proven otherwise (drugs, alkohol) • brief neuro exam (done during the primary survey): A - Alert V - responds to Verbal stimuli P - responds to Painful stimuli U - Unresponsive • Glasgow Coma Scale (GCS): GCS < 8 requires definite airway intervention to prevent aspiration pneumonitis, to insure adequate oxygen delivery and to avoid hypercarbia. If a patient is responding only to painful stimuli or is unresponsive/unconscious, the GCS is or has a high likelihood of being less than 8.

Adequacy of Gas Exchange • airway patency does not insure adequate ventilation LOOK • nature of the injury: maxillofacial trauma/airway burns - potential for airway compromise, obvious airway or chest trauma (sucking chest wounds, flail segments), cyanosis • tachypnea, use of accessory muscles of respiration or evidence of tracheal shift

Adequacy of Gas Exchange LISTEN • stridor  upper airway compromise. • hyperresonance to percussion/lack of air entry  pneumothorax • dullness to percussion/lack of air entry  hemothorax. • bowel sounds in the chest  ruptured diaphragm.

Adequacy of Gas Exchange FEEL • hand over the mouth - feel for air exchange. • Insertion of a finger - sweep to clear the mouth of any foreign bodies (especially dislodged teeth) and to evaluate for evidence of maxillofacial trauma. LAB • pulse oximetry - haemoglobin saturation; immediate feedback pitfalls - motion, peripheral vasoconstriction, carboxy/methaemoglobinemia. • ABG`s - more complete picture of the patient; feedback on oxygenation, ventilation and tissue perfusion pitfalls - a defined waiting period (institution dependent)..

Securing the Airway- endotracheal intubation (inspection of th airway, suction of blood and secretions, bag mask ventillation)- possible spinal cord or direct traumatic tracheal injuries  surgical airway - translaryngeal intubation • Immediate - apnea • Emergent - hypoventilation, significant head injury, cyanosis • Urgent - burns, maxillofacial injury and cervical hematomas will likely require a secure airway to prevent upper airway obstruction; chest wall and pulmonary injuries are usually initially well compensated but may eventually require mechanical ventilation there is often time for a history, appropriate physical exam and cervical radiographs

Securing the Airway Blind nasotracheal intubation vs direct orotracheal intubation Determined by the experience of the physician Blind nasotracheal intubation: requires a spontaneously breathing unconscious or cooperative conscious patient, unacceptable failure rate (35%) - requires 3.7 vs. 1.3 oral attempts, contraindicated if basal skull or mid-face fracture. can precipitate epistaxis (may interfere with subsequent alternative attempts at intubation if unsuccessful). high incidence of sinusitis if a tube is left in place greater than 72 hours.

Assume the cervical spine to be unstable until proven otherwise • up to 50% of patients sustaining C-spine trauma develop neurologic abnormalities (nerve root compression and weakness to quadri- plegia and death). • 10% of patients with C-spine injury are initially neurologically intact, but develop deficits during the course of emergency care • risks of airway management

C-spine evaluation • bone and soft tissue • X-ray exam: „one view is no view”, L-all 7C+Th1 (30% inj.C7Th1), AP-vertical alignment of the spinous and articular process and abnormalities in joint and disc spaces, open mouth view - integrity of the atlanto-occipital and atlanto-axial joints, the odontoid process, oblique – intervert. foramina • CT • lateral cervical spine - sensitivity of about 85% 92% in a three view series 100% when selective CT scanning is employed

Circulation • BP • HR Alghevar scheme - quantification of shock: SBP / HR >1 no or minor clinical symptoms <1 major shock • Pulses • Indirect signs: UA, skin, tachypnoe, altered consciousness, „empty” periferal veins Large bore IV lines

Circulation • warmed intravenous infusions Control: • external hemorrhage • internal hemorrhage: MAST (PASG) suit Pelvic binders Surgery  stabilisation  secondary survey

Initial assessement • Chest and abd. PE • Orthopaedic PE • Periferial Neurologic PE • Labs • X-rays, US, CT

tertiary trauma survey • ACS definition - a patient evaluation that identifies and catalogues all injuries after the initial resuscitation and operative intervention • 2 - 50% of combined life threatening and non-life threatening injuries are missed during primary and secondary surveys • timing is institution specific (typically occurs within 24 h after admission and is repeated when the patient is awake, responsive, and able to communicate any complaints). • is a comprehensive review of the medical record with emphasis on the mechanism of injury and pertinent co-morbid factors such as age, includes the repetition of the primary and secondary surveys, a review of all laboratory data, and a review of radiographic studies with an attending radiologist

Trauma – initial assessement and management.