Initial Evaluation and Resuscitation of the Trauma Patient

1. Initial Evaluation and Resuscitation of the Trauma Patient A Trauma Drama brought to you by The Department of Surgery & The Program in Emergency Medicine

2. Trauma is a Serious Problem • Injury is the leading cause of years of productive life lost • Death is the tip of the iceberg • Morbidity • Disability • Costs over $400 Billion

3. Trauma in Rural Setting even Worse • Rural citizens suffer twice the trauma mortality rates as urban dwellers • Motor vehicle--30 per 100,000 deaths versus 16 per 100,000 • In 9 out of 10 causes of fatal trauma, rural death rates are higher than urban rates • Multiple factors responsible, including quality of care • Good care takes a good system

4. Trimodal Distribution of Trauma Deaths • Unsalvageable • dead/dying at the scene • Early Deaths • Die in first hours of care • Delayed deaths • Die in the ICU of complications

5. Problems in Care of Trauma Patients • Trauma teams can save lives by restoring and supporting vital functions in the first few hours after injury • This period is the “Golden Hour” of opportunity to make a real difference in patient functional outcome as well

6. Quality of Trauma Care is Variable • In 28 studies over three decades, preventable death rates from 5% to 64% have been reported • Timely and appropriate care can make a real difference in patient outcome • Competence in the initial approach does not require enormous technical skill (optimizing ultimate functional outcomes certainly does)

7. Contributions to Excess Mortality • Immediate • Airway management problems • Failure to treat hemopneumothorax • Inadequate resuscitation of hypovolemic shock • First Hours • Delay in managing hemorrhage • Failure to treat intracranial bleeding • Late deaths • ICU care of ARDS, sepsis, brain injury, MOSF

8. Iowa’s Trauma System • EMS system • Standard triage criteria • Ambulance destination and “Major Trauma” defined • Hospitals • Inclusive and voluntary • All categories (levels I through IV) • Staff • Trained in trauma care by ATLS standards

9. Skills of the Trauma Team • Our Objectives Today: The Initial Approach • Demonstrate the importance of an organized team approach in the care of seriously injured • Define clinical priorities in the evaluation and resuscitation of a multiply injured blunt trauma patient • Understand basic management of common life-threatening emergencies • Encourage further acquisition of knowledge and skills necessary to acquire real competence

10. Clinical Priorities In Initial Trauma Care • Rapid primary survey looking for immediately life-threatening problems • Acute interventions as necessary • Resuscitation to support vital functions • Judicious use of diagnostic studies • Complete secondary survey • Consider transfer for definitive care

11. The “Trauma Drama” • Presented with a typical blunt trauma victim • “Larry, Curly and Moe” first provide attempts at evaluation and stabilization of common life-threatening problems, and bad things happen • We review what went wrong and why • “Trauma Team” will then demonstrate an appropriate approach and patient is sucessfully resuscitated • Patient care then reverts to inept team again

12. First Priority: Be Prepared Understand triage guidelines Activate the trauma team Organize the required equipment Approach the life-threatening problems systematically Apply the ABCDE approach to clinical priorities

13. Causes of Early Preventable Trauma Deaths • Obstructed airway • Inadequate ventilation • Unstable chest wall (flail) • Open sucking chest wounds • Tension Pneumothorax • Uncontrolled hemorrhage • Expanding intracranial hematoma

14. Incoming EMS unit transporting young motor vehicle crash victim Rollover with ejection mechanism BP 110/palp, P 120, R 28 with stridor, GCS 12, AOB Obvious maxillo-facial injuries, chest injury, and possible fractures of femur and pelvis Trauma Case Presentation

15. The General Approach to the Trauma Evaluation • Be personally prepared and alert the trauma team • Be systematic in the approach (ABCDE) • Expect the worst (“Murphy’s Law” rules) • Simultaneously evaluate and resuscitate “first things first”, don’t “go for the gore” • Understand that trauma is a very dynamic disease, and things change rapidly

16. Primary Survey • A - Airway • B - Breathing • C - Circulation • D - Disability • E - Exposure/Environment

17. Assessing the Airway • Check for • swelling & deformity • air movement, • stridor • foreign bodies • Basic techniques first • Chin lift/jaw thrust • C-spine precautions

18. The Decision Tree for Airway Management • Obstructed Airway • BLS techniques first • Suction and manually clear teeth, clots, food, emesis • High flow Oxygen • Nasal airway helps keep tongue clear • Attempt assisted BVMventilation • Consider urgent endotracheal intubation

19. Indications for Endotracheal Intubation • Obstructing airway • Maxillofacial fractures + edema • Major brain injury • Chest injuries impairing ventilation • Profound shock • Or generally “circling the drain”

20. Primary Survey Priorities in Trauma Care • Airway • Breathing • Circulation • Disability (Neurologic) • Exposure/Environment

21. Causes of Preventable Early Trauma Deaths • Obstructed airway • Breathing (Inadequate ventilation) • Tension pneumothorax • Unstable chest wall (flail) • Open sucking chest wounds • Uncontrolled hemorrhage • Expanding intracranial hematoma

23. Lethal Chest Injuries Managed in the ER • Tension Pneumothorax • Open Pneumothorax • “sucking chest wound” • Flail Chest - Multiple rib Fractures • mechanically unstable • pulmonary contusions • Massive Hemothorax

24. Assessing Breathing • Look • Symmetry of chest motion • Auscultation • Equal breath sounds • Rales or stridor • Feel • Chest wall instability/crepitance

25. Evaluate Oxygenation • Clinical signs • Skin color • Mental status • Monitors • PaO2 • Pulse • Lab • ABG

26. Management of Pneumothorax Decompress the air under pressure Needle thoracostomy can be literally life-saving Chest tube required Monitor blood loss from the thoracostomy

27. Primary Survey Priorities in Trauma Care • Airway • Breathing • Circulation • Disability (Neurologic) • Exposure/Environment

28. Causes of Preventable Early Trauma Deaths • Obstructed airway • Inadequate ventilation • Tension pneumothorax • Unstable chest wall (flail) • Open sucking chest wounds • Bleeding & Shock (Circulation) • Expanding intracranial hematoma

29. Circulation: Suspect Hypovolemic Shock • Commonly under resuscitated in blunt trauma • Systolic blood pressure most often not an adequate index of severity • Shock is manifested by signs of poor perfusion • Look for clinical clues and a metabolic acidosis

30. Evaluating for Effective Circulation • Heart rate • Pulses (quality) • Skin color/diaphoresis • Skin temperature • Capillary refill • Level of consciousness • Blood pressure • Urine output

31. Circulation: Early Management • Control external hemorrhage • IV Access • Fluid resuscitation • Crystalloid • Blood • Frank hypotension is associated with >30% blood volume loss

32. Blood Transfusion • Many blunt trauma patients initially arriving in obvious shock will require RBC transfusions during the resuscitation • Give two liters crystalloid as rapidly as possible • Check vitals and clinical signs of perfusion

33. Persistent Shock • Monitor vital signs, repeat ABG, and Hb/HCt serially • If clinical signs of hypovolemia persist, give warmed and diluted uncrossmatched RBCs • Identify obvious sources of hemorrhage and treat • actively bleeding external injuries • unstable long bone or pelvic fractures • As time and patient’s clinical state permit, consider systematic imaging for occult abdominal sources • If shock state persists, consider urgent transfer to the operating room

34. Circulation: Sources of Exsanguination • Head • Severe scalp and facial lacerations • Chest • Pulmonary and intercostal vessel lacerations • Abdomen • Liver, spleen and retroperitoneal structures • Bones • Especially pelvis and femurs • Peripheral vascular

35. F.A.S.T. Scan • Focussed • Abdominal • Sonography in • Trauma • Useful in the diagnosis of • Cardiac Tamponade • Solid organ injury (liver, spleen and kidneys) • Free intraperitoneal fluidt

36. Exsanguination from Pelvic Fractures • Persistant bleeding • severe fractures • Stabilization • vascular injuries • embolization • Continued transfusion

37. Primary Survey Priorities in Trauma Care • Airway • Breathing • Circulation • Disability (Neurologic) • Exposure/Environment

38. Causes of Preventable Early Trauma Deaths • Obstructed airway • Inadequate ventilation • Bleeding & Shock (Circulation) • Head Injury • Traumatic brain injury • Expanding intracranial hematoma • Acute subdural or epidural bleeding needs surgery

39. Brain Injury • Must be considered in all cases of altered mental status in trauma • A careful exam is important • Alcohol, drugs, or psychiatric illness confuse the picture • Shock and hypoxia make things worse, so pay attention to ABC’s

40. Disablility: Evaluating the Neurologic State • Glascow coma scale (GCS) • Eyes (4) • Verbal (5) • Motor (6) • Pupillary response • Sensation/movement in extremities

41. Head CT • Head CT mandatory--The questions are, “Where?” and “How soon?”

42. Neurologic Deficits: Early Definitive Care • Neurosurgical consultation • Deteriorating mental status, unequal pupils, or coma after trauma • Evacuation of hematomas • Elevation of depressed skull fractures • Management of intracranial pressure • Extremity weakness or numbness • Management of acute spinal cord injuries

43. Definitive airway important in brain injury Maintain airway patency Prevent secondary injury from hypoxemia Sedatives and paralyzing drugs often necessary Airway Revisited: Endotracheal Intubation

44. Primary Survey Priorities in Trauma Care • Airway • Breathing • Circulation • Disability (Neurologic) • Exposure/Environment

45. Last of the Primary Survey • E = Exposure/Environment • Completely undress and look at the entire body • Log roll with spine precautions • Rectal exam important • Keep patient warm (avoid coagulopathy) • Heat Lamps • Warm room and blankets • Warm fluids

46. Primary Survey Studies: Imaging • X-Rays • Chest • Pelvis • Lateral cervical spine • FAST ultrasound • Consider CT scans

47. Primary Survey Adjuncts • Cardiac and BP monitors • Oxygen saturation • Urinary catheter • Nasogastric tube • Sometimes CVP helpful

48. Primary Survey Lab Studies • Most Essential Laboratory • Hemoglobin/Hematocrit * • Arterial blood gas * • Type and screen (or type and cross)* • U/A (and HCG for women)* • Glucose* • Electrolytes, BUN and Creatinine

49. Primary Survey Completed • Evaluation of physiologic functions • Resuscitation with stabilizing interventions • Re-evaluation • Vital signs • Basic ABCD concerns • Review of available labs and images

50. Time for a Thoughtful Pause • What is the working “problems list”? • Diagnoses • Suspicions and possible “worst cases” • Patient stable or unstable? • Are the resources necessary for definitive care available here? • Are further life saving “damage control” operations immediately necessary?