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Pace Initial Assesment Trauma VIII.ppt - Airway Management

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  • 1. MULTIPLE TRAUMA
    Benjamin Pace, MD FACS
    Director of Surgery
    Queens Hospital Center
    Associate Professor of Surgery
    Mount Sinai School of Medicine
  • 2.
  • 3. MULTIPLE TRAUMA
    Injury or Shock simultaneously to several areas of the body
  • 4. TRAUMA STATS
    Leading killer of persons under 44 in the United States
    150,000 deaths annually
    44,000 MVC
    28,000 GSW
    Most expensive medical problem in terms of lost wages, initial care, rehabilitation, and lifelong maintenance
  • 5. TRAUMA
    Penetrating
    Injury caused by an object entering the body.
    Blunt
    Injury caused by the collision of an object with the body in which the object does not enter the body.
    Serious/life-threatening problems
    10% of all trauma patients.
    Must recognize difference between serious and non-serious problems and triage your care
  • 6. Types of Trauma
    Blunt
    Closed injury
    Indirect injury to underlying structures
    Transmission of energy into the body
    Tearing of muscle, vessels and bone
    Rupture of solid organs
    Organ injury
    Penetrating
    Open injury
    Direct injury to underlying structures
  • 7. Trauma Care System
    Integration of
    EMS
    Hospital care
    Reduces
    Cost
    Time to surgery
    Mortality
    Proper Care
    Immediate surgical intervention to repair hemorrhage sites
  • 8. Trauma Center Designation
    Level I
    Regional Trauma Center
    All types of surgical and medical subspecialty
    Research and teaching commitment
    Level II
    Area Trauma Center
    Majority of surgical and medical subspecialties available 24/7
    Level III
    Community Trauma Center
    Specialized ED with the majority of surgical and medical subspecialties available 24/7 (on call)
    Level IV
    Rural community hospitals
    No immediate surgical intervention necessary
    Stabilize and transfer out
  • 9. Differences between Level I and II Trauma Centers
    Level II:
    Level I:
    No minimum patient criteria
    - Surgical capability available in a “reasonably acceptable time”
    General surgeon present at resuscitation
    Desirable to have residents
    No research minimum
    1,200 trauma admissions/year
    Pts w/ ISS >15 (240 total or 35 pts/surgeon)
    Immediate surgical capability available
    In-house trauma surgeon
    General surgery residency program or trauma fellowship
    Research
  • 10. Adult Triage Criteria For TRAUMA CENTER
    >20’ fall
    Pedestrian/bicyclist versus auto
    Thrown or run over by vehicle
    Struck by vehicle traveling >5 mph
    Motorcycle impact >20 mph
    Ejected from a vehicle
    Severe vehicle impact
    >40 mph
    >12” intrusion
    >20” vehicle deformity
    Rollover with signs of serious impact
    Death of another occupant
    Extrication time >20 minutes
  • 11. Child Triage Criteria For TRAUMA CENTER
    Vehicle collision at medium speed
    Any vehicle collision involving an unrestrained infant or child
    >10’ fall
    Bicycle collision
  • 12. Triage Criteria for Trauma CenterPhysical Findings at Scene of Trauma
    Flail chest
    Pelvic fracture
    Limb paralysis
    Burn >15% BSA
    Burn to face or airway
    Penetrating trunk, neck, or head trauma
    >2 proximal long bone fracture
  • 13. Acknowlegements
    W.F. Holdefer, M.D.
    UAB Department of Emergency Medicine
    Illinois EMSC
    Sharla Owens, M.D.
    KarimBrohiBSc FRCS FRCA
    The Royal London Hospital
  • 14. 15
  • 15. Blunt Trauma
  • 16. Blunt Trauma
    Most common cause of trauma death and disability
    Energy exchange between an object and the human body, without intrusion through the skin
  • 17. Kinetics of Blunt Trauma
    Kinetic Energy
    Energy in Motion
    Double Weight = Double Energy
    Double Speed = Quadruple Energy
    SPEED
    iS THE GREATEST DETERMINANT
    Of INJURY
  • 18. Kinetics of Blunt Trauma
    Force
    Emphasizes the importance of rate at which an object changes speed (acceleration or deceleration)
  • 19. ACCELERATION AND DECELERATION FORCES
    Whiplash injury
    Aortic tear
    Hepatic artery tear
  • 20. Blunt Trauma: Automobile Crashes
    44,000 people die each year on US highways!
  • 21. Inertia and Motor Vehicle Crashes
  • 22. Blunt Trauma: Automobile Crashes
    Restraints
    Seatbelts
    Occupant slows with the vehicle
    Shoulder and Lap belts MUST be worn together
    Injuries if worn separately
    Airbags (SRS)
    Reduce blunt chest trauma
    Cause: Hand, Forearm, & Facial Injury
    Side Airbags
    Child Safety Seats
    Infants and Small Children: Rear facing
    Older Child: Forward facing
  • 23. 23
  • 24. Blunt Trauma: Automobile Crashes
    Intoxication
    Fatal Accidents: >50% involved ALCOHOL
  • 25. Blunt Trauma: Automobile Crashes
    Vehicular Mortality
    Head: 48%
    Internal (Torso): 37%
    Spinal & Chest fracture: 8%
    Extremity fracture: 2%
    All Other: 5%
  • 26. Other Types of Blunt Trauma
    Falls
    Stairs, Force, Surface
    Landing Area
    Surface Type
    Body Part
    Height of Fall
    Elderly
  • 27. 27 / 217
  • 28. Penetrating Trauma
  • 29. Introduction to Penetrating Trauma
    38,000 Deaths in US annually due to shootings.
    Mechanisms of penetrating trauma
    Knives, Gun Shots, Arrows, Nails, etc.
    Important to understand the principles of energy exchange to increase the Index of Suspicion associated with the method of injury
  • 30. Physics of Penetrating Trauma
    Recall Kinetic Energy Equation
    Greater the mass the greater the energy
    Double mass = double KE
    Greater the speed the greater the energy
    Double speed = 4x increase KE
    (continued)
  • 31. Physics of Penetrating Trauma
    Small & Fast bullet can cause greater damage than large and slow.
    Low Energy/Low Velocity
    Knives and arrows
    Medium Energy/Medium Velocity Weapons
    Handguns, shotguns, low-powered rifles
    250-400 mps
    High Energy/High Velocity
    Assault Rifles
    600-1,000 mps
    (continued)
  • 32. Physics of Penetrating Trauma
    As bullet strikes object, it slows and energy is transferred to object.
    Law of Conservation of Energy
  • 33.
  • 34.
  • 35. Damage Pathway
    Direct Injury
    Damage done as the projectile strikes tissue
    Pressure Shock Wave
    Human tissue is semi-fluid
    Solid and dense organs are damaged greatly
    Temporary Cavity
    Due to cavitation
    Permanent Cavity
    Due to seriously damaged tissue
    Zone of Injury
    Area that extends beyond the area of permanent injury
  • 36. Ballistics Cavitation
  • 37. Specific Tissue & Organ Injuries
    Density of tissue affects the efficiency of energy transmission
    Connective Tissue
    Absorbs energy and limits tissue damage
    Organs
    Solid Organs
    Dense and low resilience – lot’s of damage
    Hollow Organs
    Fluid filled: transmit energy = increased damage
    Air filled: absorbs energy = less damage
  • 38. Specific Tissue & Organ Injuries
    Lungs
    Air in lung absorbs energy
    Parenchyma is compressed and rebounds
    Pneumothorax or hemothorax can result
    Bone
    Resists displacement until it shatters
  • 39. General Body Regions
    Extremities
    Injury limited to resiliency of tissue
    60-80% of injuries with <10% mortality
    Abdomen (Includes Pelvis)
    Highly susceptible to injury and hemorrhage
    Bowel perforation: peritoneal irritation in 12-24 hrs
    Thorax
    Rib impact results in explosive energy
    Heart & great vessels may have extensive damage due to lack of fluid compression
    Any large chest wound compromises breathing
  • 40. General Body Regions
    Neck
    May damage Trachea and Blood vessels
    Neurological problems
    Sucking neck wound
    Head
    Cavitational energy trapped inside skull
    Serious bleeding and lethal
  • 41. Wound Characteristics
    Entrance Wounds
    Size of bullet
    Exit Wounds
    Appears to be “Blown” outward
    Pressure wave
  • 42. Special Concerns with Penetrating Trauma
    Impaled Objects
    Low-energy
    Dangerous to remove
    DO NOT REMOVE UNLESS YOU ARE A TRAUMA SURGEON AND IN THE OPERATING ROOM
  • 43. 43 / 217
  • 44. Trauma:Initial Management Priorities
    Anesthesiologist
    Tray
    Tray
    CRNA
    1o Nurse
    Bystander
    Bystander
    CPR person
    Line person
    Tray
    Tray
    Chest tube person
    Chest tube person
    Bystander
    Line person
    Bystander
    Examining person
    Tray
    2o Nurse
    Team Leader
    Bystander
    Coffee maker
    Tray
    Pre-arrival
    • Establish leadership- Involved leader - Remote leader
    • 45. Organize team- Number / type of personnel - Assess competency levels - Assign tasks
  • Trauma:
    Initial Management Priorities
    Resuscitation
    1oSurvey
    2oSurvey
    Reevaluation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    Arrival
    ResourceIdentification and Allocation
    1 Hour
  • 46. Trauma:Initial Management Priorities
    Pre-arrival
    1o Survey
    2o Survey
    Reevaluation
    Pre-arrival
    Pre-arrival
    Resuscitation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    1 hour
    • Can the Institution handle this patient?
    • 47. … at this time?
    • 48. Are there alternative facilities nearby?
    Assess:
    • Personnel - Primary team - Specialty teams
    • 49. Facilities - Admitting area - 1o &2o treatment areas
    • 50. Materials - “tubes”, “lines”, “trays” - Familiarity w. equipment
    Assess:
  • 51. Trauma:Initial Management Priorities
    Team leadership / organization
  • 52. Trauma:Initial Management Priorities
    Team leadership / organization
  • 53. Trauma:Initial Management Priorities
    1o Survey
    2o Survey
    Reevaluation
    Pre-arrival
    Primary Survey
    Resuscitation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    1 hour
    Assess:
    • Immediate risk for loosing limb or life?
    • 54. Potential for (rapid) deterioration?
    Airway:
    - assess - establish - maintain
    Breathing:
    - assess - support
    Circulation:
    - assess- access- stop hemorrhage - resuscitate
    A B C
  • 55. Trauma:Initial Management Priorities
    Primary Survey
    Should not take longer then 5 minutes
  • 56. Trauma:Initial Management Priorities
    Primary Survey
    Complete exposure
    Supplemental O2Airway & breathing support
    Venous accesslarge bore peripheralvs. “cordis”
    Focused examHead / neck / CNSChest / abdomenPulses / bleeding
    Vital monitoring equipmentNBP, EKG, SaO2
    Emergent primary therapytube thoracostomylateral thoracotomytemp. hemostasis
  • 57. Trauma:Initial Management Priorities
    Pre-arrival
    1o Survey
    2o Survey
    Reevaluation
    Reevaluation
    Resuscitation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    1 hour
    • Same examiner - Or formal sign out
    • 58. All systems in question
    • 59. Frequency depends on - Severity of injury - Potential for deterioration - Patient location
    • 60. Follow up studies - Labs / radiographic / other
    • 61. Goals - Stabilization - Identify 2o injuries - Prevent deterioration
  • Trauma:Initial Management Priorities
    Pre-arrival
    1o Survey
    2o Survey
    Reevaluation
    Resuscitation
    Resuscitation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    Ongoing process of assessing and restoring ABC(D)’s
    1 hour
    • Volume Restoration/- Access / equipment / type of IVFHemorrhage control - Temporary vs. definitive - Damage control operations - Angiography - Definitive operative control
    • 62. Control of related - Hypothermiapathophysiology- Hypoxia/Hypercarbia/Acidosis - Coagulopathy - Central compartment syndromes
  • Trauma:Initial Management Priorities
    Resuscitation
    • Compartment syndromes -Abdomen - edema, bleeding - - Thorax - pericardial tamponade- tension pneumothorax- reverse I:E ventilation - Cranium - edema, bleeding
    • 63. Locale - Admitting area - Operating room - ICU - Consider - Location (travel), - Equipment - Staffing, Access ent
    • 64. Monitoring progress - Clinical parameters, NBP, U/O - CVP, PA catheter, IBP - Labs
  • Trauma:Initial Management Priorities
    Pre-arrival
    1o Survey
    2o Survey
    Reevaluation
    Imaging Studies
    Resuscitation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    • F.A.S.T.
    • 65. Plain films- Lateral C-spine (3 view, 5 view) - AP CXR (flat, upright) - AP Pelvis- AP and lateral T & L-spine - Extremity films and special views
    1 hour
    • CT- Head / face / base of skull - Chest (IVcontrast) - Abdomen / pelvis (type of contrast) - Spine
    • 66. Angiography - CNS, neck - Arch / descending aorta - Visceral (+/- embolization) - Extremities
    • 67. MRI - CNS, spine, extremities
  • Trauma:Initial Management Priorities
    Pre-arrival
    1o Survey
    2o Survey
    Reevaluation
    Primary Therapy
    Resuscitation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    • A & BRelief of hemo/pneumothorax, - Pericardial tamponade
    • 68. C (Temporary) hemorrhage control - Volume resuscitation
    • 69. DICP management - Decompression/hemorrhage control - Steroids in spinal cord injury
    • 70. Orthopedics - (Splint) stabilization of fractures
    • 71. Primary wound care
    • 72. Analgesia
    1 hour
  • 73. Trauma:Initial Management Priorities
    Primary Therapy
    Goals: Stabilization (Rapid) Prevention of 2o injuryDefinitive APPROPRIATE Therapy A.S.A.P.
  • 74. Trauma:Initial Management Priorities
    Summary
    • Sytematic approach to 1o, 2o Survey and 1o therapyABC’s, prioritize injuries, therapy and patient “Golden” 1 hour
    • 75. Continuum of CareReevaluation, coordinated care plan Prevention of 20 Injury
    • 76. Management begins before patient arrivalResources: Personnel, materials, Facility Leadership, team organization
  • Trauma:Initial Management Priorities
    Pre-arrival
    1o Survey
    2o Survey
    Reevaluation
    Secondary Survey
    Resuscitation
    Basic Studies
    Specialty Studies
    1o Therapy
    Definitive Therapy
    • Systematic approach - Head to toe / all systems - One examiner - Avoid patient distraction (examine or talk)
    1 hour
    • Maximize efficiency - Documentation (examine and talk) - Prioritize injuries / patient
    • 77. Initiate care plan - Studies - Consultations - Disposition
    • 78. Continued ABC support
  • 60 / 217
  • 79. Initial Assessment of the Trauma Patient
  • 80. Advanced Trauma Life Support Guidelines (ATLS)
    Systematic approach necessary to rapidly identify injuries and stabilize the patient
    This approach is divided into:
    1. Primary Survey
    2. Resuscitative Phase
    3. Secondary Survey
    4. Definitive Care Phase
  • 81. PRIMARY SURVEY
  • 82. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 83. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 84. Airway Management in the Trauma Patient
  • 85. Objectives of Airway Management & Ventilation
    Primary Objective:
    Provide unobstructed passage for air movement
    Ensure optimal ventilation
    Ensure optimal respiration
  • 86. Objectives of Airway Management & Ventilation
    Why is this so important in the trauma patient?
    Prevention of Secondary Injury
    Shock & Anaerobic Metabolism
    Spinal Cord Injury
    Brain Injury
  • 87. Airway
    Patency is primary
    Obstruction may be due to:
    Tongue
    Swelling
    Foreign Body
    Blood and secretions
  • 88. Airway
    Evaluation begins by asking the patient a question such as 'How are you?‘
    A response given in a normal voice indicates that the airway is not in immediate jeopardy; a breathless, hoarse response or no response at all indicates that the airway may be compromised.
  • 89. Airway
    Mechanical removal of debris, chin lift and/or jaw thrust maneuver, are useful in clearing the airway in less injured patients
    If there is any question of an adequate airway, severe head injury, profound shock, severe facial trauma, voice changes, then definitive airway control is necessary
  • 90. PROTECT the CERVICAL SPINE !
  • 91. Airway Maintenance with Cervical Spine Protection
  • 92. Subluxation
    C-5 on C-6
  • 93. Airway & Ventilation Methods
    Supplemental Oxygen
    increased FiO2 increases available oxygen
    objective is to maximize hemoglobin saturation
  • 94. Impending or PotentialCompromise of the AirwayInhalation injury Facial fractures Retropharyngeal hematoma Sustained seizure activity Closed head injury (GCS < 8) Inability to maintain SaO2 by face mask oxygen
  • 95. The decision to providea definitive airway:-Apnea-Inability to maintain a patent airway -Protection of the airway from aspiration
  • 96. Airway & Ventilation Methods
    Airway Maneuvers
    Chin lift
    Jaw thrust
    (Neck extension is
    contraindicated)
    Airway Devices
    Oropharyngeal airway
    Nasopharyngeal airway
  • 97. Assessment & Recognition of Airway & Ventilatory Compromise
    Visual Assessment
    Rise & Fall of chest
    Paradoxical motion
    Audible gasping, stridor, or wheezes
    Obvious pulmonary edema
    Visual Assessment
    Skin color
    Flaring of nares
    Pursed lips
    Retractions
    Accessory Muscle Use
    Altered Mental Status
    Inadequate Rate or depth of ventilations
  • 98. Airway & Ventilation Methods
    Orotracheal Intubation- preferred in almost all situations
    Indications
    present or impending respiratory failure
    apnea
    unable to protect own airway (GCS <8)
    Advantages
    secures airway
    route for a few medications
    optimizes ventilation and oxygenation
  • 99. Orotracheal Intubation
  • 100. Orotracheal Intubation
  • 101. Airway & Ventilation Methods
    Needle Cricothyrotomy & Transtracheal Jet Ventilation
    Indications
    Same as surgical cricothyrotomy along with
    Contraindication for surgical cricothyrotomy
    Contraindications
    caution with tracheal transection
  • 102. Airway & Ventilation Methods:
    Jet Ventilation
    Usually requires high-pressure equipment
    Ventilate 1 sec then allow 3-5 sec pause
    Hypercarbia likely
    Temporary: 20-30 mins
    High risk for barotrauma
  • 103. Airway & Ventilation Methods
    Pharmacologic Assisted Intubation
    Sedation
    Used for
    induction
    anxious or agitated patient
    Contraindications
    hypotension (e.g. hypovolemia 2° to trauma)
    Neuromuscular Blockade
    Induces temporary skeletal muscle paralysis
    Indications
    When Intubation is required in a patient who
    is awake,
    has a gag reflex, or
    is agitated or comb
  • 104. Airway & Ventilation Methods
    Surgical Cricothyrotomy
    Indications
    absolute need for a definitive airway AND
    unable to perform ETT due for structural or anatomic reasons, AND
    risk of not intubating is > than surgical airway risk
    absolute need for a definitive airway AND
    unable to clear an upper airway obstruction, AND
    multiple unsuccessful attempts at ETT, AND
    other methods of ventilation do not allow for effective ventilation and respiration
  • 105. Surgical Cricothyroidotomy
  • 106. Surgical Cricothyroidotomy
  • 107. Surgical Cricothyroidotomy
  • 108. Surgical Cricothyroidotomy
  • 109. Surgical Cricothyroidotomy
  • 110. Surgical Cricothyroidotomy
  • 111. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 112. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 113. Breathing and Ventilation
  • 114. Airway patencydoes not assure adequate ventilation. Ventilationrequires adequate function of lungs, chest wall, and diaphragmExposure,assess chest wall to detect injuries that may compromise ventilation.
  • 115. Auscultationfor presence and quality of breath sounds Percussionmay demonstrate the presence of air (pneumothorax) or blood (hemothorax)
  • 116. Injuries That Acutely Impair Ventilation:Open/Tension Pneumothorax Flail Chest/Pulmonary Contusion Massive Hemothorax
  • 117. Pathophysiology of Thoracic Trauma Chest Wall Injuries
    Contusion
    Most Common result of blunt injury
    Signs & Symptoms
    Erythema
    Ecchymosis
    DYSPNEA
    PAIN on breathing
    Limited breath sounds
    HYPOVENTILATION
    BIGGEST CONCERN = “HURTS TO BREATHE”
    Crepitus
    Paradoxical chest wall motion
  • 118. Pathophysiology of Thoracic Trauma Chest Wall Injuries
    Rib Fractures
    >50% of significant chest trauma cases due to blunt trauma
    Compressional forces flex and fracture ribs at weakest points
    Ribs 1-3 requires great force to fracture
    Possible underlying lung injury
    Ribs 4-9 are most commonly fractured
    Ribs 9-12 less likely to be fractured
    Transmit energy of trauma to internal organs
    If fractured, suspect liver and spleen injury
    Hypoventilation is COMMON due to PAIN
  • 119. Pathophysiology of Thoracic Trauma Chest Wall Injuries
    Sternal Fracture & Dislocation
    Associated with severe blunt anterior trauma
    Typical MOI
    Direct Blow (i.e. Steering wheel)
    Incidence: 5-8%
    Mortality: 25-45%
    Myocardial contusion
    Pericardial tamponade
    Cardiac rupture
    Pulmonary contusion
    Dislocation uncommon but same MOI as fracture
    Tracheal depression if posterior
  • 120.
  • 121. Pathophysiology of Thoracic Trauma Chest Wall Injuries
    Flail Chest
    Segment of the chest that becomes free to move with the pressure changes of respiration
    Three or more adjacent rib fracture in two or more places
    Serious chest wall injury with underlying pulmonary injury
    Reduces volume of respiration
    Adds to increased mortality
    Paradoxical flail segment movement
    Positive pressure ventilation can restore tidal volume
  • 122.
  • 123.
  • 124. Pathophysiology of Thoracic Trauma Pulmonary Injuries
    Simple Pneumothorax
    AKA: Closed Pneumothorax
    Progresses into Tension Pneumothorax
    Occurs when lung tissue is disrupted and air leaks into the pleural space
    Progressive Pathology
    Air accumulates in pleural space
    Lung collapses
    Alveoli collapse (atelectasis)
    Reduced oxygen and carbon dioxide exchange
    Ventilation/Perfusion Mismatch
    Increased ventilation but no alveolar perfusion
    Reduced respiratory efficiency results in HYPOXIA
  • 125.
  • 126. Pathophysiology of Thoracic Trauma Pulmonary Injuries
    Open Pneumothorax
    Free passage of air between atmosphere and pleural space
    Air replaces lung tissue
    Mediastinum shifts to uninjured side
    Air will be drawn through wound if wound is 2/3 diameter of the trachea or larger
    Signs & Symptoms
    Penetrating chest trauma
    Sucking chest wound
    Frothy blood at wound site
    Severe Dyspnea
    Hypovolemia
  • 127.
  • 128. Open PneumothoraxTreatment:Occlusive dressing, sealed on three sides, creating a one-way valve Chest tube
  • 129. Pathophysiology of Thoracic Trauma Pulmonary Injuries
    Tension Pneumothorax
    Buildup of air under pressure in the thorax.
    Excessive pressure reduces effectiveness of respiration
    Air is unable to escape from inside the pleural space
    Progression of Simple or Open Pneumothorax
  • 130.
  • 131. Pathophysiology of Thoracic Trauma Pulmonary InjuriesTension Pneumothorax Signs & Symptoms
    Diminished then absent breath sounds on injured side
    Cyanosis
    Diaphoresis
    AMS
    JVD
    Hypotension
    Hypovolemia
    Tracheal Shifting
    • LATE SIGN
    Dyspnea
    Tachypnea at first
    Progressive ventilation/perfusion mismatch
    Atelectasis on uninjured side
    Hypoxemia
    Hyperinflation of injured side of chest
    Hyperresonance of injured side of chest
  • 132. Pathophysiology of Thoracic Trauma Pulmonary Injuries
    Hemothorax
    Accumulation of blood in the pleural space
    Serious hemorrhage may accumulate 1,500 mL of blood
    Mortality rate up to 75%
    Each side of thorax may hold up to 3,000 mL
    Blood loss in thorax causes a decrease in tidal volume
    Ventilation/Perfusion Mismatch & Shock
    Typically accompanies pneumothorax
    Hemopneumothorax
  • 133. Pathophysiology of Thoracic Trauma Pulmonary InjuriesHemothorax Signs & Symptoms
    Blunt or penetrating chest trauma
    Shock
    Dyspnea
    Tachycardia
    Tachypnea
    Diaphoresis
    Hypotension
    Dull to percussion over injured side
  • 134.
  • 135. Pathophysiology of Thoracic Trauma Pulmonary Injuries
    Pulmonary Contusion
    Soft tissue contusion of the lung
    30-75% of patients with significant blunt chest trauma
    Frequently associated with rib fracture
    Typical Mechanism of Injury
    Deceleration
    Chest impact on steering wheel
    Bullet Cavitation
    High velocity ammunition
    Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar tissue
    Progressive deterioration of ventilatory status
    Hemoptysis typically present
  • 136. 118/217 Break
  • 137. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 138. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 139. Circulation with Hemorrhage Control
  • 140. Blood Volume and Cardiac OutputHemorrhage is the predominant cause of post-injury deathsHypotension is due to bleeding with loss of blood volume until proven otherwise
  • 141. Observations that provide clinical information as to the adequacy of circulation:-Level of consciousness-Skin color-Pulse
  • 142. Level of consciousness Impaired cerebral perfusion = altered level of consciousness
  • 143. Skin ColorPink skin, face and extremities:rarely critically hypovolemiaAshen, gray skin:an ominous sign of hypovolemia
  • 144.
  • 145. PulsesCarotid, radial, femoral pulses assessed for quality, rate, and regularityFull, slow, and regular pulses = relative normovolemiaRapid thready pulse, usually a sign of hypovolemiaIrregular pulse may indicate potential cardiac dysfunction.
  • 146. Bleeding
  • 147. External blood lossis managed by direct pressure
  • 148. SITES of BLOOD LOSS in TRAUMA
  • 149. OBVIOUSScalp lacerations Facial injuries Open Fractures
  • 150. HIDDENIntra/retroperitoneal Hemothorax Pelvic hematoma Long-bone fracture sites Aortic disruption
  • 151. Elderly patientsLimited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of volume depletion, tachycardiaBlood pressure has little correlation with cardiac output in the older patients.
  • 152. ChildrenAbundant physiologic reserveOften demonstrate few signs of hypovolemia even after severe volume depletionWhen deterioration occurs, it is precipitous and catastrophic.
  • 153. Other Causes of Decreased Circulation that need to be considered vs. Hypovolemia in the Trauma Patient
  • 154. Pathophysiology of Thoracic Trauma Cardiovascular Injuries
    Myocardial Contusion
    Occurs in 76% of patients with severe blunt chest trauma
    Right Atrium and Ventricle is commonly injured
    Injury may reduce strength of cardiac contractions
    Reduced cardiac output
    Electrical Disturbances due to irritability of damaged myocardial cells
    Progressive Problems
    Hematoma
    Hemoperitoneum
    Myocardial necrosis
    Dysrhythmias
    CHF & or Cardiogenic shock
  • 155.
  • 156. Myocardial Contusion Signs & Symptoms
    Bruising of chest wall
    Tachycardia and/or irregular rhythm
    Retrosternal pain similar to MI
    Associated injuries
    Rib/Sternal fractures
    Chest pain unrelieved by oxygen
    May be relieved with rest
    THIS IS TRAUMA-RELATED PAIN
    Similar signs and symptoms of medical chest pain
  • 157. Thoracic Trauma Cardiovascular Injuries
    Pericardial Tamponade
    Restriction to cardiac filling caused by blood or other fluid within the pericardium
    Occurs in <2% of all serious chest trauma
    However, very high mortality
    Results from tear in the coronary artery or penetration of myocardium
    Blood seeps into pericardium and is unable to escape
    200-300 ml of blood can restrict effectiveness of cardiac contractions
    Removing as little as 20 ml can provide relief
  • 158. Cardiac Tamponade
    Beck’s triad:
    - Hypotension
    - Jugular venous distention
    -Muffled heart sounds
  • 159.
  • 160. Cardiac Tamponade
  • 161. Technique for pericardiocentesis
  • 162. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 163. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 164. Disability
  • 165. The Glasgow Coma Scale (GCS) A more precise evaluation and predictor of patient outcome
  • 166.
  • 167. A decreased level of consciousness may result from either:1. Decrease in cerebral perfusion and/or oxygenation 2. Direct cerebral injury
  • 168. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 169. The ABCDEs of trauma care sequentially identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilationC. Circulation with hemorrhage control D. Disability: Neurologic statusE. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and simultaneous management is instituted
  • 170. Exposure/Environmental Control-Completely undress to facilitate thorough examination and assessment.-Cover with warm blankets or use an external warming device to prevent hypothermia-Use warmed intravenous fluids -Maintain a warm environment (room temperature)
  • 171. ADJUNCTS to PRIMARY SURVEY and RESUSCITATION
  • 172. ECGDysrhythmias, ST changes - myocardial contusionTachycardia - hypovolemiaBradycardia – end-stage hypoxia or hypovolemia
  • 173. CathetersFoley Catheter: No transurethral catheter until genitalia, perineum, and rectal examUrethral injury indicators- meatal blood, shaft hematoma, perineal/scrotal ecchymosis, non- palpable prostate, pelvic fractureNasogastric tube: Reduces the risk, but does not always prevent aspiration
  • 174. MONITORING ADJUNCTSPulse Oximetry- indicator of O2 saturation,not partial pressure Carbon Dioxide Detector- confirms ETT is located somewhere in the airwayDoes notconfirm proper placement of the tube
  • 175. X-RAYS and Diagnostic Studies
  • 176. X-raysshould not delay patient resuscitation The AP chest film and an AP pelvis mayprovide information which may guide resuscitation efforts
  • 177. A lateral cervical spine x-ray that demonstrates an injury is an important findingA negative or inadequate film does not exclude cervical spine injury.
  • 178. Tear drop fracture
    anterior C-4
  • 179. ADJUVANT TESTS IN TRAUMA DIAGNOSIS
    Diagnostic peritoneal lavage (DPL)FAST Abdominal Ultrasonography and CT may be useful for the evaluation of intra- abdominal and retroperitoneal bleeding Early identification of the source of hidden blood loss may indicate the need for emergent operative intervention
  • 180. Detailed Secondary Survey (after stabilization)
  • 181. SECONDARY SURVEYAfter primary survey (ABCDEs) complete Head-to-toe re-examination of the patient
  • 182. Head Pupillarysize, conjunctival hemorrhages and fundi, penetrating injury,dislocation of the lens,ocular entrapment Visual acuitycan be evaluated by the reading of printed material, e.g., words on an intravenous container.Extra-ocular mobilityshould be evaluated to exclude entrapment of muscles due to orbital fractures The entire scalp and skull should be examined forlacerations, contusions, and evidence of fractures.
  • 183.
  • 184. SKULL FRACTURESCranial Vault Linear/Stellate Depressed/Non-depressed Open/ClosedBasilar Raccoon eyes, Battle’s signHemotypanum + / – CSF leak + / – VII n. palsy
  • 185. Mastiodecchymosis : an indication of a fracture of the base of the skull
    BATTLE’S SIGN
  • 186. Periorbital bruising: a sign of basal skull fracture
    RACCOON EYES
  • 187. INTRA-CRANIAL INJURYFocalEpidural SubduralIntracerebralDiffuseMild Concussion Classic Concussion Diffuse Axonal
  • 188. Diagnostic Procedures CT ScanHematomasEpidural (supradural,convex/lenticular)Subdural (concave)Intra-cerebral (high density & low density halo)MRIBetter for parenchymal and brain stem, but time to perform 45 min. vs 2-5 min for CT. MRI, at present, not initial management study
  • 189. Epidural hematoma
  • 190. Cerebral contusion with cerebral swelling and skull
    fracture
  • 191. Traumatic Brain Injury
    Epidural Hematoma
    SA Hemorrhage
  • 192. Intracranial Pressure ControlHyperventilation (controlled)Osmotic diuresis (mannitol)Barbiturates (if ICP reductionrefractory to standard Rx.)Anticonvulsants(early and short term)
  • 193. Intravenous FluidsHypovolemiaDecrease cerebral perfusion (CBF)Increase hypoxiaNormal saline or Ringer’s
  • 194. MaxillofacialMaxillofacial trauma without airway obstruction or major bleeding, treated after stabilization Mid-face fractures may involve a fracture of the cribriform plate.Beware placing NG tube..Orotrachealand gastric intubation should be performed.
  • 195. Cervical Spine and NeckPatients with maxillofacial or head trauma, assume an unstable cervical spine injury, (fracture and/or ligamentous)The absence of neurologic deficit does not exclude injury to the cervical spine
  • 196. NeckTrachea (midline, tender, crepitus) Carotids (amplitude, bruit) Venous distension C-spine (stable / unstable, fracture, ligamentous)
  • 197. Neck - cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture.
  • 198. Penetrating Neck Injury
  • 199. Carotid Arteries
    - amplitude, equality of pulsation, bruit
    -occlusion or dissection of the carotid artery can occur late in the injury
    -blunt trauma to the neck or a traction injury from a shoulder harness restraint can result in intimal disruption, dissection, and thrombosis.
  • 200. Penetrating neck trauma - vascular
  • 201. Penetrating neck trauma - vascular
  • 202. ChestWall ( expansion, paradoxical,ecchymosis, tenderness, crepitus)Sternal tenderness ( myocardial / pulmonary contusion)
  • 203. Rib Fractures1,2 (aortic disruption) 3 - 8 (hemo/pneumothorax, disruption diaphragm) 9 - 12 (liver, spleen, kidney) Flail (pulmonary contusion)
  • 204. Chest X-RayChest wall (rib, sternalfxs.) Hemothorax Simple pneumothoraxMediastinal width (upright film)
  • 205. Stomach herniated through diaphragm
  • 206. CHEST TRAUMA
    Contusions, hematomas, chest wall – possibility of additional associated injurySternaltenderness– sternal fracture, costochondralseparation Tension pneumothorax–hypotension, hyperresonance, decreased breath soundsMassive hemothorax- dullness to percussion, absent breath sounds,hypotensionCardiac tamponade– hypotension, narrow pulse pressure, distant heart sounds
  • 207. Aortic Transection
    Signs:
    - widened mediastinum, 1st rib fx, apical capping, left hemothorax, tracheal deviation to right
    - widening from bridging veins and arteries, not aorta itself
    - need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears at ligamentum
    - 90% of patients die at the scene
  • 208. Great Vessel Injury
  • 209. Tension PneumothoraxNOT AN X-RAY DIAGNOSIS
  • 210. Tension Pneumothorax
  • 211. Tension pneumothorax on right with shifted mediastinum
  • 212. AbdomenEcchymosis (flank / kidney?) Tenderness RUQ (liver) LUQ (spleen) CVA ( kidney)Suprapubic ( bladder, symphysis)
  • 213. Contusion of right lobe of liver
  • 214. AbdomenDPL, abdominal US, contrast CTTO BE DISCUSSED TOMORROWUnexplained hypotension, impaired CNS, or equivocal findingsPain from pelvic, lower rib fractures may prevent accurate diagnostic exam
  • 215. Pelvis(tenderness, crepitus, instability)Genitalia(perineal/scrotal/shaft hematoma, meatal blood)Rectum(tone, prostate, blood)Extremities(tenderness, deformity, pulses, sensation)Neurologic(detailed exam)
  • 216. Hemorrhage
    Pelvic fracture
  • 217. Perineum/Rectum/VaginaContusions, hematomas, lacerations, and urethral (meatal) blood.Rectal exam prior to inserting a urinary catheter High-riding prostate, sphincter tone, integrity of rectal wall, blood within the bowel lumenFemale patient - blood in the vaginal vault and vaginal lacerations
  • 218. MusculoskeletalPelvic fractures - ecchymosis over the iliac wings, symphysispubis, labia, scrotum, pain on palpation of the pelvic ring Mobility of the pelvis - gentle anterior-to-posterior presssurewith the heels of the hands on both anterior iliac spines and symphysis pubis Joint instability- ligament disruption Neurovascular deficit- nerve injury or ischemia (compartment syndrome)
  • 219.
  • 220. MRI image of thoracic
    vertebral fracture and
    injured spinal cord
  • 221. Illinois EMSC
    203
    PELVIS
    Apply pressure on pelvis to determine its stability
    Perform genitalia exam at one’s discretion
  • 222. Illinois EMSC
    204
  • 223. NeurologicMotor and sensory evaluation of the extremitiesReevaluation of the patient's level of consciousness GCS facilitates detection of early changes and trends in the neurologic status Protection of the spinal cord is required until a spine injury is excluded
  • 224. ADJUNCTS TO THE SECONDARY SURVEYThese include additional x-rays of the spine and extremities, CT computed tomographicscans of the head, chest, abdomen, and spine, contrast uretographyangiography, and other diagnostic procedures
  • 225. RE-EVALUATIONAfter initial life-threatening injuries are managed, other equally life-threatening problems and less severe injuries may become apparent Relief of severe pain is an important part of the management of the trauma patient Effective analgesia requires intravenous opiates and/or anxiolytics(intravenous)… Intramuscular injections are to be avoided.
  • 226. Once patient Stabilized and ResuscitatedOn to DefinitiveCare
  • 227. ?
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  • 228.
  • 229.
  • 230.
  • 231. Recognizing Life Threatening Emergenies
  • 232. Tension Pneumothorax
    Signs and Symptoms
    severe respiratory distress
     or absent lung sounds (unilateral usually)
     resistance to manual ventilation
    Cardiovascular collapse (shock)
    asymmetric chest expansion
    anxiety, restlessness or cyanosis (late)
    JVD or tracheal deviation (late)
  • 233. Traumatic Brain Injry:
    High index of suscpicion in any patient with history of or identifiable evidence of altered level of consciousness
    Best determined by GCS (a decrease of even 1-2 points is indicative of significant change in neurological status)
    Pupillary function
    Lateralizing signs
  • 234. Solid Organ Injury
    25% of all trauma victims require an abdominal exploration
    Blunt trauma caused by MVCs, MCCs, falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of injury
    High index of suspicion in those patients with c/o abdominal pain, and/or objective findings on exam (seatbelt sign)
  • 235. Pelvic Trauma
    Pelvic fx are the prototype of severe trauma, with an usually high incidence of associated injuries
    Awake pts c/o excessive pain and may have evidence of abnormal positioning of lower extremities, or unstable pelvis on exam
    Can be a major source of blood loss that is either arterial, venous, or osseous in origin