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12 trauma – initial assessement and management
 

12 trauma – initial assessement and management

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    12 trauma – initial assessement and management 12 trauma – initial assessement and management Presentation Transcript

    • 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 minutes minutes to hours GOLDEN HOUR several 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 ABC DEFG)
    • 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 / Breathing All 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 - A lert
      • V - responds to V erbal stimuli
      • P - responds to P ainful stimuli
      • U - U nresponsive
      • 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