Initial assessment of the trauma patient

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  • Fi - Fractional concentraion o fair - concentration of o2 in inspired air
  • Initial assessment of the trauma patient

    1. 1. Initial Assessment of the Trauma Patient Sharla Owens, M.D. July 10 th , 2006
    2. 2. Don’t Panic Don’t Panic Never Let Them See You Sweat..
    3. 3. ATLS Guidelines <ul><li>Systematic approach necessary to rapidly identify injuries and stabilize the patient </li></ul><ul><li>This approach is divided into: </li></ul><ul><li>1. Primary Survey </li></ul><ul><li>2. Resuscitative Phase </li></ul><ul><li>3. Secondary Survey </li></ul><ul><li>4. Definitive Care Phase </li></ul>
    4. 4. ABCDE
    5. 5. Airway Management in the Trauma Patient
    6. 6. Objectives of Airway Management & Ventilation <ul><li>Primary Objective: </li></ul><ul><ul><li>Provide unobstructed passage for air movement </li></ul></ul><ul><ul><li>Ensure optimal ventilation </li></ul></ul><ul><ul><li>Ensure optimal respiration </li></ul></ul>
    7. 7. Objectives of Airway Management & Ventilation <ul><li>Why is this so important in the trauma patient? </li></ul><ul><ul><li>Prevention of Secondary Injury </li></ul></ul><ul><ul><ul><li>Shock & Anaerobic Metabolism </li></ul></ul></ul><ul><ul><ul><li>Spinal Cord Injury </li></ul></ul></ul><ul><ul><ul><li>Brain Injury </li></ul></ul></ul>
    8. 8. Airway <ul><li>Patency is primary </li></ul><ul><li>Obstruction in trauma patients </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Foreign Body </li></ul></ul><ul><ul><li>Blood and secretions </li></ul></ul>
    9. 9. Airway <ul><li>Evaluation begins by asking the patient a question such as 'How are you?‘ </li></ul><ul><li>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. </li></ul>
    10. 10. Airway <ul><li>Mechanical removal of debris, chin lift and/or jaw thrust maneuver, are usefull in clearing the airway in less injured patients </li></ul><ul><li>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 </li></ul>
    11. 11. Airway & Ventilation Methods <ul><li>Supplemental Oxygen </li></ul><ul><ul><li>increased FiO 2 increases available oxygen </li></ul></ul><ul><ul><li>objective is to maximize hemoglobin saturation </li></ul></ul>
    12. 12. Airway & Ventilation Methods <ul><li>Airway Maneuvers </li></ul><ul><ul><li>Chin lift </li></ul></ul><ul><ul><li>Jaw thrust </li></ul></ul><ul><ul><li>(Neck extension is </li></ul></ul><ul><ul><li>contraindicated) </li></ul></ul><ul><li>Airway Devices </li></ul><ul><ul><li>Oropharyngeal airway </li></ul></ul><ul><ul><li>Nasopharyngeal airway </li></ul></ul><ul><ul><li>BVM </li></ul></ul>
    13. 13. Assessment & Recognition of Airway & Ventilatory Compromise <ul><li>Visual Assessment </li></ul><ul><ul><li>Position </li></ul></ul><ul><ul><ul><li>tripod </li></ul></ul></ul><ul><ul><ul><li>orthopnea </li></ul></ul></ul><ul><ul><li>Rise & Fall of chest </li></ul></ul><ul><ul><ul><li>Paradoxical motion </li></ul></ul></ul><ul><ul><li>Audible gasping, stridor, or wheezes </li></ul></ul><ul><ul><li>Obvious pulm edema </li></ul></ul><ul><li>Visual Assessment </li></ul><ul><ul><li>Skin color </li></ul></ul><ul><ul><li>Flaring of nares </li></ul></ul><ul><ul><li>Pursed lips </li></ul></ul><ul><ul><li>Retractions </li></ul></ul><ul><ul><li>Accessory Muscle Use </li></ul></ul><ul><ul><li>Altered Mental Status </li></ul></ul><ul><ul><li>Inadequate Rate or depth of ventilations </li></ul></ul>
    14. 14. Airway & Ventilation Methods <ul><li>Gastric Distention </li></ul><ul><ul><li>Common when ventilating without intubation </li></ul></ul><ul><ul><li>pressure on diaphragm </li></ul></ul><ul><ul><li>resistance to BVM ventilation </li></ul></ul><ul><ul><li>avoid by increasing time of BVM ventilation </li></ul></ul>
    15. 15. Airway & Ventilation Methods <ul><li>Orotracheal Intubation- preferred in almost all situations </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>present or impending respiratory failure </li></ul></ul></ul><ul><ul><ul><li>apnea </li></ul></ul></ul><ul><ul><ul><li>unable to protect own airway (GCS <8) </li></ul></ul></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>secures airway </li></ul></ul></ul><ul><ul><ul><li>route for a few medications </li></ul></ul></ul><ul><ul><ul><li>optimizes ventilation and oxygenation </li></ul></ul></ul>
    16. 16. Airway & Ventilation Methods <ul><li>Nasotracheal Intubation- rarely if ever used in the initial management of the injured patient. </li></ul><ul><li>Many drawbacks </li></ul><ul><li>Goal of safe endotracheal intubation with cervical spine precautions can be better accomplished with orotracheal intubation </li></ul>
    17. 17. Airway & Ventilation Methods <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>absolute need for a definitive airway AND </li></ul></ul></ul><ul><ul><ul><ul><li>unable to perform ETT due for structural or anatomic reasons, AND </li></ul></ul></ul></ul><ul><ul><ul><ul><li>risk of not intubating is > than surgical airway risk </li></ul></ul></ul></ul><ul><ul><ul><li>OR </li></ul></ul></ul><ul><ul><ul><li>absolute need for a definitive airway AND </li></ul></ul></ul><ul><ul><ul><ul><li>unable to clear an upper airway obstruction, AND </li></ul></ul></ul></ul><ul><ul><ul><ul><li>multiple unsuccessful attempts at ETT, AND </li></ul></ul></ul></ul><ul><ul><ul><ul><li>other methods of ventilation do not allow for effective ventilation and respiration </li></ul></ul></ul></ul>
    18. 18. Airway & Ventilation Methods: ALS <ul><li>Surgical Cricothyrotomy </li></ul><ul><ul><li>Contraindications (relative) </li></ul></ul><ul><ul><ul><li>Age < 8 years (some say 10) </li></ul></ul></ul><ul><ul><ul><li>evidence of fx larynx or cricoid cartilage </li></ul></ul></ul><ul><ul><ul><li>evidence of tracheal transection </li></ul></ul></ul>
    19. 19. Airway & Ventilation Methods <ul><li>Needle Cricothyrotomy & Transtracheal Jet Ventilation </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Same as surgical cricothyrotomy along with </li></ul></ul></ul><ul><ul><ul><li>Contraindication for surgical cricothyrotomy </li></ul></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>caution with tracheal transection </li></ul></ul></ul>
    20. 20. Airway & Ventilation Methods: <ul><li>Jet Ventilation </li></ul><ul><ul><li>Usually requires high-pressure equipment </li></ul></ul><ul><ul><li>Ventilate 1 sec then allow 3-5 sec pause </li></ul></ul><ul><ul><li>Hypercarbia likely </li></ul></ul><ul><ul><li>Temporary: 20-30 mins </li></ul></ul><ul><ul><li>High risk for barotrauma </li></ul></ul>
    21. 21. Airway & Ventilation Methods <ul><li>Pharmacologic Assisted Intubation (“RSI”) </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><ul><li>Used for </li></ul></ul></ul><ul><ul><ul><ul><li>induction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>anxious or agitated patient </li></ul></ul></ul></ul><ul><ul><ul><li>Contraindications </li></ul></ul></ul><ul><ul><ul><ul><li>hypersensitivity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>hypotension (e.g. hypovolemia 2° to trauma) </li></ul></ul></ul></ul>
    22. 22. Airway & Ventilation Methods <ul><li>Pharmacologic Assisted Intubation (“RSI”) </li></ul><ul><ul><li>Neuromuscular Blockade </li></ul></ul><ul><ul><ul><li>Induces temporary skeletal muscle paralysis </li></ul></ul></ul><ul><ul><ul><li>Indications </li></ul></ul></ul><ul><ul><ul><ul><li>When Intubation is required in a patient who </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>is awake, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>has a gag reflex, or </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>is agitated or combative </li></ul></ul></ul></ul></ul>
    23. 23. Airway & Ventilation Methods <ul><li>Pharmacologic Assisted Intubation (“RSI”) </li></ul><ul><ul><li>Neuromuscular Blockade </li></ul></ul><ul><ul><ul><li>Contraindications </li></ul></ul></ul><ul><ul><ul><ul><li>Most are specific to the medication </li></ul></ul></ul></ul><ul><ul><ul><ul><li>inability to ventilate patient once paralysis is induced </li></ul></ul></ul></ul><ul><ul><ul><li>Advantages </li></ul></ul></ul><ul><ul><ul><ul><li>reduces risk of laryngospasm </li></ul></ul></ul></ul>
    24. 24. Airway & Ventilation Methods <ul><li>Pharmacologic Assisted Intubation (“RSI”) </li></ul><ul><ul><li>Disadvantages & Potential Complications </li></ul></ul><ul><ul><ul><li>Does not provide sedation or amnesia </li></ul></ul></ul><ul><ul><ul><li>Provider unable to intubate or ventilate after NMB </li></ul></ul></ul><ul><ul><ul><li>Aspiration during procedure </li></ul></ul></ul><ul><ul><ul><li>Difficult to detect motor seizure activity </li></ul></ul></ul><ul><ul><ul><li>Side effects and adverse effects of specific meds </li></ul></ul></ul>
    25. 25. Tension Pneumothorax
    26. 26. Recognizing Life Threatening Emergenies Aka, “When to pee in your pants in the trauma bay”
    27. 27. Tension Pneumothorax <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>severe respiratory distress </li></ul></ul></ul><ul><ul><ul><li> or absent lung sounds (unilateral usually) </li></ul></ul></ul><ul><ul><ul><li> resistance to manual ventilation </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular collapse (shock) </li></ul></ul></ul><ul><ul><ul><li>asymmetric chest expansion </li></ul></ul></ul><ul><ul><ul><li>anxiety, restlessness or cyanosis (late) </li></ul></ul></ul><ul><ul><ul><li>JVD or tracheal deviation (late) </li></ul></ul></ul>
    28. 28. Great Vessel Injury
    29. 29. Aortic Transection <ul><li>Signs: </li></ul><ul><li>- widened mediastinum, 1 st rib fx, apical capping, left hemothorax, tracheal deviation to right </li></ul><ul><li>- widening from bridging veins and arteries, not aorta itself </li></ul><ul><li>- need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears at ligamentum </li></ul><ul><li>- 90% of patients die at the scene </li></ul>
    30. 30. Cardiac Tamponade
    31. 31. Cardiac Tamponade <ul><li>Beck’s triad: </li></ul><ul><li>- hypotenstion, jugular venous distention, and muffled heart sounds </li></ul><ul><li>- causes decreased diastolic ventricular filling and resultant hypotension </li></ul><ul><li>- echocardiogram shows impaired diastolic filling of right atrium initially (1 st sign) </li></ul>
    32. 32. Traumatic Brain Injury <ul><li>Epidural Hematoma </li></ul><ul><li>SA Hemorrhage </li></ul>
    33. 33. TBI: <ul><li>High index of suscpicion in any patient with history of or identifiable evidence of altered level of consciousness </li></ul><ul><li>Best determined by GCS (a decrease of even 1-2 points is indicative of significant change in neurological status) </li></ul><ul><li>Pupillary function </li></ul><ul><li>Lateralizing signs </li></ul>
    34. 34. Solid Organ Injury <ul><li>Splenic Laceration </li></ul><ul><li>Liver Laceration </li></ul>
    35. 35. Solid Organ Injury <ul><li>25% of all trauma victims require an abdominal exploration </li></ul><ul><li>Blunt trauma caused by MVCs, MCCs, falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of injury </li></ul><ul><li>High index of suspicion in those patients with c/o abdominal pain, and/or objective findings on exam (seatbelt sign) </li></ul>
    36. 36. Hemorrhage <ul><li>Pelvic fracture </li></ul>
    37. 37. Pelvic Trauma <ul><li>Pelvic fx are the prototype of severe trauma, with an usually high incidence of associated injuries </li></ul><ul><li>Awake pts c/o excessive pain and may have evidence of abnormal positioning of lower extremities, or unstable pelvis on exam </li></ul><ul><li>Can be a major source of blood loss that is either arterial, venous, or osseous in origin </li></ul>

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