Initial approach to trauma


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Initial approach to trauma

  1. 1. Initial approach to traumaDr.Shankar.HippargiConsultant & HeadA & E Deptartment
  2. 2. TRAUMA “The Neglected disease of modern developing nations”
  3. 3. Everyday we come across a story aboutsomeone’s loved one dying on the road andjust ignore it, focusing on our day to day life. One day, it could be anyone of us! Someone from our family; some loved one! Then What…?
  4. 4. Pitiable condition of our roads
  5. 5. Pitiable attitude of ourpeople
  6. 6. Traumatic injury and deathdue to trauma is the thirdleading cause of death allover the worldLeading cause of death inage group 20-40 years(great impact on family)Blunt injury due to motorvehicle crash is the leadingcause of death in traumaTraumatic injury contributesto the highest medical costsand greatest incidence oflife-long disability
  7. 7. Traumatic injuriesare broadlyclassified intoblunt andpenetratinginjuries
  8. 8. Time to Care vs Survival Evacuation Mortality Conflict Time (hrs) Rate (%) World War I 18 18.0 World War II 4-6 3.3 Korea 2-4 2.4 Vietnam 1-2 1.8What do these numbers suggest about trauma care strategies?What do these numbers suggest about trauma care strategies? --Time is life -- Time is life
  9. 9. Trimodal pattern of mortality Pre Hospital- Devastating head & major vascular injuries ED- Major head, chest & abdominal injuries ICU- Organ hypoperfusion, SIRS, MOD
  10. 10. Trimodal distribution <1 hour 1-3 hours 4 to 6 weeks
  11. 11. What can be done about these deaths?What role does EMS & ED play?
  12. 12. Golden hour The first hour following a trauma during which aggressive resuscitation can improve the chances of survival, and restore the normal functions Early pre-hospital care, early transport, aggressive resuscitation and interventions in ED, continued care in ICU have a definite and significant roles in preventing deaths due to trauma
  13. 13. Role of ED Portal of entry to all trauma patients Early triage, early recognition and rapid intervention of life / limb threatening injuries Maintaining adequate ABCs Early referral (understand your limitations) Co-ordinate other specialties
  14. 14. Indian scenario No proper pre-hospital care No trained emergency physicians No trained nursing / paramedical staff No co-ordination between different specialties Most of the trauma related deaths are preventable, and its high time to realize this fact.
  15. 15. The initial approach to trauma care is aprocess that consists of an initialprimary assessment, rapid resuscitationand a more thorough secondaryassessment, followed by diagnostictests and disposition
  16. 16. Primary assessment The goal is to identify and treat life & limb threatening conditions Assessment and management should go hand in hand Re-assess after each intervention Assess ABCDEs of trauma and do appropriate interventions as required
  17. 17. Treatable life threateningconditions Airway obstruction Tension pneumothorax Cardiac tamponade Massive hemothorax Sucking chest wound Massive bleeding Pelvic and other long bone fractures Scalp lacerations
  18. 18. ABCDEs of trauma… Airway with C-spine control Breathing with supplemental O2 Circulation with bleeding control Deformity/ Disability Exposure
  19. 19. Airway with C-spine controlSuspect C-spine injuryin all unconsciouspatients, any injuryabove the clavicals,significant mechanismof injury (do not head tiltchin lift)Manually stabilize theC-spine, look for foreignbodies, bleeding,maxillo-facial injuriesAll patients with GCS<9 needs intubation Jaw Thrust
  20. 20. Manual in line stabilizationof C-spine while doingintubationApply rigid neck collar afterintubation (look for trachealshift, distended neck veins,lacerations)Patients with severeMaxillo-facial injuries mayneed surgical airwayMaintaining adequateoxygenation is veryimportant in preventingsecondary injuriesespecially in head injurypatients
  21. 21. Breathing with supplemental O2 Inspect- Equal chest rise, paradoxical chest movements, contusions, sucking chest wound, distended neck veins Auscultate- Equal breath sounds, absence of BS Palpate- Tracheal shift, Chest wall tenderness, subcutaneous emphysema, sternum #, rib # Percuss- dullness, hyper-resonance Give 100% O 2 to all trauma patients
  22. 22. Important interventions Tension pneumothorax- Needle decompression, followed by ICD Open pneumothorax (Sucking chest wound) – 3 way occlusive dressing Cardiac tamponade- Pericardiocentesis Massive hemothorax- ICD Pelvic fracture- pelvic binder
  23. 23. Tension pneumothorax
  24. 24. Openpneumothorax
  25. 25. Circulation with bleedingcontrol Hemorrhagic shock is common cause of post injury death Look for S/O hypoperfusion- level of consciousness, PR, BP, capillary refill (>2 sec), skin colour, urine output All hemorrhages do not produce shock S/O shock not seen until 30% of blood is lost
  26. 26. Anticipate shock depending on MOI andphysical examinationControl obvious bleeding by directpressure, splinting & limb elevationTry to find source of bleeding inhypotensive patient with no externalbleeding
  27. 27. Pelvic fracture- Cardiacpelvic binder Tamponade
  28. 28. Fracture & blood loss Site of fracture Blood loss (approx)Pelvic # 2500-4000mlFemur # 1500-2000mlTibia & Fibula # 1000-1500mlHumerus # 500-800mlForearm bones # 250-400ml
  29. 29. Classification of hemorrhagicshock
  30. 30. Rate of flow is α fourth power of radius of cannula
  31. 31. Start 2 large bore iv lines, startcrystalloids (avoid colloids for initialresuscitation)Give blood as soon as possible inhemorrhagic shocksLook for other causes of shock
  32. 32. Shock in trauma Hypovolumic (hemorrhagic) most common- until proved otherwise Cardiac tamponade Tension pneumothorax Myocardial contussion Neurogenic shock Rule out by physical examination and USG
  33. 33. Disability GCS, Pupils size and reaction, motor function • GCS 13-14= mild head injury • GCS 9-12= moderate head injury • GCS <9= severe head injury (intubate)
  34. 34. ExposurePrimary assessment isincomplete withoutthorough examination oftotal body surface areaLog roll should be donein all unconsciouspatientsInspect & palpate entirespine & back, P/R foranal tone, blood &prostateMeatal bleed S/Ourethral rupture, DONOT CATHETERIZE
  35. 35. Primary survey...Any derangement identified duringprimary assessment should be treatedimmediatelySecure airway & IV lines, catheterize,insert NG tubeContinuous monitoring (rhythm, HR,BP, RR, SpO2)
  36. 36. Secondary assessment It is rapid but thorough head to toe physical examination for the purpose of identifying as many injuries as possible Resuscitation should be continued during secondary assessment Inspect & palpate for tenderness, crepitus, swelling, deformity, all peripheral pulses, motor & sensory function, scrotal hematoma
  37. 37. Do not in trauma Never try to remove any impaled foreign object (may cause severe uncontrollable bleeding, tamponade and sudden death) • Never try to put the intestinal loops back into abdomen in stab injuries (may cause strangulation) • Never insert anything nasally in head injury patients especially when there are signs of basal skull #03/21/13
  38. 38. Investigations PCV (Hb) X-ray- Chest, C- S. electrolytes spine,Pelvis & Creatinine & urea region of suspected # HIV, HbSAg, HCV CT brain, thorax & abdomen as needed FAST (USG)
  39. 39. To summarise• Organised team approach• Priorities in management & resuscitation• Rule out of most serious injuries• Treatment before diagnosis• Thorough examination• Frequent reassessment• Monitoring
  40. 40. "A good beginning almost assures success"
  41. 41. Emergencies don’t give us a second chance…..