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06 introduction to trauma


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06 introduction to trauma

  1. 1. Introduction to Trauma Richard W. Stair, MD, FACEP
  2. 2. Traumatic Trivia <ul><li>Unintentional injury is the leading cause of death in ages 1-34 years </li></ul><ul><li>Unintentional injury is the the top ten causes of death in all ages </li></ul><ul><li>Note that this does not include homicides and suicides (intentional), many cases of which may also present to an ED or trauma center </li></ul>
  3. 3. Trauma Trivia II <ul><li>There are 3 permanent disabilities for every death from traumatic injuries </li></ul><ul><li>Trauma related costs exceed $400 billion annually </li></ul><ul><li>Untold cost of patient and family suffering </li></ul>
  4. 4. Phases of Trauma Care <ul><li>Prehospital care </li></ul><ul><li>Emergency Departments and Trauma Centers </li></ul><ul><li>Rehabilitation Facilities </li></ul>
  5. 5. Prehospital Care <ul><li>Triage decision scheme to determine best level of care required </li></ul><ul><li>Initiation of care based on protocols </li></ul><ul><li>Attempt to stabilize patient </li></ul><ul><li>Rapid transport </li></ul>
  6. 6. Emergency Departments <ul><li>Variable levels of equipment, training, and capabilities, from tertiary hospitals to very small community hospitals </li></ul><ul><li>All responsible for initiation of management </li></ul><ul><li>ATLS designed primarily as a regimented, prioritized approach to trauma care (in particular for survival in small center with little staff) </li></ul><ul><li>Interhospital agreements to care for injuries beyond resources </li></ul>
  7. 7. Trauma Centers <ul><li>Committed resources dedicated to caring for trauma patients </li></ul><ul><ul><li>Level I tertiary, 24 h a day trauma attending </li></ul></ul><ul><ul><li>Level II community, not as comprehensive </li></ul></ul><ul><ul><li>Level III community, fewer resources </li></ul></ul><ul><ul><li>Level IV rural, stabilize and transfer </li></ul></ul>
  8. 8. Specialty Trauma Centers <ul><li>Pediatric Trauma </li></ul><ul><li>Burn </li></ul><ul><li>Spinal Cord Injury </li></ul><ul><li>Hand </li></ul><ul><li>Rehabilitation </li></ul>
  9. 9. Advanced Trauma Life Support (ATLS) <ul><li>Systematic, prioritized approach to trauma care </li></ul><ul><li>Guidelines for even non trauma center providers to effectively manage trauma patients until patient can get to definitive care </li></ul>
  10. 10. ATLS – The Primary Survey <ul><li>Simple ABC’s Approach </li></ul><ul><ul><li>Airway with cervical protection </li></ul></ul><ul><ul><li>Breathing </li></ul></ul><ul><ul><li>Circulation </li></ul></ul><ul><ul><li>Disability </li></ul></ul><ul><ul><li>Exposure and environmental control </li></ul></ul>
  11. 11. ATLS – The Primary Survey <ul><li>AIRWAY with C SPINE PROTECTION </li></ul><ul><ul><li>Assure patency, check for foreign material, check for injuries that may occlude the airway </li></ul></ul><ul><ul><li>Voice quality often an excellent indicator </li></ul></ul><ul><ul><li>Always assume a cervical spine injury is present if needing to manage the airway and provide immobilization </li></ul></ul><ul><ul><li>Rapid sequence intubation with backup plan </li></ul></ul>
  12. 12. ATLS – The Primary Survey <ul><li>BREATHING </li></ul><ul><ul><li>Assure adequate oxygenation and ventilation </li></ul></ul><ul><ul><li>Assess by inspection, auscultation, palpation, and pulse oximetry </li></ul></ul><ul><ul><li>Must fix tension pneumothorax, large hemothorax, flail chest, or open pneumothorax at this stage </li></ul></ul>
  13. 13. ATLS – The Primary Survey <ul><li>CIRCULATION </li></ul><ul><ul><li>Assess by checking pulses, capillary refill, pallor, cyanosis, and level of consciousness </li></ul></ul><ul><ul><li>Sources of ongoing bleeding identified and controlled </li></ul></ul><ul><ul><li>Must expand the definition of “abnormal” hemodynamics (kids, elderly, athletes, etc) </li></ul></ul><ul><ul><li>IV access </li></ul></ul><ul><ul><li>Infusion of saline, blood products if necessary </li></ul></ul>
  14. 14. ATLS – The Primary Survey <ul><li>DISABILITY </li></ul><ul><ul><li>Level of consciousness </li></ul></ul><ul><ul><li>Response to stimuli </li></ul></ul><ul><ul><li>Pupillary responses </li></ul></ul><ul><ul><li>Gross movement and sensation </li></ul></ul><ul><ul><li>GCS or other measure </li></ul></ul>
  15. 15. ATLS – The Primary Survey <ul><li>EXPOSURE and ENVIRONMENTAL CONTROL </li></ul><ul><ul><li>Will miss injuries you don’t see or feel </li></ul></ul><ul><ul><li>Fully expose patient, again assuming injuries are present (spine) </li></ul></ul><ul><ul><li>Prevent hypothermia (room temperature, blankets) </li></ul></ul>
  16. 16. ATLS – The Secondary Survey <ul><li>Primary survey completed and each area is secured </li></ul><ul><li>More thorough history </li></ul><ul><li>Head to toe physical exam </li></ul><ul><li>“Tube or finger in every hole” </li></ul><ul><li>Get off backboard as soon as possible </li></ul>
  17. 17. Secondary Survey Done, Now What? <ul><li>Is there an overt need for surgery? </li></ul><ul><li>Does the patient require further resuscitation or interventions? </li></ul><ul><li>What diagnostics should be done? </li></ul>
  18. 18. Is there a need for surgery? <ul><li>If yes because of abdominal or chest injuries, then trauma surgeon to take to the operating room without further studies, images, etc (ex: evisceration) </li></ul><ul><li>If yes for other injuries, may need further studies to eliminate more threatening injuries (ex: femur fracture) </li></ul><ul><li>In general, the belly takes priority (bleeding) </li></ul>
  19. 19. Does the patient require further resuscitation or interventions? <ul><li>Go back to ABC’s </li></ul><ul><li>Must stop blood loss </li></ul><ul><li>IV fluids for 2-3 liters (20cc/kg in children) </li></ul><ul><li>If further fluids needed, then blood </li></ul><ul><li>Additional adjuncts as necessary </li></ul><ul><ul><li>Additional IV access </li></ul></ul><ul><ul><li>Rapid infusers </li></ul></ul><ul><ul><li>Pressure monitors </li></ul></ul><ul><ul><li>Foley catheter </li></ul></ul>
  20. 20. What diagnostics should be done? <ul><ul><li>X rays </li></ul></ul><ul><ul><ul><li>The Big Three </li></ul></ul></ul><ul><ul><ul><ul><li>C spine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CXR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pelvis </li></ul></ul></ul></ul><ul><ul><ul><li>The Big Five </li></ul></ul></ul><ul><ul><ul><ul><li>The Big Three + Thoracic and Lumbar spine </li></ul></ul></ul></ul><ul><ul><ul><li>Others as needed </li></ul></ul></ul><ul><ul><ul><li>Studies to clinically clear without imaging </li></ul></ul></ul>
  21. 21. What diagnostics should be done <ul><li>Ultrasound (F.A.S.T.) </li></ul><ul><li>Focused Assessment by Sonography for Trauma </li></ul><ul><li>Assesses for free fluid, presumed to be blood </li></ul><ul><li>Positive FAST in unstable patient despite good resuscitation = OR time </li></ul><ul><li>Negative FAST does NOT mean no injury </li></ul>
  22. 22. What diagnostics should be done? <ul><li>CT scans frequently obtained </li></ul><ul><li>The PTPers </li></ul><ul><ul><li>Head </li></ul></ul><ul><ul><li>C spine </li></ul></ul><ul><ul><li>Chest </li></ul></ul><ul><ul><li>Abdomen and pelvis </li></ul></ul><ul><li>Must be stable; last place to try to resuscitate is on the CT scan table in radiology </li></ul>
  23. 23. What diagnostics should be done? <ul><li>Guiac of stool not helpful (gross blood is) </li></ul><ul><li>Urine most of the time for gross hematuria </li></ul><ul><li>Little use for most lab studies </li></ul><ul><li>CRITICAL to have type and cross match </li></ul>
  24. 24. Trauma Patient Disposition <ul><li>Operating room </li></ul><ul><li>Intensive Care Unit </li></ul><ul><li>Floor </li></ul><ul><li>Transfer to higher level of care for injuries beyond resources of institution </li></ul><ul><li>Rehabilitation centers </li></ul><ul><li>Home </li></ul>
  25. 25. Procedural skills <ul><li>Rapid sequence intubation (back up skills) </li></ul><ul><li>Access skills (peripheral and central) </li></ul><ul><li>Chest tube placement </li></ul><ul><li>Foley and nasogastric tube placement </li></ul><ul><li>Pericardiocentesis </li></ul><ul><li>Splinting </li></ul><ul><li>Thoracotomy </li></ul><ul><li>TELEPHONE </li></ul>
  26. 26. Bad trauma care <ul><li>Loud </li></ul><ul><li>Disorganized </li></ul><ul><li>Lacks consistent approach </li></ul><ul><li>Lacks leadership </li></ul><ul><li>Lacks response to changes </li></ul><ul><li>Lacks teamwork </li></ul>
  27. 27. Good trauma care <ul><li>Quiet – leader speaks, others answer report, not everyone trying to scream over each other </li></ul><ul><li>Organized – pre-assigned roles and responsibilities of team members </li></ul>Patient Airway Access Chest tube Central Line if needed Foley Leader
  28. 28. Good trauma care <ul><li>Consistent approach </li></ul><ul><ul><li>Systematic approach to minimize missed injuries </li></ul></ul><ul><ul><li>Prioritize life threatening injuries first </li></ul></ul><ul><ul><li>Reduce the gore factor </li></ul></ul><ul><li>Strong leadership </li></ul><ul><ul><li>Leader’s job to see the big picture, assign details to team members </li></ul></ul><ul><ul><li>Maintain flow of care </li></ul></ul><ul><ul><li>Start over if necessary </li></ul></ul>
  29. 29. Good trauma care <ul><li>Responds to change </li></ul><ul><ul><li>What appears stable one minute may not be so the next </li></ul></ul><ul><ul><li>Can always return to ABC’s </li></ul></ul><ul><li>TEAMWORK </li></ul><ul><ul><li>Only as strong as the weakest link </li></ul></ul><ul><ul><li>Trauma care requires coordination of many services and specialties </li></ul></ul>