12 trauma – initial assessement and management


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12 trauma – initial assessement and management

  1. 1. 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
  2. 2. “ Trauma ” - expression comprising a spectrum of severity of mechanical violation of tissues, from a little scratch to a multiply injured patient. - also surgical intervention.
  3. 3. 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
  4. 4. <ul><li>Prehospital – control airway, external hemorrhage, rapid transport </li></ul><ul><li>Primary survey - initial assesement and resuscitation of vital functions, prioritization (based on ABC DEFG) </li></ul>
  5. 5. 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
  6. 6. The primary survey – life threatening conditions are identified and management is begun simultaneously! <ul><li>A - Airway maintenance with cervical spine control </li></ul><ul><li>B - Breathing and ventilation </li></ul><ul><li>C - Circulation with hemorrhage control </li></ul><ul><li>D - Disability : neurological status </li></ul><ul><li>E - Exposure : completely undress the patient </li></ul>
  7. 7. Airway / Breathing All patients should be transported/treated initially with supplemental oxygen. <ul><li>immobilization of the C-spine </li></ul><ul><li>combination of a hard collar and sandbags on opposite sides of the head </li></ul>
  8. 8. Airway / Breathing <ul><li>establishing verbal contact with the patient - clear phonation by the patient establishes that the airway is patent. </li></ul><ul><li>further intervention depends on: </li></ul><ul><li>- neurologic stability </li></ul><ul><li>- adequacy of gas exchange and the potential for airway compromise </li></ul>
  9. 9. Neurological Stability <ul><li>decreased level of consciousness is considered to be intracranial pathology until proven otherwise (drugs, alkohol) </li></ul><ul><li>brief neuro exam (done during the primary survey): </li></ul><ul><li>A - A lert </li></ul><ul><li>V - responds to V erbal stimuli </li></ul><ul><li>P - responds to P ainful stimuli </li></ul><ul><li>U - U nresponsive </li></ul><ul><li>Glasgow Coma Scale (GCS): </li></ul><ul><li>GCS < 8 requires definite airway intervention to prevent aspiration pneumonitis, to insure adequate oxygen delivery and to avoid hypercarbia. </li></ul><ul><li>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. </li></ul>
  10. 10. Adequacy of Gas Exchange <ul><li>airway patency does not insure adequate ventilation </li></ul><ul><li>LOOK </li></ul><ul><li>nature of the injury: maxillofacial trauma/airway burns - potential for airway compromise, obvious airway or chest trauma (sucking chest wounds, flail segments), cyanosis </li></ul><ul><li>tachypnea, use of accessory muscles of respiration or evidence of tracheal shift </li></ul>
  11. 11. Adequacy of Gas Exchange <ul><li>LISTEN </li></ul><ul><li>stridor  upper airway compromise. </li></ul><ul><li>hyperresonance to percussion/lack of air entry  pneumothorax </li></ul><ul><li>dullness to percussion/lack of air entry  hemothorax. </li></ul><ul><li>bowel sounds in the chest  ruptured diaphragm. </li></ul>
  12. 12. Adequacy of Gas Exchange <ul><li>FEEL </li></ul><ul><li>hand over the mouth - feel for air exchange. </li></ul><ul><li>Insertion of a finger - sweep to clear the mouth of any foreign bodies (especially dislodged teeth) and to evaluate for evidence of maxillofacial trauma. </li></ul><ul><li>LAB </li></ul><ul><li>pulse oximetry - haemoglobin saturation; immediate feedback </li></ul><ul><li>pitfalls - motion, peripheral vasoconstriction, carboxy/methaemoglobinemia. </li></ul><ul><li>ABG`s - more complete picture of the patient; feedback on oxygenation, ventilation and tissue perfusion </li></ul><ul><li>pitfalls - a defined waiting period (institution dependent).. </li></ul>
  13. 13. 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 <ul><li>Immediate - apnea </li></ul><ul><li>Emergent - hypoventilation, significant head injury, cyanosis </li></ul><ul><li>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 </li></ul><ul><li>there is often time for a history, appropriate physical exam and cervical radiographs </li></ul>
  14. 14. Securing the Airway <ul><li>Blind nasotracheal intubation vs direct orotracheal intubation </li></ul><ul><li>Determined by the experience of the physician </li></ul><ul><li>Blind nasotracheal intubation: </li></ul><ul><li>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. </li></ul><ul><li>can precipitate epistaxis (may interfere with subsequent alternative attempts at intubation if unsuccessful). </li></ul><ul><li>high incidence of sinusitis if a tube is left in place greater than 72 hours. </li></ul>
  15. 16. Assume the cervical spine to be unstable until proven otherwise <ul><li>up to 50% of patients sustaining C-spine trauma develop neurologic abnormalities (nerve root compression and weakness to quadri- plegia and death). </li></ul><ul><li>10% of patients with C-spine injury are initially neurologically intact, but develop deficits during the course of emergency care </li></ul><ul><li>risks of airway management </li></ul>
  16. 17. C-spine evaluation <ul><li>bone and soft tissue </li></ul><ul><li>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 </li></ul><ul><li>CT </li></ul><ul><li>lateral cervical spine - sensitivity of about 85% </li></ul><ul><li>92% in a three view series </li></ul><ul><li>100% when selective CT scanning is employed </li></ul>
  17. 19. Circulation <ul><li>BP </li></ul><ul><li>HR </li></ul><ul><li>Alghevar scheme - quantification of shock: </li></ul><ul><li>SBP / HR </li></ul><ul><li>>1 no or minor clinical symptoms </li></ul><ul><li><1 major shock </li></ul><ul><li>Pulses </li></ul><ul><li>Indirect signs: UA, skin, tachypnoe, altered consciousness, „empty” periferal veins </li></ul><ul><li>Large bore IV lines </li></ul>
  18. 20. Circulation <ul><li>warmed intravenous infusions </li></ul><ul><li>Control: </li></ul><ul><li>external hemorrhage </li></ul><ul><li>internal hemorrhage: </li></ul><ul><li>MAST (PASG) suit </li></ul><ul><li>Pelvic binders </li></ul><ul><li>Surgery  stabilisation  secondary survey </li></ul>
  19. 21. Initial assessement <ul><li>Chest and abd. PE </li></ul><ul><li>Orthopaedic PE </li></ul><ul><li>Periferial Neurologic PE </li></ul><ul><li>Labs </li></ul><ul><li>X-rays, US, CT </li></ul>
  20. 22. tertiary trauma survey <ul><li>ACS definition - a patient evaluation that identifies and catalogues all injuries after the initial resuscitation and operative intervention </li></ul><ul><li>2 - 50% of combined life threatening and non-life threatening injuries are missed during primary and secondary surveys </li></ul><ul><li>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). </li></ul><ul><li>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 </li></ul>