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Clinical examination in trauma.pptx
- 1. Clinical assessment in orthopaedic trauma Mr Conrad Lee
- 2. Objectives • General trauma assessments – Primary survey – Secondary survey • Specific ortho injuries & assessments – Long bone injuries – Open fractures – Crush injury – Pelvic injuries • Trauma resuscitation – Major haemorrhage – Assessing resusitation • Damage control vs early appropriate care
- 4. • MTC • Trauma units (TWH) • Emergency hospitals
- 5. The trauma team • A&E doctor • A&E nurses • Anaesthetist • Surgeons (General Surg, T&O) • Radiographer • Porters
- 6. The Handover MIST – Mechanism of injury – Injuries – Signs (Vitals) – Treatment given & response
- 8. Primary survey Secondary survey Damage control / Early appropriate care Tertiary survey Identify and treat life threatening injuries Identify non life- threatening injuries Identify initially missed injuries
- 11. Airway and cervical spine control • How to assess the airway? • cervical spine immobilisation (block, collar, tape) • Airway maneuvers • Airway adjuncts
- 12. Breathing • Look, listen, feel • tension pneumothorax • open pneumothorax • flail chest • massive haemothorax
- 15. Circulation with haemorrhage control • Vitals (BP, HR, GCS) • Capillary refill time • Large bore IV access, VGB, bloods • External bleeding – Wounds, open # • Internal bleeding – Intra-abdominal / thoracic – Long bone, Pelvis
- 17. Recognising haemorrhage • Might not be easy in the trauma setting! • Beware of age on physiology • Use all available information – Trends in clinical and physiological parameters – Importance of re-assessment
- 18. Immediate haemorrhage control 1. Realign & splint # 2. Direct pressure 3. Pressure dressing 4. Manual artery pressure 5. Tourniquet 6. Surgical control * Pelvic binder, arterial embolisation Vascular clamping is not advised in ED
- 19. Disability (neurological) • GCS • pupillary size and reaction • limb posture and movements • Blood glucose
- 21. Trauma Imaging • Portable imaging (CXR, pelvic X ray) • FAST scan • CT Traumagram
- 22. Trauma CT • Early CT scan reduces mortality • Time to CT is a quality benchmark – TARN standard (CT within 30 mins of arrival) • Decision dilemmas – Unstable patient without obvious source of bleeding
- 23. Does C-spine need imaging?
- 25. Primary survey Secondary survey Damage control / Early appropriate care Tertiary survey Identify and treat life threatening injuries Identify non life- threatening injuries Identify initially missed injuries
- 26. AMPLE history • Allergies • Medications • Past Medical History • Last meal • Event
- 27. Secondary Survey • Head • Maxillofacial (eyes, ears, nose, mouth) • C spine and neck • Chest • Abdo / pelvis • Perineum / PR / PV • Extremities (upper limb, lower limb) • Neurology
- 28. Specific MSK trauma long bone injuries open fractures pelvic fractures crush injuries
- 29. Major MSK injuries • Life threatening MSK injuries – Major arterial injury / amputation – Multiple long bone / pelvic injuries – Crush injury • Limb threatening MSK injuries – Open fractures /dislocations – Neurological / Vascular injuries – Compartment syndrome
- 30. Life over limb! Don’t get distracted C
- 32. Fracture immobilisation • realign anatomy • prevent excessive motion • Reduce pain • Control blood loss • Reduce soft tissue compromise • Examine & document NV status pre/post reduction
- 33. Open fractures • Assessment – Site and Side – Size of wound – Skin integrity – Active bleeding – Contamination – Neurological status – Vascular status • Immediate management – Antibiotics – Tetaneus prophylaxis – Remove gross contamination – Realign and reduce – Photograph wound – Saline soaked gauze – Splint joint
- 34. • IV abx within 1 hr of injury • Check NV status • Realign and splint • Photograph, wound cover • Open # of long bone, hindfoot, midfoot should be transferred to centre with orthoplastics cover • Debride within 12 – 24 hours
- 35. Pelvic fractures
- 36. • Haemodynamics – Source of haemorrhage (contrast CT) – Transfusion requirement (>0.5unit/hr then likely arterial) • Neurological status – lumbosacral plexus – L5 and S1 nerve roots – femoral nerve (L2-4) – pudendal nerve Assessment of pelvic fracture *avoid full log rolling
- 37. • Predictors of major haemorrhage – HR >130 – Haematocrit <30 – Wide displacement of fractures – Obturator ring fractures – Large symphisis diastasis Assessment of pelvic fracture
- 38. Assessment of pelvic fracture • Other related injuries – GI – viseral injury, rectal tear (open injury) – GU – urethral / bladder injury • Blood at meatus, high riding prostate, perineal bruising • APC type – think bladder • LC type – think urethral – Morel-Lavalle Lesion
- 40. Control of pelvic haemorrhage • Pelvic binder • external fixation • Angiography embolisation • Pelvic packing • Clamp Aorta or Iliac vessels • Acute internal fixation
- 41. Pelvic fracture • Who should get a pelvic binder? – Pelvic / hip pain – Any major lower limb injury – examination suggestive of pelvic fracture – unconsciousness – In hypovolemic shock • Have a high level of clinical suspicion if high energy mech
- 42. Apply over the greater trochanters
- 43. • Pitfalls – applied too high or too low – Over tightening – Not getting a post-binder off x ray – Leaving on for too long • Safe removal of binder – no pelvic / hip pain – Normal pelvic CT – Monitor vitals on removal – Post binder off X-ray
- 44. Crush injuries
- 46. The Lethal Triad • Tissue hypoperfusion • lactic acid acumination • surrogate indicator of adequacy of resuscitation (in combination of other parameters) • Normal levels <1mmol /L • Trend is more important than single value • Don’t treat the numbers, focus on maintaining adequate tissue perfusion and early treatment
- 47. The Lethal Triad • Due to exposure, blood loss and un-warmed fluids • Directly inhibits platelet aggregation and decrease coagulation factor activity • Aim >36℃
- 48. The Lethal Triad Acute coagulopathy of trauma • Triggered by extensive endothelial damage releasing heparin-like molecules • leads to early systemic anticoagulation and hyperfibrinolysis Consumptive coagulopathy • Caused by disseminated intravascular coagulation (DIC) – imbalance of coag vs fibrinolysis Dilutional coagulopathy • Over use of crystalloids
- 49. Damage control resuscitation • Aim to reverse “lethal triad” • Time to haemorrhage control is key to determine mortality • prioritizing haemostasis over maintaining a “normal” perfusing blood pressure
- 50. Damage control resuscitation Damage control resuscitation Patient warming Blood products Tranexamic acid Time limited permissive hypotension Haemorrhage control
- 51. Damage control resuscitation Damage control resuscitation Patient warming Blood products Tranexamic acid Time limited permissive hypotension Haemorrhage control
- 52. Damage control resuscitation Damage control resuscitation Patient warming Blood products Tranexamic acid Time limited permissive hypotension Haemorrhage control • Early activation via “Code Red” trauma calls • Blood and blood products restore volume, oxygen carrying and haemostatic capacity • The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study – early administration of FFP and platelets reduces the requirement for packed red cells and decreases mortality – NICE guideline 1:1:1 strategy • MTW guideline – PACK 1 = 4 units Red cells and 2 units FFP (2:1) – PACK 2 = 6 units Red cells and 6 units FFP (1:1), 1 platelet, 1 cryo • Risk of hypocalcaemia with massive transfusions
- 53. Damage control resuscitation Damage control resuscitation Patient warming Blood products Tranexamic acid Time limited permissive hypotension Haemorrhage control
- 54. Damage control resuscitation Damage control resuscitation Patient warming Blood products Tranexamic acid Time limited permissive hypotension Haemorrhage control • Antifibrinolytic • CRASH-2 study – Giving TXA within 1 hour of injury significantly reduces mortality • Give within 3 hrs (ideally 1 hr) of injury in trauma patients with Systolic <110mm Hg, HR >110 (with haemorrhage) • Give 1g over 10 mins, then 1g over 8 hours
- 55. Damage control resuscitation Damage control resuscitation Patient warming Blood products Tranexamic acid Time limited permissive hypotension Haemorrhage control • Problem with over fluid resuscitation – risks of hydrostatically induced clot disruption – worsening dilutional coagulopathy • aims to limit fluid resuscitation until haemorrhage control achieved (time limited) • A balancing act to keep BP just low enough • Must consider type of trauma and comorbidities – Head injury: preserving cerebral perfusion pressure is most important (systolic drop <90 has 2x increase in mortality)
- 56. Damage control resuscitation Damage control resuscitation Patient warming Blood products Tranexamic acid Time limited permissive hypotension Haemorrhage control • Tourniquet, direct wound pressure • Thoracotomy • Pelvic binder, limb splints • Damage control surgery
- 57. Stability assessment • How stable is the patient? – Haemodynamics (grade of shock, Transfusion requirement, Lactate) – Temperature (Degree of hypothermia) – Coagulation (Platelet count, Fibrinogen) • Point of care viscoelastic coagulation tests – Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) – Other injuries (chest, abdo, pelvis, others) stable borderline unstable extremis
- 58. Stability assessment • How adequate is the resuscitation? • Look at trends – Lactate levels (<2.5 mmol/L) – Urine output (0.5 – 1ml/kg/hr) – Base excess (-2 to +2) • Note: early Hb measurement is not meaningful in predicting significant haemorrhage • Important to re-evaulate stable borderline unstable extremis
- 59. Primary survey Secondary survey Damage control / Early appropriate care Tertiary survey Identify and treat life threatening injuries Identify limb-threatening injuries Identify initially missed injuries
- 60. 3 peak times of death
- 61. Damage control surgery vs early total care • Damage control – Life or limb saving – haemorrhage control, decompression, decontamination, fracture splintage – Preventing further damage, minimal surgical insult – Followed by Pit stop resuscitation in theatre / ITU • Early appropriate care – Definitive fixation within 36 hrs of injury – Only if well resuscitated and stable (lactate <4, pH>7.25, BE > -5.5) – Regular intraoperative reviews on stability – Can revert to DCS if patient become unstable
- 63. Summary • Stick to the ATLS principles • Determine life vs limb threatening injuries • Haemorrhage and coagulopathy are important factors on trauma survival • Damage control resuscitation aims to reverse the lethal triad • Assess trauma patient stability for ETC vs DCO
Editor's Notes
- Taken to MTC if journey is <45 mins
- Open wounds, limb deformity, crush injury, bleeding, tourniquet time,
- Although chest isoneof the twoprimarysurvey X-rays,asignificant proportion of both rib fractures and pneumothoraces (particularly anterior) may be missed. The decision to CT scan earlier in resuscitation means that many trauma teams are foregoing the standard chest X-ray in favour of very early CT, which has a far higher diagnostic accuracy
- Palpable radial pulse, which estimates a systolic blood pressure of about 70 mm Hg
- Neurologic deficit (focal) 2. Ethanol/Intoxication 3. eXtreme distracting injury (painful injury elsewhere that could distract patient from recognizing the pain associated with a neck injury) 4. Unable to provide history (altered mental status)
- Pelvic fractures predominantlycause venous bleeding, but those patients with persistent hypotension have a high incidence of arterial bleeding.
- Severe degloving injury related to high risk of infection and skin necrosis, esp if surgery preformed through area.
- Stabilises, tamponades and reduces fractures (not decreased pelvic volume) 20% of pelvic fractures have arterial haemorrage Especially with posterior ring disruption or those with features of ongoing haemorrhage If pelvic fracture is the only cause of ongoing haemorrhage an unstable patient can be taken to angio after binder and blood
- Branches of internal iliac and sacral venous plexus are often the cause of death in unstable pelvic fractures.
- Often calf or thigh
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- the administration of packed red blood cells (PRBCs), fresh frozen plasma (FFP) and platelets had a survival benefit when compared with the administration of crystalloids and colloids in trauma The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study analyzed 905 trauma patients requiring three or more units of blood production within 24 h of the injury. It found out that an early administration of high dose FFP and platelets in a ratio of 1:1:1 significantly reduced early mortality
- the administration of packed red blood cells (PRBCs), fresh frozen plasma (FFP) and platelets had a survival benefit when compared with the administration of crystalloids and colloids in trauma The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study analyzed 905 trauma patients requiring three or more units of blood production within 24 h of the injury. It found out that an early administration of high dose FFP and platelets in a ratio of 1:1:1 significantly reduced early mortality
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure
- prioritizing hemostasis over maintaining a “normal” perfusing blood pressure