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Management of multiple trauma
This document provides guidance on the management of multiple trauma patients. It outlines the ABCDE approach and trauma concept, which emphasizes rapidly assessing and treating the most life-threatening injuries first before making definitive diagnoses. The primary survey involves simultaneously assessing the patient's airway, breathing, circulation, disability, and exposure. Adjuncts like monitoring, catheters and imaging may be used but not delayed transfer. The secondary survey obtains a more detailed history and physical exam. Special considerations for pediatric, geriatric, and pregnant trauma patients are discussed. Key physiological differences and injury patterns are highlighted. The document also reviews complications like tension pneumothorax, cardiac tamponade and hemorrhagic shock and their
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Management of multiple trauma
- 1. MANAGEMENT OF MULTIPLETRAUMA Raywat Chunhasuwankul Division of Trauma Surgery Faculty of Medicine Siriraj Hospital
- 2.
- 3. TRAUMA CONCEPT ● ABCDEapproach to evaluation and treatment ● Treat greatest threat to life first ● Definitive diagnosis not immediately important ● Time is of the essence ● Do no further harm
- 4.
- 5. ● Cap ● Gown ●Gloves ● Mask ● Shoe covers ● Goggles / face shield STANDARD PRECAUTION
- 6. INITIAL ASSESSMENT Primary surveyand resuscitation of vital functions are done simultaneously using a team approach.
- 7. WHAT IS AQUICK, SIMPLE WAY TO ASSESS A PATIENT IN 10 SECONDS? Quick Assessment
- 8. INITIAL ASSESSMENT Airway withc-spine protection Breathing / ventilation / oxygenation Circulation: stop the bleeding! Disability / neurological status Expose / Environment / body temperature
- 9. SPECIAL CONSIDERATIONS ● Traumain the elderly ● Pediatric trauma ● Trauma in pregnancy
- 10. PRIMARY SURVEY Establish patentairway and protect c-spine Occult airway injury Progressive loss of airway Equipment failure Inability to intubate Pitfalls Airway
- 15. AIRWAY MANAGEMENT ● Surgicalairway ● Cricothyroidotomy Needle Definitive Airway Surgical
- 16. PRIMARY SURVEY Assess andensure adequate oxygenation and ventilation ● Respiratory rate ● Chest movement ● Air entry ● Oxygen saturation Breathing
- 17. BREATHING & VENTILATION “Look , feel , palpate and listen “ for Tension pneumothorax Open pneumothorax Severe flail chest Resuscitation Oxygenation : FiO2 > 0.85 ( mask with bag 10 l/min )
- 18. PRIMARY SURVEY Breathing Airway versusventilation problem? latrogenic pneumothorax or tension pneumothorax? Pitfalls
- 19. TENSION PNEUMOTHORAX High pressurepneumothorax causing cardiovascular compromised status * chest injury * dyspnea & tachypnea * distended neck vein * deviated trachea * hypotension * tympanic on percussion * absent breath sound
- 21. OPEN PNEUMOTHORAX Abnormal connectionbetween pleural cavity and atmosphere causing inability to ventilate the lungs Resuscitation : three-sided dressing : ICD : Oxygenation
- 24. SEVERE FLAIL CHEST Segmentalseparation of chest wall causing inability to breath and ventilate the lungs * dyspnea & tachypnea * paradoxical movement * decreased breath sound Resuscitation : intubation & respirator : oxygenation : pain control : breathing exercise
- 26. PRIMARY SURVEY ● Controlhemorrhage ● Restore volume ● Reassess patient Elderly Children Athletes Medications Circulatory Management Pitfalls
- 27. CIRCULATION & HEMORRHAGECONTROL Stop external bleeding !! Signs of shock Grading of shock Source(s) of shock Massive Hemothorax Cardiac tamponade Massive Hemorrhage Resuscitation and Oxygenation
- 28. MASSIVE HEMOTHORAX ● Systemic/ pulmonary vessel disruption ● > 1500 mL blood loss ● Flat vs. distended neck veins ● Shock with no breath sounds and/or percussion dullness
- 29. CARDIAC TAMPONADE Obstructive shock Beck’striad : Hypotension : Distant heart sound : Engorged neck vein Pericardiocentesis Thoracotomy
- 31. HYPOVOLUMIA Class I: <15% ; HR <100 ; normal BP ; : RR ~ 14-20 Class II : 15% - 30% ; HR > 100 : normal BP ; RR ~ 20-30 Class III : 30% - 40% ; HR > 120 : hypotension ; RR 30-40 Class IV : > 40% ; HR > 140 : profound shock ** Blood volume ~ 70 cc / kg body weight
- 32. FLUID RESUSCITATION WarmRLS 2000 ml I.V. in 15 min. ( 20 ml / kg in children ) 1. Rapid response ( 10%-20% ) ( type and crossmatch ) 2. Transient response ( 20%-40% ) ( type-specific ) 3. Unresponsive ( > 40% ) ( group O Rh + )
- 33. Disability ● Baseline neurologicevaluation ● Glasgow Coma Scale score ● Pupillary response Observe for neurologic deterioration PRIMARY SURVEY Caution
- 34. Prevent hypothermia Exposure / Environment Completelyundress the patient Missed injuries Primary Survey Pitfalls Caution
- 35. EXPOSURE & ENVIRONMENTALCONTROL Undress Log-roll Missed areas P.R. Keep warm
- 38. ADJUNCTS TO PRIMARYSURVEY AND RESUSCITATION Monitoring : V/S , EKG , O2 Sat , Urine output Catheters : Foley’s , N-G Investigations : CXR , Pelvis : FAST or DPL Re-evaluation !!
- 41. ADJUNCTS TO PRIMARYSURVEY Diagnostic Tools ● FAST ● DPL
- 42. ● Use timebefore transfer for resuscitation ● Do not delay transfer for diagnostic tests Consider Early Transfer ADJUNCTS TO PRIMARY SURVEY
- 43. WHEN DO ISTART THE SECONDARY SURVEY? After ● Primary survey is completed ● ABCDEs are reassessed ● Vital functions are returning to normal Secondary Survey
- 44. SECONDARY SURVEY History :AMPLE P.E. : Head : Maxillofacial : C-spine and neck : Chest : Abdomen : Pelvis and perineum : Extremities : Neurological function
- 45. SECONDARY SURVEY History Allergies Medications Past illnesses,Personal history, Pregnancy Last meal Events / Environment / Mechanism
- 46. ADJUNCTS TO SECONDARYSURVEY Monitoring Catheters Investigations Re-evaluation !!
- 47.
- 48. PEDIATRIC TRAUMA Most commoncause of death Neurologic and respiratory derangements far exceed hemodynamic derangements.
- 49. ANATOMIC CONSIDERATIONS ANDIMPLICATIONS Prominent occiput in younger child 1” pad under torso for neutral position
- 50. PHYSIOLOGY What physiologic differenceswill impact on my management of pediatric trauma patients? • Age-specific vital signs • Smaller blood volume (70 – 80 mL / kg) • Decreased functional residual capacity • Vigorous compensatory response • Sudden deterioration • Increased vagal tone
- 51. VITAL SIGNS Sign Age Group 0– 2 years 3 – 5 years 6 – 12 years Heart Rate < 150 - 160 < 140 < 100 - 120 Blood Pressure > 60 - 70 > 75 > 80 - 90 Respiratory Rate < 40 - 60 < 35 < 30 Adequate Urine Output 1.5 – 2 cc/kg 1 cc/kg 0.5 – 1 cc/kg
- 52. FLUID MANAGEMENT • Withan isotonic solution at 20 mL / kg • Blood should be given if resuscitation is needed following two boluses of crystalloid • Early use of plasma and platelets • Bleeding of more than half the child’s blood volume in the first four hours should be resuscitated with PRBCs, and early use of plasma and platelets Resuscitation
- 53. PITFALLS • Short trachea:main stem bronchial intubation • ETT depth is 3 x ETT size • Endotracheal tube easily obstructed • Deceptive presentation of hypovolemic shock Pitfalls
- 54. PITFALLS • Gastric dilationcan increase risk of aspiration and cause hypotension • Difficult intravenous access in children < 6 years • Missed hollow viscus injury • Subtle musculoskeletal injury findings Pitfalls
- 55. GERIATRIC TRAUMA Age-relatedchanges in anatomy and physiology Preexisting diseases and co-morbidities Medications Possibility of elder maltreatment
- 56. DECLINE IN FUNCTIONWITH AGE ↓ Brain mass Eye disease ↓ Depth of perception ↓ Discrimination of colors ↓ Pupillary response ↓ Respiratory vital capacity ↓ Renal function 2- to 3-inch loss in height Impaired blood flow to lower leg(s) ↓ Degeneration of the joints Total body water Nerve damage (peripheral neuropathy) Stroke Diminished hearing ↓Sense of smell and taste ↓Saliva production ↓Esophageal activity ↓Cardiac stroke volume and rate Heart disease and high blood pressure Kidney disease ↓Gastric secretions ↓Number of body cells ↓Elasticity of skin, thinning of epidermis 15 – 30% body fat
- 57. UNIQUE AIRWAY PROBLEMS •ABCDE • Priorities are the same • Decreased cardiopulmonary reserve may require early intubation • Factors affecting airway management • Dentition (including dentures) • Nasopharyngeal mucosal fragility • Cervical arthritis
- 58. UNIQUE BREATHING PROBLEMS •Diminished respiratory reserve • Use of supplemental oxygen • COPD • Chest injuries poorly tolerated • “Minor” chest injuries with major effects
- 59. UNIQUE CIRCULATORY PROBLEMS •Decreased cardiovascular function and reserve • Cautious fluid administration • Increased BP, decreased HR, and loss of renal function with age • Anticoagulants and other medications • Pharmacologic effects • Catecholamine effects and dysrhythmias
- 60. UNIQUE NEUROLOGIC PROBLEMS •Acute and chronic subdural hematomas • Altered sensorium secondary to cerebral atrophy, hypoperfusion, and medications • Spinal osteoarthritis, leading to frequent spinal column and cord injuries
- 61. UNIQUE EXPOSURE PROBLEMS •Abnormal thermoregulatory mechanism • Increased sensitivity to hypothermia • Increased risk of infection • Lack of tetanus protection
- 62. UNIQUE MUSCULOSKELETAL PROBLEMS •Most frequent cause of morbidity • Susceptible to certain fractures • Osteoporosis • Preexisting deformities complicate evaluation • Immobility can lead to complications
- 63. DRUGS THAT AFFECTRESUSCITATION • Beta blockers • Antihypertensives • NSAIDS • Anticoagulants • Corticosteroids • Diuretics • Hypoglycemics • Psychotropics
- 64. TRAUMA IN PREGNANCY Isshe pregnant ???????
- 65. CHANGES AND RISKS 12thweek Uterus becomes an abdominal organ 20th week At umbilicus 34 – 36 weeks At costal margin 38 – 40 weeks Head engages pelvis What changes to anatomy and physiology occur with pregnancy, and what are the unique risks?
- 66. PHYSIOLOGIC CHANGES Increased • Minuteventilation • Heart rate and cardiac output • Blood volume • Glomerular filtration rate • Gastric emptying time Decreased • pCO2 • Hematocrit
- 67. PRIMARY SURVEY ANDRISKS With maternal blood loss, fetal distress precedes changes in maternal vital signs. A B D Aspiration risk C Difficult ventilation Failure to recognize blood loss early Eclampsia
- 68. EVALUATION AND MANAGEMENT Howdo I evaluate and treat two patients? • Primary survey / resuscitation of mother • Fetal assessment • Secondary survey of mother • Definitive care of mother and fetus • Rh-negative mothers receive immunoglobulin therapy (unless injury remote from uterus) • Early OB consult