2. Summary
• EMST (Early Management of Severe Trauma)-
Aust
– aka ATLS(Advanced Trauma Life Support)-USA
• Systematic, stepwise approach, identify and
treat injuries before progressing
• Focus on critical, life saving interventions
• Cases
3. Trauma
• Do we see Trauma at Cabrini?
• Effect of centralization of ED Trauma Care
• How should we manage trauma?
4. Trimodal Trauma Mortality
• Reduce Immediate
deaths with
prevention
• Early ED Mx prevents
early deaths-“Golden
Hour”
– ICH
– Haemorrhagic shock
– Haemo/Pneumothor
ax
• Late –
sepsis/DVT/Pneumo
nia
5. EMST algorithm-Primary Survey
• A irway, Cx spine
• B reathing/Ventilation
• C irculation/Hemorrhage control
• D isability-GCS/Pupils
• E xposure of pt/check Temp
6. Primary Survey
• A:
• obstruction – safe maneuvers? –
• only Jaw Thrust,
• CxSpine – ?immobilise/?image
• Trauma = Difficult Airway
• B:
• Tension PTx
• Open PTx
• Flail Chest – Definition, Real problem
• Massive Haemothorax
• C:
• Cardiac Tamponade,
• Hemorrhagic shock, External/Identified vs Occult – abdo vs pelvis
• IV access – Resistance = Length/Radius4
• D –
• expanding intracranial hematoma
7. EMST - Secondary Survey
• Brief Hx
• Head toe exam
• Log Roll
• Spring Pelvis once only
• including Neuro, check ears/spine/PR
• Check for minor injuries eg finger #
• FAST
• Adjuncts:
– “Trauma Series Xrays” Cx spine lateral/CXR/PXR
– Monitoring
– Bloods
– ECG
– IDC
• Common Language – write notes Primary/Secondary survey
8. Cx Spine with Airway
• NEXUS
– Neurologic Deficit
– Midline tenderness
– Altered Conscious State
– Intoxication
– Distracting injury
• Canadian Cx spine rules-
– 1. High risk: >65yo, mechanism (fall>3m/axial load/MVA >100km/hr/bike),
paraesthesia = image
– 2. Low Risk- non tender, sitting/walking, low speed MCA = can asses rotation
– 3. 45° rotation = clear
• If in doubt –immobilize
• Elderly at high risk for Cx spine injuries
– Osteoporosis/osteoarthritis/spinal canal stenosis
9.
10. Case 1: 80 yo F with fall
• Fall in kitchen, L forehead laceration,
confused, L shoulder pain
• On warfarin for AF
• How do you manage this patient?
11. Primary Survey:
• A - clear, Cx spine nontender ? Collar
• B - equal AE bilat O2sats 96%RA RR 16
• C - HR 95 BP 140/80 no external bleeding
• D - GCS 12 (M5 V4 E3) PEARL
• E - T 35.5
• Management?
13. Management
• Prevent Secondary Brain Injury
– Maintain cerebral perfusion (MAP – ICP)
• Head 30° up
• Maintain Normal BP/O2sats/CO2
• NeuroSurg Ref
• Reverse Warfarin (MJA 2013)
Clinical Setting Management – all w/h Warfarin
INR >1.5 + life threatening
bleeding
Vit K 5-10mg, PTX 50 Units/kg, FFP
150-300mls
INR >2.0 clinically significant
bleeding
Vit K 5-10mg, PTX 35-50 Units/kg
INR > 4.5 + bleeding risk high Vit K 1-2mg PO or 0.5-1mg iv
Any INR and minor bleeding risk Just W/H and recheck next day
14. Case 2 - 26 yo M stab to R anterior chest
• Knife insitu
• Vitals T 36 HR 130 BP 100/40 RR 35 O2sats
91% RA
• Approach?
15. Primary Survey
• A patent
• Cx spine?
• B
– Open Pneumothorax/Haemothorax
– Mx ICC at separate site, leave knife insitu
• C –
– Haemorrhagic Shock Mx IV resus – iv access/rapid
infuser, urgent Cardiothoracic surgery
18. Case 3 – High speed MCA
• 56 yo F front seat passenger 100km/hr head
on collision, seat belt worn, airbags deployed,
no cabin intrusion
• On arrival to ED T 36 HR 120 BP 90/40 RR 30
O2sats 98%RA
• Approach?
19. Primary Survey
• A - clear
• Cx Spine - ? Collar
• B – equal AE O2 sats 98%RA
• C – HR 120 BP 80/40
• D – GCS 15 PEARL
• E – T 36
20. Internal Hemorrhage in Trauma
• Adult Blood Volume 5 L
• ICH : 100-300mls (Brain volume 1.2L)
• Femoral Shaft # : 1-1.5L
• Chest/Abdo/Pelvis : Up to entire Blood
Volume
21. Where is the Blood?
• Chest – CXR/ICC
• Abdo – FAST/CT*
• Pelvis - PXR
22. Back to Case 3
• A/Cx Spine/B stable
• C – HR 120 to 140, BP 80/40 to 70/40
• D – GCS 15 to 14, PEARL
• Management?
23. • Refill the tank - IV resus – crystalloid then
blood
• Find and stop the bleeding
26. Case 4 - 18 yo M MCA
• Ejected high speed rollover Ute crash in
Malvern
• Rx in field- O2, Cx collar, 1 x IVC 500mls
N/Saline bolus
• On arrival in ED: T 34.8 HR 65 BP 80/30 RR 25
O2sats 92%RA
27. Management
• A – clear
• Cx spine – Leave Collar on
• B – RR 25 O2sats 90%RA – Rx O2, reduce AE L
side
• C – HR 65 BP 80/30 - 2nd IVC Fluid resus, seek
hemorrhage
• D – GCS 15 but unable to move legs, PEARL
• E – 34 - warm
30. C – Causes of shock?
• HR 60 BP 70/40
• Hemorrhagic
• Neurogenic:
• Spinal injury - loss of sympathetic
outflow, from injuries T6 or higher.
– Hypotension
– Bradycardia
– Peripheral vasodilatation
• Spinal Shock-Not shock but a
– flaccid areflexia after spinal cord injury,
– lasts hours to weeks,
– ‘concussion’ of spinal cord, resolves as
swelling improves
32. Spinal Injury Mx
• PR ? Complete/incomplete
• Image entire spine (10% have 2nd #)
• Immobilization - ?Keep on spinal board
• Treat Neurogenic Shock
• A/B(Diaphragm/intercostals)C/D/E
• Pressure care/IDC
• Steroids – No evidence
• Transfer
33. Case 5 – 8 yo M Bicycle accident
• Hit by car while riding his bike down Wattletree Rd
• Wearing helmet, knocked off bike, MAS scoop and
run
• On arrival Vitals T 36 HR 130(60-130) RR 30 (14-26)
O2sats 93% RA BP 90/50(85/45)
34. Primary Survey
• A - patent
• Cx spine - ? Collar
• B – contusions L lateral chest wall, reduced AE
L side
• C - HR 130 - 150 BP 90/45 – 80/45, Abdo SNT
FAST negative, Deformed swollen R mid-thigh,
• D GCS 15 PEARL
• E T 36
35. Primary Survey Interventions
• A -patent
• Cx Collar
• B – O2
• C – 2 x iv attempts unsuccessful,
– IO inserted IVF bolus 20ml/kg
– Splinted femur #
• D/E stable
36. Progress
• Post initial Mx HR 180 BP
60/30, no AE L chest,
• Possible Dx?
– L Tension Pneumothorax
– L Haemothorax
• Intervention?
– Needle decompression L
chest – hiss of air
– L ICC placed
37. Progress
• Post insertion L ICC
• HR 130 BP 95/50, but O2sats 93 – 95%
• Notice L chest wall paradoxical movement
with respiration:
• www.youtube.com/watch?v=mJ_FYwUqzsM
• What is happening, and what do you need to
do?
38. Flail segment
• Causes paradoxical chest wall movement and
ineffective breathing
• Worsened by underlying pulmonary
contusions
• Mx Intubation/Ventilation – Positive pressure
ventilation
39. Summary:
• EMST structure
• Cx spine assessment with airway
• Seek/Treat life threatening injuries in Primary
Survey – aggressive chest decompression/IVF
resus
• Prompt Warfarin Reversal with hemorrhage
