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Primary Assessment in Trauma and Advances in Management

Dr Joseph Mathew MB BS MS FACEM

Emergency/Trauma Service, The Alfred Hospital

National Trauma Research Institute

Department of Surgery, Central Clinical School,

Monash University

Head, Australia India Trauma Systems

Collaboration

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The Alfred Trauma Service

• 8,000 trauma admissions per year

• 1,400 major trauma patients

ISS>12

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By 2020 Trauma (physical injury) will be No. 3 on the WHO list - Global Burdens of Disease

• 1.25 million died globally from road trauma alone in 2013

7% increase in Indian road deaths in 2016

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Decade of Action for Road Safety 2011-2020

27 June 2017

Goal - to stabilize and reduce the forecast level of

road traffic deaths around the world.

• Pre-hospital care systems development

• Hospital trauma care systems development

• Early rehabilitation and support to injured patients

• Establishment of appropriate road user insurance schemes

• Encourage research and development

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per 100,000 per 100,000 annual

persons vehicles deaths

China 20.5 133.3 275,983 2010

India 19.5 207.5 238,562 2013

Nigeria 33.7 425.2 53,339 2010

Brazil 22.5 67.7 43,869 2010

Indonesia 17.7 58.4 42,434 2010

United States 11.6 13.6 36,166 2012

Australia 5.6 7.6 1299 2012

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Haemorrhage is responsible for over

35% of pre-hospital trauma deaths

and over 40% of trauma deaths

within the first 24 hours.

Worldwide approximately 16,500 people die each day

from injuries, including 6,000 who bleed to death.

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Objectives

Demonstrate concepts of primary and secondary patient assessment

Establish management priorities in trauma situations

Initiate primary and secondary management as necessary

Arrange appropriate disposition

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Why Trauma team training

Trimodal death distribution

• First peak instantly (brain, heart, large vessel injury)

• Second peak minutes to hours

• Third peak days to weeks (sepsis, MSOF)

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Concepts of ATLS

Treat the greatest threat to life first

The lack of a definitive diagnosis should never impede the application of an

indicated treatment

A detailed history is not essential to begin the evaluation

“ABCDE” approach

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Initial Assessment and Management

An effective trauma system needs the teamwork of paramedics, emergency

medicine, trauma surgery, and surgery subspecialists

Trauma roles

Trauma team leader

Interventionalists

Nurses

Scribe

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Trauma Team

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Primary Survey

Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms ABCDEs of trauma care A Airway and c-spine protection

B Breathing and ventilation

C Circulation with hemorrhage control

D Disability/Neurologic status

E Exposure/Environmental control

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Airway

How do we evaluate the

airway?

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A- Airway

Airway should be assessed for patency Is the patient able to communicate verbally?

Inspect for any foreign bodies

Examine for stridor, hoarseness, gurgling, pooled secretions or blood

Assume c-spine injury in patients with multisystem trauma C-spine clearance is both clinical and radiographic

C-collar should remain in place until patient can cooperate with clinical exam

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Airway Interventions

Supplemental oxygen

Suction

Chin lift/jaw thrust

Oral/nasal airways

Definitive airways

RSI for agitated patients with c-spine immobilization

ETT for comatose patients (GCS<8)

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Difficult Airway

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Breathing

What can we look for clinically to assess a patient’s ‘breathing’ status?

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B- Breathing

Airway patency alone does not ensure adequate ventilation

Inspect, palpate, and auscultate

Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds

CXR to evaluate lung fields

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Flail Chest

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Subcutaneous Emphysema

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Breathing Interventions

Ventilate with 100% oxygen

Pleural decompression if tension pneumothorax suspected

Chest tubes for pneumothorax / hemothorax

Occlusive dressing to sucking chest wound

If intubated, evaluate ETT position

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Chest Tube for GSW

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What would we do for this patient who is having difficulty breathing?

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C- Circulation

Hemorrhagic shock should be assumed in any hypotensive trauma patient

Rapid assessment of hemodynamic status

Level of consciousness

Skin color

Pulses in four extremities

Blood pressure and pulse pressure

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Circulation Interventions

Cardiac monitor Apply pressure to sites of external hemorrhage Establish IV access 2 large bore IVs

Central lines if indicated

Cardiac tamponade decompression if indicated Volume resuscitation Have blood ready if needed

Level One infusers available

Foley catheter to monitor resuscitation

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D- Disability

Abbreviated neurological exam

Level of consciousness

Pupil size and reactivity

Motor function

GCS

• Utilized to determine severity of injury

• Guide for urgency of head CT and ICP monitoring

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Disability Interventions

Spinal cord injury

Early diagnosis/treatment /decompression stabilisation

ICP monitor- Neurosurgical consultation

Elevated ICP

Head of bed elevated

Mannitol

Hyperventilation

Emergent decompression

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E- Exposure

Complete disrobing of patient

Logroll to inspect back

Warm blankets/external warming device to prevent hypothermia

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Always Inspect the Back

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Diagnostic Aids

Standard trauma bloods

FBE/UEC/LFT/Coags/Lipase/Crossmatch, EtOH, ABG

Standard trauma radiographs

CXR, pelvis, lateral C-spine (traditionally)

CT/FAST scans

Pt must be monitored in radiology

Pt should only go to radiology if stable

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Role of CPR in trauma?

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World War 1

Basic first aid

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Some blood, some fluid, some surgery

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3L crystalloid, 1L blood

Surgery

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Crystalloid, RBC, Plasma

Damage control resuscitation

Damage control surgery

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What do we know?

#VicTGR Trauma

Bleeding

TBI Chest Abdomen Limbs Pelvis

Die

ATLS

Investigations

Interventions

Medical Surgical

Blunt vs Penetrating

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Trauma systems reduce mortality and morbidity

Cameron PA, Gabbe B, Cooper DJ. A statewide system of trauma

care in Victoria: effect on patient survival. Med J Aust. 2008; 189:

546-50.

= Reduction in mortality over time

Mock CN, Adzotor KE, Conklin E, Denno DM, Jurkovich GJ. Trauma

outcomes in the rural developing world: comparison with an

urban level I trauma center. J Trauma. 1993; 35: 518-23.

= Reduction in mortality compared to no

trauma system

Gabbe BJ, Simpson PM, Sutherland AM, Wolfe R, Fitzgerald MC,

Judson R, Cameron PA. Improved functional outcomes for major

trauma patients in a regionalized, inclusive trauma system. Ann

Surg. 2012; 255(6): 1009-15.

= Reduction in disability

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Trauma management Risk reduction and error avoidance

James K Styner

Nebraska 1976

Journal of Trauma Nursing

June 2006, Volume :13 Number 2,

page 41- 44

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Trauma management Risk reduction and error avoidance

Crew Resource management grew

out of the 1977 Tenerife airport

disaster where two Boeing 747

aircraft collided on the runway

killing 583 people

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Trauma care versus the Airline industry

time

risk

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Pre-Hospital

Care

Physical / OT/ Rehab

Care

Emergency / Critical

Care

Surgery / Operative

Care

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Trauma – a quaternary speciality

Injury evolution, timing of presentation,

timeliness of intervention, time

management & coordination of resources

Pre-Hospital

Care

Emergency / Critical

Care

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Physical / OT/ Rehab

Care

Surgery / Operative

Care

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ATLS

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4 yearly review

Financial gains

Target audience

Dogma/Myth

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Up to Date?

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A single intervention in a mature Trauma System or…?

the TR&R hypothesis

‘..The greatest improvements in resuscitation

will come with improved team communication,

standardization of interventions, improved

physiological monitoring, adherence to

algorithmic treatment pathways and the

associated reduction in errors of omission…’

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#VicTGR Cervical Collar

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ICCs by chest injury

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Thoracic_Trauma

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Initial Supine CXR

• Fails to diagnose haemothorax or

pneumothorax in 32% of thoracic trauma

patients with haemodynamic compromise

• Clinical examination is the key

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Thoracic_Trauma

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A wounded British soldier in Libya lies on a cot in a desert hospital tent on June 18, 1942, shielded from the strong tropical sun. [AP Photo/Weston Haynes]

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Thoracic_Trauma

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World War 2 and tension pneumothorax

H. Fuld, Simple device for

control of tension

pneumothorax. Bri Med J 2

(1944), p. 503.

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Chest decompression

• There is no evidence that needle thoracostomy is a

reliably useful procedure for in-hospital trauma

resuscitation.

• ~1/3 of pleural cavities not reached

• Sub-Q gas under tension causes false positives

• Anatomical landmarks poorly determined1

1 ’The right place in the right space? Awareness of site for needle thoracocentesis. Ferrie E,

Collum N, McGovern S. Emerg Med J 2005;22:788-789.

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Pitfalls of needle thoracocentesis

Extrapleural placement of

catheter-over-needle

thoracocentesis.

The catheter length is

adequate but is extra-pleural.

There is no pneumothorax.

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Pitfalls of needle thoracocentesis

False positive as chest tube decompresses subcutaneous emphysema There is a left pneumothorax. The tube thoracostomy has been placed extrapleural in sub-cutaneous gas - creating a false positive with associated failure to decompress the pleural space.

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Thoracic_Trauma

pneumocath

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Thoracic_Trauma

pneumocath

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Pitfalls of needle thoracocentesis

Incorrect identification of the mid-clavicular line may result in needle decompression that is too medial, with increased risk of vascular and cardiac injury.

The recommended insertion point

(A) in the 2nd intercostal space in the midclavicular line is more lateral to the point commonly identified - which is half-way between the midline and the lateral chest wall (B).

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Binary decision

matrix for chest

decompression

Bilateral pleural

decompression

Decompress pleura

on affected side

Is air entry equal?Inspiratory breath sounds can be heard

clearly and equally in the mid axillary line

bilaterally

Is SpO2 < 90?On FiO2 100% and Endotracheal Tube

(ETT) correct distance from gums post

ETT suction

Is Systolic BP < 100

mmHg?Despite IV filling

Trauma

Arrest?

IPPV?

Await supine chest

X-ray

yes

yes

yesyes

yes

yes

no

no

no

no

mf2007

Insert chest tubewith one way valve

yes

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Positions & complications of ICCs

A Trauma to the intercostal neurovascular bundle.

B Extrapleural placement. C Correct position pleural

space. D Intrafissural placement. E Intrapulmonary placement. F Mediastinal impingement or

penetration. G Trans-diaphragmatic

placement. H Infection.

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ICC insertion

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Thoracic_Trauma

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Chest decompression and trauma resuscitation

Tube thoracostomy is indicated for tension

pneumothorax, for open pneumothorax once

closed, for patients with haemodynamic or

respiratory compromise with coinciding

pneumothorax or haemothorax and for ventilated

patients with pneumothorax.

Digitally decompress the pleural space using a lateral

approach – then insert an ICC

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Thoracic_Trauma

#VicTGR Resuscitative Endovascular Balloon Occlusion of Aorta

(REBOA)

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What do we know about blood and trauma circa 2015

Coagulopathy

Acidosis

Hypothermia

TA

C Platelet defect (TBI)

Consumption (Clot/DIC)

Endothelial injury, Fibrinolysis

DCR Medical - Blood/drug

Surgical - Laparotomy vs conservative

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12 Apr 2016

37 Recommendations

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Systolic blood pressure 80-90 mmHg

(no TBI).

Mean arterial pressure of 80 mmHg

(if TBI present)

“Restrained resuscitation” “Permissive hypotension”

Highlights

Recommendation 13

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At least 1:1:1

Highlights

Recommendation 24

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95.1% of 245 trauma centers - massive transfusion protocols

67.7% tended toward 1:1:1 ratios

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Highlights

Recommendation 25

Tranexamic acid

< 3 hours

1 g load, 1 g over 8 hr

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Developing countries

(245 centres in 40 countries)

Methodology

(selection, randomization)

(no phone!)

100% follow up

Complication screening

CRASH-2 Critics

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Highlights

Recommendation 28

Recommendation 29

Recommendation 31

Low fibrinogen: 15-20 units of Cryoprecipitate

Platelets: >50 or >100 if TBI or on-going bleeding

Anti-Platelets: give platelets

Recommendation 32

Known platelet dysfunction: desmopressin (0.3 mcg/kg)

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Highlights

Recommendation 33

Recommendation 34

Recommendation 35

PCC if Warfarin

FXa inhibitors: TXA and high dose PCC

Thrombin inhibitors: idarucizumab or

TXA and high dose PCC

Recommendation 36

Off label rFVIIa only if desperate

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1:1:1

Cryoglobulin

Calcium

Temperature

Acidosis

“Limit” crystalloids

Stop bleeding

TXA

Reversal agents

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ATLS = Basic

More TXA evidence coming

NOAC situations = new approaches

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What do we know?

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