initial assessment and primary management in trauma

1

INITIAL ASSESSMENT AND PRIMARY MANAGEMENT IN

TRAUMA

DR.ARUN VPG OMFS

2

contents Golden hour ABCDE

Airway managementShock management

AMPLE history

3

4

5

6

TIME AND TIDE WAITS FOR NONE

7

Accurate and systematic approach

25% to 30% of deaths caused by trauma can be prevented

8

GOLDEN HOUR AR Cowley The first hour following a trauma during which

aggressive resuscitation can improve the chances of survival and restore the normal functions.

Early pre-hospital care, early transport, aggressive resuscitation and interventions

9

PLATINUM MINUTES

“THE PLATINUM TEN MINUTES”

10

Three categories severe -5% of all injuries, but more than 50%

of all trauma deaths urgent - 10% to 15% Non urgent – 80 %

11

Assessment principles – American College of Surgeons

1. Preparation and transport2. Primary survey and resuscitation, including monitoring and radiography3. Secondary survey, including special investigations,such as CT scanning or angiography4. reevaluation5. Definitive care

12

PREHOSPITAL PHASE The trauma ambulance and paramedics

Convey the status and number of victims to the hospital

Provide on site care

ventilation and spine stabilization

13

Pneumatic antishock garments and the establishment of intravenous lines

administration of fluid should be reserved for transport times greater than 30 minutes or patients bleeding in excess of 50 mL per minute.

Long bone fracture – traction splint

14

Multiple casualties No. of patients and the severity of their

injuries do not exceed the ability of the facility to provide care.

MASS CASUALTIES The no. of patients and the severity of

their injuries exceed the ability of the facility to provide care.

15

TRIAGE A method of quickly identifying

victims who have immediately life-threatening injuries AND who have the best chance of surviving

16

red - Immediate (critical) yellow - Delayed (urgent) green - Minor (ambulatory) White – those who do not require

treatment Black - Deceased

17

START system

Simple Triage And Rapid Transport respiratory status, perfusion status, and

mental status

"immediate," "delayed," or "minor" category

18

HOSPITAL PHASE

19

Primary Survey A - Airway (with C-spine precautions) B – Breathing and ventilation C – Circulation and hemorrhage

control D – Disability + neurological status E – Exposure + environment

F- Frequent reassessment

20

AIRWAY MAINTENANCE WITH CERVICALSPINE CONTROL

Suspect cervical spine injury in all patients unless other vise proven

High chance in high speed impact, and in patients with altered consciousness

15% patients with supraclavicular injuries and 5 % with head injury

21

Hyperextension or hyperflexion of the patient’s neck should be avoided

Cervical collars or neck support

Neuronal deficit and paralysis

SUSPECT,PROTECT& DETECT

22

Assessment of airway As a general rule – if patient talks properly

airway is patent (A) breathing is adequate (B) sufficient delivery of oxygen through circulation (C) to transport the oxygen to the brain (D)

23

Look, Listen,and Feel Look agitated or obtunded. Agitation suggests hypoxia, and

obtundation suggests hypercarbia. pattern of breathing and use of

accessory muscles of ventilation

24

Listen abnormal sounds. Noisy breathing, Snoring, gurgling -

partial obstruction of the pharynx or larynx.

Hoarseness laryngeal obstruction. abusive patient -hypoxic

25

Feel location of the trachea and determine

whether it is in the midline

foreign objects (e.g.,fractured teeth, fillings, dentures) should be removed.

26

Reasons for airway obstruction Tongue fall aspiration of foreign bodies regurgitation of stomach contents facial, mandibular, tracheal and

laryngeal fractures retropharyngeal hematoma resulting

from cervical spine fractures Traumatic brain injury

27

jaw thrust or chin lift procedure

jaw thrust knuckles of the index fingers are placed behind the angle of

the mandible with thumbs apply pressure on the cheek bones at the same time lifts and displaces the mandible forward.

breathing spontaneously high-flow oxygen via the facemask

not breathing a facemask with a bag-valve device (AMBU bag) and is continuously bagged

28

29

Chin lift

mandible is gently lifted upward using the fingers of one hand placed under the chin. The thumb of the same hand lightly depresses the lower lip to open the mouth

30

suction should be used to clear any secretions

nasogastric tube or soft suction catheter may be used in patients without suspected midface or cranial base - tubes inadvertently passed into the cranial vault.

oral or nasal airway - keep the airway patent nasal airway is better tolerated in an awake

patient.

31

Airway devices Supraglottic Infra glottic

32

oropharyngeal airway OPA should extend from the corner of

the mouth to the angle of the mandible. introduced upside down so that its

concavity is directed upward, until the soft palate

the device is rotated 180 degrees to direct the concavity down and the airway is slipped into place over the tongue

33

Nasopharyngeal airway inserted in the nostril that appears to be

unobstructed and passed gently into the posterior

oropharynx approximate distance between the end of the

patient’s nose and the ear lobe

34

laryngeal mask airway if orotracheal intubation has failed or bag-mask

ventilation is not maintaining sufficient oxygenation

No cuff – chances of gastric distension and aspiration

35

multilumen esophageal airway two tubes, - occlusion of the esophagus

to reduce the risk of aspiration.

does not have a cuffed tube in the trachea -not a definitive airway

36

37

injuries to the larynx and trachea neck swelling, dyspnea, voice alteration, or

frothy hemorrhage

tenderness, and laryngeal or tracheal crepitus

Endotracheal intubation / surgical airway

38

Definitive Airway defined as an inflated cuffed tube in the trachea.

Orotracheal Naso tracheal

Contra indicated - frontal sinus fractures, base of skull fractures, and ant cranial fossa fractures

surgical

39

indications

Oral & Maxillofacial trauma – Fonseca Walker

40

Contraindications ability to maintain a patent airway in a less

invasive manner

41

LEMON

42Oral & Maxillofacial trauma – Fonseca Walker

43Oral & Maxillofacial trauma – Fonseca Walker

44

Rapid-sequence induction with anesthetic agents, neuromuscular blocking drugs, and esophageal occlusion by cricoid pressure

45

7 Ps Preparation Pre oxygenation Pre medication Paralysing Pressure (Cricoid) Placement Position Post intubation care

46

Premedication - LOAD L: Lidocaine O: Opioids (typically fentanyl) A: Atropine D: Defasciculating agent

47

Laryngoscopy

flexion of the neck, to align the pharyngeal and laryngeal axes.

head is extended at the atlanto-occipital joint so that the oral axis is in line with the other two

48

STOP MAID S: Suction T: Tools (e.g., blade, handle.) O: Oxygen P: Positioning M: Monitors (electrocardiogram [ECG], O2,

CO2, blood pressure [BP]) A: Assessment, airway devices, assistant I: IV access D: Drugs

49

50

51

Surgical Airway Needle Cricothyroidotomy Insertion of a wide-bore needle (or IV

cannula) via the crico-thyroid membrane into the airway

Intermittent insufflation (1 second on and 4 seconds off)

Maximum 30-45 minutess

Inadequate ventilation

52

53

54

Surgical Cricothyroidotomy

55

Surgical Cricothyroidotomy 3 cm long skin incision Cut down through the cricothyroid membrane

tracheal dilator is inserted to open up the incision, separating the thyroid and cricoid cartilages and enabling visualization of the trachea

tracheostomy tube is inserted

56

57

tracheostomy laryngotracheal trauma fractures of the thyroid or cricoid

cartilage or hyoid bone Prolonged ventilation upper airway obstruction

58

Thyroid cartilage, cricoid cartilage and tracheal rings are palpated

skin incision should be marked while the patient’s head is in a normal position

Vertical/horizontal skin incision

59

60

BREATHING Assess breathing and ventilation

Ventilation is compromised not only by airway obstruction but also altered ventilatory mechanics or CNS depression.

61

Direct trauma to the chest - # ribs - rapid, shallow breathing and hypoxemia

Intracranial injury - abnormal patterns

spinal cord injury – paralysis of intercostal muscles – unable to meet increased demand

62

life-threatening thoracic injuries A: Airway obstruction T: Tension pneumothorax O: Open pneumothorax M: Massive hemothorax F: Flail chest C: Cardiac tamponade

63

Tension Pneumothorax Air accumulation within the pleural

space Collapse of affected lung Pushing of other contents of

mediastinum to the opposite side Compression of heart and major vessels

and reduced venous return

64

Tension Pneumothorax

65

positive-pressure ventilation worsens tension pneumothorax

Maybe seen as complication of central line insertion in polytrauma

66

C/F chest pain air hunger respiratory distress tachycardia Hypotension tracheal deviation unilateral absence of breath sounds hyper resonant percussion note

67

Collins J, Stern EJ. Chest Radiology: The Essentials. Lippincott Williams & Wilkins; 2012. 360 p.

68

immediate decompression by insertion of a large-bore needle into the second intercostal space

Definitive treatment - insertion of a chest drain into the fifth intercostal space

69

Needle Thoracocentesis Identify the second intercostal space in the

midclavicular line on the affected side Insert large bore catheter (12-14 gauge) over

the top of rib into ICS Puncture the parietal pleura and push 1 cc of air

so as to remove tissue tag at the end of catheter Remove the plunger of syringe attached to

catheter Sudden escape of air happens

70

Chest Drain Insertion Identify the insertion site at the nipple level (fifth intercostal

space) anterior to the midaxillary line on the affected side.

Make a 3-cm transverse incision and bluntly dissect through the subcutaneous tissue just above rib.

Puncture the parietal pleura perform a finger sweep with a gloved finger through the

incision, to avoid injury to other organs and to clear adhesions and clots.

Insert the tube and advance into the pleural space to the desired length

71

72

Massive Hemothorax rapid accumulation of more than 1500 mL of

blood in the chest cavity. Damage to great vessels Dull percussion note Hypovolemia

Drainage followed by thoracotomy

73

Flail Chest result of trauma associated with multiple

rib fractures with a number of ribs being fractured in two places

chest wall loses bony continuity with the rest of the thoracic cage

disruption of the normal chest wall movement

74

injury to the underlying lung parenchyma - pulmonary contusion

paradoxical breathing asymmetrical and uncoordinated movement

of chest wall Crepitus

75

Treatment adequate ventilation Splinting the area with sandbag/ iv fluid

bag administration of humidified oxygen fluid resuscitation Good analgesia

76

Cardiac Tamponade Penetrating/ blunt injury pericardium fills with blood from the

heart, great vessels interfere with cardiac filling

Beck’s triaddistended neck veinsdecline in arterial pressuremuffled heart sounds

77

Kussmaul’s sign (a rise in venous pressure with inspiration when breathing spontaneously)

Aspiration of pericardial blood - pericardiocentesis

78

Puncture the skin 1 to 2 cm inferior and to the left of the xiphochondral junction, at a 45-degree angle to the skin.

Carefully advance the needle upward, aiming toward the tip of the left scapula

Once needle enters the blood-filled pericardial space, withdraw as much blood as possible

79

C: CIRCULATION AND HEMORRHAGE CONTROL Acute blood loss - 0% to 40% of trauma

deaths Leads to Shock Clincal state of cardiovascular

collapse characterized by acute reduction of effective circulating blood volume, inadequate perfusion of cells & tissues.

80

Shock is of 2 types

Primary (initial)Secondary (true) Primary –

transient attack resulting from sudden reduction of venous return

It occurs immediately following trauma, severe pain, emotional over reaction

pale & clammy limbs, weak & rapid pulse& low BP Secondary- due to hemodynamic

derangements with hypoperfusion of cells.

81

PRIMARY (Initial Shock) SECONDARY (True Shock)

HEMATOGENIC/HYPOVOLAEMIC/OLIGAMIC SHOCK

OBSTRUCTIVE SHOCK / TRAUMATIC SHOCK

NEUROGENIC SHOCK CARDIOGENIC SHOCK SEPTIC SHOCK

82

CLINICAL FEATURES

General Clinical Features Of Shock

o Hypotension (Systolic BP<70mmHg)oTachycardia (>100/min)oCold , Clammy SkinoRapid,Shallow RespirationoDrowsiness,Confusion,IrritabilityoOliguria (Urine Output<30ml/hour)oMulti-Organ Failure

83

STAGES IN SHOCK 3 STAGES INITIAL SHOCK PROGRESSIVE SHOCK IRREVERSIBLE SHOCK

84

inadequate tissue perfusion and oxygenation and anaerobic glycolysis results in lactic acid production

coagulation factor and platelet dysfunction combined with coagulation factor consumption a profound coagulopathy

Triad ofMetabolic acidosisHypothermiacoagulopathy

85

stop hemorrhage minimize contamination restore near-normal physiology

86

87

Initial Management of Hemorrhagic Shock Prevention of further blood loss and the earliest restoration of tissue perfusion

External hemorrhage is identified and controlled by direct manual pressure

Occult bleeding -thoracic and abdominal cavities, the pelvis, the retroperitoneal space

pneumatic antishock garment (PASG)

88

Long bone fractures – approx 750 ml blood loss

Femur fracture – approx 1500 ml Pelvic fracture – 2000-2500ml

89

90

Management Peripheral cannulae – large bore

cannulae rate of flow proportional to 4th power of radius

venous cut-down, made 2 cm anterior and superior to the medial malleolus into the greater saphenous vein

central line into the femoral or subclavian vein

91

Crossmatch,full blood count; RFT,LFT and electrolytes; ABG

92

Fluid Replacement restore critical organ perfusion 2 L of RL / 20 ml/kg RL

3 type of responses Responder:vital signs return toward

normal Loss of less than 20% of circulating

volume and are not actively bleeding

93

Transient responder: The vital signs initially improve but then deteriorate. still actively bleeding from an occult site.require transfusion with bloodIdentify source of bleeding

Nonresponders: The vital signs do not improve. blood loss is continuing at a rate at least equal to the

rate of fluid replacement.Central lineImmediate surgery and transfusion

94

Crystalloid, colloid and blood Colloids - larger molecular weight, and hence

expand the intravascular compartment more effectively – 1:1 ratio

improve oxygen transport, myocardial contractility and cardiac output

More risk of anaphylactic complications

Crystalloids are cheap and safe 3-4 times greater volume is required Causes hypothermia and dilution of clotting factors

95

Isotonic saline Corrects both water and electrolyte

imbalance

1. Water and salt depletion as in vomiting, diarrhoea

2. Hypovolemic shock.

CONTRA-INDICATIONS :1. Hypertensive patients2. Patients with edema due to CCF

96

RL Rapidly expands intravascular volume. The most physiological IV fluid. Sodium lactate metabolises to provide bicarbonate

1. severe hypovolemia.2. For replacing fluid in post-op patients3. For diarrhoea induced hypovolemia.4. Diabetic ketoacidosis.

97

CONTRA-INDICATIONS 1. In severe CHF.2. Severe metabolic alkalosis.

98

colloids ADVANTAGES :i. More effective in treating

hypotension than crystalloids.ii. Increase in plasma volume is for a

prolonged period.iii. Improve the hemodynamic status.iv. Higher systemic oxygen delivery.

99

DISADVANTAGES :i. Expensive.ii. Anaphylactic reactions

INDICATIONS :i. To treat sudden hypotension due to

major blood loss, till blood is awaited , or to avoid blood transfusion.

100

Type of fluid Effective plasma volume expansion/100ml

duration

5% albumin 70 – 130 ml 16 hrs

25% albumin 400 – 500 ml 16 hrs

6% hetastarch 100 – 130 ml 24 hrs

10% pentastarch 150 ml 8 hrs

10% dextran 40 100 – 150 ml 6 hrs

6% dextran 70 80 ml 12 hrs

101

Crystalloids – recommended as the initial fluid of choice in resuscitating patients from hemorrhagic shock

Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 - 141

COCHRANE Collaboration in critically ill patients – “ No evidence from RCT that resuscitation with colloids reduces the risk of death, compared with crystalloids in patients with trauma or burns after surgery” Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD 000567, 2004

102

Blood transfusion

103

Hb concentrations below 6 g/dL

no significant differences were found in 30-day mortality rates between those in whom ‘restrictive’ transfusion therapy was used and those in whom the transfusion therapy was applied ‘liberally’ (triggering Hb values between 7-8 g/dL and around 10 g/dL, respectively

Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

104

Blood transfusion

105

MABL = (Starting pt Hct – 25) X Estimated blood vol

Starting pt Hct

MABL= [EBV x (H initial- H final)]/H initial

H final = 30

Estimated blood volume – males 75 ml/kg females 65 ml/kg


106

Incompatible fluids Electrolyte and colloid solutions containing any calcium (e.g. Haemaccel, lactated Ringer’s solution)

5 % dextrose hemolyses RBCs


107

Adverse reactions 1. Immediate

acute haemolytic reactionsfebrile non-haemolytic reactionsAnaphylaxistransfusion-related acute lung injury – TRALI

2. Delayeddelayed haemolytic reactions

3. Immediate non-immunologicalbacterial contaminationcirculatory overloadAir embolism/hypothermia

108

hypotensive resuscitation target mean arterial pressure (MAP) of 50

mm Hg

decrease postoperative coagulopathy and lower the risk of early postoperative death and reduce the amount of blood product transfusions and overall IV fluid administration.

109

D: DISABILITY Level of consciousness

– Best indicator of central perfusion & deterioration of patient status

Pupils GCS

A: Alert V: responds to Vocal stimuli P: responds to Painful stimuli U: Unresponsive to all stimuli

110

13-15 mild head injury8-12 moderate<8 severe

revised in 1976- sixth point - “withdrawal from painful stimulus

Jennett and Teasdale in the early 1974

111

Infants & children

112

AVPU/ACDU

Alert Confused Drowsy Unresponsive

113

MAYO HEAD INJURY CLASSIFICATION SYSTEM FOR TRAUMATIC BRAIN INJURY Category A moderate to severe (definite) TBI:1. Death caused by this TBI2. LOC of 30 minutes or longer3. Post-traumatic anterograde amnesia of 24 hours or longer4. Worst GCS full score in the first 24 hours less than 135. One or more of the following present: EDH, SDH, Contusion Category B1. Loss of consciousness of momentary to less than 30 minutes2. Post-traumatic anterograde amnesia of momentary to less than 24 hours3. Depressed, basilar or linear skull fracture

114

115

Injury Severity Score

Abbreviated injury score

116

Revised Trauma Score (RTS)

RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR

range 0 to 7.8408 RTS < 4 – severe injury

1981 by Champion et al.

117

Mainz score

118

Acute Physiology and Chronic Health Evaluation Score (APACHE) II

clinical decision-making particularly for ICU patients

119

EXPOSURE Complete exposure is a must avoid

hypothermia

warm ambient room, overhead heating, and warmed IV fluids

120

ADJUNCTS TO THE PRIMARY SURVEY assessment of pulse and respiratory

rates; systolic and diastolic blood pressures; pulse oximetry; Temperature ECG monitoring urinary catheter recording of urine

output NG tube aspiration

121

SECONDARY SURVEY complete and comprehensive head to- toe evaluation history and circumstances leading to the injury physical examination of the patient reassessment of all vital signs.

Six potentially lethal injuries that should be evaluated Pulmonary contusion aortic disruption tracheobronchial disruptionesophageal disruption traumatic diaphragmatic hernia myocardial contusion

122

HISTORY A: Allergies M: Medications currently used P: Past illnesses and Pregnancy L: Last meal E: Events and Environment related to

the injury

123

Physical examination Scalp

LacerationsContusionshematomas bone surface irregularities

124

Eyes pupillary response - shape, equality, and light

reaction of the pupils eye injury - blunt or penetrating Direct injury to the optic nerve

125

126

Neck and Cervical Spine

unstable cervical spine injury – unless otherwise proven

Cervical spine tenderness, subcutaneous emphysema

laryngeal fracture

Lateral and AP views -seven cervical vertebrae and the first thoracic vertebra (C1- C7/T1 junction)

127

Chest Pain, dyspnea, and hypoxia pneumothorax and large flail segments Contusions and hematomas occult

pulmonary or cardiac injury Distended neck veins cardiac

tamponade or tension pneumothorax

128

Abdomen Intra abdominal bleed should be

suspected if there are fractures of the ribs that overlie the liver and the spleen

Blunt/penetrating trauma Lap belts Focused assessment with sonography

for trauma - FAST

129

Perineum, Rectum, and Vagina contusions,hematomas, lacerations, and

urethral bleeding.

Must before catheterization

130

Musculoskeletal Assessment Contusions, lacerations, deformities

Peripheral pulses Motor and sensory impairement

Pelvic fractures are suggested by:ecchymosis over the iliac wings, pubis, vagina, or

scrotum. pain on palpation.mobility of the pelvis in response to gentle

anteroposterior pressure in the unconscious patient

131

Spinal Cord Assessment

electrical shock–like pain radiating down the spine or into the limbs nerve root compression

132

133

134

Conclusion With meticulous and rapid assessment

and management it is possible to add years to peoples life

135

References Oral & Maxillofacial Trauma – Fonseca

Walker – 4th edition Maxillofacial trauma and esthetic facial

reconstruction – Wardbooth, Eppley

136

Health & Medicine

initial assessment and primary management in trauma