approach to trauma foolad eghbali m.d. vascular surgeon rasool akram hosp

APPROACH TO TRAUMAAPPROACH TO TRAUMA

Foolad Eghbali M.D.

Vascular surgeon

Rasool Akram Hosp.

ObjectivesObjectives

Demonstrate concepts of primary and Demonstrate concepts of primary and secondary patient assessmentsecondary patient assessment

Establish management priorities in trauma Establish management priorities in trauma situationssituations

Initiate primary and secondary management Initiate primary and secondary management as necessary as necessary

Arrange appropriate dispositionArrange appropriate disposition

Trauma Trauma

EpidemiologyEpidemiology– Leading cause of death in the first 4 decadesLeading cause of death in the first 4 decades– 150,000 deaths annually in the US150,000 deaths annually in the US– Permanent disability 3 times the mortality ratePermanent disability 3 times the mortality rate– Trauma related dollar costs exceed $400 billion Trauma related dollar costs exceed $400 billion

annuallyannually

Why ATLS?Why ATLS?

Trimodal death distributionTrimodal death distribution

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

– Second peak minutes to hoursSecond peak minutes to hours

– Third peak days to weeks (sepsis, MSOF)Third peak days to weeks (sepsis, MSOF) ATLS focuses on the second peak…..Deaths from:ATLS focuses on the second peak…..Deaths from:

TBI, Epidurals, Subdurals, IPH…TBI, Epidurals, Subdurals, IPH… Basilar skull fractures, orbital fractures, NEO complex injury…Basilar skull fractures, orbital fractures, NEO complex injury… Penetrating neck injuries…Penetrating neck injuries… Spinal cord syndromes…Spinal cord syndromes… Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal

injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …

Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuriesinjuries

Bladder rupture, renal contusion, renal laceration, urethral injury…Bladder rupture, renal contusion, renal laceration, urethral injury… Pelvic fractures, femur fractures, humerus fracturesPelvic fractures, femur fractures, humerus fractures

Concepts of ATLSConcepts of ATLS

Treat the greatest threat to life firstTreat the greatest threat to life first The lack of a definitive diagnosis should The lack of a definitive diagnosis should

never impede the application of an never impede the application of an indicated treatmentindicated treatment

A detailed history is not essential to begin A detailed history is not essential to begin the evaluationthe evaluation

““ABCDEABCDE” approach ” approach

Initial Assessment and Initial Assessment and ManagementManagement

An effective trauma system needs the An effective trauma system needs the teamwork of EMS, emergency medicine, teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialiststrauma surgery, and surgery subspecialists

Trauma rolesTrauma roles– Trauma captainTrauma captain– InterventionalistsInterventionalists– NursesNurses– RecorderRecorder

Trauma TeamTrauma Team

Primary SurveyPrimary Survey

Patients are assessed and treatment Patients are assessed and treatment priorities established based on their injuries, priorities established based on their injuries, vital signs, and injury mechanismsvital signs, and injury mechanisms

ABCDEs of trauma careABCDEs of trauma care– AA Airway and c-spine protectionAirway and c-spine protection– BB Breathing and ventilationBreathing and ventilation– CC Circulation with hemorrhage controlCirculation with hemorrhage control– DD Disability/Neurologic statusDisability/Neurologic status– EE Exposure/Environmental controlExposure/Environmental control

AirwayAirway

How do we evaluate the airway?How do we evaluate the airway?

A- AirwayA- Airway

Airway should be assessed for patencyAirway should be assessed for patency– Is the patient able to communicate verbally?Is the patient able to communicate verbally?– Inspect for any foreign bodiesInspect for any foreign bodies– Examine for stridor, hoarseness, gurgling, pooled Examine for stridor, hoarseness, gurgling, pooled

secrecretions or blood secrecretions or blood

Assume c-spine injury in patients with Assume c-spine injury in patients with multisystem traumamultisystem trauma– C-spine clearance is both clinical and radiographicC-spine clearance is both clinical and radiographic– C-collar should remain in place until patient can C-collar should remain in place until patient can

cooperate with clinical examcooperate with clinical exam

Airway InterventionsAirway Interventions

Supplemental oxygenSupplemental oxygen Suction Suction Chin lift/jaw thrust Chin lift/jaw thrust Oral/nasal airwaysOral/nasal airways Definitive airwaysDefinitive airways

– RSI for agitated patients with c-spine RSI for agitated patients with c-spine immobilizationimmobilization

– ETI for comatose patients (GCS<8)ETI for comatose patients (GCS<8)

Difficult AirwayDifficult Airway

BreathingBreathing

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

B- BreathingB- Breathing

Airway patency alone does not ensure Airway patency alone does not ensure adequate ventilationadequate ventilation

Inspect, palpate, and auscultate Inspect, palpate, and auscultate – Deviated trachea, crepitus, flail chest, sucking Deviated trachea, crepitus, flail chest, sucking

chest wound, absence of breath soundschest wound, absence of breath sounds CXR to evaluate lung fieldsCXR to evaluate lung fields

Flail ChestFlail Chest

Subcutaneous EmphysemaSubcutaneous Emphysema

Breathing InterventionsBreathing Interventions

Ventilate with 100% oxygenVentilate with 100% oxygen Needle decompression if tension Needle decompression if tension

pneumothorax suspectedpneumothorax suspected Chest tubes for pneumothorax / hemothoraxChest tubes for pneumothorax / hemothorax Occlusive dressing to sucking chest woundOcclusive dressing to sucking chest wound If intubated, evaluate ETT positionIf intubated, evaluate ETT position

Chest Tube for GSWChest Tube for GSW

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

breathing?breathing?

C- CirculationC- Circulation

Hemorrhagic shock should be assumed in Hemorrhagic shock should be assumed in any hypotensive trauma patient any hypotensive trauma patient

Rapid assessment of hemodynamic statusRapid assessment of hemodynamic status– Level of consciousnessLevel of consciousness– Skin colorSkin color– Pulses in four extremitiesPulses in four extremities– Blood pressure and pulse pressureBlood pressure and pulse pressure

Circulation InterventionsCirculation Interventions

Cardiac monitorCardiac monitor Apply pressure to sites of external hemorrhageApply pressure to sites of external hemorrhage Establish IV accessEstablish IV access

– 2 large bore IVs2 large bore IVs– Central lines if indicatedCentral lines if indicated

Cardiac tamponade decompression if indicatedCardiac tamponade decompression if indicated Volume resuscitationVolume resuscitation

– Have blood ready if neededHave blood ready if needed– Level One infusers available Level One infusers available – Foley catheter to monitor resuscitationFoley catheter to monitor resuscitation

D- Disability D- Disability

Abbreviated neurological exam Abbreviated neurological exam – Level of consciousnessLevel of consciousness– Pupil size and reactivityPupil size and reactivity– Motor functionMotor function– GCS GCS

» Utilized to determine severity of injuryUtilized to determine severity of injury

» Guide for urgency of head CT and ICP monitoringGuide for urgency of head CT and ICP monitoring

GCSGCS

EYEEYE VERBALVERBAL MOTORMOTOR

Spontaneous 4Spontaneous 4 Oriented 5Oriented 5 Obeys 6 Obeys 6

Verbal 3Verbal 3 Confused 4Confused 4 Localizes 5Localizes 5

Pain 2Pain 2 Words 3Words 3 Flexion 4Flexion 4

None 1None 1 Sounds 2Sounds 2 Decorticate 3Decorticate 3

None 1None 1 Decerebrate 2Decerebrate 2

None 1None 1

Disability InterventionsDisability Interventions

Spinal cord injurySpinal cord injury– High dose steroids if within 8 hoursHigh dose steroids if within 8 hours

ICP monitor- Neurosurgical consultationICP monitor- Neurosurgical consultation Elevated ICPElevated ICP

– Head of bed elevatedHead of bed elevated– MannitolMannitol– HyperventilationHyperventilation– Emergent decompressionEmergent decompression

E- ExposureE- Exposure

Complete disrobing of patientComplete disrobing of patient Logroll to inspect backLogroll to inspect back Rectal temperatureRectal temperature Warm blankets/external warming device to Warm blankets/external warming device to

prevent hypothermiaprevent hypothermia

Always Inspect the BackAlways Inspect the Back

Lets do a Case!Lets do a Case!Stabilize this patientStabilize this patient

CaseCase

28 yo M involved in a high speed motorcycle accident. He was not 28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.

HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemaskHR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask

Brief initial exam: pt is drowsy but arousable to voice, has large Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle to L ankle

ABCDEABCDE

What are the management priorities at this What are the management priorities at this time?time?

What are this patient’s possible injuries?What are this patient’s possible injuries?

What are the interventions that need to What are the interventions that need to happen now? happen now?

Secondary SurveySecondary Survey

AMPLE historyAMPLE history– Allergies, medications, PMH, last meal, eventsAllergies, medications, PMH, last meal, events

Physical exam from head to toe, including Physical exam from head to toe, including rectal examrectal exam

Frequent reassessment of vitalsFrequent reassessment of vitals Diagnostic studies at this time simultaneouslyDiagnostic studies at this time simultaneously

– X-rays, lab work, CT orders if indicatedX-rays, lab work, CT orders if indicated

– FAST examFAST exam

HEENTHEENT

What are the names of these signs?

Seatbelt SignSeatbelt Sign

Diagnostic AidsDiagnostic Aids

Standard trauma labsStandard trauma labs– CBC, K, Cr, PTT, Utox, EtOH, ABGCBC, K, Cr, PTT, Utox, EtOH, ABG

Standard trauma radiographsStandard trauma radiographs– CXR, pelvis, lateral C-spine (traditionally)CXR, pelvis, lateral C-spine (traditionally)

CT/FAST scansCT/FAST scans Pt must be monitored in radiologyPt must be monitored in radiology Pt should only go to radiology if stablePt should only go to radiology if stable

Simple PneumothoraxSimple Pneumothorax

Tension PneumothoraxTension Pneumothorax

How do you treat this?How do you treat this?

HemothoraxHemothorax Is this patient lying or upright?Is this patient lying or upright?

Widened MediastinumWidened Mediastinum What disease process does this indicate?What disease process does this indicate?

Bilateral Pubic Ramus Fractures and Bilateral Pubic Ramus Fractures and Sacroiliac Joint DisruptionSacroiliac Joint Disruption

What should this injury make you worry about?What should this injury make you worry about?

Epidural HematomaEpidural Hematoma

Subdural Hematoma with SAHSubdural Hematoma with SAH

Abdominal TraumaAbdominal Trauma

Common source of traumatic injuryCommon source of traumatic injury Mechanism is important Mechanism is important

– Bike accident over the handlebars Bike accident over the handlebars – MVC with steering wheel traumaMVC with steering wheel trauma

High suspicion with tachycardia, High suspicion with tachycardia, hypotension, and abdominal tendernesshypotension, and abdominal tenderness

Can be asymptomatic early onCan be asymptomatic early on FAST exam can be early screening tool FAST exam can be early screening tool

Abdominal TraumaAbdominal Trauma

Look for distension, tenderness, seatbelt Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal marks, penetrating trauma, retroperitoneal ecchymosisecchymosis

Be suspicious of free fluid without evidence of Be suspicious of free fluid without evidence of solid organ injurysolid organ injury

Splenic InjurySplenic Injury Most commonly injured organ in blunt traumaMost commonly injured organ in blunt trauma Often associated with other injuriesOften associated with other injuries Left lower rib pain may be indicativeLeft lower rib pain may be indicative Often can be managed non-operativelyOften can be managed non-operatively

Spleen with surroundingblood

Blood from spleenTracking aroundliver

Liver injuryLiver injury Second most common solid organ injurySecond most common solid organ injury Can be difficult to manage surgically Can be difficult to manage surgically Often associated with other abdominal injuriesOften associated with other abdominal injuries

Liver contusions

What’s wrong with this picture?What’s wrong with this picture?

May only see the nasogastric tube appear to be coiled May only see the nasogastric tube appear to be coiled in the lung.in the lung.

Left > right due to liver protection of the diaphragm.Left > right due to liver protection of the diaphragm.

Trace the Diaphragm Outline. Where is theDiaphragm on the left?

Abdominal contentsUp in the chest on theleft

Hollow Viscous InjuryHollow Viscous Injury

Injury can involve stomach, bowel, or mesenteryInjury can involve stomach, bowel, or mesentery Symptoms are a result from a combination of blood loss and Symptoms are a result from a combination of blood loss and

peritoneal contamination peritoneal contamination Small bowel and colon injuries result most often from Small bowel and colon injuries result most often from

penetrating traumapenetrating trauma Deceleration injuries can result in bucket-handle tears of Deceleration injuries can result in bucket-handle tears of

mesenterymesentery Free fluid without solid organ injury is a hollow viscus injury Free fluid without solid organ injury is a hollow viscus injury

until proven otherwiseuntil proven otherwise

Mesenteric and bowel injury from blunt abdominaltrauma. Notice the bowel and mesenteric disruption.

bowel

mesentery

CT Scan in TraumaCT Scan in Trauma

Abdominal CT scan visualizes solid organs Abdominal CT scan visualizes solid organs and vessels welland vessels well

CT does NOT see hollow viscus, CT does NOT see hollow viscus, duodenum, diaphram, or omentum wellduodenum, diaphram, or omentum well

Some recent surgery literature advocates Some recent surgery literature advocates whole body scans on all traumawhole body scans on all trauma– Keep in mind that there is an increase in Keep in mind that there is an increase in

mortality related to cancer from CT scansmortality related to cancer from CT scans

FAST ExamFAST Exam

Focused Abdominal Scanning in TraumaFocused Abdominal Scanning in Trauma 4 views: Cardiac, RUQ, LUQ, suprapubic4 views: Cardiac, RUQ, LUQ, suprapubic Goal: evaluate for free fluidGoal: evaluate for free fluid

See normalLiver and kidney

Free fluid in Morrison's Pouch between liver andkidney

momormomor

Morrison’s pouch

Non-accidental TraumaNon-accidental Trauma

Key is SUSPICION!!!Key is SUSPICION!!! Incongruent stories of mechanismIncongruent stories of mechanism Delay in seeking treatmentDelay in seeking treatment Multiple stages of injuriesMultiple stages of injuries Pattern InjuriesPattern Injuries Multiple hospital visitsMultiple hospital visits Injury mechanism beyond the scope of the age of Injury mechanism beyond the scope of the age of

child (6week old rolled over off the bed)child (6week old rolled over off the bed) Bite marks, submersion injury, cigarette burnsBite marks, submersion injury, cigarette burns

Disposition of Trauma PatientsDisposition of Trauma Patients

Dictated by the patient’s condition and available Dictated by the patient’s condition and available resources i.e. trauma team availableresources i.e. trauma team available– OR, admit, or transferOR, admit, or transfer

Transfers should be coordinated effortsTransfers should be coordinated efforts– Stabilization begun prior to transferStabilization begun prior to transfer– Decompensation should be anticipatedDecompensation should be anticipated

Serial examinationsSerial examinations– CHI with regain of consciousnessCHI with regain of consciousness– Abdominal exams for documented blunt traumaAbdominal exams for documented blunt trauma– Pulmonary contusions with blunt chest traumaPulmonary contusions with blunt chest trauma

SummarySummary

Trauma is best managed by a team Trauma is best managed by a team approach (there’s no “I” in trauma)approach (there’s no “I” in trauma)

A thorough primary and secondary survey A thorough primary and secondary survey is key to identify life threatening injuriesis key to identify life threatening injuries

Once a life threatening injury is discovered, Once a life threatening injury is discovered, intervention should not be delayedintervention should not be delayed

Disposition is determined by the patient’s Disposition is determined by the patient’s condition as well as available resources.condition as well as available resources.

SourcesSources

ATLS Student Course Manuel, 6ATLS Student Course Manuel, 6 thth edition. edition. Rosen’s Emergency Medicine Concepts and Rosen’s Emergency Medicine Concepts and

Clinical Practice, 5Clinical Practice, 5thth edition. edition. Emergency Medicine A Comprehensive Emergency Medicine A Comprehensive

Study Guide, 5Study Guide, 5thth edition. edition.