pace initial assesment trauma viii.ppt - airway management

MULTIPLE TRAUMA

Benjamin Pace, MD FACSDirector of Surgery

Queens Hospital CenterAssociate Professor of SurgeryMount Sinai School of Medicine

Injury or Shock simultaneously to several areas of the body

MULTIPLE TRAUMA

TRAUMA STATS

Leading killer of persons under 44 in the United States– 150,000 deaths annually

44,000 MVC28,000 GSW

Most expensive medical problem in terms of lost wages, initial care, rehabilitation, and lifelong maintenance

TRAUMA

Penetrating– Injury caused by an object entering the body.

Blunt– Injury caused by the collision of an object with

the body in which the object does not enter the body.

Serious/life-threatening problems 10% of all trauma patients.

Must recognize difference between serious and non-serious problems and triage your care

Blunt– Closed injury– Indirect injury to underlying

structures– Transmission of energy into the body

Tearing of muscle, vessels and boneRupture of solid organsOrgan injury

Penetrating– Open injury– Direct injury to underlying structures

Types of Trauma

Trauma Care System

Integration of– EMS– Hospital care

Reduces– Cost– Time to surgery– Mortality

Proper Care– Immediate surgical intervention to repair

hemorrhage sites

Trauma Center DesignationLevel I– Regional Trauma Center– All types of surgical and medical subspecialty– Research and teaching commitment

Level II– Area Trauma Center– Majority of surgical and medical subspecialties available 24/7

Level III– Community Trauma Center– Specialized ED with the majority of surgical and medical

subspecialties available 24/7 (on call) Level IV– Rural community hospitals – No immediate surgical intervention necessary– Stabilize and transfer out

Differences between Level I and II Trauma Centers

Level I:– 1,200 trauma

admissions/year– Pts w/ ISS >15 (240

total or 35 pts/surgeon)– Immediate surgical

capability available– In-house trauma

surgeon– General surgery

residency program or trauma fellowship

– Research

Level II:

– No minimum patient criteria

- Surgical capability available in a “reasonably acceptable time”

– General surgeon present at resuscitation

– Desirable to have residents

– No research minimum

Adult Triage Criteria For TRAUMA CENTER

>20’ fallPedestrian/bicyclist versus auto– Thrown or run over

by vehicle– Struck by vehicle

traveling >5 mphMotorcycle impact >20 mphEjected from a vehicle

Severe vehicle impact– >40 mph– >12” intrusion– >20” vehicle

deformityRollover with signs of serious impactDeath of another occupantExtrication time >20 minutes

Child Triage Criteria For TRAUMA CENTER

>10’ fall

Bicycle collision

Vehicle collision at medium speedAny vehicle collision involving an unrestrained infant or child

Triage Criteria for Trauma CenterPhysical Findings at Scene of

Trauma

Flail chestPelvic fractureLimb paralysisBurn >15% BSABurn to face or airwayPenetrating trunk, neck, or head trauma>2 proximal long bone fracture

Acknowlegements

W.F. Holdefer, M.D. – UAB Department of Emergency Medicine

Illinois EMSC Sharla Owens, M.D.Karim Brohi BSc FRCS FRCA

The Royal London Hospital

Blunt Trauma

Most common cause of trauma death and disabilityEnergy exchange between an object and the human body, without intrusion through the skin

Blunt Trauma

Kinetics of Blunt Trauma

Kinetic Energy– Energy in Motion

– Double Weight = Double Energy– Double Speed = Quadruple Energy

–SPEED iS THE GREATEST DETERMINANT Of INJURY

)()( 2speedVelocityweightMassKE

– Emphasizes the importance of rate at which an object changes speed (acceleration or deceleration)

Kinetics of Blunt Trauma

onAcceleratiMassForce

ACCELERATION AND DECELERATION FORCES

Whiplash injuryAortic tearHepatic artery tear

44,000 people die each year on US highways!

Blunt Trauma: Automobile Crashes

Inertia and Motor Vehicle Crashes

Restraints– Seatbelts

Occupant slows with the vehicleShoulder and Lap belts MUST be worn together

– Injuries if worn separately

– Airbags (SRS)Reduce blunt chest traumaCause: Hand, Forearm, & Facial InjurySide Airbags

– Child Safety SeatsInfants and Small Children: Rear facingOlder Child: Forward facing

Intoxication

–Fatal Accidents: >50% involved ALCOHOL

Vehicular Mortality– Head: 48%– Internal (Torso): 37%– Spinal & Chest fracture: 8%– Extremity fracture: 2%– All Other: 5%

Falls– Stairs, Force, Surface– Landing Area

Surface TypeBody Part

– Height of Fall– Elderly

Other Types of Blunt Trauma

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Penetrating Trauma

38,000 Deaths in US annually due to shootings.Mechanisms of penetrating trauma– Knives, Gun Shots, Arrows, Nails, etc.

Important to understand the principles of energy exchange to increase the Index of Suspicion associated with the method of injury

Introduction to Penetrating Trauma

Recall Kinetic Energy Equation

– Greater the mass the greater the energyDouble mass = double KE

– Greater the speed the greater the energyDouble speed = 4x increase KE

Physics of Penetrating Trauma

)()( 2speedVelocityweightMassKE

(continued)

Small & Fast bullet can cause greater damage than large and slow.

Low Energy/Low Velocity– Knives and arrows

Medium Energy/Medium Velocity Weapons– Handguns, shotguns, low-powered rifles– 250-400 mps

High Energy/High Velocity– Assault Rifles– 600-1,000 mps

(continued)

As bullet strikes object, it slows and energy is transferred to object.– Law of Conservation of Energy

Damage Pathway

Direct Injury– Damage done as the projectile strikes tissue

Pressure Shock Wave– Human tissue is semi-fluid– Solid and dense organs are damaged greatly

Temporary Cavity– Due to cavitation

Permanent Cavity– Due to seriously damaged tissue

Zone of Injury– Area that extends beyond the area of permanent

injury

Ballistics Cavitation

Density of tissue affects the efficiency of energy transmission

Connective Tissue– Absorbs energy and limits tissue damage

Organs– Solid Organs

Dense and low resilience – lot’s of damage– Hollow Organs

Fluid filled: transmit energy = increased damageAir filled: absorbs energy = less damage

Specific Tissue & Organ Injuries

Lungs– Air in lung absorbs energy– Parenchyma is compressed and

rebounds– Pneumothorax or hemothorax can

resultBone– Resists displacement until it shatters

Specific Tissue & Organ Injuries

General Body Regions

Extremities– Injury limited to resiliency of tissue– 60-80% of injuries with <10% mortality

Abdomen (Includes Pelvis)– Highly susceptible to injury and hemorrhage– Bowel perforation: peritoneal irritation in 12-24 hrs

Thorax– Rib impact results in explosive energy– Heart & great vessels may have extensive damage

due to lack of fluid compression– Any large chest wound compromises breathing

General Body Regions

Neck– May damage Trachea and Blood

vessels– Neurological problems– Sucking neck wound

Head– Cavitational energy trapped inside

skull– Serious bleeding and lethal

Wound Characteristics

Entrance Wounds– Size of bullet

Exit Wounds– Appears to be “Blown” outward

Pressure wave

Impaled Objects– Low-energy– Dangerous to remove– DO NOT REMOVE UNLESS YOU ARE A

TRAUMA SURGEON AND IN THE OPERATING ROOM

Special Concerns with Penetrating Trauma

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• Establish leadership - Involved leader- Remote leader

Anesthesiologist

CRNA1o Nurse

Line person

Chest tube person

Bystander

CPR person

Bystander

Team Leader

Examining person 2o Nurse

BystanderTray

Line person

Chest tube person Bystander

Coffee maker

Trauma:Initial Management Priorities

• Organize team - Number / type of personnel - Assess competency levels

- Assign tasks

Pre-arrival

Arrival

Resource Identification and Allocation

1oSurvey 2oSurvey

Basic Studies Specialty Studies

Reevaluation

Resuscitation

1o Therapy Definitive Therapy

Trauma:

Initial Management Priorities

1 Hour

• Personnel - Primary team- Specialty teams

• Facilities - Admitting area - 1o & 2o treatment areas

• Materials - “tubes”, “lines”, “trays”- Familiarity w. equipment

Assess:

1 hour

Pre-arrival 1o Survey

Resuscitation

2o Survey

Reevaluation

Pre-arrival

• Can the Institution handle this patient?• … at this time?• Are there alternative facilities nearby?

Assess:

Team leadership / organization

1o Survey

Resuscitation

2o Survey

Reevaluation

1 hour

Pre-arrival

Airway:

- assess

- establish

- maintain

Breathing:

- assess

- support

Circulation:

- assess- access- stop hemorrhage

- resuscitate

Assess:

• Immediate risk for loosing limb or life?• Potential for (rapid) deterioration?

Primary Survey

Should not take longer then 5 minutes

Vital monitoring equipment

NBP, EKG, SaO2

Focused examHead / neck /

CNSChest / abdomenPulses / bleeding

Complete exposure

Venous accesslarge bore peripheral

vs. “cordis”

Supplemental O2

Airway & breathing support

Emergent primary therapy

tube thoracostomylateral

thoracotomytemp. hemostasis

Primary Survey

Resuscitation

2o Survey

Reevaluation

1 hour• Same examiner - Or formal sign out

• All systems in question

• Frequency depends on - Severity of injury- Potential for deterioration- Patient location

• Follow up studies - Labs / radiographic / other

• Goals - Stabilization- Identify 2o injuries- Prevent deterioration

ReevaluationTrauma:Initial Management Priorities

Resuscitation

2o Survey

Reevaluation

1 hour

Resuscitation

Ongoing process of assessing and restoring ABC(D)’s

• Volume Restoration /- Access / equipment / type of IVF Hemorrhage control - Temporary vs. definitive

- Damage control operations- Angiography- Definitive operative control

• Control of related - Hypothermia pathophysiology - Hypoxia/Hypercarbia/Acidosis

- Coagulopathy- Central compartment syndromes

Resuscitation

• Compartment syndromes -Abdomen - edema, bleeding -- Thorax - pericardial tamponade - tension pneumothorax - reverse I:E ventilation- Cranium - edema, bleeding

• Locale - Admitting area- Operating room- ICU- Consider - Location (travel), - Equipment - Staffing,

Access ent

• Monitoring progress - Clinical parameters, NBP, U/O- CVP, PA catheter, IBP- Labs

Resuscitation

2o Survey

Reevaluation

1 hour

• Angiography - CNS, neck- Arch / descending aorta- Visceral (+/- embolization)- Extremities

• MRI - CNS, spine, extremities

Imaging Studies

• F.A.S.T.

• Plain films - Lateral C-spine (3 view, 5 view)- AP CXR (flat, upright)- AP Pelvis- AP and lateral T & L-spine - Extremity

films and special views

• CT - Head / face / base of skull- Chest (IV contrast)- Abdomen / pelvis (type of contrast)- Spine

Resuscitation

2o Survey

Reevaluation

1 hour

Primary Therapy

• A & B Relief of hemo/pneumothorax, - Pericardial tamponade

• C (Temporary) hemorrhage control- Volume resuscitation

• D ICP management- Decompression/hemorrhage control

- Steroids in spinal cord injury

• Orthopedics - (Splint) stabilization of fractures

• Primary wound care

• Analgesia

Goals: Stabilization (Rapid) Prevention of 2o injuryDefinitive APPROPRIATE Therapy

A.S.A.P.

Primary Therapy

Summary

• Sytematic approach to 1o, 2o Survey and 1o therapyABC’s, prioritize injuries, therapy and patient“Golden” 1 hour

• Continuum of CareReevaluation, coordinated care planPrevention of 20 Injury

• Management begins before patient arrivalResources: Personnel, materials, FacilityLeadership, team organization

Resuscitation

2o Survey

Reevaluation

1 hour

Secondary Survey

• Systematic approach - Head to toe / all systems- One examiner- Avoid patient distraction (examine or talk)

• Maximize efficiency - Documentation (examine and talk)

- Prioritize injuries / patient

• Initiate care plan - Studies- Consultations- Disposition

• Continued ABC support

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Initial Assessment of the Trauma Patient

Advanced Trauma Life Support Guidelines (ATLS)Systematic approach necessary to rapidly identify injuries and stabilize the patientThis approach is divided into:1. Primary Survey2. Resuscitative Phase3. Secondary Survey4. Definitive Care Phase

PRIMARY SURVEY

The ABCDEs of trauma care sequentially

identify life-threatening conditions A. Airway maintenance with cervical spine protection B. Breathing and ventilation C. Circulation with hemorrhage control D. Disability: Neurologic status E. Exposure: Completely undress but prevent hypothermia Life-threatening conditions are identified and

simultaneous management is instituted

Airway Management in the Trauma Patient

Objectives of Airway Management & Ventilation

Primary Objective:– Provide unobstructed passage for air

movement– Ensure optimal ventilation– Ensure optimal respiration

Objectives of Airway Management & Ventilation

Why is this so important in the trauma patient?– Prevention of Secondary Injury

Shock & Anaerobic MetabolismSpinal Cord InjuryBrain Injury

Airway

Patency is primaryObstruction may be due to:– Tongue– Swelling– Foreign Body– Blood and secretions

Airway

Evaluation begins by asking the patient a question such as 'How are you?‘ A response given in a normal voice indicates that the airway is not in immediate jeopardy; a breathless, hoarse response or no response at all indicates that the airway may be compromised.

Airway

Mechanical removal of debris, chin lift and/or jaw thrust maneuver, are useful in clearing the airway in less injured patientsIf there is any question of an adequate airway, severe head injury, profound shock, severe facial trauma, voice changes, then definitive airway control is necessary

PROTECT the CERVICAL SPINE !

Airway Maintenance with Cervical Spine Protection

Subluxation C-5 on C-6

Airway & Ventilation Methods

Supplemental Oxygen– increased FiO2 increases available

oxygen– objective is to maximize hemoglobin

saturation

Impending or Potential Compromise of the Airway

Inhalation injury Facial fractures Retropharyngeal hematoma Sustained seizure activity Closed head injury (GCS < 8) Inability to maintain SaO2 by

face mask oxygen

The decision to provide a definitive airway:

-Apnea -Inability to maintain a patent airway -Protection of the airway from aspiration

Airway Maneuvers– Chin lift– Jaw thrust(Neck extension iscontraindicated)

Airway Devices– Oropharyngeal airway– Nasopharyngeal airway

Assessment & Recognition of Airway & Ventilatory Compromise

Visual Assessment– Rise & Fall of chest

Paradoxical motion– Audible gasping, stridor, or wheezes– Obvious pulmonary edema

Visual Assessment– Skin color– Flaring of nares– Pursed lips– Retractions– Accessory Muscle Use– Altered Mental Status– Inadequate Rate or depth of ventilations

Orotracheal Intubation- preferred in almost all situations– Indications

present or impending respiratory failureapneaunable to protect own airway (GCS <8)

– Advantagessecures airwayroute for a few medicationsoptimizes ventilation and oxygenation

Orotracheal Intubation

Needle Cricothyrotomy & Transtracheal Jet Ventilation– Indications

Same as surgical cricothyrotomy along withContraindication for surgical cricothyrotomy

– Contraindicationscaution with tracheal transection

Airway & Ventilation Methods:

Jet Ventilation– Usually requires

high-pressure equipment

– Ventilate 1 sec then allow 3-5 sec pause

– Hypercarbia likely– Temporary: 20-30

mins– High risk for

barotrauma

Pharmacologic Assisted Intubation– Sedation

Used for– induction– anxious or agitated patient

Contraindications– hypotension (e.g. hypovolemia 2° to trauma)

– Neuromuscular Blockade Induces temporary skeletal muscle paralysisIndications

– When Intubation is required in a patient whois awake,has a gag reflex, oris agitated or comb

Surgical Cricothyrotomy – Indications

absolute need for a definitive airway AND– unable to perform ETT due for structural or

anatomic reasons, AND– risk of not intubating is > than surgical airway

riskabsolute need for a definitive airway AND

– unable to clear an upper airway obstruction, AND– multiple unsuccessful attempts at ETT, AND– other methods of ventilation do not allow for

effective ventilation and respiration

Surgical Cricothyroidotomy

Breathing and Ventilation

Airway patency does not assure adequate ventilation.

Ventilation requires adequate function of lungs, chest wall, and diaphragm Exposure, assess chest wall to detect injuries that may compromise ventilation.

Auscultation for presence and quality of breath sounds Percussion may demonstrate the presence of air (pneumothorax) or blood (hemothorax)

Injuries That Acutely Impair Ventilation:

Open/Tension Pneumothorax

Flail Chest/Pulmonary Contusion

Massive Hemothorax

Contusion– Most Common result of blunt injury– Signs & Symptoms

ErythemaEcchymosisDYSPNEAPAIN on breathingLimited breath soundsHYPOVENTILATION

– BIGGEST CONCERN = “HURTS TO BREATHE”

CrepitusParadoxical chest wall motion

Pathophysiology of Thoracic Trauma Chest Wall Injuries

Rib Fractures– >50% of significant chest trauma cases due to blunt

trauma– Compressional forces flex and fracture ribs at

weakest points– Ribs 1-3 requires great force to fracture

Possible underlying lung injury– Ribs 4-9 are most commonly fractured– Ribs 9-12 less likely to be fractured

Transmit energy of trauma to internal organsIf fractured, suspect liver and spleen injury

– Hypoventilation is COMMON due to PAIN

Pathophysiology of Thoracic Trauma Chest

Wall Injuries

Sternal Fracture & Dislocation– Associated with severe blunt anterior trauma– Typical MOI

Direct Blow (i.e. Steering wheel)– Incidence: 5-8%– Mortality: 25-45%

Myocardial contusionPericardial tamponadeCardiac rupturePulmonary contusion

– Dislocation uncommon but same MOI as fractureTracheal depression if posterior

Wall Injuries

Flail Chest– Segment of the chest that becomes free to move with the

pressure changes of respiration– Three or more adjacent rib fracture in two or more places– Serious chest wall injury with underlying pulmonary injury

Reduces volume of respirationAdds to increased mortality

– Paradoxical flail segment movement– Positive pressure ventilation can restore tidal volume

Wall Injuries

Simple Pneumothorax– AKA: Closed Pneumothorax

Progresses into Tension Pneumothorax– Occurs when lung tissue is disrupted and air leaks into the

pleural space– Progressive Pathology

Air accumulates in pleural spaceLung collapsesAlveoli collapse (atelectasis)Reduced oxygen and carbon dioxide exchange

Ventilation/Perfusion Mismatch– Increased ventilation but no alveolar perfusion– Reduced respiratory efficiency results in HYPOXIA

Pathophysiology of Thoracic Trauma

Pulmonary Injuries

Open Pneumothorax– Free passage of air between atmosphere and pleural

space– Air replaces lung tissue– Mediastinum shifts to uninjured side– Air will be drawn through wound if wound is

2/3 diameter of the trachea or larger– Signs & Symptoms

Penetrating chest traumaSucking chest woundFrothy blood at wound siteSevere DyspneaHypovolemia

Pulmonary Injuries

Open Pneumothorax

Treatment:Occlusive dressing, sealed on

three sides, creating a one-way valve Chest tube

Tension Pneumothorax– Buildup of air under pressure in the thorax.– Excessive pressure reduces effectiveness of

respiration– Air is unable to escape from inside the pleural space– Progression of Simple or Open Pneumothorax

Pulmonary Injuries

Dyspnea– Tachypnea at first

Progressive ventilation/perfusion mismatch– Atelectasis on uninjured side

HypoxemiaHyperinflation of injured side of chestHyperresonance of injured side of chest

Pathophysiology of Thoracic Trauma Pulmonary Injuries

Tension Pneumothorax Signs & Symptoms

Diminished then absent breath sounds on injured side

Cyanosis

Diaphoresis

Hypotension

Hypovolemia

Tracheal Shifting LATE SIGN

Diminished then absent breath sounds on injured side

Cyanosis

Diaphoresis

Hypotension

Hypovolemia

Tracheal Shifting LATE SIGN

Hemothorax– Accumulation of blood in the pleural space– Serious hemorrhage may accumulate 1,500 mL of

bloodMortality rate up to 75%Each side of thorax may hold up to 3,000 mL

– Blood loss in thorax causes a decrease in tidal volume

Ventilation/Perfusion Mismatch & Shock– Typically accompanies pneumothorax

Hemopneumothorax

Pulmonary Injuries

Blunt or penetrating chest traumaShock– Dyspnea– Tachycardia– Tachypnea– Diaphoresis– Hypotension

Dull to percussion over injured side

Pathophysiology of Thoracic Trauma Pulmonary Injuries

Hemothorax Signs & Symptoms

Pulmonary Contusion– Soft tissue contusion of the lung– 30-75% of patients with significant blunt chest

trauma– Frequently associated with rib fracture– Typical Mechanism of Injury

Deceleration– Chest impact on steering wheel

Bullet Cavitation– High velocity ammunition

– Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar tissue

Progressive deterioration of ventilatory status– Hemoptysis typically present

Pulmonary Injuries

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Circulation with Hemorrhage Control

Blood Volume and Cardiac Output

Hemorrhage is the predominant cause of post-injury deaths Hypotension is due to bleeding with loss of blood volume until proven otherwise

Observations that provide clinical information as to the adequacy of circulation:

-Level of consciousness -Skin color -Pulse

Level of consciousness

Impaired cerebral perfusion =

altered level of consciousness

Skin Color

Pink skin, face and extremities:rarely critically hypovolemia

Ashen, gray skin: an ominous sign of hypovolemia

Pulses

Carotid, radial, femoral pulses assessed for quality, rate, and regularity

Full, slow, and regular pulses = relative normovolemia

Rapid thready pulse, usually a sign of hypovolemia

Irregular pulse may indicate potential cardiac dysfunction.

Bleeding

External blood loss is managed by direct pressure

SITES of BLOOD LOSS in TRAUMA

OBVIOUS

Scalp lacerations Facial injuries Open Fractures

HIDDEN Intra/retroperitoneal Hemothorax Pelvic hematoma Long-bone fracture sites Aortic disruption

Elderly patients Limited ability to increase their heart

rate in response to blood loss, obscuring one of the earliest signs of volume depletion, tachycardia

Blood pressure has little correlation with cardiac output in the older patients.

Children

Abundant physiologic reserve Often demonstrate few signs of

hypovolemia even after severe volume depletion When deterioration occurs, it is

precipitous and catastrophic.

Other Causes of Decreased Circulation that need to be

considered vs. Hypovolemia in the Trauma Patient

Myocardial Contusion– Occurs in 76% of patients with severe blunt chest trauma– Right Atrium and Ventricle is commonly injured– Injury may reduce strength of cardiac contractions

Reduced cardiac output

– Electrical Disturbances due to irritability of damaged myocardial cells

– Progressive ProblemsHematoma

Hemoperitoneum

Myocardial necrosis

Dysrhythmias

CHF & or Cardiogenic shock

Pathophysiology of Thoracic Trauma Cardiovascular

Injuries

Bruising of chest wallTachycardia and/or irregular rhythmRetrosternal pain similar to MIAssociated injuries– Rib/Sternal fractures

Chest pain unrelieved by oxygen– May be relieved with rest– THIS IS TRAUMA-RELATED PAIN

Similar signs and symptoms of medical chest pain

Myocardial Contusion Signs & Symptoms

Pericardial Tamponade– Restriction to cardiac filling caused by blood or other

fluid within the pericardium– Occurs in <2% of all serious chest trauma

However, very high mortality– Results from tear in the coronary artery or

penetration of myocardiumBlood seeps into pericardium and is unable to escape200-300 ml of blood can restrict effectiveness of cardiac contractions

– Removing as little as 20 ml can provide relief

Thoracic Trauma Cardiovascular Injuries

Cardiac Tamponade

Beck’s triad:- Hypotension- Jugular venous distention-Muffled heart sounds

Cardiac Tamponade

Technique for pericardiocentesis

Disability

The Glasgow Coma Scale (GCS)

A more precise evaluation and predictor of patient outcome

A decreased level of consciousness may result from either:

1. Decrease in cerebral perfusion and/or oxygenation

2. Direct cerebral injury

Exposure/Environmental Control

-Completely undress to facilitate thorough examination and assessment. -Cover with warm blankets or use an external warming device to prevent

hypothermia -Use warmed intravenous fluids -Maintain a warm environment (room temperature)

ADJUNCTS to PRIMARY SURVEY and RESUSCITATION

Dysrhythmias, ST changes - myocardial contusion Tachycardia - hypovolemia Bradycardia – end-stage hypoxia or

hypovolemia

Catheters

Foley Catheter: No transurethral catheter until genitalia, perineum, and

rectal exam

Urethral injury indicators - meatal blood,shaft hematoma, perineal/scrotal ecchymosis, non-palpable prostate, pelvic fracture

Nasogastric tube:

Reduces the risk, but does not always prevent aspiration

MONITORING ADJUNCTS

Pulse Oximetry- indicator of O2 saturation,not partial pressure

Carbon Dioxide Detector- confirms ETT islocated somewhere in the airwayDoes not confirm proper placement of the tube

X-RAYS and Diagnostic Studies

X-rays should not delay patient resuscitation

The AP chest film and an AP pelvis may provide information which may guide resuscitation efforts

A lateral cervical spine x-ray that demonstrates an injury is an important finding

A negative or inadequate film does not exclude cervical spine injury.

Tear drop fracture anterior C-4

Diagnostic peritoneal lavage (DPL) FAST Abdominal Ultrasonography and CT may be useful for the evaluation of intra-

abdominal and retroperitoneal bleeding Early identification of the source of hidden

blood loss may indicate the need for emergent operative intervention

ADJUVANT TESTS IN TRAUMA DIAGNOSIS

Detailed

Secondary Survey

(after stabilization)

SECONDARY SURVEY

After primary survey (ABCDEs) complete

Head-to-toe re-examination of the patient

Pupillary size, conjunctival hemorrhages and fundi, penetrating injury,dislocation of the lens,ocular entrapment Visual acuity can be evaluated by the reading of printed material, e.g., words on an intravenous container.

Extra-ocular mobility should be evaluated to exclude entrapment of muscles due to orbital fractures

The entire scalp and skull should be examined forlacerations, contusions, and evidence of fractures.

SKULL FRACTURES

Cranial Vault Linear/Stellate Depressed/Non-depressed Open/Closed Basilar Raccoon eyes, Battle’s sign Hemotypanum + / – CSF leak + / – VII n. palsy

Mastiod ecchymosis : an indication of a fracture

of the base of the skull

BATTLE’S SIGN

Periorbital bruising: a sign of basal skull

fracture

RACCOON EYES

INTRA-CRANIAL INJURY

Focal Epidural Subdural Intracerebral Diffuse Mild Concussion Classic Concussion Diffuse Axonal

Diagnostic Procedures

CT ScanHematomasEpidural (supradural,convex/lenticular)Subdural (concave)Intra-cerebral (high density & low density halo)

MRIBetter for parenchymal and brain stem, but time to perform 45 min. vs 2-5 min for CT. MRI, at present, not initial management study

Epidural hematoma

Cerebral contusion with cerebral swelling and skullfracture

Traumatic Brain Injury

Epidural HematomaSA Hemorrhage

Intracranial Pressure Control

Hyperventilation (controlled)Osmotic diuresis (mannitol)Barbiturates (if ICP reductionrefractory to standard Rx.)Anticonvulsants (early and

short term)

Intravenous Fluids

Hypovolemia Decrease cerebral perfusion (CBF)Increase hypoxiaNormal saline or Ringer’s

Maxillofacial

Maxillofacial trauma without airway obstruction or major bleeding,

treated after stabilization

Mid-face fractures may involve a fracture of the cribriform plate.

Beware placing NG tube..Orotracheal and gastric intubation should be performed.

Cervical Spine and Neck

Patients with maxillofacial or head trauma, assume an unstable

cervical spine injury, (fracture and/or ligamentous) The absence of neurologic deficit does

not exclude injury to the cervical spine

Trachea (midline, tender, crepitus) Carotids (amplitude, bruit) Venous distension C-spine (stable / unstable, fracture,

ligamentous)

Neck - cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture.

Penetrating Neck Injury

Carotid Arteries

- amplitude, equality of pulsation, bruit

-occlusion or dissection of the carotid artery can occur late in the injury

-blunt trauma to the neck or a traction injury from a shoulder harness

restraint can result in intimal disruption, dissection, and thrombosis.

Penetrating neck trauma - vascular

Wall ( expansion, paradoxical,ecchymosis, tenderness, crepitus)

Sternal tenderness ( myocardial / pulmonary contusion)

Rib Fractures

1,2 (aortic disruption) 3 - 8 (hemo/pneumothorax, disruption diaphragm) 9 - 12 (liver, spleen, kidney) Flail (pulmonary contusion)

Chest X-Ray Chest wall (rib, sternal fxs.) Hemothorax Simple pneumothorax Mediastinal width (upright film)

Stomach herniated through diaphragm

Contusions, hematomas, chest wall – possibility of additional associated injury

Sternal tenderness – sternal fracture, costochondral separation

Tension pneumothorax – hypotension, hyperresonance, decreased breath sounds

Massive hemothorax - dullness to percussion, absent breath

sounds,hypotension

Cardiac tamponade – hypotension, narrow pulse pressure, distant heart sounds

CHEST TRAUMA

Aortic Transection

Signs:- widened mediastinum, 1st rib fx, apical capping, left hemothorax, tracheal deviation to right- widening from bridging veins and arteries, not aorta itself- need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears at ligamentum- 90% of patients die at the scene

Great Vessel Injury

Tension Pneumothorax

NOT AN X-RAY DIAGNOSIS

Tension pneumothorax on right with shifted mediastinum

Abdomen

Ecchymosis (flank / kidney?) Tenderness RUQ (liver) LUQ (spleen) CVA ( kidney) Suprapubic ( bladder, symphysis)

Contusion of right lobe of liver

Abdomen

DPL, abdominal US, contrast CTTO BE DISCUSSED TOMORROW

Unexplained hypotension, impaired CNS, or equivocal findings

Pain from pelvic, lower rib fractures may prevent accurate diagnostic exam

Pelvis (tenderness, crepitus, instability) Genitalia (perineal/scrotal/shaft

hematoma, meatal blood) Rectum (tone, prostate, blood) Extremities (tenderness, deformity, pulses, sensation) Neurologic (detailed exam)

Hemorrhage

Pelvic fracture

Perineum/Rectum/Vagina

Contusions, hematomas, lacerations, and urethral (meatal) blood.Rectal exam prior to inserting a urinary catheter High-riding prostate, sphincter tone, integrity of rectal wall, blood within the bowel lumenFemale patient - blood in the vaginal vault and vaginal lacerations

Musculoskeletal

Pelvic fractures - ecchymosis over the iliac wings, symphysis pubis, labia, scrotum, pain on palpation of the pelvic ring Mobility of the pelvis - gentle anterior-to-posterior presssure with the heels of the hands on both anterior iliac spines and symphysis pubis Joint instability- ligament disruption Neurovascular deficit- nerve injury or ischemia (compartment syndrome)

MRI image of thoracicvertebral fracture and injured spinal cord

Illinois EMSC 203

PELVISApply pressure on pelvis to determine its stabilityPerform genitalia exam at one’s discretion

Illinois EMSC 204

Neurologic

Motor and sensory evaluation of the extremitiesReevaluation of the patient's level of consciousness GCS facilitates detection of early changes and trends in the neurologic status

Protection of the spinal cord is required until a spine injury is excluded

ADJUNCTS TO THE SECONDARY SURVEY

These include additional x-rays of the spine and extremities, CT computed tomographic scans of the head, chest, abdomen, and spine, contrast uretography angiography, and other diagnostic procedures

RE-EVALUATION

After initial life-threatening injuries are managed, other equally life-threatening problems and less

severe injuries may become apparent

Relief of severe pain is an important part of the management of the trauma patient

Effective analgesia requires intravenous opiates and/or anxiolytics (intravenous)… Intramuscular injections are to be avoided.

Once patient Stabilized and

Resuscitated

On to Definitive Care

Recognizing Life Threatening Emergenies

Signs and Symptomssevere respiratory distress or absent lung sounds (unilateral usually) resistance to manual ventilationCardiovascular collapse (shock)asymmetric chest expansionanxiety, restlessness or cyanosis (late)JVD or tracheal deviation (late)

Traumatic Brain Injry:

High index of suscpicion in any patient with history of or identifiable evidence of altered level of consciousnessBest determined by GCS (a decrease of even 1-2 points is indicative of significant change in neurological status)Pupillary functionLateralizing signs

Solid Organ Injury

25% of all trauma victims require an abdominal explorationBlunt trauma caused by MVCs, MCCs, falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of injuryHigh index of suspicion in those patients with c/o abdominal pain, and/or objective findings on exam (seatbelt sign)

Pelvic Trauma

Pelvic fx are the prototype of severe trauma, with an usually high incidence of associated injuriesAwake pts c/o excessive pain and may have evidence of abnormal positioning of lower extremities, or unstable pelvis on examCan be a major source of blood loss that is either arterial, venous, or osseous in origin

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