basic trauma overview - abc
TRANSCRIPT
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Basic Trauma Overview - ABC
Dale Dangleben, MD, FACS
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Team
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Extended Team
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Team Leader
– Remains calm– Maintains control and provides direction
– Stays decisive– Sees the big picture (situational awareness)
– Is open to other team members input
– Directs resuscitation– Makes early decision to transfer the patients that exceed the local capabilities
Decrease chaos / optimize care.
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Team Members
− Know your roles in the trauma team− Remain calm− Be responsive to team leader−Voice suggestions or concerns
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– Perform the Primary and secondary survey
– Verbalize patient care – Report completed tasks
Responsibilities
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– Monitors the patient– Manual BP– Obtains IV access– Administers medications– Dresses wounds– Performs or assists in resuscitative procedures
Responsibilities
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Records data Ensures documentation
accompanies patient upon transfer
Assists team members as needed
Responsibilities
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– Obtains needed supplies
– Coordinates communication with local and external resources
– Assists team members as needed
Responsibilities
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Responsibilities
• Place Oxygen on patient• Manage ventilator if
patient intubated
• Manage airway • Hold C spine• Manage rapid infuser line
where indicated• Assists team members as
needed
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– Basic adult and pediatric equipment for:• Airway management (cart)• IV access with warm fluids• Chest tube insertion• Hemorrhage control (tourniquets, pelvic binders)• Immobilization• Medications • Pediatric length/weight based tape (Broselow Tape)
– Warming capabilities
Organization of trauma resuscitation area
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D-MIST
DemographicsMechanism/medical complaintInjuriesSigns ( vitals )Treatment
Age, sex
Mechanism of injury
Time of injury, list injuries,
inspections
First set of vitals, any changes,
include glucose
Any treatments
Only EMS is allowed to talk during DMIST ( ~ 30secs)
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Primary Survey
ABC
E
Airway -----
Breathing
CirculationDisability
Exposure
C spine
D
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Identify Immediate life-threats
A Airway open?
B Breathing?
C BP, pulse?
D Disability?
C-spine
Decompression
Control bleeding, IV access, fluids
GCS, Pupils
E Exposure Keep warm, look for hidden injuries
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Secondary Survey
Thorough Head to toe exam
– Head and Neck– Chest– Abdomen– Pelvis– Extremities
Can be delayed until all life‐threatening injuries have been dealt with …..
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History
A
P
M
E
L
Allergies
Medications
PMHx
Last Meal
Events related to injury
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Adjuncts and tests
Adjuncts
•Pulse oximeter•Cardiac monitor•Foley catheter•NG tube
Diagnostic tests
•CXR•Pelvic x-ray•C-spine x-ray•EKG•Pregnancy test•Labs
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Airway
Recognizing and managing acute airway compromise are two of the most difficult yet critical skills which the TEAMmust master in order to adequately care for the trauma patient.
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Airway: Preparation
Organized equipmentSuppliesMedicationsTeam skills
Immediate accessibility
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Recognizing Airway Compromise
Can be rapidly accomplished by talking to patient and eliciting answers to simple questions.
Look
Listen
Feel
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Head, neck and facial trauma Bleeding into airway Deformity/swelling Noisy breathing Burns Cyanosis GCS 3‐8
Recognizing Airway Compromise
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Absolute Indications for Definitive Airway
Respiratory insufficiencyGCS 3‐8 Severe maxillofacial injuriesSevere neck injury with soft tissue swellingPersistent or uncompensated hemodynamic instability
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Relative Indications for Definitive Airway
Agitation with possible injury to self or others
Impending or potential airway compromise ( flail, large pulmonary contusion, pneumatocele )
Potential neurologic deterioration during transport
Prolonged transport time
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Airway: Basic Management
High‐flow (15 liters) oxygen by mask– O2 sat monitor
In‐line stabilizationChin liftJaw thrustNaso/oropharyngeal airwayBag valve mask assist
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Airway: Advanced Options
Laryngeal mask airway (LMA)CombitubeTM or King airwayIntubation
– Orotracheal– Nasotracheal
Surgical – Cricothyroidotomy
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Rescue Airways
King Laryngeal Tracheal AirwayLTA
Laryngeal Mask AirwayLMA
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Airway: Advanced Management
In‐line stabilizationCricoid pressure (Sellick maneuver)Choose airway method Medications
– Venous access
Equipment (endotracheal tube, laryngoscope, needles, tubing, bag, suction)
(Sellick maneuver)
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Rapid Sequence Intubation (RSI)– Pre‐oxygenate with 100% O2
– Support with bag‐valve mask– Administer medications
• Sedate• Paralyze
– Intubate
Airway: Advanced Management
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Rapid sequence intubationRapid sequence intubation
Induction agentsInduction agentsEtomidate is now considered the criterion standard of induction agents in its use in RSI. Very short acting non-barbiturate hypnotic agent Its advantages are rapidity of onset, short duration of action, Lack of cardiodepressant effects, marked safety in patients with head injury
Ketamine has direct negative inotropic effect on the myocardium is masked by an increase in blood pressure, heart rate, cardiac output, and an overall decrease in myocardial oxygen consumption
Thiopental has limited role in the ED as induction agents because of their cardiorespiratory depressant activity. Of all the barbiturates, these possess the shortest onset and briefest duration of action
Propofol decreases cerebral metabolism and, consequently, ICP also it is a myocardial depressant, causing a decrease in mean arterial pressure (MAP). This is compounded by the decrease in the systemic vascular resistanceit causes. Both of these factors contribute to an overall decrease in oxygen delivery.
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Confirm ET Placement
Listen to bilateral lung fields and epigastrium
Check position of endotracheal tube
Check end tidal CO2
Check O2 saturation
Check position of endotracheal tube with x‐ray
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Pitfalls
Inability to intubateEsophageal or right main stem intubationDevelopment of tension pneumothorax Loss of airway
– After paralytic administration– Dislodged tube
Equipment failure
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Ventilation volume– Pneumothorax and hemothorax– Flail chest– Diaphragmatic hernia
Mechanics – Paralysis– Disruption of chest wall
Circulation– Shock– Tension Pneumothorax– Contusion
Breathing: Impairment
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Breathing Assessment: Look
Chest rise and symmetry
Respiratory rate
Tracheal alignment
Soft tissue abnormalities
Subcutaneous emphysema
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Breathing Assessment: Listen
Breath sounds – What do you hear?
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Breathing Assessment: Adjuncts
Pulse oximetry
Colorimetric end tidal CO2
Portable chest film
NG ‐ OG tube
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Breathing: Life-threatening Injuries
Tension pneumothorax
Massive hemothorax
Flail chest
Open pneumothoraxYou will miss 30% of
pneumothoraces on supine CXR’s
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Tension Pneumothorax
Respiratory distressUnilateral absence breath sounds ShockDistended neck veins Hyper‐resonance on percussion
Needle Decompression• Second intercostal space• Mid‐clavicular line
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Massive Hemothorax
Hemi‐thorax filled with bloodHigh mortality rateMass effect (mediastinal shift)Exsanguination
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Open Pneumothorax
‘Sucking chest wound’
Impaired ventilation
Treatment is 3‐sided dressing and chest tube
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Breathing ReassessmentHow does your team reassess the patient’s
breathing?• Repeat primary survey • Assure patient is oxygenating
and ventilating• Adjuncts
− Pulse oximetry− End‐tidal C02− Chest x‐ray− NG ‐ OG tubes
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Breathing: TreatmentsChest tube insertion
– What size chest tube?
5th intercostal space anterior to mid‐axillary line at infra‐mammary crease
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Breathing Treatment: Pitfalls
Inaccurate pulse oximeter readings
Simple to tension pneumothorax
Improper placement of chest tube
Migration of endotracheal tube
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Breathing Summary
A team approach is critical to recognize and treat life‐threatening breathing problems
Address breathing after airway is secured
Reassess after every intervention, being conscious of pitfalls
Team should have the skills and be prepared to intervene appropriately
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Circulation
The most common cause of shock in trauma is hemorrhage
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Circulation
Identify and control bleedingInitiate resuscitationDefine and recognize shock in traumaAnticipate pitfalls
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Trauma Bay Preparation
Warm room
Warm IV fluids
Dressings, splints, sutures, staples
Blood/blood products
Rapid infuser
Tourniquets
Pelvic binder
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Circulation: Physiologic Changes in Shock
Increased pulse rateDecreased mental acuityNarrowed pulse
pressure earlyDecreased capillary refillClammy skinDecreased blood
pressureDecreased urine output
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Circulation: Vascular Access
Peripheral access– 2 large bore IV's –16 gauge or larger
– Blood drawn, if not already
Central accessVenous cut downIntraosseous
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Hemorrhagic Shock
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Hemorrhage Control
Direct pressure
Close scalp lacerations
Reduce and splint fractures
Immobilize pelvic fractures
Tourniquet
Operating Room ( Lap/Thoracotomy etc )
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Circulation: Adjuncts
Urinary Catheter – Contraindications
• Blood at urethral meatus• High riding prostate• Scrotal/labial hematoma
Pulse oximeterLab evaluations
– H/H – Type and cross
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Circulation: Controlled Resuscitation
Stop bleeding as soon as possible
Tolerate systolic BP ‐ 90 – 100 until the hemorrhage is controlled
Continue resuscitation with blood after
initial crystalloid
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Circulation: Resuscitation Guidelines
Warmed IV fluid guidelines– Adults ‐ 2000 cc of lactated ringer’s or saline– Peds ‐ 20 cc/kg bolus x 2
Blood– O negative or positive until type specific available
Continue resuscitation with blood after initial crystalloid
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End Points of Resuscitation
Improving mental statusChange in skin color and temperatureImproved capillary refillUrine output begins or becomes adequatePulse normalizesSystolic BP 90 to 100 mm Hg
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Rapid Responder
Stable endpoints after:– 1 to 2 liters for adults – 20 cc/kg for children
Establish maintenance IV rateMonitor for recurrent shockReevaluate ABC’s
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Transient Responder
Shock recurs after initial fluid bolus
Reassess ABCsStop all visible bleeding Blood or repeat initial crystalloid, to keep systolic BP at 90‐100 (Peds – refer to chart)
Alert OR Alert Blood bank ‐ Check amount of blood availability
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Non-Responder
Shock persists in spite of fluid resuscitation
Reassess ABCsStop all visible bleeding Transfuse as soon as possibleAlert OR
– Damage control surgery
Blood and blood product availability ( MTP )
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Persistent Shock
Hemorrhagic– Unrecognized or uncontrolled bleeding
Non‐hemorrhagic – Cardiac tamponade– Tension pneumothorax– Neurogenic shock– Myocardial infarction– Massive gastric distension (peds)
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Circulation: Pitfalls
Over resuscitation– Increase BP = increase
bleeding if bleeding not controlled
– Pulmonary edema– Hypothermia– Coagulopathy
Under resuscitation– Usually not enough blood
given– Bleeding not controlled
Failure to: Recognize compensated shock
Recognize patients on beta blockers have blunted response
Realize tachycardia more significant in
pediatric patients
Decompress stomach of pediatric patients
Recognize patients on anticoagulant
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Circulation: Summary
Team and facility preparationIdentify and control bleedingBegin resuscitationDefine and recognize shockDefine management optionsAnticipate pitfalls
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Trauma is a Dynamic Process
Continual reassessment is necessary to identify:
Changes in patient’s conditionPossible ongoing blood loss Response to interventionsIatrogenic problems
– Tension pneumothorax– Loss of vascular access
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WE
ARE
CREATING
GUIDELINES
UTILIZE THEM
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END( Until next time )
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