initial assessment of the trauma patient
TRANSCRIPT
Initial Assessment of the Initial Assessment of the Trauma PatientTrauma Patient
Sharla Owens, M.D.Sharla Owens, M.D.
July 10July 10thth, 2006, 2006
Don’t PanicDon’t PanicDon’t PanicDon’t PanicNever Let Them See
You Sweat..
ATLS GuidelinesATLS Guidelines
Systematic approach necessary to rapidly Systematic approach necessary to rapidly identify injuries and stabilize the patientidentify injuries and stabilize the patient
This approach is divided into:This approach is divided into:
1. Primary Survey1. Primary Survey
2. Resuscitative Phase2. Resuscitative Phase
3. Secondary Survey3. Secondary Survey
4. Definitive Care Phase4. Definitive Care Phase
ABCDEABCDE
Airway Management in the Airway Management in the Trauma PatientTrauma Patient
Objectives of Airway Management Objectives of Airway Management & Ventilation& Ventilation
Primary Objective:Primary Objective:– Provide unobstructed passage for air Provide unobstructed passage for air
movementmovement– Ensure optimal ventilationEnsure optimal ventilation– Ensure optimal respirationEnsure optimal respiration
Objectives of Airway Management Objectives of Airway Management & Ventilation& Ventilation
Why is this so important in the trauma Why is this so important in the trauma patient?patient?– Prevention of Secondary InjuryPrevention of Secondary Injury
Shock & Anaerobic MetabolismShock & Anaerobic Metabolism
Spinal Cord InjurySpinal Cord Injury
Brain InjuryBrain Injury
AirwayAirway
Patency is primaryPatency is primary
Obstruction in trauma patientsObstruction in trauma patients– TongueTongue– SwellingSwelling– Foreign BodyForeign Body– Blood and secretionsBlood and secretions
AirwayAirway
Evaluation begins by asking the patient a Evaluation begins by asking the patient a question such as 'How are you?‘question such as 'How are you?‘
A response given in a normal voice A response given in a normal voice indicates that the airway is not in indicates that the airway is not in immediate jeopardy; a breathless, hoarse immediate jeopardy; a breathless, hoarse response or no response at all indicates response or no response at all indicates that the airway may be compromised. that the airway may be compromised.
AirwayAirway
Mechanical removal of debris, chin lift Mechanical removal of debris, chin lift and/or jaw thrust maneuver, are usefull in and/or jaw thrust maneuver, are usefull in clearing the airway in less injured patientsclearing the airway in less injured patients
If there is any question of an adequate If there is any question of an adequate airway, severe head injury, profound airway, severe head injury, profound shock, severe facial trauma, voice shock, severe facial trauma, voice changes, then definitive airway control is changes, then definitive airway control is necessarynecessary
Airway & Ventilation MethodsAirway & Ventilation Methods
Supplemental OxygenSupplemental Oxygen– increased FiOincreased FiO22 increases available oxygen increases available oxygen
– objective is to maximize hemoglobin objective is to maximize hemoglobin saturationsaturation
Airway & Ventilation MethodsAirway & Ventilation Methods
Airway ManeuversAirway Maneuvers– Chin liftChin lift– Jaw thrustJaw thrust
(Neck extension is(Neck extension is
contraindicated)contraindicated)
Airway DevicesAirway Devices– Oropharyngeal airwayOropharyngeal airway– Nasopharyngeal Nasopharyngeal
airwayairway– BVMBVM
Assessment & Recognition of Airway & Assessment & Recognition of Airway & Ventilatory CompromiseVentilatory Compromise
Visual AssessmentVisual Assessment– PositionPosition
tripodtripod
orthopneaorthopnea
– Rise & Fall of chestRise & Fall of chestParadoxical motionParadoxical motion
– Audible gasping, Audible gasping, stridor, or wheezesstridor, or wheezes
– Obvious pulm edemaObvious pulm edema
Visual AssessmentVisual Assessment– Skin colorSkin color– Flaring of naresFlaring of nares– Pursed lipsPursed lips– RetractionsRetractions– Accessory Muscle UseAccessory Muscle Use– Altered Mental StatusAltered Mental Status– Inadequate Rate or Inadequate Rate or
depth of ventilationsdepth of ventilations
Airway & Ventilation MethodsAirway & Ventilation Methods
Gastric DistentionGastric Distention– Common when ventilating without intubationCommon when ventilating without intubation– pressure on diaphragmpressure on diaphragm– resistance to BVM ventilationresistance to BVM ventilation– avoid by increasing time of BVM ventilationavoid by increasing time of BVM ventilation
Airway & Ventilation MethodsAirway & Ventilation Methods
Orotracheal Intubation- preferred in almost Orotracheal Intubation- preferred in almost all situationsall situations– IndicationsIndications
present or impending respiratory failurepresent or impending respiratory failureapneaapneaunable to protect own airway (GCS <8)unable to protect own airway (GCS <8)
– AdvantagesAdvantagessecures airwaysecures airwayroute for a few medicationsroute for a few medicationsoptimizes ventilation and oxygenationoptimizes ventilation and oxygenation
Airway & Ventilation MethodsAirway & Ventilation Methods
Nasotracheal Intubation- rarely if ever Nasotracheal Intubation- rarely if ever used in the initial management of the used in the initial management of the injured patient.injured patient.
Many drawbacksMany drawbacks
Goal of safe endotracheal intubation with Goal of safe endotracheal intubation with cervical spine precautions can be better cervical spine precautions can be better accomplished with orotracheal intubationaccomplished with orotracheal intubation
Airway & Ventilation MethodsAirway & Ventilation Methods
Surgical CricothyrotomySurgical Cricothyrotomy– IndicationsIndications
absolute need for a definitive airway ANDabsolute need for a definitive airway AND– unable to perform ETT due for structural or anatomic unable to perform ETT due for structural or anatomic
reasons, ANDreasons, AND– risk of not intubating is > than surgical airway riskrisk of not intubating is > than surgical airway risk
OROR
absolute need for a definitive airway ANDabsolute need for a definitive airway AND– unable to clear an upper airway obstruction, ANDunable to clear an upper airway obstruction, AND– multiple unsuccessful attempts at ETT, ANDmultiple unsuccessful attempts at ETT, AND– other methods of ventilation do not allow for effective other methods of ventilation do not allow for effective
ventilation and respirationventilation and respiration
Airway & Ventilation Methods: ALSAirway & Ventilation Methods: ALS
Surgical CricothyrotomySurgical Cricothyrotomy– Contraindications (relative)Contraindications (relative)
Age < 8 years (some say 10)Age < 8 years (some say 10)
evidence of fx larynx or cricoid cartilageevidence of fx larynx or cricoid cartilage
evidence of tracheal transectionevidence of tracheal transection
Airway & Ventilation MethodsAirway & Ventilation Methods
Needle Cricothyrotomy & Transtracheal Jet Needle Cricothyrotomy & Transtracheal Jet VentilationVentilation– IndicationsIndications
Same as surgical cricothyrotomy along withSame as surgical cricothyrotomy along with
Contraindication for surgical cricothyrotomyContraindication for surgical cricothyrotomy
– ContraindicationsContraindicationscaution with tracheal transectioncaution with tracheal transection
Airway & Ventilation Methods: Airway & Ventilation Methods:
Jet VentilationJet Ventilation– Usually requires high-Usually requires high-
pressure equipmentpressure equipment– Ventilate 1 sec then Ventilate 1 sec then
allow 3-5 sec pauseallow 3-5 sec pause– Hypercarbia likelyHypercarbia likely– Temporary: 20-30 Temporary: 20-30
minsmins– High risk for High risk for
barotraumabarotrauma
Airway & Ventilation MethodsAirway & Ventilation Methods
Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– SedationSedation
Used forUsed for– inductioninduction– anxious or agitated patientanxious or agitated patient
ContraindicationsContraindications– hypersensitivityhypersensitivity– hypotension (e.g. hypovolemia 2° to trauma)hypotension (e.g. hypovolemia 2° to trauma)
Airway & Ventilation MethodsAirway & Ventilation Methods
Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– Neuromuscular Blockade Neuromuscular Blockade
Induces temporary skeletal muscle paralysisInduces temporary skeletal muscle paralysis
IndicationsIndications– When Intubation is required in a patient whoWhen Intubation is required in a patient who
is awake,is awake,
has a gag reflex, orhas a gag reflex, or
is agitated or combativeis agitated or combative
Airway & Ventilation MethodsAirway & Ventilation Methods
Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– Neuromuscular Blockade Neuromuscular Blockade
ContraindicationsContraindications– Most are specific to the medicationMost are specific to the medication– inability to ventilate patient once paralysis is inducedinability to ventilate patient once paralysis is induced
AdvantagesAdvantages– reduces risk of laryngospasmreduces risk of laryngospasm
Airway & Ventilation MethodsAirway & Ventilation Methods
Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– Disadvantages & Potential ComplicationsDisadvantages & Potential Complications
Does not provide sedation or amnesiaDoes not provide sedation or amnesia
Provider unable to intubate or ventilate after NMBProvider unable to intubate or ventilate after NMB
Aspiration during procedureAspiration during procedure
Difficult to detect motor seizure activityDifficult to detect motor seizure activity
Side effects and adverse effects of specific medsSide effects and adverse effects of specific meds
Tension PneumothoraxTension Pneumothorax
Recognizing Life Threatening Recognizing Life Threatening EmergeniesEmergenies
Aka, “When to pee in your Aka, “When to pee in your pants in the trauma bay”pants in the trauma bay”
Tension PneumothoraxTension Pneumothorax
Signs and SymptomsSigns and Symptomssevere respiratory distresssevere respiratory distress
or absent lung sounds (unilateral usually)or absent lung sounds (unilateral usually)
resistance to manual ventilationresistance to manual ventilation
Cardiovascular collapse (shock)Cardiovascular collapse (shock)
asymmetric chest expansionasymmetric chest expansion
anxiety, restlessness or cyanosis (late)anxiety, restlessness or cyanosis (late)
JVD or tracheal deviation (late)JVD or tracheal deviation (late)
Great Vessel InjuryGreat Vessel Injury
Aortic TransectionAortic Transection
Signs:Signs:
- widened mediastinum, 1- widened mediastinum, 1stst rib fx, apical capping, rib fx, apical capping, left hemothorax, tracheal deviation to rightleft hemothorax, tracheal deviation to right
- widening from bridging veins and arteries, not - widening from bridging veins and arteries, not aorta itselfaorta itself
- need aortic evaluation in pts with significant - need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears mechanism (deceleration injuries), usually tears at ligamentumat ligamentum
- 90% of patients die at the scene- 90% of patients die at the scene
Cardiac TamponadeCardiac Tamponade
Cardiac TamponadeCardiac Tamponade
Beck’s triad:Beck’s triad:
- hypotenstion, jugular venous distention, - hypotenstion, jugular venous distention, and muffled heart soundsand muffled heart sounds
- causes decreased diastolic ventricular - causes decreased diastolic ventricular filling and resultant hypotensionfilling and resultant hypotension
- echocardiogram shows impaired diastolic - echocardiogram shows impaired diastolic filling of right atrium initially (1filling of right atrium initially (1stst sign) sign)
Traumatic Brain InjuryTraumatic Brain Injury
Epidural HematomaEpidural Hematoma SA HemorrhageSA Hemorrhage
TBI:TBI:
High index of suscpicion in any patient High index of suscpicion in any patient with history of or identifiable evidence of with history of or identifiable evidence of altered level of consciousnessaltered level of consciousness
Best determined by GCS (a decrease of Best determined by GCS (a decrease of even 1-2 points is indicative of significant even 1-2 points is indicative of significant change in neurological status)change in neurological status)
Pupillary functionPupillary function
Lateralizing signsLateralizing signs
Solid Organ InjurySolid Organ Injury
Splenic LacerationSplenic Laceration Liver LacerationLiver Laceration
Solid Organ InjurySolid Organ Injury
25% of all trauma victims require an 25% of all trauma victims require an abdominal explorationabdominal exploration
Blunt trauma caused by MVCs, MCCs, Blunt trauma caused by MVCs, MCCs, falls, assaults, and auto vs. pedestrians falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of remains the most frequent mechanism of injuryinjury
High index of suspicion in those patients High index of suspicion in those patients with c/o abdominal pain, and/or objective with c/o abdominal pain, and/or objective findings on exam (seatbelt sign)findings on exam (seatbelt sign)
HemorrhageHemorrhage
Pelvic fracturePelvic fracture
Pelvic TraumaPelvic Trauma
Pelvic fx are the prototype of severe Pelvic fx are the prototype of severe trauma, with an usually high incidence of trauma, with an usually high incidence of associated injuriesassociated injuries
Awake pts c/o excessive pain and may Awake pts c/o excessive pain and may have evidence of abnormal positioning of have evidence of abnormal positioning of lower extremities, or unstable pelvis on lower extremities, or unstable pelvis on examexam
Can be a major source of blood loss that is Can be a major source of blood loss that is either arterial, venous, or osseous in origineither arterial, venous, or osseous in origin