pace initial assesment trauma viii.ppt - airway management
TRANSCRIPT
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
15
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
2
)()( 2speedVelocityweightMassKE
Force
– 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
Blunt Trauma: Automobile Crashes
23
Intoxication
–Fatal Accidents: >50% involved ALCOHOL
Blunt Trauma: Automobile Crashes
Vehicular Mortality– Head: 48%– Internal (Torso): 37%– Spinal & Chest fracture: 8%– Extremity fracture: 2%– All Other: 5%
Blunt Trauma: Automobile Crashes
Falls– Stairs, Force, Surface– Landing Area
Surface TypeBody Part
– Height of Fall– Elderly
Other Types of Blunt Trauma
27 / 217
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
2
)()( 2speedVelocityweightMassKE
(continued)
Physics of Penetrating Trauma
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)
Physics of Penetrating Trauma
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
43 / 217
• Establish leadership - Involved leader- Remote leader
Anesthesiologist
CRNA1o Nurse
Tray
Line person
Chest tube person
Bystander
Bystander
Tray
CPR person
Bystander
Tray
Tray
Team Leader
Examining person 2o Nurse
BystanderTray
Line person
Chest tube person Bystander
Tray
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:
Trauma:Initial Management Priorities
1 hour
Pre-arrival 1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
Pre-arrival
Pre-arrival
• Can the Institution handle this patient?• … at this time?• Are there alternative facilities nearby?
Assess:
Trauma:Initial Management Priorities
Team leadership / organization
Trauma:Initial Management Priorities
Team leadership / organization
1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
1 hour
Pre-arrival
Airway:
- assess
- establish
- maintain
Breathing:
- assess
- support
Circulation:
- assess- access- stop hemorrhage
- resuscitate
Trauma:Initial Management Priorities
Assess:
• Immediate risk for loosing limb or life?• Potential for (rapid) deterioration?
Primary Survey
A B C
Trauma:Initial Management Priorities
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
Trauma:Initial Management Priorities
Primary Survey
Pre-arrival 1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
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
Pre-arrival 1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
1 hour
Trauma:Initial Management Priorities
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
Trauma:Initial Management Priorities
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
Pre-arrival 1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
1 hour
Trauma:Initial Management Priorities
• 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
Pre-arrival 1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
1 hour
Trauma:Initial Management Priorities
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.
Trauma:Initial Management Priorities
Primary Therapy
Trauma:Initial Management Priorities
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
Pre-arrival 1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
1 hour
Trauma:Initial Management Priorities
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
60 / 217
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
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 & Ventilation Methods
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
Airway & Ventilation Methods
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
Orotracheal Intubation
Airway & Ventilation Methods
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
Airway & Ventilation Methods
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
Airway & Ventilation Methods
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
Surgical Cricothyroidotomy
Surgical Cricothyroidotomy
Surgical Cricothyroidotomy
Surgical Cricothyroidotomy
Surgical Cricothyroidotomy
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
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
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
Pathophysiology of Thoracic Trauma Chest
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
Pathophysiology of Thoracic Trauma Chest
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
Pathophysiology of Thoracic Trauma
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
Pathophysiology of Thoracic Trauma
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
AMS
JVD
Hypotension
Hypovolemia
Tracheal Shifting LATE SIGN
Diminished then absent breath sounds on injured side
Cyanosis
Diaphoresis
AMS
JVD
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
Pathophysiology of Thoracic Trauma
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
Pathophysiology of Thoracic Trauma
Pulmonary Injuries
118/217 Break
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
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
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
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
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
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
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
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
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
ECG
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
Head
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
Neck
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
Penetrating neck trauma - vascular
Chest
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
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
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Recognizing Life Threatening Emergenies
Tension Pneumothorax
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