APPROACH TO TRAUMA
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Transcript of APPROACH TO TRAUMA
APPROACH TO TRAUMAAPPROACH TO TRAUMA
Waseem A Abu-JameaWaseem A Abu-Jamea
MD ,SBEM, AbEMMD ,SBEM, AbEM
Program Director KSMCProgram Director KSMC
Deputy chairman ED KSMC Deputy chairman ED KSMC
ObjectivesObjectives
Demonstrate concepts of primary and Demonstrate concepts of primary and secondary patient assessmentsecondary patient assessment
Establish management priorities in trauma Establish management priorities in trauma situationssituations
Initiate primary and secondary management Initiate primary and secondary management as necessary as necessary
Arrange appropriate dispositionArrange appropriate disposition
Trauma Trauma
EpidemiologyEpidemiology– Leading cause of death in the first 4 decadesLeading cause of death in the first 4 decades– 150,000 deaths annually in the US150,000 deaths annually in the US– Permanent disability 3 times the mortality ratePermanent disability 3 times the mortality rate– Trauma related dollar costs exceed $400 billion Trauma related dollar costs exceed $400 billion
annuallyannually
Why ATLS?Why ATLS? Trimodal death distributionTrimodal death distribution
– First peak instantly (brain, heart, large vessel injury)First peak instantly (brain, heart, large vessel injury)
– Second peak minutes to hoursSecond peak minutes to hours
– Third peak days to weeks (sepsis, MSOF)Third peak days to weeks (sepsis, MSOF) ATLS focuses on the second peak…..Deaths from:ATLS focuses on the second peak…..Deaths from:
TBI, Epidurals, Subdurals, IPH…TBI, Epidurals, Subdurals, IPH… Basilar skull fractures, orbital fractures, NEO complex injury…Basilar skull fractures, orbital fractures, NEO complex injury… Penetrating neck injuries…Penetrating neck injuries… Spinal cord syndromes…Spinal cord syndromes… Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury,
diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …tracheobronchial injuries, penetrating heart injury, aortic arch injuries …
Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuriesLiver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries Bladder rupture, renal contusion, renal laceration, urethral injury…Bladder rupture, renal contusion, renal laceration, urethral injury… Pelvic fractures, femur fractures, humerus fractures…Pelvic fractures, femur fractures, humerus fractures…
You get the pointYou get the point
Concepts of ATLSConcepts of ATLS
Treat the greatest threat to life firstTreat the greatest threat to life first The lack of a definitive diagnosis should The lack of a definitive diagnosis should
never impede the application of an never impede the application of an indicated treatmentindicated treatment
A detailed history is not essential to begin A detailed history is not essential to begin the evaluationthe evaluation
““ABCDEABCDE” approach ” approach
Initial Assessment and Initial Assessment and ManagementManagement
An effective trauma system needs the An effective trauma system needs the teamwork of EMS, emergency medicine, teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialiststrauma surgery, and surgery subspecialists
Trauma rolesTrauma roles– Trauma captainTrauma captain– InterventionalistsInterventionalists– NursesNurses– RecorderRecorder
Primary SurveyPrimary Survey
Patients are assessed and treatment Patients are assessed and treatment priorities established based on their injuries, priorities established based on their injuries, vital signs, and injury mechanismsvital signs, and injury mechanisms
ABCDEs of trauma careABCDEs of trauma care– AA Airway and c-spine protectionAirway and c-spine protection– BB Breathing and ventilationBreathing and ventilation– CC Circulation with hemorrhage controlCirculation with hemorrhage control– DD Disability/Neurologic statusDisability/Neurologic status– EE Exposure/Environmental controlExposure/Environmental control
A- AirwayA- Airway
Airway should be assessed for patencyAirway should be assessed for patency– Is the patient able to communicate verbally?Is the patient able to communicate verbally?– Inspect for any foreign bodiesInspect for any foreign bodies– Examine for stridor, hoarseness, gurgling, pooled Examine for stridor, hoarseness, gurgling, pooled
secrecretions or blood secrecretions or blood
Assume c-spine injury in patients with Assume c-spine injury in patients with multisystem traumamultisystem trauma– C-spine clearance is both clinical and radiographicC-spine clearance is both clinical and radiographic– C-collar should remain in place until patient can C-collar should remain in place until patient can
cooperate with clinical examcooperate with clinical exam
Airway InterventionsAirway Interventions
Supplemental oxygenSupplemental oxygen Suction Suction Chin lift/jaw thrust Chin lift/jaw thrust Oral/nasal airwaysOral/nasal airways Definitive airwaysDefinitive airways
– RSI for agitated patients with c-spine RSI for agitated patients with c-spine immobilizationimmobilization
– ETI for comatose patients (GCS<8)ETI for comatose patients (GCS<8)
BreathingBreathing
What can we look for clinically to assess a What can we look for clinically to assess a patient’s ‘breathing’ status?patient’s ‘breathing’ status?
B- BreathingB- Breathing
Airway patency alone does not ensure Airway patency alone does not ensure adequate ventilationadequate ventilation
Inspect, palpate, and auscultate Inspect, palpate, and auscultate – Deviated trachea, crepitus, flail chest, sucking Deviated trachea, crepitus, flail chest, sucking
chest wound, absence of breath soundschest wound, absence of breath sounds CXR to evaluate lung fieldsCXR to evaluate lung fields
Breathing InterventionsBreathing Interventions
Ventilate with 100% oxygenVentilate with 100% oxygen Needle decompression if tension Needle decompression if tension
pneumothorax suspectedpneumothorax suspected Chest tubes for pneumothorax / hemothoraxChest tubes for pneumothorax / hemothorax Occlusive dressing to sucking chest woundOcclusive dressing to sucking chest wound If intubated, evaluate ETT positionIf intubated, evaluate ETT position
What would we do for this What would we do for this patient who is having difficulty patient who is having difficulty
breathing?breathing?
C- CirculationC- Circulation
Hemorrhagic shock should be assumed in Hemorrhagic shock should be assumed in any hypotensive trauma patient any hypotensive trauma patient
Rapid assessment of hemodynamic statusRapid assessment of hemodynamic status– Level of consciousnessLevel of consciousness– Skin colorSkin color– Pulses in four extremitiesPulses in four extremities– Blood pressure and pulse pressureBlood pressure and pulse pressure
Circulation InterventionsCirculation Interventions
Cardiac monitorCardiac monitor Apply pressure to sites of external hemorrhageApply pressure to sites of external hemorrhage Establish IV accessEstablish IV access
– 2 large bore IVs2 large bore IVs– Central lines if indicatedCentral lines if indicated
Cardiac tamponade decompression if indicatedCardiac tamponade decompression if indicated Volume resuscitationVolume resuscitation
– Have blood ready if neededHave blood ready if needed– Level One infusers available Level One infusers available – Foley catheter to monitor resuscitationFoley catheter to monitor resuscitation
D- Disability D- Disability
Abbreviated neurological exam Abbreviated neurological exam – Level of consciousnessLevel of consciousness– Pupil size and reactivityPupil size and reactivity– Motor functionMotor function– GCS GCS
» Utilized to determine severity of injuryUtilized to determine severity of injury
» Guide for urgency of head CT and ICP monitoringGuide for urgency of head CT and ICP monitoring
GCSGCS
EYEEYE VERBALVERBAL MOTORMOTOR
Spontaneous 4Spontaneous 4 Oriented 5Oriented 5 Obeys 6 Obeys 6
Verbal 3Verbal 3 Confused 4Confused 4 Localizes 5Localizes 5
Pain 2Pain 2 Words 3Words 3 Flexion 4Flexion 4
None 1None 1 Sounds 2Sounds 2 Decorticate 3Decorticate 3
None 1None 1 Decerebrate 2Decerebrate 2
None 1None 1
Disability InterventionsDisability Interventions
Spinal cord injurySpinal cord injury– High dose steroids if within 8 hoursHigh dose steroids if within 8 hours
ICP monitor- Neurosurgical consultationICP monitor- Neurosurgical consultation Elevated ICPElevated ICP
– Head of bed elevatedHead of bed elevated– MannitolMannitol– HyperventilationHyperventilation– Emergent decompressionEmergent decompression
E- ExposureE- Exposure
Complete disrobing of patientComplete disrobing of patient Logroll to inspect backLogroll to inspect back Rectal temperatureRectal temperature Warm blankets/external warming device to Warm blankets/external warming device to
prevent hypothermiaprevent hypothermia
CaseCase
28 yo M involved in a high speed motorcycle accident. He was not 28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.
HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemaskHR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask
Brief initial exam: pt is drowsy but arousable to voice, has large Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle to L ankle
ABCDEABCDE
What are the management priorities at this What are the management priorities at this time?time?
What are this patient’s possible injuries?What are this patient’s possible injuries?
What are the interventions that need to What are the interventions that need to happen now? happen now?
Secondary SurveySecondary Survey
AMPLE historyAMPLE history– Allergies, medications, PMH, last meal, eventsAllergies, medications, PMH, last meal, events
Physical exam from head to toe, including Physical exam from head to toe, including rectal examrectal exam
Frequent reassessment of vitalsFrequent reassessment of vitals Diagnostic studies at this time simultaneouslyDiagnostic studies at this time simultaneously
– X-rays, lab work, CT orders if indicatedX-rays, lab work, CT orders if indicated
– FAST examFAST exam
Diagnostic AidsDiagnostic Aids
Standard trauma labsStandard trauma labs– CBC, K, Cr, PTT, Utox, EtOH, ABGCBC, K, Cr, PTT, Utox, EtOH, ABG
Standard trauma radiographsStandard trauma radiographs– CXR, pelvis, lateral C-spine (traditionally)CXR, pelvis, lateral C-spine (traditionally)
CT/FAST scansCT/FAST scans Pt must be monitored in radiologyPt must be monitored in radiology Pt should only go to radiology if stablePt should only go to radiology if stable
Widened MediastinumWidened Mediastinum What disease process does this indicate?What disease process does this indicate?
Bilateral Pubic Ramus Fractures and Bilateral Pubic Ramus Fractures and Sacroiliac Joint DisruptionSacroiliac Joint Disruption
What should this injury make you worry about?What should this injury make you worry about?
Abdominal TraumaAbdominal Trauma
Common source of traumatic injuryCommon source of traumatic injury Mechanism is important Mechanism is important
– Bike accident over the handlebars Bike accident over the handlebars – MVC with steering wheel traumaMVC with steering wheel trauma
High suspicion with tachycardia, High suspicion with tachycardia, hypotension, and abdominal tendernesshypotension, and abdominal tenderness
Can be asymptomatic early onCan be asymptomatic early on FAST exam can be early screening tool FAST exam can be early screening tool
Abdominal TraumaAbdominal Trauma
Look for distension, tenderness, seatbelt Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal marks, penetrating trauma, retroperitoneal ecchymosisecchymosis
Be suspicious of free fluid without evidence of Be suspicious of free fluid without evidence of solid organ injurysolid organ injury
Splenic InjurySplenic Injury Most commonly injured organ in blunt traumaMost commonly injured organ in blunt trauma Often associated with other injuriesOften associated with other injuries Left lower rib pain may be indicativeLeft lower rib pain may be indicative Often can be managed non-operativelyOften can be managed non-operatively
Spleen with surroundingblood
Blood from spleenTracking aroundliver
Liver injuryLiver injury Second most common solid organ injurySecond most common solid organ injury Can be difficult to manage surgically Can be difficult to manage surgically Often associated with other abdominal injuriesOften associated with other abdominal injuries
Liver contusions
What’s wrong with this picture?What’s wrong with this picture?
May only see the nasogastric tube appear to be coiled May only see the nasogastric tube appear to be coiled in the lung.in the lung.
Left > right due to liver protection of the diaphragm.Left > right due to liver protection of the diaphragm.
Trace the Diaphragm Outline. Where is theDiaphragm on the left?
Abdominal contentsUp in the chest on theleft
Hollow Viscous InjuryHollow Viscous Injury
Injury can involve stomach, bowel, or mesenteryInjury can involve stomach, bowel, or mesentery Symptoms are a result from a combination of blood loss and Symptoms are a result from a combination of blood loss and
peritoneal contamination peritoneal contamination Small bowel and colon injuries result most often from Small bowel and colon injuries result most often from
penetrating traumapenetrating trauma Deceleration injuries can result in bucket-handle tears of Deceleration injuries can result in bucket-handle tears of
mesenterymesentery Free fluid without solid organ injury is a hollow viscus injury Free fluid without solid organ injury is a hollow viscus injury
until proven otherwiseuntil proven otherwise
Mesenteric and bowel injury from blunt abdominaltrauma. Notice the bowel and mesenteric disruption.
bowel
mesentery
CT Scan in TraumaCT Scan in Trauma
Abdominal CT scan visualizes solid organs Abdominal CT scan visualizes solid organs and vessels welland vessels well
CT does NOT see hollow viscus, CT does NOT see hollow viscus, duodenum, diaphram, or omentum wellduodenum, diaphram, or omentum well
Some recent surgery literature advocates Some recent surgery literature advocates whole body scans on all traumawhole body scans on all trauma– Keep in mind that there is an increase in Keep in mind that there is an increase in
mortality related to cancer from CT scansmortality related to cancer from CT scans
FAST ExamFAST Exam
Focused Abdominal Scanning in TraumaFocused Abdominal Scanning in Trauma 4 views: Cardiac, RUQ, LUQ, suprapubic4 views: Cardiac, RUQ, LUQ, suprapubic Goal: evaluate for free fluidGoal: evaluate for free fluid
See normalLiver and kidney
Free fluid in Morrison's Pouch between liver andkidney
Non-accidental TraumaNon-accidental Trauma
Key is SUSPICION!!!Key is SUSPICION!!! Incongruent stories of mechanismIncongruent stories of mechanism Delay in seeking treatmentDelay in seeking treatment Multiple stages of injuriesMultiple stages of injuries Pattern InjuriesPattern Injuries Multiple hospital visitsMultiple hospital visits Injury mechanism beyond the scope of the age of Injury mechanism beyond the scope of the age of
child (6week old rolled over off the bed)child (6week old rolled over off the bed) Bite marks, submersion injury, cigarette burnsBite marks, submersion injury, cigarette burns
Disposition of Trauma PatientsDisposition of Trauma Patients
Dictated by the patient’s condition and available Dictated by the patient’s condition and available resources i.e. trauma team availableresources i.e. trauma team available– OR, admit, or transferOR, admit, or transfer
Transfers should be coordinated effortsTransfers should be coordinated efforts– Stabilization begun prior to transferStabilization begun prior to transfer– Decompensation should be anticipatedDecompensation should be anticipated
Serial examinationsSerial examinations– CHI with regain of consciousnessCHI with regain of consciousness– Abdominal exams for documented blunt traumaAbdominal exams for documented blunt trauma– Pulmonary contusions with blunt chest traumaPulmonary contusions with blunt chest trauma
SummarySummary
Trauma is best managed by a team Trauma is best managed by a team approach (there’s no “I” in trauma)approach (there’s no “I” in trauma)
A thorough primary and secondary survey A thorough primary and secondary survey is key to identify life threatening injuriesis key to identify life threatening injuries
Once a life threatening injury is discovered, Once a life threatening injury is discovered, intervention should not be delayedintervention should not be delayed
Disposition is determined by the patient’s Disposition is determined by the patient’s condition as well as available resources.condition as well as available resources.
SourcesSources
ATLS Student Course Manuel, 6ATLS Student Course Manuel, 6 thth edition. edition. Rosen’s Emergency Medicine Concepts and Rosen’s Emergency Medicine Concepts and
Clinical Practice, 5Clinical Practice, 5thth edition. edition. Emergency Medicine A Comprehensive Emergency Medicine A Comprehensive
Study Guide, 5Study Guide, 5thth edition. edition.