Primary Trauma Care

Dr Imran Javed.Associate Prof Surgery.Fiji National University.

Introduction• There are notable disparities in the outcome of

trauma care around the world. • 60% of preventable trauma associated deaths occur in

the first 24 hours.• Difficulties facing trauma care in developing countries

include manpower development, infrastructure, availability of equipment and organization.

• Much of the improvement in trauma care has resulted from better organization of trauma care services.

• The main focus of this module is appropriate life-saving management in the first few hours following trauma.

Learning Outcomes

• Discuss the burden of trauma

• Describe the concept of triage

• Identify common life-threatening injuries

• Adequately resuscitate and re-evaluate the trauma patient

• Manage common life-threatening injuries effectively

• Perform a secondary survey to plan the next stage of care

Triage in the emergency room

• The first is quiet and appears calm and still • The second is in excruciating pain from an obvious femoral

fracture with the foot twisted in the opposite direction

• The third patient is screaming at the site of his clothes soaked with blood from an extensive scalp laceration

• The fourth patient walks-in complaining of right sided chest pain and difficulty with breathing

Managing the severely injured patient

Initial management (resuscitation)

Catastrophic hemorrhage: the exception to “A,B,C,D,E”

• This is life threatening hemorrhage, often due to traumatic amputation or crush injury to the limbs. Bleeding is usually massive and the patient may be on the point of exsanguination.

• It is necessary to rapidly control the hemorrhage before assessing the airway.

• The bleeding vessel may be ligated if it can be identified. If not, this may be one of the exceptional cases when a tourniquet may be used. However, the duration of application must be noted.

Airway management: The conscious patient

• Speak to the patient. • Does he respond? If he responds in a normal voice giving a

logical answer then he most probably can control his airway. • However, cervical spine injury (CSI) may be present. First,

inspect the neck meticulously for wounds and other abnormalities.

• Cover any penetrating wounds with clean gauze and plaster. • Then, immobilize the cervical spine using one of these

methods:• MILS (Manual in-line stabilization)• Cervical collar Spinal board, head blocks, sandbags

Primary Survey - Airway

• Maintain C-spine precautions• Clear any obstructions• Jaw thrust instead of head tilt chin lift• Endotracheal intubation for airway protection

or expected clinical course (ie obstruction from blood or vomitus, neck hematoma, facial burns or trauma, GCS 8 or less, combative patient, potential for airway compromise while out of department.)

Primary Survey - Breathing

• Auscultation for bilateral breath sounds• Palpation for subcutaneous emphysema-needle decompression followed by chest tube for pneumothorax• Inspection for flail chest• Observation of respiratory rate, oxygen

saturation, and overall work of breathing-mechanical ventilation for inadequate ventilation or to decrease work of breathing

Primary Survey - Circulation

• Check peripheral pulses, heart rate, BP, pulse pressure, capillary refill, cyanosis

• All hypotensive trauma patients are assumed to be in hemorrhagic shock

• 2 large bore peripheral IV’s (at least 18 gauge)

• Control external bleeding

Primary Survey - Circulation

Primary Survey - Circulation

• Begin volume resuscitation with liter boluses of crystalloid for class I or II hemorrhage.

• Begin crystalloid and blood for class III or IV hemorrhage.

• O- blood until type specific is available• Constant reevaluation is paramount• If class I or II is patient still showing signs of

shock after 3L of crystalloid, begin blood• “3:1 rule” 3cc crystalloid for every 1cc of blood

loss

Primary Survey - Circulation

• 5 Places life threatening hemorrhage can occur

• -Chest• -Abdomen• -Pelvis• -Thighs• -Externally

Primary Survey - Circulation

• Cardiac Tamponade can cause hypotension with little blood loss.

• Becks triad: hypotension, distended neck veins, muffled heart sounds

• Easily confirmed with ultrasound• Pericardiocentesis• Pericardial Window.

Primary Survey - Disability

• Quick assessment of ability to move all extremities

• Glasgow Coma Scale.

Primary Survey – Exposure

• Completely undress the patient and inspect the entire patient from head to toe both front and back.

• Maintain spinal precautions during logrolling

• Inspect both axillae and Perineum. • Warm blankets!!!

Secondary Survey

• Head to toe evaluation once any derangements in primary survey have been addressed.

• AMPLE History• -Allergies• -Medications• -Past medical history (LMP, Td, transfusions) • -Last meal• -Events leading up to trauma

Imaging – Plain Films

• Choice of imaging modality depends on nature of injuries and stability of patient.

• Knowledge of injury mechanism and index of suspicion most important

• Can be performed at bedside• Useful for rapid identification of pneumothorax,

hemothorax, fractures and locating ballistics

Imaging – Ultrasound

• Quick• Can be performed at bedside• FAST: Focused Assessment with

Sonography for Trauma• Rapid examination to identify free

intraperitoneal fluid and/or pericardial fluid

Imaging – CT• Detailed• Requires patient to leave the department• Necessary for head trauma

Disposition

• To the OR• -Unstable patients with blunt or penetrating

abdominal trauma or chest trauma. Hemothorax with >1500 cc of blood out initially. Surgical injuries identified with imaging.

• Admission • -Nonsurgical, high-risk injuries• Discharge• -Stable patients, minor or no injuries

identified.