Initial Assessment of the

Trauma Patient

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 ATLS Guidelines
Systematic approach necessary to rapidly
identify injuries and stabilize the patient
This approach is divided into:
1. Primary Survey
2. Resuscitative Phase
3. Secondary Survey
4. Definitive Care Phase
ABCDE
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 Metabolism
Spinal Cord Injury
Brain Injury
 Airway
Patency is primary
Obstruction in trauma patients
– 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 usefull in
clearing the airway in less injured patients
If there is any question of an adequate
airway, severe head injury, profound
shock, severe facial trauma, voice
changes, then definitive airway control is
necessary
Airway & Ventilation Methods
Supplemental Oxygen
– increased FiO2 increases available oxygen
– objective is to maximize hemoglobin
saturation
Airway & Ventilation Methods
Airway Maneuvers Airway Devices
– Chin lift – Oropharyngeal airway
– Jaw thrust – Nasopharyngeal
(Neck extension is airway
contraindicated) – BVM
Assessment & Recognition of Airway &
Ventilatory Compromise
Visual Assessment Visual Assessment
– Position – Skin color
tripod – Flaring of nares
orthopnea
– Pursed lips
– Rise & Fall of chest – Retractions
Paradoxical motion
– Accessory Muscle Use
– Audible gasping,
stridor, or wheezes – Altered Mental Status
– Obvious pulm edema – Inadequate Rate or
depth of ventilations
Airway & Ventilation Methods
Gastric Distention
– Common when ventilating without intubation
– pressure on diaphragm
– resistance to BVM ventilation
– avoid by increasing time of BVM ventilation
Airway & Ventilation Methods
Orotracheal Intubation- preferred in almost
all situations
– Indications
present or impending respiratory failure
apnea
unable to protect own airway (GCS <8)
– Advantages
secures airway
route for a few medications
optimizes ventilation and oxygenation
Airway & Ventilation Methods
Nasotracheal Intubation- rarely if ever
used in the initial management of the
injured patient.
Many drawbacks
Goal of safe endotracheal intubation with
cervical spine precautions can be better
accomplished with orotracheal intubation
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 risk
OR
absolute 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
Airway & Ventilation Methods: ALS
Surgical Cricothyrotomy
– Contraindications (relative)
Age < 8 years (some say 10)
evidence of fx larynx or cricoid cartilage
evidence of tracheal transection
Airway & Ventilation Methods
Needle Cricothyrotomy & Transtracheal Jet
Ventilation
– Indications
Same as surgical cricothyrotomy along with
Contraindication for surgical cricothyrotomy
– Contraindications
caution 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 (“RSI”)
– Sedation
Used for
– induction
– anxious or agitated patient
Contraindications
– hypersensitivity
– hypotension (e.g. hypovolemia 2° to trauma)
Airway & Ventilation Methods

Pharmacologic Assisted Intubation (“RSI”)

– Neuromuscular Blockade
Induces temporary skeletal muscle paralysis
Indications
– When Intubation is required in a patient who
is awake,
has a gag reflex, or
is agitated or combative
Airway & Ventilation Methods
Pharmacologic Assisted Intubation (“RSI”)
– Neuromuscular Blockade
Contraindications
– Most are specific to the medication
– inability to ventilate patient once paralysis is induced
Advantages
– reduces risk of laryngospasm
Airway & Ventilation Methods
Pharmacologic Assisted Intubation (“RSI”)
– Disadvantages & Potential Complications
Does not provide sedation or amnesia
Provider unable to intubate or ventilate after NMB
Aspiration during procedure
Difficult to detect motor seizure activity
Side effects and adverse effects of specific meds
Tension Pneumothorax
Recognizing Life Threatening
Emergenies

Aka, “When to pee in your

pants in the trauma bay”
 Tension Pneumothorax
Signs and Symptoms
severe respiratory distress
 or absent lung sounds (unilateral usually)
 resistance to manual ventilation
Cardiovascular collapse (shock)
asymmetric chest expansion
anxiety, restlessness or cyanosis (late)
JVD or tracheal deviation (late)
Great Vessel Injury
 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
Cardiac Tamponade
 Cardiac Tamponade
Beck‟s triad:
- hypotenstion, jugular venous distention,
and muffled heart sounds
- causes decreased diastolic ventricular
filling and resultant hypotension
- echocardiogram shows impaired diastolic
filling of right atrium initially (1st sign)
 Traumatic Brain Injury
Epidural Hematoma SA Hemorrhage
 TBI:
High index of suscpicion in any patient
with history of or identifiable evidence of
altered level of consciousness
Best determined by GCS (a decrease of
even 1-2 points is indicative of significant
change in neurological status)
Pupillary function
Lateralizing signs
 Solid Organ Injury
Splenic Laceration Liver Laceration
 Solid Organ Injury
25% of all trauma victims require an
abdominal exploration
Blunt trauma caused by MVCs, MCCs,
falls, assaults, and auto vs. pedestrians
remains the most frequent mechanism of
injury
High index of suspicion in those patients
with c/o abdominal pain, and/or objective
findings on exam (seatbelt sign)
Hemorrhage
Pelvic fracture
 Pelvic Trauma
Pelvic fx are the prototype of severe
trauma, with an usually high incidence of
associated injuries
Awake pts c/o excessive pain and may
have evidence of abnormal positioning of
lower extremities, or unstable pelvis on
exam
Can be a major source of blood loss that is
either arterial, venous, or osseous in origin