Principles in trauma management

Timing of Death Resulting from Trauma

First peak
Second peak

Death occur within minutes of injury. Due to major neurological or vascular trauma. Medical team can rarely improve outcome.

Occur during golden hour. Due to intracranial hematoma, major thoracic and abdominal injury. Primary focus for intervention.

Third peak

Occurs after days or weeks. Due to sepsis or multiple organ failure

Trauma teams
Usually comprises an anaesthetist, general surgeon, orthopedic surgeon, A&E specialist, A&E nurses and radiographers. General surgeon and orthopedic surgeon presence can reduce delays in the emergency department, improve the early diagnosis of life threatening injuries and lead to earlier surgery when required. Team leader is responsible for assessing the patient and coordinating the work of the other members of the team.

Immediate Assessment and Management

The patient suffering trauma must be thoroughly assessed on admission so that life threatening injuries can be corrected. The condition of the patient must be stabilized and plans made for further treatment of their injuries. All trauma cases should receive: Primary survey (assessment) and resuscitation Secondary survey Definitive treatment

Primary survey and resuscitation

A = Airway and cervical spine B = Breathing and ventilation C = Circulation and hemorrhage control D = Dysfunction of the central nervous system/disability E = Exposure, environmental control and hypothermia prevention

A = Airway and cervical spine

Airway is at risk from blood, tissue debris, swelling, vomit and mechanical disruption. Examine pt for airway obstruction, if pt able to talk = airway patent. Sign of airway obstruction (stridor, cyanosis, tracheal tug, inadequate chest movement) Then give 100% O2 ,15L/min through mask.

Airway manoeuver: 1. Basic - Jaw thrust and chin lift. - Bring the tongue forward, opening up the airway 2. Airway adjunct - If basic fail, use adjunct such as oropharyngeal (Guedel airway) and nasopharyngeal airway.

3. Definitive airway - Endotracheal intubation - A tube is inserted into the trachea with a cuff inflated to prevent aspiration - Indication (apnoea, failure of basic airway, failure to maintain oxygen via mask, protection from blood and vomit, head injury requiring ventilation, progressive upper airway swelling-upper airway burns)

4. Surgical airway - If others mean of clearing airway fail or in severe facial trauma - Several techniques : a) Needle cricothyroidotomy b) Surgical cricothyroidotomy

 C-spine protection = inline immobilisation, collar brace

B = Breathing & ventilation

Obvious injuries must be noted, the trachea should be checked for deviation and both sides of the chest for expansion. The thorax must be percussed, and lung apices and the axillae auscultated The respiratory rate must be noted. A pulse oximeter is useful as it gives an indication of the adequacy of perfusion as well as arterial oxygen saturation. Life threatening conditions need immediate treatment: ATOMIC
Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Intercostal distruption Cardiac tamponade

 Tension pneumothorax
Occur when air enters the pleural space either from outside or from inside the lung. A one-way valve is formed by the pleural space during inspiration, but does not allow it to escape during expiration. Lung collapses, and the mediastinum and the trachea are deviated away from the affected side. Pt becomes SOB & cyanotic Clinical distressed, tachycardic pt, deviated trachea, hyper-resonance to percussion & absent breath sound on affected side

 Open pneumothorax ( sucking chest wound) Massive haemothorax

Greater than 1500ml

(absent breath sounds, stony dull to percussion, + shock signs) Intercostal distruption / Flail chest (paradoxical chest movement, hypoxia) Cardiac Tamponade (Becks triad = hypotension, distended neck vein, muffled heart sound)

C = Circulation and hemorrhage control

Any major haemorrhage that is visible should be controlled by direct pressure. Penetrating wounds should be identified and explored formally by a surgeon. Penetrating implements should be left in situ for formal surgical exploration. A rapid assessment of the cardiovascular system should be made including pulse rate, skin colour, capillary refill, level of consciousness and blood pressure. Place two large caliber (14G) intravenous cannulas.

Penetrating implements left in situ

 Take sample for arterial blood gasses. Give intravenous fluids. Crystalloid or colloid in adequate volume. - Warmed RL, 2000ml, colloid (Gelofusine, Hemaccel) maybe considered if need further volume expansion. - Blood only for life threatening blood loss (>30-40% blood loss) immediate type O rhesus ve. Aim to maintain Hb above 8g/dL. Send blood for cross-match, FBC, clotting, U&E. Attach patient to ECG monitor. Insert urinary catheter. Recognize the sign of shock, and look for the cause

D = Dysfunction of the central nervous system/disability

GCS (primary or secondary survey) Assess level of consciousness using AVPU method
A = alert V = responding to voice P = responding to pain U = unresponsive

Assess pupil size, equality and responsiveness

E = Exposure
All injured patients should be completely undressed. Clothes are cut off if necessary to minimize undesirable movement. This allows a proper survey of injuries. The patient should, however, not be allowed to become hypothermic and should be kept covered when possible. Injured children lose heat rapidly when exposed (even in hot environments)

Adjunct to primary survey

Monitoring : pulse, BP, ECG, pulse oximetry. Diagnostic study : X-rays (lat.cervical spine, AP chest, AP pelvis), US scan, CT scan.

Secondary survey
Following the initial survey and resuscitation, the patient should undergo a thorough secondary survey with the aim of documenting any other injuries. During this survey, however, the basics of the primary survey (airway, breathing and circulation) should be regularly reassessed to detect any unexpected deterioration. Secondary survey : - History - Head to toe assessment

History
*AMPLE

Allergies

Medications

Previous medical history

Last meal

Events leading to the injury

Head to toe assessment

Head Neck Thorax Abdominal Limbs Spine

Head
GCS should be documented. The scalp should be palpated for fractures, lacerations and other deformities. Periorbital and/or subconjunctival haemorrhage, blood or cerebrospinal fluid coming from the ears or nose (basal skull fractures).(racoons eye, battles sign, halo sign) Facial fractures must be sought by careful palpation.

 raccoon eyes, battles sign, double-ring sign)

Neck
Asked if have any neck pain. While assistant performing inline immobilization, examined for lacerations, swellings, tenderness or deformity of the cervical spine around the neck. A lateral X-ray of the cervical spine must show all the vertebrae including the body of the 1st thoracic vertebra.

Thorax
The entire chest must be examined for signs of injury. This includes palpating for fractures of the clavicles and ribs and the presence of subcutaneous emphysema. X-ray to look for aortic disruption, diaphragmatic rupture, simple pneumo-/ haemothorax.

Abdominal
Abdomen must be examine for signs of injury. Penetrating wounds should be examined at laparotomy if they breach muscle. X-ray for pelvic fractures. Also assess of penile, perineum, rectal, vaginal and gluteal regions for injury.

Limbs
Fractures, wounds and discoloration must be noted. Check pulses in all limbs even if no fracture is suspected. Contaminants and devitalised tissue should be removed. Signs such as increased limb swelling, pain and disordered sensation suggest compartment syndrome.

Spine
Log roll. At least 4 people are required for a safe log roll procedure. Inspect the entire spine from occiput to sacrum. Identify any bony abnormalities, penetrating injuries. Also palpate, percuss and auscultate posterior chest wall. Hypotension with bradycardia in a patient with a history suggestive of spinal injury (spinal cord damage). Other indicators of cord damage are acute urinary retention, diaphragmatic respiration, priapism (persistent abnormal penile erection), loose anal sphincter and flaccid paralysis of the limbs.

Log roll maneouvre

Analgesia
Provide relief of pain in initial management. Pain and anxiety can produce changes to the vital signs and it is important that adequate relief is provided. Usually by titrated IV dose of opiate. Avoid respiratory depression.

Definitive Treatment
The further treatment of the patient will depend on the injuries detected during the preceding examination. The highest priority is given to those that are life threatening.