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Primary trauma care

  1. 1. Dr. Faiez Alhmoud Department of Surgery Albashir Teaching Hospital – MOH – Amman Jordan
  2. 2. • Trauma epidemiology & the burden of trauma • Rapid & accurate assessment of the patient‟s condition (the concept of triage ) • How to identify common life-threatening injuries (Primary Survey) • Adequate resuscitation, stabilization and re- evaluation of patients according to the priority. • Performing a secondary survey and planing the next stage of care
  3. 3. Our Roads is a cause Our Attitude as a cause 13-11-2013 08:12 AM ….. [8/11/2013 12:35:08 AM] 16/11/2013 17/11/2013
  4. 4.  The leading cause of death in age group 2-40 years (great impact on family)  The third leading cause of death all over the world in all age group & in 2020 may be second cause of death  420 million injured / year worldwide  5.8 million deaths / year worldwide (>9 people/min. )  3 patients permanently disabled / death  >15% of hospital beds are consumed by injury  Great economic & social loss (2% of budgets for health or $ 750 bil. ).  Most expensive medical problem in terms of lost wages, initial care, rehabilitation, and lifelong maintenance  The neglected disease of modern developing nations Epidemiology Overview
  5. 5. Can this outcome be better? How…? TRAUMA DEATH FACTS •1 in 3 traumatic deaths occurred in hospital could have been prevented •Some deaths might be due to failure of simple early management (golden hour)
  6. 6. 1.Early pre-hospital care 2.Early transport 3.Aggressive resuscitation and interventions in ED 4.Continued care in ICU if needed Golden hour • If you are critically injured, you‟ll have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -but something has happened in your body that is irreparable” . Dr. R. Adams Cowley “Father of Trauma Medicine”
  7. 7.  The first peak……within minutes  50% - Death at the time of injury  apnea due to severe brain injury, high spinal cord injury  Primary injury to vital organs such as brain, heart, great vessels..  The injuries are nonsurvivable but rapid treatment and transfer may salvage some patients  Primary prevention
  8. 8. • 30% - Hours from the first peak • Patients have the best chance for survival if definitive care is available within an hour after injury • Morbidity and mortality are prevented by avoidance of a secondary injury due to : hypoxia, hemorrhage, (intracranial hematoma, major hemorrhage from viscera, bones fractures and vessels or hemothorax) • ATLS [Advanced Trauma Life Support] →9% • Prehospital and ER care Hero Or Zero?
  9. 9.  20%  Death occurs days or weeks after the injury in the ICU  Sepsis and or multi-organ failure is the usual cause  Advances in intensive care reduce some deaths Improvements in initial management on admission reduce the 3rd peak morbidity and mortality
  10. 10. Patients have the 1st & best chance for survival if definitive care is available within an hour after injury
  11. 11. Conflict Evacuation time (hour) Mortality rate (%) World War I 18 18 World War II 4-6 3.3 Korea 2-4 2.4 Vietnam Iraq and Afghani.. 1-2 30`-60` 1.8 1 WW I: 1914World War II: 1939Korean War: 1951 Viet Nam War : 1965-1972 Emergencies don‟t give us a second chance…..
  12. 12.  Physiologic approach  Time is of the essence  Treat greatest threat to life first  Definitive diagnosis less important  Do no further harm  Teamwork required to succeed Logical Sequence 1- Preparation 2- Triage 3- Primary Survey 4- Resuscitation 5- Secondary Survey 6- Definitive Management With frequent repetition of the primary & secondary surveys to confirm pt‟s response to therapy ATLS "When I can provide better care with limited resources” James K. Styner 1978
  13. 13. ATLS provides a common language These guidelines seek to set achievable standards for trauma treatment services which could realistically be made available to almost every injured person
  14. 14. •On the scene, the EMS action is to prevent any further harm to victims •The “primary survey” reveals obvious injuries .It includes limited interventions Airway control Oxygenation and ventilation support Hemorrhage control Spinal Immobilization Rapid Transport to appropriate facility Victim is placed on a long back-board Anti-shock trousers placed IV lines if time allows History taking ( include events )
  15. 15. “Triage : a sorting of injured people according to their need for emergency medical attention to get the : Right……….. patient to the Right……….. place at the Right……….. time with the Right……….. care provider“ Simple triage & rapid treatment “START” assesses RPM: • Respiration • Pulse • Mental Status
  16. 16. • The approach In dealing with the trauma victim cannot be routine “history, exam ,tests, diagnosis ,then treating the patient.” •Therapeutic interventions must be made “on the fly,” before the full evaluation can be completed.(Primary Survey) • A trauma surgeons have “threshold of action” a point at which the physician will aggressively intervene even without traditional “proof” of the diagnosis. • For example, the combination of low blood pressure, unilaterally decreased breath sounds, and respiratory distress Triggers a response from the physician. A chest tube is placed immediately, rather than waiting until an x-ray can “prove” the diagnosis
  17. 17.  Airway obstruction  Tension pneumothorax  Sucking chest wound  Cardiac tamponade  Massive hemothorax  Massive bleeding  Large scalp lacerations  Pelvic and other long bone fractures
  18. 18. Priorities are the same for all !!!!
  19. 19. • A quick look tells you a lot about the patient‟s status.  Is he breathing?  Does he look at you?  Is the C-spine immobilized? • Address the patient directly. If the patient gives any meaningful answer, you will know that: 1) There is an intact airway 2) Ventilation is occurring 3) Circulation is present. 4) The brain is reasonably functional If the C-spine is not immobilized in any patient at risk ask someone to stabilize it now
  20. 20. Look for : - Snoring, gurgling, stridor or hoarseness - Use of accessory muscles or “seesaw “ breathing. - Agitation or obtundation - F.B ( airway debris, blood, vomitus, teeth…. - Unconscious. - Cyanosis. - The likehood of difficult airway (Possible airway compromise)
  21. 21.  Continuous observation and “high index of suspicion” in patients with : - Maxillofacial injury - Soft-tissue injury of neck - Facial or neck burns - Neck surgical emphysema - Laryngeal pain with swallowing or talking
  22. 22. Assume C -spine injury in any pt. with ;  -Multi-trauma patient  -Blunt injury above clavicle  -Pain of neck with or without neurologic deficit.  -Unconscious patient (Immobilizing devices or special maneuvers are recommended)
  23. 23. -Chin lift / modified jaw thrust -Remove F.B & suctioning -Oropharyngeal or Nasopharyngeal airway -Laryngeal mask airway -Definitive airway -Reassess frequently Jaw Thrust If no gag reflex, prepare for intubation -All patients with GCS <9 need intubation - IN Suspected C- spine injury do not head tilt chin lift
  24. 24. Three Varities: 1-Orotracheal tube 2-Nasotracheal tube 3-Surgical airway. -Cricothyroidotomy -Tracheostomy
  25. 25. Consider the need for advanced airway management techniques in: • Persisting airway obstruction • Penetrating neck trauma with (expanding) haematoma • Apnoea • Hypoxia • Severe head injury • Severe chest trauma • Maxillofacial injury. Indications for advanced ( definitive) airway
  26. 26. (LOOK) • Penetrating injury • Presence of flail chest • Sucking chest wounds • Use of accessory muscles? • Cyanosis (FEEL) • Tracheal shift • Broken ribs • Subcutaneous emphysema • Percussion is useful for diagnosis of haemothorax and pneumothorax. (LISTEN) • Pneumothorax (decreased breath sounds on site of injury) • Detection of abnormal sounds in the chest. The respiratory rate and effort are sensitive indicators of chest trauma. They should be monitored and recorded at frequent intervals. expose the patient adequately without causing hypothermia
  27. 27. Pericardiocentesis oxygen and analgesics insert a CTTDCover the defect. & Insert (CTTD) Urgently decompress -If available, maintain the patient on oxygen until complete stabilization is achieved.
  28. 28.  Quickly re-check airway patency, breathing and oxygen supply before assessing circulation. Assess the features of hypovolemia -Cold, clammy extremities -Poor capillary refill -Tachycardia (>120 beats /minute) -Low blood pressure (systolic blood pressure <80mmHg) -Altered consciousness (hypovolemia alone can cause decreased conscious level)
  29. 29. • Children • Elderly • Athletes • Pregnancy • Medications
  30. 30. Blood pressure (SBP) can be estimated from peripheral pulse presence Largest blood loss in thorax, abdomen, pelvis, extremities Non-hemorrhagic shock  -Cardiogenic shock  -Tension pneumothorax  -Neurogenic shock 60 7080 90
  31. 31. Circulation and haemorrhage control treatment options include:  Warm fluids (crystalloids) up to 2lit. Or 20ml/kg  Arrest bleeding by direct local pressure  Arrest bleeding by splinting bones & pelvis  Avoid tourniquets and if they must be used, the duration of application must be monitored  Central line if inotropes / vasopressors are needed  Urinary catheter  Warm blood and  Blood products  Surgery („damage control‟ or definitive)
  32. 32.  There is a rapid neurological assessment  Assessing AVPU is quick and easy to do  ALERT - GCS 14-15  VERBAL STIMULATION RESPONSE - GCS 9 – 13  RESPONDS TO PAIN ONLY - GCS 4 – 8  UNRESPONSIVE - GCS 3  It is a baseline for more detailed neurological examination carried out in the secondary survey
  33. 33.  Fully expose the patient whilst assuming that other injuries are present  Prevent hypothermia by controlling room temperature or covering the patient with blankets immediately after examination.  To expose the patient, use scissors to cut along the seams of clothes to avoid worsening any injury and ensure minimal movement of the patient.  Do not forget to do a rectal examination whilst log rolling the patient Findings on rectal examination • Rectal bleeding or bone spicules suggest a pelvic fracture • A high riding prostate suggests urethral injury You may miss injuries if you do not fully expose the patient
  34. 34. Almost every patient with severe trauma should have a cross-table C-spine x-ray, chest x-ray, and pelvis x-ray. The rationale: Neck pain may be missed in a massively-injured patient, and the cost of missing a cervical fracture is great. The chest may have significant internal injury without external tenderness. Pelvic fractures are often present in patients with trunk trauma, and are often missed. Order these important x-rays before the patient leaves the emergency department for other care
  35. 35.  Stable hemodynamics.  Stable oxygen saturation.  Normal temperature.  Urinary output > 1ml /kg/hr.  No requirement of inotropic support.  Lactate level below 2 mmol / L.  No cogaulation disturbance.
  36. 36.  Is the airway patent and secure?  Is the patient receiving high flow oxygen?  Is the cervical collar in place?  Are all the tubes in place? i.e. urinary catheter, nasogastric tube and intravenous lines  Have blood samples been sent to appropriate laboratories?  Are the vital signs being recorded every 5 minutes?  Have the X-ray forms been filled? Only then can you consider a secondary survey
  37. 37. Key Components  History  Physical examination: Head-to-toe  “Tubes and fingers in every orifice”  Complete neuro-exam  Special diagnostic tests and X-rays  Monitoring and resuscitation  Special procedures  Re-evaluation
  38. 38. The history must include…….. Remember “SAMPLE”  S Symptoms  A Allergies  M Medications  P Previous medical/ surgical history  L Last meal (Time)  E Events / Exact circumstances
  39. 39. Examination of all body regions: Head & Face Neck Chest Abdomen Pelvis Extremities Neurological examination + pupils + sensation Region by region, look for: •Deformities , swellings & movements limitations •Contusions , abrasions, lacerations, punctures & penetrations •Burns •Tenderness •Pulses •Tone, power, motor
  40. 40.  Blood for lab tests can be drawn through the second IV catheter. This insures that there is no delay in starting fluids via the first  At a minimum, the victim of trauma should have a baseline blood count and urinalysis.  Severely injured patients should have a CBC, KFT, UA, electrolytes, blood gases, clotting studies, and type & crossmatch.
  41. 41.  Common special procedures for trauma are 1) FAST 2) CT of the brain, 3) CT of the abdomen and pelvis 4) Laparoscopy ??! 5) DPL • Special procedures should only be ordered when: the patient is sufficiently stable that there is little likelihood of deterioration during the time of the testing the information desired from the procedure cannot be obtained in other ways the test is necessary to determine the next appropriate step of therapy
  42. 42.  During and after the secondary survey, the physician monitors the effects of prior resuscitation efforts. This is primarily through patient color, skin temperature, mental status, blood pressure, respiratory rate, and pulse rate.  If the patient does not respond to fluid infusion, a CVP monitoring catheter must be placed.A low CVP (less than 6 indicates the need for further fluidA high CVP raises suspicion of obstructive shock The combination of inappropriate bradycardia with systolic pressures of around 80, warm extremities, and a normal CVP reading is typical of spinal shock.
  43. 43. The pulse oximeter provides a useful, rapid method of monitoring oxygenation in the patient with severe pulmonary injury. Progressive respiratory distress, or hypoxemia despite supplemental oxygen, warrants endotracheal intubation
  44. 44. Paracentesis is a rapid method of determining the need for abdominal surgery. Paracentesis (peritoneal lavage) is not needed for patients who: 1) Have a reliable and normal abdominal exam . 2) Are fully stable to wait for CT scanning, or 3) Urgently need abdominal surgery based on other findings. Assuming no contraindication, perform paracentesis on the potentially unstable trauma victim with possible abdominal injury who does not already have indications for abdominal surgery Assume that any trauma patient with decreased level of consciousness has abdominal injury until excluded by paracentesis ,FAST or CT scan Any patient with a gunshot wound requires exploration, so paracentesis is not indicated. However, peritoneal lavage may be helpful in the stabbing victim to rule out bowel perforation
  45. 45.  Obstructed airway is opened and maintained before hypoxia leads to death or permanent disability.  Impaired breathing is supported till the pt.is able to breath without assisstance  Bleeding is promptly stopped  Shock is recognized and treated  The consequences of brain injury are lessened  Intestinal and other abdominal injuries are promptly recognized and repaired.  Potentially disabling extremity injuries are corrected.  Potentially unstable spinal cord injuries are recognized and managed  Medications for the above services and for the minimization of pain are readily available when needed  What resources are available in the hospital?  Then may require surgery and/or intensive care or transfer
  46. 46. The patient does not leave the emergency department for definitive care (whether to the operating room or to a higher care facility or to ICU) until the secondary survey and critical testing are complete
  47. 47. Many of trauma related deaths are preventable, and its time to realize this fact.