Approach to trauma unc emergency Medicine Medical Student Lecture Series Objectives



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APPROACH TO TRAUMA

  • UNC Emergency Medicine
  • Medical Student Lecture Series

Objectives

  • Demonstrate concepts of primary and secondary patient assessment
  • Establish management priorities in trauma situations
  • Initiate primary and secondary management as necessary
  • Arrange appropriate disposition

Trauma

  • Epidemiology
    • Leading cause of death in the first 4 decades
    • 150,000 deaths annually in the US
    • Permanent disability 3 times the mortality rate
    • Trauma related dollar costs exceed $400 billion annually

Why ATLS?

  • Trimodal death distribution
    • First peak instantly (brain, heart, large vessel injury)
    • Second peak minutes to hours
    • Third peak days to weeks (sepsis, MSOF)
  • ATLS focuses on the second peak…..Deaths from:
    • TBI, Epidurals, Subdurals, IPH…
    • Basilar skull fractures, orbital fractures, NEO complex injury…
    • Penetrating neck injuries…
    • Spinal cord syndromes…
    • Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …
    • Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries
    • Bladder rupture, renal contusion, renal laceration, urethral injury…
    • Pelvic fractures, femur fractures, humerus fractures…
  • You get the point

Concepts of ATLS

  • Treat the greatest threat to life first
  • The lack of a definitive diagnosis should never impede the application of an indicated treatment
  • A detailed history is not essential to begin the evaluation
  • ABCDE” approach

Initial Assessment and Management

  • An effective trauma system needs the teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialists
  • Trauma roles
    • Trauma captain
    • Interventionalists
    • Nurses
    • Recorder

Trauma Team

Primary Survey

  • Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms
  • ABCDEs of trauma care
    • A Airway and c-spine protection
    • B Breathing and ventilation
    • C Circulation with hemorrhage control
    • D Disability/Neurologic status
    • E Exposure/Environmental control

Airway

  • How do we evaluate the airway?

A- Airway

  • Airway should be assessed for patency
    • Is the patient able to communicate verbally?
    • Inspect for any foreign bodies
    • Examine for stridor, hoarseness, gurgling, pooled secrecretions or blood
  • Assume c-spine injury in patients with multisystem trauma
    • C-spine clearance is both clinical and radiographic
    • C-collar should remain in place until patient can cooperate with clinical exam

Airway Interventions

  • Supplemental oxygen
  • Suction
  • Chin lift/jaw thrust
  • Oral/nasal airways
  • Definitive airways
    • RSI for agitated patients with c-spine immobilization
    • ETI for comatose patients (GCS<8)

Difficult Airway

Breathing

  • What can we look for clinically to assess a patient’s ‘breathing’ status?

B- Breathing

  • Airway patency alone does not ensure adequate ventilation
  • Inspect, palpate, and auscultate
    • Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds
  • CXR to evaluate lung fields

Flail Chest

Subcutaneous Emphysema

Breathing Interventions

  • Ventilate with 100% oxygen
  • Needle decompression if tension pneumothorax suspected
  • Chest tubes for pneumothorax / hemothorax
  • Occlusive dressing to sucking chest wound
  • If intubated, evaluate ETT position

Chest Tube for GSW

What would we do for this patient who is having difficulty breathing?

C- Circulation

  • Hemorrhagic shock should be assumed in any hypotensive trauma patient
  • Rapid assessment of hemodynamic status
    • Level of consciousness
    • Skin color
    • Pulses in four extremities
    • Blood pressure and pulse pressure

Circulation Interventions

  • Cardiac monitor
  • Apply pressure to sites of external hemorrhage
  • Establish IV access
  • Cardiac tamponade decompression if indicated
  • Volume resuscitation
    • Have blood ready if needed
    • Level One infusers available
    • Foley catheter to monitor resuscitation

D- Disability

  • Abbreviated neurological exam
    • Level of consciousness
    • Pupil size and reactivity
    • Motor function
    • GCS
      • Utilized to determine severity of injury
      • Guide for urgency of head CT and ICP monitoring

GCS

  • EYE
  • VERBAL
  • MOTOR
  • Spontaneous 4
  • Oriented 5
  • Obeys 6
  • Verbal 3
  • Confused 4
  • Localizes 5
  • Pain 2
  • Words 3
  • Flexion 4
  • None 1
  • Sounds 2
  • Decorticate 3
  • None 1
  • Decerebrate 2
  • None 1

Disability Interventions

  • Spinal cord injury
    • High dose steroids if within 8 hours
  • ICP monitor- Neurosurgical consultation
  • Elevated ICP
    • Head of bed elevated
    • Mannitol
    • Hyperventilation
    • Emergent decompression

E- Exposure

Always Inspect the Back

Lets do a Case! Stabilize this patient

Case

  • 28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”.
  • HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask
  • Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle

ABCDE

  • What are the management priorities at this time?
  • What are this patient’s possible injuries?
  • What are the interventions that need to happen now?

Secondary Survey

  • AMPLE history
    • Allergies, medications, PMH, last meal, events
  • Physical exam from head to toe, including rectal exam
  • Frequent reassessment of vitals
  • Diagnostic studies at this time simultaneously
    • X-rays, lab work, CT orders if indicated
    • FAST exam

HEENT

  • What are the names of these signs?

Seatbelt Sign

Diagnostic Aids

  • Standard trauma labs
    • CBC, K, Cr, PTT, Utox, EtOH, ABG
  • Standard trauma radiographs
    • CXR, pelvis, lateral C-spine (traditionally)
  • CT/FAST scans
  • Pt must be monitored in radiology
  • Pt should only go to radiology if stable

Simple Pneumothorax

Tension Pneumothorax

  • How do you treat this?

Hemothorax

  • Is this patient lying or upright?

Widened Mediastinum

  • What disease process does this indicate?

Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption

  • What should this injury make you worry about?

Epidural Hematoma

Subdural Hematoma with SAH

Abdominal Trauma

  • Common source of traumatic injury
  • Mechanism is important
    • Bike accident over the handlebars
    • MVC with steering wheel trauma
  • High suspicion with tachycardia, hypotension, and abdominal tenderness
  • Can be asymptomatic early on
  • FAST exam can be early screening tool

Abdominal Trauma

  • Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis
  • Be suspicious of free fluid without evidence of solid organ injury

Splenic Injury

  • Most commonly injured organ in blunt trauma
  • Often associated with other injuries
  • Left lower rib pain may be indicative
  • Often can be managed non-operatively
  • Spleen with surrounding
  • blood
  • Blood from spleen
  • Tracking around
  • liver

Liver injury

  • Second most common solid organ injury
  • Can be difficult to manage surgically
  • Often associated with other abdominal injuries
  • Liver contusions

What’s wrong with this picture?

  • May only see the nasogastric tube appear to be coiled in the lung.
  • Left > right due to liver protection of the diaphragm.
  • Trace the Diaphragm
  • Outline. Where is the
  • Diaphragm on the left?
  • Abdominal contents
  • Up in the chest on the
  • left

Hollow Viscous Injury

  • Injury can involve stomach, bowel, or mesentery
  • Symptoms are a result from a combination of blood loss and peritoneal contamination
  • Small bowel and colon injuries result most often from penetrating trauma
  • Deceleration injuries can result in bucket-handle tears of mesentery
  • Free fluid without solid organ injury is a hollow viscus injury until proven otherwise
  • Mesenteric and bowel injury from blunt abdominal
  • trauma. Notice the bowel and mesenteric disruption.
  • bowel
  • mesentery

CT Scan in Trauma

  • Abdominal CT scan visualizes solid organs and vessels well
  • CT does NOT see hollow viscus, duodenum, diaphram, or omentum well
  • Some recent surgery literature advocates whole body scans on all trauma
    • Keep in mind that there is an increase in mortality related to cancer from CT scans

FAST Exam

  • Focused Abdominal Scanning in Trauma
  • 4 views: Cardiac, RUQ, LUQ, suprapubic
  • Goal: evaluate for free fluid
  • See normal
  • Liver and kidney
  • Free fluid in Morrison's
  • Pouch between liver and
  • kidney
  • momor
  • Morrison’s pouch

Non-accidental Trauma

  • Key is SUSPICION!!!
  • Incongruent stories of mechanism
  • Delay in seeking treatment
  • Multiple stages of injuries
  • Pattern Injuries
  • Multiple hospital visits
  • Injury mechanism beyond the scope of the age of child (6week old rolled over off the bed)
  • Bite marks, submersion injury, cigarette burns

Disposition of Trauma Patients

  • Dictated by the patient’s condition and available resources i.e. trauma team available
  • Transfers should be coordinated efforts
    • Stabilization begun prior to transfer
    • Decompensation should be anticipated
  • Serial examinations
    • CHI with regain of consciousness
    • Abdominal exams for documented blunt trauma
    • Pulmonary contusions with blunt chest trauma

Summary

  • Trauma is best managed by a team approach (there’s no “I” in trauma)
  • A thorough primary and secondary survey is key to identify life threatening injuries
  • Once a life threatening injury is discovered, intervention should not be delayed
  • Disposition is determined by the patient’s condition as well as available resources.

Sources

  • ATLS Student Course Manuel, 6th edition.
  • Rosen’s Emergency Medicine Concepts and Clinical Practice, 5th edition.
  • Emergency Medicine A Comprehensive Study Guide, 5th edition.

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