Apprpoach to Trauma.pdf important for final year mbbs

Paediatric important notes

1. Approach to Trauma
Dr. Bikramjit Maity

2. Learning Objectives
●Approach to trauma
●Basic Life Support
●Advanced Trauma Life Support
●Damage control surgery and resuscitation

3. Trauma

• Trauma is defined as physiological wound or injury caused by an external source
e.g.; road traffic accidents, falls, industrial accidents, burns etc.
• Trauma is the leading cause of death in young population.

4. BLS
●Basic Life support (BLS) is a specific level of pre-hospital medical care provided
by trained responders, including emergency medical technicians, in the
absence of advanced medical care.
●BLS generally does not include the use of drugs or invasive skills, and can be
contrasted with the provision of Advanced cardiac life support (ACLS).
●CPR provided in the field buys time for higher medical responders to arrive &
provide ACLS.

5. You are at a airport and suddenly a person collapsed to the floor in front of you.
What do you do?

6. 1.ASSESS SCENE SAFETY - Assess to make sure
the scene is safe for you to respond to the down
patient.

2.ASSESS RESPONSIVENESS - Shake the
shoulder and speak to the adult asking ARE YOU
ALRIGHT? . Look at the chest and torso for
movement and normalbreathing simultaneously.

3.SHOUT FOR HELP

4.Activate emergency response system via
mobile device (if appropriate)

5.Get AED and emergency equipment (or send
someone to do so).

7. 6. LOOK FOR BREATHING AND PULSE (SIMULTANEOUSLY) - for 10 seconds

8. CARDIOPULMONARY RESUSCITATION
●Place patient In supine position on a firm and flat surface.
●Kneel down to the patient and locate the position for chest compression on
person's chest.
●LOCATION OF CHEST COMPRESSIONS - Locate the lower ⅓ of the patient's
sternum between the nipples in the midline of body
●HAND POSITION - 1. Lock your arms.
2. Place the heel of one hand over the center of the person's
chest, between the nipples.Place your other hand on top of the first hand.
3. Keep your elbows straight and position your shoulders
directly above your hands.
●FULCRUM OF MOVEMENT - Hip Joint

9. ●CHEST COMPRESSIONS : RESCUE
BREATHS - 30 : 2 with chest
compressions @ 100-120/ mins

●STERNAL DEPRESSIONS - 5-6 cm ,
press hard and fast, allow complete
recoil

●1 CYCLE OF CPR - Perform 5 cycles of
CPR (lasts approximately 2 minutes)
●If two providers are present: switch rolls
between compressor and rescue
breather every 5 cycles.

10. RESCUE BREATHING
METHODS OF RESCUE BREATHS
●Mouth-to-Mouth Rescue
●Breathing
●Mouth-to-Nose and Mouth-to-Stoma Ventilation
●Ventilation With Bag and Mask
●Ventilation With an Advanced Airway

❖ Each rescue breath should last approximately 1 second.
❖ Watch for chest rise.
❖ Allow time for the air to expel from the patient.

14. AUTOMATED EXTERNAL DEFIBRILLATOR
An AED, or automated external defibrillator, is a device that has the ability to detect
irregular heart rhythm and it automatically delivers a defibrillation shock to stop
irregular heart beat and allow normal rhythm to resume
AEDs are designed to be used
by any layperson.

Rhythms Detected - V. fib and pVT

Accept voice prompt and it delivers 200J
Biphasic DC shock

15. TRIMODAL DISTRIBUTION OF TRAUMA DEATHS

16. Death Type Timeframe Causes
Immediate
Death
Occurs within minutes of
injury
Irreversible brain injury;
Hemorrhage from injuries of: Heart, Aorta, Liver,
Lungs,
Pelvic fracture
Early Death
Occurs within hours of
arrival into
hospital
Intracranial hemorrhage;
Internal hemorrhage involving respiratory system &
abdominal organs;
Multiple injuries leading to massive blood loss;
Tension pneumothorax;
Cardiac tamponade
Late Death
Occurs day to week after
injury
Sepsis (MC); Multiple organ failure

18. Concepts of ATLS

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

19. Basic of Trauma Assessment
●Preparation - Team assembly, Equipment check.
●Triage - Sort patient by level of acuity.
●Primary Survey — (ABCDEs) with immediate resuscitation of patients with
life-threatening injuries
●Adjuncts to the primary survey and resuscitation- ECG monitoring, pulse
oximeter, resp. Rate, capnography, abg etc
●Consideration of the need for patient transfer
●Secondary survey (head-to-toe evaluation and patient history)
●Adjuncts to the secondary survey.
●Continued post-resuscitation monitoring and reevaluation
●Transfer to definitive care — ICU, ward, operating theatre or higher facility.

20. PRIMARY SURVEY
• Patients are assessed & treatment priorities established based on their
injuries, vital signs & injury mechanisms.
A Airway & c-spine protection
B Breathing
C Circulation
D Disability (neurological status)
E Exposure/environmental control

21. A - Airway
● Airway should be assessed for patency
■- is the patient able to communicate verbally?
■-inspect for any foreign bodies.
■-identifying facial, mandibular, and/or tracheal/laryngeal fractures

●Establish a patent airway while restricting cervical spine motion

●Apply cervical hard collar in suspected cervical injury.

22. AIRWAY INTERVENTIONS:
●The jaw-thrust or chin-lift maneuver often suffices as an initial intervention
●Establish a definitive airway if
■there is any doubt about the patient’s ability to maintain airway integrity.
■GCS ≤ 8
●Supplemental oxygen
●Suction

23. B - Breathing
●General principle — Adequate gas exchange is required to maximize patient
oxygenation & C02 elimination.
●Airway patency alone does not ensure adequate ventilation.
●Inspect, palpate & auscultate
- for crepitus, flail chest, sucking chest wound etc.
●Chest Xray to evaluate lung fields.

24. BREATHING INTERVENTION:
●Ventilate with 100% oxygen.
●needle decompression if tension pneumothorax suspected.
●chest tubes for pneumothorax.
●occlusive dressing to sucking chest wound

25. C - Circulation
●Haemorrhagic shock should be assumed in any trauma patient.
●Rapid assessment of hemodynamic status
- Level of consciousness
- Skin colour
- Distal pulse
- Blood pressure
Source of bleeding is usually identified by physical examination and imaging-
- chest x-ray, pelvic x-ray
- focused assessment with sonography for trauma [FAST]
- diagnostic peritoneal lavage [DPL]

26. CIRCULATION INTERVENTION:
●Establish IV access : 2 large bore peripheral venous catheter
●Initiate IV fluid therapy: 1L isotonic solution (crystalloid)
●If unresponsive to initial crystalloid therapy : Volume resuscitation by blood
transfusion.
●Fluids are administered judiciously, as aggressive resuscitation before control
of bleeding has been demonstrated to increase mortality and morbidity.
●Tranexamic acid preemptively in severely injured patients may be used

27. 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

28. GCS

29. DISABILITY INTERVENTION:
Spinal cord injury
- High dose of steroids.
ICP monitor (intracranial pressure).
Elevated ICP
- Head of bed elevated
- Mannitol
- Hyperventilation
- Emergent decompression.

30. E - Exposure
●Complete removal of clothing of the patient.
●Logroll to inspect back.
●Rectal temperature.
●Warm blanket / external warming devices
to prevent hypothermia

31. SECONDARY SURVEY
●AMPLE history:
○- Allergies
○- Medication
○- Past medical history
○- Last meal
○- Events
●Physical examination from head to toe, including rectal examination

32. ●Frequent reassessment of vitals.
●Diagnostic studies after stabilisation
○- X-rays
○- Laboratory work
○- e-FAST
○- CT examination etc.

33. DEFINITIVE CARE
●Secondary survey followed by radiographic evaluation.
●Consultation with
○-Neurosurgery
○-Orthopaedic
○-Vascular surgery
●Transfer to Definitive Care
○-Operating room
○-ICU
○-Higher level facility.

34. DAMAGE CONTROL SURGERY
Damage control surgery is defined as the rapid initial control of hemorrhage and
contamination with packing and temporary closure, followed by resuscitation in the
ICIJ, and subsequent re-exploration and definitive repair once normal physiology
has been restored.
The phases of damage control surgery (DCS) are:
●Phase 1: Surgical control of lesions to stop bleeding and contamination
●Phase 2: Physiological restoration to correct metabolic and physiological
parameters
●Phase 3: Definitive surgical repair to restore anatomy