Acute trauma management

first aid management and primary trauma care

1. Acute trauma management Dr Shambhavi Sharma 1 st year Resident

2. Introduction Traumatic injuries can range from minor isolated wounds to complex injuries involving multiple organ systems. All trauma patients require a systematic approach to management to maximize outcomes and reduce the risk of undiscovered injuries.

3. Breakdowns in the care plan and medical mismanagement typically occur due to one or more of four potential problems Communication breakdowns Failures in situational awareness ( eg,failure to perform primary and secondary survey, failure to recognize shock, failure to anticipate blood transfusion needs, failure to modify standard management for higher risk patients) Staffing or workload distribution problems Unresolved conflicts

4. Management PREPARATION Pre arrival preparation : Early notification enables emergency department (ED) staff to do the following: Notify additional personnel ( eg , ED staff, trauma surgery, obstetrics, orthopedics, radiology, interpreter services) Assure resources are available ( eg , ultrasound, CT, operating room space) Prepare for anticipated procedures ( eg , tracheal intubation, chest tube) Prepare for blood transfusion

5. The primary survey is organized according to the injuries that pose the most immediate threats to life Consists of : A irway assessment and protection (maintain cervical spine stabilization when appropriate) B reathing and ventilation assessment (maintain adequate oxygenation) C irculation assessment (control hemorrhage and maintain adequate end-organ perfusion) D isability assessment (perform basic neurologic evaluation) E xposure, with environmental control (undress patient and search everywhere for possible injury, while preventing hypothermia)

6. Airway management Airway obstruction is a major cause of death immediately following trauma May be obstructed by the tongue, a foreign body, aspirated material, tissue edema, or expanding hematoma.

7. Assessment Conscious patient: 1. Begin by asking the patient a simple question A clear accurate response verifies the patient's ability to mentate , phonate, and to protect their airway, at least temporarily 2. Observe the face, neck, chest, and abdomen for signs of respiratory difficulty, including tachypnea, accessory or asymmetric muscle use, abnormal patterns of respiration, and stridor.

8. 3.Inspect the oropharyngeal cavity for disruption; injuries to the teeth or tongue; blood, vomitus, or pooling secretions. Note if there are obstacles to the placement of a laryngoscope and endotracheal tube. 4. Inspect and palpate the anterior neck for lacerations, hemorrhage, crepitus, swelling, or other signs of injury. Palpation of the neck also enables identification of the landmarks for cricothyroidotomy .

9. In the unconscious patient, the airway must be protected immediately once any obstructions are removed indications of endotracheal entubation : life-threatening hypoxaemia caused by airway obstruction not relieved by simple means          inadequate facemask seal leading to insufficient ventilatory support                 to protect the lower respiratory tract from aspiration of blood or stomach contents

10. to preserve the airway from anticipated occlusion by: oedema          haematoma          displacement of laryngotracheal fracture     to regulate intracranial pressure by controlling CO 2       to provide a therapeutic ventilatory strategy for hypoxaemia :           flail chest              pulmonary contusion     

11. Devices that should be available at the bedside include: Suction ( ie , multiple pumps and tips) Bag-valve mask attached to high flow oxygen Oral and nasal airways Rescue airways ( eg , Laryngeal mask airway) Endotracheal tube introducer ( ie , gum elastic bougie) Video laryngoscope, if available Cricothyrotomy kit Endotracheal tubes in a range of sizes Laryngoscopes, including a range of different sized blades and handles Hard cervical collar

12. checklists improve the efficiency and reduce the complications associated with airway mangement of trauma patients by around 7% Smith KA et al Acad Emerg Med. 2015;22(8):989. Epub 2015 Jul 20.

13. Assume that an injury to the cervical spine has occurred in all blunt trauma patients until proven otherwise. patients with  isolated  penetrating trauma, no secondary blunt injury, and an intact neurologic examination typically do not have an unstable spinal column injury Routine spinal immobilization is not recommended following penetrating injury, and has been demonstrated to be associated with increased mortality Application of a cervical collar

14. The anterior portion of the cervical collar should be temporarily removed and manual in-line stabilization maintained for all patients with blunt traumatic injuries receiving airway interventions, including bag-mask ventilation

15. Management in c-spine injuries • Almost all airway maneuvers, including jaw thrust, chin lift, head tilt, and oral airway placement, result in some degree of C-spine movement. To secure the airway with direct laryngoscopy , manual in-line stabilization (MILS) of the neck is the standard care of these patients in the acute stage.

16. Manual in-line immobilization (MILI) maneuver that applies forces to the head and neck to offset any applied forces to the spine that occur during airway management There should not be additional forces applied that result in axial traction, with the overall goal of keeping the head and neck in the same position during laryngoscopy .

17. MILS is best accomplished by having two operators in addition to the physician who is actually managing the airway. The first operator stabilizes and aligns the head in neutral position without applying cephalad traction. The second operator stabilizes both shoulders by holding them against the table or stretcher. The anterior portion of the hard collar, which limits mouth opening, may be removed after immobilization.

18. Other measures and techniques: including the McCoy laryngoscope, rigid fiberoptic video laryngoscope cricothyroidotomy

19. Breathing and ventilation  — Once airway patency is ensured, assess the adequacy of oxygenation and ventilation Chest trauma accounts for 20 to 25 percent of trauma-related deaths, in large part due to its harmful effects on oxygenation and ventilation

20. Assessment : inspect the chest wall looking for signs of injury, including asymmetric or paradoxical movement ( eg , flail chest), auscultate breath sounds at the apices and axillae , and palpate for crepitus and deformity. In unstable patients, obtain a portable chest radiograph. Tension pneumothorax , massive hemothorax , and cardiac tamponade impose immediate threats life Ultrasound can provide important information about all these diagnoses during this portion of the assessment.

21. FAST Scan in chest trauma

22. Chest trauma

23. 75% patients with thoracic trauma can be managed expectantly However, thoracic injury is a contributing factor in 75% of all trauma related deaths

24. All hemodynamically stable patients with suspected chest trauma should undergo chest x ray Further diagnostics and management vary for penetrating and blunt chest trauma

25. Penetrating thoracic injuries Chest wall injury Low velocity: stab wounds, may involve intercostal artery laceration High velocity: gunshot wounds, more significant chest wall injury Pain control, local wound care, pulmonary mechanical support

26. Open pneumothorax Soft tissue defect ≥2/3 circumference of trachea Air entrainment into pleural space due to negative intrathoracic pressure during inspiration Managed with supplemental oxygen, intubation when oxygenation or ventilation inadequate Definitive treatment with chest tube placement Occlusive dressing taped on three sides to create a flap valve effect used as temporizing measure

27. Lung injuries Pneumothorax and hemothorax Hemothorax is assumed in presence of traumatic pneumothorax Managed with 32 to 36Fr tube thoracostomy Mechanical ventilation may be necessary if difficulty oxygenating or ventilating

28. Tension pneumothorax Clinically unstable patient with chest trauma: high degree of suspicion for tension pneumothorax Progressive accumulation of air pressurizes pleural caity pushing mediastinum to opposite side Patient can rapidly develop obstructive shock, with precipitous fall in blood pressure, and cardiac arrest with PEAs

29. Circulation While circulation is assessed, two large-bore (16 gauge or larger) intravenous (IV) catheters are placed, most often in the antecubital fossa of each arm, and blood is drawn for testing, particularly for blood typing and crossmatch . Intraosseous cannulation or central venous catheter placement (ideally under ultrasound guidance) can be performed

30. Hemorrhage

31. Shock may exist even in the setting of "normal" vital signs patients on cardioactive medications such as beta blockers Young patients without underlying comorbidities A bradycardic response to penetrating intraperitoneal injury, may be vagally mediated

32. DYNAMIC” MEASURES OF INTRAVASCULAR VOLUME CVP change to fluid challenge IVC/SVC Caliber changes in response to breathing Stroke Volume Variation (SVV) Pulse Pressure Variation (PPV) Dynamic Changes in Aortic Flow Velocity/Stroke Volume Assessed by Echocardiography

33. The passive leg-raising test PLR is based on the principle that it can induce an abrupt increase in venous return secondary to auto-transfusion of peripheral blood from capacitive veins of the lower part of the body

34. Disability Glasgow Coma Scale (GCS) score, assessments of pupillary size reactivity gross motor function sensation

35. Exposure completely undressed and that his or her entire body is examined for signs of injury during the primary survey Missed injuries pose a grave threat Regions often neglected include the scalp, axillary folds, perineum, and in obese patients, abdominal folds. Penetrating wounds may be present anywhere.

36. While maintaining cervical spine precautions, examine the patient's back; do not neglect examination of the gluteal fold and posterior scalp.

37. Chest trauma

38. 75% patients with thoracic trauma can be managed expectantly However, thoracic injury is a contributing factor in 75% of all trauma related deaths

39. All hemodynamically stable patients with suspected chest trauma should undergo chest x ray Further diagnostics and management vary for penetrating and blunt chest trauma

40. Penetrating thoracic injuries Chest wall injury Low velocity: stab wounds, may involve intercostal artery laceration High velocity: gunshot wounds, more significant chest wall injury Pain control, local wound care, pulmonary mechanical support

41. Open pneumothorax Soft tissue defect ≥2/3 circumference of trachea Air entrainment into pleural space due to negative intrathoracic pressure during inspiration Managed with supplemental oxygen, intubation when oxygenation or ventilation inadequate Definitive treatment with chest tube placement Occlusive dressing taped on three sides to create a flap valve effect used as temporizing measure

42. Lung injuries Pneumothorax and hemothorax Hemothorax is assumed in presence of traumatic pneumothorax Managed with 32 to 36Fr tube thoracostomy Mechanical ventilation may be necessary if difficulty oxygenating or ventilating

43. Tension pneumothorax Clinically unstable patient with chest trauma: high degree of suspicion for tension pneumothorax Progressive accumulation of air pressurizes pleural caity pushing mediastinum to opposite side Patient can rapidly develop obstructive shock, with precipitous fall in blood pressure, and cardiac arrest with PEAs

44. Clinical signs of tension pneumothorax Tachycardia Tachypnea Hypoxia Hypotension refractory to fluids Hyper expanded chest Hyperresonant percussion notes Increased JVP/CVP Increased airway pressure

45. Heart and great vessels Over 80% of patients suffering trauma to heart and great vessels expire on site Cardiac injury usually occurs through anterior chest injury between the midclavicular lines Right ventricle is most commonly involved Atrial injuries less common and less severe unless multi chamber injury occurs

46. Pericardial tamponade suspected if patient has distended neck veins, muffled heart sounds and signs of shock(Beck’s triad) Even 50mL in pericardial sac can cause tamponade

47. Diagnosis Transesophageal echocardiography is diagnostic modality of choice in hemodynamically stable patients FAST scan and transthoracic echo can also identify cardiac injury Presence of pericardial fluid on echo: emergent operative exploration Subxiphoid pericardial exploration in case of multiple injuries requiring emergent intervention

48. Subxiphoid pericardial exploration Performed under G.A Diaphragm exposed via subxiphoid approach and longitudinal incision made to expose pericardium 1 cm longitudinal incision given on pericardium to drain fluid Straw colored: negative examination Blood: definitive exploration and cardiorrhaphy

49. Diaphragmatic injuries 31% may not have abdominal tenderness 40% have normal chest x rays Undiagnosed diaphragmatic injury associated with high risk of bowel herniation Primary repair done with non absorbable horizontal mattress sutures

50. Aerodigestive system Associated with subcutaneous emphysema along with visible air fluid levels in chest x ray Tracheobronchial injury: securing airway is first priority Fibreoptic bronchoscopy to evaluate injury Esophageal injury: Secondary mediastinitis associated with very high mortality Esophagoscopy to assess mucosal injury Esophagography with aqueous contrast followed by barium can rule out esophageal injury

51. Blunt thoracic injuries 40-50% of all motorvehicle accidents associated with blunt thoracic injuries Use of bedside ultrasound can help diagnose pneumothorax with greater accuracy than traditional upright chest x ray Chest x ray and CT scan

52. Chest wall injury Chest wall or rib contusion/fracture Flail chest involves fracture of multiple ribs at multiple places separating a segment which moves independently from chest wall Underlying pulmonary contusion in flail chest can lead to respiratory compromise Early placement of epidural catheter can help prevent respiratory insufficiency and pneumonia

53. Surgical internal fixation of ribs is a newer technique which can reduce ventilator requirement and enhance recovery