Initial Management of the Trauma Patient

Initial Management of the Trauma Patient

1. Initial management of Trauma patients Dr. Hadi munib Oral and Maxillofacial surgery resident

2. outline Assessment of the severity of the injury Glasgow Trauma Scale Primary Surveys: ABC Airway Maintenance Breathing Circulation Head and Neck area References

3. Assessment of severity Significant data exist to suggest that death from trauma has a trimodal distribution: First Peak: Death within seconds; Brain injury Second Peak: Death within the first few hours of injury; Golden Hour Third Peak: Death after Days or weeks of injury; Sepsis or MOF Triage.

4. Non-urgent injuries: 80% of all injuries Urgent injuries – Not life threatening: 10 – 15% Urgent injuries – Life Threatening: 5% of all injuries but 50% of deaths by trauma. Assessment of severity

5. Vital Signs: BP HR RR Temperature Arterial oxygen tension (PaO2) [70 and 100 mm Hg.] Assessment of severity

6. Glasgow trauma Scale

7. Trauma scale and revised trauma scale The extent of injury to vital systems to provide proper triage and treatment of the patient. Trauma Score incorporated five variables: GCS, RR, Respiratory expansion, SBP, and capillary refill.

8. Primary surveys Airway Maintenance and C-Spine Breathing Circulation Disability Exposure

9. Airway Maintenance and c-spine Highest Priority; Methods Chin-Lift Jaw Thrust Oro-Pharyngeal airway Naso-Pharyngeal airway Endo-tracheal intubation Tracheostomy Cricothyroidotomy

10. breathing Look Listen Feel Exchange of air does not mean adequate ventilation

11. Pneumothorax A defect in the chest wall, allowing the air to be moved in and out of the pleural cavity with each respiration. Graded as Small 15- 60% or large > 60% Open or closed

12. Open pneumothorax Open wound Collapse on inspiration, Slight expansion on expiration Coverage of the defect with sterile occlusive dressing Chest tube.

13. Closed pneumothorax Blunt Trauma, Fractured Rib Hyper-Resonance and Absent breath sounds Upright Chest X-Ray Coverage with occlusive dressing and chest tube [Where to place it?] Midclavicular line or Mid-Axillary 2 nd intercostal space or 5 th intercostal space

14. Tension Pneumothorax One way valve Trachea and mediastinum are displaced, compression on inferior vena cava PEEP Life threatening Large bore needle (14-16 Gauge) 2 nd intercostal space Chest Tube

15. Tension PneumoThorax Severe respiratory distress Hypotension Unilateral absence of breath sounds Hyper resonance to percussion over affected hemithorax Neck vein distention (can be absent in hypovolemic patients) Tracheal deviation (late finding—not necessary to confirm clinical diagnosis) Cyanosis ( preterminal ) Rapid onset can occur after intubation and positive pressure ventilation

16. Hemothorax Blood collection in pleural cavity due to a penetrating Trauma Hypovolemic Shock, Hypotension, a decreased cardiac output, and metabolic acidosis. Treatment consists of Restoration of the circulating blood volume with transfusion of fluids through large-bore intravenous lines Control of the airway and support of the ventilation Drainage of the accumulated blood from the pleural cavity 5 th intercostal space.

17. Flail Chest Multiple Rib fractures; Paradoxic Breathing  Visually obvious Relatively high Morbidity at 12 to 50%. Management: I nitial stabilization of the loose segment with an external splint. [atelectasis if used for more than 30 minutes] Intercostal nerve blocks to block the pain from the fractured ribs A volume-cycled respirator with endotracheal intubation to provide PEEP and intermittent mandatory ventilation.

18. Circulation Hemorrhage Minimum of Two large Bore needles IV catheters should be inserted peripherally if fluid resuscitation is required Cross Matching

19. Cardiac tamponade Blunt or penetrating trauma may cause blood to accumulate in the pericardial sac. Inadequate cardiac filling during diastole, diminished cardiac output, and circulatory failure. The Beck’s triad of Decreased systolic blood pressure levels Distended neck veins – more distention during inspiration ( Kussmaul’s sign). Muffled heart sounds.

20. Control of bleeding Direct Pressure Ice bags Sutures with no cosmetic considerations Liquid Thrombin or epinephrine Next step: IV Resuscitation fluids

21. IV Resuscitation fluids Ringer’s Lactate 0.9% Normal Saline Volume Expanders: Colloids vs. Crystalloids Blood and Blood products if needed

22. Neurological examination Lack of consciousness with altered pupil reaction to light requires an immediate CT scan of the head and management with mannitol or fluid restrictions.

23. Exposure of the patient The patient should be completely disrobed so that all of the body can be visualized, palpated, and examined for injuries or bleeding sites. The clothing must be completely removed, even if the patient is secured to a spinal backboard. Frequent careful reevaluation of the injured patient’s vital signs is important to monitor the patient’s ability to maintain an adequate airway, breathing, and circulation.

24. Secondary assessment X-Rays, MRI, CT scans of Head and Skull Chest Maxillofacial Area and Neck Spinal Cord Abdomen Genitourinary Tract Extremities

25. Maxillofacial area and neck Maxillofacial injuries may cause airway compromise from blood and secretions The physical examination should begin with an evaluation for soft tissue injuries. The oral cavity should be inspected and evaluated for lost teeth The neck should be examined for injuries.

26. 10-20% of Maxillofacial injuries are associated with C-spine injuries.

27. references Chapter 18: Initial Management of Trauma Patients

28. Thank you