TRAUMA MANAGEMENT For Emergency medical technicians

Emergency management Team

1. TRAUMA MANAGEMENT SAFINA IQBAL, MSCN-CCN

2. FLUID MANAGEMENT GOAL OF FLUID RESUSCITATION To replace volume loss Improve blood pressure Improve tissue perfusion and oxygenation to maintain organ functions. Aggressive fluid resuscitation vs Restrictive fluid resuscitation? It is beneficial for increasing stroke volume and the cardiac output.

3. The 2 primary types of IV fluids: Crystalloids – normal saline and ringers lactate (FIRST LINE) 2. Colloid – albumin, dextran. (if not due to bleeding) Isotonic IV maintenance fluids reduce the risk of hyponatremia. INDICATIONS Resuscitation Rehydration Maintenance

4. Assessment of hypovolemia – National Early Warning Score Parameters. Respiration rate > 20 breaths per minute Oxygen saturation Systolic blood pressure < 100 mm Hg Pulse rate - > 90bpm Level of consciousness or new confusion Temperature - Patients benefit from Ringer’s lactate or 0.45% sodium chloride.

5. Dosage Adults – I L of warm crystalloid fluid. Paediatrics – 20ml/kg weighing less than 40kgs. Give as a bolus then reassess the vitals signs. Lethal triad for a patient include hypothermia, acidosis and coagulopathy. Remedied by damage control resuscitation – permissive hypotension, hemostatic resuscitation and damage control surgery. DCS – bleeding control, decontamination, body cavity closure,

6. THORACIC TRAUMA

7. Causes 20-25% of deaths due to trauma. Immediate death is usually due to rupture of the myocardial wall or the thoracic aorta. Early deaths are typically due to tension pneumothorax cardiac tamponade airway obstruction Uncontrolled thoracic hemorrhage.

8. RED FLAGS Hemoptysis Chest wall contusion Flail chest Open wounds Jugular vein distension Subcutaneous empysema Tracheal deviation 8. Tachpnea or bradypnea – labored, retractions 9. Absent or decreases lung sounds, unilateral; or bilateral,

9. OPEN CHEST WOUND

10. JUGULAR VEIN DISTENSION

11. SUBCUTANEOUS EMPHYSEMA

12. TRACHEAL DEVIATION

13. AIRWAY OBSTRUCTION – most common is an unconscious patient is the tongue, teeth, secretions, blood and airway edema. - intubate early Cervical spine protection 2. TENSION PNEUMOTHORAX Collapsed lung technically. When air escapes into the pleural space. This also displaces the mediastinum to the opposite side, decreasing venous return and compressing the opposite lung. Causes by penetrating chest trauma, blunt chest trauma or accidental lung puncture

14. 3. CARDIAC TAMPONADE Also referred to as pericardial tamponade. When blood accumulates in the pericardial sac putting pressure on the heart. Heart is unable to effectively fill or pump. Beck’s triad presentation Narrowing pulse pressure Jugular vein distention Muffled heart sound

15. 4. OPEN PNEUMOTHORAX Also called the sucking chest wound Also called communicating pneumo . The pleural space is exposed to the atmosphere. 5. MASSIVE HEMOTHORAX Blood collects in the pleural cavity Rapid accumulation of greater than 1500ml of blood Left sided more common than right sided.

16. 6. FLAIL CHEST Unstable segments of 2-3 of more ribs that are fractured in at least 2 different places. This results in paradoxical motion – opposite of normal chest motion.

17. Airway Obstruction Results from swelling, bleeding or vomitus. Primary survey Assess for air hunger – use of accessory muscles. Listen to air movement at the patient’s mouth, nose, lung fields Listen for stridor – partial airway obstruction Voice quality changes Crepitus over the anterior neck Rule out clavicle fracture. Intervention Clearance of vomitus and blood Placement of a definite airway

18. ii) Tension pneumothorax Occurs when there is air leak from the lung or through the chest wall. Results in lung collapse Also results in mediastinum displacement to the opposite side. This leads to decrease in venous return and hence obstructive shock. Patients who have spontaneous breathing present with air hunger and tachypnea Also divided into simple or open. CLASSICAL SYMPTOMS Hyper resonate sound Deviated traches Distended neck vein Absent breathe sounds.

19. Signs and symptoms Chest pain Air hunger 3. Tachypnea 4. Respiratory distress 5. Tachycardia 6. Hypotension 7. Tracheal deviation from the side of the injury 8. Unilateral absence of breath sounds 9. Neck vein distention 10. Cyanosis

20. Intervention 1. Simple – monitoring and supporting the respiratory function and giving supplemental oxygen. Needle decompression will be necessary where there are significant symptoms. iii) Open pneumothorax Clinical signs and symptoms Pain Difficulty breathing Tachypnea Decreased breath sounds on the affected side Noisy movement of air through the chest wall injury

21. Management Sterile dressing overlapping the edges of the wound Occlusive dressing, three side taped, one side untapped to allow air out. All sides if patient has a chest tube insitu.

22. iv) Massive hemothorax More than 1500 ml of blood in the chest cavity Management Large bore cannula Fluid resuscitation Support ventilation and breathing Blood transfusion Chest tube insertion Transfer to hospital for thoracotomy

23. RIB CAGE TRAUMA Complete or incomplete fracture of any of the 12 ribs on either side. Accompanied by sprain or rupture of surrounding musculature. Commonly rib 4-9 Signs and symptoms Severe pain Tenderness to touch Feeling of wind being knocked out. Abdominal pain if ribs are below the diaphragm Severe chest pain when coughing, sneezing. Swelling and bruising over the fracture site

24. Possible complications Ruptured lung Injured liver if the right 11 th and 12 th ribs are injured Ruptured spleen if left Prolonged pain Slow healing Pneumonia Lung abscess