TRAUMA MANAGEMENT IN A MINOR TRAUMA UNIT.pptx

Trauma Management in a minor trauma unit

1. TRAUMA MANAGEMENT IN A MINOR TRAUMA UNIT KIRENGO T. MBChB, MBA, MSC, MRCS

2. OBJECTIVES

3. INTRODUCTION Injury is a leading cause of disability and death worldwide >5 million deaths each year (10% of deaths) In Kenya, 86.3 deaths per 100,000 Most common mechanisms of injury: RTI (36.8%) Falls (26.4%) Struck/hit by a person or object (20.1%) Burns in <5 years Body regions injured: Lower extremity (35.1%) Upper extremity (33.4%) Head (26.0%)

4. APPROACH

5. PREPARATION Coordination with prehospital personnel/ patients/well-wishers Gather information- SBAR Give advice Pre-Hospital treatment focus: Maintain airway Control external bleeding & shock Immediate/ early transfer to the Hospital Accept or Recommend escalation depending on injuries

6. REFERRAL TO MAJOR TRAUMA UNIT ANATOMY OF INJURY All penetrating injuries to head, neck, torso and extremities proximal to the elbow and knee Chest wall instability or deformity (e.g., flail chest) Two or more proximal long-bone fractures Crushed, degloved, mangled, or pulseless extremity Amputation proximal to wrist or ankle Pelvic fractures Open or depressed skull fracture Paralysis MECHANISM OF INJURY Falls Adults > 20 feet or 6 meters (2 stories) Children > 10 feet or 3 meters (2-3 x height of child) High-risk motor vehicle crash Intrusion, including roof: > 12 inches (30 cm) occupant side; > 18 inches (45 cm) any side Ejection (partial or complete) from vehicle Death in same passenger compartment Vehicle telemetry data consistent with high risk of injury Auto vs. pedestrian/bicyclist thrown, run over, or with significant (> 30 Kph) impact Motorcycle crash >30 Kph Extensive Burns

7. INJURY SEVERITY SCORE (ISS): Major trauma is defined by a score > 15

8. Primary Survey: ABCDE Initial Assessment: Identify life-threatening conditions >> Rx based on priority Look, Listen, Feel Quick A-D (10 sec)- ask pts name & what happened? Response = no major airway, breathing or consciousness impairment Airway Breathing Circulation Disability Environment

9. AIRWAY & c-spine restriction Restrict c-spine motion- Triple immobilization (Collar, Strap, & Blocks) or manual restriction during examination Inspection (Look): Foreign bodies, fractures, other injuries, bleeding, secretions (Listen) Clear if patient talking, ?none or noisy breathing, stridor Palpation (Feel): Fractures, deformity, subcut emphysema Suction to clear bleed or secretions GCS <9 requires definitive airway ie. Cuffed, secured, tracheal tube Initial airway relief: jaw-thrust or chin-lift maneuvers Surgical airway (intubation unsuccessful): Cricothyroidotomy, Tracheostomy

10. BREATHING & VENTILATION Anatomy: Lung, chest wall, & diaghram Gas exchange: oxygenation & CO 2 removal Inspection (Look): expose (neck::chest) >> jugular vein distention, trachea position, chest wall movement Auscultation (Listen): bilat air-entry Palpation (Feel): trachea, chest wall, percussion Measure: Pulse ox/ Sats, RR Adjuncts: CXR, eFAST Interventions: Supplemental O 2 for all patients: high-flow (15L/min) via mask-reservoir

11. Breathing Injuries Condition Findings Tension pneumothorax One-way valve air injuries to chest >> mediastinum shift, hypotension, unilat. absence of breath sounds, neck vein distention, tachy, hyperresonance, chest pain Massive Hemothorax >1.5L (1/3) blood in one side of chest >> neck vein distended or flat, shock, absent breath sounds, dull percussion Open pneumothorax Pain, DIB, tachypnoea, dec. breath sounds on affected side, resonant percussion Tracheal or Bronchial injuries Hemoptysis, cervical subcut emphysema, cyanosis, tension pneumo Simple pneumothorax Chest bruising, laceration, contusion, red. Breath sounds, hyperresonance Simple hemothorax <1.5L blood, chest wall injuries, red. Breath sounds, dull percussion Fracture ribs Pain, bruising, deformity, red. expansion Flail chest Segment of ribs/ chest wall lacks continuity with thoracic cage, multiple # ribs (>2 ribs, in >2 places) Pulmonary contusion Bruising of lung, chest injury, pain, #ribs

12. INTERVENTION: CHEST DRAIN

13. CIRCULATION & HAEMORRHAGE CONTROL Control any external bleeding >> manual pressure Avoid Blind clamping of bleeders Obs : Level of consciousness, Pulse, BP, Skin Examine: Abdo, Pelvis, Limbs Essentials: Vascular access (x2 Large bore cannulas), Blood samples, IV fluids/ blood transfusion 1L IV bolus crystalloid >> Blood transfusion if unresponsive Consider Tranexamic 1gm IV STAT Aggressive fluids w/o control of bleeding inc. morbidity & mortality Consider internal haemorrhage : chest, abdomen, retroperitoneum, pelvis, & long bones Adjuncts: CXR, Pelvic X-ray, FAST Interventions: Chest tube, Pelvic binding, limb splints, Urinary catheter (monitor output) Consider: definitive care & transfer

14. FLUID RESUSCITATION RESPONSE

15. CARDIAC PHYSIOLOGY

16. TYPES OF SHOCK

17. SHOCK: CLASSIFICATION

18. DISABILITY

19. GCS SCORE

20. ENVIRONMENT

21. ADJUNCTS TO PRIMARY SURVEY

22. SPECIAL POPULATIONS: Population Consideration Children High physiologic reserve & few signs of hypo >> followed by precipitous decline Volume of fluids, i.e. 1. Hrly 4:2:1 = 4 ml/kg/hr 1 st 10kg of wt. >> 2 mg/kg/hr >> 1 mg/kg/hr remaining wt (>20kg) 2. Daily 100:50:20 = 100 ml/kg 1 st 10 kg of wt. >> 50 ml/kg >> 20 ml/kg remaining wt. (>20kgs) Urine output 1ml/kg/hr Pregnant women hCG test for all women Older adults Reduced physiologic reserve, chronic conditions, medications (eg Beta blockers) can alter physiologic response to injury Obese patients Difficult anatomy for assessment and procedure Athletes Excellent conditioning, don’t manifest early signs of shock (Tachycardia or tachypnea), normally low BP & HR

23. ESCALATION/ REFERRAL/ TRANSFER ANATOMY OF INJURY All penetrating injuries to head, neck, torso and extremities proximal to the elbow and knee Chest wall instability or deformity (e.g., flail chest) Two or more proximal long-bone fractures Crushed, degloved, mangled, or pulseless extremity Amputation proximal to wrist or ankle Pelvic fractures Open or depressed skull fracture Paralysis MECHANISM OF INJURY Falls Adults > 20 feet or 6 meters (2 stories) Children > 10 feet or 3 meters (2-3 x height of child) High-risk motor vehicle crash Intrusion, including roof: > 12 inches (30 cm) occupant side; > 18 inches (45 cm) any side Ejection (partial or complete) from vehicle Death in same passenger compartment Vehicle telemetry data consistent with high risk of injury Auto vs. pedestrian/bicyclist thrown, run over, or with significant (> 30 Kph) impact Motorcycle crash >30 Kph Extensive Burns

24. SECONDARY SURVEY Head to Toe examination Complete Hx and physical exam AMPLE hx: Allergies, Medications, Past illness/ Pregancy, Last meal, Events/ Environment After Primary survey and initial management Improved/ stable vitals Additional staff available Re-evaluation if deterioration Definitive care planning

25. ADJUNCTIONS TO SECONDARY SURVEY

26. HEAD INJURIES Traumatic Brain Injury Mild (GCS 13-15) Mod (GCS 9-12) Severe (GCS <9) CT-scan Indication: GCS <15 2hrs after injury GCS <13 Suspected # or Spine injury Any sign of base of skull #(hemotympanum, black eye, CSF oto /rhinorrhea, Battle’s sign) Vomiting >2 Age >65yrs Anticoag use Hx of loss of consciousness Amnesia Dangerous mechanism (fall>3ft, pedestrian hit by car, ejection from vehicle) Convulsions Neurological losses Visual disturbances Unequal pupils Severe headaches Confusion or strange behavior Cushing's triad: bradycardia, irregular respirations, & widened pulse pressure.

27. CHEST INJURIES

28. ABDOMINAL INJURIES Laparotomy if: Blunt abdominal trauma with hypotension, positive FAST or clinical intraperitoneal bleeding, or without another source of bleeding Hypotension with penetrating abdominal wound Gunshot wounds to abdo Evisceration Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma Peritonitis Free air, retroperitoneal air, or rupture of the hemidiaphragm Contrast-enhanced CT: ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma

29. BURNS Fluids: Flame: Adult(>14yrs) 2ml/kg/%TBSA; Child 3ml/kg/%TBSA Electrical: 4ml/kg/%TBSA Inhalation injury Hoarseness, stridor, DIB Facial burns Hx of injury Refer to burns unit if: Partial-thickness >10% (adult), 5% (children) Special areas: face, hands, feet, genitalia, perineum, joints 3 rd Degree (full thickness) burns Electrical, Chemical, and Inhalational injuries Pre-existing co-morbidities e.g. DM, Renal Failure Burn + Trauma (e.g. #) Pts with special social, emotional, or rehab needs

30. BURNS: Rule of Nines

31. CONCLUSION

32. QUESTIONS?

33. REFERENCE: Botchey IM Jr, Hung YW, Bachani AM, Paruk F, Mehmood A, Saidi H, Hyder AA. Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study. Surgery. 2017 Dec;162(6S):S45-S53. doi: 10.1016/j.surg.2017.01.030. Epub 2017 Apr 3. PMID: 28385178. Wesson HK, Stevens KA, Bachani AM, Mogere S, Akungah D, Nyamari J, Masasabi Wekesa J, Hyder AA. Trauma systems in Kenya: a qualitative analysis at the district level. Qual Health Res. 2015 May;25(5):589-99. doi: 10.1177/1049732314562890. Epub 2015 Jan 6. PMID: 25563630. ATLS 10 TH Edition. 2018