Trauma management protocol (ABCDE)

Trauma management protocol (ABCDE)

1. March 28,2017 1 Dr. Abhishek Neupane Medical Officer Medical Department , SIRC

2. Trauma management protocol (ABCDE) INTRODUCTION In physical medicine, major  trauma  is injury or damage to a biological organism caused by physical harm from an external source. Major  trauma  is also injury that can potentially lead to serious long-term outcomes like chronic pain and disabilities.

3. Mechanisms of Trauma (leading to SCI) Road Traffic Accidents Falls Natural disasters like earthquake Sports injury Violence/war Carrying heavy loads

4. Preparedness(at hospital setup) Pre-arrival preparation and Trauma Team- a multidisciplinary group of healthcare workers who collectively work together on the assessment and treatment of those who are severely injured along with availability of equippments required(ALS).

5. Primary Evaluation and Management (at the site of injury) Triage ie classification of patients on priority basis- (including other severe injuries check for suspicious spinal injuries and handle it accordingly)

6. Management Protocol after proper assesment (ABCDE/CABDE) A ) Airway - Assessment Talk to the patient! Protect Cervical Spine Give Oxygen Assess Airway: look, Listen and Feel - Intubation IF REQUIRED(at hosp setup) Further steps if airway is obstructed ( cricothyrotomy may be considered)

7. B- Breathing and ventilation Oxygenation if required and if available Management: oxygen/assisted ventilation(artificial respiration)/decompression of tension pneumothorax /draining of haemo / pneumothorax Asses Chest movement-Further steps if required

8. C- Circulation Blood pressure/heart rate(pulse) monitoring, exclude the state of shock Check for Hemorrhage -sites of Hemorrhage , Shock, Hypovolumia and Resuscitation/Management- consider Blood Transfusion or start IV fluids if possible -Detection of site of Hemorrhage -Causes of Hemorhhage from different sites - Head/chest/Abdomen/Pelvis/ limbs (if ventillation and proper circulation is not noticed go for CPR protocol)

9. Consider Nonhemorrhagic causes of shock This occurs secondary to sympathetic denervation , resulting in arteriolar dilation and pooling of blood in the venous compartment, and interruption of cardiac sympathetic innervation (T1–T4) with unopposed vagal activity promotes bradycardia and reduced myocardial contractility. Neurogenic shock is suggested by decreased blood pressure and systemic vascular resistance with a variable heart rate response. March 30, 2017 9

10. D- Disability and neurologic evaluation -assessment for neurological disability from Brain(GCS) or spinal cord E- Exposure and environmental control -Undress the patient and look for hidden injuries

11. Go for Available Diagnostic studies (if possible) - Portable radiographs - Ultrasound (FAST exam) - Emergency computed tomography (CT) - Diagnostic peritoneal tap or lavage - Electrocardiogram - Laboratory tests

12. Secondary evaluation Physical examination - Head and face - Neck - Chest - Abdomen - Rectum and genitourinary - Musculoskeletal - Neurologic - Skin

13. Additional imaging (if possible for hosp setup) - Plain radiographs - Computed tomography, including total body CT

14. Pitfalls and pearls (what may be obscured during assessment and management) Esophageal intubations Hemorrhagic shock Cardiac tamponade Thoracoabdominal injury Penetrating bowel injury Open book pelvic fractures Ocular injuries Elder patients Analgesia and sedation

15. Consider following -Paediatric Trauma -Trauma in Pregnancy -Trauma in old age At the extremes of age, or in the presence of a preexisting spine deformity, provide patient care in the position of greatest comfort while maintaining immobilization.

16. “Spinal cord injury often does not exist in isolation. Other traumatic and medical conditions of the patient must be considered when selecting management strategies. As with all trauma patients, the acute management of a patient with SCI requires rapid restoration of the airway, breathing, and circulation”

17. Post injury disabilities- signs of SCI (spinal cord injury)   Weakness / paralysis   Loss/impaired sensation   Change of tone   Bladder dysfunction   Bowel dysfunction   Blood pressure dysfunction   Thermo-regulation dysfunction   Sexual dysfunction

18. For any suspected cases of SCI Consider Immobilization of spine: -If the immobilization is indicated then the whole spine must be immobilized. -Immobilization should be maintained until the individual reaches hospital.

19. Transportation   A major obstacle to transporting injured patients to health facilities in resource limited settings is the lack of adequate prehospital systems.   Long transportation time , lack of appropriate airway , cervical spine and monitoring equipment makes concurrent airway management and spine immobilization difficult.  In settings where no specialized transport equipment such as backboard exits, use of blanket or tarpaulin is reasonable alternative.

20. Before a patient with a spinal cord injury is transported from one facility to another, the following protocol should be completed to ensure that the patient’s condition is sufficiently stabilized: March 30, 2017 21 1 )Spine immobilization is adequate and secure. 2)The airway is clear and can be maintained during transfer;consider intubation prior to transfer if PaCO2 is elevated or if ventilatory failure is likely to develop during a prolonged transfer. 3)A chest tube is in place for any pneumoor hemothorax , especially if air transport is considered. 4)Supplemental oxygen is being administered and ventilation (spontaneous or assisted) is adequate. 5)IV (intravenous fluid) is patent and infusing at the desired rate. 6)Hemodynamic parameters have been stabilized and can be monitored during transport. 7)When indicated, nasogastric tube is in situ, draining freely, and connected to low suction. Indwelling urinary catheter is in situ and draining freely.

21. March 30, 2017 22 8) Skin is protected from injury due to excessive pressure, especially over bony prominences, such as the sacrum, that contact the support surface, and any apparatus or debris that could cause pressure sores is cleared away. 9)Neurological level and completeness of injury,as determined from a motor and sensory examination according to the International Standards Neurological Classification of SCI /AIS Scoring are documented immediately prior to transferring the patient. 10)All imaging and other records accompany the patient.

22. Management at Hospital:   Immediate care : Principles for “FIRST 72 HOURS”   Transfer the patient with a potential spinal injury as soon as possible off the backboard into a firm padded surface while maintaining spinal alignment.

23. . Altered mental status. Evidence of intoxication. Suspected extremity fracture or distracting injury. Focal neurological deficit. Spinal pain or tenderness. Emergency medical service (EMS) providers should use the following five clinical criteria to determine the potential risk of cervical spinal injury in a trauma patient:

24. March 30, 2017 25 In cases of confirmed spinal or spinal cord injury, maintain spine immobilization until definitive treatment

25. Neuroprotection : Pharmacologic Neuroprotection in Patients with Spinal Cord Injury No clinical evidence exists to definitively recommend the use of any neuroprotective pharmacologic agent, including steroids, in the treatment of acute spinal cord injury to improve functional recovery. - Methylprednisolone . -GM-1: ganglioside GM-1 - Gacyclidine . - Tirilazad and naloxone . -Other promising pharmaceutical agentscurrently undergoing investigation include a tetracycline derivative, minocycline (phase II investigationin Calgary, Canada), and erythropoietin, the hormonethat regulates erythropoiesis . March 30, 2017 26

26. Take home message : Most of the spinal injuries are flared up while transportation that lacks proper immobilization ( consider ABCDE before referral )

27. March 30, 2017 28 Thank you