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									     Trauma – initial assessement and

                                 management.




Paweł Grala
Klinika Chirurgii Urazowej, Leczenia Oparzeń, Chirurgii Plastycznej AM w Poznaniu
Kierownik Kliniki: Prof. dr hab. med. Krzysztof Słowiński
             “Trauma”
    - expression comprising a
      spectrum of severity of
mechanical violation of tissues,
from a little scratch to a multiply
          injured patient.
   - also surgical intervention.
Trauma - the leading cause of death in the first four decades of life

Death from trauma has a trimodal distribution:
within

 seconds to minutes

 minutes to hours
 GOLDEN HOUR

 several days or weeks
•Prehospital – control airway, external hemorrhage, rapid
               transport

•Primary survey - initial assesement and resuscitation of vital
             functions, prioritization (based on ABCDEFG)
 An organized consistent approach to the
   trauma patient  optimal outcome.

The Advanced Trauma Life Support (ATLS)
   adopted by the American College of
           Surgeons in 1979.

 The primary focus of ATLS is on the first
   hour of trauma management - rapid
      assessment and resuscitation
          THE GOLDEN HOUR
          The primary survey –
    life threatening conditions are
    identified and management is
         begun simultaneously!

• A - Airway maintenance with cervical spine
  control
• B - Breathing and ventilation
• C - Circulation with hemorrhage control
• D - Disability: neurological status
• E - Exposure: completely undress the patient
       Airway / Breathing
     All patients should be
transported/treated initially with
     supplemental oxygen.

 • immobilization of the
   C-spine
 • combination of a hard
   collar and sandbags
   on opposite sides of
   the head
          Airway / Breathing

• establishing verbal contact with the patient -
  clear phonation by the patient establishes that
  the airway is patent.

• further intervention depends on:
- neurologic stability
- adequacy of gas exchange and the potential for
   airway compromise
          Neurological Stability
• decreased level of consciousness is considered to be
    intracranial pathology until proven otherwise (drugs,
    alkohol)
• brief neuro exam (done during the primary survey):
A - Alert
V - responds to Verbal stimuli
P - responds to Painful stimuli
U - Unresponsive
• Glasgow Coma Scale (GCS):
GCS < 8 requires definite airway intervention to prevent
    aspiration pneumonitis, to insure adequate oxygen
    delivery and to avoid hypercarbia.
If a patient is responding only to painful stimuli or is
    unresponsive/unconscious, the GCS is or has a high
    likelihood of being less than 8.
   Adequacy of Gas Exchange
• airway patency does not insure adequate
  ventilation
                     LOOK
• nature of the injury: maxillofacial
  trauma/airway burns - potential for airway
  compromise, obvious airway or chest
  trauma (sucking chest wounds, flail
  segments), cyanosis
• tachypnea, use of accessory muscles of
  respiration or evidence of tracheal shift
     Adequacy of Gas Exchange
                     LISTEN
•   stridor  upper airway compromise.
•   hyperresonance to percussion/lack of air
    entry  pneumothorax
•   dullness to percussion/lack of air entry 
    hemothorax.
•   bowel sounds in the chest  ruptured
    diaphragm.
    Adequacy of Gas Exchange
                               FEEL
• hand over the mouth - feel for air exchange.
• Insertion of a finger - sweep to clear the mouth of any
   foreign bodies (especially dislodged teeth) and to evaluate
   for evidence of maxillofacial trauma.
                                LAB
• pulse oximetry - haemoglobin saturation; immediate
   feedback
pitfalls - motion, peripheral vasoconstriction,
   carboxy/methaemoglobinemia.
• ABG`s - more complete picture of the patient; feedback on
   oxygenation, ventilation and tissue perfusion
pitfalls - a defined waiting period (institution dependent)..
            Securing the Airway
- endotracheal intubation (inspection of th airway, suction of
        blood and secretions, bag mask ventillation)
- possible spinal cord or direct traumatic tracheal injuries 
         surgical airway - translaryngeal intubation
• Immediate - apnea
• Emergent - hypoventilation, significant head
  injury, cyanosis
• Urgent - burns, maxillofacial injury and cervical
  hematomas will likely require a secure airway to
  prevent upper airway obstruction; chest wall and
  pulmonary injuries are usually initially well
  compensated but may eventually require
  mechanical ventilation
there is often time for a history, appropriate
  physical exam and cervical radiographs
         Securing the Airway
Blind nasotracheal intubation vs direct orotracheal
                        intubation
Determined by the experience of the physician
Blind nasotracheal intubation:
requires a spontaneously breathing unconscious
   or cooperative conscious patient, unacceptable
   failure rate (35%) - requires 3.7 vs. 1.3 oral
   attempts, contraindicated if basal skull or mid-
   face fracture.
can precipitate epistaxis (may interfere with
   subsequent alternative attempts at intubation if
   unsuccessful).
high incidence of sinusitis if a tube is left in place
   greater than 72 hours.
  Assume the cervical spine to be
  unstable until proven otherwise

• up to 50% of patients sustaining C-spine
  trauma develop neurologic abnormalities
  (nerve root compression and weakness to
  quadri- plegia and death).
• 10% of patients with C-spine injury are
  initially neurologically intact, but develop
  deficits during the course of emergency
  care
• risks of airway management
           C-spine evaluation
• bone and soft tissue
• X-ray exam: „one view is no view”, L-all 7C+Th1
  (30% inj.C7Th1), AP-vertical alignment of the
  spinous and articular process and abnormalities
  in joint and disc spaces, open mouth view -
  integrity of the atlanto-occipital and atlanto-axial
  joints, the odontoid process, oblique – intervert.
  foramina
• CT
• lateral cervical spine - sensitivity of about 85%
   92% in a three view series
  100% when selective CT scanning is employed
Circulation


• BP
• HR
Alghevar scheme - quantification of shock:
SBP / HR
  >1 no or minor clinical symptoms
   <1 major shock
• Pulses
• Indirect signs: UA, skin, tachypnoe, altered
  consciousness, „empty” periferal veins
               Large bore IV lines
                    Circulation

• warmed intravenous infusions
Control:
• external hemorrhage
• internal hemorrhage:
MAST (PASG) suit
Pelvic binders


Surgery  stabilisation  secondary survey
           Initial assessement


•   Chest and abd. PE
•   Orthopaedic PE
•   Periferial Neurologic PE
•   Labs
•   X-rays, US, CT
          tertiary trauma survey
• ACS definition - a patient evaluation that identifies and
  catalogues all injuries after the initial resuscitation and
  operative intervention
• 2 - 50% of combined life threatening and non-life
  threatening injuries are missed during primary and
  secondary surveys
• timing is institution specific (typically occurs within 24 h
  after admission and is repeated when the patient is
  awake, responsive, and able to communicate any
  complaints).
• is a comprehensive review of the medical record with
  emphasis on the mechanism of injury and pertinent co-
  morbid factors such as age, includes the repetition of the
  primary and secondary surveys, a review of all
  laboratory data, and a review of radiographic studies
  with an attending radiologist

								
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