Podcast
Questions and Answers
What is the primary focus during the first hour of care for a traumatized patient?
What is the primary focus during the first hour of care for a traumatized patient?
Which of the following actions should be performed first in the management of a trauma patient?
Which of the following actions should be performed first in the management of a trauma patient?
What does the 'golden hour' concept emphasize regarding trauma care?
What does the 'golden hour' concept emphasize regarding trauma care?
During the management of major trauma, when should the secondary survey be initiated?
During the management of major trauma, when should the secondary survey be initiated?
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Which of the following describes a major trauma mechanism?
Which of the following describes a major trauma mechanism?
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What is the primary goal during the primary survey of a trauma patient?
What is the primary goal during the primary survey of a trauma patient?
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What is crucial to be monitored constantly during the trauma management process?
What is crucial to be monitored constantly during the trauma management process?
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Which of the following procedures may be performed simultaneously with the primary survey?
Which of the following procedures may be performed simultaneously with the primary survey?
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What is a critical condition to reassess during trauma management?
What is a critical condition to reassess during trauma management?
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Which of the following is NOT a principle of trauma management?
Which of the following is NOT a principle of trauma management?
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Study Notes
Trauma Initial Management
- Trauma is defined as a tissue injury occurring suddenly due to violence or an accident. It triggers hypothalamic-pituitary-adrenal axis and immunologic and metabolic responses for restoring homeostasis.
- Trauma involves an event causing injury to the body, leading to mental and emotional damage.
- Initial management focuses on triage and emergency care during the first critical hour of patient arrival at the hospital.
- Key procedures include: opening and maintaining the airway, performing life-saving procedures, managing active bleeding, placing an intravenous line, and learning shock management.
- The "golden hour" concept highlights the increased risk of death and the need for rapid intervention during the first critical hour following major trauma.
- Trauma care management has six phases: Triage, Primary Survey/Resuscitation, Secondary Survey, Stabilization, Transfer, and Definitive Care.
- Management goals include a primary survey to quickly examine, diagnose, and treat life-threatening injuries using the simplest possible treatments to stabilize the patient's condition.
- A secondary survey involves a complete thorough examination to ensure no further injuries are missed. Resuscitation begins simultaneously with the primary survey. The secondary survey shouldn't start until the primary survey is complete.
- Major trauma can be defined by a fall greater than 3 meters, a road traffic accident with a net speed greater than 30 km/h, being thrown from or trapped in a vehicle, being a pedestrian or cyclist hit by a car, or an unrestrained occupant of a vehicle, or injury from a high or low-velocity weapon.
- Physical findings in major trauma include airway or respiratory distress, blood pressure <100 mmHg, Glasgow Coma Scale <13/15, and penetrating injuries or more than one area injured.
Triage (Phase I)
- Triage prioritizes patients based on medical necessity, personnel skills, and available equipment.
- Vital signs include pulse rate, blood pressure, respiratory rate, SpO2%, temperature, AVPU (Alert, Verbal, Pain, Unresponsive), and urine output.
Primary Survey (Phase II)
- The primary survey follows the ABCDE approach.
- Assess the airway: Talk to the patient. If obstructed, open and clear the airway.
- Assess breathing: Check for cyanosis, wounds, deformities, ecchymosis, amplitude, paradoxical movement, reduced breath sounds, and dullness.
- Assess circulation: Check for signs such as confusion, lethargy, pallor, cold extremities, weak or absent pulses, tachycardia and hypotension, tenderness or guarding of abdominal area for bleeding, and perform pelvic stability checks.
Secondary Survey (Phase III)
- Conduct a comprehensive examination (AMPLE history) of all injuries, with sequence focusing on head, maxillofacial structures, cervical spine and neck, chest, abdomen and pelvic, perineum and vagina, musculoskeletal system and neurologic system.
- Common injuries include Head/scalp, Eyes, Ears, Nose, Mouth, Neck, Chest, Abdomen, Pelvis, Extremities, Back.
- Assess specific elements like a skin assessment for wounds, open wounds, scars, etc.
- Include a full neurologic exam (GCS) to evaluate neurological function.
- Assess possible retroperitoneal hematomas, spleen (40-55%), liver (35-45%), and small bowel (5-10%) injuries with blunt trauma.
Techniques for Opening the Airway (No Trauma vs Trauma)
- No trauma: Position the patient on a firm surface, tilt their head, lift their chin to open the airway, clear secretions, and administer supplemental oxygen (5 L/min).
- Trauma: Stabilize the cervical spine, do not lift their head, open the airway using the jaw thrust technique, clear secretions, and administer supplemental oxygen (5 L/min).
Airway Devices
- Oropharyngeal airway: Used in unconscious patients. Measure from earlobe to corner of the mouth. Insert over the tongue.
- Nasopharyngeal airway: Used for semi-conscious patients. Pass well-lubricated into one nostril and push posteriorly towards the throat.
Indications for Chest Decompression
- Absent or diminished breath sounds on one side.
- Evidence of chest trauma or rib fracture.
- Open or "sucking" chest wound.
- Pneumothorax.
- Tension pneumothorax.
- Hemothorax.
- Hemo-pneumothorax.
Open Chest Wound Treatment
- Apply a prompt occlusive dressing with a taped border (three sides taped, leaving one open for air to escape).
- Place a chest drain (never through the wound).
- Administer high-flow oxygen.
- Give antibiotics.
- Debride the wound and consider closure.
Insertion of Chest Drain
- Mark the incision above a rib in the mid-axillary line. Use the nipple as a landmark.
- Inject local anaesthetic to prepare the area.
- Puncture the pleura above the rib to avoid injury.
- Use forceps to introduce and position the chest tube.
Tension Pneumothorax
- Air from a lung puncture enters the pleural space and cannot escape.
- Progressive increase in intrathoracic pressure, leading to mediastinal shift and hypotension.
- Patient exhibits shortness of breath, hypoxia, decreased breath sounds, requiring urgent needle decompression followed by a chest drain.
Assessing Breathing
- Assess for respiratory distress.
- Visual inspection for cyanosis, wounds, deformities, ecchymosis, amplitude, paradoxical movements.
- Palpate painful areas, abnormal movements, perform percussion (dullness), and auscultate for reduced breath sounds.
Circulatory Assessment
- Assess for signs of hypoperfusion (confusion, lethargy, agitation, pallor, cold extremities, weak/absent pulses, tachycardia, hypotension).
- Examine the abdomen for tenderness and guarding.
- Assess pelvic stability.
Preventing Bleeding
- Apply pressure to external wounds.
- Splint potential femur fractures.
- Apply a pelvic binder.
- In pregnant patients, position on left side, not back.
- Send blood for type and crossmatch.
Stopping Bleeding
- Apply direct pressure to the wound, then put on a compression dressing.
- Only apply enough pressure to stop the bleeding.
- In life-threatening cases, use a tourniquet (pressure cuff or wide elastic) over padded skin.
- Transfer the patient urgently if necessary.
Disability (Phase II)
- Assess for neurological damage via an abbreviated exam. Common elements include assessing if the patient is alert, verbal, painful, or unresponsive.
- Use the Glasgow Coma Scale (GCS) to determine the severity of head injury (severe—GCS 8 or less, moderate—GCS 9-12, mild—GCS 13-15). The GCS should be repeated frequently.
Exposure (Phase II)
- Remove all patient's clothing.
- Examine the whole patient covering the front and back. Log roll carefully.
- Ensure that the patient doesn't get cold (especially children).
Imaging
- X-rays including chest, pelvis, cervical spine
- Ultrasound (FAST scan).
Additional Points
- For a secondary survey, implement the AMPLE questionnaire.
- Always reassess ABCs during the primary survey and follow up if condition deteriorates.
- If definitive treatment is unavailable, have a plan to transfer the patient to another clinic. The use of an AMPLE history is useful.
- Maintain in-line stabilization for the neck exam (remove the collar temporarily).
Equipment needed
- Intravenous catheters
- 500 mL boluses of Ringer's Lactate or NS (normal saline)
- Various sized oropharyngeal and nasopharyngeal airways
- Dressing materials
- Chest tubes
- Oxygen supply
- Blood for type and crossmatch
- Pelvic binders
- Splints
- Tourniquet
- Gauze dressings
Monitoring
- Use EKG and pulse oximetry if available.
- Simple physiological monitoring is essential in the surgical theatre.
- Regularly monitor vital signs (blood pressure, heart rate, oxygen saturation, respirations)
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Description
Test your knowledge on the initial management of trauma cases. This quiz covers the key procedures, the importance of the 'golden hour', and the six phases of trauma care management. Assess your understanding of triage, primary surveys, and life-saving interventions during the first critical hour after trauma.
