Trauma Management Overview

Trauma Management

• Trauma is defined as a tissue injury that occurs more or less suddenly due to violence or accident, initiating the hypothalamic-pituitary-adrenal axis, immunologic and metabolic responses for restoring homeostasis.
• Trauma includes:
  • An event that causes injury to the body.
  • Mental damage.
  • Emotional damage.

Initial Management Objectives

• Basic triage and emergency care techniques within the first critical hour of patient arrival at the hospital.
• Open and maintain airway.
• Perform life-saving procedures.
• Manage active bleeding.
• Place intravenous lines.
• Understand shock management.

The Golden Hour

• The "golden hour" concept emphasizes the increased risk of death and the need for rapid intervention during the first hour of care following major trauma.

Six Phases of Trauma Care Management

• Phase I: Triage.
• Phase II: Primary Survey and Resuscitation.
• Phase III: Secondary Survey.
• Phase IV: Stabilization.
• Phase V: Transfer.
• Phase VI: Definitive Care.

Management Goals

• Primary Survey:
  • Examine, diagnose, and treat life-threatening injuries as soon as identified.
  • Use the simplest possible treatment to stabilize the patient's condition.
• Secondary Survey:
  • Perform a complete and thorough examination of the patient to ensure no other injuries are missed.

Important Considerations

• Start resuscitation at the same time as performing the primary survey.
• Do not start the secondary survey until the primary survey is completed.
• Constantly reassess the patient's response to treatment; if condition deteriorates, reassess ABCs (Airway, Breathing, Circulation).
• Do not start definitive treatment until the secondary survey is completed, unless required as a life-saving measure.
• When definitive treatment isn't available, have a plan for a safe transfer to another center.

Major Trauma Mechanism

• A fall greater than 3 meters.
• Road traffic accident with a net speed greater than 30 km/h.
• Thrown from or trapped in a vehicle.
• Pedestrian or cyclist hit by a vehicle.
• Unrestrained occupant of a vehicle.
• Injury from a high or low velocity weapon.
• Emergency and Essential Surgical Care (EESC) program.

Major Trauma Physical Findings

• Airway or respiratory distress.
• Blood pressure less than 100 mmHg.
• Glasgow Coma Scale less than 13/15.
• Penetrating injury.
• More than one area injured.
• Perform a full primary and secondary survey of any injured patient, especially if major trauma is suspected.

Triage - Phase 1

• Sorting and treating patients according to priority.
• Identify patients with life-threatening conditions first.

Phase 1: Triage Factors

• Medical necessity.
• Personnel skills.
• Available equipment.
• Vital signs (pulse rate, blood pressure, respiratory rate, SpO2%, temperature).
• AVPU (Alert, Verbal, Pain, Unresponsive)
• Urine output.

Phase 2: Airway, Breathing, Circulation, Disability, Exposure (ABCDE)

• Expose the patient to identify and treat life-threatening injuries, such as airway obstruction, breathing difficulties and severe hemorrhage.

Airway Assessment and Management

• Assess the airway by talking to the patient (free and clear speech indicates an open airway).
• Look and listen for signs of obstruction (snoring, gurgling, stridor, noisy breathing).
• Foreign body or vomit in the mouth.
• If airway obstructed, open airway and clear obstruction.

Techniques for Opening the Airway

• No Trauma: Position patient on a firm surface, tilt the head, lift the chin, clear secretions, give oxygen (5 L/min). Remove visible foreign bodies.
• Trauma: Stabilize the cervical spine, do not lift head, open airway using jaw thrust, clear secretions, give oxygen (5L/min). Remove visible foreign bodies.

Airway Devices

• Oropharyngeal airway: For unconscious patients; measure from front of ear to corner of mouth; slide over the tongue. Remove immediately if resistance, gagging, or vomiting occurs.
• Nasopharyngeal airway: Better tolerated by semi-conscious patients; insert into nostril, posteriorly towards the throat.

Breathing Assessment and Management

• Assess ventilation (is the patient in respiratory distress?).
• Look for cyanosis, wounds, deformities, ecchymosis, amplitude, paradoxical movement.
• Feel for painful areas and abnormal movement.
• Percuss for dullness.
• Listen for reduced breath sounds.
• 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 Management

• Requires very prompt treatment with a closed occlusive "plastic pack" dressing taped on 3 sides to allow air escape from the wound.
• Place a chest drain.
• Never insert the chest tube directly through the wound.
• Give high-flow oxygen.
• Give antibiotics.
• Debride wound and consider closure.

Chest Drain Insertion

• Mark incision just above rib in mid-axillary line, using the nipple as a landmark.
• Prepare area with antiseptic and local anaesthetic.
• Make small transverse incision just above the rib to avoid vascular injury.
• Use a pair of curved artery forceps to penetrate the pleura and enlarge the opening.

Tension Pneumothorax

• Air from a lung puncture enters the pleural space and cannot escape.
• Progressive increase in intrathoracic pressure causes mediastinal shift and hypotension.
• Patient becomes short of breath and hypoxic.
• Diminished breath sounds on the affected side.
• Requires urgent needle decompression, then chest drain insertion as soon as possible.

Tension Pneumothorax Management

• Give high-flow oxygen.
• After aseptic skin preparation, insert a large-bore needle over the 2nd intercostal space at the mid-clavicular line over the 3rd rib.
• Listen for hissing sound of air escaping.
• Insert chest drain.

Insertion of Chest Drain and Underwater Seal Drainage

• Use forceps to grasp the tube, introduce into chest cavity, and position the tube past the holes at the end of the tube.
• Close incision with interrupted skin sutures.
• Apply gauze dressing.
• Connect tube to underwater-seal drainage system.
• Mark level of fluid in drainage bottle.

Circulation: Hemorrhagic Shock

• Assess circulation (signs of hypoperfusion: confusion, lethargy, agitation; pallor or cold extremities; weak or absent radial and femoral pulses; tachycardia, hypotension).
• Examine abdomen (tenderness or guarding).
• Carefully assess pelvic stability.
• To decrease bleeding: Apply pressure to external wounds, apply splint for possible femur fracture, apply pelvic binder for possible pelvic fracture.
• If patient is pregnant, place her on her left side.
• Send blood for type and crossmatch.

Circulation: Hemorrhagic Shock Management

• Obtain two large-bore IV catheters.
• If systolic BP <90 mmHg or pulse >110 bpm, give 500 ml of Ringer's Lactate or NS.
• Keep patient warm.
• Reassess vitals (blood pressure, pulse).
• If still hypotensive after 2 L of crystalloids, transfuse blood.

Stop the Bleeding

• Apply direct pressure to the wound, followed by a compression dressing.
• Apply only enough pressure to stop the bleeding.
• Apply a tourniquet only if bleeding is life-threatening and cannot be controlled.
• Use a blood pressure cuff or wide elastic band over padded skin.
• Transfer urgently.

Disability/Damage Assessment

• Check for neurological damage, a vital part of the primary survey.
• Perform an abbreviated neurological examination (ALERT, VERBAL, PAIN, UNRESPONSIVE).

Glasgow Coma Scale (GCS)

• Score eyes, verbal, and motor responses to assess neurological status.

Head Injury Deterioration

• Unequal or dilated pupils may indicate increased intracranial pressure.
• Avoid sedation or analgesics as these interfere with neurologic examinations and reduce breathing (increased CO2 causes increased intracranial pressure).
• Bradycardia and hypertension may indicate a worsening condition.

Exposure

• Remove all patient's clothing.
• Examine entire patient front and back.
• Log-roll the patient carefully.
• Do not allow the patient to become cold (especially children).

Imaging

• X-rays (chest, pelvis, cervical spine).
• Ultrasound (FAST scan).

Phase III: Secondary Survey

• Head exam (scalp, eyes, ears, soft tissues).
• Neck exam (penetrating injuries, swelling, crepitus).
• Neurological exam (GCS, motor/sensory examination, reflexes).
• Chest exam (clavicles, ribs, breath sounds, heart sounds).
• Abdominal exam (penetrating injury, blunt injury: NG tube, rectal exam, urinary catheter).
• Pelvis and limbs exam (fractures, pulses, lacerations, ecchymosis).

Secondary Survey - AMPLE

• Allergies.
• Medications.
• Past illnesses/Pregnancy.
• Last meal.
• Events/Environment (related to the injury).

Possible Abdominal Injuries from Blunt Trauma

• Spleen (40%-55%).
• Liver (35%-45%).
• Small bowel (5%-10%).
• Retroperitoneal hematoma (15%).

Restraint Device Injuries

• Lap seat belt: -Tear or avulsion of bowel mesentery (bucket handle).
• Shoulder harness:
  • Sliding under the seat belt ("submarining").
• Air bag:
  • Contact/deceleration with flexion and hyperextension.
• Injury to thoracic and abdominal organs.

Reassessment

• Always perform ABCDE primary survey if patient deteriorates.
• Look for signs of adequate resuscitation (slowing of tachycardia, normalizing urine output and increasing blood pressure).

Monitoring

• Use EKG monitoring if available.
• Pulse oximetry.
• Widely used physiological monitoring device for heart rate and oxygenation.
• Especially useful in anaesthesia, ICU.
• Simple to use.
• Standard in surgical theatre.
• Blood pressure (manually or automated machine).

Additional Notes

• Maintaining in-line stabilization is essential when examining the neck.
• The AMPLE history is a useful guide for the secondary survey.
• Skin folds in obese patients can mask trauma evidence.
• Abdominal exam (scars, wounds, seatbelt sign, peritoneal signs, and absence/presence of tenderness).
• Pelvis exam (tenderness, bony structures, and possible bruising).
• Vaginal exam is important in circumstances of possible trauma.
• Assess symmetry and limb length, presence of deformity, swelling, skin integrity, and circulation in extremities.
• Assess neurologic function in the back and extremities using symptom-specific guidelines.
• Reassessment is critical for ongoing patient monitoring after initial interventions.

This quiz covers essential concepts in trauma management, including the definition of trauma, initial management objectives, and the critical 'golden hour' for patient care. It explores the six phases of trauma care to enhance the understanding of emergency response techniques and interventions.