Understanding Trauma Assessment and Management PDF

**Understanding Trauma Assessment and Management** - Introduction to the presentation and interactive format. - Importance of understanding trauma for effective patient assessment. - Encouragement for questions and engagement during the session. **Mechanism of Injury** - Critical for in...

**Understanding Trauma Assessment and Management** - Introduction to the presentation and interactive format. - Importance of understanding trauma for effective patient assessment. - Encouragement for questions and engagement during the session. **Mechanism of Injury** - Critical for initial patient assessment. - Helps in risk profiling primary injuries. - Predicts patient progression during care. **Topics Covered** - Initial assessment and primary survey video. - Trauma resuscitation techniques. - Chest and abdominal trauma management for interns. - Focus on physical trauma, with acknowledgment of mental health issues. **Statistics and Trends** - Trauma is a significant issue for younger populations. - Majority of injuries at Royal Brisbane from motor vehicle collisions. - Increasing cases of falls, particularly among older adults. **Types of Trauma** - Distinction between blunt and penetrating trauma. - Blunt trauma involves global body forces; penetrating trauma involves a single tract of injury. - Different management approaches required for each type. **Historical Context** - Evolution of vehicle safety features, such as seat belts. - Increased awareness of the impact of forces in motor vehicle crashes. - Efforts by medical professionals to improve safety regulations. **Understanding the Importance of Seat Belts and Trauma Response** - **Introduction of Seat Belts in Australia:** - Efforts by the College of Surgeons aimed at improving safety. - Focus on enhancing safety rather than limiting free will. - **Injury Mechanisms:** - Significant abrasions indicate the use of lap belts. - Lap belts can lead to flexion injuries during sudden deceleration. - Lap sash belts and airbags help dissipate force, reducing impact. - **Vehicle Design and Safety:** - Older vehicles transmit all crash forces to occupants. - Modern cars are designed with crumple zones to absorb impact. - A mangled car indicates effective crumpling and force absorption. - **Types of Trauma:** - Blunt trauma leads to increased cytokine release and inflammation. - Coagulopathy and endotheliopathy complicate trauma treatment. - Poor outcomes are linked to comorbidities and genetic factors. - Piercing trauma causes less overall tissue damage compared to blunt trauma. - **Crash Dynamics:** - Side impacts can lead to severe injuries for occupants. - Airbags deploy to protect drivers in frontal impacts. - Lateral forces can cause neck injuries or whiplash. - **Injury Prediction:** - Significant intrusion or capsular injury can predict injury profiles. - Compression forces can lead to pelvic and other injuries. - Wide force distribution can affect legs, pelvis, and chest. - Head and neck injuries are also a concern in side impacts. **Understanding Trauma Forces and Injuries** **Types of Forces in Trauma** - Lateral forces differ from vertical forces. - Vertical shear injuries occur when patients fall from a height, often landing on one leg. - Such falls can lead to injuries in the feet, legs, pelvis, spine, and head. - Forces travel upward through the body, unlike lateral compression injuries (e.g., T-bone accidents). **Anterior-Posterior Forces** - Common in motorbike accidents where the rider strikes the front of a vehicle. - Forces travel through the motorbike to the rider\'s pelvis, causing \"open book\" injuries. - Multi-system injuries may occur, affecting the head, spine, chest, and abdomen. - Initial assessment should prioritize based on the forces involved. **Penetrating Trauma** - Divided into low and high-velocity trauma. - Midline stab wounds raise concerns about potential injury to the abdominal aorta. - Challenges include uncertainty about the exact tract of injury. - CT scans can help visualize the injury tract. **Injuries \"In the Box\"** - Key concerns include injuries to the heart, lungs, esophagus, and diaphragm. - Significant organs in the upper abdomen include the liver, spleen, and pancreas. **High-Velocity Injuries** - High-velocity injuries often result from ballistic trauma. - Bullets can create complex injury patterns due to tumbling (yaw) and fragmentation. - Injuries differ based on whether bullets pass through soft tissue or hit bony structures. - Some bullets are designed to cause extensive tissue destruction. **Conclusion** - Most gun injuries are less complicated, but they can still result in significant damage. - Understanding the mechanisms of injury is crucial for effective trauma care. **Challenges in Trauma Management and Mechanisms of Injury** **Bullet Fragments and Self-Inflicted Injuries** - Deciding on retrieval of bullet fragments depends on body location. - Self-inflicted injuries are prevalent, especially among farmers. - Ballistics may cause significant tissue damage without being fatal. - Penetrating injuries differ from blunt injuries and have unique features. **Blast Injuries in Queensland** - Blast injuries are rare in Australia, mostly seen in military contexts. - Recent incident in Queensland involved a mining worker and an explosive drum. - Blast injuries can be categorized into: - Explosive shock waves - Flying fragments - Patient being thrown - Thermal impact - Burn injuries - Quinary blast injuries relate to hyperinflammatory states from chemical, biological, or radiological exposure. - Enclosed environments, such as methamphetamine production sites, can lead to blast injuries. - Throwing petrol on a fire may cause thermal injuries but not true blast injuries. **Primary Mechanisms of Injury** - Majority of injuries in Queensland result from blunt force trauma. - Common causes include: - Motor vehicle collisions - Motorbike crashes - Pedestrian impacts - Increase in major trauma cases among older patients due to falls. - Rise in penetrating trauma, particularly from knife crime. - Minimal cases of penetrating trauma from ballistics or blast injuries. **Impact on Trauma System** - Trauma triage pathway at Royal Brisbane involves: - Initial notification from pre-hospital systems. - Mobilization of hospital teams for trauma patients. - Physiologically stable patients require localized emergency department responses. - Patients with normal physiology do not need full hospital activation. - Trauma-respond is activated for unstable patients with critical signs: - Tachycardia or hypotension - Traumatic cardiac arrest - Severe respiratory distress despite intubation **Challenges with Penetrating Trauma** - Unknowns in penetrating trauma make it particularly concerning. - Example of a patient with a minor neck stab wound leading to severe complications. - Penetrating trauma requires careful assessment due to hidden injuries. **Trauma Assessment Overview** - The \"box\" includes the thorax and abdomen, with attention to junctional areas (neck, axilla, groins). - Junctional areas are highly vascular and more susceptible to injury. **Assessment Focus** - Assessment must be completed within five minutes to identify life threats. - Focus on actual patient issues rather than preconceived ideas based on mechanism and triage-reported physiology. **Key Causes of Trauma Mortality** - Primary cause of death in trauma: bleeding. - Secondary concerns include obstructive shock (e.g., cardiac tamponade, tension pneumothorax). - Traumatic brain injury can obstruct the airway and cause hypoxia. - Distributive shock should be considered in patients with low GCS or motor/sensory deficits. **Primary Survey Methodology** - Emphasis on identifying bleeding sources, starting with external hemorrhage. - Airway assessment: check if the patient is talking and breathing, and look for obstructions. - Breathing and ventilation assessment: check for signs of obstructive shock. - Return to circulation (C): assess hemorrhage control and need for hemodynamic support. - Disability assessment: determine potential traumatic brain injury or spinal cord involvement. - Exposure: maintain patient warmth to prevent coagulopathy. **Team Coordination** - Multidisciplinary team approach is essential for trauma care. - Roles include airway team, procedural team, assessment team, and team leaders. - Simulation-based training enhances coordination and response. **Immediate Red Flags in Trauma** - Rapid volume infusion and ultrasound for concealed bleeding assessment. - Pelvic binder indicates potential major pelvic trauma. - Traction splint on the leg suggests possible femoral fracture. - Patient exposure to cold is a concern; heated trauma bays are beneficial. **Primary Survey in Trauma Management** **Importance of the Primary Survey** - Vital for identifying and managing life-threatening injuries. - Guided by the C-A-B-C-D-E mnemonic for prioritizing interventions. **Execution of the Primary Survey** - Can be performed by a team or a single provider. - Findings should be communicated clearly to the leader for effective prioritization. - Initial exposure of the patient for full injury visualization. - Control bleeding with direct pressure or a tourniquet. **Assessment Areas** - **Hemorrhage Check:** Inspect concealed sites under dressings and bandages. - **Airway and Cervical Spine:** - Assess airway adequacy and obstruction risk using the 12C assessment. - Remove collar with minimal C-spine movement until injury is ruled out. - Communicative patients can indicate airway obstruction risk through voice quality. - Examine oropharynx for foreign bodies if the patient is obtunded. - **Chest Examination:** - Check for symmetry and deformities. - Palpate for tenderness, crepitus, or emphysema. - Auscultation for breath sounds is less effective in noisy environments. - **Circulation Assessment:** - Check perfusion adequacy and sources of blood loss. - Palpate peripheral pulses and assess capillary refill. - **Abdomen and Pelvis:** - Inspect abdomen for swelling, bruising, wounds, and tenderness. - Visually inspect pelvis for alignment and injury signs. - Avoid springing the pelvis; ensure binder is correctly placed. - **Long Bones:** - Assess for bruising, swelling, tenderness, deformity, and leg length. **Neurological Assessment** - Complete the Glasgow Coma Scale, focusing on the motor score. - Administer painful stimulation to check for spinal cord pathology. - Examine pupils for symmetry and light response. - Exclude medical causes for altered consciousness, such as hypoglycemia. **Radiological Investigations** - Chest X-ray for major chest wall destruction and hemothorax. - Pelvic X-ray to assess ring disruption and binder position. - Extended FAST scan to detect hemoperitoneum, hemothorax, and pericardial effusion. **Conclusion of the Primary Survey** - Ensure the patient is fully exposed while maintaining dignity and warmth. - Focus on identifying global injuries that could compromise the patient. - Immediate treatment is necessary for identified pathologies. - Determine next steps for investigation, including history and examination. **Further Resources** - Visit Queensland Trauma Education at csds.qld.edu.au/QTE for more information. **Important Trauma Investigations** - FASt scale - ROTEM - Vital signs **Management of Significant Limb Injury and Vascular Bleeding** - Direct compression - Use of bandaging - Application of a tourniquet **Airway Management During Primary Survey** - Jaw thrust technique - Use of Guedel airway and supplemental oxygen - Intubation as a last priority after controlling hemorrhage **Considerations for Intubation** - Medications can cause hypotension due to vasodilation - Paralyzing a patient with significant blood volume can decrease blood pressure - Priming the patient is crucial before intubation - Intubation may be necessary for certain head injuries **Control of External Hemorrhage** - Use of tourniquets and dressings - Application of direct pressure - Consideration of potential bleeding areas (e.g., pelvis) - Availability of pelvic splints, binders, and long bone splints **Airway and Breathing Management** - Open airway and apply oxygen - Use of tools like Guedel or LMA - Address life-threatening issues in breathing and circulation - Possible decompression of the chest or thoracotomy **Trauma Activation System** - Two-tier response system - Presence of a trauma surgeon upon patient arrival - Minimization of time between arrival and definitive care **Key Principles in Trauma Care** - Pre-notification and shared team mental model - Early assessment within the first five minutes - Addressing life threats and ensuring patient care - Importance of maintaining patient temperature **Challenges in Managing Cardiac Tamponade** - Significant issue in trauma patients - Demonstrated challenges in a surgical setting - Direct pressure control during surgical procedures - Risks associated with suturing fragile myocardium **Video Demonstration Insights** - Surgeon controlling injury with direct pressure - Significant bleeding with each heartbeat - Challenges of accessing and visualizing the wound - Need for good lighting during procedures **Wound Control Challenges and Emergency Assessment** **Wound Control Issues** - Wound is difficult to control due to location and visibility. - Heavy bleeding complicates control efforts. **Assessment Goals** - Perform procedures both roadside and in the emergency department. - Utilize clinical assessment, ultrasound, and injury mechanism for patient evaluation. - Aim to transfer patients to definitive care in the operating theater. **Bedside Tests in Emergency Department** - Glucose reading via fingerstick. - Blood tests, particularly venous gases instead of arterial blood gases (ABG). - Venous gases provide information on shock state, acid-base balance, and electrolyte therapy. **Additional Bedside Procedures** - ECG to assess for arrhythmias and blunt cardiac injury. - Chest and pelvic x-rays for radiological assessment. **ECG Considerations** - Indicated for patients with a medical event leading to trauma. - Less than 1% of trauma patients experience blunt cardiac injury. - ECG may show non-specific changes, often deprioritized in trauma cases. **Vital Signs and Urine Tests** - Blood pressure and heart rate are part of vital signs. - Urine tests useful for: - Pelvic injuries. - Motor vehicle accidents. - Assessing intoxication impact. - Crush injuries. **Imaging and Toxicology Testing** - CT imaging considered for patients with hematuria and no other trauma signs. - Toxicology testing is not routinely conducted in Queensland unless necessary. **Management of Trauma Patients in Queensland** - Focus on current patient condition, not drug/alcohol use. - Alcohol testing in Queensland is forensic team-requested; differs from Victoria\'s routine testing for trauma patients. **Blood Tests Ordered** - Full blood count with cross-match - Electrolytes - Group and hold - Chem 20 **Discussion of Blood Tests** - Full Blood Count: - Not immediately helpful in early trauma phase. - Hemoglobin levels drop post-resuscitation. - Chem 20: - Useful for sodium levels; venous gas provides similar info. - Liver function tests identified clinically; results may arrive late. - Lipase Test: - Detects subtle pancreatic injuries not visible on CT. - Important for patients with specific injury mechanisms. - Coagulation Tests: - Replaced by viscoelastic testing (Rotem, TEG). - Lactate Measurement: - Indicates hypoperfusion and metabolic acidosis. **Radiological Assessments** - Chest and pelvic X-rays provide quick initial information. **Special Tests Considered** - Creatine Kinase (CK): - Useful for tracking crush injuries. - Transthoracic Echo (TTE): - Used for suspected blunt cardiac injury; may require transesophageal echo. - Urethrogram: - Indicated for suspected urethral injury, especially in pelvic injuries. - Contrast injected to check for leaks. **Clinical Indicators for Urethrogram** - No urine output may suggest shock or urethral tear. - Blood at the meatus indicates potential injury. - Examine for bruising, swelling, discoloration, and deformity. **Emergency Department Management of a Trauma Patient** **Patient Overview** - 33-year-old male involved in a high-speed crash (100 kph). - Significant cabin intrusion; wearing a seatbelt; airbags deployed. - Complaints of chest pain and difficulty breathing. **Vital Signs and Initial Concerns** - Tachycardic. - Borderline hypotension. - Borderline hypoxia. - Tachypneic. **Potential Injuries** - Blunt chest injury (e.g., pneumothorax). - Rib fractures. - Pelvic fracture. - Pulmonary contusion. - Multisystem injuries due to crash mechanism. **Assessment Approach** - Standard trauma assessment focusing on external hemorrhage. - Localized chest examination to identify intervention needs. - Assessment for tension pneumothorax and major chest wall injuries. - Prioritization of life-threatening conditions in the first five minutes. **Diagnostic Tests** - Immediate venous blood gas analysis. - FAST scan to identify bleeding locations. - Chest and pelvic X-rays. - Clinical examination for long bone integrity. - CT scan for advanced imaging of injuries. **Considerations for Further Testing** - ECG for potential blunt cardiac injury. - CT angiography to assess for great vessel injuries. - Evaluation of solid organs (liver, spleen, kidneys). **Management Focus** - Fluid management in trauma resuscitation. - Stabilization for definitive care and bleeding control. **Modern Trauma Resuscitation: A Shift from Past Practices** **Historical Context** - Past trauma resuscitation involved excessive fluid administration to normalize physiology. - Military medicine initially used whole blood for trauma victims. - Research in the 1950s and 60s promoted saline use, leading to large volume infusions. - Current understanding shows that excessive saline dilutes coagulation factors and reduces oxygen-carrying capacity. **Current Resuscitation Strategy** - Focus on minimal fluid necessary to support organ function. - Aim to prevent multi-organ failure and reduce ICU ventilator time. - Open abdomen cases post-trauma laparotomy are now rare. - Prevent the \"lethal diamond\": hypothermia, coagulopathy, acidosis, and hypocalcemia. **Transfusion Practices in Australia and New Zealand** - Use of fractionated components: red cells, FFP, platelets, and cryoprecipitate. - Citrate in components reduces calcium, worsening coagulopathy. - Blunt trauma leads to trauma coagulopathy; about 30% of major trauma patients are coagulopathic. **Transfusion Strategy Evolution** - Shift from condition-based judgment to ratio-based resuscitation. - Utilization of viscoelastic testing (Rotem and TEG) for faster insights into clot function. - Viscoelastic tests can be interpreted in five minutes, compared to 45 minutes for standard tests. **Initial Resuscitation Steps** - Administer red cells or FFP to replace lost volume. - Assess for coagulopathy and apply targeted therapy. **Logistical Considerations** - Availability of viscoelastic testing machines in the emergency department affects timing. - Decisions can be made quickly once testing begins, improving patient outcomes. **Massive Hemorrhage Protocol (MHP)** - Discussion on MHP terminology: Massive Hemorrhage Protocol or Massive Hemorrhage Pathway. **Modern Approach to Trauma Resuscitation** **Transition from MTPs to MHPs** - Previously known as Massive Transfusion Protocols (MTPs). - Aim to provide appropriate volume resuscitation rather than massive transfusions. - Blood product administration in major trauma patients has halved over the last decade. - Focus on recognizing massive hemorrhage and appropriate patient resuscitation. **MHP-Guided Pathway** - Ratio-based resuscitation activated in most centers. - Blood bank delivers packs containing red cells, plasma, and cryoprecipitate. - Utilization of viscoelastic tests like ROTEM to tailor patient-specific needs. - Continued volume replacement with red cells and FFP, targeting coagulation deficits. **Considerations for Obstetric Patients** - Standard targets for volume resuscitation and coagulopathy, except for obstetric patients. - Increased fibrinogen needs during pregnancy due to natural coagulopathy. - Different guidelines for resuscitating pregnant patients, emphasizing warmth and calcium levels. **Focus on Physiology** - Aim not for normal hemoglobin but for physiological response to resuscitation. - Standard coagulation testing uses a platelet count of 75. - ROTEM can indicate platelet deficits, guiding ongoing assessments. **Practical Points for Resuscitation** - Ensure adequate vascular access for blood product delivery. - Preferably use two large cannuli in the antecubital fossae. - Intraosseous lines are effective alternatives, requiring pressure for delivery. - Avoid IV or intraosseous lines below the pelvis in case of pelvic injury. **Maintaining Warmth** - Keep blood warm using portable or dedicated blood warmers. - Maintain patient warmth to prevent coagulopathy, referred to as the \"diamond of death.\" **Dedicated Trauma Team** - Team includes circulation doctor and nurse focusing on access during sampling. - Dedicated team interprets ROTEM results and decides on blood products. - Complicated procedures require careful consideration of timing and product administration. **Repeated Blood Sampling** - Repeat all blood sampling 10 minutes after administering blood products or coagulation factors. - Viscoelastic strategies provide quick information for real-time decision-making. **Understanding Endpoints in Trauma Transfusion** - Endpoints indicate sufficient product administration. - Patient stability is the key indicator of successful resuscitation. **Understanding Permissive Hypotension and Organ Perfusion** - Permissive hypotension aims to maintain circulation to the brain and vital organs. - Focus on providing adequate volume for oxygen-carrying capacity with red cells. - Ensure sufficient coagulation factors to address endothelial injuries. - Avoid excessive fluid resuscitation to reduce sheer stress and bleeding risk. - Endpoints now emphasize organ perfusion evidence over arbitrary blood pressure and heart rate targets. - Key indicators of perfusion include: - Presence of a radial pulse - Warm extremities - Alertness if not intubated - Normal capillary refill **Chest Trauma Overview** - Common in motor vehicle collisions and falls, especially in older patients. - Chest wall injuries often include rib fractures. - Primary survey and management are critical; many patients may not require hospital admission. - Consider long-term outcomes related to analgesia and oxygen needs. **Understanding \'Mentating\'** - Refers to a patient\'s alertness and responsiveness. - Patients should be able to open their eyes and respond minimally. - Important for assessing brain perfusion and oxygen supply. **Obstructive Shock and Chest X-Ray Interpretation** - Chest X-rays can be useful even in obstructive shock cases. - Signs of obstructive shock include hypotension, tachycardia, and hypoxia. - Mediastinal shift indicates compromised blood flow to and from the heart. - Possible hypoxia due to lung compression on one side. **Clinical Signs and Interventions** - Trifecta of obstructive shock: muffled heart sounds, deviated trachea, shock state. - Tracheal deviation may not always indicate obstructive shock; rely on clinical assessment. - Relieving obstructive shock can lead to rapid improvement in vital signs. - Hypoxia may take longer to resolve as lung reinflates. **Neck Injuries and Tracheal Issues** - Direct neck injuries can lead to bleeding and trauma affecting the trachea. - Examples include accidents like hitting a fence while riding a motorbike. **Management of Chest Injuries and Pain Assessment** **Overview of Chest Injuries** - Chest injuries can lead to significant complications, including trachea problems. - Obstructive shock from the chest does not affect the trachea. - Functionality is the primary focus in treatment decisions. **Pain Assessment and Functional Evaluation** - Rib fractures are particularly painful due to movement with each breath. - Assessment includes evaluating pain, breathing, and coughing ability. - PICS score is used to combine these factors for assessment. - Patients may report varying pain levels regardless of injury severity. **Functional Assessment Techniques** - Incentive spirometer is used to assess breathing limitations. - Cough assessment is crucial as it can be painful. - Subcutaneous emphysema indicates significant injury. **Pain Management Strategies** - Patients are reviewed twice daily for analgesia management. - Pain typically peaks in the first few days post-injury. - Effective pain relief is essential for breathing, coughing, and mobility. - Multi-modal analgesia strategy is employed for better cumulative effect. **Analgesic Protocol** - Initial treatment includes paracetamol and ibuprofen. - Oral analgesia escalates to Endone (oxycodone) as needed. - Proactive treatment for opiate side effects like nausea and constipation. - Inpatient admission may be required for patient-controlled analgesia. **Advanced Pain Management Techniques** - Ketamine infusion and regional blocks are utilized to reduce opiate use. - Epidurals may be used for bilateral chest wall injuries. - Continuous review of pain management strategies is conducted. **Considerations for Older Patients** - Special attention is given to patients over 65 to minimize opiate use. - Aim to prevent complications such as delirium. **Patient Discharge and Rib Fixation Strategies** - Graded analgesic strategy for discharged patients. - Rib fixation for patients with: - Significant chest wall pain. - Progressive respiratory failure. - Ventilator dependence. - Rib stabilization devices are used to hold ribs in place permanently. - Special attention to patients deteriorating during hospitalization. - Younger patients or those with minor rib fractures are more likely to be discharged. **Medication Management** - Excessive medication risks for discharged patients. - Strict criteria for opiate analgesia: - Short courses only. - Follow-ups required to ensure progress. - Monitoring for complications like hemothorax or chest wall displacement. **Blunt Abdominal Trauma** - Common injuries involve liver and spleen due to their location. - Solid organ injuries classified using a standardized grading system via CT scans. - Angiography performed on all trauma patients to identify vascular lesions. - Conservative splenic preservation approach with embolization leads to 80% preservation. **Pelvic Trauma Management** - Major pelvic trauma often occurs in vehicle accidents. - Initial actions include applying a pelvic binder to stabilize fractures. - Pelvic binder helps reduce bleeding risk by holding bony fragments together. - Proper application of the binder is crucial for effectiveness. - Contrast exams are essential for identifying complications like blood clots. **Essential Considerations in Surgical Management of Abdominal and Pelvic Injuries** **Importance of Imaging** - CT scans are crucial for surgical management. - Interventional radiology (IR) is often required. - In centers without IR, patients may undergo pelvic packing and stabilization before orthopedic care. **Management Options** - Non-operative management includes observational medicine and IR. - Evaluate for hemodynamic instability or failure of conservative management. - Post-angiography, damage control surgery (DCS) may be necessary to control bleeding. **Fluid Management and Resuscitation** - Resuscitation continues in the operating theatre. - Focus on volume status and coagulopathy endpoints. **Pain Management** - Analgesia is complex due to limited access to chest wall injury blocks. - PCA and ketamine are commonly used for significant abdominal trauma. **Post-Injury Care** - Patients with splenic and hepatic trauma require repeat imaging for complications. - Most patients with significant injuries are hospitalized for approximately one week.