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Trauma basics

Up Trauma basics Basic trauma crit care Traumatic shock Trauma in elderly Abdomen & pelvis Chest injuries Fat embolism Head injury Larynx & trachea Maxillofacial Pregnancy Spinal injury


Triage

Most patients with severe injury can be distinguished early by:

  • depressed consciousness

  • breathing difficulty

  • shock

Basic treatment principles

Primary survey

During primary survey assessment and resuscitation should be concurrent

Airway

  • consider possibility of  cervical spine #
  • check patency of airway
    • Look, feel and listen for air movement
    • Look for evidence of increased work of breathing
    • Listen for sounds which suggest incomplete obstruction:
      • Snoring
      • Stridor
      • Gurgling
      • Noisy breathing
  • Restore patency if necessary
    • Elevate mandible and open the mouth. Do NOT extend the neck unless a cervical spine injury has been excluded.

    • Adjunctive devices such as a properly sized oropharyngeal or nasopharyngeal airway may be useful
    • Oropharyngeal airway is intended to hold the base of the tongue forward toward the teeth and away from the glottic opening. The plastic flange should rest against the outer surface of the teeth while the distal end curves around the base of the tongue. It is, therefore, important that an airway of an appropriate length is chosen. If the airway is too small it may push the tongue back over the glottic opening. If it is too large it may stimulate gagging and vomiting. To ensure the correct size place the airway over the side of the face with the flange at the lips. A correctly sized airway will end at the angle of the jaw
    • If airway patency cannot be restored by simple methods active airway intervention may be needed. Choice of method will depend on the estimated difficulty of orotracheal intubation and skills of the available personnel. In the absence of indicators of difficult intubation, orotracheal intubation under direct laryngoscopy, with the application of cricoid pressure, is probably the optimal method. Manual in-line stabilization should be performed during intubation

  • surgical airway if not possible to intubate patient and airway compromised: needle, dilational or surgical cricothyroidotomy. Jet ventilation for former: connect cannula to wall oxygen at 15 l/min with either a Y connector or side hole cut in tubing. Intermittent ventilation (1 sec on, 4 sec off) can be achieved by placing thumb over open end of hole. Patient can only be adequately ventilated for about 30-45 mins using this technique

Breathing

  • Rapid assessment of breathing should be carried out in conjunction with assessment of the airway
  • Look for:
    • signs of increased work of breathing
    • hypoxia
    • abnormal chest movement
    • external signs of chest injury
  • Palpate, percuss and auscultate the chest
  • Check for tracheal deviation
  • L
  • 3 conditions which most often compromise ventilation:

  • other important/frequently missed problem: massive haemothorax

  • give oxygen +/- mechanical ventilation

Circulation

  • 3 clinical features enable rapid assessment of circulatory status

    • level of consciousness: when blood volume £ half cerebral perfusion is critically impaired and unconsciousness occurs

    • skin colour: pink face and extremities suggest patient is not critically hypovolaemic. Ashen grey skin of face and white extremities indicate ³ 30% blood loss if due to hypovolaemia. Patient with cold, pale peripheries has shock until proved otherwise.

    • pulse

  • Other useful signs include blood pressure and respiratory rate

    The table below gives a rough guide to estimating blood loss but it should be noted that there may be discordance between clinical signs and that changes in signs are more important than absolute values

    Blood loss (%)

    <15

    15-30

    30-40

    >40

    Systolic BP (mmHg)

    >110

    >100

    <90

    <90

    RR (bpm)

    16

    16-20

    21-26

    >26

    Mental status
    Capillary refill

    Anxious  
    Normal

    Agitated  
    Delayed

    Confused
    Delayed

    Lethargic  
    Delayed

 

  • Tachycardia is not always present and hypotension is a late sign of shock

  • Age is an important determinant of the manifestations of hypovolaemia. Young patients tend to compensate well initially but may develop sudden cardiovascular collapse when compensatory mechanisms are exceeded

  • Base excess good guide to degree of shock and adequacy of resuscitation in first few hours

  • NB although  usual cause of shock is hypovolaemia this is not invariable. If  neck veins are distended consider:

    • tension pneumothorax

    • concurrent MI

    • cardiac tamponade

    • myocardial contusion

  • Important/frequently missed problems:

    • intra-abdominal or intra-thoracic injury

    • # of femur and/or pelvis

    • penetrating injuries with arterial or venous involvement

    • external haemorrhage from any source

  • Cross match 6 units and basic blood tests

  • Fluid resuscitation via 2 large IV cannulae in upper limb or external jugular veins. Use saline or colloid. Extensive fluid resuscitation in penetrating trauma of torso prior to haemostasis may be detrimental (possible explanations include hydraulic acceleration of haemorrhage caused by elevated systemic pressure, mechanical dislodging of active soft clot formation, dilution of clotting factors when large volumes of fluids have been infused)

Neurological

Assess GCS after initial resuscitation

Secondary survey

History

  • mechanism of injury: gives clues to likely injuries
    • blunt trauma: mostly due to automobile accidents. Direction of impact and damage sustained by car and in particular the passenger compartment give an indication of likely injury

    Mechanism of injury

    Related injuries

    Frontal impact: bent steering wheel, knee imprint in dashboard, bulls-eye fracture of windscreen

    Cervical sp #, anterior flail, myocardial contusion, pneumothorax, transection of aorta, ruptured liver/spleen, post #/dislocation of hip and/or knee

    Side impact

    Contralat neck strain, cerv sp #, lat flail, pneumothorax, ruptured spleen/liver (depending on side of impact), # of pelvis/acetabulum

    Rear impact

    Cervical spine injury

    Ejection from vehicle

    Precludes meaningful prediction of injury patterns but places patient at greater risk from virtually all injury mechanisms. Mortality significantly increased

    Motor vehicle-pedestrian

    Head injury, thoracic and abdominal injuries, # lower extremities

    • penetrating injury: type of injury determined by region of body and speed of missile

  • allergies, drug history, past medical history, last meal, events/environment related to injury

Physical examination

Head

  • Include examination of eyes including fundi, and visual acuity (for optic nerve injury)

  • Check pupillary response and motor and sensory examination of extremities in addition to GCS

  • Important/frequently missed problems: hyphaema, optic nerve injury, lens dislocation or penetrating injury, head injury, posterior scalp laceration

Maxillofacial trauma

  • Palpate facial bones and mandible for tenderness and crepitus
  • Important/frequently missed problems: impending airway obstruction, changes in airway status, cervical spine injury, exsanguinating  midface #s, lacrimal duct laceration, facial nerve injuries

Cervical spine/neck

  • examination includes both visual inspection and palpation

  • absence of neurological deficit, pain or tenderness does not rule out injury

  • important/frequently missed problems: cervical spine injury, oesophageal injury, tracheal/laryngeal injury, carotid artery injury

Chest

  • Examination

    • Inspection and palpation of entire chest feeling each rib and clavicles individually

    • Breath sounds

    • Heart sounds

    • Neck veins

  • Narrow pulse pressure may be only reliable indicator of cardiac tamponade

  • Decreased breath sounds may be only indication of tension pneumothorax

  • Important/frequently missed problems: tension pneumothorax, open chest wound, flail chest, cardiac tamponade, aortic rupture

Abdomen

  • specific diagnosis not as important as the fact that an abdominal injury exists

  • frequent re-evaluation important

Perineum/rectum/vagina

  • ? perineal contusions, haematomas, lacerations, urethral bleeding

  • rectal examination: ? blood, high-riding prostate, pelvic #s, integrity of rectal wall, sphincter tone

  • Insert urinary catheter in the absence of contraindications:

    • blood at urethral meatus

    • severely fractured pelvis

    • abnormal position of prostate on examination

Musculoskeletal

  • palpation of bones with rotational or three-point pressure checking for tenderness, crepitation or abnormal movements along the shaft

  • anterior to posterior pressure on ASIS and symphysis pubis can identify pelvic #s

  • log roll to examine and palpate back

  • check peripheral pulses

Sites of occult blood loss

  • major fractures

  • pleural cavity

  • peritoneal cavity

  • retroperitoneum

Radiology

  • CXR is only XR justified in an unresuscitated patient

  • Cervical spine XR for all patients with head injury or multiple injuries

  • Pelvis XR for all multiple injuries except for those patients who are awake and have no pelvic abnormalities

  • Other XRs should be performed in OT, ICU or XR dept.

Drugs

  • take history of medicinal and recreational drug use
  • drug effects may interact with effects of trauma or impair compensatory mechanisms
  • drug effects may be precipitant for trauma
 

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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