MANAGEMENT OF MULTIPLE TRAUMA Raywat Chunhasuwankul Division of Trauma Surgery Faculty of Medicine Siriraj Hospital
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MANAGEMENT OF MULTIPLE TRAUMA
Raywat Chunhasuwankul Division of Trauma Surgery Faculty of Medicine Siriraj Hospital
TRIMODAL DEATH DISTRIBUTION
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Trimodal Death Distribution There are three peaks of death from trauma. First peak: Immediate – unsurvivable injuries, impacted by trauma prevention. Second peak: Early – golden hour of care, impacted by ATLS and early hospital care. Third peak: Late – caused by sepsis and multiple organ dysfunction syndrome (MODS), impacted by optimal early care and trauma center management.
TRAUMA CONCEPT
● ABCDE approach to evaluation and treatment
● Treat greatest threat to life first
● Definitive diagnosis not immediately important
● Time is of the essence
● Do no further harm
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ATLS Concept ABCDE is the universal language for the primary exam. ABCDE is the order in which the injuries will kill patients. Definitive diagnosis and an in-depth history are not required initially.
ATLS
Transfer
Reevaluation
Adjuncts
Adjuncts
Primary Survey
Resuscitation
Reevaluation
Detailed Secondary Survey
Injury
Optimize patient status
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Initial Assessment / Management The primary survey, adjuncts and resuscitation should occur simultaneously. Waiting for tests should not delay resuscitation and treatment. Patients should be re-evaluated frequently after resuscitation and treatments. Patients who exceed the capabilities of your facility should be identified early and arrangements made for transfer while continuing with resuscitation.
● Cap ● Gown ● Gloves ● Mask ● Shoe covers ● Goggles / face shield
STANDARD PRECAUTION
INITIAL ASSESSMENT
Primary survey and resuscitation of vital functions are done simultaneously using a team approach.
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1-5Initial Assessment We recognize that, when a team is present, many individuals accomplish disparate tasks simultaneously. The ABCDE format is somewhat artificial, but it serves the purpose of establishing priorities and helping the student to return to “A” (home base) whenever the patient’s condition worsens or the patient does not respond as anticipated during the initial assessment process.
WHAT IS A QUICK, SIMPLE WAY TO ASSESS A PATIENT IN 10 SECONDS?
Quick Assessment
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1-7Quick Assessment What is a quick, simple method to assess the patient in 10 seconds? After asking this question, allow the students adequate time to consider the most efficient way of assessing for a patent airway, sufficient respiratory reserve to speak, and the level of cognition to process the question and respond appropriately. Answers appear on next slide.
INITIAL ASSESSMENT
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation: stop the bleeding!
Disability / neurological status
Expose / Environment / body temperature
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ATLS Concept Re-emphasize and discuss these concepts interactively with students.
SPECIAL CONSIDERATIONS
● Trauma in the elderly
● Pediatric trauma
● Trauma in pregnancy
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1-12Special Considerations Remind the students that there are special issues to consider with each of these types of trauma patients, but that the priorities remain the same.
PRIMARY SURVEY
Establish patent airway and protect c-spine
Occult airway injury
Progressive loss of airway
Equipment failure
Inability to intubate
Pitfalls
Airway
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1-13Primary Survey: Establish patent airway and protect c-spine Concerns regarding the c-spine may be new to those students who are familiar with cardiac life support procedures, but have not taken the ATLS Course. Emphasize the need to protect the c-spine during airway management, especially avoiding the ACLS head-tilt maneuver. You may then query the students about what pitfalls they may encounter with managing the airway or, depending on available time, caution the students to avoid these pitfalls.
AIRWAY MANAGEMENT
● Surgical airway ● Cricothyroidotomy Needle
Definitive Airway
Surgical
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2-20Airway Management: Definitive Airway Describe pictures.
PRIMARY SURVEY
Assess and ensure adequate oxygenation and ventilation
● Respiratory rate
● Chest movement
● Air entry
● Oxygen saturation
Breathing
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1-14Primary Survey: Assess and ensure adequate oxygenation and ventilation Emphasize the need to attend to adequate oxygenation and ventilation in the injured patient, recognizing that altered chest wall mechanics may be new to those doctors who have taken only the cardiac life support course. Emphasize that, if the patient is receiving high-flow oxygen, adequate oxygenation is no guarantee of adequate ventilation.
BREATHING & VENTILATION
“ Look , feel , palpate and listen “ for Tension pneumothorax Open pneumothorax Severe flail chest Resuscitation Oxygenation : FiO2 > 0.85 ( mask with bag 10 l/min )
PRIMARY SURVEY
Breathing
Airway versus ventilation problem?
latrogenic pneumothorax
or tension pneumothorax?
Pitfalls
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1-15Primary Survey: Assess and ensure adequate oxygenation and ventilation Emphasize the need to attend to adequate oxygenation and ventilation in the injured patient, recognizing that altered chest wall mechanics may be new to those doctors who have taken only the cardiac life support course.
TENSION PNEUMOTHORAX
High pressure pneumothorax causing cardiovascular compromised status
* chest injury * dyspnea & tachypnea * distended neck vein * deviated trachea * hypotension * tympanic on percussion * absent breath sound
OPEN PNEUMOTHORAX
Abnormal connection between pleural cavity and atmosphere causing inability to ventilate the lungs
Resuscitation : three-sided dressing : ICD : Oxygenation
SEVERE FLAIL CHEST
Segmental separation of chest wall causing inability to breath and ventilate the lungs
* dyspnea & tachypnea * paradoxical movement * decreased breath sound Resuscitation : intubation & respirator : oxygenation : pain control : breathing exercise
PRIMARY SURVEY
● Control hemorrhage
● Restore volume
● Reassess patient
Elderly Children Athletes
Medications
Circulatory Management
Pitfalls
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1-17Primary Survey: Circulatory Management Emphasize the need to control hemorrhage or stop the bleeding. Also emphasize that the patient may require an operation to stop the bleeding. Stress the importance of reassessing the patient’s response to treatment.
CIRCULATION & HEMORRHAGE CONTROL
Stop external bleeding !! Signs of shock
Grading of shock Source(s) of shock Massive Hemothorax Cardiac tamponade Massive Hemorrhage Resuscitation and Oxygenation
MASSIVE HEMOTHORAX
● Systemic / pulmonary vessel disruption
● > 1500 mL blood loss
● Flat vs. distended neck veins
● Shock with no breath sounds and/or percussion dullness
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4-15Massive Hemothorax What is the cause and how do I identify if the patient has a massive hemothorax? Note that this type of injury results in a ‘B’ and ‘C’ problem. X-ray courtesy of Ray McGlone, Royal Lancaster Infirmary; UK
CARDIAC TAMPONADE
Obstructive shock Beck’s triad : Hypotension : Distant heart sound : Engorged neck vein Pericardiocentesis Thoracotomy
HYPOVOLUMIA
Class I : <15% ; HR <100 ; normal BP ; : RR ~ 14-20 Class II : 15% - 30% ; HR > 100 : normal BP ; RR ~ 20-30 Class III : 30% - 40% ; HR > 120 : hypotension ; RR 30-40 Class IV : > 40% ; HR > 140 : profound shock ** Blood volume ~ 70 cc / kg body weight
FLUID RESUSCITATION
Warm RLS 2000 ml I.V. in 15 min. ( 20 ml / kg in children ) 1. Rapid response ( 10%-20% ) ( type and crossmatch ) 2. Transient response ( 20%-40% ) ( type-specific ) 3. Unresponsive ( > 40% ) ( group O Rh + )
Disability
● Baseline neurologic evaluation ● Glasgow Coma Scale score ● Pupillary response
Observe for neurologic
deterioration
PRIMARY SURVEY
Caution
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1-18Primary Survey: Disability Emphasize that it is essential to identify neurologic injury using the tools of GCS score and pupil response early in order to avoid secondary brain injury, identify surgically correctible lesions rapidly, and provide a baseline GCS score to identify trends and changes.
Prevent hypothermia
Exposure / Environment Completely undress the patient
Missed injuries
Primary Survey
Pitfalls
Caution
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1-19Primary Survey: Exposure and Environment The ‘E’ of the ABCDEs. Emphasize the need to completely undress the patient to adequately assess the entire patient, while at the same time preventing hypothermia.
EXPOSURE & ENVIRONMENTAL CONTROL
Undress Log-roll Missed areas P.R. Keep warm
ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION
Monitoring : V/S , EKG , O2 Sat , Urine output Catheters : Foley’s , N-G Investigations : CXR , Pelvis : FAST or DPL Re-evaluation !!
ADJUNCTS TO PRIMARY SURVEY
Diagnostic Tools
● FAST
● DPL
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1-23Adjuncts to Primary Survey DPL and FAST may also be used during the primary survey to detect intraabdominal blood.
● Use time before transfer for resuscitation
● Do not delay transfer for diagnostic tests
Consider Early Transfer
ADJUNCTS TO PRIMARY SURVEY
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1-24Adjuncts to the Primary Survey: Consider Early Transfer Emphasize that the time to initiate the transfer process is when the need is recognized. Therefore, the need to transfer must be considered early. The sooner the need is recognized and communicated, the more efficiently it occurs. In addition, transfer should not be delayed to perform the secondary survey or to perform diagnostic tests such as CT scans. The time spent waiting for transportation to arrive should be spent stabilizing the patient.
WHEN DO I START THE SECONDARY SURVEY?
After ● Primary survey is completed
● ABCDEs are reassessed
● Vital functions are returning to normal
Secondary Survey
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1-26Secondary Survey: When do I start it? These slides transition the student to the secondary survey. Emphasize that issues identified during the primary survey have been addressed and reevaluated before proceeding to the secondary survey.
SECONDARY SURVEY
History : AMPLE P.E. : Head : Maxillofacial : C-spine and neck : Chest : Abdomen : Pelvis and perineum : Extremities : Neurological function
SECONDARY SURVEY
History
Allergies
Medications
Past illnesses, Personal history, Pregnancy
Last meal
Events / Environment / Mechanism
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1-28Secondary Survey: History Introduce this simple mnemonic for obtaining an “AMPLE” or complete patient history.
ADJUNCTS TO SECONDARY SURVEY
Monitoring
Catheters Investigations Re-evaluation !!
DEFINITE CARE
O.R. ICU IPD OPD Consult Refer
PEDIATRIC TRAUMA
Most common cause of death Neurologic and respiratory derangements far
exceed hemodynamic derangements.
ANATOMIC CONSIDERATIONS AND IMPLICATIONS
Prominent occiput in younger child
1” pad under torso for neutral position
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10-10 Anatomic Considerations and Implications: What aspects of childhood anatomy do I need to consider? Explain the importance of hand position in basic airway maneuvers to avoid inadvertent airway obstruction during endotracheal intubation.
PHYSIOLOGY
What physiologic differences will impact on my management of pediatric trauma patients? • Age-specific vital signs
• Smaller blood volume (70 – 80 mL / kg)
• Decreased functional residual capacity
• Vigorous compensatory response
• Sudden deterioration
• Increased vagal tone
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10-16 Physiology: What physiologic differences will impact on my management of pediatric trauma patients?
VITAL SIGNS
Sign Age Group
0 – 2 years
3 – 5 years
6 – 12 years
Heart Rate < 150 - 160 < 140 < 100 -
120 Blood Pressure > 60 - 70 > 75 > 80 - 90
Respiratory Rate < 40 - 60 < 35 < 30
Adequate Urine Output
1.5 – 2 cc/kg 1 cc/kg 0.5 – 1
cc/kg
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10-17Vital Signs Average vital signs for three age groups are shown in the table on the slide.
FLUID MANAGEMENT
• With an isotonic solution at 20 mL / kg
• Blood should be given if resuscitation is needed following two boluses of crystalloid
• Early use of plasma and platelets
• Bleeding of more than half the child’s blood volume in the first four hours should be resuscitated with PRBCs, and early use of plasma and platelets
Resuscitation
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10-18 Fluid Management: Resuscitation The concept of balanced resuscitation is as important in the child as it is in the adult; see notes from Shock Chapter.
PITFALLS
• Short trachea: main stem bronchial intubation • ETT depth is 3 x ETT size
• Endotracheal tube easily obstructed
• Deceptive presentation of hypovolemic shock
Pitfalls
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10-25Pitfalls Describe the pitfalls, as identified on the slide.
PITFALLS
• Gastric dilation can increase risk of aspiration and cause hypotension
• Difficult intravenous access in children < 6 years
• Missed hollow viscus injury
• Subtle musculoskeletal injury findings
Pitfalls
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10-26Pitfalls Describe the pitfalls, as identified on the slide.
GERIATRIC TRAUMA
Age-related changes in anatomy and physiology
Preexisting diseases and co-morbidities
Medications
Possibility of elder maltreatment
DECLINE IN FUNCTION WITH AGE
↓ Brain mass
Eye disease
↓ Depth of perception
↓ Discrimination of colors
↓ Pupillary response
↓ Respiratory vital capacity
↓ Renal function
2- to 3-inch loss in height
Impaired blood flow to lower leg(s)
↓ Degeneration of the joints
Total body water
Nerve damage (peripheral neuropathy)
Stroke
Diminished hearing
↓Sense of smell and taste
↓Saliva production
↓Esophageal activity
↓Cardiac stroke volume and rate
Heart disease and high blood pressure
Kidney disease
↓Gastric secretions
↓Number of body cells
↓Elasticity of skin, thinning of epidermis
15 – 30% body fat
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11-8Decline in Function with Age Review and explain the effects of aging on organ systems. Do not spend excessive time on this slide.
UNIQUE AIRWAY PROBLEMS
• ABCDE • Priorities are the same • Decreased cardiopulmonary reserve may
require early intubation
• Factors affecting airway management • Dentition (including dentures) • Nasopharyngeal mucosal fragility • Cervical arthritis
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11-10 Unique Airway Problems What are the unique airway problems with elderly patients? Emphasize that the initial approach to the airway in the elderly patient is the same as with any injured patient. Problems that can be encountered with intubating the elderly patient are identified on the slide. To elicit appropriate responses from the students, you may ask the secondary question, “What problems might I encounter when intubating the elderly patient?”
UNIQUE BREATHING PROBLEMS
• Diminished respiratory reserve
• Use of supplemental oxygen • COPD
• Chest injuries poorly tolerated
• “Minor” chest injuries with major effects
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11-11 Unique Breathing Problems What are the unique breathing problems in elderly trauma patients? There is a loss of respiratory reserve with aging. Some patients with COPD may lose their “hypoxic respiratory drive” and hypoventilate with oxygen administration. In spite of this, oxygen should be administered. Endotracheal intubation is performed if somnolence from rising PC02 develops. The elderly are intolerant of rib fractures, pulmonary contusions, and even simple pneumothoraces and hemothoraces. The onset of respiratory failure may be insidious because of the increased work of breathing and decreased energy reserve. Pulmonary complications (atelectasis, pneumonia, and pulmonary edema) occur with greater frequency. Marginal cardiopulmonary reserve, coupled with overzealous crystalloid infusion, can complicate management, leading to pulmonary edema or worsening pulmonary contusions. Pitfalls in management include failure to treat hypoxemia and failure to recognize that even “minor” injury may require hospitalization.
UNIQUE CIRCULATORY PROBLEMS
• Decreased cardiovascular function and reserve
• Cautious fluid administration • Increased BP, decreased HR, and loss of renal
function with age
• Anticoagulants and other medications
• Pharmacologic effects • Catecholamine effects and dysrhythmias
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11-12 Unique Circulatory Problems What are the unique circulatory problems in elderly trauma patients? The initial approach to “C” is the same. Emphasize that blood pressure generally increases and the maximal heart rate decreases with age. So, “normal” blood pressure and heart rate do not equate with hemodynamic normality. The elderly may be chronically volume-contracted and potassium and sodium depleted with loss of renal function. Overly aggressive crystalloid infusion may not be well tolerated. Although the optimum hemoglobin level for the elderly is controversial, current consensus is to maintain the Hgb at >10g/dl. However, indiscriminate transfusion should be avoided. The surgeon should be involved early in the management of any injured elderly patient with early institution of cardiorespiratory system monitoring. Many patients arrive on anticoagulants, and this should be reversed if possible.
UNIQUE NEUROLOGIC PROBLEMS
• Acute and chronic subdural hematomas
• Altered sensorium secondary to cerebral atrophy, hypoperfusion, and medications
• Spinal osteoarthritis, leading to frequent spinal column and cord injuries
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11-13 Unique Neurologic Problems What are the unique neurologic problems that I may encounter in geriatric patients? Due to cerebral atrophy, the dural bridging veins become stretched and more susceptible to rupture. Changes in mental status, preexisting disease, and medication may cause injury and often complicate evaluation. Changes in the intervertebral discs put the aged spine at increased risk of injury, predispose to further injury, affect the facets, ligaments and muscles, and lead to spinal stenosis. This sagittal T2 weighted image shows severe multilevel degenerative changes affecting disc spaces and posterior elements, associated with severe central canal stenosis, cord compression and small foci of myelomalacia at the C4-C5 level.
UNIQUE EXPOSURE PROBLEMS
• Abnormal thermoregulatory mechanism
• Increased sensitivity to hypothermia
• Increased risk of infection
• Lack of tetanus protection
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11-14 Unique Exposure Problems What are the unique exposure problems that I may encounter? The skin and connective tissue of the elderly undergo extensive changes, resulting in loss of thermoregulatory ability, increased risk of infection, and impaired wound healing. These changes make the elderly trauma patient particularly susceptible to hypothermia. The elderly often fail to keep their tetanus immunization status up to date. Hypothermia that is not attributable to shock or exposure may be from occult disease, sepsis, pancreatitis, hypothyroidism, or phenothiazine overdose.
UNIQUE MUSCULOSKELETAL PROBLEMS
• Most frequent cause of morbidity
• Susceptible to certain fractures
• Osteoporosis
• Preexisting deformities complicate evaluation
• Immobility can lead to complications
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11-15 Unique Musculoskeletal Problems What unique musculoskeletal problems do I need to consider in the management of elderly patients? Musculoskeletal disorders are the most common complaint of the elderly patient and are the most likely cause of restrictions. Osteoporosis is endemic, clinically affecting almost 50% of the elderly. The elderly are particularly susceptible to certain fractures. Hip fractures occur in 1%/year in men and 2%/year in women over 85 years of age. Falling on an outstretched hand may cause a fracture of the humerus. Falling on an outstretched, dorsiflexed hand may cause a Colles fracture of the wrist. The median nerve and motor function of the finger flexors should be carefully examined. X-rays are needed to exclude a more complex injury. A nonimpacted fracture often requires an operation. Management of musculoskeletal injuries involves the least invasive treatment that will permit early mobilization. Prolonged inactivity and disuse often limits the ultimate functional outcome and impacts survival.
DRUGS THAT AFFECT RESUSCITATION
• Beta blockers
• Antihypertensives
• NSAIDS
• Anticoagulants
• Corticosteroids
• Diuretics
• Hypoglycemics
• Psychotropics
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11-18 Drugs That Affect Resuscitation What medications can affect my resuscitation efforts? Medications can complicate management and predispose to injury. Common medications include beta blockers, calcium channel blockers, diuretics, and chronic anticoagulant use. Beta blockers may limit chronotropic activity. Calcium channel blockers may prevent vasoconstriction and contribute to hypotension. Nonsteroidal agents block platelet function and contribute to blood loss. Steroids reduce the inflammatory response. Volume contraction, potassium and sodium deficits may result from chronic diuretic use. Hypoglycemia may cause the injury event and alter the response to injury. Psychotropics may be a cause for the injury and may mask injuries. Additionally, withdrawal symptoms may occur if the psychotropic drug is stopped suddenly.
TRAUMA IN PREGNANCY
Is she pregnant ???????
CHANGES AND RISKS
12th week Uterus becomes an abdominal organ
20th week At umbilicus
34 – 36 weeks At costal margin
38 – 40 weeks Head engages pelvis
What changes to anatomy and physiology occur with pregnancy, and what are the unique risks?
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12-7 A & P Changes and Risks: What changes occur with pregnancy, and what are the unique risks? What are the changes? Describe the changes that occur during pregnancy. Summarize the anatomic locations of the fundus of uterus by gestational age.
PHYSIOLOGIC CHANGES
Increased • Minute ventilation • Heart rate and cardiac
output • Blood volume • Glomerular filtration
rate • Gastric emptying time
Decreased • pCO2
• Hematocrit
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12-11 Physiologic Changes Discuss the physiologic changes shown on the slide.
PRIMARY SURVEY AND RISKS
With maternal blood loss, fetal
distress precedes
changes in maternal vital
signs.
A
B
D
Aspiration risk
C
Difficult ventilation
Failure to recognize blood loss early
Eclampsia
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12-12 Primary Survey and Risks Explain how pregnancy affects each of the ABCDE’s of the primary survey.
EVALUATION AND MANAGEMENT
How do I evaluate and treat two patients?
• Primary survey / resuscitation of mother • Fetal assessment • Secondary survey of mother • Definitive care of mother and fetus • Rh-negative mothers receive immunoglobulin
therapy (unless injury remote from uterus) • Early OB consult
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12-14 Evaluation and Management: How do I evaluate and treat two patients? How do I evaluate and treat two patients? Emphasize the importance of early consultation for obstetric care. Explain that fetal resuscitation is optimized by resuscitation of the mother.
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