trauma

Early assessment andmanagement of trauma

Dr.Muddather A.A. Mohammed

OBJECTIVES

At the end of this lecture you should be able to:• Identify the sequence of priorities in the earlyassessment of the injured patient.• Learn The principle of triage in immediatemanagement of the injured patient.• Know the concepts of injury recognition prediction based on the mechanism and energy of injury.• Apply the principles of primary and secondarysurveys in the assessment and management oftrauma• To recognize certain important groups of patients and theirdiffering management

Introduction

trauma can be divided into two basic types:• Serious and life-threatening injury; • Significant trauma requiring treatment but not immediately life threatening.

Types of injury■ Blunt■ Penetrating■ Blast■ Crush■ Thermal

Crush injury■ Muscle cells die. If reperfused, they release myoglobin■ Injured tissue sequesters fluid■ Renal shutdown results■ Treatment is fluid loading with monitoring of renal output to maintain diuresis

The approach to the traumatised patient is very different from that of a patient with an undiagnosed medical condition as, in the latter, an extensive history, past medical history, physical examination, differential diagnosis and investigations ordered to confirm or refute this diagnosis are undertaken. In the trauma setting, it is often not possible to obtain such information immediately; hence, a standardised protocol of management is required. The Advanced Trauma Life Support (ATLS) system was therefore created initially in the USA and rapidly taken up globally.

The steps in the ATLS philosophy■ Primary survey with simultaneous resuscitation – identify and treat what is killing the patient + AMPL HISTORY■ Secondary survey – proceed to identify all other injuries■ Definitive care – develop a definitive management plan


WHO IS THE
MULTIPLE TRAUMA PATIENT

PREPERATION

Planning arrival Trauma room with equipment: For resuscitation Monitoring Warmed solutions Trauma staff Laboratory and radiology personnel Personnel protection from communicable diseases (hepatitis & AIDS)
Initial trauma management

Triage

Sorting of patients based on the need for treatment and the available resources to provide that treatment Based on ABC
Initial trauma management


1 pre-hospital triage – in order to despatch ambulance and prehospital care resources;2 at the scene of trauma;3 on arrival at the receiving hospital.

Multiple casualties. Here, the number and severity of injuries do not exceed the ability of the facility to render care. Priority is given to the life-threatening injuries followed by those with polytrauma. 2 Mass casualties. The number and severity of the injuries exceed the capability and facilities available to the staff. In this situation, those with the greatest chance of survival and the least expenditure of time, equipment and supplies are prioritised .

Triage

RED --- FIRST PRIORITY-MOST URGENTYELLOW---SECOND PRIORITY- URGENTGREEN --- THIRD PRIORITY – NOT URGENTBLACK --- FOURTH PRIORITY (DEAD)


Primary survey
ABC’s - Identified and simultaneous management of the life-threatening conditionsA – Airway management with C-spine controlB – BreathingC – Circulation & hemorrhage controlD – Disability: neurologic statusE – Exposure: completely undress the patient Initial trauma management


Airway assessment with C-spine protection■ Check verbal response■ Clear mouth and airway with large-bore sucker■ If GCS ≤ 8, consider a definitive airway; otherwise use jaw thrust or oropharyngeal airway.


B – Breathing Adequate gases exchange: O2 transfer & CO2 elimination Involves adequate function of the lungs, chest wall and diaphragm Expose the patient chest Visual inspection & palpation Percussion Auscultation
Initial trauma management

Is the patient breathing? Look, listen, & feel for 10 seconds

Ventilation Impair
Tension pneumothorax Open pneumothorax Flail chest with pulmonary contusion ----- TREAT AS NEEDED+ START THE PROPER VENTOLATORY SUPPORT + high flow 100%O2
Initial trauma management

Circulation

(assessment and warning signs)■ Deteriorating conscious state■ Pallor■ Rapid thready pulse is a more reliable and earlier warning sign than a fall in blood pressure


TO STOP OR MINIMIZE FURTHER BLOOD LOSS

VOLUME REPLACEMENT

Resuscitation - IV Fluid therapy
Balanced salt solution: Ringer’s LactateIn hypovolemic patient - 2 l rapidlyRapid responseTransient response UnresponsiveBloodType specific cross-matchedO – negative Initial trauma management

D--- DISABILITY

The GCS allows for a very rapid assessment of the patient’s level of consciousness. Pupillary size should be also assessed. It should be noted, however, that hypoglycaemia, alcohol and drug abuse may also alter the level of consciousness and should also be excluded.

Glasgow Coma Scale (GCS)

Adjuncts to the primary survey■ Blood – FBC, urea and electrolytes, clotting screen, glucose, toxicology, cross-match■ ECG■ Two wide-bore cannulae for intravenous fluids■ Urinary and gastric catheters■ Radiographs of the cervical spine ,chest and pelvis

E – Exposure / Environmental control Undressing Protection from hypothermia

Initial trauma management

History

A Allergies M Medications P Past illness L Last meal E Events/ environment related to the injury Mechanism of injury Types of injury
Initial trauma management

SECONDARY SERVEY HEAD TO TOE EXAM *DO NOT FORGET HEDDEN AREA * NEEDED INVEVSTIGATIONS

MTP.
*PRIMARY SERVEY *AMPLE *SECONDARY SERVEY *DEFINITIVE MANAGEMENT *CONT. RE-EVALUATION *PATIENT REFFERAL & DISPOSITION


in children, the signs of severe injury may be delayed on account of their greater physiological capacity to respond to the injury initially. However, once the physiology decompensates, the rapid deterioration can be devastating.


Trauma in the elderly population presents many challenges for the treating physicians. Some of these are not easily overcome due to the fragility of the patient’s physiological status and comorbid medical conditions. Despite these poor outcomes, several reviews have advocated an aggressive approach to management because as many as 85% of elderly people return to independent function after significant trauma.