Trauma Lecture by Dr.

Regal Taken from the PDF uploaded at Eleap, Edited without permission by Arvin 09/16/08 The Concept Treat the greatest threat to life first Lack of a definitive diagnosis should never impede treatment A detailed history was not an essential prerequisite to begin the evaluation of an acutely injured patient The Result A Airway with cervical spine control B Breathing C Circulation D Disability or neurologic status E Exposure (undress) with temperature control INITIAL ASSESSMENT (A systematic approach that can be reviewed and practiced) 1. Preparation 2. Triage 3. Primary Survey (ABCs) 4. Resuscitation 5. Secondary Survey (head-to-toe) 6. Continued post-resuscitation monitoring and reevaluation 7. Definitive care Primary Survey A - Airway maintenance with cervical spine control B - Breathing and Ventilation C - Circulation with hemorrhage control D - Disability ; Neurologic status E - Exposure / Environmental Control; Completely undress the patient, but prevent hypothermia Life threatening conditions are identified and management is begun simultaneously Priorities for the care of the pediatric patient are basically the same as for adult Airway with Cervical Spine Control Ascertain patency foreign bodies facial, mandibular, tracheal or laryngeal fractures Chin-lift or jaw-thrust maneuver Cervical spine immobilization C-7 to T-1 cross-table lateral cervical spine x-ray Multi-system trauma, altered level of consciousness, or a blunt injury above the clavicle Breathing Assure adequate ventilation Function of the lungs, chest wall, and diaphragm Injuries that acutely impair ventilation Tension pneumothorax Flail chest with pulmonary contusion Open pneumothorax Injuries that compromise ventilation to a lesser degree Hemothorax, simple pneumothorax, fractured ribs, and pulmonary contusion Circulation with Hemorrhage Control Blood volume and cardiac output Level of consciousness

Skin color Pulse Bleeding o External, severe hemorrhage is identified and controlled in the primary survey o External blood loss is managed by direct manual pressure o Hemorrhage into the thoracic or abdominal cavities, into muscles surrounding a fracture, or as a result of penetrating injury can account for major blood loss Disability (Neurologic Evaluation) Level of consciousness and pupillary size and reaction A Alert V Responds to Vocal stimuli P Responds to Painful stimuli U Unresponsive Decreased level of consciousness Decreased cerebral oxygenation and/or perfusion Alcohol and drugs Exposure / Environmental Control Patient should be completely undressed Cover and protect from hypothermia Warm blankets Intravenous fluids should be warmed Maintain warm environment Resuscitation Airway Jaw-thrust or chin-lift maneuver Nasopharyngeal airway Oropharyngeal airway Breathing / Ventilation / Oxygenation Endotracheal intubation Surgical airway Chest decompression Supplemental oxygen therapy Circulation Two large-caliber IV catheters Blood type, crossmatch, pregnancy test Balanced salt solution Blood transfusion Type-specific blood, O-negative blood, unmatched type specific blood Hypovolemic shock should NOT be treated by: vasopressors, steroids, or sodium bicarbonate Hypothermia ECG monitoring Urinary and Gastric Catheters Routine urine analysis Urethral injury is suspected if there is: Blood at the penile meatus Blood in the scrotum Prostate is high-riding or can not be palpated Blood in the gastric aspirate may represent: Swallowed blood Traumatic insertion Actual injury to the stomach If the cribriform plate is fractured or fracture is suspected, NGT should be inserted orally Monitoring Ventilatory rate and arterial blood gases End-tidal carbon dioxide monitoring Pulse Oximetry

Appropriate oxygenation is a reflection of proper airway, breathing and circulatory status Blood pressure ECG monitoring Consider the need for patient transfer Remember: Life-saving measures are initiated when the problem is identified, rather than after the primary survey During the primary survey and the resuscitation phase, the evaluating physician frequently has enough information to indicate the need for transfer of the patient to another facility Referring physician to receiving physician communication is essential Roentgenograms Should be used judiciously and NOT delay patient resuscitation In blunt trauma, x-rays to be obtained: Cervical spine Chest (AP) Pelvis (AP) After all life-threatening injuries are identified: Complete cervical, thoracic and lumbar spine In penetrating injuries, x-rays are: Chest (AP) Films pertinent to the site of wounding Secondary Survey Tubes and fingers in every orifice The secondary survey does not begin until the primary survey (ABCs) is completed, resuscitation is initiated, and the patients ABCs are reassessed Head-to-toe evaluation Complete neurologic examination (GCS) Special procedures o Peritoneal lavage, radiologic evaluation, and laboratory studies History A Allergies M Medication currently taken P Past illnesses L Last meal E Events / environment related to the injury Blunt trauma Penetrating trauma Burns Hazardous environment Physical Examination Head Scalp and skull examination Eye and ear examination Maxillofacial Cribriform plate fracture - orogastric intubation Cervical spine and Neck presume injury in patients with maxillofacial or head trauma Extreme care must be taken when removing helmet Chest Visual evaluation Open pneumothorax, flail chest Palpation Fractures Auscultation o Cardiac tamponade - distant heart sounds and narrow pulse pressure, distended neck veins Tension pneumothorax - decreased breath sounds, shock, distended neck veins Chest X-ray

Widened mediastinum, pneumohemothorax, fractures

Abdomen A normal initial examination of the abdomen DOES NOT exclude intra-abdominal injury Candidates for peritoneal lavage Unexplained hypotension Neurologic injury Impaired sensorium secondary to alcohol or drugs Fractures of the pelvis or lower rib cage may hinder adequate abdominal examination Perineum / Rectum / Vagina Rectal Examination Presence of blood within the bowel lumen High-riding prostate Pelvic fractures Integrity of the rectal wall Quality of the sphincter tone Vaginal Examination Blood in the vaginal vault Vaginal lacerations Pregnancy test Musculoskeletal Extremities o Deformity, abnormal movement, tenderness, crepitation Pelvis Pressure over anterior iliac spine and symphysis pubis Assessment of peripheral pulses Ligament rupture, muscle-tendon injury, nerve injury or ischemia Neurologic Motor, sensory, level of consciousness, pupillary reaction Immobilization of the entire patient Cervical collar If there is neurologic deterioration, ABCs must be reassessed Re-Evaluation New findings are not overlooked Discover deterioration Underlying medical problems Effective analgesia Monitoring Vital signs Urinary output Arterial blood gas Cardiac monitoring devices Definitive Care The CLOSEST APPROPRIATE hospital should be chosen based on its overall capabilities to care for the injured patient Roentgenogram Cervical Spine X-ray Cross-table lateral C-1 to C-7 Chest X-ray (AP) Pneumothorax Pelvic fracture Airway Chin-lift maneuver Nasopharyngeal airway Endotracheal Intubation Cricothyroidotomy

End Arvin- 09/16/08