Initial Assessment of the Trauma Patient

VALERIE SUGE-MICHIEKA

ATLS Guidelines
Systematic approach necessary to rapidly identify injuries and stabilize the patient This approach is divided into: 1. Primary Survey 2. Resuscitative Phase 3. Secondary Survey 4. Definitive Care Phase

ABCDE

Airway Management in the Trauma Patient

Objectives of Airway Management & Ventilation

Primary Objective:
Provide unobstructed passage for air movement Ensure optimal ventilation Ensure optimal respiration

Objectives of Airway Management & Ventilation

Why is this so important in the trauma patient?
Prevention of Secondary Injury
Shock & Anaerobic Metabolism Spinal Cord Injury Brain Injury

Airway
Patency is primary Obstruction in trauma patients
Tongue Swelling Foreign Body Blood and secretions

Airway
Evaluation begins by asking the patient a question such as 'How are you? A response given in a normal voice indicates that the airway is not in immediate jeopardy; a breathless, hoarse response or no response at all indicates that the airway may be compromised.

Airway
Mechanical removal of debris, chin lift and/or jaw thrust maneuver, are usefull in clearing the airway in less injured patients If there is any question of an adequate airway, severe head injury, profound shock, severe facial trauma, voice changes, then definitive airway control is necessary

Airway & Ventilation Methods

Supplemental Oxygen
increased FiO2 increases available oxygen Fi - Fractional concentraion of air concentration of o2 in inspired air
objective is to maximize hemoglobin saturation

Airway & Ventilation Methods

Airway Maneuvers
Chin lift Jaw thrust (Neck extension is contraindicated)

Airway Devices
Oropharyngeal airway Nasopharyngeal airway BVM

Assessment & Recognition of Airway & Ventilatory Compromise

Visual Assessment
Position
tripod orthopnea

Visual Assessment
Skin color Flaring of nares Pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or depth of ventilations

Rise & Fall of chest

Paradoxical motion

Audible gasping, stridor, or wheezes Obvious pulm edema

Airway & Ventilation Methods

Gastric Distention
Common when ventilating without intubation pressure on diaphragm resistance to BVM ventilation avoid by increasing time of BVM ventilation

Airway & Ventilation Methods

Orotracheal Intubation- preferred in almost all situations
Indications
present or impending respiratory failure apnea unable to protect own airway (GCS <8)

Advantages
secures airway route for a few medications optimizes ventilation and oxygenation

Airway & Ventilation Methods

Nasotracheal Intubation- rarely if ever used in the initial management of the injured patient. Many drawbacks Goal of safe endotracheal intubation with cervical spine precautions can be better accomplished with orotracheal intubation

Airway & Ventilation Methods

Surgical Cricothyrotomy
Indications
absolute need for a definitive airway AND unable to perform ETT due for structural or anatomic reasons, AND risk of not intubating is > than surgical airway risk OR absolute need for a definitive airway AND unable to clear an upper airway obstruction, AND multiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for effective ventilation and respiration

Airway & Ventilation Methods: ALS

Surgical Cricothyrotomy
Contraindications (relative)
Age < 8 years (some say 10) evidence of fx larynx or cricoid cartilage evidence of tracheal transection

Airway & Ventilation Methods

Needle Cricothyrotomy & Transtracheal Jet Ventilation
Indications
Same as surgical cricothyrotomy along with Contraindication for surgical cricothyrotomy

Contraindications
caution with tracheal transection

Airway & Ventilation Methods:

Jet Ventilation
Usually requires highpressure equipment Ventilate 1 sec then allow 3-5 sec pause Hypercarbia likely Temporary: 20-30 mins High risk for barotrauma

Airway & Ventilation Methods

Pharmacologic Assisted Intubation (RSI)
Sedation
Used for
induction anxious or agitated patient

Contraindications
hypersensitivity hypotension (e.g. hypovolemia 2 to trauma)

Airway & Ventilation Methods

Pharmacologic Assisted Intubation (RSI)
Neuromuscular Blockade
Induces temporary skeletal muscle paralysis Indications
When Intubation is required in a patient who is awake, has a gag reflex, or is agitated or combative

Airway & Ventilation Methods

Pharmacologic Assisted Intubation (RSI)
Neuromuscular Blockade
Contraindications
Most are specific to the medication inability to ventilate patient once paralysis is induced

Advantages
reduces risk of laryngospasm

Airway & Ventilation Methods

Pharmacologic Assisted Intubation (RSI)
Disadvantages & Potential Complications
Does not provide sedation or amnesia Provider unable to intubate or ventilate after NMB Aspiration during procedure Difficult to detect motor seizure activity Side effects and adverse effects of specific meds

Tension Pneumothorax

Recognizing Life Threatening Emergenies

Tension Pneumothorax
Signs and Symptoms
severe respiratory distress or absent lung sounds (unilateral usually) resistance to manual ventilation Cardiovascular collapse (shock) asymmetric chest expansion anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late)

Great Vessel Injury

Aortic Transection
Signs: - widened mediastinum, 1st rib fx, apical capping, left hemothorax, tracheal deviation to right - widening from bridging veins and arteries, not aorta itself - need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears at ligamentum - 90% of patients die at the scene

Cardiac Tamponade

Cardiac Tamponade
Becks triad: - hypotenstion, jugular venous distention, and muffled heart sounds - causes decreased diastolic ventricular filling and resultant hypotension - echocardiogram shows impaired diastolic filling of right atrium initially (1st sign)

Traumatic Brain Injury

Epidural Hematoma SA Hemorrhage

TBI:
High index of suscpicion in any patient with history of or identifiable evidence of altered level of consciousness Best determined by GCS (a decrease of even 1-2 points is indicative of significant change in neurological status) Pupillary function Lateralizing signs

Solid Organ Injury

Splenic Laceration Liver Laceration

Solid Organ Injury

25% of all trauma victims require an abdominal exploration Blunt trauma caused by MVCs, MCCs, falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of injury High index of suspicion in those patients with c/o abdominal pain, and/or objective findings on exam (seatbelt sign)

Hemorrhage
Pelvic fracture

Pelvic Trauma
Pelvic fx are the prototype of severe trauma, with an usually high incidence of associated injuries Awake pts c/o excessive pain and may have evidence of abnormal positioning of lower extremities, or unstable pelvis on exam Can be a major source of blood loss that is either arterial, venous, or osseous in origin