TRAUMA

Surgical unit II Tuesday, 4rth Oct 2011 9:30-11:30 AM

The Scheme

Recitation How it started Why is it important for US Primary Trauma Approach (Triage, BLS, ATLS) Dr Shafiq Chughtai, PGT 4 Deadly dozen Dr Asif Reza, PGT 4 Cases Dr Sundas Dr Hena Mortality Dr Shafiq Chughtai, PGT 4 Discussion/Questions

Recitation

How it started

ATLS has its origins in the United States in 1976, when James K. Styner, an orthopedic surgeon piloting a light aircraft, crashed his plane into a field in Nebraska. His wife was killed instantly and three of his four children sustained critical injuries

He carried out the initial triage of his children at the crash site. Dr. Styner had to flag down a car to transport him to the nearest hospital; upon arrival, he found it closed.

Even once the hospital was opened and a doctor called in, he found that the emergency care provided at the small regional hospital where they were treated was inadequate and inappropriate. Upon returning to work, he set about developing a system for saving lives in medical trauma situations.

First ATLS course which was held in 1978.

1980, American College of Surgeons committee on Trauma adopted ATLS. Styner himself recently recertified as an ATLS instructor, teaching his Instructor Candidate course in the UK and then in the Netherlands.

Why is it important for US

Approximately twenty million people are killed or injured every year due to the road traffic accidents.
1.66 million deaths were attributed to violence in the year 2000.

The situation in Pakistan is worse because

There is an ever increasing number of trauma victims due to road traffic accidents. Increasing violence. There is lack of timely provision of appropriate pre hospital/ hospital based medical care.

A study from Karachi reported that 58% of the victims of violence died before they could reach the hospital. National road safety secretariat estimated that about two million accidents occurred in Pakistan in year 2006 and 0.418 million were of serious nature

Increase of 55% was noted in homicidal attacks during a ten year period (1985-1994) in one study.
Another study estimated the loss of 31.94 healthy life years per 1000 population in Pakistan due to injuries in 1990. Today with worst law and order situation and violence, the situation has aggravated considerably in Pakistan.

It has been clearly proved in a study, that the mortality rates for seriously injured victims were six times more in the under developed countries than at the level 1 trauma centre in US. Most of these deaths occurred in the early hours after trauma and were attributed to (A) airway compromise (B) respiratory failure and (C) uncontrolled haemorrhage.

The Aim Today Is

To inculcate basic knowledge and approach in you so that we can bring a change and save more precious lives ..

Approach To Trauma

Triage

BLS

ATLS

Primary Survey

Secondary Survey

Triage
The greatest good for the greatest number.

Segregate & Priorities casualties into different groups on the basis of there injuries. Used since Neopolianic wars.
Studies show 10-15% casualties are serious enough! Patient status is dynamic and therefore, triage is done in

Field, Before evacuation At hospital.

Basic Life Support

Head tilt & Chin Lift

11

Ventilation

In patient with compromised breathing / apnea, there is need to take control of the airway.

Mouth to mouth/ mouth to nose ventilation. Bag Valve Mask Ventilation (BVMV) Endotracheal Intubation

Mouth to mouth ventilation is proven to be of value but considerable hesitancy exist leading to the tendency of not doing cpr in victims.

Provision of chest compression without mouth-to-mouth ventilation is far better than not attempting resuscitation at all.
Reference Van Hoeyweghen RJ, Bossaert LL, Mullie A, Calle P, Martens P, Buylaert WA, Delooz H, Belgian Cerebral Resuscitation Study Group. Quality and efficiency of bystander CPR. Resuscitation.. 1993;26:4752.[Medline] [Order article via Infotrieve]

BVM-Ventilation

BVM-V, Indications & Contraindications

BVM ventilation is absolutely contraindicated in the presence of complete upper airway obstruction.
BVM ventilation is relatively contraindicated after paralysis and induction (because of the increased risk of aspiration).

Technique of BVM-V

One hand C & E Technique Two hand technique

One hand, C & E Technique

Two Hand Techniques

Provide a volume of 6-7 mL/kg per breath (approximately 500 mL for an average adult.

During cardiopulmonary resuscitation (CPR), give 2 breaths after each series of 30 chest compressions until an advanced airway is placed. Then ventilate at a rate of 8-10 breaths per minute.

Endotracheal Intubation

Patient dies from lack of O2, not lack of ETT! Pre oxygenation. 8 deep breaths in 60 seconds. Apneia time increases to 8 minutes. Confirm that balloon of tube is functional.

Rough guide to size of tube is little finger diameter.

Hold your breath while passing tube, when u feel uncomfortable, stop and start ventilating patient. ETT requires considerable practice.

Cardiac Arrest

Advanced Trauma Life Support

Primary Survey

Primary Survey

A Airway and C Spine Protection

B Breathing & Ventilation

C Circulation

D Disability

E Exposure

The Golden Hour Concept

"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable.
Dr Cowley University of Maryland USA

Airway & C Spine Protection

1.

Look, listen feel for air movement and chest wall movement. Look for direct injury to airway, presence of edema, FBs and secretions. Listen for stridor. Can the patient protect his airway.

2.

3.

4.

Immobilize C-spine in all till Chin lift, jaw thrust, suction. Open mouth , inspect for secretions , FBs , broken teeth . Finger swap.remove FBs.

Intubate if

apnea gcs < 8 respiratory distress

Emergency cricothyrotomy if:

Oral/nasal attempts fail Significant maxillofacial trauma

There is little role of emergency tracheostomy.

Children
Shorter anterior lyranx. Floppy epiglottis, Short & small trachea Large tongue.

Airway insertion only in unconscious child , only in oro-phyranx

Vomiting risk reduced. Minimize iatrogenic injury to soft palate.

Surgical cricothyroidiotomy is contraindicated in less than 12 yrs. Cricothyroid membrane is not developed.

Breathing & Ventilation

Assess chest for defects, instablity and asymmetry. Assess respiratory rate, depth and chracter of respiration. Percuss the chest. Listen for breath sound.

Evaluate for

Neck
Trachea Chest wall

distended veins
central vs deviated. open sucking wounds, Symetry, paradoxical movement cerpetus, emphysema.

Lung percuss and ascultate. Back don t forget it. Diaphram rises to nipple level, do not forget abdomen.

Oxygenate with FiO2 -85%. Ventilate with Bag valve mask. Seal an open pneumothorax.

Emergent chest tube for tension pneumothorax or large heamothorax.

Hypoxic patient get very irritable. They pull and push and fight with health care workers.
Sedation might be required. Midazolam (dormicum) 1-2.5mg diluted iv push may work. RR of children is 20/min and infants are 4060/min.

Circulation

Assess
Pulses, hr, rhythm, Blood pressure, heart sounds, Neck veins, skin color, temperature.

Sources of bleeding:

Chest, abdomen , Open Extremity Wounds

Direct pressure to external bleed. Insert two large bore IV catheters Rapidly infuse Lactated Ringers.

Start blood if hypotension does not respond to crystalloids

Resuscitation and intervention goes side by side!! If iv access has failed twice, IO access should be tried specially in less than 6 yrs old. Pulse is an unreliable indicator in elderly.

Disablity

What is patients response?

A Alert V responds to Verbal P responds to Pain U Unresponsive

Assess pupils size, equality, reaction to light. ENT bleed/ CSF.

Protect from secondary injury:

Avoid hypothermia, Hypoxemia, hypercapnea, Hypotension, hypoglycemia, Volume excess.

Urgent neuro consult for signs of increased ICP or SCI. Presume SCI in all patients.

Exclude

Hypoglycemia, Alcohol, drugs. Blunt head injury has the worst prognosis in this age group.

Children

Elderly
Brain atrophy in this age group has protection from contusion. Large amount of blood can collect around the brain without overt symptoms.

Exposure

Remove all of pts clothing. Fully exposed front and back via log roll via in line traction All orifices, haired areas, axilla, perineum etc. Assess for hypothermia.

Detect easily missed injuries. Re warm with blankets, air devices, reflective shield, warm IV fluids.

IMPORTANT

Most trauma surgeons do primary survey twice before embarking on secondary survey.
Patients status changes rapidly, re evaluation is of critical importance from time to time.

Inx and Mx at a glance

O2 inhalation , May need Pulse Oximeter Ecg Monitor. Double iv access 16/14 G, take grouping and cross match at the same time, ringer lactate / normal saline / RCC. IV antibiotics, Tetnus, good pain killer.

ER profile if time permits. Xray

skull , c spine, chest , pelvis , limbs if indicated.

FAST DPL

Foleys catheter (blood at urethreal meatus is a contraindication)

Adults 0.5 ml/kg/hr. Infants 2ml/kg/hr. 1-5 yrs 1.5ml/kg/hr. 6-16yrs 1 ml/kg/hr.

IMPORTANT

Once the primary survey along with all the investigations and appropriate intervention is done , then one embarks on secondary survey.

Secondary Survey

This is the through head to toe examination.

AMPLE Palpate

Head, orbital margins, zygomatic arches, nose and ears, Cervical spine and neck, anteriorly and posteriorly for crepitus, heamatoma, tenderness

Assess throughly

Chest Abdomen CNS Extremities

REEVALUATION can not be stressed enough. Injuries to the Abdomen , back , perineum , hands and feet and even dislocations are picked up late if this step is missed!

Trauma management at SU 2
The Trauma Scoring System

The Deadly Dozen

Dr Asif Reza PGT 4

Case 1
Dr Sundas House Surgeon

Case 2
Dr Hena House Surgeon

Mortality
Dr Shafiq Chughtai PGT 4

Ambreen 18/ f, unmarried

Resident of Mandra
Victim of FAI while traveling in bus on which unidentified men opened fire

Referred from local health care facility after taking first AID and brought by relatives, 2 hrs after the initial event.
Arrival at emergency department at 1215 hrs.

At Presentation

Airway

Intact, pt was able to talk in complete sentences

20/min, regular, no cyanosis, trachea central, breath sound decreased left lower zone Radial not palpable, carotid 120/min, blood pressure 90/60mm Hg E3M5V6 14/15, PEARL, complete sensory and motor deficit in both lower limbs

Breathing

Circulation

Disability

Exposure

Management In Er Room

Oxygen via air mask Double iv access, transfusion of heamacel and ringer lactate (2 Ltrs). Grouping x match Tetnus prophylaxis and injection dicloran

Secondary Survey

Chest.

Decreased breath sounds left side of chest.Trachea was central.

Unremarkable Flaccid lower limbs, power 0/5 in both limbs, no sensory perception to painful stimuli.

Abdomen.

CNS.

Impression

Shock due to external bleed. Left haemo thorax.

Plan

X ray chest ------- proceed to tube thoracostomy if indicated ** X ray skull X ray pelvis FAST.

1230 hrs

CXR

Shows complete haziness in left hemi thorax.No gas under diaphragm. Pulse was 110/ min, BP 100/60 mmHg after 2 ltrs of haemacel and ringer lactate combined. Shifted to OT for tube thoracostomy.

1235 hrs

Patient on OT table. Stats were

P 110/min, BP 110/60 mm Hg No respiratory distress

Left shoulder wound started bleeding.

I closed it with silk sutures as significant ooze was coming out of it and patient had been in shock.

1240 hrs 1005 hrs

Patient started bleeding from the back wound. When I turned the patient on the right because there was blood on the OT table and floor, there was gush of blood as if it was coming from some cavity, almost 200ml.

I packed the wound, BP dropped to 90/60 mm Hg.

After 30 seconds I removed the pressure, again there was a gush of blood from the wound almost 300 cc. Patient blood pressure dropped to 80/60mmHg and she became unresponsive. I removed the stitches and inspected the wound.

On Inspection, there was shattered vertebrae beneath but there was no cavity or track. I applied pressure for 5 minutes and infused 500 cc of R/L. Her BP climbed to 100/60 mm Hg and there were some sounds made by the patients as well.

I approximated the muscles in an attempt to control bleeding.

It took me 2 minutes and bleeding stopped.

Once I was done with the posterior wound, patient BP dropped to 58/40 mmHg. I turned the patient on her back, put in chest tube in 5th ICS left side.

Immediately 50 ml blood came.

During the initial attempts to take control of posterior bleed, I lost left sided iv access. Patient had one iv access on right side from which we pushed in blood which we had arranged by then on non donor basis. Afterwards, BP became nil & she became apnic.

At the same time, patient was intubated, attached to ventilator and ventilated. Carotids were impalpable and CPR started immediately. Multiple attempts and cannulations and an emergency cut down was attempted in left inguinal region to get an iv access which failed.

During the next 20 min, 900 cc blood came in chest tube.

0115 hrs

CPR done for 20 minutes. Patient did not respond. Patient died at 0115 hrs. Relatives were explained while the resuscitation was in progress about the critical condition of the patient. There were almost 50 people with her and whole the ER was filled with them. However, no unpleasant event took place.

My Assessment

Cause of death

Hypovolemic Shock

Haemo thorax with Lung contusion

Spinal shock T12 level

External bleed Intra abdominal bleed?

Patient was in shock when she came due to external bleed as well as haemothorax.
Initially due to low blood pressure, the bleed was contained. Due to fluid resuscitation, her blood pressure elevated and she started bleeding from the back wound which was in communication with thorax. The bleeding was rapid and patient was compromised already so she went in irreversible shock.

Looking back

Immediate tube thoracostomy and thoracotomy / laprotomy.