Principles Of Trauma Care

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Principles Of Trauma Care

• Dr. A. Campbell FRSCS
• Assistant Professor
• Division of Orthopedic Surgery

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Objectives

• Appreciate the societal cost of trauma
• Know common causes of death in golden hour
• Know the components and order of the primary
  survey
• Know causes of hypotension in trauma
• Know common sources of hemorrhage
• Know basic resuscitation of the trauma patient

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Epidemiology

• Leading cause of death lt 40 years
• Number of Mortalities increasing
• Seatbelts and airbags decrease deaths
• 31 death to permanent disability

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Epidemiology

• Young productive people
• Swift onset and slow recovery
• Devastating and costly

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Epidemiology

• Multiple injuries confusion
• Protocols and teams designed to reduce mortality
  and morbidity and mistakes
• ATLS gold standard
• - be careful about dogma

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Trauma Deaths

• Trimodal Distribution
• Minutes massive injury to brain, brain stem,
  heart, aorta, great vessels
• Hours golden hour
• Days- sepsis or multisystem organ failure

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Trauma Deaths Golden Hour

• Main focus of trauma management.
• Effective assessment and resuscitation to reduce
  Mortality and disability.
• Death due to sub/epidural hematoma,
  hemo/pneumothorax, ruptured spleen, liver
  laceration, pelvic fractures, multiple injuries
  with extensive blood loss.

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Assessment

• In case of
• -High Energy Injury
• -Loss of or altered consciousness
• -Details of accident unknown
• Assume patient to be multiply traumatized and
  completely assess.

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Assessment Overview

• AMPLE history
• Primary Survey ( ABCs) - Treat in order
• Adjuncts (monitors, xrays, bloodwork prn)
• Secondary survey (head to toe)
• Adjuncts (other tests) and emergency care
• Definitive Care

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Primary Survey

• Airway maintenance with C-spine control
• Breathing (ventilation)
• Circulation
• Disability
• Exposure/Environment

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Airway

• Assume c-spine injury
• Immobilize collar, towels, assistant
• Chin lift/jaw thrust
• Check for debris
• Assess LOC and ability to maintain airway
• ? Need for definitive airway (tube)

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Breathing

• Open airway does not ventilation
• Ventilation necessary for oxygenation
• Supplementary oxygen
• Expose and examine
• Resp. rate greater than 20 think
• -Pneumo (Tension/Hemo-Pneumo)
• -Flail
• -Contusion

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Circulation

• Hypotension in trauma- neurogenic
• - cardiac
• -
  hypovolemic
• Hypotension is hypovolemic (hemorrhage) until
  proven otherwise
• Rapid and accurate assessment
• Controlexternal bleeding with direct pressure
• Assessment of sources of occult bleeding (chest,
  abdomen, pelvis)

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Shock

• Inadequate tissue perfusion
• Recognition important
• Systolic pressure maintained by compensatory
  mechanisms
• Pulse rate, resp rate, skin, and pulse pressure
  better indicators of early shock

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Disability

• Assess LOC (AVPU/ GCS)
• Alert
• Verbal
• Pain
• Unresponsive
• Altered decreased cerebral oxygenation/perfusion,
  injury, drugs/etoh
• Reassess

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Exposure/Environment

• Must fully expose patient to completely assess
• Must also think about hypothermia and controlling
  environment to keep patient warm while assessing

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Resuscitation

• Problems in Primary survey are treated as they
  are found / prophylatically
• All patients get
• -C-spine control
• -Supplementary oxygen
• -Large bore IV access
• -Assessment of vital parameters
• -Fluids (not pressors)

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Resuscitation

• Fluid depends on situation
• Generally 2L crystalloid and reassess
• Extremis requires blood early
• Monitoring of Temp., RR, BP, pulse, O2, ECG
• Urinary output, ABGs when able

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Secondary survey

• Head to toe
• Fingers and tube in every orifice
• Urinary and Gastric catheters as soon as safely
  possible (if not done).
• Xrays (c-spine lateral, chest, pelvis )and other
  tests as required
• May not be completed for hours if problems in
  primary survey

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Definitive Care

• Damage control
• Surgery / treatment of life or limb threatening
  injuries early
• Treatment of less severe injuries when stable
• Early mobilization

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Case 1

• 50 year old male
• MVA
• LOC at scene
• Mumbling
• Coughing and spitting up blood
• Right leg deformity with blood on pant leg

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?
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Case 1-Vitals

• 85 sats on 10L
• BP 110/70
• HR 100
• RR 25

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Exam

• Decreased air entry on left
• Crepitus right leg
• 2 cm laceration

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Management

• Airway
• Femur

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Xrays
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Xrays
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Definitive Airway

• Tube in trachea with cuff inflated and connected
  to O2 rich ventilation
• Orotracheal
• Nasotracheal
• Surgical

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Indications for Definitive Airway

• Apnea
• Cant maintain patent airway
• Need to protect airway
• Impending compromise
• Closed head injury (GCS lt 9)
• Inability to maintain sats by mask

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Case 2

• 40 yr old female construction worker
• 30 ft fall ( 9m)
• Obvious scalp laceration
• Right leg deformity below knee
• Talking, feels cold and is confused

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?
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Vitals

• HR 130
• BP 90/30
• RR 30
• Sats 95

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Exam

• Distended Abdomen
• Bruised perineum
• Pelvis unstable
• Closed fracture of right tibia

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Xray
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Case 3

• 40 yr female
• MVA
• Ejected
• Tubed

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Case 3 Vitals

• Sats 90 on 02
• HR 60
• BP 80/30
• RR 12 on ventilator

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Case 3 Exam

• Collar
• Trachea central
• Bruised chest
• Symmetrical breath sounds

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Case 3 Exam

• Distended abdomen
• Left femur crepitus

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xray
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xray
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Xray
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