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Issues in Trauma
Lynne Fulton
May 27, 2009
Intro
• No basics
• My backround
• “Demanded efficient and thoughful care by other team members”
• Observing a patient is often more valuable than DOING SOMETHING
OBJECTIVES
• DISCUSS:• CONTROVERSIES IN TRAUMA
MANAGEMENT• PENETRATING NECK TRAUMA• UNUSUAL PROBLEMS• GERIATRIC ISSUES• QUESTIONS - for which I will not have
answers!
Controversies
• Fluid resuscitation and intubation in trauma patients
• Trauma = 2nd most important condition for children and 4th most important for adults in pre-hospital care
OPALS Major Trauma Study
• 2008, CMAJ
• Major trauma (ISS>12)
• Adults (>16 years)
• 17 urban centres
• Pre and post Advanced Life Support being introduced
• 2867 patients
• Stats re age, sex, mechanism, injury severity matched
• Excluded: Toronto and Hamilton, dead at scene, injuries 8 hours prior to EMS being called
• All treated at lead trauma hospitals
• Previous study showed no impact on outcomes for patients with cardiac arrests
• Previous study showed improved outcome in patients with respiratory distress
• Primary interventions were intravenous fluids and endotracheal intubation
• No substantial difference in survival to discharge (81.8% for basic life support, and 81.1% for advanced life support)
• No difference in early deaths (<24 hrs)
• No difference in morbidity based on GCS and functional independence at discharge and 6 months
• If GCS less than 9, survival was lower with advanced life support
• ALS associated with increased mortality, intubation associated with increased mortality, IV therapy associated with no change in mortality
• Other studies have come to similar conclusions
• Penetrating torso injuries have increased survival, earlier discharge, and fewer complications with delayed fluid administration
• Increased compartment syndromes with aggressive fluid administration early in limb trauma
?
• Rural versus urban situations
• Why- increased scene time- increased bleeding due to increased BP
- hyperventilaton
• Scoop and run seems more effective in urban settings
Penetrating Neck Injuries
• 5-10% of traumatic injuries in US
• Increased incidence in Canada
• Mass casualty situations
Zones
• Zone 1 = clavicle to cricoid cartilage
• Zone 2 = cricoid cartilage to angle of the mandible
• Zone 3 = angle of the mandible to base of the skull
Incidence by Zone
• Zone 2 most common
• Zone 1 second
• Zone 3 least
Associated Injuries
• Aerodigestive tract- 10% laryngeal or tracheal injuries- 9.6% esophageal injuries- Vascular - venous 9%
- Arterial 6.7%
• Zones can be transgressed
Principles
• Immediate transfer to nearest trauma centre
• Do not remove projectile if present
• Do not explore the wound
Airway
• Oral intubation preferred
• If airway injury is present (sucking wound or subcu emphysema or bubbling wound) bag valve mask can lead to problems
• Consider chest injuries
• Control bleeding with direct pressure
• Transport in position to allow adequate respirations
• A neuro deficit may be due to a vascular injury, and intact pulses do not rule out vascular injury
Cases
• A 25 year old woman is struck by a car while standing at a bus stop, and thrown 20 feet. She is VSA. She is intubated and given epi (1 dose) and regains a pulse and blood pressure.
• What is her primary injury?
Cases
• A young woman is a belted driver in a car involved in a minor motor vehicle accident on Bayview Avenue and her airbag deployed. She was DOA on arrival at the hospital.
• What happened?
Cases
• A young man presented from a motor vehicle accident with a decreased level of consciousness and a laceration of his cheek.
• Ventilation was attempted with a bag valve mask, and was not successful.
• Why?
Cases
• A head injured patient, who was hyperventilating, was nasally intubated, and aspirated the tube.
• What happened?
Geriatric Issues
• Under-triage is the norm
• Outcomes are poorer
• Reflexes are slower
• Meds are more common
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