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