Initial assessment of the trauma patient

Initial Assessment of the Initial Assessment of the Trauma PatientTrauma Patient

Sharla Owens, M.D.Sharla Owens, M.D.

July 10July 10thth, 2006, 2006

Don’t PanicDon’t PanicDon’t PanicDon’t PanicNever Let Them See

You Sweat..

ATLS GuidelinesATLS Guidelines

Systematic approach necessary to rapidly Systematic approach necessary to rapidly identify injuries and stabilize the patientidentify injuries and stabilize the patient

This approach is divided into:This approach is divided into:

1. Primary Survey1. Primary Survey

2. Resuscitative Phase2. Resuscitative Phase

3. Secondary Survey3. Secondary Survey

4. Definitive Care Phase4. Definitive Care Phase

ABCDEABCDE

Airway Management in the Airway Management in the Trauma PatientTrauma Patient

Objectives of Airway Management Objectives of Airway Management & Ventilation& Ventilation

Primary Objective:Primary Objective:– Provide unobstructed passage for air Provide unobstructed passage for air

movementmovement– Ensure optimal ventilationEnsure optimal ventilation– Ensure optimal respirationEnsure optimal respiration

Objectives of Airway Management Objectives of Airway Management & Ventilation& Ventilation

Why is this so important in the trauma Why is this so important in the trauma patient?patient?– Prevention of Secondary InjuryPrevention of Secondary Injury

Shock & Anaerobic MetabolismShock & Anaerobic Metabolism

Spinal Cord InjurySpinal Cord Injury

Brain InjuryBrain Injury

AirwayAirway

Patency is primaryPatency is primary

Obstruction in trauma patientsObstruction in trauma patients– TongueTongue– SwellingSwelling– Foreign BodyForeign Body– Blood and secretionsBlood and secretions

AirwayAirway

Evaluation begins by asking the patient a Evaluation begins by asking the patient a question such as 'How are you?‘question such as 'How are you?‘

A response given in a normal voice A response given in a normal voice indicates that the airway is not in indicates that the airway is not in immediate jeopardy; a breathless, hoarse immediate jeopardy; a breathless, hoarse response or no response at all indicates response or no response at all indicates that the airway may be compromised. that the airway may be compromised.

AirwayAirway

Mechanical removal of debris, chin lift Mechanical removal of debris, chin lift and/or jaw thrust maneuver, are usefull in and/or jaw thrust maneuver, are usefull in clearing the airway in less injured patientsclearing the airway in less injured patients

If there is any question of an adequate If there is any question of an adequate airway, severe head injury, profound airway, severe head injury, profound shock, severe facial trauma, voice shock, severe facial trauma, voice changes, then definitive airway control is changes, then definitive airway control is necessarynecessary

Airway & Ventilation MethodsAirway & Ventilation Methods

Supplemental OxygenSupplemental Oxygen– increased FiOincreased FiO22 increases available oxygen increases available oxygen

– objective is to maximize hemoglobin objective is to maximize hemoglobin saturationsaturation


Airway ManeuversAirway Maneuvers– Chin liftChin lift– Jaw thrustJaw thrust

(Neck extension is(Neck extension is

contraindicated)contraindicated)

Airway DevicesAirway Devices– Oropharyngeal airwayOropharyngeal airway– Nasopharyngeal Nasopharyngeal

airwayairway– BVMBVM

Assessment & Recognition of Airway & Assessment & Recognition of Airway & Ventilatory CompromiseVentilatory Compromise

Visual AssessmentVisual Assessment– PositionPosition

tripodtripod

orthopneaorthopnea

– Rise & Fall of chestRise & Fall of chestParadoxical motionParadoxical motion

– Audible gasping, Audible gasping, stridor, or wheezesstridor, or wheezes

– Obvious pulm edemaObvious pulm edema

Visual AssessmentVisual Assessment– Skin colorSkin color– Flaring of naresFlaring of nares– Pursed lipsPursed lips– RetractionsRetractions– Accessory Muscle UseAccessory Muscle Use– Altered Mental StatusAltered Mental Status– Inadequate Rate or Inadequate Rate or

depth of ventilationsdepth of ventilations


Gastric DistentionGastric Distention– Common when ventilating without intubationCommon when ventilating without intubation– pressure on diaphragmpressure on diaphragm– resistance to BVM ventilationresistance to BVM ventilation– avoid by increasing time of BVM ventilationavoid by increasing time of BVM ventilation


Orotracheal Intubation- preferred in almost Orotracheal Intubation- preferred in almost all situationsall situations– IndicationsIndications

present or impending respiratory failurepresent or impending respiratory failureapneaapneaunable to protect own airway (GCS <8)unable to protect own airway (GCS <8)

– AdvantagesAdvantagessecures airwaysecures airwayroute for a few medicationsroute for a few medicationsoptimizes ventilation and oxygenationoptimizes ventilation and oxygenation


Nasotracheal Intubation- rarely if ever Nasotracheal Intubation- rarely if ever used in the initial management of the used in the initial management of the injured patient.injured patient.

Many drawbacksMany drawbacks

Goal of safe endotracheal intubation with Goal of safe endotracheal intubation with cervical spine precautions can be better cervical spine precautions can be better accomplished with orotracheal intubationaccomplished with orotracheal intubation


Surgical CricothyrotomySurgical Cricothyrotomy– IndicationsIndications

absolute need for a definitive airway ANDabsolute need for a definitive airway AND– unable to perform ETT due for structural or anatomic unable to perform ETT due for structural or anatomic

reasons, ANDreasons, AND– risk of not intubating is > than surgical airway riskrisk of not intubating is > than surgical airway risk

OROR

absolute need for a definitive airway ANDabsolute need for a definitive airway AND– unable to clear an upper airway obstruction, ANDunable to clear an upper airway obstruction, AND– multiple unsuccessful attempts at ETT, ANDmultiple unsuccessful attempts at ETT, AND– other methods of ventilation do not allow for effective other methods of ventilation do not allow for effective

ventilation and respirationventilation and respiration

Airway & Ventilation Methods: ALSAirway & Ventilation Methods: ALS

Surgical CricothyrotomySurgical Cricothyrotomy– Contraindications (relative)Contraindications (relative)

Age < 8 years (some say 10)Age < 8 years (some say 10)

evidence of fx larynx or cricoid cartilageevidence of fx larynx or cricoid cartilage

evidence of tracheal transectionevidence of tracheal transection


Needle Cricothyrotomy & Transtracheal Jet Needle Cricothyrotomy & Transtracheal Jet VentilationVentilation– IndicationsIndications

Same as surgical cricothyrotomy along withSame as surgical cricothyrotomy along with

Contraindication for surgical cricothyrotomyContraindication for surgical cricothyrotomy

– ContraindicationsContraindicationscaution with tracheal transectioncaution with tracheal transection

Airway & Ventilation Methods: Airway & Ventilation Methods:

Jet VentilationJet Ventilation– Usually requires high-Usually requires high-

pressure equipmentpressure equipment– Ventilate 1 sec then Ventilate 1 sec then

allow 3-5 sec pauseallow 3-5 sec pause– Hypercarbia likelyHypercarbia likely– Temporary: 20-30 Temporary: 20-30

minsmins– High risk for High risk for

barotraumabarotrauma


Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– SedationSedation

Used forUsed for– inductioninduction– anxious or agitated patientanxious or agitated patient

ContraindicationsContraindications– hypersensitivityhypersensitivity– hypotension (e.g. hypovolemia 2° to trauma)hypotension (e.g. hypovolemia 2° to trauma)


Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– Neuromuscular Blockade Neuromuscular Blockade

Induces temporary skeletal muscle paralysisInduces temporary skeletal muscle paralysis

IndicationsIndications– When Intubation is required in a patient whoWhen Intubation is required in a patient who

is awake,is awake,

has a gag reflex, orhas a gag reflex, or

is agitated or combativeis agitated or combative


Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– Neuromuscular Blockade Neuromuscular Blockade

ContraindicationsContraindications– Most are specific to the medicationMost are specific to the medication– inability to ventilate patient once paralysis is inducedinability to ventilate patient once paralysis is induced

AdvantagesAdvantages– reduces risk of laryngospasmreduces risk of laryngospasm


Pharmacologic Assisted Intubation (“RSI”)Pharmacologic Assisted Intubation (“RSI”)– Disadvantages & Potential ComplicationsDisadvantages & Potential Complications

Does not provide sedation or amnesiaDoes not provide sedation or amnesia

Provider unable to intubate or ventilate after NMBProvider unable to intubate or ventilate after NMB

Aspiration during procedureAspiration during procedure

Difficult to detect motor seizure activityDifficult to detect motor seizure activity

Side effects and adverse effects of specific medsSide effects and adverse effects of specific meds

Tension PneumothoraxTension Pneumothorax

Recognizing Life Threatening Recognizing Life Threatening EmergeniesEmergenies

Aka, “When to pee in your Aka, “When to pee in your pants in the trauma bay”pants in the trauma bay”

Tension PneumothoraxTension Pneumothorax

Signs and SymptomsSigns and Symptomssevere respiratory distresssevere respiratory distress

or absent lung sounds (unilateral usually)or absent lung sounds (unilateral usually)

resistance to manual ventilationresistance to manual ventilation

Cardiovascular collapse (shock)Cardiovascular collapse (shock)

asymmetric chest expansionasymmetric chest expansion

anxiety, restlessness or cyanosis (late)anxiety, restlessness or cyanosis (late)

JVD or tracheal deviation (late)JVD or tracheal deviation (late)

Great Vessel InjuryGreat Vessel Injury

Aortic TransectionAortic Transection

Signs:Signs:

- widened mediastinum, 1- widened mediastinum, 1stst rib fx, apical capping, rib fx, apical capping, left hemothorax, tracheal deviation to rightleft hemothorax, tracheal deviation to right

- widening from bridging veins and arteries, not - widening from bridging veins and arteries, not aorta itselfaorta itself

- need aortic evaluation in pts with significant - need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears mechanism (deceleration injuries), usually tears at ligamentumat ligamentum

- 90% of patients die at the scene- 90% of patients die at the scene

Cardiac TamponadeCardiac Tamponade

Cardiac TamponadeCardiac Tamponade

Beck’s triad:Beck’s triad:

- hypotenstion, jugular venous distention, - hypotenstion, jugular venous distention, and muffled heart soundsand muffled heart sounds

- causes decreased diastolic ventricular - causes decreased diastolic ventricular filling and resultant hypotensionfilling and resultant hypotension

- echocardiogram shows impaired diastolic - echocardiogram shows impaired diastolic filling of right atrium initially (1filling of right atrium initially (1stst sign) sign)

Traumatic Brain InjuryTraumatic Brain Injury

Epidural HematomaEpidural Hematoma SA HemorrhageSA Hemorrhage

TBI:TBI:

High index of suscpicion in any patient High index of suscpicion in any patient with history of or identifiable evidence of with history of or identifiable evidence of altered level of consciousnessaltered level of consciousness

Best determined by GCS (a decrease of Best determined by GCS (a decrease of even 1-2 points is indicative of significant even 1-2 points is indicative of significant change in neurological status)change in neurological status)

Pupillary functionPupillary function

Lateralizing signsLateralizing signs

Solid Organ InjurySolid Organ Injury

Splenic LacerationSplenic Laceration Liver LacerationLiver Laceration

Solid Organ InjurySolid Organ Injury

25% of all trauma victims require an 25% of all trauma victims require an abdominal explorationabdominal exploration

Blunt trauma caused by MVCs, MCCs, Blunt trauma caused by MVCs, MCCs, falls, assaults, and auto vs. pedestrians falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of remains the most frequent mechanism of injuryinjury

High index of suspicion in those patients High index of suspicion in those patients with c/o abdominal pain, and/or objective with c/o abdominal pain, and/or objective findings on exam (seatbelt sign)findings on exam (seatbelt sign)

HemorrhageHemorrhage

Pelvic fracturePelvic fracture

Pelvic TraumaPelvic Trauma

Pelvic fx are the prototype of severe Pelvic fx are the prototype of severe trauma, with an usually high incidence of trauma, with an usually high incidence of associated injuriesassociated injuries

Awake pts c/o excessive pain and may Awake pts c/o excessive pain and may have evidence of abnormal positioning of have evidence of abnormal positioning of lower extremities, or unstable pelvis on lower extremities, or unstable pelvis on examexam

Can be a major source of blood loss that is Can be a major source of blood loss that is either arterial, venous, or osseous in origineither arterial, venous, or osseous in origin

Health & Medicine

Initial assessment of the trauma patient