trauma management

MANAGEMENT OF TRAUMA : 

MANAGEMENT OF TRAUMA Dr Sukalyan Chandra Basu

Slide 2: 

INTRODUCTION Trauma is the leading cause of death in first four decades of life. TRIMODAL PEAK OF DEATH 1-First peak: seconds to minutes 2-Second peak: minutes to hours 3-Third peak: several days to weeks from initial trauma

Principles of early management : 

Principles of early management Treat the greatest threat to life first Lack of definitive diagnosis should never impede the application of an indicated treatment. A detailed history is not a prerequisite to begin the evaluation of an acutely injured patient.

GOLDEN HOUR : 

GOLDEN HOUR Concept given by Dr R Adams Cowley First sixty minutes after the occurrence of multi-system trauma Victims chance of survival is greatest if they receive definitive care in this period. Reduce the death cause in second peak Recently the validity of Golden Hour as a rigid timeframe is scrutinized. Core principles of rapid intervention in trauma cases is universally accepted.

: 

"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." R Adams Cowley

Main Steps Of Early Management : 

Main Steps Of Early Management Primary assessment Resuscitation (1 & 2 go hand in hand) Reassessment of Airway, Breathing & Circulation Secondary assessment

PRIMARY ASSESSMENT : 

PRIMARY ASSESSMENT A- Airway with in-line cervical spine immobilisation B- Breathing with oxygen supplementation C- Circulation with haemorrhage control D- neurological status, as expressed by the patient E- Exposure of the entire body ,looking for occult injuries.

AIRWAY : 

AIRWAY Clear speech is a good indicator of clear airway Noisy breathing is a indicator of airway obstruction Always assume that the patient has a cervical spine injury Chin lift jaw thrust manoeuvre along with suctioning prevents airway obstruction Manual in-line stabilisation of spine

BREATHING : 

BREATHING Hypoxia most serious problem: early interventions aimed at reversing it Once the airway is established, oxygen is administered using high flows of reservoir mask to insure high fraction of inspired oxygen concentration Inspection, palpation and auscultation of chest (LOOK,LISTEN, FEEL)

Circulation with haemorrhage control : 

Circulation with haemorrhage control PULSE NEUROLOGICAL STATUS BLOOD PRESSURE The assessment of circulation begins with the insertion of 2 wide bore canullae Initial fluid bolus of 2 lit of Ringer’s lactate Haemorrhage control End point of volume resuscitation is unclear

DISABILITY : 

DISABILITY Glasgow Coma Scale

GCS : 

GCS Severe - 8 or less Moderate - 9 – 12 Mild – 13 – 15 E(c) when patient cannot open eyes V(t) when patient cannot speak

RESUSCITATION : 

RESUSCITATION

SECONDARY ASSESSMENT : 

SECONDARY ASSESSMENT Head-to-toe systemic and comprehensive evaluation of all organ system History HEAD AND NECK THORAX ABDOMEN EXTREMITIES

Signs Of Airway Obstruction : 

Signs Of Airway Obstruction Hoarse voice Decreased air entry and exit Stridor Retraction of suprasternal, supraclavicular and intercostal space Tracheal tug Restlessness Cynosis

Challenges In Airway Management : 

Challenges In Airway Management Urgency Full stomach Neck injury Head injury Cardiovascular compromise Respiratory compromise Co-morbidity Challenging anatomy Inadequate assistance Inadequate equipment

Primary Management : 

Primary Management NON EQUIPMENTAL Chin lift Jaw thrust EQUIPMENTAL Oropharyngeal airway Nasopharyngeal airway LMA and Combitube Definative airway

Algorithm approach To RSI : 

Algorithm approach To RSI PREOXYGENATE AND BLS MANOEUVERS RSI,CRICOID PRESSURE,MILS LARYNGOSCOPY WITH McCoy ORAL INTUBATION WITH GEB/INTRODUCER ILMA CRICOTHYROIDOTOMY SUCCESS FAILURE REOXYGENATE,RETRY

Definitive Airway : 

Definitive Airway INDICATIONS Apnoea Inability to maintain a patent airway by other means Closed head injury requiring hyperventilation Anticipated need Definitive airway are of 3 varieties 1-Orotracheal intubation 2-Nasotracheal intubation 3-Surgical airway-needle or surgical cricothyroidotomy

DIFFICULT AIRWAY : 

DIFFICULT AIRWAY Predict a difficult airway based on clinical criteria Plan for appropiate action Initiate appropiate plan for CICV situation Become informed about some new airway options

Identify Difficult Airway : 

Identify Difficult Airway Pre medical history Basic physical examination Thyromental distance <7 cm Dr Binnions Lemons law L-LOOK E-Evaluate 3-3-2 M-Mallampati O-Observation N-Neck mobility 5. Mallampati Classification

What to do : 

What to do A-Adjust-Type of blade Length of blade Position B-Blind intubation Combitube LMA Retrograde intubation C-Cricothyroidotomy

SUMMARY : 

SUMMARY Failed intubation should never occur to the unprepeared Bag mask ventilation is the easiest and most effective way to secure airway Never paralyze when you can’t ventilate RSI is not indicated for difficult airway Know how to use LMA

TRIAGE : 

TRIAGE The word triage comes from the french word trier that literally means to sort Dominique Larrey a Surgeon General during the reign of Napoleon Bonaparte used this concept for determining treatment priorities among casualties Right patient gets the right treatment at right time

Primary Objectives Of Triage : 

Primary Objectives Of Triage Identification of immediate life threatening situations Reduce severity of the condition by ensuring immediate intervention Reduce delay in the treatment

Formats of Triage : 

Formats of Triage Priority I Priority II Priority III

Pathophysiology of Head Injury : 

Pathophysiology of Head Injury Primary : . Occurs at the moment of impact No treatment possible Secondary : . Begins the instant after trauma . Limiting this is the basis of all head injury management Factors causing secondary injury Mass effect Hypotension Hypoxia Pyrexia Hyperglycemia Seizures hyponatremia

CPP = MAP - ICP : 

CPP = MAP - ICP CPP-Cerebral perfusion pressure MAP- Mean arterial pressure ICP- Intra cranial pressure

Evaluation In Casualty : 

Evaluation In Casualty Stabilize cervical spine Airway Breathing Circulation History Demographic Mode of trauma Time of trauma H/o consciousness H/o seizures/vomiting H/o blood loss Prior medical problem

Examination : 

Examination A B C do not proceed until satisfactory GCS (time) Pupils Hemiparesis Scalp, skull, spine X ray Cervical spine first X ray skull ? Chest x ray Others as necessary

Early Management : 

Insert needle here Early Management ABC Clinical assessment as above Clean thoroughly, explore and suture scalp lacerations Decision on referral Avoid aspiration Position lateral (difficult) Keep nil orally with a NG tube (*) to dependant drainage Monitor pulse, BP, respiration, GCS, pupils and power At least hourly for the first 6 hours At least 2 hourly after that IV fluids – normal saline Keep sugar under control Administer Anticonvulsants Drugs to prevent GI bleed Analgesics / antipyretics Antibiotics as required for scalp / chest / other trauma

Early management (contd) : 

Early management (contd) Administration requires experience Sedation Narcotic analgesia Mannitol Raised ICP Elevate head end 30o, neck straight Good airway and breathing Adequate blood pressure Temperature Seizures Relieve pain

To refer or not to refer : 

To refer or not to refer Non-neurological Hemodynamic and respiratory sufficiency and the available facilities for continued treatment of the same Other trauma and it's necessary treatment Neurological History of deterioration Bradycardia or falling pulse rate GCS < ? or a drop in GCS Pupillary asymmetry (unless fully conscious) Focal deficit No improvement in 24 hours X-ray findings Distance to the nearest neurosurgical referral centre

Referral : 

Referral A B C Wound first aid completed If any deterioration, mannitol just before transport Clinical material Available history Admission findings* Treatment given* Progress / reason for referral* Investigations if any

SUMMARY : 

SUMMARY Early management of trauma is a definite established protocol, which needs to be methodically followed The primary assessment provides basic data essential for the patient’s survival when life or limb is threatened. Airway is of primary importance. No other therapeutic assessment or intervention should take place before airway is secured. Resuscitation goes hand in hand with the Primary Assessment, It is performed when the component of Primary Assessment appears unstable Secondary Assessment is to be provided after the completion of Primary Assessment and resuscitation.

Slide 37: 

Thanks For your patience

Esophageal Trauma : 

Esophageal Trauma Penetrating more than blunt Lethal if not recognized High suspicion if… …left pneumothorax and hemothorax without rib fracture …shock out of proportion to apparent blunt chest trauma …particulate matter in chest tube