Major Trauma A standard approach - Ballarat Health...

Major Trauma

A standard approach

Steve Costa

Ballarat Health Services

Emergency Medicine Training Hub

Learning objectives

To understand the Victorian State Trauma System and the role of Ballarat Health Services in that system.

To be familiar with BHS protocols for trauma including trauma teams

Management of suspected cervical spine injuries

Pre reading

Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK : John Wiley & Sons, 2011. Chapter 8 Trauma; primary survey. Chapter 9 Trauma; secondary survey. Chapter 10 Major head and neck injury. Chapter 11 Minor head & neck injury

Refer to ED lecture series and self directed workbooks

Other learning resources

http://www.health.vic.gov.au/trauma/links.htm

http://www.health.vic.gov.au/trauma/triage.htm

Relevant guidelines for Ballarat Health Services

Trauma – General Approach BHS Intranet Link

http://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-31766~intranet-search

Trauma Team Activation BHS Intranet Link


Cervical spine BHS Intranet Link


All available via http://bhsnet/gov-doc-search

http://www.health.vic.gov.au/trauma/links.htm

http://www.health.vic.gov.au/trauma/triage.htm




http://bhsnet/gov-doc-search





Introduction

Trauma leading cause death 1-40yo

Peak age 15-30

Cost in A$ 11 billion

Up to 40% trauma deaths preventable

Improvements largely due to social education Seat belts

Speed limits

Drink driving

Helmets

For each death estimated to be 10 serious non-fatal injuries

Essence of Trauma Care

Right patient to the right resources as soon

as possible

Achieved by:

Integrated system - ‘Trauma Network’

Seniority or experience of providers

Decision Pathways and education

Trauma Network

Ministerial Taskforce on Trauma and

Emergency Services - 1997

ROTES report (Trauma deficiencies) – 1999

Victoria State Trauma Network – 2000 Two adult and one paediatric hospital as major trauma services (MTS)

Statewide system organisation and management of trauma response

Trauma triage and transfer protocols

Enhanced retrieval and transfer services (ARV)

Education and training

Research, service and technology developments

Quality management.

http://www.ambulance.vic.gov.au/

http://www.ambulance.vic.gov.au/Media/docs/ARV Reference Manual_Jan2011-16629a6b-ddd2-4886-97ed-ad5c6cdb52a6-1.PDF

Results

80 per cent of all major trauma patients are

treated at a MTS

a reduction in mortality rates with fewer than

expected deaths according to international

benchmarks

positive trends in preventable deaths

reduced length of stay in hospitals.

Introduction

Medical management has shown far less improvement

Standardisation of approach has helped improve outcomes

Concept of “Golden Hour”

50% deaths <1/24 due to major vessel, CNS, spinal injury

benefit from prevention

30% deaths patients major truncal injuries causing respiratory &

circulatory compromise

benefit from prevention and timely intervention

20% die from sepsis, organ failure etc.

benefit from prevention, timely intervention and possibly from integrated

approach to recovery

Phases of care

Pre-hospital

Triage

Primary survey

Secondary survey

Disposition

Prehospital

Very little evidence to support major interventions in

the field

Oxygenation

Immobilisation cervical spine

Ventilation (unproven)

Fluids (unproven)

Lights and sirens (increases mortality and

community risk)

Triage to trauma centre

http://docs.health.vic.gov.au/

http://docs.health.vic.gov.au/docs/doc/9382EC200E82017BCA25784000739B22/$FILE/Prehospital triage Victorian State Trauma Committee 2010.pdf


Associations with increased risk of death

Demographics

Age <5 >55

Know chronic cardiac/respiratory disease

Vital signs

BP <90

HR >124/min

RR <12 or >24

GCS < 13

O2 sats <90%

Trauma score >14 (not assessable prospectively)


Injuries

Penetrating injury to chest, abdomen, head,

neck or groin

Significant injuries to two or more body

regions

Severe injury to head, neck or trunk

Two or more proximal long bone fractures or

pelvis

Limb amputations (incl. partial or compound)

Burns >20% or involving face or airway


Mechanism

High speed >60 kph (>30kmh cyclists)*

Fall > 3m*

Struck on head by falling object >3m*

Ejection from vehicle*

Explosion*

Prolonged extrication

Pedestrian vs vehicle

And

>55 y.o. OR

Pregnant OR

Significant co-morbidity

Trauma reception

Prior warning

Prepare

Staff

Area

Paramedical services

Trauma teams

Team leader Overview

Resus

Assessment Communication

Internal & external

Airway team

Assess and secure airway

Control cervical spine

Ventilation

NGT

Procedure team

IV access & bloods

IDC

ICC

Scribe

Scout

Radiographers

• Assessment

• primary

• secondary surveys

Handover

Patient should transferred to trauma trolley prior to hand over

Parallel processing Team listens in ‘silent’ handover OR if pt unstable

Airway and procedure teams commence assessment

And

leader receives handover

Assume the worst & protect against unforeseen injuries do not focus on obvious injuries – protocol of ATLS

Primary survey

Airway & cervical spine

Assess & secure airway

Patency

Look, listen, feel

Jaw trust (no chin lift as cervical spine uncleared)

Oropharyngeal airway, nasopharyngeal airway?

RSI

Maintain cervical protection until spine cleared

In-line immobilization

Consider NGT

Primary survey

Ventilation/Breathing

Oxygen is the most important drug in the trauma room

Ensure adequate ventilation

Assess adequacy

Exclude pneumothorax, haemothorax

Bag/mask, ETT if required to maintain ventilation

Aim for normocarbia

CXR

Intervention may precede investigation if required

Primary survey

Circulation

Assess adequacy & effect of blood loss

Conscious state

Pallor

Capillary return

BP

HR

visual estimation of blood loss unreliable

FAST scan – ‘rule in’ test

Primary survey

Circulation

Control haemorrhage

pressure dressings

Tourniquets

Haemostatic dressings

Splinting

Thoracotomy (Cardiac manoeuvres/Aortic compression)

Theatre

Primary survey

Haemorrhage classification

Class Loss BP HR RR CR UFR CS

Class I <15% N N/+ N N/+ N N

Class 2 <30% N + + + anx

Class 3 <40% ++ ++ ++ leth

Class 4 >40% +/- +/- ++

coma

Primary survey

Circulation Access 2x >16G peripheral IV’s

Fluids initially crystalloid 20mlkg (repeat if required) warmed

Crystalloid vs colloid (no proven benefit)

Blood O negative Class III/IV haemorrhage

Continuing need for crystalloid

Consider need for clotting factors and plateletes ‘1:1:1’

Hypotensive resuscitation

Primary survey

Disability

Level of consciousness

AVPU

ALERT

VOICE

PAIN

UNCONSCIOUS

GCS – E4M6V5

Pupil response

Don’t ever forget the glucose

Primary survey

Exposure

Remove

Clothes

Jewellery

Avoid hypothermia

Primary survey

Monitoring

ECG, BP, SaO2, GCS +/- ventilator obs

Analgesia

Radiology

CXR, Cx spine, AP pelvis

IDC traditionally part of 1° survey but usually

done later

Secondary survey

AMPLE history

Allergy

Medications

Past history

Last food

Event

Secondary survey

Head to toe examination – ‘all over and all

holes’

Look, feel, move, listen

Log roll

PR examination

Consider

Tetanus toxoid

Antibiotic prophylaxis

Review

Constantly reassess and review

Any change repeat 1° survey

After any corrective procedure repeat 1°

survey

Disposition

Parallel thinking from before patients arrival

Direct to appropriate services

Definitive care made aware of patient

Discharge with appropriate support

Questions?

Summary

You are all part of a trauma network

Education saves lives

Reassess, reassess, and reassess again

(and intervene if required of course . . .)

Thankyou

Go and get coffee

See you in 20mins

Major Trauma

Practical and Scenarios

Ballarat Health Services

Emergency Medicine Training Hub

Fitting a cervical collar

Young man diving from a

pier…

http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Injury/


Fingers between jaw and

trapezius



Adjust or choose collar



Apply!



Your turn!

Primary Survey

A – Talk to the patient first!

B – Listen for air and blood

C – Cyanosis, CRT, HR, BP

D – GCS, Spinal and Limb assessment, BSL

E – Full exposure and environmental control

Trauma Scenario 1

You receive a phone call from the ambulance

service. They have a 27 yr old male involved

in a MCA, he is conscious alert, the car has

rolled he has been ejected from the vehicle.

He has a probable # femur and compound

# tib/fib

How are you going to prepare?

Trauma preparation

Trauma call

personnel

trauma team

radiology

pathology

department

equipment

Trauma Scenario 1 Arrival

history as above

patient conscious, alert,

orientated

HR145 BP100/50 RR30

complaining of severe pain in

R leg

Deformity upper leg and

obvious compound R tib/fib

What is your approach? http://lifeinthefastlane.com/ortho-library/open-fractures/

http://lifeinthefastlane.com/ortho-library/open-fractures/





Trauma Scenario 1

Primary survey

Airway intact

Breathing decreased air entry L hemi-thorax

What else would you look for?

Assessment of pneumothorax

Tension pneumothorax

RR30

BP100/50

HR145

tracheal deviation

decreased chest movement

venous engorgement

What are you going to do now?

Management tension

pneumothorax

Needle decompression

Then ICC

CXR

re-check ABC

Trauma Scenario 1

Once AB stable

re-check C continued hypotension N saline

bolus

D

E

rest of trauma series radiology

analgesia femoral N block + iv analgesia

Prepare for ankle reduction

head to toe examination – secondary survey

Questions?

next case . . .

Trauma Scenario 2

Trauma Scenario 2

A patient presents following a MVA, the other

driver was killed, she left the scene and

brought herself to hospital. She is

complaining of abdominal discomfort and

back pain.

What is you approach?

Approach to trauma

• Primary survey

• AcBC

• CXR, C-Spine, Pelvis XRs

• Secondary survey

• head to toe

• include log roll (if not already done)

• IDC

• NGT

Primary survey

primary survey

Airway normal

Cervical collar applied and immobilised

Breathing RR35, otherwise normal

Circulation HR140 BP100/45

Describe your subsequent management

Hypotensive trauma

Resuscitate circulation

Hypotensive trauma


Analgesia

Hypotensive trauma


Analgesia

Exposure of abdomen in 1° survey

marked seat belt bruising over mid/lower

abdomen

abdomen tender generalised guarding

log roll

Thoraco-lumbar junction tender with bruising

PR NAD

Hypotensive Abdominal

trauma

Surgical registrar review asks for:

CXR

Lateral lumbar spine

what other injuries are likely?

what further investigations do you require?

What does the patient need?

Reproduced from http://www.radiologyassistant.nl


trauma


CXR


What other injuries are likely?

Upper abdominal visceral injury

What further investigations do you require?



trauma


CXR




CT



trauma


CXR





Adequate fluid resuscitation – Crystalloid and Blood

Theatre?

Chance fracture

Fracture of L1 hyperflexion

Transverse fracture through posterior

elements +/- body

Associated injury to

pancreas

duodenum 4th part

kidney

liver/spleen

retroperitoneal haemorrage


trauma

Investigation

CT abdomen dual contrast

Additional treatment

NGT, IDC

Tetanus toxoid/Antibiotics if required

police bloods

next of kin

Disposition

Questions?

next case . . .

Trauma scenario 3

A 20 yr old presents via ambulance after

falling from his motorcycle. He is conscious,

complains of neck discomfort and shortness

of breath.

What is your approach?

Approach to trauma

• Primary survey

• AcBC

• CXR, C-Spine, Pelvis XRs

• Secondary survey

• head to toe

• include log roll (if not already done)

• IDC

• NGT

Primary survey

Airway - intact

Cervical collar and sand bags

Breathing - limited chest expansion but equal

air entry

Circulation

HR 70 BP90/50 RR 30

What is the likely cause of this patient’s

hypotension?

Hypotensive trauma

Loss-haemorrhage

internal/external

Redistribution eg vasodilatation 2° spinal shock

Pump failure

cardiac contusion

loss cardio-accelerator

Substance use/abuse

Hypotensive trauma response

Exclude obstruction to venous return

Fluid bolus

CXR normal

What now?

Hypotensive trauma

Repeat fluid bolus if no response Re-do 1° survey, include ‘D’ in assessment of ‘C’

Debility GCS 15/15

flaccid paralysis of both legs

sensory level at level of upper chest

Priapism

BP 100/50 HR 80

What do you do next?

Hypotensive trauma

Trauma series X-rays?

Cervical spine

CXR

Pelvis

Hypotensive trauma


Cervical spine

CXR

Pelvis

CX spine/CT shows # dislocation at C6/7

Reproduced from JBJS Journal of Bone and Joint Surgery Br June 2006 vol 88-B No.6 771-775

http://www.bjj.boneandjoint.org.uk/content/88-B/6/771/F1.large.jpg

Hypotensive trauma


Cervical spine

CXR

Pelvis

CX spine/CT shows # dislocation at C6/7

What are the priorities with this patient?

Spinal trauma

Treatment priorities

breathing loss of intercostals exhaustion

spinal shock

temperature control

fluid balance important risk of over-filling

IDC important

Steroids

controversial increases morbidity

Referral to specialist unit

Referral

Be familiar with specialist unit provision

Consider moving to Major Trauma Service

provider early

Engage retrieval service early with

appropriate detail

http://docs.health.vic.gov.au/docs/doc/6A955B0E117A3E7FCA257B630021EA74/$FILE/cervical_spine_guidelines.pdf


Reproduced from Radiopaeia.org

Reproduced from JBJS Journal of Bone and Joint Surgery Br June 2006 vol 88-B No.6 771-775

http://www.bjj.boneandjoint.org.uk/content/88-B/6/771/F2.large.jpg

Questions?

Trauma scenario 4

47 yr old woman presents via ambulance she

was trapped between her car and a car that

reversed into her in the supermarket car park.

She is conscious but confused, complaining

of pain in her “tummy”.

What is your approach?

Primary survey

ABCx normal

C HR120 BP 80/60 RR 32

Approach to hypotension?

Hypotensive trauma

Fluid bolus

CXR & CX spine normal

Pelvic Xray shows

# body pubis with separation anteriorly

# through sacrum

no response to initial fluid bolus

What is the cause of the hypotension?

What is your assessment & management?

Pelvic Fracture

Open book AP compression pelvic fracture

Hypotension due to haemorrhage

pelvic veins

other abdominal injury

Approach to pelvic fracture

secondary survey

Including AMPLE history

abdominal examination

tender and guarding lower abdomen

approach ?

PV blood at meatus

IDC blood

Log roll sacral pain and tender

Pelvic # and Hypotension

Call orthopaedic Reg ASAP Repeat fluid bolus +/- blood

close # MAST suit

wrap

“C” clamp

Exclude other abdominal organ injury

CT abdomen dual contrast

US “FAST”

Summary

You are all part of a trauma network

Education saves lives

Reassess, reassess, and reassess again

(and intervene if required of course . . .

And then reassess)

Further reading

More cases http://lifeinthefastlane.com/tag/trauma-tribulation/

Online education resource

http://www.surgicaltutor.org.uk/defaulthome.htm?core/trauma/spinal.htm~rig

ht

http://lifeinthefastlane.com/tag/trauma-tribulation/



http://www.surgicaltutor.org.uk/defaulthome.htm?core/trauma/spinal.htm~right

http://www.surgicaltutor.org.uk/defaulthome.htm?core/trauma/spinal.htm~right

Resources

ARV Medical Reference Manual http://www.ambulance.vic.gov.au/Media/docs/ARV%20Reference%20Manual_Jan2011-16629a6b-ddd2-4886-97ed-

ad5c6cdb52a6-1.PDF

Vicotrian State Trauma Committee 2010 Adult pre Hospital Major trauma

Criteria http://docs.health.vic.gov.au/docs/doc/9382EC200E82017BCA25784000739B22/$FILE/Prehospital%20triage%20Victo

rian%20State%20Trauma%20Committee%202010.pdf


The Royal Children’s Hospital Melbourne – Cervical Spine Assessment http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Injury/

Life in the Fastlane http://lifeinthefastlane.com/ortho-library/open-fractures/

Radiology Assistant http://www.radiologyassistant.nl/























http://www.radiologyassistant.nl/

Thankyou

Major Trauma A standard approach - Ballarat Health...

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