Med 542 Review Trauma Ken Stewart MD, FRCSC Assistant Professor Division of Thoracic Surgery,...
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Transcript of Med 542 Review Trauma Ken Stewart MD, FRCSC Assistant Professor Division of Thoracic Surgery,...
Med 542 Review
Trauma
Ken Stewart MD, FRCSC
Assistant Professor
Division of Thoracic Surgery, University of Alberta
Trauma
• Precipitous, ubiquitous phenomenon affecting all ages, races.– Various forms (blunt, penetrating, burns)– Disease or process in evolution– Outcomes based on severity of injury, pre-
existing conditions, and timing and appropriateness of treatment.
Objectives
• Describe the principles of assessment of the injured patient
• Describe the principles of resuscitation of the injured or critically-ill patient
• Describe the indications for and the important steps in the procedure of emergency cricothyroidotomy
Objectives --2
• Outline the principles of assessment and management of blunt and penetrating injury of the chest
• List the indications for trauma thoracotomy
• List the indications for tube thoracostomy
• Describe the proper technique for tube thoracostomy
• List the indications for emergency needle decompression of the chest
Objectives --3
• Define “shock”, and list the signs and symptoms of the different types of shock
• Describe the management of the different types of shock
• Outline the principles of assessment and management of blunt and penetrating injury of the abdomen
• List the indications for a trauma laparotomy
Internet Resources
American College of Surgeons– www.FACS.org– Links to ATLS
Trauma.org– www.trauma.org– trauma care website with links to care
related areas
ATLS
Advanced Trauma Life Support– Program developed by the American
College of Surgeons– Emerged as a result of experience with
conflict, and health care revision in the US.– Need for organized approach to
recognition, assessment and treatment of all types of trauma
ACS outline on ATLS
• Injury is precipitous and indiscriminate ・• The doctor who first attends to the
injured patient has the greatest opportunity to impact outcome ・
• The price of injury is excessive in dollars as well as human suffering
ATLS--2
• Program: ・ CME program developed by the ACS Committee on Trauma ・
• One safe, reliable method for assessing and initially managing the trauma patient ・
• Revised every 4 years to keep abreast of changes • Audience: ・ Designed for doctors who care for
injured patients ・ Standards for successful completion established for doctors ・
• ACS verifies doctors' successful course completion
ATLS--3
• Benefits: ・ An organized approach for evaluation and management of seriously injured Patients ・
• A foundation of common knowledge for all members of the trauma team
• Applicable in both large urban centers and small rural emergency departments
ATLS--4
• Objectives: ・ Assess the patient's condition rapidly and accurately
• ・ Resuscitate and stabilize the patient according to priority ・
• Determine if the patient's needs exceed a facility's capabilities ・
• Arrange appropriately for the patient's definitive care ・
• Ensure that optimum care is provided
ATLS--5
• Trauma Team, and Team Leader concept– One person responsible for making
decisions and starting treatment
• Organized into algorithms for the benefit of systematic recognition and treatment
Assessment and Treatment
• Ongoing assessment from the time of original notification to response to any treatment measures.
• Mechanism of injury, timing and pre-existing conditions are important historical features
Systematic Assessment by “Trauma Team Leader”
Primary SurveyAirway
• Ensure patency
Breathing• Rule out distress
Circulation• Provision for large
bore (14-16 gauge) IV access
• Crossmatch for blood for severely injured
Secondary SurveyABC again
Disability– C-spine precautions and
neuro assessment
Exposure
exam front and back of patient, then keep warm
Fingers in every orifice and foley catheter
Assessment Principles
Primary surveyTry to recognize the immediately life-threatening
injuries1. Tension Pneumothorax
2. Massive Hemothorax
3. Open Pneumothorax
4. Cardiac Tamponade
5. Flail Chest
Airway,Breathing,Circulation
Assessment Principles
Secondary SurveyMore detailed and complete examination,
aimed at identifying all injuries and planning further investigation and treatment.
Airway,Breathing,Circulation, Disability, Exposure, Fingers, Foley
Resuscitation/Treatment
After airway and breathing have been assured, infuse IV fluids, keep npo and decide on relevant imaging, and lab testing.
C-spine immobilization and any limb injuries need to be addressed with dressings, splints and fracture reduction if vascular or nerve injury apparent.
Decision on where patient should be treated definitively needs to be determined.– Consideration of personel and resources.
Airway Assessment
Midline position of trachea
Stridor,presence of hemoptysis
Work of breathing– Use of accessory muscles– Respiratory rate– SaO2 and hypoxemia and hypercapnea on ABG
Level of consciousness– Depressed GCS--inability to protect the airway
Airway--treatment
Classified as “Simple to Surgical”
Mask, Oropharyngeal airway, nasopharyngeal airway, laryngeal mask, endotracheal tube, cricothyrotomy, tracheostomy
Airways
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Endotracheal intubation
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Endotracheal intubation
Indications– Hypoxemia– Hypercapnea– Impending respiratory
arrest– Cardiac arrest, multi
trauma– Readying for OR
Need suction, Laryngoscope, Muscle paralysis (?rapid sequence induction)
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Surgical Airways
Cricothyroidotomy– Needle– tube
Tracheostomy
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Cricothyroidotomy
Indications– Severe facial or nasal injuries (that
do not allow oral or nasal intubation)
– Massive midfacial trauma
– Anaphylaxis
– Chemical inhalation injuries
Contraindications– inability to identify landmarks
(cricothyroid membrane)
– Underlying anatomical abnormality (tumor)
– Tracheal transection, acute laryngeal disease by infection or trauma
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Cricothyroidotomy technique
1.With a scalpel, create a 2 cm horizontal incision through the cricothyroid membrane
2.Open the hole by rotating the scalpel 90 degrees or by using a clamp
3.Insert a size 6 or 7 endotracheal tube or tracheostomy tube
4.Inflate the cuff and secure the tube5.Provide venilation via a bag-valve
device with the highest available concentration of oxygen
6.Determine if ventilation was successful (bilateral ausculation and observing chest rise and fall)
7.No attempt should be made to remove the endotracheal tube in a prehospital setting.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Assessment of treatment
Auscultate
CXR
End tidal CO2
SaO2
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Tracheostomy
Definitive surgical
airway
Dedicted appliance or
endotracheal tube
Indications similar for
cricothyroidotomy
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Chest Trauma
Commonest cause of death in blunt and penetrating trauma
• Immediate causes of death– Tension pneumothorax, massive hemothorax,
cardiac tamponade, flail, open pneumothorax
• Delayed causes of death– Pulmonary contusion, cardiac contusion,
pneumothorax, hemothorax, aortic disruption, tracheobronchial disruption, diaphragmatic disruption
Chest trauma
• Assessment with physical exam, CXR, ABGs and SaO2 monitoring
• CT scan
• Echocardiography, ECG
• Serum studies for cardiac injury (troponin and creatinine kinaseMB fraction)
Tension Pneumothorax
Typically from penetrating trauma.– Can be spontaneous– Bronchopleural fistula from lacerated, or
disrupted lung, open pneumothorax• Symptoms of dyspnea, syncope, surgical
emphysema, “impending doom”• Signs of hypotension, tachypnea, tachycardia,
distended neck veins, cyanosis
Hemodynamic mechanism
Axis of the cavae, point of fixation with the aorta and great vessels
Lack of right heart filling, leading to shock
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Tension pneumothorax
Treatment– Suspected: needle
decompression• 14 gauge angiocath• Midclavicular line• Use syringe with plunger
removed
– Leave in place and then insert standard chest tube thoracostomy
– What to do if patient is too thick?
– What if there is no tension noted with needle insertion?
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Tension pneumothorax vs Cardiac tamponade
• In contrast to a pericardial tamponade in setting of penetrating chest trauma
• Pulse--both elevated• Percussion-- tympani with tension• Pulsus paradoxus with tamponade• Neck veins distended with both• Trachea shifted with tension
Chest tube thoracostomy
• Indications– Pneumothorax– Hemothorax– Unstable patient
following blunt or penetrating trauma
– Non trauma• Pleural effusion,
chylothorax, empyema,post operative
– Relative contraindication=diaphragm disruption
• Technique– Local anesthetic* – Sterile field*– Scalpel, kelly or
hemostat forcep– Chest tube and
pleurevac device– Securing suture
*if time permits
Chest tube insertion
• Location is typically, nipple height, mid-axilla sparing the latissimus, and pectoralis muscle
• No tunnels needed• CXR post procedure• Connect to
pleurevac
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Trauma thoracotomy
• Emergency situation with penetrating chest injury– Rarely of benefit in
blunt trauma– Suspect major
vessel laceration or cardiac laceration
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Indications
• Penetrating injury to chest, abdomen or retroperitoneum
• Signs of life prior to assessment in ER then shock
• normothermia
• Clamp aorta• Defibrillate heart• Internal cardiac
massage• Pericardial
decompression• Repair of lacerated
vessel or heart
Shock
• Hypovolemic– Following blood loss– Burns and
hypothermia
• Cardiogenic– Pump failure– Ischemia, contusion,
acute valvular dysfunction
• Distributive– Sepsis– Neurogenic
• Obstructive– Pulmonary embolism– Tamponade, tension
pneumothorax
• Endocrine– Manifests like distributive
shock– Hypothyroidism,
hypoadrenalism
Diagnosis
• Mechanism of injury, illness
• CXR• Bloodwork
– ABG, lactate, Hgb, Creatinine
• Response to trial of IV fluids
• Monitoring of blood pressure
• CVP• SVRI from swan
ganz catheter measurements
• Response to vasopressor therapy
Treatment
• Directed at specific diagnosis– Fluid resuscitation
• Crystalloid, colloid• Blood and blood
products
– Vasopressors• Specific agents for
specific types of shock
• Definitive treatment where possible depending on etiology.
Blunt Injuries to the abdomen
• Physical signs • Distension• Peritonitis• Retroperitoneal
bleeding• Intraabdominal
pressure ( measured with foley catheter and tonometer)
• Diagnosis– Fast scan
(ultrasound)– CT scan– Hemodynamic
monitoring– Diagnostic peritoneal
lavage
Diagnostic peritoneal lavage
• Used to assess need for laparotomy following trauma– Cutdown technique to
midline of abdomen– Initial aspiration, if
clear…..– Infusion of one litre of
saline with IV tubing and then collection
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Diagnostic peritoneal lavage
• Indications for laparotomy– GI contents on aspirate
or lavage• Feces, bile, peas and
corn
– Urine on aspirate– Blood
• 10 mLs of gross blood on aspirate
• >100 000 rbc/ mL on analysis (newspaper test)
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Role of CT scan
• Use for blunt injury management– Assess liver and
spleen injuries– Presence of
pneumoperitoneum, free fluid
– Vascular injuries– Retroperitoneal
injuries
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Indications for laparotomy following trauma
• Blunt– Hemodynamic instability
despite resuscitation– Positive DPL– Findings on CT scan
• High grade spleen or liver injury
• Pneumoperitoneum
• Retroperitoneal organ injury
• Vascular injury
• Penetrating– Hemodynamic
instability despite resuscitation
– Evisceration, pneumoperitoneum
– Positive DPL– CT scan findings
similar to blunt