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Primary Assessment in Trauma and Advances in Management
Dr Joseph Mathew MB BS MS FACEM
Emergency/Trauma Service, The Alfred Hospital
National Trauma Research Institute
Department of Surgery, Central Clinical School,
Monash University
Head, Australia India Trauma Systems
Collaboration
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2
2
The Alfred Trauma Service
• 8,000 trauma admissions per year
• 1,400 major trauma patients
ISS>12
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By 2020 Trauma (physical injury) will be No. 3 on the WHO list - Global Burdens of Disease
• 1.25 million died globally from road trauma alone in 2013
7% increase in Indian road deaths in 2016
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Decade of Action for Road Safety 2011-2020
27 June 2017
Goal - to stabilize and reduce the forecast level of
road traffic deaths around the world.
• Pre-hospital care systems development
• Hospital trauma care systems development
• Early rehabilitation and support to injured patients
• Establishment of appropriate road user insurance schemes
• Encourage research and development
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per 100,000 per 100,000 annual
persons vehicles deaths
China 20.5 133.3 275,983 2010
India 19.5 207.5 238,562 2013
Nigeria 33.7 425.2 53,339 2010
Brazil 22.5 67.7 43,869 2010
Indonesia 17.7 58.4 42,434 2010
United States 11.6 13.6 36,166 2012
Australia 5.6 7.6 1299 2012
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Haemorrhage is responsible for over
35% of pre-hospital trauma deaths
and over 40% of trauma deaths
within the first 24 hours.
Worldwide approximately 16,500 people die each day
from injuries, including 6,000 who bleed to death.
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Objectives
Demonstrate concepts of primary and secondary patient assessment
Establish management priorities in trauma situations
Initiate primary and secondary management as necessary
Arrange appropriate disposition
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Why Trauma team training
Trimodal death distribution
• First peak instantly (brain, heart, large vessel injury)
• Second peak minutes to hours
• Third peak days to weeks (sepsis, MSOF)
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Concepts of ATLS
Treat the greatest threat to life first
The lack of a definitive diagnosis should never impede the application of an
indicated treatment
A detailed history is not essential to begin the evaluation
“ABCDE” approach
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Initial Assessment and Management
An effective trauma system needs the teamwork of paramedics, emergency
medicine, trauma surgery, and surgery subspecialists
Trauma roles
Trauma team leader
Interventionalists
Nurses
Scribe
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Trauma Team
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Primary Survey
Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms ABCDEs of trauma care A Airway and c-spine protection
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability/Neurologic status
E Exposure/Environmental control
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Airway
How do we evaluate the
airway?
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A- Airway
Airway should be assessed for patency Is the patient able to communicate verbally?
Inspect for any foreign bodies
Examine for stridor, hoarseness, gurgling, pooled secretions or blood
Assume c-spine injury in patients with multisystem trauma C-spine clearance is both clinical and radiographic
C-collar should remain in place until patient can cooperate with clinical exam
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Airway Interventions
Supplemental oxygen
Suction
Chin lift/jaw thrust
Oral/nasal airways
Definitive airways
RSI for agitated patients with c-spine immobilization
ETT for comatose patients (GCS<8)
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Difficult Airway
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Breathing
What can we look for clinically to assess a patient’s ‘breathing’ status?
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B- Breathing
Airway patency alone does not ensure adequate ventilation
Inspect, palpate, and auscultate
Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds
CXR to evaluate lung fields
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Flail Chest
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Subcutaneous Emphysema
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Breathing Interventions
Ventilate with 100% oxygen
Pleural decompression if tension pneumothorax suspected
Chest tubes for pneumothorax / hemothorax
Occlusive dressing to sucking chest wound
If intubated, evaluate ETT position
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Chest Tube for GSW
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What would we do for this patient who is having difficulty breathing?
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C- Circulation
Hemorrhagic shock should be assumed in any hypotensive trauma patient
Rapid assessment of hemodynamic status
Level of consciousness
Skin color
Pulses in four extremities
Blood pressure and pulse pressure
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Circulation Interventions
Cardiac monitor Apply pressure to sites of external hemorrhage Establish IV access 2 large bore IVs
Central lines if indicated
Cardiac tamponade decompression if indicated Volume resuscitation Have blood ready if needed
Level One infusers available
Foley catheter to monitor resuscitation
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D- Disability
Abbreviated neurological exam
Level of consciousness
Pupil size and reactivity
Motor function
GCS
• Utilized to determine severity of injury
• Guide for urgency of head CT and ICP monitoring
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Disability Interventions
Spinal cord injury
Early diagnosis/treatment /decompression stabilisation
ICP monitor- Neurosurgical consultation
Elevated ICP
Head of bed elevated
Mannitol
Hyperventilation
Emergent decompression
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E- Exposure
Complete disrobing of patient
Logroll to inspect back
Warm blankets/external warming device to prevent hypothermia
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Always Inspect the Back
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Diagnostic Aids
Standard trauma bloods
FBE/UEC/LFT/Coags/Lipase/Crossmatch, EtOH, ABG
Standard trauma radiographs
CXR, pelvis, lateral C-spine (traditionally)
CT/FAST scans
Pt must be monitored in radiology
Pt should only go to radiology if stable
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Role of CPR in trauma?
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World War 1
Basic first aid
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Some blood, some fluid, some surgery
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3L crystalloid, 1L blood
Surgery
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Crystalloid, RBC, Plasma
Damage control resuscitation
Damage control surgery
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What do we know?
#VicTGR Trauma
Bleeding
TBI Chest Abdomen Limbs Pelvis
Die
ATLS
Investigations
Interventions
Medical Surgical
Blunt vs Penetrating
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Trauma systems reduce mortality and morbidity
Cameron PA, Gabbe B, Cooper DJ. A statewide system of trauma
care in Victoria: effect on patient survival. Med J Aust. 2008; 189:
546-50.
= Reduction in mortality over time
Mock CN, Adzotor KE, Conklin E, Denno DM, Jurkovich GJ. Trauma
outcomes in the rural developing world: comparison with an
urban level I trauma center. J Trauma. 1993; 35: 518-23.
= Reduction in mortality compared to no
trauma system
Gabbe BJ, Simpson PM, Sutherland AM, Wolfe R, Fitzgerald MC,
Judson R, Cameron PA. Improved functional outcomes for major
trauma patients in a regionalized, inclusive trauma system. Ann
Surg. 2012; 255(6): 1009-15.
= Reduction in disability
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Trauma management Risk reduction and error avoidance
James K Styner
Nebraska 1976
Journal of Trauma Nursing
June 2006, Volume :13 Number 2,
page 41- 44
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Trauma management Risk reduction and error avoidance
Crew Resource management grew
out of the 1977 Tenerife airport
disaster where two Boeing 747
aircraft collided on the runway
killing 583 people
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Trauma care versus the Airline industry
time
risk
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Pre-Hospital
Care
Physical / OT/ Rehab
Care
Emergency / Critical
Care
Surgery / Operative
Care
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Trauma – a quaternary speciality
Injury evolution, timing of presentation,
timeliness of intervention, time
management & coordination of resources
Pre-Hospital
Care
Emergency / Critical
Care
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Physical / OT/ Rehab
Care
Surgery / Operative
Care
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ATLS
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4 yearly review
Financial gains
Target audience
Dogma/Myth
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Up to Date?
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A single intervention in a mature Trauma System or…?
the TR&R hypothesis
‘..The greatest improvements in resuscitation
will come with improved team communication,
standardization of interventions, improved
physiological monitoring, adherence to
algorithmic treatment pathways and the
associated reduction in errors of omission…’
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#VicTGR Cervical Collar
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ICCs by chest injury
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Thoracic_Trauma
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Initial Supine CXR
• Fails to diagnose haemothorax or
pneumothorax in 32% of thoracic trauma
patients with haemodynamic compromise
• Clinical examination is the key
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Thoracic_Trauma
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A wounded British soldier in Libya lies on a cot in a desert hospital tent on June 18, 1942, shielded from the strong tropical sun. [AP Photo/Weston Haynes]
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Thoracic_Trauma
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World War 2 and tension pneumothorax
H. Fuld, Simple device for
control of tension
pneumothorax. Bri Med J 2
(1944), p. 503.
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Chest decompression
• There is no evidence that needle thoracostomy is a
reliably useful procedure for in-hospital trauma
resuscitation.
• ~1/3 of pleural cavities not reached
• Sub-Q gas under tension causes false positives
• Anatomical landmarks poorly determined1
1 ’The right place in the right space? Awareness of site for needle thoracocentesis. Ferrie E,
Collum N, McGovern S. Emerg Med J 2005;22:788-789.
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Pitfalls of needle thoracocentesis
Extrapleural placement of
catheter-over-needle
thoracocentesis.
The catheter length is
adequate but is extra-pleural.
There is no pneumothorax.
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Pitfalls of needle thoracocentesis
False positive as chest tube decompresses subcutaneous emphysema There is a left pneumothorax. The tube thoracostomy has been placed extrapleural in sub-cutaneous gas - creating a false positive with associated failure to decompress the pleural space.
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Thoracic_Trauma
pneumocath
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pneumocath
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Pitfalls of needle thoracocentesis
Incorrect identification of the mid-clavicular line may result in needle decompression that is too medial, with increased risk of vascular and cardiac injury.
The recommended insertion point
(A) in the 2nd intercostal space in the midclavicular line is more lateral to the point commonly identified - which is half-way between the midline and the lateral chest wall (B).
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Binary decision
matrix for chest
decompression
Bilateral pleural
decompression
Decompress pleura
on affected side
Is air entry equal?Inspiratory breath sounds can be heard
clearly and equally in the mid axillary line
bilaterally
Is SpO2 < 90?On FiO2 100% and Endotracheal Tube
(ETT) correct distance from gums post
ETT suction
Is Systolic BP < 100
mmHg?Despite IV filling
Trauma
Arrest?
IPPV?
Await supine chest
X-ray
yes
yes
yesyes
yes
yes
no
no
no
no
mf2007
Insert chest tubewith one way valve
yes
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Positions & complications of ICCs
A Trauma to the intercostal neurovascular bundle.
B Extrapleural placement. C Correct position pleural
space. D Intrafissural placement. E Intrapulmonary placement. F Mediastinal impingement or
penetration. G Trans-diaphragmatic
placement. H Infection.
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ICC insertion
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Thoracic_Trauma
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Chest decompression and trauma resuscitation
Tube thoracostomy is indicated for tension
pneumothorax, for open pneumothorax once
closed, for patients with haemodynamic or
respiratory compromise with coinciding
pneumothorax or haemothorax and for ventilated
patients with pneumothorax.
Digitally decompress the pleural space using a lateral
approach – then insert an ICC
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#VicTGR Resuscitative Endovascular Balloon Occlusion of Aorta
(REBOA)
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What do we know about blood and trauma circa 2015
Coagulopathy
Acidosis
Hypothermia
TA
C Platelet defect (TBI)
Consumption (Clot/DIC)
Endothelial injury, Fibrinolysis
DCR Medical - Blood/drug
Surgical - Laparotomy vs conservative
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12 Apr 2016
37 Recommendations
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Systolic blood pressure 80-90 mmHg
(no TBI).
Mean arterial pressure of 80 mmHg
(if TBI present)
“Restrained resuscitation” “Permissive hypotension”
Highlights
Recommendation 13
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At least 1:1:1
Highlights
Recommendation 24
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95.1% of 245 trauma centers - massive transfusion protocols
67.7% tended toward 1:1:1 ratios
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Highlights
Recommendation 25
Tranexamic acid
< 3 hours
1 g load, 1 g over 8 hr
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Developing countries
(245 centres in 40 countries)
Methodology
(selection, randomization)
(no phone!)
100% follow up
Complication screening
CRASH-2 Critics
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Highlights
Recommendation 28
Recommendation 29
Recommendation 31
Low fibrinogen: 15-20 units of Cryoprecipitate
Platelets: >50 or >100 if TBI or on-going bleeding
Anti-Platelets: give platelets
Recommendation 32
Known platelet dysfunction: desmopressin (0.3 mcg/kg)
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Highlights
Recommendation 33
Recommendation 34
Recommendation 35
PCC if Warfarin
FXa inhibitors: TXA and high dose PCC
Thrombin inhibitors: idarucizumab or
TXA and high dose PCC
Recommendation 36
Off label rFVIIa only if desperate
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1:1:1
Cryoglobulin
Calcium
Temperature
Acidosis
“Limit” crystalloids
Stop bleeding
TXA
Reversal agents
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ATLS = Basic
More TXA evidence coming
NOAC situations = new approaches
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What do we know?
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