Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma

Trauma is the leading cause of death in the western world for people aged 1-44. Severe trauma is a major global public health issue resulting in the annual worldwide death of more than 5.8 million people. The appropriate management of trauma patients with massive bleeding and coagulopathy remains a major challenge in routine clinical practice.

About

• Trauma is 37% of ED visits
• Deaths - Motor vehicles, homocides, falls
• Organised trauma care improves outcomes
• Retention of ATLS principles is good

Causes

• Motor vehicle collisions
• Falls, Burns, Machinery, Drowning
• Electrical injuries
• Use of Weapons - knives, guns, clubs
• War, Earthquakes, Floods, Avalanches, Tsunamis

The Trauma Team should be activated immediately when a patient meeting ANY of the following criteria arrives:

• Systolic BP < 90 mmHg
• Respiratory rate < 10 breaths/min or > 30 breaths/min
• GCS < 12 with torso or extremity trauma
• Pregnant patient (> 20 weeks) with foetal heart rate < 120 bpm or > 160 bpm
• Amputation proximal to elbows or knees
• 2 or more proximal long bone fractures
• Suspected spinal cord injury
• Severe maxillofacial injury with airway compromise
• Burns > 15% TBSA
• Pregnant patient with penetrating injury or significant blunt injury
• Gunshot wound proximal to knee or elbow
• Significant penetrating wound to head, neck, chest, abdomen, or groin
• Ejection from vehicle
• Pedestrian thrown (hit by a car) or rolled over
• Fall from a height > 6 metres (20 feet)
• Simultaneous arrival of 3 or more multi-trauma patients
• Emergency Doctor feels trauma team is necessary for an injured patient

The Trauma team comprises a group of emergency department doctors/clinical officers and nurses, surgeons, anaesthetists and theatre staff, radiographers and other support personnel, who work together as a team to assess and manage the trauma patient. Their actions are coordinated by a team leader who should not touch the patient. The aim of the trauma team is to provide a safe and efficient evaluation of the patient. Identify all injuries and instigate the definitive management of such injuries. Most trauma teams will have about 30 minutes to accomplish this and should work towards achieving this goal.

General Principles

• Treat the greatest threats to life first
• Reasonable to Commence treatment before you have made a complete diagnosis
• Do not delay evaluation for a delayed history

Trimodal Distribution of Deaths

• 1. Seconds to minutes: Major CNS or respiratory/vascular injury
• 2. Minutes to hours: Major head, chest and abdominal/pelvic injury and exsanguination. Need a golden hour of rapid triage, assessment and management.
• 3. Days/Weeks: Sepsis and multiorgan failure usually in an ITU setting
• Caution: Golden Hour and Trimodal Distribution of Death concepts too rigid

Primary Survey CABCDE

• Catastrophic haemorrhage
  • This just refers to any obvious, major bleeding points such as stab wounds where pressure can be applied to try and stem the flow of blood. Apply pressure to wound with dressings. For bleeding from limbs consider a tourniquet.
• Airway: (control and protect C-spine)
  • Ensure airway protected and secure. If not check no foreign bodies in the airway, from blood, saliva or broken teeth. Low conscious level - anyone with a head injury and a subsequent low GCS can develop airway obstruction.
  • Check for stridor and that airflow is unimpeded. There may be facial fractures or bleeding. Look for cyanosis and signs of distress, agitation. Look for hypoxia or hypercarbia. If unsure then summon help and consider intubation or use of other airway adjuncts.
  • May need to remove the collar to examine neck ensuring spine immobilised. Examine mouth and visible airway. Check that any tube is in the right place. A head-tilt should be avoided in all trauma patients, due to the risk of cervical spine injury. See C-spine injury topic
• Breathing
  • Give high flow oxygen. If respiratory rate low and compromised then use Bag valve mask with or without an oral airway as a bridge to consider intubation and ventilation.
  • There can be a loss of ventilator drive or neurological control in patients with severe head injury or a high cervical spine lesion (the phrenic nerve, which controls the diaphragm, has its cervical roots at C3, C4 and C5).
  • Check no PTX/Tension PTX and no haemothorax that requires chest drain. If unsure CXR, if in extremis and high suspicion then insert. Look for flail chest and rib fractures.
• Circulation
  • Control of haemorrhage or spinal shock. Low BP, poor capillary return > 2 seconds, cold shut down, tachycardia, oliguria.
  • Simple direct pressure, use of tourniquets short term. Large IV catheters x 2. IV fluids and crystalloids first off. Crossmatch blood.
  • Massive transfusion policy. Reverse any coagulopathy. The Key is balanced resuscitation and aggressive resuscitation should be avoided.
  • The standard use of 2 litres of crystalloid resuscitation as the starting point for all resuscitation has been modified to initiation of 1 litre of crystalloid. Early use of blood and blood products for patients in shock is also emphasized, without mandating or suggesting any specific ratio of plasma and platelets.
  • The focus of bleed internally is the thorax, the abdomen, the pelvis and the long bones. It is perfectly possible to exsanguinate from haemorrhage into one of these cavities which may not be visible.
• Disability
  • Assess CNS. If reduced GCS then may need to intubated an ventilate. Use the AVPU scale also. unilateral dilated pupils suggest brainstem herniation syndromes.
  • Get CT head to assess for structural cause. Neurosurgical consult if needed.
• Exposure and environment
  • Assess of the rest of the body (including the back) to identify any other injuries. The temperature should also be checked, as patients can easily become cold, especially if they have been lying outside.
  • At this point, you may wish to provide analgesia. This will usually be in the form of intravenous morphine

Reasons to Intubate

• Apnoea or inadequate respirations
• Protection of the airway from aspiration
• Impending airway compromise/obstruction
• Persisting hypoxia
• Closed head injury GCS <9

Helpful Airway interventions

• Chin lift and jaw thrust to help
• Oropharygeal airway
• Nasopharyngeal airway
• laryngeal mask airway
• Endotracheal intubation
• Surgical Cricothyroidotomy

The patient making no attempt

• Bag-valve mask or Intubate and ventilate
• Reverse any sedation

Causes of death to quickly manage

• HaemorrhageUse simple dressings with direct pressure to control external haemorrhage. In patients with major limb trauma use a tourniquet if direct pressure has failed to control life-threatening haemorrhage. If active bleeding is suspected from a pelvic fracture after blunt high energy trauma: apply a purpose-made pelvic binder or consider an improvised pelvic binder, but only if a purpose-made binder does not fit. Use intravenous tranexamic acid as soon as possible in patients with major trauma and active or suspected active bleeding.
• Tension Pneumothorax: insert venflon in 2nd ICS in MCL or 5th ICS MAL. Resonant over PTX and trachea pushed away and reduced air entry. JVP elevated. Usually in extremis and hypotensive. If able get a portable CXR and look on the digital display. Give Oxygen.
• Open Pneumothorax: a defect in the chest wall allows air to enter the pleural space which is trapped as the wound forms a one-way valve letting air out and not in. Place a sterile occlusive dressing over the defect and seal with tape on all three sides creating a flutter valve. Place chest drain at a separate site. Give Oxygen.
• Flail chest: with 2 or 3 rib fractures allows a segment of the chest to move paradoxically which can impair lung function. May place dressing to splint wound. Give Oxygen.
• Massive haemorrhage: Pressure to site and Tourniquets where appropriate. If more than 1500 mls of blood loss is 33% of the total blood volume. Get good access with grey and green venflons and replace blood with 1 L 0.9% NaCl crystalloid and then blood. May need O rhesus negative until cross-matched blood is available. Initiate massive transfusion protocol and watch coagulation. May need packed cells, clotting factors and platelets. Reverse any anticoagulation
• Cardiac tamponade: the collection of blood or fluid in pericardial space prevents ventricular filling. The JVP is up and the heart sounds difficult to feel. Needs urgent POCUS if available and urgent needle pericardiocentesis.
• Coma Needs urgent CT scan and if structural issue e.g. SAH/SDH/EDH then urgent neurosurgical referral. Consider mannitol if suspected of coning. If EDH needs urgent burr holes to decompress. Always exclude hypoglycaemia and opiate toxicity

Trauma/ASHICE briefing and preparation "SPORT"

• Staffing – Introductions, sign in, name stickers and personal protective equipment
• Patient details – pre-hospital information relayed to team
• Organise – Assign roles(see box 1), medications pre-drawn (analgesia, anti-emetics, tranexamic acid.) Equipment checking (by relevant team members) and consideration of code red and/or specialist teams if not already present
• Reception of patient – lookout posted outside, logistics of transfer, immediate needs addressed, Amb/HEMS handover, prompt booking onto system by reception staff, blood forms printed, imaging requested
• Treatments – identification of potential further procedures such as intubation/chest drain/catheter etc

Trauma Imaging and Interventional Radiology

Are there clinical signs or a mechanism of injury suggesting a possible solid organ or pelvic injury?

• Obtain full CT Traumogram and radiologist report (Radiographer XXX Radiologist: YYY)
• Is there CT evidence of:
  • Hepatic, Renal or Splenic Injury with active arterial bleeding or significant haematoma?
  • Pelvic Injury (without or without fractures) with active arterial bleeding or significant haematoma?
  • Aortic Dissection or Transection?
• Contact consultant interventional radiologist on call via switchboard and ensure immediate surgical review has been requested
• The decision to undertake embolisation will depend on:
  • Grade and position of injury
  • Patient stability and estimated blood loss
  • Surgical opinion and potential alternative (especially in high grade injuries)
• If a decision is made to embolise for haemorrhage control: Refer to prompt cards 2 and 2a for preparation for transfer to the IR Suite
• Seek anaesthetic support in all cases

Pre-Transfer Checks – TO BE READ ALOUD TO TEAM:

• SAFE for Transfer?
  • Based on A.B.C.D.E. assessment in the last 5 minutes?
  • If intubated has patient had enough sedation +/- paralysis
  • Are appropriate airway management skills present?
• Get TRANSFER EQUIPMENT
  • Green transfer bag, working suction, drugs, monitoring
  • Set alarm limits
  • Ventilator checked
  • Adequate battery life for portable equipment?
• ON OXYGEN?
  • Do you have enough for transfer?
  • Once on cylinder O₂, REPLACE the FLOW METER TO THE WALL
• PLAN YOUR ROUTE
  • Does someone need to go ahead to clear corridors/hold lifts?
• DESTINATION ready? – (Inform ITU/HDU 15 minutes in advance)
  • If for CT then contact Radiographer (bleep 8800) [PRH – 6157]
  • If for X-ray then contact Radiographer (RSCH X-Ray ext 4242)
  • Ensure you have enough staff to move/log roll patient
  • Ensure IV cannula is sited and flushed for contrast.
• If all team members are in agreement then commence transfer

Arrival Checks

1. Arrival at destination
   • Plug oxygen into the wall at the earliest opportunity
   • If at CT then plug equipment into the wall and ensure monitoring is visible
   • If at ITU/HDU then ensure team at bedside ready to receive; leave portable equipment on at first
2. Reassess Patient:
   • Re-assess A.B.C.D.E including observations and capnography on portable monitor
   • Ensure patient stable enough for scan
   • Allow anaesthetist and nurse to establish ICU ventilation if this is destination
3. Staff: Do you have enough staff to log roll the patient for scan?
4. Moment of silence: Team introductions, clarify lead, verbal handover, roles assigned for transfer
5. Transfer of patient: ITU/HDU nurse to establish monitoring and doctor to review

PLEASE DO PRE-TRANSFER CHECKS IF RETURNING TO RESUS