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Initial management in trauma

Section: Trauma Curriculum: Curriculum, page 75

(AT) MIST

  • A - Age - name, age, sex
  • T - Time of incident
  • M - Mechanism of injury and Medical Complaint
  • I - Injuries sustained and Illness
  • S - Signs and Sx
  • T - Treatment

Principles

  • Simultaneous assessment and resuscitation
  • Life-saving surgery
  • Complete physical examination
  • Diagnostic studies if pt becomes hemodynamically stable
  • Broad Concepts
    • 60% of severe trauma pts die within 1st 4 hrs in hospital
      • Haemorrhage or CNS damage
    • Require rapid restoration of adequate tissue perfusion and haemorrhage control
  • Goals
    • Unstable pt → Theatre or ICU within 30 mins (unless emergency ED surgery)
    • Stable pt → ED time 30-60 mins
      • In CT or ICU within 60 mins
    • Can only move onto secondary survey from primary once H/D stable
      • If not, needs OT or ICU

Primary Survey

  • Goals
    • Identify and treat life threatening injuries
    • A→E
      • Identified in the order that the injuries will cause death
    • Establish patent airway and c-spine control
    • Adequate ventilation
    • Maintaining circulation (including intravascular control volume and cardiac function)
    • Assessing the global neurological status

ABCDE

  • Systematic and simultaneously assess and treat

AIRWAY and C-spine

  • Early ETT with cervical spine protection
    • In severe trauma when unconscious or in shock
    • Indications for Surgical Airway Cricothyroidotomy
      • Laryngeal #
      • Penetrating throat and neck injuries
      • Severe maxfax injuries with bleeding, deformity, oedema
      • Airway burns/inhalation injuries
      • Can’t intubate can’t ventilate
  • Options
    • Emergency cricothyroidotomy
    • Elective tracheostomy
  • Priorities
    • Clear upper AW
    • Give high flow O2
    • Obtain definitive airway → ETT (cuffed tube) or surgical

BREATHING

  • Midline trachea
  • RR/Sats/adequacy of breathing
  • Tension PTX
    • Finger thoracostomy and 3 sided occlusive dressing
    • Then chest drain
  • Massive HTX/flail chest/contusion/tamponade/tracheobronchial injury
    • Chest drain

CIRCULATION

  • = assessment for shock, IVL large bore, bloods (FBC, G+H, coags, gas), resus fluids, MTP, prevent and treat lethal triad
  • Shock
    • Cool/pale peripheries, prolonged CRT, thready pulse, reduced LOC
  • Blood on the floor and 4 more
    • Floor - External bleeding
    • Chest - CXR
    • Abdomen - eFAST
    • Pelvis – Pelvic XR
    • Extremities/long bones - Clinical exam and XR
  • Neck veins and shock
    • Assume hypovolaemic hemorrhagic shock if flat
    • If dilated then assess for:
      • Tension Pneumothorax
      • Tamponade
      • Myocardial contusion (cardiogenic)
      • MI (cardiogenic)
      • Air Embolism
  • Tension PTX - CXR/clinical dx → Chest drain
  • Tamponade
    • Penetrating torso injuries → Cardiac box (nipples, clavs and costal margin)
    • Distended neck veins, peripheral shut down, pulsus paradoxus
    • Drop in BP on inspiration by > 10mmHg
    • USS dx
    • Options for tx
      • Needle pericardiocentesis (not preferred in trauma)
        • Guided with USS
      • Subxiphoid pericardial window via emergency thoracotomy
  • Myocardial contusion - rare
  • MI - common in elderly and may have caused the trauma
  • Air Embolism
    • Air in systemic system due to bronchopulmonary fistula
    • Causes - blunt trauma (rib #) or gunshot/stab
    • Can have neurology without hx of head injury - air bubble occlusion
    • Check fundoscopy - air bubbles in retinal vessels
    • Surgery
      • Thoracotomy and hilar clamping
      • Resuscitate (expand IV volume) and aspirate air from heart
      • Repair or lobar resection
  • Haemorrhagic shock
    • Goal
      • Stop the bleeding - if not possible
        • IV access, blood sample and appropriate resus
        • Identify cause/location of bleed
        • Prevent and treat coagulopathy
        • Prevent and treat hypothermia
    • Access - Preferably central
      • Subclavian/jugular/femoral
      • Seldinger vs open cut down
    • Bloods - Routine and blood gas
    • Assess for occult blood loss
      • Pleural cavity → CXR/USS
      • Thigh → Clinical and X-ray
      • Abdomen (incl retro and pelvis)
      • If CXR/USS and leg ok → laparotomy
    • Resuscitation fluids
      • Crystalloid to start but quick change to blood products
      • MTP activation
        • Use of 2 units
        • Ongoing bleeding requiring transfusion
        • Local protocol for ratios
        • Monitoring with bloods (incl. goal directed TEG/ROTEM)
      • TXA when indicated
      • Permissive hypotension in unstable bleeders
      • Criteria for adequate resuscitation
        • Maintain peripheral perfusion
        • UO 0.5mL/kg/hr (1mL/kg/hr child)
        • Keep atrial filling P at normal level
  • Don’t give 2L crystalloid bolus
  • Early haemostatic resuscitation
  • Guided by TEG
  • 1:1:1 ratio early and minimize crystalloid in hypotensive shock

DISABILITY

  • GCS, pupils, gross neuro (lateralizing signs)
  • Key components
    • Determine LOC
    • Assess pupil size and reactivity
    • Check eye movements and oculovestibular responses
    • Document skeletal and spontaneous movements
    • Determine pattern of breathing
    • Peripheral sensory exam
  • GCS
    • Consciousness made up of:
      • Awareness - Goal directed/purposeful behaviour
        • Use of language
        • Protection from painful stimulus
      • Arousal - Simple wakefulness
      • Brainstem function - Any eye opening
      • Coma - Loss of awareness and arousal
  • Key marker is deterioration in GCS - prompts emergent CT head

ENVIRONMENT/ EXPOSURE

  • Remove clothes and log roll

  • Check temperature and warming measures

  • Body temperature fluids via rapid infusers, warmed mattresses, warm air blankets

  • Prevent heat loss - blanket, Bair hugger, environment

  • Hypothermia shifts O2 curve left → Reduced oxygen delivery

    • Reduce ability for liver to metab citrate/lactic acid
    • Arrhythmia

  • Primary Survey Diagnostic Studies for unstable pt ADJUNCTS

    • CXR
    • Pelvic XR
    • FAST scan - blood in abdomen/chest/pericardium/tension PTX
      • Focused Assessment with Sonography for Trauma
        • LUQ - Between Spleen and Kidney
        • RUQ - Between Liver and Kidney
        • Pelvis - Between Bladder and Rectum
        • eFAST - Pericardial window and HTX as well
      • Can be repeated if clinical change

  • Blood gas

  • ECG

  • NGT

  • IDC

  • Monitoring - oximetry, BP

  • Then figure out disposition: based on haemodynamics and resus response

    • CT
    • Surgery

Secondary Survey

  • Cannot do it until patient is stable
  • What is it
    • AMPLE HISTORY
      • Allergies
      • Meds
      • PMHx or pregnant
      • Last meal
      • Events and environment
        • Pt, responders, family
      • Tetanus
  • Top to toe and front to back examination
  • If H/D normal pt - time for full assessment and CT
  • If H/D stable pt - time for CT
  • If H/D unstable
    • Can’t leave resus
    • Fast USS/XR chest and pelvis
    • DPL if FAST neg but still suspicious or in mass casualty setting
  • Penetrating Trauma
    • Knives, missiles and impalement
    • Velocity dependent on type
    • Secondary effects → Infection - FB introduction and intra-abdo soiling
    • Can use paperclips to see wounds on x rays - Help determine what is injured

Emergency Department Surgery

Head Trauma

  • Surgical AW with indications listed above
  • Scalp lac suturing/clipping with pressure
  • ICH
    • Dilated pupil and contralateral hemiplegia → Coning
    • Hyperventilation
      • Hyperventilation = blow off CO2
      • Hypocapnia reduces ICP
      • By reducing CBF
      • Keep ETCO2 (proxy for PaCO2) ABOVE 30mmHg
    • Mannitol IV 1g/kg bolus or hypertonic saline 7.5% 1mmol/kg
      • Temporize
    • Immediate decompression
      • Burr hole/Craniotomy

Chest Trauma

  • Tension PTX
    • Clinical dx
      • Tracheal deviation, hypertympany, reduced BS
      • Neck vein distension
    • Treatment - Needle decompression and chest drain on UWSD
  • Cardiac Tamponade
    • Only done in ED if SBP < 50mmHg with no time to go to OT
    • Or low SBP despite volume resus
    • Treatment
      • Left anterolateral thoracotomy
        • Relieve tamponade
        • Control bleeding source
      • For ventricular penetrating injury
        • Foley catheter in defect and inflate balloon
          • Clamp foley and don’t traction it!
        • Suture defect
  • IC vessel bleed or lung parenchymal bleeding (haemothorax) (from rib #)
    • Self-limiting usually
    • Collect blood, if possible, for auto-transfusion
  • Aortic transection
    • Dx
      • Widened mediastinum on CXR
      • CT arteriogram
    • Tx
      • Maintain BP ~ 100 systolic

Abdominal Trauma

  • DPL if FAST negative but high suspicion or pt still unwell

Pelvic Trauma

  • Binder or external fixation (time consuming) to return pelvis to normal anatomy
  • Majority of bleeding is venous so settles with binder
  • If binded and still unwell → ? Arterial
    • Angiogram/CT-A
    • Embolisation or
    • Laparotomy and extraperitoneal pelvic packing
  • Long Bone #’s
    • Reduction and splinting initially!
    • External fixation eventually
    • Put traction on distal limb to allow femoral alignment
    • Allows thigh to become cylindrical again → Tamponades bleed
    • Monitor distal pulses → If absent → CTA
    • Requires arterial repair and bony fixation (perfusion over # tx)
  • Peripheral Vascular Injuries
    • Assess vascularity with doppler/CTA/Angio

Tertiary Survey

  • Ideally within 24 hours of admission and repeated when pt is awake
  • Repeat primary and secondary survey
  • Review all notes/bloods/scans
  • Pick up any missed injuries

Cervical Spine Clearance

  • Can be done clinically for some patients
  • Intubated | Sedated | Distracting injury | Booze
    • CT neck
      • Normal → Neuro exam gross motor
        • Ok = Clear
        • Can’t do = ASPEN collar and ortho/MRI neck
      • Abnormal = ASPEN collar and ortho/MRI neck
  • Awake | No EtOH | No distracting injury
    • Clinical assessment
      • Midline tenderness or focal neurology
        • Yes - X-rays | CT | ortho
        • No - clear

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