Presentation on theme: "Major Trauma A standard approach"— Presentation transcript:
1 Major Trauma A standard approach Ballarat Health ServicesEmergency Medicine Training Hub
2 Refer to ED lecture series and self directed workbooks Learning objectivesTo be familiar with BHS protocols for trauma including trauma teamsManagement of suspected cervical spine injuriesTo understand the Victorian State Trauma System and the role of Ballarat Health Services in that system.Pre readingHughes 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 injuryRefer to ED lecture series and self directed workbooks
3 Other learning resources Relevant guidelines for Ballarat Health ServicesTrauma – General ApproachBHS Intranet LinkTrauma Team ActivationBHS Intranet LinkCervical spineBHS Intranet LinkAll available via
4 IntroductionTrauma leading cause death 1-40yoPeak age 15-30Cost in A$ 11 billionUp to 40% trauma deaths preventableImprovements largely due to social educationSeat beltsSpeed limitsDrink drivingHelmetsFor each death estimated to be 10 serious non-fatal injuriesWhat improvement?
5 Essence of Trauma CareRight patient to the right resources as soon as possibleAchieved by:Integrated system - ‘Trauma Network’Seniority or experience of providersDecision Pathways and education
6 Trauma NetworkMinisterial Taskforce on Trauma and Emergency ServicesVictoria State Trauma Network – 1998ROTES report (Trauma deficiencies) – 1999Ongoing governance
7 The Trauma ApproachStandardisation of approach has helped improve outcomesConcept of “Golden Hour”50% deaths <1/24 due to major vessel, CNS, spinal injurybenefit from prevention30% deaths patients major truncal injuries causing respiratory & circulatory compromisebenefit from prevention and timely intervention20% die from sepsis, organ failure etc.benefit from prevention, timely intervention and possibly from integrated approach to recovery
8 Phases of carePre-hospitalTriagePrimary surveySecondary surveyDisposition
9 Pre-hospitalVery little evidence to support major interventions in the fieldOxygenationImmobilisation cervical spineVentilation (unproven)Fluids (unproven)Lights and sirens (increases mortality and community risk)
10 Triage to trauma centre PhysiologicalPre-hospital treatment requirementAnatomical injury/deficitsMechanism (high ‘false alarm’ rate)
11 Triage to trauma centre Increased risk of death:DemographicsAge <5 >55Known chronic (e.g. cardiac/respiratory) diseaseVital signsBP <90RR <10 >29GCS < 13Trauma score >14Under-triage (transport to non-trauma centers) more likely if:Fallsfemale genderage greater than 65 yearsAsk Jason where this is from
12 Triage to trauma centre InjuriesPenetrating injury to chest, abdomen, head, neck or groinSignificant injuries to two or more body regionsSevere injury to head, neck or trunkTwo or more proximal long bone fracturesBurns >15% or involving face or airway
13 Triage to trauma centre Mechanism (high ‘false alarm’ rate)High speed >60 kph*Fall > 6m*>50 cm intrusion into vehicleEjection from vehicle*Death of other occupantRollover*Pedestrian*
14 Trauma reception Prior warning Preparation Staff Area Paramedical services
15 Trauma teams Assessment Team leader Airway team Scribe Scout OverviewResusAssessmentCommunicationInternal & externalAirway teamAssess and secure airwayControl cervical spineVentilationNGTAssessmentprimarysecondary surveysScribeScoutRadiographersProcedure teamIV access & bloodsIDCICC
16 HandoverPatient should transferred to trauma trolley prior to hand overParallel processingAirway and procedure teams commence assessmentleader receives handover (silent team handover)Assume the worst & protect against unforeseen injuries do not focus on obvious injuries – protocol of ATLS
20 Primary survey Ventilation/Breathing CXR Oxygen is the most important drug in the trauma roomEnsure adequate ventilationAssess adequacyExclude pneumothorax, haemothoraxBag/mask, ETT if required to maintain ventilationAim for normocarbiaCXRIntervention may precede investigation if required
21 Primary survey Circulation Assess adequacy & effect of blood loss Conscious statePallorCapillary returnBPHRvisual estimation of blood loss unreliableFAST scan – ‘rule in’ test
23 Primary survey Haemorrhage classification Class Loss BP HR RR CRT UFR CSClass I <15% N N/+ N N/+ N NClass 2 <30% N anxClass 3 <40% lethClass 4 >40% /- +/ coma
24 Primary survey Circulation Access 2x >16G peripheral IV’s Fluids initially crystalloid 20mlkg (repeat if required) warmedCrystalloid vs colloid (no proven benefit)Blood O negativeClass III/IV haemorrhageContinuing need for crystalloidConsider need for clotting factors and plateletes ‘1:1:1’Hypotensive resuscitation
25 Primary survey Disability Don’t ever forget the glucose Level of consciousnessAVPUALERTVOICEPAINUNCONSCIOUSGCS – E4M6V5Pupil responseDon’t ever forget the glucose
35 Major Trauma Scenarios Ballarat Health ServicesEmergency Medicine Training Hub
36 Trauma Scenario 1You 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/fibHow are you going to prepare?
37 Trauma preparation Trauma call personnel department equipment trauma teamradiologypathologydepartmentequipment
38 Trauma Scenario 1 Arrival history as above patient conscious, alert, orientatedHR145 BP100/50 RR30complaining of severe pain in R legDeformity upper leg and obvious compound R tib/fibWhat is your approach?
39 Trauma Scenario 1 Primary survey Airway intact Breathing decreased air entry L hemi-thoraxWhat else would you look for?
40 Assessment of pneumothorax Tension pneumothoraxRR30BP100/50HR145tracheal deviationdecreased chest movementvenous engorgementWhat are you going to do now?
45 Trauma Scenario 2A patient presents following a MCA, 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?
46 Approach to trauma Primary survey AcBC CXR, C-Spine, Pelvis XRs Secondary surveyhead to toeinclude log roll (if not already done)IDCNGT
47 Primary survey primary survey Describe your subsequent management Airway normalCervical collar applied and immobilisedBreathing RR35, otherwise normalCirculation HR140 BP100/45Describe your subsequent management
50 Hypotensive trauma Resuscitate circulation Analgesia Exposure of abdomen in 1° surveymarked seat belt bruising over mid/lower abdomenabdomen tender generalised guardinglog rollThoraco-lumbar junction tender with bruisingPR NAD
51 Hypotensive Abdominal trauma Surgical registrar review asks for:CXRLateral lumbar spinewhat other injuries are likely?what further investigations do you require?What does the patient need?
52 Reproduced from http://www.radiologyassistant.nl
53 Hypotensive Abdominal trauma Surgical registrar review asks for:CXRLateral lumbar spineWhat other injuries are likely?Upper abdominal visceral injuryWhat further investigations do you require?What does the patient need?
54 Hypotensive Abdominal trauma Surgical registrar review asks for:CXRLateral lumbar spineWhat other injuries are likely?What further investigations do you require?CTWhat does the patient need?
55 Hypotensive Abdominal trauma Surgical registrar review asks for:CXRLateral lumbar spineWhat other injuries are likely?What further investigations do you require?What does the patient need?Adequate fluid resuscitation – Crystalloid and BloodTheatre?
56 Chance fracture Fracture of L1 hyperflexion Transverse fracture through posterior elements +/- bodyAssociated injury topancreasduodenum 4th partkidneyliver/spleenretroperitoneal haemorrage
57 Hypotensive Abdominal trauma InvestigationCT abdomen dual contrastAdditional treatmentNGT, IDCTetanus toxoid/Antibiotics if requiredpolice bloodsnext of kinDisposition
59 Trauma scenario 3A 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?
60 Approach to trauma Primary survey AcBC CXR, C-Spine, Pelvis XRs Secondary surveyhead to toeinclude log roll (if not already done)IDCNGT
61 Primary survey Airway - intact Cervical collar and sand bags Breathing - limited chest expansion but equal air entryCirculationHR 70 BP90/50 RR 30What is the likely cause of this patient’s hypotension?
64 Hypotensive trauma What do you do next? Repeat fluid bolus if no responseRe-do 1° survey, include ‘D’ in assessment of ‘C’DebilityGCS 15/15flaccid paralysis of both legssensory level at level of upper chestPriapismBP 100/50 HR 80What do you do next?
65 Hypotensive traumaTrauma series X-rays?Cervical spineCXRPelvis
66 Hypotensive trauma Trauma series X-rays? Cervical spineCXRPelvisCX spine/CT shows # dislocation at C6/7
67 Reproduced from JBJS Journal of Bone and Joint Surgery Br June 2006 vol 88-B No.6 771-775
69 Hypotensive trauma Trauma series X-rays? Cervical spineCXRPelvisCX spine/CT shows # dislocation at C6/7What are the priorities with this patient?
70 Spinal trauma Treatment priorities Steroids breathing loss of intercostals exhaustionspinal shocktemperature controlfluid balance important risk of over-fillingIDC importantSteroidscontroversial increases morbidityReferral to specialist unit
71 Referral Be familiar with specialist unit provision Consider moving to Major Trauma Service provider earlyEngage retrieval service early with appropriate detail
82 Trauma scenario 447 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?
83 Primary survey ABCx normal C HR120 BP 80/60 RR 32 Approach to hypotension?
84 Hypotensive trauma Fluid bolus CXR & CX spine normal Pelvic Xray shows # body pubis with separation anteriorly# through sacrumno response to initial fluid bolusWhat is the cause of the hypotension?What is your assessment & management?
85 Pelvic Fracture Open book AP compression pelvic fracture Hypotension due to haemorrhagepelvic veinsother abdominal injury
86 Approach to pelvic fracture secondary surveyIncluding AMPLE historyabdominal examinationtender and guarding lower abdomenapproach ?PV blood at meatusIDC bloodLog roll sacral pain and tender
87 Pelvic # and Hypotension Call orthopaedic Reg ASAPRepeat fluid bolus +/- bloodclose #MAST suitwrap“C” clampExclude other abdominal organ injuryCT abdomen dual contrastUS “FAST”
88 Image gallery – e.g radiology First slide with image /question