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Major Trauma A standard approach

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1 Major Trauma A standard approach
Ballarat Health Services Emergency Medicine Training Hub

2 Refer to ED lecture series and self directed workbooks
Learning objectives To be familiar with BHS protocols for trauma including trauma teams Management of suspected cervical spine injuries To understand the Victorian State Trauma System and the role of Ballarat Health Services in that system. Pre reading Hughes 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 injury Refer to ED lecture series and self directed workbooks

3 Other learning resources
Relevant guidelines for Ballarat Health Services Trauma – General Approach BHS Intranet Link Trauma Team Activation BHS Intranet Link Cervical spine BHS Intranet Link All available via

4 Introduction Trauma leading cause death 1-40yo Peak age 15-30 Cost in A$ 11 billion Up to 40% trauma deaths preventable Improvements largely due to social education Seat belts Speed limits Drink driving Helmets For each death estimated to be 10 serious non-fatal injuries What improvement?

5 Essence of Trauma Care Right patient to the right resources as soon as possible Achieved by: Integrated system - ‘Trauma Network’ Seniority or experience of providers Decision Pathways and education

6 Trauma Network Ministerial Taskforce on Trauma and Emergency Services Victoria State Trauma Network – 1998 ROTES report (Trauma deficiencies) – 1999 Ongoing governance

7 The Trauma Approach Standardisation of approach has helped improve outcomes Concept of “Golden Hour” 50% deaths <1/24 due to major vessel, CNS, spinal injury benefit from prevention 30% deaths patients major truncal injuries causing respiratory & circulatory compromise benefit from prevention and timely intervention 20% die from sepsis, organ failure etc. benefit from prevention, timely intervention and possibly from integrated approach to recovery

8 Phases of care Pre-hospital Triage Primary survey Secondary survey Disposition

9 Pre-hospital Very little evidence to support major interventions in the field Oxygenation Immobilisation cervical spine Ventilation (unproven) Fluids (unproven) Lights and sirens (increases mortality and community risk)

10 Triage to trauma centre
Physiological Pre-hospital treatment requirement Anatomical injury/deficits Mechanism (high ‘false alarm’ rate)

11 Triage to trauma centre
Increased risk of death: Demographics Age <5 >55 Known chronic (e.g. cardiac/respiratory) disease Vital signs BP <90 RR <10 >29 GCS < 13 Trauma score >14 Under-triage (transport to non-trauma centers) more likely if: Falls female gender age greater than 65 years Ask Jason where this is from

12 Triage to trauma centre
Injuries Penetrating injury to chest, abdomen, head, neck or groin Significant injuries to two or more body regions Severe injury to head, neck or trunk Two or more proximal long bone fractures Burns >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 vehicle Ejection from vehicle* Death of other occupant Rollover* Pedestrian*

14 Trauma reception Prior warning Preparation Staff Area
Paramedical services

15 Trauma teams Assessment Team leader Airway team Scribe Scout
Overview Resus Assessment Communication Internal & external Airway team Assess and secure airway Control cervical spine Ventilation NGT Assessment primary secondary surveys Scribe Scout Radiographers Procedure team IV access & bloods IDC ICC

16 Handover Patient should transferred to trauma trolley prior to hand over Parallel processing Airway and procedure teams commence assessment leader receives handover (silent team handover) Assume the worst & protect against unforeseen injuries do not focus on obvious injuries – protocol of ATLS

17 Primary Survey Ac B C D

18 Primary Survey Ac – Airway Assessment (with C-Spine immobilsation)
B - Breathing C - Cardiovascular D – Disability (GCS and don’t ever forget the glucose) XRs

19 Primary survey Airway & cervical spine Consider NGT
Assess & secure airway Patency Look, listen, feel Jaw trust (no chin lift as cervical spine uncleared) Oropharyngeal airway, nasopharyngeal airway? RSI Maintain cervical protection until spine cleared In-line immobilization Consider NGT

20 Primary survey Ventilation/Breathing CXR
Oxygen is the most important drug in the trauma room Ensure adequate ventilation Assess adequacy Exclude pneumothorax, haemothorax Bag/mask, ETT if required to maintain ventilation Aim for normocarbia CXR Intervention may precede investigation if required

21 Primary survey Circulation Assess adequacy & effect of blood loss
Conscious state Pallor Capillary return BP HR visual estimation of blood loss unreliable FAST scan – ‘rule in’ test

22 Primary survey Circulation Control haemorrhage pressure dressings
Tourniquets Haemostatic dressings Splinting Thoracotomy (Cardiac manoeuvres/Aortic compression) Theatre

23 Primary survey Haemorrhage classification
Class Loss BP HR RR CRT UFR CS Class I <15% N N/+ N N/+ N N Class 2 <30% N anx Class 3 <40% leth Class 4 >40% /- +/ coma

24 Primary survey Circulation Access 2x >16G peripheral IV’s
Fluids initially crystalloid 20mlkg (repeat if required) warmed Crystalloid vs colloid (no proven benefit) Blood O negative Class III/IV haemorrhage Continuing need for crystalloid Consider need for clotting factors and plateletes ‘1:1:1’ Hypotensive resuscitation

25 Primary survey Disability Don’t ever forget the glucose
Level of consciousness AVPU ALERT VOICE PAIN UNCONSCIOUS GCS – E4M6V5 Pupil response Don’t ever forget the glucose

26 Primary survey Exposure Remove Clothes Jewellery Avoid hypothermia

27 Primary survey Monitoring Analgesia Radiology
ECG, BP, SaO2, GCS +/- ventilator obs Analgesia Radiology CXR, Cx spine, AP pelvis IDC traditionally part of 1° survey but usually done later

28 Secondary survey AMPLE history Allergy Medications Past history
Last food Event

29 Secondary survey Head to toe examination – ‘all over and all holes’
Look, feel, move, listen Log roll PR examination Consider Tetanus toxoid Antibiotic prophylaxis

30 Review Constantly reassess and review Any change repeat 1° survey
After any corrective procedure repeat 1° survey

31 Disposition Parallel thinking from before patients arrival
Direct to appropriate services Definitive care made aware of patient Discharge with appropriate support

32 Questions?

33 Summary You are all part of a trauma network Education saves lives
Reassess, reassess, and reassess again (and intervene if required of course . . .)

34 Thankyou Go and get coffee See you in 20mins

35 Major Trauma Scenarios
Ballarat Health Services Emergency Medicine Training Hub

36 Trauma Scenario 1 You 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/fib How are you going to prepare?

37 Trauma preparation Trauma call personnel department equipment
trauma team radiology pathology department equipment

38 Trauma Scenario 1 Arrival history as above
patient conscious, alert, orientated HR145 BP100/50 RR30 complaining of severe pain in R leg Deformity upper leg and obvious compound R tib/fib What is your approach?

39 Trauma Scenario 1 Primary survey Airway intact
Breathing decreased air entry L hemi-thorax What else would you look for?

40 Assessment of pneumothorax
Tension pneumothorax RR30 BP100/50 HR145 tracheal deviation decreased chest movement venous engorgement What are you going to do now?

41 Management tension pneumothorax
Needle decompression Then ICC CXR re-check ABC

42 Trauma Scenario 1 Once AB stable
re-check C continued hypotension N saline bolus D E rest of trauma series radiology analgesia femoral N block + iv analgesia head to toe examination

43 Questions? next case . . .

44 Trauma Scenario 2

45 Trauma Scenario 2 A 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 survey head to toe include log roll (if not already done) IDC NGT

47 Primary survey primary survey Describe your subsequent management
Airway normal Cervical collar applied and immobilised Breathing RR35, otherwise normal Circulation HR140 BP100/45 Describe your subsequent management

48 Hypotensive trauma Resuscitate circulation

49 Hypotensive trauma Resuscitate circulation Analgesia

50 Hypotensive trauma Resuscitate circulation Analgesia
Exposure of abdomen in 1° survey marked seat belt bruising over mid/lower abdomen abdomen tender generalised guarding log roll Thoraco-lumbar junction tender with bruising PR NAD

51 Hypotensive Abdominal trauma
Surgical registrar review asks for: CXR Lateral lumbar spine what 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: CXR Lateral lumbar spine What other injuries are likely? Upper abdominal visceral injury What further investigations do you require? What does the patient need?

54 Hypotensive Abdominal trauma
Surgical registrar review asks for: CXR Lateral lumbar spine What other injuries are likely? What further investigations do you require? CT What does the patient need?

55 Hypotensive Abdominal trauma
Surgical registrar review asks for: CXR Lateral lumbar spine What other injuries are likely? What further investigations do you require? What does the patient need? Adequate fluid resuscitation – Crystalloid and Blood Theatre?

56 Chance fracture Fracture of L1 hyperflexion
Transverse fracture through posterior elements +/- body Associated injury to pancreas duodenum 4th part kidney liver/spleen retroperitoneal haemorrage

57 Hypotensive Abdominal trauma
Investigation CT abdomen dual contrast Additional treatment NGT, IDC Tetanus toxoid/Antibiotics if required police bloods next of kin Disposition

58 Questions? next case . . .

59 Trauma scenario 3 A 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 survey head to toe include log roll (if not already done) IDC NGT

61 Primary survey Airway - intact Cervical collar and sand bags
Breathing - limited chest expansion but equal air entry Circulation HR 70 BP90/50 RR 30 What is the likely cause of this patient’s hypotension?

62 Hypotensive trauma Loss-haemorrhage Redistribution Pump failure
internal/external Redistribution eg vasodilatation 2° spinal shock Pump failure cardiac contusion loss cardio-accelerator Substance use/abuse

63 Hypotensive trauma response
Exclude obstruction to venous return Fluid bolus CXR normal What now?

64 Hypotensive trauma What do you do next?
Repeat fluid bolus if no response Re-do 1° survey, include ‘D’ in assessment of ‘C’ Debility GCS 15/15 flaccid paralysis of both legs sensory level at level of upper chest Priapism BP 100/50 HR 80 What do you do next?

65 Hypotensive trauma Trauma series X-rays? Cervical spine CXR Pelvis

66 Hypotensive trauma Trauma series X-rays?
Cervical spine CXR Pelvis CX 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

68 Computerised tomography reformation illustrating a typical cervical spine injury resulting from a fall in alpine skiing: a 43-year-old male with fracture dislocation C6/7 and concomitant tetraplegia. Franz T et al. Br J Sports Med 2008;42:55-58 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

69 Hypotensive trauma Trauma series X-rays?
Cervical spine CXR Pelvis CX spine/CT shows # dislocation at C6/7 What are the priorities with this patient?

70 Spinal trauma Treatment priorities Steroids
breathing loss of intercostals exhaustion spinal shock temperature control fluid balance important risk of over-filling IDC important Steroids controversial increases morbidity Referral to specialist unit

71 Referral Be familiar with specialist unit provision
Consider moving to Major Trauma Service provider early Engage retrieval service early with appropriate detail

72

73

74 Reproduced from Radiopaeia.org

75 Reproduced from JBJS Journal of Bone and Joint Surgery Br June 2006 vol 88-B No.6 771-775

76 Questions?

77 Summary You are all part of a trauma network Education saves lives
Reassess, reassess, and reassess again (and intervene if required of course And then reassess)

78 Further reading More cases Online education resource
Online education resource

79 Thankyou

80 End

81

82 Trauma scenario 4 47 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 sacrum no response to initial fluid bolus What is the cause of the hypotension? What is your assessment & management?

85 Pelvic Fracture Open book AP compression pelvic fracture
Hypotension due to haemorrhage pelvic veins other abdominal injury

86 Approach to pelvic fracture
secondary survey Including AMPLE history abdominal examination tender and guarding lower abdomen approach ? PV blood at meatus IDC blood Log roll sacral pain and tender

87 Pelvic # and Hypotension
Call orthopaedic Reg ASAP Repeat fluid bolus +/- blood close # MAST suit wrap “C” clamp Exclude other abdominal organ injury CT abdomen dual contrast US “FAST”

88 Image gallery – e.g radiology First slide with image /question

89 Image gallery 2nd slide with answer

90 Summary of learning


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