Major Trauma A standard approach Ballarat Health Services Emergency Medicine Training Hub
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
Other learning resources http://www.health.vic.gov.au/trauma/links.htm http://www.health.vic.gov.au/trauma/triage.htm Relevant guidelines for Ballarat Health Services Trauma – General Approach BHS Intranet Link http://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-31766~intranet-search BHS Intranet Link Trauma Team Activation BHS Intranet Link http://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-32235~intranet-search BHS Intranet Link Cervical spine BHS Intranet Link http://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-32499~intranet-search BHS Intranet Link All available via http://bhsnet/gov-doc-searchhttp://bhsnet/gov-doc-search
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
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
Trauma Network Ministerial Taskforce on Trauma and Emergency Services - 1997 Victoria State Trauma Network – 1998 ROTES report (Trauma deficiencies) – 1999 Ongoing governance
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
Phases of care Pre-hospital Triage Primary survey Secondary survey Disposition
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)
Triage to trauma centre Physiological Pre-hospital treatment requirement Anatomical injury/deficits Mechanism (high ‘false alarm’ rate)
Triage to trauma centre Increased risk of death: Demographics Age 55 Known chronic (e.g. cardiac/respiratory) disease Vital signs BP <90 RR 29 GCS < 13 Trauma score >14 Under-triage (transport to non-trauma centers) more likely if: Falls female gender age greater than 65 years
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
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*
Trauma reception Prior warning Preparation Staff Area Paramedical services
Trauma teams Team leader Overview Resus Assessment Communication Internal & external Airway team Assess and secure airway Control cervical spine Ventilation NGT Procedure team IV access & bloods IDC ICC Scribe Scout Radiographers Assessment primary secondary surveys
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
Primary survey Ventilation/Breathing 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
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
Primary survey Haemorrhage classification Class Loss BPHRRRCRTUFRCS Class I <15% NN/+NN/+ NN Class 2 <30% N +++ anx Class 3 <40% ++++++ leth Class 4 >40% +/-+/-++ coma
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
Major Trauma Scenarios Ballarat Health Services Emergency Medicine Training Hub
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?
Trauma preparation Trauma call personnel trauma team radiology pathology department equipment
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?
Trauma Scenario 1 Primary survey Airway intact Breathing decreased air entry L hemi-thorax What else would you look for?
Assessment of pneumothorax Tension pneumothorax RR30 BP100/50 HR145 tracheal deviation decreased chest movement venous engorgement What are you going to do now?
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
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?
Reproduced from http://www.radiologyassistant.nl
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?
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?
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?
Chance fracture Fracture of L1 hyperflexion Transverse fracture through posterior elements +/- body Associated injury to pancreas duodenum 4th part kidney liver/spleen retroperitoneal haemorrage
Hypotensive Abdominal trauma Investigation CT abdomen dual contrast Additional treatment NGT, IDC Tetanus toxoid/Antibiotics if required police bloods next of kin Disposition
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?
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
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?
Hypotensive trauma response Exclude obstruction to venous return Fluid bolus CXR normal What now?
Hypotensive trauma 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?
Hypotensive trauma Trauma series X-rays? Cervical spine CXR Pelvis
Hypotensive trauma Trauma series X-rays? Cervical spine CXR Pelvis CX spine/CT shows # dislocation at C6/7
Reproduced from JBJS Journal of Bone and Joint Surgery Br June 2006 vol 88-B No.6 771-775
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?
Spinal trauma Treatment priorities 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
Referral Be familiar with specialist unit provision Consider moving to Major Trauma Service provider early Engage retrieval service early with appropriate detail
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?
Primary survey ABCx normal C HR120 BP 80/60 RR 32 Approach to hypotension?
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?
Pelvic Fracture Open book AP compression pelvic fracture Hypotension due to haemorrhage pelvic veins other abdominal injury
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
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”
Image gallery – e.g radiology First slide with image /question