Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Major Trauma A standard approach Ballarat Health Services Emergency Medicine Training Hub."— Presentation transcript:

1

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

3 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

4 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

5 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

6 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

7 Trauma Network Ministerial Taskforce on Trauma and Emergency Services - 1997 Victoria State Trauma Network – 1998 ROTES report (Trauma deficiencies) – 1999 Ongoing governance

8 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

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

10 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)

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

12 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

13 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

14 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*

15 Trauma reception Prior warning Preparation Staff Area Paramedical services

16 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

17 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

18 Primary Survey Ac B C D

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

20 Primary survey Airway & cervical spine 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

21 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

22 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

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

24 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

25 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

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

27 Primary survey Exposure Remove Clothes Jewellery Avoid hypothermia

28 Primary survey Monitoring ECG, BP, SaO 2, GCS +/- ventilator obs Analgesia Radiology CXR, Cx spine, AP pelvis IDC traditionally part of 1° survey but usually done later

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

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

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

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

33 Questions?

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

35 Thankyou Go and get coffee See you in 20mins

36 Major Trauma Scenarios Ballarat Health Services Emergency Medicine Training Hub

37 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?

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

39 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?

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

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

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

43 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

44 Questions? next case...

45 Trauma Scenario 2

46 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?

47 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

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

49 Hypotensive trauma Resuscitate circulation

50 Hypotensive trauma Resuscitate circulation Analgesia

51 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

52 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?

53 Reproduced from http://www.radiologyassistant.nl

54 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?

55 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?

56 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?

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

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

59 Questions? next case...

60 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?

61 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

62 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?

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

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

65 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?

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

67 Hypotensive trauma Trauma series X-rays? Cervical spine CXR Pelvis CX spine/CT shows # dislocation at C6/7

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

69 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.

70 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?

71 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

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

73

74

75 Reproduced from Radiopaeia.org

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

77 Questions?

78 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)

79 Further reading More cases http://lifeinthefastlane.com/tag/trauma-tribulation/ Online education resource http://www.surgicaltutor.org.uk/defaulthome.htm?core/trauma/spinal.htm~rig ht http://www.surgicaltutor.org.uk/defaulthome.htm?core/trauma/spinal.htm~rig ht

80 Thankyou

81 End

82

83 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?

84 Primary survey ABCx normal C HR120 BP 80/60 RR 32 Approach to hypotension?

85 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?

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

87 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

88 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”

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

90 Image gallery 2 nd slide with answer

91 Summary of learning


Download ppt "Major Trauma A standard approach Ballarat Health Services Emergency Medicine Training Hub."

Similar presentations


Ads by Google