Trauma (main): Difference between revisions

Line 36: Line 36:


====Airway and cervical spine stabilization====
====Airway and cervical spine stabilization====
*Clinical Presentation
**Patients can present with poor respiratory effort, altered mental status, inability to phonate, hypoxia, tachypnea, bradypnea, etc.
**Look for signs of airway obstruction: blood, hematoma, edema, vomitus, facial or neck trauma, foreign bodies
*Diagnosis and Evaluation
**Assess airway patency, phonation, and ability to protect airway
***If a patient can clearly phonate and protect their airway, move to “B” or Breathing, but continually reevaluate
***If airway not patent or patient cannot phonate or protect airway, consider intubation
**If there is any concern for a cervical spine (c-spine) injury base on history or exam, take care to limit c-spine movement and place c-collar
***If intubation is warranted, have a second provider maintain c-spine immobilization during procedure
**If time permits, perform a neurologic examination prior to intubation and sedation
***The need for an emergent airway always takes priority and need not be delayed
*Treatment
**Although not a definitive airway, a supraglottic airway may be useful when a patient has significant facial trauma or is difficult to intubate or ventilate
***These devices are contraindicated in awake patients and those with inability to open the mouth
**Avoid nasal airway if suspected basilar skull fracture
**Suction the airway of blood or emesis, and remove foreign bodies and dentures before laryngoscopy
**Video laryngoscopy with rapid sequence intubation (RSI) is the recommended first line approach to minimize cervical spine motion and provide superior laryngeal views
**A cricothyrotomy or another surgical airway may be necessary if endotracheal intubation fails or there is significant facial trauma or airway obstruction
**Use capnography, auscultation and post-intubation CXR to confirm tube placement


====Breathing====
====Breathing====

Revision as of 23:54, 21 November 2019

Background

  • The emergency clinician plays a critical role in coordinating a multi-disciplinary team to stabilize, resuscitate, and manage multiple trauma patients
  • A structured assessment, namely the ABCDE method, can be used to systematically assess the trauma patient to quickly identify and prioritize injuries, simplifying the thought process in a chaotic environment
  • Multiple trauma is defined as any trauma associated with two or more injuries, of which, one injury is classified as life threatening
    • The two most common mechanisms of multiple trauma are blunt and penetrating trauma
  • The ABCDE method is used to assess these trauma patients: airway and cervical stabilization, breathing, circulation, disability, and exposure/environmental control
  • General Approach to Multiple Trauma Patients
    • Pre-hospital and Triage
    • Primary Survey
    • Secondary Survey
    • Laboratory and Radiographic Evaluation
    • Disposition

Initial evaluation objectives

  1. Rapidly identify life-threatening injuries
  2. Initiate supportive therapy
  3. Organize definitive therapy

Locations of Possible Life-Threatening Bleeding

Lethal Triad of Major Trauma

  1. Hypothermia
  2. Coagulopathy
  3. Acidosis

Clinical Features

Primary Survey

  • The goal of the primary survey is to immediately identify and manage life-threatening injuries
  • There are five components of ABCDE: airway and cervical stabilization, breathing, circulation, disability, exposure and environmental control
  • As critical conditions are encountered, initiate treatment without delay before continuing to the next step of the assessment
    • Often multidisciplinary team involved who can address treatment while primary survey can continue
  • After the primary survey, evaluate whether the patient needs to be transferred to a facility that can provide definitive treatment not available at the initial hospital
    • Specifically if not a level 1 trauma center
  • Continually reassess components of the primary survey

Airway and cervical spine stabilization

  • Clinical Presentation
    • Patients can present with poor respiratory effort, altered mental status, inability to phonate, hypoxia, tachypnea, bradypnea, etc.
    • Look for signs of airway obstruction: blood, hematoma, edema, vomitus, facial or neck trauma, foreign bodies
  • Diagnosis and Evaluation
    • Assess airway patency, phonation, and ability to protect airway
      • If a patient can clearly phonate and protect their airway, move to “B” or Breathing, but continually reevaluate
      • If airway not patent or patient cannot phonate or protect airway, consider intubation
    • If there is any concern for a cervical spine (c-spine) injury base on history or exam, take care to limit c-spine movement and place c-collar
      • If intubation is warranted, have a second provider maintain c-spine immobilization during procedure
    • If time permits, perform a neurologic examination prior to intubation and sedation
      • The need for an emergent airway always takes priority and need not be delayed
  • Treatment
    • Although not a definitive airway, a supraglottic airway may be useful when a patient has significant facial trauma or is difficult to intubate or ventilate
      • These devices are contraindicated in awake patients and those with inability to open the mouth
    • Avoid nasal airway if suspected basilar skull fracture
    • Suction the airway of blood or emesis, and remove foreign bodies and dentures before laryngoscopy
    • Video laryngoscopy with rapid sequence intubation (RSI) is the recommended first line approach to minimize cervical spine motion and provide superior laryngeal views
    • A cricothyrotomy or another surgical airway may be necessary if endotracheal intubation fails or there is significant facial trauma or airway obstruction
    • Use capnography, auscultation and post-intubation CXR to confirm tube placement

Breathing

Circulation

Disability

Exposure

Classes of hemorrhagic shock[1]

Class I II III IV
Approximate blood loss <15% 15-30% 30-40% >40%
Heart rate ↔/↑ ↑↑
Blood pressure ↔/↓
Pulse Pressure (mmHg)
Respiratory Rate (per min) ↔/↑
Urine Output (mL/hr) ↓↓
Glasgow coma scale score
Base deficit^ 0 to -2 mEq/L -2 to -6 mEq/L -6 to -10 mEq/L -10 or less mEq/L
Need for blood products Monitor Possible Yes Massive transfusion protocol

^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.

Secondary Survey

  • Head to toe evaluation for additional injuries

Differential Diagnosis

Head trauma

Neck Trauma

Torso Trauma

Extremity trauma

Pediatric trauma

Evaluation

  • Consider FAST
  • Consider CT

Management

Complications

Disposition

  • Depends on underlying injury

See Also

External Links

References

  1. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81