Trauma (main): Difference between revisions
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====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
- Rapidly identify life-threatening injuries
- Initiate supportive therapy
- Organize definitive therapy
Locations of Possible Life-Threatening Bleeding
- External
- Internal
- Thoracic cavity
- Peritoneal cavity
- Retroperitoneal space (i.e. pelvic fracture)
- Femur fracture (into muscle/subcutaneous tissue)
Lethal Triad of Major Trauma
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
- Assess airway patency, phonation, and ability to protect airway
- 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
- 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
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
- Traumatic brain injury
- Orbital trauma
- Maxillofacial trauma
- Scalp laceration
- Skull fracture
- Pediatric head trauma
Neck Trauma
- Penetrating neck trauma
- Blunt neck trauma
- Cervical injury
- Neurogenic shock
- Spinal cord injury
Torso Trauma
Extremity trauma
Pediatric trauma
Evaluation
- Consider FAST
- Consider CT
Management
- Address dysfunctions in airway, breathing, circulation, disability
- Massive transfusion protocol
Complications
- Hypothermia
- Acidosis
- (Dilutional) coagulopathy
- Hypocalcemia
Disposition
- Depends on underlying injury
See Also
External Links
References
- ↑ American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81