initial assessment of the trauma patient

1. Initial Assessment of the Trauma Patient Sharla Owens, M.D. July 10th, 2006

2. Don�t Panic Don�t Panic

3. ATLS Guidelines Systematic approach necessary to rapidly identify injuries and stabilize the patient This approach is divided into: 1. Primary Survey 2. Resuscitative Phase 3. Secondary Survey 4. Definitive Care Phase

4. ABCDE

5. Airway Management in the Trauma Patient

6. Objectives of Airway Management & Ventilation Primary Objective: Provide unobstructed passage for air movement Ensure optimal ventilation Ensure optimal respiration

7. Objectives of Airway Management & Ventilation Why is this so important in the trauma patient? Prevention of Secondary Injury Shock & Anaerobic Metabolism Spinal Cord Injury Brain Injury

8. Airway Patency is primary Obstruction in trauma patients Tongue Swelling Foreign Body Blood and secretions

9. Airway Evaluation begins by asking the patient a question such as 'How are you?� A response given in a normal voice indicates that the airway is not in immediate jeopardy; a breathless, hoarse response or no response at all indicates that the airway may be compromised.

10. Airway Mechanical removal of debris, chin lift and/or jaw thrust maneuver, are usefull in clearing the airway in less injured patients If there is any question of an adequate airway, severe head injury, profound shock, severe facial trauma, voice changes, then definitive airway control is necessary

11. Airway & Ventilation Methods Supplemental Oxygen increased FiO2 increases available oxygen objective is to maximize hemoglobin saturation Fi - Fractional concentraion o fair - concentration of o2 in inspired airFi - Fractional concentraion o fair - concentration of o2 in inspired air

12. Airway & Ventilation Methods Airway Maneuvers Chin lift Jaw thrust (Neck extension is contraindicated) Airway Devices Oropharyngeal airway Nasopharyngeal airway BVM

13. Assessment & Recognition of Airway & Ventilatory Compromise Visual Assessment Position tripod orthopnea Rise & Fall of chest Paradoxical motion Audible gasping, stridor, or wheezes Obvious pulm edema Visual Assessment Skin color Flaring of nares Pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or depth of ventilations

14. Airway & Ventilation Methods Gastric Distention Common when ventilating without intubation pressure on diaphragm resistance to BVM ventilation avoid by increasing time of BVM ventilation

15. Airway & Ventilation Methods Orotracheal Intubation- preferred in almost all situations Indications present or impending respiratory failure apnea unable to protect own airway (GCS <8) Advantages secures airway route for a few medications optimizes ventilation and oxygenation

16. Airway & Ventilation Methods Nasotracheal Intubation- rarely if ever used in the initial management of the injured patient. Many drawbacks Goal of safe endotracheal intubation with cervical spine precautions can be better accomplished with orotracheal intubation

17. Airway & Ventilation Methods Surgical Cricothyrotomy Indications absolute need for a definitive airway AND unable to perform ETT due for structural or anatomic reasons, AND risk of not intubating is > than surgical airway risk OR absolute need for a definitive airway AND unable to clear an upper airway obstruction, AND multiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for effective ventilation and respiration

18. Airway & Ventilation Methods: ALS Surgical Cricothyrotomy Contraindications (relative) Age < 8 years (some say 10) evidence of fx larynx or cricoid cartilage evidence of tracheal transection

19. Airway & Ventilation Methods Needle Cricothyrotomy & Transtracheal Jet Ventilation Indications Same as surgical cricothyrotomy along with Contraindication for surgical cricothyrotomy Contraindications caution with tracheal transection

20. Airway & Ventilation Methods: Jet Ventilation Usually requires high-pressure equipment Ventilate 1 sec then allow 3-5 sec pause Hypercarbia likely Temporary: 20-30 mins High risk for barotrauma

21. Airway & Ventilation Methods Pharmacologic Assisted Intubation (�RSI�) Sedation Used for induction anxious or agitated patient Contraindications hypersensitivity hypotension (e.g. hypovolemia 2� to trauma)

22. Airway & Ventilation Methods Pharmacologic Assisted Intubation (�RSI�) Neuromuscular Blockade Induces temporary skeletal muscle paralysis Indications When Intubation is required in a patient who is awake, has a gag reflex, or is agitated or combative

23. Airway & Ventilation Methods Pharmacologic Assisted Intubation (�RSI�) Neuromuscular Blockade Contraindications Most are specific to the medication inability to ventilate patient once paralysis is induced Advantages reduces risk of laryngospasm

24. Airway & Ventilation Methods Pharmacologic Assisted Intubation (�RSI�) Disadvantages & Potential Complications Does not provide sedation or amnesia Provider unable to intubate or ventilate after NMB Aspiration during procedure Difficult to detect motor seizure activity Side effects and adverse effects of specific meds

25. Tension Pneumothorax

26. Recognizing Life Threatening Emergenies Aka, �When to pee in your pants in the trauma bay�

27. Tension Pneumothorax Signs and Symptoms severe respiratory distress ? or absent lung sounds (unilateral usually) ? resistance to manual ventilation Cardiovascular collapse (shock) asymmetric chest expansion anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late)

28. Great Vessel Injury

29. Aortic Transection Signs: - widened mediastinum, 1st rib fx, apical capping, left hemothorax, tracheal deviation to right - widening from bridging veins and arteries, not aorta itself - need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears at ligamentum - 90% of patients die at the scene

30. Cardiac Tamponade

31. Cardiac Tamponade Beck�s triad: - hypotenstion, jugular venous distention, and muffled heart sounds - causes decreased diastolic ventricular filling and resultant hypotension - echocardiogram shows impaired diastolic filling of right atrium initially (1st sign)

32. Traumatic Brain Injury Epidural Hematoma SA Hemorrhage

33. TBI: High index of suscpicion in any patient with history of or identifiable evidence of altered level of consciousness Best determined by GCS (a decrease of even 1-2 points is indicative of significant change in neurological status) Pupillary function Lateralizing signs

34. Solid Organ Injury Splenic Laceration Liver Laceration

35. Solid Organ Injury 25% of all trauma victims require an abdominal exploration Blunt trauma caused by MVCs, MCCs, falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of injury High index of suspicion in those patients with c/o abdominal pain, and/or objective findings on exam (seatbelt sign)

36. Hemorrhage Pelvic fracture

37. Pelvic Trauma Pelvic fx are the prototype of severe trauma, with an usually high incidence of associated injuries Awake pts c/o excessive pain and may have evidence of abnormal positioning of lower extremities, or unstable pelvis on exam Can be a major source of blood loss that is either arterial, venous, or osseous in origin