Trauma Management - EMC

Dr Dane Horsfall FACEMCabrini Hospital

Summary

• EMST (Early Management of Severe Trauma)-Aust– aka ATLS(Advanced Trauma Life Support)-USA

• Systematic, stepwise approach, identify and treat injuries before progressing

• Focus on critical, life saving interventions • Cases

Trauma

• Do we see Trauma at Cabrini?• Effect of centralization of ED Trauma Care• How should we manage trauma?

Trimodal Trauma Mortality• Reduce Immediate

deaths with prevention

• Early ED Mx prevents early deaths-“Golden Hour”– ICH– Haemorrhagic shock– Haemo/Pneumothorax

• Late – sepsis/DVT/Pneumonia

EMST algorithm-Primary Survey

• A irway, Cx spine• B reathing/Ventilation • C irculation/Hemorrhage control • D isability-GCS/Pupils • E xposure of pt/check Temp

Primary Survey• A:• obstruction – safe maneuvers? –• only Jaw Thrust, • CxSpine – ?immobilise/?image• Trauma = Difficult Airway

• B:• Tension PTx • Open PTx • Flail Chest – Definition, Real problem• Massive Haemothorax

• C: • Cardiac Tamponade, • Hemorrhagic shock, External/Identified vs Occult – abdo vs pelvis • IV access – Resistance = Length/Radius4

• D – • expanding intracranial hematoma

EMST - Secondary Survey• Brief Hx• Head toe exam • Log Roll• Spring Pelvis once only• including Neuro, check ears/spine/PR• Check for minor injuries eg finger #• FAST

• Adjuncts: – “Trauma Series Xrays” Cx spine lateral/CXR/PXR– Monitoring– Bloods– ECG– IDC

• Common Language – write notes Primary/Secondary survey

Cx Spine with Airway• NEXUS

– Neurologic Deficit– Midline tenderness– Altered Conscious State– Intoxication– Distracting injury

• Canadian Cx spine rules-– 1. High risk: >65yo, mechanism (fall>3m/axial load/MVA >100km/hr/bike),

paraesthesia = image– 2. Low Risk- non tender, sitting/walking, low speed MCA = can asses rotation – 3. 45° rotation = clear

• If in doubt –immobilize• Elderly at high risk for Cx spine injuries

– Osteoporosis/osteoarthritis/spinal canal stenosis

Case 1: 80 yo F with fall

• Fall in kitchen, L forehead laceration, confused, L shoulder pain

• On warfarin for AF

• How do you manage this patient?

Primary Survey:

• A - clear, Cx spine nontender ? Collar• B - equal AE bilat O2sats 96%RA RR 16• C - HR 95 BP 140/80 no external bleeding• D - GCS 12 (M5 V4 E3) PEARL• E - T 35.5

• Management?

CT Brain

Management• Prevent Secondary Brain Injury– Maintain cerebral perfusion (MAP – ICP)• Head 30° up• Maintain Normal BP/O2sats/CO2

• NeuroSurg Ref• Reverse Warfarin (MJA 2013)

Clinical Setting Management – all w/h Warfarin

INR >1.5 + life threatening bleeding

Vit K 5-10mg, PTX 50 Units/kg, FFP 150-300mls

INR >2.0 clinically significant bleeding

Vit K 5-10mg, PTX 35-50 Units/kg

INR > 4.5 + bleeding risk high Vit K 1-2mg PO or 0.5-1mg iv

Any INR and minor bleeding risk Just W/H and recheck next day

Case 2 - 26 yo M stab to R anterior chest

• Knife insitu• Vitals T 36 HR 130 BP 100/40 RR 35 O2sats

91% RA• Approach?

Primary Survey

• A patent• Cx spine?• B – Open Pneumothorax/Haemothorax– Mx ICC at separate site, leave knife insitu

• C – – Haemorrhagic Shock Mx IV resus – iv access/rapid

infuser, urgent Cardiothoracic surgery

Patient Removes Knife…

• Sucking chest wound• Mx

Case 3 – High speed MCA

• 56 yo F front seat passenger 100km/hr head on collision, seat belt worn, airbags deployed, no cabin intrusion

• On arrival to ED T 36 HR 120 BP 90/40 RR 30 O2sats 98%RA

• Approach?

Primary Survey

• A - clear• Cx Spine - ? Collar• B – equal AE O2 sats 98%RA• C – HR 120 BP 80/40• D – GCS 15 PEARL• E – T 36

Internal Hemorrhage in Trauma

• Adult Blood Volume 5 L

• ICH : 100-300mls (Brain volume 1.2L)• Femoral Shaft # : 1-1.5L• Chest/Abdo/Pelvis : Up to entire Blood

Volume

Where is the Blood?

• Chest – CXR/ICC• Abdo – FAST/CT*• Pelvis - PXR

Back to Case 3

• A/Cx Spine/B stable• C – HR 120 to 140, BP 80/40 to 70/40• D – GCS 15 to 14, PEARL

• Management?

• Refill the tank - IV resus – crystalloid then blood

• Find and stop the bleeding

Abdo vs Pelvis

• FAST +ve• Pelvic #

Haemostasis

• Pelvic Binder• Laparotomy• Embolization

Case 4 - 18 yo M MCA

• Ejected high speed rollover Ute crash in Malvern

• Rx in field- O2, Cx collar, 1 x IVC 500mls N/Saline bolus

• On arrival in ED: T 34.8 HR 65 BP 80/30 RR 25 O2sats 92%RA

Management

• A – clear• Cx spine – Leave Collar on• B – RR 25 O2sats 90%RA – Rx O2, reduce AE L

side• C – HR 65 BP 80/30 - 2nd IVC Fluid resus, seek

hemorrhage• D – GCS 15 but unable to move legs, PEARL• E – 34 - warm

B – Deep Sulcus Sign Rx L ICC

C – Causes of shock?• HR 60 BP 70/40• Hemorrhagic• Neurogenic:• Spinal injury - loss of sympathetic outflow,

from injuries T6 or higher.– Hypotension– Bradycardia– Peripheral vasodilatation

• Spinal Shock-Not shock but a – flaccid areflexia after spinal cord injury,– lasts hours to weeks, – ‘concussion’ of spinal cord, resolves as

swelling improves

Management

• Haemorrhagic – fluid resus, stop bleeding• Neurogenic- Fluid Resus, Atropine,

Vasopressors-Noradrenaline, Inotropes-Adrenaline, address Spinal injury

Spinal Injury Mx

• PR ? Complete/incomplete• Image entire spine (10% have 2nd #)• Immobilization - ?Keep on spinal board• Treat Neurogenic Shock• A/B(Diaphragm/intercostals)C/D/E• Pressure care/IDC• Steroids – No evidence• Transfer

Case 5 – 8 yo M Bicycle accident

• Hit by car while riding his bike down Wattletree Rd• Wearing helmet, knocked off bike, MAS scoop and

run• On arrival Vitals T 36 HR 130(60-130) RR 30 (14-26)

O2sats 93% RA BP 90/50(85/45)

Primary Survey

• A - patent• Cx spine - ? Collar• B – contusions L lateral chest wall, reduced AE

L side• C - HR 130 - 150 BP 90/45 – 80/45, Abdo SNT

FAST negative, Deformed swollen R mid-thigh, • D GCS 15 PEARL• E T 36

Primary Survey Interventions

• A -patent• Cx Collar• B – O2 • C – 2 x iv attempts unsuccessful, – IO inserted IVF bolus 20ml/kg– Splinted femur #

• D/E stable

Progress

• Post initial Mx HR 180 BP 60/30, no AE L chest,

• Possible Dx?– L Tension Pneumothorax– L Haemothorax

• Intervention?– Needle decompression L

chest – hiss of air– L ICC placed

Progress

• Post insertion L ICC• HR 130 BP 95/50, but O2sats 93 – 95%• Notice L chest wall paradoxical movement

with respiration:• www.youtube.com/watch?v=mJ_FYwUqzsM• What is happening, and what do you need to

do?

Flail segment

• Causes paradoxical chest wall movement and ineffective breathing

• Worsened by underlying pulmonary contusions

• Mx Intubation/Ventilation – Positive pressure ventilation

Summary:

• EMST structure• Cx spine assessment with airway• Seek/Treat life threatening injuries in Primary

Survey – aggressive chest decompression/IVF resus

• Prompt Warfarin Reversal with hemorrhage

References

• EMST/ATLS Course Manual 8th Edition• www.mja.com.au/journal/2013/198/4/update

-consensus-guidelines-warfarin-reversal• www.lifeinthefastlane.com