Trauma Initial Assessment and Management Airway and ... Trauma.pdf · Trauma in Women Transfer to Definitive Care ... trauma with burns Consider trauma centre for ... Multiple casualties

Trauma

Initial Assessment and Management

Airway and Ventilatory Management

Shock

Thoracic Trauma

Abdominal Trauma

Head Trauma

Spine and Spinal Cord Trauma

Musculoskeletal Trauma

Injures Due To Burns And Cold

Paediatric Trauma

Trauma in Women

Transfer to Definitive Care

Trauma & Resuscitation 3.J.1.1 James Mitchell (December 24, 2003)

Initial Assessment and Management

PreparationPre-hospital

Minimize scene timePriorities

Airway maintenanceControl external bleeding and shockImmobilizationImmediate transport to the closest appropriate facilityObtain information for hand over

Criteria for transfer to trauma centreGCS <14, RR <10 or >29, systolic <90 mmHg, RTS <11, PTS <9Flail chest, >2 proximal long bone fractures, amputation proximal to wrist or ankle, penetrating trauma proximal to elbow or knee, limb paralysis, pelvic fracture, trauma with burns

Consider trauma centre forEjection from car, death in same compartment, pedestrian thrown or run over, high speed crash, extrication time >20 min, fall >6 m, roll over, pedestrian struck at >8 km/h, motorcycle crash at >32 km/h or with separation of bike and riderAge <5 or >55, pregnancy, immunosuppression, cardiac or respiratory disease, diabetes, cirrhosis, morbid obesity, coagulopathy

In hospitalResuscitation area

Airway equipment, warm IV solutions, monitoringMeans to summon medical help, means to summon diagnostic servicesTransfer agreement with trauma centreUniversal precautions to be observed

TriageRevised Trauma Score

Respiratory rate>29 4

10-29 36-9 21-5 10 0

Systolic BP>89 4

76-89 350-75 21-49 1

0 0GCS

13-15 49-12 36-8 24-5 1<4 0


Paediatric Trauma ScoreWeight

<20 kg 210-20 kg 1<10 kg -1

AirwayNormal 2

O2 1Intubated -1

Systolic BP>90 2

50-90 1<50 -1

ConsciousnessAwake 2

Any LOC 1Coma -1

FractureNone 2

Single closed 1More / open -1

SkinIntact 2

Lac. <7 cm 1More -1

Score >8 should have zero mortality.Priorities

Multiple casualties are treated in order of severity.Mass casualties (exceeding capacity of available facilities) are treated in order of probability of survival with least expenditure of resources.

Primary SurveyExamination and management take place simultaneously

Airway maintenance with cervical spine protectionAssess patency of the airway: fractures, foreign bodiesEstablish a patent airwayDefinitive airway is usually required if GCS ≤ 8Cervical spine must be immobilized in any multi-system traumaDeterioration of conscious state may demand reassessment of airway

Breathing and ventilationRequires function of lungs, chest wall and diaphragmExamine the chest for acute causes of impaired ventilation

Tension pneumothorax, open pneumothorax, flail chest with pulmonary contusion, massive haemothorax

Intubation may worsen pneumothoraxChest x-ray is required as soon after intubation as practical


Circulation and haemorrhage controlHaemorrhage is the commonest cause of post-injury death treatable in hospitalVolume status is assessed by conscious state, skin colour and pulse rate and strengthHypotension is caused by hypovolaemia until proved otherwiseBleeding is controlled by local pressureOccult haemorrhage occurs into the chest or abdomen, retroperitoneum following pelvic fracture or soft tissues following long bone fractureBlood pressure is not a good indicator of volume status

Disability (neurologic evaluation)Rapid assessment of GCS or AVPU statusImpaired consciousness after correction of hypoxia and hypovolaemia is usually due to CNS traumaDrugs may confuse examination findingsFrequent reassessment is required

Exposure and environmental controlComplete exposure is required for examinationPrevention of hypothermia is required, using warming blankets, warmed IV fluids and early control of haemorrhage

ResuscitationAirway

Definitive airway if there is doubt about the patient’s ability to maintain an airwayApplication of a hard collar for cervical spine immobilization

Breathing and ventilationAll patients should receive supplemental oxygen

CirculationTwo large IVs should be insertedBlood taken for crossmatch, baseline bloods and pregnancy testIV fluid administration, initially warmed Hartmann’s 2-3 lHypovolaemic shock is treated with operative intervention to stop bleeding and continued fluid resuscitation, not pressors, steroids or bicarbonate

Adjuncts to primary survey and resuscitationECG monitoring

Signs of cardiac injury, pulseless electrical activity, hypoxia or hypoperfusion

Urinary and gastric cathetersUrine output provides an indication of volume statusCatheter should not be inserted if the urethra might be injured

Blood at meatus, perineal ecchymoses, blood in scrotum, high riding prostate, pelvic fracture

Gastric catheter reduces the risk of regurgitation and aspiration, but does not eliminate itNasogastric insertion is contraindicated if the cribriform plate might be disrupted

Other monitoringVentilatory rate and ABGsCO2 confirmation of ETT placementPulse oximetryBlood pressure


Diagnostic studiesCXR and pelvis x-ray can guide resuscitation but must not cause delayLateral cervical spine x-ray is useful if it shows an injuryFurther tests during secondary survey

Consider need for transferHowever life saving interventions should start at the time the problem is identified

Secondary surveyBegins when resuscitation is underway and vital signs are normalizingHistory

Allergies, medications, past illnesses or pregnancy, last meal, events related to the injury (mnemonic: AMPLE)

Physical examinationHead

Complete examination for soft tissue or bony injuryEye examination for acuity, pupils, hyphaema, penetrating injury, contact lenses, lens dislocation, muscle entrapmentFacial bones for fractures

Cervical spine and neckHead or face injury implies cervical spine injury until it is excludedPenetrating injuries should be explored in theatreCervical spine injury should be excluded as soon as convenient and hard collar removed

ChestInspection and palpation of the entire thoraxAuscultation for heart sounds and breath soundsBony or soft tissue injury makes visceral injury likelyChildren have a more compliant chest wall which may hide deeper injuries

AbdomenSpecific diagnosis is not as important as recognizing that an injury existsRepeat examination for changing signs may be necessaryIf injury is suspected

Ultrasound or lavageCT if stable

PerineumInspection, PR, PV, urinary catheter

MusculoskeletalLimbs must be inspected and palpatedPelvis integrity should be assessedThe back must be examinedSoft tissue injury may be difficult to detect in an unconscious patient

NeurologicalAssess conscious state (and reassess)Examine for peripheral signs of nerve or cord injuryPrevent abrupt rises in ICP in head-injured patients


Specialized diagnostic tests (as indicated)X-rays

CXR, pelvis, cervical spine, thoracolumbar spine, sites of injuryCT

Head (±MRI), chest, abdomen, spineContrast studies

Urography, angiographyUltrasound

Abdomen, gynaecological, transoesophagealEndoscopy

Bronchoscopy, gastroscopyTests requiring transport demand a stable patient

ReevaluationContinuous monitoring of vital signs

ECG, BP, SpO2, conscious state, urinary output, ABG, ETCO2

AnalgesiaDefinitive care

Surgical interventionTransfer to an appropriate facility

DocumentationEssential for continuity of medical care and evidence in case of medicolegal problemsA dedicated record-taker is needed in the resuscitation settingConsent should be obtained before procedures if possibleIf criminal involvement is likely, evidence must be preserved


Airway and Ventilatory Management

AirwayProblems

Maxillofacial trauma, neck trauma, laryngeal traumaSigns

Talking patient: airway is patent and not compromisedAgitation, obtundation, cyanosis, rib retraction, accessory muscle useNoisy breathing, stridor, hoarseness, confusion (hypoxia)Palpable larynx and trachea

VentilationProblems

Airway patency, chest and lung integrity, innervation, CNS functionSigns

Chest movementBreath soundsOximetry

ManagementAll require protection of cervical spine if injury is suspectedAirway maintenance

Chin lift, jaw thrust, Guedel airway, nasopharyngeal airwayDefinitive airway

“A tube present in the trachea with the cuff inflated, the tube connected to some form of oxygen-enriched assisted ventilation, and the airway secured in place with tape.”Orotracheal, nasotracheal, surgical optionsIndications

Apnoea, inability to maintain a patent airway, protection from aspiration, impending or potential airway compromise, closed head injury (GCS ≤8), inadequate oxygenation with face mask ventilation

IntubationMethod depends on practitioner’s experience, usually orotrachealCervical immobilization, preoxygenation, cricoid pressure, drugs (if required), laryngoscopy, ETT placement, auscultation, CO2 analysis, CXRNasotracheal intubation is only used in spontaneously breathing patientInduction agents typically suxamethonium and benzo.

Surgical AirwayNeedle cricothyroidotomy

12g or 14g cannula inserted through cricothyroid membraneIntermittent jet O2 insufflation (1 s on 4 s off)Contraindicated in glottic obstruction (→ barotrauma)Provides 30-45 minutes oxygenation (limited by PCO2)

Surgical cricothyroidotomyPalpate thyroid notch and sternal notch, find cricothyroidLocal anaesthetic if required, prepare skinStabilize trachea with one hand, transverse incision through skin and cricothyroid membraneInsert scalpel handle or artery and dilate openingInsert cuffed tube (5-6 mm), inflate cuff and check ventilationSecure tube


OxygenationAll patients require supplemental oxygenOximetry should be used where available

unreliable with poor peripheral perfusion, anaemia, abnormal HbVentilation

Bag-valve-mask is best performed with two operatorsVentilation is required during prolonged attempts at intubationPressure-limited ventilation is required post-intubation


Shock

AssessmentSigns

Peripheral vasoconstriction, tachycardia, narrowed pulse pressureHypotension is a late sign (>30% volume loss)Haemoglobin is not a measure of volume status

CausesHaemorrhagic

Present in most patients with multiple injuries, responds to fillingNon-haemorrhagic

Cardiogenic, tension pneumothorax, neurogenic, septicHaemorrhagic shock

Haemorrhage is the acute loss of circulating blood volumeNormal blood volume is 70 ml/kg in adults (80-90 ml/kg in children)Classification

Class ILoss up to 15% of blood volumeUsually fully compensatedRecovers by transcapillary refill within 24 hours

Class II15%-30% blood volume lostTachycardia, tachypnoea, reduced pulse pressure, anxietyUrine output 20-30 ml/hResponsive to crystalloid filling

Class III30%-40% blood volume lostMarked tachycardia, tachypnoea, hypotension, mental changesUrine output low 5-15 ml/hWill require transfusion

Class IVMore than 40% blood volume lostImmediately life-threateningMinimal urine outputRequires immediate transfusion and usually surgery

Soft-tissue haematoma may consume litres of blood.Management

ExaminationABCDEGastric decompressionUrinary catheter insertion

Vascular accessLarge peripheral IVs initially (16g or 14g short)Cut-down if required depending on level of experienceIntraosseous infusion if under 6 years and no other accessCVC insertion is not the best choice for rapid infusionBlood taken for crossmatch, investigations including ßhCG, ABG

Initial fluid therapy20 ml/kg Hartmann’s as a bolusFurther therapy guided by response to initial bolus and on-going lossesResponse

Urine output, conscious state, peripheral perfusion, CVP


Evaluation of resuscitationNormalization or improvement of HR, BP and pulse pressureUrine output >0.5 ml/kg/h (1 ml/kg/h in children, 2 ml/kg/h in infants)CVP or PAOP or CO (if PA catheter inserted)ABG

Initial respiratory alkalosis followed by metabolic acidosisPersistent metabolic acidosis if peripheral perfusion is inadequate

Response to initial therapyRapid response

Haemodynamic normalization with bolus fluidTransient response

Deterioration following initial response to bolus fluid indicates inadequate resuscitation or ongoing lossesLikely requirement for transfusion and surgery

Minimal or no responseLikely exsanguinating haemorrhage requiring surgery, orNon-haemorrhagic cause for shockDifferentiate using CVP or echocardiography

Choice of fluidBlood

Usually packed cellsUsed to replace oxygen carrying capacityNot the first choice for volume replacementType-specific or O negative can be used in extreme urgencyComponent therapy for coagulopathy as indicated by pathology tests

CrystalloidsHartmann’s or normal salineHeated to 39˚C

Special considerationsUse of vasopressors is contraindicated in haemorrhagic shock

↑ SVR, ↓ CO → “death spiral”Elderly have reduced physiological reserveTachycardia may be a poor sign if on ß-blockers or pacemaker or in athletesHypothermia may prevent a response to fluidAlways suspect ongoing haemorrhage if response is poorUnder-resuscitation is far more common than fluid overloadCVP can guide fluid therapy


Thoracic Trauma

Primary SurveyAirway

Assess air movement at nose and mouth, inspect oropharynx, observe for intercostal retractionLaryngeal injury or posterior dislocation of sternoclavicular joint can obstruct the airway

BreathingExpose chest, observe, palpate and auscultateTension pneumothorax

Decompress with large Jelco in second intercostal space in midclavicular line followed by chest tube in the fifth intercostal space between the midaxillary and anterior axillary lines

Open pneumothoraxFlap-valve dressing, surgical closure and chest tube

Flail chestUnderlying pulmonary contusion is usually the major concernAdminister oxygen, limit IV fluids unless shock is present, analgesiaMay require intubation and ventilation

CirculationAssess pulse, blood pressure, JVPMonitor ECG and SpO2

Massive haemothoraxRapid accumulation of more than 1500 ml in the chest cavity, usually manifest as shock with absent breath sounds and dullness on one side of the chestRapid IV fluid administration, decompression with a chest tube, thoracotomy likely if >1500 ml or >200 ml/h evacuated or persistent transfusion requirement or penetrating injury medial to nipple or scapula

Cardiac tamponade15-20 ml in pericardial space is enough to cause haemodynamic compromiseDifficult to diagnose acutely, echocardiography may helpIV fluid may produce transient improvementPericardiocentesis may be performed without definitive diagnosisOpen pericardiotomy may be required to evacuate clot and inspect the heart

Resuscitative thoracotomyMay be helpful in penetrating chest injury with pulseless electrical activityOnly performed by an appropriate surgeon

Secondary surveyFurther examination

Upright CXR, ABG, SpO2, ECGSimple pneumothorax

Decreased breath sounds, resonant percussionChest tube inserted in fifth intercostal space, underwater seal drain, CXR to confirm lung re-expansion all required before IPPV or air transport


HaemothoraxUsually due to laceration of intercostal or internal thoracic arteries, bleeding is usually self-limitingChest tube allows drainage of blood and monitoring ongoing lossThoracotomy for severe bleeding

Pulmonary contusionMost common potentially lethal chest injury, gradual respiratory failurePaO2 >65 mmHg or SpO2 <90% demands intubation and ventilationRepeated assessment of ABG, ECG and SpO2

Tracheobroncheal tree injuriesMost injuries are within 2.5 cm of the carina and cause death at the sceneHaemoptysis, subcutaneous emphysema or tension pneumothoraxLarge air leak after chest tube insertion, two chest tubes may be requiredDiagnosis confirmed at bronchoscopy, may require double lumen tube, may require urgent surgical repair

Blunt cardiac injuryPain, hypotension with ↑ CVP, wall motion abnormality, conduction abnormalities (PVCs, ST, AF, RBBB, ST∆)Treatment of arrhythmia as indicated, ECG monitoring

Traumatic aortic disruptionCommon cause of death after severe deceleration injurySurvivors to hospital have contained haematomaSigns on CXR: widened mediastinum, obliterated aortic knob, tracheal deviation to right, no space between aorta and PA, depressed left main bronchus, deviation of oesophagus to right, widened paratracheal stripe, widened paraspinal interfaces, apical cap, left haemothorax, fractures of first or second rib or scapulaDiagnosed at angiography or TOE

Traumatic diaphragmatic injuryCommonly missed, may be diagnosed on CXR with NGT or contrast, or by drainage from chest tube of DPL fluid, or at thoracoscopy or laparotomyTreated by direct repair

Mediastinal traversing woundsPenetrating injury crossing from one hemithorax to the other or with metallic fragment lodged in the mediastinum50% unstable, 20% mortalityEarly surgical consultationInjury to great vessels, tracheobronchial tree, oesophagus, heart, spinal cord and lung must be consideredChest tubes may be required bilaterally, early operation if unstableStable patients require angiography, contrast swallow, gastroscopy, bronchoscopy, CT or echocardiography

Associated problemsSubcutaneous emphysemaCrush injuryRib, sternum and scapula fractures

Ribs 1-3 protected by upper limb; fracture suggests great vessel injuryRibs 4-9 most commonly injured, require greater force in the youngRibs 10-12 fracture suggest hepatic or splenic injuryAnalgesia is required for good ventilation


Blunt oesophageal ruptureDue to forced expulsion of gastric contents with oesophageal tearing or instrumentationMay present as left pneumothorax without rib fracture, particulate matter in chest tubeRequired operative repair to prevent mediastinitis and sepsis

CXR examinationConfirm ID of filmTrachea and bronchi

Interstitial or pleural air, pneumomediastinum, pneumothorax, subcutaneous or interstitial emphysema, pneumoperitoneum

Pleural space and lung parenchymaLung infiltrate, consolidation or haemothorax

MediastinumAltered cardiac silhouette, signs of aortic rupture (above)

DiaphragmElevation, disruption, obscured, mass above or air below

Bony thoraxClavicle, scapula, ribs, sternum fractures or dislocation

Soft tissuesTubes and lines


Abdominal Trauma

AssessmentHistory

Mechanism of injury: e.g. vehicle crash, speed, direction, position in car etc. or weapon and range in penetrating traumaLocation of pain and referral of pain

ExaminationInspection

Including posterior abdomen and chest and perineumAuscultation, percussionPalpation

Guarding, pregnancyEvaluation and local exploration of penetrating wounds

Dependent on surgical experience25%-33% of anterior stab wounds do not penetrate peritoneum

Assess pelvic stabilityPerineal, penile/vaginal and rectal examination

Signs of pelvic fracture or urethral injuryGluteal examination

IntubationInsertion of NGT, urethral catheter (if no indication of injury)

Blood and urine samplingImaging

Screening x-rays: cervical spine, CXR, pelvisSupine and erect AXR (lateral decubitus if can’t be sat up)Contrast studies

Urethrography, cystography if injury suspectedIVP only if contrast CT unavailableGI contrast studies if injury suspected and patient stable

Special investigationDiagnostic peritoneal lavage

98% sensitive for intraperitoneal bleedingIndications

Haemodynamically abnormal, multiple blunt injuriesAltered conscious stateSpinal cord injuryEquivocal abdominal examinationProlonged “loss of contact” with abdomen expected (e.g. CT)CT or US not available

Relative contraindicationsPrevious surgery, morbid obesity, cirrhosis, coagulopathy

Lavage catheter inserted and aspiratedIf no aspirate, 1000 ml Hartmann’s used for lavagePositive if ≥100,000 RBC/mm3, ≥500 WBC/mm3 or gram stain +ve

UltrasoundAs good as DPL or CT in experienced handsGives views of pericardium, hepatorenal fossa, splenorenal fossa, pelvisRepeat scan at 30 minutes to detect slow bleeding

Computed tomographyTime-consuming, only for stable patientsMost specific test for injuryWill miss some diaphragmatic, bowel and pancreas injuries


Special investigation in penetrating traumaLower chest wounds

Serial examination and imaging, laparoscopy, thoracoscopyAnterior abdominal stab wounds

Serial examination or DPL help to detect asymptomatic penetration of peritoneum

Back or flank stab woundsSerial examination or contrast CT or DPL plus follow up beyond 24 hours if asymptomatic

Indications for laparotomyBlunt trauma with

Positive DPL or ultrasoundHypotension despite resuscitation

PeritonitisPenetrating trauma with

HypotensionBleeding from GI or urogenital tractGunshot wounds

EviscerationAXR with free air, diaphragmatic defect or retroperitoneal airCT with ruptured viscus, injury to bladder, renal pedicle or other viscus

Pelvic fracturesClassification

Anteroposterior compression injuryCommonly sacral fracture or dislocationHaemorrhage from posterior venous or internal iliac vessels

Lateral compression injuryPubis commonly injures bladder or urethraHaemorrhage less common

High energy shear force injuryDisrupts sacrospinous and sacrotuberous ligamentsMajor instability

AssessmentInspection for bruising, lacerations, urethral injury, PRManual test of mechanical stabilityX-ray

ManagementExsanguination

ABCDE, PASG, operate if open or DPL positive, post-op fixationAngiography if unstable and DPL negative

Stable following resuscitation and unstable fractureABCDE, PASG, operate if DPL positive, post-op fixation, angiography if still unstable

Normal BPABCDE, PASG if hypotension develops, treat other injuries, fix

DPL techniqueUrinary catheter, NGTPrep, local below umbilicusVertical incision to fascia, peritoneal incision (alternatively Seldinger tech.)Insert catheter, advance into pelvisAspirate, irrigate, agitate, drain after 5-10 minSend sample for RBC, WBC counts and gram stain


Head Trauma

ClassificationMechanism: blunt or penetrating (dura)Severity: by GCS: severe 3-8, moderate 9-13, mild 14-15Morphology

Usually determined at CT scanSkull fractures

Vault: linear or stellate, open or closed, depressed or notBasilar: with or without CSF leak, VII nerve palsy

Intracranial lesionsFocal

Extradural haematoma9% of comatose head injuriesLenticular lesion, usually arterial

Subdural haematoma30% of severe head injuriesCover entire hemisphere, usually venous

Intracerebral haematoma or contusionsUsually frontal and temporal and associated with subdural

Diffuse “concussion”Mild, classical and diffuse axonal injury

ManagementMild

80% of head-injury presentationsAll require CT scan if any LOC, amnesia or headacheSkull x-rays only for penetrating injuryUsual cervical spine x-rays, blood tests etc.Avoid narcotics12 hours of observation (can be at home) even if normal CTDischarged only if asymptomatic, uninjured, living nearby and in the company of a responsible adult

Moderate10% of head-injury presentations

10 - 20% will deteriorateHistoryExaminationInvestigations

CT head (40% abnormal), baseline bloodsSurgery if indicated (8% on CT scan)Admission for observation

Repeated examination and CT if any deterioration


Severe10% of head-injury presentationsABCDE

Hypotension and hypoxia are associated with 75% mortalityRequire rapid resuscitation

Early intubation, moderate hyperventilation (PCO2 25-35 mmHg)Maintenance of cerebral perfusion pressureManagement of other injuries as indicatedPriority of CT versus DPL/US depends on response to fluid resuscitation: poor response → DPL/US first

High incidence of other injuriesLong bone or pelvic fracture 32%Mandible or maxillary fracture 22%Major chest injury 23%Thus detailed secondary survey

Neurologic examinationGCS and pupils at least prior to relaxationSerial examinations over time, recording best responses on each side

Diagnostic proceduresEmergency CT scan unless precluded by instabilityLooking for lesions and midline shift

Medical management of head injury36% mortality for severe head injuryIV fluids: maintain euvolaemia with saline or Hartmann’s (not glucose)Maintain perfusion pressure ≥70 mmHgModerate hyperventilation: PCO2 25-35 mmHgMannitol for oedema if normotensiveFrusemide and anticonvulsants with surgical consultationSteroids and barbiturates probably not beneficial

Surgical managementScalp laceration without underlying fracture

Closed after shaving and irrigationDepressed fracture

Elevated surgically if depressed more than the skull thicknessMass lesions

Transfer to neurosurgical unitEmergency burr holes by a non-specialist are rarely justified


Spine and Spinal Cord Trauma

Epidemiology450 spinal injuries per year in Australia, 2% mortalityLevel of injury

C4-7 48%T3-6 13%T10-12 18%other 21%

Classification of injuryLevel

The most caudal segment with normal sensory and motor functionDermatomesMyotomes

C5 deltoidC6 wrist extensionC7 elbow extensionC8 middle finger flexionT1 finger abductionL2 Hip flexionL3 Knee extensionL4 Ankle dorsiflexionL5 Toe extensionS1 Ankle plantar flexion

Differs from bony level of injurySeverity

Complete, incompleteCord syndromes

Central cordAnterior spinal artery compromiseUsually cervical extension injuryUpper limb weakness > lower limb

Anterior cordAnterior spinal artery infarctionPain and temperature sensation loss, paraplegiaIntact vibration, proprioception

Brown-SequardCord hemisectionIpsilateral motor and vibration/proprioception lossContralateral pain and temperature loss two segments lower

MorphologyFracture, fracture dislocation, SCIWORA, penetrating injuryStable or unstable (all assumed to be unstable)

X-ray evaluationCervical spine

Must see BOS to T1May require lateral and swimmer’s views: 85% sensitivity for fracturesAddition of AP and open-mouth views: 92% sensitivityAddition of oblique views: slight ↑ in sensitivityCT scan if unable to see low vertebrae or injury suspected10% of cervical spine fractures have a second vertebral fractureTo detect spinal cord compression: MRI or CT myelography

Thoracic and lumbar spineAP views routineLateral or CT if injury suspected


ManagementRules for cervical spine

Paraplegia or quadriplegia suggests cervical instability.Alert, normal and pain-free patients can be cleared if full-range voluntary movement is pain-free.Alert, normal patients in pain need lateral, AP and open-mouth films. If a flexion lateral film is also of good quality and clear there is no need for CT.Unconscious or confused or uncommunicative patients require AP, lateral and, if possible, open-mouth films before assessment by a surgeon before being cleared.If there is doubt, the collar should be left on.Neurosurgical or orthopaedic referral is required for all suspected injuries.Paralyzed patients should be removed from a backboard as soon as practicable.Never force the neck.If operation is required prior to clearing the neck, the collar should be left on.Assess the cervical spine x-rays for

Bony deformityFracture of the vertebral body or processesLoss of alignmentIncreased distance between spinous processesNarrowing of the canalIncreased prevertebral soft-tissue shadow

ImmobilizationA semirigid collar does not ensure immobilization.A collar, backboard, tape and straps should be applied before definitive transfer.Sedation, paralysis and intubation may be required to maintain immobilization.Two-handed technique for cricoid may reduce cervical spine movement

SteroidsNot used in Australia for spinal cord injury


Musculoskeletal Trauma

Primary surveyOccur in 85% of trauma patientsMajor importance in primary survey is haemorrhage

Control with local pressureFracture immobilization

Aim to reduce fracture, minimize pain and bleedingNot more important than ABCDE

X-raysObtained when convenientAP pelvis is indicated early in multi-trauma

Secondary surveyHistory

Detail of mechanism of injury: time, force…Environment: temperature, poison, fragments, contaminationPreinjury status: AMPLE…Prehospital observations

Physical examinationComplete exposureDetection of life-threatening, limb-threatening and other injuriesSystematic examination: skin, neuromuscular, circulation, skeletal and ligamentous

Look, feel, pulses/circulation, x-rayPotentially life-threatening extremity injuries

Major pelvic disruption with haemorrhageFalls, motorcycle or pedestrian accidents are associated with ring-opening injuries: sacroiliac disruption and major haemorrhageMotorcar accidents are associated with lateral force injuries with genitourinary injury and less incidence of haemorrhageSigns

Progressive swelling or bruisingFailure to respond to fluid resuscitationSigns of urethral injuryMechanical instabilityX-ray findings

ManagementHaemorrhage control with immobilization ± PASGRapid fluid resuscitationEarly surgical consultation

Major arterial haemorrhagePenetrating or blunt injury with fracture or dislocationSigns of ischaemia or haematomaManagement

Direct pressureFluid resuscitationSurgical consultation

Crush syndromeProlonged crush injury to muscle causes rhabdomyolysisSigns: dark urine, hypovolaemia, acidosis, hyperkalaemia, hypocalcaemia, DICManagement fluid loading, osmotic diuresis, urinary alkalinization


Limb-threatening injuriesOpen fractures and joint injuries

Communication between external environment and boneManagement sterile dressing, examination of soft-tissue, circulatory and neurological involvement, surgical consultationTetanus prophylaxis

Vascular injuries, traumatic amputationSuggested by circulatory insufficiency associated with limb traumaMay result from circumferential dressings or castsUrgent surgical revascularizationReplantation is indicated only in isolated limb injuries, not in patients requiring intensive resuscitation

Amputated part is washed in Hartmann’s, wrapped in penicillin-soaked gauze and transported on crushed ice

Compartment syndromeCaused by injury within a closed fascial space or external compressionCompartment pressure exceeds perfusion pressureHigh risk: tibial and forearm fractures, tight dressings or casts, severe crush injuries, interstitial oedema due to reperfusion, increased capillary permeability or exerciseSigns

Unexpectedly severe pain, worse with stretchingDysfunction of nerves in the compartmentTense swellingWeakness and loss of pulses are late signsCompartment pressure >35-45 mmHg

ManagementRemoval of dressings or castsFasciotomy if no improvement over 30-60 min.

Neurologic injury secondary to fracture dislocationAssessment of nerve function requires a cooperative patientDocumentation of progression of disability and repeat examination is important, especially after reduction manoeuvres (table below)

Other extremity injuriesContusions and lacerations

Examine for associated injurySuperficial injury from crushing or degloving may be minorTetanus risk increased: >6 h old, abraded, >1 cm deep, due to burn, cold or missile, contaminated

Joint injuriesMay not be associated with fracturesHyperextension or hyperflexion soft tissue injuryExamine for associated nerve or vessel damageImmobilize

FracturesUsually associated with soft tissue injuryClinical examination to make diagnosis, accompanied by x-rays in two planesJoint above the injury must also be x-rayedExamine for associated nerve or vessel injuryImmobilize


Nerve Motor Sensation InjuryUlnar Index finger

abductionLittle finger Elbow injury

Median (distal) Thenar opposition Index finger Wrist dislocation

Median (anterior interosseous)

Index tip flexion Supracondylar fracture of humerus

Musculocutaneous Elbow flexion Lateral forearm Anterior shoulder dislocation

Radial Thumb, finger MCP extension

1st dorsal web space Distal humeral shaft, anterior shoulder dislocation

Axillary Deltoid Lateral shoulder Anterior shoulder dislocation, proximal humerus fracture

Femoral Knee extension Anterior knee Pubic rami fractures

Obturator Hip adduction Medial thigh Obturator ring fractures

Posterior tibial Toe flexion Sole of foot Knee dislocationSuperficial peroneal Ankle eversion Lateral dorsum of foot Fibular neck fracture,

knee dislocation

Deep peroneal Ankle/toe dorsiflexion Dorsal 1st to 2nd web space

Fibular neck fracture, compartment syndrome

Sciatic Plantar flexion Foot Posterior hip dislocation

Superior gluteal Hip adduction Acetabular fracture

Inferior gluteal Gluteus maximus hip extension

Acetabular fracture

Physical ExaminationLook

Age, sexWounds, deformity, positionColour of extremitiesSpontaneous activity: evidence of pain or paraplegiaUrine colour

FeelPalpate pelvis for instabilityPeripheral pulses and capillary refillMuscle compartment palpationJoint stabilityNeurological examination: sensory and motor


Injures Due To Burns And Cold

Immediate managementABCDEAirway

Immediate intubation if inhalational injury likelyFacial burns, eyebrows or nasal hair singed, acute inflammation or carbon deposits in mouth, carbonaceous sputum, history of confinement in burning environment, explosion with burns to head or torso, COHb > 10%

Stop the burning processRemove all clothing, chemical residueRinse with water

Intravenous accessRequired if burns > 20% of BSALarge bore, upper limb preferable, unburned area preferable

AssessmentHistory

AMPLE history, tetanus statusExamination

Area burned“Rule of nines” for adults, modified for children

Adult: head, arm, half of leg, quarter of torso = 9%Infant: head = 18%, half of leg = 7%Palm excluding fingers = 1%

Depth of burnFirst degree

Erythema, pain, no blisters e.g. sunburnSecond degree, partial thickness

Red or mottled, blisters, weeping, hypersensitiveThird degree, full thickness

Dark and leathery, painless, dry“Major” burns

>10% full thickness or >25% partial or inhalational injuryStabilization

AirwayEarly intubation if any suggestion of inhalational injury

BreathingInjury mechanisms

Thermal injuryUpper airway oedema, obstruction

Inhalation of smoke and toxinsTracheobronchitis, oedema, pneumonia

CO poisoning< 20% COHb asymptomatic20-30% headache and nausea30-40% confusion40-60% coma> 60% deathTreat with high FiO2 (hyperbaric if pregnant)

CirculationIV access and IDC required for managementAim for urine output 1 ml/kg/h in children, 30-50 ml/h in adultsInitial fluids

Hartmann’s 2-4 ml/kg/%burn over 24 hTrauma & Resuscitation 3.J.1.23 James Mitchell (December 24, 2003)

Half given in 8 hours, half in next 16Plus acute losses and fasting requirementsAdjust according to urine output, vital signs

ExaminationDocument extent and depth of burnsAssess for associated injuriesWeigh patient

InvestigationsFBE, XM, ABG (COHb), glucose, U&E, ßhCG if indicated

Adjuncts to initial managementAssessment of limbs with circumferential injury for circulatory compromise, escharotomy if necessaryNGT insertion for gastric stasis and nausea initially

Later may be required for hyperalimentationAnalgesia with IV narcotic or ketamine

Small graduated doses, as circulation is centralized in shockMay worsen hypotension, hypoxia if not adequately resuscitated

Dress burns with clean linenPrevent hypothermia

Special burnsChemical injury

Alkali, acid or petrochemical burnsAlkali burns are generally the most seriousRemove all traces of chemical and irrigateBurns to the eye may require continuous irrigation

Electrical burnsFrequently small entry and exit burns with extensive deep tissue injury underlyingRhabdomyolysis commonManage the same except

High index of suspicion of rhabdomyolysis, cardiac injuryECG monitor, urine colour observationOsmotic diuresis ± alkalinization of urine


Paediatric Trauma


Trauma in Women

Alterations in pregnancyUterus

Intrapelvic until week 12, thick-walled, embryo well cushionedAt umbilicus by week 20At costal margin at week 34-36, thin-walled, vulnerable to injuryProtects bowel from blunt traumaHigh risk of placental abruption with trauma

CVS↑ blood volume, ↓ Hb, ↑ WCC (15-25,000 mm-3), ↓ albumin (22-28 g/l)↑ CO (by 1-1.5 l/min), ↑ HR (10-15/min), ↓ BP (5-15 mmHg), ECG LAD

Resp↑ MV, ↓ PCO2, ↓ RV, FRC

Other↑ gastric emptying time↑ RBF, GFR, uterine compression of ureters↑ pituitary sizeligamentous laxity

Assessment and managementPrimary survey and resuscitation

MotherUsual ABCDEExcept left lateral tilt with uterine displacement unless spinal injury suspectedVigorous fluid resuscitation to prevent uterine vasoconstriction and fetal hypoxiaIndicated x-rays must be performed, risk to fetus is low

FetusGood maternal resuscitation is good fetal managementAssessment by abdominal examination

Signs of uterine ruptureSigns of abruption

Fetal heart sounds, ultrasound, CTGSecondary survey

Usual, including DPL or ultrasoundExcept DPL must be above the umbilicusAdditional attention to uterine contraction, obstetric pelvic examinationAdmission and fetal monitoring is required for even minor injuries

Specific conditionsUterine rupture

Massive haemorrhage and shock if severeAbnormal fetal position, extended limbs, free intraperitoneal airLaparotomy required if rupture suspected

AbruptionLeading cause of fetal death after traumaVaginal bleeding, pain, uterine rigidity, shock30% show no external bleeding

Amniotic fluid embolismHypotension, hypoxia, DIC

Fetomaternal haemorrhageFetal anaemia and deathMaternal isoimmunisation (use anti-D even if Kleihauer negative)

Perimortem Caesarean section


Indicated after 4-5 minutes of failed acute resuscitation


Transfer to Definitive Care


Documents

Trauma Initial Assessment and Management Airway and ... Trauma.pdf · Trauma in Women Transfer to Definitive Care ... trauma with burns Consider trauma centre for ... Multiple casualties