This document provides guidance on emergency room resuscitation of unstable trauma patients. It discusses:
1) The primary and secondary survey approach to assess life threats and injuries. As part of this, it outlines how to manage the ABCs - airway, breathing, and circulation.
2) Specific skills for airway management, needle thoracostomy, chest tube insertion, IV access, and other procedures.
3) Evaluation of injuries like pneumothorax, shock, head trauma, and fractures. It provides criteria for interventions like intubation and priorities like fluid resuscitation or surgical intervention.
4) Indications for investigations and how to interpret chest x-rays. It emphasizes stabil
This document provides guidance on emergency room resuscitation of unstable trauma patients. It discusses:
1) The primary and secondary survey approach to assess life threats and injuries. As part of this, it outlines how to manage the ABCs - airway, breathing, and circulation.
2) Specific skills for airway management, needle thoracostomy, chest tube insertion, IV access, and other procedures.
3) Evaluation of injuries like pneumothorax, shock, head trauma, and fractures. It provides criteria for interventions like intubation and priorities like fluid resuscitation or surgical intervention.
4) Indications for investigations and how to interpret chest x-rays. It emphasizes stabil
This document provides guidance on emergency room resuscitation of unstable trauma patients. It discusses:
1) The primary and secondary survey approach to assess life threats and injuries. As part of this, it outlines how to manage the ABCs - airway, breathing, and circulation.
2) Specific skills for airway management, needle thoracostomy, chest tube insertion, IV access, and other procedures.
3) Evaluation of injuries like pneumothorax, shock, head trauma, and fractures. It provides criteria for interventions like intubation and priorities like fluid resuscitation or surgical intervention.
4) Indications for investigations and how to interpret chest x-rays. It emphasizes stabil
This document provides guidance on emergency room resuscitation of unstable trauma patients. It discusses:
1) The primary and secondary survey approach to assess life threats and injuries. As part of this, it outlines how to manage the ABCs - airway, breathing, and circulation.
2) Specific skills for airway management, needle thoracostomy, chest tube insertion, IV access, and other procedures.
3) Evaluation of injuries like pneumothorax, shock, head trauma, and fractures. It provides criteria for interventions like intubation and priorities like fluid resuscitation or surgical intervention.
4) Indications for investigations and how to interpret chest x-rays. It emphasizes stabil
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Emergency Room Resuscitation of the
Unstable Trauma Patient
N.K. Jain, MD, FRCSC General Surgeon, North York General Hospital Toronto, Canada March 2007 Objectives: Trauma Resuscitation Review approach
Review knowledge and technical skills
Discuss appropriate investigations
Discuss transfer of care Goals of trauma resuscitation Maintain: Systemic oxygenation Systemic perfusion Neurologic function Approach to unstable trauma patient Primary survey Detect and manage life threatening injuries
Secondary survey Detect other injuries and formulate treatment plan Examples: Hypoxia, tension pneumo, shock, tamponade, herniation How: ABCD Examples: All other injuries or fractures How: Expose patient Head-toe exam Investigations Airway The first step is assessing the adequacy of the airway
Ventilatory inadequacy may result from the a mechanical obstruction of the airway e.g. tongue, foreign body, vomitus, food, blood, or from inadequate ventilatory effort.
A partially obstructed airway is indicated by: 1. Noisy and laboured breathing ( stridor) 2. Use of accessory muscles of breathing ( sternomastoid) 3. Soft tissue retraction of the intercostal, supraclavicular,and suprasternal areas. 4. Paradoxical or seesaw breathing. Normally in the unobstructed airway the chest and abdomen rise and fall together. If the airway is partially or completely obstructed and cardiac arrest has not occurred, the chest is sucked in as the abdomen rises. 5. Cyanosis. A circulating reduced Hb level of < 5gms% is associated with cyanosis- this is a late sign of hypoxia esp if the pt is anemic.
Ventilatory failure is noted by minimal or absent chest or abdominal movement and an inability to detect air movement through the mouth or nose.
The most important step for successful resuscitation is immediate opening of the airway , establishing an adequate airway and maintaining adequate ventilation
AIRWAY MANAGEMENT Head tilt Chin lift Mandibular thrust- forward displacement Oropharngeal airway-only in unconscious/stuporous pt Bag and mask
Intubation Indications -
Esophageal obturator- comotose pts Nasotracheal in suspected cervical Fx, neck injuries as neck need not be extended, seizures Can be done with pt awake, without producing gagging, retching, straining or vomiting Oropharyngeal- most rapid. Cricoid pressure. Stomach decompression should be done with NG tube Surgical Cricothyroidotomy Tracheostomy
Apnea / Hypoxia Inability to protect airway (GCS < 8) Facial or cervical trauma / burns Persistent shock Breathing Knowledge Indications for inserting chest tube
Skills Needle thoracostomy Chest tube insertion
Possible tension pneumo Simple pneumo Hemothorax
Pneumothorax Circulation Knowledge Differential diagnosis of shock in trauma Hemorrhagic / hypovolemic Obstructive (tension pneumo, tamponade) Neurogenic (usually not cardiogenic, septic, or anaphylactic) Fluid resuscitation 2L crystalloid, then blood (uncrossmatched or matched) Skills IV Central line (femoral) Interosseus line Cut down Arterial puncture (femoral) Classification of Hemorrhage Class1- 15% blood volume- normal BP, min inc in pulse and resp, blanching of nail capillaries by pressure may be increased indicating peripheral vasoconstriction,Tilt test neg pt sits up for 90secs without vertigo or dec BP Give crystalloid 3:1rule- 3 times as much crystalloid is given as estimated volume loss. Class 2 20-25% blood loss-Hypotension, tachycardia and tachypnoea, Tilt test +, capillary blanch +. Give blood if there is continued blood loss eg pelvic / femur fractures Class 3 30-40% blood loss- Shock. Give crystalloid 3:1 and blood Class 4- 40-50% blood loss- Pt obtunded
Hemorrhagic Shock External bleeding Control with direct pressure / staples / sutures Fluid resuscitation usually successful
Internal bleeding May be from thorax, abdomen, or pelvis Usually requires surgical intervention if fluid resuscitation unsuccessful Disability Knowledge Familiarity with GCS & basic neuro exam Managing raised ICP Hyperventilate (pCO2 28-30) Mannitol 1g / kg IV Gently raise head of bed
Skills Applying a collar (Most of us cannot do burr holes) Glasgow Coma Scale Motor Response Verbal Response Eye Openinig Obeys command-6 Oriented-5 Opens spont-4 Localizes to pain-5 Confused -4 Opens to speech- 3 Withdraws from pain-4 Inappropriate words-3
Opens to pain-2 Flexor posturing-3 Unintelligible -2 No eye opening-1 Extensor posturing-2 No sounds - 1 No movement -1 Evaluation-Secondary Survey Exposure cut clothing Head to toe exam Assess pelvic stability Log roll DRE (high riding prostate, blood, tone) Foley insertion NG insertion (prevent aspiration, look for blood) Applying a pelvic brace if indicated(bedsheet) FRACTURES Stablisation Investigations 1) Blood work (including cross match) 2) CXR 3) Pelvic X-ray
In unstable patient, do not usually need further X-rays or CT prior to transfer In stable patient, further investigations as indicated Interpretation of CXR Look for: 1) Widened mediastinum (>8cm at aortic knob) 2) Loss of aortopulm window 3) Pneumomediastinum 4) Displaced NG 5) Displaced Left mainstem bronchus 6) Pleural cap 7) Rib # (esp 1 st / 2 nd ) 8) Diphragmatic hernia 9) Hemo-pneumothorax 10) Line placement Ruptured Aorta Just distal to subclavian artery in 95% cases 30-50% having aortography for widened mediastinum will have aortic rupture Of those who reach the hospital alive early death caused by completion of tear of the aorta occurs in 30% in 6 hrs and 60% in 48 hrs Blunt vs. penetrating trauma Blunt vs. penetrating trauma Similar management If implement still present (eg, knife), leave it in place, should be removed intra-op Look for entry and exit sites Give tetanus if indicated Transfer of unstable patient Call for help early Prior to transfer, carefully consider need to intubate or insert chest tubes Ensure adequate IV access Send with blood Send with trained personel Send with CXR / pelvic X-ray if possible Unnecessary investigations will delay transfer Summary - Knowledge Indications for intubation Indications for chest tube insertion Approach to shock / fluid resuscitation Familiarity with GCS Managing raised ICP
Summary - Skills Intubation Surgical airway (needle cricothyrodotomy) Needle thoracostomy or chest tube insertion Intravenous Central line insertion Interosseus insertion Arterial stab Applying a C-spine collar Foley / NG Applying a pelvic brace (FAST or DPL to look for intra-abdominal bleeding usually in trauma centre or by local surgeon) Remember Managing an unstable trauma patient can be stressful.
Following the primary / secondary survey approach will help you organize your thoughts and prioritize management. Scenarios 45M self-inflicted gunshot wound to hard palate Intoxicated