The Approach to Trauma
WRITTEN BY: NICHOLAS E. KMAN, MD EDITED BY: DAVID MANTHEY, MD
THE OHIO STATE UNIVERSITY WAKE FOREST MEDICAL SCHOOL
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"We have a motor vehicle accident 5 minutes out per EMS report."
47 year old male unrestrained driver, ejected 15 ft from car arrives via EMS. Vital Signs: BP:
100/40, RR: 28, HR: 110. He was initially combative at the scene, but now difficult to arouse. He does not open his eyes, withdrawals only to pain, and makes gurgling sounds. EMS placed a C-collar and Backboard, but could not start an IV.
What do you do?
Trauma is the leading cause of death in the first four decades of life in most developed countries. To this end, there are more than 5 million trauma-related deaths each year worldwide. Motor vehicle crashes cause over 1 million deaths per year. Injury accounts for 12% of the world's burden of disease.
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What initial actions should you take to care for the trauma patient?
As with all of your patients, your assessment should always begin with addressing airway, breathing and circulation. Each problem is addressed prior to moving to the next priority (ie, manage airway prior to treating hemorrhage).
First you'll need to judge if the airway patent?
Have the patient speak to you to establish patency and to evaluate for voice change and stridor
Is there evidence of pooling secretions or cyanosis?
While you may have an intact airway now, look for problems which may cause the patient to lose that airway in the near future. It is usually easier to act now before the airway is gone, then to deal with a patient who progressed to an inability to ventilate or oxygenate.
facial injury causing obstruction or bleeding laryngeal fractures expanding hematomas
GCS of 9 or less requires intubation
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If you feel the patient's airway isn't intact, you'll need to act!
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ALWAYS MAINTAIN C-SPINE IMMOBILIZATION
Consider performing jaw thrust to establish patency of the airway.
Consider use of a naso or oro-pharyngeal airway during bag-valve mask ventilations (BVM)
Rapid Sequence intubation if needed for airway stabilization or protection (e.g. for GCS of 9 or less) Evaluate neck for landmarks associated with cricothyroidotomy and to assess the patient for subcutaneous emphysema or tracheal deviation.
Breathing
A patent airway DOES NOT mean adequate ventilation! Ventilation requires adequately functioning lungs, chest wall, and diaphragm to produce the depth and rate of respiration as well as the appropriate gas exchange.
In order to assess for adequate breathing, you'll need to look, listen and feel the chest.
Inspect: look for cyanosis, JVD (tension pneumothorax or cardiac tamponade), asymmetric movement of the chest (flail chest), accessory muscle use (tension pneumothorax) or open chest wounds (open pneumothroax).
Ausculate: listen for stridor (upper airway injury), lung breath sounds (pneumo or hemothorax) Percuss: feel for hyper-resonance (pneumothorax) or dullness (hemothorax), subcutaneous emphysema (airway injury), paradoxical movements (flail chest) crepitence & point tendnerness(rib fractures) or bruising (pulmonary contusion).
Tension Pneumothorax
Tension Pneumothorax presents as progressive deterioration and worsening of a simple pneumothorax, associated with the formation of a one-way valve at the point of a rupture in the lung.
Air becomes trapped in the pleural cavity between the chest wall and the lung, and builds up, putting pressure on the lung and keeping it from inflating fully. Hypotension due to:
Increased intrathoracic pressure decreasing preload
Loss of left heart blood flow due to loss of pulmonary vasculature to affected lung
Compression of mediastinum
Tension pneumothorax is a CLINICAL diagnosis and Xrays are not appropriate in this setting. If tension pneumothorax is suspected, immediate needle decompression is undertaken
The treatment is a needle decompression using 14-16 gauge long angiocath inserted at midclavicular line in the second intercostal space, over the rib to avoid the neurovascular bundle (shown in picture below).
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