Clinical assessment of severely injured patients

Clinical assessment of severely injured patients

Assessment of Trauma Patients


Incidence

Trauma is the commnest cause of death in developed countries (30%)
The patients are often less than 40 years of age.

Aim of trauma care

  • To reduce preventable deaths
  • To reduce  prolonged disability & loss of productivity

Causes of trauma

  • Road Traffic Accidents
  • Falls
  • Assault
  • War Wounds  (gunshot, stab injury & antipersonnel mines)
    •  military
    •  nonmilitary

Categories of trauma

  • Blunt injury
  • Penetrating injury
  • Combination of both

Blunt trauma is ususally more difficult to assess and treat

TRIMODAL DEATH DISTRIBUTION – U.S Pattern

  • 1st peak within minutes (major brain/vascular injury)- non salvageable
  • 2nd peak within hours (airway/circulatory problems) – treatable (GOLDEN HOUR)
  • 3rd peak  within days (sepsis)- preventable & treatable (not always)

This pattern is not seen in all countries.

The Trauma team

A dedicated team of doctors (Surgeons, Anaesthetists & Intensive care specialists) and nurses constitute the trauma team. The composition of the team will depend on local infra structural resources.An ideal team consists of :

  • Team Leader
  • Airway Doctor
  • Circulation Doctor
  • Other Doctor – for implementation of  practical procedures &
  • Nurses – 1 Coordinator + 3 others with  predetermined roles
  • Radiographer

Pre hospital management

The Ambulance Crew must  have resuscitation skills (Advanced Trauma Life Support certification etc.)

    • Triage

Serious trauma is recognised by the presence of :  depressed conciousness, breathing difficulty &shock

  • Scoop & Run + Resuscitation tasks
      • Airway
      • Breathing
      • Circulatory control
      • Cervical & Spine control
      • Correction of major biochemical disorders
      • Correction of thermal disorders
      • Communication with hospital trauma team
  • Airway
      • Chin lift
      • 0ropharyngeal / Nasopharyngeal Airway
      • Endotracheal intubation if above measures fail
  • Breathing
      • O2 by mask
      • Seal open chest wound if present
  • Circulatory control
      • External haemorrhage control by direct pressure
      • Internal haemorrhage control by  Pneumatic Antishock garment – controversial
        • May be used selectively in blunt trauma
        • Contra indications : Head Injury, Cardiopulmonary dysfunction,Thoracic  haemorrhage.
        • Increases mortality in penetrating Cardiovascular injuries
      •  IV infusion
  • Cervical & Spine control
      • neck in neutral position, semirigid collar / sandbags / tape
      • backboard / special scoop stretcher / log roll patient
  • Correction of major biochemical disorders
      • Eg. Insulin for Diabetic coma
  • Correction of thermal disorders
      • Eg. hypothermia from exposure – cover with space blanket
  • Analgesia
      • Intravenous route
      • Opioids under monitoring
  • Communication with hospital trauma team

In hospital management

  • Preplanning and preparation to receive trauma victim by the trauma team
  • History of incident from Ambulance crew / family / eye witnesses
      • Visualise mechanism of injury –> Anticipate pattern of injury
      • Details of : Allergy, Medication, Previous illness, Last meal, Events of  injury  (AMPLE)
  • Exposure of patient – Remove clothing, label, preserve for Forensic evidence, Cover the patient.

Emergency assessment (Primary survey)

This consists of assessment, diagnosis & treatment of life threatening problems.

  • Airway &Cervical control
  • Breathing
  • Circulation
  • Neurological deficit
  • Investigation & Monitoring

AIRWAY& CERVICAL CONTROL ACTION PLAN
 

PATIENT CONDITION ACTION FURTHER CARE
Patient can talk High flow 02, Cervical control Monitor
Patient unconcious Clear mouth, Open airway by jaw thrust, Insert  Oropharyngeal or Nasopharyngeal  airway, 
Give 02 by  bag
Airway secured  -> Monitor 


No airway secured    -> Proceed to Advanced airway care 

No airway secured Endotracheal intubation (crash induction if necessary) Failed Endotracheal intubation
No airway secured Needle Cricothyrotomy. 30 minutes time available.  Proceed to Tracheostomy

 
 BREATHING

Look Respiratory rate, Cyanosis, Chest wall movement, Fluids leaks, Foreign body 
Listen Voice quality, breath sounds
Feel Airflow, Tracheal position, Subcutaneous Emphysema 

 

    •   Use High flow 02 & Normal tidal volume ( Jet ventilation in Cricothyrotomy patients)
    •   Diagnose & treat the 6 life threatening Chest lnjuries

1.Upper Airway Obstruction

            •   Diagnosis :Stridor, Hoarseness, Inspiratory sound
            •   Treatment : Provide Airway

2.Tension Pnuemthorax

            • Diagnosis: Needle Thoracocentesis
            • Treatment : Intercostal Chest drain

3.Massive Haemothorax

            1. Diagnosis :Needle Thoracocentesis >1500 ml of blood
            2. Treament : Venous access & Circulatory support, InterCostal Chest drai

4.Sucking chest wound

            • Diagnosis : See
            • Treatment : Cover with dressing taped on three sides, Follow with  definitive treatment

5.Flail Chest

            • Diagnosis: See
            • Treatment : IPPR

6.Cardiac Tamponade

          • Diagnosis: Needle Pericardiocentesis
          • Treatment : Urgent Thoracotomy
          • Serious but uncommon injuries to the heart and great vessels take precedence over all else.

   CIRCULATION

        •  Assess: Pulse, B.P, Skin (cold, clammy etc)
        •  Action: 2 (I8G) cannulas are inserted into the veins of the forearm or antecubital fossa.   If unable to secure lines in 5 minutes, resort to advanced procedures of circulatory access :
          • Cut down to Saphenous vein / Median Basilik vein
          • Percutaneous cannulation of Femoral vein or neck vein (by Seldinger technique)
          • lntraosseous infusion in children
        • Arrest: External  haemorrhage by direct pressure, lnternal haemorrhage by splinting fractures etc.
        • Algorithm for fluids :

No shock — > moniter.                Shock present  –> 2L RL rapid infusion

    If there is a maintained response there has been a <20% fluid loss  –> moniter patient and maintainence replacement as required.

      If there is a transient response, there has been a 20- 40% blood loss. Is Surgery required ?

        If there is no response –> replace blood and undertake appropriatesurgery

           

            NEUROLOGICAL DEFICIT

            Preliminary survey :

            • Is the patient alert?
            • Does he respond to vocal stimulus/pain ?
            • Is the patient unresponsive ?

            INVESTIGATION & MONITORING

            • Attach : ECG, B.P moniter, Pulse Oximeter, Urinary catheter, ? Nasogastric tube,
            • Investigations :
                • Group & cross match blood,
                • Portable  xrays – initial imaging :
                  • chest (supine). Erect films often impractical
                  • cervical spine (lateral)
                  • pelvis
            • Moniter clinically every 15 minutes

              DETAILED ASSESSMENT ( SECONDARY SURVEY)

            • Head: Detailed Neurological assessment (including Glasgow Coma Scale)
            • Face : Check for bony & soft tissue injury
            • Neck : Recheck for fractures
            • Chest: Recheck for rib fractures
            • Abdomen: Special attention to perineum/genitalia, PR/PV, sensation in the saddle area
            • Spine: logroll the patient & palpate
            • Limbs: Recheck for fractures &  Immobilise fractures
            • Soft tissue :Check for abrasions, contusions etc.
            • Further lnvestigations :
                • Imaging (xrays of skull, spine, limbs, CT in severe head injuries, Aortography for suspected aortic rupture etc.)
                • Diagnostic Peritoneal lavage, CT abdomen etc.
            • Medication : Tetanus & Antibiotic prophylaxis
            • Completion of case notes : medicolegal implications
            • Handing over of the patient by the Trauma team to the admitting unit / specialists

              
            MORBIDITY & MORTALITY

            • Factors influencing mortality are :
                • Severity of individual injury
                • The combined effect of multiple injuries (as measured by Injury Severity Score ).
                • Age of patient
                • Pre existing illness
                • Physiological derangement at presentation (as measured by Revised Trauma Score )
                • Prehospital management
                • Early management in hospital (ie : correction of shock)
                • Management of complications
            • Assessing the outcome of trauma may be done by scoring systems such as TRISS Severity Index
            • Death is commonly associated with severe head injury, multiple injuries of head, abdomen and chest.

            Uma Krishnaswamy MS, FRCSEd, FAIS, MA
            Consultant General Surgeon
            Email :[email protected] 

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