Abordagem inicial do traumatizado Flashcards
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KEY POINTS
Trauma remains the most common cause of death for all
individuals between the ages of 1 and 44 years and is the
third most common cause of death regardless of age.
The initial management of seriously injured patients consists
of performing the primary survey (the “ABCs”—Airway
with cervical spine protection, Breathing, and Circulation);
the goals of the primary survey are to identify and treat conditions
that constitute an immediate threat to life.
All patients with blunt injury should be assumed to have unstable
cervical spine injuries until proven otherwise; one must
maintain cervical spine precautions and in-line stabilization.
Patients with ongoing hemodynamic instability, whether
“nonresponders” or “transient responders,” require prompt
intervention; one must consider the four categories of shock
that may represent the underlying pathophysiology: hemorrhagic,
cardiogenic, neurogenic, and septic.
Indications for immediate operative intervention for penetrating
cervical injury include hemodynamic instability and
significant external arterial hemorrhage; the management
algorithm for hemodynamically stable patients is based on
the presenting symptoms and anatomic location of injury,
with the neck being divided into three distinct zones.
The gold standard for determining if there is a blunt
descending torn aorta injury is CT scanning; indications
are primarily based on injury mechanisms.
Blunt injuries to the carotid and vertebral arteries are usually
managed with systemic antithrombotic therapy.
The abdomen is a diagnostic black box. However, physical
examination and ultrasound can rapidly identify
patients requiring emergent laparotomy. Computed
tomographic (CT) scanning is the mainstay of evaluation
in the remaining patients to more precisely identify the
site and magnitude of injury
Manifestation of the “bloody vicious cycle” (the lethal
combination of coagulopathy, hypothermia, and metabolic
acidosis) is the most common indication for damage
control surgery. The primary objectives of damage
control laparotomy are to control bleeding and limit GI
spillage.
The abdominal compartment syndrome may be primary
(i.e., due to the injury of abdominal organs, bleeding, and
packing) or secondary (i.e., due to reperfusion visceral
edema, retroperitoneal edema, and ascites).
Trauma, or injury, is defined as cellular disruption caused by
an exchange with environmental energy that is beyond the
body’s resilience which is compounded by cell death due to
ischemia/reperfusion.
trauma must be considered
a major public health issue
Airway Management with Cervical Spine Protection
Ensuring
a patent airway is the first priority in the primary survey.
all patients with blunt trauma require cervical
spine immobilization until injury is excluded
This is typically
accomplished by applying a hard collar or placing sandbags on
both sides of the head with the patient’s forehead taped across
the bags to the backboard. Soft collars do not effectively immobilize
the cervical spine.
Patients who have an abnormal voice, abnormal breathing
sounds, tachypnea, or altered mental status require further airway
evaluation. Blood, vomit, the tongue, foreign objects, and soft
tissue swelling can cause airway obstruction; suctioning affords
immediate relief in many patients. In the comatose patient, the
tongue may fall backward and obstruct the hypopharynx; this
can be relieved by either a chin lift or jaw thrust. An oral airway
or a nasal trumpet is also helpful in maintaining airway patency
Establishing a definitive airway (i.e., endotracheal intubation) is
indicated in patients with apnea; inability to protect the airway
due to altered mental status; impending airway compromise due
to inhalation injury, hematoma, facial bleeding, soft tissue swelling,
or aspiration; and inability to maintain oxygenation. Altered
mental status is the most common indication for intubation. Agitation
or obtundation, often attributed to intoxication or drug use,
may actually be due to hypoxia.
Options for endotracheal intubation include nasotracheal,
orotracheal, or operative routes
Patients in whom attempts at intubation have failed or
who are precluded from intubation due to extensive facial
injuries require operative establishment of an airway. Cricothyroidotomy
(Fig. 7-1) is performed through a generous vertical
incision, with sharp division of the subcutaneous tissues
In patients under the age of 11, cricothyroidotomy is
relatively contraindicated due to the risk of subglottic stenosis,
and tracheostomy should be performed
yes
Breathing and Ventilation
Once a secure airway is obtained,
adequate oxygenation and ventilation must be ensured
The following conditions constitute
an immediate threat to life due to inadequate ventilation
and should be recognized during the primary survey: tension
pneumothorax, open pneumothorax, flail chest with underlying
pulmonary contusion, and massive air leak. All of these diagnoses
should be made during the initial physical examination.
Nos países em vias de desenvolvimento, as mortes em acidentes de viação já são superiores às mortes por doenças infecciosas
Atinge principalmente a população jovem
É a principal causa de morte antes dos 35 anos, nos
países industrializados
Em 2020 será a segunda ou terceira causa de morte, em todos os países
Mortalidade trimodal Minutos iniciais Lesões neurológicas Lesões vasculares 40% evitáveis com programas de prevenção
Primeiras Horas
Problemas respiratórios
Problemas circulatórios
Mortes maioritariamente evitáveis
Dias ou Semanas
Sépsis
ARDS
sim!
