Management of multiple trauma Flashcards
What are the categories under the trimordial death distribution?
Immediate deaths: death within 2 hours e.g. cardiac rupture, aortic rupture, brainstem detachment (not much can be done at this stage)
Early deaths: 24-72hrs e.g. tension haemothorax, flail chest
Late death: 3 weeks
What is the ATLS algorithm?
ATLS (Advanced Trauma Life Support) the algorithm follows a Primary Survey (ABCDE Approach) and Secondary Survey approach, both aimed at quickly identifying and managing life-threatening conditions
How do you clear the airway, non-surgically and surgically if the prior methods fail?
Purse check if the patients airway is patent by asking them to say their name
- chin lift (however this can worsen a c-spine injury)
- jaw thrust (applying a longitudinal tracture
if these methods fail…create a definitive airway
- surgical airway (tracheostomy) - long term
- needle into the trachea: a small cut is made below the cricothyroid - short term
- oropharyngeal airway: goes over the tingue and pulls the tongue forward
- endotracheal tube
- laryngeal mask airway
What are the steps of initial assessment?
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation: stop the bleeding!
Disability / neurological status
Expose / Environment / body temperature
What are the 4 ways to stabilize a c-spine?
- Rigid cervical collar (philadelphia in collar)
- Rigid spine board
- Sand bags (prevents the head from moving sideways)
- Head strap (to strap the head to the spine board)
normal respiratory rate for adults and children
16-20 breaths per minute - adults
What is a tracheostomy? When is an emergency tracheostomy indicated?
A tracheostomy is a medical procedure in which a surgical opening is made in the trachea (windpipe) to allow for breathing. A tube is inserted into the opening to provide a direct airway, bypassing the upper airways. This is often done when someone has difficulty breathing due to an obstruction, injury, or disease affecting the upper respiratory tract.
An emergency tracheostomy is indicated if the patient is deeply cyanosed or apnoeic and an endotracheal tube cannot be inserted safely.
What is a cricothyrotomy or needle cricothyroidotomy?
This is an emergency procedure used to establish an airway when someone is unable to breathe and other methods (like intubation) aren’t possible or effective
In this procedure, a needle or small catheter is inserted through the cricothyroid membrane (the space between the thyroid and cricoid cartilage in the neck) to create a temporary airway. It allows for immediate airflow into the lungs while a more permanent solution, like a tracheostomy, might be arranged if needed.
The needle cricothyrotomy is often used in life-threatening situations, such as when there is swelling or trauma to the upper airway that blocks normal breathing
How do you manage a patients breathing and vetilation?
- this deals with the lower respiratory tract
- it involves the lungs pleural cavity and chest wall
- Assess and ensure adequate oxygenation and ventilation
- observe for manifestation of breathing obstructions
- excessive breathing cycles will require a ventilator/ life support
- asymmetrical elevation of the chest if one lung collapses
Check the:
● Respiratory rate
● Chest movement
● Air entry
● Oxygen saturation
What is a normal Oxygen saturation rate and what is considered hypoxic? What intrument is used to measure it?
Normal is 96-100%
Hypoxia is <96%
This is measured with a pulse oximeter
The lungs can be compressed due to what conditions?
Pneumothorax: The presence of air in the pleural space, causing a lung to collapse.
Haemothorax: The accumulation of blood in the pleural space, often due to injury or trauma.
Pyothorax: The accumulation of pus in the pleural space, typically due to infection.
Chylothorax: The presence of lymphatic fluid (chyle) in the pleural space, often from a disrupted lymphatic duct
What is flail chest? How do we resusciate such a patient?
Segmental separation of chest wall causing inability to breath and ventilate the lungs
Clinical features:
* dyspnea & tachypnea
* paradoxical movement
* decreased breath sound
Tension Pneumothorax: Clinical Features and Presentation
High pressure pneumothorax causing cardiovascular compromised status
Clinical features include:
* chest injury
* dyspnea & tachypnea
* distended neck vein
* deviated trachea
* hypotension
* tympanic on percussion
* absent breath sound
On Breathing and Ventilation your should Look, feel, palpate and listen for what?
Tension pneumothorax
Open pneumothorax
Severe flail chest
What is open pneumothorax? How do you resuscitate a patient with open pneumothorax?
Abnormal connection between pleural cavity and atmosphere causing inability to ventilate the lungs
Resuscitation:
three-sided dressing
ICD
Oxygenation
- Three-sided dressing:
This refers to the method of covering the open wound with a dressing and securing it with tape on three sides only, leaving the fourth side open. This allows air to escape from the chest cavity but prevents it from being sucked in, helping to prevent worsening of the pneumothorax and the risk of developing a tension pneumothorax.
- ICD (Intercostal Chest Drain):
This refers to the placement of a chest tube (also called a chest drain) between the ribs to remove air, blood, or fluid from the pleural space (the area between the lungs and chest wall). This is a more definitive treatment to relieve a pneumothorax or haemothorax and to help the lung re-expand.
- Oxygenation:
This refers to the process of supplying the patient with oxygen, usually through a mask or a ventilator. In the case of pneumothorax, oxygenation helps ensure the patient gets enough oxygen, particularly if they are struggling to breathe due to collapsed lung or reduced lung capacity
Primary Survey
Circulatory Management
● Control hemorrhage
● Restore volume
● Reassess patient
How to manage circulation (blood volume and cardiac output) haemorrhage and hypovolemic shock?
Stop external bleeding!
Observe for:
1. Signs of shock
2. Grading of shock
3. Source(s) of shock include:
Massive Hemothorax
Cardiac tamponade
Massive Hemorrhage
Resuscitation (with normal saline) and Oxygenation
Ensure adequate IV access (2 large bore peripherals)
What can percussion reveal?
- pyothorax/haemothorax: dull sound
- pnuemothorax: hyperesonance
What is the needle thoracotomy?
Needle thoracostomy is an emergency procedure for tension pneumothorax, using a large-bore needle inserted into the 2nd intercostal space (midclavicular line) or 4th/5th intercostal space (anterior/midaxillary line) to release trapped air.
It provides temporary relief and must be followed by chest tube placement.
What occurs in cardiac tamponade? And it’s treatment?
- Obstructive shock: Cardiac tamponade causes obstructive shock by preventing the heart from filling properly, leading to decreased cardiac output and systemic hypoperfusion.
- Beck’s triad: Hypotension
Distant heart sound
Engorged neck vein - Treatment: Pericardiocentesis
Thoracotomy
What is a massive hemothorax?
● Systemic / pulmonary vessel disruption
● > 1500 mL blood loss
● Flat vs. distended neck veins
● Shock with no breath sounds and/or percussion dullness
What is the glasgow coma scale and when is it used?
When does the GCS score represent a coma?
The Glasgow Coma Scale is a clinical scale used to reliably measure a person’s level of consciousness after a brain injury
It evaluates:
Eyes
Speech
Motor response
Patients with associated head injuries must be monitored using the Glasgow coma scale
GCS score represents a coma when it’s <8
What are the signs of hemorrhage?
The diagnosis is based on finding the signs of hypovolaemic shock - a pale, anxious, sweaty patient with with cold extremities, a rapid, thready pulse, tachypnoea and hypotension.
These signs occur when the body redistributes the circulation in an attempt to maintain the blood flow to the vital organs (heart and brain).
3 quick killers when evaluating breathing
Tension pneumothorax
Massive hemothorax
Open pneumothorax
What are the classes of Hypovolemia?
Class I : <15% ; HR <100 ; normal BP ;
: RR ~ 14-20
Class II : 15% - 30% ; HR > 100
: normal BP ; RR ~ 20-30
Class III : 30% - 40% ; HR > 120
: hypotension ; RR 30-40
Class IV : > 40% ; HR > 140
: profound shock
** Blood volume ~ 70 cc / kg body weight
Fluid resuscitation
Warm RLS (ringers lactate solution) 2000 ml I.V. in 15 min (warm fluid is to prevent hypothermia)
(20 ml / kg in children )
1. Rapid response ( 10%-20% )
( type and crossmatch )
2. Transient response ( 20%-40% )
( type-specific )
3. Unresponsive ( > 40% )
( group O Rh + )
Adjuncts to primary survey
Monitoring : V/S , EKG , O2 Sat , Urine output
Catheters : Foley’s , N-G
Investigations : CXR , Pelvis
: FAST (focused assessment with sonography in trauma) or DPL (diagnostic peritoneal lavage)
Adjuncts to primary survey
Monitoring : V/S , EKG , O2 Sat , Urine output
Catheters : Foley’s , N-G
Investigations : CXR , Pelvis
: FAST (focused assessment with sonography in trauma) or DPL (diagnostic peritoneal lavage)
What are the diagnostic tools FAST and DPL used for?
FAST: A rapid bedside ultrasound used to detect free fluid (blood) in the peritoneal, pericardial, or pleural cavities.
DPL: An invasive procedure where a catheter is inserted into the peritoneal cavity to check for blood or intestinal contents.
What are the diagnostic tools FAST and DPL used for?
FAST: A rapid bedside ultrasound used to detect free fluid (blood) in the peritoneal, pericardial, or pleural cavities.
DPL: An invasive procedure where a catheter is inserted into the peritoneal cavity to check for blood or intestinal contents.
What must be considered after the ornate survey?
Do you need to transfer?
- Use time before
transfer for
resuscitation
● Do not delay transfer
for diagnostic tests
When do you start the secondary survey?
After
● Primary survey is completed
● ABCDEs are reassessed
● Vital functions are returning to normal
When do you start the secondary survey?
After
● Primary survey is completed
● ABCDEs are reassessed
● Vital functions are returning to normal
What does the secondary survey begin with and how to we get it?
History
Allergies
Medications
Past illnesses, Personal history, Pregnancy
Last meal
Events / Environment / Mechanism (blunt, penetrating, burn)
What does the secondary survey begin with and how to we get it?
History
Allergies
Medications
Past illnesses, Personal history, Pregnancy
Last meal
Events / Environment / Mechanism (blunt, penetrating, burn)
What is the second stage in secondary survey?
Physical exam
Head
: Maxillofacial
: C-spine and neck
: Chest
: Abdomen
: Pelvis and perineum
: Extremities
: Neurological function
Adjuncts to secondary survey?
Monitoring
Catheters
Investigations
Re-evaluation !!
How would you manage disability?
Check neurological status:
● Baseline neurologic evaluation
● Glasgow Coma Scale score
● Pupillary response
How to manage exposure and environment?
Expose the patient to view any missed injuries
Avoid hypothermia
Check pulse rate
What are the signs of an obstructed airway?
Cyanosis (blue)
Apnoea (not breathing)
Stridor (a rasping noise on respiration)
3 major causes of circulatory embarrassment
Cardiac damage/tamponade
Hemorrhage
