Surgery SC083: Trauma Evaluation And Management (TEAM) Flashcards
1
Q
TEAM, Goals / Principles of Trauma Care
A
TEAM: Trauma Evaluation and Management
Goals:
- Rapid, accurate, physiologic assessment
- Resuscitate, stabilise, monitor by priority
- Prepare for transfer to definitive care
- Team work for optimal, safe patient care
2
Q
Need for Early TEAM
A
- Leading cause of death from 1-44 yo
- Disabilities exceed deaths by ratio of 3:1
- Trauma-related costs >$400 billion per year
- Lack of public awareness for injury prevention
3
Q
Injury Prevention (ABCDE)
A
ABCDE:
- Analyse injury data
- Build local coalitions
- Communicate the problem
- Develop prevention activities
- Evaluate the interventions
4
Q
Trimodal death distribution of trauma
A
- Immediate deaths (death at scene)
- most patients
- **airway compromises, **C-spine injuries, ***breathing: pneumothorax, haemothorax, hypoxia
- need prevention from policies - Early deaths (2 hours after injury)
- **bleeding: “Blood on the floor and Four more”
—> On the floor: Bleeding from visible wound
—> Four more: Chest, Abdomen, Pelvis, Fractured long bone (e.g. femur)
- preventable by **golden hour management + early transfer to appropriate care - Late deaths (A few weeks later)
- usually due to surgical complications e.g. multiorgan failure, pneumonia (preventable by ICU care), renal failure, sepsis, UTI, aspiration, post-op complications
5
Q
TEAM Principles
A
- Treat greatest threat to life first
- Secure Airway, C-spine —> then treat Breathing (e.g. pneumothorax, give O2) —> Circulation (e.g. give fluid) - Definitive diagnosis less important
- Physiologic approach
- correct any aberrant physiology first then getting the diagnosis - Time is of the essence
- Do no further harm
- Teamwork required for TEAM to succeed
6
Q
TEAM members
A
- Team leader
- Airway manager
- Nurse
- Assistant x2
Trauma call:
- Surgeon
- Junior surgeon
- Anaesthetist
- AED physician
- Orthopaedic surgeon
- Neurosurgeon (if head injury, reduced consciousness)
- Nurse
7
Q
Pre-hospital preparation and In-hospital preparation
A
Pre-hospital preparation:
- Closest, appropriate facility
- Transport guidelines / protocols
- On-line medical direction
- Mobilisation of resources
- Periodic review of care
In-hospital preparation:
- Pre-planning essential
- Team approach
- ***Trained personnel
- ***Proper equipment (e.g. ETT tube, Laryngoscope, Bag-valve mask, Fluids, IV cannula)
- ***Environment (e.g. Resuscitation room)
- Lab / X-ray capabilities
- Standard precautions (cap, gown, gloves, mask, shoe covers, goggles / face shield)
- Transfer agreements
- Quality Improvement (QI) program
8
Q
Triage
A
Sorting of patients according to:
- ABCDE
- Available resources
- Other factors e.g. Salvageability
9
Q
TEAM Sequence
A
- Primary Survey + Resuscitation of vital functions
- ABCDE
- Adjuncts
—> Pulse oximeter
—> Capnography (end-tidal CO2)
—> BP monitor
—> ABG
—> ECG
—> Urinary catheter for Urine output (aim ***0.5 ml/kg/hr)
—> X-ray (Chest (pneumothorax, broken ribs, mediastinum, diaphragm, lung shadows, soft tissues, placement of chest tubes), C-spine, Pelvis)
—> FAST scan (Pelvis, Perihepatic (Morrison’s pouch X look at parenchyma), Perisplenic / Splenorenal recess, Subxiphoid for pericardium)
—> DPL
—> Orogastric tube to decompress stomach / prevent aspiration (unless confident no head trauma —> NG tube)
—> Take blood: CBC, Cross match, Type and Screen etc. - Secondary survey + Re-evaluation of vital functions
- Head-to-toe examination (skeletal survey, CT, log-roll to see the back)
- Adjuncts - Continuous re-evaluation
- Safe transfer
- Definitive care
10
Q
***Primary survey (ABCDE)
A
- **ABCDE:
1. Airway with C-spine protection - ask for the name: A: patent airway, B: some degree of breathing, C: adequate cerebral perfusion, D: not confused
- assess airway patency
- hoarseness, stridor, snoring, gurgling, rocking chest wall motions, charcoal particles (if burn)
- maxillofacial trauma / laryngeal injury
- C-spine injury
- Breathing / Ventilation / Oxygenation / Life-threatening chest injury
- noisy breathing
- tracheal deviation
- auscultate chest
- foreign body / blood in airway
- signs of pneumothorax —> chest tube to decompress
(- chest rise, symmetry, expansion pattern (Kussmaul?)
- air entry
- RR / Effort
- SaO2
- accessory muscles
- tracheal position
- central cyanosis
- sensorium (hypoxic, confused, AMS)
- diaphoresis
- chest wall injury
- JVP) - Circulation / Stop the bleeding
- large bore IV access (>16F) —> IV fluid (warm crystalloid) to resuscitate / volume replacement —> up to ***1L initially for adults —> if no response —> give blood
- large intraabdominal bleeding —> emergency laparotomy
(- monitor BP / P / ECG) - Disability (Neurological status) / Intracranial mass lesion (e.g. ICH)
- pupillary responses
- GCS score (Comatose: <8: need intubation) - Exposure / Environment / Body temp
- room temperature should be high enough
11
Q
***Adjuncts
A
- Take blood
- CBC
- LRFT
- ***Cross match / Type and Screen
- Clotting
- Glucose
- Amylase
- Toxicology: Alcohol, Paracetamol, Salicylate
- Pregnancy test in child-bearing age women -
**Urinary catheter
- Blood?
- Decompress bladder
- Monitor urine output (aim **0.5 ml/kg/hr)
- Caution: pelvic fracture, blood at urethral meatus, ecchymosis at perineum, high-riding prostate - Gastric catheter / ***Orogastric tube
- Blood / bile?
- Decompress stomach
- Caution: skull base fracture (CSF rhinorrhea / otorrhoea, periorbital ecchymosis, mid-face instability, haemotympanum) - ***Monitor
- Vital signs
- ABG
- ECG
- Pulse oximeter
- End-tidal CO2 -
**Diagnostic tool
- **X-ray: Chest / Pelvic / C-spine (not compulsory ∵ CT scan available now)
—> CXR: pneumothorax, broken ribs, mediastinum, diaphragm, lung shadows, soft tissues, placement of chest tubes
- ***FAST —> Pelvis, Perihepatic (Morrison’s pouch X look at parenchyma), Perisplenic / Splenorenal recess, Subxiphoid for pericardium (may miss retroperitoneal space e.g. haematoma around kidneys / aorta but not rupture into peritoneal cavity)
- DPL (not use now)
- CT scan (ONLY when haemodynamically stable) - Consider need for transfer
12
Q
Decision making
A
Haemodynamically normal patients:
- ***ample time for full evaluation of patients to decide on treatment strategy
Haemodynamically stable patients:
- investigations aiming at establishing ***source of bleeding + whether the bleeding stops
Haemodynamically unstable patients:
- CT not possible (contraindicated)
- FAST scan: operator dependent, good at identifying intra-abdominal free fluid (e.g. blood)
- DPL: accurate, fast, negative finding in shock patients —> may signify retroperitoneal bleeding
Positive DPL:
—> presence of bowel content / frank blood
—> RBC >=100,000
—> Unspun specimen WCC >=500
13
Q
Resuscitation: Airway
A
- Chin lift / Modifed jaw thrust
- No head tilt to maintain C-spine immobilisation - Look, listen, feel
- obstruction (foreign body, loose teeth, vomitus)
- laryngeal deformities - Remove particulate matter
- Definitive airway as necessary
- Intubate if necessary (see indications next slide) —> monitor with end-tidal CO2
- ETT
- Airway adjuncts: OPA
- Cricoid pressure: prevent aspiration
- Cricothyroidotomy - Reassess frequently
- e.g. inhalational burn injury —> swollen airway - Protect C-spine
- neutral position of head and neck with bimanual in-line stabilisation
(7. Medications
- BDZ, Opioid, Short-acting muscle relaxants)
14
Q
Indications for Intubation
A
- Airway problems
- Obstruction (e.g. facial injury, burns)
- GCS <=8 - Breathing problems
- Paralysis: Spinal injury, Drug-induced
- GCS <=8
- Apnea
- CO2 retention with respiratory acidosis
- Hypoxaemia
- Haemodynamic instability
15
Q
Resuscitation: Breathing
A
- Observe
- Chest rise, symmetry, expansion pattern (Kussmaul?)
- Air entry
- RR / Effort
- SaO2
- Accessory muscles
- Tracheal position
- Central cyanosis
- Sensorium (hypoxic, confused, AMS)
- Diaphoresis
- Chest wall injury
- JVP - Supplemental O2
- High flow O2 (even for COAD patients —> if too much O2 inhibit respiratory drive —> simply mechanically ventilate —> so don’t worry) - Ventilate as needed
- Variable performance device: Facial mask
- Fixed performance device: Venturi mask, Ventilator
- Monitor with end-tidal CO2
- Minute volume: 6-8L (8-10 ml/kg BW)
- Frequency: 12-14 / min
- ***Avoid hyperventilation + Ensure PaCO2 35-40mmHg —> Avoid respiratory alkalosis —> left shift of O2 dissociation curve —> ↑ Hb O2 affinity + ↓ tissue O2 availability - Tension / Open pneumothorax —> tackled in Primary survey
- Tension pneumothorax: needle then chest tube decompression (size 16, 8 cm, 5th ICS, MAL)
- Open pneumothorax: occlusive 3 sided dressing - Reassess frequently
16
Q
Resuscitation: Circulation
A
- Haemorrhagic shock (until proven otherwise)
- Blood on the floor + Four more
- **External: Apply direct pressure / tourniquet (need to mark down time of putting on, do not release until arrive hospital / OT)
—> avoid blind clamping
- **Internal: Chest, Abdomen, Pelvis, Retroperitoneum
—> pelvic binder, rotate ankles internally to further decrease size of pelvis
—> interventional embolisation
—> +ve FAST scan (large intraabdominal bleeding) —> emergency laparotomy
—> -ve FAST scan —> review other causes of shock + CT for retroperitoneal haemorrhage
- ***Long bone fracture: Traction splint
- Identify: history, P/E, investigations - Non-haemorrhagic shock
- Cardiac tamponade —> Pericardiocentesis + Direct operative repair
- Tension pneumothorax —> Needle decompression + Tube thoracostomy
- Massive haemothorax —> Volume resuscitation + Tube thoracostomy
- Neurogenic shock (rare) (cardinal feature: warm periphery vs cold clammy in haemorrhagic shock (bradycardia may still been seen in ↑ICP, ∴ not cardinal feature))
- Septic (late complication) - Assess organ perfusion
- level of consciousness
- skin colour
- pulse rate, character
- have to stop bleeding!!! —> if simply give fluid to maintain adequate BP —> bleeding may ↑ with ↑ BP
- maintain reasonable BP before operation —> maintain adequate cerebral perfusion but not too high BP —> ***normotension before definitive measures may cause more bleeding
S/S:
- Tachycardia
- Vasoconstriction
- ↓ CO
- Narrow pulse pressure
- ↓ MAP
- ↓ Blood flow
Caution:
- Children (lower BP generally)
- Elderly (higher BP generally)
- Athletes (may be bradycadic originally)
- Pregnancy (hypervolaemic)
- Medications
- Large IV bore access
- **x2 on each arm
- **Size >16
- **Warm IV fluid (Ringer’s lactate / Normal saline)
- **1-2L full rate
- **Packed RBC if transient response / no response
- **Consider early transfusion for transient / non-responder
- Group O blood
- FFP if coagulopathy
- Platelet concentrates
- Class 1 / 2 shock (<30% loss): Crystalloid, not much further intervention
- Class 3 / 4 shock (>30% loss): Crystalloid + Blood, require further investigation with FAST / CT / Laparotomy - Surgery
- Reassess frequently
17
Q
Fluid resuscitation
A
Large IV bore access:
- ***x2 on each arm
- ***Size >16
- ***Warm IV fluid (Ringer’s lactate / Normal saline)
- ***1-2L full rate
- ***Packed RBC if transient response / no response
***Consider early transfusion for transient / non-responder:
- Dilutional effect of fluid resuscitation (crystalloid only improves volume but not O2 capacity) to blood O2 carrying capacity
- CO = HR X SV
—> SV depends on 1. Preload (IV volume) 2. Afterload (Peripheral resistance), 3. Contractility (possible cardiac failure in elderly / diseased heart)
(Rmb: CO cannot be increased if venous return does not increase)
Size matters:
- Maximum flow rate (ml/min)
—> 14G (brown): crystalloid (125), colloid (90)
—> 16G (grey): crystalloid (85), colloid (65)
—> 18G: crystalloid (60), colloid (35)
Crystalloid vs Colloid:
- t1/2 of crystalloid (balanced salt solution BSS): ~20 mins
- t1/2 of colloid (e.g. Gelofusin): ~4-6 hours
- NO evidence to support superiority of colloid over crystalloid —> crystalloid reduce risk of fluid overload (colloid: may induce ***hypersensivity (gelatin), impair clotting (starch))
- trauma leads to leaky cells in pulmonary capillary bed —> greater risk of ***pulmonary edema with colloid
18
Q
Blood transfusion
A
- No level 1 evidence to define threshold for transfusion
- Transient / Non-responder: Blood transfusion indicated
—> when infusion of BSS >30 ml/kg —> transfusion indicated
—> ratio of RBC:FFP:Plt = 1:1:1 - ***NO steroid, vasopressor to treat hypovolaemic shock in trauma patients
- Surgical intervention: stop the bleeding!!!
Complications: 1. Storage defect in blood product - 2,3 DPG degradation: ↓ O2 affinity - HyperK (40-70 mmol/L) - Coagulation abnormality: Factor 5 / 8 decline quickly for 24 hours after collection - Haemostatic failure —> Hypothermia —> Acidosis (citrate + lactate)
- Blood transmitted infections:
- HBV / HCV
- HIV
- CMV
- Malaria - Haemolytic transfusion reactions
- Immunosuppression
- ↑ ratio of suppressor to helper T cell —> infection - Massive blood transfusion protocols
- whole blood / packed cells / platelets / FFP
19
Q
Resuscitation: Disability
A
- Baseline neurologic evaluation
- Pupillary response
- GCS score
- Neurosurgical consult as indicated - Observe for neurologic deterioration
- ICP can rise rapidly past threshold of compensation —> Hernia
20
Q
Resuscitation: Exposure
A
- Completely undress patient
- Remove helmet if present
- Look for visible / palpable injuries
- Log-roll, protect spine
- Prevent hypothermia
21
Q
Resuscitation: Summary
A
- If in doubt, establish definitive airway (cricothyroidotomy if needed)
- O2 for all trauma patients
- Chest tube may be definitive for chest injury
- Stop the bleeding
- 2 Large caliber IV
- Prevent hypothermia
22
Q
Special considerations in Children
A
- Trauma: leading cause of death
- Immature anatomic / mechanical features
1. Airway - larynx anterior + cephalad
- short tracheal length
- Breathing
- chest wall pliability
- mediastinal mobility - Circulation
- vascular access (may need ***Intraosseous access), fluid volume, vital signs, urinary output - Neurologic
- vomiting, seizures, diffuse brain injury (***hypotension is enemy of neurosurgery) - Musculoskeletal
- immature skeleton
- different fracture patterns
- Vigorous physiologic response
- Limited physiologic reserve
- Size, dosage, equipment, surface area, psychology
- Outcome depends on early, aggressive care
23
Q
Special considerations in Pregnancy
A
- Anatomic / Physiologic changes modify response to injury
1. Viscera - pushed upward
- Circulation
- relative hypervolaemic state
- physiologic anaemia
- supine hypotension (∵ pressure on IVC) - Breathing:
- ↓ gastric emptying —> risk of aspiration
- hyperventilatory state —>↓ PCO2 - Resuscitation
- IVC compressed by fetus —> limit venous return to heart - Gestation and position of uterus
- Isoimmunisation
- may need to give Anti-RhD to Rh -ve mothers during blood transfusion - Sensivity of fetus
- see if need delivery
- Need for fetal assessment
- 1st Priority: Maternal resuscitation (best way to resuscitate baby is to resuscitate the mum)
- Rupture amniotic membrane —> inevitably need to deliver baby (dead / alive)
- Outcome depends on early, aggressive care
24
Q
Special considerations in Elderly
A
- Injury: 5th leading cause of death
- Diminished physiologic reserve / response
- Cannot mount compensatory response effectively e.g. tachycardia, vasoconstriction - Comorbidities: Diseases
- Co-existing HT —> mask underlying haemorrhage (normal BP may already signify shock) - Medications
- Aspirin, Anticoagulants —> coagulopathy
- β-blockers: mask tachycardic response
- Outcome depends on early, aggressive care
Cardiovascular:
- Diminished pump function + lower CO
- Inability to mount appropriate response to intrinsic / extrinsic catecholamines
- Reduced flow to vital organs
- Co-existing medication blunting normal physiologic response
Respiratory:
- Decreased lung elasticity + pulmonary compliance
- Atrophy of bronchial epithelium leading to decreased clearance of particulate foreign matter
Renal:
- Decrease in renal mass
- Increased vulnerability to nephrotoxic agents
Musculoskeletal:
- Osteoporosis with inclination to fractures
- Decrease in muscle mass
Comorbidities:
- DM / Liver disease / Malignancy / Neurological / Spinal disease
25
Q
***Secondary survey
A
- Start after —> Primary survey completed (i.e. patient stabilised / improved) —> Resuscitation in process —> ABCDE reassessed —> Vital functions returning to normal
- ***Head to toe examination
- Undressing + log-roll
- Head
—> complete neurologic exam
—> GCS score determination
—> comprehensive eye / ear exam (pupillary response, otoscopic exam, visual acuity)
—> caution: unconscious patient, periorbital edema, occluded auditory canal
- Maxillofacial —> bony crepitus / instability —> palpable deformity —> comprehensive oral / dental exam —> caution: potential airway obstruction, cribriform plate fracture, frequently missed injury
- C-spine —> palpate for tenderness —> complete motor / sensory exams —> reflexes —> C-spine imaging (preferably CT scan) —> caution: injury above clavicles, altered LOC, other severe / painful injury
- Neck —> blunt vs penetrating —> airway obstruction, hoarseness —> crepitus, haematoma, stridor, bruit —> caution: delayed S/S, progressive airway obstruction, occult injuries
- Chest —> inspect, auscultate, palpate, percuss —> re-evaluate frequently —> CXR —> caution: missed injury, ↑ chest tube drainage
- Abdomen —> inspect, auscultate, palpate, percuss —> re-evaluate frequently —> FAST, DPL, CT —> caution: hollow viscus and retroperitoneal injuries (not apparent on FAST scan), excessive pelvic manipulation (may disrupt haematoma —> further bleeding)
- Perineum —> contusions —> haematoma, ecchymosis —> lacerations —> urethral blood
- Rectum —> blood —> sphincter tone —> high-riding prostate —> pelvic fracture —> rectal wall integrity
- Vagina
—> blood, lacerations
—> caution: pregnancy (amniotic fluid leaking)
- Musculoskeletal —> potential blood loss —> limb / life threat (Primary survey) —> missed fractures —> soft tissue / ligamentous injury —> occult compartment syndrome (esp. with altered LOC / hypotension) —> examine patient’s back —> splint long bones, analgesia
- Pelvis —> pelvic fracture (major source of haemorrhage —> volume resuscitation, reduce pelvic volume, external fixator, angiography / embolisation) —> pain on palpation —> symphysis width ↑ —> leg length discrepancy —> instability —> pelvic X-ray
- CNS —> frequent re-evaluation —> prevent secondary brain injury —> imaging as indicated —> early neurosurgical consultation
- Spine —> stepping / local tenderness —> complete motor + sensory exam —> imaging as indicated —> maintain in-line immobilisation —> early neurosurgical consultation —> caution: incomplete immobilisation, subtle ↑ in ICP with manipulation, rapid deterioration
- Adjuncts
- Blood tests
- Urinalysis
- X-ray
- CT
- Urography
- Angiography
- USG / Echo
- Bronchoscopy
- Esophagoscopy
—> do NOT delay transfer - ***AMPLE history
- Allergy
- Medication (Antiplatelet, Anticoagulant, β-blockers, Anti-HT)
- Past medical history / Pregnancy
- Last meal
- Events / Environment - Complete neurologic examination
- Special diagnostic tests
- Skeletal survey (e.g. femoral X-ray, skull X-ray) - Re-evaluation
- Vital signs
- Interventions (e.g. chest tube still in place?)
- Missed injury
—> high index of suscipion
—> frequent re-evaluation
—> continuous monitoring
—> rapidly recognise patient deterioration
26
Q
Preparation for operation
A
- Inform anaesthetist + OT staff
- Initiate massive transfusion protocol
- replacement of 100% of patient’s blood volume <24 hours
- administration of 50% of patient’s blood volume in 1 hour - +/- Arrange post-op ICU care
- Maintain reasonable BP before operation —> maintain adequate cerebral perfusion but not too high BP —> ***normotension before definitive measures may cause more bleeding
- SBP ~90
- MAP ~70 - Warm operating theatre
- Prepare fluid warmer, suction
- Prepare cell saver (i.e. Scavenge the lost blood —> for autotransfusion)
27
Q
***Operative management
A
- Generous midline laparotomy incision
- from xiphisternum to pubic symphysis - 4 quadrants packing
- RUQ + LUQ + R iliac fossa + L iliac fossa - Scoop out all blood clots
- Allow anaesthetist to administer blood products + clotting factors
- Remove packs from least bleeding site first (one by one)
- Locate the bleeding site - Definitive surgery (if stable) / Damage control surgery (DCS)
DCS:
- Stop bleeding
- Control contamination: staple off injured bowel ***without anastomosis
- Temporary abdominal closure: limit heat / fluid loss + protect bowels
- After DCS —> Correction of acid/base balance, clotting, body temp —> Allow more time in definitive surgery since physiology is optimised —> Definitive surgery in 24-48 hours
28
Q
Pattern of injury
A
Depends on:
- Anatomy
- Physiology
- Mechanism of injury
29
Q
Burn injury
A
- Inhalation injury: Intubate, 100% O2
- Chemical burns: Brush + irrigate (large amount)
- Administer ***2-4 mL/kg/% BSA burn in 24 hours (+ Maintenance in children) —> Parkland formula
- Monitor urine output
- Expose + prevent hypothermia
- Antibiotic + Tetanus prophylaxis
Measurement:
- Palm + Fingers = 1% BSA
- Rule of 9
- BSA: ***only for >=2nd degree burn (NOT for 1st degree burn)
30
Q
Cold injury
A
Frost bite:
- Rewarm with moist heat (40oC)
- Wait for demarcation
Hypothermia:
- Passive / Active rewarming
Monitor:
- Not dead until warm and dead
31
Q
Pain management
A
- Relieve pain + anxiety as appropriate
- Fast acting, IV opioid
- Careful patient monitoring is essential (SaO2, BP, End-tidal CO2, RR, HR)
32
Q
Safe transfer
A
When patient’s needs > institutional resources
- think about it during Primary survey
- use time before transfer for resuscitation
- do NOT delay transfer for diagnostic tests
- physician-to-physician communication
Transfer to:
- Trauma centre
- Specialty centre
33
Q
Emergency preparedness
A
- Simple plan
- Command structure
- Disaster triage scheme
- Traffic control system
