Trauma Management

Trauma Management Dr. Zohair Alaseri, MD FRCPc, Emergency Medicine FRCPc, Critical Care Medicine Intensivest and Emergency Medicine Consultant Director, Department of Emergency Medicine King Khalid University Hospital Chairman Disaster Committee King Saud University Hospitals, Riyadh, KSA

Trauma Management Introduction These patients benefit from skillful resuscitation; they are healthy, young individuals who, if salvaged, have a normal life expectancy.

Trauma Introduction • a disease of the youth • the leading cause of death in those 1 to 37 years old. • majority of trauma deaths occur either before reaching the hospital or within four hours of arrival.

Trauma Management Introduction Blunt trauma patient + Hypotension + Altered mental status = Diagnostic and Therapeutic Dilemma

Trauma Management Requirements • broad knowledge • sound judgment • technical skill • leadership capabilities. NO MORE ONE MAN SHOW Often what happens in the initial phase of resuscitation period often determines the outcome of care

Trauma System • Incorporate regional planning with designated trauma centers • Quality improvement programs NO MORE ONE MAN SHOW

Trauma System • It reduce the preventable trauma death rate. • Proper field triage ensures that injured patients are taken to the closest facility capable of delivering definitive care. NO MORE ONE MAN SHOW

Trauma Management Mechanism of Injury • Knowledge of the mechanism greatly enhances the management of trauma patients. anticipation Example: Supine impact axial skeletal injury Renal artery thrombosis from intimal tear

Trauma Management Prehospital Phase begins at the scene of the trauma. The prehospital roles • prevention of additional injury • rapid transportation • advance notification • initiation of treatment • triage.

Trauma Management ED Phase 7 A well-planned, organized approach to such patients provides optimal management.

1 Trauma Management ED Phase Organized Team Approach • Trauma Team Leader (TTL) • coordinates and controls the resuscitation and provides the leadership. • should be a senior member of the team with previous experience in trauma care.

1 Trauma Management Organized Team Approach ED Phase Trauma Management Outcomes Associated With Nonsurgeon Versus Surgeon Trauma Team Leaders Jennifer M. Ahmed From the Faculty of Medicine, Dalhousie U. Canada. • Objective : the effectiveness of surgeon and nonsurgeon trauma team leaders. • Methods: Retrospective study was conducted using data from a Canadian trauma registry database. • Conclusion: No differences were found in the outcome of trauma patients treated [Ann Emerg Med. 2007;50:7-12.] Trauma Team Leader (TTL)

1 Trauma Management ED Phase Organized Team Approach Main Responsibilities • assessing the patient • ordering needed procedures and diagnostic studies • managing fluid administration • monitoring the patient's progress. • controls the area • making therapeutic and the transportation decisions • subspecialty consultations and coordinates their activities Trauma Team Leader (TTL)

1 Trauma Management ED Phase • has the overall responsibility for patients during their stay in the emergency department • should not be so involved with procedures Organized Team Approach Trauma Team Leader (TTL)

1 Trauma Management ED Phase Organized Team Approach Trauma Code NO MORE ONE MAN SHOW What is the point of Trauma Code Activation?  Likely to reduce mortality  Likely to expedite a life/limb saving procedure

1 Trauma Management ED Phase Organized Team Approach Trauma Code NO MORE ONE MAN SHOW Code Activation Protocol contains predetermined guidelines for an interdisciplinary team approach to the initial care and management

1 Trauma Management Organized Team Approach ED Phase Trauma Code The primary objectives : NO MORE ONE MAN SHOW • Provide clearly delineated roles and responsibilities for members of the Trauma Team. • Establish and utilize Advanced Trauma Life Support principles as the standard of care for the trauma patient. • Assure rapid, efficient, systematic evaluation and treatment of the patient.

1 Trauma Management Organized Team Approach ED Phase Trauma Code Procedure: • Should be initiated by the ED Consultant upon a report of a pending arrival or upon arrival of the trauma patient meeting the CODE criteria • may be upgrade or downgraded at any time as the patient’s condition dictates. NO MORE ONE MAN SHOW

1 Trauma Management Organized Team Approach ED Phase Trauma Code Procedure: Members Team Leader Anaesthetist RT General Surgeon Radiologist Emergency Physician Critical Care Physician Two Nurses. (Three if no RT) Radiographer Scribe NO MORE ONE MAN SHOW

1 Trauma Management Organized Team Approach ED Phase Trauma Code Procedure: NO MORE ONE MAN SHOW CT Scanner & Theatres Certain areas need early notification of the trauma victim.

1 Trauma Management Organized Team Approach ED Phase Trauma Code Procedure: Radiographer NO MORE ONE MAN SHOW should immediately start with the trauma series of X-rays, in the order Cervical Spine, Chest and Pelvis, unless directed otherwise by the team leader. should also act as liaison to the CT scanning department.

1 Trauma Management Organized Team Approach ED Phase Trauma Code Procedure: NO MORE ONE MAN SHOW Scribe The scribe is responsible for the full record of the trauma call.

monitor AN Intubation Cart with difficult AW RT ventilator ICU Crush Cart RN RN GS Procedure Tray RN TL N.Super P scr

Trauma Management 2 Priorities in Management and Resuscitation ED Phase High-Priority Areas Low-Priority Areas

3 Trauma Management Assumption of the Most Serious Injury ED Phase The TL should give consideration to the worst possible injury and act accordingly until the diagnosis is confirmed or excluded.

4 Trauma Management Treatment before Diagnosis ED Phase The urgency of the situation in trauma cases often demands treatment based on an initial brief assessment without substantiation by radiographic or laboratory data.

Trauma Management 5 Thorough Examination ED Phase • The presence of one injury is no guarantee that a second or third injury does not exist. • Most missed injuries occur in severely injured patients

6 Trauma Management Frequent Reassessment ED Phase • A patient's status is dynamic. • Intoxicated patient Examples: Delayed presentation like duodenal injuries and lung contusions Frequent examinations can help detect early changes in the physical findings and thus lead to prompt corrective actions.

7 Trauma Management ED Phase Monitoring • V/S • continuous pulse oximetry • end-tidal carbon dioxide (CO2) monitoring when applicable. • Precise knowledge of the type and amount of fluid the patient has received is needed in determining subsequent fluid orders. • Certain laboratory tests should also be obtained serially.

Trauma Management ED Phase Vascular Access & IO Choice of Resuscitation Fluid SAFE Study Transfusion. Fully crossmatched blood may take 30 to 45 minutes to obtain. Type-specific blood is a safe alternative and is usually ready in 5 to 15 minutes. ?

End-tidal CO2 • Indirect Fick equation Central Venous Oxygen Saturation Indices of Successful Resuscitation • V/S Perfusion UOP Lactate Clearance • The overall goal of all resuscitation procedures is to improve oxygenation and perfusion of body tissues. Lactate concentration Clinical Exam BD

Be Careful Causes of missed injuries Traumaseverity • Multiple systems • Severe brain injury Conditions that complicate the complete clinical evaluation • Altered consciousness•Braintrauma•sedation-intubation•Intoxication Error • Inadequate physical examinationInaccurate interpretation of diagnostic investigationsInadequate surgical sequence

Critical success factors for establishing traumaas an institutional priority. • Set specific, measurable goals • Understand your own data • Identify support in your institution • Recruit a multidisciplinary team • Establish severe trauma program deliverables and targets • Broadly communicate severe trauma improvement goals • Measure your success Establish trauma as an Institutional Priority

Trauma Management