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Initial Evaluation and Treatment of the Multiple Trauma Victim

Initial Evaluation and Treatment of the Multiple Trauma Victim. Epidemiology. Trauma is a disease of the young, and is the leading cause of death in patients between the ages of 1-44. In 2001 there were 38,000 traffic fatalities, 39% were alcohol related.

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Initial Evaluation and Treatment of the Multiple Trauma Victim

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  1. Initial Evaluation and Treatment of the Multiple Trauma Victim

  2. Epidemiology • Trauma is a disease of the young, and is the leading cause of death in patients between the ages of 1-44. • In 2001 there were 38,000 traffic fatalities, 39% were alcohol related. • In 1999 28,000 deaths from firearms, 115,000 injuries annually • Fatalities represent only a fraction of all patients that suffer from traumatic injuries.

  3. Mechanism of Injury • Knowledge of the mechanism of injury can alert one to specific injuries. • Auto crashes: Broken windshield, bent steering wheel, knees to dashboard, restraint type, type of accident, speed of accident, extrication time. • Penetrating injuries • GSW’s • Falls : LD50 for falls is 4 stories (48 ft) • Strangulation

  4. Initial Triage of the Trauma Patient • Assess Vital Signs and LOC: SBP<90, RR<10 or >29, GCS <14, or RTS

  5. Initial Triage of the Trauma Patient • Assess Injury: Penetrating injuries, flail chest, trauma with burns, two or more proximal long bone injuries, pelvic fx, paralysis, amputations. • Assess Mechanism: Ejected, death in same accident, long extrication time, fall >20 ft, rollover, high speeds, intrusion, major auto damage, motorcycle crash >20 mph, auto-ped or auto-bicycle over 5 mph • Consideration of Other factors: extremes of age, pregnancy, bleeding d/o, serious underlying diseases like cardiac or pulmonary disease, diabetes, cirrhosis, etc.

  6. Initial Approach • Team approach with team leader directing care is optimal, may vary with institution. • Assume the most serious injury is present • Treatment based on limited assessment, before diagnosis. • Start with brief initial survey, followed by resuscitation, then secondary survey as patient is stabilized. • Frequent reassessment and constant monitoring.

  7. Primary Survey • A: Airway with c-spine control • B : Breathing • C : Circulation -control external bleeding. • D : Disability-neurological status • E : Exposure (undress patient)/Environment (Warmed fluids/blankets)

  8. Initial Stabilization • ABC’s- initial assessment of airway and ventilation. • Assess airway: look for obstruction with debris, blood, teeth, etc. vs. obstruction from displaced anatomical structures. • Assess ventilation: look at the rate and quality of respirations. Ventilation may be compromised by decreased LOC, flail segments, penetrating wounds, look for tracheal deviation, distended neck veins.

  9. Airway Maintenance with Cervical Spine Protection. • GCS score of 8 or less require the placement of definite airway. • Spinal precautions must be maintained during airway manipulation. • A normal neurological exam alone does not exclude a cervical spine injury. • Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or distracting injury.

  10. Circulation • Look for signs of shock by assessing • LOC • skin color • pulse • urine output • Control bleeding • Direct pressure • Limited use for tourniquets, MAST • Establish IV access

  11. Circulation • Initial Fluid with crystalloid • Blood loss replaced with 2-3x volume in crystalloid • Hypertonic saline • Indications for Transfusion • Patient clinically unstable after 2-3 Liters or 40-50 ml/kg crystalloid • Type O uncrossmatched blood/type specific blood • On-going blood loss usually located in one of the three body cavities: chest, abdomen, retroperitoneum.

  12. Disability ( Neurological Evaluation) • Assess Patient’s level of consciousness • A : Alert • V : Responds to Vocal stimuli • P : Responds to Painful stimuli • U : Unresponsive to all stimuli • P: Assess pupils • Assess patient for signs of impending herniation • Keep patient in full spinal precautions until full evaluation is complete

  13. Exposure / Environmental Control • Completely undress patient, • Warm ambient temperature, warmed blankets to decrease heat loss • All fluids/blood products should be warmed • Early control of hemorrhage.

  14. Initial Evaluation • Multiple trauma patients should have constant cardiac monitoring, continuous pulse ox, and initial set of vitals upon arrival. • Vitals should be reassessed frequently to determine response to initial resuscitation • Oxygen should be routinely administered. • In patients who do not need immediate intervention based on primary survey should have initial radiological evaluation including a chest and pelvis.

  15. Secondary Survey • AMPLE history • Physical consists of a head to toe evaluation of patient. • Thorough evaluation of neurological status, and complete exam of cardiac, abdominal, musculoskeletal and soft tissue systems. • Reassess vitals/EKG • Placement of NG tube/ Foley after evaluation for contraindications

  16. Secondary Exam: Neurological Evaluation

  17. Secondary Exam - Neuro • Complete Neuro exam should include evaluation of level of consciousness, pupil responses, careful cranial inspection, and evaluation for spinal tenderness and spinal and peripheral nerve function, including rectal tone • Head injury Classification: • Mild : GCS 14-15 • Moderate : GCS 9-13 • Severe : GCS 3-8

  18. Secondary Exam- Neuro

  19. Intracranial NG Tube Placement

  20. Incomplete Cord Syndromes

  21. Secondary Exam :Lethal Thoracic Injuries

  22. Lethal Thoracic Injuries • Tension pneumothorax • Hemothorax • Pulmonary contusion • Tracheobronchial-bronchial tree injury • Cardiac contusion/tamponade • Traumatic aortic disruption • Traumatic diaphragmatic injury • Mediastinal traversing wounds.

  23. Secondary Exam: Abdominal Evaluation

  24. Secondary Exam- Abdominal Evaluation • Initial stabilization of vital signs with fluid/blood. • Any patient with altered mental status, or distracting injuries requires an objective evaluation of the abdomen via DPL, CAT scan, or Ultrasound. • CAT scan is noninvasive, and sensitive. Also allows evaluation of the retroperitoneum. Limited use in patients who are unstable and do not respond to initial resuscitation.

  25. Secondary Exam- Abdominal Evaluation • Ultrasound is noninvasive and can be used at bedside to detect hemoperitoneum. • Useful in unstable patients • FAST exam evaluates the RUQ (Morison’s pouch), LUQ(splenorenal recess), pericardium, and pouch of Douglas in less than 5 minutes.

  26. FAST Exam

  27. Secondary Exam- Abdominal Evaluation • Unstable patients with decreased level of consciousness and + DPL or U/S needs urgent laparotomy; head CT should not be performed unless there is lateralizing neurological findings. • Unstable patients with a wide mediastinum and + DPL or U/S; laparotomy is recommended before arch aortography

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